key: cord- -eciycfpr authors: matthews, dr david title: board of directors nominations date: - - journal: aust vet j doi: . /j. - . .tb .x sha: doc_id: cord_uid: eciycfpr nan the nomination form must be accompanied by the following documents (these can be emailed to ceo@ava.com.au): a citation, written in the rd person and not exceeding words. this should provide information that will indicate to the members that the candidate has the skills and qualities required to lead and serve the association for the next three years. this will be printed on the ballot papers. a passport size colour photograph. you will also need to provide a word "why you should vote for me" statement, written in the st person, by march (send to lstace@ava.com.au). this will be published in the april edition of the australian veterinary journal to assist members in casting their vote. nominees will be notified of receipt of their nomination in writing. if you have not received notification of the receipt of your nomination by the closing date, please contact the company secretary on ( ) . t he current ava subscription for membership is complex and daunting to any prospective new member as well as to some members. discussion for simplifying the subscription matrix (some combinations) was instigated at the agm in a president's workshop. this letter examines a number of issues and makes some suggestions that will widen the debate and hopefully succeed in simplifying the subscription matrix. more than years ago i joined the ava as i believed that i gained benefit from my professional association. the association has grown and many opposing pressures have slowly evolved with divisional/branch versus sig structures. i am now being challenged to sort out just what membership subscription i have to pay. i feel for any prospective member trying to sort out just what cost and what sectors they should tick in the application for membership. i have great empathy for hard-working staff who are required to ensure that the correct fee is submitted and recorded. the association can benefit by keeping subscription fees simple, as more veterinarians will be likely to join. my proposal is to standardise the membership subscription to a single ava membership (national and divisional sub) and drop all branch fees. sig subscriptions should be grouped into three levels. additionally we should have a standard donation by all members to the five trust accounts. at this basic level the discounts for specific situations would be at , and per cent of the standard fee. life membership and life fellows, etc, would remain as is. debate on this rather simple concept should identify that: • ava is a prestigious national body with increasing political and community respect. that in itself is a good reason to be a member. • branches are about getting down to the immediate fellowship and community association. they have very successful gatherings and any specific costs should be borne by those attending them. • divisions are needed to manage and co-ordinate responses to political/community pressures. • co-operation within divisions and branches can result in divisional activities, such as scientific gatherings and get-togethers, which can generate funds for both levels of management. it also provides opportunity to geographically challenged divisions for the chance to meet with all members in a timely fashion. • branches need not charge a membership fee as all ava members in an area would be automatic members. • the five voluntary donation programs managed by ava, namely the australian companion animal health foundation, the veterinary benevolent fund, the ava animal welfare trust, comfund and petpep, should be contributed to by all members. as an example, our canberra colleagues who had such a disastrous january this year did not foresee the need to be supported by the benevolent fund. the comfund is there for the benefit of all. so why not have an agreed contribution by all members rather than the much higher voluntary contribution that now exists? the gst legislation will need to be assessed to ensure that these trust funds do not attract gst. mills raised a number of interesting points regarding the recent availability in australia of a vaccine to protect dogs against both coronavirus and leptospira icterohaemorrhagiae. it is hoped that this response will help to clarify a number of the issues and further encourage debate on the importance of these two diseases. the prevalence of leptospirosis in dogs is the highest in queensland (where it is caused by a number of serovars of which the most common is currently sv australis), but other states are not free from the disease. although the disease is generally under reported, there are some reports of outbreaks of clinical leptospirosis in urban areas in nsw . according to surveys, , per cent of dogs in the south-east of australia have titres against leptospira suggesting previous infection. these infections are especially associated with organisms from the icterohaemorrhagiae serogroup (sv copenhageni or sv icterohaemorrhagiae). around urban centres, with a higher concentration of dogs and rodents (the main reservoir of leptospirosis), vaccination might be considered useful, in particular for dogs exposed to rodents or their excreta. travel to areas where the prevalence of leptospirosis is higher is also a factor to be considered. dr mills states that infection with canine coronavirus (ccv) normally causes a transient, rarely fatal diarrhoea. this can, however, be fatal despite intensive medical care when concurrent with a parvovirus infection . in one study ccv was isolated in - per cent of dogs with severe enteritis. clinical signs of gastroenteritis are indeed mostly seen in pups, but clinical infections do also occur in adult dogs. although dr mills might consider this a minor problem, dog owners may perceive it differently. there are data available on the prevalence and significance of ccv in australia . these data show that sera from . per cent of the open population and . per cent of kennelled dogs were positive for ccv antibodies. of those dogs that were presented with clinical signs of gastroenteritis such as diarrhoea and vomiting, per cent were positive in the igm elisa for antibodies to ccv (suggesting recent infection). these results indicate that infection with ccv in dogs is widespread throughout australia. dog owners expect their animals to be protected from prevalent diseases when they are vaccinated, despite the fact that the diseases might rarely be fatal. there are numerous vaccines on the market that protect humans and animals from nonfatal diseases. the widespread use of the canine cough vaccine is a good example of this practice in the veterinary world. fort dodge australia is part of an international company that develops and manufactures veterinary vaccines and pharmaceuticals in australia and elsewhere to provide a wide selection of research-based animal health products. ultimately it is up to the clinician and the client to make an informed decision regarding the vaccination protocol of a specific animal. national leptospirosis surveillance report number . who/fao/oie collaborating centre for reference & research on leptospirosis a serological survey of dogs, cats and horses in south-eastern australia for leptospiral antibodies leptospirosis icterohaemorrhagiae in dogs in tasmania infectious canine enteric disease diagnoses at necropsy in the missouri veterinary medical diagnostic laboratory during update on canine coronavirus infections and interactions with other enteric pathogens of the dog canine coronavirus in australian dogs key: cord- - qwbkg o authors: hoddle, mark s. title: biological control of vertebrate pests date: - - journal: handbook of biological control doi: . /b - - / - sha: doc_id: cord_uid: qwbkg o nan several species of vertebrates, especially mammals, have been successful invaders and colonizers of new territories, in particular, insular island ecosystems. others have exhibited high environmental tolerance and adaptability after careful and repeated introductions to new locales by humans. following establishment, several vertebrate species have become important pests. these pests harm agricultural systems by damaging agricultural lands [e.g., rabbits (oryctolagus cuniculus linnaeus) in australia and new zealand], by attacking crops [e.g., european starlings (sturnus vulgaris linnaeus) in the united states], and by acting as sources for communicable diseases [e.g., brushtail possums, (trichosurus vulpecula kerr) , are reservoirs for bovine tuberculosis (mycobacterium bovis karlson and lessel) in new zealand]. other pest vertebrates damage natural systems by threatening the continued existence of endangered flora [e.g., goats (capra hircus linnaeus) on the galapagos islands] and fauna [e.g., brown tree snake (boiga irregularis { merrem }) on guam], and by adversely affecting wilderness areas by changing ecosystem functions and diversity (vitousek et al., ) . the continued relocation of vertebrates exacerbates the ongoing problem of global homogenization of biota (lodge, ) . movement of particular vertebrates into areas where they had not previously existed has, in some instances, occurred naturally without human intervention [e.g., the passerine bird (zosterops lateralis { latham }) arrived in new zealand unassisted from australia]. the vast majority of vertebrate translocations have been human assisted. accidental introduction has occurred as a consequence of human transportation [e.g., brown tree snakes, mice (mus musculus lin-naeus) , and rats such as rattus rattus linnaeus and r. norvegicus berkenhout) ]. some releases have been intentional (but illegal) to serve self-centered private interests [e.g., monk parakeets (myiopsitta monachus { boddaert }) in new york, florida, and texas]. other species have been legitimately introduced to procure public benefit by providing: ( ) new agricultural products [e.g., european wild boars (sus scrofa linnaeus); sheep (ovis aries linnaeus); cows (bos taurus linnaeus), goats and rabbits for meat, and brushtail possums for fur in new zealand], ( ) recreation [e.g., red deer (cervus elaphus linnaeus), fallow deer (dama dama linnaeus), and trout (salmo trutta linnaeus and s. gairdneri richardson) in new zealand]; ( ) companionship [e.g., cats (felis domesticus linnaeus) and dogs (canis familiaris linnaeus)]; or ( ) biological control agents [e.g., the european fox (vulpes vulpes linnaeus), stoats (mustela erminea linnaeus), weasels (m. nivalis linnaeus) , and ferrets (m. putorius furo linnaeus) for the control of rabbits in australia or new zealand; cane toads chemical and cultural control of vertebrate pests is expensive and nonsustainable, and at best provides a temporary local solution to problems (hone, ; williams & moore, ) . biological control of vertebrates, a potentially less expensive and self-sustaining method of population suppression, has focused primarily on mammalian pests. predators, parasites, and pathogens specific to mammals with two notable exceptions (the myxoma and calici viruses that infect rabbits) have failed to provide satisfac-tory control (shelford, ; howard, ; davis et al., ; wood, ; smith & remington, ; whisson, ) . historical records indicate that the majority of attempts at vertebrate biological control have been ad hoc efforts and not the product of careful studies designed to elucidate factors and conditions likely to affect the impact of natural enemy introductions on pest populations. furthermore, failure of biological control of vertebrates by predatory vertebrates has compounded problems associated with exotic vertebrates because control attempts result in addition of new species that cause biological and conservation problems. the level of control achieved by natural enemies is dependent on ratios of natality to mortality of control agents and their host species (davis et al., ) . for vertebrates these ratios are affected by many factors: advanced learning; social, territorial, and breeding behaviors; chemical, physical, and immunological defenses; temporal and spatial escape strategies; and genetic selection in both natural enemy and host populations for persistent coexistence. these complex interrelated factors, coupled with opportunistic feeding habits, have made vertebrate pests difficult targets for biological control with natural enemies. advances in understanding of mammalian fertilization biology have provided molecular biologists with necessary information to develop and investigate the concept of immunocontraception for vertebrate pest control. immunocontraception utilizes genetically modified pathogens that express surface proteins from the target pest's egg or sperm to induce an immune response in the host. antibodies then attack gametes in the host's reproductive tract causing sterilization (tyndale-biscoe, b . computer models indicate that immunocontraception may provide long-term control of vertebrate pests because genetically modified pathogens reduce net reproductive rates without killing hosts (barlow, (barlow, , . in this chapter, i discuss attributes that have aided vertebrate establishment; damage resulting from colonization and uncontrolled population growth; biological control of mammalian pest species with predators, parasites, and pathogens; and future directions that biological control research for vertebrates is taking with genetically engineered microorganisms. permissive to successful introductions of new species. e ton's ( ) predictions have been substantiated in part by paleobiological reconstructions of invasions between newly joined communities (vermeiji, ) and by mathematical modeling describing multi-species interactions in communities (macarthur, ; case, ) . isolated oceanic islands (e.g., new zealand), and insular continents and habitats (e.g., australia and lakes) often have a low diversity of native species. such environments have typically experienced little immigration and are susceptible to invasion by vertebrates (brown, ) . stable, speciose communities with high levels of interspecific competition appear to resist invasion by new species and are sources of successful colonists into less speciose or disturbed communities (macarthur, ; brown, ; lodge ) . this phenomenon has produced asymmetrical patterns of colonization, with successful vertebrate invaders usually being native to continents or extensive nonisolated habitats within continents with more diverse biotas (brown, ; vermeiji, ) . continental herbivores and predators have been very successful in establishing self-sustaining populations in insular habitats, in part because such habitats often lack large generalist vertebrates and essentially have just two trophic levels, producers and decomposers (if specialist herbivores and their predators are excluded) (vitousek, ) . niches equivalent to those on the mainland are largely unoccupied (brown, ) . insular ecosystems therefore often appear to readily accommodate generalist herbivores and predators, perhaps because of low levels of competition for resources that are often inadequately defended chemically or physically (vitousek, ; vermeij, ; bowen & van vuren, ) . organisms from insular habitats that have not coevolved closely with predators or herbivores lack life history features that deter attack or permit survival despite high mortality from predation or herbivory (bowen & van vuren, ) . lack of such biological attributes may increase the competitive advantage of exotics (case, ; coblentz, ; vitousek, ) . introduced vertebrates can also be extremely disruptive in continental regions when habitat disturbance by urbanization or agriculture occurs. european wild boars have detrimental effects on gray beech forests in the great smoky mountains in the southeast united states. habitat disturbance-through pig rooting, trampling, and browsing-and human removal of predators (pumas and wolves) aided pig establishment and spread in this area (bratton, ; singer et al., ; vitousek, ) . communities vary in their ability to accommodate the establishment and proliferation of new species (primack, ) . elton ( ) suggested that species-poor communities (e.g., islands) or highly disturbed habitats are more although there are well-recognized exceptions to general rules that characterize successful vertebrate colonists (ehrlick, ; williamson & fitter, b) , species that establish self-sustaining populations outside their native range typically exhibit some of the following general characters: ( ) short generation times, ( ) high dispersal rates, ( ) high tolerance for varying geographic and climatic conditions, ( )polyphagy, ( ) low attack rates from upper trophic level organisms, and ( ) human commensalism (ehrlich, (ehrlich, , lodge, ; williamson & fitter, a) . the assumption of a high intrinsic rate of increase is generally unnecessary for establishment (ehrlich, ; lodge, ) , although it is important for the establishment of some exotic bird species (veltman et al., ) . the spread of the european rabbit in australia and new zealand, countries that both historically lacked significant eutherian mammal fauna, illustrates some of the preceding points. the european rabbit originated in spain and portugal (corbet, ) and spread through most of europe over years ago following deforestation by humans for agriculture and overgrazing by livestock. animals reared in captivity were carried through europe in advance of naturally spreading populations (flux, ) . the spread of the european rabbit throughout australia following its introduction in varied from km/year to approximately km/year. rate of spread was fastest across dry savannas where conditions were most similar to mediterranean climates and slowest through woodlands (myers et al., ) . in australia, habitat alteration by humans such as conversion of land to pasture, overgrazing of rangelands, and predator eradication [e.g., dingos (canis familiaris dingo meyer)] aided rabbit survivorship and spread. rabbits are polyphagous and feed on grasses and browse shrubs. during severe food and water shortages, bark, fallen leaves, seed pods, tree roots, and termites are consumed (myers et al., ) . rabbits are highly fecund and exhibit rapid population growth under good conditions. individual female rabbits to months of age can produce litters averaging to young, and with abundant food to offspring per year are produced (gibb & williams, ) . behavioral adaptability, sociality, and territoriality, in addition to use of elaborate underground warrens, have also aided rabbit proliferation in marginal habitats (myers et al., ) . assistance in establishment some of the first introductions of exotic vertebrates were those commensal with humans as they colonized new areas. among well-documented early human introductions are dingoes in australia (brown, ) and polynesian rats [rattus exulans (peale)] on pacific islands (roberts et al., ) . as early europeans explored the planet, other commensal species such as r. rattus, r. norvegicus, and mus musculus expanded their geographic range without deliberate human assistance and are now cosmopolitan in distribution (brown, ) . not all vertebrate pests cohabitat with or are associated with human disturbance of the environment. red deer and feral cats, for example, inhabit much of new zealand's pristine habitats with no human management. most vertebrate translocations fail even with human assistance. failure of exotics to establish may depend on life history parameters, responses to abiotic factors, inability to outcompete native species for resources or enemy free space, or chance (cornell & hawkins, ) . deliberate releases of exotic birds have establishment rates of around to % (veltman et al., ) . establishment estimates for intentional vertebrate releases are biased because successes are more often recorded than failures (ehrlich, ; veltman et al., ) . the amount of effort directed toward introduction is an important variable affecting successful colonization by vertebrates, and establishment rates increase with high levels of management and numbers of individuals released (ehrlick, ; griffith et al., ; williamson & fitter, b; veltman et al., ) . in contrast, organisms that are casually introduced into new areas have much lower probabilities of establishing and proliferating. this phenomenon is expressed in the tens rule, a statistical characterization of probability outcomes for different levels of invasion success (williamson & fitter, a , b . for a variety of plants and animals, a general rule holds that in species imported (i.e., brought into new areas intentionally or accidentally) appear in the wild, in of those now found in the wild become established, and that in of those established with self-sustaining populations become pests (williamson & fitter, b) . following establishment, proliferation, and rise to pest status, control of exotic vertebrates is often prompted by economic, environmental, or conservation concerns. several control strategies may be pursued, the most common being chemical control (e.g., poisoning) and cultural control (e.g., trapping, fencing, and shooting). the least used option has been biological control. chemical and cultural control of vertebrate pests has been covered by hone ( ) and williams and moore ( ) . biological control is the intentional use of populations of upper trophic level organisms (e.g., predators, parasites, and pathogens) commonly referred to as natural enemies to suppress populations of pests to lower densities than would occur in the absence of natural enemies (debach, ; van driesche & bellows, ) . biological control programs for vertebrates have employed all three classes of natural enemies: predators, parasites, and pathogens. in contrast to weeds and pestiferous arthropods, however, biological control as a population suppression tactic for management of vertebrate pests has historically received much less attention. predators of vertebrates in the few instances they have been used have not been particularly successful. some vertebrate predator introductions also had severe impacts on nontarget organisms. consequently, early unpromising results discouraged intensive development of this technology (howard, ; davis et al., ; wood, ) . there is a need for increased effort using biological control agents against vertebrates, especially where resistance to toxins has developed, or behavior and terrain makes chemical and cultural control difficult and expensive (wood, ; bloomer & bester, ) . biological control should be fostered internationally because many countries experience similar problems (e.g., rabbits are agricultural pests in argentina, australia, chile, europe, and new zealand; rats, cats, and dogs attack endangered faunas on many oceanic islands; feral pigs and goats in new zealand, australia, and the united states degrade habitat and threaten endangered flora). biological control can be aided by the establishment of institutions to help coordinate regional and international research activities. for example, in , the australian federal government supported the creation of the cooperative research center for biological control of vertebrate pest populations (also known as the vertebrate biocontrol center), an unincorporated collaborative venture between state and federal organizations with international cooperators (anonymous, a) . the principle research goal of this institution is population suppression of noxious vertebrate species by regulating reproductive rates (tyndale-biscoe, a). a fundamental issue that has important implications for biological control is understanding the regulatory effects predators have on prey populations. determining impact of introduced predators on pest and nontarget populations is becoming increasingly more important as public awareness of potential nontarget impacts increases and the impact of past introductions on nontarget organisms has become clearer (howarth, ; van driesche & hoddle, ) . introductions of vertebrate predators as biological control agents against vertebrates have in some instances had disastrous impacts on nontarget wildlife, especially insular communities that have lacked an evolutionary history with generalist predators (case, ) . an example is the impact the small indian mongoose on native rail populations in hawaii following its release in the s for rat control (loope et al., ) . the mongoose has little demonstrable effect on rats (cagne, ) and mongoose populations are now poisoned to protect native birds (loope et al., ) . exotic predators may enhance the success of introduced pest species by moderating the competitive impact of natives on introduced pests should predators reduce densities of native species (case, ) . on the other hand, there is very good evidence that under certain circumstances introduced exotic predators can regulate target vertebrate pests. in such cases, predator efficacy may be affected by ecosystem complexity; by influence of such extrinsic factors as weather, disease, or human intervention on pest population growth; and by the availability of alternative food sources to sustain predators when pest populations are low. in simple ecosystems such as islands, establishment of reproducing predator populations can result in the extinction of target pests. in the absence of alternative prey, releases of cats for rabbit control on berlinger island near portugal by a lighthouse keeper resulted in the eradication of the rabbits, and subsequently cats died from starvation (elton, ) . in complex communities, alternate prey may be taken when primary prey populations are low for prolonged periods, as is the case for some microtine rodent species in europe. european rodent populations exhibit fluctuations in size as a response to variation in food availability. these fluctuations are also influenced by predation. population cycles are not observed in southern hemisphere countries where european pests and predators have been transferred (korpim~iki & krebs, ; sinclair, ) . rabbit populations in australia and new zealand are maintained at low levels by introduced predators, but regulation only occurs after pest numbers have been reduced by other means. poisoning programs in new zealand in the s and s substantially reduced rabbit densities and populations were maintained at low levels by introduced predators, in particular, ferrets and cats (newsome, ) . similarly in australia, european foxes and cats maintain rabbit populations at low densities following population crashes caused by prolonged hot summers that reduce forage and browse (newsome et al., ; newsome, ) . mouse populations are regulated in a similar fashion by predators (raptors and foxes) in australia (sinclair et al., ) . introduction of two foxes dusicyon culpaeus (molina) and d. griseus (gray) native to mainland chile onto the chilean side of tierra del fuego island regulated rabbit populations after rabbit densities were substantially reduced by the myxoma virus (jaksic & yhfiez, ) . the suppressive action of predators on rabbits in australia has been demonstrated through predator removal experiments [referred to as perturbation experiments by sinclair, ( ) ] in which european foxes and cats were shot from four-wheel drive vehicles at night. removal of predators resulted in rapid rabbit population growth compared with rabbit densities in control plots in which predators were not removed (newsome et al., ) . the "predator pit" first conceptualized by may ( ) describes rabbit regulation in australia and new zealand by generalist predators. the model suggests that once prey populations fall below certain densities (i.e., because of culling or disease) predators can prevent recovery to higher levels. generalist predators achieve this by maintaining relatively high numbers by attacking alternate prey species, and low but persistent levels of predation on species in the pit prevents pest populations from outbreaking. for the rabbit-fox system in australia, a predator pit operates at densities of to rabbits per kilometer of linear transect. below these densities foxes utilize alternate food sources (e.g., native animals) and above this critical density rabbit populations escape regulation by predators (newsome, ) . in new zealand, rabbits are contained in the pit by cats and ferrets when densities are . rabbits per hectare (barlow & wratten, ) . the effect of predators on long-term population dynamics of alternate prey species is generally difficult to disentangle from confounding effects of habitat degradation and competition for food and breeding sites from other introduced species (pech et al., ) . foxes regulate mice and rabbits through positive density dependence at low prey densities. increasing pest densities during outbreaks results in inverse density-dependent predation and type iii functional responses (sinclair et al., ; pech et al., ) . rabbit and mouse populations escape predator regulation when favorable weather provides good breeding conditions, or when predators are controlled by shooting or poisoning (newsome, ; sinclair et al., ; pech et al., ) . predator control may be necessary for lifestock protection or for conservation of endangered wildlife and when implemented resurgence of pest populations occurs (newsome et al., ; newsome, ) . predator numbers may increase when primary prey (e.g., rabbits) are abundant. predation by abundant predators on secondary prey (e.g., native animals) result, leading to declines in secondary prey density. under such circumstances native prey species may only persist in refugia or in areas with artificially reduced predator pressure (pech et al., ) . altematively, declining densities of a primary pest prey species (either through management or disease) can intensify predator attacks on nontarget organisms. therefore, when conservation of endangered natives is a concern, culling of predators may be undertaken either concurrently with the decline in prey density or in anticipation of such a decline (grant norbury, personal communication, ) . in such situations an integrated approach to managing vertebrate pests and their predators is necessary (newsome, ) . predator efficacy can be enhanced either through habitat modification or resource provisioning. cats can maintain rat and mouse populations around farm buildings below environmental carrying capacity as long as they are provisioned with additional food (e.g., milk). dietary supplementation prevents rodent extermination and the subsequent extinction of cats. sustaining a cat population prevents uncontrolled invasions by rodents and low pest densities are maintained (elton, ) . provision of nesting boxes for barn owls (tyto alba javanica) reduces crop damage by rats in malaysian oil palm plantations; rodenticide use declined, and in some instances use was eliminated (wahid et al., ) . changes in management practices can improve predator efficacy. rodent control by tyto alba (scopoli) in pinus radiata don plantations in chile was enhanced by clearing -m wide strips between trees (for owls to maneuver in while in flight) and construction of perches in forests (for resting and surveillance). bam owl numbers and predation rates on rodents increased following habitat modification (mufioz & murfa, ) . under increased predation pressure, rodents will modify foraging behaviors by reducing activity when owls are flying or making hunger calls (abramsky et al., ) . learning in this manner produces behavioral adaptations because of strong selection pressures to minimize predation risks on pest populations (davis et al., ) . parasites or macroparasites (e.g., helminths, lice, ticks, fleas, and other metazoans) do not typically kill their hosts as a prerequisite for successful development as insect parasitoids do. they tend to be enzootic (i.e., remain at fairly constant levels through time) and usually must pass through a free-living stage to complete an entire life cycle (anderson, ; mccallum, ) . the potential of parasites to regulate vertebrate host populations was first proposed as early as (lack, ) and later was demonstrated theoretically with lotka-voltera models in which parasites increased host mortality rates may, ) . parasites act in a positive density-dependent manner by adversely affecting host survival or reproduction dobson & hudson, ; scott & dobson, ) . host parasite load also affects the ability of individual parasites to grow, reproduce, and survive in definitive hosts; and the severity of density dependence on host and parasite fitness is affected by patterns of parasite distribution in host populations (scott & lewis, ) . helminths, for example, tend to be aggregated within host populations so that few hosts are heavily burdened while most are lightly infected (scott & lewis, ) . density-dependent constraints on parasite survival and reproduction occur in the few heavily infected hosts, and under such conditions, helminth population stability is enhanced . furthermore, parasites with low-to-moderate pathogenicity exert stronger regulatory actions on populations than highly pathogenic species that cause their own extinction by killing hosts before transmission (anderson, ) . parasite regulation of vertebrate populations has been observed under field conditions. botfly (cuterebra grisea coquillett) parasitism of voles [microtus townsendii (bachman)] in vancouver canada, is inversely density dependent; and botfly infestation significantly reduces vole survival, reproduction, and development (boonstra et al., ) . the parasitic helminth trichostrongylus tenuis (cobbold) is the primary agent responsible for long-term population cycles in red grouse [lagopus lagopus scoticus (latham)] inhabiting scottish heathlands (dobson & hudson, ) . the regulatory effect of t. tenuis has been demonstrated by reducing parasite infestations with helminthicides in experimental birds. treated grouse showed increased overwintering survival, clutch sizes, and hatching rates when compared with untreated birds (dobson & hudson, ) . in the laboratory, introduction of the nematode heligmosomoides polygyrus dujardin reduced mice densities by % in comparison with control populations. reduction of nematode transmission rates and elimination of parasites with helminthicides allowed infested mouse populations to increase (scott, ) . although host and parasite densities in this study were higher than those found in nature, the data showed that introduction of a parasite regulated host population abundance. the potential effectiveness of nematodes as biological control agents in field situations has been evaluated for control of the house mouse, an introduced pest in australia (singleton & mc-callum, ; spratt, ) . mouse (mus domesticus) populations erupt every to years in cereal-growing regions of southeastern australia (singleton & mccallum, ; mccallum, ) and economic losses to mouse plagues exceed $ million (australian) (beckman, ; singleton, ) . outbreaks are associated with high autumn rainfalls following prolonged periods of drought that extend the growing season for grasses that set seeds. this high-quality food source increases high mouse survivorship and breeding throughout winter. population crashes occur when food supplies are exhausted (singleton, ) . saunders and giles ( ) suggested that droughts are necessary to remove the regulating effects of natural enemies, and this removal combined with favorable weather conditions permitted mouse numbers to increase rapidly. capillaria hepatica (bancroft), a parasitic nematode that infests mice, is naturally occurring and widely distributed in pestiferous rodents in coastal areas of australia. it is, however, absent in mouse populations in cereal-growing areas . this nematode is unique because it is the only known helminth with a direct life cycle that requires host death for transmission. female nematodes deposit eggs in the host's liver; and these eggs are liberated by predation, cannibalism, or necrophagy with subsequent digestion of infected liver. unembryonated nematode eggs voided after ingestion undergo embryonation to become infective and are probably consumed when mice preen their fur and feet (fig. ) . ground beetles (carabidae) may vector c. hepatica eggs after they have been eaten (mobedi & arfaa, ). firststage larvae emerge from ingested embryonated eggs and move into the liver through the hepatic portal system (wright, ) . nematode infestation significantly reduces natality and numbers of young mice weaned by infected females (mccallum & singleton, ; singleton & mc-callum, ; . capillaria hepatica is associated with introduced rat and mouse species in urban areas, and naturally occurring infections in native australian mammals are rare probably because of the susceptibility of nematode eggs to ultraviolet radiation and desiccation singleton et al., ) . native australian mice and marsupials are susceptible to experimental infection in laboratories . rats (r. norvegicus and r. rattus) are major reservoirs for c. hepatica in urban areas and infestation rates range from to % (childs et al., ; singleton et al., ) . infestation levels are lower in sympatric mice populations ( to %, singleton et al., ) . low rat numbers in cereal-growing regions of australia may be a factor contributing to the nonpersistence of c. hepatica in these areas . infestation of nonrodent mammals by c. hepatica is rare but has occurred in rabbits (gevrey & chirol, ) , dogs (leblanc & fagin, ) , horses (munroe, ) , and humans (pannenbecker et al., ) . human infections can be treated successfully (pereira & franca, ) . exploratory models investigating the impact of c. hepatica on mouse populations indicated that the requirement of host death for parasite transmission is strongly destabilizing. in the absence of resource limitation mouse densities increase similarly to disease-free populations before parasites have an impact and infected populations decline in density (mccallum & singleton, ) . slow regulation of mouse populations occurs because of the need for host death for transmission. consequently, the nematode's life cycle operates on the same time scale as that of its host instead of being orders of magnitude faster, as is the case with other parasites that do not require host death for transmission (mccallum & singleton, ; singleton & mc-callum, ) . the destabilizing influence of c. hepatica on mouse parasitology today, , [ ] [ ] [ ] [ ] populations may contribute to localized host and parasite extinctions. these extinctions, coupled with very low mouse densities in nonoutbreak years, result in population bottlenecks and may explain why nematodes do not persist in regions where mouse outbreaks occur. soil type, temperature, and moisture content do not affect nematode egg survival and embryonation under favorable conditions in outbreak regions (spratt & singleton, ) . outbreak intensity can theoretically be reduced by c. hepatica if populations are inoculated early, preferably year before an outbreak is expected (mccallum, ) . releases of high doses of nematode eggs in the summer or autumn when mouse densities are sufficient to enable high levels of transmission may offer the best chance for successful control (mccallum & singleton, ; mccallum, ) . field experiments in enclosures and with increasing populations of free-ranging mice have failed to demonstrate long-term regulation on mouse population growth with periodic inoculative releases of c. hepatica eggs. unexpected declines in control populations (i.e., populations not treated with nematodes) have to some degree masked the effect of c. hepatica on mice populations singleton et al., ; singleton & chambers, ) . transmission of c. hepatica in treated populations is not density dependent and can occur at low levels for to months. transmission rates show seasonal trends influenced by soil temperatures and increasing aridity singleton & chambers, ) . improved understanding of the influence of factors (such as temperature and rainfall on nematode persistence, survival, and transmission in field situations) and timing of releases of parasite eggs may improve releases of c. hepatica for control of mouse outbreaks (singleton et al., ; singleton & chambers, ) . vertebrate species that successfully colonize new habitats have reduced parasite loads in comparison with mother populations from which they originated (dobson & may, ) . lower infestation levels probably occur because individuals that make up small founding populations either were uninfected or had only a limited subset of the total potential parasite species found in the area of origin, or intermediate hosts required for parasite persistence were absent in the new range. sparrows and starlings, both successful colonizing species from europe, have two to three times fewer parasites in north america compared with populations from which they originated. populations established outside of europe may have benefited from reduced parasite burdens, although there are no quantitative data to indicate that this aided establishment and proliferation (dobson & may, ) . investigating the role of parasites on population dynamics of rabbits in europe with the view for possible introduction into countries where rabbits are pests is also warranted (boag, ) . introduced mammals such as rats, goats, and cats on oceanic islands exhibit depauperate parasite faunas (dobson, ) . fewer parasites coupled with presumed low genetic diversity of small founding populations, and reduced selection pressures for parasite resistance may make these pest vertebrates vulnerable to introduced host-specific parasites. the ideal parasite introduced into a high-density pest population that originated from a small founding population should have low-to-intermediate pathogenicity, because such parasites establish and maintain themselves in populations at lower densities than more pathogenic species do . macroparasites that reduce both host longevity and fecundity may have the potential to cause sustained reductions of host population densities (dobson, ) . low genetic variability among target populations should theoretically enable introduced parasites to become more evenly distributed among hosts, and reduction in parasite aggregation would increase natural-enemy efficacy (dobson & hudson, ) . the possibility of reassociating parasites with vertebrate pests is not limited to mammals and birds. host-specific parasites may have the potential to reduce reproduction and longevity of pest reptile (dobson, ) and amphibian species (freeland, ) . the brown tree snake is the proximate cause of native bird extinctions on guam following its accidental introduction after world war ii on military equipment (pimm, ; savidge, ; jaffe, ; rodda et al., ) . the snake also has caused declines of native reptile and small mammal populations, and enters houses and attacks sleeping human infants (rodda et al., ) . additionally, the brown tree snake has caused eco-nomic losses by adversely affecting domestic animals (e.g., chickens and pets), and high densities of snakes on power lines regularly cause short circuits that interrupt electrical supplies and necessitate repairs. control of the brown tree snake has been attempted through trapping, but the snake's extreme preference for live bait over artificial lures has made this approach impractical (rodda et al., ) . the brown tree snake mnative to eastern indonesia, the solomon islands, new guinea, and northeastern australiambelongs to the family colubridae. it is the only member of this family on guam. there is one native species of snake on guam, the blind snake, rhamphotyphlopys braminus (daudin), which belongs to the family typhlopidae and is the only snake occurring on many islands in the central pacific region (t. fritts, personal communication, ) . the brown tree snake has extended its range and is now established on the previously snake-free island of saipan, and this snake has been intercepted in hawaii; corpus christi, texas, and spain (rodda et al., ) . given the propensity for the brown tree snake to be dispersed to new habitats within cargo loads on planes and ships, the major social, economic, and ecological problems that are caused on islands after colonization, in addition to its distant taxonomic relationship to snakes common to pacific islands, make the brown tree snake an excellent target for biological control. the taxonomic relationship between colubrids and typhlopids may simplify the task and reduce the cost of finding natural enemies unique to the brown tree snake. parasites or pathogens that are host specific just to the family (i.e., colubridae) or genus (i.e., boiga) level may be safe to nontarget snakes (e.g., typhlopids) because these organisms have not evolved the ability to cause disease in distantly related hosts. extreme caution should be exercised when implementing a biological control program against vertebrate pests with parasites. parasites and pathogens can pose major threats to populations of endangered animals (mccallum, ; mccallum & dobson, ) . the susceptibility of nontarget organisms, especially endemic species, to infection by candidate biological control agents should be investigated thoroughly prior to parasite releases. reassociating parasites that preferentially infect a competitively dominant pest species may increase species diversity of invaded communities by reducing the pest's prevalence. in this instance, the natural enemy would assume the position of a keystone parasite (marcogliese & cone, ) . pathogens or microparasites include viruses, bacteria, and protozoans. pathogens tend to be unicellular and exhibit epizootic (i.e., boom or bust) life cycles due to rapid proliferation in hosts (anderson, ; mccallum, ) . the potential of pathogens to regulate vertebrate population densities by reducing the longevity and fecundity of infected hosts has been demonstrated theoretically with mathematical models and by perturbation experiments using vaccines (smith, ) . as with macroparasites, models indicate that microparasites of intermediate pathogenicity are more effective biological control agents (anderson, ) . highly virulent pathogens kill themselves by destroying hosts before they can be transmitted and avirulent strains are not transmitted because they are removed by the immune system. the immune system is theorized as being responsible for maintaining the intermediate virulence of vertebrate microparasites (anita et al., ) . pathogens that are readily transmitted (i.e., microparasites spread by water, air, and vectors) or have high-density host populations are more contagious than those with low transmission rates (i.e., spread is by host-to-host contact) or low host densities (ebert & herre, ) . new associations between pathogens and novel hosts are generally not more harmful than those that have evolved closely with the host. experimental evidence indicates that novel disease-causing organisms are on average less harmful, less infectious, and less fit than the same parasite strain infecting the host it is adapted to (ebert & herre, ) . also, a microparasite's ability to infect and exploit novel hosts decreases with increasing geographic and presumably genetic distance from the host to which the pathogen is adapted (ebert, ) . exceptions do occur, however, and pathogens can have devastating impacts on hosts that have no evolutionary history with the disease organism. an example is the myxoma virus, the causative agent of myxomatosis in european rabbits. the use of this natural enemy against rabbits in australia and europe has been the most thorough biological control program against a vertebrate pest. the myxoma virus is a member of the genus leporipoxvirus (poxviridae) and originated from south america where it was first recognized as an emerging disease of european rabbits in laboratories in montevideo, uruguay, in . infected laboratory rabbits died of a fatal febrile disease that caused tumors on the head and ears. the tumors resembled myxomas (a benign tumor composed of connective tissue and mucous elements) and the disease was subsequently named infectious myxomatosis of rabbits (fenner & marshall, ; fenner & ratcliffe, ; fenner, ) . the indigenous host for myxoma virus in south america is the forest rabbit [sylvilagus brasiliensis (linnaeus)]. unlike its effect on european rabbits, myxoma inoculum injected into forest rabbits caused benign fibromas at the site of inoculation that persisted for many months, although death did not occur. mosquitoes were implicated in vectoring the disease from forest rabbits to european rabbits being bred in south american rabbitries. another leporipox-virus has been isolated in california from the brush rabbit, sylvilagus bachmani (waterhouse), and is closely related to the myxoma virus (fenner & marshall, ; fenner & ratcliffe, ; fenner, ; fenner & ross, ; ross & tittensor, ) . myxoma virus has been used in australia, europe, chile, and argentina for biological control of european rabbits. the virus was first imported into australia from brazil in and but was not released (fenner & ratcliffe, ) . work by australians with the virus began again in the united kingdom in and continued with caged rabbits on wardang island off the south coast of australia. the virus was successfully established on mainland australia in (fenner, ) and within years it had established itself over most of the rabbit's range (fen-ner& ratcliffe, ) . the virus initially had a major impact on the estimated million rabbits and on the damage they caused, reducing population density by to %. efficacy was dependent on climate and rabbit population susceptibility. populations have subsequently increased and stabilized at around million because of myxomatosis. damage attributable to rabbits still amounts to $ million (australian) annually, including both lost agricultural production and cost of control applications (robinson et al., ) . in addition to agricultural losses, rabbits severely affect native flora by eating foliage and inducing wind and water erosion of soils by overgrazing. native fauna are also affected as rabbits out-compete indigenous herbivores and dense rabbit populations sustain exotic predator populations that feed on native animals (gibb & williams, ; myers et al., ; robinson et al., ) . within a few years of the initial panzootic, field isolates of the virus showed less virulence when compared with the original strain that had been released. the original strain killed > % of laboratory rabbits on average . days after infection, while circulating strains caused % mortality after . days. genetic resistance in rabbits was also detected (fenner & marshall, ; fenner & ratcliffe, ) . dual natural selection had occurred, the virus had attenuated, and rabbits had increased in resistance to the disease. mosquitoes have been responsible for vectoring myxoma virus in australia. the european rabbit flea, spilopsylus cuniculi (dale), an important vector in europe, was introduced into australia in and increased the geographic distribution of the disease. this flea did not persist in areas with rainfall < mm. the xeric adapted spanish rabbit flea, xenopsylla cunicularis smit, was introduced in and active redistribution is still ongoing (fenner & ross, ) . new zealand also has inordinate numbers of rabbits, and attempts to establish the myxoma virus from to failed because of inclement weather and a paucity of suit-able arthropod vectors. further attempts at establishment were not undertaken because poisoning programs had reduced rabbits to very low numbers, additional control expenditure was unjustifiable, and the new zealand public was not in favor of using lethal myxoma virus for rabbit control on humanitarian grounds (gibb & williams, ) . until the s, myxomatosis was the only disease known to severely affect rabbit numbers. a second highly contagious viral disease emerged in the mid- s and was accidentally introduced onto mainland australia (o'brien, ) . it is the first pathogenic natural enemy to have established in new zealand for biological control of rabbits. rabbit calicivirus disease (rcd) [also known as rabbit hemorrhagic disease virus (rhdv)] emerged as a fatal disease in in angora rabbits exported from east germany to jiangsu province of china (liu et al., ) . in , the disease appeared in italy where million rabbits were estimated to have died. the disease spread rapidly through rabbit populations in europe reaching the united kingdom in (chasey, ) . the probable mechanism for dispersal in continental europe was the movement of live rabbits and rabbit products. transmission of rcd from france into coastal areas of southeast england is thought to have occurred by wind-borne aerosols containing virus, birds, and transchannel ferry traffic (chasey, ) . outbreaks of rcd occurred in mexico in and (gregg et al., ) and in rrunion island in the indian ocean in . movement of rcd to these areas probably occurred with imports of frozen rabbit carcasses from china because the virus can survive freezing to temperatures of - ~ (chasey, ) . the rcd virus belongs to the caliciviridae and consists of a positive sense, single-stranded rna genome, enclosed by a sculptured capsid composed of multiple copies of a single major protein of kda, and is to nm in diameter (ohlinger et al., ; parra & prieto, ) . disease symptoms are characterized by high morbidity and mortality in rabbits over weeks of age. younger rabbits often survive infection and may develop antibodies to rcd virus (nagesha et al., ) . clinically, rcd symptoms are expressed after an incubation period of to h in which a febrile response and increasing lethargy are observed. infected rabbits typically die within to h postinfection and % mortality is observed after days. necropsies show a pale swollen friable liver, enlarged spleen, and clots in blood vessels. death is ascribed to acute necrotizing hepatitis and possible hemorrhaging (fuchs & weissenbrck, ; studdert, ) . however, necropsies close to the time of death show an absence of hemorrhaging and inclusion of hemorrhagic in the name of this rabbit disease that indicates the cause of death is misleading (studdert, ) . a different viral disease is responsible for european brown hare syndrome (ebhs) which causes severe hepatic necrosis in hares (lepus europaeus pallas and l. timidus linnaeus). the disease was first recorded in sweden in , and spread through continental europe and reached the united kingdom in (fuller et al., ) . in sweden, losses of hares to ebhs occurred years prior to sympatric rabbit populations developing rcd. similar observations were made in the united kingdom where hares began dying from ebhs years before rcd was observed in rabbit populations (fuller et al., ) . electron microscopy, nucleotide sequencing, and experimental cross-transmission studies have indicated that rcd virus and ebhs virus are closely related (le gall et al., ) but distinct members of the caliciviridae (chasey et al., ; nowotny et al., ) . disease symptoms are generally similar for rabbits and hares but show distinguishing characteristics in necrosis of liver lobules and clotting of blood vessels (fuchs & weissenbrck, ) . serological studies on rabbit sera collected in from czechoslovakia and austria indicate that rcd virus probably evolved from an apathogenic strain endemic to europe from at least this time (nowotny et al., ) . studdert ( ) speculates that the causative agent of rcd probably existed in europe as a quasi species, a collection of indifferent mutants with a variety of accumulated nucleotide changes. in this scenario, mutants occupied a specific ecological niche until one strain better adapted to prevailing conditions became the dominant member of the population. adaptation may have occurred because mutations caused increased virulence in an avirulent rabbit virus or increased the host range of hare-infecting viruses by allowing mutant strains to bind more efficiently to surface receptors on rabbit hepatocytes. given studdert's ( ) speculative scenario, rcd virus may be a highly evolvable organism. european rabbits appear to be the only animals susceptible to infection by rcd virus, and vaccines have been developed to protect domestic animals (boga et al., ) . other rabbits including cottontail rabbits (sylvilagus spp.), black-tailed jack rabbits (lepus californicus gray), volcano rabbits [romerolagus diazi (ferrari-prrez)] (gregg et al., ) , and hares (gould et al., ) are not affected. the limited host range of rcd virus makes it an obvious candidate for use in a biological control program against european rabbits in new zealand and australia. a joint biological control program between these two countries using rcd virus was initiated in and a strain of virus from the czechoslovakia republic was imported into australian quarantine facilities in to test effects on nontarget species (robinson & westbury, ) . host-specificity testing of nontarget species in australia for susceptibility to rcd virus further verified the limited host range of this natural enemy. test subjects in-cluded domestic lifestock (horses, cattle, sheep, deer, goats, pigs, cats, dogs, and fowls) , noxious exotic vertebrates (foxes, hares, ferrets, rats, and mice), native mammals (eight species), birds (five species), and reptiles (one species). there was no evidence for viral replication, clinical signs, or lessions in any organisms tested (gould et al., ) . artificial inoculation of rcd virus in north island brown kiwis (apteryx australis mantelli bartlett) and lesser short-tailed bats (mystacina tuberculata gray), both native to new zealand, also failed to produce disease symptoms (buddle et al. ) . the apparent host specificity of rcd virus to rabbits, rapidity of action, and the capacity to infect rabbits from other rabbits, [through feed and feces, or from a contaminated environment (o'brien, ) ] prompted further evaluation of this biological control agent under field quarantine conditions in australia. studies monitoring the effects of rcd virus on rabbit populations were initiated on wardang island near adelaide off the south coast of australia in (rudzki, ; robinson & westbury, ) . in september , rcd breached quarantine and appeared on mainland australia, possibly carried there by calliphorid flies and onshore winds (cooke, ; lawson, ) . attempts at containment failed (seife, ) . within months of the initial discovery of rcd virus on the mainland, an estimated million rabbits were killed in south australia. in dry areas, to % of infected populations died (anderson, ) with dead rabbits averaging per hectare. elsewhere, fatality rates were closer to % (anonymous, b) . in the period from october to november , an estimated total of million rabbits died from rcd in south australia and the majority of surviving rabbits were less than weeks of age (cooke, ) . the development of resistance in young rabbits may have profound effects on the long-term population dynamics on the rabbit-rcd virus system. ten arthropod vectors of rcd virus have been identified and include flies, mosquitoes, and rabbit fleas (anonymous, b) . rates of spread of rcd are greatest in spring and autumn at to km a day and are correlated with peaks of insect activity. dispersal of the disease probably has been assisted by humans moving contaminated material to new areas (cooke, ) . increased attacks on native fauna by exotic predators such as foxes because of declines in rabbit numbers do not appear to have occurred because predator populations have declined with rabbit numbers (anonymous, b). the virus is now endemic in australia and will probably be officially declared as a biological control agent under the biological control acts of the commonwealth and states (robinson & westbury, ) . rcd virus was smuggled into the south island of new zealand by high country farmers in august and illegally disseminated by feeding rabbits carrots and oats satu-rated with contaminated liquefied rabbit livers. a network of cooperators spread the virus over large areas of the south island and its subsequent spread (human assisted through the movement of carcasses, baiting, and insect vectors) made containment and eradication of the disease impossible. such actions by farmers clearly violated new zealand's biosecurity act, which was enacted in part to protect agriculture from unwanted introductions of pests. the new zealand government has sanctioned controlled virus releases into new areas. the short-term impact of rcd on new zealand rabbit populations has resulted in to % mortality in central otago and large-scale field studies are planned (g. norbury, personal communication, ) . cats on oceanic islands have been subjected to biological control with pathogens. six cats were introduced onto marion island in the indian ocean in (howell, ) ; by , numbers were in excess of and were increasing an average of % per year (van rensburg et al., ) . populations were sustained by consuming approximately , seabirds yearly and cats were probably responsible for the local extinction of the common diving petrel pelecanoides urinatrix (gmelin) (bloomer & bester, ) . surveys of cats on marion island revealed the presence of feline herpes virus and feline corona virus, but the highly contagious feline parvo virus was absent in the population (howell, ) . initiation of a biological control program with feline parvo virus, the causative agent of feline panleucopenia, began in with the release of artificially inoculated feral cats collected from the island (howell, ) . the disease reduced cat numbers by % after years by reducing fecundity and increasing mortality of juvenile cats (van rensburg et al., ) . virions found in high concentrations in feces, urine, saliva, and vomit were transmitted through direct contact between cats or contact with contaminated objects (howell, ) . annual declines of cat numbers were % from to . this rate decreased to % per year from to and was accompanied by lower titers of virus in serum samples collected from feral cats, indicating that viral efficacy was decreasing (van rensburg et al., ) . at reduced densities, hunting and trapping became viable and have been incorporated into an ongoing eradication program that may be assisted by the use of trained dogs (bloomer & bester, ) . sexually transmitted diseases have adverse effects on domestic and wild vertebrates by reducing survival, conception rates, and numbers of offspring born and successfully weaned (smith & dobson, ) . rabbits are susceptible to infections of venereal spirochetosis (treponema cuniculi), which causes sterility (smith & dobson, ) . goats can develop trichomoniasis, a sexually transmitted disease caused by the flagellated protozoan trichomonas foetus (reidmuller). this pathogen has been suggested as a bio-logical control agent for goat populations on oceanic islands that lack this microparasite (dobson, ) . sexual transmission of diseases may further guarantee host specificity in biological control programs. it also enhances the ability of parasites and pathogens to persist in low-density populations or solitary species (e.g., predators). the rate of spread of sexually transmitted organisms is tightly correlated with mean and variance of the numbers of sexual partners per host because of the need for host-tohost contact (horizontal transmission) for transmission. host population density is not important with respect to persistence or rate of spread of sexually transmitted diseases. this property, coupled with asymptomatic carrier states, long infectious periods, or vertical transmission (infective propagules are passed from mother to offspring), greatly enhances the ability of pathogens to persist in lowdensity host populations (smith & dobson, ) . because sexually transmitted organisms can persist in low-density populations or populations of declining density, the potential of genetically engineering sexually transmitted viruses to sterilize infected hosts is being investigated (barlow, ) . viruses that have antigens from the host sperm, or the zona pellucida around host eggs engineered into the genome provoke an immune system response that renders the recipient sterile. immunocontraception (also referred to as immunosterilization) as a means to control noxious vertebrates is being actively pursued by australia and new zealand (mccallum, ) . an alternative approach to immunocontraception is to use genetically modified microparasites to prevent lactation in females so that juveniles are not successfully weaned or to interfere with hormonal control of reproduction (cowan, ; jolly, ; rodger, ) . many species that become pests are distinguished from nonpestiferous species by their higher intrinsic rates of increase (rm). pest vertebrates have high rm values characterized by large litters, and by maturing sexually at young ages. agents that reduce reproductive rates may be more effective for control than mortality-inducing biological control agents are because resistance development should take longer to occur and population recovery would be slower (tyndale-biscoe, b) . resistance development may be further delayed by combined use of multiple agents that affect fertility in different ways [e.g., using agents that cause sterilization, alter levels of reproductive hormones, or affect lactation (cowan & tyndale-biscoe, ) ]. in sexually reproducing vertebrates, proteins associated with male and female gametes are potentially foreign antigens in the opposite sex. exposure to reproductive antigens occurs when females receive sperm and accessory fluids from males during copulation. as a general rule, females do not develop antibodies to these antigens because physiological and immunological mechanisms have evolved to prevent this (robinson & holland, ) . inoculation of sperm into females of the same species either subcutaneously or intramuscularly produces high sperm antigen antibody titers in recipients. in most cases, this causes either permanent or temporary infertility in females. such results indicate that sperm antigens in the reproductive tract are tolerated and that exposure to these antigens by different routes overcomes protective mechanisms, with infertility resulting (robinson & holland, ) . sperm antibodies in females that can arise from either systemic or local immune responses are found in cervical mucus, genital fluids (e.g., endometrial, tubal, and follicular fluids), and blood. antibodies bind to sperm, often in specific locations such as the head, midpiece, tail shaft, or tail tip. once bound to sperm, antibodies cause agglutination (e.g., irreversible binding to cervical mucus that normally aids sperm transport) or immobilization of sperm. antibodies may also interfere with acrosome reactions preventing ovum penetration and fertilization, or they block the binding of sperm to the zona pellucida (shulman, ) . the zona pellucida (zona) that surrounds growing oocytes and ovulated eggs is antigenic and available to circulating antibodies during oocyte growth and ovulation. nonreproductive tract inoculation of females with zona preparations leads to infertility (millar et al., ) . antibodies produced in response to administered zona antigens bind to the zona and prevent sperm penetration (millar et al., ) . zona glycoproteins are highly conserved among mammals, for example, nonspecific pig zona preparations cause infertility in humans, primates, dogs, rabbits, horses, and deer (robinson & holland, ) . a major objective in immunocontraception research is isolation of species-specific zona glycoproteins that do not cause sterility induced by immune response in species from which zona preparations were not derived. low variability among zona glycoproteins may limit the number of species-specific zona preparations for immunocontraception (millar et al., ) . immunocontraception for wildlife population control has been successfully implemented for horses (equus caballus linnaeus) (kirkpatrick et al., (kirkpatrick et al., , . free-ranging feral mares inoculated by dart gun with porcine zona pellucida showed depressed urinary estrogen concentrations and failure to ovulate. zona booster inoculations given years after initial inoculations prevented conception in treated horses for a third year compared with control populations that were not vaccinated. contraceptive effects were reversible after years of consecutive treatment, but prolonged treatment ( to years) with zona preparations caused irreversible ovarian dysfunction and fertility loss (kirkpatrick et al., (kirkpatrick et al., , . similar results have been achieved with porcine zona pellucida inoculations in whitetail deer [odocoileus virginianus (zimmerman)] (kirkpatrick et al., ) . gametic antigens that induce immune response can be administered by baits that are ingested by target organisms or can be inoculated directly into hosts with darts or bullets (tyndale-biscoe, b). injection of foxes with sperm antigens reduces fertility from to %. baits are considered the favorable method for delivering antigens to foxes in australia. potential baits include dried meats that contain microencapsulated antigens. use of recombinant bacterial vectors (e.g., salmonella typhimurium) also are being considered. an orally administered agent needs to reach the lower gastrointestinal tract to stimulate a response in the common mucosal immune system in the gut-associated lymphoid tissue. this in turn induces mucosal immunity in the reproductive tract of female foxes and causes sterilization (bradley et al., ) . at present, an effective bait specific to foxes that is environmentally stable and easy to manufacture has not been developed. nontarget impact is a concern because most antigens exhibit some specificity to the family level only. effective vaccines for rabies have been delivered as oral baits to foxes in europe, demonstrating the baiting technique is an effective dissemination method (bradley et al., ) . models indicate density-independent factors such as drought and rain (which affect pasture growth and rabbit numbers) strongly influence the effectiveness of baitdelivered fertility control in reducing fox abundance . an alternative proposal to deliver antigens orally is to develop transgenic plants to produce and deliver gametic antigens in palatable form to herbivorous pests. plants could be sown over target areas and allowed to become self-propagating vaccines. transgenic seeds, fruits, or leaves (e.g., transgenic carrots or maize) could be harvested and used as oral baits delivered to specific sites such as fenced watering points that allow pest animals access while excluding lifestock (smith et al., ) . baiting is an expensive form of control that requires monitoring of dosage and uptake rates and multiple areawide applications. problems of hormonal modification of behavior and delayed population control are additional drawbacks. one advantage is that baits can be used to treat localized populations that are problematic. similar shortcomings exist with antigen inoculations by projectiles where cost estimates are significant. to control the estimated , wild horses in australia with dart-delivered porcine zona pellucida would cost $ (australian) per horse per year compared with cents for permanent control with a bullet (tyndale-biscoe, ) . lethal methods of control provide immediate impact on pest populations and reduce pest status rapidly, with control being quickly observable. in contrast, fertility impairment is not immediate, population responses are delayed, and large proportions of populations need to be sterilized for this technique to be effective. large-scale distribution of gametic antigens might be possible through releases of host-specific microparasites expressing species-specific antigen genes (tyndale-biscoe, a , b . self-spreading and replicating parasitic vectors that have been genetically engineered and that may require periodic reinoculation into populations are analogous to augmentative biological control programs with traditional natural enemies (e.g., parasitoids, predators, or pathogens) released periodically for the control of pest arthropods. host-specific viruses carrying foreign dna could be cheap and effective biological control agents that have the potential to disseminate widely by sexual transmission, contagion, or arthropod vectors. the selected micro-or macroparasite must be able to carry foreign dna coding for gametic antigens, as well as promoters to express foreign genes and cytokines to enhance effectiveness (tyndale-biscoe, b). such agents must be able to reduce growth rates of infected populations and to maintain reproductive rates at lower levels (caughley et al., ) , and should not interfere with sexual behavior or social organization (caughley et al., ; robinson & holland, ; tyndale-bisoce, b) . with some pests such as rabbits and foxes, dominant members of populations make the main contribution to reproduction and inhibit breeding by subordinate members by occupying prime territories. ideally, a sterilizing agent should not change social hierarchies by allowing individuals with lower social status to successfully rear more offspring because this will cause pest populations to increase substantially (caughley et al., ) . genetically engineered agents should sterilize females because models predict greater population suppression with infertile females than with sterilized males (barlow, ; caughley et al., ) . in the absence of arthropod vectors, sexually transmitted diseases engineered to cause sterilization are superior to nonsexually transmitted ones because multiple matings with sterilized females increases contact rates and the competitive ability of the engineered agent with nonsterilizing strains. the impact of immunocontraception is further enhanced if the sterilizing agent causes limited host mortality and there is low naturally occurring immunity to sexually transmitted diseases (barlow, ) . sexually transmitted herpes-type viruses are being proposed as vectoring agents to induce sterilization in brushtail possums in new zealand (barlow, ; barlow, ) . the recently identified borna disease virus that causes wobbly possum disease in new zealand may be a suitable alternative to a herpes virus (atkinson, ) . the myxoma virus and murine cytomegalovirus are being investigated as gamete antigen delivery agents for rabbits and mice, respectively, in australia (mccallum, ; tyndale-bisoce, b; shellam, ) . four potential insertion sites for genes coding for gametic antigens have been identified in myxoma virus and recombinants have been constructed to express two esherichia coli (escherich) enzymes and influenza virus hemagglutinin genes. the ability of a novel myxoma virus to compete and spread among existing myxoma strains in field situations has been demonstrated by monitoring the spread of virus containing identifiable gene deletions (robinson et al., ) . the myxoma virus that can express foreign genes may operate as a vector for gametic proteins (robinson et al., ) . work is continuing on isolating and inserting rabbit gamete antigen genes into the myxoma virus genome (robinson et al., ) . the responses of experimental rabbit and fox populations in australia to imposed sterility by surgical ligation of fallopian tubes in females have been studied in an attempt to simulate the effects of virally mediated immunocontraception after recombinant virus establishment in wild populations. this technique prevents conception among predetermined proportions of females in populations without interfering with hormones or reproductive behavior (williams & twigg, ) . the dynamics of rabbit populations enclosed by rabbit-proof fencing that exhibited , , , or % sterilization of females were studied in each of two locations in western and eastern australia where climate patterns differed. females born into treatment populations were trapped and sterilized to maintain the same overall sterility levels (williams & twigg, ) . juvenile rabbits born into populations with sterilized females exhibited greater survivorship because of lowered competition for resources. this greater survival compensated for decreased fertility, but recruitment rates were ultimately constrained by environmental factors (e.g., depletion of vegetation). in populations with % sterility, reduced juvenile mortality did not compensate fully for lowered reproduction, smaller numbers of rabbits were recruited into these populations, and numbers subsequently declined. these results indicate that levels of sterilization with a genetically altered micorparasite have to reach at least % to achieve reductions in population density (williams & twigg, ) . surgical sterilization does not affect reproductive behavior in treated populations. sterile dominant female rabbits maintain hierarchical dominance, increased body weight over control females, continued to defend prime territory, and engaged in normal reproductive behavior including breeding burrow construction (tyndale-bisoce, b). birth rates of sexually mature females were in direct proportion to the level of fertility in experimental populations, indicating that fertile females did not respond to female infertility or decreased densities of young by producing larger litters (williams & twigg, ) . sterilized females tended to live longer than unsterilized females. this increased longevity suggests that sterile females may proportionately increase as treated populations reach an equilibrium density. obviously, larger proportions of sterile females reduce population productivity and the numbers of fertile females that a sterilizing microparasite would have to infect and sterilize. higher proportions of sterile females may reduce numbers of infective individuals harboring sterilizing microparasites and numbers of vectors (e.g., fleas that would spread an engineered myxoma virus), and may contribute to decline of transmission rates. these interactions need to be clarified and mathematical models may be of use here (williams & twigg, ) . engineered microparasites that sterilize pest animals offer the possibility of humane control without killing or causing animals to suffer the effects of debilitating disease. as a form of biological control, immunocontraception may also reduce the need for broadcast distribution of toxins for pest suppression, thereby reducing environmental contamination and nontarget mortality. this is of special concern when pests inhabit suburbs, urban parks, government and state campuses, nature reserves, military bases, or other areas where lethal controls may no longer be legal or safe (kirkpatrick et al., ; williams, ) . the concept of virally mediated immunocontraception has generated considerable debate on legal and ethical issues concerning releases of engineered microorgansims into the environment. once contagious recombinant agents that cause permanent sterilization in animals are released into the environment they cannot be recalled (tyndale-bisoce, ) . several potential risks are recognized. first, engineered viruses that are host specific and contain species-specific antigens could mutate and infect and sterilize nontarget species after release (anderson, ) . under such conditions it may be difficult if not impossible to contain and eradicate a mutant virus from an infected animal population that is abundant, secretive, and free ranging. second, sterilizing viruses either might cross international boundaries accidentally or be maliciously moved to sterilize desirable organisms in new areas (tyndale-bisoce, b) . for example, viruses engineered with little host specificity to sterilize widely dispersed marsupial pests in new zealand may enter australia and infect endangered wildlife (rodger, ; mccallum, ) ; engineered myxoma viruses may spread from australia into the americas and sterilize native rabbit species (tyndale-biscoe, ) . third, dart-delivered contraceptives used for wildlife control in the past have had adverse effects on individuals within target populations. changes in morphology of repro-ductive organs, secondary sexual characteristics, and behavior have been observed. viruses that induce sterility could alter genetic profiles of target populations because infectious agents may act as a new reproductive disease and individuals may exhibit differential susceptibility (nettles, ) . fourth, public concerns over the use of viruses and genetic engineering indicate substantial apprehension about the use of sterilizing viruses for pest management, these fears that need to be fully alleviated may delay or prevent field trials and widespread application (lovett, ) . despite potential drawbacks, immunocontraception is a potentially cost-effective method for reducing pest impact on endangered native species (sinclair, ) and on agricultural yields, and is an additional tool for sustainable pest management (williams, ) . a sterilizing agent that does not cause painful disease symptoms is an ethically acceptable form of pest control that is justifiable from animal rights perspectives, because it does not cause the suffering typical of current lethal methods (e.g., trapping, shooting, poisoning, and introduced disease) ( oogjes, ; singer, ) . under certain circumstances, the use of vectors to disseminate genetically engineered viruses is warranted (mccallum, ) . experience with the myxoma virus in australia indicates that it has not been deliberately or accidentally spread to any other country since its introduction in the s because of either the lack of suitable arthropod vectors or the inability of the virus to establish where different strains are already present. this history may indicate possible difficulty for unintentional establishment of genetically engineered microparasites in new areas, and establishment of engineered myxoma viruses may be possible only with carefully timed and repeated releases into rabbit populations (tyndale-biscoe, ) . however, such safeguards may be moot if a highly competitive sterilizing strain is engineered and released. quarantine legislation designed to prevent accidental or intentional but illegal importation of unwanted organisms would be exercised by countries under current international obligations and should impede establishment in new countries if rigorously enforced. however, current legal safeguards may be insufficient. new zealand's experience with rcd indicates it is possible for lay people to illegally import and establish reproducing populations of exotic pathogens. in australia, rcd breached a carefully planned quarantine on an offshore island. unintended establishment and proliferation of engineered viruses may be contained if outbreaks are recognized early, and if proportions of susceptible individuals are removed rapidly from the population either by culling or by immunizing against the pathogen (tyndale-b iscoe, ) . this has never been tried with wild animal populations. the containment of contagious pathogens, such as foot and mouth disease in livestock, indicates such an approach may be possible. highly attenuated forms of myxoma virus are used to protect wild and domestic rabbits in france and the united states, indicating the availability of such technology for this virus at least (fenner & ross, ; tyndale-biscoe, ) . limited field trails with sterilizing microorgansisms are unlikely before (anderson, ). there is abundant evidence that introduced exotic vertebrates that establish feral reproducing populations have disastrous consequences for agriculture and preservation programs for native plants and animals. sources of current vertebrate introductions include sellers and buyers of exotic pets; acclimatization societies that import, establish, and relocate game animals and whose constituents include hunters and fishermen; and farmers and ranchers who import and experiment with novel lifestock (e.g., fitch farming). exotic vertebrates have in some instances great economic importance (as with lifestock and game animals), they also enjoy public popularity because of interest in hunting, fishing, eating, or viewing large and unusual animals in familiar environments. the negative ecological aspects of introduced vertebrates may be poorly understood by the public at large. such limited understanding may hinder control efforts and prevention of importation (bland & temple, ) . legislation has been passed in the united states to minimize risks of importing new and relocating existing vertebrate species. the lacey act passed in and ammended in was enacted to protect certain animals and endangered habitats, and to prevent introduction of noxious pests. under the act, violation of the law can result in fines and imprisonment [see usc w importation or shipment of injurious mammals, birds, fish (including mollusks and crustacea), amphibia, and reptiles; permits, specimens for museums; regulations m for more details]. similar legislation has been developed in new zealand. the biosecurity ( ) and hazardous substances and new organisms (hsno) ( ) acts were devised to protect the environment by preventing or managing the adverse effects of hazardous substances and exotic organisms. campbell ( ) points out that existing laws have many loopholes and are not effective when applied, indicating a need to improve existing regulations and to develop new laws to curtail unwanted entry by alien vertebrates. one proposal is to require importers of exotic organisms to develop "clean lists" and to prove that organisms are not potentially invasive and disrupting to native ecosystems (campbell, ) . legislative approaches limiting imports and exports of organisms may encounter complaints under the general agreement of tariffs and trade (gatt) that stricter quarantine measures are an unacceptable imposition of one country's environmental standards on others (camp-bell, ) . there is an obvious need for greater cooperation among interest groups, scientists, and legislators to devise solutions to problems associated with continuing introductions of exotic species and to provide direction for future action. as an evolutionarily stable control strategy development of resistance (behavioral or physiological) to pesticides (e.g., rodenticides) by vertebrates, and the need for repeated or multiple simultaneous control strategies (e.g., poisoning combined with trapping and hunting) indicate that control of vertebrates is an ongoing endeavor that attempts to reduce agricultural damage and losses (greaves, ) or to protect wilderness areas (cowan, ; morgan et al., ; payton et al., ) from pest damage. biological control has several advantages over chemical and cultural control practices (van driesche & bellows, ) : ( ) it is relatively cheap and biological control programs are often quicker to implement than to develop and to register new pesticides; ( ) use of carefully screened natural enemies increases selectivity of attack toward target pests; ( ) natural enemies in many instances are self-perpetuating and self-distributing; and ( ) development of resistance to natural enemies is extremely rare. one documented case of pests developing resistance to natural enemies is the development of resistance to myxomatosis by rabbits and corresponding attenuation of highly virulent strains of the myxoma virus to strains of intermediate virulence (fenner & ross, ) . the myxoma virusrabbit system in australia and europe is dynamic with increasing rabbit resistance selecting for more virulent strains of virus. this suggests that for the short-term, at least, the system is coupled in an antagonistic coevolutionary arms race (dwyer et al., ) . flexible natural-enemy behavior patterns and physiology have the potential to weaken evolutionary responses that can cause pest resistance to introduced control agents (holt & hochberg, ; jervis, ) . in comparison, pesticides and cultural controls tend to target a fixed physiological or behavioral function or pattern, and the resulting selection regime is constant allowing pests either to increase tolerance to poisons or to learn and develop avoidance behaviors (e.g., bait and trap shyness). spatial heterogeneity of natural-enemy attack limits selection pressure on hosts by natural enemies, thus reducing the rate of resistance development by pests compared with uniformly applied selection pressures such as pesticides. pests that escape attack move into enemy-free areas and continue breeding; thus, the rate of coevolution is reduced by susceptible pests in transient refuges (jervis, ) . at the metapopulation level, natural enemies may be ineffective selection agents because of widespread extinction and establishment of pest subpopulations that maintain pest susceptibility. additionally, resistance development may involve costs leading to a corresponding decrease in fitness. for example, increased tolerance to attack may reduce the pest's reproductive capacity and ability to compete for resources, or may increase susceptibility to other mortality agents (holt & hochberg, ) . there are opportunities to enhance biological control programs against vertebrate pests that cause social, agricultural, and conservation problems. in many instances, biological control offers the best chances for long-term control, particularly in isolated areas with rugged terrain, in suburban areas with high-density human populations, or in places where pests are nocturnal or secretive. biological control will not totally alleviate vertebrate pest problems. it may, however, reduce the vigor of pest populations, thereby reducing damage, minimizing nuisance value, or allowing native species to compete more effectively for food and breeding sites. programs could be initiated to simply reassociate host-specific micro-and macroparasites with pest populations that have depauperate natural-enemy faunas (dobson & may, ) , and there is no shortage of targets as small founding populations of vertebrates continue to invade and proliferate in new habitats. genetically engineered natural enemies are additional tools to aid biological control efforts. research with agents that cause immunocontraception will likely diversify as advances in molecular biology continue, and routes alternative to sterilization may be taken. this area of vertebrate biological control will be tested more thoroughly once small-scale and long-term field trials begin with sterilizing microorganisms. the effect of barn owls (tyto alba) on the activity and microhabitat selection of gerbillus allenbyi and g. pyramidum runaway rabbit virus kills millions alarm greets contraceptive virus regulation and stability of hostparasite population interactions i. regulatory processes parasite pathogenicity and the depression of host equilibria theoretical basis for the use of pathogens as biological control agents within-host population dynamics and the evolution and maintenance of microparasite virulence the cooperative research center for biological control of vertebrate pest populations rabbit virus vectors named can the nematode capillaria hepatica regulate abundance in wild house mice? results of enclosure experiments in southeastern australia predicting the effect of a novel vertebrate biocontrol agent: a model for viral-vectored immunocontraception of new zealand possums ecology of predator-prey and parasitoid-host systems: progress since nicholson modeling immunocontraception in disseminating systems mice on the farm biological pollution: the control and impact of invasive exotic species control of feral cats on sub-antarctic marion island, indian ocean population dynamics of parasites of the wild rabbit a single dose immunization with rabbit haemorrhagic disease virus major capsid protein produced in saccharomyces cerevisiae induces protection impact of botfly parasitism on microtus townsendii populations insular endemic plants lack defenses against herbivores a bait delivered immunocontracpetive vaccine for the european fox (vulpes vulpes) by the year ? the effect of the european wild boar sus scrofa, on gray beech forest in the great smoky mountains patterns, modes and extents of invasions by vertebrates response of the north island brown kiwi, apteryx australis mantelli and the lesser short-tailed bat, mystacina tuberculata to a measured dose of rabbit haemorrhagic disease virus conservation priorities in hawaiian natural systems biological pollution: the control and impcat of invasive exotic species invasion resistance, species build up and community collapse in metapopulation models with interspecies competition global patterns in the establishment and distribution of exotic birds effect of fertility control on a population's productivity european brown hare syndrome in the uk: a calicivirus related to but distinct from that of viral haemorrhagic disease in rabbits possible origin of rabbit haemorrhagic disease in the united kingdom the comparative epizootiology of capillaria hepatica (nematoda) in urban rodents from different habitats of effects of feral goats on island ecosystems. biological conservation field epidemiology of rabbit calicivirus disease in australia the european rabbit, the history and biology of a successful colonizer accumulation of native parasitoid species on introduced herbivores: a comparison of hosts as natives and hosts as invaders the eradication of introduced australian brushtail possums, trichosurus vulpecula, from kapiti island, a new zealand nature reserve possum biocontrol: prospects for fertility control australian and new zealand mammal species considered to be pests or problems. reproduction theory and practice of biological control the scope of biological control patterns of invasion by pathogens and parasites parasites, disease and the structure of ecological communities restoring island ecosystems: the potential of parasites to control introduced mammals population biology of trichostrongylus tenuis in the red grouse lagopus lagopus scoticus a simulation model of the population dynamics and evolution of myxomatosis virulence and local adaption of a horizontally transmitted parasite the evolution of parasitic diseases the use of cats in farm rat control the ecology of invasions by animals and plants which animal will invade attributes of invaders and the invading process: vertebrates parasitic and infectious diseases, epidemiology and ecology a comparison of the virulence for european rabbits (oryctolagus cuniculus) of strains of myxoma virus recovered in the field in australia the european rabbit, the history and biology of a successful colonizer the european rabbit, the history and biology of a successful colonizer the need to control cane toads comparative histopathological study of rabbit haemorrhagic disease (rhd) and european brown hare syndrome (ebhs) rabbit haemorrhagic disease in the united kingdom a propos d'un cas de capillariose a capillaria hepatica observe dans un elevage de lapins croises garenne the rabbit in new zealand the complete nucleotide sequence of rabbit haemorrhagic disease virus (czech stain c v ): use of the polymerase chain reaction to detect replication in australian vertebrates and analysis of viral population sequence variation resistance to anticoagulant rodenticides viral haemorrhagic disease or rabbits in mexico: epidemiology and viral characterization translocation and a species conservation tool: status and strategy when is biological control evolutionary stable (or is it analysis of vertebrate pest control biological control of vertebrate pests classical biocontrol: panacea or pandora's box? an evaluation of the biological control of the feral cat felis catus (linnaeus, ) and no birds sing: the story of ecological disaster in a tropical paradise rabbit and fox introductions in tierra del fuego: history and assessment of the attempts at biological control of the rabbit infestation parasitoids as limiting and selective factors: can biological control be evolutionary stable? biological control of possums long-term effects of porcine zonae pellucidae immunocontraception on ovarian function in feral horses (equus caballus) case studies in wildlife immunocontraception: wild and feral equids and white-tailed deer predation and population cycles of small mammals the natural regulation of animal numbers rabbit virus threatens ecology after leaping the fence capillaria hepatica infection: incidental finding in a dog with renal insufficiency european brown hare syndrome virus: molecular cloning and sequencing of the gonome a new viral disease in rabbits biological invasions: lessons for ecology comparative conservation biology of oceanic archipelagoes birth control for feral pests fluctuations of animal populations and a measure of community stability food webs: a plea for parasites thresholds and breakpoints in ecosystems with a multiplicity of stable states regulation and stability of hostparasite population interactions ii. destabilizing processes depression of host population abundance by direct life cycle macroparasites models to assess the potential of capillaria hepatica to control population outbreaks of house mice evaluation of a nematode (capillaria hepatica bancroft, ) as a control agent for populations of house mice (mus musculus domesticus schwartz and schwartz, ). revue scientifique et technique office international des epizooties quantifying the impact of disease on threatened species immunocontraception for wildlife population control detecting disease and parasite threats to endangered species and ecosystems vaccination with a synthetic zona pellucida peptide produces long-term contraception in female mice probable role of ground beetles in the transmission of capillaria hepatica why do possums survive aerial poisoning operations control of small mammals in a pine plantation (central chile) by modification of the habitat of predators (tyto alba, stringiforme and pseudalopex sp. canidae). acta oecologia pyloric stenosis in a yearling with an incidental finding of capillaria hepatica in the liver the european rabbit, the history and biology of a successful colonizer self assembly, antigenicity, and immunogenicity of the rabbit haemorrhagic disease virus (cezchoslovakia strain v- ) capsid protein expressed in baculovirus potential consequences and problems with wildlife contraceptives prolonged prey suppression by carnivores: predator-removal experiments the control of vertebrate pests by vertebrate predators phylogenetic analysis of rabbit haemorrhagic disease and european brown hare syndrome viruses by comparison of sequences from the capsid protein gene the social and economic implications of rhd introduction identification and characterization of the virus causing rabbit haemorrhagic disease ethical aspects and dilemmas of fertility control of unwanted wildlife: an animal welfarist's perspective schwerer leberbefall durch capillaria hepatica. monatsschrift fur kinderheilkunde purification and characterization of a calicivirus as the causative agent of lethal haemorrhagic disease in rabbits response of selected tree species to culling of introduced australian brushtail possums trichosurus vulpecula at waipoua forest limits to predator regulation of rabbits in australia: evidence from predator removal experiments predation models for primary and secondary prey species can foxes be controlled by reducing their fertility? successful treatment of capillaria hepatica infection in an acutely ill adult the snake that ate guam essentials of conservation biology a primer of conservation biology the effect of habitat on the helminth parasites of an island population of the polynesian rat (rattus exulans) testing the concept of virally vectored immunosterilization for the control of wild rabbit and fox populations in australia progress towards using a recombinant myxoma virus as a vector for fertility control in rabbits. reproduction, fertility and development the australian and new zealand calicivirus disease program the disappearance of guam's wildlife likely targets for immunocontraception in marsupials the establishment and spread of myxomatosis and its effect on rabbit populations escaped rabbit calicivirus highlights australia's chequered history of biological control a relationship between plagues of the house mouse mus musculus (rodentia: muridae) and prolonged periods of dry weather in south-eastern australia extinction of an island forest avifauna by an introduced snake regulation of mouse colony abundance by heligmosomoides polygyrus population dynamics in wild and laboratory rodents the role of parasites in regulating host abundance a harebrained scheme the potential of murine cytomegalovirus as a vital vector for immunocontraception. reproduction, fertility and reproduction immunological reactions and infertility can predators regulate small mammal populations? evidence from house mouse outbreaks in australia mammal populations: fluctuation, regulation, life history theory and their implications for conservation fertility control of mammal pests and the conservation of endangered marsupials effects of wild pig rooting in a deciduous forest the effects of capillaria hepatica (nematoda) on natality and survival to weaning in balb/c mice population dynamics of an outbreak of house mice (mus domesticus) in the mallee wheatlands of australia: hypothesis of plague formation the potential of capillaria hepatica to control mouse plagues the geographic distribution and host range of capillaria hepatica (bancroft) (nematoda) in australia an experimental field study to examine whether capillaria hepatica (nematoda) can limit house mouse populations in eastern australia a manipulative field experiment to examine the effect of capillaria hepatica (nematoda) on wild mouse populations in southern australia neither human nor natural: ethics and feral animals parasitic and infectious diseases, epidemiology and ecology sexually transmitted diseases in animals plant-derived immunocontraceptive vaccines food specificity in interspecies competition studies of the life cycle infectivity and clinical effects of capillaria hepatica (bancroft) (nematoda) in mice, mus musculus experimental embryonation and survival of eggs of capillaria hepatica (nematoda) under mouse burrow conditions in cereal growing soils the role of helminths in the biological control of mammals rabbit haemorrhagic disease virus: a calicivirus with differences fertility control in wildlife the crc for biological control of vertebrate pest populations: fertility control of wildlife for conservation virus-vectored immunocontraception of feral mammals vermin and viruses: risks and benefits of viral-vectored immunosterilization changing social views of the desired degree of host range specificity of natural enemies of arthropods effects of feline panleucopaenia on the population characteristics of feral cats on marion island correlates of introduction in exotic new zealand birds when biotas meet: understanding biotic interchange science biological invasions and ecosystem processes: towards an integration of population and ecosystem studies the extent of biological control of rats with barn owls, tyto alba javanica in malaysian oil palm plantations. the planter biological control of vertebrate pest effectiveness and cost-efficiency of control of the wild rabbit, oryctolagus cuniculus (l.), by combinations of poisoning, ripping, fumigation, and maintenance fumigation response of wild rabbit populations to imposed sterility development and use of virus-vectored immunocontraception the characters of successful invaders the varying success of invaders biological control of vertebrates--a review, and an assessment of prospects for malaysia observations of the lifecycle of capillaria hepatica (bancroft, ) with a description of the adult acknowledgments i thank vincent d'amico, iii of bean's art ink for preparing the states geological survey provided information on the brown tree snake. key: cord- - gdfo vd authors: nan title: tsanz oral abstracts date: - - journal: respirology doi: . /j. - . . .x sha: doc_id: cord_uid: gdfo vd nan introduction very little is known about adult health of survivors of extreme preterm birth. the aim of this study was to assess the burden of respiratory symptoms in a cohort of young adults born prematurely compared to sibling controls. method one hundred and fifty six children born prematurely ( - weeks gestation) at the mater hospital brisbane between [ ] [ ] were mailed questionnaires to assess their respiratory symptoms using a modified version of the european community health survey. term-born siblings were invited to act as controls. results thirty six responses were received ( %). the studied cohort consisted of cases ( % female) and controls ( % female). the median age was years ( - ) in the cases and years ( - ) in the control group (p = ns). shortness of breath (sob) was reported in % of the preterm cases, but nil in the control group (p = . ). there was a higher incidence of day/night cough ( % vs. %, p = . ) and morning cough ( % vs. %, p = . ) in the preterm cases compared to controls. the preterm cases were also more likely to experience a chest infection before the age of five ( % vs. % of controls, p = . ). sob was unrelated to a history of asthma, atopy, exposure to smoke or domestic animals as there was no difference between controls and cases. conclusion a higher incidence of sob was reported in young adults who were born prematurely compared to sibling matched controls, and this appears to be unrelated to asthma and atopy. further subjects will be enrolled interstate to assess predictors of respiratory symptoms in early adulthood. background currently all protocols for checking patient readiness for oral intake post fibre optic bronchoscopy (fob) are non-evidence based. there is a need to establish the shortest safe time to implement resumption of oral intake following administration of local anaesthesia for various reasons. we examined return times for the gag reflex and swallow response. method a prospective study of consecutive patients presenting for a fob, age - , were assessed for optimum time to check the gag and swallow reflex. the gag was checked pre and post fob by the touch method (tickle back of throat), swallow was checked post fob with a sip of water at various times. results after hour % and % of patients had a gag reflex (n = ) and swallow response (n = ) respectively. this increased to % and % at ½ hours, % and % at hours, % and % at ½ hours. the amount of sedation or length of procedure did not correlate with the return of the gag reflex or swallow response. none of the patients who swallowed with the gag still absent coughed or aspirated. eighteen patients did not have a gag reflex pre fob. conclusion the gag reflex and swallow response are separate. data shows it is possible to swallow safely without a gag reflex. the time to safe swallow is much shorter than recommended in current protocols. however, we consider it safer to allow oral intake when both reflexes are present, if the gag is present pre fob. otherwise the patient should wait for ½ hours post fob as % have a returned gag reflex, if swallow response is also back. nomination none. introduction home monitoring in copd may identify acute exacerbations earlier, enabling prompt treatment, thus improving morbidity and mortality. reactance (x rs ), measured by forced oscillation technique has a potential role in home monitoring. the aim of this study was to determine within-and between-day repeatability of resistance (r rs ), x rs , and spirometry in stable copd subjects. methods ten copd subjects underwent seven consecutive home visits consisting of three measures of fot ( minute recording) and spirometry before and after mcg ventolin via spacer. results subject characteristics mean (sd) -age . years ( . ), smoking history . pack years ( . ), post-bd (post-bronchodilator) fev . % predicted ( . ), fev /fvc ratio . ( . ). repeatability measures are reported as intra-class correlation coefficient (icc) and sd of within subject variance (sw). introduction chronic obstructive pulmonary disease (copd) is the single most important risk factor for lung cancer (affecting - % of those diagnosed). considerable overlap exists between smokers who develop copd and/or lung cancer, suggesting involvement of shared pathogenic pathways (inflammation, matrix remodeling and cell death). in a prospective study of high and low risk smokers we have combined snps from gwas and candidate gene studies to develop a susceptibility score for lung cancer (lcss). methods seven hundred and twenty eight high risk individuals (chronic smokers, > years old, > pack years, spirometric confirmed copd), and smokers without copd were recruited and followed for a mean of years. cohorts were matched for smoking history, ethnicity, gender and age, thereby excluding confounding from these variables. all volunteers completed spirometry, modified ats respiratory questionnaire and gave blood for dna. iplex and taqman systems were used to genotype the snp panel. cases are in the high risk (copd) cohort ( % over years, mean score = . ) and ( %) from the low risk cohort, normal lung function ( % over years, mean score . ). the healthy unaffected smokers' mean score was . . this prospective study confirms the risk status assigned by the lcss with ( %) vs. ( %) lung cancers over the year follow up (or = . (%% ci . - . , p = . ).the performance characteristics of the lcss reported here, confirm its utility, in correctly identifying smokers at greatest lung cancer risk. conclusion in this prospective study, we show that the lcss identifies those at greatest risk of lung cancer who might benefit from aggressive preventive strategies such as cessation and chemoprevention. the author is not aware of any conflict of interest. malignant mesothelioma (mm) remains an incurable cancer and its global incidence is rising rapidly. alternative therapeutic strategies are therefore required. bacterial products have been trialled in an effort to enhance local immunity and have demonstrated tumouricidal activity. staphylococcal enterotoxins (se) are classic models of superantigens that have potent mitogenic activity on t cells and demonstrated anti-tumour effects in several cancer models. intrapleural delivery of staphylococcal enterotoxin c (sec) has been used in china for many years as a pleurodesing agent. however, it is unknown whether sec actually kills cancer cells. in this study, we examined the efficacy of sec in the treatment of mm. sec was added at various concentrations ( - ng/ml) to several human and murine mm cell lines and a human benign mesothelial cell line in vitro. dose dependant cytotoxicity was observed in all cell lines resulting in a significant reduction in viability at higher doses ( ng/ml) when using trypan blue exclusion and wst- assays ( . < p < . ). in an effort to elucidate the mechanism of action of sec, annexin v staining and flow cytometry were used to measure apoptosis. results demonstrated a significant increase in apoptosis in mm cells when treated with sec compared to untreated controls ( . < p < . ). on the contrary, benign mesothelial cells appeared to be resistant to the apoptotic effects of sec at equivalent concentrations (p > . ). elisa based assays were used to examine cytokine profiles in culture supernatants of sec treated mm cells and benign mesothelial cells. levels of the pro-inflammatory cytokine il- decreased in sec treated mm cells ( . < p < . ) compared to a significant increase in levels observed in benign mesothelial cells ( . < p < . ). these results suggest that sec kills mm cells in vitro with some specificity and its activity against mm in vivo warrants investigation. conflict of interest no. purpose we examined age trends in the distribution of stage at diagnosis in patients presenting with non-small cell lung cancer (nsclc) at tertiary hospitals. methods we used the queensland integrated lung cancer outcomes project (qilcop), a clinical registry which collects information on about % of all lung cancer patients in queensland, to analyse the distribution of clinical (tnm) stage among , patients diagnosed with nsclc between and . differences in stage distribution across age were analysed using tests of proportions and multivariable logistic regression with stage as the dependent variable and other demographic characteristics as covariates. results the median age at diagnosis of patients in the study was years (range - ) and % were males. the overall proportions of stages i, ii, iii, and iv were, respectively, %, %, %, and %. the percentage of stage i disease increased with age (p < . ), from % in those younger than years to %, %, and % in those aged - , - , and years or older, respectively. age differences in stage distribution remained significant in multivariable analysis controlling for gender, rural residence, and socioeconomic status. among the other characteristics, only gender differences in stage was significant, with stage i cancer being more common in women compared to men ( % vs. %, p = . ). australia has the world's highest incidence of mesothelioma, a disease which has no proven effective therapy. the median survival of less than months and five year survival of % have not changed in two decades. radical resection has a high attrition rate with most cases recurring locally, and few patients have durable responses to chemotherapy. symptoms are related to local disease which compresses the lung and causes severe chest pain from enlarging tumour masses. aim to improve local control of mesothelioma by high dose radiotherapy using advanced technologies that precisely define the active tumour and reduce toxicity to normal tissues. methods all patients had fdg pet scans co-registered with a simulation ct scan to define the target volume, and follow-up pet scans were analysed to assess the residual total glycolytic volumes (tgv) after radiotherapy. acute and long term toxicities were assessed. results between and thirty patients with incompletely resected pleural mesothelioma were treated with radiation doses of to gy to part or all of one hemithorax. all patients who received chemotherapy had progressed prior to radiotherapy. in we introduced a program using a new technique called intensity-modulated radiotherapy (imrt). tgvs reduced by % after radiotherapy, median survival was extended to months and there were no major radiation toxicities, the most common being grade two pneumonitis. relapses were frequent on extended follow-up, the majority in areas outside the radiotherapy field. conclusions imrt is effective in maximising local control in mesothelioma patients who have had extrapleural pneumonectomies, and for selected patients with an intact lung. toxicities are manageable and locoregional control is very good. high dose radiotherapy is recommended for most mesothelioma patients for long term palliation and control of locoregional progression. introduction mortality benefits for ldct screening are not yet known. the queensland lung cancer screening study is screening up to high risk volunteers based on the nlst/acrin protocol. aims observational cohort study to assess: disease detection rate; lung nodule work-up; cost; quality of life issues; smoking cessation; biomarker collection feasibility. methods recruitment via local advertisement and press release. major inclusion criteria: age - years; smoking history ‡ pack years; fit for surgery. volunteers have one prevalence and two incidence scans and follow-up for three more years. ldct parameters: phillips brilliance slice multidetector scanner; low-dose protocol; . mm slice width. scan reporting: two radiologists independently; independent cad reading (phillips brilliance software); final report is agreed by consensus. results see table -to be updated. magnetic resonance imaging (mri) is a useful modality for assessing chronic thromboembolic pulmonary hypertension (cteph) before pulmonary endarterectomy (pea). cardiac mri provides more accurate right ventricular (rv) data than echocardiography. mr angiography demonstrates vascular changes reliably to a segmental level and mr perfusion shows disease distribution. aim to examine the relationship between changes in mri parameters with clinical and haemodynamic outcomes post-pea. methods rv end-diastolic volume (rvedv), rv ejection fraction (rvef), vessel abnormalities and lobar perfusion defects were determined with mri before and after peas performed during [ ] [ ] [ ] [ ] . changes in new york heart association (nyha) functional class, six minute walk distance ( mwd), mean pulmonary artery pressure (mpap) and cardiac output (co) were collected retrospectively from patient charts. results nineteen patients assessed pre-pea were of mean ± sd age ± years, nyha class . ± . , mwd ± metre and mpap ± mmhg. immediately post-pea, mpap fell by ± mmhg which was related to changes in rvedv of ± % (r = . , p = . ). at - months post-pea, mwd improvement ( ± metre) was related to changes in rvef of ± % (r = . , p = . ) but angiographic changes had a weak relationship with nyha class shift (r = . , p = . ). perfusion generally improved after pea relating weakly with rvedv (r = . , p = . ) but not clinical outcomes. conclusions this study shows that improvements in mri parameters (rv data more than angiographic findings) after pea correspond to clinical and haemodynamic outcomes. we have demonstrated a useful imaging test for monitoring patients post-pea with no radiation exposure. purpose allergic reactions to antibiotics are very common in cystic fibrosis (cf) patients and can complicate treatment in patients with multi-or pan-resistant bacterial species. we hypothesised that post-transplant immunosuppression may reduce the requirement for desensitisation. methods and materials a retrospective review was performed in june to detect prescribing practices and any changes in allergy patterns before and following lung transplantation in cf. since antibiotic desensitisation has not been used post-transplant at our institution, our aim was to review our experience with antibiotic rechallenge, without desensitisation, in the post-transplant setting. results fifty eight cf patients, ( %) female, aged years, range - years, heart-lung, heart-lung liver have undergone transplantation at our institution. ( %) had a pre-transplant history of ige (angioedema - %) or non-ige (e.g. rash, nausea, arthralgia or liver dysfunction - %) mediated reactions to at least one antibiotic ( % penicillin, % cephalosporin, % carbapenem, % aztreonam and % others). desensitization to antibiotics with non ige mediated reaction was attempted in out of the patients pre-transplant and successful on all occasions. in other patients, alternative antibiotics were selected and desensitisation was not required. after transplantation, ( %) patients with non ige mediated reactions were rechallenged without desensitisation on occasions. no life-threatening reactions were observed. only two episodes required antibiotic cessation and both recovered without incident. new onset of adverse reaction to iv colistin and voriconazole occurred in two patients following transplantation. conclusions cautious antibiotic rechallenge can be successfully achieved without desensitisation in the majority of patients who have had non ige mediated allergic phenomena to the same compound prior to transplantation. idiopathic pulmonary fibrosis (ipf) is characterised by marked collagen deposition. the receptor subunit gp has been associated with the progression of fibrosis. the interleukin (il)- family of cytokines all require gp to initiate signal transduction to activate either the extracellular regulated kinase (erk) or signal transducer and activator of transcription (stat) pathways. the il- family of cytokines consist of il- , il- , oncostatin m (osm), leukaemia inhibitory factor (lif), cardiotrophin- (ct- ), ciliary neurotrophic factor (cntf), il- and il- . previous studies performed in our laboratory have demonstrated that exaggerated gp -stat signalling is fundamental to the development of bleomycin-induced lung fibrosis in a murine model. we hypothesise that pulmonary fibrosis is mediated by il- family cytokine/gp -stat / signalling. the aim of the current study was to identify which of the il- family cytokines are important in the development of bleomycin-induced pulmonary fibrosis. bleomycin or control saline was administered intranasally to individual il- knockout (il- -/-) mice and dual il- and il- a-receptor knockout (il- -/-;il- ar -/-) mice. collagen production was examined by histology and hplc in lung tissue days post treatment. no significant increase in collagen was observed in bleomycin treated il- -/or il- -/-;il- ar -/mice implicating a role for il- in the development of pulmonary fibrosis. interestingly, the histology of il- -/-;il- ar -/mice displayed marked emphysema which was not observed in individual il- -/mice suggesting this is an il- -mediated response. the role of il- family cytokines in proliferation, myofibroblast differentiation and collagen expression were examined using fibroblasts isolated from wildtype (wt) and genetically engineered mice containing point mutations to prevent gp -erk / signalling (gp f ) or gp -stat / signalling (gp stat ). overall, there was no significant increase in proliferation hours post cytokine stimulation as assessed by wst- reagent. il- and il- did not stimulate a-sma or collagen expression above control, measured by real time pcr. in conclusion, increasing evidence suggests that il- plays an important role in the development of bleomycininduced pulmonary fibrosis but this does not appear to be induced by direct effects of il- on fibroblast proliferation, differentiation or collagen production. mannose binding lectin (mbl) is a key mediator of innate immunity and efferocytosis (clearance of apoptotic cells) and is thus important in protecting against tissue damage. reduced mbl is implicated in airways disease including infection, copd and bos, however, 'normal' plasma levels of mbl are highly variable due genetic polymorphisms complicating correlation with disease processes. we have previously shown reduced mbl and defective efferocytosis in bal from patients with post-transplant bos, but there are conflicting reports of the link between low plasma mbl levels, increased complement activation and graft rejection. to compare mbl levels in the peripheral blood and bal compartments, we investigated mbl in paired plasma and bal from lung transplant recipients ( stable; stable with infection, with lymphocytic bronchiolitis and with bos) and in plasma from and bal from controls. in plasma, mbl levels were highly variable. no significant differences were noted among the transplant groups although levels were significantly reduced in all transplant patients vs. controls. there was no correlation between mbl and time post-transplant or pre-transplant diagnosis. in bal, mbl levels were less variable and significantly reduced in patients with bos (mbl ng/ml: controls: . ± ; stable . ± . ; stable infected . ± . ; bos . ± . ). interestingly, in all patients with lb, mbl levels were very low in both plasma (mean . ng/ml) and bal ( ng/ml). low levels of mbl in the airway may play a role in reduced efferocytosis, leading to tissue damage and airways disease post-transplant. in normal subjects, external dead space with exercise is associated with a slower deeper breathing pattern compared at the same ventilation. with simulated lung restriction and constant intensity exercise, we tested the hypothesis that dead space combined with reduced exercise intensity to match ventilation, would alter pattern of breathing, reduce inspiratory reserve volume (irv) and thus increase dyspnea. methods eleven healthy male subjects, aged ( ) (sd) years completed separate visits with (a) no restriction and (b) chest wall strapping to reduce fvc by ( ) introduction glossopharyngeal breathing (gpb) is used by competitive breath-hold divers to increase lung gas content above tlc to improve performance. this occurs by both lung expansion and gas compression. whilst gpb is known to induce hypotension and tachycardia, little is known about the changes that occur to both the pulmonary circulation and the structural integrity of the thorax. the aim of this study was to investigate these changes within an elite cohort. methods six male breath-hold divers were studied. exhaled vc was measured before and after gpb. subjects were studied in the supine position at baseline tlc and after maximal gpb above tlc at least hours apart. tc m labelled macro aggregated albumin was injected and a computed tomography (ct) of the thorax was performed during breath-hold. dynamic and single photon emission ct (spect) images were generated and analysed by two blinded nuclear medicine physicians for perfusion intensity (wilcoxon signed rank test) and dynamic regional blood flow. a paired t-test was used to assess physiological parameters. registered ct images were used to determine structural change in the thorax. results five subjects increased exhaled vc with gpb [mean (sd)] by . ( . ) l (p < . ). there was a reduction in perfusion intensity following gpb in the anterior (p < . ) and inferior (p < . ) lung segments. there was no change in the timing of blood flow. % of the increase in expired lung volume above baseline tlc was via thoracic expansion ( . ( . ) l (p < . )) with a caudal displacement of the diaphragm. one subject who was not proficient at gpb had no change in exhaled volume, ct appearance or lung perfusion. background we have developed a sensitive method to determine conductance-lung volume (conductance profile) and distensibility-lung volume (distensibility profile) relationships using the forced oscillation technique (fot). using this method, we aimed to assess the effect of a short-acting bronchodilator (bd) on these profiles in asthma. methods twenty two asthmatics and healthy controls completed distensibility measurements (fot) and lung function tests before and after bd. the conductance and distensibility profiles were described continuously and determined at specific lung volumes, residual volume (rv), frc, tlc and midway between frc and tlc (mid). results following administration of bd: the conductance profile in the asthma group was shifted upwards, and the distensibility profile was altered such that significant increases in distensibility were observed at rv (p < . ) and frc (p < . ), but not at mid or tlc. in contrast, no changes were seen in the conductance or distensibility profiles in the control group. post-bd distensibility in asthma remained reduced compared to controls. conclusion using a sensitive method for determining conductance and distensibility profiles, we found that both conductance and distensibility are reduced in asthma across a range from low to high lung volumes. both these profiles are altered in asthma after bd but not in controls. we propose that in asthma the remaining deficit in distensibility after bd will provide unique insight into to altered airway mechanical function due to airway remodelling. cigarette smoke exposure is a major risk factor in susceptibility to serious respiratory infections, particularly in children. although smoke exposure is known to alter immunity to infection, the underlying molecular mechanisms are not well understood. aim identify regulatory mechanisms that drive impaired macrophage function. methods the mh-s alveolar macrophage cell line was exposed to a short minute pulse of cigarette smoke extract (cse) prior to challenge with lps or fitc-e.coli. results cse blocked phagocytosis of e.coli and inhibited lps activation of canonical and alternative tlr pathways. both nfjb translocation and transactivation pathways were compromised as cse inhibited ijba degradation and p phosphorylation. cse also blocked ap- activity by inhibiting p , but not jnk or erk / . we next excluded lps tolerance mechanisms involving receptor internalisation or induction of negative regulators. as free radical species are abundant in cse we investigated their role using the potent scavenger, reduced glutathione (gsh). since gsh restored all responses, we screened a panel of oxidative/nitrosative stress markers and identified carbonylation as the only cse inducible marker. oxyblot analysis confirmed that cse potently introduced carbonyl groups to many proteins ( - kda range) in a dose and time dependent manner that inversely correlated with tnf-a expression. cse treated macrophages also displayed heavily carbonylated pseudopodia that was reversed by gsh as determined by immunocytochemistry (icc). conclusion macrophage sensing and ingestion of pathogen is compromised by protein carbonylation of the outer membrane where phagocytic receptors cluster and also penetrates cytoplasmic regions where signalling moieties reside. therefore, targeting single pathways will not restore macrophage function due to the global nature of cse mediated carbonylation. support nhmrc. background asthma shows varying levels of resistance to effective treatment by glucocorticoids. in studies on tgfb-induced epithelial mesenchymal cell transition (emt) using the a type ii human epithelial cell line, the regulatory effect of the glucocorticoid, dexamethasone (dex, . - nm) on interleukin- a (il- a)-induced interleukin- (il- ) generation was markedly reduced in the presence of tgf-b pm (n = ; p < . ). aim our studies were designed to characterise the mechanism of the glucocorticoid resistance. results the resistance induced by tgf-b was: concentration dependent ( - pm); a glucocorticoid class effect as it also occurred with budesonide; independent of emt: it was observed within hours, whereas emt requires days; also observed in the central airway epithelial cell line, beas- b and passaged, primary bronchial epithelial (nhbe) cells. treatment of a cells with sb , a tgfb receptor type i kinase inhibitor, restored the dex inhibitory effect on il- release (from control ± % to ± %, inhibition in sb lm, n = ; p < . ). in a cells transfected with a glucocorticoid response element (gre)-driven reporter gene, tgfb ( pm) inhibited the gre response to dex ( . - nm) by more than %. in addition, tgf-b impaired dex regulation of the gre-dependent gene, ijb. pge plays a protective role in asthma by inhibiting airway inflammation. it is predominantly produced by epithelial cells in response to pro-inflammatory stimuli and acts as an autocrine and paracrine mediator. prostanoids have been shown to regulate expression of enzymes involved in their metabolism, as well as expression of their receptors and that regulation is tissue-and cell-specific. despite its importance, however, mechanisms underlying the regulation of expression of enzymes involved in pge metabolism and its receptors in human lung epithelial cells have remained elusive. therefore, we hypothesised that pge regulates expression of pge synthase (pges ) and its receptors (e prostanoid (ep) - ) in human airway epithelial cells. methods real time rt pcr and facs analysis were used to assess mrna and protein expression, respectively in human airway epithelial cells hbe before and after pge stimulation. results pge up-regulates pges in time and concentration dependant manner. in addition, ep receptors (ep , ep and ep ) were up-regulated following pge stimulation at mrna level. however, these receptors show different dynamics in expression. while ep reaches peak in mrna expression at hour, peak expression for ep and ep is at hour post stimulation. monocyte derived dendritic cells (dcs) have been recognised for their potential role in immune responses and their functional relevance with regard to adaptive immune responses although more detailed knowledge of dc biology in human airways is required. the objective of this study was to modify the monocyte derived dcs from peripheral blood and direct the cells via exposure to pro-inflammatory conditions as seen in copd, with a view to identifying novel targets for cellular therapy. we characterised monocyte-derived dcs in culture and evaluated the effects of human rhinovirus infected bronchial epithelial cells, pi:c (polyinosine-polycytidytic acid) and bc (bacterial extract) on directing dc differentiation and maturation in culture. we found an impaired adaptive immune response, and in particular, an impaired cd effector cell function in copd patients. our dc culture results showed that both mhc-i and mhc-ii expression on dcs from copd were significantly down regulated compare to healthy controls, which could affect mhc restricted ag presentation, and lead to a failure to activate responder t cells. furthermore, we tested the capability of monocyte-precursors to differentiate into functional dcs. only a very small percentage of cultured monocytes from patients with copd was capable of differentiating into mature dcs, compared with healthy controls. during dc activation, there was up-regulation of co-stimulatory (cd / ) and maturation markers (mhcs), enabling dc to activate naïve t cells in mixed lymphocyte culture both in copd patients and healthy controls. our preliminary data indicated that this activation leads to the generation of effector t cells, further study is needed. defective dc activation of t cells may underlie poor t cell responsiveness in copd in response to inflammation and may, in part, determine the response to therapy. our data suggest a promising role in vitro for pharmacologic treatment as a means of generating functional dcs and will further stimulate speculation regarding their potential clinical application. support nhmrc australia. anxiety and depression are the two most common and the least treated comorbidities associated with chronic obstructive pulmonary disease (copd). they have been found to have a statistically significant and independent adverse association with mortality, longer length of hospital stay, persistent smoking and worse physical and social function. evidence for various interventions to overcome these symptoms in copd is limited or inconclusive. methods this is a cochrane review. all randomised controlled trials (rcts) and cross over trials (cots) dealing with pharmacological and/or psychological interventions for anxiety and/or depression in adults with copd were considered. search was performed via various medical search engines and cochrane database register. duration of follow-up in the studies was generalised as short-term ( - months), medium-term ( - months) and long-term ( - months). the data was analysed using the fixed effect model and difference in symptom control by interventions as mean difference (md) or the standardised mean difference (smd) depending upon the heterogeneity of various scales used. results eight rcts/cots were included. pharmacotherapy showed nil significant effect to control anxiety (smd of - . , p value . , n = ), however, showed significant benefit in controlling depression symptoms (smd - . , p value . , n = ) in copd over short-term. on the other hand, cbt was found to be beneficial in controlling both anxiety (md - . , p value . , n = ) as well as depression (md - . , p value . , n = ) in copd over short term. conclusion cbt is superior as compared to pharmacotherapy over short-term to control anxiety and depression in copd. background the emergence of clonal pa and associated risk of cross-infection is a major cause for concern in cf centres in several countries, including australia. two clonal pa strains (aes and aes ) have been detected in several eastern australian cf centres, but the overall prevalence of these and other strains throughout australia remains unknown. methods a cross-sectional study involving cf centres ( paediatric, adult, combined) was performed. in total, sputum-producing children and adults with documented pa infection provided two sputum samples, months apart, and pa isolates from each sample were genotyped by reppcr-based cluster analysis. results collectively, aes and/or aes strains were identified in % of pa infected cf patients and found in all participating cf centres. several other minor clonal strains were also identified in many centres. only % of patients were infected with unique (non-clonal) pa strains and % of patients were infected with more than one clonal strain. conclusion clonal pa strains are common in australian patients with cf. there is marked variation in prevalence of both major and minor clonal strains between cf centres and within states. longitudinal analysis of the clinical impact of clonal pa infection is urgently required so as to allow an evidence-based approach to patient management and infection control. reduced glutathione (gsh), a major component of anti-oxidant defence, is transported into the lung via cftr. gsh protects against myeloperoxidase (mpo)-induced oxidative stress by undergoing oxidation to gssg and gsa. excess mpo induces chlorination of tyrosine ( -cl-tyr) via the production of hypochlorous acid. we undertook a cross-sectional survey of young children with cf participating in our early surveillance program that includes annual bronchoalveolar lavage (bal) and chest ct scan. markers of neutrophilic inflammation and of the gsh system were determined in bal and the presence of bronchiectasis (b) and air trapping (at) determined on chest ct. samples from children with cf (mean age . years) and nine samples from children without cf (mean age . years) undergoing investigation for chronic respiratory symptoms (ncf) were studied. cf samples had more neutrophils that ncf samples (geometric mean . vs. . · /ml fluid retrieved), more mpo ( . vs. . ng/ml, p < . ), lower levels of gsh ( . vs. . nm, p < . ) and a trend for a lower gsh:gssg ( . vs. . , p = . ). within the cf samples levels of mpo correlated with gssg (p = . ), and gsa (p < . ) and -cl-try correlated with gssg (p = . ) and gsa (p < . ) indicating neutrophilic inflammation exceeding anti-oxidant defence capability. however, after controlling for age and the presence of free neutrophil elastase, there were no relationships between gsh, gssg or gsa and either b or at. while our data demonstrate gsh deficiency and defective anti-oxidant defence, these are not related to structural lung disease. longitudinal studies will be required to determine the impact of gsh deficiency in the initiation and progression of lung disease in cf. support cfft, inc (usa); nhmrc, acfrt, mcri and pmh foundation (aust). introduction there are no australasian guidelines for the detection and eradication of pseudomonas aeruginosa in preschool children with cf. the optimal eradication regimen for preschool children remains uncertain. aims to develop australasian guidelines for p. aeruginosa detection and eradication in preschool children with cf based on a national multi-centre randomized control trial. methods an electronic web-based questionnaire was sent to every tertiary paediatric cf centre in australasia to determine current detection and eradication practices. results all eleven centres completed the survey. a combination of positive oropharyngeal culture (opc) and confirmatory bronchoalveolar lavage (bal) culture was the most common method of p. aeruginosa detection ( %), with surveillance frequencies varying; annually (n = , %), every clinic visit ( , %) and clinically indicated ( , . %). eradication treatment was instigated on one positive culture (opc n = , bal culture n = centres) for p. aeruginosa at any bacterial density ( %) or bacterial density ‡ cfu/ml ( % of centres). eradication regimens varied between centres with most ( %) using intravenous antibiotics either alone (n = - ); in combination with - months nebulised antibiotics (n = ); or with - months nebulised and oral antibiotics (n = ). choice of regimen was influenced by clinical status in three centres. two centres used combinations of inhaled and oral antibiotics alone. failure to eradicate resulted in a change in treatment in % of centres. inhaled tobramycin mg ( days and months) was considered the least acceptable regimen for preschool children in terms of efficacy and burden of care with most favouring more aggressive iv treatments. conclusion this survey supports a call for evidenced based australasian guidelines for the detection and eradication of p. aeruginosa in preschool children. comparative trials of the most favoured eradication regimens would enhance this process. pseudomonas aeruginosa is the most important respiratory pathogen in cystic fibrosis (cf). although unproven, it is generally thought to be acquired from the environment. however, molecular typing studies indicate person-to-person transmission by some clonal strains may also occur. clonal p.aeruginosa strains have not been compared previously with isolates collected from non-cf patients, animals or the environment. aim to determine sequence-based clonality of p.aeruginosa isolates collected from several different ecological niches. methods mlst and sequence type (st) analysis was performed on isolates collected from cf patients (n = ), non-cf patients (n = ), animals (n = ), and the natural environment (n = ). cf isolates included each of the major and minor clonal australian strains and a range of unique strains isolated from patients residing in se qld. non-cf, animal and environmental isolates were collected from the same region. results of the individual strains detected, ( . %) were found in more than one niche. overall, unique and minor clonal cf strains were detected in at least one other niche; including cf strains found in the environment. to date, none of the three major qld cf clonal strains have been detected in another niche. conclusions in cf, environmental exposure to p aeruginosa seems important for acquiring unique and minor clonal strains. finding that the three major clonal strains were confined to cf patients further suggests person-to-person transmission is occurring and/or strain associated adaptation to the cf lung. support nhmrc, acfrt, tpch foundation. background clostridium difficile colitis remains a rare but potentially life threatening complication in cf patients particularly in the post lung transplant setting. aim ( ) to review the incidence of c. difficile colitis among non-transplant and post-lung transplant cf patients attending our centre. ( ) to identify the clinical features in cf patients presenting with cdad. method retrospective study on c. difficile toxin status in all fecal samples collected in cf patients between to was reviewed. patients with positive c. difficile toxin were identified as index cases, those with negative samples were selected as control cases. results two hundred and twenty-three fecal samples were collected from cf patients. nineteen cdad cases were identified in patients including non-transplant and two post-transplant patients. thirteen had mild colitis and two had fulminant colitis. incidence density of cdad in non-transplanted cf patients ( . / patient-days) is comparable to the transplanted group (two episodes/ patient-days). time to diagnose cdad among post-transplant patients is shorter than non-transplant patients ( vs. days). a significantly proportion in the cdad group had recent ciprofloxacin when comparied to controls ( . % vs. %, p-value: . .). a significantly higher proportion of patients in the cdad group are currently on gastric suppression therapy than control ( % vs. %, p-value: . ). conclusion the incidence density of cdad is comparable between pre and post transplant cf patients. cdad is more common among patients with prolonged ciprofloxacin treatment and concurrent gastric acid suppression. improving patient awareness by optimising patient education particularly during prescription of ciprofloxacin or gastric acid suppression treatment can prompt early presentation and management of cdad. conflict of interest no. g karmakar , d milne , m wilsher green lane respiratory services, and department of radiology, auckland city hospital, auckland, new zealand introduction major (massive or submissive) pulmonary embolism (pe) is a potentially lethal condition particularly if associated with cardiogenic shock. thrombolysis is accepted as standard treatment for massive pe with hypotension, but it carries substantial risk of bleeding and risk may outweigh the benefit in sub-massive pe. the objective of this study was to examine risk factors for and the outcome of major pe in this institution. methods we collected data retrospectively from all patients with mpe requiring icu admission in auckland city hospital (ach) over a year period. the primary outcome variable was mortality with secondary variables including precipitating factors and morbidity. results twenty-eight subjects ( massive pe) were identified. eight of with massive pe were thrombolysed and four were treated conservatively with day mortality of % and % respectively. twelve of patients with sub-massive pe received thrombolysis with no mortality. significant bleeding complications were reported in four of thrombolysed patients. prior surgery without dvt prophylaxis was identified as a precipitant in patients. conclusions massive pe carries significant mortality irrespective of thrombolysis but such treatment appears safe in sub-massive pe. in spite of evidence of efficacy, failure to offer prophylaxis of dvt in the perioperative setting appears an ongoing risk factor for major pe. introduction there is a need to improve general understanding of the epidemiology, pathophysiology, outcome and therapies for rare (orphan) lung diseases. aims ) to establish an electronic reporting registry of orphan lung diseases in australasia. ) to provide a useful resource for physicians and patients. methods a website (www.arnold.org.au) was developed containing information on orphan lung diseases, useful links and an on-line patient discussion forum. tsanz members were invited to participate in reporting cases electronically by a quarterly email reminder. the following data were entered: first two letters of given and family name, date of birth, postcode and whether the patient was new or old to the physician. results ethical approval in new zealand is still awaited. results twenty-three h n cases of mean ± sd age . ± years were confirmed from known lt recipients (incidence . %). cases peaked in new south wales (n = ) and queensland (n = ) consistent with epidemiology in the general community. clinical manifestations included allograft dysfunction in of ( . %), upper respiratory tract symptoms only . %, fever . %, myalgias . %, hypoxia . % and radiological infiltrates . %. mean hospitalisation was ± . days. cases were diagnosed in the hospital setting (n = ) and in the community (n = ). other risk factors included obesity n = , diabetes n = and malignancy n = . treatment consisted of oseltamivir mg bd initially for days in all cases, extension beyond days n = (mean ± . days) due to ongoing symptoms, steroid therapy n = , mechanical ventilation n = and noninvasive support n = . patients ( . %) have not returned to baseline lung function and there were four deaths (bos grade three n = and grade n = prior to diagnosis). conclusions the incidence of h n in the australian lt population was less than that estimated for the broader community but mirrored the geographical distribution. the majority experienced allograft dysfunction with most deaths recorded in those with preexisting bos grade . we recommend h n vaccine (panvax, csl) for all lt recipients. as the only commonly transplanted organ exposed to the atmosphere, the lung allograft may be uniquely susceptible to iga deficiency. since igg deficiency is common after transplantation, we hypothesised that iga production may be similarly affected and may contribute to bos pathogenesis. methods we conducted a cross-sectional evaluation of our transplant cohort. total iga, igm, igg, and igg subclasses were measured in serum using elisa. demographic data, immunosuppression and bos status were recorded. results one hundred and twenty three patients ( % of the total cohort, aged . years (range . - . ), % female, % cf, % copd) were evaluated. the median iga level was . g/l (normal range - g/l). patients ( %) were iga deficient, and ( %) of these were pan-hypogammaglobulinaemic. iga levels were lower in patients with bos (median, iq range; . , . - . vs. . , . - . , p = . ). iga deficiency was not associated with age, sex, diagnosis, transplant type or time post-transplant. the median igg level was . g/l (normal range - g/l) and patients ( %) were deficient. igg levels were lower in bos (median, iq range; . , . - . vs. . , . - . , p = . ) and igg deficiency was more common in copd ( %, p = . ). igg levels were negatively correlated with age (r = . , p = . ). multivariate logistic regression models identified iga deficiency as independently associated with bos (p = . ), while the association of igg deficiency with bos was explained by interaction between bos, age and copd. igm deficiency was present in patients ( %) and was more common in males ( %, p < . ), but was not significantly different in bos. igg, iga and igm levels were not associated with immunosuppression or the use of basiliximab induction conclusions serum iga deficiency is common after transplantation and is independently associated with bos. impaired defence of mucosal surfaces because of iga deficiency may contribute to bos pathogenesis. results rv infection alone led to induction of, pstat- , cxcl and release of ifn-k sirna, knockdown of mda- reduced cxcl , ifn-b and pstat- and also reduced ifn-k. silencing of tlr- and rig-i alone had no effect. when combined both sirna for tlr- and mda- had no additional effect. treatment of becs with bx inhibited the production of type i ifn but only partially inhibited ifn-k release. blockade of p mapk however led to substantial blocking of ifn-k release and also led to a marked reduction in the typeiifn response. conclusion we found that following infection with rv, becs type i ifn responses, pstat- induction as well as release of ifn-k was dependent on mda- . blockade of tbk- /ikk by bx reduced type i ifn response, but ifn-k release was only partially inhibited blockade of p mapk resulted in suppression of both ifn-k and type ifn, suggesting this pathway is crucial in the antiviral response to rv infection. conflict of interest none. introduction pregnant women have increased susceptibility to respiratory virus infection. human rhinovirus (hrv) and influenza are the most common respiratory viruses isolated during severe exacerbations in pregnant asthmatics and are high risk factor for respiratory-related maternal and neonatal morbidity and mortality. understanding the innate and adaptive immunological processes underlying respiratory virus infection in pregnancy will lead to improved treatments, resulting in better health outcomes for both mother and baby. methods cross-sectional study of pregnant asthmatics, pregnant non-asthmatics, non-pregnant asthmatics and healthy non-pregnant women. blood mononuclear cells were cultured with hrv (rv or rv b), influenza a (h n ), phytohaemagglutinin or tlr and tlr agonists, polyinosinic:polycytidylic acid and imiquimod, respectively. protein concentrations of ifn-a, ifn-k ifn-c, il- and il- were quantified from culture supernatant by elisa and cba. results pregnant asthmatics had significantly increased il- a and il- (median . pg/ml and . pg/ml, respectively) compared to healthy women (median pg/ml and . pg/ml, respectively, p < . ). ifn-c was significantly reduced in pregnant asthmatics (median . pg/ml) compared to healthy women ( . pg/ml, p = . ). ifn-a and ifn-k were induced by hrv and influenza in response to rv , pregnant women had decreased ifn-a production ( . pg/ml) compared to healthy controls ( . pg/ml, p = . ) whilst ifn-k production was significantly reduced in both pregnant asthmatics ( . pg/ml, p = . ) and pregnant non-asthmatics ( pg/ml p < . ). conclusion increased il- and il- production and reduced ifn-c, ifn-a and ifn-k are important inflammatory and anti-viral alterations during pregnancy and asthma; providing important insight into why pregnant women are more susceptible to respiratory virus infections. support nhmrc. conflict of interest no. nomination nil. the incidence of ntmld is increasing markedly in australia. it is not known why patients with ntmld are susceptible to these organisms, as most patients do not have identifiable risk factors or a documented immune defect. as cell-mediated immunity is crucial for control of mycobacterial disease, we assessed whether ntmld is associated with diminished th immune responses. methods our study cohort consisted of patients with ntmld at different stages of treatment, offspring of patients and unrelated healthy controls. plasma levels of cxcl and il- were assayed on all subjects by cytometric bead array or elisa. in a subset of subjects, pbmc were assessed for production of ifng, il- , il- and il- in response to stimulation with mitogen (seb) and purified protein derivative (ppd). all data was analysed using non-parametric statistical tests. results plasma levels of both cxcl and il- were higher in ntm patients compared with unrelated controls and/or offspring (p < . ). cxcl levels were lower in patients who responded well to treatment compared to those who responded poorly (p = . ). compared with healthy controls, pbmc from ntm patients produced similar levels of ifng, il- and il- , less il- (p < . ) in response to seb, but more il- in response to ppd (p < . ). conclusions ntmld is not associated with diminished th responses. elevated levels of cxcl indicate ongoing ifng release in vivo. ntm patients may have a bias towards il- production in response to mycobacterial antigens and/or harbour an intrinsic defect in th immunity. paracetamol is commonly used in infants as an analgesic and antipyretic. cross sectional studies have reported an association between frequent paracetamol consumption in early life and risk of childhood asthma. to date, no study has controlled for indication for use of paracetamol, or confounders such as history of respiratory infections, which is independently associated with asthma. aim to examine, in a prospective cohort study, whether frequent paracetamol exposure during early life increases the risk of childhood asthma. method six hundred and twenty infants with an atopic family history were recruited. paracetamol exposure was prospectively documented on occasions to years of age, including the number of days and the indication for use. an interviewer-administered questionnaire was used at and years to ascertain asthma in the previous months. results exposure to paracetamol occurred in % of participants by two years of age. increasing frequency of use of paracetamol was associated with increased risk of childhood asthma (or = . , %ci . - . per doubling of days of use). adjustment for frequency of respiratory infections substantially reduced the strength of these associations (aor = . , . - . ). paracetamol use for non-respiratory tract infections and injury was not associated with asthma (or = . , . - . ). conclusions in children with a family history of allergic disease, we found no association between early paracetamol use and risk of subsequent allergic disease when adjusted for respiratory infections, or when only paracetamol use for non-respiratory tract infections was examined. these findings do not support suggestions that paracetamol use up to age two years increases the risk of asthma. support nhmrc. aim to determine whether a water-based exercise program was effective in improving exercise capacity and quality of life in people with copd with physical co-morbidities compared to a land-based exercise program or no exercise. methods participants with copd referred to pulmonary rehabilitation and who had a physical co-morbidity were randomly allocated to one of three groups: land-based exercise, water-based exercise or a control group of no exercise. the two exercise groups trained for eight weeks, three exercise sessions per week. participants underwent measurements of respiratory function, exercise capacity and quality of life by a blinded investigator at baseline and following intervention. results of participants (mean (sd) age ( ) knowledge of airway dimensions is critical for bronchoscopists assessing airway stenoses requiring interventions. it is also important for evaluating phenotypic features of obstructive lung diseases (old). however, real-time quantification of airway dimensions during bronchoscopy is lacking. inserted into the airways via a bronchoscope, anatomical optical coherence tomography (aoct) is a light-based imaging technique with the unique capacity to obtain such measurements. we describe the validation, research and clinical applications of bronchoscopic aoct. methods (study ) aoct was validated in a phantom model, excised porcine airways and in human subjects. (study ) airway compliance curves were constructed and compared from aoct-based measurements in volunteers with and without old during bronchoscopy. (study ) stenosis dimensions (length, calibre) were measured compared in patients with symptomatic airway stenosis using pre-procedure computed tomography (ct) and intra-procedure aoct (bland altman analysis) to determine interventional strategy. results in phantom and porcine airways, aoct measurements were accurate and reliable. mean ct-aoct diameter measurements differed by . ± . mm. ( ) airway compliance was increased in copd (n = ) relative to control (n = ) and asthma ( ) subjects, which were similar. ( ) in patients, the mean difference between ct and aoct-based stenosis measurements was . ± . mm. aoct proved more reliable when ct image quality was poor or where a delay occurred between ct and bronchoscopy. conclusions aoct provides real-time measurements of airway dimensions which are accurate and reliable and can be used for research and clinical applications. nomination ann woolcock young investigator award. support nhmrc. disclosure to declare yes. a notable feature of allergic asthma is the infiltration of mast cells into human airway smooth muscle (hasm) bundles. thus, mast cells and hasm can likely exhibit mutual functional modulation via direct cell-cell contact or through released factors. to examine this possibility, we have used a human mast cell line (hmc- ) to evaluate mast cell modulation of hasm cell function. methods hmc- cells were transfected with human fcria, and fcri expressing cells were flow sorted. the functional activity of these cells (hmc- a) was examined by measurement of released cytokines via ige/antigen stimulation. hasm cells were co-cultured with hmc- a cells, or with conditioned media derived from hmc- a cells, to examine the impact on cytokine release. methods hmc- a cells were activated by ige/antigen to release il- . the co-culture of hasm cells with hmc- a cells, induced both il- (n = , p < . ) and eotaxin (n = , p < . ) production from hasm cells and this effect was greatly amplified when hmc- a cells were antigen-activated. the effect of hmc- a co-culture could be reproduced by addition of conditioned media derived from activated hmc- a cells. a bio-plexÔ cytokine array showed release of mcp- and mip- b was strongly induced from hmc- a cells upon ige/antigen stimulation. however, treatment of hasm cells with these cytokines did not elicit il- release. conclusions our study provides further evidence that the release of soluble mediators from activated mast cells can induce cytokine production from hasm cells. further work is currently ongoing to identify the factor/s responsible for this effect. we have previously demonstrated that gp -mediated stat signaling is required for bleomycin-induced lung fibrosis in mice. to determine the role of phosphorylated stat (pstat ) in the development of human lung fibrosis we examined stat and the regulation of stat expression in lung tissue from idiopathic pulmonary fibrosis (ipf) patients. immunohistochemistry revealed nuclear localization of pstat in fibroblastic cells within fibrotic foci. suppressor of cytokine signaling- (socs ) is a known negative regulator of gp -induced stat activation. we tested the hypothesis that reduced socs expression may account for elevated pstat in cells within the fibroblastic foci of ipf lungs. rt pcr profiler analysis of the jak/stat pathway demonstrated that il- up-regulated socs mrna in both ipf and hlf. western blot analysis confirmed that socs expression was not aberrant in these cells, although a trend towards reduced socs expression was evident. our analysis identified six jak-stat pathway associated genes that were significantly altered in ipf cells following il- exposure for minutes but of those, only il- was up-regulated. examination of other known regulators of stat signaling including socs , socs , socs , socs , pias , pias and protein tyrosine phosphatase non-receptor type (ptpn ) was performed but only socs expression was reduced in ipf. in summary, dysregulation of socs does not appear to cause high stat levels in ipf tissue but the potential regulation by socs is the subject of ongoing investigations. the phosphoinositide kinase (pi k) signal transduction pathway contributes to the airway remodelling associated with asthma; however, the precise roles of the specific pi k isoforms are currently unknown. in this study, we investigated the roles of the class ia pi k isoforms p a, p b and p d in airway smooth muscle (asm) cells derived from asthmatic subjects and asm cells and lung fibroblasts from non-asthmatic subjects. methods cells were stimulated with transforming growth factorb (tgfb; ng/ml) and/or % fbs in the presence or absence of specific pi k inhibitors pik (p a), tgx (p b) or ic (p d) (all . - lm) or vehicle control (dmso). fibronectin deposition, vegf and il- secretion were measured using elisa, mitochondrial activity was assessed by mtt assay and proliferation by bromodeoxyuridine (brdu) incorporation assay. results in non-asthmatic asm cells inhibition of p a and p b decreased vegf and il- secretion and cell proliferation (n = ; p < . ), whereas in asthmatic asm cells, only inhibition of p a (n = - , p < . ) but not p b (n = - , p > . ) had an effect. furthermore, we demonstrated isoform specific roles with p a (n = , p < . ) but not p b (n = - ) or p d (n = - ) modulating fibronectin deposition in asm cells and lung fibroblasts. conclusion specific pi k isoforms have distinct roles in the regulation of inflammatory cytokines (il- ), growth factors (vegf) and extracellular matrix proteins (fibronectin) associated with airway remodelling. intrinsic differences exist in the roles of the pi k isoforms in asthmatic asm. acute respiratory distress syndrome is characterized by inflammation and fibrosis. cellular therapies potentially restore pneumocytes and reduce inflammation. aims we evaluated the role of term human umbilical cord mesenchymal stem cells derived from wharton's jelly (umscs) and human amnion epithelial cells (haecs) in treating a bleomycin-induced model of lung injury. methods cells were administered systemically into a mouse model of acute lung injury hours following intra-nasal administered bleomycin. results both haecs and umscs reduced inflammation with decreased tnf-a, il- , il- and tgf-b. collagen in the lung was significantly reduced by both umscs and haecs as a possible consequence of increased degradation by matrix metalloproteinase- (mmp- ) and down-regulation of their endogenous inhibitors the tissue inhibitors of matrix metalloproteinases (timps) - and - . umscs were detected in the lung at weeks postinjection, vs. weeks for haecs. in addition, umscs did not demonstrate lung differentiation while haecs developed an alveolar phenotype. conclusions both umscs and haecs, have anti-inflammatory properties and reduce fibrosis in lung injury but haecs adopt a lung phenotype support small grant monash university. nomination nil. background with improvement in clinical care and longer survival of patients with cystic fibrosis, pregnancy has become commonplace. however the impact of cystic fibrosis on maternal health and foetal outcomes requires ongoing review. methods a retrospective study of pregnancies from women with cystic fibrosis during the period - was performed. changes in lung function, body mass index, and development of gestational diabetes were recorded. foetal outcomes and maternal survival were examined and the influence of pre-pregnancy parameters on outcomes were evaluated. results mean age of pregnancy was . years with a mean pre-pregnancy fev of . % predicted. eleven out of twenty pregnancies had a pre-pregnancy fev < % predicted. during pregnancy, fev fell by . % (ci . - . ), but recovered to baseline within months post-partum. mothers gained a mean weight of . kg and gestational diabetes developed in . % of women. all women delivered live births apart from one therapeutic abortion. five infants were preterm and three had low birthweight for age. four mothers either died or required lung transplantation after pregnancy on follow up. fev < % predicted and body mass index < kg/m were significant predictors of foetal complications. background carrier screening for cf has been available for many years but there is no national program for population-based screening in australia. knowledge of australian cf healthcare professionals' attitudes towards carrier screening would provide useful information about how a program could be implemented. the aim of this study was to investigate the attitudes of cf respiratory physicians and cf clinic coordinators in australia towards population-based carrier screening for cf. method a purposed designed questionnaire assessing knowledge and attitudes towards cf carrier screening was distributed to respiratory physicians and cf clinic coordinators throughout australia. results there were respiratory physicians registered with the cf special interest group of tsanz and cf clinic nurses identified through the cf coordinators network. seventy-five responded, respiratory physicians ( . %) and coordinators ( %). forty-two ( %) respondents were in favour of population-based carrier screening for cf. sixty-four ( %) rated raising a child with cf as difficult/very difficult, ( %) rated the shortened life span as a significant concern and ( %) the daily treatment regimen as a significant concern. disadvantages of screening were perceived anxiety amongst carriers (n = , %) and discrimination of carriers (n = , %). respondents rated the following barriers as most important: limitations of predicting clinical outcomes (n = , %) and insufficient time and resources for providers (n = , %). fifty-four ( %) of respondents believed they had a role in the development of a cf carrier screening program. adherence to medication regimens in patients with cystic fibrosis (cf) vary substantially. direct measures of adherence using electronic monitors attached to medication bottles enable the precise recording of usage. the macrolide antibiotic, azithromycin has demonstrated clinical benefit when used in cf patients with moderate to severe impairment of lung function. aim this study compares the adherence levels of cf patients randomised to two different treatment regimens of azithromycin, measured by electronic monitoring. methods patients were prescribed the medication once ( mg) or three times ( mg) a week. data were collected over weeks using electronic monitoring devices. adherence measures were defined as: total adherence (total amount of medication taken divided by total medication prescribed) and total number of days adhered (number of days where prescribed doses were taken divided by number of days monitored). results the study recruited participants ( % male; mean age = . sd = years, mean fev % = . , sd = . ). total adherence in patients prescribed the weekly regimen (m = . , sd = . %) were significantly different compared to the three times a week regimen (m = . , sd = . %, p < . ). no significant difference was observed in total number of days adhered. fev % predicted negatively correlated with adherence to medication (total adherence r = - . , p< . , days adhered r = - . , p < . ) and to bmi (r = . ,p < . ). positive correlation was observed between age of the participant and adherence to medication (total adherence r = . , p < . , days adhered r = . , p < . ). conclusion participants adhered better to a once weekly regimen than a three times a week regimen. preclinical studies in non-human primates (nhp) are essential to estimate effectiveness and safety in developing gene transfer protocols to treat cystic fibrosis (cf) airway disease prior to clinical trials. lentiviral (lv) vectors can provide in vivo gene expression and persistence suited to long lasting cf airway correction in mice. we have begun examination of lv gene transfer in lungs of marmosets (callithrix jacchus), a small non-human primate with lung anatomy and physiology similar to humans. methods lysophosphatidylcholine (lpc, . %) pre-treatment was followed by a lv vector encoding the lacz (lv-lacz) reporter gene, pseudotyped with the vsv-g surface protein. doses were delivered into the trachea of four intubated marmosets. trachea and lungs in two animals were examined after week; blood taken daily was tested for presence of vector particles. results epithelial cell lacz gene expression was present primarily in conducting airways in a patchy distribution. a transient o desaturation was noted in some animals after lpc administration; behavioural and physiological indices were normal postoperatively. limited patches of haemorrhage and neutrophil / mononuclear cell infiltration were deemed unremarkable by a veterinary pathologist. serum p lv capsid protein levels that appeared after dosing were absent after day two. conclusions these first studies indicate lpc/lv dosing procedures are well tolerated and can induce target-cell gene expression. further histological and immunological analyses are in progress. the remaining two animals will undergo longer-term assessment of the success of lentiviral lung gene transfer. background bronchiectasis and air trapping are important features of cystic fibrosis (cf) structural lung damage, however data on disease progression in young children are lacking. aim to assess longitudinal changes in ct-detected early structural lung damage in. methods subjects included children (age range . to . years) who underwent annual ct scans, with paired scans. each ct scan consisted of three slices at endinspiration and three slices at end-expiration. the left and right upper, middle and lower zones were assessed for the presence and extent (none, less than %, more than %) of bronchiectasis and air trapping using previously described methods. infection and inflammation were assessed using bronchoalveolar lavage at the time of ct scan. results bronchiectasis was present in % of initial scans, persisting in % of subsequent scans. median extent increased from initial to subsequent scan (p = . ). previous psa infection and neutrophilic inflammation was associated with increased prevalence of bronchiectasis at subsequent scan (or = . ). air trapping was present in % of initial scans, persisting in % of subsequent scans. median extent increased from initial to subsequent scan (p = . ). infection and inflammation did not increase risk of air trapping, but air trapping was more common in girls (or = . ). bronchiectasis and air trapping commonly occurred together. the minute walk test ( mwt) and incremental shuttle walk test (iswt) are commonly used to assess functional exercise capacity, prescribe the training intensity and measure the efficacy of pulmonary rehabilitation. no studies have compared these tests in patients with non-cf bronchiectasis. aims to compare peak dyspnea and heart rate (hr), and nadir oxygen saturation (spo ) during the mwt and iswt in subjects with non-cf bronchiectasis. methods twenty-seven participants (aged ± year, fev ± %pred, fvc ± %pred) with non-cf bronchiectasis enrolled in a trial of pulmonary rehabilitation, completed two mwts and two iswts in random order. results the minute walk distance ( mwd) and the incremental shuttle walk distance (iswd) were significantly greater on the nd test (both p < . ). the mean ( % ci) increase in the mwd was m ( to m); % ( to %) and in the iswd was m ( to m); % ( to %). the greatest mwd and iswd was ± m and ± m respectively. there was a strong relationship between the mwd and iswd (r = . , p < . ). peak dyspnoea was higher for the iswt ( . ± . vs. . ± . , p = . ) but there was no difference in peak hr ( ± vs. ± % age pred maximal hr, p = . ) or nadir spo ( . vs. . %, p = . ). conclusion although peak hr was similar, the externally paced, incremental nature of the iswt may account for the higher dyspnea scores in these subjects with non-cf bronchiectasis. future research will determine the responsiveness of the iswt and mwt following pulmonary rehabilitation in this population. the six minute walk test ( mwt) is extensively used in clinical practice. however, the role of this test in people with dust-related lung disease remains unclear. aim the aims of the study were to investigate the relationships between exercise capacity measured by the mwt and the incremental peak and endurance cycle tests, the mwt and health-related quality of life, and the mwt and activity levels in people with dust-related lung disease. methods thirty male participants with asbestos related pleural disease, asbestosis or silicosis performed two mwts separated by minutes with the better of the tests used for analysis. during the rest period, participants completed the st george's respiratory questionnaire (sgrq). on a separate day, participants performed spirometry, lung volumes, dlco and a peak and endurance cycle test. participants wore an activity monitor (sense-wear pro ) for a period of seven days. results mean (sd) age of participants was ( ) there was a significant correlation between mwt distance and peak watts (r = . , p < . ) but not with endurance cycle time. there were significant correlations between the mwt and all components of the sgrq, the strongest correlation being with the 'activity' domain (r = - . , p < . ) and significant correlations between mwt and average daily steps (r = . , p = . ) and average mets (r = . , p < . ). conclusion findings suggest the mwt may be a useful measure of exercise capacity and may reflect daily activity in people with dust-related lung disease. the minute walk test ( mwt) is used to assess prognosis and evaluate exercise capacity in interstitial lung disease (ild), however the physiological load imposed by the mwt is unknown. this study compared cardiorespiratory responses to mwt and cardiopulmonary exercise testing (cpet) in ild. methods fifteen participants with ild (nine ipf), mean age (standard deviation ) years and tlco ( ) %predicted undertook cpet and mwt on the same day in random order. pulmonary oxygen uptake (vo ), ventilation (ve), carbon dioxide production (vco ), oxyhaemoglobin saturation (spo ) and heart rate were compared between the tests using a portable metabolic cart. relationships between minute walk distance ( mwd) and peak cardiorespiratory responses on cpet were evaluated using correlations. results peak vo measured during the mwt was lower than during cpet ( . ( . ) vs . ( . ) ml.kg/min, p = . ). oxygen consumption during mwt reached a mean of % of vo peak achieved on cpet ( % confidence interval - %vo peak). peak ventilation, carbon dioxide production and peak heart rate were significantly lower during mwt, but there was no difference in nadir spo ( ( )% vs. ( )% on mwt and cpet respectively, p = . ). a higher mwd was associated with a higher peak work rate (r = . , p < . ) but there were no relationships between mwd and peak cardiorespiratory responses on cpet. conclusions the mwt elicits a high but submaximal oxygen uptake in people with ild. given the poor relationship between mwd and peak cardiorespiratory responses elicited by cpet, the prognostic value of the mwt may be related to the degree of oxygen desaturation elicited by this test. results there were no differences between groups at baseline for age, gender, body mass index or respiratory function. after twelve months both groups had similar improvement in fef - %(mean . l/sec, % confidence interval . - . l/sec). there was no significant effect on fev or fvc due to either treatment allocation or time. both groups demonstrated significant improvements in all domains of both the sgrq and lcq but there was no difference between groups. conclusion the inhalation of both isotonic ( . %) and hypertonic ( %) saline improved small airways function and improved quality of life over months, however both treatments were equally effective. introduction this project aimed to develop, implement and evaluate an innovative primary care model in community pharmacy for screening, monitoring and education of people with or at risk of sleep disorders (sd). methods a randomised control trial comparing two approaches was conducted: ) risk assessment only (rao) or ) risk assessment plus overnight nasal flow monitoring using the flowwizardÒ device (ra+). the risk assessment tool collected data on lifestyle, medical conditions, medications and included validated instruments for detecting sd. twentythree pharmacies ( rao/ ra+) recruited patients during a month period. patients at significant risk for a sd were provided with information and referred to a gp. results patients were recruited (rao n = , ra+ n = ). of these, . % (rao %, ra+ %) had an increased risk of daytime sleepiness, . % (rao %, ra+ %) were at risk of significant insomnia, . % (rao %, ra+ %) at risk of obstructive sleep apnea, and . % (rao %, ra+ %) at risk of restless legs syndrome (rls). pharmacists recorded a total of interventions and patients were referred to their gp ( of screened). preliminary results showed that patients (rao, n = , ra+, n = ) have completed the follow-up questionnaire with gp referrals being taken up and seven sd diagnosed ( % of those who took up a referral, rao, n = , ra+, n = ). nine patients ( %) received a diagnosis other than a sd and patients reported still awaiting sleep specialist assessment or testing. conclusion the results of this study indicate that community pharmacy is a potential site for sd screening. support the pharmacy guild of australia, investigator initiated grants. nomination nil. conflict of interest nil. jm foster , l smith , sz bosnic-anticevich , t usherwood , sm sawyer , cs rand , hk reddel university of sydney, australia, royal childrens hospital melbourne, australia, and johns hopkins university, baltimore, usa aim to identify beliefs and behaviours associated with poor adherence which could be used to guide tailored interventions in primary care. methods patients aged ‡ years with doctor-diagnosed asthma and a current ics/laba prescription completed questionnaires on beliefs and behaviours, side-effects, asthma control (acq), and underwent spirometry. adherence with ics/laba was measured over weeks by smartinhalers which electronically recorded the time and date of each actuation. univariate and multivariate analyses of questionnaire items identified predictors of adherence. results ninety-nine of patients completed the study ( female; mean ± sd fev % predicted ± ; acq . ± . ). mean adherence was % ± (n = ). thirty one beliefs or behaviours were significantly associated with poor adherence (p < . ). factor analysis of these items identified themes: f . perceived necessity; f . safety concerns; f . acceptance of asthma chronicity and ics/laba effectiveness; f . advice from friends/family; f . motivation/routine; f . ease of use; and f . satisfaction with asthma management. regression analysis demonstrated that items in themes independently predicted poor adherence (model adj. r sq. = . ; p < . ) including 'my preventer is necessary to keep my asthma under control'(f ), 'i get side effects from my steroid inhaler'(f ), 'i think i will have asthma for a long time'(f ), 'my family/ friends tell me i should use my preventer inhaler more often'(f ), 'i have a fixed daily routine for taking my asthma medications'(f ). adherence was lower for patients who attributed dental deterioration or dry eyes to their ics, but not for hoarseness. conclusions this study identified key beliefs or behaviours associated with poor adherence which may be amenable to change in patient-specific primary care interventions. support asthma foundation nsw, glaxosmithkline (medications investigation of pulmonary embolism with ctpa is often performed despite low clinical risk and results in unnecessary exposure to radiation and radiocontrast as well as inefficient use of medical resources. risk stratification with a validated prediction tool (wells score) complements clinical decision making and rationalises the use of ctpa to appropriate patient groups. methods prospective assignment of wells score by requesting clinicians on a formal algorithm form was instituted in . all patients being investigated for pulmonary embolism were required to have the form filled prior to performance of ctpa. patients stratified low clinical risk (wells £ ) did not proceed to ctpa unless a senior physician override was applied. intermediate risk patients (wells - ) proceeded to d-dimer measurement and if above the laboratory cutoff ( . ) proceeded to imaging. all high risk patients (wells > ) proceeded to ctpa directly. ctpa outcomes, d-dimer levels, request locations and dates were recorded. data were collected from february to august . results a total of patients were investigated with ctpa in this period. patients ( %) did not have the wells score assigned but patients ( %) had complete data. ( %) request originated from the emergency department, ( %) from inpatient wards and ( %) and ( %) from icu and outpatients respectively. the prevalence of pulmonary embolism in our study population was % similar to data from wells and others. ( %) patients were stratified to low risk, ( %) to intermediate risk and ( %) to high risk. the prevalences of pulmonary embolism were %, % and % respectively in these risk groups, comparable with published data. when evaluated against the same period in , there was an absolute reduction of ( %) ctpas performed. conclusion institutional implementation of a formal clinical prediction tool into the decision making process is feasible and yields significant reduction in ctpas performed, with substantial cost savings and patient benefits. aim to conduct an rct to measure the impact of the practitioner asthma communication and education program (pace) on general practitioner (gp) management of paediatric asthma. methods gps recruited through local practice networks identified patients aged - with diagnosed asthma. gps received two hour interactive workshops. results outcome data were collected from intervention and control gps, and intervention and control families. a significantly higher percent of intervention gps than control gps reported frequently providing a written asthma action plan ( . %, p = . , nnt = . ).intervention gps reported higher rates of giving written instructions to adjust medication ( . %, p = . , nnt = . ) and of providing spacers ( . %, p = . , nnt = . ). a significantly higher percent of intervention group children had received a written asthma action plan in the last year ( . %, p = . , nnt = . ). fewer intervention group children with infrequent intermittent symptoms were using regular ics ( . %, p = . , nnt = . ). intervention gps had higher improvements in confidence ( . %, p = . ), helpfulness ( . %, p = . ) and frequency of using the taught communication strategies ( . %, p = . ). conclusion the pace program is the most robustly evaluated program of gp asthma education in australia. our results provide high level evidence that paediatric asthma management is improved by pace. pace may be useful for educating other health professionals involved in chronic disease management. support australian government department of health and ageing. nomination nil. conflict of interest nil. vincent siaw, karmen yai, anand rose department of respiratory medicine, flinders medical centre, bedford park, south australia, australia pulmonary embolism is a common cause for presentation to the emergency departments of tertiary hospitals. if undiagnosed it has a % mortality. the diagnostic algorithm includes a clinical assessment, d'dimer assays and imaging in the appropriate patient. the preferred tool in our institution for confirming a diagnosis of a pulmonary embolism is the ct pulmonary angiogram (ctpa). we decided to audit our practise of doing a clinical assessment using a standardised risk score (eg.wells score) prior to requesting a ctpa. aim to audit the use of standardised clinical risk assessments prior to requesting a ctpa when a pulmonary embolism is suspected. methods ctpa requests from the emergency department from february and march were retrieved. cases notes were screened for mention of the wells or geneva scores. individual symptoms were also studied in attempt to reconstruct the score from the notes. results of the ct pulmonary angiograms performed - requests were from the emergency department. of these requests . % ( patients) were positive studies. systematic clinical risk assessment had been used in . % ( cases). when a systematic clinical score was performed . % of the ctpa studies were positive. this was greater than when no risk score was performed ( % of ctpa studies returned positive). we aimed to compare gp and parent reports of asthma management styles from an rct of practitioner asthma communication and education (pace). methods gps recruited through local networks identified patients aged - with diagnosed asthma. intervention gps participated in two hour workshops of patient education and communication techniques. results at months, gps ( intervention, control) and parents ( intervention, control) provided data. more intervention gps ( . %) reported checking device use (vs. . %; diff = . %, p = . ). intervention parents ( . %) reported that gps checked their device use more frequently (vs. . %; diff = . %, p = . ). more intervention gps ( . %) reported providing educational messages (vs. . %; diff = . %, p = . ). however, more control parents ( . %) (vs. . %; diff = - . %, p = . ) reported receiving messages. more control gps ( . %) said they asked patients about new medication fears (vs. . %; diff = - . %, p = . ), but more intervention parents ( . %) reported being asked about this (vs. . %; diff = . %, p = . ). conclusions gp and parental reports of device use checking were consistent. reports of educational messages and communication were less consistent, though these may have been provided or used but not recognised by parents. these findings highlight that parents and their gps can have very different perceptions of some aspects of a child's asthma management. care should be taken when selecting outcome measures for clinical trials. support australian government department of health and ageing. nomination nil. conflict of interest nil. to background smoking cessation interventions in outpatient settings has been clearly demonstrated to be one of the most cost effective strategies available in reducing disease burden. given the evidence of superior benefits with over nicotine replacement therapy, we aimed to evaluate its benefit in the inpatient setting for smokers admitted with acute smoking related events. methods adult patients (n = , - years) recruited from the respiratory, cardiology, neurology, vascular and general medical wards of the queen elizabeth hospital, lyell mcewin health service and the royal adelaide hospital were randomised to receive either vt (varenicline tartrate) plus quit sa counselling (n = ) or quit sa counselling alone, (n = ). results preliminary analysis shows that after three months of follow-up, smoking abstinence was achieved by . % in the control and . % in the intervention group, (p = . ). preliminary subgroup analysis indicates that cardiac patients, (n = ) have gained the most benefit with . % obtaining continuous abstinence. conclusion whilst a beneficial smoking cessation trend is evident at three months, these are only preliminary results. our recruitment target sample size is likely to provide sufficient power to identify significant differences in abstinence rates between treatment and control groups, and permit sub-group analyses of treatment effect based upon inpatient characteristics. support nil. nomination nil. introduction cigarette smoking prevalence has been in decline in australia over many decades but prevalence remains high in lower socioeconomic groups. hospital employees span the socioeconomic spectrum but there are few data on smoking prevalence from these sites. the visibility of smoking on campus conflicts with the health message that hospitals should promote but cessation services are often not provided. the queen elizabeth hospital (tqeh) has had an ongoing stop smoking service (using cost-price nrt and counselling) provided by tej since and -yearly surveys are conducted to assess benefits and ongoing need. methods employees of three metropolitan teaching hospitals (royal adelaide -rah, flinders medical centre -fmc and tqeh) and the alice springs hospital (ash) were sent a single page questionnaire asking about smoking status and views about smoking on campus. returns were voluntary but encouraged via a small monetary prize. tqeh was surveyed thrice ( , and ) , the other hospitals were surveyed once (late / early ) . results almost all employees reported knowing smoking is a health hazard. most employees (smokers & non-smokers) at all hospitals, thought smoking in public view was unacceptable but support for a total ban was less than for suitable areas where smoking was allowed. tqeh smoking prevalence is much lower than the comparator hospitals where prevalence is similar to national prevalence ( introduction interleukin- a is a cytokine released from t helper (th ) cells which induces and mediates various pro-inflammatory responses. as a result, il- a has been linked to many immune/autoimmune related diseases but its role in copd has not been explored. in the present study we investigated whether il- a regulates cigarette smoke (cs)-induced lung inflammation. methods wild-type (wt) or mice deficient in il- a (il- a -/-) were placed in a perspex chamber and exposed to cs generated from nine cigs per day for days. in separate experiments, cs-exposed wt mice were treated with anti-il- a antibody. on the fifth day, mice were killed, the lungs lavaged with pbs and then harvested for genomic analysis. results wt mice exposed to cs for days had significantly more balf macrophages ( . ± . (sem) · ) and neutrophils ( . ± . · ) than sham-exposed mice ( . ± . · and , respectively) (n = - , p < . ). however, cs-exposed il- a -/mice had significantly fewer macrophages ( . ± . · ) and neutrophils ( . ± . · ) than cs-exposed wt mice (n = - , p < . ). macrophage and neutrophil numbers in sham-exposed il- a -/mice ( . ± . · and . ± . · ) were similar to those of sham-exposed wt mice. gene expression analysis by qpcr showed that cs-exposed il- a -/mice had markedly reduced mcp- , tnfa, il- a, il- and mmp- expression compared to cs-exposed wt mice. treatment of cs-exposed mice with anti-il- a antibody significantly reduced cs-exposed balf macrophages and neutrophils (n = , p < . ). in addition, we found that lungs of nod-scid mice deficient in t & b lymphocytes expressed il- a in response to cs. conclusions these data show that il- a regulates cs-induced lung inflammation and that targeting il- a may have therapeutic utility in inflammatory lung diseases where cs plays a role. introduction in utero exposure to tobacco constituents may contribute to respiratory health problems later in childhood. glutathione s-transferases (gsts) are important in detoxification of xenobiotics. a reduction in the mother and fetus's detoxification ability due to genetic variation in gsts could expose the fetus to higher levels of toxins. objective to investigate the interactive effects of maternal smoking during pregnancy with maternal and infant gst genotypes on airway responsiveness (ar) and lung function in infancy at , and months and longitudinally throughout the first year. methods gstt , gstp and gstm were genotyped in infants and mothers using pcr. in utero exposure to maternal smoke was evaluated by questionnaire, ar was assessed by histamine challenge and v'maxfrc was measured using the rapid thoracoabdominal compression technique. results gstt non-null in infants, mothers or both was associated with reduced ar at months and throughout the first year and increased v'maxfrc at months. maternal gstp val/val or ile/val was associated with increased v'maxfrc at months. in infants exposed to in utero smoke, gstt non-null infants, mothers or both was associated with reduced ar at month and throughout the first year and increased v'maxfrc throughout the first year. there were no significant associations with gstm . conclusion gst genes may be especially important during fetal development as they may modify, through proficient detoxification, the effects of in utero maternal smoke exposure on ar and lung function in infants. funding nhmrc. conflict of interest no. introduction there are few birth cohort studies in which frequent, contemporary measures of tobacco smoke exposure have been related to lung function and airway responsiveness in later childhood. aim to examine the effects of in utero and post natal exposure to ets on lung function and airway responsiveness at age years. methods children with a family history of asthma were recruited antenatally into a randomized trial of house dust mite avoidance and dietary modification results a total of subjects were enrolled ( indigenous australians, indonesians). in the indigenous australian setting the sgrq total score was independently associated with exacerbation frequency and lung function (% predicted fev ) whilst the symptom score was associated more strongly with ae frequency and activity score with lung function. in indonesians with ptb the total sgrq score correlated with treatment response over time as well as lung function (% predicted fvc), exercise tolerance ( mwt) and the extent of involvement on cxr. conclusions in an indigenous australian and indonesia, setting respiratory-related qol using a modified sgrq correlates with lung function, exercise performance, disease activity and treatment. these tools should be a useful addition to evaluating interventions in this setting. background epithelial mesenchymal transition is a process in which airway epithelial cells disaggregate and then migrate through the reticular basement membrane (rbm) into the lamina propria to become myofibroblasts. the aim of this study was to identify if emt is active in the airways in smokers, and whether relevant to copd. methods endobronchial biopsies (ebb) from current smokers with copd (cs; n = ) and ex-smokers with copd (es; n = ), smokers with normal lung function (ns; n = ) and never-smoking controls (nc; n = ) were stained for emt markers, s a a fibroblast protein, epidermal growth factor receptor (egfr) and matrix metalloproteinase- (mmp- ). computer-assisted image analysis was used to quantify the expression of markers in biopsies and slides were counted by an observer blinded to subject and diagnosis. we used non-parametric statistics. results compared to nc, there was significant fragmentation of the rbm in cs, es and ns groups (p < . ), which was especially marked in cs and was positively related to pack years in copd subjects (r = . , p = . ). cs, ns and es demonstrated increased staining for: basal epithelial s a (p < . ), epithelial egfr (p < . ) and mmp- (p < . ) for cells in rbm 'clefts', and rbm cell s a (p < . ) compared to nc. there was increased rbm cell s a staining in cs vs. es and ns (p < . ). basal epithelial cells staining for s a correlated negatively with airflow limitation (r = - . , p = . ) in cs, and dual staining revealed that basal s a positive cells co-stained with vimentin (an additional mesenchymal marker). conclusions our findings suggest that emt is active in smokers, and is most evident in current smokers with copd, suggesting a role in copd pathogenesis. pulmonary emphysema is a major component of the chronic obstructive pulmonary disease (copd), and also predisposes affected individuals to lung cancer. emphysema can be a familial or acquired disease, with the great variation in development of disease in atrisk populations reflecting the influence of other susceptibility determinants. in this regard, the il- cytokine family has been linked with emphysema pathogenesis. however, studies into the definitive mechanisms by which these cytokines cause emphysema have been hampered by the absence of informative animal disease models. to address this issue, we have utilized a sophisticated animal model (gp f/f mice) with a subtle mutation in the il- cytokine family receptor gp which, as a consequence of abolishing binding of both shp and socs , simultaneously mediates stat / hyper-activation and impaired shp -mapk and -pi k activation. the gp f/f mice spontaneously develop emphysema by months of age characterized by increased static compliance. lung stereology has further confirmed emphysematous changes, revealing increases in volumes of airspace and lung. among the il- cytokine family, il- expression is significantly up-regulated in the lungs of gp f/f mice, and genetic ablation of il- in gp f/f mice prevents the development of emphysema. notably, an increased apoptosis of alveolar cells has been identified as the underlying cellular mechanism associated with the emphysema in gp f/f mice. collectively, our observations identify for the first time that deregulated gp signalling by il- cause's alveolar cells to undergo apoptosis, which coincide with the pathogenesis of emphysema. furthermore, this mouse model has the enormous potential to allow us to explore common mechanistic links between copd and lung cancer. supported by the nhmrc, australia. conflict of interest no. introduction despite smoking cessation, susceptible copd patients continue to decline in lung function. understanding biological pathways and their gene ontologies would help to develop better treatments and diagnostic methods for copd. the aims of this study were to identify gene ontologies associated with mild and moderate copd by (i) profiling mrna and (ii) mirnas and their predicted targets. methods profiling was performed on total rna extracted from lung tissue of copd patients undergoing resection for lung cancer. microarray platforms (operon v and agilent g v ) were used to characterise mrnas and mirnas respectively. analysis was performed using brb array tools v . and gsea. results the patients were caucasian former smokers with mean (sd) age ( ), fev ( ) % predicted, kco ( )% predicted and pack years ( ). we identified authentic candidate genes (p < . ) that predicted copd progression with % accuracy in in-house and public datasets. genes involved in cell cycle, proliferation, development and growth were identified. increasing expression of mir- c, a candidate mirna for emphysema progression, on lung fibroblast and epithelial cells downregulated predicted mrna targets with potential biological role in copd. conclusions we have identified multiple gene ontologies associated with copd severity. these targets have promising biological roles in copd and can be further developed as biomarkers or therapeutic targets. cigarette smoke (cs)-induced oxidative stress is known to drive the pathogenesis of copd. the antioxidant glutathione (gsh) is essential for efficient macrophage functions including phagocytosis of apoptotic cells (efferocytosis) which we have shown to be defective in copd. gsh synthesis is controlled by a cd /xct cysteine transporter pathway. cd is also a ligand for galectin- (gal- ), a lectin important for macrophage phagocytosis and gsh synthesis. we hypothesised that targeting oxidative stress in copd by increasing gsh would increase gal- levels and improve efferocytosis. we investigated (a) ex vivo: oxidative stress markers ( -isoprostane; mmp ), gsh and gal- in bal from controls and current-and ex-smoker copd subjects (b) in vitro: the effects of cs on alveolar macrophage production of gal- and gsh (c) in vivo: the effects of treatment with a gsh precursor, procysteine, on efferocytosis, gal- and gsh in smokeexposed mice. procysteine was administered in semi-solid mouse feed. efferocytosis was investigated in lung tissue and bal macrophages. -isoprostane and mmp were significantly increased in bal in current-and ex-smokers with copd. gsh and gal- were decreased in copd (gal- , ng/ml: current . ± . , ex-smoker . ± . vs. controls . ± . ). in vitro cs treatment decreased gal- expression. in vivo, cs caused decreased efferocytosis that was significantly improved by procysteine (control; smokeexposed; procysteine + smoke-exposed: bal . %; . %; . %; tissue . %; . %; . %). gsh and gal- were also significantly increased by procysteine (gal- , ng/ml: control . ± . ; smoke-exposed . ± . ; procysteine + smoke-exposed . ± . ng/ml). targeting oxidative stress is a viable approach to improve macrophage dysfunction in copd. support nhmrc, arc. introduction our knowledge about the effects of inhaled corticosteroids (ics) on airway remodelling in chronic obstructive pulmonary disease (copd) is limited. we have previously reported that in bronchial biopsies (bb) from copd subjects the reticular basement membrane (rbm) is fragmented and hypervascular. in this study we have examined the effects of ics on these airway remodelling changes in copd. methods in a double blind and randomised study we compared the effects of months of fluticasone propionate (fp, . mg/twice daily) with placebo. bb were stained with collagen iv antibody to mark vessel endothelial basement membrane. the length of rbm splits and the number and area of vessels in the rbm were compared before and after treatment. results copd subjects were randomized : to receive either fp (n = ) or placebo (n = ). there were no differences between the groups before treatment. introduction copd is a complex disease characterised by fixed airflow obstruction and neutrophilic airway inflammation. markers of systemic inflammation such as serum amyloid a (saa) are elevated in copd. however, little is known about the relationship between airway and systemic inflammation. this study tested the hypothesis that systemic inflammation is associated with airway neutrophils in copd. methods participants with copd (n = , > years, with fev /fvc < and fev % predicted < ) and healthy controls (hc; with normal lung function n = > years) underwent clinical assessment, spirometry, blood collection for saa, il- and crp and sputum induction. sputum was processed for differential cell count and mediators. results airway proportions of neutrophils and eosinophils, levels of il- , total mmp- and gene expression of il- were increased in participants with copd. serum il- (median q -q ; ( . ( . - . )) vs. asbestos-related lung cancers (arlc) account for - % of all lung cancer, and are difficult to distinguish from non-asbestos related tumours (narlc) by clinical and histological criteria. we hypothesised that whole genome array comparative genomic hybridization (acgh) profiling could identify regions of gain and loss common and specific to asbestos-related lung cancer. methods the acgh profiling by agilent cgh b arrays was performed on primary non-small cell lung cancers obtained from the prince charles hospital (tpch) lung tumour bank. lung cancers occurring in individuals with >= asbestos bodies/gram wet weight (ab/gww) of lung tissue were defined arlc and individuals with ab/gww were defined narlc. genome breakpoints were called using the circular binary segmentation algorithm implemented in dnacopy. recurrent regions of amplification and deletion were identified using the genomic identification of significant targets in cancer (gistic) algorithm developed by the broad institute, controlling for false discovery rates (q < . ). results gistic identified recurrent copy number gains in q and narlc at q < . but none for arlc at the same threshold. to introduction the relationship between asbestos exposure and asbestos related diseases (ard) such as asbestosis, lung cancer and mesothelioma are well established. less is known about asbestos exposure and non-ard respiratory diseases. aim to investigate respiratory symptoms and lung function in former workers and residents from wittenoom who have not developed an ard. methods an annual review, which includes lung function, plain chest x-ray and respiratory questionnaire, is conducted on a cohort of ex-workers and ex-residents from wittenoom. only those who had been reviewed within the previous years and had not developed an ard, nor had plain chest radiographic evidence of asbestosis, were included in the analyses. the prevalence of respiratory symptoms was determined and standardised lung function z-scores calculated. predictors of symptoms and lung function were assessed using both multiple logistic and linear regression. results questionnaire data was available for subjects ( women, ex-workers; mean age . ± . years), while acceptable lung function data was available for subjects ( women, ex-workers). the prevalence of reported symptoms ranged between and % for wheeze, cough, sputum, shortness of breath and bronchitis. pack years of smoking and/or being an ex-worker were the main risk factors for symptoms. standardised lung function scores ( %ci) for the total group were - . (- . -- . ), - . (- . -- . ) and . ( . - . ) for fev, fvc and fev/fvc respectively. both pack-years and cumulative asbestos exposure were independently associated with reduced fev and fvc. conclusions people previously exposed to asbestos, particularly ex-workers, have high rates of respiratory symptoms which are mostly related to smoking. reduced lung function in the cohort was associated with both smoking and cumulative asbestos exposure. conflict of interest none. introduction malignant mesothelioma (mm) is an aggressive cancer with a very poor prognosis. interactions of the components of the extracellular matrix (ecm) are now known to be important for the growth and regulation of cancer cells. tgfb is an important regulator of the ecm and in particular collagen. previous data in our laboratory has shown that blocking tgfb signaling by using tgfb antibodies inhibits collagen production and mm growth. aim to determine the signaling pathways downstream of tgfb that are important in the regulation of collagen expression in mm. methods components of the tgfb pathway were inhibited by use of chemical inhibitors and overexpression of the endogenous inhibitor smad in control and mm cell lines. collagen levels were measured by realtime pcr. results collagen regulation is thought to occur through the classic smad / signaling pathway. our data show that smad overexpression inhibits tgfb-induced collagen production in normal mesothelial cells and the mesothelial cell line met- a but not in the mm cell lines investigated. therefore, the smad / pathway for collagen regulation appears to be altered in malignant mesothelioma. it was shown that smad / are expressed, phosphorylated and activated by tgfb in the mm cell lines. our results indicate that nuclear import of smad , which is responsible for the nuclear import of smad / , is altered in mm. aim to characterise impedance variability at hz in asthma and its relationship to asthma severity. methods a school-based cohort of non-asthmatic children, aged (mean (sd)) . ( . ) years (uptech feasibility study) were tested on two occasions weeks apart. an asthma camp cohort of asthmatics, aged . ( . ) years, were tested daily for days. mean resistance (rrs ) and reactance (xrs ) of at least three technically acceptable one minute recordings were reported. medications were not withheld. variability was assessed by intraclass correlation coefficient (icc) and within-subject standard deviation (sd w ) using first and last testing day data, and all days of data for sd w severity comparison amongst asthmatics. results repeat fot measures at hz were obtained in / non-asthmatic children. mean (sd) rrs and xrs was . ( . ) and - . ( . ) for the uptech cohort, and . ( . ) and - . ( . ) cmh o/l/s in the asthma camp cohort respectively. rrs variability was increased in asthmatics. rrs variability tended to be higher in persistent vs. intermittent asthmatics but did not reach statistical significance (p = . ). non asthmatic (n = ) introduction our cochrane review examining the efficacy of using feno to tailor the dose of inhaled corticosteroid showed that feno cannot be routinely recommended for clinical practice at this stage and remains uncertain. however all the studies used a single feno cut-off. in this rct we determined if asthma monitoring using feno (using two different cut-offs dependent on atopy) is better than control (symptoms and fev ) in preventing asthma exacerbations in children on inhaled corticosteroids. methods over -months, children underwent spirometry, feno, qol and asthma/ cough diary during every visit. treatment for asthma was adjusted according to pre-determined criteria taking into account atopy status and dependent on allocation group (feno or control). results about children were randomised-feno group (n = , median age . , iqr . ), or control group (n = , median age . , iqr . ). significantly fewer children in the feno group had asthma exacerbations compared to the control group ( vs. ; p = . ) over -months. number needed to treat (nnt) to prevent one child from having any exacerbation in months = ( %ci , ). parental qol improved in feno group at final visit in comparison to the qol in control group (p = . ). fev increased in both groups over the duration of the study but there was no difference between the groups when measured at baseline (p = . ) and at final (p = . ). conclusion tailoring of asthma medications in accordance to feno levels (compared to usual management), taking into account atopy status, reduces asthma exacerbations and improves asthma qol. however both strategies equally improved fev . background inhaled corticosteroids have a modest effect on improving symptom control in preschool asthmatic children. delivery of inhaled steroids with pmdi-spacers are influenced by children's proficiency in spacer technique, and adherence to prescribed medication. aim to investigate the influence of an incentive spacer (funhaler), on spacer technique, adherence to treatment, and asthma control in preschool asthmatic children. methods about children aged - years, and being prescribed regular inhaled steroids in the community were randomised to receive regular inhaled fluticasone through either an aerochamber plus Ò , of a funhaler Ò . subjects were followed up three monthly for a year. proficiency in spacer technique was measured at each visit by measuring the amount of salbutamol inhaled from spacer onto a filter interposed between subject and spacer. adherence was monitored by smartinhaler Ò electronic devices. symptoms were recorded on diary cards for a week before each study visit. results there was no difference between the funhaler group and the aerochamber group in terms of adherence to medication or measures of asthma control (p > . ). spacer technique was significantly better in the funhaler group in subjects younger than years of age at time of randomisation (p < . ). there was large inter subject variation in drug dose inhaled on filter, ranging from - % (drug dose recovered from filter, as percentage of total dose recovered), and mean adherence over each month period ranging from - %. discussion the funhaler Ò does not improve clinical outcome, but improves spacer technique in children younger than years of age. the large variability in adherence and drug delivery should encourage both efforts to improve adherence, and efforts to standardise inhaled drug delivery in preschool children. - and - . about % of ob cases were notified within year of arrival. of the australianborn cases were close household contacts of an adult tb case. about cases had culture confirmed disease ( fully sensitive to first line drugs, one multidrug resistant). % had pulmonary and % had lymph node tb. about cases completed the treatment, two were lost to follow-up and one died. compared to adult tb cases, children were more likely to be refugees (or . (ci . - . )), diagnosed on contact screening (or . ( . - . )), have lymphatic tb (or . (ci . - . )), and less likely to be culture-confirmed (or . (ci . -. )). the png child visitors' cases diagnosed in queensland had a higher level of severe and culture-confirmed disease. conclusion queensland has a very low burden of childhood tb, indicating low levels of tb transmission in the community. hrgm children, especially refugees, will remain at risk due to infection acquired overseas. contact screening is an important method of diagnosing early tb, and refugee screening and preventive treatment may play a role in protecting this group. funding support nil. conflicts of interest nil. introduction in response to injury, normal and efficient epithelial repair is essential in order to maintain barrier integrity and immune function. however, aberrant repair has been suggested as a contributor to disease progression in asthma. many studies have only included subjects with atopic asthma and thus any intrinsic epithelial abnormality common to all asthmatic phenotypes is difficult to isolate. this study aimed to assess whether epithelial repair is dysregulated in asthmatic subjects and if this is common to the disease or is phenotype specific. the regulatory mechanisms promoting the cellular proliferation and migratory aspects of the repair process were also assessed. methods paediatric airway epithelial cells (paec) of atopic and non-atopic healthy and asthmatic subjects were isolated by non-bronchoscopic bronchial brushings. culture monolayers were wounded using an in-house wounding device, and the percentage of wound closure determined daily. proliferation and migration were also assessed over the course of repair using western blot. results paecs from healthy non-atopic (paec hna ) and healthy atopic (paec ha ) subjects successfully achieved full wound closure between - days. in contrast, atopic asthmatic (paec aa ) and non atopic asthmatic (paec naa ) subjects failed to fully repair and only achieved % wound closure by days. protein analysis showed a -fold increase in proliferation and -fold increase in migratory markers during repair in paec hna . however, reduced proliferation and no migration activity were seen in paec aa. conclusion atopic and non-atopic asthmatic epithelial cells possess dysfunctional repair profiles in response to mechanical wounding. results suggest dysregulated repair is an intrinsic epithelial abnormality in asthma and this appears to be independent of phenotypic criteria or atopy. introduction refractory chronic cough is associated with increased cough sensitivity. speech pathology intervention has been shown to be an effective intervention for refractory cough but the mechanism behind the improvement is not known. this study provides objective measures of the mechanism and the number of treatments required to effect a response. methods adults with chronic cough (n = ) were assessed before, during and after speech pathology intervention. the primary outcome measures were capsaicin cough reflex sensitivity, automated cough frequency detection and cough-related quality of life. results participants responded to the treatment with a significant improvement in coughrelated quality of life, p = . , cough reflex sensitivity, c : mean ± sd . ± . vs. c : . ± . lmol/l, p = . , cough frequency cf: . ± . vs. ± . coughs/hr, p = . , cough threshold ct: . ± . vs. . ± . lmol/l, p = . , and urge-to-cough utc: median (iqr), ( ) vs. ( ), p = . . conclusion speech pathology management is an effective treatment for refractory chronic cough. the mechanism behind the improvement is due to reduced laryngeal irritation which results in decreased cough sensitivity, improvement in cough symptoms, laryngeal symptoms, and cough quality of life. introduction airway hyperresponsiveness (ahr) is a characteristic feature of asthma. in young asthmatics, severity of ahr is related to exhaled nitric oxide (eno), a marker of eosinophilic airway inflammation, and ventilation heterogeneity in the conducting airways (scond). with increasing age, eosinophilic inflammation decreases and ventilation heterogeneity in the very peripheral, acinar, airways worsens. aim to determine if the predictors of ahr differ in young and older asthmatics. methods about young ( - ) and older ( - ) asthmatic subjects underwent baseline spirometry, body plethysmography, eno, multiple breath nitrogen washout (mbnw), and methacholine (mch) challenge. ahr was expressed as dose response slope (drs = %fall fev /lmol mch). ventilation heterogeneity of the conducting (scond) and acinar (sacin) airways were calculated from the mbnw. predictors of ahr in each group were determined by multiple linear regression. results compared to younger asthmatics, older asthmatics had lower values of eno, less severe ahr, worse acinar heterogeneity; however there were no differences in scond values. in younger asthmatics, ahr was predicted by fev /fvc (partial r = . ), eno (partial r = . ) and scond (partial r = . ) (overall r = . , p < . ). in older asthmatics, ahr was predicted by rv % predicted (partial r = . ), sacin (partial r = . ) and fev % predicted (partial r = . ) (overall r = . , p < . ). conclusions the predictors of ahr are different in young and old asthmatics. in older asthmatics, eno is not a significant predictor of ahr, which may reflect the changing inflammatory profile associated with aging. the association between ahr and both rv and sacin suggests that ahr in older asthmatics is determined by abnormalities in very peripheral airways. introduction in this systematic review and meta-analysis, we sought to establish if maternal asthma is associated with an increased risk of adverse perinatal outcomes associated with size at birth and timing of birth. methods electronic databases were searched for the following terms: (asthma or wheeze) and (pregnan* or perinat* or obstet*). cohort studies published between and march were considered for inclusion. articles were identified, and publications involving , , subjects met the inclusion criteria, by reporting at least one perinatal outcome in pregnant women with and without asthma. meta-analysis was conducted with subgroup analyses by study design and active asthma management. results maternal asthma was associated with an increased risk of low birth weight (relative risk [rr] . , % confidence interval [ci] . , . ), small for gestational age (sga, rr . , ci . , . ), very sga (rr . , ci . , . ), significantly reduced mean birth weight (weighted mean difference - g, ci - , - g), and reduced risk of high birth weight (rr . , ci . , . ). maternal asthma was associated with an increased risk of preterm labor (rr . , ci . , . ), early preterm labor (rr . , ci . , . ) and preterm delivery (rr . , ci . , . ). the risk for preterm labor and delivery was reduced to a non-significant level in those studies reporting active management of asthma during pregnancy (rr . , ci . , . ; rr . , ci . , . ). conclusion pregnant women with asthma are at increased risk of perinatal complications which affect the baby's size and timing at birth. active asthma management may reduce the risk of preterm labor and delivery. with threats of new pandemic strains of influenza a virus and resistance to anti-virals there is a need for novel therapeutics that reduce viral replication and lung pathology. the pathology arising from pandemic influenza is due to an excessive host response characterised by a rapid, massive infiltration of inflammatory cells of the innate immune system into the airways leading to excessive reactive oxygen species (ros) production. thus, we investigated the primary enzymatic source of inflammatory cell ros, nox -containing nadph oxidase, as a novel target against lung inflammation and pathology caused by influenza a viruses of varying virulence. wt and nox -/--mice were pfu/mouse) or high virulence following infection with x- , lungs of nox -/-mice displayed a significant reduction in viral titre (~ - %), macrophages, peribronchial inflammation and mcp- compared to virusinfected wt mice. lung levels of il- b were approximately -fold higher in nox -/-mice. balf macrophages, neutrophils, and t lymphocytes of nox -/-mice produced minimal superoxide compared to controls. the magnitude of balf and spleen influenza-specific dbnp + and dbpa + cd + t cells were similar in wt and nox -/-mice indicating that the major mechanisms of the adaptive immune response that effectively clear influenza a virus are preserved in nox -/-mice. in vivo administration of the nox inhibitor apocynin ( mg/kg/day) significantly suppressed viral titre, airways inflammation and inflammatory cell superoxide following infection with x- or pr/ strains. in conclusion, nox inhibition should be considered for seasonal and pandemic control of the mortality/ morbidity induced by influenza a virus, irrespective of the strain department of respiratory medicine australia, cooperative research centre for asthma and airways, new south wales, australia, and department of respiratory medicine therefore the aim, of this study was to examine the impact of a standard, -week exercise-based pr program on pal. methods about subjects ( ( ) years) with copd (fev % predicted = ( )) completed pr where they undertook twice weekly exercise classes consisting of one hour of upper and lower limb strengthening exercise and aerobic exercise. pal was estimated using a multi-sensor device (sensewear, healthware bodymedia) worn for a day period. an index of pal was derived by dividing total daily energy expenditure in metabolic equivalents (mets) by whole night sleeping energy expenditure (average of nights sleeping). pal was measured in the week immediately prior and in the immediately following pr. results despite a significant increase in six minute walk distance ( mwd), pr resulted in no change in pal copd patients failed to increase their pal. while changes in pal may take longer to elicit i.e. the change in pal may be delayed following pr, it is possible that the current focus of pr on increasing outcomes such as mwd may be too narrow to elicit changes in pal little is known regarding the use of acts in patients admitted with aecopd in australia. this survey aimed to identify current practice and opinion of australian hospital physiotherapists concerning acts. methods paper-based surveys were distributed to physiotherapists of 'large' and 'principal referral' australian public hospitals (identified via a government health report). a response rate of % (n = hospitals) yielded surveys for analysis. results most physiotherapists ( %) prescribe acts for - % of patients with ae-copd, with % of act treatments lasting - minutes. the techniques most frequently used for airway clearance were physical exercise ( %) and the active cycle of breathing technique ( %). the main influences on choice of act were precautions or contraindications to individual techniques ( %) and the degree of patient dyspnoea ( %). many physiotherapists ( %) prescribe acts with the aim of enhancing a patient's recovery from aecopd and % perceive airway clearance to be fairly or very important to the overall management of aecopd. there was mixed awareness of the evidence for acts in aecopd, with % of physiotherapists citing it as supportive conclusion australian physiotherapists frequently use acts for patients with aecopd and perceive their role to be important. physical exercise is the present modality of choice to achieve airway clearance acknowledgements nh&mrc, cure cf foundation sa. conflict of interest no. aim to examine the health outcomes of , children first exposed to blue asbestos at wittenoom when they were less than years of age. methods standardised mortality ratios (smr's) calculated to compare wittenoom children's mortality with the western australian population. results about , females and , males were children at wittenoom, mean age of arrival years (sd years); ( %) were born there or moved there soon after birth. median duration of residence was months (iqr - months). there were deaths ( females and males) between and end of . deaths were from malignant mesothelioma ( % of all deaths - females, males, - pleural, peritoneal). among males, there was excess mortality from all causes (smr = . ), all cancers (smr = . ), mm (smr = ), accidents, injuries and poisonings (smr = . ) and circulatory disease (smr = . ). mortality from suicide and transport accidents were also in excess but not statistically significantly increased. among females there was excess mortality from all causes (smr = . ), and all cancers (smr = . ) and mm (smr = ). conclusion former children of wittenoom experience high cancer mortality. support nhmrc. nomination nil. conflict of interest nil. introduction blue asbestos (crocidolite) was mined and milled at wittenoom between and . tailings from the mine were distributed and used extensively throughout the town. exposure to children also occurred from the laundering of workers clothes at home. earlier work has shown a lower risk of malignant mesothelioma (mm) in children from wittenoom than in those exposed to blue asbestos as adults.a case report of a year old ex-forestry worker with an pack year smoking history is presented. he was referred with two distinct periods of hemoptysis, one months prior to referral for which he declined investigation or follow up, and another three weeks prior to referral. on each occasion, he described two tablespoons of hemoptysis daily lasting approximately month. he lives on an acreage at mt kilcoy, km north of brisbane, with his wife, one goat, three dogs, one cat, deer and wild birds. emphysema manifesting as gradually worsening exertional dyspnoea with wheeze, had been diagnosed years ago by his local doctor. he described symptoms of obstructive sleep apnoea including witnessed apnoea, choking arousals and loud snoring. he also reported intermittent diarrhoea for years but denied weight loss or rectal blood or mucous. a ct chest showed multiple bilateral nodules of varying size the largest being . cm, and multiple low density liver lesions. the provisional diagnosis was metastatic colorectal cancer. bronchoscopy with ebus guidance did not yield the diagnosis which was eventually made by trans-thoracic needle aspiration without complication. echinococcus serology performed post procedure was > , consistent with echinococcus infection. this case of echinococcus disease is presented and the vectors discussed. echinococcus disease was previously prevalent in australia and new zealand, with a reduction in incidence from improved animal husbandry. with an increasing deer population in south east queensland and subsequent rising human contact, clinical awareness is necessary to avoid potential complications from biopsy and ensure cases are promptly treated rather than mistakenly diagnosed as incurable disease. introduction community-acquired pneumonia (cap) is a leading cause of mortality, morbidity and hospital admission places strain on our healthcare system. procalcitonin (pct) is a biomarker of bacterial infection which may help gauge the severity and prognosis of patients with cap. aim to examine the role of pct measurement in reducing hospital admissions, length of stay (los), and antibiotic (ab) usage in patients with cap. methods prospective, single-blinded, externally controlled study of consenting adult patients admitted with cap. pct levels were obtained on day and day (if indicated). the investigator evaluated clinical parameters and the pct values to determine the timing of oral ab switch and discharge. this process was used to compare with standard practice but was not actually implemented for the purpose of this study. results sixty patients were included in the study. the mean age was . ± . y and . % were male. the average psi was ± (class iv) and the median curb- was . the mean los for this cohort was . ± . d and the calculated los using pct guidance pathway was . ± . d. (p = . ) a multivariate analysis will be presented. conclusions our study supports the hypothesis that the incorporation of pct levels can reduce the requirement for hospital admission and los in patients with cap. a randomised prospective clinical trial is planned to help clarify these findings. support nil. introduction children in the highlands of papua new guinea (png) suffer on average . acute lower respiratory infections (alris) before age months, / of which are moderate or severe. while streptococcus pneumoniae and haemophilus influenzae are the primary bacterial cause of alri in png, the role of viruses in the aetiology of alri is uncertain. aim determine identification rates of respiratory viruses in nasal samples collected from children with moderate/severe alri and healthy children aged < months in png. methods as part of a neonatal pneumococcal conjugate vaccine trial in the png highlands, we collected pernasal swabs from children with moderate/severe alri (n = ) and at routine follow-up (n = ). rt-pcr methods were used to identify a broad range of respiratory viruses. the frequency of viral detection was compared between groups of samples collected during an alri and routinely using chi-square analysis. results several viruses were detected more frequently in alri than routine samples: adenoviruses . / . (% of alri samples positive/% of routine samples positive) p = . , influenza viruses . / . p = . and respiratory syncytial virus (rsv) . / . p = . . human metapneumovirus and parainfluenza viruses were detected in four and three samples, with no difference between groups. human coronaviruses and human rhinoviruses (hrv) were less commonly detected in alri than in routine samples ( . / . p = . and . / . p = . , respectively). a total of different hrv strains were identified. conclusion in young children in png, viral identification rates are high, with rsv, adenoviruses and influenza viruses associated with moderate/severe alri and a large amount of genetic diversity of rhinoviruses in both sick and healthy children. introduction to increase the documentation and documented provision of an electronic asthma action plan (e-aap) to children discharged with asthma from the emergency department (ed) at chw. methods an electronic aap (e-aap) was introduced in april by a multidisciplinary team comprising representatives. at chw, aaps were available to be printed off by the intranet. to be entered into the electronic medical record (emr), the medical officer had to photocopy the completed plan which would then be scanned into the emr. evidence suggested that busy doctors, particularly in the ed, were either not providing patients with aaps on discharge or not photocopying them for the medical record. the evaluation of the e-aap consisted of a review of the documented provision of asthma action plans in the hospital wide emr (powerchart) for a year pre & post the introduction of the e-aap, a review of patients discharged from the ed with a diagnosis of asthma for similar six month periods pre and post intervention and a medical staff satisfaction survey. results the total number of plans recorded in emr increased by %, from - to - . the number of plans recorded for ed discharges increased significantly from % to % [p < . ]. the number of patients recorded as leaving the ed with a plan increased significantly from % to % (p < . ). the use of the e-aap in the ed is now standard of care and this is also being adopted hospital wide as more staff became familiar with its usefulness.conclusion the e-aap significantly increased the number of recorded aaps and patients discharged with a recorded aap. support nil. nomination asthma/allergy. conflict of interest no. lisa wood , , manohar garg , amber wood , , peter gibson , centre for asthma and respiratory diseases, university of newcastle, new south wales, australia, and nutraceuticals research group, university of newcastle, new south wales, australiaintroduction dietary fat activates innate immune responses, leading to an increase in systemic inflammation. however, the effect of dietary fat on airway inflammation has not been investigated. we hypothesised that a high fat intake may lead to increased airway neutrophilia in asthma. the aim of this study was to examine the effect of a high fat versus low fat food challenge on airway inflammation in asthma. methods non-obese subjects with asthma were randomized to receive a high fat/ high energy (hf) (n = ) or low fat/ low energy (lf) (n = ) food challenge. obese subjects also received a hf challenge. subjects on the hf challenge consumed a meal containing kj, including % of energy ( g) from fat. subjects on the lf challenge consumed a meal containing kj, including % of energy ( g) from fat. at baseline, hypertonic saline challenge and clinical assessment were performed. induced sputum samples were collected at baseline and at hours. airway inflammatory markers included induced sputum total and differential cell counts, il- and neutrophil elastase, measured by commercial assay. tlr mrna expression from sputum cells was measured using rt-pcr. results at hours after the food challenge, subjects on the hf challenge, had a significantly higher increase in %sputum neutrophils ( . ( . (sem)) % vs. . ( . ) %, p = . ) and higher fold increase in tlr mrna expression ( . ( . - . (iqr)) vs. . ( . - . ), p = . ), compared to the lf challenge. subjects on the hf challenge also had an impaired bronchodilator response, with a lower increase in fev /fvc% at hours compared to the lf challenge ( . (- . - . (iqr)) % vs. . ( . - . ) %, p = . ). there were no differences in the responses of obese vs. non-obese asthmatics to the hf challenge. conclusions a high fat/ high energy challenge causes an increase in airway inflammation and suppresses bronchodilator response in asthma. strategies aimed at reducing dietary fat intake may be useful in reducing inflammation in asthma. support nhmrc project grant. introduction longitudinal fev data in children with non-cystic fibrosis (non-cf) bronchiectasis is contradictory and there is no multi-factor data on the evolution of lung function and growth in this group. we longitudinally reviewed lung function and growth in children with non-cf bronchiectasis and explored biologically plausible factors associated with changes in these parameters over time.methods fifty-two children with ‡ years of lung function data were retrospectively reviewed. changes in annual anthropometry and spirometry at year- and year- from baseline were analysed. the impact of gender, age, aetiology, baseline fev , exacerbation frequency, radiological extent and period of diagnosis was evaluated. results over years, the group mean fef - %predicted and bmi z-score improved by . (p = . , %ci . - . ) and . (p = . , %ci . - . ) per annum, respectively. fev %predicted, fvc %predicted and height z-score all showed non-significant improvement. over years, there was improvement in fvc %predicted (slope . , p = . ) annually but only minor improvement in other parameters. children with immunodeficiency and those with low baseline fev had significantly lower bmi at diagnosis. frequency of hospitalized exacerbation and low baseline fev were the only significant predictors of change in fev over years. decline in fev %predicted was large (but nonsignificant) for each additional year in age of diagnosis. conclusions spirometric and anthropometric parameters in children with non-cf bronchiectasis remain stable over - year follow-up period once appropriate therapy is instituted. severe exacerbations result in accelerated lung function decline. increased medical cognizance of children with chronic moist cough is needed for early diagnosis, better management and improving overall outcome in bronchiectasis. introduction it is well established that many survivors of very low birth weight (vlbw; < g at birth) have impaired lung function. the aim of this study was to determine whether abnormal lung function at years of age is established in childhood. a second aim was to see if abnormal lung function at years of age tracks through the period of normal lung development to predict impaired maximal lung function and may be a precursor to copd in adult years. methods a cohort of vlbw (n = ) and normal birth weight (nbw; > g at birth; n = ) has been followed for years. very low birthweight participants completed spirometry and lung volumes at , , , and years of age and nbw at , and years of age. restricted maximum likelihood modeling was used for longitudinal fev z-score as it allows for analysis of data from different time points that are not necessarily evenly spaced, without being affected by missing data. results about vlbw children completed lung function testing at years of age, ( . %) had abnormal fev z-scores (defined as > sd's below the mean). vlbw survivors showed minimal 'catch-up' in fev z-score over the years of the study; those without (bronchopulmonary dysplasia) fev improved . (p = . ) z-scores, those with bpd fev improved . (p = . ) z-scores. vlbw with bpd survivors did not return to within normal limits. conclusions the reduced lung function in adult survivors of low birth weight is established in early childhood. while there is some improvement in growth of those with abnormal fev z-scores in early childhood, those with bpd remain below two sd's from the mean, and at the age of have a reduced peak lung function. introduction bronchopulmonary dysplasia (bpd) is a common complication of preterm birth. although there is evidence that individuals with a history of bpd have respiratory abnormalities in childhood, there remains a paucity of evidence regarding the outcome of the disease in adulthood. in a pilot study we recently described high resolution computed tomography (hrct) appearances of emphysema in young adults with a history of bpd. aims to describe the structural pulmonary sequelae of bronchopulmonary dysplasia in adulthood and to evaluate a scoring system originally designed for paediatric subjects. methods about adult survivors of bpd underwent hrct of the chest, along with lung function testing (spirometry, lung volumes and diffusing capacity) and a respiratory health survey. the ct studies were scored by two thoracic radiologists blinded to the patient's clinical details, using a previously described system developed for children and adolescents who were born prematurely using parameters. results abnormal findings were seen in all scans, the most common findings were subpleural triangular opacities ( %), linear opacities ( %), air trapping ( %) and emphysema ( %). agreement between the two observers for total score and common abnormalities varied with a linear weighted kappa value of . for linear opacities, . for triangular opacities, . for air trapping, and . for emphysema. conclusions linear and sub-triangular opacities on hrct chest are almost universal in young adults with a history of bpd. findings of emphysema and gas trapping are common and there is good interobservor agreement for these abnormalities. introduction pulmonary surfactant (ps) is synthesised by alveolar type ii epithelial cells to regulate the surface tension at the air-liquid interface of the air breathing lung. developmental maturation of ps is controlled by many factors including oxygen, glucose, catecholamines and cortisol. the intrauterine growth restricted (iugr) fetus is hypoxemic and hypoglycaemic, with elevated plasma catecholamines and cortisol. aim to determine the impact of iugr induced by chronic placental restriction via the carunclectomy model on ps maturation. methods we investigated the expression of surfactant protein (sp) -a, -b and -c and their genes in lung tissue of fetal sheep at days and days gestation (term, ± days) from control and carunclectomised merino ewes. results placentally restricted (pr) fetuses had a body weight < sd from the mean of control fetuses and a mean gestational pao < mmhg. pr fetuses had a reduced absolute, but not relative lung weight, decreased plasma glucose and increased plasma cortisol concentration. lung sp-a, -b and -c protein and mrna expression were reduced in pr compared with control fetuses at both ages. sp-b and -c, but not sp-a mrna expression and sp-a, but not sp-b or -c protein expression increased with gestational age. mean gestational pao was positively correlated with sp-a, -b and -c protein and sp-a and -c mrna expression. sp-a and -b gene expression were inversely related to plasma cortisol concentration. conclusion chronic placental restriction and hypoxemia results in an inhibition of ps maturation and thus iugr fetuses are at risk of lung complications, especially if born prematurely. support by the arc & nhmrc. nomination nil. conflict of interest nil. to sue jenkins , , , nola cecins , , sir charles gairdner hospital, perth, western australia, australia, curtin university of technology, perth, western australia, australia, and lung institute of western australia, perth, western australia, australiaintroduction the mwt is widely used to assess patients with chronic lung disease (cld). anecdotal reports and studies in small numbers of patients suggest that adverse events associated with the mwt are rare in patients with cld. this study reports observed adverse events and predictors of oxygen desaturation during the mwt in patients with stable cld referred to an out-patient pulmonary rehabilitation service. methods about consecutive patients completed the mwt in accordance with a standardised protocol that included continuous monitoring of oxygen saturation (spo ) and heart rate (hr, polar). the respiratory diagnoses of the patients were chronic obstructive pulmonary disease (copd), n = ( %); interstitial lung disease (ild), n = ( %); bronchiectasis, n = ( %) and asthma n = ( %). results observed adverse events occurred in tests ( %). one test was terminated when the patient reported chest pain and one patient developed persistent tachycardia (hr > bpm) immediately following the test. in tests ( %), the tester instructed the patient to stop walking due to profound oxygen desaturation (spo < %). six patients prematurely terminated the mwt due to intolerable symptoms. forty-seven per cent (n = ) of patients demonstrated oxygen desaturation, defined as a decrease in spo ‡ % to < % during the test. pre-exercise spo was a significant predictor of desaturation in the copd ( . , . to . , adjusted odds ratio [or], % confidence intervals) and ild (or . , . to . ) cohorts with fev also a predictor in patients with copd (or . , . to . ). conclusions profound oxygen desaturation is the commonest adverse event observed during the mwt in patients with stable cld. this finding questions the american thoracic society guidelines for the mwt which state that oximetry is optional. introduction there is weak support for use of opiates in palliation of refractory dyspnea; respiratory depression is perceived as a major risk. we evaluated the effect of i.v. morphine on dyspnea in controlled conditions and related this to concomitant respiratory depression. methods with ethical approval, healthy subjects received . mg/kg morphine sulphate or saline on separate days in a randomised controlled design. before and for hours after administration, subjects performed (i) dyspnea responses (measured with a visual analog scale) to increasing p et co with ventilation () constrained at resting levels (ii) unconstrainedresponses to increasing p et co to assess respiratory drive. results pre morphine with constrained , all subjects tolerated an elevated p et co of - mmhg; mean dyspnea rating was % ( (sem)). post morphine, at the same p et co , mean dyspnea rating fell to % ( , p < . , paired t). all subjects reported reduced dyspnea at minutes and this was sustained for hours. no changes in dyspnea scores were seen following saline. with unconstrained, at equivalent levels of p et co , morphine, but not saline, was associated with a lower in each subject for up to hours; mean fell from ( ) to ( ) l/min (p < . ). to assess if respiratory depression could account for reduced dyspnea, scores were compared at the different p et co levels that induced equivalent unconstrainedlevels with and without morphine; mean dyspnea scores were not different ( ( ) vs. ( ) %). conclusion a clinically moderate dose of morphine results in substantial and sustained relief of laboratory dyspnea in a small group of healthy subjects consistent with the associated degree of respiratory depression. support breathlessness research charitable trust uk; nih, usa. nomination nil. introduction pulmonary rehabilitation (pr) is a cornerstone of management for patients with chronic obstructive pulmonary disease (copd) and its efficacy is supported with level evidence. despite the known benefits of pr, up to one third of those people with copd who are referred to pr choose not to participate. there is little information regarding perceived barriers to attendance in an australian health care context. methods nineteen people with copd ( women and nine men, gold stage i-iv, age range - years) who had declined to take part in an outpatient pr program at a metropolitan teaching hospital participated in a qualitative study. semi-structured interviews were used to establish reasons for failing to attend the pr program. these interviews were transcribed verbatim and analysed using the principles of grounded theory. results three major themes were identified regarding barriers to attendance at pr. the first related to difficulties with getting there, including a lack of available transport and poor mobility. the second theme related to a lack of perceived benefit, including perceptions that pr would not improve their health or that they were currently doing enough exercise. the third major theme involved restrictions imposed by underlying medical conditions and included the influence of comorbidities and pain. minor themes that arose included competing demands, age, fatigue and program timing. conclusions in australia many patients with copd who are invited to attend pr do not perceive the program would be beneficial, feel they are too unwell to attend or have difficulty with access. further support should be offered to pr candidates and alternative methods of delivering pr to enhance uptake should be considered. introduction pulmonary rehabilitation has emerged as recommended standard care for people with chronic lung disease. however potential demand to access these services far exceeds the available resources. this study's aim was to determine if baseline measures of the bode index, dyspnea (modified medical research council questionnaire), minute walk distance ( mwd), physical activity, taunton respiratory quality of life questionnaire (trq), smoking status, and frequency of hospitalisations can predict responders to pulmonary rehabilitation. methods we retrospectively evaluated all participants with a diagnosis of copd, who attended the pulmonary rehabilitation program at the prince charles hospital between and . a participant was considered a responder to pulmonary rehabilitation if benefit was achieved in exercise capacity ( ‡ % increase in mwd) and/or quality of life ( ‡ . sd decrease in trq as described by cohen's effect size). prediction of responders was assessed using chi square cross tabulations and t-tests with significant measures analysed using a binary logistic regression model. results one hundred and forty-two participants ( males, mean age ( sd) years, mean fev . ( . ) %) who completed pulmonary rehabilitation were analysed. sixtyfive ( . %) people were categorised as responders using the above criteria. significant mean differences were: trq . ( . ) for responders vs. . ( . ) for non-responders p < . ; bode index . ( . ) vs. . ( . ) p = . ; mwd ( ) m vs. ( ) m p = . . the binary logistic regression model showed a higher trq score was the only factor that predicted a responder to pulmonary rehabilitation. no other measure added to the predictive power of the model. conclusion higher trq scores may be useful in predicting which participants are most likely to benefit from referral to pulmonary rehabilitation. further study is underway investigating other factors that may improve these findings. support nil. nomination nil. conflict of interest no. key: cord- - n wroj authors: devinney, timothy; dowling, grahame title: what are the strategies of australia’s universities? arenas, vehicles, differentiators, staging and economic logic date: - - journal: the strategies of australia&#x ;s universities doi: . / - - - - _ sha: doc_id: cord_uid: n wroj because australia’s universities have multiple missions, they also have a broad scope of operations. notwithstanding this, there are a set of institutional mechanisms that ensure a large degree of sameness across the academic footprint of the universities. they lack fundamental differentiation. also, the cost structure of the universities requires some faculties (cash cows) to generate free cash flow to fund the research operations of other faculties. because university research is expensive, universities are trying to convince industry to fund more of this activity. however, universities have many obstacles to overcome in this endeavour. what are the strategies of australia's universities? arenas, vehicles, differentiators, staging and economic logic . arenas figure . earlier suggests that each of australia's universities is probably two enterprises-one for education and the other for research. each university differs somewhat according to the range of arenas (faculties) over which it practises these activities. for most universities their mix of faculties seems to be the result of circumstance as much as a grand design. in contrast, in the post-war years when stanford university started its rise to stardom, the decision was made to concentrate on postgraduate programmes (where national reputations were forged), and a relatively few areas where government funding signalled national importance-one of which was electronics research. the aim was to do a few things with distinction rather than 'creating excellent programs in fields no one cares about'. a strategic decision that is very costly for a university is its choice of arenas. as just noted, stanford chose some of these because the government of the day was prepared to underwrite much of the cost. if a university chooses to do world-class teaching and research in the natural and physical sciences, it can involve significant investments in infrastructure. in contrast, research in many fields of the humanities is far less costly. the number, variety and size of arenas define the scope and academic footprint of a university. from a strategic perspective, when the logic guiding the choice of arenas is not clear it • makes positioning the institution more complicated, • increases the costs of administration (due to complexity) and • complicates decisions about which areas to prioritise for funding. a criticism of australia's public universities is that their scope is too broad. to illustrate this point, consider the profiles in fig. . . each circle represents an academic faculty scaled to size. their relationship is depicted by their distance from each other. an issue we will raise in chap. is that each of australia's universities looks more like comprehensive university, one with a scattered academic footprint, than focused university where the logic of its collection of faculties is more apparent. and if the numerous research centres and institutes that a comprehensive university has were added to fig. . , the picture would look much more complex. the major vehicles used to codify education, such as the common range of degrees; deliver education, such as teaching philosophy, curriculum design, lectures, tutorials and web-based materials; assess learning, such as assignments and examinations; and do research, such as academic time and research equipment, are similar across all of australia's universities. thus from both a student and an academic perspective, 'going to university' means that they are joining a fairly well-defined type of institution and committing to a broadly similar experience. yes, each university has some unique aspects, but universities have a high degree of 'sameness'. the vietnamese have a saying that captures this situation: history and what is called isomorphism (imitation) create this sameness. this is the way that universities were organised in the past (history), and this is the way that a university's peers are currently organised, and so each tends to conform (isomorphism). also, the rankings are designed to reflect this structure. so to look like a university, this is the dominant design. the value of this structuring of operations is that it clearly positions all universities as 'a university'. stakeholders, both internal and external, are comfortable with this model. consultants as we noted earlier suggest that it should be shattered. it is interesting to delve deeper into the issue of sameness for two reasons. one is to expose the weakness of some consulting suggestions for change. at the present time many are simply infeasible. the other is to uncover the structural mechanisms that will impede any significant attempts to change. four institutional mechanisms cement the essential sameness of australia's universities. the first is the overwhelming reliance on government funding. it is anchored to the grand bargain mentioned earlier, which comes with strings attached, namely, to be public institutions committed to the three traditional missions of teaching, research and community engagement. no university has the courage to publicly jettison any of these missions. the second factor creating sameness is three powerful agencies. one is the tertiary education quality and standards agency (teqsa). stemming from the bradley review of australian higher education, this government regulator now imposes quality assurance mechanisms to set and review sector standards in the areas of teaching, learning, scholarship, research and research training. the second agency is the australian research council's excellence in research australia (era) programme. as noted earlier, this initiative produces an australian university league table that encourages a degree of sameness of research across the universities by recognising discipline-based journal ranking lists which identify the set of de facto target journals for much university research. these are then used in the individual performance appraisal of staff. thus, the requirements of these journals create the parameters for what is judged to be the type of research one should do and what quality means. the third agency is the national tertiary education union. this union negotiates the basic workplace agreements employed throughout the university system. while each university negotiates a different agreement with this powerful workforce union, they are very similar in structure and content. we would argue that these union agreements are designed more to protect the 'average' employee than to foster excellence across the system. one of their key conditions illustrates this opinion, namely, the duration of the paid working week. currently this is typically . hours per week. for an academic . hours is far too short! it is impossible to be an excellent teacher and world-class researcher and then do some university service, and then some industry and community engagement by working . hours per day. so here is the problem: • work . hours per week and do part of the job, or • work . hours per week and do all the job at average quality or • the university is deliberately underpaying its academic staff (and it should be taken to the fair work commission). when one of us first joined the australian university system, our terms and conditions of employment would easily fit a . hours per week. the employment contract was one page in length. it had three main paragraphs: . welcome to the university. . your level is xyz and your pay is $pqr pa. . if you have any questions please talk to your head of school. in essence, the deal was 'you pretend to work and we will pretend to pay you'. there were no formal university expectations (regular performance appraisals), and some academic staff treated their employment as a form of paid social welfare. and yes, mediocrity was prevalent. in contrast, the last union-negotiated employment contract for one of us was pages long. it was dense with terms and conditions of employment. the third factor cementing sameness is the rise of npm / professional management in universities. much of this is directed at responding to the requirements of the teqsa, the era and the legislation under which each university receives its charter. also, there now seems to be a need to manage an ever-growing number of risks within the university environment, such as oh&s, staff welfare, student welfare, student malpractice, research malpractice, cyber risk, data risk, ethical risk, operational risk, financial risk, regulatory risk, crisis risk, climate risk, reputation risk. professional risk consultants have targeted universities to help them assess their vulnerability, design programmes to manage risk and recover from risk failures. a rich and successful history plus these institutional mechanisms have combined to produce a higher-education sector with few meaningful differences. in commercial situations where there is an inherent sameness across members of a strategic group, such as the big australian banks, one often observes artificial attempts to differentiate one institution from another. corporate identity, branding and communication are often used for this purpose. the websites of the universities are revealing here. they are marketing devices. the first screen looks more like the package of a supermarket product than the front door to an organisation with a deep purpose. and from here they explode to reveal all the complexity of the institution's operations. at our last university there was a group of administrators tasked with managing the institution's marketing and communications, and a further responsible for brand strategy and engagement. as old marketers, we think that people are not necessary to tell students about the university, especially when research suggests that many students get most of their information via wom-word-ofmouth and word-of-mouse. the strategic narratives of most universities suggest that they are constantly making changes to their operations to exploit opportunities and overcome obvious problems. explore the website of any university and it is easy to find examples of new programmes being launched and new people being appointed to run such initiatives. there is no shortage of activity. for example, in the area of education each university seems to have adopted a different approach to learning. their websites reveal learning philosophies like blended learning, block learning, flipped learning, group-based learning, case-study learning, student-led learning, workbased learning, problem-based learning, active learning, active and inquiry-based learning, flipped classrooms, design thinking, moocs and so forth. long gone it seems is the era of 'chalk and talk'. in the area of research while most activity still occurs within faculties, these endeavours have been supplemented with cooperative research centres, university and industry partnerships, and cross or multi-disciplinary research centres. the easiest way to explore new areas of interest seems to be to bolt-on a new research centre. the university of western australia's annual report notes it has of these. from an npm perspective these are an interesting idea because they allow the university's administrators to measure efficiency and performance. it is clear what they cost to run, what independent money they attract and what they produce. and because of their insular nature, they can be closed down if performance does not meet expectations. another staging mechanism is the branch office. some are local, such as a regional university with an office in the near-by capital city, and some are located in a foreign country, such as dubai, hong kong, singapore, thailand, vietnam. many overseas universities have also followed this approach. all sorts of reasons are provided for why such endeavours are a good idea. however, many are not strategically sound. for example, some years ago both of us attended a meeting where the senior administration of the university suggested that a branch office of our school be opened in hong kong. the idea originated with an industry advisory group-'asia is booming, there are lots of students, why aren't you up there!' at the end of the meeting one old strategy professor (who was an exmanagement consultant) summed up the idea as follows: as a small institution with limited financial resources let's be a late entrant into a highly competitive market where it is not clear about the regulatory requirements for accreditation; where some local universities are very good, and where recent overseas entrants like us are not making any money. and, to succeed we will have to redeploy from our current programs some of our best resources in order to establish our quality. this comment was all it took to bring sanity back to the discussion. it was also a good example of the value of harsh academic scrutiny of the 'free advice' from people without deep knowledge of higher education and no skin in the game-the industry advisors were not willing to bankroll the venture. on a number of occasions we have been critical of the lack of a clear line-of-sight between key aspects of strategy and the financial management of the university. while we were at the university of new south wales, one of the vice chancellors (fred hilmer) made the effort to inform the senior academics about the revenues and costs of the university. at our last university this information appears in the annual business plan. also, each university publishes a set of accounts in its annual report. given that the annual report is a public document, we will use it to raise some important strategic issues in the next section. chapter noted that australia's universities are happy to argue that they are under-funded. so a key question is whether this is true? a second question is whether our universities waste some of the funds they receive? answers to both questions help to expose the business model and the profit and loss statement of a university. the university of south australia is one of the few universities to discuss some of these factors. for example, by their plan is to: • grow the student body to , , with % of these learning online. unisa online is the core asset that will support this (ad)venture. • generate % of their revenue from research activities, % of which will come from industry partnerships and % from research grants. now how will they grow student numbers and change the mix of research funding? presumably, the student body will grow via the introduction of online courses. hopefully it will not grow by lowering entry standards. so the first challenge is to make sure that these online courses do not cannibalise the revenue from their current courses. the second challenge is to do this without reducing quality. the third challenge is that they will have to compete against the online programmes of other universities in australia and overseas. on the research front the idea is-'by growing the scale and focus of research by building capacity in areas that have demonstrated excellence and shown potential for growth'. with a large budget this might be feasible, but do they have these funds? they don't say. on the teaching front what puts grand plans like this at risk is price discounting. for example, there is an emerging trend for universities to offer substantial tuition fee discounts, especially to attract international students. phil honeywood, president of the international education association of australia, said that many of these discounts were dressed up as scholarships. so, there is a downward pressure on fees-revenue. competitors are just as desperate as unisa to grow their numbers. on the research front unisa is exposed by its lack of reputation. a quick look at the era rankings doesn't put the university in the top echelon, and as noted elsewhere, many australian academics and their universities do not have a very good reputation for their commercial acumen. so while universities would like to generate more money from industry, many research academics simply don't care what industry wants. getting favourable recognition from peers is far more important than getting research money from industrialists that is targeted to specific projects, and some of which the university may tax. because the economic logic of a university can be partly deciphered from its annual accounts, this is where we turn to next. at the australian financial review higher education summit, anthony walker, a director of sovereign and international finance ratings at s&p global, said that there is a game being played by the government and the universities. because of budget pressures, the government wants to reduce its funding of universities while they want more funding, so the truth about what is an appropriate level of funding is likely to be somewhere in between. his analysis suggests that many universities have operating margins of between and % and quite healthy cash flows. yes, some universities might be in less than good financial health, but there is a moral hazard here-the government is highly unlikely to let one of them become insolvent. so, maybe the overall financial health of the universities is not as woeful as often claimed. at this summit philip clark, a former federal government advisor on education, makes another point about the funding of the universities, namely that relying on the high numbers of overseas students, many of whom come from china, is a risky strategy. there are two financial risks here. one is that if overseas student revenue is used to 'balance the books', a downturn in demand puts the university's short-term revenue at risk. this was dramatically illustrated during the covid- pandemic. the other is that if this revenue source is used to fund long-term investments in infrastructure or research, a downturn here puts these at risk. so, even though it is a luxury good in china to have an education from a groupof-eight university, if the chinese government or other circumstances mean that these students stop coming to australia, this revenue steam will stop very quickly. also, an adverse change in the exchange rate or more restrictive student visa requirements quickly reduces the flow of international students. strategists like to look at what they call the revenue model of a business enterprise. in the university context, the focus is on the principal sources of revenue. to illustrate this, we will look at the annual report of the university of western australia (uwa). here we see that uwa had $ million income for an underlying result (sustainable surplus) of $ million. approximately % of this revenue was sourced from the federal and western australian state governments. fees and charges were $ million ( %), other income was $ million ( %), research income was approximately $ million ( %) and interest was $ million ( %). in summary, uwa is a big enterprise that relies for about half of its income from government funding, and it generates about one-third of its income from student fees. hence, government relations, cost control and financial management are key skills. there is nothing surprising here. however, think about research. the reputation of the university is only strong enough to generate % of income from this source. this is the same amount generated by the investment committee of council. what these figures suggest is that the external demand for uwa research seems to be very small. a little further digging through the annual report reveals another interesting observation. the university had , students of whom , were fee-paying undergraduates, and , were fee-paying coursework postgraduates. these students are serviced by five faculties (one of which is very small). one of the super-faculties comprised the cheap-to-run faculties, namely, arts, business, law and education. this group educates % of the university's undergraduates, % of coursework postgraduates and % of research postgraduates. this pattern suggests that this faculty is the cash cow for the rest of the university. it is like a giant atm from which other parts of the university withdraw their weekly allowance. as a member of this super-faculty, you could feel proud-your efforts fund much of the rest of the university, or unappreciated-your efforts are unrecognised by others. getting the economic mix of this core funding cross-subsidy game correct can make or break the finances of a university. it can also damage the reputation of the university if in a faculty like education, student entry standards are lowered to fill up the numbers. at the time of writing, this was a topic of conversation in the media. when compared to the great universities in the usa, the piece of the revenue model that is largely missing from australia's universities is its endowment. while there are many reasons that might account for the paucity of australian university endowments, the stark fact is that these institutions do not have access to a significant amount of this revenue. much of the money given to universities comes with constraints, such as to be used for a specific piece of infrastructure or type of research. and even sponsored academic positions, such as named chairs, are rare. as government funding becomes more constrained, the need for this type of income becomes greater. imagine the opportunities that could be pursued by an australian university with a couple of billion dollars in its war chest! the cross-subsidy game all australian universities have a group of low-cost faculties and degreesthe cash cows that are used to fund the high-cost degrees-the stars. the star disciplines are generally the ones that underpin the major university reputation ranking systems. they are also the disciplines that tend to make the major scientific breakthroughs that get publicity on the nightly news and in television natural science documentaries. the deans of these disciplines are generally the most powerful academic voices inside the university. at uwa these are all sciences-science, health and medical sciences, engineering and mathematical sciences. notwithstanding the economic significance of the cash cow faculty to uwa finances, in the annual report, the exploits of the sciences are given much more prominence than law, business and education. cross-subsidies lie at the heart of university growth. if an institution decides to grow by increasing the size of its high-cost faculties, it will generally have to generate more revenue from its less costly faculties. this can be done by enrolling more students, raising tuition fees, reducing the delivery costs of teaching and research or clawing back more of the current revenue from these faculties. however, if the institution grows only the less costly faculties, it has free cash flow to spend as it pleases. thus, the economic modelling of these institutions is a critical component of strategy. this is seldom mentioned outside the executive suite. cross-subsidies, however, come at a price to reputation and social equity. consider the following paradox-or as ross gittins, economics editor of the sydney morning herald, calls it 'short-changing their students'. step is to attract students to cheap-to-provide occupational degrees-that have good job prospects like commerce, or a good image but fewer job prospects like law. step is to teach these undergraduates in large classes or substitute technology for face-to-face teaching. step is to agree to charge them a premium price. step is to use the free cash flow to pay the university administrators and cross-subsidise research and teaching in other areas. now the paradox here is that even though our universities wish to project themselves as model social citizens, an unemployed or underemployed student from a cash cow faculty soon discovers that they have been sold a degree that is not worth as much as they thought. just like most of their business counterparts, transparency is not generally one of a university's core values. in big business, and this is what our universities are, you keep your business model out of public view. the alternative to cross-subsidy is internal privatisation. for example, some us and european universities have allowed their business schools to retain their revenue and pay only a minimal contribution to the rest of the university. as david kirp describes for one us school, this allowed it to raise salaries and improve facilities while salaries were frozen and faculty needs were not met in other parts of the university. any faculty with strong student demand and/or demand for its research could advocate for such a strategy. so from a strategic perspective, should a university allow any or some or all its faculties to 'privatise'? you will not find this strategic question discussed in any public statement. however, the pressure to (partially) privatise can be seen in the internal budgeting practices of the university. when universities adopt performance as opposed to activity budgets, it encourages their units to become (more) self-supporting. chief financial officers argue that it brings more discipline to the budget process and greater internal transparency. academics in smaller faculties might argue that it diminishes the overall contribution of the university. vice chancellors need to make some tough strategic choices here. public universities by their nature have adopted an open, distributed model of research transfer through publishing research and educating people who then enter the workplace. while education provides revenue, publishing gives away much of the university's new knowledge to the publishing houses, which then sell it back to them (through subscriptions to their journals). to try to get some return from their research, some universities have entered the publishing game via their university press or by publishing a journal or two or three. if successful, both revenue and reputation flow back to the university. however, in australia the more likely outcome is a university press that publishes short production runs and seeks not to put too much drain on the parent institution's finances. the open model of research transfer puts a considerable strain on university finances. to help counter this, the universities now ask their academics to raise more of their own research funding. securing australian research council competitive research grants is highly prized, both for revenue and for reputation. however, this and other forms of funding come at a cost. the grant writing and peer-review process are very timeconsuming and highly problematic. they generate considerable amounts of stress for the people forced to seek these funds. and then when funds are secured, most academics need help navigating the university accounting, reporting and intellectual property policies. at a national press club address professor ian jacobs lamented about the underperforming state of business-university collaboration in australia. his model is that the entire research pipeline moves from discovery, to translation, to application, to commercialisation. our universities tend to focus on discovery, and industry on commercialisation. his strategy to help fill the gap was to ask government for more help in the form of things like better tax incentives for university-business projects, government co-investment in research projects and specific funding for translational research. the strategy here is to move down the value chain. along these lines, in the british commercialisation company ip group committed $ million to help some the group-of-eight universities commercialise their research. because this is such an important issue, it is worthwhile thinking about alternative models of research transfer and the roadblocks to such initiatives. the different initiatives respond to the different needs of organisations. here are some further ideas. one was noted earlier in our description of working in the australian graduate school of management. business (and engineering) schools are closer to industry than many other faculties on a university campus. in the business school where industry collaboration was easiest to achieve, and where it seemed to have most impact, was when we were invited into a company to educate its managers. this generally involved customising our mba course material to address a specific internal need. one crucial design element of many of these in-house courses was that the presenter would emphasise the role of evidence and research as inputs to management decisions. this was a good way to get research inside a company and to get decision-makers comfortable with using research in management practice. this is a good example of industry collaboration based on the perceived strength of the academic community (teaching). however, unlike the harvard business school we did not leverage this activity into writing case studies and selling them to other business schools. our performance appraisal kpis did not reward such 'clinical' activity. they do at harvard. a second approach is for the university to encourage and help its students to start their own enterprises, using what they have learned and discovered at university. this goes beyond offering courses in entrepreneurship. it requires a venture-capital approach to funding and mentoring new enterprise development. the idea here is for universities to formally invest in the new enterprises created by their students. the ip group has also put $ . million into australian university research start-ups. a third approach is for universities to promote to their researchers the benefits of working more closely with national laboratories (like the csiro), and government departments and agencies (like the australian institute of sport). there are hundreds of these that span many areas of interest to the academic community. they also have their own funding that will support various types of research projects. these alliances are generally perceived as 'safer' than the next option. a fourth approach is for the universities to develop strategic partnerships with key innovative companies. old companies like cisco, exxon, general electric, hoechst a.g., ibm, monsanto, rolls-royce and siemens have collaborated with universities for years, and new companies like amazon, facebook and google also work with universities. because many companies adopt an open innovation approach to new product development, the basic research done in universities extends the workbench of both parties. the challenge is to get both parties to work together. what will often impede the development of a close working relationship is different goals, expectations and rewards of the parties and, more recently, squabbles over intellectual property rights. a fifth approach is to start a new academic hub. for example, the australian national university has created its a innovation institute (autonomy, agency and assurance) to create new applied science focused on managing the artificial intelligence and big data revolution. many universities are 'playing' in this space with similar academic-industry collaborations. many are also trying to entice students to join these initiatives by offering specialist (master's) degrees. a sixth approach is to start or expand university consulting units. this type of work tends to focus more on problem solving than innovation. for example, the university of new south wales has a professional enterprise called unisearch that provides expert witness services. the university of south australia has the ehrenberg-bass institute for marketing science that collects money from companies to gather data on patterns of consumer behaviour, which are analysed to provide insights back to these companies. other universities do sponsored research for specific industrial companies. while this is not without controversy, especially in some fields like pharmacy, in other fields like market research, there are fewer pitfalls. where difficulties arise is when working with industry becomes transformative and some vocal staff claim that the institution's academic values may be compromised. then contracts are required to provide confidence that conflicts can be managed, and leadership is required to endorse the principle that externally funded research is permissible and desirable. a strategic advantage of building up industry engagement is that it often provides insight into future research opportunities. thus, engagement becomes a dynamic capability focused on sensing research opportunities and seizing other-peoples' money to explore these issues. in the usa one of the biggest sources of funding for such future-oriented research is the military. from a goal-setting and incentive point of view, industry engagement activities need to align with university and individual key performance indicators. three current metrics are funding, impact and engagement. so research that is of interest to industry can secure new funding. then to create impact, the university and its research teams need to add an advocacy element to their research. this can be done by a public relations effort to explain who needs to know about the research and what policy is necessary to implement the findings. finally, engagement can be facilitated by the research team 'consulting' with the parties who will use the research findings. they help organisations use the findings to solve their problems. research funding without specific advocacy and engagement often falls short of its promise. while all these initiatives could be helpful, they don't address some of the key reasons why too few academics work directly with industry and why many business enterprises are somewhat reluctant to work with academics and their universities. here are some roadblocks that need to be addressed before a university's goal of significantly greater industryuniversity collaboration is likely to be met: • we don't understand each other: business often find it difficult to identify if a university has any knowledge of interest to them. research academics have their own interests that may or may not have any practical implications. so the base condition for both parties is to politely ignore each other. • training and focus: doing a phd can be a brutal process that imprints a certain way and timescale for doing research. also, the motivation for doing this piece of research is often grounded in the existing scholarly literature rather than in the field of practice. so in many disciplines phd students follow the university mission outlined earlier by brian schmidt, namely, they want to add to the stock of knowledge rather than solve a problem that is troubling industry. • because approximately % of new phd graduates now enter industry, various programmes have been designed to help these graduates migrate to a non-university workforce. for example, the apr.intern programme focuses on getting students internships across all sectors of industry. what both employers and graduates are finding is that doctoral training provides many transferable skills that enhance workplace performance. however, many of these skills often need some reshaping before they 'work' in the workplace. • in academic performance appraisals, working with industry tends to rate behind research publications in the top-rated journals. also, few of these journals focus on industry problems. and excellent teaching evaluations are often not related to industry engagement. so if universities really want their academics to work more with industry partners, they might consider rewriting the contracts of some chosen academics. the harvard business school case noted earlier has solved this problem. • taxing industry funding: in order to pay for overheads, there are a number of ways in which universities can 'tax' research money from outside sources. hence, from the point of view of the patron, not all their money goes to the nominated research topic. this can detract from the perceived value of their contribution. • academic reputations: in australia many academics have a reputation for being not very commercially astute. they live and work 'in an ivory tower'. their research is 'just academic'. they are too slow. doing linkage research with an industry partner is too bureaucratic. and so the list goes on. so many australian academics are handicapped by their reputation and that of their parent university. many organisations would rather seek help from dedicated research institutions like the csiro or hire a freshly minted phd who has not been too 'corrupted' by the academic environment. in many cases what makes academic research so powerful is also what makes it less than timely in a commercial setting. good research especially big-bang breakthroughs, takes time and is plagued by missteps, things that industry can't easily accommodate. • track record: over many years we have seen repeated intellectual failures across many sciences. so if open research transfer is laudable but expensive, and industry collaboration is somewhat problematic, there is a lot of work to be done before industry will come rushing to seek help from australia's universities. yes, there will be ad hoc pockets of success, but universities need to take a realistic look at their strategic and financial goals for this activity. like every large organisation universities have a diverse cost base. however, a quick look at the university of western australia's (uwa) annual financial statements reveals that the biggest cost is people. about % of total expenditure is classified as 'employee-related expenses'. so the people in administrative roles outnumber the front-line academics ( . - . %). this situation is slightly more in favour of the administrators if we add some of the . % of professional staff in the academic units to the administration count. these percentages reveal direct administrative costs. but it gets worse. because nearly every academic will be involved in some form of faculty administration, then part of their salary should also be allocated to the total university administration cost. for example, in in the university of sydney there were more than faculty committees involved in administration. another interesting picture emerges if we look at non-salary costs. for example, in the non-salary budget was just under $ million. then add to this-student expenses of $ million, materials and supplies of $ million, repairs and maintenance of $ million, finance costs of $ million and other expenses of $ million and we get a total of $ million before a single class is taught or a single research paper published. this is a lot of money to run a medium-size university. most other australian universities look similar. multinational corporations and other large organisations spend millions of dollars and millions of hours of employee time each year on compliance. the belief is that rigorous compliance programmes reduce the motivation for employee wrongdoing. also, if an employee does something wrong, the regulator and the institution's insurance provider will note that at least the organisation actively tried to avoid such a problem. the aims of these programmes are (a) to get employees to behave ethically and adhere to best practice, and (b) to eliminate the time-consuming and distracting regulatory and legal processes that accompany regulatory failure. but as is all too evident, these programmes don't always stop employee wrongdoing. an aggressive organisational culture and financial incentives will often drown out compliance training, especially when meeting stretch goals determine salary and promotion. for example, there are still periodic cases of administration (admissions scandals), academic (falsifying research) and student (cheating) misconduct. all universities require that their staff do compliance training. for an administrator this is part of what they are paid to do. however, for a student or an academic it is not clear what compliance training crowds out of the daily agenda. for example, as most academics will acknowledge, teaching crowds out research and service. anything to do with delivering or administering a course will take priority over other activities, even sometimes one's family. however, what comes next in the priority list depends on who asks for help. in the latter part of our academic careers, we have seen the people in central administration jump up the priority list, not by asking for help, but by demanding compliance. for example, this occurs when say a new teaching or reporting protocol is launched and everybody has to make changes to what they were doing previously. another example of a compliance cost was noted earlier. recall that the university of technology sydney requires training for all staff on issues such as equal opportunity, mental health awareness, privacy essentials, communication and collaboration, consent (unwanted sexual behaviour), health and safety, legal affairs, preventing bullying and safety and well-being. at the time of writing, the consent training was being pushed throughout the university-for all staff and all students. it was mandatory for everybody. the online course took approximately one hour to complete and required a % pass on the quiz that followed the training module. students were threatened with the withholding of their grades if they did not successfully complete the course; casual academics were offered one hours' worth of salary for their participation, and old professors were sent escalating emails (first by the hr system, then the head of school, then the dean of the business school, then the vice chancellor) when the system reported that they had not completed the course. leaving aside the legal and moral issues of such a request, the costs of this programme can be estimated as follows. from the university website we see that there were now if we take an hourly rate of $ , we see that this exercise has cost the university more than $ , for staff. and at, say, a notional $ per hour for the students, it also has a cost of $ , for the students (minus one hour of their study time). so here is an administrative initiative with about a $ million price tag. all this to address a social issue that the senior administrators in the university thought would signal the institution's commitment to social justice. to cover themselves, they sought legal advice before embarking on this course of action. there is an important ethical issue here. imagine the cost to a finalyear student who can't get a job because there is an embargo on their grades because they did not complete and pass a non-curriculum course on a social issue for an organisation that they are about to leave. second, there is no research that supports the claim that sexual harassment training actually works. so here we see the university imposing a dead-weight economic cost on the institution and a dead-weight social cost on some of its members. another largely hidden cost in our universities is due to quality assurance programmes. they are used to signal institutional quality. for example, there are a number of organisations that have developed best practice protocols for education. these organisations promote their programmes, and once a couple of institutions 'sign on', they chase other similar universities to 'catch up'. many university faculties sign onto such programmes with little evidence that they work and without due consideration for the total compliance costs. for example, the business schools of many of australia's universities have signed up to various accreditation programmes. the university of new south wales business school advertises its membership of two such accrediting bodies, namely, the aacsb (association to advance collegiate schools of business) and equis (european foundation for management development). the school pays to join, pays to be certified and pays to be recertified every few years. inside the business school, degree programmes need to be (re)shaped to fulfil the accrediting scheme's standards and someone is tasked with checking compliance. then information has to be collected to report compliance each period. the costs easily accumulate into the hundreds of thousands of dollars for each such certification. however, there is little empirical evidence to suggest that these sorts of accreditation lead to more effective or efficient education, that they attract more students or that they allow the institution to charge higher course fees-especially when all competitors have signed onto the same programmes. however, what these programmes do is to lead to a lack of differentiation across the schools who sign on. all of australia's universities are plagued with hidden compliance costs. the key question is whether they deliver noticeably better outcomes. one of the great paradoxes of modern times is that as information technology has advanced in leaps and bounds, it is much harder to find if these advances have had a general effect on increasing productivity. within the university context, the productivity gains from new technology have been patchy. many gains are the result of faster communication between people rather than better communication. but as the overuse of social media has demonstrated, new or upgraded information technology doesn't necessarily lead to better outcomes. on a university-wide basis, many of the changes in technology are introduced because the suppliers of a platform have upgraded their offer. so the university 'keeps up to date' by adopting the latest version. however, the benefits of these upgrades are seldom realistically estimated relative to the compliance costs of requiring thousands of staff, and students make changes to accommodate the new system. hence, an upgrade usually causes some pockets of frustration and costly time in compliance, especially for the people who are not as it proficient as their colleagues. universities could save hundreds of thousands of dollars in cost if they had more staff and student input into what really needs to be upgraded as opposed to being 'led' by their suppliers. is the australian taxpayer getting good value for money from its public universities? if a typical university like the university of western australia costs hundreds of millions of dollars annually before it produces a single key output, is this money well spent? and if not, where might cost savings be found? these are difficult questions. and because universities know more about universities than governments or the media, the universities are best placed to provide the answers. our analysis suggests that the problem is of two parts, namely, that the strategies of the institutions are underdeveloped and thus complexity and coordination costs accumulate. the other related cost is that the institutions become overstaffed and too bureaucratic. so one strategy for the government is to tighten up its funding and make each university find its own solution. universities would do well to avoid this brute-force solution by seeking greater efficiency and effectiveness in their operations. . towards the end of a report to the council revealed that many students found that the course was inappropriate to their concerns and that many had yet to complete it. so teaching staff were asked to remind the students that their grades would be withheld! . for example, on the unsw website you can't find what the letters aacsb actually stand for. you have to go to the association website and then search beyond the first page to find what they stand for. so how can these five letters really affect the decision-making of a new student if they are essentially meaningless? campus leadership and the entrepreneurial university: a dynamic capabilities perspective discounts catch on as international lure unis banking upside to defy funding cuts and lift margins', australian financial review we've turned our unis into aimless, money-grubbing exploiters of students for example, while a degree in medicine costs much more than a degree in commerce (at the time of writing down payment made on $ m start-up bet how to create productive partnerships with universities developing successful strategic partnerships with universities advancing australia's knowledge economy: who are the top phd employers? a note to the annual financial statements indicates that this group's salary is slightly less than that of the academics improving our organizational design some people might want to add $ million of asset depreciation, amortisation and impairment to this figure at this time, the pay rate for the casual staff was either $ . or $ . per hour (depending on their qualification) while sexual harassment training is the most traditional approach to preventing sexual harassment, it has not been shown to do so key: cord- - l lk x authors: hertzog, paul j; mansell, ashley; van driel, ian r; hartland, elizabeth l title: sculpting the immune response to infection date: - - journal: nat immunol doi: . /ni - sha: doc_id: cord_uid: l lk x this report describes advances in the understanding of how microbes elicit and evade immune responses and the sensing of pathogens by host cells that leads to the activation and production of intra- and extracellular signaling molecules. o n - february , approximately scientists met in lorne, located hours from melbourne on the great ocean road, victoria, australia, for the inaugural lorne infection and immunity conference. this multidisciplinary, international meeting was designed to stimulate collaborative research in infection and immunity by bringing together researchers specialized in the study of pathogen biology and host immune responses. the meeting built on the reputation of more than years of lorne annual conferences on proteins, cancer and genomes. sessions covered diverse topics, including innate and adaptive immune mechanisms, microbial-host genomics and adaptation, microbial invasion, evasion and molecular pathogenesis, as well as structural biology of host and pathogen molecules and their effect on immunity. here we summarize some of the newest ideas about infection and immunity research presented at the meeting that are shaping beliefs about how pathogens infect their hosts and how the host resists infection, as well as the translation of such ideas into the clinic. the human body has many innate receptors that probably evolved to sense microbial prod-ucts such as nucleic acids and microbial cellsurface macromolecules from both pathogenic and commensal organisms. these receptors are now also known to sense endogenous molecules that may be present in an inappropriate time, place or form. for example, several classes of receptors sense pathogen nucleic acids but also respond to endogenous dna that can arise from cell damage . e. latz (bonn, germany) opened the proceedings by introducing the nucleic acid-sensing receptors of the innate immune system and highlighted the importance of receptor-mediated trafficking of dna into intracellular compartments for certain inflammatory responses. the toll-like receptors (tlrs) are known from structural studies to facilitate the assembly of large aggregates of adaptors such as myd , which form a scaffold for assembly of the subsequent components in tlr signaling. indeed, the assembly of receptors and signaling molecules into large multimeric complexes is a common thread in the biology of signal transduction. the discovery and characterization of one such aggregate, called the 'myddosome' , has provided new insights into the mechanism and regulation of myd -dependent signal transduction by tlrs , . the myddosome is a highly oligomeric signaling scaffold assembled sequentially from death domains of the receptor signaling adaptor myd and protein kinases irak and irak -irak . it has a complex and variable stoichiometry and drives the formation of large signaling macro-complexes. the assembly process probably involves positive cooperation and takes place in lipid-rich membrane microdomains. these findings have important implications for the therapeutic targeting of tlr pathways in diseases as diverse as rheumatoid arthritis and neurodegeneration (n. gay, cambridge, uk). this suggests that effective therapies will need to target critical protein-protein interactions in the myddosome, such as the toll-interleukin (il- ) receptor domains at the heart of these assemblies, whose initial interactions are weak and are probably more readily disrupted. signaling specificity is probably achieved by the localization of kinase and ubiquitin ligase substrates to the protein scaffold. indeed, e ubiquitin ligases have key roles in regulating signaling in many biological processes, including the initiation, progression and maintenance of immune responses . using mice with targeted genes, m. pellegrini (melbourne, australia) has characterized the critical role of a newly identified e ligase in maintaining the immune system in a quiescent state. the absence of this e ligase causes late embryonic death due to overwhelming immune activation. it seems to function in dendritic cells (dcs) to terminate spurious responses by the transcription factor nf-kb, and deficiency in this ligase results in enhanced and protracted transcriptional responses driven by the nf-kb subunit p . other sensors of infection, belonging to the nod-like receptor family of proteins, are reported to recognize pathogens as well as sterile inflammatory stimuli such as crystals via activation of the il- b-generating inflammasome . a. kupz (melbourne, australia) has identified and characterized a previously unknown in vivo pathway by which salmonella enterica serovar typhimurium (s. typhimurium) elicits cytokine production by distinct lymphocyte subsets involving inflammasomemediated recognition of the bacteria by dcs. although it has been known for some time that distinct cytokines are critical for the control of clinical and experimental infection with s. typhimurium, the exact regulation of their secretion during such infection has remained unclear. this inflammasome-mediated mechanism invokes intricate crosstalk between dcs and the responding lymphocyte subsets. the activation of this pathway has a substantial effect on the ability of infected mice to control the replication of s. typhimurium in vivo. in discussing another gram-negative pathogen, helicobacter pylori, m. kaparakis (melbourne, australia) reported the use of bacterial outer membrane vesicles as a means of delivering bacterial products into the cytoplasm. the contents of outer membrane vesicles enter a compartment in which recognition by the cytosolic pattern-recognition receptor nod occurs, leading to autophagy, inflammation and immune responses in the gut. c. mackay (melbourne, australia) showed how important the chemoattractant receptor gpr is for the normal regulation of inflammatory responses, particularly in the lower gut, in preventing inflammatory bowel disease. gpr is expressed by innate-type immuneresponse cells and binds short-chain fatty acids such as acetate, which are produced in the gut through bacterial fermentation of dietary fiber. mackay proposed that diet, the makeup of the intestinal microbiota and bacterial production of acetate may account for changes in the incidence of asthma and autoimmune diseases in developed countries. interestingly, acetate is emerging as an important factor produced by certain probiotic strains of bacteria . although the innate immune system has evolved to generate a rapid and effective inflammatory response to invading infectious organisms, it is no surprise that many microbial pathogens have evolved to avoid detection by this system and/or to deactivate the immune response. c. roy (new haven, connecticut, usa) presented work on legionella pneumophila, the causative agent of legionnaire's disease, demonstrating that this opportunistic and accidental intracellular pathogen stimulates almost every pathway of the innate immune response as it infects and subsequently replicates in macrophages . indeed, l. pneumophila has proven a useful tool with which to study innate immune responses, particularly the nlrc inflammasome, which recognizes l. pneumophila flagellin . l. pneumophila is an environmental organism whose natural hosts are unicellular eukaryotes, and this bacterium has thus not evolved to avoid detection by mammalian immune systems. in contrast, the closely related organism coxiella burnetii, a cause of q fever, is highly adapted to the host and evades detection by the immune system via mechanisms that are poorly appreciated. both pathogens translocate virulence effector proteins into the host cell through the use of the dot/icm type iv secretion system, yet the effector protein repertoires of the two organisms are very different. the adaptation of c. burnetii to a mammalian host is evident in its ability to inhibit mammalian proapoptotic signaling. the c. burnetii dot/icm effector ankg binds the host protein gc qr (p ) and inhibits apoptosis in dcs, whereas l. pneumophila lacks this effector and induces rapid apoptosis in dcs in a p -dependent manner . further work on the c. burnetii dot/icm effectors will undoubtedly identify additional mechanisms of host adaptation and microbial evasion of the immune response. new information on host-cell invasion by the intracellular pathogen s. typhimurium presented by r. teasdale (brisbane, australia) showed that there is still much to learn about the dynamic interaction between host and pathogen that enables s. typhimurium to form its intracellular niche. after invading the host, s. typhimurium stimulates a process similar to macropinocytosis to mediate its uptake into cells. by screening host-cell proteins involved in macropinocytosis through the use of small interfering rna-mediated knockdown or pharmacological inhibition, researchers have discovered that phosphatidylinositol-( )kinase (pikfyve) is essential for the replication of s. typhimurium inside cells . the product of this kinase, phosphatidylinositol-( , )-bisphosphate, is required for the fusion of 'macropinosomes' (large vesicles filled with extracellular fluid that are formed through macropinocytosis) with late endosomes-lysosomes and proper maturation of the s. typhimurium-containing vacuole. further screening has also identified a role for the sh -px-bar-domain family of sorting nexins in macropinosome formation and the initial stages of s. typhimurium infection. several presentations described the ongoing battle between clearance by the immune system and subversion of the immune response by viruses. new aspects of the host response were reported by m. beard (adelaide, australia), who has used transcriptome analysis of liver infected with hepatitis c virus (hcv) to show that the interferon-stimulated gene product viperin and members of the interferon-inducible transmembrane family of proteins have distinct anti-hcv properties and act via inhibition of viral replication and entry, respectively, which thereby raises new possibilities for targeting chronic hcv infection. s. lemon (chapel hill, north carolina, usa) contrasted the ability of hcv to avoid immune responses and clearance with that of hepatitis a virus as a means of identifying and characterizing viral evasion strategies. both viruses use a series of virus-produced proteases to target critical elements of the innate response machinery, yet surprisingly, it seems that hepatitis a virus is more evasive in a chimpanzee model of hepatitis infection, eliciting a minimal interferon response. these results suggest that although both viruses have evolved evasion strategies to target the same innate immune mechanisms, their survival and subsequent clearance rely on distinct processes . further exploring the host-hepatitis virus interaction, z. yuan (shanghai, china) described the various strategies used by hepatitis b virus (hbv) to evade the host immune response. liver biopsies of patients infected with hbv obtained before and after treatment have shown that hbv uses at least two mechanisms to avoid the innate immune response. first, impaired tlr-induced cytokine expression correlates with higher expression of hbv surface antigen and inhibition of the jnk kinase pathway. second, hbv polymerase inhibits the phosphorylation, dimerization and nuclear localization of the transcription factor irf to dampen immune responses. together these studies suggest hbv targets signaling by the innate immune response to evade detection by the immune system and establish chronic infection. reporting a twist on evasion of the immune system by hepatitis viruses, g. ebert (munich, germany) harnessed the ability of ′-triphosphorylated small interfering rnas to trigger innate immune interferon responses. this research used small interfering rnas designed to silence hbv replication in concert with more interferon production to suppress hbv replication in both cell-culture and transgenic hbvinfection models, which provides hope for volume number july nature immunology new insight into immune regulation by 'old' molecules such as interferons is constantly being acquired. progress in understanding the biology of the type iii interferon ifn-l (il- -il- ) has led to considerable advances in the understanding of immunity. m. o'keefe (melbourne, australia) discussed the cellular specificity of ifn-l production and expression of the ifn-l receptor by cells of the immune response. her studies and those of others have shown that expression of this receptor is not ubiquitous, like that of receptors for other members of the interferon family, but instead is restricted to epithelial cells and, as described here, also plasmacytoid dcs (pdcs). in further contrast to other interferons, it seems that ifn-l is produced by restricted subsets of dcs in response to specific ligands such as the synthetic rna duplex poly(i:c), which makes ifn-l a nonubiquitous protein of the immune response. these subtle differences may account for the diverse immune functions now attributed to this newly identified cytokine. a. thompson (melbourne, australia) elaborated further on the role of ifn-l in the pathogenesis of and therapeutic responses to hcv. genome-wide association studies have identified polymorphisms in the region of il b (which encodes ifn-l ) on chromosome that correlate well with treatment outcome in patients infected with hcv genotype who are treated with ifn-a (with covalently attached polyethylene glycol polymer chains) and ribavirin . patients carrying the 'goodresponse' variant have enhanced phase-one kinetics and two-to threefold higher rates of viral eradication. furthermore, differences between patients of different ethnic background in allele frequency explain much of the recognized ethnic disparity in cure rates . moreover, il b polymorphisms have also been associated with spontaneous clearance of hcv infection . the underlying biological mechanisms, however, remain unclear, which provides an important area for future research. emerging and re-emerging infections further evidence of the adaptation of microbes to their host or environment is apparent from genomic approaches to understanding buruli ulcer, an emerging but neglected tropical disease. this is a disease of subcutaneous tissue that affects humans and other animals that is caused by infection with mycobacterium ulcerans and for which there is no vaccine. t. stinear (melbourne, australia) has used genomics to address some key research issues, including how m. ulcerans is transmitted to humans. using multistrain comparative genomics, the group has shown that m. ulcerans evolved from the closely related mycobacterium marinum by lateral gene transfer and genome reduction. genes found in m. ulcerans but not in closely related mycobacteria are predicted to encode m. ulcerans-specific antigens, and recombinant proteins derived from these genes seem to elicit specific serum antibody responses in humans living in a region in which buruli ulcer is endemic . this suggests it may be possible to use serology to assess exposure to the bacterium. k. holt (melbourne, australia) discussed a study of the microevolution of shigella sonnei, a common agent of endemic dysentery. wholegenome sequencing and phylogenetic analysis of a collection of over isolates from global sources has categorized the population into several distinct clusters, with most of the recent isolates restricted to a single cluster. analysis of isolates from ho chi minh city has shown nearly all local cases can be attributed to the local expansion of a single clone. similar rapid microbial adaptation is evident in sub-saharan africa, where a distinct sequence type of s. typhimurium has emerged as a frequent cause of invasive disease. m. levine (baltimore, maryland, usa) reported that the high disease burden and case fatality caused by this strain has made vaccine development an urgent priority. this emergence was discovered through a comprehensive surveillance program and highlights the importance of monitoring infectious diseases in vulnerable populations. microbes also form an unusual interaction with hosts such as bats, which serve as the reservoirs for many emerging viruses, including paramyxoviruses (hendra and nipah viruses), coronaviruses (severe acute respiratory syndrome coronaviruses) and filoviruses (ebola and marburg viruses). wild bat populations or experimentally infected bats, however, do not show any clinical signs of disease. work by l. wang (geelong, australia) is focused on understanding virus-bat interactions from the perspective of genomics and 'transcriptomics' (expression profiling). considerable progress has also been made in establishing bat cell lines and in functional studies of key molecules in bat innate immunity, such as tlrs and the interferon system. ultimately, these fundamental investigations may help to explain why bats seem to be asymptomatic carriers of some viruses that are deadly to humans. an effective immune response requires the ordered, sequential expression and secretion of inflammatory cytokines by the appropriate cells. j. stow (brisbane, australia) has used live-cell imaging to show that cytokines traffic through recycling endosomes in macrophages, which allows the orchestrated release of multiple cytokines through the secretory and lysosomal pathways. these studies have demonstrated that recycling endosomes coordinate cytokine release while allowing macrophages to engulf and destroy invading pathogens. macrophage activation and the induction of a robust immune response are critical for the generation of protective immunity to mycobacterium tuberculosis. b. saunders (sydney, australia) proposed that macrophages use a previously unknown communication strategy that involves the release of microparticles after stress induced by bacillus calmette-guérin. these microparticles contain m. tuberculosis antigens that are processed by antigen-presenting cells, thereby inducing antigen-specific t cell responses. therefore, microparticles may represent a mode of immunological transfer that induces cell migration and the inflammatory response to infection with m. tuberculosis. the signal-transduction programs of core cells of the innate immune response, such as macrophages, are mediated by key transcription factors such as the irf proteins. for example, irf controls the differentiation of m -type macrophages in both mice and humans . p. pitha (baltimore, maryland, usa) discussed the phenotype of irf -deficient mice, which includes b cell abnormalities and a propensity to develop autoimmunity. this finding underscores the role of key transcription factor-mediated genetic programs in the interface between the innate and adaptive immune systems. these factors mediate the innate responses of both mrna and microrna in cells of the innate immune system, such as macrophages, whose coordinated induction was presented by s. forster (melbourne, australia). additional functions for another innate cell type, the pdc, were reported by d. ang (melbourne, australia). although pdcs have a recognized role as producers of type i interferon during viral infection, here pdcs were also shown to combat the intracellular bacterial pathogen l. pneumophila. depletion of pdcs in mice infected with l. pneumophila exacerbates volume number july nature immunology this field and the second lorne infection and immunity conference in february . liver dis we apologize to the many presenters whose work was not included here because of space constraints. the lorne infection and immunity conference was hosted by the victorian infection and immunity network (the university of melbourne infection and immunity domain, monash university, walter and eliza hall institute, victorian infectious disease reference laboratory, the burnet institute, the commonwealth scientific and industrial research organisation) and was sponsored by pfizer centres of therapeutic innovation, roche, csl, gilead life research and bio-rad. the authors declare no competing financial interests. into how cd c hi and cd c lo-int cells regulate the development of il- -producing t helper type cells and immunopathology differently.how il- acts on a large number of genes in diverse cells is unclear at present. c. mccoy (melbourne, australia) and colleagues have built on published work showing that expression of the microrna mir- is inhibited by il- . this microrna has been linked to the modulation of inflammatory responses, inflammation-induced cancer and the pathogenesis of autoimmunity. this latest work suggests that through mir- , il- regulates a set of genes previously unknown to be regulated by this cytokine, which helps to explain its biological potency. this work also strengthens the case for the development of therapeutics based on mir- and surely other micrornas that regulate immune responses. the field of host-pathogen interactions has seen discoveries that extend far beyond greater knowledge of pathogen or immune-response factors. multidisciplinary approaches to understanding the complex interaction between the pathogen and the immune response during infection have led to a heightened appreciation of the adaptation of pathogens to their host as well as greater insight into so-called 'sterile' inflammation, innate and adaptive immune control and autoimmunity. the first lorne infection and immunity conference was established to bring together aspects of infection, the pathogen and the immune response. collaborations and ideas that result from discussions at these meetings are set to change the way researchers view infection, leading to improved basic knowledge and its translation into better treatment and prevention of infectious and inflammatory diseases. we look forward to further rapid developments in infection , whereas supplementation of pdcs into the lungs ameliorates infection by diminishing the bacterial load. notably, resistance to pulmonary l. pneumophila infection is independent of type i interferon signaling, which shows that pdcs control bacterial infection in the lungs by a mechanism distinct from antiviral pathways such as type i interferons. in summary, these presentations confirmed the idea that the presence of pathogen-associated stimulating molecules and their detection by cells of the innate immune system drive the signaling and production of cytokines, in a context-dependent manner, that shape the nature of the response that ensues.modulation of the adaptive response innate sculpting of adaptive immunity occurs through cytokines such as il- , a potent immunosuppressive cytokine with wide-ranging effects on t cells and b cells as well as cells of the innate immune response, such as macrophages and dcs. the tropical disease visceral leishmaniasis is characterized by splenomegaly, remodeling of the red and white pulp compartments of the spleen and local il- -mediated immunosuppression. p. kaye (york, uk) presented data that have extended published work to show that the cellular control of splenic remodeling is highly compartment specific. although inflammatory monocytes negative for matrix metalloproteinase and positive for the neutrophil marker ly g (mmp -ly g + ), not mmp + ly g + neutrophils, are responsible for regulating vascular changes in red pulp, neither of these populations has a substantial role in regulating the destruction of follicular dcs or fibroblastic reticular cells in the white pulp. through the use of a model in which mice were depleted of cd c + cells during chronic infection and then were reconstituted by adoptive transfer, this work has provided new insight key: cord- -j sfiyz authors: ward, kirsten; seale, holly; zwar, nicholas; leask, julie; macintyre, c. raina title: annual influenza vaccination: coverage and attitudes of primary care staff in australia date: - - journal: influenza other respir viruses doi: . /j. - . . .x sha: doc_id: cord_uid: j sfiyz please cite this paper as: ward et al. ( ) annual influenza vaccination: coverage and attitudes of primary care staff in australia. influenza and other respiratory viruses ( ), – . background annual influenza vaccination is recommended for all australian health care workers (hcws) including those working in primary health care. there is limited published data on coverage, workplace provision, attitudes and personal barriers to influenza vaccination amongst primary health care staff. the aim of this study was to contribute to the limited literature base in this important area by investigating these issues in the primary health care setting in new south wales (nsw), australia. methods a postal survey was sent to general practitioners (gps) and practice nurses (pns) from inner city, semi‐urban and rural areas of nsw, australia. there were responses in total (response rate %) from gps (response rate %) and pns (response rate %). results reported influenza vaccination coverage in both and was greater than %, with gps reporting higher coverage than pns in both years. the main barriers identified were lack of awareness of vaccination recommendations for general practice staff and concern about adverse effects from the vaccine. conclusions rates of influenza vaccination coverage reported in this study were higher than in previous studies of hospital and institutional hcws, though it is possible that the study design may have contributed to these higher results. nevertheless, these findings highlight that more needs to be done to understand barriers to vaccination in this group, to inform the development of appropriate strategies to increase vaccination coverage in primary health care staff, with a special focus on pns. influenza is a serious respiratory virus which costs the australian healthcare system $ million annually. primary health care workers (hcws) like general practitioners (gps) and practice nurses (pns) have found to be at higher risk for influenza than the general population. this may be because of: (i) exposure to influenza infection in both the general community and the workplace; and (ii) close proximity to visitors and patients. , vaccines remain the cornerstone of influenza prevention in many countries worldwide and are considered to be - % effective in healthy persons aged - years. annual influenza vaccination of australian hcws is recommended by the national health & medical research council (nhmrc), the australian committee on safety and quality in healthcare and various jurisdictional health departments, including new south wales (nsw). the royal australian college of general practitioners recommend that general practice staff members are offered immunisation appropriate to their duties. whilst there have been numerous australian studies on influenza vaccine uptake amongst hospital and institutional hcws , [ ] [ ] [ ] [ ] [ ] and some studies on attitudes of primary care clinicians to influenza vaccination for their patients , , there has been limited published studies to date on influenza vaccination coverage, barriers and enablers amongst primary health care staff in australia. influenza vaccination coverage amongst gps in australia was % in . in neighbouring new zealand, coverage amongst gps was % and % in pns in . other countries have reported lower coverage estimates, with only % of canadian family physicians from québec and % of gps from the netherlands vaccinated in and , respectively. a study across all primary health care professions in israel reported an average of % coverage across physicians, nurses, pharmacists and administration staff. factors associated with influenza vaccination status have been examined in primary health care clinicians in other countries. [ ] [ ] [ ] [ ] [ ] amongst this group of hcw's, significant predictors for vaccine acceptance include the following: agreement that hcw's have professional responsibility to be vaccinated, on-site access to free vaccine, workplace recommendation for staff influenza vaccination, desire for self-protection and belief that the benefits of vaccination outweigh the risk of vaccine side effects. , furthermore, previous influenza vaccination has been significantly associated with current vaccine acceptance in both hospital hcws and primary care physicians. factors significantly associated with lack of vaccine acceptance include the following: no medical indication for vaccination, belief that regular medical exposure will protect against the disease, low risk of contracting influenza, fear of vaccine side effects and lack of time or priority. , , some of these factors are similar to those cited by hospital hcws whilst others differ. in a review of attitudes and predictors to influenza vaccination of hospital hcw's, lack of convenient access to vaccine and poor knowledge about influenza infection were prominent reasons for lack of vaccination with the desire for self-protection and belief in the vaccine's effectiveness the most prominent reasons for vaccine acceptance in this group. to the best of our knowledge, there have been limited studies which specifically examine: influenza vaccination coverage, workplace provision of vaccination, knowledge, attitudes and personal barriers to influenza vaccination amongst gps and pns in australia. the aim of this study therefore was to contribute to the limited literature base in this important area by investigating this in the primary health care setting in nsw, australia. a paper-based survey was developed based on pilot work undertaken by the authors and commonly identified barriers to vaccination from the literature. , , it elicited demographic data about the respondents, their influenza vaccination status from to and identified barriers to being immunised. it also posed questions intended to determine the respondent's attitude towards vaccination, based on seven statements about efficacy, safety, adverse events and recommended target groups for influenza vaccine and was part of a wider survey that incorporated questions on pandemic influenza. the survey was piloted with four gps and pns from outside the study area. feedback from this process contributed to enhanced content, altered survey structure and modified wording. our sample was drawn from divisions of general practice (dgp) in nsw. dgps are government-funded organisations that provide support to a defined geographical catchment of general practices in australia. they are classified by population and locality into five categories based on rural, remote metropolitan areas (rrma). , nsw has the highest number of dgps, with . purposive sampling by the authors was used to select four dgps in nsw to represent a diverse sample from metropolitan, semiurban and rural areas. the final sample size for each participating division was weighted according to how many gps and pns were practicing in the area. the study was undertaken from the st february to st april , prior to the pandemic (h n ) influenza which was identified in late april . authors were blinded to participant selection, as they were randomly selected from de-identified dgp databases of gps and pns. surveys were posted by dgps and were accompanied by personalised explanatory letter and a reply-paid envelope. non-responders were sent a second letter and survey by the dgps within weeks. quantitative data was entered into microsoft access and was analysed using microsoft excel. responses to the geographical location question were categorised into inner city, semi-urban and rural areas. questions about influenza vaccine-related barriers, attitudes and beliefs were categorised into either agree, disagree or uncertain. the categories were compared with demographic characteristics and selfreported vaccination status of respondents using categorical data analysis. ethical approval was granted by the university of new south wales ethics committee. of the staff that was sent a survey, completed and returned it, giving an overall response rate of %. fifteen surveys were returned uncompleted as the staff member was no longer at the practice. response rates were higher amongst pns ( %) than gps ( %). the demographic and occupational characteristics of the respondents are summarised in table . there was some variation in geographical location of respondents, with ae % ( ⁄ ) located in semi-urban areas, % ( ⁄ ) in the inner city and the remaining ae % ( ⁄ ) in rural locations. of the respondents, % ( ⁄ ) were working in practices with £ gps. our sample parallels the findings of the - bettering the evaluation and care of health (beach) survey in terms of the spread in gp age, years worked in general practice and geographical location. the beach program is a continuous national study of general practice activity in australia. it provides a reliable, ongoing, representative description of general practice activity nationwide. just over % of respondents were vaccinated against influenza in ( ae %, ⁄ , % ci: ae - ae ) and in ( ae %, ⁄ , % ci: ae - ae ). differences in vaccination coverage between gps and pns for both (p = ae ) & (p = ae ) (see table participants indicated that free influenza vaccine was most commonly provided at the practice for gps ( ae %, ⁄ , % ci: ae - ae ), administration staff ( ae %, ⁄ , % ci: ae - ae ) and pns ( ae %, ⁄ , % ci: ae - ae ). of the gps working at a practice which provided free influenza vaccine for gps, ae % ( ⁄ ) were vaccinated in in contrast to ae % ( ⁄ ) coverage in gps from practices that did not provide the vaccine free of charge for them. for pns, ae % ( ⁄ ) vaccinated in worked at a practice where the vaccine was provided free and % ( ⁄ ) were vaccinated despite the vaccine not being provided free for pns at their practice. respondents' knowledge, attitudes and perceptions of influenza vaccination are summarised in table . over % of the participants believe that the influenza vaccine is attitudes towards vaccination barriers amongst the respondents are presented in table . while there was a low level of agreement with all of the statements provided (< %), the most commonly identified barriers were lack of awareness of any recommendation for general practice staff to receive influenza vaccination ( ae %, ⁄ , % ci: ae - ae ) and unacceptable nature of vaccination side effects ( ae %, ⁄ , % ci: ae - ae ). having to pay for the vaccine was identified as a barrier to getting vaccinated by ae % ( ⁄ ) of respondents. five of the twelve gps, who worked in a practice that did not provide free vaccine, felt that paying for a vaccine was a barrier. our study of primary health care staff found much higher influenza vaccination coverage than hospital hcws in australia. overall reported coverage of gps and pns was markedly higher than those for australian institutional and hospital hcws which have been found to range from % to %. , [ ] [ ] [ ] [ ] self-reported vaccination coverage for gps in our study (for ) was higher than the percentage reported for australian hospital-based doctors from the northern territory ( ae % versus %) and western australia ( ae % versus ae %). pns in our study had higher coverage when compared to nurses in residential aged care facilities (racf) ( ae % versus %) , and hospital-based nurses ( ae % versus ae %) yet had lower coverage than pns from the australian capital territory (act) ( ae % versus %). the australian national influenza & pneumococcal survey provides the earliest available influenza vaccination coverage estimates for gps in australia. results of this survey found coverage for nsw gps was the lowest of any jurisdiction, with % vaccinated in , and just over % for the preceding years. comparing these rates to those observed in our study, influenza vaccination coverage amongst gps in nsw appears to have risen substantially from to . more recently, a national survey from the australian general practice network (agpn) assessed influenza vaccination coverage in gps and pns in the same years as our study ( ⁄ ) with similar response rates ( % versus %). comparing vaccine uptake between the studies for both gps and pns in nsw only, the agpn study reported slightly lower coverage ( %) across both years in both groups. as data was collected at a practice level in the agpn study, individual vaccination status may have been incorrectly reported and may be underestimating the actual coverage rate. however, our results may overestimate actual coverage because of a number of reasons including the low response rate and use of self-reported vaccination status. studies into gp influenza vaccination coverage have been performed in other countries. [ ] [ ] [ ] [ ] [ ] cowen et al. in the united states (us) had a similar response rate to our study ( % versus %), but reported a much higher vaccination coverage rate for us family physicians ( %). semaille et al. and brunton et al. reported influenza vaccination coverage as % amongst french gps and % amongst new zealand gps, respectively. in contrast, studies from the netherlands and israel found lower coverage rates for gps with % and %, respectively. even though the majority of our respondents worked in a practice that provided free vaccine for their staff, many felt that paying for the vaccine was a barrier to getting vaccinated. the wording of the question may have impacted on the result, as respondents could have taken it to mean for gps in general and not for them personally. however, it is interesting to note, of the gps who said their practice does not provide free vaccine, % stated that paying for the vaccine was a barrier to receiving it. further qualitative research would assist in addressing these gaps in understanding. the gps and pns in our study largely disagreed with the common vaccination myths presented in the survey (see table ). in contrast, the most frequently reported reason amongst dutch gps for not being vaccinated was having no medical indication for influenza vaccination and in israel; physicians were much less frequently influenced by the fear that vaccination would cause influenza when compared to other practice staff. there was almost no consistency of agreement with both these misconceptions in our sample or that of litt et al., who found that the main reasons indicated by australian gps for being vaccinated against influenza were concern about getting influenza or its complications and to prevent having time off work because of influenza. live viruses in the influenza vaccine was the most common myth supported by respondents ( ae %, ⁄ ) yet a decade ago, less than % of australian gps gave this as a reason for not getting influenza vaccine. the reasons behind this shift in belief is unknown; however, technology could play a part, with increased access to a variety of information sources. in the light of this, gp education should continue to focus on dispelling this myth through use of evidence-based information. other barriers to influenza vaccination identified in our study were lack of awareness of any recommendations for general practice staff to receive the influenza vaccine ( %) and unacceptable side effects of vaccination ( %). these are similar to those commonly cited by hcws in other countries. [ ] [ ] [ ] for hospital doctors, being too busy has been identified as a major barrier to getting vaccinated against influenza. , , in contrast, only a small number of participants, all of whom were gps, identified lack of time as a barrier as did approximately % of gp respondents the australian influenza and pneumococcal vaccination survey ( ) in the elderly. a previous investigation of general practice staff across dgps in australia found a significant association between workplace influenza vaccination policy and staff vaccination. we found that interrelationship between staff beliefs and practice policies may be an important determinant of hcw immunization behaviours in these practices. office policies demanding immunisation and operating within an effective hierarchy can lead staff members to re-evaluate their beliefs about influenza immunization in the light of their own experience. continued efforts at the practice level to make formal commitments to staff health by developing policies for influenza vaccination of staff may assist in increasing coverage in this group. provision of the influenza vaccine to patients along with consistent, direct, exposure to influenza like illness by this population may further impact on their decision to be vaccinated. pandemic (h n ) influenza is also likely to increase awareness of influenza vaccination and instigate new policies and practices surrounding vaccination of primary health care staff as has been seen in other countries during heightened awareness of an impending influenza pandemic threat. there are a number of limitations to this study including sample size, generalisability and use of self-report for vaccination status. although the sample size was small, compared to other general practice-based surveys, it would be considered reasonable in the light of the challenges with surveying this population. , there is potential for selection bias in this study towards those who are particularly concerned about influenza and ⁄ or vaccination or those who accept vaccination. furthermore, using self-reported vaccination status in adults has been shown to overestimate coverage. , there may also be limitations with generalisability because our study was conducted only in one state of australia. this study did not collect any data on nonrespondents or outcomes for those who intended to be vaccinated in . in addition, the barriers in our survey may not have covered all possible options, thus may have influenced participants response. qualitative research is needed to further explore these findings. despite these limitations, influenza vaccination coverage was found to be relatively high amongst the gps and pns in our study; however, there is still room for improvement. understanding barriers to vaccination is the first step to developing effective strategies to overcome them. for institution-based hcws, there is now an extensive literature base around knowledge, attitudes and practices towards influenza vaccination, whereas, there are only a few studies exploring these topics in the primary health care setting in australia. to enhance development and targeting of strategies to increase coverage, a more complete and current understanding of coverage in this group is needed to build on the estimates presented here. we believe this study to be a basis for future investigations and interventions to increase influenza vaccination rates in primary health care staff in australia. influenza-related disease: the cost to the australian healthcare system the role of influenza vaccine in health care workers in the era of severe acute respiratory syndrome national health and medical research council (nhmrc). the australian immunisation handbook, th edn. canberra: australian government world health organization. influenza vaccines vaccines for preventing influenza in healthy adults discussion paper: influenza vaccination amongst health care workers policy directive: occupational assessment, screening & vaccination against specified infectious diseases royal australian college of general practitioners. infection control standards for office based practices co-ordinated approach to healthcare worker influenza vaccination in an area health service influenza vaccine coverage among health care workers in victorian public hospitals influenza vaccination of staff in aged care facilities in the act: how can we improve the uptake of influenza vaccine? influenza immunisation of doctors at an australian tertiary hospital: immunisation rate and factors contributing to uptake attitudes amongst australian hospital healthcare workers towards seasonal influenza and vaccination barriers and facilitators to influenza vaccination among high-risk groups aged less than years -views from general practitioners and practice nurses differences in attitudes, beliefs and knowledge of hospital health care workers and community doctors to vaccination of older people australian national influenza and pneumococcal survey in the elderly knowledge and attitudes about influenza vaccination amongst general practitioners, practice nurses, and people aged and over vaccination practices of quebec family physicians. influenza vaccination status and professional practices for influenza vaccination influenza immunization of dutch general practitioners: vaccination rate and attitudes towards vaccination influenza vaccination among primary healthcare workers influenza vaccination status and influenza-related perspectives and practices among us physicians influenza vaccination of health care workers in hospitals -a review of studies on attitudes and predictors general practice network influenza survey report national foundation of infectious diseases. improving influenza vaccination rates in health care workers. strategies to increase protection for workers and patients. atlanta: centre for disease control and prevention australian institute of health & welfare (aihw). rural, regional and remote health: a guide to remoteness classifications fast facts: rural remote metropolitan area (rrma) classification initial human transmission dynamics of the pandemic (h n ) virus in north america general practice series no. . (cat. no.gep ). canberra: australian government influenza vaccination in act nurse immunisers evaluation of the vaccine coverage of the general practitioners in the french community organizational culture influences health care workers' influenza immunization behaviour annual report of the national influenza surveillance scheme high coverage of influenza vaccination among health care workers can be achieved during heightened awareness of impending threat response rates of victorian general practitioners to a mailed survey on miscarriage: randomised trial of a prize and two forms of introduction to the research the effect of cash and other financial inducements on the response rate of general practitioners in a national postal study sensitivity and specificity of patient self-report of influenza and pneumococcal polysaccharide vaccinations among elderly outpatients in diverse patient care strata validity of self-reported influenza and pneumococcal vaccination status among a cohort of hospitalized elderly inpatients influenza vaccine coverage and attitudes in australian primary care staff ª thanks to the following for their support in this study; central sydney general practice network, albury wodonga regional gp network shire gps (sutherland division of general practice) and went west ltd. j leask is an investigator on a grant which is part funded by sanofi pasteur. c. r. macintyre receives funding from influenza vaccine manufacturers gsk and csl biotherapies for investigator-driven research. k ward has received funding from wyeth to attend an immunisation conference. all other authors of this manuscript have no conflicts of interest to declare. national centre for immunisation research and surveillance is supported by the australian government department of health and ageing, the nsw department of health and the children's hospital at westmead. key: cord- -rr xua authors: nan title: news date: - - journal: aust vet j doi: . /avj. sha: doc_id: cord_uid: rr xua nan photo: istock adelaide vet speaks out against dog anti-vaxxers an adelaide vet has taken to the air to address a growing number of pet owners who believe that vaccinations cause autism in dogs. speaking to the fiveaa radio station, dr derek mcnair expressed concern that certain areas of adelaide had low vaccination rates as a new trend of using herbal remedies instead of vaccines grows in popularity. "i'm not anti-holistic treatments and helping for some things, but to use it in place of vaccines is totally ridiculous and stupid." the trend comes as "anti-vax" material floods the internet, with the british veterinary association recently forced to publicly deny that dogs can get autism. similar discussions have been across the media throughout australia. the avas president, dr paula parker, has been responding to the media with a clear message that it is dangerous to forgo pet vaccinations. shipments of australian and new zealand dairy cows to sri lanka have been halted after a large number of the imported livestock have died on-farm. the sri lankan government has ordered an inquiry into the high mortality rates, along with reports of poor milk yields, low conception rate, stillbirths, and unrecognised diseases. queensland country live reports that , holstein-jersey heifers have been shipped to sri lanka under a government program to increase the country's fresh milk production. local farmers say the cows are unsuited to sri lanka's hot and humid tropical conditions, despite the same australian-bred cows have been performing well in indonesia. the ava is monitoring the story, particularly additional disclosures on the compliance with the nutritional, veterinary and animal husbandry recommendations made. woolworths over price rise news report a number of pet food brands have recently gone missing from supermarket shelves following a pricing dispute with manufacturer mars petcare. coles and woolworths' customers will have to go elsewhere for their pet's favourite brand after mars pulled the plug on distribution to the two supermarket giants following a price rise disagreement. mars produce different pet food brands globally, including royal canin, pedigree, whiskas, dine and my dog. representatives from the supermarkets said they expected a deal to be brokered soon. you can't be what you can't see i spent much of january and february of this year buried in research and thinking about women, leadership and the future of our profession. social media is littered with quotes and catchphrases about leadership. one that stuck with me through the data and the papers is 'you can't be what you can't see'. if you can't see someone that seems similar to you in a position of leadership, then it can be difficult to believe that that role, or one similar to it, is possible for you, or although it might be possible, the cost of forging a scarcely trodden path may be too great. there is some veterinary specific data that outlines this well. in the november report 'motivation, satisfaction and retention: understanding the importance of vets' day to day work experiences' from the bva and the university of exeter, two of the key findings included 'feeling like one fits in with those who have been successful before you, and having role models' as being important to motivating veterinarians, facilitating their professional satisfaction and retaining them in the profession. of the myriad of issues that our profession faces and cares deeply about, the financial security of veterinarians, and particularly of women, is the one closet to my heart. i have seen several members of our profession profess that as a natural consequence of more women in the profession, there will be increasing gender representation in leadership positions overtime. this is an alluring proposition, but not one supported by the data. vertical segregation describes the phenomenon where there is predominance of men in more senior positions, and a predominance of women in more junior positions. vertical segregation occurs across every aspect of the australian economy, and even in female dominated professions, women are under-represented in leadership roles. the reasons for this are a complex interaction of unconscious bias, structural and cultural factors that require more discussion than can be accommodated in this column. one of the recommended interventions however, is to shed light on diverse role models. one of the greatest pleasures of being the ava president, is the opportunity to work with leaders across our profession, in all of the contexts where we contribute to the community. so, in this column, i wanted to introduce you to some of the women i have had the privilege of seeing in action and whom i admire for their leadership, their integrity and their service. i hope that you can see them too and know that regardless of the leadership role you would like to play, that there is someone who has forged a path. • if you want to be a pillar of your community, meet melissa rogers. • if you want to steward the standards of our education and be proud to promote them to the world, meet julie strous. • if you want to be a young veterinary business owner, meet kat lovell. • if you want to be a part of our leadership of animal health in the world, meet jennifer davis. • if you want to lead a global animal health company, meet stephanie armstrong. • if you want to be excited about nutrition and life, meet penny dobson. • if you want to champion collaboration across our sector, meet janet murray. • if you want to know how to exemplify excellence, compassion and grace, meet liisa ahlstrom. • if you want to be a pioneer in our sector and do so with ethics, charisma and a smile, meet rachel chay. • if you want to meet a leader who understands how looking after your team makes good business sense and puts it into practice, meet jacqui von hoff. • if you want to change the face of dairy medicine, meet gemma chuck. • if you want to feel excited about being a veterinarian and putting that out there into the world, meet zoe vogels. • if you want to lead the education of the next generation of veterinarians, meet cristy secombe. corey snell, ceo achieving better health outcomes for pets as you read this column our flagship ava annual conference in perth will have concluded. this year the theme was "the profession: better working together". here we introduced an innovation symposium and our food security day. the food security day focused on biodiversity and welfare, bringing experts from around the world together to discuss the challenges and opportunities faced to sustainably feed more than . billion people by . both of these broke new ground for the ava and our aim is to continue these inaugural events. breaking new ground is not limited to our conference events. at the ava we have been asking ourselves how the ava could assist you in contributing to the optimum health and welfare outcomes for australian pets. most importantly how could we assist our members in providing better care to ensure happier clients? as i have learned more about the challenges our veterinarians face, i have been particularly concerned by the pressure experienced by veterinarians resulting from the inherent tension between cost of veterinary care and our clients propensity to pay for services. i understand that this is one of the biggest causes of stress for the profession. i imagine it must be heartbreaking when a pet's owner is unable to pay for veterinary treatment and they are forced to make a decision that is not in the best interests of the animal. one of the tools which can help the financial preparedness of our clients is pet insurance. at the ava annual conference, we launched our partnership with guild insurance in the development of an ava endorsed pet insurance offering called 'vets choice'. guild insurance and the ava have collaborated to develop a pet insurance solution that that has been designed to meet the needs of our profession and our customers. it is my hope that by increasing the proportion of pet insurance in australia will lead to a more sustainable veterinary practices and i am particularly excited at the opportunity this provides not only the broader public but our profession and our members as well. we've got something exciting coming… vets choice is a modern pet insurance product, packed with market leading features and benefits, brought to you by the ava and guild insurance. we'd love to tell you what the product is, but it's different now than it was three weeks ago, and we're still working to refine and respond to the needs of what both you as the vet and your patients need most. send an email to vetschoice@guildinsurance.com.au if you want to be among the first to be part of it… is the dingo really just another type of dog? the dingo has been present in australia for at least the past few thousand years, with the earliest dated fossil being around years old. they are recognised native animals, but are also classified as a pest species in many jurisdictions and often defined as 'wild dogs'. since the commencement of livestock farming across australia over the past years, the dingo has had a negative relationship with graziers. early on, many efforts were made to eliminate populations and this has resulted in the dingo being absent from many parts of its historical range. the control of wild dogs is an ongoing issue for graziers because they can cause significant financial losses through predation of sheep, goats and calves. by sight alone, it is often difficult to differentiate dingoes and their hybrids from wild dogs and it is this dilemma that lead to the western australian government to recently consider removing the dingo's status as native wildlife and classify them as 'non-fauna'. this would make them no different to any other dog and allow them to be killed throughout the state. the canidae is a diverse group that includes the domestic dog, wolves, coyotes and dingoes. individuals can interbreed and produce fertile offspring and therefore technically could be classified as one species using the 'biological species' concept. istock photo news n a paper published in the veterinary record last month investigated the presence of bacterial contamination in commercially available raw meat pet food products in sweden. samples were taken from raw meat pet food products sold in supermarkets in sweden and produced by different pet food manufacturers. results showed all samples were contaminated with enterobacteriaceae bacteria, suggesting faecal contamination because these bacteria are found in the gastrointestinal tracts of animals. the presence of e. coli and other enterobacteriaceae bacteria is often used as an indicator of hygiene during processing. in addition to the presence of enterobacteriaceae bacteria being found on the samples, salmonella species were found in four of the samples and campylobacter species in three samples. in two samples, the level of clostridium perfringens bacteria exceeded bacteria/g, which is above the maximum limit for anaerobic bacteria permitted by swedish national guidelines. the authors concluded that raw pet meat food sold commercially in sweden should be handled carefully, with owners needing to implement strict hygiene protocols when storing, handling and feeding raw meat pet food products. they also discussed the potential health risks that raw meat pet food products present to both humans and animals, particularly geriatric, neonatal and immunocompromised individuals. these findings come at a time when raw meat-based diets for pets are becoming increasingly popular. the proliferation of both commercially available raw diets such as 'biologically appropriate raw food (barf)', as well as homemade diets, is leading to growth in the raw pet meat sector. although commercial dry and canned pet foods still dominate the pet food market, the introduction of raw diets and homemade diets is leading to a small but passionate group of owners who promote raw diets for health and philosophical reasons. the pet food industry in australia is currently under review. after a senate inquiry examined regulatory approaches to ensure the safety of pet food in late , the resulting inquiry's report recommended widespread changes to both oversight and safety standards of the sector. the federal department of agriculture and water resources is currently leading a working group comprising representatives from state governments, the australian veterinary association, rspca australia and food standards australia and new zealand. this working group is examining how best to regulate and improve safety standards in the pet food industry. commercially available raw pet meat products will be included in this review, as well as treats and manufactured pet food. it is currently unknown if the results of this swedish study are replicated in the raw pet meat market here in australia. similar results were found when raw pet meat products were tested in the netherlands in , with high levels of bacterial contamination as well as several parasites including sarcocystis species and toxoplasma gondii detected. if owners insist on feeding raw pet meat products to their pets, the authors of the veterinary record paper recommend the following risk reduction tips: keep raw pet meat frozen until use, always handle raw pet meat with separate utensils as well as wash hands thoroughly after contact and do not feed raw pet meat products in households with immunocompromised individuals. in early april the animal health quadrilateral group (quads), senior animal health officials from australia, canada, new zealand and the united states met for their annual meeting. the issue of attracting, developing and retaining government veterinarians was an item of keen interest on the agenda. government veterinarians play critical, unique and diverse roles in a country's veterinary services, which underpin a country's animal health status and trade. the risks and opportunities in animal health will continue to evolve, as will the expectations, interests and demographics of the veterinary profession. the future will bring new information and diagnostic technologies; changes to risk and community expectations; and evolving communication needs. therefore, we need to be proactive, and ensure the skills of future veterinarians reflect this changing context. in the field of government veterinary services there may be a need for increased veterinary public health specialist expertise, such as epidemiology, risk management, and diagnostics. it's also expected that we will need to increase our collaboration with experts from other disciplines such as information technology and data analysis; laboratory, public health, social and environmental scientists; communications professionals; and economists. the world organisation for animal health (oie) is currently developing their th strategic plan ( - ) and they too are looking at their future role, particularly on global issues such as food security, climate change, species conservation and the future of the veterinary profession. as president of the oie, i have been leading discussions in the development of the oie's th strategic plan. in reviewing the external forces that will impact the organisation's future we see the issues of big data, centrality of social media, changing public perceptions and declining trust in governments, and we need to take these issues into account. at home, the australasian veterinary boards council (avbc) has discussed the future of the veterinary profession, and therefore how to educate the veterinarians of the future. similar to the quads group and the oie, the avbc also recognised that the profession's future is inherently linked to broader global issues. veterinarians will be managers of expert knowledge and will need to work in the one health space, where environmental, human and animal health intersect. technology is playing an increasing and positive role in veterinary science education. assisted and virtual reality enhance practical learning and learning is expected to become increasingly collaborative with students study virtually across a range of institutions. it reminds me of the plenary presentation by jordan nguyen at last year's ava conference on 'the boundaries between human and technological evolution and intelligent technologies'. he certainly opened my eyes to what the future might look like! and speaking of the future, i have recently really enjoyed getting around to a few of our veterinary schools during my travels and speaking with the veterinarians of the future. i recently dropped in to the campus in gatton and met with university of queensland staff and students. i really value the perspectives gained from these visits and hearing what's happening at the forefront of our profession. this month, following the ava conference in perth, i'll return to my alma mater, murdoch university, to speak with and meet staff and students about the importance of one health and the broad range of opportunities available to us as veterinarians. vets really do play such an important role in animal and human health and we have the opportunity to truly contribute to the important issues facing the globe. following the ava conference and trip to perth, i will be flying to paris for oie council meetings in mid-may and the general session at the end of the month, my first as president of the oie assembly. i look forward to introducing you to a couple of members of the australian delegation to the oie general session so they can tell you about their veterinary career paths. assisted and virtual reality enhance practical learning and learning is expected to become increasingly collaborative with students study virtually across a range of institutions. veterinarians have been thinking about preventive care protocols in their clinics for some time now offering annual wellness checks. these annual checks may include vaccination based on the patient's individual needs, and may or may not include diagnostics. for some, the decision not to include diagnostics in the wellness check has been due to consideration of whether there is value in adding diagnostic testing when a patient has an unremarkable history and clinical examination, but the evidence to do so is mounting. several peak bodies have produced guidelines on care of dogs and cats at different life stages, including the american association of feline practitioners (aafp) , , the american animal hospital association (aaha) , , and the australian veterinary association . all of these recommend regular health checks (annual for adults, and every months for seniors and older), with diagnostic testing included, especially as animals age. add to this, a series of published studies evaluating the results of diagnostic testing in apparently healthy adult and senior pets, and we can start to draw some evidence-based conclusions around the value of diagnostics in this preventive care setting. in a study of cats and one involving dogs , there were significant numbers of patients with changes on blood and urine screens, and a more recent study undertaken in australia involving dogs and cats showed . % of dogs and . % of cats with significant changes that warranted further investigation . aaha however, were interested in leveraging the huge volumes of data produced by the industry each year to understand the issue on a much larger scale, and took a somewhat different approach to data collection . in their 'big data' study -the aaha research team evaluated over , patients, but not necessarily in the same detail as the previous studies. here are some details from the study that all veterinarians should be aware of: • data was gathered from , consenting practices and harvested from their practice management software • investigators evaluated profiles on patients that were classified as 'wellness examinations' in the practice information management system • the patient visit needed to include a cbc, full chemistry profile including idexx sdma®, and ideally a urinalysis. • for some parameters, the reference interval was widened slightly to a critical threshold before a result was abnormal (for example for liver enzymes the lower range was set to zero, and in dogs the upper end of phosphorus was increased by %). • for the majority of biochemical parameters, the requirement was that at least three or more results had to be abnormal before the findings were considered significant. • a single abnormal sdma result was considered significant. • for haematology, only numerical values were assessed (changes on blood film reviews were not included), and abnormalities identified included: • anaemia • reticulocytosis • leucocytosis • stress leucogram (lymphopaenia and eosinopaenia) • eosinophilia in many regards the approach taken was a conservative one and means that potentially significant changes preventive care were under-reported. this in-built 'conservativism' is because not all the haematological parameters were evaluated, and there was no comparison to previous results. where we now recognise the benefits of evaluating the health status of the pet by using an individual reference interval (comparing current results to previous results obtained for that patient in health) for a number of routine parameters, creatinine being a good example. in the aaha study the results were as follows, with respect to results that warranted further investigation. in this study the addition of sdma made a significant difference to the number of patients warranting further evaluation. in the adult and senior populations there were an extra per patients who required further investigation, whereas it was per for geriatric patients. in conclusion, and as we seek to enhance the health and wellbeing of pets, people and livestock, i would suggest that studies such as the ones discussed here provide supporting evidence that the inclusion of diagnostic testing in discussions on wellness and preventive care is critical. moreover, observation suggests that it is also something that clients have come to expect. the animal medicines australia pet ownership report showed nearly as many clients presented their pets to the vet to keep them well as those presenting for illness . dr graham swinney bvsc, fanzcvs (canine medicine) the eastern bettong is a small marsupial that was once common across the east coast of australia. shortly after the introduction of predators, particularly the fox, their populations crashed and they became extinct on the australian mainland around years ago. fortunately for the eastern bettong, tasmania is free of foxes and as a result is a remaining stronghold for the species. breeding programs for the bettong exist in predator-proof areas in the act and the animals in these protected areas are continuing to flourish. in , eastern bettongs were introduced to the wild near the lower cotter river catchment, kilometres southwest of canberra in an area that had been heavily baited to reduce fox population numbers. eight months after their initial release and through intense monitoring, ecologists involved with the program discovered that every female bettong found showed signs of breeding success. at the time this was a huge success for the program as it was the first time that wild-bred eastern bettongs were present on the mainland in the past years. some concerns were raised at this time, because survival rates of released bettong were found to be around %, but there was hope that the new joeys being born would help boost future populations. act parks and conservation was responsible for controlling feral pests in the release area and at the peak of the project were servicing bait stations on a weekly basis as well as monitoring between and wildlife cameras to identify the animals present in the area. unfortunately, abc news has recently reported that all eastern bettongs released into the wild as part of the project have now died and foxes are being held responsible. although the project was not as great a success as had initially been hoped for, director of act parks and conservation services, daniel iglesias said that the team has still gained valuable information through the project because during the early months the bettongs were coexisting and reproducing in the presence of foxes. however, this only occurred when the fox population was low enough to allow the bettongs to survive, and the methods used to achieve this low level of foxes in the wild are not practical on an ongoing or widespread basis. the introduction of predators to australia has been a contributing factor to the demise and extinction of our native mammals and given us the world's worst rate of mammal extinction. it is not possible to ever eliminate the threat of introduced predators from the wild, but finding ways to successfully manage their populations on a large scale is something that will need to be focussed on and invested in by the government, if we wish to slow down or reverse our rapid extinction rates of native wildlife. if this ever becomes a reality, we may one day find eastern bettongs scurrying around in areas they've been absent from for over years. the complexity of chf means a multitude of treatment approaches are required to ensure a good quality of life and longevity in our pets. in her thesis, mariko examines current treatments of chf, posing vital questions on how they can be improved. a new focus in congestive heart failure? it is well known that pimobendan, in conjunction with other drugs, is key to the treatment of chf. it is currently most commonly used and prescribed in tablet form; however, mariko assesses the use of a pimobendan oral solution in dogs. the pimobendan solution was seen to enhance echocardiographic measures of cardiac systolic function, reaching a maximal effect at - hours following administration. this study is notably the first to use non-invasive imaging of the acute cardiovascular effects of pimobendan. in addition to validating the efficacy of this solution, it raises the possibility of therapeutic monitoring in the future. mariko then examined the use of pimobendan in cats and her findings clearly showed reduced metabolism of pimobendan to its active metabolite in cats compared with dogs. interestingly, the cardiovascular effects of pimobendan could not be readily identified on echocardiography. these interspecies differences highlight the necessity for further research into the role and optimal dosing regimen of this drug in feline cardiovascular disease. in addition to examining existing treatment options for chf, mariko also studied the potential of the natriuretic peptide system as a therapeutic target in dogs with chf. in a recently published article, she identified that the cardiorenal effects of bnp - (a type of natriuretic peptide) were diminished in dogs with chf caused by myxomatous mitral valve disease. this suggested defects in what is essentially a protective mechanism in the context of chf and is a finding that prompts further investigations into therapeutics targeting this system. a recent case involving a fashion industry start up being penalised around $ , for underpaying staff has brought the issue of unpaid work into the spotlight. this came only weeks after a prominent australian company director was slammed for making comments around millennials "not wanting to work for free". these situations -while very different -both raise the question: is unpaid work permissible? the case. it's important to first outline exactly how and why this particular fashion start up fell foul of the fair work commission. over a -year period, the business was reported to have underpaid separate employees around $ , . one particular worker was said to be on an "unpaid internship" for a -month period -even though the nature of their engagement was that of an employee. the commission found that the business had failed to pay the workers their minimum entitlements under relevant employment legislation including minimum hourly rates, penalty rates and leave entitlements. as a result of the underpayment, the company was penalised around $ , and the sole director was individually penalised a further $ , . back pay was also ordered in full to the three workers. the severity of the penalty was largely due to the fact the company were said to have known they were under paying staff, with the commission labelling the underpayments "significant and deliberate". in short, yes, but be careful. as highlighted by the fair work ombudsman, sandra parker in the wake of the case, "unpaid placements are lawful where they are part of a vocational placement related to a course of study. however, the law prohibits the exploitation of workers when they are fulfilling the role of an actual employee." if you have been approached by a student looking for work experience, ensure it is part of a genuine placement through their learning institution. it might also be prudent to contact the institution (tafe, university etc.) directly to discuss the finer details including insurance and whether it can genuinely be unpaid. other than student placements -are there any other situations where unpaid work is permissible? there may be other situations where work can be unpaid, but this is assessed on a case by case basis and employers should check with the ava hr advisory service before providing any unpaid work. when the work is not part of a vocational placement, some of the major factors when considering whether work can be unpaid include; • will the work be for the benefit of the individual, or the business? • if the work primarily benefits the business, it is likely to require payment. • how long did the arrangement last? • the longer the arrangement, the more likely it is to requirement payment. • what was the nature of the work? productive work that is meaningful to the business will almost certainly requirement payment. observing, learning and performing very rudimentary tasks that give the individual a general "feel" for a role or industry may form part of an unpaid working arrangement. considering the above, unpaid work should almost solely benefit the individual (not the business), should only be for a brief period and should be largely observational. an unpaid trial can be permissible if it is purely to demonstrate a skill or skills associated with a particular role. the engagement should be brief (maximum one shift) and the individual should be under direct supervision the entire time. let it be clear -this is unrelated to a probation period which is sometimes referred to as a trial period. a probation period is generally between to months and must be paid as an employment relationship has already commenced. in summary. if you are considering engaging someone to perform unpaid work, ensure what you are doing is lawful and permissible. ask yourself the following; • is it part of a vocational placement related to a course of study? • if so, check with the learning institute to ensure it is unpaid. • -is it an individual wanting to gain experience in the industry (no vocational placement)? • ensure they do not perform any productive work, and their engagement is brief and observational. • is it a trial? it must be purely about the individual demonstrating skill/s relating to the role, it must be brief and the individual must be directly supervised for the entire engagement. if your plan to engage someone doesn't match any of the above, it is likely they will be an employee and will require payment. if you are unsure about anything in this article, contact the ava hr advisory service on or email hrhotline@ava.com.au. the material contained in this publication is general comment and is not intended as advice on any particular matter. no reader should act or fail to act on the basis of any material contained herein. the material contained in this publication should not be relied on as a substitute for legal or professional advice on any particular matter. wentworth advantage pty ltd, expressly disclaim all and any liability to any persons whatsoever in respect of anything done or omitted to be done by any such person in reliance whether in whole or in part upon any of the contents of this publication. without limiting the generality of this disclaimer, no author or editor shall have any responsibility for any other author or editor. for further information please contact wentworth advantage pty ltd. results from the survey revealed there were more than , volunteer wildlife rehabilitators in nsw, with almost half of those belonging to the largest wildlife rehabilitation group wires. on average, , animals go through wildlife rehabilitator hands every year and more than , calls for assistance and education are provided to the public annually. it was estimated it would cost the government, conservatively, more than a$ million to replace the time and resources spent by volunteer wildlife carers every year in nsw alone. most wildlife rehabilitation is conducted in the homes of volunteers, although a small number of wildlife hospitals and centrally based facilities supplement this home care. stemming from surveys and consultation work with peak bodies, the work of private veterinary practices was recognised as an essential element in the wildlife rehabilitation sector. it was estimated around , wild animals are seen by nsw private veterinary practices annually at a cost of more than a$ . million of pro bono services and products. this differs significantly from a previously published survey by orr and tribe, which estimated around , wild animals were seen annually by nsw private practices. it is currently unknown just how many wild animals pass through veterinary practices every year, although the strategy did recognise that "balancing the running of a private practice with the lack of time, facilities and resources for treating free-living wildlife is very challenging." through the findings of the two surveys and stakeholder consultation, several challenges facing the sector were identified. wildlife rehabilitators overwhelmingly identified the finding and keeping of new volunteers as a significant issue, with social demographics, time, financial demands, group politics, burnout and conflict all affecting increased participation rates. other challenges identified in this process were the lack of succession planning in many groups, particularly because of the older demographic of wildlife rehabilitators. this may lead to a loss of skills, less community support and fragmented and inefficient use of volunteer time if unmitigated. three-quarters of wildlife rehabilitators who responded to the survey indicated their support for stronger standards of care for wildlife as well as improved access to mentoring. one of the aims of this draft strategy is to standardise training and introduce a minimum standard of care for the sector. this would include a standard induction for all volunteers, as well as specialised species training to improve volunteers' depth of knowledge. it's important to note that the strategy acknowledges this is an ambitious goal. other challenges identified by volunteers as affecting the sector included a lack of strategic support from a strong, unified peak body. even though more than half of all wildlife carers belong to the group wires, most carers wanted improved advocacy and leadership for the sector and greater access to funding opportunities. less than % of all respondents were satisfied with the current level of support provided by the state government. unsurprisingly, a lack of funds was another key challenge facing volunteers. around % of wildlife carers surveyed reported incurring out-of-pocket expenses in the year prior. specific issues facing private veterinary practices many of the veterinarians and nurses surveyed reported their formal education wasn't very useful for dealing with injured free-living wildlife. additionally, the most common complaint from veterinary respondents was in relation to the behaviour of volunteers and their group leaders, as well as response times for collecting injured wildlife. the role of wildlife rehabilitation in environmental management was recognised as a key strength of the sector. most volunteers considered their efforts as greatly benefiting the environment. increasing the collection and use of data captured by the wildlife rehabilitation sector would improve wildlife and threatened species management, which was identified as an important outcome of this strategic document. additionally, much-needed research into post-release outcomes could be facilitated by better engaging with the wildlife rehabilitation community to improve treatment options and management decisions. several of the changes proposed by this draft strategy could have important outcomes for improving wildlife health and welfare in nsw. the strategy aims to: • develop a peak body for wildlife rehabilitation in nsw by either encouraging the two main bodies to unite or create an advisory board comprised of government, wildlife rehabilitation, animal welfare, veterinary and natural resource representatives • develop standards to be adopted by the sector • develop a charter for volunteer engagement with veterinary practices • commit a$ . million to implement the strategy • introduce minimum standards for volunteer training, with learning outcomes and performance criteria to demonstrate proficiency • commit a$ . million (of the $ . million total) to deliver standard resources for veterinarians and veterinary nurses in the handling, triage and treatment of wildlife; this will be delivered by taronga zoo in partnership with the university of sydney and the office of environment and heritage • streamline data capture via online reporting of wildlife rehabilitation statistics and prepare annual reports for the sector and community • fund post-release monitoring of rehabilitated koalas • fund a single wildlife rescue telephone number for the public. nsw is not the only state that will see changes to the wildlife rehabilitation sector in . at the start of the year, western australia introduced licensing for all wildlife carers to keep track of volunteers and the relevant department in tasmania is currently finalising resources for veterinarians and nurses to aid in the triage and treatment of wildlife. it is expected the final nsw strategy will be implemented from july . news n i've recently been involved in the development of a business plan as part of my role as the ava student president. given my 'young grasshopper' status i found myself thinking, what does it take to be an entrepreneur in the veterinary industry? do people just find themselves taking over the mantle of head vet/ business owner as a rite of passage? is it a matter of luck, just serendipitously having the opportunity present itself, or can a fresh out of school veterinarian manifest it through sheer will power and effort? personally, i'm still holding out for a small loan of $ million from my parents. to find out more i had a chat with zachary lederhose, a recent graduate who has stepped into the world of business ownership. it might be more accurate to describe his current success in the field as 'hitting the ground running' but he won't claim as much. what motivated you to start your own business, zach? well, like just about every new graduate, i started out working as a general practitioner. loved the job and was a fantastic learning experience. that said, the main thing that stood out for me was not being able to have as much say in the direction we took as a team that i wanted. it wasn't that anything was wrong, it was a great atmosphere and we all got along really well. the sense of autonomy was what i sought. did it change much for your income? i wouldn't say it was the main driver behind my ambition to start a business. i was doing well in my previous role and could have very happily continued as such in that space. it all depends on what you, as a professional, value and where you get satisfaction in your job. for me, it felt like my earning potential was capped as an associate and that limited my opportunities. being my own boss makes it easier to pursue some of the things that interest me. for example, being able to purchase certain medical equipment to provide niche services or the flexibility to attend conferences that interest me. how do you find being responsible for a team? i think i was very fortunate that in my first job i had a great mentor in mike mesley at snowy vets. mike taught me a lot and we share similar opinions on practice management. with that behind me, i was confident in my abilities and i think that's a big part of the equation, believing you can actually do it. i also invested a lot of effort into developing my communication skills and bring the same focus to my current clinic. it's such an important skill -not just for interacting with clients and achieving the best outcome but to make sure we're working well together. the feedback i get from my team is important to me. as great as it is to have the constant loop of positives and 'yes men', sometimes i just need to be told i'm being a bit of an idiot. keeping my team comfortable to be that voice of reason helps me take stock of what i'm doing and means they are engaged in the decisions we make for the clinic. do you find your age and experience level makes it harder? to be honest, not a great deal. sure, i've faced some challenges along the way but nothing that anyone else starting out wouldn't come across. i would probably put it down to having a fantastic support network, including people from my private life. i can acknowledge i've been fortunate in that regard and it probably isn't the case for many of my peers. in a lot of ways, it comes down to having someone you can relate to who's been through the process. with a shifting demographic in the profession, i can imagine that's not always easy. that said, i did have a client ask how work experience was going for me the other day… i've certainly drawn some inspiration from my conversation with zach. hopefully for some of you reading it does the same, giving you that extra bit of encouragement to be brave and take a leap. similarly, if you're already a business owner keep an eye out; there are a fair few sharp minds coming through the ranks that could use your help. i'm fascinated by the prospect of more people like zach taking steps forward in business and the impact their innovation has on the profession, even if it's just one workplace at a time. all things considered, i should probably pick up that copy of barefoot investor that's been sitting on my coffee surprisingly, cats of all ages, and with both effusive (wet) and non-effusive (dry) forms, responded equally well to the treatment. the response was dramatic, with fever typically resolving within - hours of commencement and concurrent daily improvements in appetite, activity levels and weight gain were seen. cats with the effusive form had a reduction in abdominal effusion over a - -week period within - days of commencing treatment. after weeks of treatment, all cats that had responded to treatment appeared normal, or near normal, to their owners. the safety profile of gs- was also impressive, with no systemic signs of toxicity based on complete blood counts and serum chemistry values monitored over the treatment periods of - weeks in almost all individuals, with only one possible exception. a single cat showed a mild increase in renal parameters, but month later these abnormalities were not detected and the cat was also in remission. the study suggests using gs- at a dose of . mg/kg by subcutaneous injection every hours for weeks is a feasible way to treat fip. although the number of animals in this field trial study was limited, there were very promising results for commercialisation of this or similar nucleoside analogues in the future and someday fip may no longer be considered an untreatable disease. the studies examined the effects of two manufactured chemicals; diethylhexyl phthalate (dehp) and polychlorinated biphenyl (pcb ). dehp is a common plasticiser found in many household items (e.g. containers, toys, upholstery) and is used as a fragrance carrier in cosmetics, laundry detergents and air fresheners. pcb was used in coolant liquid but is now banned globally. both chemicals are widely detectable in the environment and one of the most common routes of exposure is ingestion of food. the researchers exposed sperm samples from both species to these two chemicals at concentrations that have been previously detected in the male reproductive tract and at levels commonly found in the environment. in both species, the exposure to these chemicals at these levels resulted in reduced sperm motility and increased the fragmentation of dna, which negatively affects overall fertility. as we increasingly share our homes with our pets, they are exposed to the same environmental and household contaminants as us and it is this exposure that researcher associate professor richard lea believes may be responsible for the fall in sperm quality in both dogs and humans in recent years. this finding also highlights the opportunity to use dogs as an effective model for future research into the effects of pollutants on human fertility, as other external influences, such as diet, are much easier to control in dogs than humans. stephen reinisch even more surprisingly, when used to inseminate ewes, both samples had almost the same pregnancy rate, with a rate of % for the -year-old sperm compared with % for the recently frozen sperm. this finding of the long-term viability of frozen semen is significant because it shows that genetics from individuals can be stored and used long after the original male has passed away, which could prove useful for breeding programs for many species in the future. the lambs produced from the study will also provide a useful baseline for the researchers to examine the genetic progress made by the wool industry through selective breeding over the past years. these lambs displayed characteristics that were common in merinos at that time, with large body wrinkles to maximise skin surface area and therefore wool yields. that particular characteristic has since gone out of favour, having been found to increase the risk of fly strike and create difficulties with shearing. stephen reinisch veterinary writer stephen reinisch veterinary writer delivery terms and legal title prices include delivery of print journals to the recipient's address. delivery terms are delivered at place (dap); the recipient is responsible for paying any import duty or taxes. title to all issues transfers free of board (fob) our shipping point, freight prepaid. we will endeavour to fulfil claims for missing or damaged copies within six months of publication, within our reasonable discretion and subject to availability. printing and despatch printed in australia by ligare pty ltd. all journals are normally despatched direct from the country in which they are printed by surface air-lifted delivery. copyright and copying copyright © australian veterinary association ltd. all rights reserved. no part of this publication may be reproduced, stored or transmitted in any form or by any means without the prior permission in writing from the copyright holder. this consent does not extend to other kinds of copying such as copying for general distribution, for advertising or promotional purposes, for creating new collective works or for resale. authorisation to photocopy items for internal and personal use is granted by the copyright holder for libraries and other users registered with their local reproduction rights organisation (rro), eg. copyright clearance center (ccc), rosewood drive, danvers, ma , usa (www.copyright.com), provided the appropriate fee is paid directly to the rro. this consent does not extend to other kinds of copying such as copying for general distribution, for advertising or promotional purposes, for creating new collective works or for resale. special requests should be addressed to permissions@wiley.com offprints printed offprints may be ordered online for a fee. please click on the following link and fill in the necessary details and ensure that you type information in all of the required fields: www.sheridan.com/wiley/eoc. policy predicaments or precedents i write with concern that the current ava live export policy has serious implications and potentially sets a precedent that is detrimental to the advancement of the profession. through its constitution , the ava seeks to speak on behalf of the profession (members and non-members) to government, authorities, any person, or company. policy and position statements are drafted by the policy council or the board and once approved by the board become official statements of the association. the ava uses policy and position statements to outline the position of the association when talking on behalf of the profession and these form the basis of advice given to government, other authorities, media, etc. the ava live export policy states: "where live export occurs, an australian-registered shipboard veterinarian must accompany each shipment and this veterinarian must be independent and thus not employed by either the exporting company or the shipping company." background information is provided in policy statements and is supposed to explain the rationale and scientific evidence supporting the policy position. the background information in the ava's live export policy does not provide any rationale or evidence why australian-registered shipboard veterinarian must not be employed by the exporter or shipping company. the exporter, in many cases, is the owner of the animals during the export voyage. if ownership has been transferred to another party, the exporter is the owner's representative and responsible for the animals during the export voyage. the rest of the policy is concerned about animal welfare, it is assumed the reason for the non-employment recommendation is to ensure animal welfare. this is concerning for a number of reasons. firstly, it implies that the legislative system regulating veterinarians in australia is broken, as the peak professional body is recommending the only way to ensure animal welfare is for veterinarians to be independent and not employed by the animal owner or owner's representative. it seems, the ava does not believe that the state and territory veterinary surgeons boards or the federal government have effective legislation or are able to effectively regulate against the current legislation. secondly, it implies there is a problem with fee-for-service arrangements between veterinarians and animal owners and achieving acceptable animal welfare outcomes. nearly all veterinarians providing clinical services to any species, either as an owner of a veterinary business or employee veterinarians, operate under this fee-forservice arrangement with the animal owner. how does the ava systematically review and assess policies for possible unintended consequences, implications, misrepresentation of the profession, or the possibility of setting a precedents that is not in the interest of the profession as whole? should the board review the live export policy, will the ava stand by its recommendations to the moss review and ensure that relevant people with leadership skills, deep knowledge and understanding of the industry, animal health and welfare, and epidemiology are sought? dr andrew way face the facts: gender equality corporate-site/documents/ animals-and-plants/native-animals/volunteerwildlife-rehabilitation-sector-strategyconsultation-draft- animal welfare implications of treating wildlife in australian veterinary practices tel: + ( ) japan: for japanese speaking support, email: cs-japan@wiley.com. visit our online customer help available in languages at www.wileycustomerhelp.com/ask production editor sylvia cheong. email: avj@wiley.com information for subscribers australian veterinary journal is published in issues per year. institutional subscription prices for are: print & online: us$ (australia & new zealand), us$ (us), € (europe), £ (uk), us$ (rest of world). prices are exclusive of tax. asia-pacific gst, canadian gst/hst and european vat will be applied at the appropriate rates. for more information on current tax rates, please go to www.wileyonlinelibrary.com/tax-vat. the price includes online access to the current content and all online back files to ava members communication live export update # this will be going to policy council and the chair of the policy council will provide a response following this meeting.access it on the go across any device -where you want, when you want.the avj will be a tap and swipe away from july www.ava.com.au key: cord- - slh aha authors: rossell, s.; neill, e.; phillipou, a.; tan, e.; toh, w. l.; van rheenen, t.; meyer, d. title: an overview of current mental health in the general population of australia during the covid- pandemic: results from the collate project date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: slh aha the novel coronavirus disease (covid- ) poses significant mental health challenges globally; however, to date, there is limited community level data. this study reports on the first wave of data from the collate project (covid- and you: mental health in australia now survey), an ongoing study aimed at understanding the impact of the covid- pandemic on the mental health and well-being of australians. this paper addresses prevailing primary concerns related to the covid- pandemic, current levels of negative emotions and risk factors predicting these negative emotions. on april st to th , adult members of the australian general public completed an online survey. participants ranked their top ten current primary concerns about covid- , and completed standardized measures to ascertain levels of negative emotions (specifically, depression, anxiety and stress). socio-demographic information was also collected and used in the assessment of risk factors. the top three primary concerns were all related to the health and well-being of family and loved ones. as expected, levels of negative emotion were exceptionally high. modelling of predictors of negative emotions established several risk factors related to demographic variables, personal vulnerabilities, financial stresses, and social distancing experiences; particularly being young, being female, or having a mental illness diagnosis. the data provides important characterization of the current mental health of australians during the covid- pandemic. critically, it appears that specific groups in the australian community may need special attention to ensure their mental health is protected during these difficult times. the data further suggests the need for immediate action to combat high levels of psychological distress, along with the exacerbation of mental health conditions, in relation to the covid- pandemic in australia. these results may provide some direction for international researchers hoping to characterize similar issues in other countries. the novel coronavirus disease emerged in china in late and has spread rapidly across the globe. it is a contagious viral infection presenting with respiratory, neurological, gastrointestinal, and cardiac symptoms that range in severity from non-symptomatic through to causing death (mao et al., ) . the first case in australia reported symptoms on january th -ncov national incident room surveillance team, . this was followed by an exponential increase in infections, and unfortunately, deaths (the first australian death occurred on february th). since covid- was declared a pandemic by the world health organization (who) on march th (who, ) , the world has been engulfed in an unprecedented global crisis characterized by threatened or actual healthcare system collapse, job losses, and a failing global economy. in australia, the crisis has been compounded by the implementation of government-regulated restrictions to contain the virus affecting social liberties. in light of this, covid- poses a significant mental health challenge to the australian population, both now and in the long term. however, at the time of conducting this project there was no community level data in relation to the mental health implications of the covid- pandemic in australia, and only one published study from another western country. in that study of adults in spain, heightened negative emotions were associated with being female, being younger, and having negative self-perceptions (losada-baltar et al., ) . four studies on the psychological impacts of covid- have also emerged from china. one study analyzed weibo (chinese social media platform) posts from , active users using online ecological recognition based on machine-learning predictive models . the results showed that negative emotions increased (e.g., anxiety, depression and indignation), while positive emotions (e.g., happiness) and life satisfaction decreased over a two-week period from january th to january th . two other studies compared the psychological status of medical and non-medical (administration) health workers, illustrating increased insomnia, fear, anxiety, depression, somatization, and obsessive-all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july , . . https://doi.org/ . / compulsive symptoms in medical health workers (lu et al., , zhang et al., . living in rural areas, being female, and being in contact with covid- -positive patients were reported as risk factors for negative emotions. finally, wang et al. , using an online survey and snowball sampling in the general population between january st and february nd , reported that ~ % of the respondents rated the psychological impact of covid- as moderate-to-severe, with % reporting moderate-to-severe anxiety. student status, being female and poor self-rated health were reported as risk factors for negative emotions. in australia, several health and economic measures had been implemented by march st , in an attempt to control the spread of covid- and stave off economic recession (e.g. $ b towards keeping australians employed). while a recent funding announcement of $ . b to boost digital mental health services is welcome, if we are to adequately manage this covid- mental health crisis, there is a time-critical need to empirically characterize the current psychological impacts of the pandemic on the australian population. this is particularly relevant given the australian government's current implementation of 'social distancing', a key transmissionprevention measure that describes the maintenance of minimum physical space between oneself and those outside of one's home. social distancing restrictions, which limit one's out-of-home movements unless absolutely essential, have been found to increase social isolation and loneliness (zhang et al., ) , alcohol abuse (wu et al., ) , and domestic violence (galea et al., ) . this could translate to widespread fear, anxiety, and depression in general society, particularly exacerbated in persons with existing mental health conditions who have an increased susceptibility to the adverse impacts of stress (duan and zhu, ) . here we report on the first wave of data collected from the collate project (covid- and you: mental health in australia now survey), an ongoing study aimed at understanding the impact of the covid- pandemic on the mental health and wellbeing of australians. the collate project all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july , . . https://doi.org/ . / (described below) focuses on identifying the current concerns, emotional experiences and risk factors for adverse covid- -related mental health outcomes in people currently living in australia. in our initial analysis of wave data, we focused on characterizing the primary concerns of respondents related to the current covid- pandemic as of april st to th . levels of negative emotion (depression, anxiety, and stress) were examined and compared with existing australian population norms; and were modelled as an outcome to identify possible risks factors related to demographic variables, personal vulnerabilities, financial stresses, and social distancing experiences. this study received ethics approval from swinburne university human ethics review committee (approval number: - ) and complied with the declaration of helsinki. on april st , adult members of the australian general public (aged +) were invited to participate in an anonymous ~ - mins online survey, completed at their convenience (i.e. the inclusion criteria to participate were being aged + years and currently residing in australia). participants were informed that surveys would be issued over the course of the project. these would be active for hours per month, from am on the st to : am on the th (australian eastern standard time), occurring monthly for the first year and then annually for the subsequent four years . participants were informed that they could complete as many or as few surveys as they wanted, with surveys from the same respondent being linked by a personalized pseudonym (thus a subsample would provide us with longitudinal data, with the remaining data cross-sectional snapshots over the surveys). all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july , . . https://doi.org/ . / after online consent, participants completed the survey which covered three broad topics: a) current were provided. as noted, the data described here relate to survey round : april , and only the measures addressing our aims for this manuscript are described below. invitations to complete the survey were placed on digital university and community noticeboards and social media (e.g. facebook, linkedin, instagram, and twitter) as well as participant registries held within the centre for mental health at swinburne university, which included participants with identified mental health conditions. exponential non-discriminative snowball sampling was used, with all participants asked to pass the invitation onto their networks. primary concerns: participants were asked to identify and rank their top current concerns (out of ) relating to the covid- pandemic, with being their greatest concern (see table for the full list of concerns). negative emotions: the depression anxiety stress scale (dass- ) was used. it is a -item selfreport measure yielding three subscalesdepression, anxiety, and stresseach containing seven all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint items (lovibond and lovibond, ) . individual items are scored on a four-point likert scale ( to ). dass- raw scores were doubled to render them comparable to full-length dass scores ( items). risk factors: measurement of risk factors were divided into four categories: demographics including: age, gender, education, living situation, geographical location/state, whether born in australia, ethnicity, and religion; personal vulnerabilities including: being someone at increased mortality risk (e.g. immune-compromised, > years), having lived experience of mental illness, being a carer of someone with a mental illness or special needs, and being a healthcare professional or 'essential' worker; financial stresses: fortnightly take-home pay, cash savings, mortgage repayments/rent, self-employment, job loss, and occupation; social distancing experiences: perceived positives of the situation, perception of government restrictions on mental health, perception of social distancing measures duration, and working from home. data were analyzed in spss v . . for all analyses, weights were used to adjust for imbalances in the sample based on the australian bureau of statistics (abs) population data for age, gender and geographical location/state (abs, ) . in all, there were categories for age ( - ; - ; - ; - ; - ; - ; - ; - ; - ; - ; - ; +) , two categories for gender (male; female) and four categories for state (victoria; new south wales; queensland; australian capital territory + northern territory + western australia + south australia + tasmania). by march st : australian eastern standard time (aest) there were , confirmed cases of covid- in australia, with deaths. the majority of confirmed cases were in the states of new south wales (n= , ), queensland (n= ) and victoria (n= ), with the other states and territories reporting a total of cases together. given confirmed case numbers, we stratified by state by examining these three states independently from the other states and territories, which were combined. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint primary concerns: to characterize the top ten primary concerns, the number of respondents endorsing each concern was obtained and mean rankings were computed for the ten most commonly selected options. rankings of zero were assigned to options not endorsed by a participant, and rankings of to were computed for endorsed concerns, with for the option of greatest concern. in this case, the weights developed used the joint distributions of the three weighting variables ensuring that the sum of weights assigned was (i.e. the total number of respondents to this question who also provided age, gender and geographical location/state data). negative emotions: depression, anxiety, and stress subscales and total dass scores were compared to australian population norms (lovibond and lovibond, ) using t-tests. additionally, the percentage of participants (weighted and non-weighted) were calculated across the four defined severity levels (normal, mild, moderate, severe/extremely severe) for the three negative emotions. respondents who failed to complete more than % of the dass items were removed from the analysis. remaining missing items were imputed using the em algorithm as little's mcar test showed items were missing completely at random. for this analysis, the sum of weights and sample size were equal to . risk factors: using a transformed (sqrt) total dass, the relationships between negative emotions and the four domains (demographics, personal vulnerabilities, financial stresses and social distancing experiences) were explored using general linear model analyses. participants started the survey, with n= respondents (~ % attrition) completing the primary concerns ranking question and providing demographic data. for the negative emotion analyses n= respondents completed the dass. demographic data is displayed in table . the sample was biased in favour of females aged - living in the state of victoria, making the use of post-stratification weighting essential in subsequent analyses. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint primary concerns: the primary concern data, with the percentage of respondents rating their top concerns, is presented in table . mean rankings were ordered from to in declining order of importance (mean and standard deviations calculated for the rankings of each concern). all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint "implications for health and wellbeing of family loved ones" was the most commonly endorsed concern, however, it ranked rd in terms of mean rankings. "loved one dying of coronavirus" and "loved one catching coronavirus" were the next most commonly endorsed primary concerns, and had the highest mean rankings. legend: ^ analyses weighted to adjust for imbalance in the sample of respondents based on australian bureau of statistics (abs)(abs, ) population data for age, gender and geographical location (state). # rankings of zero were assigned to options not endorsed by a participant and, for endorsed concerns, rankings of to were computed, with for the option of greatest concern. ~ on st march , australia was at stage activity restrictions, with australians told to stay at home except for four reasons -food and essential supplies, medical attention, exercise, and work and study if cannot do so remotely. the first collate survey was launched the following day, st all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint april . black text = top ten concerns in rank order, grey text = remaining thirteen concerns in rank order. negative emotions: figure (also see supplementary table ) shows mean values for the dass scores compared to australian norms. in all cases, they were significantly greater than the norms (ps<· ); with people self-identifying as having a mental health diagnosis (mh dx) scoring - · -fold higher than those without such a diagnosis, who themselves scored times higher than normative levels. table presents the score distributions across the four severity levels (normal, mild, moderate, severe/extremely severe); - % of the population demonstrated moderate-toextremely severe depression, anxiety and stress. legend: norms in australia from lovibond & lovibond (lovibond and lovibond, ) , mh = mental health all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint table ). people with a higher mortality risk, lived experience of mental illness, carer responsibilities for someone with a all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july , . . https://doi.org/ . / mental illness or special needs, as well as people in "essential" occupations, all had higher levels of negative emotions. financial stresses -adding finance-related variables to the model explained an additional · % of the variation (supplementary table ). individuals with higher fortnightly incomes and cash savings demonstrated lower levels of negative emotions. higher levels of negative emotions were experienced by people under financial stress to meet mortgage and rental payments as well as those expecting to lose their jobs. additionally, highest negative emotions were present for the unemployed, closely followed by homemakers, volunteers, or retired people. social distancing experiences -an additional · % of the variation was explained by adding social distancing variables (supplementary table ). generally speaking, higher negative emotions were recorded for those who found they now had more free time. this included those who had more down-time, more time to spend communicating with family, more time to do jobs around the house and for those who identified no positive influences in the current situation. however, negative emotions were lower for those who found they now had more time for hobbies. negative emotions were higher for those who reported that the government restrictions were adversely impacting their mental health, and for those who thought that the current restrictions might continue for more than months. finally, negative emotions were higher for those not working from home. risk factor summary -the four domains explained · % of the variance in negative emotions (summarized in table ). important predictors for high negative emotions (i.e.  ≥ · ) were being young ( - ), being female, being single, living in states with lower covid- cases (qld, act, sa, was, tas, nt), being at higher risk of mortality and having a lived experience of mental illness. the perceived negative effect of government restrictions on mental health was also highly associated with negative emotions, demonstrating the largest effect size,  = · . having sizeable cash savings, owning one's own home and predicting a short duration of the current situation were protective factors against experiencing negative emotions. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint legend: all selected predictors with partial effect sizes  ≥ . the first wave of data from the collate project provides an important characterization of the current mental health of australians during the covid- pandemic. the top three primary concerns among the general public were all related to the health and well-being of family and loved ones, specifically loved ones catching or dying from covid- . as expected, levels of negative emotions (depression, anxiety and stress) were exceptionally high, approximately three times greater than existing population norms in those with no pre-existing mental health conditions. of concern was the finding that those with a pre-existing mental health condition demonstrated negative emotions to . times greater than population norms. when the current australian dass data was compared with chinese data , two differences emerged. first, the mean total dass score from china of · (sd · ) was lower than that of australia, even for individuals not reporting a mental health condition ( - years: · (sd · ) and years+: · (sd . )). second, more australians were classified as having moderate-to-extremely severe negative emotions (see table ). these apparent cross-cultural differences will need to be further investigated with a specifically designed comparison study, with differences in social norms and civil liberties between the two countries being possible influences. nonetheless, both the all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july , . . https://doi.org/ . / australian and chinese data speak to the elevation of negative emotions in the general population during the covid- pandemic. in our data, modelling predictors of negative emotions established several risks factors related to demographic variables, personal vulnerabilities, financial stresses, and social distancing experiences. this included young people ( - years) as well as those that are approaching middle-age ( - years) . given that the number of young people experiencing mental health conditions has been rising over the last decade in australia (carlisle et al., ) , and internationally (miron et al., ) , this current data of such high levels of negative emotions in young people (up to age here) is of particular concern. increased negative emotions in our middle-aged respondents were associated with increased childcare duties and/or financial stresses that are specific to the immediate situation. this speaks to the importance of monitoring negative emotions in both young people and the middle-aged group longitudinally, that is, in the short and long term. being female was another significant risk factor for high levels of negative emotions (lu et al., , zhang et al., . while possible reasons for this remain to be determined, we speculate this could relate to juggling work and increased childcare duties, heightened risk of being in a domestic violence situation, as well as the higher risks of job loss and/or higher likelihood of being an 'essential' worker. those under financial strain and those who were unemployed are also at increased risk of psychological distress. thus, methods for targeting this 'financial strain' population to offer them more affordable options for mental health support will be important. finally, those with pre-existing mental illness are of specific concern van rheenen et al, ) , and existing mental health services will likely need increased all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july , . . https://doi.org/ . / support to meet the rising needs of these consumers. it is notable that since this survey was conducted, the australian government has announced a significant boost in funding to support mental health ($ m over the next two years) with initiatives including dedicated websites and phone lines to support people experiencing stress and anxiety from prevailing covid- related pressures, as well as a public information campaign. the current findings strongly underlie the need for such initiatives to be more targeted to specific groups. two other findings in our data warrant discussion. first, respondents from the two states with the highest number of covid- cases, new south wales and victoria, were found to have lower negative emotions. while this was unexpected, further examination of risk factors established there were a number of protective personal vulnerabilities and financial stresses for persons living in these two states. that is, these states encompassed a lower percentage of respondents with lived experience of a mental illness and a greater percentage of respondents with financial stability. another important, albeit unsurprising, finding from our data was that individuals who perceived that current government restrictions were very negatively impacting their mental health also had the most pronounced negative emotions. in the context of respondents' primary concerns with the health and well-being of family members, this finding reinforces that government restrictions, such as social distancing, may be better be framed in public messaging as necessary for protecting loved ones and ourselves from contracting the virus. such a refocusing on positive outcomes may provide individuals with a sense of agency that tempers the powerlessness of being given a legal mandate to stay home. a limitation of the study was the snowballing approach to survey recruitment; this resulted in a nonrepresentative sample of the australian population, which included some respondents with known mental health diagnosis. to address this, weightings were used based on abs data (abs, ) to statistically correct for any bias. however, even with statistical weighting, it is difficult to account all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint for specific subgroups, for example those without access to the internet. furthermore, despite > participants starting the survey, only ~ had useable datasets due to considerable attrition ( %), which is albeit typical of online research. this data provides a snapshot of mental health and well-being of australians in april in relation to covid- ; to do so we compared current negative emotions to existing australian norms. it is possible differences in sampling factors related to the current sample data and existing norms may explain some of the differences rather than covid- itself. however, given the magnitude of our findings in terms of elevated negative emotions in the general community such sampling differences are unlikely to explain the large variance between current and norm data. we also did not assess the mental health of school-aged children and adolescents in the current survey, the majority are whom are being home-schooled and not permitted face-to-face contact with their peers in australia at present. school-age children may thus be particularly vulnerable to stress and anxiety, and a critical avenue for future work will be to examine this group specifically. the data collected from the collate project will provide a reference for healthcare professionals in terms of current mental health needs in australia, in addition to guiding policymakers in making accurate provisions within mental health services and actionable policies. the findings are predicted to be applicable across other nations with similar healthcare systems and government management of the covid- pandemic. important findings from the data are that: a) people with existing mental health conditions have very high levels of negative emotions (as per (duan and zhu, ) ) , in addition, there are b) high levels of psychological distress in the general community, with some individuals particularly vulnerable (as per ). the fluid nature of the situation throughout this pandemic makes our continuing and longitudinal comparisons of the mental health effects of government restrictions and lock-down duration forecasts a priority for future study. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july , . . https://doi.org/ . / overall, this data has made it clear that increased mental health support will be of paramount importance as the world faces the consequences of the covid- pandemic. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july , . (lovibond and lovibond, ) , nwt = weighted sample size, m= mean, sd = standard deviation, md = median, mh = mental health, dx = diagnosis all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july , . . https://doi.org/ . / -ncov national incident room surveillance team . -ncov acute respiratory disease psychological interventions for people affected by the covid- epidemic the mental health consequences of covid- and physical distancing: the need for prevention and early intervention we're staying at home". association of self-perceptions of aging, personal and family resources and loneliness with psychological distress during the lock-down period of covid- manual for the depression anxiety stress scales. sydney: psychology foundation monograph psychological status of medical workforce during the covid- pandemic: a cross-sectional study neurologic manifestations of hospitalized patients with coronavirus disease suicide rates among adolescents and young adults in the united states alcohol use in australia during the early days of the covid- pandemic: initial results from the collate project eating and exercise behaviours in eating disorders and the general population during the covid- pandemic in australia: initial results from the collate project considerations for assessing the impact of the covid- pandemic on mental health in australia. australian and new zealand journal of psychiatry survey fundamentals: a guide to designing and implementing surveys. madison: board of regents mental health status of individuals with a mood-disorder during the covid- pandemic in australia: initial results from the collate project covid- ) epidemic among the general population in china who director-general's opening remarks at the media briefing on covid- - alcohol abuse/dependence symptoms among hospital employees exposed to a sars outbreak mental health and psychosocial problems of medical health workers during the covid- epidemic in china (gnt ), and ejt (gnt ) and tvr (gnt ) hold early career nhmrc key: cord- -bfmpxtoy authors: currie, geoff title: covid impact on nuclear medicine: an australian perspective date: - - journal: eur j nucl med mol imaging doi: . /s - - -z sha: doc_id: cord_uid: bfmpxtoy nan the covid pandemic will redefine the way we live. the immediate threat from covid to health and to the nuclear medicine community is rapidly changing. it is useful to consider how covid is shaping nuclear medicine practice globally. the covid pandemic requires reconsideration of the risk:benefit equilibrium in nuclear medicine practice [ ] . here, a perspective from an australian context is provided. consideration should be given to the interplay between the resilience and crisis management skills developed during the multiple australian mo crises of and then , and the challenge fatigue these events have produced. casting an eye forward, the silver lining, if we can be brave enough to consider, might be more sustainable practices. the nuclear medicine profession is also gifted with inherent capabilities associated with radiation safety management that confer agility in the changing landscape; radiation control provides an infection control barrier in practice, alara (as low as reasonably achievable) principles are transferrable, foundations of radiation safety (time, distance and shielding) translate to infection control and the concept of justification, optimisation and limitation can provide immediate guidance for decision making in the covid crisis. across australia, at the time of writing, society was in lockdown. only essential travel was permitted. staff, who could work at home, were required to do so. public gatherings of more than people were outlawed and fines issued for breaches. crossing state borders was banned. the downstream effects of this have seen a reduction in demand for nuclear medicine services; however, this was already being experienced with the implementation of urgent/acute only services in many departments. during the last week of march, centralised pharmacies had experienced a % reduction, % in larger centres like sydney and only % in rural areas. referrals had significantly reduced for sites remaining on full service with a representative example being a major site where general practitioner referrals reduced by % and specialist referrals by % for the last week of march. one report indicated a % reduction in general practitioner referrals to a normally busy private hospital. this scenario raises a number of questions. what tools are used to determine which patients are sufficiently urgent to warrant scanning during the crisis? the process varies substantially across the sector. furthermore, scans are not simply postponed as there is no clear point where lockdown and recommencement of usual services will commence. does this change the threshold we apply to triaging an urgent scan? postponement really represents cancellation. does an urgent or acute scan in a patient positive for covid or presenting with symptoms change triage? do symptomatic patients get rescheduled until after confirmatory testing or are they redirected to other services? rosenthal [ ] reminds us that the four pillars of bioethics are autonomy, beneficence, non-maleficence and justice. in this time of crisis, decisions should be grounded in beneficence, non-maleficence and equity; the patient themselves are perhaps not in the best position to determine urgency but in many cases, autonomous decisions not to attend appointments have been made. rosenthal [ ] suggest that deprioritisation should be on the basis of: these are decisions australian nuclear medicine teams are grappling with on a daily basis. the mean age of australian nuclear medicine patients is over years of age and patients generally present with multiple comorbidities. the typical nuclear medicine patient is not only high risk for contracting covid but is the most vulnerable to dire or fatal outcomes. this, in itself, justifies limiting elective and non-urgent procedures. it also demands specific strategies to limit the risk of transmission to all patients and staff, but in particular our most vulnerable. strategies adopted in variable combinations in some australian nuclear medicine departments include, without being limited to: over the last decade, there has been a redefining of the work function of the nuclear medicine technologist with diagnostic ct not only being part of the scope of practice but the foundation qualifications. spect/ct and pet/ct systems are frequently used as overflow for diagnostic ct when caseload on the stand-alone ct scans is excessive. one of the early responses to covid imaging with chest ct in some australian departments was to shunt covid cases to nuclear medicine. this reflected the larger role ct plays in urgent and acute patients and the decreasing caseloads in nuclear medicine during the crisis. this approach allowed the high-volume diagnostic ct scanner to be a covid -free zone for negative patents with the lower volume symptomatic or covidpositive patients circulating through ct on hybrid nuclear medicine systems. while sensible, it has put additional risk, stress and strain on the nuclear medicine staff. the other significant discussion point in australia is the role of ventilation perfusion lung scanning. it is possible patients presenting for pulmonary embolism evaluation (an emergent study) are covid positive. the lung scan appears less useful for evaluating covid itself. perfusion only scans allow a normal perfusion to clear the patient of pulmonary embolism and avoid the higher risk ventilation study. concurrent covid is likely to cause perfusion defects in the absence of pulmonary embolism [ ] . there are concerns that the ventilation scan requires staff to spend more time close to the patient during a ventilation scan that is known to be a high risk of area contamination from patients breaking the apparatus seal or coughing. furthermore, aerosol units are difficult to decontaminate. departments performing spect/ct (common in australia) may forgo the ventilation scan in favour of using the ct scan to represent airways and potential mismatch for pulmonary embolism diagnosis. technegas is in widespread use in australia and offers a number of clear advantages in the covid patient. the ventilation procedure is faster, reducing time and improving compliance which in turn decreases the risk of room and staff contamination. the apparatus is single use without recirculation and so poses no risk between patients. in either case, subject to ppe availability, staff should wear a n mask, gown and gloves with all equipment being sanitised afterward. as previously outlined, in some departments, all lung scans have been routinely diverted to ctpa. nuclear medicine is a highly specialised discipline and staff are not readily substituted. it is essential, therefore, to protect the workforce to ensure the highly trained physicians, technologists and scientists are available to provide the life-saving and life-changing services required for acute or emergent situations. as discussed above, part of that solution is to limit services to those in most need. to protect and preserve services and functions, a number of approaches have been used across australia. single centre departments, as described above, have split staffing between equipment with no cross-over to ensure a covid patient team and a negative team. some multicentre sites have split staff into teams to operate wholly at one site without cross-over. this allows protection of teams from covid exposure in another team. for example, if a member of site team a was suspected of being covid positive, the entire team would be quarantined but patients could continue to be serviced by site b team. in the larger public sector, a single hospital nuclear medicine department may be open to service patients while all others are in lockdown. if covid is suspected amongst any of that team, that hospital service can be closed and the next public hospital team opened. both of these scenarios are possible because of the downturn in patient demand for services. the australian nuclear medicine community relies on ansto for mo/ mtc supply. as seen in the and then mechanical failure-based supply crisis, the single supplier model has a degree of vulnerability. in any number of processes, if a single staff member was suspected of being covid positive, the entire supply chain would be disrupted. ansto have split process staff into teams with no cross-over between the teams. on the global scale, it is a small operation. while the reactor can produce % of global mo demand, ansto only produces generators weekly for domestic use. with the split teams comes inefficiency and this number has been reduced to , forcing rationing measures in practice. some demand has fallen for sites not operating and through lower use in centralised pharmacies. mo production remains high which allows the fewer generators to be loaded with larger amounts of mo that, for some departments, provides a -week supply, stretching the weekly generators to meet national needs. if one of the teams is taken out of production due to suspected covid , clearly an acute shortage of generators will result ( weekly). a number of nuclear medicine staff are particularly vulnerable to covid including older staff, those with health issues, those with diabetes and those indigenous staff. it is a micro-version of the national dilemma; how do we restrict the entire population behaviour to protect the most vulnerable? most centres simply redirect at risk staff into other areas like radiopharmacy or the covid -free imaging team. working from home is not possible for clinically active staff but for some in management or reporting physicians, working remotely provides a good solution. others have opted to take leave during the crisis, for some that is paid leave due to long service entitlements while others, it is unpaid. at the time of writing, i had not heard of any situations but no doubt some older staff have used covid as the catalyst for retirement. not all departments work in teams; with australia being geographically sparse and vulnerable, staff often find themselves as the only operator for their region. a single example is the -km stretch of the well-populated region north of sydney (newcastle to port macquarie) that has a single nuclear medicine department (taree), a single nuclear medicine technologist and remote physicians reporting. the technologist is years old and no doubt torn between maintaining services to the community and protecting her own health and wellbeing. the covid crisis has seen significant disruption to professional life in australia. with the geographic and professional isolation of nuclear medicine services and the population we serve, cancellation of conferences (e.g. anzsnm ), branch meetings and personal travel have increased the sense of professional isolation. rains (rural alliance in nuclear scintigraphy) has worked hard to keep rural and regional nuclear medicine communities and those professionally isolated in metropolitan areas connected and supported via facebook. rains has also used zoom virtual conferencing to deliver professional development activities and to have social gatherings remotely (virtual version of the traditional friday beer after work). the mental health and wellbeing of our communities will be challenged during this social and professionally isolating period. restrictions on non-essential travel have driven patients to reconsider their travel. in remote and rural communities, this might result in patients opting out of medically important nuclear medicine procedures. the small community of wagga wagga for example ( , population) services a very large health community of , people dispersed over , square kilometres. it is not uncommon for patients to drive several hours for services, often requiring time off work and overnight stays. covid and associated restrictions have discouraged many remote patients to travel for services. in western australia, remote patients often fly to centralised nuclear medicine services and there are also fly in/fly out nuclear medicine services in several remote communities. with decreased domestic flight availabilities, these services, often to our most vulnerable australians, have been limited. there have also been significant challenges for nuclear medicine staff. the downturn in patient numbers has created acute financial pressure expected to be protracted beyond months. the public sector (state government owned) will accommodate this and given the decrease in service utilisation, while carrying salary costs, the remainder of the department budget is likely to be lower. the private sector is more vulnerable to fluctuations in demand and many staff face the prospect of redundancy, direct pay cuts, indirect pay cuts through fewer hours ( days per week for all reduces salaries by %), forced unpaid leave and forced paid leave (annual leave and long service leave). a number od sites have closed operations, many staff made redundantnad even more staff now working - % of their usual hours. at the same time, access to and availability of ppe are becoming increasing limited. some sites have reported running out of alcohol swabs to use for patient injections short term. generally, a very difficult situation when staff feel both insecure in their employment and unsafe in their work environment. impact on radiopharmaceutical supply ansto had major ( weeks each) maintenance periods scheduled in april and june of . during this time, australia would rely on imported mo for the reactor maintenance period, and ansto mo being shipped internationally and returned as generators for the generator production facility maintenance period. with borders closed, flights grounded and economic crisis globally, these periods would leave australian nuclear medicine very vulnerable. ansto have delayed one of these periods and at the time of writing, working on solutions for the second. furthermore, australia relies on importation of a number of radionuclides (e.g. i, ga, tl and more) whose supply now confronts production and transport barriers. in australia, we have already seen some limitations associated with cold kit importation. domestically, significant disruption to the transport network (air and road) has caused widespread delays in deliveries and increased costs. for example, the government has chartered a flight routinly to bring i mibg into australia from japan. largely research and clinical trial recruitment has come to a stop due to covid . multidisciplinary meetings have largely been moved to virtual platforms which in some cases enriches the meeting. some physicians have moved to a remote reporting model which is not new but more widely used during the covid crisis. the latter of these impacts are different and perhaps challenging during the strain of the covid crisis but may enhance outcomes and provide sustainability moving forward. student training has been a big challenge during the covid crisis. at charles sturt university, we had a great deal of agility in student delivery which allowed very rapid conversion from face to face in class teaching to online delivery and student support. students have been off campus since mid-march and staff are working from home. not an easy feat given we have , students on campus across major campuses and several smaller sites, and staff; but we already have over , students learning online. for nuclear medicine, the challenge was how to manage student clinical placements. at the time of writing, the position was that students already on clinical placement should stay on clinical placement if the clinical site continued to operate. this essentially related to residency students completing weeks of training in their th year who had already been embedded in a clinical team for months. the risk of bringing in new students to a team was considered unacceptable, especially for a short block of weeks. consequently, short placements for second and third year students had been postponed. this also recognises the decreasing demand for services, decreasing the learning opportunities for junior students. indeed, most of these students requested delaying placement not for covid reasons but to ensure the learning environment was richer and more diverse. the governing body (ahpra) has been very responsive to the crisis and provided clear directions that if educational providers need to modify approved programs to traverse the covid crisis, they do not need to provide approval if the learning outcomes for students do not change. the focus in managing student placements is on patient safety, staff safety, student safety, community safety and ensuring students demonstrate the requisite learning outcomes and capabilities. covid is the greatest challenge most of us will experience in our lifetimes. in nuclear medicine, the effects and implications are far reaching. australia's geographic isolation provides a degree of both insulation from global crisis and vulnerability to ramifications. while both issues and solutions are shared across the globe during this time, there will also be some unique characteristics for individual international communities. the australian perspective may provide a helpful perspective for our international family. this article does not contain any studies with human participants or animals. diagnostic evaluation of pulmonary embolism during the covid- pandemic ethical issues in radioisotope shortages: rationing and priority setting publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord- -f jzbtjj authors: raphael shulman, n. title: hepatitis-associated antigen date: - - journal: am j med doi: . /s - ( ) - sha: doc_id: cord_uid: f jzbtjj nan n. raphael shulman, m.d. from the clinical hematology branch, national institute of arthritis and metabolic diseases, national institutes of health, bethesda, maryland, requests for reprints should be addressed to dr. n. raphael shulman. identification of an antigen that is intimately related to the causative agent of viral hepatitis has given impetus to hepatitis research. blumberg and associates [ ] found this antigen incidentally while working on precipitins of ~-iipoprotein allotypes. the precipitin was in the serum of a patient with hemophilia who had received multiple transfusions, and the antigen happened to be in serum from an australian aborigine. the precipitin line that formed in ouchterlony double diffusion differed in specificity from known #-iipoproteins, and the antigen was called australia antigen or au ( ) . the antigen was considered to be inherited as a recessive trait based on statistical analyses of its occurrence in large tropical populations [ ] . a relationship was gradually recognized over the next four years between australia antigen and leukemia, down's syndrome, lepromatous leprosy and hepatitis, and the possibility was considered that the au( ) trait might be associated with susceptibility to viruses [ , ] . okochi and murakami [ ] confirmed the association between australia antigen and hepatitis and demonstrated the appearance of antigen during the incubation period and acute phase of classic post-transfusion viral hepatitis. prince [ ] reported similar observations on patients with serum hepatitis and called the antigen, sh. examination of an immune precipitate of au( ) by electron microscopy showed aggregates of a particles [ ] , and shortly thereafter the close relationship between australia antigen, the occurrence of viral hepatitis and the presence of virus-like particles in antigenic serum was confirmed [ , [ ] [ ] [ ] [ ] . although several different names have been applied to the antigen, only a single well documented specificity exists, and many workers have adopted the more general term, hepatitis-associated antigen (haa), rather than the genetic nomenclature, au( ), of blumberg et al., or the more circumscript sh antigen of prince. this review summarizes information on the physical and chemical characteristics of the hepatitis-associated antigen (haa), the clinical circumstances under which haa and anti-haa occur, the association between haa and transmission of hepatitis, the relationship between anti-haa and immunity, and the suitability of various technics for measuring haa and anti-haa. first peak of serum filtrates on sephadex | gel, traveled as an ~ globulin in gel electrophoresis, appeared to contain a small amount of lipid on the basis of a weak reaction with sudan black, and differed from other lipoproteins in its immunoreactions and density. haa was more dense than #-iipoproteins, being in fractions that sedimented in potassium oromide at specific gravities between . and . , and lighter than most serum proteins which were in fractions of specific gravity > . . the antigen was considered to be possibly an altered, partially delipidized lipoprotein until its virus-like nature was revealed by electron microscopy of precipitates of haa formed with specific antiserum [ ] . these precipitates contained conglomerates of particles approximately a in diameter with some elongated structures of the same diameter varying in length up to , a. within a year several groups of investigators reported the presence of the same virus-like particles in serum that was positive for haa by immunologic tests [ ] [ ] [ ] [ ] . virus-like characteristics. haa particles aggregated by antibody can be pelleted in ten minutes at , g and are readily seen after negative staining ( figure ). the particles have a modal diameter of approximately a ( figure a ); in some preparations, an occasional particle appears to have a central core [ ] . ( figure b ); and usually a few conspicuously large spherical particles are seen ( figure c ). different serum specimens contain varying numbers of tubular or filamentous forms which show periodicity ( figure c ). because of their size, filamentous and large spherical forms can be separated from the more uniform a spherical forms by differential rate sedimentation in cesium chloride gradients [ ] . organic solvents disrupt tubular forms, suggesting that they may consist of spherical particles inside a common lipid-containing membrane [ ] , perhaps of cellular origin. ether treatment reduces the diameter of the spherical particles by approximately a (figure ), suggesting removal of a a outer coat. the coat may contain some lipid, for the density of the particles measured in cesium chloride gradients increases from approximately . before treatment to approximately . after treatment with organic solvents [ ] . one report [ ] suggests that treatment with mild detergents such as tween | , or freezing and thawing, may remove lighter capsid material and increase the density of haa to the range of . to . on cesium chloride gradients; the apparently heavier haa could be detected only by complement fixation and not by electron microscopy. some investigators think that particles with apparent "core" material or "inner bodies" represent complete virus or infectious virion, but these particles have not been separated as yet from the more numerous apparently "empty" particles to determine whether they contain nucleotides. dane et al. [ ] have reported /~, particles, similar to the larger spherical particles shown in figure c , which they considered to be the complete virus in haa-positive specimens from three patients. these particles probably were not aggregates of smaller spheres, for they were not disrupted by ether [ ] as are tubular forms [ ] . although the a particles appeared to be slightly more dense than the a particles in cesium chloride gradients, the two sizes could not be separated by isopycnic banding. millman et al. [ ] , have reported that tests for nucleotides were negative on purified haa used in sufficient amount to permit measurement of ribonucleic acid (rna) if it were per cent, or deoxyribonucleic acid (dna) if it were per cent of the total weight of protein in the preparation. similar attempts by other investigators to measure rna or dna in purified haa have given negative results. the low density of most haa preparations therefore appears to be clue to lack of nucleotides in the particles as well as to presence of some lipid. the size of the haa particle is the same as that of the small viruses in the picornavirus, p~rvovirus, arborvirus or enterovirus groups, but precise classification has not been possible because the attributes of the particles are not characteristic of any one group. the angularity of the outline of some particles and the apparent surface structures of approximately a subunits with no uniform arrangement (figure ), resemble features of defective adeno-associated virus [ , ] . however, the picornaviruses, parvoviruses and adeno-associated virus contain no lipid and have a higher buoyant density of . to . in cesium chloride, reflecting a relatively high nucleotide content [ , ] . haa resembles some arborviruses in size, lipid content, and density; and resembles some enteroviruses in size and stability. however, haa differs serologically from the known arborviruses, enteroviruses and other viruses, for complement fixation reagents representing serotypes of picorna-, parvoand arborviruses failed to fix complement with haa or anti-haa [ ] . the particles are very stable. morphologic characteristics of haa and its antigenicity by immunodiffusion and complement fixation remain unchanged after heating at ~ for one hour, after storage at room temperature for at least six months, or at -- ~ for more than twenty years [ , ] . after treatment with organic solvents minor changes, such as shown in figure , are evident, but antigenicity may actually be increased, perhaps because flew sites are uncovered by removal of lipid or associated antibody [ ] . correlation with observations on infectivity. mc-collum's filtration experiments in [ ] to determine the size of the serum hepatitis agent as judged by infectivity in human beings showed that the serum hepatitis agent could pass through a filter of a average pore diameter. since the particle would have to be approximately half the diameter of the filter pore, or < a, to permit its passage, the infectious agent is probably the size of the most abundant haa particles. by titering infectious plasma in experimental subjects, murray [ ] estimated the concentration of infectious particles in serum from patients with serum [ ] [ ] [ ] [ ] [ ] density [ , , , ] n ucleotide content [ ] stability [ , , , , ] protein-like characteristics [ ] distribution of haa in cohn ethanol fractionations of highly contaminated plasma [ ] was based chiefly on incubation period after the implicated parenteral exposure, short-incubation (two to six weeks) being called infectious hepatitis, long-incubation (six to twenty-six weeks) serum hepatitis. most cases in which there was no parenteral exposure were considered to be infectious hepatitis, and some were not differentiated. the ms- and ms- cases were all produced by jnjecting material known to produce short-and long-incubation-period hepatitis, respectively. ms- and ms- cases were excluded from the totals, as were the cases of hirschman et al. which were subsequently analyzed with the more sensitive complement fixation technic (shulman et al.) . hepatitis in the acute phase (acute phase serum) to be /ml [ ] . the concentration of haa particles counted by electron microscopy in similar acute phase serum is usually greater than ~ in view of this disparity and biologic evidence (presented later) for transmission of hepatitis by materials conraining haa, it seems likely that material identified as haa is chiefly "noninfectious" empty virus coat. although incomplete virus predominates some complete infectious virus is present. this observation on the physical and chemical stability of haa are consistent with the known stability of the i~fectious agent of hepatitis, for contaminated plasma transmits the disease after similar treatment with heat or solvents, and after similar peribds of storage [ ] . physical and chemical attributes of haa, including the distribution of haa in cohn ethanol fractions of human plasma [ ] , are summarized in table i . haa in acute hepatitis. frequency of haa in acute hepatitis: after the initial suggestion in by blumberg and co-workers [ ] that australia antigen might be related to the infectious agent of viral hepatitis, and the demonstration in by okochi and murakami [ ] and prince [ ] that the antigen appeared in blood of patients during the incubation period of serum hepatitis, a number of investigators reported further evidence for existence of a hepatitis-associated antigen (table ii) . the over-all frequency of haa in the cases of acute viral hepatitis was per cent. in control populations (table iii) only . to . per cent of hospital personnel and patients without liver disease had haa in their blood; the same low frequency was seen in patients with liver disease or hepatitis clearly unrelated to viral hepatitis as in patients without liver disease. the frequency of haa in blood donors in new york was . per cent; and in different groups of blood donors in tokyo, . to . per cent (table ii i) . patients with viral hepatitis show a variable frequency of positive tests for haa depending not only on differences in the number of samples taken per patient and on the stage of the disease at which serum is tested, but also on the technic used for measuring haa. the highest frequencies are found when sampling is early in the course of the disease rather than late in the active phase or in the convalescent phase [ , , [ ] [ ] [ ] , when more than one sample is taken at about weekly intervals [ , , ] , and when a more sensitive technic such as complement fixation (cf) is used rather than the immunodiffusion technic [ ] [ ] [ ] . identity between "haa-positive" and "long-incubation" hepatitis: generally the frequency of haa was greater in patients with documented post-transfusion or post-injection hepatitis than in patients with no history of parenteral exposure. in those series in which all patients were tested during the early acute phase of the disease, the frequency of haa varied from to per cent for hepatitis acquired parenterally and from to per cent for sporadic cases of hepatitis that were considered to be infectious (table ii) . none of the patients listed in table ii were involved in a so-called "single source" outbreak of shortincubation infectious hepatitis, and well documented epidemics of short-incubation viral hepatitis involving person to person spread have not as yet been associated with positive tests for haa [ ] . diagnosis of serum hepatitis can be established with certainty by the incubation period after parenteral exposure, but if there is no reasonable history of parenteral exposure the diagnosis is usually considered to be infectious hepatitis even if the source of infection and the incubation period are uncertain. therefore, in table ii both long-incubation and short-incubation viral hepatitis cases are no doubt included in the groups of patients with the diagnosis of infectious hepatitis. in view of the following evidence that the long-incubation type of viral hepatitis is associated with haa and the short-incubation type is not, and that both types can be transmitted parenterally or orally, it is possible that all the haa-positive cases listed in table ii in which the diagnosis was infectious hepatitis were long-incubation hepatitis. early work on the oral and nasopharyngeal transmission of long-incubation hepatitis was equivocal or negative [ , ] . however, there is a noteworthy epidemiologic study indicating that this form of hepatitis can be spread by intimate contact [ ] ; there are recent reports on epidemics of long-incubation hepatitis in patients and staff on renal dialysis units sug- [ ] . gesting person to person spread [ , ] ; and epidemiologic and experimental observations by krugman and co-workers [ ] indicating that institutional, endemic, long-incubation hepatitis can be transmitted nonparenterally. the studies of krugman et al. clearly demonstrate two distinct hepatitis agents, one responsible for long-and the other for short-incubation hepatitis. the short-incubation agent, called ms- , produces hepatitis thirty-five to forty-seven days after injecting or feeding infectious serum or stool filtrates, whereas the long-incubation agent, called ms- , produces hepatitis forty-one to days after injection and approximately seventy to days after feeding infectious serum. it is noteworthy that the oral dose necessary to produce the delayed long-incubation hepatitis was fiftyfold higher than the pa- figure and in the patients of okochi and murakami [ ] and of gocke and kavey [ ] . duration of haa in gocke and kavey series estimated from data given. haa in each series measured by agar gel diffusion. renteral dose, indicating that infectivity is markedly decreased when the agent is transmitted orally. giles and co-workers [ ] found that almost all patients given the long-incubation ms- agent have haa in their serum during the incubation period or acute stage of hepatitis, whereas patients given the short-incubation ms- agent never have haa in their serum (table il) . in our experience, haa found in patients diagnosed as having "serum" or "infectious" hepatitis has identical immunologic specificity [ , ] . short incubation (infectious) hepatitis and long-incubation (serum) hepatitis are known to confer homologous but not heterologous immunity [ , ] as do the ms- and ms- agents of krugman, et al. [ , ] . thus, at least two viral agents cause the same clinical manifestations of hepatitis and can be transmitted in the same ways, but one has a longincubation period and produces haa, whereas the other has a short incubation period and has not yet been defined immunologically. appearance and persistence of haa: the temporal relationships between exposure to hepatitis, appearance of haa in blood, and development of symptoms and abnormal liver function tests were well documented in studies involving serum specimens collected from sixty subjects who had been inoculated with icterogenic plasma in hepatitis transmission experiments carried out between and [ , , ] . figure is a cumulative plot with time of subjects in whom jaundice developed and in whom the complement fixation and immunodiffusion tests for haa became positive. figure shows the duration of haa in these same patients and in additional patients studied by other investigators [ , ] . with the more sensitive complement fixation technic, haa appeared, on the average, four weeks before clinical or laboratory evidence of liver dysfunction, although this interval varied in individual cases from one day to seven weeks. krugman and giles [ ] , using complement fixation technics, found that haa appeared two weeks to two months before abnormal levels of serum glutamic oxalic transaminase (sgot) in patients inoculated with the ms- hepatitis agent. the less sensitive agar gel diffusion technic detected haa about two weeks after the complement fixation technic ( figure )at about the same time that elevation of serum glutamic pyruvic transaminase (sgpt) could be measured [ , ] . haa that appeared during the incubation period of experimental hepatitis persisted in almost all cases until onset of symptoms and abnormal liver function tests [ , ] . in most cases of naturally occurring hepatitis, serum obtained in the first week of the acute phase was most likely to be positive for haa [ , , ] , although among patients studied by cossart and vahrman [ ] antigen developed in more patients during the second week of illness. persistence of antigen in blood ( figure ) has been the american journal of medicine found by a number of investigators to range from a few days to many years [ , , , , , [ ] [ ] [ ] . in most cases haa disappeared before symptoms subsided or biochemical abnormalities returned to normal, although in some cases the reverse was true. there was no significant difference in duration of haa in the eighty patients diagnosed as having "serum" hepatitis in (figure ), the six patients diagnosed by gocke and kavey [ ] as having "infectious" hepatitis, in the patients diagnosed by cossart and vahrman [ ] as having "serum or infectious" hepatitis, or in subjects inoculated with the ms- agent [ ] . in all the various studies there appeared to be no consistent correlation between persistence of antigen up to sixteen weeks and time at which haa was first detected in the blood, titer of haa or severity of hepatitis [ , , , ] . the "carrier" state. of eighty-six haa-positive patients in experimental hepatitis transmission studies ( figure ), eight had antigen in their blood at sixteen weeks, and it was still present in serum samples of all eight taken three years later. in the studies of krugman and giles [ ] , per cent of institutionalized children who had a positive test for haa after inoculation with the ms- agent retained the antigen in their serum for many months or many years, and the frequency of haa persisting more than twenty-four months in asymptomatic adult patients in the same institution was approximately per cent. ordinarily, when haa could be detected in a patient at four months after the onset of acute hepatitis, it was present indefinitely [ , ] . those who have been observed to retain haa recovered from the acute illness in a routine fashion and had either very mild or no laboratory or clinical evidence of hepatitis at the time haa was still present four months to many years later. although persistence of antigen may occur after hepatitis of all degrees of severity, it appears to occur more commonly after very mild or subclinical hepatitis than after overt clinical disease [ , , , , , ] . hence many carriers of haa rnay be unaware of an antecedent episode of acute hepatitis. this is in keeping with recent observations that asymptomatic subjects who have haa in their blood will also have histologic evidence of chronic liver disease [ , , ] even when their liver function tests, including transaminase values, are normal and they have no history of antecedent hepatitis. the frequency of subclinical chronic hepatitis as judged by the incidence of haa in apparently healthy populations would be about . per cent in the united states, to per cent in many tropical regions and as high as per cent in certain endemic areas [ ] . evidence suggests that subclinical chronic hepatitis occurs more frequently the lower the dose of infectious virus (see section "relationship between viral dose, mode of transmission and severity of hepatitis"). haa in symptomatic chronic liver disease. pro-gressive changes in serial liver biopsy specimens from acute viral hepatitis to cirrhosis have been well documented [ , ] , and recently sherlock and coworkers [ ] observed these changes over a ten month period during which tests for haa remained positive. since haa-positive acute viral hepatitis can be fol, lowed by a spectrum of chronic liver lesions, it is not surprising that a high frequency of haa has been associated with certain categories of chronic liver disease (table iv) . there is a high frequency of haa in prolonged viral hepatitis whether the lesion is that of unresolved classic hepatitis or subacute hepatic necrosis (table iv) . the difference between these patients and asymptomatic carriers of haa appears to be one of degree of hepatic involvement, the level of haa does not seem to vary with fluctuations in liver function tests and is not related to the degree of abnormality of these tests or severity of the symptoms. haa occasionally has been observed to disappear in the face of persistent symptoms and abnormal laboratory tests but tends to persist even when activity of the disease is suppressed by adrenal corticosteroid therapy [ ] . in all instances in which haa was present in the blood of subjects who had liver biopsies, histologic lesions of chronic hepatitis were found even during remission when there were no symptoms and no abnormalities in liver function tests [ , , ] . patients in london with chronic persistent hepatitis have not had haa in their blood [ , ] . however, all but one of the patients studied in one series had "infectious" hepatitis rather than "serum" hepatitis as the initial illness [ ] , and a high proportion of patients in the other london series probably had "infectious" hepatitis [ ], whereas there was epidemiologic evidence of "serum" hepatitis in every case of prolonged hepatitis studied by wright et al. [ ] in the united states. chronic active hepatitis: although some cases of chronic active hepatitis (cah) (or active chronic hepatitis) appear to result from unresolved viral hepatitis, cah seems to be a syndrome rather than a single disease [ ] , for many cases in this category appear to be closely related to lupus-like disorders. in several studies in the united states, to per cent of patients with cah have had positive tests for haa [ , [ ] [ ] [ ] . the titers of haa in patients with cah are the same as in patients with acute viral hepatitis, i.e., usually : or greater by complement fixation; but in contrast to the transient nature of haa in acute ' hepatitis, the titer tends to remain constant for many months to several years in cah despite fluctuations in liver function tests and in face of various forms of treatment including adrenal corticosteroids [ , ] . however, haa disappeared in several patients with cah over a period of many months while clinical improvement occurred [ , ] . although patients with cah are predominantly female, those with cah who have circulating haa are predominantly male [ ] and usually have had an antecedent episode of acute hepatitis with a strong history of parenteral exposure. although about per cent of patients with cah have a positive lupus erythematosus cell phenomenon [ ] , a much lower per cent of patients with cah and haa have had a positive lupus erythematosus cell test [ , , ] , and almost all reported patients with cah and a positive lupus erythematosus cell test, have not had a positive test for haa. thus the test for haa seems to differentiate two groups of patients in the category of cah: the haa.positive group that most likely progressed from acute viral hepatitis, and the lupus erythematosuspositive, haa.negative group that probably represents an immunologic aberration with lupus-like features. subdivision of cah cases in this way may prove to be of prognostic and therapeutic importance, particularly with respect to the use of ad renocorticosteroids. similar cases of cah in england and australia were not associated with positive tests for haa [ , ] . since levels of haa in positive cases in the united states were usually high and easy to detect even with weak antibodies, technical differences do not seem to account for this discrepancy. perhaps cah in the united states is more often a sequela of haa-positive viral hepatitis than it is in other countries in which this type of hepatitis is not as prevalent, cirrhosis: cryptogenic cirrhosis or inactive postnecrotic cirrhosis, which in some instances may represent the inactive phase of cah or the healed stage of acute viral hepatitis [ ] , has a low incidence ofhaa (table iv) . although it is considered that acute viral hepatitis may be the etiology of some cases of primary biliary cirrhosis, the disease is most likely not related to the haa-positive form of hepatitis, for of eightythree cases studied by two groups of investigators all were negative for haa (table iv) . laennec's (alcoholic) cirrhosis is not associated with haa unless the patients have received transfusions (table iii) . recently prince and burke [ ] reported positive tests for haa in nine of ten patients with primary biliary cirrhosis, using a high voltage counterelectrophoresis technic, but found no positive reaction with a lower voltage technic [ ] . we have found that the high voltage and low voltage technics are identical in sensitivity, but the high voltage technic according to prince and burke is subject to false positive reactions. perhaps this is the basis for the apparent increased sensitivity of the high voltage over the low voltage technic and also for the discrepancy between their results in biliary cirrhosis and those of others. conditions possibly predisposing to haa-positive hepatitis. a number of reports by blumberg and coworkers suggest that patients with down's syndrome, lepromatous leprosy, leukemia or uremia have a high frequency of haa'because they are unusually susceptible to hepatitis by virtue of a genetic or acquired immunologic defect [ , , , , ] . moreover, on the basis of extensive family studies, blumberg et al. concluded that the presence of haa in blood is determined by an autosomal recessive trait [ , , ] . in view of the following considerations, some of these interpretations may be rejected in favor of those that stress environmental factors in transmission and persistence of disease. down's syndrome: blumberg and co-workers in [ ] found that approximately per cent of eightyfour patients with down's syndrome had haa in their serum. this was the highest frequency they had found in any of the different categories of patients tested. subsequent studies by sutnick et al. [ ] indicated that the frequency of haa in down's syndrome was highest in patients in large institutions ( to per cent), was relatively low in patients in small institutions ( per cent) and was not detected in noninstitutionalized patients with the same disorder. con-trois, who were similarly retarded patients in the same institutions, had a to per cent frequency of haao the patient's with down's syndrome who had haa in their serum generally had mildly elevated sgpt levels but normal bilirubin levels and other liver function tests; those who underwent biopsy showed histologic evidence of chronic viral hepatitis [ ] . these findings were interpreted as indicating that patients with down's syndrome were uniquely susceptible to hepatitis and that the hepatitis was transmitted orally, more in larger institutions, in which the environment seemed less hygienic, than in smaller institutions. they concluded that an environmental as well as a genetic, i~erhaps immunologic, host factor was involved. krugman and giles [ ] did not find a higher frequency of haa in adult patients with down's syndrome than in other patients of the same age group with similar mental retardation. they considered that the highep frequency of haa in children with down's syndrome resulted from their being admitted at an earlier age than other mentally retarded children and being more ambulatory. hence they were exposed to environmental factors responsible for transmitting hepatitis over a longer period than most patients. they also suggested that studies by blumberg et al. which were based on a single bleeding might not reflect accurately the over-all epidemiology of hepatitis in the institutions that were studied. epidemiologic studies carried out over a long period by szmuness and co-workers [ ] on institutional transmission of haa-positive viral hepatitis in patients with down's syndrome and other forms of mental retardation led them to conclude, as did krugman and giles [ ] , that the occurrence, distribution and persistence of haa in institutionalized mentally retarded patients of all types is influenced more by the age at which patients are exposed and the duration of exposure than by the etiology of mental retardation [ ] . lepromatous leprosy: blumberg sugggsts that patients with lepromatous leprosy have a high frequency of haa because of an abnormal immune response, possibly genetically determined, that predisposes them to a number of illnesses including viral hepatitis, lepromatous leprosy and leukemia [ , , ] . the frequency of haa in patients with lepromatous leprosy was . per cent and in seventy-one patients with "borderline" lepromatous leprosy . per cent; whereas in patients with tuberculoid leprosy it was . per cent and in apparently normal persons in the nearby population . per cent [ ] . these differences were considered to be significant despite the high frequency of haa in the control population. moreover, almost all the lepromatous leprosy patients were confined to a leprosarium, whereas the patients with tuberculoid leprosy were almost all outpatients. it is well known that haa is prevalent in institutionalized patients with down's syndrome but not in out-patients. just as in the case of institutionalized mentally retarded patients, the prevalence of haa in institutionalized lepromatous leprosy cases was the highest in the youngest age group, suggesting, as in down's syndrome, that age of exposure, intimacy of exposure and duration of exposure to endemic hepatitis are more important than genetic or immunologic factors in determining the prevalence of haa. renal dialysis: patients receiving long-term hemodialysis have been cited as examples of people with impaired immune mechanisms that alter the usual manifestations of hepatitis [ ] . of seventeen patients on maintenance hemodialysis studied by turner and white [ ] , eight eventually had definite positive tests for haa. two of the eight had no clinical evidence of hepatitis; four had anicteric hepatitis; and two had the usual manifestations of symptomatic hepatitis with icterus. none were receiving immunosuppressive therapy. over the two and a half year period that these cases were collected, hepatitis developed in eleven nurses and technicians on the staff of the hemodialysis unit, and seven of the nine whose blood was available within the first two weeks after onset had haa in their serum. in ten of the eleven affected staff members typical hepatitis developed with elevated bilirubin levels in contrast to the chiefly asymptomatic and anicteric hepatitis of the patients on dialysis. the positive tests for haa in the dialysis patients persisted as long as tested from four months to over two years, whereas haa disappeared within four weeks from the blood of staff members with hepatitis. blumberg and co-workers [ ] also observed anicteric hepatitis with persistent haa in eight patients receiving long-term hemodialysis, but acute viral hepatitis with icterus and transient haa developed in six staff members of the dialysis unit. thus, in two studies, in patients with uremia on long-term dialysis anicteric hepatitis developed with persistence of haa whereas normal subjects who contracted hepatitis through intimate contact with the uremic patients had typical acute hepatitis with transient haa. the source of hepatitis in some of the patients was no doubt transfused blood; however, others may have received low doses of virus parenterally or orally through contamination. whether staff members were infected parenterally or otherwise is not known. since severity of disease and duration of haa may be related to dose of infectious agent (see section on transmission), the different manifestations of hepatitis in patients and staff may be attributable just as much to differences in dose of infectious agent or possibly to route of infection as to host response. it should be mentioned that most dialysis units do not have a problem with hepatitis in patients or staff. inherited traits: the early studies on inheritance of haa, carried out when the antigen was considered to be a protein allotype, called au( ), showed segregation of the antigen in families that was consistent with simple autosomal recessive inheritance [ ] . later statistical analysis of the occurrence of haa in family members of a different population showed highly significant agreement with the same genetic hypothesis [ ] . since much information suggested that haa was linked to an infectious agent, the findings were considered compatible with an inherited susceptibility to a number of chronic infections including the agent that prouced haa. a predominance of the antigen in male subjects and decreased prevalence in the older age groups were explained by factors which might affect susceptibility and resistance. the gel diffusion technic that was used to detect haa in the genetic studies is relatively insensitive. it is apparent that observed values for haapositive family members would be two to three times higher if the more sensitive complement fixation [ , ] , or counterelectrophoretic technics [ , ] , were used and that these values would not agree so closely with calculated theoretic values for autosomal recessive inheritance. studies should be performed with more sensitive tests for haa to see whether the evidence for recessive inheritance of susceptibility to hepatitis is upheld. clinical value of tests for haa. for differential diagnosis: since haa is a specific manifestation of the agent of long-incubation hepatitis, the test for haa can be used to differentiate the two major types of viral hepatitis. a positive haa test defines the form of hepatitis precisely as "haa-positive hepatitis." however, a diagnosis of "haa-negative hepatitis" cannot be made on the basis of a negative haa test, for the antigen may be present transiently or at a level too low to be detected by current methods of measurement. a patient can be assumed to have haa-negative hepatitis only if it is known that the incubation period is short. the terms "serum" or "infectious" seem to be ambiguous in describing hepatitis and probably should not be used. in any obscure or chronic liver disease the test for haa may, if positive, be valuable in establishing a diagnosis for variants of the usual clinical manifestations of long-incubation hepatitis can be deceptive. moreover, at least one diagnostic category of chronic liver disease, cah, which is based chiefly on hepatic histology, can now be subdivided into "haa-positive cases" that are most likely sequelae of long-incubation hepatitis and "haa-negative (:ases" which may or may not be a consequence of viral hepatitis. for prognosis: in keeping with the general impression that long-incubation hepatitis is usually more severe than short-incubation hepatitis, cossart and vahrmam [ ] found that per cent of their patients with haa-positive hepatitis had a more prolonged hospital course with sgot remaining usually above units until the eighth week, compared to those with haa-negative hepatitis who usually had sgot values below units by the fifth week. sequential tests during acute hepatitis may be of further help in prognosis, for unusually long persistence of haa indicates progression to chronic hepatitis whether or not symptoms subside and other laboratory tests become normal. differentiation of cah cases into those that are "haa-positive" and those that are "haa-negative" but have positive lupus erythematosus tests may prove to be valuable prognostically and therapeutically. for prophylaxis: since pooled normal gamma globulin is effective prophylactically in short-incubation (haa-negative) hepatitis, but offers little or no protection against long-incubation (haa-positive) hepatitis [ , , ] , documentation of haa in a case of acute hepatitis would obviate the need for giving prophylactic gamma globulin to the patient's contacts. also, identifying the type of hepatitis establishes the specificity of immunity that will develop; there is a high degree of immunity, although not absolute, to the homologous virus but no cross immunity between long-incubation (haa-positive) and short-incubation (haa-negative) hepatitis [ ] [ ] [ ] . highly sensitive tests specific for anti-haa that are currently under investigation (see section on immunity) may permit identifying specificity of prior hepatitis infections. tests for haa may be used to screen patients and medical staff in situations that predispose to endemic or frequent iatrogenic hepatitis, e.g., renal dialysis units, institutions for mentally retarded, groups of patients given multiple transfusions; for knowledge of the carrier state may help prevent contact cases. for the same reason, those in a position to transmit hepatitis, such as food handlers, surgeons and dentists should probably be tested for haa. the most important application of screening tests is identification of blood donors who are carriers of haa; a|l evidence indicates that haa-positive blood transmits hepatitis (see section on transmission). currently available tests for haa and anti-haa are valuable, within the limits of their sensitivity, for all of these purposes, realizing that only positive tests are significant. the tests are simple and inexpensive, and should be employed as routine laboratory procedures in hospitals and blood banks. there is no direct evidence that haa is an infectious agent. physical and chemical characteristics of the antigenic material suggest that it is chiefly noninfectious empty virus coat, but the amounts of haa that circulate are so great that only a small fraction would have to be infectious virion to approach the blood concentration of virus characteristic of other viral illnesses. as yet there is no known laboratory animal that can be used for passing the agent, and appropri- haa in animals, outbreaks of hepatitis among handlers of higher apes and occurrence of a disease similar to human hepatitis in chimpanzees have iraplicated apes as hepatitis carriers [ , ] . apparently normal chimpanzees and other higher apes have a relatively high frequency of haa in their blood (table v) [ , , , ] , and seven chimpanzees that were carriers of haa all had histologic evidence of mild active hepatitis on biopsy. antigen that is immunologically indistinguishable from haa found in human serum was detected in seven chimpanzees, three orangutans and three gibbons but not in several species of monkeys [ , ] , although others have mentioned the presence of haa r in monkeys [ ] . marmoset monkeys have been used as a possible animal model for human viral hepatitis [ ] , but even those animals with liver lesions after inoculations with blood from hepatitis patients have not been found to have haa in their serum [ ] . according to a recent report [ ] marmosets may be susceptibee to infection with short-incubation hepatitis virus rather than the type that produces haa. it is not known whether haapositive hepatitis is a natural infection of higher apes or whether they acquire the infection from contact with man or through the common practice of animal dealers giving infant apes transfusions of human blood. transfusions. okochi and murakami [ ] noted the development of haa-positive hepatitis in three recipients of antigen-positive blood, but also found the antigen in six post-transfusion hepatitis patients who had not received antigen-positive blood. failure to detect haa in the transfused blood was considered to be a reflection of the insensitivity of the agar gel technic. gocke et al. [ ] , in a retrospective study of twelve patients who had received antigen-positive blood, found that hepatitis developed in nine and that serum from seven of the nine was positive for haa. more recently gocke [ ] has found that the frequency of hepatitis in forty patients given transfusions of blood containing haa was approximately per cent [ ] , whereas only four cases of hepatitis were seen in sixty-nine recipients of antigen-negative blood [ ] . giles [ ] demonstrated the regular appearance of haa-positive hepatitis in recipients of haa positive serum obtained from a patientduringthe acute phase of long-incubation hepatitis. they also observed apparent "second passage" of haa in two subjects who received serum from a donor who had been inoculated with the ms- agent and had been an asymp- note: inoculation was i ml subcutaneously. each of the inoculated materials, when concentrated on a cesium chloride gradient [ ] , were found to contain virus.like particles characteristic of haa on electronmicroscopy. data are taken from barker et al. [ ] . * acute phase serum was obtained ten days after appearance of clinical symptoms and icterus in a subject inoculated ninetyfour days prior to that time with an icterogenic plasma pool that contained haa by immunologic and electronmicrographic criteria. t the donor was suspected of being a hepatitis carrier because hepatitis developed in a recipient of his blood, although the donor had no history of liver disease. $ the thrombin was suspected of transmitting hepatitis after clinical use. haa could not be detected in the undiluted plasma by agar gel diffusion, but virus-like particles typical of haa were seen on electronmicroscopy after the plasma was concentrated on a cesium chloride gradient. data are taken from barker et al. [ ] . tomatic carrier of haa for almost four years after inoculation. in studies involving over recipients, barker et al. [ ] showed that plasma and a purified plasma protein that contained haa transmitted haa-positive hepatitis (table vi) . the materials that produced hepatitis and the weekly serum samples obtained from inoculated subjects had been stored at -- ~ from the time of the transmission studies in to [ ] until analyzed for haa in [ ] . haa and viruslike particles characteristic of haa were present in the inoculated materials. most of the recipients in whom hepatitis developed also had haa in their blood during the incubation period and acute phase of the disease, and many recipients in whom clinical or laboratory evidence of hepatitis did not develop nevertheless had haa in their serum. haa appeared in the asymptomatic recipients only after a delay consistent with the incubation period of hepatitis. the experiment with acute phase serum (table vi) is a documented second passage of haa-positive hepatitis with serum from an haa-positive donor in whom hepatitis had developed after inoculation with an haa-positive plasma pool. table vii [ ] and additional observations by barker et al. [ ] indicate that recipients of low doses of infectious virus (plasma dilutions - to - in table vii ) have a mild illness that is anicteric and frequently subclinical, have hepatitis and haa after an unusually long incubation period and tend to retain the antigen indefinitely. of twelve subjects who became persistent carriers of haa after participation in hepatitis transmission studies, eight had minimal symptoms of hepatitis and bilirubin elevations no greater than mg, and the remaining four had no symptoms and no laboratory abnormalities [ ] . others [ , ] have also observed prolongation of the incubation period of hepatitis after the administration of low infectious doses and noted that the hepatitis that developed was usually mild and anicteric. these observations imply that, conversely, those in whom mild or subclinical hepatitis develops and who retain haa for unusually long periods most likely were infected by relatively low doses of virus. in subjects prone to the development of persistent circulating haa without significant liver disease, viz., patients with down's syndrome [ , , , , ] , or lepromatous leprosy [ , , ] , hemodialysis patients [ , ] and carriers in tropical populations in whom haa is prevalent [ , ] , may all have been infected by low doses of virus and may not necessarily have unusual susceptibility to hepatitis. additional observations relating to mode of transmission, severity of disease and apparent infectious dose are those of mirick and shank [ ] that epidemic long-incubation hepatitis which appeared to spread by person to person contact was usually anicteric, and those of krugman [ ] and szmuness [ ] et al. that institutional transmission of haa-positive hepatitis by apparent contact requires a long period of exposure, suggesting low infectivity. it is apparent from the dilution studies in table vii that if haa is the virus particle responsible for hepatitis, the minimum amount which can transmit hepatitis is far below that which is detectable by the most sensitive tests for haa currently available. haa in the undiluted icterogenic plasma pool had a titer of : by complement fixation; virus-like particles were visible by electronmicroscopy only after the plasma was concentrated on a cesium chloride gradient; and the undiluted plasma gave a negative test for haa in agar gel. nevertheless, overt clinical haa-positive hepatitis was transrflitted by ml of a : , dilution of the plasma, and apparent subclinical hepatitis as judged by replication of haa was transmitted by ml of plasma diluted as high as " , , . compared to the most sensitive laboratory tests currently available, the biologic test for haa by transmission of hepatitis in man is more sensitive by a factor of approximately ~. the high infectivity of virus by the parenteral route suggests that hepatitis can be caused by amounts of blood that could be transferred by hematophagous insects. insect vectors, whether bed bug, louse or mosquito, could account for transmission that appears to involve person to person contact in institutions or in tropical regions in which haa carriers are prevalent. adding weight to this possibility are the recent findings by prince [ ] that in some tropical populations from africa, asia and south america where haa is ten to a hundred times more prevalent than in new york, there is no significant difference in the prevalence of haa between male and female subjects and no apparent decline with increasing age in the frequency of serum containing antigen. there is no definite information on transplacental transmission of haa-positive hepatitis. three patients with perinatal hepatitis whose mothers had haa-positive hepatitis during pregnancy were found to have haa in their blood [ ] . the cord blood of two infants whose mothers were haa-positive at the time of delivery was negative for antigen; cord blood in the other infant was not tested. transplacental transmission seems less likely than infection of the infant shortly after birth. attempts to identify haa in body fluids other than blood. in view of the apparent transmission of longincubation hepatitis by person to person contact under some circumstances, the possibility has been considered that infection may occur via the fecal-oral route, through urine or through pharyngeal secretions. however, early attempts to identify the agent of long-incubation hepatitis in feces and in nasopharyngeal secretions by human transmission studies were not successful [ , ] . recent attempts to measure haa directly in various body fluids also have not been successful. patients with haa in their blood that could be measured at dilutions greater than : , by complement fixation technics did not have detectable haa in saliva concentrated tenfold, in urine concentrated a hundredfold or in per cent stool extracts [ ] . although haa was not found in extracts of stool from patients who had haa in their serum, a different protein antigen associated with hepatitis was found in these extracts [ ] . the new antigen was precipitated in agar gel diffusion and electrophoretic tests by serum from to per cent of patients receiving multiple transfusions and from some patients with haa-positive acute viral hepatitis. the antigen was found in extracts of stool from five of five patients with acute viral hepatitis, two of five patients with chronic hepatitis and one patient who had received multiple transfusions, but not in stool extracts from twenty-five normal subjects and patients without liver disease. as shown in figure , the material in stools does not appear to share any antigenic determinants with haa, although half of the serums that precipitated the stool antigen contained anti-haa. the antigen appeared to be a protein of molecular weight > , . because of the association with hepatitis the new antigen could be an altered component of the virus that produces haa, or a different viral agent that may complement or accompany that virus. a detailed report on the new antigen is forthcoming [ ] . haa in plasma fractions. all of the cohn cold ethanol plasma fractions except for fraction ii contain measurable amounts of haa if the unfractionated plasma is heavily contaminated with antigen (table i) [ ] . these findings corroborate the extensive clinical experience indicating that fraction ii (pooled normal gamma globulin) does not transmit hepatitis, whereas other fractions such as i (fibrinogen) and iii (thrombin) are implicated often. fraction ii probably does not contain significant amounts of specific antibody against haa; attempts to neutralize the long-incubation hepatitis agent with fraction ii [ ] or to measure anti-haa in fraction ii [ ] have not been successful. fraction v (albumin) contains relatively small amounts of haa, and haa in albumin remains immunologically stable by precipitation tests after the albumin has been heated at ~ for ten hours [ ] . since heated albumin does not transmit serum hepatitis, simply finding a positive test for haa does not necessarily indicate infectivity. on the other hand, failure to find haa in a plasma fraction does not give assurance that the fraction is free of infectious agent; many commercial fraction i preparations known to have transmitted long-incubation hepatitis [ ] do not contain detectable amounts of antigen by agar gel or complement fixation technics [ , ] . it can be assumed that most pools of plasma prepared commercially, and fractions from pooled plasma except for gamma globulin, contain sufficient virus to transmit hepatitis but insufficient haa to be detected by in vitro tests, as in transmission experiments shown in table vii . prevalence of haa in different blood donor populations measured by the insensitive agar gel diffusion table ii . complement fixation technics are at least a hundredfold more sensitive than agar gel diffusion [ ] and detect approximately twice as many haa carriers among blood donors [ ] . it has been estimated that the insensitive agar gel diffusion technic detects to per cent of the carrier population among blood donors [ ] . if these estimates are correct, then by screening with complement fixation it should be possible to eliminate at least to per cent of donors who transmit hepatitis. in our experience the counterelectrophoretic technic [ , ] which is approximately ten times more sensitive than agar gel diffusion, but ten-to twentyfold less sensitive than complement fixation, detects the same haa carriers as complement fixation technics. thus it appears that most haa carriers are detectable by a technic only ten times more sensitive than simple agar gel diffusion, and the additional sensitivity of complement fixation technics does not appear to reveal a significantly greater number. although further study is necessary, indications are that carriers tend to have levels of haa that are easily detected by currently available simple and inexpensive tests. screening donors for haa by technics equivalent in sensitivity to counterelectrophoresis or complement fixation seems to be a necessary function of blood banks, for the association between the presence of haa and transmission of hepatitis is conclusive. anamnestic antibodies. the antibodies used diagnostically to measure haa by precipitin and complement fixation technics all come from patients who have received multiple transfusions and in whom high titer "hyperimmune" anti-haa developed apparently as a result of repeated exposure to antigen in transfused blood. okochi and murakami [ ] using an agar gel precipitin technic observed fifteen instances in which anti-haa appeared after transfusions of haapositive blood and an additional seven instances in which anti-haa appeared following transfusion of blood in which haa was not found, a circumstance considered to reflect the insensitivity of the method of measuring haa. in fourteen of the patients antibody developed within two weeks and in six patients between two and four weeks after transfusion; in the remaining two patients antibody was detected fiftysix and sixty days after transfusion, respectively. development of relatively high titer anti-haa shortly after transfusion suggests that antibody response was anamnestic; for, as shown in figure , detectable haa does not usually appear in blood until five weeks or more after inoculation of infectious plasma. whether or notthe hepatitis developed in the patients who received these transfusions or whether or not they had a history of prior hepatitis or transfusion was not mentioned in the study by okochi and murakami. others have noted apparent anamnestic appearance of complement-fixing anti-haa within two weeks after transfusion [ , ] ; and krugman and giles [ ] also observed occasionally low titer complement fixation anti-haa in patients who had been re-exposed to haa-positive serum a year after an initial exposure. these various observations suggest that antibodies measurable by agar gel precipitin or complement fixation technics arise commonly under clinical conditions that permit an anamnestic response, but antibodies of this type can rarely be detected during the course of a primary, acute or chronic hepatitis infection. anti-haa in acute and chronic hepatitis. in none of the many cases of acute and chronic hepatitis studied by wright et al. [ ] (tables ii and iv) , did anti-haa detectable by agar gel precipitin technics develop. cossart and vahrman [ ] did not find antibodies by complement fixation technics in serum obtained during the convalescent state from two patients with haa-positive acute hepatitis using haa that had been present in the homologous serum as antigen. krugman and giles [ ] did not find anti-haa by complement fixation after primary acute haapositive hepatitis in a large series of experimentally infected patients. shulman et al. [ ] tested serum obtained at weekly intervals from twenty-two patients with haa-positive hepatitis during a one to two month period after onset of disease and found only one antibody detectable by agar gel precipitin technics and two antibodies of low titer detectable only by complement fixation. none of sixty additional patients from whom one or two random samples were obtained during the recovery phase of acute hepatitis or during chronic hepatitis had antibody by complement fixation or agar gel precipitin technics. however, with a recently developed highly sensitive hemagglutination test for anti-haa, many of the same eighty-two patients with acute and chronic hepatitis were found to have antibodies (table viii) . the hemagglutination test, which involves coating red cells with isolated haa and agglutinating these cells with anti-haa, is approximately , -fold more sensitive than agar gel precipitin tests and approximately a hundredfold more sensitive than complement fixation tests for measuring antibody. with the hemagglutination test the frequency of anti-haa formation in patients recovering from haa-positive acute hepatitis was approximately per cent; in patients with prolonged hepatitis, per cent; and in chronic active hepatitis, about per cent. that antibody was detected in three of four cases of hepatitis associated with drug use may reflect anamnestic response to intermittent reexposure to antigen. the presence of anti-haa did not seem to influence the course or severity of disease. significance of antigen-antibody complexes. of special note is the finding that haa occasionally can be measured in the presence of anti-haa. in the patient recovering from acute hepatitis (table viii) , haa was measured at a relatively low titer ( : by complement fixation) in face of a relatively high titer antibody ( : by complement fixation). this circumstance may reflect readily reversible antigen-antibody complexes involving a high concentration of low avidity antibody. the other two instances of haa being measured in the presence of anti-haa were in cases of chronic active hepatitis. both of these antibodies we re low tite r ( : a n d : , res pe ctive ly, by the hemagglutination technic) and haa measured in the presence of these antibodies was in one instance low titer ( : by complement fixation) and in the other instance high titer ( : by complement fixation). antigen coated red cells used in the hemagglutination test are effective in competing with antigen-antibody complexes for anti-haa probably because the cell agglutinate that forms favors the competitive reaction. although antigen and antibody could not be measured directly in many patients, the presence of antigen-antibody complexes was often reflected by anticomplementary activity [ , ] . anticomplementary activity is the ability of serum alone without further addition of antigen or antibody to inactivate complement. an example of the characteristic temporal relationship between development of anticomplementary activity and appearance of circulating haa that occurred in three patients in whom hepatitis developed after receiving a transfusion is shown in figure . these findings suggested that antigen-antibody complexes capable of fixing complement can appear early in the course of the disease, can no longer fix complement when antigen is in excess, and can regain the ability to fix complement as the antigen to antibody ratio decreases. evidence that the anticomplementary activity is caused by antigen-antibody complexes is the presence of virus-like particles in anticomplementary serum, the neutralization of anticomplementary activity by addition of excess purified haa which appears to change complexes into noncomplement fixing antigen-excess forms and the ability of organic solvents which reverse antigen-antibody complexes to decrease anticomplementary activity and permit immunologic detection of haa in the treated serum [ ] . almeida and waterson [ ] have interpreted electronmicrographs of serum specimens obtained from patients with different forms of haa-positive hepatitis as showing either randomly distributed particles indicative of free antigen or clumped particles suggesting immune complexes. they considered that it was possible to differentiate by electronmicroscopy between complexes formed in antigen or in antibody excess. recently millman and co-workers [ ] also obtained evidence by an immunodiffusion technic that haa and anti-haa can be present together in the serum of patients with viral hepatitis. the presence of antigen-antibody complexes in some patients with viral hepatitis and depression of complement levels in some instances during the acute phase of illness suggest that certain of the multisystem manifestations of hepatitis may be immune in nature. for example, acute arthralgia or artl~ritis, mya!gia, rash and urticaria, generalized vasculities and hyperglobulinemia which may accompany acute or chronic viral hepatitis, may all be manifestations of circulating antigen-antibody complexes. bulkley et al. [ ] found a high frequency of arthritis and arthral-gias among patients with chronic active hepatitis whose serum was positive for haa. alpert et al. [ ] found that serum complement levels in patients with acute hepatitis were depressed in those who had arthralgias or arthritis associated with either fever or urticaria and circulating haa. gocke et al. [ ] observed four patients with polyarthritis who had circulating haa and, on the basis of immunofluorescent studies, possibly deposits of haa complexed with antibody in small blood vessels. it is known that attacks of acute viral hepatitis confer a high degree of immunity to the homologous form of hepatitis [ ] [ ] [ ] ; but immunity is not absolute; and as indicated by the following observations, it cannot be correlated with anti-haa levels. during the incubation period of hepatitis antibody can arise without preventing further development of haa or progression of disease (figure ) , hepatitis can even follow marked anamnestic antibody responses (figure ), but under these circumstances the disease is mild. the patient whose data appear in figure was treated with cryoprecipitate from donors over a one week period. within five days after the start of therapy, anti-haa appeared in the patient's serum and reached peak titer within two weeks. approximately two months later, when antibody had decayed, anicteric mild hepatitis developed with elevation of sgot and sgpt levels [ ] . krugman reported a similar case [ ] of accidental reinfection with haa-positive material that elicited transient anti-haa response followed by anicteric mild hepatitis with elevation of sgot values and circulating haa. two similar instances of hepatitis following what appeared to be anamnestic antibody responses have also been reported by holland et al. [ ] . these two patients also had mild anicteric hepatitis after decay of anti-haa that had appeared within two weeks after transfusion. they described a third patient with more severe hepatitis in the presence of high titer anti-haa, but cytomegalovirus infection could not be ruled out. these various observations suggest that the usual anti-haa is probably not an effective neutralizing antibody. it is not clear whether immunity is due in part to antibody or entirely to the thymus-dependent system, for example as in measles [ ] . pooled normal gamma globulin does not seem to protect against haa-positive hepatitis compared to its high degree of effectiveness in protecting against short-incubation hepatitis, but it may modify the severity of the disease [ ] . the finding of circulating complexes of antibody with viral antigen is novel in human disease, but circulating virus-antibody complexes are well documented in animals. for example, in mice, lactic dehydrogenase virus (ldv) stimulates antibodies that combine with virus, but virus-antibody complexes remain infectious and the animals have lifelong viremia in the presence of anti-ldv [ !] . the ldv-antibody complex is relatively resistant to neutralization with antibodies, and the complex transmits the disease when inoculated into other animals [ ] . moreover, heterologous, non-neutralizing antibodies are elicited bycertain viruses; forexample, rabbit anti-herpes simplex virus (hsv) which forms a complex with the virus but does not prevent viral infectivity [ ] . as in the case of complexes of ldv and hsv with antibody, complexes of haa with anti-haa appear to retain infectivity. persistence of haa and low grade hepatitis following low doses of virus, and development of chronic hepatitis following acute infections may involve variations in the immune response, but at present this cannot be assessed. the possibility of using anti-haa therapeutically in severe haa-p sitive hepatitis is attractive; but, in view of the following considerations, it would be difficult to predict the outcome. levels of haa cannot be correlated with severity of illness, most human anti-haa antiserum does not appear to neutralize infectivity, intracellular virus would not be affected by antibody, large amounts of antibody would be needed to bind the usual amounts of haa that circulate, and potentially complexes of haa with anti-haa would be harmful. experimental use of antise-rum appears to be justified only as a last resort. use of anti-haa experimentally as a prophylactic agent in high risk patients seems reasonable. although pooled normal gamma globulin does not prevent longincubation hepatitis, the question of whether it ameliorates the disease is still open. known doses of hyperimmune anti-haa would permit critical evaluation of the possible protective effects of this antibody. whole antiserum could not be used prophylactically because of the possibility of its containing infectious virus-antibody complexes, but purified gamma globulin should be free of virus. haa used as a vaccine after physical or chemical treatment to inactivate infectious virus would no doubt elicit specific antibodies and perhaps confer some protection. however, partial protection, if equivalent to low dose infection, conceivably could predispose to the carrier state associated with low grade chronic hepatitis. methods. agar gel diffusion: ouchterlony gel diffusion was used by those who first defined haa and is still the most commonly employed technic because it is the simplest. however, immunodiffusion has two disadvantages: it is relatively insensitive, and it is a slow test requiring one to three days for completion. most antigenic serum will not produce precipitin lines if diluted more than : or : in immunodiffusion tests [ ] . only serum with unusually large amounts of antigen can be diluted as much as : . similarly, most serum containing antibodies cannot be used for detecting antigen if diluted more than : or " . figure shows a typical immunodiffusion pattern with lines of identity between haa samples from different sources. the use of agarose rather than agar gel increases the sensitivity about twofold. sensitivity can also be increased by concentrating the serum samples by dehydration or by repeated filling of the wells [ ] . it has been estimated that immunodiffusion technics detect only to per cent of blood donors who are carriers of haa [ ] . counterelectrophoresis in gel: pesendorfer et al. [ ] and gocke and howe [ ] reported a simple electrophoretic technic which increases the sensitivity of the immunodiffusion test approximately tenfold and permits development of precipitin lines within hours rather than days. prince and burke [ ] reported a similar test using somewhat higher voltage. the sensitivity of counterelectrophoresis is greater than immunodiffusion because the reactive components placed in opposite wells travel toward each other and concentrate at an interface rather than diffuse in all directions. figure a shows titration by counterelectrophoresis of a serum containing haa, and figure b shows a simultaneous test for antigen or antibody suggested by krassnitzky et al. [ ] in which the patient's serum is placed between wells containing antigen and antibody. in figure b , serum in positions , , and contains haa and serum in position contains anti-haa, whereas that in position conta ins neither. the counterelectrophoresis test is rapid and practical. in our experience it detects twice as many carriers of haa in blood donor groups as does immunodiffusion. counterelectrophoresis is also helpful in detecting antibodies in some anticomplementary serums that contain antigen-antibody complexes and are difficult to assay in complement fixation systems. cellulose acetate immunoelectrophoresis: saravis et al. [ ] , have reported electrophoresis of serum on cellulose acetate membranes impregnated with anti-haa as a test for haa. the presence of antigen is indicated by a precipitin pattern which forms with haa-positive serum. this technic employs large amounts of antibody, is more difficult to perform than counterelectrophoresis, and is no more sensitive than immunodiffusion. the cellulose acetate test has no apparent advantages. complement fixation: complement fixation procedures for measuring haa appear to be the most sensitive and rapid available. this technic also has the unique advantage of being able to detect antigenantibody complexes through measurements of anticomplementary activity. complement fixation tests for measuring antigen or antibody quantitatively or qualitatively can be completed within two hours and are a hundred-to two hundredfold more sensitive than immunodiffusion technics for detecting antigen and twenty-to fortyfold more sensitive for detecting antibody. the complement fixation test for haa and anti-haa can be automated like other complement fixation tests. semiquantitative or qualitative complement fixation with microtiter plates, shown in figure , can be performed in a routine manner by laboratories using this method for other serologic tests. a recently developed qualitative complement fixation test in which measurement depends on diffusion of complement in agarose gel can be carried out as easily as immunodiffusion tests ( figure ) [ ] . the gel containing sensitized indicator cells can be stored for at least one week and supplied to laboratories not equipped to standarize reagents. the various adaptations and modifications of complement fixation tests have approximately the same sensitivity. although some workers use overnight incubation at ~ to fix complement [ ] , this pro-longed incubation is unnecessary for maximum complement fixation takes place in thirty to sixty minutes at ~ complement fixation technics are more sensitive than any other technic except hemagglutination for detecting haa. complement fixation tests and hemagglutination tests are equally sensitive for detecting haa, but the complement fixation tests are simpler for this purpose. although complement fixation tests are ten-to twentyfold more sensitive than counterelectrophoresis for detecting haa, the titer of haa in blood of most carriers is high enough to be detected by counterelectrophoresis. availability of suitable antibodies might limit application of complement fixation for routine testing, for not all antiserums that precipitate haa in agar gel are suitable for complement fixation [ ] . however, high quality complement fixation antibodies can be produced in higher apes [ ] and, in limited amounts, in guinea pigs [ ] . hemagglutination: a hemagglutination assay recently developed in this laboratory involves coating red cells with purified antigen using chromic chloride as a coupling agent [ ] . hemagglutination reactions were performed in microtiter plates and read by the pattern of agglutination shown in figure i . this test, including coating of cells with antigen, can be carried out in about two hours. equipment.and reagents, except for purified antigen, are readily available in blood banks. the purified antigen, prepared from haa-positive plasma by a combination of rate and isopycnic banding in cesium chloride (csci) density gradients [ ] is stable indefinitely at ~ and coated cells may be preserved for long-term use with glutaraldehyde [ ] . red cells with haa attached are agglutinated by extremely small amounts of anti-haa. the sensitivity of hemagglutination appears to be at least , -fold greater than that of immunodiffusion, a hundredfold greater than that of complement fixation and approximately the same as that of a radioimmunoassay for measuring anti-haa. in view of the simplicity of the hemagglutination assay compared to radioimmunoassay, the latter appears to be of little value. data ob-tained by hemagglutination on anti-haaformed during acute and chronic viral hepatitis is presented in table viii. to detect antigen by hemagglutination, antibody that could produce agglutination at a dilution of : was mixed with an equal volume of serum suspected of containing haa. neutralization of antibody by antigenic serum prevented hemagglutination. of serum samples tested by hemagglutination inhibition and complement fixation, all those that were positive in complement fixation gave positive results in hemagglutination [ ] . the hemagglutination test, like complement fixation, lends itself to automation. electron microscopy: all serum positive for haa by immunologic tests contain virus-like particles of the type shown in figures and . haa in serum can be concentrated by pelletting in an ultracentrifuge, after addition of anti-haa to form aggregates, as shown in figure . electron microscopy, although rapid, is not a practical routine test for antigen because of its complexity and expense. it is, however, an especially useful test for detecting haa in gradients and in sensitivity directly proportional to number of times wells refilled or degree to which specimen concentrated by dehydration can test for haa and anti-haa simultaneously; sensitive enough to detect most carriers of haa; excellent for screening blood donors excellent for screening blood donors; can be automated; unique for detecting haaantibody complexes best test for anti-haa; can be used routinely for haatests; can be automated too complex for routine use purified concentrates, for haa retains its morphologic characteristics but may lose its antigenic activity during purification procedures . (table i) . electron microscopy is also valuable in identifying circulating antigen-antibody complexes which may not be detected by immunologic tests [ , ] . radioimmunoassay: an immunologic assay using purified haa labeled with radioactive iodine has been described recently [ ] . the test involves incubating the labeled antigen for two to three days with serum being tested for antibody, performing "chromatoelectrophoresis" to separate free labeled antigen from antibody-bound labeled antigen, staining to locate the separated peaks and drying of the paper strips for counting in an automatic strip scanner. the assay for antibody takes approximately six days. in detecting antibody, the radioimmunoassay and hemagglutination assay are about equally sensitive, but hemagglutination is simpler and faster. in detecting haa the radioimmunoassay appears to have about the same sensitivity as complement fixation or hemagglutination but is too complicated for routine use. haa was not detected by complement fixation in extracts of liver biopsy specimens from patients who had haa-positive hepatitis [ ] . however, millman and co-workers [ ] described a fluorescent antibody technic for detecting haa in liver cells. this involves flooding smears of minced tissure preparations with rabbit anti-haa labeled with fluorescein isothiocyanate. fluorescent granules considered to be specific for haa were observed within or on the nuclei of almost every liver cell in four patients with haa-positive hepatitis but not in patients without hepatitis. the same group of workers [ ] described specific haa granules in spleen, bone marrow, testes and mesentery of some patients with haa-positive hepatitis as well as in the liver. in addition fifteen patients who did not have haa in their blood showed granules in the liver, a finding interpreted to indicate that the fluorescent test is more sensitive than the agar gel immunodiffusion test in detecting haa. the fluorescent antibody technic is difficult to perform, but as blumberg et al. [ ] state, the test will prove very useful if the findings already published are supported by additional studies and confirmed in other laboratories. virus culture and animal transmission: subhuman primates, especially those higher in the scale of evolution, appear to be the only animals in which haa can be propagated, for haa as well as anti-haa has been found in the blood of chimpanzees, orangutans and gibbons, but not in monkeys (table v) . although a number of preliminary reports have appeared in the past on adaptation of viral hepatitis agents to chick embryos, or tissue cultures, haa has not as yet been propagated in tissue culture or in any of the usual laboratory animals. the goal of those attempting to develop biologic tests involving tissue culture infectivity is to approach the sensitivity of human susceptibility to infection. only tests of this sensitivity will permit detection of the minimum amounts of virus that transmit disease and evaluation of the immune responses in terms of virus neutralization. table ix compares the various technics for measuring haa and anti-haa in blood. reagents. sources of antibody and antigen: patients given repeated transfusions of blood or blood products are the best source of high titer igg precipi-tating and complement fixation antibodies. about one-third of those with severe hemophilia who require frequent treatment with plasma, cryoprecipitate or fraction i have antibodies that can be utilized for diagnostic purposes [ ] . the best antibodies are anamnestic or "hyperimmune" antibodies that reach peak titer about two weeks after therapy with blood or blood products that by chance contain haa. these antibodies, which are especially suitable for complement fixation tests, arise and decay characteristically as shown in figure . all antiserums have both precipitin and complement fixation properties, although diffefent antiserums may be better for one type oftestthan the other. human immunization occurs less frequently in countries such as england in whidh haa carriers are less prevalent than in the united states. less than half of the patients with hemophilia or other patients whose serums contain high titer anti-haa have a history of hepatitis. excellent precipitating antibodies against haa can be produced in animals by sensitizing them with human plasma containing haa and absorbing the antiserum with normal plasma. antiserums produced in this way give a line of identity with human anti-haa [ ], but these antiserums are not suitable for complement fixation procedures because the absorption step makes them markedly anticomplementary. haa separated from plasma by double isopycnic banding in cesium chloride followed by rate zonal centrifugation in sucrose is pure enough to stimulate specific complement fixation anti-haa antibodies in guinea pigs [ ] . high quality complement fixation antibodies were found in chimpanzees that were immunized for other purposes with chimpanzee blood that inadvertently contained haa [ , ] , and similar antiserums have been produced in chimpanzees by intentional immunization with partially purified haa [ ] . antiserums from chimpanzees are as specific as human antibodies for haa. immunization of higher primates could provide a good source of standard high titer complement fixation antibodies. specificity of reagents: lines of identity like those shown in figure have been obtained with antigen from different sources and with fifty-three different antiserums [ , , , ] . all antigens tested, whether from blood of patients clinically diagnosed as having "serum" or "infectious" hepatitis, fresh or stored up to twenty years at -- ~ or separated as a purified suspension of particles, gave lines of identity in agar gel diffusion and reacted similarly in complement fixation. haa from nonhuman primates was in all respects identical to haa from human beings [ , , ] . although one might expect the i, structure which contains haa to be antigenically multispecific, as yet there is no firm evidence that the hepatitis virus produces more than one antigen. proteins of small viruses consist of multiple units of a single polypeptide, or at most several polypeptides [ ] , and therefore have few antigenic determinants. haa is evidently the major antigenic determinant of the long-incubation hepatitis virus, but it would not be surprising if antiserums are found that distinguish antigenic subtypes. there is a report by levene and blumberg [ ] concerning an antiserum that appears to recognize a second hepatitis associated antigen. this antiserum formed early in the course of immunizing one rabbit with human plasma containing haa and disappeared with further immunization of the same rabbit. the spur in ouchterlony double diffusion that was considered to represent a line of nonidentity with the known haa was too faint for photographic reproduction. this finding conceivably could reflect differences in diffusion rates of rabbit s and s antibodies of the same specificity rather than antibodies of different specificity. different haa antigens no doubt will be identified in the future. for example, zuckerman et al. [ ] have found particles similar in structure to corona virus in a patient with chronic active hepatitis but have not found these particles in serum known to transmit short-incubation or long-incubation hepatitis. also, the finding of a new antigen in stools of many patients with haa-positive hepatitis suggests that other agents, perhaps helper viruses, may be involved in hepatitis. when additional hepatitis associated antigens are documented a system of nomenclature will be necessary. a "new" antigen in leukemia sera et ah family studies of a "new" human serum isoantigen system (australia antigen) association between lepromatous leprosy and australia antigen et ah a serum antigen (australia antigen) in down's syndrome, leukemia, and hepatitis observations on australia antigen in japanese an antigen detected in the blood during the incubation period of serum hepatitis particles associated with australia antigen in the sera of patients with leukaemia, down's syndrome and hepatitis viruslike particles in sera of patients with infectious and serum hepatitis et ah some antigenic and physical properties of virus-like particles in sera of hepatitis patients viral hepatitis and the australia-sh antigen biophysical properties of australia antigen further studies on a "new" human isoprecipitin system (australia antigen) virus-like particles in serum of patients with australia.antigen-associated hepatitis et ah australia antigen (a hepatitis-associated antigen). purification and physical properties properties of a small virus associated with adenovirus type the biology of animal viruses evidence for a single-stranded adenovirus-associated virus genome. formation of a dna density hybrid on release of viral dna preparation and characterization of complement-fixing hepatitis-~sociated anti~.en and antiserum virus-like antigen, antibody, and antigen-antibody complexes in hepatitis measured by complement fixation the size of serum hepatitis virus viral hepatitis infectious hepatitis and serum hepatitis, viral and rickettsial infections of man australia antigen: distribution during cohn ethanol fractionation of human plasma hepatitis and leukemia: their relation to australia antigen hepatitis antigen: correlation with disease and infectivity of blood-donors australia antigen in acute and chronic liver disease studies of australia-sh antigen in sporadic viral hepatitis in london viral hepatitis viral hepatitis: relationship of australia/sh antigen to the willowbrook ms- strain hepatitis antigem detection of infectious blood donors hepatitis-associated antigen in chronic liver disease et ah failure to detect hepatitis-associated antigen in a community epidemic viral hepatitis: new light on an old disease transmission experiments in man homologous serum hepatitis and infectious (epidemic) hepatitis an epidemic of serum hepatitis studied under controlled conditions sh antigen in haemodialysisassociated hepatitis et ah an epidemic of hepatitis in a chronic hemodialysis unit: australia antigen and differences in host response infectious hepatitis: evidence for two distinctive clinical, epidemiological, and immunological types of infection transmission of serum hepatitis histologic changes in the liver of haa carriers with normal serum transaminase levels the role of serum hepatitis virus in chronic liver disease (abstract) progression .of acute hepatitis to postnecrotic cirrhosis chronic liver disease and primary liver-cell cancer with hepatitis-associated (australia) antigen in serum australia antigen in chronic active liver disease with cirrhosis chronic active hepatitis: distinctions based on circulating hepatitis associated antigens australia antigen in chronic hepatitis in australia prognosis of chronic persistent hepatitis serum hepatitis antigen (sh): rapid detection by high voltage immunoelectroosmophoresis immunelektrophoretischer nachweis von "hepatitisassociated-antigen" (au/sh-antigen) active chronic hepatitis australia antigen as a hepatitis virus. variation in host response anicteric hepatitis associated with australia antigen hepatitis and australia antigen: autosomal recessive inheritance of susceptibility to infection in humans the serum hepatitis virus specific antigen (sh): a preliminary report of epidemiologic studies in an institution for the mentally retarded shulman nr: a rapid, sensitive and easy test for hepatitis associated antigen (abstract) modification of post-transfusion hepatitis by gamma globulin an outbreak of infectious hepatitis among chi,mpanzee handlers at a united states air force base chimpanzee-associated hepatitis identification of the virus-like antigen of human hepatitis in nonhuman primates prince am: studies on human serum hepatitis in primates. presented at the nd conference on experimental medicine and surgery in primates studies on the transmission of human viral hepatitis to marmoset monkeys. i. transmission of disease, serial passages, and description of liver lesions hepatitis in marmosets: induction of disease with coded specimens from a human volunteer study hepatitis due to the injection of homologous blood products in human volunteers prevalence of serum hepatitis related antigen (sh) in different geographic regions hepatitis associated antigen (australia antigen) in mother and infant a new hepatitis associated antigen in stools of patients with acute and chronic viral hepatitis major surgery in classic hemophilia using fraction i hemagglutination assay for antigen and antibody associated with viral hepatitis failure of australia antibody to prevent post-transfusion hepatitis detection of australia antigen and antibody by means of radioimmunoassay techniques immune complexes in hepatitis australia antigen-antibody complexes arthritis associated with hepatitis: complement component studies (abstract) polyarthritis and the australia antigen: a new association (abstract) burner fm: measles as an index of immunological function infectious virus-antibody complex in the blood of chronically infected mice neutralization of an infectious herpes simplex virus-antibody complex by anti--y-globulin rapid detection of australia antigen by counterimmunoelectrophoresis a rapid screening test for detecting hepatitis-associated antigen a complement-fixation test for measuring australia antigen and antibody australia in the nuclei of liver cells of patients with viral hepatitis by the fluorescent antibody technique the localization of australia antigen by immunofluorescence production of antibody against "australia antigen" in rabbits chimpanzee antibodies to australia antigen additional specificities of australia antigen and the possible identification of hepatitis carriers presence of particles other than the australia-sh antigen in a case of chronic active hepatitis with cirrhosis key: cord- -h xovybl authors: musk, a.w. (bill); james, alan l.; palmer, lyle j.; ryan, gerard f.; lake, fiona; golledge, clayton l.; de klerk, nicholas h. title: respiratory infections and lung function in an australian aboriginal community date: - - journal: respirology doi: . /j. - . . .x sha: doc_id: cord_uid: h xovybl background and objective: to investigate the association between serological evidence of past infections with common respiratory pathogens and lung function in members of an isolated community of aborigines from tropical coastal north‐western australia. methods: fev( ) and fvc were assessed by dry bellows spirometer. serum igg titres to common respiratory pathogens were assayed. smoking history was assessed by questionnaire. reciprocal positive igg titres were taken as ≥ for all pathogens with the exception of legionella spp. (≥ ) and burkholderia pseudomallei (≥ ). linear regression analysis examined associations between titres and lung function after adjustment for age, height, gender and smoking, separately for adults (age > years) and children. results: an increased total number of positive igg titres was significantly associated with reduced fev( ) (p = . ) and fev( )/fvc ratio (p = . ) suggesting the presence of airflow obstruction. this association was independent of age, gender, height, weight and smoking status. conclusions: the burden of past respiratory infections may be an important determinant of airway function in this aboriginal community. respiratory disease is a major cause of morbidity and mortality in australian aboriginal people; agestandardized hospital admission rates for chronic obstructive airways disease in western australia between and were . and . times greater for aboriginal men and women, respectively, compared with non-aboriginal western australians. diseases of the respiratory system account for . % of total hospital admissions for men and . % for women. in the standardized mortality ratio for respiratory diseases was . for indigenous men and . for indigenous women. similar observations have been made in the northern territory of australia and also indicate that this health disparity has not improved with time. studies of members of an isolated coastal australian aboriginal community in the tropical kimberley region of western australia have shown that levels of lung function measured by fev and fvc were lower than those of australians of european descent. the difference in these indices from age-and gendermatched australians of european descent was as much as %, even in asymptomatic individuals. [ ] [ ] [ ] [ ] airway hyper-responsiveness and the presence of respiratory symptoms were associated with lower levels of lung function, as was a history of 'asthma'. the reduced levels of fev and fvc relative to height occurred in both children and adults. therefore, reduced lung growth and/or a more rapid decline with age in adults may contribute to poor lung function. cigarette smoking, poor nutrition, overcrowding and other adverse external conditions, including respiratory infections, may be responsible for these differences between aboriginal and non-aboriginal populations. no evidence of ig deficiency or alpha- antitrypsin deficiency has been shown; in fact ig levels tend to be higher in aboriginal people compared with non-aboriginal australians. a number of studies have shown increased frequency of bacterial upper respiratory infections and lower respiratory infections in australians of aboriginal descent with central australian aboriginal people having the highest rates of invasive pneumococcal disease, as well as rates of haemophilus influenzae infection. however, there is no direct evidence concerning the potential contributions of viral and other respiratory infections to reduced lung function in australian aboriginal people. studies in other populations have provided some evidence that the presence of viral respiratory infections may be associated with decreased spirometric indices or respiratory disease. in a cross-sectional community study in norway the level of serum respiratory syncytial virus (rsv) antibodies was associated with reduced fev , suggesting that rsv infection or re-infection was an independent predictor of reduced lung function in those adults. consistent with this observation, hogg showed that potential latent adenovirus infection may be associated with the presence of copd. there is also evidence from experimental studies that latent adenovirus infection increases the inflammatory response to an acute exposure to cigarette smoke by increasing the numbers of macrophages and helper t cells in the airway epithelium. the aim of the current study was to determine if there was an association between previous infection with common respiratory pathogens and lung function in a community-based sample of indigenous australians. study subjects were from an aboriginal community in the tropical coastal kimberley region of north-west western australia. a survey of the community was carried out over days early in the dry season. seasonal effects on the traits measured could not be examined and were not considered. all individuals (n = ) over the age of years who were present in the community during the survey period were considered eligible and were invited to participate. informed personal or parental consent was obtained with the assistance of local community health workers who were employed in the project. approval for the study was granted by the human rights committee of the university of western australia and by the community council. individual results were provided to each participant and the overall results have been communicated back to the community by way of written and verbal reports to its council and health staff. demographic information and histories of respiratory symptoms and smoking were assessed at interview using the british medical research council questionnaire. questionnaires relating to children were administered to a parent (usually the mother). modifications to the questionnaire were made with the aid of the local medical officer by translation of questions into the local idiom as required. stated age was verified from community health records. cigarette smoking was defined as current or past use assessed by questionnaire; smokers (ever) reported smoking Ն cigarette/day for at least a year. bronchitis was defined as cough or sputum production on most days for as much as months each year. weight and standing height were measured without footwear. fev and fvc were measured in the sitting position using a dry wedge spirometer (vitalograph, model s, buckinghamshire, uk) according to the guidelines of the american thoracic society (ats). data were excluded for five subjects who did not fulfil ats criteria for reproducibility after repeated attempts. venous blood was collected from all subjects. specific igg titres to adenovirus; influenza a; influenza b; parainfluenza ; parainfluenza ; parainfluenza ; mycoplasma; rsv and psittacosis were assayed in serum by complement fixation tests. specific igg titres to legionella spp. and burkholderia pseudomallei were assayed by indirect immunofluorescence. positive reciprocal igg titres were taken as greater than for all pathogens with the exception of legionella spp. (> ) and burkholderia pseudomallei (> ) as these are the conventional cut-off levels for complement fixation titres for these pathogens. serology for common bacterial infections with haemophilus influenzae, streptococcus pneumoniae, and staphylococcus aureus was not performed because these organisms occur almost ubiquitously in people with chronic airway disease and are usually mucosal infections without significant humoral antibody responses. linear regression was used to model the effects of multiple covariates on the continuous spirometric outcomes. two sets of models were derived separately for adults ( years of age and over) and children, including terms for age (both linear and non-linear terms), gender, height, weight, smoking, and interactions with gender, in predicting fev , fvc and the fev /fvc ratio. smoking (ever smoked = ' ', never smoked = ' ') was considered as a binary covariate. residuals from both these sets of models (i.e. all ages combined) were then regressed on positive individual titres and then the sum of all positive (yes/no) igg titres. by using these methods, no reference was required to 'predicted normal' levels derived from external data sources that may not have been appropriate. all analyses were carried out using stata ver . there were male ( %) and female participants with satisfactory lung function and serology data included in the study analysis. the mean age was . years (sem = . years). adults (subjects Ն years) comprised % (n = ) of the study population. there was a high prevalence of cough and sputum in both children and adults, particularly in men ( table ) . the average number of positive igg titres per person was . (sd = . ; range = - ). positive titres for influenza a and b and legionella were more common among adults than children, whereas the response rates to other pathogens were comparable ( table ). all those who were positive for mycoplasma (four children, seven adults) were also positive for influenza a and % ( of ) of those positive for parainfluenza were also positive for rsv. using residuals from the separate models for adults and children adjusted for age, height, gender, weight to examine the robustness of these findings, analyses were repeated with the result for each pathogen in turn removed from the total positive titres. for fev the regression coefficients varied only - ml each way, with consistent sem and p-values. similar results were found for fev % fvc. there was no significant separate association of lung function with rsv titres, as found in norway, although fev was reduced in those positive to parainfluenza (coefficient - ml, sem = ml, p = . ), and as described above, these subjects were nearly all positive to rsv. in this tropical aboriginal community, serological evidence of the burden of previous infections with known viral and other respiratory pathogens was associated with significant decreases in the levels of airway function, consistent with airflow obstruction. this association was independent of age, gender, height, weight and smoking status. other possible confounders such as diet, living conditions and alcohol consumption (alcohol was prohibited within this community), were not considered relevant especially as they were homogeneous in this population. influenza vaccination, offered annually to community members from the age of years, partly explains why positive adult influenza titre rates were almost double those of children. it was not possible to determine which individuals took up the vaccination each year. vaccination status would tend to reduce the likelihood that an association between positive titres and lung function would be apparent, unless vaccination itself was detrimental to lung function. smoking status was included in the analysis, but measures of the amount of smoking were not (apart from age as a surrogate for duration), as the information was not considered reliable. it seems unlikely that passive smoking in childhood is important in this population as so much time is spent in the open air in this tropical community and the houses are not sealed. smoking in pregnancy by mothers could not be assessed but could be important in determining subsequent lung function; this would require a separate investigation. an association between smoking and the frequency of viral infections would be necessary for smoking to be responsible for our observations. no particular pathogen appeared to dominate the association between serological responses and lung function in this study; rather the number of positive titres was the factor that explained the observations. there was no way of determining the temporal relationship between any infection and changes in lung function. the results of the present study are consistent with the results of a cross-sectional community study in norway, which found evidence that previous rsv infection is associated with lower levels of fev . in the current study there was no separate association of rsv titre with the level of lung function, which is consistent with the concept that any effect of respiratory viral infections on lung function is not an exclusive effect of past rsv infection. the relationship of fev and fev /fvc ratio with the total number of positive titres in this study suggests that repeated infections with common respiratory pathogens may have a cumulative detrimental effect on airway function or increase susceptibility to other agents such as tobacco smoke. the study does not indicate that any particular organism is likely to be more detrimental than any other; a positive titre to an organism does not indicate that it is more significant than any other. viral respiratory infections are known to be associated with subsequent bacterial infection and exacerbations of copd, which may be an intermediate step in a process of accelerated rate of decline in lung function, leading to irreversible airflow obstruction. however, a role for exacerbations in causing accelerated decline in other populations has not been consistently observed, and excessive rates of decline in lung function have not been directly demonstrated in aboriginal people in remote communities, although it is the subject of ongoing investigation in the community in which the present study was carried out. the previous demonstration of possible latent adenovirus infection in subjects with copd is consistent with a direct effect of viral infections on the airways, but also consistent with abnormal airways such as may result from cigarette smoking giving rise to increased susceptibility to infection with viruses and other respiratory pathogens. additionally, vitalis et al. showed that latent adenovirus- infection increased the inflammatory cell response to an acute exposure to cigarette smoke in guinea pig lungs, increasing the number of macrophages and helper t cells in the airway epithelium. recruitment of cd + lymphocytes in response to viral infections may cause pulmonary damage as suggested by o'shaughnessy et al. and cannon et al. fryer and jacoby suggested that viral infections may decrease m muscarinic receptor function in airways, thereby increasing vagally mediated bronchoconstriction; the duration of this effect for acute viral infection is not known. viral infection with rhinovirus, coronavirus, influenza a and b, rsv and parainfluenza virus and infection with chlamydia have all been associated with exacerbations of asthma. serology for h. influenzae, streptococcus pneumoniae and staphylococcus aureus was not performed in this study, nor was sputum culture available in this remote community, so that the effect of these organisms was not assessed as an a priori decision. the pathogens were selected because they are more likely to be primary pathogens. while selection bias may affect the results of crosssectional studies, all subjects over years of age who were present in the community at the time of the study were assessed. full participation was therefore achieved. the age distribution of the study subjects reflects the increased mortality rates of indigenous australians , , and reduces the power of the study to identify effects that may cause cumulative lung damage (as these would more easily be seen in older people). recall bias of questionnaire measures is also unlikely to have influenced our findings, as both the principal explanatory variables (specific antibodies to known pathogens) and the outcome variables (lung function measures) were based on objective measurements. some random misclassification of questionnaire responses may have occurred owing to language difficulties, although self-reported smoking status was validated with urinary cotinine measurements in a previous survey and showed concordance with both tobacco smoking and chewing histories (p le soeuf et al., unpubl. data, ) . the classification of participants in this study as previously infected or not, may have been subject to error because antibody titres decline with time following infection with these agents and because the patients were not examined for rhinoviruses and coronaviruses, which frequently cause the common cold syndrome, nor for chlamydia pneumoniae. this was because reliable antibody tests for these agents were not available. some unidentified previous infections may therefore have occurred in subjects and resulted in their being misclassified when examining the effect of total number of positive igg titres. however, this potential bias would, if anything, have tended to reduce the ability of the study to demonstrate differences between subjects with and without evidence of repeated previous respiratory pathogen infections. this study was performed over a short period ( days) early in the dry season. therefore, seasonal effects were not examined. no seasonality of respiratory infections in isolated tropical aboriginal communities has been described. the results of this study provide some insight into the consistent observation that australian aboriginal people have lower levels of lung function than do australians of european descent. [ ] [ ] [ ] [ ] some of the observed difference may well be due to inherited factors, and therefore not amenable to intervention. however, it is likely that environmental factors are as important. the prevalence of diagnosed asthma, and to a lesser extent allergy to aeroallergens, is low in aboriginal communities, , although 'asthma' admission rates are higher than for non-aboriginal people. it has long been recognized that chronic respiratory disease is common in aboriginal communities. , there is a high prevalence of bacterial infection of the sputum and invasive pneumococcal disease. , the present study suggests that repeated episodes of respiratory infection with common respiratory viral pathogens may be directly or indirectly associated with impaired lung growth in childhood and/or excessive loss of lung function in adulthood. therefore, in addition to smoking control, targeted public health measures such as vaccination, early pharmacological (anti-biotic) intervention for (superimposed) bacterial infection, or efforts to reduce rates of transmission by the provision of better housing or nutrition could all result in reduced morbidity and mortality from respiratory disease in these people. this isolated community is similar to others in northern australia, although it is more geographically isolated than most. because alcohol is prohibited in the community the effects of aspiration pneumonias and their sequelae on lung function are less likely to confound the observations of this study. the study provides evidence of a detrimental effect of respiratory infections on lung function in individuals from any aboriginal community; this particular aboriginal community simply provided an opportunity to examine the relationship. as the relationship between infections and lung function is likely to be similar in other communities, this study provides an important public health message regarding preventive measures. the health and welfare of australia's aboriginal and torres strait islander peoples. australian bureau of statistics (cat. . ), commonwealth of australia the impact of tobacco smoking and alcohol consumption on aboriginal mortality and hospitalization in wa - mortality in the northern territory - . territory health services respiratory symptoms and lung function in aborigines from tropical western australia the physical health of aboriginal adults in bourke ventilatory standards for clinically well aboriginal adults respiratory function in aboriginal children the deviation of serum immunoglobulins g, a, and m in australian aboriginal infants etiology of acute lower respiratory tract infection in central australian aboriginal children the epidemiology of invasive haemophilus influenzae infections in children under five years of age in the northern territory: a three year study serum respiratory virus antibodies: predictor of reduced one-second forced expiratory volume (fev ) in norwegian adults persistent and latent viral infections in the pathology of asthma the effect of latent adenovirus infection on cigarette smoke-induced lung inflammation national health and medical research council. national health and medical research council guidelines on ethical matters in aboriginal and torres strait islander health research research council committee on the aetiology of chronic bronchitis. definition and classification of chronic bronchitis for clinical and epidemiological purposes standardisation of spirometry, update manual of clinical microbiology statistical methods in medical research statacorp. stata statistical software v . stata corporation endogenous and exogenous reinfections with haemophilis influenzae in patients with chronic obstructive lung disease: the effects of antibiotic treatment on persistence the natural history of chronic airflow obstruction inflammation in bronchial biopsies of subjects with chronic bronchitis: inverse relationship of cd + t lymphocytes with fev cytotoxic t cells clear virus but augment lung pathology in mice infected with respiratory syncytial virus effect of inflammatory cell mediators on m muscarinic receptors in the lungs respiratory viruses and exacerbations of asthma in adults overview of aboriginal health status in western australia. australian institute of health: aboriginal and torres strait islander health series respiratory morbidity and lung function in two aboriginal communities in western australia hospitalization of aboriginal and non-aboriginal patients for respiratory tract diseases in western australia, - invasive pneumococcal disease in central australia invasive pneumococcal disease in the northern territory we are grateful to the members and staff of the community for willingly taking part in this study. community nurses monica frain and lex criddle (western australian department of public health) provided invaluable assistance in the collection of data. professor michael gracey and dr randolph spargo (western australian department of public health) facilitated planning and conduct of the survey. dr ian sampson (pathwest) conducted serological assays. we also thank our colleagues who assisted in the collection, analysis and interpretation of the data. this study was supported by the medical research foundation of western australia. key: cord- - gbktpt authors: van brussel, kate; carrai, maura; lin, carrie; kelman, mark; setyo, laura; aberdein, danielle; brailey, juliana; lawler, michelle; maher, simone; plaganyi, ildiko; lewis, emily; hawkswell, adele; allison, andrew b.; meers, joanne; martella, vito; beatty, julia a.; holmes, edward c.; decaro, nicola; barrs, vanessa r. title: distinct lineages of feline parvovirus associated with epizootic outbreaks in australia, new zealand and the united arab emirates date: - - journal: viruses doi: . /v sha: doc_id: cord_uid: gbktpt feline panleukopenia (fpl), a frequently fatal disease of cats, is caused by feline parvovirus (fpv) or canine parvovirus (cpv). we investigated simultaneous outbreaks of fpl between and in australia, new zealand and the united arab emirates (uae) where fpl outbreaks had not been reported for several decades. case data from cats and clinical samples from additional cats were obtained to determine the cause of the outbreaks and epidemiological factors involved. most cats with fpl were shelter-housed, to weeks old at diagnosis, unvaccinated, had not completed a primary vaccination series or had received vaccinations noncompliant with current guidelines. analysis of parvoviral vp sequence data confirmed that all fpl cases were caused by fpv and not cpv. phylogenetic analysis revealed that each of these outbreaks was caused by a distinct fpv, with two virus lineages present in eastern australia and virus movement between different geographical locations. viruses from the uae outbreak formed a lineage of unknown origin. fpv vaccine virus was detected in the new zealand cases, highlighting the difficulty of distinguishing the co-incidental shedding of vaccine virus in vaccinated cats. inadequate vaccination coverage in shelter-housed cats was a common factor in all outbreaks, likely precipitating the multiple re-emergence of infection events. feline panleukopenia (fpl) is a highly contagious and often fatal disease characterised by acute severe enteritis, severe dehydration and sepsis due to lymphoid depletion and pancytopenia [ ] . fpl is usually associated with infection by feline parvovirus (fpv), a member of the genus protoparvovirus (formerly feline panleukopenia virus). protoparovirus is one of eight genera of vertebrate viruses within the subfamily parvovirinae of the family parvoviridae. collectively, fpv and canine parvovirus (cpv), along with associated variants found in various carnivore species such as mink and raccoons, constitute the species carnivore protoparvovirus [ ] . until the s, fpv was the only reported viral cause of fpl in cats. fpv is able to infect cats by first binding to the feline transferrin receptor (ftfr) expressed on the surface of cells, followed by clathrin-mediated endocytosis to initiate infection [ ] . canine parvovirus cpv- emerged in the late s and was initially unable to infect cats, as it could not bind to the ftfr [ ] . however, infectivity for feline cells was acquired soon after by the genetic variant cpv- a, which emerged in and replaced cpv- [ ] . the ability to infect cats has also been retained by subsequent antigenic variants of cpv- a, termed cpv- b and cpv- c, which only differ from cpv- a at a single amino acid position (vp ). these and other antigenic variants of cpv can cause fpl in both naturally acquired and experimental infections of cats [ ] [ ] [ ] [ ] . in contrast to parvoviral enteritis in dogs, estimated to cause , cases per year in australia, clinical cases of fpl have rarely been diagnosed in australia since the mid- s, and there have been no reports of fpl outbreaks for over years [ ] . in , fpl re-emerged in eastern australia, and subsequent outbreaks occurred between and in several locations in this region. similarly, outbreaks of fpl occurred in new zealand (nz) between and , as well as in the united arab emirates (uae) in , with no outbreaks of fpl reported in either country in recent decades, likely due to the widespread use of fpl vaccines. the contemporaneous re-emergence of fpl in geographically distinct settings long considered fpl-free has raised questions as to whether virus-related or other unknown risk factors played a role in the observed fpl outbreaks. herein, case data and clinical samples from and cats, respectively, were analysed to identify the lineages of carnivore protoparvovirus responsible for the outbreaks of fpl in australia ( to ), the uae ( ) and nz ( - ) and evaluate epidemiological factors associated with these outbreaks, including vaccination status. inclusion criteria for cases of fpl were (i) clinical signs typical of fpl (lethargy, fever, hypothermia, anorexia, vomiting, diarrhoea and/or sudden death) and a positive confirmatory test (faecal cpv antigen test or pcr) or (ii) clinical signs typical of fpl in a cat from a shelter with a confirmed contemporaneous outbreak of fpl. australian case data were extracted from a national online companion animal disease surveillance-reporting database launched in january [ ] and from the medical records of animal shelters and/or veterinary hospitals in outbreak regions for the period january to august . data recorded included case occurrence date, shelter location, shelter post code, age at diagnosis, sex, post code of owner residence or where found as a stray before entry into shelter, clinical signs at presentation, date of last vaccination, vaccination type (inactivated or modified live virus (mlv) vaccine), time interval between last vaccination and onset of clinical signs (days), method of diagnosis and outcome. data obtained were searched to identify cases for which serial monitoring of faecal shedding of fpv or cpv using qpcr testing had been performed. information about animal movements, biosecurity and vaccination protocols was obtained from shelter veterinarians and/or managers. new zealand case data were obtained from one shelter, comprising summary data of case diagnoses for two fpl outbreaks occurring between and as well as individual data for cases in which clinical samples were available for pcr and sequencing. individual case data for uae cases were available during the period of the outbreak in . data were analysed using microsoft excel ® for mac version . . and statistix ® version . (analytical software, tallahassee, fl, usa). descriptive statistics were generated for fpl case numbers, age at disease diagnosis, interval between vaccination and disease and interval between admission and disease. frequency distributions were created for age at disease diagnosis. mapping and geospatial analysis was performed with arcgis ® version . (ersi, redlands, ca, usa). residual diagnostic faecal samples or tissue (intestine or mesenteric lymph node) obtained post-mortem were collected prospectively in australia from april until august and from the uae and new zealand during suspected outbreaks of fpl in . in addition, a stored faecal sample from a cat diagnosed with fpl in the first outbreak in australia in was obtained for study. dna was extracted for sequencing of the carnivore protoparvovirus vp gene from tissue using the qiagen dneasy blood and tissue kit (qiagen, hilden, germany) or from faecal samples using the qiaamp fast dna stool mini kit (qiagen, germany) or by homogenisation, boiling and centrifugation, as previously described [ ] . the extracted dna was amplified by conventional pcr using u/µl of my taq hs red dna polymerase (bioline, usa), - ng of dna, x mytaq red reaction buffer and a final primer concentration of . µm in a final reaction volume of µl. three sets of overlapping primers were used to amplify the entire vp region ( bp) as described previously, with minor modifications (table ) [ ] . an initial denaturation step at • c for min, followed by - cycles of denaturation at • c for s, annealing at or • c for s and extension at • c for s, ending with a final extension at • c for min, was used for dna amplification. the pcr products were separated by electrophoresis on a % agarose gel (bio-rad laboratories, hercules, ca, usa) in × tris-acetate edta and visualized using sybr safe dna (invitrogen, carlsbad, ca, usa). sanger sequencing of positive pcr products was performed commercially (macrogen, seoul, korea). vp sequences were edited, assembled and aligned using the clustalw algorithm in geneious prime (biomatters ltd., auckland, new zealand) (although alignment was uncontroversial with no gaps needed). sequences were translated in megax, and amino acid substitutions compared to the ictv reference fpv sequence (fvp- genbank accession no. eu ) were identified. to determine the evolutionary history of the outbreak sequences from australia, new zealand and dubai, we performed a phylogenetic analysis including these sequences and representative vp sequences of fpv and cpv taken from genbank. in addition, we included an fpv vp sequence obtained from tissues of a healthy feral cat from tasmania, australia, sampled in (genbank accession no. mn ), for comparison. this resulted in a total data set of sequences, nt in length. phylogenetic analysis of these was performed using the phyml program [ ] and employing the gtr+i+Γ model of nucleotide substitution and a combination of nearest-neighbor interchange (nni) and sub-tree pruning & re-grafting (spr) branch swapping. nodal support was assessed using sh-like branch support. finally, the five cpv sequences included were used as an outgroup clade to root the tree. an fpv strain identical to that used in a commercially available mlv fpv vaccine was detected in faecal samples from new zealand cases. subsequently, qpcr was performed to determine fpv viral loads in dna extracts of mesenteric lymph nodes and tissues from these cases using a taqman qpcr assay as described previously [ ] . faecal samples containing vaccine virus were also submitted to a commercial laboratory for batch testing on a multiplex qpcr panel to detect potential faecal co-pathogens including feline coronavirus, tritrichomonas foetus, clostridium perfringens, giardia spp, salmonella spp, campylobacter jejuni, campylobacter coli and toxoplasma gondii (idexx pty ltd.). tissues (duodenum, jejunum, colon, liver, spleen, kidney, mesenteric lymph node, heart, lung, pancreas, brain and/or bone marrow) from representative australian fpl cases that had died or been euthanised, ranging in age from weeks to months, including one from melbourne in and from sydney in and , were available for histological examination. tissues (intestine, +/− mesenteric lymph node) from six suspected cases of fpl from new zealand were also examined. all tissues were collected post-mortem and animals were not euthanised for the purposes of this study. data were received from cases of fpl diagnosed in australia between january and september from animal shelters, rescue societies and veterinary hospitals. of the cases, % were shelter-housed, % were privately owned cats presenting to veterinary hospitals, and % were from foster carers working with rescue societies without premises. the distribution of australian cases by geographic region and year is shown in table and figure . figure s ). the distribution of cases varied with month of presentation and is shown in figure . frequent transfer of cats in victoria between shelters in mildura (outbreak site) and melbourne (outbreak site) suggested direct spread of the infection between these regions. cats from two private shelters in mildura were transported for rehoming to a shelter in melbourne in and . two of five shelters in nsw did not vaccinate cats while under their care. the other three shelters vaccinated healthy cats on admission using an inactivated fpv vaccine, whereas sick cats with suspected viral respiratory tract infections were not vaccinated until their clinical signs resolved. none of the three shelters in mildura vaccinated cats. of the three shelters in melbourne, one did not vaccinate cats, while two vaccinated cats on admission, one using an inactivated vaccine and the other an mlv vaccine. all shelters that used vaccinations gave a primary course to kittens starting at a minimum age of weeks, then every to weeks, finishing at to weeks of age, while adult cats were given two vaccinations one month apart. both rescue societies, one in nsw and one in victoria, accepted unvaccinated cats and kittens for adoption from municipal pounds (shelters), that were fostered until adoption. for shelter-housed cats, the median time from admission to diagnosis of fpl was days (iqr - ; range - days). of the cats diagnosed with fpl, ( %) had never been vaccinated or had an unknown vaccination history. sixty-five of the ( %) cats that had received at least one vaccination were < weeks of age at the time of their last vaccination. for cats ≥ weeks of age at the time of last vaccination, the vaccination-to-disease interval was > days for / cats vaccinated with ≥ inactivated vaccines and > days for / cats vaccinated with at least one mlv vaccine; vaccine type was unknown for one cat. for all vaccinated cats, the median time from last vaccination to diagnosis was . days (iqr - ; range - days). age, sex and breed data were available for fpl cases. the median age at diagnosis was weeks (iqr - weeks; range weeks- months). the frequency distribution of age at diagnosis is shown in table males ( %) and females ( %) were equally represented among fpl cases. most cats ( %) were domestic crossbred (domestic shorthair or domestic longhair). data on specific clinical signs were available for cats. the most common clinical signs were diarrhoea ( %), lethargy ( %), vomiting ( %), anorexia ( %), weight loss or failure to gain weight ( %) and sudden death ( %). diarrhoea was reported to be haemorrhagic in of cats ( %) with diarrhoea. overall mortality for all cats was %, noting that cases diagnosed in shelters were routinely euthanised at diagnosis to contain the infection. two fpl outbreaks occurred in wellington, new zealand, in december and january . the seasonal distribution of cases in the second outbreak is shown in figure . in total, cases of fpl were diagnosed, including in the first outbreak and in the second. during both outbreaks, % of feline admissions to the shelter were diagnosed with fpl. the median age at diagnosis was weeks (iqr - weeks, range - weeks). at diagnosis of fpl, % of cats were unvaccinated, % had received one vaccine, % had been vaccinated twice, and % had been vaccinated three times. the median time since the last vaccination was days (iqr - . days, range - days). the median time from shelter admission to diagnosis was days (iqr - days, range - days). of the nine cases for which clinical samples were available for pcr and sequencing, all cats had a positive faecal cpv antigen test result (fastest parvo strip, megacor hoerbranz, austria) and were euthanised at diagnosis. all cats had been vaccinated on admission using an mlv fpv vaccine (felocell or felocell , zoetis pty. ltd.). clinical data are presented in table . fourteen cases of fpl from dubai, uae, were diagnosed in domestic crossbreds with positive faecal cpv antigen test results. all cats were strays or strays that had been recently adopted, and all were unvaccinated, except an -month-old cat that had received a primary course of kitten vaccinations and a booster vaccination at months. clinical signs included vomiting, diarrhoea and lethargy, and the median age at diagnosis was months (range - months). all cats were treated, and outcomes were known in cases, of which died or were euthanised, and survived. in sections of duodenum and jejunum from the representative cases, there was a mild to severe necrotizing lymphoplasmacytic-to-suppurative enteritis, characterized by variable blunting, fusion and loss of villi, collapse of the lamina propria, loss of crypts and replacement by abundant coccobacilli and necrotic debris. the remaining crypts were often ectatic, with variable numbers of crypt abscesses ( figure ). evidence of multifocal crypt regeneration was also variably present. the submucosa and tunica muscularis were variably expanded by congestion, fibrin, oedema, haemorrhage, perivascular lymphocytes and plasma cells, macrophages exhibiting erythrophagocytosis, occasional neutrophils and rare eosinophils. in sections of mesenteric lymph nodes, the most common finding was multifocal follicular and paracortical lymphoid depletion with accentuation of the reticuloendothelial architecture ( figure ). depleted lymphoid follicles were small, poorly populated and contained central accumulations of hyalinized eosinophilic material (follicular hyalinosis) with variable numbers of tangible body macrophages. the subcapsular and medullary sinuses were expanded by erythrocytes, oedema fluid and moderate to markedly increased numbers of macrophages, some exhibiting erythrophagocytosis. mild-to-moderate multifocal lymphoid depletion was also apparent in splenic sections. extramedullary haematopoiesis characterized by the presence of myeloid and erythroid precursors was variably present within spleen and lymph nodes. sections of bone marrow examined were either hypocellular, characterised by increased numbers of, predominantly, adipocytes and extravasated erythrocytes interspersed with very low numbers of erythroid and myeloid precursors and megakaryocytes, or hypercellular, with increased numbers of myeloid and erythroid precursors. some sections of the liver demonstrated hepatocellular atrophy and congestion, with minimal periportal mononuclear infiltrates. among the sections of myocardium examined, there were no significant lesions. histopathology of the small intestine was performed in six cases, including five in which samples were collected for pcr and sequencing (table ). in four of these, lesions of mild enteritis (n = ) or fibrosis of the lamina propria (n = ) were present. in one case ( , table ), histological lesions were typical of fpl ( figure ) , with multiple sections of jejunum and ileum showing mild multifocal loss and replacement of crypts by karyorrhectic and cellular debris (necrosis) and low-to-moderate numbers of neutrophils within the lamina propria. low numbers of the remaining crypts were variably lined by degenerate or necrotic epithelium with intraluminal degenerate neutrophils, debris and sloughed necrotic epithelial cells (crypt abscesses). neutrophils frequently invaded the remaining crypt epithelium. rare epithelial cells contained - µm-diameter polygonal-to-ovoid, eosinophilic-to-amphophilic intranuclear inclusion bodies that occasionally marginated the chromatin. there was moderate multifocal crypt regeneration, and crypts were frequently lined by large epithelial cells with vesicular nuclei that were piled up or in mitosis. intestinal lymphoid tissue appeared mildly depleted. the morphological diagnosis was moderate diffuse acute neutrophilic enteritis with crypt necrosis, epithelial regeneration and rare intranuclear viral inclusions. these findings were consistent with fpv/cpv infection. (table ). of the cases where sections of mesenteric lymph nodes (n = ) or thymus (n = ) were available, lesions of mild follicular lymphoid depletion were present in one case, which was the same animal with small intestinal lesions consistent with fpv (case ). affected cortical follicles were small and poorly populated. histopathology was also performed on intestine and mesenteric lymph nodes from one unvaccinated cat with clinical signs of fpl, but for which samples were not collected for pcr and sequencing. changes in the duodenum were similar to but more severe than those described above in case , including crypt necrosis and abscessation, neutrophilic infiltration of the lamina propria and the presence within epithelial cells of intranuclear inclusion bodies which variably marginated the chromatin. there was moderate lymphoid depletion in mesenteric lymph node tissue. these findings were also consistent with fpv/cpv infection. the entire vp region of carnivore protoparvovirus was amplified from suspected cases of fpl, comprising from australia, from dubai and from new zealand. amino acid substitutions compared to the fpv reference strain are listed in table . all vp sequences in this study were identified as fpv, with no cases attributed to cpv. phylogenetic analysis of these vp sequences in comparison to a background global data set of fpv sequences revealed the presence of four distinct clades of australian viruses ( figure ). the first, denoted clade a, comprises viruses ( of which were identical) sampled from a wide geographic area (melbourne, geelong and mildura) between and . in contrast, australia clade b comprised just two identical sequences sampled in nsw in . these viruses were detected in the faeces collected from two cats in the same shelter in sydney, nsw, in november . both cats had severe diarrhoea and tested positive for salmonella spp. and carnivore protoparvovirus on a multiplex faecal qpcr panel (idexx pty ltd.). the largest australian clade (c) comprised viruses from nsw and one from queensland, collected between december and february . viruses collected from cats in north western nsw (gunnedah) and south eastern queensland (nambour) in were identical to those sampled from cats from four shelters and from privately owned cats in sydney. viruses from cats from the nsw central coast also fell into this clade. finally, one sequence isolated from a cat from melbourne in (fpv_ ) was identical to viruses in clade c, with the exception of a mutation at position (a g) that resulted in an amino acid substitution i to v. this mutation was also present in viruses in clade a. this study - a fourth (although not strictly monophyletic) clade (d) of viral sequences from australian cats contained three vp sequences identical to that of an fpv vaccine strain (purevax; genbank accession no. eu ) and two sequences that are very closely related to the vaccine strain. in one of these, from a -week-old kitten with acute vomiting and failure to gain weight, the vaccine strain was unlikely to be the cause of the cat's clinical signs. fpl was suspected because a multiplex qpcr faecal panel was positive for giardia spp. and canine protoparvovirus . however, the cat, from canberra in the australian capital territory, had been vaccinated days before with the same mlv vaccine strain. no littermates were affected, the cat recovered, and no other cases of suspected fpl were encountered in this region. another sequence in this clade was from a -week-old stray kitten with vomiting, diarrhoea and failure to gain weight. the kitten, from a shelter in melbourne, had been vaccinated days before with the same mlv vaccine. it also tested positive on a multiplex qpcr faecal panel for giardia spp. and canine protoparvovirus . the third sequence was from an owned -week-old kitten in sydney with acute onset vomiting and diarrhoea, vaccinated days before (vaccine type unknown). of the two closely related vp sequences, one (fpv_ ) was from a -week-old kitten vaccinated days before with the same vaccine strain, which presented for diarrhoea, vomiting and lethargy. it also tested positive for giardia spp. on a faecal antigen test. the other (fpv_ ) was from an unvaccinated stray -month-old cat that presented with vomiting, diarrhoea and anorexia and tested positive on a faecal cpv antigen test. finally, two other australian sequences-fpv / and tasmania/ -did not fall into a distinct clade but were relatively closely related to each other and to the vaccine cluster (clade d). all vp sequences from cats from dubai fell into a single clade containing four unique sequence types and which was not clearly related to any other of the fpv sequences. in contrast, those viruses sampled from new zealand in were either identical (eight of nine animals) or clearly very closely related to a vaccine strain (felocell, zoetis pty ltd.) and taken from cats with a history of recent vaccination. the single sequence that was not identical to that of the vaccine strain exhibited just two nucleotide substitutions, one of which was non-synonymous (e k) ( table ). the results of the qpcr analyses to quantify fpv viral load in faeces of nz cats and to detect faecal co-pathogens are presented in table . medical records were obtained from two unvaccinated kittens with fpl from australia, where serial monitoring of fpv faecal shedding using qpcr was performed on pooled faecal samples after diagnosis. testing was done at a single commercial laboratory, and results were reported as positive or negative (table ). table . results of serial monitoring of faecal shedding of fpv in faecal samples from two cats diagnosed with fpl. an understanding of the drivers of the re-emergence of fpl, the oldest known viral disease of cats, is essential to contain this fatal infection. we provide strong evidence of multiple outbreaks of fpl in three countries. there are no previous published reports of fpl outbreaks in any of these regions for comparison, although there is anecdotal first-hand experience of fpl among veterinarians practicing in australia from the late s to the mid- s, before commercial vaccines were used routinely [ ] . despite the widespread circulation of cpv in australia, this virus was not detected in any samples tested in these fpl outbreaks. canine parvovirus causes approximately % of fpl cases globally, but these have been confined to sporadic individual cases, and there are no reports of fpl outbreaks caused by cpv in multi-cat environments [ , , ] . whether this is due to viral or to host factors is currently unknown and warrants further investigation. a single fpv lineage (clade a) was responsible for disease in both outbreak regions in victoria, australia, even though these are geographically distant ( km) from each other. phylogenetic analysis revealed the closest related virus was taken from a domestic cat in japan in (genbank accession no. ab ), although it is likely that a closer ancestral virus exists but has not been sampled here. the % sequence identity of vp sequences from cases in mildura and melbourne is consistent with the epidemiological investigation, which found evidence supporting direct viral spread through transport of unvaccinated cats for adoption in and . the nonenveloped virions of fpv, shed in high titres in all excretions of infected animals, are environmentally resilient and remain viable in infected premises such as shelters for over a year [ , ] . indirect transmission by fomites is a major mechanism of parvovirus transmission among cats and dogs and was likely a crucial contributing factor to the canine global cpv pandemic in the late s [ ] . unexpectedly, the fpl outbreak in sydney, nsw, was not caused by spread of the victorian strain, but rather by a separate clade (c) comprising a relatively distinct virus [ , ] . this finding, together with the detection of additional australian fpvs (clades b and d), is consistent with multiple independent virus entries into australia, including the virus from an unvaccinated cat (clade d), which was seemingly derived from an fpv vaccine strain. three recently vaccinated cats, in which the same vaccine virus was detected (clade d), likely did not have fpl, including two with giardia co-infections initially diagnosed with fpl from a positive commercial faecal qpcr assay. mlv vaccine virus shed in faeces can be detected in qpcr assays and cpv faecal antigen tests [ , ] . quantifying viral loads can assist in the discrimination of vaccine and field strains. however, quantification data were not provided by the commercial laboratory for these two cases. cpv vaccine viral loads in recently vaccinated dogs are -to -fold lower than those of dogs infected with field strains [ ] . similarly, a recent report found several recently vaccinated cats had low fpv viral loads (< . × copies/mg of faeces) over a -day period of surveillance [ ] . before this investigation, only one fpv vp sequence from australia had been deposited in the genbank database (fpv / , genbank accession no. x ). the evolutionary relationships with fpv / cannot be inferred reliably, since the isolate, obtained from a -month-old cat in melbourne with peracute fatal fpl, had been serially passaged in vitro before sequencing in . interestingly, fpv / falls notably close to a clade of vaccine viruses in our analysis. in addition, we generated the vp sequence of an fpv strain detected in a healthy feral cat from tasmania in , which was genetically distinct from outbreak strains in this study and also fell into clade d, suggesting a vaccine-related origin. these findings, together with a report of fpv detection in the bone marrow of a healthy feral cat from melbourne in [ ] , provide evidence that fpv has been circulating widely in australia, at least since the s, although the viruses are phylogenetically unrelated to the - outbreaks. one possible explanation for the multiple independent fpv introductions described here is that fpv viruses circulating in the feral cat population may occasionally spill over into domestic cats. in comparison to the owned cat population, estimated at . million [ ] , some . to . million feral cats (free-roaming, unowned, unsocialised cats) inhabit australia [ ] . an fpv seroprevalence of % among feral cats in victoria and nsw, documented in , provides evidence of widespread fpv exposure [ ] . viral introductions could also have been anthropogenic, for example through fomite spread during international travel. we were also able to analyse sequence data from a contemporaneous fpl outbreak in the uae in . this is the first study to characterise full-length vp sequences from the middle east. viruses most closely related to the uae viruses, which formed a phylogenetically distinct lineage, were from a range of locations in europe, asia and the americas, but the long lineage leading to the uae viruses suggests that we have not yet sampled their ultimate ancestor. the vp sequence data from cases analysed from a third country with contemporaneous fpl outbreaks showed that the nz fpv strains segregated with fpv vaccine viruses. the virological findings from these cases yet again highlight the difficulty of diagnosing fpl in cats that have recently received mlv vaccines, as well as raising important questions about the potential capacity of reversion to virulence of mlv vaccines. the diagnosis of fpl in cases from nz was initially based on consistent clinical signs and a positive faecal antigen test. point-of-care immunochromatographic assays designed to detect cpv faecal antigen also detect fpv, so are used in practice for the diagnostic investigation of cats with clinical signs consistent with fpl [ ] . however, faecal antigen tests detect both field and vaccine strains of fpv and cpv. in one study evaluating three commercial cpv faecal antigen kits, % of cats vaccinated against fpv in the preceding days returned positive test results [ ] . the sensitivity of faecal antigen tests for the detection of parvoviruses is influenced by viral load in faeces, as well as by the presence of gut antibodies that can sequestrate viral particles and prevent binding to the test antibody [ ] . cpv vaccine viral loads in recently vaccinated dogs are usually below the limit of detection of antigen tests, ranging from . × to . × copies/mg of faeces in one study [ ] and from ≈ to . × copies/mg of faeces in another [ ] . the lower limit of detection of faecal antigen tests for cpv in dogs is to viral dna copies per mg of faeces [ ] . low titres of gut fpv antibodies in the new zealand cats could explain the positive faecal antigen test results in those cats with low faecal viral loads. all but one of the vp sequences obtained from the new zealand cases were identical to the fpv vaccine strain that the cats had been inoculated with. co-infection with other pathogens including feline coronavirus or giardia spp. could account for the clinical signs in five of these cases, which, although consistent with fpl, were non-specific. however, in one cat, high loads of vaccine strain virus were detected concurrently in lymph node and faeces (fpv_ , table ), which is more consistent with loads attained by pathogenic virus strains than with those attained by vaccine virus strains. further, unequivocal support of the diagnosis of fpl in this case was obtained from histological examination of the intestine, where lesions pathognomonic for fpl were identified ( figure ). an fpv-vaccine strain was detected in this cat, and the sequencing chromatogram showed no evidence of a coinfecting fpv or cpv. however, deep sequencing of the sample with examination of the metatranscriptome or metagenome would be required to rule out co-infection with other pathogenic viruses not included in the qpcr test panel. an alternative explanation is that there was reversion to virulence of the vaccine strain, although this has not been described previously in cats. molecular analysis of faeces from dogs displaying signs of acute gastroenteritis shortly after cpv vaccination ruled out reversion to virulence of cpv mlv, since co-infection with field strains of cpv or other pathogens including canine coronavirus, canine distemper virus and isospora canis was detected [ ] . in three pups in which only the vaccine virus was detected, cpv vaccine loads were lower than those associated with enteritis from cpv field strains, ranging from . × to . × dna copies/mg of faeces [ ] . the re-emergence of fpl in two australian states in relatively quick succession over a three-year period, caused by two distinct fpv lineages, raises the question as to why this disease is re-emerging now, after decades of apparent quiescence. animal shelters are conducive environments for pathogen emergence or re-emergence because of a large number of susceptible hosts living in a confined area. this is exacerbated by factors including young age, immunological naivety or immunosuppression, close contact and co-morbidities such as heavy parasite burdens. similarly, suboptimal biosecurity protocols favour pathogen persistence and fomite transmission [ ] . failure to vaccinate or inadequate or inappropriate vaccination in shelter-housed cats were major contributors to the re-emergence of fpl in australia. before these outbreaks, over half of the shelters from which cases were derived did not administer fpv vaccinations. in general, fpv vaccines are a highly effective tool in parvovirus control. for example, protective fpv antibody titres were measured in % of vaccinated cats in a field study of adult cats after mlv vaccination, of which % had pre-existing protective titres [ ] . in addition, viral challenge studies of fpv-vaccinated cats usually show vaccine efficacy > % [ ] . although state legislation mandates vaccination of owned cats in commercial boarding facilities in nsw and victoria, vaccination is not enforced for cats admitted to private or municipal animal shelters, until they are sold for rehoming. most shelters that did vaccinate, completed the primary course of vaccinations in kittens by to weeks of age and used inactivated vaccines, in contravention of the current guidelines. the world small animal veterinary association (wsava) vaccination guidelines recommend the use of mlv vaccines in shelter-housed cats for rapid induction of long-lasting humoral immunity [ , ] . a minimum age of weeks for the final vaccination in the primary course is recommended, based on the failure of % of kittens to seroconvert after vaccinations at and weeks of age with the commercial fpv mlv vaccination [ , ] . this immunity gap relates to persistent maternally derived antibodies (mda) in kittens, which decline below protective titres yet effectively neutralize the vaccine virus and thereby prevent seroconversion [ ] . persistent mda would explain the presence of vaccination non-responders in our study that were < weeks of age at the time of diagnosis of fpl, highlighting that vaccination alone cannot prevent disease in environments where susceptible kittens are exposed to fpv. among the % of vaccination non-responders that were older than weeks, some were likely exposed to fpv prior to seroconversion, either before or after admission to the shelter, as indicated by the median vaccination-to-diagnosis interval of . days. the incubation period for fpl is between and days [ ] . other reasons for apparent vaccine failure include persistence of mda for > weeks in kittens born to queens with high anti-fpv antibody titres or failure to mount an immune response to vaccination because of immunodeficiency (acquired or genetic), incorrect vaccine administration or storage errors [ , ] . the median time from shelter admission to diagnosis of fpl was days. the minimum holding time for unidentified cats in municipal shelters in the states of victoria and nsw is days, after which cats can be euthanised or rehomed (domestic animals act , companion animals act ). changes in euthanasia practices resulting in longer length of stay (los) may have contributed to a cumulative increase in selection pressure for fpl re-emergence, especially in shelters where vaccination was not practiced. the likelihood of exposure to infectious diseases increases within a shelter environment with increasing los [ ] . national data from royal society of prevention to cruelty (rspca) shelters show a progressive decline in euthanasia rates from % in to % in [ , ] . similar declines in euthanasia have occurred in shelters in other countries such as canada [ ] . a seasonal pattern of fpl was identified in australia and new zealand, with an annual peak in case numbers from december to may. this pattern may reflect waning maternal immunity lagging two to three months behind the peak kitten births. similar seasonality of fpl outbreaks was reported in the northern hemisphere, where seasons are inverted; case numbers peaked from july to december and were correlated with an influx of kittens born annually in spring and waning of maternal immunity over the subsequent two to three months [ ] . the duration of faecal shedding of fpv, which is relevant to infection control, has been inadequately studied. this study demonstrates that virus can be shed in faeces for an extended period of up to weeks from diagnosis. faecal shedding of vaccine virus was detected by qpcr post vaccination for the duration of one four-week study [ ] . shedding of field cpv strains in dogs has been detected by qpcr for - days [ , ] , while cpv vaccine virus was shed for - days on average [ , ] . further studies are warranted in cats to further define the duration of faecal shedding of both field and vaccine strains of fpv detectable by qpcr. inadequate vaccination coverage was identified in the fpl outbreaks described here and was a major contributor to the re-emergence of this disease. these outbreaks highlight the importance of adherence to vaccination guidelines for shelters, recommended by professional bodies such as the wsava. further research is needed to identify the duration of fpv shedding in naturally infected cats, as well as the potential for reversion to virulence of mlv vaccines. feline panleukopenia: a re-emergent disease combinations of two capsid regions controlling canine host range determine canine transferrin receptor binding by canine and feline parvoviruses binding site on the transferrin receptor for the parvovirus capsid and effects of altered affinity on cell uptake and infection isolation of canine parvovirus from a cat manifesting clinical signs of feline panleukopenia feline host range of canine parvovirus: recent emergence of new antigenic types in cats the pathogenicity of canine parvovirus type- b, fp strain isolated from a domestic cat, in domestic cats canine parvovirus type c infection in a kitten associated with intracranial abscess and convulsions the geographic distribution and financial impact of canine parvovirus in australia companion animal disease surveillance: a new solution to an old problem? spat. spatio-temporal epidemiol a minor groove binder probe real-time pcr assay for discrimination between type -based vaccines and field strains of canine parvovirus genetic analysis of feline panleukopenia viruses from cats with gastroenteritis new algorithms and methods to estimate maximum-likelihood phylogenies: assessing the performance of phyml . a real-time pcr assay for rapid detection and quantitation of canine parvovirus type in the feces of dogs characterisation of canine parvovirus strains isolated from cats with feline panleukopenia canine parvovirus c infection in a cat with severe clinical disease pathogenesis of feline panleukopenia virus in susceptible newborn kittens i. clinical signs, hematology, serology, and virology feline panleucopaenia virus. iii. some properties compared to a feline herpes virus host range relationships and the evolution of canine parvovirus some properties of feline panleukopenia virus. arch. fur die gesamte virusforsch nucleotide sequence of feline panleukopenia virus: comparison with canine parvovirus identifies host-specific differences effect of vaccination on parvovirus antigen testing in kittens faecal shedding of parvovirus deoxyribonucleic acid following modified live feline panleucopenia virus vaccination in healthy cats faecal shedding of canine parvovirus after modified-live vaccination in healthy adult dogs identification of parvovirus in the bone marrow of eight cats pets in australia: a survey of pets and people enumerating a continental-scale threat: how many feral cats are in australia? protozoan and viral infections of feral cats characterization of the cutaneous mycobiota in healthy and allergic cats using next generation sequencing canine parvovirus-a review of epidemiological and diagnostic aspects, with emphasis on type c long-term viremia and fecal shedding in pups after modified-live canine parvovirus vaccination evaluation of an in-clinic assay for the diagnosis of canine parvovirus occurrence of severe gastroenteritis in pups after canine parvovirus vaccine administration: a clinical and laboratory diagnostic dilemma common and emerging infectious diseases in the animal shelter antibody response to feline panleukopenia virus vaccination in healthy adult cats use of serologic tests to predict resistance to feline herpesvirus , feline calicivirus, and feline parvovirus infection in cats wsava guidelines for the vaccination of dogs and cats vaccination against feline panleukopenia: implications from a field study in kittens descriptive epidemiology of feline upper respiratory tract disease in an animal shelter risk factors affecting length of stay of cats in an animal shelter: a case study at the guelph humane society natality and herd immunity in feline panleukopenia clinical and virological findings in pups naturally infected by canine parvovirus type glu- mutant maternally-derived antibodies in pups and protection from canine parvovirus infection canine parvovirus post-vaccination shedding: interference with diagnostic assays and correlation with host immune status this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the authors are grateful to the many shelters, veterinarians and veterinary nurses who contributed to this study. the authors declare no conflict of interest. the funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results. key: cord- - wkes nk authors: goggin, gerard title: covid- apps in singapore and australia: reimagining healthy nations with digital technology date: - - journal: nan doi: . / x sha: doc_id: cord_uid: wkes nk widely and intensively used digital technologies have been an important feature of international responses to the covid- pandemic. one especially interesting class of such technologies are dedicated contact and tracing apps collecting proximity data via the bluetooth technology. in this article, i consider the development, deployment and imagined uses of apps in two countries: singapore, a pioneer in the field, with its tracetogether app, and australia, a country that adapted singapore’s app, devising its own covidsafe, as key to its national public health strategy early in the crisis. what is especially interesting about these cases is the privacy concerns the apps raised, and how these are dealt with in each country, also the ways in which each nation reimagines its immediate social future and health approach via such an app. a striking feature of the covid- pandemic has been the use of and appeal to digital technologies -fusing together what these technologies might offer in terms of efficacious communication and public health responses to help individuals and communities cope and contain the pandemic, on the one hand, as well as extending resources for social practices, expression, making sense, persisting with and reconfiguring rituals, and conjuring with the profound affective dimensions wrought by illness, death, loss, fear and isolation, on the other. in the pandemic, digital technologies have been used across societies, in a way that harked back to earlier ideas from the s of social life being nigh wholly dependent on life in 'cyberspace', and 'virtual communities'. with widespread access to and ownership and use of internet, mobile phones, social media, data, artificial intelligence (ai) and associated technologies already deeply, if very unequally, distributed globally, especially in middle-and high-income countries, the inception of the pandemic saw extended reliance on digital technologies -where terms of digital inclusion allowed for it. in a number of countries, governments also took the opportunity to issue calls to the acceleration of digitalisation, especially across groups and demographics where digital inclusion and take-up had been low, due to infrastructure, literacy and education, information and affordability. one stand-out area in this regard was apps. apps have been around since the s and s; however, it was the 'smartphone moment' of the launch of the apple iphone in , and subsequent development of the apps for apple mobile operating system devices (ios) and launch of its apps store, that kicked off the process by which apps became an integral part of everyday life for billions of users (goggin, ; miller and matyivenko, ; morris and murray, ) . from until the present day, technology companies around the world have offered their own apps and apps store, first with the 'app store' wars of - featuring many of the handset vendors that were household names in the worlds of g and g mobiles such as nokia and blackberry. competition was much more suggestion in china, evidenced by the many chinese app stores that dominate its huge market, and are significant distribution points for many users and communities internationally -especially given digital technologies being at the centre china's external trade, finance and soft power 'going out' (keane and wu, ) . thus, apps are key to what has been recently called 'infrastructural imaginaries' (nielson and pedersen, ; see also anand et al., ; athique and baulch, ; mansell, ) . so it is no surprise that apps formed a key part of the infrastructures woven into the pandemic, but also a specific, highly visible and 'normalized' response (hoffman, ) , in the form of dedicated apps -especially for tracing people and their 'contacts'. apps were used for many significant purposes during the pandemic. existing popular apps such as whatsapp were used in some countries to send official government messages and distribute crucial public health information. the data sets generated by smartphones, computers, apps and people's use of them, such as that data collected by apple and google, were used by public health officials, researchers and journalists to map population or district-level activity and movement, leading to the very interesting charts, graphs and visualisations in news and current affairs reports and features seeking to map and analyse the spread of covid and its impact on social and economic activity. apps allied with machine learning and ai were also used by medical researchers and clinicians to assist in the diagnosis of covid, by asking millions of users to track and enter their symptoms, diary-like, to offer a way of pinpointing when someone might have become positive. among the many varieties of covid-dedicated apps were apps devoted to the purpose of tracking people and their potential contacts, in case they contracted the virus. so many countries developed apps for tracking and contact tracing, with so many prototypes in development and implemented, that mit launched a contact tracing app database (https://www.scl.org/ news/ -the-mit-contact-tracing-app-database), based on key questions from american civil liberties union (aclu) white paper (aclu, ), to provide an authoritative reference point for those seeking to find their way through the claims and counter-claims of effectiveness. apple and google joined forces to amend their policies and create a joint protocol to make it easier for countries to use such data for contact tracing via apps (michael and abbas, ) . a full treatment of covid contact tracing apps is outside the scope of this article (see, for instance, cattuto et al., ; hoffman, ; vinuesa et al., ) . instead i focus on two especially interesting cases that offer us early insights into the socio-technical dynamics at play in such apps and the pandemic itself. these are singapore's tracetogether app and australia's covidsafe app. asian countries were often referred to for their decisive and often authoritative responses to the pandemic. however, it was singapore that attracted considerable early notice for its pioneering role in developing a particular kind of covid contact tracing app -that captured the imagination of many other countries. singapore was a pioneer in the development of covid bluetooth app in the form of its tracetogether app. what was less publicised was that, shortly after launch of tracetogether, singapore changed tack. this modification of the app deployment and promotion, and place in the overall public health strategy, was less evident outside the city-state. instead, singapore's tracetogether app became a stand-out model for other countries, rather than the various other apps being implemented around the world such as those developed by the united states, south korea, china, india or israel (babones, ) . australia comes into the picture because it is australia who first and most systematically sought to build on the tracetogether model, including its privacy safeguards, with its own covidsafe app. in the capstone analysis of their series of timely interventions into the privacy debates on the introduction of australia's covidsafe, leading privacy scholars graham greenleaf and katherine kemp ( ) note, 'australia's experiment is further advanced than most [countries] that are attempting to build a system based on voluntary uptake, protected by legislation (abstract, para ). the australian government sought to deploy covidsafe as a centrepiece of its effort to re-open australian society after the national and state lockdowns occasioned by the 'first wave' of infections from march to may . where public concern regarding and discussion of privacy issues was clearly presented but publicly muted in singapore, in australia there was furious debate. to explore the emergence, dynamics and implications of these two covid apps, i will proceed as follows. first, i introduce and discuss singapore's tracetogether, its development and first phase of take-up and deployment. second, i turn to australia's covidsafe and consider its fast journey from incubation and policy idea to the touchstone to warrant the country's re-opening, a veritable 'national service' (as prime minister morrison couched it). third, i return to singapore, to discuss the rebooting of tracetogether, after nearly months of tepid take-up, as that country's leadership sought to reassure its population that conditions were safe to re-open social life. finally, i offer concluding remarks about covid apps, social and technological imaginaries and digital media, as the nation state returns (flew et al., ) , and seek to gauge and exert its brittle powers, in a still deeply interconnected world. to great fanfare, a dedicated contact tracing app was unfurled as a breakthrough in monitoring outbreaks of covid- at the population level. while many teams around the world produced similar versions, the singapore government rolled out the first such app -called 'tracetogether'. tracetogether is an open source app based on bluetooth, using the 'bluetrace' protocol devised by a singapore government team led by the govtech agency -who have a track record of developing new kinds of open government apps, such as the parking.sg app. in a interview, for instance, janil puthucheary ( ), minister-in-charge of govtech, discussed how the 'govtech guys, as a result of having to do the code for the service . . . are having to . . . hack policy'. puthucheary explained, 'you have to be able to codify the policy', however that 'some of our governmental processes and regulations result in extremely inelegant code' (puthucheary, : ′ ″, ′ ″) . tracetogether was made available for adoption elsewhere via github. it is a combination of centralised contact tracing and follow-up (undertaken by government health authorities) and 'decentralised contact logging'. the user downloads the app and activates bluetooth on her device. the app can then detect another device in its vicinity, exchanging proximity information. to do so, the app uses information generated by the bluetooth relative signal strength indicator (rssi) readings that occur between devices over time to estimate proximity and duration of an encounter between users (team tracetogether, c). if a person fell ill with covid- , they could grant the ministry of health access to gather their tracetogether bluetooth proximity data -to assist in contacting people who had close contact with the infected app user. for their part, the developers emphasised their view that tracetogether would 'complement contact tracing, and is not a substitute for professional judgement and human involvement in contact tracing' (team tracetogether, d) . interestingly, they also underscored that the 'hybrid model' of decentralised and centralised approach is what they feel 'works for singapore' and that they 'built it specifically for singapore' (team tracetogether, b) . released on march by the ministry of health and govtech (baharudin and wong, ) , tracetogether received over half a million downloads in its first hours. a month later, the singapore government claimed the app had achieved a % adoption rate -some . million users, of an overall estimated population of . million users (team tracetogether, a). upon launch in singapore, there was relatively little public discussion of the privacy implications of tracetogether in mainstream media and fora -although there was considerable disquiet, criticism and debate evident in blogs, social media and elsewhere. for the most part, this is due to the structure and dynamics of singaporean society, and its political arrangements, public policy traditions and strong systems of social control and clear support for or alternatively discouragement and sanctioning of different kinds of expression and voicessomething well established in the scholarly literature (chua, ; george, george, , lee, lee, , , especially via various studies published in media international australia (most recently, lee and lee, ) . in recent years, the singapore government, following the dampened level of votes received by governing people's action party (pap), that has ruled since the , in the election, and a more sceptical populace (barr, ; zhang, ) , it has sought to extend consultation and formal 'listening' mechanisms to provide additional opportunities for citizens' voices. furthermore, while there has been increased discussion of privacy with the rise of digital technologies and unprecedented expansion of data generation, collection and use, the legal and regulatory framework is relatively weak in relation to privacy rights taken-for-granted in many jurisdictions (chesterman, (chesterman, , , even in the wake of the european general data protection directive (gdpr). however, as we shall see, such debate did build over some months, as tracetogether evolved. what is also important to note is that the singaporean government clearly acknowledged the strength of attitudes and importance of privacy and data protection concerns, and sought to anticipate debates by building in some level of privacy protection. the vision of tracetogether is that proximity data gathering is 'done in a peer-to-peer, decentralised fashion, to preserve privacy', and that it relies upon a 'trusted public health authority, committed to driving adoption' (team tracetogether, c). the developers and government emphasised that the privacy safeguards in the tracetogether app are in effect an effort of the longstanding ideal of 'privacy-by-design' (hustinx, ) . the government emphasised that the information was stored on a user's phone for days, and then deleted -and user's phone numbers are not exchanged, no geolocation data, personal identification data are not exchanged, so, as minister puthucheary noted, 'the engineering has preserved the privacy of the users from each other'-calling the app 'fairly elegant', in the way it 'preserves a fair degree of privacy' (ng, ; see also govtech, ). almost immediately the app did receive notice and discussion internationally, as one of a growing number of examples of covid- contact tracings apps raising privacy concerns (hu, ) . meanwhile in singapore, tracetogether downloads flatlined. this occasioned international deliberation, such as an article in the wall street journal entitled 'singapore built a coronavirus app, but it hasn't worked so far' (lin and chong, ) . the stalled downloads of tracetogether brought into view the conversations about privacy concerns, and whether this was a factor in user's lack of motivation to download the app. another reason advanced was that the app posed challenges for battery draining, due to the need to keep phones on. this was a view put by the ceo of singapore's investment or sovereign wealth company temasek holdings, madame ho ching who has a reputation as a prolific commentator on public affairs by dint of her regular controversial facebook posts (ho is also the wife of prime minister lee hsien loong) in a facebook post of may on the problems with tracetogether (ho, a) . whether by design or dawning acceptance, the government eased back its public communication and encouragement for citizens and other residents alike to download and use tracetogether. instead, it encouraged businesses, organisations, government offices and other entities to use a range of techniques to gather information about people's movements -especially when they visited or spend significant time in public places. check-in was principally done via scanning of a national identity card or employment or work permit id card, or via an app called safeentry. based on scanning of qr codes specific to each location, the safeentry app, and the policy it supported, was comprehensively promoted by government. this contrasted with tracetogether, which was only lightly promoted by the singaporean government, with the major campaign at the outset of its launch. presumably, on a small island -city-state, with strong civil service corps, existing id systems (singpass), and tightly managed immigrant and foreign worker id and records, and digital government and technology capabilities, this evolving contact tracing system did not need to premised on an app such as tracetogether, which presumably government was happy to allow to 'fail fast', given the bugs it faced. despite the effectively prototypical status of tracetogether, one of the first jurisdictions to adopt the technology was australia. prime minister scott morrison referred to such an app as a key requirement in australia's ability make its transition out of lockdown (prime minister et al., ) . in a radio interview with national talk show host alan jones, morrison's language is instructive, because it imagines technology, especially automated technology, as taking the vagaries and morally dubious qualities of human agency out of the picture: '[w]e need to get an automatic industrial level tracing of the coronavirus . . . now, we've been working on this automatic process through an app that can ensure that we can know where the contacts were over that infection period and we can move very quickly to lock that down' (morrison, a: para ) . this kicked off a heated debate about privacy implications, leading a high-profile member of his own coalition government, rural parliamentarian barnaby joyce to declare that he would not be downloading the app -countered by many other public figures who promised to do so. despite the widespread criticism and concern, there was also significant support with some million downloads in the first day of its release, topping the million mark in early may (koslowski, ) , then . million by june (meixner, ) . these figures raise various concerns, such as whether those who download the app used or continued to use it. also what the rate of downloads were in different parts of the nation (slonim, ) . let alone whether the covidsafe app was playing a role in helping to trace contacts and find positive cases of the virus (preiss and dexter, ) . for the prime minister, the covidsafe app was a rhetorical centrepiece of his policy initiative to vouchsafe a loosening of restrictions and begin to repair the economic damage the virus caused: the chief medical officer's advice is we need the covidsafe app as part of the plan to save lives and save livelihoods. the more people who download this important public health app, the safer they and their family will be, the safer their community will be and the sooner we can safely lift restrictions and get back to business and do the things we love. (prime minister et al., : para ) while he drew attention to the voluntary, consent-based nature of the app, morrison also sought to exert maximal symbolic pressure by framing adoption in patriotic terms, likening it to national service in wartime (and also not ruling out making it mandatory) (gredley, ) : i'll be calling on australians to do it as a matter of national service. in the same way people used to buy war bonds, back in the war times, you know, to come together to support the effort . . . if you download this app you'll be helping save someone's life. (morrison, b: sec : ) on may , morrison announced that australia had earned an 'early mark', with restrictions being lifted in a week. in doing so, he spoke of the download numbers being a 'critical element' in deciding to what extent the easing would occur: 'mr morrison said not installing the app was like going into the "blazing sun" without wearing sunscreen' (armstrong and minear, ) . various commentators and researchers expressed their views on how to promote downloading and take-up of the app. in the australian financial review, a piece by technology editor paul smith, entitled 'think like a founder', reported, 'entrepreneurs and health technology experts have urged the government to adopt all the tricks of the start-up trade to get more australians downloading the covidsafe contact tracing app' (smith, ) . the australian chief scientist through his rapid research information forum commissioned a brief on motivators for use of the covidsafe app, supported by the australian academy of humanities, with professor genevieve bell as lead author, and various leading media, communications and humanities researchers among the contributing authors (bell et al., (disclosure: i was a peer reviewer of this brief)). the brief suggested that 'illustrating that covidsafe works as intended may assist decision-making for those yet to download the app' (bell et al., : ) . it also concluded that the stories we will tell about australian responses to, and uses of, covidsafe will matter too. the voices of trusted figures, community leaders, healthcare workers and citizens will likewise inform the adoption, and continued use of, covidsafe. (bell et al., : ) many of these 'stories' clustered about the public perceptions and debate about the privacy, data and surveillances implications of the covidsafe app (bell et al., ) , driven by long-standing sensitivities and attitudes of australians concerning privacy. stretching back to the infamous and ill-fated australia card proposal of , citizens' privacy concerns had been more recently exacerbated by the federal government's poor handling of the ramp-up of its national e-health records registration system, myhealth, which switched from an 'opt-in' to 'opt-out' basis in (komesaroff and kerridge, ; goggin et al., ) . with much at stake in terms of public health concerns at a critical juncture of the covid pandemic, the australian government emphasised that it was keen to adopt a 'consent-based' model, hence its interest in adapting the singapore tracetogether app. the government sought a formal privacy impact statement from a leading law firm -which it published, with a detailed response from the department of health ( b; maddocks, ) . this privacy impact documentation put important details of the workings of the covidsafe application, and the production, storage and handling, of resulting user data on the public record. in response, the government emphasised that participation would be voluntary (department of health, a); however the privacy impact statement noted the potential for third-parties such as workplaces or businesses put pressure on or require people to use the app (maddocks, ) . deleting the app would also delete the data stored on a user's device, but not data in the national data store (however, the government guaranteed that all data held would be deleted at the end of the pandemic). the government was at pains to reassure the public on the secure hosting of the covidsafe data store, undertaken by amazon web services (aws). their guarantees related to the data privacy and security obligations applying to aws, but also to any prospect that such data might be requested and commandeered by the us government (given aws is headquartered in the united states, and subject to their laws). over some weeks a furious debate ensued, and the australian government proposed legislation to address the key concerns. this safeguard took the form of the privacy amendment (public health contact information) act . the bill quickly passed through the house of representatives and the senate and received assent on may . the act creates several serious offences dealing with covid app data, including 'non-permitted, use, or disclosure', 'uploading covid app data without consent', 'retaining or disclosing uploaded data outside australia', 'decrypting encrypted covid app data' and 'requiring participation in relation to covidsafe' (privacy amendment, : ). 'covid app data' is defined as 'data relating to a person . . . collected or generated . . . through the operation of covidsafe' and is either 'registration data' or 'is stored, or has been stored . . . on a communication device' (s. d ( ) (a-b), privacy amendment, : - ). while the bill was passed containing significant safeguards, it contained serious flaws. as summarised by greenleaf and kemp, these included key information upon which the law was based and would operate was not made available to the public, including advices to the minister upon which he relied to make the earlier determination, and, crucially, the agreements between the commonwealth and states and territories regarding the operation of the covidsafe app, and collection and sharing of app data; lack of public assessment of the law by the federal and states and territories privacy commissioners; and only the source code for the covidsafe app was released, not the code for the national covidsafe data store (i.e. the server-side of the system, where security and privacy issues often manifest) (greenleaf and kemp, ) . in addition, greenleaf and kemp critique the narrow focus of the privacy act amendment on 'covid app data', suggesting instead that what is being created is an information system they dub the 'covidsafe system' (greenleaf and kemp, ) . as well as the specific defects of the new law, then, the major issue it raises is precisely the one feared by many experts and members of the public alike: that the app-based contact tracing represented by covidsafe, and other apps around the world, represent a deepening of technologies of surveillance in social life. while such apps and measures in which they are embedded are justified as exigent public health measures crucial in the emergency conditions of a pandemic, there is wellfounded fears that this increase in surveillance will not be automatically or easily rolled back once countries feel the threat of covid is ended or at least contained. as australian debates over covidsafe privacy subsided, there was a slow return to tracetogether emerging in singapore as the country's leadership gingerly considered how to effect its re-opening from its -month circuit breaker. a task all the more urgent, given the ruling party's dwindling time to call a national election. singapore's was regarded an international model of wise and swift response with its handling of its 'first wave' of infections. however, in the second week of march , singapore tightened its measures, enacting a general shutdown and stay-at-home policy that it dubbed a 'circuit breaker'. initially the circuit breaker was announced to last for month, but with the rising tide of positive cases in the crowded migrant worker dormitories, the government quickly extended for a second month. a disturbing feature of singapore's data gathering and public reporting and communication during this period was the distinction clearly drawn and maintained in the daily bulletins between; cases in the migrant worker dormitories; and 'community cases' (these community cases were in turn divided between figures on singapore citizens, permanent residents (prs), migrant workers on work permits and workers on employment passes) (han, ; palma, ) . the migrant workers were quarantined in the dormitories, with many then moved to across other repurposed facilities. and the numbers of cases were similarly quarantined, in a communicative-epistemological manner, to emphasise that the 'real' community spread remained low (usually below cases in the 'community'). those numbered among the community included citizens and prs initially, but subsequently, foreign pass holders who do not reside in dormitories but lived among the regular population, became part of these statistics once the dormitory cases started subsiding. ahead of the planned end to the circuit breaker on june, the government made some mention of tracetogether at various times in its public communications. however, its main focus remained racking movement and individuals' location via check-in at the public places and business still open, such as convenience stores and shopping centres, or in taxis and ride-hailing services, especially via the safeentry app discussed above. as the re-opening loomed, there was increasing discussion in government, and in parliament, on measures that would need to be implemented to contain and reduce the number of infections via contacts with migrant workers, especially once they were allowed to more regularly leave the dormitories, where they had been quarantined during the circuit-breaker period, and so circulate in the 'community'. the government announced a new app, sgworkpass, to 'show which migrant workers can leave their dormitories for work' . workers will 'get a "green status" on the app to indicate that their employer has been granted approval to resume operations, and that the dorm they stay in has been cleared' . otherwise, the app will show red to indicate they 'cannot go out for work' . this is reminiscent of the chinese app, also adopted by india, which uses qrs, to show a user's status as green (when they may enter offices, restaurants, malls or parks), or yellow (at risk) or red (strict quarantine) (hu, ; india today, ) . at this stage, tracetogether returned -this time, as a central feature of the strategy. the government had been at pains to keep tracetogether opt-in, with foreign minister vivian balakrishnan, also minister-in-charge of the smart nation initiative, providing reassurance that the app would remain voluntary 'as long as possible' (balakrishnan, ) . in early june, balakrishnan noted the problems with tracetogether, including the technical issues with the app not running properly on apple. as a result, he let it be known that singaporean government was developing a 'portable wearable device' that will achieve the same end, that if it worked could be 'distributed to everyone in singapore': 'i believe this will be more inclusive, and it will ensure that all of us will be protected' (balakrishnan, ) . the government emphasised that there would no 'gps chip' on the device, nor any internet connectivity. even then, the tracetogether token would need to be physically handed to the health ministry for uploading of the data, if a user tested positive for covid- (yu, ) . the government's keenness to be seen to address privacy was doubtless fuelled by a public backlash against the token. as policy researcher and commentator carol soon, from the institute of policy studies, noted, 'within a short span of three days, a petition against the development of the device attracted about , signatories' (soon, ) . concerns of singaporeans regarding data privacy were addressed in a report authored by her colleagues, which found attitudes vary according to the technology involved, illustrated by the finding that nearly in respondents supported use of cctv to monitor people's movements during the covid 'circuit breaker period', but less than % were comfortable with having their mobile phone data tracked for contact tracing without their consent (tay, ) . to address such deep-seated concerns, soon suggested the need for singapore to urgently 'achieve a working compromise between personal data and public good', establishing principles and considering measures such as formation of a citizen's panel for public deliberation (soon, ) . regardless, the first batch of , tracetogether tokens were distributed to seniors shortly on the eve of the july general election -with officials from the smart nation and digital government group (sndgg) suggesting they were settling in for a long haul, saying the government will 'continue to generate more awareness about the token among our prioritised population' (sndgg officials quoted in yip, ). at the time of writing, the pandemic rages globally, and the career of covid- contact tracing apps is still unfolding -with little evidence as yet of their efficacy. however, there are already clear grounds for concerns. the strange thing about the australian embrace of bluetooth-based covid tracing apps is how strongly it figured, for a time at least, as instrumental to the country's public health response. various commentators noted the irony that at the point covidsafe was being pushed upon the public, australia was at a positive inflection point in terms of infections. as greenleaf and kemp note, this set the bar because other measures had already appeared to be successful in greatly abridging the spread of the virus (greenleaf and kemp, : ) . the other obvious thing is that where apps did play a role in diminishing infection rates, these were not: ( ) bluetooth-based tracing apps, ( ) and the apps used were integrated into a wider system of cross-referencing and marshalling personal identification and contact information and database systems (greenleaf and kemp, ). yet the australian government, for a short time at least, was very keen on the app as a symbolic game-changer in its public health approach to the pandemic -showing that it was taking charge. rather like british health secretary, matt hancock some weeks later, when he promoted the english app-based test-and-trace system, telling the public 'it is your civic duty': do it for the people you love. do it for the community. do it for the nhs and do it for all the frontline workers . . . you'll have the knowledge that when the call came you did your bit, at a time when it really mattered. (hancock quoted in bosley and stewart, ) in july , there was an outbreak of covid- cases that saw a lockdown re-imposed, and fuelled national concerns. at the time victorian chief medical officer brett sutton said the 'app has not added a close contact' that authorities had not already discovered via traditional contact tracing (borys, ) . federal health minister greg hunt advised that at least contacts nationally had been identified via the covidsafe app (borys, ) . for her part, nsw's chief health officer kerry chant, the state next in line for a potential resurgence of cases described the app as 'one of the tools', but not a 'major feature' in contact tracing (borys, ) . in his parsing of the app's effectiveness, australian deputy chief medical officer, dr nick coatsworth, suggested that because of movement restriction, people had not been circulating, so the 'app hasn't identified those cases', and that as 'numbers go up then the app can come into its own' (coatsworth, ) . with the groundswell for mask use in mind, coatsworth ( ) cleverly sought to link the two, suggesting 'if you are a supporter of mask use, you must also be based on the modelling, a supporter of downloading and activating the app' (here he refers to the study by sax institute, see currie et al., ) . for its part, singapore took a less dramatic, more considered approach, especially in the first phase as it developed and launched its tracetogether app. singaporean leaders and health officials were also preoccupied with promoting the app to gain the maximum take-up and adherence. yet, for reasons not entirely clear as yet, singapore was reluctant to push the adoption of the app to the extent that australia did -an interesting situation given earlier critiques of singapore technocratic approach to health care, in particular (barr, ) . as well as the privacy concerns that emerged in the second phase of the tracetogether token initiative, it may be that singaporean actors thought the app was promising but not the main game. this would be because of the already well entrenched systems of requiring and using personal data, through an extensive infrastructure of technologies (including the cctvs that featured in the ips report), without the kind of concomitant privacy rights and practices that would be expected in some other jurisdictions such as australia. the task of enlisting and normalising singaporeans participation in these aspects of its surveillance-extensive 'smart nation' policies, over cumulative implementation of technology is taken to be essential, but it is increasingly fraught (lee, ) . in the first months of pandemic response, then, the central element was singapore's established singpass and other systems of identification cards and passes, which could be used in coordination with video recordings, and the wealth of digital data available from urban transportation systems, stored valued and transit cards, ride-hailing accounts and so on. as well as also as the citizen and netizen sousveillance and activism that saw recordings of potential miscreants breaching the regulations circulated online. in addition in the early weeks of the pandemic, identifying details of people's residential locations, down to building numbers, were published in daily updates from ministry of health, and reprinted in media outlets. such measures point to the differences in privacy laws and protections in singapore, as compared to australia. whereas australian privacy act dates back to , singapore only enacted its first comprehensive law in , the personal data protection act. at the time, legal scholar simon chesterman suggested that singaporean had taken a 'pragmatic approach', potentially striking a balance between european and us approaches: in singapore, at least, reform is not being driven by the desire to defend the rights of data subjects; rather, it is based primarily on economic considerations, as well as the desire to position singapore as a leader in the region for data storage and processing. (chesterman, : ) . the singapore laws and approach to privacy and data protection have not substantially changed since (chesterman, ; ong, ). yet clearly citizens do have concerns -as the public response to the tracetogether token suggest. from a broader perspective, the return of tracetogether to the fore of the singaporean government's strategy, especially to assist with the re-opening process after its 'circuit breaker', is very interesting indeed in the context of the country's digitally underpinned governmentality (ho, ; lee, lee, , willems and graham, ) . this is worth being in mind in interpreting the election, in which the government received some strong criticism by opposition candidates for its poor handling of the pandemic, especially concerning the continuing high number of cases in migrant worker dormitories. the pap was returned to government, still with a 'super majority', of seats out of the available . however, it was chastened by its share of the vote being reduced to . % (from its . % share in the election) -and an unprecedented seats won by the opposition workers' party (loh, ) . in the aftermath, the government has signalled its willingness on listening to electorate concerns, especially those of young voters (yong, ) . all in all, in both these case studies, we see that the variations of the covid- contact tracing apps, and the technical, social, policy and design dynamics of these, offer rich food for thought when it comes to understanding apps. health information is an area of considerable sensitivity for most people. trust is key, and with the widespread diffusion of mobile communication there has been considerable work on how to design and implement systems that can support cooperative and sustainable sharing of information between people and authorities to map the spread of infectious diseases (lwin et al., ) . however, it is now evident that the task of assembling appropriate social and cultural understandings of people's lives and identities, their data selves (lupton, ) , the intricacies of technologies, the enmeshing of privacy expectations in design, and the construction of suitable legal, policy and governance arrangements, is challenging. in the covid- pandemic, many countries across the world have had recourse to apps, as flexible agents with capacity to encode, materialise, represent and integrate such requirements, including some contradictory ones, and imagine and forge majoritarian supported social action. it is difficult not to see the turn to tracing apps as a pivotal moment in the expansion and entrenchment of surveillance technology in digital societies, of which singapore in particular has been a leading example (lee, ) -but is also playing out in contests and debates in many countries especially in europe and asia. how this ultimately turns out, and with what benefits for health, as well as legacies for democratic freedoms and daily life, we must wait and see. american civil liberties union (aclu) ( ) aclu white paper -principles for technology-assisted contact trading the promise of infrastructure coronavirus: australia set to start easing covid- restrictions, donald trump's plan to punish china countries rolling out coronavirus tracking apps show why they can't work coronavirus: singapore develops smartphone app for efficient contact tracing. straits times skype interview with annelise nielson, sky news australia. transcript, may. available at singapore: the limits of a technocratic approach to health care ordinary singapore: the decline of singapore exceptionalism what motivates people to download and continue to use the covidsafe app? rapid research brief government says coronavirus app has identified contacts, as victorian authorities say it has not helped them hancock: it is public's 'civic duty' to follow test-and-trace instructions in england. guardian, may the institutionalisation of digital public health: lessons learned from the covid- app data protection law in singapore: privacy and sovereignty in an interconnected world after privacy: the rise of facebook, the fall of wikileaks, and singapore's personal data protection act liberalism disavowed: communitarianism and state capitalism in singapore deputy chief medical officer press conference about covid- . australian government department of health stemming the flow: how much can the australian smartphone app help to control covid- . public health research & practice ( ): e . department of health ( a) covidsafe app the covidsafe application privacy impact assessment: agency response global media and national policies: the return of the state. houndsmill: palgrave macmillan the air-conditioned nation: essays on the politics of comfort and control incomplete: reflections on a first world nation's arrested political development ubiquitous apps: politics of openness in global mobile cultures data and digital rights: recent australian developments help fight the spread of covid- with virus mobile tracking app may be mandatory. canberra times australia's covidsafe experiment, phase iii: legislation for trust in contact tracing singapore locks away migrants in pandemic fight one of the key tenets of agile development is to put aside face. facebook, may smart subjects for a smart nation? governing (smart)mentalities in singapore which workers can leave dorm for work? corona tracing apps-an infrastructural perspective. paper presented to technology policies and data governance in times of crisis, online session of communication policy & technology section beijing rolls-out color coded qr system for coronavirus tracking despite concerns over privacy, inaccurate ratings privacy by design: delivering the promises india follows china's lead to widen use of coronavirus tracing app lofty ambitions, new territories and turf battles: china's platforms 'go out the my health record debate: ethical and cultural issues covidsafe downloads reach million as experts question technical flaws. sydney morning herald, may from contempt of court to fake news: public legitimisation and governance in mediated singapore the media, cultural control and government in singapore. london media governmentality in singapore tracing surveillance and auto-regulation in singapore: 'smart' responses to covid- singapore built a coronavirus app, but it hasn't worked so far singapore election results give pap supermajority as rivals rise. nikkei asian review data selves: more-than-human perspectives a st century approach to tackling dengue: crowdsourced surveillance, predictive mapping and tailored communication the covidsafe application: privacy impact assessment imagining the internet: communication, innovation, and governance how many people have downloaded the covidsafe app and how central has it been to australia's coronavirus response? abc news getting behind covid- contact trace apps: the google-apple partnership the imaginary app appified: culture in the age of apps interview with alan jones interview with brian carlton coronavirus pandemic changes how your privacy is protected infrastructural imaginaries: collapsed futures in mozambique and mongolia singapore report: data protection in the internet surge in covid cases shows up singapore's blind spots over migrant workers all the right things': mcdonald's praised as covidsafe app yet to find a case in victoria. the age, may minister for health, minister for government services and chief medical officer ( ) covidsafe: new app to slow the spread of coronavirus. media release, april privacy amendment conversation with dr janil puthucheary. moderator: peter ho. stack conference, suntec singapore conference and exhibition centre, october here's why the government should share what it knows. the conversation, may think like a founder: how to get people to download the covid app getting buy-in for tracetogether device and future smart nation initiatives singaporeans accept some privacy loss in covid- battle but surveillance method methods: ips study. strait times, may team tracetogether ( b) can you make tracetogether available to other countries? media release how does tracetogether measure distance and duration of contact? what thresholds constitute close contact? media release team tracetogether ( d) what is blue trace? media release available at a socio-technical framework for digital contact tracing the imagination of singapore's smart nation as digital infrastructure: rendering (digital work) invisible. east asian science yip wy ( ) coronavirus: , seniors get first batch of tracetogether tokens. straits times ge : signs of young voters' crucial role in election outcome singapore looks to ease privacy fears with 'no internet' wearable device. zd net social media and elections in singapore: comparing my thanks to two reviewers for helpful suggestions. thanks also to rosemary curtis for her proofing of this article. the author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article. the author(s) received no financial support for the research, authorship and/or publication of this article. https://orcid.org/ - - - key: cord- -jcpyrlw authors: lichtenstein, bronwen title: from “coffin dodger” to “boomer remover”: outbreaks of ageism in three countries with divergent approaches to coronavirus control date: - - journal: j gerontol b psychol sci soc sci doi: . /geronb/gbaa sha: doc_id: cord_uid: jcpyrlw objectives: this article compares responses to coronavirus control in australia, the united kingdom, and the united states, countries in which public ageism erupted over the social and economic costs of protecting older adults from covid- . methods: thirty-five ( ) newspapers, media websites, and current affairs magazines were sourced for the study: for australia, for the united kingdom, and for the united states. searches were conducted daily from april to june , using key words to identify age-related themes on pandemic control. results: despite divergent policies in the countries, ageism took similar forms. public responses to lockdowns and other measures cast older adults as a problem to be ignored or solved through segregation. name-calling, blame, and “so-be-it” reactions toward age vulnerability were commonplace. policies banning visits to aged care homes angered many relatives and older adults. indefinite isolation for older adults was widely accepted, especially as a vehicle to end public lockdowns and economic crises. discussion: older adults have and will continue to bear the brunt of covid- in terms of social burdens and body counts as the pandemic continues to affect people around the globe. the rhetoric of disposability underscores age discrimination on a broader scale, with blame toward an age cohort considered to have lived past its usefulness for society and to have enriched itself at the expense of future generations. many people view covid- as an "older adult" problem (fraser et al., ) . from health advisories on age vulnerability, to the ghettoizing of older adults for risk mitigation, ageist rhetoric has been a dominant theme for pandemic control. as a social fact, ageism has roots in the postindustrial era, where age-graded subgroups (e.g., "employees" and "retirees") emerged to meet the specialized demands of modern society (hagestad and uhlenberg, ; north and fiske, ) . the "us" and "them" narratives arising from this development prompted sociologist james coleman ( ) to claim that age segregation is the root cause of ageism. this article analyzes covid- -related discourse in three countries in which age segregation is a core principle of mitigation policies and is a contested space in terms of "people first" or "economy first" responses to managing the pandemic. ageism has infused medical decision making for covid- . a rhetoric of disposability has surfaced in questions about who should live or die when medical resources are scarce, hospital systems overwhelmed, and covid- roils the globe. older patients are deemed disposable when " [they] are not being resuscitated and die alone without appropriate palliative care. . ." (nacoti et al., ) . italy, spain, brazil, united kingdom, and some u.s. states have faced this reality. but even when covid- is largely contained, as in australia, new zealand, taiwan, and vietnam, medical rationing by age and morbidity is mooted in "what if" or second wave scenarios in which curative therapies and vaccine are still elusive. even caring messages create them-and-us dichotomies in which being older is a separate country, to use hagestad and uhlenberg's ( ) phrasing, and, in ayalon et al.'s ( ) analysis, a clearly defined outgroup in terms of health policies to isolate older adults. this research brief examines public ageism in official statements and debates over managing the crisis in three english-speaking countries with different approaches to coronavirus control. the first country (australia, population million) enacted timely control measures for covid- and has flattened the curve to a large extent. in both the united states (population million) and united kingdom (population . million), control measures were tardy and death rates among the highest in the world (worldometer, ) . all three countries adopted age-segregated policies in order to protect older adults on a temporary (if long-lasting) basis until a "cure" was found. the primary sources for this analysis include major broadsheets such as the age and sydney morning herald in australia; the guardian (and three tabloids, daily mail, the telegraph, and the sun) in the united kingdom; and the new york times and the washington post in the united states. thirty-five ( ) newspapers, media websites, and current affairs magazines were sourced for the study: for australia, for the united kingdom, and for the united states. (australia has a smaller population compared to the united kingdom and united states, and its media resources are fewer.) nonprint sources include the australian broadcasting commission (abc), the british broadcasting commission (bbc), health policy platforms (e.g., center for disease control and prevention [cdc]), and advocacy websites for older adults in each country. daily searches for source material were conducted from april to june , a period of widespread panic over mounting illness and the global death toll. the task for this brief was to examine these newspaper and media sites by matching keywords such as age/d, older, elderly, elders, seniors, pensioners, and grandparents with terms such as "covid- ," "sars-cov- ," "pandemic," and "coronavirus" to identify relevant policies and debates over coronavirus control. this targeted approach yielded three main themes for the analysis: lockdown of aged care homes, indefinite stay-at-home orders, and controversy over herd immunity. a fourth theme-access to ventilators-was salient in the early days of the pandemic but did not relate directly to initiatives for covid- control and was not included for analysis. the following paragraphs describe the results of the three themes. news items and postings on age segregation peaked in march-april , when cases were surging, officials were scrambling, and people feared the onslaught of a deadly virus that seemed out of control. on the first theme (lockdown of aged care homes), official policies in the three countries were similar in one respect: nursing home visits would be curtailed because of the high risk of death among residents who contracted the virus. table presents relevant news excerpts and postings for each country, as organized by government policy, aged care policy, and public responses to walling off older adults from the outside world (ayalon et al., ) . only a few responses are included to meet the word limits of this brief. table shows that visitors to aged care homes were officially banned in the united states, but not in australia and the united kingdom, which permitted family visits to some extent. australia's low infection rate could account for the difference in that country, although the aged care industry took issue with the government and itself instituted a total ban with strong support from the general public (karp, ) . the united kingdom's aged care industry also rejected the government's decision to allow healthy visitors and banned everyone without exception. in the united states, the industry followed cdc advice to ban all visitors; many families could not visit their relatives prior to death. family members in the three countries expressed grief and outrage at being denied access to their loved ones; they cited neglect and lack of institutional oversight of residents in their absence. the second theme (isolating older adults) affected anyone over in australia and in the united kingdom (table ) . "older" was defined as over in the united states, where restrictions were laxer and policies varied from state to state. in both australia and the united states, advocacy groups for older adults published stricter guidelines than their governments. only the united kingdom's national pensioners' convention adopted a softer policy after angry pushback from members about self-isolating for months on end. in all three cases, older adults were depicted as demented or medically compromised, despite a large majority rating their own health as good or excellent in recent studies (graham, ) . older adults were also deemed irresponsible. in the united states and united kingdom, they were scolded for ignoring health warnings to keep away from other people (chakelian, ; peterson, ) . a different story emerged from survey research in which older respondents proved more fearful of covid- than younger people, and less willing to visit grocery stores, friends' homes, crowded parties, and restaurants during lockdown (pew research center, a, b). terms such as "boomer remover," "boomer ( ) united kingdom: over s must self-isolate for up to four months. • official statement: "pensioners will be told to stay in their homes for months as part of a 'war-time-style' isolation plan to combat the coronavirus" (health secretary matt hancock, quoted in the sun news, march , ). • advocates' response: "the possibility of long-term selfisolation for our age group is unprecedented and hugely concerning. the main feedback we have heard from our members covers multiple worries about the impact and indeed the feasibility of social distancing" (national pensioners' convention website, march , ). • readers' response: "if i, (elderly and very spritely) choose to continue to lead a normal life and i contract covid- , i will either recover or die at home"; "at least if we die at home rather than in hospital then we have the consolation of not unduly affecting health authority statistics"; "i shall carry on as normal. i shall also ignore any rules about over- s staying in because they are being made by people who won't have to follow them" (chatroom postings, the telegraph, march , ). ( ) united states: self-isolation for up to two years, if necessary. • official statement: "older adults and people with underlying conditions should stay home as much as possible" (centers for disease control and prevention [cdc], april , ). • advocates' response: "the cdc recommends that those age and older avoid crowds, and that those in a community with an outbreak stay home as much as possible" (american association of retired persons [aarp] website, april , ). • public response: "you know what i'd really like to do right now if i'm being honest? i'd like to find a bat and ball and go break a few windows" ( -year old op-ed writer, washington post, may , ). "covid- killing me isn't my biggest concern. boredom, depression, or general frustration is"; "i have been alone for days and weeks before that. i am lonely and need human contact" (chatroom postings, the new york times, march , ). doomer," "yolo grandparents," "grey shufflers," and "moldy oldies" illustrate the degree to older people were denigrated in covid- -related postings and (occasionally) news sources analyzed for this brief. the third theme ("herd immunity") was the most contentious of the three topics, with fierce debate over whether lockdowns to protect vulnerable people were worth the cost to society (table ) . explicit in this debate was the assumption that covid- should be allowed to run its course, a proposition in which the majority, or "herd" of survivors (presumed to be immune), constitutes a shield to prevent the virus from regaining a foothold (rossman, ) . the problem with this proposition relates to uncontrolled illness and death until (or if) immunity is achieved. out of the three countries, australia alone rejected herd immunity as inhumane and morally unacceptable. protecting lives was the more important goal in australia, and strict lockdown was the way to achieve it. this people-first strategy was not without detractors who believed that herd immunity per se would protect the economy from collapse and the planet from environmental disaster. supporters of herd immunity referenced nationally scarring events, such as australia's bush fires, floods, droughts, and dust storms of . older readers expressed dismay at being deemed disposable and culled from society in survival-ofthe-fittest fashion. support for herd immunity faded in the wake of containment, reemerging only briefly in reference to second-wave threats and the cost of protecting ". . . older australians over who aren't worth as much as younger australians" (smith, ) . the united kingdom adopted herd immunity on ideological (libertarian) grounds with a caveat to protect older adults through self-isolation. an editorial in the guardian proclaimed: "the concept [of the free-born englishman] was fundamental to the government's decision-making in the crucial months of february and march [ ] ." this modified approach was abandoned when caseloads and death rates rose to alarming levels (worldometer, ) , nursing homes became hotbeds of disease, and hospitals were stretched to capacity (matthews, ) . proponents of the strategy offered familiar arguments about culling unproductive bodies from society but differed from their australian counterparts by claiming that herd immunity was a rational course of action in pandemic conditions (conn and lewis, ) . detractors expressed alarm at sacrificing older people to the tory government's pro-market policies and brexit machinations. as shown in the table, older adults had mixed feelings about being sequestered indefinitely under the government's modified plan, but abandonment, loneliness, and despair were evident in comments and postings in news sources used for this brief. the united states did not initially enact a policy of herd immunity, although bureaucratic delays, lack of testing, and official temporizing (schneider, ) were no match for a fast-moving viral foe. covid- soon became the leading cause of death in the united states (dowdy and ( ) australia: herd immunity rejected on moral grounds. • official statement: "we've seen what herd immunity has done in other parts of the world, so we won't be doing that" (deputy chief medical officer paul kelly, quoted on abc news, april , ). • herd immunity proponents: "we've grown too big for our own good, now nature replies by thinning us out a bit. at the end of all this, we will be stronger as a group, with the elderly and sick no longer being a burden" (chatroom posting, sydney morning herald, april , ). "provide government support to help the s+ stay at home but don't wreck the economy along with millions of jobs and lives" (letter to the age, march , ). • older readers: "we've faced our inevitable mortality, but i really don't enjoy being treated as one of the expendable"; "us older people are getting a bad rap. we have been blamed for grinding our social and economic system to a standstill" (the age, march , ). ( ) united kingdom: herd immunity until april (replaced by lockdowns). • official statement: "our aim is to build up herd immunity, so more people are immune to this disease and we reduce the transmission, at the same time protect those who are most vulnerable to it" (chief science advisor patrick vallance, quoted in the guardian, march , ). • herd immunity proponents: "pensioners? meh, they've had a good run"; "old people are an increasing burden, but must our young be the ones to shoulder it?" (postings to the guardian, april & may , d'souza, ). states belatedly imposed restrictions and lockdowns to flatten the curve, but with financial disaster looming, president trump urged american "warriors" to self-sacrifice for the economy (nakamura, ) . there was little question about which warriors would be sacrificed after a texas official proclaimed: "lots of grandparents would rather die than see health measures damage the us economy" (beckett, ) . the easing of state and municipal lockdowns left older adults to their own devices, perhaps to self-isolate indefinitely. america's debate over herd immunity erupted most strikingly at state capitols, where armed protesters demanded an end to lockdown orders in multistate demonstrations. protest signs evoked herd immunity with: "my virus, my choice"; "my right to die"; "sign up to die for the economy"; "natural immunity over manmade poison"; and even "sacrifice the weak." on the american association of retired persons' [aarp] website, worried retirees pondered their future as untouchables in covid- society. posters to other forums debated the pros and cons of isolating older people, with herd immunity proponents offering the harshest views of older adults as a drain on society. in counterpoint, "prophet of honor" voiced this experience of being rendered invisible in age-segregated america: my granddaughter ( ) was driving me home from chemo when i suggested she stop at a liquor store so i could get a couple of bottles of louis jadot to go with sunday dinner. she got my wheelchair out and we went inside. the clerk looked at me and then said to her "you know it's not safe to bring people like him out in public?" as if i were some "object." concern is all well and good, but don't overdo it (posted to thorbecke, ). the three countries in this brief have adopted different approaches to covid- control. at time of writing, the coronavirus is mostly contained in australia, but the united kingdom, and especially the united states, continue to experience severe outbreaks of the disease (worldometer, ) . each country has treated older adults as a special class for coronavirus control, and age-centric debates over who should live, die, and self-isolate have reflected widespread panic over rising death tolls. this focus can be explained, in part, by the twinning of "elderly" with "economy" in speeches about coronavirus control and in debates about herd immunity to avert economic catastrophe. australia alone diverged from herd immunity and relied on health expertise after witnessing the tragic death toll of other countries. with lower birthrates, smaller households, and older populations than in less developed regions of the world (united nations, ), these countries have gravitated toward institutionalizing older adults, prompting claims that age segregation is the root cause of ageism (coleman, ; hagestad and uhlenberg, ) . official policies to isolate older adults during covid- have accelerated this process. ageism has been blamed for islands of death in nursing homes (mueller, ) , and for a spike in intergenerational animosity, as captured in internet epithets such as "grandma/grandpa killer," boomer remover," and "boomer doomer" (pre-covid- ; "coffin dodger"). these hostile ageisms contrast with government bromides about protecting older adults, stereotyped as frail, incompetent, and obsolete prior to the pandemic (chonody, ) . the architects of benevolent ageism in the three countries failed to anticipate how sequestration exposed residents to covid- in aged care settings, where they were concentrated and infected in large numbers. this out-of-sight out-of-mind response also underscored support for herd immunity and opposition to public lockdowns. chonody ( ) argued that "us" versus "them" ageism reflects a fear of mortality and an effort to cope though avoidance, blame, and other tactics. the comparative approach to analyzing covid- related responses in australia, the united kingdom, and united states has highlighted a rhetoric of disposability and blame for an age cohort considered to have enriched itself at the expense of the climate, progress toward social equality, and the well-being of future generations (harris, ; whelan, ) . the analysis has also identified explicit name-calling and the infantilization of older adults for their vulnerability to covid- . this response has served to obscure systemic failures in timely and effective responses to covid- in the united kingdom and united states, where cost-cutting and small-government ideologies have undermined public health capability and created of a spectacle of death for the ages (lawrence et al., ; schneider, ) . age discrimination therefore occurs on multiple levels for older adults who will continue to bear the brunt of covid- in terms of social burdens and body counts as the pandemic continues its grim march across the globe. none declared. aging in times of the covid- pandemic: avoiding ageism and fostering intergenerational solidarity all the psychoses of us history": how america is victim-blaming the coronavirus dead. the guardian yolo grandparents" and "immortal boomers": are older people less afraid of coronavirus? the new statesman positive and negative ageism: the role of benevolent and hostile ageism the asymmetric society documents contradict uk government stance on covid- "herd immunity early herd immunity against covid- : a dangerous misconception ageism and covid- : what does our society's response say about us? why so many americans rate their health as good or even excellent. kaiser health network the social separation of old and young: a root of ageism coronavirus has deepened prejudice against older people. the guardian essential poll: two thirds of australians back aged-care homes on covid- visitor bans. the guardian how a decade of privatization and cuts exposed england to coronavirus. the guardian britain drops its go-it-alone approach to coronavirus. foreign policy on a scottish isle, nursing home deaths expose a covid- scandal. the new york times at the epicenter of the covid- pandemic and humanitarian crises in italy: changing perspectives on preparation and mitigation trump labels americans as "warriors" in risky push to reopen admid pandemic. the washington post an inconvenienced youth? ageism and its potential intergenerational roots frustrated millennials say they can't get their ageing parents to cancel their cruises, stop going to church, and take coronavirus seriously. business insider younger americans view coronavirus outbreak more as a major threat to finances than health can herd immunity really protect us from coronavirus? world economic forum failing the test -the tragic data gap undermining the u.s. pandemic response the ugly and dangerous debate simmering in australia i'm scared": how coronavirus is delivering a double blow for older americans department of economic and social affairs what is "boomer remover" and why is it making people so angry? newsweek covid- coronavirus pandemic none declared. key: cord- - jjuwc r authors: usher, kim; bhullar, navjot; durkin, joanne; gyamfi, naomi; jackson, debra title: family violence and covid‐ : increased vulnerability and reduced options for support date: - - journal: int j ment health nurs doi: . /inm. sha: doc_id: cord_uid: jjuwc r family violence refers to threatening or other violent behaviour within families that may be physical, sexual, psychological, or economic, and can include child abuse and intimate partner violence (peterman et al. , van gelder et al. ). family violence during pandemics is associated with a range of factors including economic stress, disaster-related instability, increased exposure to exploitative relationships, and reduced options for support (peterman et al. ). due to the social isolation measures implemented across the globe to help reduce the spread of covid- , people living in volatile situations of family violence are restricted to their homes. social isolation exacerbates personal and collective vulnerabilities while limiting accessible and familiar support options (van gelder et al. ). in many countries, including australia, we have already seen an increase in demand for domestic violence services and reports of increased risk for children not attending schools (duncan, ); a pattern similar to previous episodes of social isolation associated with epidemics and pandemics (boddy, young & o'leary ). family violence refers to threatening or other violent behaviours within families that may be physical, sexual, psychological, or economic, and can include child abuse and intimate partner violence , van gelder et al. . family violence during pandemics is associated with a range of factors including economic stress, disaster-related instability, increased exposure to exploitative relationships, and reduced options for support . due to the social isolation measures implemented across the globe to help reduce the spread of covid- , people living in volatile situations of family violence are restricted to their homes. social isolation exacerbates personal and collective vulnerabilities while limiting accessible and familiar support options (van gelder et al. ) . in many countries, including australia, we have already seen an increase in demand for domestic violence services and reports of increased risk for children not attending schools (duncan, ) , a pattern similar to previous episodes of social isolation associated with epidemics and pandemics (boddy, young & o'leary ) . in australia, as stay-at-home orders came into force, the police in some parts of the country reported a % drop in crime overall, but a % increase in domestic abuse call-outs (kagi ) . at the same time in australia, google reported a % increase in internet searches relating to support for domestic abuse (poate ) . this pattern is repeated internationally. reports of domestic abuse and family violence have increased around the world since social isolation and quarantine measures came into force. recently, anecdotal evidence from the united states, china, brazil, and australia indicates increases in intimate partner, women, and children violence due to isolation and quarantine (campbell ; peterman et al. ; van gelder et al. ) . china, the first country to impose mass quarantine in the wuhan province, saw reported domestic abuse incidents rise threefold in february compared to the previous year (allen-ebrahimian ). as europe imposed quarantine measures in an effort to slow the tide of infection, the italian government began commissioning hotels to provide shelter to the increasing number of people fleeing abusive situations (davies & batha ) . similarly, france reported a % - % increase in domestic abuse complaints following the implementation of self-isolation and quarantine measures (reuters news agency ). france also began commissioning hotels as shelters for those fleeing abuse. as quarantine measures extended to the united states, individual states reported similar increases in domestic abuse incidents ranging from % to % (wagers ) . back in europe, the uk has also seen concerns about increase in family violence (bradbury-jones & isham ). there have been reports of homicide associated with family violence in several countries (bradbury-jones & isham ; reuters news agency ). the national domestic abuse hotline in the uk saw a % increase in calls since stay-at-home measures were implemented (kelly & morgan ) , recording at least eight family violence-related deaths (knowles ). as the novel coronavirus outbreak has intensified globally, countries are adopting dedicated measures to slow the spread of the virus through mitigation and containment (van gelder et al. ; campbell ) . social distancing and isolation are central to the public health strategy adopted by many countries, and in many settings, penalties are in place for any person who breaches these imposed restrictions. social isolation requires families to remain in their homes resulting in intense and unrelieved contact as well as the depletion of existing support networks, such as through extended family as well as through social or community-based support networks for families at risk. additionally, isolation places children at greater risk of neglect as well as physical, emotional, sexual, and domestic abuse (national society for the prevention of cruelty to children [nspcc] ). due to (necessary) imposed social distancing and isolation strategies, and the resulting shortages of essential resources and economic consequences of these measures, people globally are living under stressful conditions. while social isolation is an effective measure of infection control, it can lead to significant social, economic, and psychological consequences, which can be the catalyst for stress that can lead to violence. isolation paired with psychological and economic stressors accompanying the pandemic as well as potential increases in negative coping mechanisms (e.g. excessive alcohol consumption) can come together in a perfect storm to trigger an unprecedented wave of family violence (van gelder et al. ). in australia, as social distancing measures came into place, alcohol good sales rose more than % (commonwealth bank group ), and as restaurants, bars, and pubs closed, people are now drinking more within the confines of their homes. unemployment figures around the world have rapidly risen into the double digits, with millions signing up for welfare payments and a worldwide recession predicted in the near future (kennedy ) . substance misuse, financial strain, and isolation are all wellknown domestic abuse risk factors (richards ). during isolation, there are also fewer opportunities for people living with family violence to call for help. isolation also helps to keep the abuse hidden with physical or emotional signs of family violence and abuse less visible to others (stark ). reports show that covid- is used as a coercive control mechanism whereby perpetrators exert further control in an abusive relationship, specifically in the use of containment, fear, and threat of contagion as a mechanism of abuse. in australia, charities providing support to people experiencing domestic abuse have highlighted concerns specifically related to reports from people whose intimate partners are using covid- as a form of abuse. there have been reports of misinformation used by intimate partners related to the extent of quarantine measures (gearin & knight ) and other forms of covid- -related abuse (fielding ) . further, there are reports that those experiencing domestic abuse may be afraid to go to hospital for fear of contracting covid- (fielding ) . we recognize that these are challenging times for all of us, but especially for the most vulnerable families and children. the united nations secretary-general antonio guterres recently called for countries to prioritize support and set up emergency warning systems for people living with family violence (news wires ). pharmacies and grocery stores in france are now providing emergency warning systems to help enable people to indicate that they are in danger and need support (guenfound ) , through the introduction of code words to alert staff they need help (davies & batha ) . domestic abuse support agencies in some areas have published specific guidance on domestic abuse in covid- focussing on what friends and family can do to support people who are isolated (domestic violence resource centre australia [dvrca] ). charities are also recognizing the role that neighbours can play in supporting people living with family violence, providing advice on what to listen for and look for while they themselves are home, and encouraging conversation with neighbours (gerster ). the fear and uncertainty associated with pandemics provide an enabling environment that may exacerbate or spark diverse forms of violence. actions such as social distancing, sheltering in place, restricted travel, and closures of key community resources are likely to dramatically increase the risk of family violence (campbell, ). governments and policymakers must create awareness about an increased risk of violence during pandemics and highlight the need for people to keep in touch with each other (while observing precautionary measures) and the great importance of reporting any concerns of abuse. it is important to remember that maintaining social connectedness is an important strategy during times of isolation (usher et al. ) , even more so with family or friends you suspect may be at risk of family violence. in addition, information about services available locally (e.g. hotlines, telehealth, respite services, shelters, rape crisis centres, and counselling) must be made known to the general public through a range of sources, including social media, the mainstream media, and health facilities. mental health professionals can support people by providing first-line psychological support, including listening empathetically and without judgment, enquir- china's domestic violence epidemic the pandemic paradox: the consequences of covid- on domestic violence cabin fever': australia must prepare for the social and psychological impacts of a coronavirus lockdown an early look at how the coronavirus is affecting household spending global economic & markets research; commonwealth bank group australia. retrieved on th april europe braces for domestic abuse 'perfect storm' amid coronavirus lockdown domestic violence resources centre australia (dvrca) ( ) nsw domestic violence support groups warn coronavirus isolation is prompting surge in demand for services family violence perpetrators using covid- as a form of abuse we have not experienced before when home isn't safe: how coronavirus puts neighbours on front lines of abuse french women use code words at pharmacies to escape domestic violence during coronavirus lockdown in quarantine with an abuser: surge in domestic violence reports linked to coronavirus. the guardian. retrieved on th april crime rate in wa plunges amid coronavirus social distancing lockdown measures coronavirus: domestic abuse calls up % since lockdown, charity says jobs destroyed worldwide as coronavirus triggers deep recession murder-warning-domestic-abuse-boris-johnson national society for the prevention of cruelty to children (nspcc). ( ). coronavirus (covid- ) and keeping children safe from abuse. national society for the prevention of cruelty to children (nspcc). retrieved on un chief decries 'horrifying' rise in domestic violence amid virus lockdown. france . retrieved on th april pandemics and violence against women and children centre for global development % increase in domestic violence searches since coronavirus as domestic abuse rises in lockdown, france to fund hotel rooms dash: domestic abuse, stalking and harassment and honour-based violence risk identification and assessment and management model coercive control: the entrapment of women in personal life editorial: the covid- pandemic and mental health impacts covid- : reducing the risk of infection might increase the risk of intimate partner violence. eclinicalmedicine, retrieved on domestic violence growing in wake of coronavirus outbreak. the conversation covid- and violence against women: what the health sector/system can do key: cord- -pqy bikp authors: hayes, adrian c.; jupp, james; tsuya, noriko o.; brandon, peter title: book reviews date: journal: j popul res (canberra) doi: . /bf sha: doc_id: cord_uid: pqy bikp nan the common picture of the health of populations around the world today is confusing. on the one hand, death rates in most developing countries have declined dramatically over the past years and people live longer; on the other hand, infectious diseases once thought to have been conquered are making a comeback and hiv/aids could become the worst epidemic in history. in this book mcmichael argues that the way to make sense of this paradox is to use a broad human ecological perspective on population health. he gives a masterful and engaging account of the 'long history of the changing patterns of human ecology and disease' from the pleistocene to the dawn of the twenty-first century. patterns of health and disease are examined as the product of ever-changing interactions between human biology and the social and physical environments. new patterns of disease emerging today may reflect the fact that humans are stressing ecological life support systems beyond the limits of their tolerance. in the space of this review i can only mention a few of the many topics mcmichael skilfully weaves into the story. biology establishes some fundamental parameters for population health. mcmichael's first three chapters discuss relevant aspects of human evolution. human and chimpanzee genuses diverged in africa - million years ago as the cooling of the pliocene produced an ecological niche 'for an ape able to survive mostly out of the forest' (p. ). then the enhanced cooling of the pleistocene (beginning about million years ago) led to rapid speciation of the homo genus. it is now generally agreed that a succession of homo species migrated out of africa, with extensive periods of co-existence among different homo species. homo sapiens and homo neanderthalis, for instance, shared much of western eurasia for thousands of years before the latter species became extinct around , years ago. since then homo sapiens has been the sole survivor of the homo genus -and, as mcmichael poignantly points out, if the current anthropogenic decline of species continues, it could become the sole representative of the whole great ape family. many distinctive characteristics of human biology were established as adaptations to environmental conditions of the pleistocene. as conditions changed, some of those adaptive responses became no longer so 'adaptive', and the resulting imbalances between biology and environment can manifest themselves as a tendency to disease. one example discussed by mcmichael is adaptations in insulin metabolism. insulin is an 'ancient vertebrate hormone' (p. ) that plays a vital role in the way the human body processes ingested carbohydrates and fats and converts them into energy for cell metabolism. the australopithecines (our pre-homo ancestors, including the celebrated 'lucy') appear to have been mostly vegetarian. as the tropical vegetation thinned during the global cooling of the pliocene, however, 'the survival benefit gained from supplementary high-quality meat protein would have increased ' (p. ) . certainly the hominines (species of the homo genus) emerging during 'the even cooler pleistocene … took to meat-scavenging and hunting … the product of an evolutionary branch that invested in cognition rather than mastication ' (pp. - ) . we would expect natural selection to have a corresponding effect on the way the body uses insulin. mcmichael, drawing on the work of j.v. neel and others, hypothesizes that 'meat-dependent hunter-gatherers may have reached the end of the pleistocene, around , years ago, with a reduced insulin sensitivity by comparison with their australopithecine ancestors ' (p. ) . this sets the stage for mcmichael to advance a 'provisional thesis' (p. ) to account for the prevalence pattern of 'type ii' (non-insulin-dependent) diabetes in the world today. the prevalence of type ii among major population groups varies by more than a factor of ten, and the variation is still striking even after controlling for obesity. europeans have low rates. assuming that reduced insulin sensitivity was the 'background' genotypic condition , years ago mcmichael speculates that a few neolithic populations might have diverged from this condition and developed a more insulin sensitive metabolism. moreover those few populations could well have included the proto-europeans, who were after all among the first to develop settled agriculture, implying a diet with more carbohydrates again. middle eastern farmers domesticated not only plants, but also goats, sheep, and later cattle. 'from around , - , years ago these agrarian communities began consuming milk and milk products. the result, today, is that genetically based tolerance of lactose (milk sugar) is much more prevalent in european than in most non-european populations' (p. ). genetic adaptation of populations to diets with differing glycaemic loads could help account (in conjunction with dietary changes and obesity levels) for their different levels of glucose intolerance and frank diabetes. mcmichael's line of reasoning takes more twists and turns than i can repeat here, and lack of direct confirmatory evidence means much of it remains speculative. as the late stephen jay gould ( : ) remarked, paleoanthropology has 'more minds at work than bones to study'. but his account shows how mismatches between biology and environment can affect population health. 'patterns of health and disease are the product of antecedent biological evolution interacting with current social and physicalenvironmental conditions' (p. ). other selection pressures he discusses, aside from food availability, are climate (leading to adaptations in skin pigmentation and the immune system) and infection (chapter includes a fascinating account of the co-evolution of parasite and host in the case of malaria). chapters - explore how a succession of changes in human ecology during the period of recorded history have affected patterns of health and disease by virtue of their impact on the co-evolutionary interplay between microbes and humans. this interplay is ubiquitous wherever there are human populations and is older than 'history' itself. when early humans became meat-eaters they exposed themselves to various animal parasites; when they migrated out of africa they encountered unfamiliar microbes. in these chapters, however, mcmichael emphasizes three broad historical transitions. the first corresponds to the rise of settled agriculture and the concentration of population in the early civilizations of the middle east, egypt, south asia, east asia and central and south america. this created a new web of relationships among animals, humans and microbes, facilitating the migration of microbes from animal to human populations. 'smallpox arose via a mutant pox virus from cattle. measles is thought to have come from the virus that causes dis-temper in dogs, leprosy from water buffalo, the common cold from horses, and so on' (p. ). most of the well-known infectious 'crowd' diseases appear to have developed during this transition; although the 'leap' from animal species to humans can still occur today, of course, as hiv and sars attest: writing before the recent sars outbreak mcmichael notes: 'in southern china, the intimate pig/duck farming culture creates a particularly efficient environment in which multiple strains of avian viruses infect pigs. the pigs act as "mixing vessels", yielding new recombinant-dna strains of virus which may then infect the pig-tending humans ' (pp. - ) . each of the ancient civilizations acquired its own repertoire of locally evolving infectious diseases. the second transition corresponds to the era of fluctuating contact among the eurasian civilizations through trade and warfare from around bc to ad . mcmichael builds on mcneill's ( ) thesis that this contact resulted in the transmission and swapping of microbes, leading to episodic epidemics followed by periods of gradual re-equilibration between the infectious agent and human host population. the complex aetiology of the black death in mid-fourteenth century europe, for example, seems to include an outbreak of bubonic plague in china during the s. 'after many turbulent centuries, this transcontinental pooling resulted in an uneasy eurasian equilibration of at least some of the major infectious diseases' (p. ). the third great historical transition refers to europe's exploration and conquest of distant lands, and (using language reminiscent of diamond ) the export of 'its lethal, empire-winning, germs to the americas and later to the south pacific, australia and africa' (p. ). the large aztec and inca populations had no herds of wild animals they could domesticate and remained relatively free of 'crowd' infectious diseases until they were decimated by smallpox, measles and influenza introduced by europeans. falciparum malaria and yellow fever were brought to the americas in the seventeenth century by the trans-atlantic slave-trade. in similar fashion the aborigines of australia suffered deadly epidemics following the arrival of europeans on that continent. and within years of captain cook's first visit to hawaii in the native population declined from around , to less than , . mcmichael points out that the third transition was more a 'dissemination' of microbes that had co-evolved with the eurasian population to other parts of the world than an 'exchange'; and he is sceptical that syphilis was really introduced to europeans from the amerindians, as is often claimed. in any event the third transition represents another major process re-equilibrating the balance between microbes and humans, this time across transoceanic populations. are we experiencing a fourth major historical transition today? around many experts thought that tuberculosis, cholera and malaria would soon be conquered; it was time 'to close the book on infectious diseases', declared the us surgeon-general (p. ). but now these diseases are increasing again, and a host of other diseases or their pathogens have been newly identified; they include lyme disease, hepatitis c and e, human herpes viruses and , ebola virus and legionnaires' disease. something 'unusual' seems to be happening to patterns of infectious diseases (p. ). to explain this mcmichael suggests we must look at contemporary human-induced social-environmental changes which provide new opportunities for microbes to invade and colonize the human body: worldwide urbanization, intravenous drug use, changing sexual practices, changes in medical practice (blood transfusion, organ transplants), intensive food production, poverty and inequality, irrigation, deforestation, eutrophication of rivers, and so on. in the last three chapters mcmichael draws together these themes in a more prospective view, detailing the risks to population health inherent in the way we are currently 'depleting or disrupting many of the ecological and geophysical systems that provide lifesupport' (p. ). chapter includes a discussion of the health impact of climate change. as in his earlier work ( ) mcmichael adds his voice, with eloquence and authority, to the imperative of establishing more sustainable ways of living. mcmichael's book is impressive in the way it marshals research findings from diverse fields, and even more important for the way it clarifies our contemporary situation. however, in telling the story about population health from a social ecological perspective his narrative is ahead of his analytics. he criticizes the conventional epidemiological approach (taking the individual as the unit of analysis) for its reductionism, but gives no systematic exposition of his own more holistic conceptual framework detailing precisely how it is 'some important health-determining factors operate essentially at the population level' (p. ). similarly his conceptualization of anthropogenic environmental change (building on peter vitousek and others) is pretty all-embracing and not yet structured to help us focus on those parts or processes most relevant for population health. the persuasive force of this book comes more from the weight of its examples of social-ecological processes influencing patterns of health and disease in populations than from any systematic theory describing these relationships. mcmichael is clearly aware of these limitations; we hope he can address them in future work. a more explicit analytics will facilitate a more felicitous telling of the story. experts and advanced students from any number of population-and healthrelated disciplines will find this book useful and stimulating. demographers will especially like the way it clearly positions 'population' centre stage; and the book's central thesis is certainly a boost to those of us who like to see demography in a strategic position at the intersection of the human and natural sciences. for those working in family planning, there is a challenging section on the health consequences of modern reproductive interventions ( pp. - ). institutions which have supported this fine work deserve some credit too. mcmichael was professor of epidemiology at the london school of hygiene and tropical medicine when he wrote this book; he is now with the national centre for epidemiology and population health (nceph) at the australian national university. the disciplinary structure of modern universities is not always conducive to bold synthetic research like mcmichael's. this book shows how important it can be: in fact the future health of human populations could well depend on it. the basic proposition of this interesting and timely book is that 'irregular migration occurs because states make rules about who can legally cross their borders. under conditions of globalization, these rules promote transnational economic activity, but limit who can work and stay ' (p. ) . in other words, there is a contradiction between increasing globalization and a declining willingness to accept mobility of labour as opposed to capital and goods. this contradiction is especially apparent in the european union and the united kingdom, with which much of this book is concerned. britain, france and the netherlands had a long tradition of free entry for imperial subjects, which they eventually found politically embarrassing. they now have the practice of free entry for european union subjects, which they may also find embarrassing as the eu extends to eastern europe and even turkey. with its focus on britain, this study sees irregulars as mainly those who arrive through legal means but then work, which they are forbidden to do. peoplesmuggling, which has become so controversial, is not central to their analysis. because the majority entering britain do not need visas, it is easy to get in. because there is no national identity card, it is easier to work illegally than in most european states. serious criminal activity is a matter for the police, who are relatively indifferent to breaches of immigration rules. the basic problem remains that britain, like several other european states, does not really have an immigration program. those who wish to remain permanently and to become citizens must either be closely related to those already there, or make a successful asylum application, or gain access to the very restricted working-visa or business-visa system. only recently, and since the publication of this study, has the government moved towards developing a coherent system allowing a quota of permanent residents; it has done so in response to widespread hysteria, worked up by the populist media, against asylum seekers. one weakness of this study is that it concentrates on economic motivations; yet the recent surge of asylum seekers, as in australia, includes many who are genuinely fleeing wars in afghanistan and iraq. the british situation is made more acute by many from collapsing african states, or balkan romanies, making well-based claims of ethnic persecution. these latter will probably have full access to britain once their states have joined the european union. at the core of this study is an analysis in depth of irregular migrants living and working in london. the groups chosen are brazilians, who have no strong historic connections with england; poles, who have stronger links; and kurdish turks, the only ones who can make plausible claims to be asylum seekers. other than some of the kurds -who are highly politicized -the irregulars simply come to make more money than at home, have no real desire to settle permanently and are ready to work for low wages and below their level of qualification. one interesting feature of these irregulars, which may well apply generally, is that they are young and well educated. they may come from poor countries but they are not peasants or labourers. what little we know about asylum seekers suggests that they are also well educated and skilled. the difference is that they have few places left to go, whereas many of the openly 'economic irregulars' have every intention of returning home in due course. because they are relatively well-qualified, many of those studied here have access to the variety of non-government organizations which have sprung up to help them and represent them to the authorities. they are certainly not voiceless even if inclined to avoid direct contact with government for fear of deportation. because london has a long history of immigrant labour in service industries, there does not seem to be much concern with the present situation. as host to millions of tourists it needs a mobile labour force, and it does not have a serious unemployment problem except in some declining enclaves in the east end. many of those interviewed have worked illegally for years and have rarely encountered any attempt to discourage or remove them. there is a contrast between this liberal approach to casual labour and the much stricter attempts to discourage permanent settlement. however, the flood of asylum seekers in recent years is changing this. the book's publication was too early to account for the recent moves in britain towards a regime reminiscent of that in place in australia. as presented here the british authorities do not really mind people coming to work in low-wage industries because they do not expect them to settle. london is now so cosmopolitan that racial tensions are less politically significant than in some smaller cities which have recently experienced violent reactions. as is regrettably common in texts published in europe and north america, there are only passing references to australia. this reflects our isolation, which also makes the 'dilemmas' of irregular migration less pressing than for states with long land boundaries or short sea crossings. however, australia does have a complex, planned and longstanding immigration program, with some principles and practices extending back for over a century. this is in contrast to the united kingdom situation studied at the heart of the book. some issues which are of interest to australian scholars and addressed by this book include: will irregular immigration increase despite increasingly rigorous attempts to prevent it? does the admission of large numbers of students, tourists and working-holiday temporary migrants make this more likely to happen? is flexibility needed in assessing asylum seekers as against 'economic migrants'? how can immigration policy be insulated against populist agitations and political expedience? can sydney hope to be a 'world city' without a degree of 'irregular migration' to supply transient labour in services? does our expanding relationship with the island states of the south pacific make regularization of immigration on a more generous basis more likely? does it really matter if there are thousands of 'irregular migrants' working in the economy? how can people-smuggling, trafficking in women, drug-smuggling and terrorism best be controlled without draconian restrictions on legitimate movement? this is an interesting and useful book. its tendency to see all movement as essentially motivated by economic inequality is of prime importance, even if that is only part of the story. globalization without liberal migration regimes, on this view, could be oppressive. but are the rich societies ready to modify this? this study ends on the note that 'globalisation has consisted in the development of the world economy under conditions most favourable for capital and the first world countries, and under terms that discriminated against the developing countries in the liberalisation of trade. … for these reasons, it is doubtful whether an international regime for managing migration, would be a step towards international justice' (p. ). australian national university this volume offers anthropological accounts of the evolution, production, and consumption of various social policies in contemporary japan. consisting of nine chapters, it is a collection of papers prepared originally for an international conference. chapter , by goodman, discusses the evolution of applied anthropology, and explains what anthropology can offer to the studies of social policy. the anthropology of social policy is not only the study of meanings ascribed to slogans and symbols associated with the policy but also that of its production and consumption. as goodman argues, social policies not only emerge from a particular socio-cultural context, but they also provide important clues to how social values are constructed and altered. chapter , by bestor, attempts to sketch a 'cultural biography' of civil society in contemporary japan. it first traces the postwar development of the notion of civil society; it next examines the multiple uses of related terms such as civil society, volunteerism, npo, and ngo; and then provides an example of the development of civil society by describing a sudden rise in volunteer activities and the enactment of the npo law following the hanshin earthquake in . instead of devoting many pages to explanations of the meanings of different terms, the chapter would have been more interesting if it were focused more on the processes that gave rise to volunteerism and the ensuing legislation by illustrating the interaction between volunteer activities and the policy responses. in chapter , roberts analyses the problems associated with low fertility, by examining programs within the angel plan -the comprehensive policy to increase the rapidly falling birthrate -and public discourse associated with its implementation. roberts demonstrates that the policy initiatives are not consistent with, therefore not effective in altering, the prevailing gender division of labour. by identifying some of the voices influencing the production and implementation of the policy, she also illustrates the nature of changing social norms and the roles of policy in bringing about such changes. although some demographic facts are misrepresented, the chapter nevertheless offers vivid information regarding how the plan is produced and consumed, therefore furthering our understanding of the importance and difficulties of balancing work and family in contemporary japanese society. in chapter , stevens and lee analyse how two sets of government policies, those of the ministry of health and welfare and the others of the ministry of justice, influence the provision of maternal and child healthcare for foreigners in japan. they argue that legal and cultural stresses, exerted by the way the policies determine the eligibility and provisional guidance for healthcare, make it difficult for foreign women to have the care they need, and that in turn leads to higher-risk pregnancies. public policies and laws are influenced by the perception of ethnicity, and the lack of policies to deal specifically with health problems of foreign mothers suggests a dual reality of health and welfare in different segments of the population. however, their arguments are not fully supported by empirical evidence, according to which the mothers who suffer higher health risks are those from developing countries in southeast asia whereas the risks for other foreign mothers are similar to, or significantly lower than, those for japanese mothers. providing that foreigners comprise vastly different groups, it seems necessary to account for their differences in socio-economic status, demographic features, and legal status before we determine whether foreign mothers indeed suffer higher health risks. chapter , by ben-ari, examines the interrelation between the organizational features of japanese preschools and the way by which they are predicated on notions of normal development of children. based on participant observations, visits to childcare institutions, and secondary analyses of administrative documents used by these institutions, ben-ari shows how organizational arrangements of institutions of early childhood education are related to the ways that children are socialized according to a uniform set of ideas that the state deems normal and ideal. this chapter is, like chapter , an example of practical anthropology at its best. it offers useful and interesting information based on two primary methods of applied anthropology: field work and content analysis of documents. in chapter , goodman analyses the 'discovery' of child abuse in japan and the development of social policy to deal with the problem. his view is that the upsurge of reported cases of child abuse in the s was largely a result of the campaigns by the media and child-welfare institutions. mothers are found to be the main abusers of children, and these groups viewed the increasing child abuse as a consequence of nuclearization of the family, combined with the prevalent myth of motherhood. goodman shows that through the implementations of regulations and policies, this discovery altered the relationship between the state and parents by giving greater powers to authorities to intervene in what had previously been seen as the exclusive and private domain of the family. chapter , by thang, offers an overview of programs to promote interaction between the elderly and school-aged children and teenagers in japan. through an attempt to interpret intergenerational interactions in the context of the japanesestyle welfare society, thang seeks to show the needs for and significance of intergenerational interaction programs. although we cannot deny the need for programs to promote intergenerational interactions, i cannot help feeling that such programs are supplementary in an array of policies designed to support and care for the elderly. given the rapidity of population ageing and the pervasiveness of its socio-economic, demographic, and political consequences, more attention should be paid to how these programs are related to mainstream elderly policies such as the golden plan and the long-term care insurance, and to how these policies and programs together alter the perceptions and treatment of the elderly in contemporary japan. in chapter , tsuji examines the evolution of death-related policies in japan over the last years. tsuji shows that mortuary practice is shaped by interplay among policies, individual actors, and traditions, being conditioned by wider socio-economic and demographic changes. though it is a little too long on explanations of prewar development, i found the chapter interesting and informative, illustrating skilfully that since meiji the government has used death policies to exert control over the family and individuals, and that mortuary practices have changed in recent decades in the face of constraints driven by low fertility. chapter , by mackie, discusses some of the ways in which social policy affects individuals differently. it argues that the archetypal citizen in the contemporary japanese political system is a male, heterosexual, able-bodied, fertile, white-collar worker. this in turn suggests that our understanding of citizenship can be broadened if we view citizens as embodied individuals whose positions are situated somewhere in a spectrum, shaped and constrained by legal and institutional structures. while the typology of citizens provided by this chapter is useful in understanding how citizenship is defined by the society, it falls short of explaining how changes in social policy are related to changes in the notion of citizenship in contemporary japan. there are general weaknesses in the volume, stemming largely from the very nature of the enterprise. in all, however, the volume provides useful insights into how problems and policy issues shared by many industrialized countries are tackled in japan. thus it will be of interest not only to japan specialists but also to those who are interested in social policy in industrialized societies in general. is an ambitious book. the first book in a series on the australian economy and society, it provides informative analyses about education, work, and welfare in australia over the last decades of the twentieth century. this important work on contemporary australia creatively presents data on shared and divergent attitudes among australians, social trends over time, comparisons among social groups, and comparisons with other nations. the book is distinctive in using large, representative samples of australians and persons from other nations to make conclusions and inferences. three principal sources of data are used: the international social science surveys/australia, the international social survey program, and the international survey of economic attitudes. combined, the three surveys yield a sample numbering over , individuals. the surveys are nationally representative and, depending upon the topic under investigation, permit the authors to make generalizations to the populations as a whole. with the improvements in measurement theory and survey questionnaire design, the authors can provide authoritative statements about people's attitudes and behaviours within countries and compare australians' attitudes and behaviours to those of persons in other nations. with some exceptions, the nations with which australia is most often compared are english-speaking or european. two chapters that provide interesting applications of the comparative analysis approach using survey data are chapter , 'conflict between the unemployed and workers in nations' and chapter , 'participation in the labour force'. the tabulations in each chapter develop the authors' stories as eloquently as the accompanying narratives. furthermore, the large amounts of data collected from the surveys permit the authors to exploit more advanced multivariate techniques. throughout the book, various multivariate modelling strategies are used to better understand relationships between such topics as education and earnings; job complexity and earnings; upbringing and attitudes about trade unions; and risky lifestyles and ideals about societal responsibility for diseases. obviously, in the interests of science and effective policy development, debate should surround the methods used and the conclusions reached. notwithstanding the need for such debate, the book carefully documents its methods and justifies the statistical approaches taken. readers concerned about empirical social science will welcome the multivariate models featured in the book, especially since most of its predecessors, which aimed for the same grand scale and scope, often omitted multivariate models. that omission was rarely made by choice, but was usually due to data constraints. attention to methods, creative use of surveys, and strategically placing findings in national and international contexts produce some fascinating findings in the book. some of the more notable findings include workers' desires for job security, even if it means less pay; stronger support for trade unionism among public service employees than among blue-collar workers; australians' desires to see the influence of unions no further weakened after many years of sustained government efforts to do so; a tension between australians' feeling sorry for their fellow australians who have suffered from diseases as outcomes of risky health behaviours on the one hand, yet also feeling one must take responsibility for one's own life-style choices on the other hand. and, lastly, a finding that australians do more complex jobs than their counterparts in five european nations, but that complexity is not the most important determinant of salaries. rather, the apparent determinants of australian salaries are status and maleness. the book accomplishes its goal of clearly and concisely presenting its findings and interpreting what they mean for contemporary australian life. topic vi, 'retirement', which contains three chapters, is a good example of the clarity and compactness of the writing style and presentation of facts. however, readers may sometimes find the book too dense and the huge number of graphs, figures, statistics, replicated survey questions, and technical notes distracting instead of illuminating. perhaps the commendable effort to document rigorous scientific analyses is occasionally counterproductive. overall, the work is essential reading and it offers researchers, policymakers, and others concerned about australia's future a myriad of social and economic data in one source. if this book is indicative of future volumes in the series, then the series will have great utility. guns, germs and steel: the fates of human societies planetary overload: global environmental change and the health of the human species plagues and people key: cord- - whrbuq authors: wong, fui lin; antoniou, georgia; williams, nicole; cundy, peter j. title: disruption of paediatric orthopaedic hospital services due to the covid- pandemic in a region with minimal covid- illness date: - - journal: j child orthop doi: . / - . . sha: doc_id: cord_uid: whrbuq purpose: this study was designed to evaluate the impact of the covid- pandemic on paediatric orthopaedic services in a paediatric tertiary hospital in south australia. methods: a retrospective audit was conducted of orthopaedic activity at a major paediatric tertiary hospital with a level paediatric trauma centre, where no patients were admitted with covid- illness. orthopaedic emergency department (ed) presentations, outpatient clinics and hospital admissions for the period between march to april were studied and compared with the same period in ( march to april ). chi-square tests were performed with p < . indicating statistical significance. results: in total, patients presented to the ed with orthopaedic complaints during the pandemic (versus in ). however, there was minimal change in the number of ed presentations requiring admission ( in versus in ). among patients discharged directly from ed, . % received hospital outpatient referral (versus . % in ), with the remaining patients referred to community health services or discharged directly. there was a . % increase in telehealth (video and phone) outpatient consultations compared to and a . % decline in face-to-face appointments. there was a total of orthopaedic admissions (elective and emergency) compared to in . admissions for children under seven remained unchanged ( . % reduction in children aged seven and above). conclusion: despite an overall decline in all paediatric orthopaedic hospital activity, the number of emergency admissions for musculoskeletal conditions did not change. elective surgery numbers for children aged under seven were also unchanged. appropriate planning and hospital resources allocation are necessary to meet this service requirement in future pandemics. level of evidence iv conclusion despite an overall decline in all paediatric orthopaedic hospital activity, the number of emergency admissions for musculoskeletal conditions did not change. elective surgery numbers for children aged under seven were also unchanged. appropriate planning and hospital resources allocation are necessary to meet this service requirement in future pandemics. the covid- disease first reached australia on january and, as of may , the commonwealth of australia reported confirmed cases of covid- including deaths. australia has not been significantly affected by previous zoonotic coronavirus outbreaks, experiencing only one case of sars infection and no cases of mers infection. thus, evaluation of the impact of this pandemic could provide valuable lessons for future pandemic planning. covid- was first declared a public health emergency in south australia on march and declared a major emergency a week later. , a national lockdown was declared, restricting travel and movements within the country and across international borders. population-based non-pharmaceutical interventions including social distancing, household quarantine and case isolation were enforced by public health authorities in order to flatten the curve and prevent health care systems from being overwhelmed. on march , the state coordinator of south australia made a direction under the emergency management act to limit surgery to category (emergency) and urgent category surgery and procedures only, which include those performed for medical conditions where failure to do so will lead to loss of life, loss of limb or permanent disability. these restrictions on hospital services were put in place to contain covid- infection, as well as to conserve valuable resources such as personal protective equipment (ppe) and surgical appliances in preparation for an anticipated severe outbreak. in contrast to other developed countries with advanced healthcare systems, such as the usa and uk, australia has seen rapid control of covid- case numbers with minimal mortality rate, despite initiating lockdown and restricting non-urgent elective surgeries in a similar timeframe (table ) . however, similar to many healthcare institutions worldwide, australian hospital services have been impacted by covid- preparations, with a nationwide response and state-based adaptation. a literature review of previous studies of infection epidemics revealed minimal data regarding the effects of pandemics on hospital services in the field of paediatric orthopaedics. this article aims to provide the first description of the changes in paediatric orthopaedic hospital services as a result of the covid- pandemic. as a direct result of the pandemic, our hypotheses were that ( ) emergency department (ed) presentations and admissions would remain the same or decrease and ( ) elective admissions and outpatient numbers would rapidly decline during the pandemic. the setting for this study was unique as the hospital has no admitted cases of covid- illness. as such, rather than the effects of the disease itself, this study represents the effects of government restrictions, the associated changes in local departmental policies and the change in patients' healthcare-seeking behaviour due to the pandemic. musculoskeletal problems are the sixth most common presentation in children and adolescents and a better understanding of the impact of this pandemic provides guidance for planning of resource allocations in the face of future pandemics, or a potential second wave of covid- . a retrospective population-based cohort study was conducted in the department of paediatric orthopaedics at the women's and children's hospital, a major tertiary referral teaching hospital with a level major paediatric trauma centre in south australia. data were sourced for outpatient clinics attendance, ed presentations, musculoskeletal-related hospital admissions and surgeries performed within a six-week period between march and april (weeks to of ). the study period corresponds to the time period between the initiation of lockdown within the state and the lifting of restrictions on elective surgeries in south australia. this was compared to the corresponding six-week period (weeks to ) in ( march to april ). cases in ed were identified through the electronic ed information system database by searching keywords (trauma, swelling, pain, fracture and injury). identified cases were then reviewed for type of injury, subsequent disposition and referral on departure. outpatient data included determination of face-to-face appointments versus telehealth consultations (telephone and video conference mediums) with direct communication to patients and/or general practitioners. all patients admitted to the hospital for paediatric orthopaedic surgery within the study period were identified and reviewed for: demographics, diagnosis, admission category (elective, emergency), type of surgical procedures and length of stay. patients having simple forearm reductions in the ed under nitrous inhalation/ sedation were not formally admitted and as such did not appear in admission data numbers. our outcome measures were the number of ed presentations with orthopaedic conditions and their subsequent disposition on departure, number of face-to-face and telehealth outpatient consultations, the number and type of surgical procedures, as well as the total orthopaedic admissions all data were collated and analysed using microsoft excel . statistical analyses included percentages and chi-square tests comparing the two time periods ( and ) on the categorical outcome variables of interest and using p < . to indicate statistical significance. a database search identified children under years old that presented to the ed with musculoskeletal-related issues from march to april . this represented a . % reduction from presentations in . the types of musculoskeletal presentations between the two periods were similar, with upper limb injuries accounting for more than half the presentations. there was negligible change in the number of patients who had hospital admission for orthopaedic injuries, with admissions in and in ( table ) . during the pandemic, patients presented to the ed who did not require inpatient management, representing a . % reduction from . among the patients that were discharged, only . % received an outpatient referral within the hospital (including allied health), compared to . % in the preceding year. the remaining patients were either referred to external health providers (including general practitioners, community mental health and private health providers) for ongoing management or did not require follow up. a total of and appointments (including face to face and telehealth) were scheduled during the study period in and respectively (table ). in all, . % of patients failed to attend their appointments in , up from . % in . there was a . % drop in the number of consultations that were held face to face during the pandemic in comparison to (fig. ) . there was an associated % increase in the use of telehealth services, up from in to in the corresponding six-week period in . the department operates six general orthopaedic clinics and five fracture clinics per week during routine times. the changes in modalities used were especially evident for orthopaedic clinic appointments where telehealth consultations had a % increase between the start and end of the pandemic, far surpassing face-toface consultations. this was distinct from fracture clinic appointments, where face-to-face consultations remained the more common method used, despite an increase in telehealth consultations. comparing all attendances, the paediatric orthopaedic outpatient clinic functioned at . % capacity in comparison to . there was a . % decrease in the number of total admissions under orthopaedic surgery (elective and emergency) from in to children in . elective admissions were halved from in to . emergency admissions were reduced by . % from to . as a result, the ratio of emergency to elective admissions increased to : during the pandemic from the usual : , showing a shift in total workload towards emergency surgeries. of the emergency admissions, were surgery for forearm fractures, other upper limb (mainly supracondylar humerus), lower limb, and nine for tumour or infection (fig. ) . not all emergency admissions required surgery, with the 'no surgery' columns in fig. including conditions such as osteomyelitis, cellulitis, spinal injury and injuries requiring elevation and splintage. upper limb injuries, especially forearm, remained the most common paediatric injuries, with a decreased incidence of lower limb injuries during the pandemic. however, despite an overall downtrend of hospital admissions, elective and emergency admissions for children under the age of seven did not change during the study period (p = . ) (fig. ) . in contrast, there was a statistically significant difference in admissions of children aged seven and above, especially for elective admissions, decreasing from . % in to . % in (p < . ). bed occupancy for paediatric orthopaedics was noted to have a . % reduction with hours for the sixweek period in , compared to hours in . the state of south australia, with a population of . million, recorded only cases of covid- and four deaths, as of may . additionally, the hospital studied had no admitted cases of covid- illness and no deaths. as such, this study is unique as it measures the effect of preparation for a 'disaster' scenario rather than the direct burden of large numbers of infected persons on hospital services. there was a rapid but progressive restriction of activities within the state from march , including indoor and outdoor sporting activities. the requirement for a minimum of . metres social distancing curtailed organized sport. this is consistent with the . % decline in ed presentations for injury observed in the study during the lockdown period. the decline in lower limb injuries requiring hospital admissions could be attributed to widespread restrictions in team sports such as soccer, netball and australian football, which are known causes of injuries involving lower extremities. it is unclear whether activity restrictions resulted in an overall drop in minor injuries or if it could be inferred that minor injuries still occurred in the community, but children did not present to the ed due to social distancing practice and/or parents' anxiety to avoid hospital attendance. this apparent change in healthcare-seeking behaviour supports the observation of a decreased number of ed presentations, while patients with injuries requiring expert medical care still presented. this contrasts with reports in italy that described parents with children avoiding hospital in fear of covid- infection, leading to potentially avoidable deaths. this trend is useful for resource allocation in future pandemics for young, healthy patients with mild injuries to be treated in the community and avoid hospital exposure and consumption of resources. our data suggest that the rate of injury requiring admission in south australia did not change despite being in lockdown. it is likely that the proportion of admissions for inpatient forearm fracture reduction was increased by changes in clinical practice during the pandemic. previously, nitrous oxide/sedation was commonly used in the ed for fracture reduction, however due to the risk of aerosol generation in a less-controlled environment, these forearm reductions were performed in the main operating suite. in the context of hospital admissions from the ed, our results contrast strongly with uk and new zealand data, which had a % and % decrease in musculoskeletal injury requiring hospitalization respectively. , the lockdown measures in uk and nz were different, with strict closures of playgrounds, schools and more limitations on outdoor activities in contrast to the progressive restrictions in south australia. other regions in australia had different local measures with the adjacent state of victoria, with a population of over six million, having a strict lockdown. it is apparent that a continued burden of paediatric orthopaedic injuries remained in our community with its less restrictive lockdown instructions. in terms of future pandemic planning, service provisions for these injury admissions need to be maintained as a minimum. additionally, unlike some countries with high population density, australians tend to have larger areas in their homes and backyards for activities, with many families owning large play equipment and not needing to attend open public facilities such as playgrounds. the increase in popularity of trampolines during the lockdown period has been associated with a rise in trampoline injuries. it has previously been demonstrated that low levels of parental supervision are associated with higher odds of injury requiring inpatient management. thus, further emphasis could be placed on raising awareness on injury prevention in home environments, especially since children are spending more time at home in the current pandemic. unsurprisingly, outpatient clinic numbers decreased significantly during this period. a contributing factor of this was the reduction in outpatient referrals from ed, in addition to the cancellations of many elective visits. the reduction in number of referrals from ed is likely due to a change in practice: all referrals required discussion with the orthopaedic team prior to referral. in many cases, alternative definitive care outside hospital settings was recommended, such as providing instructions for community health services to remove a cast. this is in line with an audit performed by the team shortly before the pandemic through the choosing wisely programme. it was identified that % of outpatient fracture appointments were considered unnecessary and either no follow up was required or alternative follow up with local health services would have been more beneficial. as such, the orthopaedic team has renewed enthusiasm for definitive care at point of service and to support hospital avoidance via community care. community care has also supported by the addition of new temporary medicare benefits schedule telehealth items since early march . previous studies have reported telephone calls and virtual outpatient clinics as safe and preferred alternatives to routine clinic follow up post-operatively in adult and paediatric settings. , the rapid scaling up of the use of telehealth services was supportive in minimizing the risk of covid- transmission to health professionals and patients/families. government restrictions permitted surgeries for limb or life-threatening conditions as well as time-sensitive conditions that should be performed within days of decision of need to treat. clinicians were given the responsibility to determine this, with supervision by hospital administrators and random police checks. surgery thus consisted mainly of time-sensitive interventions in young children, such as closed reductions for dislocated hips in developmental dysplasia of the hips and clubfoot tenotomies, which in turn facilitated the unchanged numbers of surgeries in children under the age of seven. whenever surgeries were performed, there was no change in the standard operative management of these conditions. surgeries for conditions that did not meet the strict criteria, such as removal of implants, non-urgent sports surgery and other non-urgent cases in older children, were not performed during this time. these cancellations will place additional numbers on existing waiting lists and will require careful management to limit any harm to patients. the observed changes in the number of ed presentations and outpatient appointments has provided a positive stimulus for clinicians to improve the triaging of referrals during routine times. the changes in practice during the pandemic has allowed our junior orthopaedic team members to be more involved in providing definitive treatments in ed, offering referral from ed to community resources for continued care and assessing both telephone and written outpatient referrals for appropriateness. we anticipate long-term benefits in terms of efficiency and reduced wait times with these changes in the post-covid era. the paediatric and combined obstetric hospital studied had no admitted cases of covid- illness, despite community cases and nearby adult hospitals admitting covid- patients. as such, this study did not assess the additional effects covid- patient admissions may have on overall hospital services but is unique in assessing the effect of government restrictions and patients' behaviours during the pandemic in isolation. some avoidance of presentation to the ed may have occurred due to travel restrictions, fear of acquiring covid- from hospital attendance and self-initiated sourcing of local management. the hospital also established a covid- testing centre adjacent to the main entrance, which may have deterred attendance. this study demonstrated an overall decline in all hospital services provided by the paediatric orthopaedic department. the majority of patients presented to ed did not require admission and were referred to external health providers or discharged directly. however, there was a minimal change in musculoskeletal-related emergency admissions across all age groups. while elective admissions for children aged seven and above decreased markedly, admissions for children aged under seven remained unchanged during the pandemic. these results are distinct from reports in other countries and are potentially unique to the south australian population. appropriate planning and hospital resources allotment are necessary to ensure these services are provided as a minimum to the local community in future pandemics. received june ; accepted after revision july no benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. this article is distributed under the terms of the creative commons attribution-non commercial . international (cc by-nc . ) licence (https://creativecommons.org/ licenses/by-nc/ . /) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed. ethical approval: all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the helsinki declaration and its later amendments or comparable ethical standards. approval for this audit was granted by the women's and children's hospital human research ethics committee (approval number a/ / ). informed consent: informed consent was not necessary for this work. none declared. flw: design of the study, analysis and interpretation of data, drafting and critical revision of manuscript ga: analysis of data, drafting and critical revision of manuscript. nw: design of the study, drafting and critical revision of manuscript. pjc: design of the study, drafting and critical revision of manuscript. covid- ) current situation and case numbers state government of victoria. severe acute respiratory syndrome (sars) government of south australia. declaration of public health emergency emergency declaration and appointment of assistant state coordinator emergency management (appropriate surgery during covid- pandemic no . direction) musculoskeletal conditions in children and adolescents managed in australian primary care kawasaki-like disease: emerging complication during the covid- pandemic the clinical and immunological features of pediatric covid- patients in china disruptive effect of covid- on orthopaedic daily practice: a cross-sectional survey results of decades of injury surveillance and public release of data in the australian football league delayed access or provision of care in italy resulting from fear of covid- variation in volumes and characteristics of trauma patients admitted to a level one trauma centre during national level lockdown for covid- in new zealand an audit of the delivery of paediatric orthopaedic services at the bristol royal children's hospital in response to the british orthopaedic association standards for trauma (boast) covid- guidance the paediatric trauma burden of uk lockdown -early eesults in the covid- era supervision and risk of unintentional injury in young children covid- temporary mbs telehealth services virtual outpatient clinic as an alternative to an actual clinic visit after surgical discharge: a randomised controlled trial postoperative follow-up: is a phone call enough? european centre for disease prevention and control covid- situation update for the eu/eea and the uk, as of key: cord- -lezggdjb authors: hannah, adam; baekkeskov, erik title: the promises and pitfalls of polysemic ideas: ‘one health’ and antimicrobial resistance policy in australia and the uk date: - - journal: policy sci doi: . /s - - - sha: doc_id: cord_uid: lezggdjb recent scholarship posits that ambiguous (‘polysemic’) ideas are effective for coalition building between diverse stakeholders: their capacity to be interpreted differently attracts different interests. hence, in search of political solutions to ‘wicked’ and similarly complex problems, deploying polysemic ideas would be critical to effective policy-making. this paper scopes the policy-making potential of polysemic ideas by examining the impact of an ambiguous concept known as ‘one health’ on responses to antimicrobial resistance (amr) in australia and the uk. it offers two primary arguments. firstly, polysemic ideas can help mobilise broad attention to complex problems: since one health became associated with amr, political and administrative attention has grown more intense and coordinated than previously. secondly, however, a polysemic idea alone may be insufficient to generate effective action: the contrast between australian and uk amr policies illustrates that polysemic ideas do not suspend interests, institutions, or ideas that can be readily deployed. electronic supplementary material: the online version of this article ( . /s - - - ) contains supplementary material, which is available to authorised users. how much can conceptual ambiguity help policy-makers when they address difficult public problems? this article focuses on potentials for ideas with a 'polysemic' or 'chameleonic' character to aid in forming and sustaining policy-making coalitions (smith ) . that ideas are critical for understanding public policy outcomes is now well established. the literature in recent decades has outlined various types of and roles for ideas at all stages of the policy process. observing that ideas may mean different things to different people or groups if their meanings are ambiguous ('polysemic'), béland and cox ( ) argue that polysemic ideas can pull together actors with different interests or mobilise disengaged interests. this account of ideas suggests that ambiguous concepts or frames can be crucial in contemporary policy design and development. public policy-making is described as increasingly complex because public problems are 'wicked' and crises frequent (head and alford ) . contemporary policy-making combines difficult problems with fragmentation of interests, scientific uncertainty, and decentralised authority. polysemic ideas may aid policy-making by attracting to coalitions or networks actors who tend to disagree over interests and specific ideas. such 'big tent' coalitions appear to promise higher likelihood for policy solutions. the crucial potential for overcoming intractable policy inaction in the face of contemporary policy challenges motivates further study to understand how far polysemic ideas can take policy-making. what follows explores this potential empirically through analysis of a polysemic idea's impact on policy-making in australia and the uk against a difficult problem. the 'one health' concept is a polysemic idea par excellence. it has no established meaning beyond the assumption that human, animal, and environmental health are interdependent. yet from about , it has emerged as the global approach to countering the growing threat of antimicrobial resistance (amr) (world health organization ) . our australian and uk case analyses first examine whether introducing one health resulted in diverse stakeholder coalitions for amr responses. they then investigate whether amr responses depended on one health approaches. the cases show that australian and uk governments both developed strategies against amr while consulting broad arrays of stakeholders across human and animal health, food production, and the research sector. for amr responses, the uk has relied on existing centralised institutions for health governance and established economic ideas to generate accountability and initiatives. australia has mainly relied on its consultative approach while leaving accountability and initiatives to emerge from below the national level. in turn, the uk has arguably made greater progress than australia in the fight against amr. hence, the case comparison suggests that one health, on its own, is insufficient for movement towards effective amr policy. instead, established governance modes and ideational constructs appear important and necessary for such policy to develop. as such, the analysis qualifies the impact potentials of polysemic ideas. polysemy can generate broad attention to solving difficult problems by activating and engaging stakeholders. but even mediated by polysemic ideas, paths to policy remain defined by interests, institutions, and specific ideas. crises, complex problems, and ideas have long been linked in public policy literature. peter hall's ( ) formative work on policy paradigms, for example, suggested that crisis may pave the way for dominant policy paradigms to be usurped by fresh ideas. more recently, ideational scholars have studied cases where paradigm shifts have not followed crises (carstensen ) . this has prompted investigation of subtle modes of ideational change, such as interparadigm shifts (carstensen and matthijs ) , ideational path dependence (baekkeskov ) , and relationships between ideas and forms of power (parsons ) . equally, scholars of 'wicked' problems have studied ideational phenomena, such as framing and discourse (reinecke and ansari ) , learning (termeer et al. ) , and evidence uses (smith ) . more broadly, change rarely occurs without conceptualised alternatives to the policy status quo or ideational links between 'functional problems' and action (vis and van kersbergen ) . within recent literature linking ideas and complex problems, a particular claim stands out: that 'highly ambiguous and polysemic ideas that mean different things to different people are likely to have broader appeal for coalition builders than better-defined, narrower ideas' (béland and cox , p. ; see also skogstad and wilder ) . ideas are often central to political coalitions. in the advocacy coalition framework, actors in policy subsystems rally around shared core beliefs (sabatier ) . however, such coalitions have generally been seen as stable rather than shifting (although see nohrstedt ) . in work on epistemic communities, knowledgeable actors (typically experts) in a field assemble around shared ideas about the nature and causes of problems, and 'a common policy enterprise' related to solving these problems (dunlop ; haas , p. ) . similarly, the recent literature has identified various groups that come together around narrow policy elements, such as problem definitions (e.g. 'problem brokers', knaggård ) or policy tools and techniques ('instrument constituencies') (béland and howlett ; haelg et al. ) . however, while these groupings may be transnational, they are most often focused on ideational agreement between similar kinds of actors, rather than forming coalitions between different powerful interests. coalition building is probably most valuable where several powerful actors are needed to create effective policies and where costs of inaction are high, but agreements about the existence, characteristics, or causes of problems and solutions are difficult to reach. given that such challenges can be seen in cases of complex or 'wicked' problems and transboundary crises, polysemic ideas may be particularly important in such situations. crises convey urgency, uncertainty, and threat to core functions (ansell et al. ) . they are extraordinary, can be unexpected, and challenge the legitimacy of dominant ideas and procedures (boin et al. ; nohrstedt ) . 'wicked' problems are generally thought of in terms of complexity and intractability (rittel and webber ) . although not all crises are complex and not all complex problems will be crises, overlaps are plausible. complex problems suggest risks of future crisis (climate change being an obvious example). where potential crises are identified long before their effects appear, political and economic incentives lead actors to discount the future (levin et al. ). contemporary problems and crises often cross borders, policy sectors, and levels of government, leaving no actor capable of alone responding effectively (ansell et al. ). as such, they can be characterised by uncertainty and fragmentation of authority, and coordination challenges. in béland and cox's ( ) view, polysemic ideas are successful because they allow policy instruments that are potentially divisive on their own to be attached to broader ideas that garner support from diverse stakeholders. it is therefore no coincidence that the 'coalition magnets' they discuss ('solidarity', 'social inclusion', and 'sustainability') deal with poverty, inequality, and environmental protection-three complex and longstanding public policy problems. this argument is also reflected in more recent work emphasising the virtues of more malleable ideas and frames. for example, skogstad and wilder ( ) claim that 'multidimensional ideas' not only help create a 'bandwagoning' effect, but also ensure that opposition remains fragmented. similarly, faling and biesbroek ( ) emphasise the importance of employing multiple frames in building cross-sectoral coalitions. while claims regarding the power of broader or more ambiguous frames are not unfamiliar in public policy scholarship (e.g. baekkeskov on public-private partnership and contracting out; schmidt and thatcher on neoliberalism), this more recent literature highlights potentially significant consequences for attempts to address generally intractable problems: ideas that allow multiple interpretations should not only be seen as links between problem and solution, but also as tools that can help overcome disagreements or mobilise passive actors (béland and cox , p. ). reiterating the key contention, deploying polysemic ideas can create powerful coalitions by attracting diverse powerful actors. this augments the broadly held view that interest groups presenting a united front are more likely to successfully navigate the policy process (baumgartner and jones ) . there is also reason to examine how far polysemic ideas can drive meaningful action on problems characterised by complexity or potential conflicts of interests and values. affected stakeholders will often be drawn from several interest and expert communities. without some means of resolving pre-existing conflicts, a 'big tent' of diverse actors may be little more than a talk shop, with agenda-setting success, but difficulty in policy formulation or decision-making . in addition, having opposing interests 'inside' creates opportunities for opponents of some courses of action to exercise veto or obstruct bargaining. attention from diverse stakeholders is of little value if it does not generate effective coalitions. some participants in broad deliberations could be among those contributing to problems. béland and cox ( ) describe the example of mcdonalds collaborating with the environment defense fund to reduce packaging and waste under the guide of 'sustainability'. but the case is extraordinary rather than representative (cashore et al. ). absent serious action, outcomes of diverse stakeholder collaborations could resemble what mcconnell ( , p. ) calls 'placebo policies': superficial action without tackling the underlying problem. moreover, as béland and cox ( ) describe, mcdonalds saved money from the partnership. but in complex problem areas (such as climate change) we do not know whether all coalition members will gain from the effective solutions. moreover, there is a risk that an emphasis on consensus will lead to avoidance of more intractable issues, in favour of lower hanging fruit (van de kerkhof ) . indeed, stakeholders may conceivably enter the 'tent' in a bid to co-opt policy-making (o'toole and meier ). at the same time, polysemic ideas may predicate themselves on building a broad coalition ('solidarity'-cross-class; 'social inclusion'-cross-class; and as the next section describes, 'one health'-cross-sector, cross-species). this means that the ideas partly derive their legitimacy from maintaining broad coalitions. narrowing of actors involved is therefore difficult. of course, another possibility in relation to complex problems is that there is little need to narrow down the scope of solution sets. given the multi-sectoral, cross-boundary nature of some complex problems (such as transboundary crises), an array of instruments may need to be employed. still, the questions remain of what actually is done, who coordinates these efforts, and who is accountable for setting and reaching goals. solving complex problems may require short-term losses in some places to prevent steeper longer-term pain. and short-term losses may be imposed on actors who do not have prospects for equal or greater long-term gains (i.e. a collective action problem- olson ) . for government, unavoidably driven by short-term incentives, delaying decisions or avoiding blame may seem much more attractive than dealing with these political difficulties. to scope the role of polysemic ideas in actual policy-making, we next investigate the political implications of 'one health', a concept that has become accepted among global and national public health authorities as the key 'approach' to emerging infectious diseases (one health ). universal recognition of one health constitutes a political feat in itself, accomplished at least in part through the efforts of entrepreneurial health professionals (bresalier et al. ; cassidy ) . one health is also a polysemic rather than a specific idea. its core can be stated simply: human, (farm) animal, and (wild) environmental health are interdependent (e.g. world health organization , p. vii). that is, diseases cannot be controlled in one sector only, but must be addressed in all sectors. however, different agencies offer different definitions of one health, which has led some scholars to characterise it as 'an "umbrella concept" for a variety of expert perspectives and disciplinary agendas' (degeling et al. , p. ) . while the need for coordinative action rather than siloing of policy responses is generally recognised, the proverbial devil is in the policy details: what actions? by whom, where, and when? coordinated by whom? funded how? antimicrobial resistance (amr) is an emerging crisis that both fits the basic remit of one health and demonstrates the fundamental challenges in applying it. amr cannot altogether be prevented because microbial species unavoidably evolve towards immunity to antimicrobial agents (e.g. antibiotics) when these agents are in use. any policy response will necessarily involve sectors like human and animal medicine, regulators, and food production. hence, proposed approaches are often multi-sectoral (laxminarayan et al. ; review on antimicrobial resistance ; world health organization ). however, at each stage of specifying actions and policy, polities seeking to adopt and adapt one health to the amr challenge face choices with potentially significant costs (roca et al. ; walsh ) . for instance, contemporary food production is often dependent on antibiotics; eliminating antibiotics can thus threaten farming outputs and raise the prospect of higher food prices. similarly, choices may present more opportunities for some actors than others. for instance, pharmaceutical developers can benefit from policies that boost government subsidies for developing new antimicrobials, while limits on antimicrobial uses may threaten their revenues. specifying the multi-sectoral and multi-jurisdictional amr policies and actions that follow from one health thus has the potential to become intensely contested. moreover, if 'losers' can exercise a veto, then the potential for political settlements on specific policies against problems such as amr becomes more limited. although described as an emerging crisis, amr is an old problem. amr has received several waves of global and domestic policy attention, beginning in the s (podolsky ). at the same time, the current wave of attention to amr both has been closely associated with one health and has led to more sustained attention than in previous eras. one health and renewed problematisation of amr arose separately, but in parallel in the new millennium (gibbs ; kahn et al. ; lee and brumme ; podolsky ) . amr captured policy-makers' attention around . during the mid- s, other public health issues such as pandemic influenza competed for political attention (chien ) . amr then returned to political agendas with greater force in the years after . using the who as an example, the organisation has made varying levels of effort against amr in recent decades. to illustrate, mentions of amr in who publications peaked between and , declined between and , and increased during - to higher levels than in preceding years (see online appendix ). the match of amr and one health happened during this recent period of renewed political attention to amr. in , the world health organization (who) released a six point 'policy package' to guide national-level amr policy-making with no mention of one health (world health organization ). the first who document on amr that mentioned one health was published in (online appendix ). just years later, the who's core guidance on amr policy, the global action plan (gap), was framed explicitly as part of a 'one health approach' (world health organization : vii). world leaders meeting in the un general assembly (unga) on september made a political declaration on amr stating that 'without an effective one health approach', amr is likely to have 'massive social, economic and global public health repercussions' (united nations general assembly ). hence, within a few short years, the one health approach had become the guiding frame for global response to the amr problem. the recent political attention to amr appears to have spurred significant response action. the who's gap (and similar guidance from the un agencies for animal health and agriculture) and the unga declaration called on countries around the world to articulate national action plans (naps) for dealing with amr. since , the number of naps has increased rapidly. however, to understand the role of one health as a polysemic idea, we must examine two elements of its role in shaping responses to amr: firstly, whether it has helped to generate response coalitions and secondly, whether government responses to amr have made greater headway than they might have in the absence of the one health idea, for instance, by mobilising multiple sectors to act or progressing response across all sectors that contribute to the amr problem. the next section analyses one health's role in amr policy-making by comparing recent developments in australia and the uk. both countries have long had relatively highly developed regulation of antibiotic use and other contributors to amr in their health and food production systems. however, in the current wave, the uk was among the first to take renewed action (indeed, by some accounts it spurred the renewed drive; podolsky ), and with one health as just one among several ideas used. in contrast, australia's new amr strategy was developed one or years later and explicitly framed by the one health perspective. as such, while there are no available cases in which one health is absent from recent amr policy-making, comparison of these two cases allows an opportunity to consider what work it did in these countries' amr policy processes. the case analyses assess whether the following two expectations are fulfilled: . introducing the one health idea rallied stakeholders to support amr response. . one health made effective amr policy more likely. while many actors have been consulted on and tasked with amr response in both australia and the uk, the available evidence on these processes suggests resolving amr has been more strongly associated with the idea of one health in australia than in the uk. in australia, the national government held a one health antimicrobial resistance colloquium in july the department sought feedback on its initial draft of the strategy. as such, both governments called on a wide range of sectors and stakeholders as they developed plans to address amr nationally. calling on many kinds of stakeholders is consistent with the one health approach. many stakeholders heeding both calls is consistent with one health functioning as an amr attention 'magnet'. notably, governments called on stakeholders to assemble, rather than stakeholders coalescing spontaneously around their common interest in stopping amr. the stakeholders might have heeded calls to consultation simply due to their government's authority rather than one health's persuasive appeal. in turn, while calling on many stakeholders was consistent with a one health approach, the two governments' motivations for action against amr appear differently linked to one health. the uk's published strategy against amr mentions one health five times, in the context of a broad need for collaboration rather than linked to specific initiatives (department of health and department of environment, food & rural affairs , p. ). australia's published strategy is a document of very similar length and content to the uk's (department of health and department of agriculture ). it mentions one health twenty times, particularly in relation to specific initiatives on public and professional awareness and disease surveillance. the uk's amr strategy describes government's role as 'leadership, stewardship and strategic direction…by holding national bodies to account and ensuring different parts of the system work properly together' (department of health and department of environment, food & rural affairs , p. ). it also assigns all proposed actions to a government department or agency (uk government ). this implies that the uk tackles amr through central leadership coupled with agency and departmental accountability. one health in the form of horizontal collaboration between sectors is absent from this strategy. australia's amr strategy emphasises multi-sectoral collaboration and one health in each of its seven priority areas. in turn, australia's report on implementation categorises separate actions in relationship to one health. the australian approach has emphasised communication, delegation, and consensus on amr. from the outset of planning for the national amr strategy, the australian process aimed to be 'cooperative and designed to benefit all parties' (australian commission on quality and safety in health care , p. ), with the one health approach to action providing 'an opportunity to find common ground across sectors' (australian commission on quality and safety in health care , p. ). in turn, of the actions listed in the implementation plan are delegated to bodies that are not federal government departments or agencies (department of health and department of agriculture ). congruent with the mutual interdependency inherent to the one health concept, distributed initiative and voluntary collaboration appears to be how australia manages amr response. this evidence on amr strategy development and implementation is broadly consistent with the first contention about polysemic ideas, which is that they are capable of rallying otherwise contending interests to agree on a public problem. both governments rallied numerous stakeholders to planning consultations. notably, governments were central in both cases. in turn, australia's amr strategy asked for action from non-governmental actors, with few explicit accountability mechanisms or central controls on who did what. in contrast, the uk's amr strategy suggests that embracing one health was not essential in creating amr response. rather, the uk's strategy largely articulated amr response as a multi-sectoral, but centralised endeavour that bears easy similarity to standard uk governance. we return to the meaning of these differences in the discussion section below, after considering the impact of one health on the contents of policy responses in more detail. close examination of the national strategies and subsequent achievements suggests that 'big tents' associated with wide consultation have resulted in more than talk. australian and uk implementation plans for the amr strategies outline hundreds of actions, in many cases involving collaboration between government and various stakeholders (department of health and department of agriculture ; uk government ). responses developed during the current, one health-linked wave of attention to amr are also more extensive than responses that emerged during the early s (department of health ; joint expert advisory committee on antibiotic resistance ). according to annual self-assessment surveys of countries conducted by un agencies starting in - , countries including australia and the uk have developed amr naps in line with the global action plan and adopted integrated, multi-sectoral approaches to implementation. the un surveys allow systematic comparison of australian and uk responses across six major categories (public and professional awareness; education and training; stewardship ; infection prevention and control (ipc); surveillance of am usage; and surveillance of am resistance). in turn, response scores in these categories range from no action ( ) to highly developed activity ( ) (see online appendix ). these self-reported data yield indications about national amr responses. both countries report considerably more activity in human health than in veterinary health and agriculture. to realise a one health approach, both would need considerably more intersectoral coordination. however, the uk has reported higher scores than australia across four of the six areas, slightly more similar policy scores between sectors, and higher average scores for each of the three sectors. this indicates a more advanced and coordinated response to amr than australia has achieved. as previously described, uk amr strategy relies less than the australian on the one health framing. this potentially sets our expectation that polysemic ideas ease policy-making at odds with actual responses. however, the gap between human health and other sectors is also variable across areas. in the uk, the largest gaps in response scores between sectors are in awareness and ipc, while the australian responses indicate substantial gaps in the development of integrated surveillance programmes. qualitative analysis of national implementation reports generally confirms the broad patterns indicated by the un surveys (see online appendix). both countries have implemented an array of actions, particularly in human health. to promote more appropriate uses of antimicrobials, they run nationwide amr awareness campaigns targeted at healthcare providers and the public. both have also updated accreditation standards, educational materials, and curricula for healthcare providers (australian commission on safety and amr response has also taken different qualitative turns in the two countries. in several areas of human health, the uk has taken more initiatives than australia. these include provision of detailed localised data on prescribing and resistance to health providers, monitoring of public awareness, and the use of financial incentives for providers to make improvements to practice. in turn, australia appears to have placed more emphasis on coordination between sectors in relation to awareness and ipc, including across human and animal sectors through the commission on quality and safety in health care, and the australian government's 'one health amr' website that provides information for consumers, food producers, and health professionals. a significant area of difference between the countries is sectoral levels of amr surveillance. both countries have amr surveillance systems for human health with regular reporting. but the uk has more developed surveillance than australia in the other sectors. through a mandatory eu programme and monitoring by its own animal and plant health authority, the uk has comprehensive surveillance of resistance in animals and collects data on sales of antimicrobials for animals (public health england ) . this has enabled a cross-sector 'targets task force' to establish voluntary usage targets for food producers (uk government , pp. - ) . in contrast, australia has lagged in animal health surveillance. progress has stopped at development proof-of-concept surveillance programmes with industry bodies like meat and livestock australia. hence, as of a progress report, australia describes integrated one health surveillance as a 'long-term goal' (department of health and department of agriculture and water resources , p. ). comprehensive amr also include research and development, and international engagement (these are not measured by the un survey). comparison of national implementation documentation indicates that the uk has placed more emphasis than australia on funding research towards new drugs, therapeutics, and diagnostics, and on the need for international action. in its - amr strategy, the uk government claims to have 'invested more than £ million in research and development on amr' since , through various channels, including the uk global amr innovation fund and the uk-china amr innovation collaboration (uk government , p. ). the uk has also supported amr surveillance in lower-and middle-income countries, by contributing £ million to a private foundation (uk government , p. ). in , it hosted a global leaders event on one health and amr (uk amr strategy high level steering group , p. ). moreover, its implementation strategy nominated a un political declaration on amr as a national aim, and the uk's chief medical officer was a crucial advocate for renewed global action (podolsky ). australia has not contributed resources to r&d or international initiatives at the same scale, even when adjusting for its relatively smaller economy. the progress review (department of health and department of agriculture and water resources , p. ) notes that it has funded million aud worth of research into various aspects of amr, and states that it 'remain [s] open to contributing to new research initiatives'. however, aside from contributing $ million through three product development partnerships, largely focused on tuberculosis and malaria in the asia-pacific region, there is little evidence of concrete action (department of health and department of agriculture and water resources , p. ). one health has clearly influenced current amr-related policy-making. the match-up of amr and one health after , growing global policy attention to amr in the same period, and escalating national amr initiatives in the wake of the gap and unga statement collectively support that deployment of polysemic ideas can be associated with more policy-making on complex problems. in addition, australia and the uk both appear to have attempted coordinated, multi-sectoral approaches to the amr challenge, consistent with the one health idea. moreover, development of policy is still ongoing. as such-where responding to a problem requires diverse coalitions-the analysis suggests that framing responses around an attractive polysemic concept can help draw actors together in initial deliberative stages of policy formulation. however, the comparison of amr policy-making in australia and the uk suggests limitations on the reach of one health. the uk and australia have taken different interpretations of government's part in amr response. the uk government appears to use centralised governance with delegation to and reporting back by multiple departments. australia's government seems to merely convene stakeholders while leaving initiatives, action, and even much of the reporting to local or private actors. in turn, as described, indications are that uk responses to amr have been more extensive and integrated across sectors than australian. we are not suggesting that amr policy-making in either case has been a failure. however, a fundamental claim of one health activism is that rethinking established (siloed) modes of policy is critical for success. as such, asymmetries, particularly those in the australian case, given the relatively stronger emphasis on the one health concept observed there, allow us to identify some of the limits of a polysemic framing. the contrasts between the cases first suggest that institutional context may have so far been more important to amr response than the one health idea. the integrated nature of the uk's national health service lends strong government direction to uk health governance, and the uk reports making particularly strong progress against amr in the human health sector. while australia also reports making reasonable progress against amr in human health, it faces institutional barriers to intersectoral coordination that are largely unrelated to one health. these include a mixed public-private hospital system, the authority and funding of which are also divided between the national and state governments (duckett ) . the presence of such divisions of authority align well with australia's general approach to amr, which is to define government's role as 'working with stakeholders' and forming 'new partnerships' (department of health and department of agriculture , p. ), and its emphasis on specific actions in this domain, such as the development of a 'one health amr website', which is mentioned repeatedly in strategic and review documents. amr responses' dependency on such institutional factors is made more plausible by looking closely at surveillance programmes. surveillance of antimicrobial drug use and resistance are fundamental components of an effective response. without understanding how medicine is used and patterns of resistance, programmes to improve stewardship and applications of such agents are inhibited. yet, as already discussed, in australia the most obvious disparity between sectors is in its surveillance programmes. progress has been much slower in animal health and food production than in human health despite the strong presence of one health discourse in discussion of the need for comprehensive surveillance. in contrast, the uk's success with regard to surveillance is partly due to its participation in european union (eu) programmes that predate the conceptual pairing of amr and one health (department of health and department of environment, food & rural affairs , p. ). the uneven australian surveillance system may also speak to our contention that diverse coalitions can hinder certain initiatives because some resist policy change to protect their interests. for example, in submissions to a senate hearing on australia's response to amr, the australian chicken meat federation and animal health australia emphasised that surveillance should be conducted only in proportion to risk, with the chicken federation suggesting that surveillance every years would be sufficient (finance and public administration references committee , p. ). maintaining a high engagement process that emphasises stakeholder consent seems likely to help stakeholders (in this case australia's meat industry) protect their interests more than leaving government to mandate changes (such as more amr surveillance). finally, the case analyses also suggest something of a paradox regarding polysemic ideas. in the academic literature, one health is often presented as an interdisciplinary paradigm or unifying frame that can be applied to various global health, environmental, social, and economic issues (kingsley and taylor ) . however, in policy-making terms it is usually construed more narrowly as an appeal to multi-sectoral collaboration among professional stakeholders. this can be observed, for example, even in the way in which international progress on amr is measured (exemplified previously). yet, multi-sectoralism alone cannot solve amr, nor are useful responses to amr necessarily multi-sectoral. when one health and amr were initially paired, uk policy-makers had already hit upon a clear problem framing, what wernli et al. ( ) call 'amr as an innovation issue'. rather than linking amr to poor coordination between sectors, amr is often described as a 'market failure' linked to slowing development of new antimicrobials by pharmaceutical and chemicals businesses. key uk government documents on amr, including the chief medical officer's annual report and the national strategy, discuss not only the 'economic burden' of amr, but also economic opportunities in new diagnostics and therapeutics (davies examine and boost awareness of the economic issues surrounding the development, spread and containment of antimicrobial resistance (amr), with a particular focus on…research and development of new antimicrobial drugs. in contrast, equivalent australian documents mention only that the problem has economic 'dimensions', and relegate economic impact analyses to the future (australian commission on quality and safety in health care , p. x; department of health and department of agriculture , p. ). this difference aligns with the previously described disparity between uk and australian efforts on amr-related r&d and international engagement. one health can work with other ideas. some academic literature on one health takes economic dimensions of problems and responses into account (see mackenzie et al. ). however, an approach like the uk's would be inconsistent with the australian government's role in advancing a 'one health solution' by coordinating stakeholders, rather than direct intervention to correct market failure. like the plausible importance of each institutional context, the contrast between economic ideas illustrates that one health on its own offers little actionable guidance for amr response. supplementing the polysemic idea with more specific problem and solution framings may therefore provide pathways to action. contemporary discussions of public policy are often characterised by frustration with the difficulties that complex problems and emerging crises pose for political systems. in search of broad agreement, policy-makers and scholars have turned to broad concepts, such as 'sustainability' or 'social inclusion' in relation to environmental and social problems. this article has probed the promises and pitfalls of these 'polysemic' ideas, supporting that they can help bring stakeholders to the table, but also showing that movement towards making effective policies can require favourable institutional conditions and specific ideas about what to do. particularly at the agenda-setting stage, there are good reasons for advocates to present a united front of stakeholders and to foster cooperation between otherwise siloed sectoral interests. however, our analysis of the linkage between one health (a polysemic concept par excellence) and amr response (an emerging global crisis) in australia and uk also suggests that the rallying of stakeholders around a polysemic concept is of limited value. while both countries have responded to amr with national strategies and more specific policy initiatives, particularly in human health, australia appears to be making less progress than the uk in critical areas such as surveillance in the veterinary health and food sectors. moreover, australia's primary one health thrust appears to have been to assemble stakeholders for talks. in contrast, the uk government has assigned departmental responsibilities for amr policy implementation, coupled with accountability targets. it is too soon to tell which country is doing better in amr response. instead, the analysis suggests that rather than the polysemic idea of one health, institutions (e.g. uk centralised government v australia's multi-level federal system) and actionable paradigms (e.g. market failure and well-understood strategies to overcome it) may be more essential factors driving amr response. governments may need to impose on the interests of stakeholders or act as 'gatekeepers', narrowing the range of possible solutions and ensuring accountability. while this governance can complement deployment of polysemic concepts like one health, the ideational emphasis on inclusiveness can mean that real politics is overlooked: sometimes losers need to be shut out to reach a political bargain. moreover, where polysemic ideas become dominant problem and solution framing, the importance of actionable ideas may be ignored. therefore, while malleable concepts are likely to continue to draw wide stakeholder agreement in similar cases, for meaningful and, above all, sufficient responses to be implemented, such agreement is only a beginning. managing transboundary crises: identifying the building blocks of an effective response system report of the australian one health antimicrobial resistance colloquium natio nal-safet y-and-quali ty-healt h-servi ce-stand ards-secon d-editi on issue framing and sector character as critical parameters for government contracting-out in the uk same threat, different responses: experts steering politicians and stakeholders in h n vaccination policy-making agendas and instability in american politics ideas as coalition magnets: coalition building, policy entrepreneurs, and power relations how solutions chase problems: instrument constituencies in the policy process governing after crisis: the politics of investigation, accountability and learning one health: the theory and practice of integrated health approaches institutional bricolage in times of crisis of paradigms and power: british economic policy making since thatcher designing stakeholder learning dialogues for effective global governance one health? building an interdisciplinary bandwagon at the interfaces of animal health, human health and the environment how did international agencies perceive the avian influenza problem? the adoption and manufacture of the 'one world, one health' framework infections and the rise of antimicrobial resistance. london: department of health a delphi survey and analysis of expert perspectives on one health in australia dh uk antimicrobial resistance strategy and action plan the health and social care act : code of practice on the prevention and control of infections and related guidance responding to the threat of antimicrobial resistance: australia's first national antimicrobial resistance strategy - . canberra: author australia's first national antimicrobial resistance strategy the australian health care system epistemic communities cross-boundary policy entrepreneurship for climate-smart agriculture in kenya monitoring global progress on addressing antimicrobial resistance: analysis report of the second round of results of amr country self-assessment survey the evolution of one health: a decade of progress and challenges for the future introduction: epistemic communities and international policy coordination. international organization the role of actors in the policy design process: introducing design coalitions to explain policy output policy paradigms, social learning, and the state: the case of economic policy-making in britain wicked problems: implications for public policy and management streams and stages: r econciling k ingdon and policy process theory the use of antibiotics in food-producing animals: antibiotic-resistance bacteria in animal and humans. canberra: author emerging infections: a tribute to the one medicine, one health concept one health: competing perspectives in an emerging field the multiple streams framework and the problem broker extending the cure: policy responses to the growing threat of antibiotic resistance operationalizing the one health approach: the global governance challenges overcoming the tragedy of super wicked problems: constraining our future selves to ameliorate global climate change one health: the human-animalenvironment interfaces in emerging infectious diseases: the concept and examples of a one health approach understanding policy success: rethinking public policy the politics of crisis policymaking: chernobyl and swedish nuclear energy policy desperately seeking selznick: cooptation and the dark side of public management in networks the logic of collective action: public goods and the theory of groups ideas and power: four intersections and how to show them the evolving response to antibiotic resistance uk one health report: joint report on human and animal antibiotic use, sales and resistance taming wicked problems: the role of framing in the construction of corporate social responsibility tackling drug-resistant infections globally: final report and recommendations. london: author dilemmas in a general theory of planning the global threat of antimicrobial resistance: science for intervention. new microbes and new infections an advocacy coalition framework of policy change and the role of policy-oriented learning therein resilient liberalism in europe's political economy strangers at the gate: the role of multidimensional ideas, policy anomalies and institutional gatekeepers in biofuel policy developments in the usa and european union beyond evidence based policy in public health: the interplay of ideas governance capabilities for dealing wisely with wicked problems review on antimicrobial resistance uk year antimicrobial resistance (amr) strategy - : annual progress report uk year antimicrobial resistance (amr) strategy - : annual progress report and implementation plan government response to the review on antimicrobial resistance. london: author tackling antimicrobial resistance - : the uk's five-year national action plan. london: author political declaration of the high-level meeting of the general assembly on antimicrobial resistance making a difference: on the constraints of consensus building and the relevance of deliberation in stakeholder dialogues towards an open functional approach to welfare state change: pressures, ideas, and blame avoidance a one-health approach to antimicrobial resistance mapping global policy discourse on antimicrobial resistance world health day policy package to combat antimicrobial resistance global action plan on antimicrobial resistance. geneva: author acknowledgements versions of this paper were presented and discussed at the 'ideas and crisis response' workshop held at the university of melbourne in december and the public policy network meeting at the university of queensland in january . we are very grateful to the organisers and participants for feedback on earlier drafts.funding n/a. key: cord- - kfo da authors: dawson, nik; molitorisz, sacha; rizoiu, marian-andrei; fray, peter title: layoffs, inequity and covid- : a longitudinal study of the journalism jobs crisis in australia from to date: - - journal: nan doi: nan sha: doc_id: cord_uid: kfo da in australia and beyond, journalism is reportedly an industry in crisis, a crisis exacerbated by covid- . however, the evidence revealing the crisis is often anecdotal or limited in scope. in this unprecedented longitudinal research, we draw on data from the australian journalism jobs market from january until march . using data science and machine learning techniques, we analyse two distinct data sets: job advertisements (ads) data comprising , journalist job ads from a corpus of over . million australian job ads; and official employment data from the australian bureau of statistics. having matched and analysed both sources, we address both the demand for and supply of journalists in australia over this critical period. the data show that the crisis is real, but there are also surprises. counter-intuitively, the number of journalism job ads in australia rose from until , before falling into decline. less surprisingly, for the entire period studied the figures reveal extreme volatility, characterised by large and erratic fluctuations. the data also clearly show that covid- has significantly worsened the crisis. we can also tease out more granular findings, including: that there are now more women than men journalists in australia, but that gender inequity is worsening, with women journalists getting younger and worse-paid just as men journalists are, on average, getting older and better-paid; that, despite the crisis besetting the industry, the demand for journalism skills has increased; and that the skills sought by journalism job ads increasingly include social media and generalist communications. in australia, the news about the news is not good. in early march , newswire service the australian associated press announced it would be shutting down its operations after years. 'investors look to salvage parts of aap as newswire faces closure', reported the sydney morning herald on march ( samios ) . the australian broadcasting corporation (abc) predicted that people would lose their jobs as a result (khadem and pupazzoni ) . in the us, the news about the news is just as bad, if not worse. 'on a rough day for american newspapers, investors arent buying gannetts story and tribunes not done chopping' was the headline on a nieman journalism lab story published on february (benton ) . according to the report, layoffs looked likely at the countrys no. and no. newspaper chains, while the countrys no. chain (mcclatchy) had already declared bankruptcy a fortnight earlier. as the nieman lab notes: the internet has brought forth an unprecedented flowering of news and information. but it has also destabilized the old business models that have supported quality journalism for decades. good journalists across the country are losing their jobs or adjusting to a radically new news environment online (nieman- lab ) . is journalism in crisis? a wealth of research in australia, the us and comparable countries suggests yes. profits are hard, if not impossible, to come by; many firms are struggling or collapsing; and layoffs and redundancies are the norm. as fenton ( ) wrote in a paper centred on the uk, 'news media are in crisis. the crisis is being managed by closing papers or shedding staff [and] these cuts are having a devastating effect on the quality of the news.' that was nearly a decade ago. since then, the situation has only worsened. in australia, the commonly cited figure based on research by the journalists union is that , journalism positions have been lost since (ricketson et al. ) . for instance, it is estimated that in news publisher fairfax media employed about , editorial staff across the sydney morning herald, the age, the australian financial review, and its sunday papers, the sun herald and the sunday age. by mid- , however, half of those jobs were gone (zion et al. ) , including the job of one of this papers authors. and then the coronavirus wielded its scythe. as we discuss below, the impact of covid- on journalism jobs is proving devastating, with widespread job losses, particularly in regional areas (crerar ) . this research aims to assess the extent of the claimed 'journalism crisis' in australia by analysing labour market data from to . our findings confirm that there is a crisis in journalism; a crisis that is now in full bloom due to the coronavirus pandemic. however, the data also yields more granular findings, including several surprises. one finding is that advertised journalism jobs only started to decline from , not before. a second is that as the journalism jobs market becomes more volatile, gender inequity is worsening: women journalists who remain are younger and worse paid than the men who remain. and a third is that according to our skill similarity calculations, generalist 'communications', 'public relations', and 'social media' are skills that are becoming more important to journalism, as opposed to traditionally specialist journalism skills such as 'reporting', 'editing', and 'investigative journalism'. these findings, together with others, reveal that the crisis in journalism is not only real, but in some ways more concerning than was previously understood. to fulfil this research aim, we analyse a range of longitudinal data sources from job advertisements (ads) and official australian employment statistics. the breadth and detail of these data provide us with the opportunity to comprehensively assess the journalism jobs market in australia and how it has changed. we apply data science and machine learning techniques to analyse how the underlying skills of journalists in australia have evolved. this allows us to build a data-driven methodology to determine which are the top journalism skills per year and identify the occupations in possession of these skills. finally, we use these skill-level results to determine where people with journalism skills are likely finding alternative career paths. the main contributions of this research include: • providing a comprehensive and longitudinal assessment of journalism jobs in australia from to by analysing both job ads data and occupational employment statistics; • implementing a data-driven methodology to explore the nature of the oft-cited 'crisis' in journalism jobs in australia,; • applying this data-driven methodology to tease out more granular and specific trends in journalism jobs, including the impact of the current coronavirus pandemic, the contrasting impacts on regional and urban journalism jobs, and the gendered nature of ongoing impacts; and • analysing the data to identify the skills sought in journalism jobs, and where people with journalism skills are likely finding alternate career paths. journalism jobs in crisis. if there is a crisis, the simple explanation is the internet. (putting aside covid- , to which we will return.) while digital channels have given journalism bigger audiences, they have also strangled income. once, advertising funded journalism, but now advertising has largely migrated online. as the australian competition and consumer commission (accc) found in , in the final report of its digital platforms inquiry, 'the reduction in advertising revenue over the past years, for reasons including the rise of online advertising, appears to have reduced the ability of some media businesses to fund australian news and journalism'. the accc cited census data showing that 'from to , the number of australians in journalism-related occupations fell by % overall, and by % for traditional print journalists (including those journalists working for print/online news media businesses)'. further, the accc cited data provided by leading media companies showing that the number of journalists in traditional print media businesses fell by % from to a time of growth for australia's population and economy (accc ). however, the pressures on news media are not spread evenly. for instance, local news is bearing a particular brunt. between and , local and regional newspaper titles closed across australia, representing a % decrease in the number of such publications. as a result, local government areas previously served by a newspaper were now without coverage, including local government areas in regional australia (accc ). these figures are mirrored in the us. in , abernathy ( ) from the hussman school of journalism and media at unc released a report, 'the expanding news desert', which found that the us had lost almost papers since , with remaining ( dailies and weeklies). this means that the us lost roughly % of its newspapers between and . these closures included large dailies such as the tampa tribune and the rocky mountain news, but also many newspapers that had circulations of fewer than and served small, impoverished communities. the big picture reveals that, in an era of misinformation, social media and news aggregators, news media companies are under pressure, and journalism jobs are being cut. there is some hope in the shape of new players entering the market and hiring journalists, including in the shape of digital natives such as vice and buzzfeed. however, in these two companies were among the many that announced significant staff layoffs (goggin ) . what's more, as australia's accc notes, these publications 'tend to employ relatively few journalists' (accc ). even accounting for new arrivals, the number of journalism jobs in australia is falling (see jobs data analysis and results), and as a result there are areas (including local government, local court, health and science issues) that journalism is no longer covering adequately (accc ). further research is also revealing a clearer profile of the typical journalist, and also the typical journalist who loses his/her job. drawing on data, one study found that journalism jobs internationally are largely filled by a young, inexperienced and itinerant workforce (josephi and oller alonso ) . meanwhile, research suggests that it is journalists with extensive experience who are losing their jobs (at least in australia) . and those who lose their jobs face decidedly uncertain futures. in longitudinal research tracking the post-journalism careers of australian journalists who had been made redundant, many of those surveyed revealed they were experiencing job precarity. further, a significant minority had moved into strategic communications or public relations (zion et al. ) . the impacts of covid- . the advertising crisis for journalism has been described not as a single black swan, but as a flock of black swans (doctor ) . according to one estimate, from to , us newspapers lost more than percent of their ad dollars (doctor ) . and then came covid- . just as the coronavirus has been claiming lives, it has also been claiming journalism jobs, with particularly devastating impacts on regional and local news outlets. this is true in many countries, including the us. in march, layoffs were announced at the detroit metro times and its six sibling mastheads, with remaining staff told their pay would be cut (flynn ) . with concerts cancelled and restaurants shuttered, promoters and restaurateurs had nothing to advertise. on march , , the atlantic ran a story under the headline, 'the coronavirus is killing local news' (waldman and sennott ) . the story called for government and philanthropic intervention, and for people to subscribe: 'among the important steps you should take during this crisis: wash your hands. don't touch your face. and buy a subscription to your local newspaper.' in a matter of weeks, many american news websites' advertising revenues are said to have fallen by as much as %. as one media expert noted in late march, 'advertising, which has been doing a slow disappearing act since , has been cut in half in the space of two weeks' (doctor ) . flynn ( ) reported in march, 'at least people have lost their jobs in media over the past two weeks, with most outlets citing coronavirus as the direct cause.' in the uk in april, the guardian reported that newspapers were set to lose million if the outbreak lasted for another three months (sweney ) . this was partly because advertisers were refusing to place their ads next to stories about the pandemic, which they deemed to be inappropriate content. in australia too, as we have seen, there were widespread closures and job losses before coronavirus, but covid- compounded the problem. in late march, rupert murdoch's publishing business news corp warned of 'inevitable' job cuts and the closure of regional titles (meade b) . soon afterwards, news corp australia's biggest publishersuspended the print editions of australian newspapers, including the manly daily and wentworth courier in sydney, the brisbane news and the mornington peninsula leader in victoria (meade b) . the cuts came in the wake of a dramatic drop in advertising from the entertainment, restaurant and real industries, the titles' main revenue sources. in many countries, governments have announced assistance packages. on april , the australian government announced it would bring forward the release of $ million from its regional and small publishers innovation fund to support public interest journalism during covid- (fletcher ) . in april , the danish government allocated approximately m to save local media. 'the scheme can compensate for the lost advertising revenue,' said culture minister joy mogensen (zalan ) . by contrast, however, some governments are making the coverage of coronavirus harder. in china, authorities have cracked down on doctors and reporters who exposed the outbreak (kuo ) ; in the us, journalists are being barred from talking to staff at public hospitals (carville et al. ) ; and in countries including venezuela, niger and india, journalists have been arrested and intimidated (cpj ) . job ads as a proxy for labour demand. job ads provide 'leading' indicators of shifting labour demands as they occur, as opposed to the 'lagging' indicators from labour market surveys. consequently, job ads are increasingly used as a data source for analysing labour market dynamics (markow et al. ; blake ) . for instance, job ads data have also been used to assess labour shortages. dawson et al. ( ) defined a range of indicators to evaluate the presence and extent of shortages, such as posting frequency, salary levels, educational requirements, and experience demands. they also built a metric based on the forecasting error from machine learning models trained to predict posting frequency. intuitively, occupations experiencing high posting volatility are difficult to predict. subsequent work showed these indicators to be predictive of labour shortages in the australian labour market . in the present research, in jobs data analysis and results, we use a similar set of indicators to analyse labour demand for journalists. further details on job ads data are provided in the supplemental material. analysing journalism jobs with job ads. journalism jobs have also previously been analysed using job ads. young and carson ( ) collected and assessed how australian media outlets defined journalism job positions when hiring journalists from november to november . the authors used a content analysis methodology and manually labelled data fields, such as employer, educational qualifications, job responsibilities, experience requirements, location, work hours, media platform, skill demands, job title, and any other miscellaneous information. the authors found that journalism was not a high priority during this period; instead employers advertised four times as many job ads for sales, marketing, and advertising positions. more recently, guo and volz ( ) conducted content analysis on journalist job announcements from us media organisations, as posted on indeed.com from july to december . the authors' objective was to define, compare, and analyse the journalists' expertise requirements as expressed through job ads. to achieve this objective, the authors manually reviewed and codified job vacancies. this research found that 'multi-skilled' journalists are experiencing higher levels of demand. the authors also found that journalists' ability to flexibly adapt to changing situations was a characteristic of growing importance. these studies, while significant, are relatively limited in scope. in this paper, we analyse a nine-year long dataset which allows us to uncover longitudinal dynamics of journalism jobs. limitations of job ads data. job ads data are an incomplete representation of labour demand. some employers use traditional forms of advertising for vacancies, such as newspaper classifieds, their own hiring platforms, or recruitment agency procurement. furthermore, anecdotal evidence reveals that some vacancies are filled informally, using channels such as word of mouth, professional networks and social media. job ads data also overrepresent occupations with higher-skill requirements and higher wages, colloquially referred to as 'white collar' jobs (carnevale et al. ). finally, just because a job is advertised, does not mean that the position will be, or has been, filled. employment statistics and occupational standards. employment statistics provide data on populations employed in standardised occupational classes. occupations in australia correspond to their respective occupational classes according to the australian and new zealand standard classification of occupations (anzsco) (australian bureau of statistics ). there are significant shortcomings to analysing occupations within anzsco categories. official occupational taxonomies (like anzsco) are often static and are rarely updated, therefore failing to capture emerging skills, which can misrepresent the true labour dynamics of particular jobs. for example, the occupational class of 'print journalist' has been a constant in australian occupational statistics. yet, the underlying skills of a 'print journalist' have changed dramatically in recent decades. to overcome the above-stated limitations, in our data construction, we leverage the bgt occupational ontology together with the anzsco ontology. we also use the rich skill-level information from job ads that are missing from occupational employment statistics to build an encompassing journalism job ads dataset. this research uses both labour demand and labour supply data to analyse journalism jobs. on the labour demand side, we use a detailed dataset of over . million australian job ads, spanning from january to march . these data were generously provided by burning glass technologies * (bgt). for labour supply data, we leverage official employment statistics (australian bureau of statistics a) and salary levels (australian bureau of statistics b) provided by the australian bureau of statistics (abs) over the same period. these data sources provide longitudinal employment and salary information that have been disaggregated by gender, location, and types of employment (full-time and part-time). further details of data sources and data construction are provided in the supplemental material. to analyse the underlying journalism skills within occupations, we implement a skill similarity methodology adapted from alabdulkareem et al. ( ) and then by dawson et al. ( ) to calculate the pairwise similarities between skills from job ads. skill similarity. two skills are similar when the two are related and complementary, i.e. the two skills in a skills-pair support each other. for example, 'journalism' and 'editing' have a high pairwise similarity score because together they enable higher productivity for a journalist; whereas 'journalism' and 'oncology' have a low similarity because they are generally seldom used jointly. we measure the similarity of skill-pairs based on their co-occurrence patterns in job ads, while accounting for skill ubiquity and specialisation. to capture how journalism skills have changed over time, we measure skill similarity during calendar years. formally, given j as the set of job ads posted during a specific calendar year, we measure the similarity between two skills s and s as: where j and j are individuals jobs ads from the set j, and e(s, j) ∈ { , } measures the importance of skills s for job j using theory from trade economics (hidalgo et al. ). skills s and s are considered as highly complementary if they commonly co-occur and are both 'important' for the same job ads. finally, θ(s, s ) ∈ [ , ], a larger value indicates that s and s are more similar, and it reaches the maximum value when s and s always co-occur (i.e. they never appear separately). we build the top yearly lists of journalism skills by computing θ(journalism, s) -i.e. the similarity between the skill 'journalism' and each unique skill that occurs for each year from - . the yearly top most similar skills to 'journalism' are shown in the supplemental material together with the full details of the θ measure. journalism skill intensity. finally, we determine the occupations that most require the top journalism skills uncovered from the above. we propose η, the 'journalism skill intensity', for each standardised bgt occupation, defined as percentage of journalism skills relative to the total skill count for the job ads related to an occupation o. formally: where d is the set of journalism skills, and o is the set of job ads associated with the occupation o. this method allows us to adaptively select occupations based on their journalism skill intensity. in this section, we perform a data-driven analysis of journalism jobs in australia based on job ads data and official occupational statistics. first, we longitudinally examine key features of jobs data, such as employment levels, job ads posting frequency, salaries, and posting frequency growth and predictability level. we also analyse how the underlying skills of journalists have changed over time, and which skills and occupations are growing in similarity to journalism. in australian journalism, is considered a watershed year. an estimated , journalists were made redundant, the majority of those from australia's two largest print companies, fairfax media (now nine entertainment) and news limited (now news corp australia) (zion et al. ) . the severity of this industrial shock can be observed in fig. . against the left y-axis, the blue line shows quarterly job ads posting frequency for journalism jobs. as the graph depicts, posting frequency for journalism job ads experienced extremely low levels in until , when they began to increase. the volume of vacancies increased until mid- , before plummeting in late- to the levels last seen in . from , journalism job ads experienced strong growth, reaching a peak in mid- . since then, journalism job ads have trended downward until the end of , albeit with volatile peaks and troughs. in summary, the data shows that journalism job ads have not been in freefall since . rather, there was erratic growth in journalism job ads until a peak in , followed by erratic decline. similarly, employment levels underwent immense volatility from to . against the right y-axis of fig. , the orange line shows the number of quarterly employed for 'journalists & other writers' at the anzsco unit level. employment levels peaked in mid , before dramatically dropping in early . this is an effect of the the mass journalist redundancies made in , given that employment statistics are 'lagging indicators' and it takes time for labour markets to reflect changes in occupational statistics. early marked the lowest point of journalist employment seen in this time-series. as also observed in job ads data, journalist employment levels grew until - and has since trended downwards, exhibiting volatile quarterly changes through to the end of . covid- and journalism jobs. the early effects of covid- are apparent in the posting frequency of job ads in australia. this is the case for most occupations, including journalists. at the time of writing, official australian employment statistics were not yet available, making it difficult to determine the extent of job losses caused by the pandemic. however, job ads provide a leading indicator of labour demand (dawson et al. ). higher vacancy rates typically mean higher levels of labour demand by employers, which is a critical component of healthy labour markets. as fig. highlights, vacancy volumes have declined for both journalism jobs and at aggregate levels in australia. since mid-february, weekly posting frequency has decreased across all australia job ads, as seen in fig. a . such a decline this early in the year is atypical. as show, the frequency of job ad postings follow a yearly seasonal pattern, with late february and early march typically being a period of upward trend growth. however, late february and early march coincided with the international outbreak of covid- . during this period, the australian government instituted widespread quarantine and social distancing measures, which significantly constrained economic activity (boseley and knaus ) . the impacts of these covid- containment laws are starkly apparent in fig. b . posting frequency for journalism jobs are down % when comparing march volumes to march . this is significantly higher than the aggregate market of all australian job ads, which is down % over the same period. fig. b shows that melbourne appears to be the city hardest hit, recording no journalism job ads in march and only posts for the first quarter of . clearly the pandemic is having a highly damaging effect on the journalism jobs market. we compare salaries extracted from job ads with abs reported wage data for 'journalists and other writers' † . fig. reveals two main findings regarding journalist salaries. first, according to job ads data, journalists attract considerably lower annual wage levels (solid blue line) than the market average (dashed blue line). as of , job ads indicate that journalists earn approximately $ , less than the market average. these findings, however, are somewhat contrary to the wage earnings data collected by the abs (australian bureau of statistics b), according to which 'journalists and other writers' (solid orange line) have been earning a growing wage premium over the market average (dashed orange line) since . this discrepancy can be explained by the fact that job ads data tend to overrepresent occupations in the 'professional' and 'manager' classes (carnevale et al. ) , which typically attract higher wages. as a result, the average salary levels from job ads data (dashed blue line) are about $ , higher than average salary levels from abs data (dashed orange line), from to . however, the salary levels for journalists are very similar when comparing across the two data sources. fig. yields a second observation: journalist salary levels increased in both absolute and relative terms compared to average market levels, between to in both data sources. more importantly, the relative salary growth of journalists has exceeded the market averages, during the period studied. * bgt is a leading vendor of online job ads data. https://www.burning-glass.com/ † abs wage data is reported biennially, with the latest reporting year being . therefore, wage values in the 'odd' years in between the reporting periods were interpolated, calculated as the mean of the previous and the subsequent years. posting trends. we constructed an auto-regressive machine learning model to predict posting frequency of journalism job ads in australia (dawson et al. quantify labour demand volatility. when constructing machine learning models, it is standard procedure to use error metrics to evaluate the prediction accuracy. volatility in posting volumes inherently lead to lowered prediction performance. here we use the prediction error measured using the 'symmetric mean absolute percentage error' (scott armstrong ; makridakis ) as a proxy for the the volatility of labour demand for different occupations (see the technical section in the supplemental material for more details). for the volume of 'all australian job postings'. we use a sliding window approach to obtain multiple predictions (see the supplemental material) that we aggregate as boxplots. the higher the error score on the vertical axis, the lower the predictive abilities for that occupation. as fig. reveals, predicting the daily posting frequency of journalism jobs is consistently more difficult than for the other occupations, and the market as whole. 'data scientists', an occupation undergoing strong relative growth, is also showing a high prediction error compared to the market as a whole, indicative of experiencing a degree of volatility. however, it is not nearly commensurate to the predictive difficulties, and volatility, of journalists. this was true from to , and has become worse in with the spread of covid- . there have been growing gender differences of employed journalists in australia since . fig. a shows that the ratio of female employed journalists has increased relative to male journalists (anzsco unit level) (australian bureau of statistics a). in , the female-to-male employment ratio was . . in , the proportion more than doubled, with almost . female journalists employed for every male journalist. it has since declined in to . , but this proportion is still almost double that of . fig. b also shows that wage inequality between female and male journalists has worsened (australian bureau of statistics b). since , the annual salaries for female journalists increased by only au$ , , whereas annual salaries for male journalists increased by more than au$ , . male journalists thus experienced an average wage growth that was ten times greater than female journalists from to . there are also changing age demographics of employed journalists during the studied period. the markers on fig. b highlight the average age of journalists by gender, per year. male journalists have been getting older, their average age increasing by two years from to . female journalists, however, have been steadily getting younger. the average age for female journalists decreased by more than four years from to . fig. plots the location and volume of employed journalists in australia. fig. a shows the absolute and relative number of job ads posted for each of the capital cities, and outside them, and fig. b shows the location of employed journalists per state. unsurprisingly, sydney and melbourne, the respective capital cities of new south wales (nsw) and victoria (vic), consistently have the highest job ad posting frequencies. however, the relative share of job ad posting frequency in australian capital cities has shrunk in recent years, with fig. a showing an increase outside of major cities, both in relative and absolute terms. this trend reached a peak in , when less than % of all journalist job ads were for positions inside capital cities. a small rebound followed, and in sydney commanded approximately one-third of all journalism job ads. figs. a and b show respectively the number of years of formal education required for journalists, and the experience requirements (both per year, extracted from job ads data) the education requirements consistently remained at market average levels, with journalists required to possess a bachelor-level degree (approximately years of education). by contrast, the experience requirements have been more variable. since , employers have required fewer years of experience from journalists than is required in the market generally. however, the gap is narrowing. in , employers demanded of journalists, on average, one additional year of experience compared to . this counters the general market trend of employers demanding less experience of prospective employees. casual and temporary work have become more commonplace in australia (gilfillan ) , and we study if this is also the case for australian journalism jobs. in fig. we plot the number of permanent and temporary journalism jobs, per calendar year. the number of 'temporary' journalism jobs has increased in absolute terms since , and they have made up the majority of all journalism ads in every year. it is noteworthy too that the share of 'permanent' journalism vacancies has also increased since . however, this trend should be interpreted with a degree of scepticism as only ∼ % of all journalism job ads specify whether the roles advertised are permanent or temporary. growing demand for journalism skills. here we perform a detailed analysis of the top journalism skills that we identify for each year from to (see data & methods for details, and the supplemental material for the top skills for each year). we calculate (and show as stacked bar charts in fig. a ) the posting frequency of three of the fundamental journalism skills within job ads: ( ) 'journalism', ( ) 'editing', and ( ) 'writing'. these skills are counted across all job ads in australia, regardless of their occupational class. while fig. shows that labour demand for journalists has decreased since , fig. a presents the more nuanced story that the posting frequency for each of these core journalism skills has increased every year from to . the relative rankings of these three skills have also increased. for each year, we count the posting frequency of each unique skill that appears in job ads. we then rank these skills by posting frequency as a proxy for labour demand. fig. b shows that the rankings of all three of these fundamental journalism skills have improved from to . in other words, not only has the posting frequency of these three journalism skills increased in job ads, but their importance relative to all other skills has also increased. changing importance of journalism skills. here, we aim to determine whether a change occurred in the relative importance of the core journalism skills over time. given the dynamics of skill requirements in job ads, skills can become increasingly more (or less) similar over time. we use the similarity measures in eq. ( ) to identify the skills that are becoming more relevant to being a journalist. fig. a shows the changes in similarity scores between the skill 'journalism' and each of the eight other top journalism skills (as per the top yearly journalism skills lists). the greater the area covered in the radar chart, the greater the similarity score, with the blue area representing and the red area . visibly in fig. a , 'social media' related skills are becoming increasingly relevant for journalists, with the relative ratio of more traditional skills such as 'editing' and 'copy writing' diminishing with respect to 'social media', from to . occupations that require journalism skills. here we study which are the occupations that require most journalism skills, and their dynamics over time. given the yearly lists of top journalism skills (described in skill similarity), we use eq. ( ) to determine the occupations with the highest intensities of journalism skills, for each year from to . intuitively, this allows us adaptively to identify occupations that become more or less similar to 'journalism', based on their underlying skill usage. it also provides a means to assess likely transitions between occupations, as workers are more likely to transition to occupations where the underlying skill requirements are similar (bechichii et al. ) . higher similarity lowers the barriers to entry from one occupation to another. high in , their growth since was relatively low. in comparison, 'photography', 'communications', 'social media', and 'public relations' experienced higher journalism skill intensity growth from to . this provides evidence as to where workers with journalism skills might be finding employment outside of journalism. drawn from job ads and employment statistics, our findings reveal the highly volatile nature of the journalism industry. compared to other industries, journalism experiences dramatic fluctuations that are unpredictable and irregular. the data also confirms that journalism is an industry in crisis, particularly since the spread of covid- (see below). however, the data also reveals surprises, including that the number of journalism jobs ads and employment levels increased from until . since then, though, journalism jobs in australia have been in decline. the volatility of journalism jobs in australia is clearly apparent in posting frequency & employment levels. posting frequency of job ads have ranged from near zero levels in and to more than posts per quarter in . these violent swings are also apparent in the quarterly employment statistics of 'journalists and other writers'. following the mass redundancies of , employment levels plummeted, reaching their lowest levels in . they have since increased. however, the data confirms that volatility of employment has been a constant for journalism, and that this has worsened during covid- . fig. reveals this extreme volatility. the error metrics from the machine learning model used to predict daily posting frequencies of job ads (as detailed in trend analysis & predictability) highlight the difficulties of making predictions about journalism employment. this lack of predictability is indicative of volatility. the higher the error scores for a given occupation, the higher the likelihood that the occupation is experiencing significant disruption. this becomes apparent when we compare journalism to other occupations. for example, the volatility of 'journalists' dwarfs that of 'data scientists', an occupation experiencing significant demand and volatility in australia (dawson et al. ) . the volatility of journalism jobs is further revealed by a time series analysis of journalism compared to other occupations (fig. ) , a gender-based analysis (fig. ) , a geographical analysis (fig. ) and an analysis of the temporary nature of journalism jobs (fig. ) . what is indisputably clear is that the advertising market for news and journalism has collapsed, and continues to collapse. meanwhile, consumers have consistently shown an unwillingness to pay for digital journalistic content. in , australian news consumers admitted they would much would rather subscribe to a video streaming service such as netflix ( %), than pay for online news ( %) (dnr australia ). the internet has detonated the advertising model that once sustained journalism, and simultaneously re-adjusted consumer expectations on the monetary value of journalism content. the fact that journalism is struggling is confirmed in several ways by the data, including by the unpredictability of job ads posting frequency and the clear shifts in employment levels, as shown in fig. . to say that journalism is being disrupted is an understatement. volatility exacerbated by covid- . in a fragmenting news ecosystem, consumer demand for news and journalism is difficult to quantify. the digital news report: australia has found that many consumers are disengaging, with the proportion of australians avoiding news increasing from % in to % in (fisher et al. ) . demand for 'quality' and 'public interest' journalism is even harder to quantify, given ongoing debates as to what exactly constitutes 'quality' and 'public interest' (wilding et al. ) . nonetheless, demand for journalism has surged dramatically since the outbreak of covid- . the irony of the coronavirus pandemic is that even as it has been killing off journalism jobs, it has also created a heightened demand for, and appreciation of, journalism among the general public. as news analyst doctor ( ) wrote of the us situation in late march, 'the amount of time americans spend with journalists work and their willingness to pay for it have both spiked, higher than at any point since election , maybe before ... [but] how many journalists will still have jobs once the initial virus panic subsides?'. in the uk in march, the guardian received . billion page views, an increase of more than million above its previous record, set in october (bedingfield ) . since the outbreak of covid- , the volatility of the journalism jobs market has worsened dramatically. we noted above that in early april news corp suspended the publication of newspapers nationally. then, on april , australian community newspapers, which publishes community titles, said it was suspending publication of some of its non-daily newspapers; as a result, four printing presses were closed and an unspecified number of staff were stood down (meade a ). the following day, the federal government announced a $ million package to support public interest journalism across tv, newspapers and radio in regional and remote australia (hayes and rubbo ) . and on april , the government announced that digital platforms including google and facebook would be forced to pay for content as the internet advertising business would be overhauled to help local publishers survive the economic fallout of the coronavirus crisis (crowe ) . the scheme, which would involve a mandatory code imposed on digital giants, would potentially set a global precedent. the combined and ongoing impact on journalism jobs of these sudden, cumulative developments are hard to predict, but will no doubt be profound. at first glance, the data seems to suggest that gender equity is finally arriving in australia for journalism -an industry that has traditionally been male-dominated -as more women than men are employed. as the data shows, in there were . female journalists employed for every male journalist, but by the proportion of female-to-male employment more than doubled, with almost . female journalists employed for every male journalist. it then declined in to . , a proportion still almost double that of . however, further detail reveals that equity remains elusive. specifically, wage inequality has worsened. since , annual salaries for female journalists increased by au$ , , compared with an increase for male journalists of over au$ , over the same period. from to , average wage growth for male journalists was more than ten times greater than for female journalists. meanwhile, the average male journalist has been getting older, while the average female journalist has been getting younger. in , the average age for a journalist, whether male or female, was roughly the same: late s. by , the average age for a male journalist was , whereas for a female journalist it was . the potential impacts of this worsening disparity are concerning. it is likely that senior positions responsible for major editorial decisions are increasingly being dominated by men, whereas junior roles are being filled by women who are younger and worse-paid. this may be having a flow-on effect as to which news stories are being covered, and how those stories are being covered. in other words, the gender gap and age gap may be having an impact on the content of the news. further research is needed into related issues of the industrys composition, including, for instance, the ethnicity of journalists. a vast body of literature exists regarding the importance of diversity in news (rodrigues and paradies ; budarick and han ) . further work is needed into diversity (and its various sub-categories), and what effect diversity has, for instance, on the proportion of people who are actively avoiding the news. as discussed above, the sustained pressures on regional and local journalism have led to a worrying growth of news deserts in countries including australia and the us. this trend has been accelerating alarmingly since the outbreak of covid- , leaving many areas without any regional or local news coverage. hence we might assume that journalism jobs in regional and local areas have been drying up, and that an ever-increasing proportion of journalism jobs are in urban centres. the data, however, is not so clear. as fig. a shows, in fewer than a quarter of australias journalism job ads were for jobs outside sydney, melbourne, brisbane, canberra and the act or perth. in every subsequent year, the proportion of job ads for journalism positions outside these urban centres has been considerably higher. the peak came in , when nearly half of all job ads were for positions outside the major cities. does this suggest that in there were as many jobs for journalists in the regions as in the centres? surely not. the explanation, we would suggest, lies in various factors. these include that regional journalism jobs are hard to fill, perhaps because they offer relatively low salaries, and are hence re-advertised. it is also possible that there is a high turnover for some regional positions. in short, the job ads data may simply be an indication that the journalism industry is even more volatile in the regions than in major urban centres. research consistently and emphatically reveals that regional and local journalism are suffering, with an increasingly bleak prognosis of cuts and closures. while the data shows a surprisingly high proportion of journalism job ads for positions outside the main metropolitan centres, this cannot be taken to suggest that journalism is holding steady in these areas. skills are the building blocks of jobs and standardised occupations. in this regard, occupations can be characterised as 'sets of skills'. intuitively, skills that are similar can be interpreted as complementary when they are paired together or relatively easy to acquire (in either direction) when one skill is already possessed. this intuition provides insight into how journalism skills are evolving and where journalists might be finding alternate career paths. as fig. shows, both the demand for and supply of journalists have been declining in australia since . therefore, a growing number of former journalists, who presumably possess an assortment of journalism skills, have needed to transition between occupations to find new work. there are, however, significant transition costs moving between jobs (bechichii et al. ; bessen ) . these costs can come in the form of education, training, physically moving for new employment and other barriers. to reduce the friction of these transition costs, workers tend to leverage their extant skills, in concert with acquiring new skills, to make career transitions. as seen in fig. a , the skill 'journalism' has become more similar to 'social media' and more 'generalist' communications skills. after applying the skill intensity formula from eq. ( ), we identified the top occupations with highest intensities of journalism skills from - . the fig. b chart reinforces that top journalism skills are becoming more important to other occupations, such as 'photographers', 'social media strategists', 'public relations professionals', and 'communications specialists'. from the data, we suggest, three conclusions can be drawn. first, to be hired, journalists are required to have a wider array of skills, such as photography and social media aptitude. second, jobs in journalism are increasingly jobs in social media, generalist communications, and public relations rather than in reporting and editing. and third, we see hints as to where onetime journalists are finding alternate career paths. as employment conditions progressively worsen, journalists are seemingly pursuing new careers in the occupational areas seen in fig. b , such as photography or public relations. at a time of great uncertainty, with employment prospects deteriorating, it is no wonder that journalists look beyond traditional journalism for their futures. for society, however, the implications are significant. in this time of economic uncertainty and polarising politics, the people who possess the journalism skills required to keep the public informed and hold leaders to account are, in many cases, employing their talents elsewhere. this places enormous strain on the health and quality of journalism in australia. the data reveals a contradiction: demand for journalism skills has increased at the same time that demand and employment for journalists has declined. indeed, this is one of several contradictions in a volatile industry. for an increasing number of news media organisations, a sustainable business model remains elusive. our findings give a clearer outline of the problem. unfortunately, the solutions remain less clear. quality journalism is expensive. good reporting is often slow and laborious, fixed to the unfolding story. what is required of quality journalism is, therefore, at odds with the prevailing employment conditions. this paper highlights the stresses experienced by journalism in australia by analysing jobs data. we observe the volatility and downward trajectory of the occupation both in job ads and employment statistics. these unfavourable employment conditions are being worsened by the unfolding covid- crisis. our longitudinal analysis also yields important findings regarding gender inequity. while women are representing a greater share of employed journalists, they are earning less, and the wage gap is growing. further, this paper has also identified top journalism skills. adopting a data-driven method, we described which skills are most similar to 'journalism'. we then used these yearly skill sets to adaptively similar occupations. this enabled us to quantitatively show that the skill demands of journalists are becoming similar to those of 'social media strategists', 'public relations professionals', 'communications specialists', and others. this suggests where people with journalism skills are likely finding alternate career paths, but also raises a related concern. on the face of it, the journalism jobs data we have analysed does not look so bad after all. on reflection, however, it suggests that the thinning ranks of 'journalism' are populated by fewer journalists, and more public relations specialists. future research could compare these results to other labour markets to assess the validity of these findings. for example, the skill similarity methodology could be applied in other labour markets to compare the resulting top journalism skills in different locations. additionally, labour demand analyses could be conducted on occupations most similar to journalists to better understand the incentives to transition to other vocations. the results from this research both reinforce the welldocumented difficulties of journalism in australia and provide granular details that isolate and reveal these challenges. the implications are global. the hope is that these analytical methods and insights can contribute to the health and well-being of the fourth estate, and hence to the health and well-being of society. here, we describe the data sources we used to analyse journalism jobs. we also outline the skill similarity methodology that enables us to construct temporal (yearly) sets of top journalism skills. lastly, we describe how these temporal sets of top journalism skills then allow us to adaptively identify occupations that are 'most similar' to journalism, at the granular skill level. journalism job ads. this research draws on more than . million australian online job ads from - - until - - , courtesy of data provided by burning glass technologies ‡ (bgt). bgt also granted access to the aggregated job ads data from - - to - - , allowing us to address the early impacts of the unfolding coronavirus pandemic (covid- ) on journalism jobs in australia. bgt collected the job ads data via web scraping and systematically processed it into structured formats. the dataset consists of detailed information on individual job ads, such as location, salary, employer, educational requirements, experience demands, and more. the skill requirements have also been extracted (totalling > , unique skills) and each job ad is classified into its relevant occupational and industry classes. there are two occupational ontologies in the job ads dataset. the first is anzsco, which is the official occupational classification standard in australia and new zealand. the other is the bgt occupational ontology, which has been developed due to shortcomings of official occupational standards (as described in related work & background). to ensure selection accuracy, we instituted the following search query conditions over the dataset: . all job ads with anzsco occupation labels of 'newspaper or periodical editor', 'print journalist', 'radio journalist', 'television journalist', and 'journalists and other writers nec' (where 'nec' stands for 'not elsewhere classified'). . or all job ads with the bgt occupation label of 'journalist / reporter' and 'editor' (the two primary bgt occupational classes for journalists); . or all job ads with the 'journalist', 'news', or 'editor' in any part of the job title. after manually reviewing the returned job ad features for accuracy, the selection process resulted in a sample of , australian journalism job ads from - - until - - . we used the same search query and approach for the - - to - - period to supplement this sample. this returned journalism job ads, amounting to a total of , journalism job ads from - - to - - . the job ads during the period are observed aggregated daily, with limited skill level details. however, much of the analysis that follows requires access to the features within individual job ads, so only fig. leverages the data. further details on job ads data. it is estimated that approximately % of australian job ads are posted online (department of employment, skills, small and family business ). at aggregate levels, online job advertisements (ads) provide valuable indicators of relative labour demands. this includes demand features, such as salaries, educational requirements, years of experience, and, most importantly, skill-level information. here, a distinction must be made between skills, knowledge, abilities, and occupations. 'skills' are the proficiencies developed through training and/or experience (oecd ); 'knowledge' is the theoretical and/or practical understanding of an area; 'ability' is the competency to achieve a task (gardiner et al. ) ; and 'occupations' are standardised jobs that are the amalgamation of skills, knowledge, and abilities used by an individual to perform a set of tasks that are required by their vocation. throughout this paper, the term 'skill' will incorporate 'knowledge' and 'ability'. skills, in this sense, are the constituent elements that workers use to perform tasks, which ultimately define jobs and occupations. advantages of job ads data. understanding how the composition of skill sets evolve within an occupation is essential to understanding trends in that occupation. however, occupational data rarely captures skill-level data. most often, official occupational standards are static, rarely updated classifications, which fail to capture the changing skill demands of occupations, or to detect the creation of new types of jobs. journalist employment statistics. employment data (labour supply) were collected from the 'quarterly detailed labour force' statistics by the abs (australian bureau of statistics a). these employment data are organised into standardised occupations called the australia and new zealand standard classification of occupations (anzsco). anzsco provides a basis for the standardised collection, analysis and dissemination of occupational data for australia and new zealand. the structure of anzsco has five hierarchical levels -major group, sub-major group, minor group, unit group and occupation. the categories at the most detailed level of the classification are termed 'occupations'. a shortcoming, however, is that the lowest level of occupational employment data available by the abs is at the -digit unit level, which is one hierarchical level above specific occupations. as our research is focused ‡ bgt is a leading vendor of online job ads data. https://www.burning-glass.com/ on the employment unit class of 'journalists and other writers', all abs employment statistics cited in this research include the following occupations: 'copywriter', 'newspaper or periodical editor', 'print journalist', 'radio journalist', 'technical writer', 'television journalist', and 'journalists and other writers nec' . while the inclusion of the 'copywriter' and 'technical writer' occupations in these statistics could distort results pertaining to 'journalists' to an extent, we consider this impact to be limited in scope. as we describe in jobs data analysis and results, the employment statistics highlight important trends in journalism occupations, which are confirmed by findings from the job ads data. another shortcoming of employment statistics is their 'lagging' nature. the inertia of labour markets means that it takes time for changes to materialise in employment statistics. additionally, the official reporting of employment statistics takes time. employment statistics are often published several months or years after the reported period. as a result, these 'lagging' characteristics are not available for the most recent periods in our work (such as for the second half of and later.) in this section, we detail the methodology previously employed in (alabdulkareem et al. ; dawson et al. ) to dynamically measure skill similarity. here, we present the building blocks for this method, applying it for journalism related skills and occupations. intuition. two skills are similar when the two are related and complementary, i.e. the two skills in a skills-pair support each other. for example, 'journalism' and 'editing' have a high pairwise similarity score because together they enable higher productivity for the worker, and because the difficulty to acquire either skill when one is already possessed by a worker is relatively low. our goal, therefore, is to calculate the similarity of each unique skill relative to every other unique skill in the dataset. such a measure allows us to identify which skills have the highest pairwise similarities to a specific skill or set of skills. we also want to identify how skill similarity evolves over time. to achieve this, we have instituted a temporal split of a calendar year. this enables us to assess yearly changes to the underlying skill demands of journalism jobs. the revealed comparative advantage of a skill. we implement a data-driven methodology to measure the pairwise similarity between pairs of skills that cooccur in job ads. one difficulty we encounter is that some skills are ubiquitous, occurring across many job ads and occupations. we address this issue by using the revealed comparative advantage (rca), which maximises the amount of skill-level information obtained from each job ad, while minimising the biases introduced by overexpressed skills in job ads. formally, rca measures the relevance of a skill s for a particular job ad j as: where x(j, s) = when the skill s is required for job j, and x(j, s) = otherwise; s is the set of all distinct skills, and j is the set of all job ads in our dataset. rca(j, s) ∈ , j ∈j,s ∈s x(j , s ) , ∀j, s, and the higher rca(j, s) the higher is the comparative advantage that s is considered to have for j. visibly, rca(j, s) decreases when the skill s is more ubiquitous (i.e. when j ∈j x(j , s) increases), or when many other skills are required for the job j (i.e. when s ∈s x(j, s ) increases). rca provides a method to measure the importance of a skill in a job ad, relative to the total share of demand for that skill in all job ads. it has been applied across a range of disciplines, such as trade economics (hidalgo et al. ) (vollrath ) , identifying key industries in nations (shutters et al. ) , and detecting the labour polarisation of workplace skills (alabdulkareem et al. ) . measure skill similarity. the next step is measuring the complementarity of skill-pairs that co-occur in job ads. first, we compute the 'effective use of skills' e(j, s) defined as e(j, s) = when rca(j, s) > and e(j, s) = otherwise. finally, we compute the skill complementarity (denoted θ) as the minimum of the conditional probabilities of a skills-pair being effectively used within the same job ad. skills s and s are considered as highly complementary if they tend to commonly co-occur within individual job ads, for whatever reason. formally: note that θ(s, s ) ∈ [ , ], a larger value indicates that s and s are more similar, and it reaches the maximum value when s and s always co-occur (i.e. they never appear separately). top journalism skills. following the procedure outlined in (dawson et al. ) for building sets of highly complementary skills, we use the θ function together with 'journalism' as the 'seed' skill to create top yearly lists of journalism skills. more precisely, we compute θ(journalism, s) -i.e. the similarity between the skill 'journalism' and each unique skill that occurs during a given year. skills on each yearly list are ordered by their descending pairwise skill similarity scores. when inspecting the yearly skill lists, we make two observations. first, the skills in and appear of notably lower quality than from onward. we posit that this has to do with imperfect skills extraction methods during the early years of the bgt dataset. as a result, we decided to measure the top yearly journalism skill sets from to (the last available full year of data for which we had access). § second, we decided to retain only the top skills on each yearly list. through qualitative analysis, we determined that this threshold of is both sufficiently exclusive for defining journalism skills and reasonably inclusive for detecting the evolution of new, emerging skills in journalism. the purpose of these top journalism skills lists is to capture journalism labour trends; it is not intended to represent a complete taxonomy of journalism skills. the yearly lists of top journalism skills, and their similarity scores, can be observed in the supplemental material sec. top journalism skills by year. compute journalism skill intensity. for the occupational similarity analysis in sec. journalism skills, we decided to use the bgt occupational ontology as opposed to anzsco. this is because the bgt occupational classes appear more reflective of current job titles. for example, a job title advertised for a 'social media manager' is classified by bgt as a 'social media strategist / specialist'. whereas the same job title would be classified by anzsco as an 'advertising specialist' or 'marketing specialist'. we use the prophet time-series forecasting tool developed by facebook research (taylor and letham ). prophet is an auto-regressive tool that fits non-linear time-series trends with the effects from daily, weekly, and yearly seasonality, and also holidays. the main model components are represented in the following equation: where g(t) refers to the trend function that models nonperiodic changes over time; s(t) represents periodic changes, such as seasonality; h(t) denotes holiday effects; and t is the error term and represents all other idiosyncratic changes. we evaluate the forecasting performance using a temporal holdout setup. that is, we split the available time-series into a training part (the first part of the sequence) and a testing part (the latter part of the sequence). we train the prophet model on the training part, and we generate job ad posting forecasts by "running time forward" in eq. ( ) for time t in the testing period. finally, we measure the accuracy of the forecast against the observed posting volumes using the symmetric mean absolute percentage error (smape) (scott armstrong ; makridakis ) . smape is formally defined as: where a t denotes the actual value of jobs posted on day t, and f t is the predicted value of job ads on day t. smape ranges from to , with indicating a perfect prediction and the largest possible error. when actual and predicted values are both , we define smape to be . we selected smape as an alternative to the more widely used mape because it is ( ) scale-independent and ( ) robust to actual or predicted zero values. to evaluate the uncertainty of the forecast, we adopt a 'sliding window' approach. this consists of using a constant number of training days (here , days) to train the model, and we test the forecasting performance on the next days. we then shift both the training and the testing periods right by one day, and the process is repeated. consequently, we train and test the model times, and we obtain smape performance values. top journalism skills calculated by skill similarity methodology in sec. skill similarity. governments around the world crack down on journalists covering covid- the expanding news desert digital platforms inquiry -final report unpacking the polarization of workplace skills australian bureau of statistics ( ) . -anzsco -australian and new zealand standard classification of occupations -employee earnings and hours moving between jobs: an analysis of occupation distances and skill needs coronavirus news fatigue is real and it could become a big problem on a rough day for american newspapers, investors aren't buying gannett's story and tribune's not done chopping learning by doing: the real connection between innovation, wages, and wealth dynamics of data science skills australia's coronavirus social distancing rules explained: state by state guidelines. the guardian minorities and media:: producers, industries, audiences understanding online job ads data hospitals tell doctors they'll be fired if they speak out about lack of gear coronavirus and the crisis in regional news digital giants will have to pay for news coronavirus infecting australian jobs: vacancy rates down since early february. the conversation url adaptively selecting occupations to detect skill shortages from online job ads predicting labor shortages from labor demand and labor supply data: a department of employment, skills, small and family business ( ) sixty per cent of job vacancies in australia are advertised online newsonomics: what was once unthinkable is quickly becoming reality in the destruction of local news deregulation or democracy? new media, news, neoliberalism and the public interest media release: critical funding for public interest journalism in covid- coronavirus is speeding up the collapse of local newsrooms skill requirements in big data: a content analysis of job advertisements characteristics and use of casual employees in australia people have lost their jobs so far this year in a media landslide re) defining journalistic expertise in the digital transformation: a content analysis of job announcements ) $ m coronavirus bailout announced for regional media the product space conditions the development of nations re-examining age: journalism's reliance on the young aap newswire service closes after years with job losses, including journalists they're chasing me': the journalist who wouldn't stay quiet on covid- . the guardian accuracy measures: theoretical and practical concerns the quant crunch: how the demand for data science skills is disrupting the job market dozens of australian newspapers stop printing as coronavirus crisis hits advertising. the guardian news corp australia warns of coronavirus crisis job cuts as smaller regional papers close. the guardian . nieman-lab ( ) about nieman lab oecd skills strategy -skills to shape a better future like being shot in the face" or "i'm glad i'm out": journalists' experiences of job loss in the australian media industry - news consumption habits of culturally diverse australians in the digital era: implications for intercultural relations investors look to salvage parts of aap as newswire faces closure long-range forecasting: from crystal ball to computer once a journalist, always a journalist? constrained pathways to a creative urban economy newspapers to lose £ m in online ads as firms use coronavirus 'blacklist'. the guardian forecasting at scale a theoretical evaluation of alternative trade intensity measures of revealed comparative advantage the coronavirus is killing local news. the atlantic the impact of digital platforms on news and journalistic content what is a journalist? the view from employers as revealed by their job vacancy advertisements journalism hit hard by corona crisis it has a bleak future new beats report: mass redundancies and career change in australian journalism we would like to thank burning glass technologies for generously providing the data for this research. we would also like to thank google for generously providing cloud computing resources for this research. key: cord- -sxh mq q authors: milne, d. j.; armstrong, m.; fisher, a.; flores, t.; pavey, c. r. title: structure and environmental relationships of insectivorous bat assemblages in tropical australian savannas date: - - journal: austral ecol doi: . /j. - . . .x sha: doc_id: cord_uid: sxh mq q abstract patterns in the composition of assemblages of microbat species sampled during the late dry season (the ‘build‐up’) in north australian savannas were assessed against a range of environmental factors as well as four a priori defined habitat types (riparian, escarpments, coastal and woodlands). distinct species assemblages were most strongly associated with topographic and climatic variables. there were also limited associations with vegetation structure, fire and local roost potential but no associations with insects or water availability. total species diversity at sample sites was associated with distance to rivers and rainfall. in general, species assemblages were not clearly defined and the number of significant environmental associations was relatively few. we compare these associations with those reported for bat assemblages elsewhere in australia. understanding of the diversity and evolutionary ecology of australia's mammal fauna has not been uniform across orders. in particular, most detailed tests of evolutionary hypotheses (e.g. johnson ; fisher et al . ) omit bats (order chiroptera). assessments of population trends and extinction proneness have also excluded chiroptera (e.g. johnson ) . this is a significant shortcoming as bats represent over % of australia's mammal species, many of which are endemic. although australian mammal diversity peaks in the tropical forests of eastern queensland including cape york peninsula, significant diversity also occurs in the savannas of north-western australia where species are known ). an assessment of the response of mammals within this region to environmental variables revealed that a single environmental gradient (of substrate and disturbance) described the distribution of all species, excluding bats . rock-inhabiting mammals are a significant component of this fauna, however, diversity of this assemblage decreases with decreasing outcrop size and increasing isolation. identified three other trends. first, that the mammal fauna of eucalypt open forest/woodland habitats of north-western australia is characterized by extensive distributions of its component species. sec-ond, that monsoon forests support a depauperate mammal fauna. last, that the mammal fauna of this region undergoes substantial latitudinal change associated with a steep north-south rainfall gradient. did not include systematic sampling of bats, preventing a rigorous examination of the response of the bat fauna to environmental measures. however, data from captures (mist netting, harp trapping, roost searches) indicated that most bat species were present across the environmental range sampled ). here we revisit the issue of the response of bats to environmental variables in the tropical savanna of the northern territory and north-west queensland using a more rigorous data set. our data collection incorporated the use of ultrasonic detectors to sample bats and geographic information system (gis) derived variables to represent environmental conditions. the study region supports a rich microbat fauna ( of australia's species, of australia's genera), including one endemic species ( taphozous kapalgensis ), and both of australia's monotypic genera ( rhinonicteris , macroderma ). we assessed environmental factors at two levels, first at the landscape scale, using data available from a gis, and second at a local scale where information was collected on the physical environment and food resource availability (insects) at individual sampling sites. we predicted that the high vagility of bats would result in species responding broadly to environmental variables. however, specific responses to a number of environmental variables were expected. in particular, we predicted that the distribution, composition and segregation of bat assemblages would respond to geographical patterns in annual rainfall, presence of rocky escarpments, water bodies and canopy cover. although a relationship with insect abundance and composition was examined, we predicted that this relationship would not be significant given the generalist feeding ecology of most insect-eating bats (fenton ) . the bat assemblages of tropical australian savannas are also compared with assemblages elsewhere in australia. specifically, we compared our results with community composition and environmental association studies in north queensland rainforest (crome & richards ) , mangroves in north-western western australia (mckenzie & muir ) , and open forest/ woodland in victoria (kutt ; lumsden & bennett ; herr ) , south-east new south wales (nsw) (law et al . ) and tasmania (taylor & o'neill ) . the study area, called the top end of australia, included the tropical savanna of the northern terri-tory and north-west queensland, north of ° s, but excluding offshore islands (fig. ) . across this area, maximum mean weekly temperature ranges between ° c and ° c and mean annual rainfall between mm and mm (houlder ; fig. ). rainfall is highly seasonal with almost all precipitation occurring from november to april. topographic relief is relatively low. the maximum elevation is m on the arnhem land plateau, with the main areas of topographic relief being the kakadu escarpment and the eastern edge of the kimberley region in the southwest of the study area. eucalypt woodlands and forests dominate % of the study area (fox et al . ) . other notable environments include monsoon rainforests and floodplains dominated by sedgelands and grasslands. on average, over half ( %) of the top end is burnt every year (a. edwards, pers. comm. ) . a total of sampling sites were located across the top end (fig. ) . map of the study area showing the location of sampling sites and site labels as well as average annual rainfall isohyets (in millimetres). sites are symbolized according to bat assemblage (diamond = group , square = group , cross = group , triangle = group , circle = group ). sonal variation on species composition. each site was a circular plot of m radius. plots were primarily selected to cover a large geographical area and to sample four broad habitat types: . riparian -adjacent to perennial rivers, creeks or permanent waterholes ( sites). . escarpments -sandstone cliffs ( sites). . coastal -coastal and near coastal environments (excluding estuaries and mangroves) (eight sites). . woodlands -continuous areas of eucalypt woodlands or open forests not associated with the other habitats types ( sites). habitat types were chosen a priori and were based on information gleaned from species' distribution maps and descriptions of microbat habitat preferences (strahan ; churchill ) that suggested these habitats may contain distinctive species assemblages. two sites were usually sampled at a time on the same nights. with one exception, no two sites within a sampling pair sampled the same habitat type. distances between sampling pairs ranged between km and km (mean km). at each site we used a range of sampling techniques to maximize the likelihood of obtaining a full inventory of bat species (kuenzi & morrison ; murray et al . ; o'farrell & gannon ) . bats were sampled using two ( sites) or three ( sites) harp traps over two consecutive nights as well as one night of shot sampling for a -h period after dusk. harp traps were usually placed across 'flyways' (tracks, streams or other gaps within the vegetation where bats are more likely to be trapped) and were either positioned side by side or spaced between and m apart. we also conducted active searches of caves, road culverts and any other features potentially used as diurnal roosts by bats within m of the centre of the sampling site. in addition, bat calls were recorded at every site with ultrasonic bat-detectors (anabat ii, titley electronics, ballina, australia) using two methods. the first method involved placing a detector on the ground, elevated to approximately ° , and operated from dusk for a cumulative total of at least six recording hours over two consecutive nights (maximum h, mean h). this time period has been shown to sample % of species calls at a given site (milne et al . ) . detectors were connected to either an anabat ii delay switch with output recorded to -min cassette tape (sony chrome ux, tokyo, japan) via tape recorder (optimus ctr- d, fort worth, usa) ( sites) or an anabat v zcaim and computer (toshiba portégé ct or toshiba tecra ct d, tokyo, japan) running anabat software in monitor mode ( sites). there are no differences in the species detected between these two recording techniques (milne et al . ) . for the second method, an anabat detector was held in the hand and manually activated on detection of a bat-call and actively pointed in the direction of the call. calls were recorded via tape-recorder and cassette tape, for h after dusk for one night. all recorded calls were identified according to milne ( ) . at several sites ( ), shot sampling was not permitted. instead we trapped bats using mist-nets at these sites. it is likely therefore, that some 'high-flying' bat species that are readily detected using shot sampling, may not have been trapped at these sites. however, we expect this will have a negligible effect on our results as shot sampling at all other sites, used in conjunction with anabat detectors, enabled us to collect an extensive reference call library for 'high-flying' bat species for the entire study area (milne ) . anabat detectors were systematically used at all sites and will normally detect 'high-flying' species that are not readily trapped (o'farrell & gannon ) . we collated environmental data for each site from field habitat measurements, analysis of spatial data and insect sampling. at the centre of each site we measured tree basal area, canopy cover and stem count, m either side of a -m transect ( . ha) in an area of undisturbed vegetation usually adjacent and parallel to flyways where harp traps were set. on escarpment sites, the transects either traversed the escarpment or were situated at the base of the escarpment. basal area and stem counts were derived by measuring diameter at breast height (d.b.h.) of every tree along the transect, whereas canopy cover was measured using a spherical densiometer at m, m and m along the transect. for the entire site ( . ha), we measured slope, maximum canopy height, crown cover, rock cover, distance to water and local roost potential. crown cover in three height classes ( - m, - m and > m) was estimated using crown separation ratios (mcdonald et al . -mostly large trees and rock outcrop with large cracks and holes we chose to assess whole trees and rock outcrops rather than count individual hollows because small microbats ( < g) can roost in hollows equivalent to their own body diameter (pers. obs. ). entrances to these hollows are very small and would regularly be overlooked if we attempted to count hollows directly. large trees have been shown to contain more tree hollows than smaller trees (whitford ) and are preferred roost sites for many bat species (lunney et al . ; herr & klomp ; law & anderson ; lumsden et al . ) . several variables were derived using gis from a s ( c . m) digital elevation model (dem, provided by the department of defence) including elevation, ruggedness index (the range in cell values of the dem within a × cell neighbourhood), and distance to and m 'escarpments' (defined here as any adjacent dem cells having an altitude difference of or m). climate variables (annual mean temperature, minimum monthly temperature and annual rainfall) were derived using bioclim (houlder ) . other gis data included fire frequency (number of years in which the site was burnt over the preceding years) and years since last fire (data sets provided by the bushfires council of the northern territory), distance to perennial rivers, and ndvi (normalized difference vegetation index, which is a measure of vegetation 'greenness' derived from satellite imagery) and projective foliage cover (meakin et al . ) . at each site we trapped flying nocturnal insects for one night concurrently with bat sampling. the insect trap was constructed from a white cotton sheet ( . m × . m), suspended off the ground by strings tied to the corners to form a funnel, one end higher than the other. at the bottom of the funnel a hole was cut in the sheet and a plastic jar ( mm diameter × mm depth) partially filled with % ethanol was attached to hang underneath. a -v fluorescent light ('col-light' brand col-lite, maleny, australia) was hung from the higher end of the sheet to attract insects. the trap was positioned approximately m from the anabat detector so as not to disturb bats from natural flight habits in the vicinity of the detector, and left unattended for the entire night. insects that fell into the jar were collected the following morning. in the laboratory, insect samples were filtered through a -mm sieve to remove the smallest insects (mostly < mm in length) and then identified to order and assigned to four size (head-body length) classes: < mm, - mm, - mm and > mm. the choice of size classes was based on the range of body sizes found to be prey items of bats in tasmania (o'neill & taylor ) . analysis of bat communities was based on species presence-absence at each site derived from the combination of all sampling methods. anabat calls for the following combinations cannot be reliably separated in the top end: (i) chalinolobus nigrogriseus , scotorepens greyii and scotorepens sanborni ; (ii) miniopterus schreibersii and pipistrellus westralis ; and (iii) nyctophilus arnhemensis , nyctophilus bifax and nyctophilus geoffroyi (milne ) . anabat call sequences that were attributed to these species combinations were therefore excluded from the analysis, although species within these combinations were included if identified using one of the physical sampling methods. the one exception was s. greyii and s. sanborni which cannot be readily separated in the field (churchill ) and were treated here as a single species although in some areas their distributions are allopatric (mckenzie & muir ) . species assemblages were assessed using patn software (belbin ) . similarities in species composition between sites were calculated using the bray-curtis association measure. cluster analysis (unweighted pair group mean) was used to define assemblages (groups of sites) following visual inspection of the dendrogram. anosim (clarke & green ) was used to test whether bat species composition differed significantly between the defined assemblages as well as the four a priori habitat types. the relationship between sites was also portrayed by ordination (multidimensional scaling) of sites by their bat species composition. in both analyses, only sites with at least three species were included. all environmental variables (table ) were continuous or rank ordered. variables were initially compared using the spearman rank correlation test. where pairs of variables had a correlation coefficient greater than . , one of the pair was excluded from further analysis. the mean of each environmental variable was calculated for each group of sites derived from the cluster analysis and the significance of differences between bat assemblage groups was tested using kruskal-wallis anova . the relationship between environmental variables and the arrangement of sites in the ordination space was also tested using vector fitting (kantvilas & minchin ) . finally, generalized linear modelling (glm; crawley ) was used to develop a predictive habitat model for total site species richness. a poisson error distribution and log link function was used and a backward stepwise procedure was adopted to generate the minimum adequate model with only those variables having a significant correlation in the vector fitting included in the model development. a total of microbat species were identified from the sites, representing over % of the species recorded from north-western australia . two species known to occur in the top end , macroderma gigas (ghost bat) and saccolaimus saccolaimus were not detected in this study. we identified five groups from the classification of all sites by their species composition (fig. ) . the initial classification divided the sites into four groups. we subdivided the largest of these groups into two and assigned two outlying sites to group based on the relative position of these sites in the ordination. anosim analysis confirmed that the groups differed significantly in composition ( r = . , p < . ) and that there was a significant difference between each pair of groups ( p < . or better). the occurrence of bat species within the derived groups and habitat types is summarized in table and the geographical distribution of sites (classified according to group) is shown in fig. . four species were ubiquitous throughout the groups and habitats ( chaerephon jobensis , pipistrellus adamsi, mormopterus loriae and saccolaimus flaviventris ) while three species were each detected at single sites only ( hipposideros diadema , hipposideros stenotis and m. schreibersii ). the distribution of sites in ordination space and the relationship with environmental vectors is shown in fig. . a total of environmental variables were significantly correlated with variation in species composition between sites (table ) . a summary of mean values for these variables for each group is provided in table . a description of species composition and the environmental characteristics for each group is provided below. species that were detected most often in this group include chalinolobus gouldii (present in all sites), c. jobensis, s. flaviventris, s. greyii/s. sanborni and p. adamsi. chalinolobus gouldii was strongly associated with this group (i.e. tended to occur in group more than the other four groups). group had the highest total species richness and mean site species richness of all groups. sites were characterized by high percent-age canopy cover, frequent burning and high annual rainfall and were located in the north and west of the top end. the greatest number of sites occurred in this group ( ) . species that were detected most often include vespadelus caurinus (present at all sites), s. flaviventris , taphozous georgianus and c. jobensis . v. caurinus was strongly associated with this group. sites were characterized by rugged, steep rocky slopes, high elevations and short distances to escarpments and rivers. minimum temperatures were cool and annual rainfall low. sites were widely distributed across the top end, except the coastal zone. species detected most often in this group include s. flaviventris, n. arnhemensis, myotis macropus and s. greyii/s. sanborni. n. arnhemensis was strongly associated with this group. group was not clearly associated with any of the environmental variables measured and occupied an intermediate value on most environmental gradients. however, this group displayed the highest mean values for minimum temperature. figures represent percentage of sites within each group or habitat in which each species was detected. differences in proportions were tested using χ statistic and differences in mean species richness were tested using kruskal-wallis anova (ns, not significant; *p < . ; **p < . ; ***p < . ). this group had equal fewest sites (five) and had the lowest total and mean site species richness. species detected most often include c. jobensis (present at all sites) s. flaviventris, m. loriae and c. nigrogriseus. there were no strong species associations, although c. nigrogriseus occurred at proportionately more sites in this group than any other. sites were characterized by lower mean annual temperatures, long distances to rivers and no rock cover. species detected most often include s. flaviventris, p. westralis (both present at all sites), p. adamsi, m. loriae and t. kapalgensis. p. westralis and t. kapalgensis were strongly associated with this group. group also had relatively few sites and low species richness, but was associated with the minima or maxima of several environmental variables including long distances to escarpments, flat terrain at low elevations with no rock, low local roost potential, high annual temperatures and low fire frequency. all five sites were located near the coast (fig. ) . there was a significant difference in species composition between habitat types (anosim, r = . , p < . ) as well as between all pairwise combinations of habitats except between 'woodland' and 'riverine' (r = . , p = . ). v. caurinus and t. georgianus were detected most often in 'escarpment' habitat. both of these species, as well as rhinonicteris aurantius and c. nigrogriseus, were absent from 'coastal' habitat. p. westralis was strongly associated with 'coastal' habitat and absent from both 'escarpment' and 'riparian' habitat. n. arnhemensis was also absent from 'escarpment' habitat. all habitats had similar total and site species richness, with slightly lower species richness in the 'coastal' habitat. the relationship between groups and habitats is summarized in table . the habitat type of each site was not independent of group classification (χ = . , p < . ). most of the 'escarpment' sites occurred in group (steep, rocky, rugged sites) with two further sites in group . 'coastal' sites mainly occurred in group (few environmental correlates) and group (flat, low elevation), whereas 'riparian' sites occurred across four of the groups and 'woodland' sites were evenly represented across all five groups. we found no significant associations between bat species assemblages and various measures of insect availability including total number of insects, total number of insect orders, total number of insects in various size classes, proportion of insects in various size classes or total number of insects in each order. values are the mean for sites in each group, h-values refer to the kruskal-wallis statistic (ns; not significant; *p < . ; **p < . ; ***p < . ). habitat modelling identified distance to perennial rivers and annual rainfall as the major predictors for site species richness (table ). the minimum adequate model was only moderately robust with % of the deviance captured. this suggests that there was considerable 'noise' in the data or that some important explanatory variables were not quantified. as predicted, the insectivorous bat fauna of northwestern australia responded broadly to most environmental variables. the main environmental feature associated with the distribution of microbat assemblages in the study area was topography (variation in elevation, slope, topographic ruggedness and distance to escarpments). not surprisingly, therefore, species considered to be obligate cave roosters (hipposideros ater, h. diadema, h. stenotis, m. macropus, m. schreibersii, r. aurantius, t. georgianus, v. caurinus, vespadelus finlaysoni) , mainly occurred in (but were not restricted to) groups and which were associated with high values for the topographic variables. although we expected a relationship between microbat assemblages and distance to escarpments, the significant effect of elevation was not predicted. elevation generally increased away from the coast and was auto-correlated with 'distance to coastlines', making it unclear which of these features was most important in influencing bat composition. the second factor influencing bat composition was climate, specifically annual rainfall (corrolated with maximum temperature and latitude), mean temperature and minimum temperature (corrolated with temperature range; refer table ). the influence of annual rainfall was expected given the relationship between rainfall and species composition exhibited by the entire mammal fauna of north-western australia . a similar pattern was shown by the vegetation (bowman et al. ) and birds (whitehead et al. ) of north-western australia. in contrast to the significant relationship identified between bat assemblages and mean climatic variables, there was no significant relationship between ambient temperature (measured at pm each sampling night) at each site and species composition. at the time of year that we sampled, temperature was unlikely to limit the number of bat species that were active. however, during the dry season, low inland temperatures may reduce insect activity, restrict bat activity to the earlier, warmer times of the night and/or induce some species to enter torpor. therefore, restricting our sampling to one period of the year may have affected our results but sampling at different times of the year would have required a much greater sampling effort. between years, there was no observable difference in general weather patterns during each sampling period, therefore inter-year variations were unlikely to have affected our results. there were significant associations between bat species assemblages and fire frequency (corrolated with time since fire). the effects of fire on landscapes in northern australia can depend on the number of times an area is burnt and on the time since last fire (assessed here), fire intensity, seasonal timing of fires and spatial extent of burning (dyer et al. ; andersen et al. ) . the link between fire and bat species composition is likely to be an indirect one. it is also possible that characteristics of the landscape such as fuel loads, geography and habitat type are actually the primary influence for species assemblages and fire frequency is a secondary consequence of these landscape characteristics. therefore, our results should be viewed with caution and further investigation into the effects of fire on bat species assemblages is required before conclusions can be drawn. we assessed several variables involving insect availability at each site. none of the variables showed any significant relationship with microbat assemblages. this suggests that, in the top end at least, available food resources do not influence the composition of bat communities. this conclusion was consistent with previous research on insect-eating bats that indicated most species capture prey opportunistically (fenton minimum adequate models and explanatory power (per cent of deviance captured) are shown. probability levels *p < . , **p < . . ). specific research on tasmanian bats also concluded that bat assemblages were generally opportunistic foragers (o'neill & taylor ) . four aspects of our sampling strategy may have influenced our analysis. first, we did not sample non-volant insects and other arthropods that are eaten by some bat species in the top end (e.g. spiders, c.r. pavey, unpubl. data ) . second, high flying insects that are preyed on by bats such as taphozous spp. were probably not attracted to our light trap. third, bats may only show a response to insects at certain times of the year. it is likely that at the time of sampling (late dry season), insects were abundant and food resources did not affect the activity of bats. fourth, insect sampling was limited to one night per site, which may not have been sufficient to provide an adequate representation of overall insect availability. therefore, we suggest that a combination of insect sampling methods should be used in future assessments of prey availability and bat assemblages, particularly when the diversity of bats is high. these methods should aim to sample volant and non-volant invertebrates. did our study adequately sample a cross section of the major environmental gradients in the top end? compared with much of australia, the environment of the top end is relatively uniform. landscape relief is low, woodlands dominate most of the landscape, temperature varies little throughout the year and the climatic gradients are gradual. therefore, environmental variation is relatively small, and fewer sampling sites should be required compared with areas with greater topographic, climatic and vegetative variation. however, there may have been two significant deficiencies in our sampling. first, the highly seasonal rainfall in the monsoon tropics results in starkly contrasting 'wet' and 'dry' seasons. from our study, we were unable to say how bat composition may vary seasonally and there are no data available to assess seasonal patterns. second, the chosen study area was huge ( km ) and most of the north-east of the top end (arnhem land) was unsampled. therefore, clearer patterns of bat assemblages may have emerged if we had sampled more comprehensively, both spatially and temporally. most sites ( ) were sampled in pairs and the minimum distance between any two sites was km (mean km). bats can travel long distances during the night. foraging distances for a selection of species range between km and km (herr & klomp ; law & anderson ; lumsden et al. ) , therefore some of our results were potentially autocorrelated due to the same bats being sampled at both sites within a pair. therefore, we assessed the similarity in site species composition using the bray-curtis index. this index was calculated by dividing the number of shared species between pairs of sites by the total number of species of both sites. the resulting value was plotted against the distance between each pair of sites (fig. ) . the scatter of points was highly variable, however, the slope of the regression line was shallow. this pattern indicated that the relative change in species composition as a result of geographical separation was small. one of the environments largely neglected during sampling was monsoon rainforest, although 'riverine' sites did sample components of monsoon rainforest environments. we considered this had little effect on our results because monsoon rainforests occupy just . % of the landscape (based on mapping by fox et al. ) and usually occur in patches less than ha (russell-smith ) . in addition, menkhorst and woinarski ( ) found no bat species that were tightly associated with monsoon rainforests in the top end and these forests support a depauperate mammal fauna in general . some of the environmental variables that we found to be significantly correlated with bat assemblages in the top end differed from those related to bat community variation in other areas of australia. waterbodies have been found to support high species diversity and some species are strictly associated with them (law et al. ; south-west slopes of nsw.; young & ford ; central western queensland) . in the top end, glm analysis suggested bat species richness increases with decreasing distance to perennial rivers. however, species richness was not exceptionally high at our 'riparian' sites. further, group , which was on average closest to rivers, did not have the highest species diversity. also, we found no significant difference in species assemblages between 'riverine' and 'wood- fig. . similarity in bat species composition between pairs of sites (using the bray curtis similarity index, refer text) plotted against the distance between each pair. graph also displays the fitted linear regression line. land' habitats and there was no relationship with distance to available surface water. given that sampling was carried out during the driest time of the year (late dry season september-november) the likelihood of detecting significant associations with waterbodies was maximized. a relationship between vegetation structural complexity and microbat diversity has been established in studies in western australia (mckenzie & muir ) and nsw (law et al. ) . by contrast, we found significant correlations of bat species diversity with canopy cover but no associations with structural complexity. compared with the vegetation in the areas sampled by mckenzie and muir ( ) and law et al. ( ) , the vegetation of the top end is usually shorter and contains fewer understorey layers (d. lewis pers. comm. ). this limits the degree of vegetation structural complexity in the top end that likely accounts for the lack of correlation between structural complexity and bat communities. although we identified significant differences between the species assemblages within classification groups and habitat types, the assemblages were not clearly defined. most species occurred in more than one group and some were present in all groups. in addition, there were no associations between insect variables and bat assemblages and relatively few associations with environmental variables. this pattern is not restricted to microbats. birds, reptiles and nonvolant mammals also exhibit 'loose' patterns of species composition (woinarski & fisher ; woinarski et al. ) and limited associations with particular environments and environmental gradients woinarski et al. ) in the top end. woinarski et al. ( ) suggested this trend was a consequence of the homogeneity of eucalypt woodlands and forests that dominate the top end landscape. this relatively uniform environment militates against highly specialized and habitat-specific faunas. however, there were exceptions. specifically, some microbat species had a clear association with rugged rocky areas, particularly escarpments and adjacent areas. these areas provided a complex mix of habitats that contained foraging and roosting sites suitable for both cave and tree roosting species. this pattern extended to other vertebrate species as well. rocky escarpment regions in the top end support high species diversity as well as a number of endemic or habitat restricted species (woinarski & gambold ; . vegetation corridors beside rivers and surrounding areas (but not the waterbodies themselves) appeared to be important environments as they supported high bat species richness. bats are regularly characterized by the foraging strategy they employ within their immediate environment (mckenzie & rolfe ; neuweiler ; schnitzler & kalko ) . rivers are often associated with environments with tall dense vegetation. these areas do not appear to be of conservation significance because we did not observe high species richness at our 'riparian' sample sites. however, riverine environments usually have a distinct outer 'edge' and vegetation surrounding these areas is usually shorter and relatively open. we propose that these areas had greater species richness as they provide a diversity of environments for bats that employ different foraging strategies. we recommend that further research be conducted to examine the relationship between rivers and bats in the top end. our study did not take into account longer-term bat population dynamics. bats in the top end are poorly surveyed and, with few exceptions, surveys have been unstructured and unsystematic. therefore, attempting to identify and compare historical trends in bat populations is very difficult. given the top end environment is (currently) relatively unmodified, it could be assumed that mammal populations will remain stable and secure over the short to medium term. unfortunately, this is not the case. woinarski et al. ( ) described a case of decline in terrestrial small mammals in a conservation reserve in the top end that could not be confidently attributed to any clear environmental factor(s). further cases have also emerged (e.g. pardon et al. ; watson & woinarski ) . therefore, we recommend establishing longterm monitoring programs to track changes in bat populations so that changes may be quickly identified, assessed and appropriately managed. this is a highly challenging task that can only be achieved through a considerable commitment of time and resources. fire in tropical savannas: the kapalga experiment patn. pattern analysis package. csiro division of wildlife & ecology preliminary biogeographic analysis of the northern territory vascular flora australian bats statistical design and analysis for a 'biological effects' study glim for ecologists bats and gaps: microchiropteran community structure in a queensland rain forest the foraging behaviour and ecology of animal-eating bats the ecological basis of life history variation in marsupials the vegetation of the australian tropical savannas. environmental protection agency aspects of the ecology of insectivorous forestdwelling bats (microchiroptera) in the western slopes of the australian alps preliminary investigation of roosting habitat preferences of the large forest bat vespadelus darlingtoni (chiroptera, vespertilionidae) anuclim version . . centre for resource and environmental studies rarity in the tropics: latitudinal gradients in distribution and abundance in australian mammals determinants of loss of mammal species during the late quaternary 'megafauna' extinctions: life history and ecology, but not body size an analysis of epiphytic lichen communities in tasmanian cool temperate rainforest detection of bats by mist-nets and ultrasonic sensors activity and stratification of microchiropteran bat communities in thinned, unthinned and old lowland regrowth forest, east gippsland roost preferences and foraging ranges of the eastern forest bat vespadelus pumilus under two disturbance histories in northern new south wales a bat survey in state forests on the south-west slopes region of new south wales with suggestions of improvements for future surveys bat communities in a fragmented forest landscape on the south-west slopes of new south whales bats of a semi-arid environment in south-eastern australia: biogeography, ecology and conservation location of roots of the lesser long-eared bat nyctophilus geoffroyi and gould's wattled bat chalinolobus gouldii in fragmented landscape in south-eastern australia roost selection by gould's long-eared bat, nyctophilus gouldi, tomes (chiroptera: vespertilionidae) in logged forest on the south coast of australian soil and land survey field handbook bats of the southern carnarvon basin structure of bat guilds in the kimberley mangroves nor-for. mapping the forest cover of the nt. document field methodology and fpc indexing. department of lands planning and environment distribution of mammals in monsoon rainforests of the northern territory key to the bat calls of the top end of the northern territory a comparison of three survey methods for collecting bat echolocation calls and species accumulation rates from nightly anabat recordings surveying bat communities: a comparison between mist nets and the anabat ii bat detector system foraging ecology and audition in echolocating bats a comparison of acoustic versus capture techniques for the inventory of bats feeding ecology of tasmanian bat assemblages determinants of survival for the northern brown bandicoot under a landscape-scale fire experiment classification, species richness, and environmental relations of monsoon rain forest in northern australia how echolocating bats search and find food the mammals of australia. reed books composition of the bat (chiroptera: vespertilionidae) communities in tasmanian forests vertebrate monitoring and re-sampling in kakadu national park biogeographic patterns, environmental correlates and conservation of avifauna in the northern territory hollows in jarrah (eucalyptus marginata) and marri (corymbia calophilla) trees. i. hollow sizes, tree attributes and ages gradient analysis of a tropical herpetofauna: distribution patterns of terrestrial reptiles and amphibians in stage iii of kakadu national park wildlife of lancewood, acacia shirleyi thickets and woodlands in northern australia. . variation in vertebrate species composition across the environmental range occupied by lancewood vegetation in the northern territory gradient analysis of the distribution of mammals in stage iii of kakadu national park, with a review of the distribution patterns of mammals across north-western australia distribution patterns of vertebrates in relation to an extensive rainfall gradient and variation in soil texture in the tropical savannas of the northern territory bird distribution in riparian vegetation in the extensive natural landscape of australia's tropical savanna: a broad-scale survey and analysis of a distributional data base changes in mammal populations in relatively intact landscapes of kakadu national park bat fauna of a semi-arid environment in central western queensland our thanks go to bryan baker, chaz delacoeur, chris grant, david holland, marieke lettink, tony mitchell, steve owen, terry reardon, nathalia velez and felicity watt for their help with field work. greg connors, andrew edwards and peter brocklehurst assisted with various aspects of the analysis. john sheppard tracked down many of the references. thanks to irene rainey and peta jones who did a wonderful job with data entry. many parks and wildlife rangers and landholders assisted in planning surveys and locating suitable sampling sites. john woinarski, chris johnson, brad law, michael bull and an anonymous referee provided valuable comments on the manuscript. d.m. also thanks john woinarski for his support throughout this project. the tropical savannas crc provided funding for this project. animal sampling procedures were approved by the n.t. animal ethics committee (ref: a ). key: cord- - rrlap authors: field, h. e.; mackenzie, john s.; daszak, p. title: henipaviruses: emerging paramyxoviruses associated with fruit bats date: journal: wildlife and emerging zoonotic diseases: the biology, circumstances and consequences of cross-species transmission doi: . / - - - - _ sha: doc_id: cord_uid: rrlap two related, novel, zoonotic paramyxoviruses have been described recently. hendra virus was first reported in horses and thence humans in australia in ; nipah virus was first reported in pigs and thence humans in malaysia in . human cases of nipah virus infection, apparently unassociated with infection in livestock, have been reported in bangladesh since . species of fruit bats (genus pteropus ) have been identified as natural hosts of both agents. anthropogenic changes (habitat loss, hunting) that have impacted the population dynamics of pteropus species across much of their range are hypothesised to have facilitated emergence. current strategies for the management of henipaviruses are directed at minimising contact with the natural hosts, monitoring identified intermediate hosts, improving biosecurity on farms, and better disease recognition and diagnosis. investigation of the emergence and ecology of henipaviruses warrants a broad, cross-disciplinary ecosystem health approach that recognises the critical linkages between human activity, ecological change, and livestock and human health. the apparent temporally clustered emergence of hendra virus and nipah virus in australia and malaysia, respectively, and the identification of species of fruit bats ( pteropus spp., commonly known as flying foxes) as likely reservoir hosts, poses a number of important questions on the ecology of henipaviruses. what factors precipitated their emergence? why did they emerge at this time? what are the spillover mechanisms? what is their geographic occurrence? what are the potential impacts on humans and domestic species? the more recent description of nipah virus-attributed disease in humans in bangladesh reinforces the need for a comprehensive understanding of the ecology and, more broadly, epidemiology of these agents. this chapter describes the emergence of hendra and nipah viruses and the search for their natural hosts, discusses the impacts of emergence, and suggests factors putatively associated with emergence. hendra virus was first described in in australia when it caused an outbreak of severe acute respiratory disease with high mortality in thoroughbred horses in a training stable in the city of brisbane (murray et al. b) . a member of the family paramyxoviridae , hendra virus was initially called equine morbillivirus, but was later re-named hendra virus, after the brisbane suburb where the outbreak occurred. to date there have been five known foci of hendra virus infection in horses: brisbane , mackay , cairns , cairns , and townsville . the putative index case in the brisbane outbreak was a heavily pregnant mare at pasture. she was observed to be ill on september , and moved to the hendra training facility for intensive care, but died days later. over the following days, of thoroughbreds in the facility and a neighbouring stable became ill and died acutely or were euthanised terminally ( fig. ) (murray et al. a) . clinical signs included fever, facial swelling, severe respiratory distress, ataxia, and terminally, copious frothy (sometimes blood-tinged) nasal discharge. there were four non-fatal cases, two of which retained mild neurological signs. a further three horses in the stable were subsequently found to have seroconverted without apparent clinical signs. all seven were subsequently euthanised douglas et al. ) . the trainer and a stable hand, both directly involved in nursing the index case, became ill with a severe influenza-like illness within a week of contacting the index case. the trainer was hospitalised and subsequently died after respiratory and renal failure. infection with hendra virus was demonstrated in both cases . the mackay ( ) spillover chronologically preceded the brisbane outbreak by weeks, but was only retrospectively identified in october after the hendra virus-attributed death of a thoroughbred stud-owner suffering a murray et al. a) relapsing encephalitis. two horses were infected on the mackay property, both fatally rogers et al. ) . the first horse, a -year-old heavily pregnant thoroughbred mare died on august , after exhibiting severe respiratory distress, ataxia, and marked swelling of the cheeks and supraorbital fossa over a -h period. the second horse, a two-year-old colt in an adjoining paddock was reported to have licked the muzzle of the dead mare. the colt died days later, again after a -h clinical course, during which he exhibited aimless pacing, muscle trembling and haemorrhagic nasal discharge (allworth et al. ) . serological studies were an integral part of the outbreak investigations of the brisbane and mackay incidents. no evidence of hendra virus infection was found in domestic animals surveyed on the case properties or on incontact properties. they included horses, cattle, goats and pigs, dogs, cats, and poultry rogers et al. ) . particular effort was directed towards surveying the broader horse population in the state of queensland, with a further , horses from properties sampled in a structured survey (ward et al. ) . with the exception of the seven horses that survived infection in the hendra outbreak, none of the surveyed domestic animals showed serological evidence of exposure to hendra virus. the negative surveillance findings (based on a highly sensitive serum neutralisation test) provided a high level of confidence that hendra virus was not being sustained by in-contact domestic animal transmission, was not established in the queensland horse population, and that the outbreak was unlikely to have originated from domestic species. because of the temporal clustering of the mackay and brisbane incidents, efforts were made to identify possible links between the two properties. these investigations, undertaken in late , and focused primarily on horse movements, personnel movements, and management practices, found no evidence to directly link the two outbreaks. in january , a third spillover was identified in a non-pregnant mare near cairns in north queensland. the horse deterioriated despite symptomatic treatment and was euthanised. a companion horse was unaffected on clinical and serological examination . in late , again in north queensland, in two spatially and temporally clustered events in cairns and townsville, a further two horses (both geldings) were fatally infected and a human case non-fatally infected. the human case, a veterinarian who undertook a necropsy on the first (cairns) horse, and two assisting handlers, reported influenza-like symptoms - days after the necropsy. all three were negative for antibodies to hendra virus by immunofluorescent antibody test (ift) and enzyme-linked immunosorbent assay (elisa) at that time. a follow-up sample taken from the veterinarian was positive by ift and elisa, and neutralising antibodies to hendra virus were detected by serum neutralisation test. the two handlers remained seronegative. the veterinarian made an uneventful recovery. the horse was retrospectively diagnosed as a presumptive case on clinical grounds-no samples were available for laboratory confirmation (field et al. ). a major outbreak of disease in pigs and humans occurred in peninsular malaysia between september and april , resulting in the death of of human cases, and the culling of over million pigs (chua et al. ; nor et al. ) . initially attributed to japanese encephalitis virus, the primary disease aetiology was subsequently shown to be another previously undescribed virus of the family paramyxoviridae . preliminary characterisation of an isolate at the centers for disease control and prevention in fort collins, colorado, and atlanta, georgia, usa, showed that the new virus, subsequently named nipah virus, had ultrastructural, antigenic, serologic and molecular similarities to hendra virus (cdc ) . the epidemic primarily impacted on pig and human populations. infection in pigs was highly contagious, and clinical disease was characterised by acute fever with respiratory and/or neurological involvement. incubation was estimated to be - days. crude case mortality was low (< %), and notably, a large proportion of infected pigs was asymptomatic. the clinical course appeared to vary with age. sows primarily presented with neurological disease, but sometimes died suddenly without evident signs. in weaners and porkers, a respiratory syndrome predominated, frequently accompanied by a harsh non-productive (loud barking) cough. the predominant clinical syndrome in humans was encephalitic rather than respiratory, with clinical signs including fever, headache, myalgia, drowsiness, and disorientation sometimes proceeding to coma within h (chua et al. ; goh et al. ) . the majority of human cases had a history of direct contact with live pigs. most were adult male chinese pig farmers (chua et al. ; parashar et al. ) . evidence of nipah virus infection was also been found in dogs, cats and horses (chua et al. ; nor et al. ) . the initially high prevalence of infection in dogs in the endemic area during and immediately following the removal of pigs suggested that dogs readily acquired infection from infected pigs. the much lower antibody prevalence and restriction of infection to within km of the endemic area suggests that nipah virus did not spread horizontally within dog populations, and that dogs were effectively a dead-end host ). five outbreaks of nipah virus-associated disease in humans were described in bangladesh between april and february (anonymous (anonymous , a (anonymous , b (anonymous , b hsu et al. ) . to february , a total of cases were recognised by the bangladesh directorate of health services, at least ( %) of which were fatal. a number of the characteristics of the bangladesh outbreaks are similar to the outbreak in malaysia; delayed recognition, a primary presentation with fever and central nervous system signs, and a high case fatality. however, in marked contrast to the malaysian outbreak, infection in humans was not associated with disease in pigs (indeed pigs are uncommon in bangladesh), and there was evidence of horizontal human transmission (discussed sect. ). the first reported outbreak ( cases, nine fatal) was in meherpur in april-may . the index case, a -year-old farmer, developed symptoms on april , and died days later. four other persons in the same household became cases - days after the index case. a further four of the cases were relatives of the index case. the second reported outbreak of cases (eight fatal) occurred in naogaon in january . the index case was a -yearold boy. cases occurred in eight households. a cluster of cases occurred in one household after the head of the household became ill and later died. two weeks later, his wife and his three eldest daughters became ill; his wife and one daughter died. in both the meherpur and naogaon outbreaks, handling or exposure to patient secretions was a risk factor for illness (hsu et al. ). the third reported outbreak occurred simultaneously in goalanda (rajbari district) and seven other districts between january and february . a total of cases were reported, of whom died. there was a predominance of young boys in the goalanda cluster, suggesting that a specific activity (such as climbing trees or ingesting fruits contaminated with the secretions of infected bats) may have led to exposure (anonymous a) . the fourth reported outbreak occurred in the faridpur district in april . of identified cases, were fatal. this outbreak differed from previous outbreaks in two important ways. firstly, at least six patients developed an acute respiratory distress syndrome, in contrast to the previously observed predominant fever/neurological presentation; and secondly, the epidemiological evidence clearly indicated that person-to-person spread (possibly through large droplet transmission) was the primary mode of transmission. a fifth reported outbreak ( cases, fatal) was reported in january , in the northern district of tangail. cases predominantly exhibited fever and neurological symptoms. drinking raw date palm juice was the only surveyed exposure significantly associated with illness. bats reportedly frequently drink from the open pots into which dripping juice is collected overnight, and bat excrement is reportedly common on or in the pots (anonymous b) . the pattern of the bangladesh outbreaks suggests a sporadic, geographically scattered introduction of infection to humans. nucleotide sequence data also supports a different epidemiology in bangladesh. overall, the nucleotide sequences of the genomes of the nipah viruses isolated in bangladesh in and in malaysia in share % identity. while the size and distribution of the open reading frames and the sequences of key regulatory elements are conserved, the amount of genetic diversity present in sequences obtained in malaysia and bangladesh varies (harcourt et al. ) . those obtained from human cases in malaysia suggest a single source of human infection from the porcine amplifying host (abubakar et al. ; chan et al. ; chua et al. ) ; those from bangladesh cases formed a cluster clearly distinct from the malaysian sequences, but differed from each other by approximately . %, suggesting possible multiple introductions of virus into humans. as yet, sequence data are unavailable from virus isolates obtained from putative person-to-person transmission chains to suggest genetic changes potentially associated with adaptation to the novel human host. sequence changes in sars coronavirus isolated from palm civets and from humans suggest active selection of novel genotypes, including genotypes potentially adapted to a novel human reservoir host song et al. ) . such genetic adaptation is a significant transition point in the evolution of specific human pathogens by which agents can emerge as pandemic threats, such as hiv and influenza a subtypes (see the chapter by childs et al., this volume; childs ). the emergence of hendra virus caused consternation for both animal and public health authorities in australia. zoonotic infections of horses were previously unknown, yet it quickly became evident that the infection and consequent death of the trainer was attributable to his close contact with the index horse case. when the aetiological agent was established as a novel virus of the family paramyxoviridae , the search for its origin began. the phylogenetic analysis suggested that the virus had not resulted from single or multiple point mutations from a closely related virus, and that emergence from a natural host was the most probable explanation of its origin (murray et al. b ). serosurveillance of wild-caught wildlife, initially in the brisbane index case paddock, and later the mackay index case property, was undertaken to evaluate this hypothesis. negative findings prompted broadening of the sample base to include sick and injured wildlife in temporary captivity. apart from increasing the number of species and locations sampled, this approach offered the advantages of a convenient and cost-effective sample, and access to that subset of the greater wildlife population in sub-optimal health. access to the latter was of particular interest, because if infection in a natural host was associated with disease or debility, then infected animals would be over-represented in this group and thus more readily detected. species that were common to the two locations and able to move readily between the two locations were given the highest surveillance priority . flying foxes (genus pteropus , order chiroptera ) were the only mammalian species meeting these criteria. the knowledge that viruses of the family paramyxoviridae had previously been isolated from bats elsewhere (henderson et al. ; pavri et al. ) reinforced this focus. of flying foxes screened using this approach, % had antibodies neutralising hendra virus (field )a major breakthrough in the search for the origin of hendra virus. subsequently, virus was isolated from two species (halpin et al. ) . investigations of the role of flying foxes in the ecology of the virus continued, and subsequent studies showed evidence of previous exposure to hendra virus in all four mainland australian flying fox species across their range. species ( pteropus alecto ) and increasing age were risk factors for infection in flying foxes. retrospective studies identified evidence of infection in flying foxes well before the first known spillover to horses (field ) . these features suggest a major role for flying foxes in the ecology of hendra virus, and are consistent a mature host-agent relationship. subsequent studies identified neutralising antibodies to hendra virus in multiple flying fox species in papua new guinea to the immediate north of australia . current research priorities include modelling virus maintenance in flying fox populations ) and defining flying fox population dynamics by genetic and satellite telemetry studies (daszak et al. ). investigation of the origin of nipah virus was an integral part of the malaysian outbreak response, and as the outbreak in pigs and humans came under control, the focus of part of the investigating team shifted to identifying the source of the infection in pigs. molecular and serologic evidence indicating that nipah and hendra viruses were closely related made malaysian bat species a logical surveillance priority. malaysia has a great diversity of bat species: at least described species of fruit bat (sub-order megachiroptera ), including two flying fox species, and described species of insectivorous bats (sub-order microchiroptera ) in peninsular malaysia alone (medway ) . wildlife rescue networks are less extensive in malaysia than in australia, thus an opportunistic sampling methodology was not a realistic option in the nipah virus investigations, as it was in australia with hendra virus, and wild-caught bats were the primary survey target. over a -week period, bat populations at multiple locations across peninsular malaysia were sampled, with sampling locations including but not limited to the outbreak areas. neutralising antibodies to nipah virus were found in bats from five species, but predominantly in pteropus hypomelanus and pteropus vampyrus (johara et al. ). subsequently, chua et al. ( ) recovered nipah virus from the urine of p. hypomelanus and from partially eaten fruit which had been contaminated by bat saliva or, less likely, bat urine. current research priorities include investigation of the population dynamics of p. vampyrus in malaysia and across its range, and the dynamics of nipah virus infection in p. vampyrus and p. hypomelanus (daszak ) . ubiquitous peridomestic species were also extensively surveyed in seeking the origin of nipah virus in malaysia. the uniformly negative serology results from surveyed peridomestic rodents, insectivores, and birds in malaysia (asiah et al., unpublished data) indicate that these animals did not play a role as secondary reservoirs for nipah virus. however, dogs did readily acquire infection following close association with infected pigs, and while horizontal transmission was not evident in dog populations, infected dogs possibly played a role in farm-to-farm transmission. a serologic survey of domestic and wild animals undertaken after the meherpur and naogaon outbreaks in bangladesh identified evidence of infection only in the flying fox pteropus giganteus . other (unidentified) bats showed no evidence of infection (anonymous a; hsu et al. (sendow et al. ) and cambodia (olson et al. ) , and the isolation of nipah virus from flying foxes in cambodia (reynes et al. ) strongly supported the hypothesis of halpin et al. ( ) that henipaviruses likely exist across the entire global distribution of pteropid bats. a comprehensive investigation of the ecology of niv in p. giganteus is needed to underpin risk management strategies in bangladesh. obvious research priorities include population dynamics of p. giganteus , nipah virus infection dynamics in the species, potential modes of transmission to humans, and identification of factors precipitating emergence. the mode of transmission of hendra virus infection to horses in australia has yet to be established. however, epidemiological investigations of natural infections in horses and flying foxes, and the outcomes of experimental infections in a range of species, provide useful information. firstly, respiratory spread has not been demonstrated experimentally in any species, and the spatial pattern in naturally infected horses has not been consistent with respiratory spread. secondly, hendra virus has been isolated from the kidney and urine of horses and cats experimentally infected with hendra virus, and cat-to-cat transmission and suspected cat-to-horse transmission have been attributed to exposure to infected urine (westbury et al. ; williamson et al. ) . thirdly, horses have been experimentally infected by the naso-oral route (williamson et al. ) . thus, hypotheses involving ( ) the excretion of an infective dose of hendra virus from a flying fox, ( ) contamination of pasture, and ( ) ingestion of the contaminated pasture by a susceptible horse are plausible. young et al. ( ) proposed that transmission from flying foxes to horses was effected by contact with infected foetal tissues or fluids via the ingestion of recently contaminated pasture. this hypothesis was largely based on the august-september temporal overlay of the brisbane and mackay spillovers with the late gestation of p. alecto and p. poliocephalus in queensland, the isolation of the virus from uterine fluid and foetal tissues of a naturally infected pregnant flying fox (halpin et al. ) , and on the absence of evidence of infection in flying fox carers regularly exposed to other potential routes of excretion such as urine, faeces and oro-nasal secretions. notwithstanding the latter, an alternative hypothesis is that the ingestion of pasture contaminated with infected flying fox urine is the mode of transmission to horses. although hendra virus has yet to be isolated from flying fox urine, the previously described isolation of nipah virus from the urine of free-living p. hypomelanus (chua et al. ) supports urine as a plausible route of excretion for hendra virus. the urine hypothesis is also supported by the experimental studies described above that attribute cat-to-cat and probable cat-to-horse transmission to exposure to infected urine. another plausible hypothesis is that the ingestion of spats (the fibrous remains of masticated fruit dropped by feeding flying foxes) is the mode of transmission to horses. the quantity of these spats under food trees bearing fibrous fruit (such as the ficus species present in the brisbane index case paddock) can be substantial, and they may represent an attractive source of salivaladen virus to grazing horses. the viability of virus in spats is also likely to be prolonged due to slowed desiccation, heat and ultraviolet action. hendra virus has been isolated from the oral cavity of experimentally infected horses (williamson et al. ) and as previously noted, the closely related nipah virus has been isolated from fruit partially eaten by bats (chua et al. ) , supporting saliva as a plausible route of excretion of hendra virus from flying foxes. it should be recognised that the mode of transmission between flying foxes and the mode of transmission from flying foxes to horses may differ. the infectious dose, the routes of infection, and the physiological risk factors for infection in both species are unknown or incompletely understood. managing the risk of spillover to horses is further constrained by the lack of knowledge of the incidence of infection and the temporal pattern of infection (and thus excretion) in flying foxes. regardless of the mode of transmission to horses, it is evident from natural infections and experimental studies that horse-to-horse transmission is not readily effected. the apparent exception is the first recognised outbreak in the brisbane stables that involved equine cases. however, the temporal pattern of infection in this outbreak suggests that the index case was the source of infection for all cases and that no secondary infection occurred . indeed, it is probable that horse-to-horse transmission in this instance was inadvertently facilitated by husbandry practices or other actions in the stable that resulted in the direct transmission of infected body fluids. two plausible scenarios have been proposed: that a common syringe and needle was used to administer medication to the index case and to other (subsequently infected) horses; or that a cloth, bridle or other piece of equipment contaminated with infectious oral secretions from one horse was used on other (subsequently infected) horses. likewise it is evident that horse-to-human transmission does not readily occur. many people were potentially exposed to infection in the investigation of the brisbane outbreak in particular, yet only the trainer and a strapper succumbed: both were closely involved in nursing the index case. it is also evident that bat-to-human transmission does not readily occur. after the identification of flying foxes as the origin of hendra virus, a serologic survey of persons with high occupational or recreational exposure to flying foxes found none of had neutralising antibodies to hendra virus . whether the apparently low infectivity for horses and humans is a reflection of the innate infectivity of hendra virus, the instability of the virus outside the host, or of ineffective contact is unclear, although experimental studies support the former. the putative mode of transmission of nipah virus in malaysia is from flying foxes to pigs to humans. the epidemiological evidence indicates that the spillover from flying foxes to pigs occurred in northern peninsular malaysia (nor et al. ) . chua et al. ( ) , having isolated nipah virus from flying fox urine and from fruit partially eaten and discarded by flying foxes, hypothesised that transmission to pigs was effected by infected flying foxes feeding in trees overhanging pig pens. epidemiological (nor et al. ) and experimental (middleton et al. ) findings indicate that pigs are highly susceptible to infection, and thus once infection is introduced to a farm, on-farm spread is rapid. the primary mode of on-farm transmission was believed to be via the oro-nasal route; the primary means of spread between farms and between regions was the movement of pigs. secondary modes of transmission between farms within localised farming communities may have included roaming infected dogs and cats, and sharing of boar semen (although at present, virus has not been identified in porcine semen). trucks transporting pigs may also have introduced the virus onto farms (nor et al. ) . while the timing of the spillover (or spillovers) from flying foxes to pigs and the early epidemiology of infection in pig farms in northern peninsular malaysia are unclear, retrospective investigations suggest that nipah virus has been responsible for sporadic disease in pigs in peninsular malaysia since late . it is suggested that the disease was not recognised as a new syndrome because the clinical signs were not markedly different from those of several endemic pig diseases, and because morbidity and mortality were not remarkable (bunning et al. ) . epidemiological modelling also supports an earlier spillover event (daszak et al. ) . they contend that a second introduction of infection was likely necessary for infection to become endemic in the , -pig index-case farm and thus provide a sustained reservoir of nipah virus from which to infect other farms. conclusive evidence of person-to-person transmission of nipah virus was not found during investigations in malaysia and singapore. however, it should be noted that excretion of nipah virus in urine and mucous obtained by throat swabs was readily demonstrable by isolation of virus from clinical samples obtained from acutely infected humans (chua et al. a) . these data suggest the potential for person-to-person transmission of nipah virus in southeastern asia was epidemiologically plausible. the evident horizontal human infection and the apparent absence of an intermediate domestic animal reservoir in the bangladesh outbreaks are disturbing epidemiologic features not evident in malaysia and singapore. the earlier bangladesh outbreaks suggested that close contact (handling or exposure to patient secretions) was necessary for person-to-person transmission, but the appearance of an acute respiratory syndrome in the faridpur outbreak flagged the potential for much more efficient transmission. however, to date, person-toperson transmission appears to have been limited to a single generation, and no cases of transmission from patients to healthcare workers have been reported. a number of authors contend that a series of commonly occurring anthropogenic environmental changes drives disease emergence by pushing pathogens outside their normal population parameters (krause ; lederberg et al. ; morse ; smolinski et al. ) . they argue that the introduction of pathogens via global air travel and trade, the encroachment of human activities into wilderness regions, urbanisation, climatic changes and agricultural intensification are common drivers of emergence. for zoonotic diseases associated with wildlife reservoirs, anthropogenic factors that alter wildlife population structure, migration patterns and behaviour may also drive emergence of disease in human populations (daszak et al. (daszak et al. , . for example, human population encroachment into wildlife habitat may increase the risk of lyme disease and other tick-borne encephalitides by driving the loss of less competent reservoir hosts and promoting a more efficient one, namely the white-footed mouse, peromyscus leucopus (ostfeld and keesing ) . likewise, the introduction of a "new" infection into a human or domestic animal population may follow the incursion of humans (accompanied by their domestic animals) into previously remote natural habitats where unknown disease agents exist in harmony with wild reservoir hosts. upon contact with new species, an agent may jump species barriers, thereby spilling over into humans or livestock. unlike the natural host, the new host may have no natural immunity or evolved resistance. additionally, high population densities and management practices may facilitate the rapid spread of pathogens throughout livestock populations. infection may be transmitted to humans directly from the natural host or via an intermediate host. the available evidence suggests that hendra and nipah viruses are phylogenetically distinct from other members of the paramyxoviridae (gould ; murray et al. b) , well adapted to their natural flying fox hosts, and in whose populations they have long circulated . the close phylogenetic relationship between hendra and nipah suggests a common progenitor. however, it also appears that flying fox populations in australia and malaysia have been separate for a length of time sufficient for the respective viruses to evolve further in geographic isolation. so what precipitated their emergence? can environmental factors be identified that altered flying fox ecology and facilitated the movement of henipaviruses (and other bat-associated zoonoses) (breed et al. ) beyond their natural ecological niche, precipitating their emergence? disease emergence requires, in addition to the presence of an agent, an effective bridge from the natural host to a susceptible spillover host. such bridges result from anthropogenic or natural changes to the agent, the host, or the environment. available data on many fruit bat species suggests that populations in australia and asia are in decline and disruption throughout their range. in south-east asia, anthropogenic activities (primarily habitat loss and hunting) have been identified as constituting the major threats. deforestation, whether for agricultural land, commercial logging, or urban development, is widespread and results in loss or abandonment of roosting sites, and the loss of feeding habitats. secondarily, habitat loss due to clearing is commonly exacerbated by tropical storms, the remnant forest being particularly prone to high wind damage (mickleburg et al. ) . hunting, whether for consumption or crop protection, and at both a local and a commercial level, results in the abandonment of roost and feeding sites (mickleburg et al. ) . a scenario emerges of bat populations under stress, of altered foraging and behavioural patterns, of niche expansion, and of closer proximity to man. in eastern australia, the increasing urban presence of flying foxes [thought to be due to more reliable and abundant food resources (parry-jones and augee )] and the associated changes in flying fox population dynamics, represents a similar emergencepromoting scenario for hendra virus. the emergence of nipah virus disease clearly illustrates the two-step process described by morse ( ) . the establishment of pig farms within the range of the natural host supported the initial introduction into the pig population; the maintenance of high densities of pigs and the transport of pigs led to the establishment and rapid dissemination of infection within the pig population in peninsular malaysia. amplification of virus within pig populations then facilitated transmission to humans. a combination of factors likely increased the opportunity for effective contact between flying foxes and pigs, and thus the initial introduction of infection into the pig population. plausible hypotheses include: • the unsustainable hunting of pteropus bat species has caused localised niche vacuums (sinks) with relative resource abundance, creating regional gradients along which neighbouring bat populations move, resulting in a net movement of virus into human-inhabited areas and so an increased probability of effective contact and spillover. • regional deforestation has changed the seasonal foraging movements of pteropus bats and lead to an increased reliance on horticultural crops, resulting in a relative increased density of bats proximate to human and livestock populations. (climatic changes, forest fires and associated haze events have similarly been hypothesised to influence flying fox movement patterns (chua ). • the marked increase in the number, density and distribution of the malaysian pig population in the last years has led to an increased probability of contact between flying foxes and pigs. this probability has been further increased by the practice of planting fruit orchards immediately adjacent to piggeries (daszak et al. ) . worldwide, there are approximately species of bats in the genus pteropus (family pteropodidae , sub-order megachiroptera ). their distribution extends from the west indian ocean islands of mauritius, madagascar and comoro, along the sub-himalayan region of pakistan and india, through southeast asia, the philippines, indonesia, new guinea, southwest pacific islands as far east as the cook islands, and australia (fig. ) . although other genera of pteropodidae are present on mainland africa (i.e. eidolon , hypsignathus , rousettus , etc.) and in asia (i.e. rousettus ), the genus pteropus is restricted to madagascar and surrounding islands in africa; megachiropterans are absent from europe and the americas. three of the four species of flying foxes found on mainland australia are also found outside australia. black flying foxes ( p. alecto ), spectacled flying foxes ( p. conspicillatus ) and little red flying foxes ( p. scapulatus ) also occur in new guinea, with the regional distribution of p. alecto extending to the indonesian islands of sulawesi, lombok, kangean and baeween, and p. conspicillatus extending to the indonesian island of halmahera (hall and richards ; mickleburg et al. ; nowak ) . thus the distributions of two australian species overlap with those of the island flying fox ( p. hypomelanus ) and the malayan flying fox ( p. vampyrus ) in new guinea and indonesia. these species, at the northern extent of their range, overlap the indian flying fox ( p. giganteus ) , whose distribution extends eastward from thailand and burma across to india and pakistan. where distributions overlap, roosting camps are commonly shared. such a scenario would facilitate the transmission of infectious agents between neighbouring species, leading to the plausible existence of related viruses in flying fox populations across their range, as previously hypothesised (daszak et al. ; halpin et al. ) . based on maximum species diversity, flying foxes are believed to have originated from sulawesi and eastern new guinea (to the north of australia) and to have radiated to their present distribution (hall and richards ; mickleburg et al. ; nowak ) . thus, by extension, if henipaviruses have co-evolved with flying foxes, it is likely that they exist across their entire geographic distribution. this hypothesis could readily be tested by screening long-isolated populations from the western extent of the global pteropid range. host management strategies have been discussed by the authors elsewhere ( mackenzie et al. ; field et al. ). effective disease management requires an understanding of the epidemiology of the disease (knowledge of its cause, maintenance and transmission, host range of the aetiologic agent, and the nature of the host-agent relationship), an ability to detect disease (surveillance and diagnostic capabilities) and political, public and industry support (see the chapter by childs, this volume). broadly, current strategies for the management of henipaviruses are directed at minimising direct or indirect contact with the natural host, monitoring intermediate hosts, improving biosecurity on farms, and better disease recognition and diagnosis. the sporadic (and apparently rare) nature of hendra virus spillover events from flying foxes to horses, the low infectivity for horses (and consequently the limited economic impact), and the apparent absence of direct transmission from flying foxes to people has resulted in more emphasis on management strategies for horses than for flying foxes. quarantine of infected premises, movement controls on stock, and disinfection have proved effective strategies . a hendra virus vaccine is not currently available and development of one is not foreseen. australian veterinarians have a high awareness of hendra virus, and hendra virus exclusion is routinely undertaken for horses exhibiting an acute respiratory syndrome. veterinarians involved in these disease investigations wear appropriate protective equipment and use a limited necropsy approach, as horses have been the source of infection for all four human cases. putative risk factors for infection in horses have been previously proposed -breed (thoroughbred), sex (female), age (> years), pregnancy status (late pregnancy), housing (paddocked), season (late gestation or the birthing season of local flying foxes), and the presence of favoured flying fox food trees in the index case paddock . in the two cases, the putative association with age, paddock status, season and flying fox food source was maintained (field et al. ) . a considerable research focus on the ecology of hendra virus has yet to define the route of virus excretion or any temporal pattern of infection in flying foxes. this information, and knowledge of the actual mode of flying fox-to-horse transmission would facilitate a risk management approach to spillover infection in horses. in strong contrast to hendra virus, the nipah virus outbreak in peninsular malaysia in had an enormous economic and social impact. nipah virus was highly infectious for pigs, with all classes of pigs susceptible. the pattern of on-farm infection was consistent with respiratory transmission; betweenfarm spread was generally associated with the movement of pigs. the extensive post-outbreak surveillance program in malaysia showed that farms that did not receive pigs generally remained uninfected even when neighbouring farms were infected. human infections were predominantly attributed to contact with live pigs; none was attributed to contact with bats. horizontal transmission was not a feature of infection in humans (although the potential for person-to-person transmission was noted previously). recommended host management strategies primarily target pig-to-pig transmission, secondarily the flying fox-pig interface (that is, the natural host-spillover host interface). the central strategy is the implementation of sound farm management practices, such as monitoring herd health and early recognition of disease syndromes. the latter includes maintaining the high level of farmer and veterinarian awareness of the disease generated by the outbreak. a second key strategy is the strict application of farm-gate biosecurity (daniels ) , with clearly defined protocols for the introduction of new stock. these may include quarantine and/or exclusion testing. a nipah virus vaccine is not currently available and development of one is unlikely in the near future. overarching the above is a strategy of advanced planning for emergency management of disease outbreaks. this involves established surveillance, detection, and emergency response capabilities. the pre-existence of the latter in malaysia enabled the implementation of effective quarantine, movement controls, and culling to bring the outbreak under control. the malaysian pig population is now free of nipah virus infection. while strategies directed at the flying fox-pig interface are limited by our incomplete knowledge of the ecology of nipah virus, several simple on-farm measures can be taken to reduce the likelihood of spillover events occurring. the removal of fruit orchards and other favoured flying fox food trees from the immediate vicinity of pig sheds greatly reduces the probability of flying fox-pig contact. similarly, the wire screening of open-sided pig sheds is a simple and inexpensive strategy to prevent direct contact between flying foxes and pigs. indirect contact (with flying fox urine, faeces or spats, or with partially eaten fruit) can be avoided by ensuring roof run-off does not enter pig pens (chua ) . the emergence (or detection) of apparently directly transmitted infection from the natural reservoir to humans and subsequent person-to-person transmission (as appears to be the case in bangladesh) presents a new and formidable risk management challenge. initial ultrastructural studies (hyatt and selleck ; murray et al. b) indicated that hendra virus was a member of the family paramyxoviridae , possibly genus paramyxovirus or morbillivirus . comparative sequence analyses by pcr of a portion of the matrix protein supported this, with phylogenetic analysis indicating that the virus was distantly related to other known morbilliviruses (murray et al. b) . hence the name equine morbillivirus was tentatively ascribed to the virus. subsequently the natural hosts of the virus were shown to be flying foxes ( pteropus spp.) rather than horses, and sequencing of the entire genome identified significant differences from morbilliviruses (including a larger genome size) that supported the creation of a new genus (wang et al. ) . the authors proposed henipavirus as the new genus, with hendra virus the type species and nipah virus the second member. this was later accepted by the international committee for the taxonomy of viruses. several other previously unknown members of the family paramyxoviridae have been described in recent years. these include phocine distemper virus and cetacean morbillivirus (genus morbillivirus ), responsible for disease epidemics in marine mammals (osterhaus et al. ; taubenberger et al. ) ; menangle virus (genus rubulavirus ), which caused severe reproductive disease in a commercial piggery in australia in (philbey et al. ) ; salem virus (unclassified), possibly associated with a disease outbreak in horses in new hampshire and massachusetts, usa in (renshaw et al. ) ; tupaia paramyxovirus (unclassified), isolated from an apparently healthy tree shrew ( tupaia belangeri ) in thailand (tidona et al. ) ; tioman virus (genus rubulavirus ) and pulau virus (unclassified) isolated from flying foxes in malaysia during attempts to isolate nipah virus (chua et al. b) . tioman and menangle are phylogenetically closely related. tupaia virus and salem virus both share some sequence homology with hendra and nipah, yet have features that preclude their inclusion as henipaviruses or as morbilliviruses. while palau virus has yet to be fully characterised, it too appears not to fit readily into either genus. figure presents a phylogenetic representation of the family paramyxoviridae . there are two reports of isolations of paramyxoviruses from bats prior to the description of hendra virus in flying foxes in ; a sub-type of parainfluenza virus type from rousettus leschenaulti in india (pavri et al. ) and mapuera virus from sturnira lilium in brazil (henderson et al. ) . both of these viruses belong to the genus rubulavirus (though unrelated to menangle and tioman viruses); the bat genera rousettus (sub-order megachiroptera) and sturnia (sub-order microchiroptera) are not closely related to flying foxes. a search for the ancestors of henipaviruses might best target bat species taxonomically closer to the genus pteropus . changes in biodiversity due to human activities were more rapid in the past years than at any time in human history, and the drivers of change that cause biodiversity loss and lead to changes in ecosystem services are either steady, show no evidence of declining over time, or are increasing in intensity. under the four plausible future scenarios developed by the millennium ecosystem assessment report (anonymous a) , these rates of change in biodiversity are projected to continue or to accelerate. there is increasing realisation of the interconnectedness of the ecosystem and human health, and the relationship between the environment, human and non-human hosts, and pathogens. daszak et al. ( ) argue that most emerging diseases exist within a finely balanced host-agent continuum between wildlife, domestic animal and human populations. taylor et al. ( ) , in examining risk factors for disease emergence, conclude that emerging diseases are three times more likely to be associated with zoonotic pathogens than with non-zoonotic pathogens. an ecosystem health approach recognises the critical linkages between human activity, ecological change and health, and fosters a multidisciplinary approach that considers a range of influencing factors such as medical, environmental, economic and socio-political factors. the complexity of the emergence and epidemiology of the henipaviruses warrants such a broad, cross-disciplinary ecosystem health approach if the associated mechanisms are to be understood and future risks managed. henipaviruses appear to have only recently emerged. their ability to dramatically impact human and animal health, and the associated societal and economic consequences, has been clearly illustrated. horizontal transmission of henipaviruses in humans, absent in australia and malaysia, appears to be an alarming feature of nipah virus outbreaks in bangladesh. if transmission in humans becomes efficient, the potential exists for a worst-case emergence scenario. further, if henipaviruses, and the necessary and sufficient precipitating emergence factors exist across the distribution of all pteropid species, the emergence of further novel agents can be expected unless factors associated with emergence are addressed. isolation and molecular identification of nipah virus from pigs equine morbillivirus in queensland outbreaks of encephalitis due to nipah/hendra-like viruses, western bangladesh nipah encephalitis outbreak over wide area of western person-to-person transmission of nipah virus during outbreak in faridpur district millennium ecosystem assessment ecosystems and human well-being report nipah virus outbreak from date palm juice epidemiological investigations into the equine morbillivirus outbreaks in queensland australia volant viruses: a concern to bats, humans and other animals epidemiological trace-back studies of the nipah virus outbreak in pig farms in the ipoh district of malaysia, - outbreak of hendra-like virus-malaysia and singapore complete nucleotide sequences of nipah virus isolates from malaysia zoonotic viruses of wildlife: hither from yon nipah virus outbreak in malaysia fatal encephalitis due to nipah virus among pig-farmers in malaysia nipah virus: a recently emergent deadly paramyxovirus the presence of nipah virus in respiratory secretions and urine of patients during an outbreak of nipah virus encephalitis in malaysia tioman virus, a novel paramyxovirus isolated from fruit bats in malaysia isolation of nipah virus from malaysian island flying foxes the nipah virus outbreak in malaysia: overview of the outbreak investigation and the issues that remain the henipavirus ecology collaborative research group (herg) project overview emerging infectious diseases of wildlifethreats to biodiversity and human health anthropogenic environmental change and the emergence of infectious diseases in wildlife the henipavirus ecology research group (herg) ( ) the emergence of nipah and hendra virus: pathogen dynamics across a wildlife-livestock-human continuum outbreak investigation of an emerging disease (equine morbillivirus) the ecology of hendra virus and australian bat lyssavirus a fatal case of hendra virus infection in a horse in north queensland: clinical and epidemiological features epidemiological perspectives on hendra virus infection in horses and flying foxes the natural history of hendra and nipah viruses novel viral encephalitides associated with bats ( chiroptera ) -host management strategies clinical features of nipah virus encephalitis among pig farmers in malaysia comparison of the deduced matrix and fusion protein sequences of equine morbillivirus with cognate genes of the paramyxoviridae flying foxes: fruit and blossom bats of australia isolation of hendra virus from pteropid bats: a natural reservoir of hendra virus genetic characterisation of nipah virus characterization of mapeura virus: structure, proteins and nucleotide sequence of the gene encoding nucleocapsid protein the retrospective diagnosis of a second outbreak of equine morbillivirus infection ultrastructure of equine morbillivirus the origins of plagues: old and new emerging infections: microbial threats to health in the united sates sars transmission pattern in singapore reassessed by viral sequence variation analysis emerging viral diseases of southeast asia and the western pacific managing emerging diseases borne by fruit bats (flying foxes) with particular reference to henipaviruses and australian bat lyssavirus old world fruit bats: an action plan for their conservation. internation union for the conservation of nature and natural resources experimental nipah virus infection in pigs and cats factors in the emergence of infectious diseases a novel morbillivirus pneumonia of horses and its transmission to humans a morbillivirus that caused fatal disease in horses and humans nipah virus infection of pigs in peninsular malaysia walker's bats of the world antibodies to nipah-like virus in bats mass mortality in seals caused by a newly discovered morbillivirus biodiversity and disease risk: the case of lyme disease case-control study of risk factors for human infection with a novel zoonotic paramyxovirus nipah virus, during a - outbreak of severe encephalitis in malaysia factors affecting the occupation of a colony site in sydney new south wales by the grey-headed flying-fox pteropus poliocephalus (pteropodidae) isolation of a new parainfluenza virus from a frugivorous bat rousettus leschenaulti, collected at poona india an apparently new virus (family paramyxoviridae) infectious for pigs, humans and fruit bats disease ecology of hendra virus: epidemiological modelling to test theories for emergence. abstracts wildlife disease association international conference (wildlife health in a shrinking world: ecology, management and conservation) nipah virus in lyle's flying foxes cambodia investigation of a second focus of equine morbillivirus infection in coastal queensland infection of humans and horses by a newly described morbillivirus henipavirus in pteropus vampyrus bats indonesia cross-host evolution of severe acute respiratory syndrome coronavirus in palm civet and human two morbilliviruses implicated in bottlenose dolphin epizootics risk factors for human disease emergence isolation and molecular characterisation of a novel cytopathogenic paramyxovirus from tree shrews the exceptionally large genome of hendra virus: support for creation of a new genus within the family paramyxoviridae negative findings from serological studies of equine morbillivirus in the queensland horse population susceptibility of cats to equine morbillivirus transmission studies of hendra virus (equine morbillivirus) in fruit bats, horses and cats nipah virus infection in bats (order chiroptera) in peninsular malaysia serologic evidence for the presence in pteropus bats of a paramyxovirus related to equine morbillivirus finding the wildlife reservoir of equine morbillivirus. in: asche v (ed) recent advances in microbiology acknowledgements hume field is supported by the department of primary industries and fisheries, queensland, australia, the australian biosecurity cooperative research centre for emerging infectious disease, and by an nih/nsf "ecology of infectious diseases" award from the john e. fogarty international center (ro -tw ). john mackenzie is supported by western australian government office of science and innovation, curtin university, and the australian biosecurity cooperative research centre for emerging infectious disease. peter daszak is supported by the consortium for conservation medicine and by nih/nsf "ecology of infectious diseases" award from the john e fogarty international center (ro -tw ). there were two further separate equine cases of hendra virus infection in australia in : in the south-east of queensland (june), and in the north of the adjacent state of new south wales (october). these cases had a number of features in common with previous index cases, including apparent spatial and temporal clustering (field et al, ) . in addition, a cluster of human cases of suspect nipah virus disease was reported in the kushtia region of eastern bangladesh and neighbouring west bengal (india) in april, . the disease presented as an acute neurological syndrome. (promed , april ) . key: cord- -c mzcu authors: shukla, nagesh; pradhan, biswajeet; dikshit, abhirup; chakraborty, subrata; alamri, abdullah m. title: a review of models used for investigating barriers to healthcare access in australia date: - - journal: int j environ res public health doi: . /ijerph sha: doc_id: cord_uid: c mzcu understanding barriers to healthcare access is a multifaceted challenge, which is often highly diverse depending on location and the prevalent surroundings. the barriers can range from transport accessibility to socio-economic conditions, ethnicity and various patient characteristics. australia has one of the best healthcare systems in the world; however, there are several concerns surrounding its accessibility, primarily due to the vast geographical area it encompasses. this review study is an attempt to understand the various modeling approaches used by researchers to analyze diverse barriers related to specific disease types and the various areal distributions in the country. in terms of barriers, the most affected people are those living in rural and remote parts, and the situation is even worse for indigenous people. these models have mostly focused on the use of statistical models and spatial modeling. the review reveals that most of the focus has been on cancer-related studies and understanding accessibility among the rural and urban population. future work should focus on further categorizing the population based on indigeneity, migration status and the use of advanced computational models. this article should not be considered an exhaustive review of every aspect as each section deserves a separate review of its own. however, it highlights all the key points, covered under several facets which can be used by researchers and policymakers to understand the current limitations and the steps that need to be taken to improve health accessibility. appropriate and timely access to healthcare is of the utmost importance; if not provided, it can lead to several concerns like missed scheduled appointments, delayed medication, and potential fatality. the barriers to accessibility are varied and are dependent on location, affected disease and patient characteristics. australia is a vast country with a very diverse population where settlement is spread thinly over vast areas [ ] . the country also has an aging population which will require healthcare support in the future. therefore, understanding the models used to analyze barriers to healthcare access across various diseases is crucial. in terms of geographic patterns, % of the population live in rural and remote areas; they have lower usage rates due to the distance-decay relationship. the distance-decay association suggests that people who live farther from healthcare facilities have lower rates of usage, after the adjustment of other factors for need, than those who we also analyzed the states where the studies were conducted. the results reveal that % of the studies were conducted on a national level. the studies conducted in specific states are illustrated in figure . the analysis was performed based on the state where the study was conducted irrespective of covering a small part of the state. we also analyzed the states where the studies were conducted. the results reveal that % of the studies were conducted on a national level. the studies conducted in specific states are illustrated in figure . the analysis was performed based on the state where the study was conducted irrespective of covering a small part of the state. we also analyzed the states where the studies were conducted. the results reveal that % of the studies were conducted on a national level. the studies conducted in specific states are illustrated in figure . the analysis was performed based on the state where the study was conducted irrespective of covering a small part of the state. healthcare access was classified into categories in [ ] , which are: (a) availability, (b) accessibility/proximity, (c) affordability, (d) acceptability and (e) accommodation. the first two (availability, accessibility) can be considered spatial whereas the remaining factors are non-spatial [ ] . geographic information systems (gis) is considered a powerful tool to integrate both spatial and non-spatial factors [ ] . however, most studies analyzed hindrance to access in the spatial context irrespective of disease type. the studies focusing on spatial accessibility were analyzed using three different techniques: (i) distance/time to nearby services, (ii) gravity models and (iii) population versus provider services: doctor-population ratio (dpr) or bed-population ratio (bpr) [ , ] . the first approach is a simple technique wherein the distance between population residence and service provider (proximity) is determined without considering the availability aspect of spatial accessibility. the determination of accessibility was usually carried out by determining travel time. however, some studies used the line-of-sight measure, in which distances were used as a measure of access [ ] [ ] [ ] [ ] . this concept can be used in some scenarios as access to cars is one of the highest in the world for people residing in urban areas of australia, due to a highly developed road network [ ] . the second approach considers both aspects (availability and proximity); however, the limitation of using gravity models is a challenge for the determination of the distance-decay function [ , ] . the population versus provider services approach uses a classification of the population and health services within a defined region instead of the spatial movement as used in the other two approaches. the determination of the ratios is easy to compute, as the data for both the population and the health centers are usually available. the use of such an approach involves two assumptions: (a) that the population is expected to use health services within the defined region, and (b) that the proximity aspect is negligible within the region [ ] . the significant difference lies in the selection of defined regions. as the name suggests, the floating catchment area (fca) method uses floating areas or "windows" instead of defined regions, the size of which is determined by the availability of the required services within a region. the use of fca leads to the major challenge of not considering the demand aspect with respect to supply-demand concerns. this challenge was addressed by [ ] , which introduced the spatial decomposition method, and this approach was then used by [ ] , which introduced the two-step fca or sfca method. the sfca method is performed in two steps, first calculating the size of the population within the catchment area, and then determining the available services in the catchment area. evaluation of the accessibility of healthcare is usually conducted using gis techniques, which measure the travel distance and time required for using public or private transportation systems. the studies can be categorized as revealed accessibility or potential accessibility [ ] . revealed accessibility is the actual time taken to reach health centers, whereas potential accessibility analyses the potential to access healthcare determined using either gravity models or specialized gravity models like the sfca method. after collecting and determining the relevant health barriers, statistical models were applied to analyze the association of the factors with survivability along with the interrelationship of the barriers. the present review looks at the models used to understand the barriers to healthcare access for various diseases in australia. the aim is also to analyze survivability or outcomes in relation to the barriers. the review was conducted based on several categories including disease, study area, models used, number of patients, rural vs. urban, consideration for indigenous people, and the dataset (source and time period) used. the australian healthcare system is considered a hybrid model where people can purchase private insurance coverage along with the public insurance they already receive, making both public and private hospitals available [ ] . the vast geographical area of the country, varied residential locations and their uneven distribution of population, network of roads and traffic conditions and the allocation of hospital resources lead to an imbalance of health service access for the people [ ] . in terms of practicing physicians, australia has . per people, which is one of the highest in the world [ ] . it also spends the most on healthcare among the organization of economic cooperation and development (oecd) countries, which are a consortium of countries dedicated towards developing policies for various social and economic challenges [ ] . a detailed understanding of the australian healthcare system can be found in [ ] . it has been well established that following illness, health outcomes can get worse upon traveling a greater distance to health centers. similar bias is often visible among residents living in rural areas as compared to urban areas. the variation between survivability among rural and urban residents for various health cases has been analyzed by several studies [ ] [ ] [ ] . the rural population suffers from higher fertility and perinatal mortality rates compared to the urban population. the chance of health cases (e.g., diabetes, high cholesterol, cancer, heart disease) is higher than in the urban population, which lowers their life expectancy by years. the national rural health alliance found that the barriers dividing remote areas from major cities are enormous: for example, in the case of remote/very remote areas, over % of people reported not having a specialist nearby as compared to only % in the case of major cities. such startling differences are also present across different disease types and health visits. the geographical classification of the country is based on the australian statistical geography classification (asgc) framework provided by the australian bureau of statistics (abs) (figure ). this classification was initiated in ; prior to it the australian statistical geography standard (asgs) classification was used. the studies conducted determined the geographical location of their respective study region based on census classification, which has been modified over the years. the population can be based on either place of enumeration (based on the location on census night) or place of usual residence (based on the location where they usually live). the studies relating to healthcare access were conducted based on place of usual residence. before , the census was based on statistical local area (sla), which was changed to collection district (cd) level in the next census. for the census, the australian statistical geography standard (asgs) was used, in which the data were available at statistical area (sa ) level, which could be aggregated to higher spatial scales of geography. the remoteness of a place can be categorized into one of five classifications: major cities, inner regional, outer regional, remote and very remote [ ] . remoteness has been defined based on the asgc-ra (remoteness area) classification ( figure ). this classification determines the physical distance of a location and allows the quantitative comparison between metropolitan and rural regions. to compute asgc-ra, the accessibility/remoteness index of australia (aria+) score is determined. this is an index of remoteness with values ranging from zero (high accessibility) to (high remoteness) based upon the physical distance of a location from the nearest urban center according to census data on population size [ ] . the remoteness of a place can be categorized into one of five classifications: major cities, inner regional, outer regional, remote and very remote [ ] . remoteness has been defined based on the asgc-ra (remoteness area) classification ( figure ). this classification determines the physical distance of a location and allows the quantitative comparison between metropolitan and rural regions. to compute asgc-ra, the accessibility/remoteness index of australia (aria+) score is determined. this is an index of remoteness with values ranging from zero (high accessibility) to (high remoteness) based upon the physical distance of a location from the nearest urban center according to census data on population size [ ] . . the other critical factor while determining accessibility is socio-economic status (ses), which is based on the socio-economic index for areas (seifa) developed by the australian bureau of statistics (abs) and is a set of four indexes: the index of relative socio-economic disadvantage (irsd); the index of relative socio-economic advantage and disadvantage (irsad); the index of education and occupation (ieo); and the index of economic resources (ier). the seifa comprises five categories, which are: most disadvantage; above average disadvantage; average disadvantage; below average disadvantage; and least disadvantage [ ] . generally, a socio-economic index is assigned using area-based measurement, which tends to be biased and often inaccurate. this was highlighted by [ ] which used individual-based demographic data and compared survival disparity when considering local government area (lga) and cd classification in the new south wales region. the results highlight the underestimation of survival disparity with little variation when relative excess risk (rer) is calculated. factors like patient characteristics including smoking, employment, ethnicity, disability, indigeneity, stigma and discrimination have also been explored by researchers under various circumstances [ , ] . the covid pandemic has revealed new barriers and challenges for healthcare workers and patients affected by it. this has caused patients with several necessary and critical health conditions to prematurely die in several oecd countries. among the oecd countries, australia has conducted a commendable job in addressing the barriers for healthcare professionals. although the situation is still unfolding, a few research articles and news reports are attempting to understand the gravity of the situation. some have reflected on the emotional state of healthcare professionals [ ] , while others have suggested the importance of linguistic and communication barriers. in the australian context, lakhani [ ] a conducted spatial analysis to understand the most vulnerable populations in the melbourne region depending on their characteristics. finally, the survivability of patients is determined by utilizing either the overall survival or relative survival measures. overall survival is defined as an estimate of survival from the initiation of either the diagnosis or medication, whereas relative survival is defined as an estimate of net survival which measures the deaths specifically associated with cancer diagnoses [ ] . such risks are also dependent on ses. therefore, relative excess risk (rer) has been defined; this is the ratio of excess risk of death in a particular ses quintile compared to that of the reference (least disadvantaged) ses group, controlling the other factors. the other critical factor while determining accessibility is socio-economic status (ses), which is based on the socio-economic index for areas (seifa) developed by the australian bureau of statistics (abs) and is a set of four indexes: the index of relative socio-economic disadvantage (irsd); the index of relative socio-economic advantage and disadvantage (irsad); the index of education and occupation (ieo); and the index of economic resources (ier). the seifa comprises five categories, which are: most disadvantage; above average disadvantage; average disadvantage; below average disadvantage; and least disadvantage [ ] . generally, a socio-economic index is assigned using area-based measurement, which tends to be biased and often inaccurate. this was highlighted by [ ] which used individual-based demographic data and compared survival disparity when considering local government area (lga) and cd classification in the new south wales region. the results highlight the underestimation of survival disparity with little variation when relative excess risk (rer) is calculated. factors like patient characteristics including smoking, employment, ethnicity, disability, indigeneity, stigma and discrimination have also been explored by researchers under various circumstances [ , ] . the covid pandemic has revealed new barriers and challenges for healthcare workers and patients affected by it. this has caused patients with several necessary and critical health conditions to prematurely die in several oecd countries. among the oecd countries, australia has conducted a commendable job in addressing the barriers for healthcare professionals. although the situation is still unfolding, a few research articles and news reports are attempting to understand the gravity of the situation. some have reflected on the emotional state of healthcare professionals [ ] , while others have suggested the importance of linguistic and communication barriers. in the australian context, lakhani [ ] a conducted spatial analysis to understand the most vulnerable populations in the melbourne region depending on their characteristics. finally, the survivability of patients is determined by utilizing either the overall survival or relative survival measures. overall survival is defined as an estimate of survival from the initiation of either the diagnosis or medication, whereas relative survival is defined as an estimate of net survival which measures the deaths specifically associated with cancer diagnoses [ ] . such risks are also dependent on ses. therefore, relative excess risk (rer) has been defined; this is the ratio of excess risk of death in a particular ses quintile compared to that of the reference (least disadvantaged) ses group, controlling the other factors. in terms of diseases, numerous studies have been conducted for various types, of which the greatest number have been performed for cancer ( %), followed by primary health care ( %), dental care ( ) and cardiovascular conditions ( %). figure depicts the studies conducted for various diseases. in terms of diseases, numerous studies have been conducted for various types, of which the greatest number have been performed for cancer ( %), followed by primary health care ( %), dental care ( ) and cardiovascular conditions ( %). figure depicts the studies conducted for various diseases. studies focused on understanding the inequalities in healthcare access based on various traits like location (rural, urban), origin (indigenous, nonindigenous), and access to health services. among the various regions, most studies were performed in queensland ( %), followed by new south wales ( %), victoria ( %) and the entire country ( %). cancer is the most significant global public health problem and a leading cause of death and illness in the world in the st century, including australia [ ] . breast cancer is estimated to have been the most commonly diagnosed cancer in , followed by prostate cancer. the distribution of the studies related to cancer types has also been varied with most studies being conducted on colorectal cancer followed by breast, prostate and lung cancer. generally, the studies conducted form a framework in which barriers were analyzed independently as well as in terms of their interrelationship and their relationship with health outcomes. general accessibility factors like age, sex, patient characteristics and disease stage (incidence, various cancer stages) were collected from the respective state's cancer registry. the distance to the health facility was determined by geocoding the distance of all the facilities to the centroid of each sla or to the address of the patient if available. there seems to be a set framework when studying barriers to cancer care that considers various geographic and demographic parameters, thereby determining the survival rate. studies focused on understanding the inequalities in healthcare access based on various traits like location (rural, urban), origin (indigenous, nonindigenous), and access to health services. among the various regions, most studies were performed in queensland ( %), followed by new south wales ( %), victoria ( %) and the entire country ( %). cancer is the most significant global public health problem and a leading cause of death and illness in the world in the st century, including australia [ ] . breast cancer is estimated to have been the most commonly diagnosed cancer in , followed by prostate cancer. the distribution of the studies related to cancer types has also been varied with most studies being conducted on colorectal cancer followed by breast, prostate and lung cancer. generally, the studies conducted form a framework in which barriers were analyzed independently as well as in terms of their interrelationship and their relationship with health outcomes. general accessibility factors like age, sex, patient characteristics and disease stage (incidence, various cancer stages) were collected from the respective state's cancer registry. the distance to the health facility was determined by geocoding the distance of all the facilities to the centroid of each sla or to the address of the patient if available. there seems to be a set framework when studying barriers to cancer care that considers various geographic and demographic parameters, thereby determining the survival rate. the remoteness index (aria+) and socio-economic index are considered when determining the effects on patient survival. the models used to determine survivability included the poisson regression model [ ] and the cox proportional hazards model [ ] . survivability can be expressed in either a spatial [ ] or a temporal context [ ] . yu et al. [ ] used the poisson regression model to determine survivability by analyzing residential location in diagnoses of colorectal cancer. however, frowen et al. [ ] investigated the impact of pre-treatment factors including demographic parameters. baade et al. [ ] determined the survival rate among colorectal cancer patients residing in queensland. the study introduced a multilevel approach to assess area-level variation in colorectal cancer survival due to causative factors (disease stage, comorbidity, patient characteristics and healthcare access) and analyze their individual contribution to survival. baade et al. [ ] analyzed the relation between distances to radiotherapy facilities and survival outcomes for rectal cancer patients in queensland using the cox proportional hazards regression model. the results revealed that survival rate is low in areas of socio-economic disadvantage, remoteness and greater distance to radiotherapy facilities. hsieh et al. [ ] quantified the additional barriers that impacted treatment among women in queensland diagnosed with breast cancer. a bayesian spatial modeling approach was used to analyze the spatial inequalities of utilizing adjuvant therapy and found that socio-economic aspects did not play a significant role. however, the choice of therapy (radiotherapy, chemotherapy, hormonal therapy) was dependent on the age of the patient. coory et al. [ ] studied the disparity in cancer-related deaths among people residing in regional and remote areas for a period of years ( - ). they used an arithmetic methodology wherein the number of deaths precluded in australia and excess cancer deaths in regional areas were computed. the results revealed a slight improvement in curtailing the disadvantage of such areas, with a death rate lower than metropolitan areas. an interesting study was conducted in [ ] , which introduced a new parameter, "country of birth", along with socio-economic status, remoteness and ethnicity among patients diagnosed with cancer in the new south wales region. a logistic regression model was used to analyze the relation between variables and the distant summary stage. the results revealed that people born outside of australia were more likely to be diagnosed, with socio-economic status also playing a significant role. mahmud et al. [ ] used multivariate analysis to analyze the trends associated with cancer incidence, hospitalization, and fatality for several barriers. the study was conducted for the period - and the results revealed that socio-economic and geographical access play a significant role in patient outcome. even though there was improvement over the time period, significant improvements need to be made to improve the lifespan of people residing in regional areas. access to primary health care (phc) via general practitioners (gp) is critical as a key to improving health outcomes, with more than % of people visiting at least once every year [ , ] . access is quite varied among people residing in rural and urban areas and therefore the focus has been more on understanding access to phc in rural areas. it has been proven and accepted that with an increase in distance to health centers the utilization of such centers becomes less [ , ] . studies have primarily focused more on the spatial context. the sfca method has been heavily used to analyze barriers to primary health care services in australia for both small and large catchment areas. there have been several improvements in the use of the sfca approach studied in [ ] . these improvements include the addition of the distance-decay function and the variable distance-decay function. the distance-decay function included the consideration of distance/time when calculating barriers within a catchment area, whereas the inclusion of the variable distance-decay function considers situations in which travel distance is greater according to the health service required. such a situation is quite evident in rural areas where a patient may need to travel farther for a specific health service requirement as the services are sparsely distributed. this variation was explored in [ ] for the victoria region where the number of health services was limited to with a travel time of up to min. mcgrail et al. [ ] developed a national index of access which contributed towards an improved understanding of spatial accessibility, which helped locate areas with access disadvantages and could be used for proper health planning. similar studies were conducted [ , ] for five communities in the victoria and new south wales regions and the metropolitan adelaide region, respectively. the results revealed that travel behavior needs to be considered when analyzing accessibility. however, the variation was understood only by categorizing the population into rural and urban, which may not provide accurate results when analyzing a large study area. this was overcome by the same authors [ ] when they defined rules for selection of the catchment area with respect to travel time and the number of health services and performed the study for the entire country. the fundamental challenge of using the sfca method is the definition of catchment areas, and researchers have attempted to define new ways with the ability to accurately assess the disparity in access to gps in rural and urban regions [ ] . however, these studies failed to consider the socio-economic status of the population studied. this aspect was explored in [ ] , which was performed in the inner regional area of new south wales. the study applied a bivariate analysis to understand the relationship between remoteness and socio-economic status, leading to the construction of a composite score of deprivation. thereafter, a pairwise correlation matrix between the number of physicians, remoteness and socio-economic status was performed and validated with the health outcomes. the results revealed that socio-economic status plays a significant role compared to remoteness and physician numbers for determining risk per persons. schofield et al. [ ] utilized six different variables (sex, age, income, remoteness, health status, employment status) to understand gp access, focusing on people with low socio-economic status residing in rural areas. the results indicated that gp services do not depend on the per capita utilization of the services, irrespective of whether they are based in rural or non-rural areas. however, this relation may not be accurate when considering indigenous people. the inclusion of indigenous people in understanding barriers to accessing phc services was studied in [ ] , which highlighted the need for also considering indigenous staff as social and cultural biases may exist. gibson et al. [ ] conducted an in-depth study by reviewing articles related to the barriers faced by indigenous people when assessing phc. it is evident that primary health care is probably the most basic and frequently visited health service by the population regardless of region, ethnicity, and socio-economic status. therefore, it is imperative to understand the various barriers faced by every section of society. the focus has primarily been on understanding the association between remoteness and health outcomes. several other regions are yet to be explored with the focus shifting towards local areas and considering the social and cultural aspects of the population, which would provide an accurate understanding of these access barriers. the studies involving dental care were more focused on the spatial understanding of access barriers [ ] [ ] [ ] [ ] ] . the focus also seemed to be on analyzing the difference between public and private dental clinics, where roughly % of the population visit private clinics [ ] . most of the studies used the line-of-sight method to measure distances to dental care instead of determining travel time as they focused on metropolitan regions with a focus on using geospatial tools to identify accessibility [ , ] . the study in [ ] focused on private dental clinics in the western australia region and found that rural areas were more disadvantaged compared to the metropolitan areas. mcguire et al. [ ] conducted a study in victoria and found that almost three-quarters of the population resided within km of a dental clinic. almado et al. [ ] analyzed dental clinic accessibility for eight metropolitan cities of australia. the analysis revealed that only - % of people were able to avail of dental services depending on various capital city locations. however, an interesting study was conducted in [ ] analyzing the barriers faced by people with disabilities residing in adelaide. the study was analyzed using bivariate and multivariate models and the results revealed that access was poor for people with disabilities living in rural areas compared to people in community settings. the study also found that a significant barrier to accessing dental care is the unwillingness of dentists to treat disabled people. a similar study was conducted in [ , ] for homeless people in brisbane and identified fear as a barrier among the homeless population. mental health is essential but can be considered as the poorest service in terms of access, especially in rural and remote areas of the country [ ] . taylor et al. [ ] studied the state of patients experiencing mental health issues who needed to be transferred to metropolitan health centers. qualitative analysis was performed through interviews conducted among six patients and medical staff in the southern australia region to understand the barriers faced while transferring patients. fennell et al. [ ] conducted a similar study for adults living in rural parts of south australia and suggested that health professionals needed to be educated about these barriers. they also used evidence-based approaches to understand the concerns faced by patients. saurman et al. [ ] analyzed the mental health emergency care (mhec) rural access project implemented in new south wales ensuring h access to specialists over video conferencing using a concurrent mixed-methods approach. wohler and dantas [ ] conducted a review of the barriers faced by immigrant and refugee women when accessing mental health services in australia. the study highlighted that the barriers include factors like religion, self-reliance and resilience, suggesting that measures need to be undertaken to address these concerns. maas et al. [ ] conducted a spatial analysis using autocorrelation indexes and spatial regression to determine patterns of referral for a mental health program in the western sydney region. the results revealed that the distribution formed a pattern covering the areas with low socio-economic status. the factors affecting easy access to mental healthcare programs are varied and efforts need to be made to analyze the barriers at a local scale and implement steps to overcome them. however, the work surveyed clearly shows that indigenous people, remote areas and low-income people are the most affected. cardiovascular disease (cvd) contributes to almost % of deaths in the country and is the second most prevalent disease after cancer [ ] . this section discusses studies related to cardiovascular diseases and cardiac rehabilitation services. studies relied on gis to determine remoteness and accessibility. bamford et al. [ ] developed cardiac aria to quantify the accessibility of cardiac services via the available road networks. the significant difference between aria and cardiac aria lies in the selection of a location for accessibility modeling: aria uses population location whereas cardiac aria uses the location of the health service. cardiac aria measures travel time to relevant health centers in two categories: (a) acute cardiac aria, which determines the travel time by ambulance in the event of an acute cardiac arrest, and (b) aftercare cardia aria, which evaluates the travel time by private transport after hospital discharge. coffee et al. [ ] calculated the cardiac aria index for the entire country based on both categories and concluded that the current system provides timely access for the majority of the population. cardiac rehabilitation serves as a primary step for preventing cvd and access to it has been a major concern, especially in remote areas [ ] . higgins et al. [ ] reported that the percentage of people attending rehabilitation programs after coronary artery bypass graft surgery varied from - % and identified the lack of effective referral protocols as a major factor. they based their study on patients admitted to the royal melbourne hospital, victoria, and used a logistic regression model to determine patient characteristics as well as visiting the rehabilitation programs. the uneven distribution of cardiovascular services in the country was highlighted in [ ] , which argued that barriers are not only confined to distance and transport reliability but are multidimensional, involving other socio-economic parameters. van gaans et al. [ ] developed the spatial model of accessibility, involving both the geographic and the socio-economic factors. the model determined ratings based on the patients who enrolled in the program versus completion rate of the program. the other diseases where the relation between barriers and the health outcome was studied included obesity, kidney transplants, diabetes, strokes, and services such as clinical trials and maternity. the number of people who are obese has increased drastically over the last three decades [ ] . remoteness and socio-economic disadvantage have been found to be the most critical factors affecting obesity [ , ] . the relationship between these factors and body mass index among australian immigrants was studied using statistical analysis in [ ] . in terms of wait listing for kidney transplantation, [ ] studied the various barriers faced by patients. the study was conducted using univariate and multivariate models and found that access to the waitlist is based on numerous factors like sex, ethnicity and remoteness. the disparity between indigenous people and nonindigenous people in kidney transplant accessibility was studied by [ ] . statistical analysis including the cox proportional hazards model was used to understand this disparity. scott et al. [ ] used regression models to analyze the demographic relationship with healthcare service coverage for the hepatitis c virus. the results revealed that despite the cost of the drug being low, more than % of the geographical area treated less than % of people suffering with the virus. gilbert et al. [ ] conducted a qualitative study to understand the barriers faced by patients when accessing cataract surgery. they found five significant parameters, i.e., travel time, reputation of the health center, surgeon experience, cost and the wait time for surgery. sabesan et al. [ ] analyzed the willingness for clinical trials among rural and regional patients in north queensland. using data from patients and statistical analysis, they found that rural patients are more willing compared to the urban patients. zdenkowski et al. [ ] analyzed the barriers faced by patients when enrolling in a clinical trial for cancer medication. the study was performed by conducting interviews among people under various scenarios ranging from variation in travel time, change in oncologist, trial type and increase in cost. logistic regression was used, and the results revealed that if the cost and the oncologist remained same, the willingness of participants were greater. however, an increase in travel time led to a decrease in participation, whereas there was no difference concerning trial type. the outcome of this review could be useful for researchers for understanding the various modeling approaches used for understanding barriers to healthcare access in australia and could also be used in other countries with similar diversity. it provides a broad understanding of the techniques being used, which could serve as a starting point for researchers looking to work in this domain for the first time. the analysis can be useful for identifying some existing shortcomings and the important research questions to be addressed in the future. the findings from the study are illustrated in figure , which depicts three different domains on which the present article has focused, with the various barrier types, the models used to understand the barriers and the diseases for which the study has been conducted. after analyzing all the components of the different domains, we conclude by summarizing the current focus of the research study and providing future directions on which research should focus. the first gap is the need to focus on other diseases than cancer. primarily, more research has been conducted towards cancer, which is understandable due to the high number of patients suffering and the rate of fatality. however, more efforts need to be put towards focusing on other major health issues. the second issue is the lack of studies on a finer scale, as most of the studies conducted were either of an entire state or of the whole country. certain barriers for a specific disease type are pertinent at a local level and their effect on accessibility is also critical. therefore, emphasis should be on moving towards understanding barriers at a local scale. the covid pandemic has shown the gaps present in the healthcare system in dealing with infectious diseases and our lack of research towards handling barriers for both patients and healthcare workers. although the australian health system has considerably performed well compared to other economically developed countries, our understanding of the relevant barriers needs to be comprehensively studied ahead of future infectious disease outbreaks. in general, the main barriers are providing sufficient testing capacities, emotional and physical stress among the health workers and the dispersion of accurate information among the general public. in understanding various healthcare barriers, accessibility, specifically spatial accessibility, is one specific area where a lot of improvements can be made. the spatial mobility aspect can be considered as the most significant barrier to healthcare access. while the topic has been very well studied in the fields of traffic monitoring and congestion, its application to healthcare studies in australia has been limited. in terms of the spatial accessibility of health facilities, it can be broadly categorized into two sections: (i) navigation to health centers, which could be proximity to the health center as well as distance or travel time between a certain location and the health center, which would be critical in cases of medical emergencies, (ii) setup of new health facilities, which can be achieved by considering the population demand according to the diseases being suffered from along with the first gap is the need to focus on other diseases than cancer. primarily, more research has been conducted towards cancer, which is understandable due to the high number of patients suffering and the rate of fatality. however, more efforts need to be put towards focusing on other major health issues. the second issue is the lack of studies on a finer scale, as most of the studies conducted were either of an entire state or of the whole country. certain barriers for a specific disease type are pertinent at a local level and their effect on accessibility is also critical. therefore, emphasis should be on moving towards understanding barriers at a local scale. the covid pandemic has shown the gaps present in the healthcare system in dealing with infectious diseases and our lack of research towards handling barriers for both patients and healthcare workers. although the australian health system has considerably performed well compared to other economically developed countries, our understanding of the relevant barriers needs to be comprehensively studied ahead of future infectious disease outbreaks. in general, the main barriers are providing sufficient testing capacities, emotional and physical stress among the health workers and the dispersion of accurate information among the general public. in understanding various healthcare barriers, accessibility, specifically spatial accessibility, is one specific area where a lot of improvements can be made. the spatial mobility aspect can be considered as the most significant barrier to healthcare access. while the topic has been very well studied in the fields of traffic monitoring and congestion, its application to healthcare studies in australia has been limited. in terms of the spatial accessibility of health facilities, it can be broadly categorized into two sections: (i) navigation to health centers, which could be proximity to the health center as well as distance or travel time between a certain location and the health center, which would be critical in cases of medical emergencies, (ii) setup of new health facilities, which can be achieved by considering the population demand according to the diseases being suffered from along with considering other factors like affordability, and indigenous status. for both these aspects, the use of gis integrating with the transport model and the concept of spatio-temporal paths should be encouraged [ ] . the effects of spatial accessibility during the pandemic outbreak have revealed some serious gaping holes in the system and its decisionmakers. while the studies in the australian context focused more on the use of the sfca and other statistical models to calculate distance to health centers, focus should shift towards considering different techniques, e.g., the three-step floating catchment area ( sfca), which uses distance, proximity and population demand. it could also help in identifying disparities in healthcare access in a regional-level study. apparicio et al. [ ] analyzed the accessibility of health services using various distance and aggregation methods. such analysis needs to be performed at various spatial scales (national, regional and local) to standardize the basic methodology to be used, which can then be improved in the future. in addition, the input data used for conducting similar studies rely heavily on google earth/maps or openstreetmap. efforts need to be made to use a high spatial dataset [ ] which would improve the spatial mobility significant in health scenarios. such use of a high spatio-temporal dataset would help in identifying the nearest health center along with the shortest route to reach it considering population density [ ] . this would immensely support decisionmakers and stakeholders in gaining better access to health centers. the recent work in [ ] on determining distance and travel time for helsinki, finland using several transportation modes provides a model for deciding the travel mode to be used in cases of medical emergency, clinical check-up and rehabilitation. such development of a disease-specific travel time dataset, e.g., check-ups for breast and prostate cancer, dental care and gps, could better aid people in deciding which health facility to go to. it has been well acknowledged that remote areas suffer from an inadequate number of health centers, but the type of health centers for a specific disease type is also quite erratic even in urban areas. although the specialized field of analyzing the setup of new health centers is a separate entity, we attempted to look at it solely from the different barrier point of view. the lack of facilities can be overcome by setting up new facilities, but the challenges could range from accessibility to cultural difficulties and affordability. the accessibility component can be solved by utilizing the measures mentioned above; however, the other challenges would be detrimental which could be understood by conducting interviews and understanding specific requirements at a community level. the challenge lies in setting up new health centers specific to community-based barriers with the consideration of socio-economic status as well as cultural and regional biases. the steps to set up a new health center could begin with the understanding of broader aspects like accessibility and affordability, and thereafter fill in the gaps of cultural differences with the capacity to upgrade in the future. another important aspect found while conducting this review was the comparison between rural and urban healthcare accessibility, with a few studies comparing different metropolitan regions. however, comparison between accessibility and health outcomes among the rural regions in a state or across several states was not heavily researched. such analysis would be interesting to understand which states struggle to provide rural healthcare services and thereafter necessary steps can be taken by the respective state health departments to improve these services. care must be taken when analyzing the rural regions as patient characteristics like indigeneity, cultural and linguistic barriers would be critical when addressing rural health issues. this review paper is an attempt to analyze the models used in understanding barriers to healthcare access and the survivability of the patient across various disease types. current research practice is lacking in various domains ranging from spatial accessibility techniques to the consideration of patient characteristics and the analysis of different disease types as well as studies concerning only rural/remote areas. additionally, our understanding of the barriers for infectious disease outbreak is still in infancy and the covid situation would help in determining the various concerns among patients and health workers that should be considered in the future. the study highlighted the key areas on which research has focused: cancer and primary health care-related studies, the sfca method and rural vs. urban health outcomes. the conclusions from the study are as follows: • it is important to note that the barriers are multifaceted, of which the major ones are geography, ethnicity and socio-economic status. the most deprived section for healthcare access is indigenous people, and this could be even worse if their economic status is poor. the focus needs to shift towards addressing cultural and linguistic barriers, especially for indigenous people. there are also several other barriers which are specific to the disease the patient is suffering from. as most studies have focused on a large geographical area, the distance/time determination using the smallest administrative boundary for better accuracy has been missed. the emphasis should be on analyzing at the smallest administrative boundary. the focus has also primarily been on a few diseases only, such as cancer and primary health care, and the location of the study has focused primarily on a few states only. both aspects need to be improved, the type of disease and the study area. the distance/time calculation to health centers is determined spatially using gis and various geospatial tools. it is encouraging that the available models, such as the sfca method, have been tested very extensively for different regions and have been proved to be performing well. however, new models and techniques like sfca and machine learning need to be attempted for better accuracy. the increase in the availability of data would help in developing machine learning-based tools aimed at identifying key shortcomings and the steps needed to be taken for better healthcare access at both local and regional scales. geographical access to health care. in access health care are differences in travel time or distance to healthcare for adults in global north countries associated with an impact on health outcomes? a systematic review understanding shortages of sufficient health care in rural areas the distribution of maternity services across rural and remote australia: does it reflect population need? cultural barriers lead to inequitable healthcare access for aboriginal australians and torres strait islanders. chin cultural barriers to health care for aboriginal and torres strait islanders in mount isa the concept of access: definition and relationship to consumer satisfaction spatial accessibility of primary care: concepts, methods and challenges assessing spatial and nonspatial factors for healthcare access: towards an integrated approach to defining health professional shortage areas measuring spatial accessibility to primary care in rural areas: improving the effectiveness of the two-step floating catchment area method spatial and temporal variations of spatial population accessibility to public hospitals: a case study of rural-urban comparison travel patterns for government emergency dental care in australia: a new approach using gis tools the geographic distribution of patient seeking emergency dental care at the royal dental hospital of melbourne weekend emergency dental care demand: a study of the geographic and socioeconomic catchment for a major metropolitan dental hospital in australia application of spatial analysis technology to the planning of access to oral health care for at-risk populations in australian capital cities measures of spatial accessibility to health care in a gis environment: synthesis and a case study in the chicago region spatial decompositions, modeling and mapping service regions to predict access to social programs a review of the australian healthcare system: a policy perspective australian health services: too complex to navigate: a review of the national reviews of australia's health service arrangements; australian health policy collaboration access to waitlisting for deceased donor kidney transplantation in australia development of the australian cancer atlas: spatial modelling, visualisation, and reporting of estimates are suspected stroke patients identified by paramedics transported to appropriate stroke centres in victoria the dilemma of distance: patients with kidney cancer from regional australia present at a more advanced stage impact of geographic area level on measuring socioeconomic disparities in cancer survival in new south wales, australia: a period analysis access to dental care among adults with physical and intellectual disabilities: residence factors does a facilitated pathway improve access to dental services for homeless and disadvantaged adults? mental health challenges for healthcare workers during the covid- pandemic-impact and management strategies which melbourne metropolitan areas are vulnerable to covid- based on age, disability, and access to health services? using spatial analysis to identify service gaps and inform delivery emerging cancer incidence, mortality, hospitalisation and associated burden among australian cancer patients, - : an incidence-based approach in terms of trends, determinants and inequality area variation in survival from colorectal cancer distance to the closest radiotherapy facility and survival after a diagnosis of rectal cancer in queensland spatial inequalities in colorectal and breast cancer survival: premature deaths and associated factors spatio-temporal relative survival of breast and colorectal cancer in queensland impact of demographics, tumor characteristics, and treatment factors on swallowing after (chemo) radiotherapy for head and neck cancer a multilevel study of the determinants of area-level inequalities in colorectal cancer survival geographic variation in the intended choice of adjuvant treatments for women diagnosed with screen-detected breast cancer in queensland australia is continuing to make progress against cancer, but the regional and remote disadvantage remains socio-demographic disadvantage and distant summary stage of cancer at diagnosis-a population-based study in new south wales the index of rural access: an innovative integrated approach for measuring primary care access access to primary health care services for indigenous peoples: a framework synthesis an evaluation of access to health care services along the rural-urban continuum in canada accessing doctors at times of need-measuring the distance tolerance of rural residents for health-related travel spatial accessibility of primary health care utilising the two step floating catchment area method: an assessment of recent improvements a new index of access to primary care services in rural areas equity of access in the spatial distribution of gps within an australian metropolitan city measuring spatial accessibility to primary health care services: utilising dynamic catchment sizes index of access: a new innovative and dynamic tool for rural health service and workforce planning. aust. health rev use of measures of socioeconomic deprivation in planning primary health care workforce and defining health care need in australia access to general practitioner services amongst underserved australians: a microsimulation study enablers and barriers to the implementation of primary health care interventions for indigenous people with chronic diseases: a systematic review application of geographic information systems to the analysis of private dental practices distribution in western australia oral health impacts and quality of life in an urban homeless population responding to mental health emergencies: implementation of an innovative telehealth service in rural and remote new south wales improving transfer of mental health care for rural and remote consumers in south australia a comparison of barriers to accessing services for mental and physical health conditions in a sample of rural australian adults barriers accessing mental health services among culturally and linguistically diverse (cald) immigrant women in australia: policy implications a spatial analysis of referrals to a primary mental health programme in western sydney from to measuring national accessibility to cardiac services using geographic information systems accessibility to general practitioners in rural south australia: a case study using geographic information system technology cardiac rehabilitation: under-referral and underutilisation cardiac rehabilitation program attendance after coronary artery bypass surgery: overcoming the barriers inequitable provision of optimal services for patients with chronic heart failure: a national geo-mapping study the development of a spatial model of accessibility to phase cardiac rehabilitation programs neighbourhood disadvantage, geographic remoteness and body mass index among immigrants to australia: a national cohort study weight and place: a multilevel cross-sectional survey of area-level social disadvantage and overweight/obesity in australia do neighbourhood socioeconomic circumstances not matter for weight status among australian men? multilevel evidence from a household survey of adults disparity of access to kidney transplantation by indigenous and non-indigenous australians heterogeneity in hepatitis c treatment prescribing and uptake in australia: a geospatial analysis of a year of unrestricted treatment access investigation of attributes which guide choice in cataract surgery services in urban sydney attitudes, knowledge and barriers to participation in cancer clinical trials among rural and remote patients. asia-pac results of a survey of cancer patients' willingness to travel to participate in a clinical trial gis and transport modeling-strengthening the spatial perspective the approaches to measuring the potential spatial access to urban health services revisited: distance types and aggregation-error issues a global map of travel time to cities to assess inequalities in accessibility in towards integration of remote sensing and gis to manage primary health care centers longitudinal spatial dataset on travel times and distances by different travel modes in helsinki region this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license key: cord- -mvxz lx authors: barraclough, simon title: australia's international health relations in date: - - journal: aust new zealand health policy doi: . / - - - sha: doc_id: cord_uid: mvxz lx a survey for the year of significant developments in australia's official international health relations, and their domestic ramifications, is presented. the discussion is set within the broader context of australian foreign policy. sources include official documents, media reports and consultations with officers of the department of health and ageing responsible for international linkages. in broad terms, these health relations encompass a range of interactions with consequences for health, including: membership of global and regional bodies; the negotiation of international agreements; action to counter particular external threats to health; assistance to developing countries; and international trade and investment in health-related goods and services. in there were continuing developments in all these areas within a wider foreign affairs context overshadowed by official policy concerns about global and regional security, the deployment of the australian armed forces in various theatres of service, and renewed fears of the human and economic costs of infectious diseases. balancing these concerns with national defence were renewed efforts to forge bi-lateral trade links in global trade environment characterized by the emergence of trade blocs centred in north america, europe and southeast asia. although consultation occurs with states and territories, it is the australian government that is constitutionally responsible for conducting australia's international relations. these responsibilities include appointing representatives to international bodies and organizations, such as the united nations and its various agencies, including the world health organization and assenting to agreements and regulations promulgated by international agencies. the formulation and implementation of policy with direct or indirect international health ramifications is not centralized, but is usually the result of consultations between various relevant government departments and statutory authorities. an important element of the australian government's foreign affairs powers relates to international treaties. while a degree of consultation with state and territory governments and with the public occurs, and the national parliament is able to scrutinize and comment upon international treaties, it is the executive that has the final decision on such agreements. in australia continued to play a strategically important and respected role in international organizations concerned with health, especially the world health organization. at the world health assembly, the governing body of the who, the australian delegation supported resolutions concerned with strengthening nursing and midwifery and child and adolescent health. in the wake of sars, australia also supported the review of the international health regulations and is likely to subscribe to them [ ]. the voluntary nature of who standards and regulations, which can be accepted or rejected by member states, is well illustrated by the international health regulations since australia and papua new guinea declined to accept them when they were last promulgated. australia should be better placed to influence developments in who in the next three years as a result of being nominated for a term on the executive board. the department of health and ageing was closely involved with international comparative health data projects including who's world health survey and the health systems performance survey of the organization for economic cooperation and development. australia's participation in the health mandate of the commonwealth of nations was illustrated by the therapeutic goods administration's provision of a secretariat for the clearing house of commonwealth agencies for chemical safety. australia also participated in the meeting of commonwealth health ministers on the eve of the annual world health assembly of who in geneva [ ]. in december australia signed the framework convention on tobacco control (fctc) the first multilateral treaty negotiated under the auspices of the world health organization. for the first time, nations were invited to implement control measures covering such issues as health warnings, advertising, packaging and labelling, sales, and smuggling. they were also called upon to embrace policy measures designed to counter the global tobacco epidemic [ ] . the fctc provided an impetus to the domestic policies of many countries with limited progress on tobacco control and also allowed for the transnational activities of tobacco corporations to be countered with global policy action. the fctc has limited potential to further australian domestic policy, which is in advance of that in most countries. if necessary, the australian government could call upon its "external affairs" to assert constitutional primacy over this policy area. however, this is unlikely in the context of close cooperation between various levels of government in australia in establishing national tobacco control policies. australian leadership was evident in who's formulation of the fctc, having been nominated by the western pacific region as vice-chair of the bureau for the negotiating body. a reciprocal health care agreement with norway was signed, further expanding the rights of australian residents to immediate and necessary treatment in the national health systems of countries with which australia has reciprocal treaties. these include new zealand, uk, italy, malta, holland, sweden, finland, and the republic of ireland. these arrangements are "cost neutral" and do not include costly accounting or administrative procedures. in terms of domestic policy, the continuing "internationalisation" of medicare (pioneered by the hawke labor party ministry at the time of medicare's introduction) by the liberal-national party coalition is paradoxical since local citizens are being encouraged to opt out of public hospital treatment through a rebate on private health insurance and penalties for higher income earners who do not insure privately. whilst these agreements have cemented closer diplomatic ties, their potential benefits to international travellers, especially those subject to punitive insurance premiums or the refusal of insurance due to old age or infirmity, remain inadequately publicized. treaties are also being negotiated with denmark and belgium. following years of negotiations and planning, a treaty was signed with new zealand establishing a single joint therapeutic goods agency. this body, due to commence operations in , will regulate prescription and retail drugs, therapeutic devices and also complementary medicines. it will replace the australian therapeutic goods administration and its new zealand counterpart. to a large extent, the two regulatory systems will have been integrated, although there are still areas of disagreement (e.g. policies on the advertising of pbs medicines) which will need to be negotiated. this joint agency creates a model in international health relations which other states could profitably emulate where they share common concerns and have similar health systems. in december the two countries finalized treaty arrangements establishing both a joint standards code and a joint statutory authority, food standards australia new zealand [ ]. these arrangements parallel bi-lateral developments for the joint regulation of food standards. these developments have furthered australian foreign policy concerned with establishing trans-tasman free trade, commenced some two decades ago with the negotiation of the closer economic relations agreement with new zealand. the new regulatory arrangements have created a virtual trans-tasman free market in food (subject to plant and animal quarantine considerations) and therapeutic drugs. while not having the legal status of a treaty, for some years the department of health and ageing has had memoranda of understanding with its counterparts in china, indonesia, thailand and japan. in further activities were undertaken under the auspices of these agreements. during the state visit of china's president hu jinta, a plan of action was signed between the two health ministries. the indonesian relationship continued with the inclusion of a health delegation to the sixth australia indonesia ministerial forum in jakarta in march, preceded by two rounds of meetings between officials of the indonesian and australian health departments. the australia-japan partnership in health and family services formed the basis for negotiations for joint research on mental health and an international conference on suicide prevention [ ] . in a related development, the department of foreign affairs and trade promoted aged care expertise as an export service through the australia japan conference. in the course of australia finalized free trade agreements (in reality, preferential trade agreements) with singapore and thailand and continued negotiations with the usa [ ] . from the perspective of the australian health industry, the agreement with singapore offered tariff-free trade in pharmaceuticals and other therapeutic goods and the gradual removal of tariffs in the case of thailand. all countries imposed reservations on free trade in the sensitive areas of health services, although traditional thai massage exponents will be permitted to operate in australia. domestically, these agreements required intersectoral policy collaboration in the interests of health. policy makers in the department of health needed to intensify their understanding of the dynamics of international trade, while those making foreign policy had to consider the health dimensions of ostensibly commercial arrangements. the free trade agreement with the usa raised controversies about attempts to include the pharmaceutical benefits scheme (pbs) in concessions demanded by us negotiators. these issues have been outlined in the account of developments in the pbs elsewhere in this series of review articles. the emergence and rapid spread of severe acute respiratory syndrome (sars) to several countries in east and southeast asia and to canada revived popular atavistic fears of pandemics and damaged the tourism and travel industry, as well as some australian suppliers of goods and services to asia. who issued a global alert on the disease in march, and the last reported case of international occurred in july. so serious was the threat of sars to the economies of some countries that a special meeting of health ministers, attended by australia, was organized by asia-pacific economic cooperation (apec) to discuss the situation. a task force was subsequently established by apec to deal with sars. an example of the economic costs of the disease was the decision by the governments of singapore and australia to postpone negotiations on a greater share of the sydney-los angeles air route (dominated by qantas) for the singapore carrier, due to uncertainty about demand. in australia sars was declared a quarantinable disease under the quarantine act and policy guidelines for health professionals, airline and border control staff and the general public were developed by the department of health and ageing, which also led an inter-departmental task force to monitor world developments. until july , when the who announced that no country was still considered sars-affected, international aircraft arriving at australian airports were required to obtain "sarsfree" clearance, nurses were posted at airports and restrictions on elective surgery were placed on travellers returning from affected countries [ ] . during the period of who's alert, australia had reported only five probable, and one laboratory-confirmed, case of sars. australia's official international development assistance programme is an important foreign policy tool, especially in the asia-pacific region. some $ m. (of a total of $ . b.) was allocated to health-related international development assistance in - budget of the australian agency for international development (ausaid). however, while australia's contribution to hiv/aids control and its regional advisory role associated with sars were acknowledged by the foreign affairs minister in his report to parliament, health assistance received little prominence. security, good governance and counter-terrorism were emphasized as the focus for the official foreign aid programme. support for essential services in papua new guinea continued as a major imperative [ ] . the lower priority of health was further underscored by a decision to no longer appoint designated health advisors to the permanent staff of ausaid. it should be noted, however, that the emergence of sars served to reinforce health as an important element on the international assistance agenda. the fact that the domestic health workforce is now part of a global market for skilled workers was further demonstrated by continuing efforts to recruit nurses from overseas, the decision of the australian health ministers conference to sanction dentists from selected commonwealth countries to work in public clinics. in addition, a scheme to recruit overseas-trained medical practitioners was included in the australian government's medicare plus policy initiatives [ ] . it is intended that these doctors will work in rural and remote areas officially designated as having medical workforce shortages and also in positions within aboriginal controlled community health services. yet, metropolitan hospitals are have also become reliant upon overseas-trained doctors for their staffing. this policy, accompanied by the liberalization of immigration arrangements for medical doctors, has represented a volte face from previous policies deliberately designed to discourage foreign doctors from immigrating in the belief that controlling the number of doctors would contribute to cost-containments of medicare. it also continues to raise the ethical danger of australia contributing to a "brain drain" of medical staff from countries that are themselves short of such expertise. in the commonwealth of nations had agreed to a code of practice for the international recruitment of health workers to help safeguard the interests of developing nations. australia has endorsed the code. the australian government will need to handle policies associated with the recruitment of overseas-trained health personnel with care due to professional sensitivities and the need for legislation at the state level to regularize the status of some professions. this brief review of australia's international health relations in has demonstrated that health must be seen as an integral part of trade and security within the wider foreign policy context. the protection of health in free trade arrangements is important for their domestic legitimacy. it is vital that those involved in health policy are aware of its potential international dimensions, while those responsible for foreign affairs include health in their approach. official health linkages have served to promote good will in some otherwise difficult relationships, as has been the case with indonesia. they have also helped to promote a positive international image for australia. world health organization, who framework convention on tobacco control wto and free trade agreements department of health and ageing the opinions expressed in this article are the sole responsibility of the author. key: cord- -z vhxg authors: gardiner, fergus w.; de graaff, barbara; bishop, lara; campbell, julie a; mealing, susan; coleman, mathew title: mental health crises in rural and remote australia: an assessment of direct medical costs of air medical retrievals and the implications for the societal burden date: - - journal: air med j doi: . /j.amj. . . sha: doc_id: cord_uid: z vhxg objective: adequate mental health service provision in rural and remote australian communities is problematic because of the tyranny of distance. the royal flying doctor service provides air medical retrieval for people in rural and remote areas. the economic impact on both the royal flying doctor service and the public hospital system for mental health–related air medical retrievals is unknown. we aimed to estimate the direct medical costs associated with air medical retrievals and subsequent hospitalizations for mental and behavioral disorders for the calendar year. methods: all patients with a primary working diagnosis of international statistical classification of diseases and related health problems, th version, australian modification f to f (mental and behavioral disorders) who underwent an air medical retrieval were included in this cost analysis. international statistical classification of diseases and related health problems, th edition, australian modification codes were mapped to australian refined diagnosis related group codes, with hospital costs applied from the national hospital cost data collection ( / ). all costs are reported in australian dollars (auds). results: one hundred twenty-two primary evacuations and interhospital transfers occurred with an in-flight diagnosis of f to f , most commonly psychotic disorders, including schizophrenia and schizotypal disorders. the total direct medical costs were estimated to be aud $ , , . costs for primary evacuations accounted for % (aud $ , , ), with the majority of this associated with the subsequent hospital admission (aud $ , , ). similarly, the majority of the costs associated with interhospital transfers (total costs = aud $ , , ) were also related to hospital costs (aud $ , , ). conclusion: direct medical costs associated with air medical retrievals for people experiencing a mental health crisis are substantial. the majority of costs are associated with hospital admission and treatment; however, the indirect (loss of productivity) and intangible (quality of life) costs are likely to be far greater. demonstrated by suicide rates, which increase in line with the degree of remoteness, ranging from . per , persons in major cities to . per , in very remote settings. although the drivers of this unbalanced burden of mental health conditions are many and complex, of the key factors is the supply of mental health services. the majority of mental health professionals, measured as full-time equivalent (fte) per , population, are located in major cities. specifically, . fte psychiatrists per , persons are based in major cities compared with . per , in outer-regional settings, . per , in remote settings, and . per , in very remote areas of australia. similar trends are observed for mental health nurses ( . fte nurses/ , persons in major cities, . / , in remote setting, and . / , in very remote settings) and clinical psychologists ( . / , in major cities, . / , in remote settings, and . / , in very remote settings). in addition to these supply-side issues, demand for mental health services differs from that in major cities and many urban centers. although the overall prevalence of mental health conditions is similar across settings, people in rural and remote settings experience higher rates of substance use and acuity of mental health conditions along with the aforementioned rates of suicide. , furthermore, increased environmental challenges including drought, fires, and climate change, and the recent coronavirus pandemic, are placing greater pressure on the mental health of many rural and remote communities. [ ] [ ] [ ] [ ] in this context, the royal flying doctor service (rfds) provides air medical retrievals for australians living in rural and remote communities experiencing health crises, including acute mental health presentations. patients are typically transferred by aircraft to large metropolitan or inner regional public hospitals for urgent acute care. the economic costs of this approach, including those incurred by the rfds and public hospitals, has not been quantified. the primary aim of this article is to determine the annual air medical retrieval and in-patient hospital-direct medical costs associated with mental and behavioral disorders from a health payer perspective. a secondary aim includes determining the mismatch of the supply and the capacity of rural and remotely located mental health services with the demand of acute presentations, with retrieval signaling as a potential proxy for this unmet need. the rfds provides air medical, road ambulance, and primary health care to rural and remote areas of australia without traditional medical services, such as those associated with the medicare benefits schedule, a listing of the medicare services subsidized by the australian government. the focus of this article is on air medical retrievals for mental health crises from a health care payer perspective. , design and participants a partial economic evaluation was undertaken using routinely collected air medical data for patients diagnosed in flight with a mental and behavioral disorder (international statistical classification of diseases and related health problems, th edition, australian modification [icd- am], chapter v) between january , , and december , . participants included all rfds patients who underwent an air medical retrieval, including a primary evacuation and interhospital transfer, for mental and behavioral disorders within australia in . the majority of the rfds air medical retrievals are conducted in western australia, central australia, queensland, and new south wales, with limited air medical retrievals coming from tasmania and victoria. tasmania and victoria air medical services are mainly conducted by other services; however, the rfds in / conducted substantial road transportation in victoria and tasmania (n = , ). for the primary aim, data were collected and coded on each patient's in-flight working diagnosis using the icd- -am coding method. the in-flight primary working diagnosis was based on referral assessment information and an assessment of the current medical status by the in-flight medical team, which, in this patient group, mainly consisted of a senior medical officer and/or a senior flight nurse. the in-flight primary working diagnosis was then coded by trained administrative staff and cross-checked by of the authors (l.b. and f.g.). data were collected within flight on the patient's sex, age, and indigenous status. both paper-based and electronic methods were used in data collection. detailed patient histories were not routinely collected. all air medical retrieval patients with a primary working diagnosis of icd- -am chapter v codes f -f (mental and behavioral disorders) were included in the analysis. all other diagnoses were excluded from analysis. we defined separate types of air medical retrievals: ) primary evacuations of a patient and ) interhospital transfers that involve an rfds air medical evacuation from, typically, a small regional hospital to an inner regional or major city hospital. to determine the economic costs per primary evacuation, we collected the costs incurred by each rfds section and operation (loosely state based), including the queensland section, western operations, south eastern section, and central operations. this included determining the individual primary evacuation costs by rfds base from each section and operation. to protect patient and rfds base confidentiality (particularly for those bases conducting a small number of retrievals), these costs were then averaged. costs included engine hour and staffing by an rfds registered nurse (present on all flights) and rfds medical officer as required. the costs for interhospital transfers were based on $ , per engine hour, which includes an rfds registered nurse. for transfers in which an rfds medical officer was also required, an additional $ , per hour was added to the cost of each interhospital transfer. this formula is consistent with other published literature. to estimate inpatient admission costs, we mapped the icd- -am codes to australian refined diagnosis related group (ar-drg) codes provided in the national hospital cost data collection ( / ) ( table ) . this mapping was performed by of the authors (b.d.g.) and independently checked by of the authors (f.g. and m.c.). it is important to note that although there are > , icd- -am codes and > , ar-drg codes, the national hospital cost data collection only contains codes. cost data were then extracted from the / national hospital cost data collection for each relevant ar-drg ( table ) . the costs were then applied to each primary evacuation and interhospital transfer, respectively. for interhospital transfers, the costs associated for the first admission (ie, the hospital from which the patient was transferred from) were not included because no icd- -am or ar-drg data are collected for this. the total aggregate costs were estimated for both primary evacuations and interhospital transfers. to further understand where costs are incurred, the disaggregated "cost buckets" reported in the national hospital cost data collection were assessed. these disaggregated costs include ward medical, ward nursing, nonclinical salaries, pathology, imaging, allied pharmacy, critical care, operating room, emergency department, ward supplies, specialist procedure suites, prostheses, oncosts (eg, indirect salary costs such as superannuation), hotel and depreciation (ie, domestic services within the hospital that are not directly related to patient care), and emergency department (ed) to determine the secondary aim, we used the rfds service planning and operational tool (spot) to map service provision throughout australia. spot uses data from the australian bureau of statistics and data from health direct to derive geographic population estimates reflective of mental health services. primary evacuation statistical areas were defined according to the australian bureau of statistics statistical area level code. spot has been designed to help determine the geographic coverage of health care in australia. spot graphically represents population concentrations and health care services and calculates the proportion of the australian population who are covered by specific health care facilities (in this case, general mental health services) within a -minute drive time. to map the location of air medical retrievals for diagnoses associated with mental health, we used tableau mapping software (tableau software, salesforce company, seattle, wa united states of america). this study used descriptive statistics to summarize findings. cost data were extracted from the / national hospital cost data collection for each ar-drg derived from the icd- -am mapping exercise. costs associated with rfds air medical retrievals were applied to each ar-drg. these costs were then summed and multiplied by the number of retrievals per ar-drg. expenditure based on cost buckets was extracted from the / national hospital cost data collection. each item in the cost bucket was multiplied by the number of air medical transfers with the corresponding ar-drg. costs for each cost bucket were summed for all ar-drgs, allowing for the calculation of the proportion of the total expenditure associated with each cost bucket. all costs are reported in australian dollars. analyses were conducted in excel (microsoft, redmond, wa). in addition, cell sizes with or less patients are supressed for confidentiality. this project was deemed a low-risk quality assurance project by the rfds clinical and health services research committee, which provides oversight for rfds research projects, on march , . because this project involved routinely collected data, specific patient consent forms were not required. over the calendar year, the rfds conducted primary evacuations and interhospital transfers for patients with an inflight diagnosis associated with a mental and behavioral disorder (icd- -am chapter v f -f ). all of the primary evacuations and interhospital transfers were from remote and very remote areas to inner regional or metropolitan centers (fig. a) . the primary evacuation statistical areas level included alice springs (northern territory) ( . %, n = ), the far north (northern queensland) ( . %, n = ), gold fields (western australia) ( . %, n = ), and the kimberly ( . %, n = ). figure b provides an illustration of the supply of mental health services derived from spot. when looking at the general mental health service coverage within these areas reflective of population concentrations, the gold fields ( . %, n = , ) had the highest remote and very remote population level without coverage followed by alice springs ( . %, n = , ), kimberly ( . %, n = , ), and the far north ( . %, n = , ). for primary evacuations, the leading diagnoses were for the f to f group of psychotic disorders, including schizophrenia, schizotypal, delusional disorders, and other non−mood-related psychotic disorders ( . %, n = ). schizophrenia ( . %, n = ), acute and transient psychotic disorders ( . %, n = ), and unspecified nonorganic psychosis ( . %, n = ) were the most common diagnoses. one similar to primary evacuations, the majority of interhospital transfers were associated with f to f , schizophrenia, schizotypal, delusional disorders, and other non−mood-related psychotic disorders ( . %, n = ). one fifth of the transfers were for f to f , mood (affective) disorders ( . %, n = ); . % (n = ) were for f to f , mental and behavioral disorders caused by psychoactive substance use; and . % (n = ) for f to f , organic, including symptomatic, mental disorders. small numbers of interhospital transfers were reported for f to f , disorders of adult personality and behavior ( . %, n = ); f to f , neurotic, stress-related, and somatoform disorders ( . %, n = ); f , unspecified mental disorders ( . %, n = ); and f to f , behavioral syndromes associated with physiological disturbances and physical factors ( . %, n = ). five or less evacuations were reported for f to f , behavioral and emotional disorders with onset usually occurring in childhood and adolescence; f to f , disorders of psychological development; and f to f , mental retardation. the total costs for all mental and behavioral disorder air medical retrievals and subsequent hospital admissions in was $ , , . the cost associated with the primary evacuations was estimated to be $ , , . two thirds of this ($ , , , . %) was related to in-patient admissions (ar-drg costs) and the remaining $ , on air retrieval costs. reflecting the numbers of patients, the highest combined air retrieval and in-patient costs were for u a (schizophrenia disorders, major complexity; $ , ), u a (paranoia and acute psychotic disorders, major complexity; $ , ), and u a (major affective disorders, major complexity; $ , ). the average cost per primary evacuation patient was $ , . the total cost related to interhospital transfers was $ , , . similar to primary evacuations, the majority of these costs were related to in-patient admission costs ($ , , ) . reflecting the numbers of interhospital transfers, the greatest total costs were associated with u a (schizophrenia disorders, major complexity; $ , , ), u a (paranoia and acute psychotic disorders, major complexity; $ , , ), and u a (major affective disorders, major complexity; $ , , ). the average cost per interhospital transfer patient was $ , (see table for cost breakdowns for primary evacutations and interhospital transfers). almost one third of all hospital costs (for both primary evacuations and interhospital transfers) were associated with the ward nursing cost bucket ( . %) (fig. ) . these costs are associated with nursing care provided in general wards. the ward medical cost bucket, which includes both salaries and wages for medical officers, accounted for . % of hospital costs. other notable cost buckets were . % for ward supplies (costs for medical and surgical supplies, ward and clinical department overheads, and goods and services), . % for nonclinical salaries (other costs of service provision, predominantly wages for carers such as patient care assistants), . % for oncosts (eg, superannuation, fringe benefits tax, long service leave, worker's compensation, and recruitment), and . % for ed product (ie, the average cost per admitted ed patient). this is the first study to quantify the direct medical costs associated with air medical retrievals of patients experiencing mental health crises in australian rural and remote settings. we estimated that the annual direct medical cost associated with this was $ , , for . most of these costs were attributable to hospital costs, with over % of this expended on ward nursing staff, medical staff, and ward supplies. importantly, this total cost represents a substantial underestimate of both the health payer and the societal impacts of these acute mental health events in the rural and remote areas of australia. more specifically, in regard to the direct medical costs, the costs of the first hospital (or retrieval site) admission for the patients who received an interhospital transfer were not included. furthermore, the substantial indirect costs associated with air medical retrievals have not been assessed. these costs include those associated with the lost productivity of patients, their families, and caregivers. in addition, intangible costs, largely the suffering associated with a condition that can be captured using quality of life instruments, is likely to be substantial from both a physical and, importantly, from a psychosocial perspective and has not been assessed in this study. for patients, particularly for those experiencing a first episode of psychosis, inpatient admission in addition to air medical retrieval and dislocation from usual social supports and networks can be a traumatic experience, with a recent systematic review reporting % of firstepisode psychosis patients experienced symptoms of post-traumatic stress disorder. although the impact of this experience is partially understood with patients, less is known regarding the impact and costs for families and caregivers. further research is required to fully understand the true costs, including indirect (loss of productivity) and intangible costs (quality of life), associated with air medical retrievals for mental health care and the current level of service provision to rural and remote communities in location. ultimately, the implications of these health payer and societal costs need to be understood in the context of considered funding and capacity considerations for rural and remote mental health services and providers. tough longer-term health care policy decisions are required by governments and health planners through the prism of the known economic costs for air medical retrievals, albeit as an underestimate of the likely true costs identified in this study. additional attention and research are required to qualify the grossly under-researched costs to rural and remote communities of retrieving patients with mental and behavioral disorders out of their communities from a societal impact perspective. the severe lack of psychiatrists, mental health nurses, psychologists, and social workers in rural and remote areas requires structural change to the supply of a qualified and competent rural and remote workforce. the recent australian senate inquiry into the burden of mental health conditions on rural and remote communities recommends longer-term and more flexible funding and contract processes, in addition to working with professional colleges to improve support and training of workers in rural and remote communities, with the goal of supporting high-quality workers and services to remain in communities, thereby providing consistency of service provision. importantly, our article suggests that rfds air medical retrievals are a symptom of this unmet demand and also a potential proxy for the services and capacity that currently does not exist in rural and remote communities. to provide high-quality mental health services to rural and remote communities will require adequate resourcing. although the costs to governments will likely be substantial, we suggest that the societal benefits that will be gained from resourcing action to meet the unmet demand are likely to outweigh these costs. in other words, the poor mental health outcomes experienced by people in rural and remote communities deserves and demands action. furthermore, we do not understand the impact of high-acuity mental illnesses, the high rates of suicide and substance use on the indirect (productivity) and intangible (quality of life) costs for rural and remote communities, and the australian society more broadly. it is important to quantify these costs because they are likely to be substantial and offset much of the costs related to the provision of high-quality mental health services for rural and remote communities. a strength of this article is that it has provided annual direct medical costs associated with air medical retrievals in australia. these costs have not been quantified before and are important because they can be used to assess the total costs associated with the current approaches to mental health service provision in rural and remote communities. a limitation of this study is that to apply hospital costs from the national hospital cost data collection, we mapped icd- -am codes (of which there are > , ) to the ar-drg codes costed by the national hospital cost data collection. as such, the costs reported here are an estimate of the costs to governments through the public hospital system. a further limitation was that we were unable to access the icd- -am codes that were listed for the initial hospital admission before interhospital transfers; therefore, we were unable to apply these costs. in conclusion, the direct medical costs of air medical retrievals for mental and behavioral disorders in australia's most remote communities are substantial. the societal implications of these costs to the families and communities of these regions is unknown; nevertheless, the flow-on effects of these societal costs are likely to far exceed the direct medical costs. we challenge policy and decision makers to understand these societal implications for future health policy and planning of mental health services in australia's rural and remote communities. australian institute of health and welfare. rural and remote health. canberra, australia: australian institute of health and welfare time to end the drought in the bush the orange declaration on rural and remote mental health suicide and hospitalised self-harm in australia: trends and analysis australia's future health workforce − psychiatry. department of health australian institute of health and welfare. mental health services in australia: mental health workforce tables time to end the drought in the bush australian institute of health and welfare. national drug strategy household survey : detailed findings royal flying doctor service covid- activity and surge modelling in australia health care access, mental health, and preventive health: health priority survey findings for people in the bush suicide and mental health in rural, remote and metropolitan areas in australia drought-related stress among farmers: findings from the australian rural mental health study department of health. mbs online. australian government methods for the economic evaluation of health care programmes consolidated health economic evaluation reporting standards (cheers) statement international statistical classification of diseases and related health problems, th revision the medical and retrieval costs of road crashes in rural and remote northern queensland independent hospital pricing authority. national hospital cost data collection report, public sector, round (financial year - ). canberra: ihpa who we are volume -main structure and greater capital city statistical areas aeromedical retrievals of people for mental health care and the low level of clinical support in rural and remote australia the traumatic experience of first-episode psychosis: a systematic review and meta-analysis the australian senate: community affairs references committee. accessibility and quality of mental health services in rural and remote australia acknowledgmentin-flight patient data were extracted from the confidential royal flying doctor service data set, and cost data for australian refined diagnosis related groups codes were sourced from the publicly available national hospital cost data collection ( / ) website.*address for correspondence: fergus gardiner, phd medicine, royal flying doctor service, , level , - brisbane avenue, barton, act , e-mail address: fergus.gardiner@rfds.org.au (f.w. gardiner). key: cord- -rb gpsvn authors: wozniak, teresa m.; miller, esther; williams, kevin j.; pickering, amelia title: championing women working in health across regional and rural australia – a new dual-mentorship model date: - - journal: bmc med educ doi: . /s - - -w sha: doc_id: cord_uid: rb gpsvn background: mentoring is a critical component of career development and job satisfaction leading to a healthier workforce and more productive outputs. however, there are limited data on mentorship models in regional areas and in particular for women aspiring to leadership positions. mentorship programs that leverage off experienced mentors from diverse disciplines have the potential to foster the transfer of knowledge and to positively influence job satisfaction and build capacity within the context of workforce shortage. methods: this study describes a dual-mentorship model of professional development for women working in health in regional and rural australia. we present the framework and describe the evaluation findings from a -month pilot program. results: both academic and corporate mentors provided diverse perspectives to the mentees during the -month period. on average, corporate mentors met with mentees more often, and focused these discussions on strategy and leadership skills whilst academic mentors provided more technical advice regarding academic growth. mentees reported an improvement in workplace interconnectedness and confidence at the completion of the program. conclusion: we developed a framework for establishing a professional mentorship program that matches women working in regional health with mentors from diverse sectors including business, government, philanthropy and health, to provide a holistic approach to improving career satisfaction, institutional productivity and supporting a diverse workforce in regional or resource-poor settings. despite the high overall health status of many australians, rural and regional areas within this country continue to experience comparatively poor health outcomes [ ] . health inequity is a complex issue which is complicated by workforce shortages [ , ] and high turnover of staff in regional and remote parts of australia [ ] . while retention of health professionals is a complex issue [ ] , initiatives to recruit and retain regional and remote staff have traditionally focused on financial reimbursement [ ] [ ] [ ] . far less attention has been paid to the benefits of professional networks and formalized mentorship programs in regional settings [ ] . literature shows that professional networks and formalized mentoring programs provide an opportunity to exchange knowledge, develop leadership skills and advance careers [ ] . mentorship can improve mentee productivity, self-efficacy and career satisfaction [ ] [ ] [ ] [ ] and be a personally fulfilling experience for mentors [ , ] . wellstructured and inclusive mentoring programs are highly beneficial for health professionals, including training researchers across varied disciplines [ , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . mentoring relationships that offer the greatest impact on success are likely to be influenced by individual attributes [ ] and the social context within which the program is instituted [ ] . mentoring can be didactic [ ] , peer-peer [ ] , formal or informal, delivered face to face or distance [ ] . it is widely recognized that career advancement in medicine, research and health more broadly, remains in favor of men [ ] . not only do women receive less mentoring than men [ , ] , they are under-represented in senior roles [ ] , continue to be asked about their job commitment [ , ] , and get paid less. while women comprise roughly % of all employees in australia, they take home $ . less than men each week (in november ) and the national gender "pay gap" has remained around - % for most of the past two decades [ ] . we sought to identify the needs of women working in the geographically isolated north of australia and used these to inform the key elements of a new dual-mentor model, called the catalyse mentorship program ("program") for women working in healthcare within a resource-poor setting. in , a professional network called women in tropical health (with) was established as part of a large health research program, 'improving health outcomes of northern australia' (hot north). in november , a needs analysis survey was conducted to determine the requirement for a formalized mentoring program in regional and rural australia (supplement table s ). within the scope of the with network was the pilot and a formative evaluation of the catalyse mentorship program (the 'program') ( table ) . the primary aim of the program is to facilitate diverse partnerships which provide women with opportunities to reflect on and grow their leadership capabilities, build professional networks, and more effectively navigate career progression and development . there are four main objectives: . to provide a safe environment where professional knowledge, experience and advice is shared between and within mentees and the program facilitator . to cultivate a strategic approach to career planning and to foster innovation . to expose mentees to alternative career pathways and opportunities to consider advancing their work . to improve visibility of the mentee and their research the program employs a dual-mentor design that is concentrated on matching a female healthcare professional with an academic and corporate mentor, supported by facilitated mentoring resources and career-development workshops (table s ). the dual-mentor model is designed to not only provide guidance on a broader range of skills, but also to introduce women to potential external funders, influential supporters and strategic counsellors and mentors (corporate, philanthropic and academic) who may be able to assist in advancing their work interests and careers. in the pilot program, a aud $ bursary was offered to each mentee to be used on professional development activities. mentees were expected to meet with both mentors four times throughout the program, as well as attend five workshops. as part of the workshop resource packs, participants were provided with a meeting framework, with objectives and discussion points for each meeting. the strategic framework is described in table . program pilot - / the program pilot period was march until march . during this period, each of the mentees were assigned two mentors; one academic mentor and one corporate mentor, recognizing that both mentor groups would bring specific skills and knowledge to the program. this unique feature of the program originated from a qualitative need's assessment which identified diversity of expertise and networks as a challenge for women working in regional australia. the mentees were members of the with network and included healthcare professionals from across multiple institutions, including menzies school of health research, charles darwin university, flinders university and torres and cape hospital health services. academic mentors were either known contacts of the program management team who had previously expressed an interest in mentoring early/mid-career women or were identified by the team as possessing the skills and attributes which would lend them to be appropriate mentors in this program. corporate mentors were selected from a pool of industry supporters and ambassadors cultivated by the menzies development team over several years. a few however were recruited specifically for the program due to their mentoring experience and/or desired expertise. most mentors were located along the eastern seaboard of australia and have extensive networks nationally. therefore, these pairings aimed to further offer exposure, scope and relational opportunities beyond northern australia, or the nature of which mentees may ordinarily not have access to. although many had experience as mentors previously, mentor training and support was provided in the form of an initial resource pack including guidelines and expectations, on-going intermittent e-resources, regular 'check-ins' and access to a mentor helpline (table ) . furthermore, mentees were provided an opportunity to put forward a name of a 'dream mentor' i.e. someone they have researched and believe had valuable insights, experience or connections that would enhance their personal and professional progression. of the nine mentees who completed the program, five secured dream mentors, two were unsuccessful and matched with an alternative mentor, and two did not submit a request. during the first of the five mentee training workshops (described in greater detail in supplement table s ), the participants collaborated to collectively articulate their shared expectations of the program. these were summarized as: -to be linked up to people who are further in their career for mentorship -to have a toolkit to develop leadership skills -to have considered with the support of the program facilitator a - -year career plan -to decide the next career step and why -to gain increased confidence -to be able to promote myself and my work -to gain a more strategic approach to career development and change direction if needed -to have dedicated time to reflect on my career -to develop relationships with those who have blazed the path before me at each of the subsequent workshops, these expectations were reviewed, and mentees participated in a selfassessment survey to assess progress made towards these objectives, as well as to identify broader learnings ( table and table s ). a formative evaluation was conducted between november and may to ensure that the program was achieving its aims, and to document necessary adjustments or improvements for future program development. the evaluation considered the suitability of the program resources, the application and selection processes, the matching process, the program format and duration, and the inclusion of financial support. it also considered whether the program met its objectives through achievement of short-term outcomes. an online, anonymous survey was sent to each participant of the program, which included nine mentees, nine academic mentors and nine corporate mentors (supplement table s and table s ). the surveys did not include questions relating to demographic information or current workplaces, projects or other information that could be used by the evaluators to identify any of the respondents. data analysis was performed in excel with differences expressed as the number and percentage of responses. women working in regional settings want formalized mentoring programs that offer diverse perspectives there were responses provided to the need's assessment survey conducted in and prior to starting the pilot program (table s ). most of these respondents were women who reported being mid-career (n = , •potential for career advancement %), with % (n = ) early career and % (n = ) in established leadership roles. despite % (n = ) of survey participants requesting a formalized mentorship program, the majority did not have the opportunities to participate in one (n = , %). the majority ( %) considered mentoring as a discussion about personal and professional goals whilst others thought it as an opportunity to be coached on a particular task. when asked "what main areas of development the participant would benefit from the most", the two main themes that emerged were "clear career pathways" and "diverse perspectives". the process of self-matching mentee-mentor pairs was appropriate the program used a 'self-matching' process to pair up mentors with mentees. this process was recommended by corporate mentors based on their experience that appropriate matching which facilitates 'good chemistry fit' was critical to a productive pairing. to this end, both mentors and mentees had input into the matching process by providing feedback and preferencing their matches. mentors and mentees were provided with a portfolio of possible matches and were asked to identify their three "top choices". the mentor portfolio included professional bios, as well as a personal statement regarding "what i can offer that is not in my bio". the mentee portfolio included the professional bio and mission statement compiled in workshop one (table s ) , as well as the mentees top three challenges that they would like to address with mentors' support. mentors and mentees used this information to do an informal personal evaluation to determine who they would be best suited with: mentors from the perspective of whose challenges they identify with and whose work they are interested in supporting; and mentees from the perspective of who portrayed aspirational attributes, skills and experience. preferences were then collated and compared in order to identify obvious matches (i.e. where both the mentor and the mentee ranked each other as a 'top choice'). all parties were given an opportunity to contact the program facilitator at any stage of the process, should they believe the pairing unsuitable. one mentee reported being 'disengaged' with their academic mentor however she did not request any changes be made with this arrangement. the formative evaluation found that the majority of mentors and mentees agreed or strongly agreed that the matching process used in the program was appropriate. three mentees ( . %) were neutral, as was one academic mentor and no participants disagreed with the process of self-matching. the -month pilot included nine mentees from northern australia and one international mentee, with one mentee not completing the pilot ( % completion). each mentee was matched with two mentors, five of which were 'dream' mentors. a total of mentors were recruited to the program. the mentees represented a diverse group of health professional (academic, nonacademic) at various levels of seniority. the mentors represented males ( %, n = ) and females ( %) from a range of sectors including health, academia, transport, banking and insurance. the mentees met with corporate mentors more often than with academic mentors and raised different topics the evaluation survey showed that on average, mentees met with their academic mentors . times, and with their corporate mentors times. during these meetings, academic mentors discussed fellowship applications, work/life balance and career planning, whilst corporate mentors mainly discussed the latter (fig. ) . academic mentors provided specific 'technical' advice regarding the explicit and implicit academic growth pathway i.e. explicit pathways such as formal academic progression process and implicit avenues such as the advantages of connections, types of journals to publish in, and how to distinguish one's specific work. corporate mentors provided broad and specific objective advice on strategy, leadership and interpersonal skills. specific examples include how to generate consensus within a team and with external stakeholders, how to have difficult conversations, how to build and express a personal brand in business. the evaluation questionnaire asked program mentees to report any changes (increase, decrease or no change) to various measures of mentoring benefits during the pilot. eighty percent of the mentees reported an increase in feeling of interpersonal connectedness in the workplace; and % (n = ) reported an increase in job satisfaction. one mentee reported an increase in their technical skills (fig. ) . at the completion of the program, % of the mentees self-assessed an increase in confidence and "dedicated time to reflect on where things are and new goals to set" (table ). almost one third of the mentees reported having tools that can develop their leadership skills. as part of the program workshops, mentees were asked to list three goals which they had hoped to achieve by the end of the program. the goals were categorized into three areas of focus: [ ] 'here and now' e.g. manage workload, streamline tasks, repair relationships [ ] ; 'what's next?': e.g. actions needed to move towards the participants vision, upskill in certain areas, do investigations about options; and [ ] 'self-care': e.g. identifying practises that can be incorporate into day-to-day life that will provide openings for transformation or creativity. at the completion of the program, the evaluation questionnaire asked both mentees and mentors to reflect on how well the mentee achieved these goals. only one third (n = , %) of the mentees rated achieving this goal as very well or well, whilst the remainder were either neutral or poorly achieved. all the corporate mentors and % academic mentors felt that their mentees had achieved the goals which were set in the beginning of the program. mentees describe how the program has improved their relationship with their employing organization, by improving their strategic acumen, perspectives on organizational interdependencies and by reinforcing personal motivation and purpose. furthermore, many mentees reference an increase in confidence, and as a result identifying or being identified as suitable candidates for greater or different career progression opportunities. "incidental" outcomes of the program the program resulted in several promising and notable outcomes that were not initially intended. a summary of these is listed below . additional 'dream' mentors secured to the program. as quoted by a mentee when asked what by one of the program mentees. as quoted by a mentee (self-assessment during a workshop) to be a highlight of the program "the wonderful support group that the participants created. i didn't expect there would be so much laughter and jokes." . a new networking group established by a partnership from a program mentee and corporate mentor . a new feasibility study conducted in collaboration with a program mentee and corporate mentor to improve health service delivery in regional australia . a business case to test the commercialization of a research intellectual property concept developed by program mentee and corporate mentor for future career interests: "connection with the corporate mentor opened up opportunities i never would have explored by myself." . prestigious academic awards and accolades . philanthropic sponsorship to the menzies school of health research from a program corporate mentor, who had no connection to the organization prior to the program. we describe the successful pilot of the catalyse mentorship program (the "program"). a formal evaluation combined with self-reported surveys demonstrates that the program resulted in the mentees experiencing positive 'discomfort', by being pushed out of their 'comfort zones' and requiring them to think differently. many have changed their behaviors, as demonstrated by improving time management and priority-setting; and being "more inclined to meet people and make the first move". this is further demonstrated through first-time activities undertaken by the mentees such as: business case development, establishment of peer-to-peer networking groups; application for (or nomination and receipt of) prestigious awards and accolades. for some, the program has not had the same immediate affect "i'm not as clear about my next step as i would like to be. but that's ok." in this instance, it has provided these mentees a way forward through the "tools i learned about in this program." we found that within the regional context, relying on one style of mentoring (i.e. didactic or peer-peer support) may not be suitable. traditional hierarchical mentoring with unidirectional mentor-mentee relationships have worked well in large research institutes and shown transformative mentorship for junior faculty in the short [ ] and long-term [ ] . however, these relationships in regional settings can be time-consuming and challenging when mentors are faced with demands of working multiple roles (clinical, research, teaching) and having overlapping roles as mentors and supervisors [ ] . we were not able to identify published literature that describes a dualmentor model (i.e. mentee is matched with an academic expert and a corporate mentor). however, there is strong evidence for the benefits of interdisciplinary perspective and cross-cultural mentorship [ ] [ ] [ ] [ ] . hence, choosing a mentorship program which emphasizes the reciprocity and co-learning of a mentoring experiences [ ] adapted to local context was the model that we found most suitable. linking across healthcare and industry sectors provides opportunities for a more diverse pool of mentors and mentees providing broader scope and exposure both vocationally and geographically, and a more inclusive and sustainable approach in the regional context. not all measures of a perceived successful mentorship program were achieved. we found a divergence in responses relating to achieving specific, measurable, achievable, relevant, time-bound (smart) goals set at the beginning of the program. an explanation of this is likely multifactorial and may be a combination of recall table program expectations as reported by mentees "self-assessment survey" expectation of the program, n = mentees who felt this expectation was met (%) to gain increased confidence to have dedicated time to reflect on my career to be linked up to people who are further in their career for mentorship to have considered with the support of program facilitator a - year career plan to decide the next career step and why to gain a more strategic approach to career development and change direction if needed to have a clearer understanding of where i want to go next to be able to promote myself and my work to develop relationships with those who have blazed the path before me to have a toolkit to develop my leadership skills bias (as formative evaluation survey asked to recall goals set more than months prior) or differences in the interpretation of 'achievement' by mentees and mentors as it relates to goal progress [ ] . to more clearly understand this, in-depth interviews would have been a more appropriate measure of assessing goal attainment in the program. assessing the impact of mentorship programs should ideally use a mixed methodology approaches. these include quantitative measures of "what" improved for participants and qualitative approaches that provide a deeper understanding of "how" programs work best. the dual mentorship model as evidenced in the program, provides an outstanding example of corporate female leadership to a cohort of women who are likely missing out on such opportunities. in the program pilot, only % of the academic mentors were women, whilst all the corporate mentors were female. this may be a factor of a lack of female representation in senior academia [ ] and more broadly across the global health sector [ ] . the meetings with corporate mentors offered an alternative perspective. in this program, academic mentors provided technical academic pathway advice, whereas meetings with corporate mentors focused more on interpersonal skills, teamwork and leadership pathways. together, the dual mentorship model provides a rounded approach for mentees, offering both the discipline-based technical advice and external guidance on personal attributes and strategic thinking needed to lead. the successful implementation of the program does not automatically imply creating a mentorship culture but it's a start. to leverage the gains from the program pilot, mentees and mentors were asked if they would contribute in future programs and all agreed. importantly, mentees expressed interest in participating in the next iteration of the program in leadership roles, ranging from program facilitators, mentors or personal supporters. we believe that the program has offered personal and professional opportunities to its participants to be both leaders and learners. it provides a framework for mentorship embedded into the institutional culture, which is suitable to the local context. we acknowledge that institutional support is a salient influencer of the success of formalized mentorship programs [ ] . though workforce retention was not an initial aim of the catalyse mentorship program, we believe that providing strong professional networks in regional australia may prove to be one initiative, in addition to others [ ] [ ] [ ] [ ] , to assist in the reduction of avoidable turnover. regional australia suffers from high staff turnover in healthcare [ ] . women who leave their place of employment or who are not able to contribute their full potential represent a loss of institutional return on investment [ ] . for institutions, staff leaving creates gaps in leadership, knowledge of system-specific effectiveness, and experience with the evolving field of healthcare and academic medicine at large [ ] . institutions lose the productivity of staff, with an added burden for those remaining and the additional costs for recruiting and training. from a workforce perspective, lack of staff retention represents a loss of investment and potential productivity which is not sustainable long term [ ] . in environments that are increasingly resource-poor, this lack of organizational self-awareness and inertia seems a critical and costly oversight [ ] . sustainable networks which offer innovative solutions to connecting professionally and providing career advancement for health researchers are important for maintaining research quality and health outcomes in regional areas. we acknowledge several limitations in the present study. these include that the findings are from a pilot program with relatively low number of participants. it is a descriptive study which is not controlled and may therefore be subject to bias. this is mostly likely selection bias due to the selection of mentees from a small pool of healthcare professionals that may not be representative of the sector. additionally, the formative evaluation collected data which required that mentees recal long periods of time (approximately - months) and their responses may therefore suffer from recall bias. we did not conduct in depth interviews as part of the formative evaluation and were therefore limited in gaining detailed insight of impact. future evaluations of this program and other similar programs should consider investing resources in conducting in depth interviews to assess meeting program objectives and outcomes. despite these limitations, the current study provides tangible measures of outcomes both for the health research sector and those wanting to develop mentoring programs within academic institutions and/ or resourcepoor settings. this program has shown promise in providing an interdisciplinary environment and professional networking to specifically deal with aspects of women's career development, job satisfaction and regional workforce retention. in the future, designing programs that deliberately engage with the corporate sector; that actively support peer-peer mentoring, and offer distance mentoring (i.e. virtual) would be beneficial. in this cohort, % of the mentees were off-site and attended all workshops via video conferencing. given the current travel and meeting restrictions due to covid- , we would envisage that virtual workshops and distance mentoring may be an effective conduit to maintain momentum and career progression during such challenging times. australian institute of health and welfare. rural and remote health (web report) australia's health workforce when the tide goes out: health workforce in rural, remote and indigenous communities patterns of resident health workforce turnover and retention in remote communities of the northern territory of australia how best to measure health workforce turnover and retention: five key metrics supervision, support and mentoring interventions for health practitioners in rural and remote contexts: an integrative review and thematic synthesis of the literature to identify mechanisms for successful outcomes recruitment and retention of occupational therapists and physiotherapists in rural regions: a meta-synthesis rural allied health scholarships: do they make a difference? rural remote health mentoring as a retention strategy to sustain the rural and remote health workforce a review of mentoring in academic medicine career choice in academic medicine: systematic review mentoring in academic medicine: a systematic review characteristics of success in mentoring and research productivity -a casecontrol study of academic centers policies, activities, and structures supporting research mentoring: a national survey of academic health centers with clinical and translational science awards medical leadership: why it's important, what is required, and how we develop it being a mentor: what's in it for me? the association between mentoring and training outcomes in junior doctors in medicine: an observational study mentoring translational science investigators identifying future scientists: predicting persistence into research training independent investigator incubator (i( )): a comprehensive mentorship program to jumpstart productive research careers for junior faculty psychosocial and career outcomes of peer mentorship in medical resident education: a systematic review protocol mentoring perception and academic performance: an academic health science centre survey mentoring perception, scientific collaboration and research performance: is there a 'gender gap' in academic medicine? an academic health science centre perspective mentorship training is essential to advancing global health research culturally diverse undergraduate researchers' academic outcomes and perceptions of their research mentoring relationships defining attributes and metrics of effective research mentoring relationships mentor networks in academic medicine: moving beyond a dyadic conception of mentoring for junior faculty researchers the positive impact of a facilitated peer mentoring program on academic skills of women faculty distance mentoring of health researchers: three case studies across the career-development trajectory australian human rights commission mentoring programs for underrepresented minority faculty in academic medical centers: a systematic review of the literature why do women choose or reject careers in academic medicine? a narrative review of empirical evidence a mixed-methods investigation of the motivations, goals, and aspirations of male and female academic medical faculty factors impacting the departure rates of female and male junior medical school faculty: evidence from a longitudinal analysis gender pay gap statistics independent investigator incubator (i ): a comprehensive mentorship program to jumpstart productive research careers for junior faculty long-term impact of a faculty mentoring program in academic medicine developing mentorship in a resource-limited context: a qualitative research study of the experiences and perceptions of the makerere university student and faculty mentorship programme mentoring in global health: formative evaluation of tuberculosis research training programs in ethiopia and georgia bear cage: mentoring through engagement culturally aware mentorship: lasting impacts of a novel intervention on academic administrators and faculty a new approach to mentoring for research careers: the national research mentoring network the effects of self-criticism and self-oriented perfectionism on goal pursuit advancing women leaders in global health: getting to solutions building blocks of global health mentorship: motivation, expectations, and institutional support an explanation of turnover intention among early-career nursing and allied health professionals working in rural and remote australia -findings from a grounded theory study up close and real: living and learning in a remote community builds students' cultural capabilities and understanding of health disparities outcomes of australian rural clinical schools: a decade of success building the rural medical workforce through the education and training continuum supports for medical students during rural clinical placements: factors associated with intention to practise in rural locations promoting academic careers of women in medicine retaining faculty in academic medicine: the impact of career development programs for women publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we would like to thank all the catalyse mentorship program mentors and mentees.authors' contributions tw concept development, manuscript preparation and review. em formative evaluation and manuscript review. kw concept development and review of supplementary information accompanies this paper at https://doi.org/ . /s - - -w.additional file : table s . needs assessment questionnaire. table s . catalyse mentorship program workshops - . table s . evaluation questionnaires for mentors. table s . evaluation questionnaires for mentees.abbreviations aud: australian dollar; with: women in tropical health the authors declare that they have no competing interests.received: june accepted: september key: cord- - i nu l authors: o’sullivan, belinda; leader, joelena; couch, danielle; purnell, james title: rural pandemic preparedness: the risk, resilience and response required of primary healthcare date: - - journal: risk manag healthc policy doi: . /rmhp.s sha: doc_id: cord_uid: i nu l pandemic situations present enormous risks to essential rural primary healthcare (phc) teams and the communities they serve. yet, the pandemic policy development for rural contexts remains poorly defined. this article draws on reflections of the rural phc response during the covid- pandemic around three elements: risk, resilience, and response. rural communities have nuanced risks related to their mobility and interaction patterns coupled with heightened population needs, socio-economic disadvantage, and access and health service infrastructure challenges. this requires specific risk assessment and communication which addresses the local context. pandemic resilience relies on qualified and stable phc teams using flexible responses and resources to enable streams of pandemic-related healthcare alongside ongoing primary healthcare. this depends on problem solving within limited resources and using networks and collaborations to enable healthcare for populations spread over large geographic catchments. phc teams must secure systems for patient retrieval and managing equipment and resources including providing for situations where supply chains may fail and staff need rest. response consists of rural phc teams adopting new preventative clinics, screening and ambulatory models to protect health workers from exposure whilst maximizing population screening and continuity of healthcare for vulnerable groups. innovative models that emerge during pandemics, including telehealth clinics, may bear specific evaluation for informing ongoing rural health system capabilities and patient access. it is imperative that mainstream pandemic policies recognize the nuance of rural settings and address resourcing and support strategies to each level of rural risk, resilience, and response for a strong health system ready for surge events. world-wide, primary healthcare (phc) is the foundation of an accessible and costeffective health system. strong phc strongly underpins the achievement of the sustainable development goals, particularly those related to health and equity, in rural communities worldwide. however, when it comes to pandemic responsiveness, including the current global effort against covid- , the nuance of the rural phc pandemic context is somewhat hidden. the focus of clinical interventions has been on urban and metropolitan locations (somewhat driven by the disease infection, severity and mortality rates that may occur in high-density areas). despite this, there is a difference with respect to pandemic planning and action in rural areas. in particular, describing the role and function of rural phc teams in such emergencies has the potential to inform rural health system preparedness to all-nature of hazards of biological, chemical and radio nuclear varieties, whether naturally occurring or not. our aim was to draw on our collective expertise in rural public health, clinical and academic knowledge, to provide a commentary as to our perceptions of the activity and experiences of the rural phc sector during the covid- pandemic. we considered this would be applicable for informing future pandemic policy and planning and ensuring that national responses are tailored to rural contexts. we particularly drew on experiences from canada and australia, as two countries with similar health systems, geography, and rural population distributions. in order to do this, we first discussed the pandemic response we observed in our own country's rural and remote communities to draw out three themes representing interacting phases that were common in both countries: risk, resilience and response. the working definitions for these are summarised in table and explored in the paper as follows. despite the recognition that effective pandemic management requires specific attention to at-risk populations, there is very little literature concerning the nature of risk for rural populations. , although many rural people are affected by covid- around the world, the focus tends to centre on population risk and disease severity in highdensity urban communities. anecdotally, much of the media coverage about case counts and deaths also revolves around urban areas and city hospitals, with limited demarcation of what is going on in rural places. despite this, nearly half the global population lives rurally and has specific risks related to transmissible infections (table ) . many rural communities entered the current pandemic already chronically under-serviced, facing inadequate healthcare infrastructure, limited clinical resources and equipment, and healthcare personnel shortages ( % lacking critical healthcare access). - with respect to their populations, rural communities include more aged, first peoples and socio-economically disadvantaged people, many with higher levels of pre-existing chronic illnesses. some rural and first peoples face extreme socio-cultural barriers related to access to healthcare as well as housing, basic services and digital infrastructure, affecting lower levels of health service access and use relative to their needs. , pre-existing unmet needs may exacerbate pandemic risks unless the healthcare response is adequate, culturally and socially relevant. further, despite the concept that rural communities are safe from pandemic exposures, the high levels of interaction between rural communities, with metropolitan areas and with international communities is an important factor to consider within pandemic policies. some rural communities have strong patterns of using fly-in fly-out workers and short-term rotating locum staff. [ ] [ ] [ ] in australia and canada, around % and % of the rural medical workforce is overseas-trained, many of whom visit their home country and have regular family visiting. , moreover, in rural communities, goods and services are often traded in a relatively informal economy through local entrepreneurship and reciprocity as a vital part of sustainable development. commodities available in one community may not be in another, only reinforcing travel between communities. rural populations may also rely on more multi-site employment (intra-rural and rural to urban) and educational models, including boarding schools, posing other infection risks. , rural locations may also experience significant numbers of people visiting holiday homes (sometimes to get away from pandemics 'hot spots'), as well as mobile tourist groups including many "grey nomads", people who are post-retirement, taking lengthy holidays, some of whom may be trapped in rural locations by border closures during a pandemic. , together, the patterns of rural mobility increase the threat that rural communities will be exposed to infectious diseases, with potentially dire consequences unless specifically acknowledged and managed. with respect to the risk of community transmission, the conditions in rural areas may pose particular challenges. first peoples have high rates of short-term inter and intra community movement patterns within regions (around trips per year, often related to kinship), and are subject to over-crowded housing ( . % of housing considered not adequate for the number of people per dwelling). , mainstream policies to promote or mandate self-isolation during pandemics may be impractical to implement and work against the goal of reducing the rate of infection in rural and remote settings. instead, rural communities may need to identify specific ways to respectfully adjust normal community movement patterns and consider ways to provide safe sheltering options for isolating unwell people. these considerations must address the social, economic, and cultural determinants of health in order to be effective. chronically under-serviced, with higher rates of chronic illness and limited clinical resources and equipment and health personnel. communities of a high fly-in-fly-out workforce over diverse borders, high levels of overseas-trained health workers. inter-community sharing of goods and services. multi-site employment, boarding schools, tourists and particular industries. host of a number of holiday homes and roving tourists. inter-personal interaction between community members and mobility between first peoples visiting family/kin on-country. co-location of hospitals and aged care services. overcrowded personal spaces (housing), make it challenging to isolate unwell people. risk communication challenges, related to lower education levels, different language groups and potential stigma of illness. diverse population with greater access to employment, education and health services. mostly within city population movement, using a higher proportion of locally available healthcare workers. visitors may include more "short-stay" individuals, often related to employment. fewer students leaving home to attend rural boarding schools. large gatherings more common, high-density community and over-crowded communal spaces and office buildings that need to be managed. hospitals, a potential source of exposure. risk communication tailored to more educated population. resilience the potential of the system and population to withstand possible ill-effects from the threat/hazard. within-city networks and transfers rapid. administrative staff capacity sound. policies already tailored to setting so easier to apply. long-term staff and staffing stability. less staff burnout and impact of staff isolation policies as overall numbers of trained health workers and phc teams greater. stockpiles required, but supply chains turn on more rapidly. (continued) perceived and real risks may be exacerbated unless risk communication accounts for the lower education levels of rural populations, different language groups and the potential stigma related to illness in rural and remote communities. failing to do so may also reduce perceived risk and compliance with public health information and negatively impact health service use. , finally, in rural areas, health services may be colocated with other human services, in multipurpose centres, which operate as part of networked and integrated service models that aim to support health and human services for people as close to home as possible. these potentially place long-term aged care residents within proximity of infectious patients, warranting site-specific risk assessment and adjustment. mindful of different risks in rural settings, mainstream policies for health services, border control, population monitoring, self-isolation and closure of essential services require rural tailoring. the mainstream population health and health service resilience to covid- has largely centred on building hubs for testing, upscaling tracing and isolation activity along with building hospital service capacity including equipment and intensive care unit beds. but rural resilience relies on the availability of strong qualified phc teams covering services most relevant to the population's needs. , the focus on strong phc is essential as most rural towns have small (< bed) (minimal high dependency care), or no hospitals and more remote communities rely on community clinics, nursing stations or visiting primary healthcare teams (table ) . [ ] [ ] [ ] [ ] these are connected to a network of rural hospitals some distance away by road or air, demanding rural people undergo significant personal travel or use retrieval services. , when patients need higher-level care elsewhere, this imposes substantial financial, cultural and emotional burden on rural people whereby the phc team aims to optimise prevention and early intervention to mitigate infection and minimise the need for patients to travel. resilience is challenging as many rural phc teams are small and need to sustain a high workload and strong community leadership during a pandemic response. an australian national survey of general practitioners (gps) working during the covid- pandemic identified that gps in rural areas were more likely to maintain or increase patient numbers relative to gps based in urban areas (where patient numbers dropped). this may be because small rural phc teams absorb any pandemic clinical services on top of their normal workload with few buffers from other doctors in town. further, there may be a much higher administrative burden on phc leaders to digest and implement rapidly evolving policies and guidelines. these policies may be inadequately tailored to the rural context. one study identified that guidelines from various official agencies involved in healthcare may be in direct conflict with each other, making it challenging to interpret the correct course of local action needed. a real-time system allowing rural phc staff to pose questions and receive rapid answers (such as the one recently set up by project echo, university of new mexico, usa), may be suitable to use within each nation's pandemic response. potential impacts on the mental health and fatigue levels of phc staff are also probable in rural settings. although there are no rural-specific figures, a national cross-sectional survey of australian doctors during the covid- pandemic identified that . % of gps reported felt "tense, restless, nervous or anxious or unable to sleep at night because his/her mind is troubled all the time" a lot more than usual. some stressors may be concerns about being exposed to infection as a frontline healthcare worker, despite the strength of screening and triaging processes. of all occupations, healthcare practitioners have the highest likelihood of exposure to diseases. other stressors relevant to rural phc teams may relate to any overlapping and conflicting patientprovider relationships they may experience around rising rates of community mental illness, job losses and poverty, domestic violence or crime during pandemic periods. these may have strong effects on rural healthcare workers whose professional lives are intertwined with their personal connections to people in their community. resilience in rural areas strongly depends on local phc teams spending time analysing the strengths and opportunities of their local healthcare networks and patching any gaps. this may require the development of new collaborative frameworks to build resilience in various regions or local populations. to some extent, these depend on the level of pre-existing community trust they have and their relationships with other health services. this is enabled when primary healthcare workers have been working in the same area for some time. however, for many small rural and remote communities, poor stability of the workforce is a threat to resilience. phc staff turnover is more common in more remote locations than in regional and urban centres and there is a stronger reliance on locum or other short-term staff (for example, in australia's remote primary care clinics only % of nurses continue to work in the same remote clinic months after commencing). , in the event of pandemic responses becoming quite protracted, rural resilience may also be threatened by the potential burnout of rural phc workers, a group that already works more hours and has higher turnover than its urban counterparts. burnout threatens rural community health and local health system leadership because of the small number of health workers in rural settings. , surge policies to provide additional staffing to rural phc teams could be activated early in pandemic situations to embed more capacity of "super-numeri" staff within the response, and enable viable rosters for phc workers to get enough rest. this arrangement also serves to allow any exposed/unwell staff to undergo self-isolation, without impacting the rest of the team and the community's access to care. whilst states/provinces and nations clamber to find enough personal protective (ppe) and other infection control equipment during pandemics, this infrastructure becomes increasingly centred on large hospitals and cities facing the most progressive levels of illness. this may leave many rural phc providers unprotected, sometimes with no assurance they will get ppe. the lack of ppe poses a critical threat in rural settings where the pool of available phc workers is precariously small and serves an undifferentiated caseload of infectious and non-infectious people dispersed across large geographic catchments. if sufficient protective equipment cannot be obtained, then rural phc teams strongly depend on non-contact treatment methods and community support for making their own protective gear or using home-grown methods of sterilizing. ideally, some assurance by government that sufficient baseline supplies and any scaled up resources will be provided where needed, would buffer the resilience of individual phc units. in the same vein, an additional resilience factor for rural communities is having access to adequate clinical testing capabilities and relevant treatments. a study of the perspectives of first nations peoples about the influenza pandemic identified that "supplies" (ordering, maintaining and providing pandemic supplies) were a key "overlooked" aspect of existing pandemic plans. finally, rural resilience depends on phc teams and the community having specific advice about sensible systems for patient retrieval for higher level care. phc teams are well placed to understand the best pathways for patient transfer but this may require government support for negotiating the guarantee of transport and higher-level services accepting unwell rural patients. feeling resilient depends on knowing that this plan will allow for situations where the local caseload may rapidly rise. such continuity business planning has been described as essential in other pandemics. meanwhile, other research has identified that those communities with rural hospitals, should bolster their capabilities to manage infected individuals for interim periods, where transferring acutely unwell patients to larger centres is not feasible, nor immediate enough. the healthcare response to covid- has anecdotally been portrayed in the media as hospital care. however, in rural areas, the response phase related to phc teams introducing of a differentiated range of treatment services for infectious and non-infectious members of the community as well as adopting new preventative clinics that are readily accessible by rural populations (table ) . this often involves delivery of more ambulatory clinical services, including new in-and out-of-clinic services, collaborating with community public health services and introducing innovative triaging and testing systems for unwell people. unlike urban models which are fixed, rural phc services are highly needs-based and flexible and this is exacerbated in line with emerging pandemic and local conditions. other than treating regular clients and managing potentially infectious patients, new or revamped preventative clinics may be needed, including targeted vaccination clinics, prescription services by phone and advanced care planning. these serve to better position the community and free up the available primary resources for responding to new infectious cases. there is some potential that these add to the service loads of rural phc teams, and this should be explored and linked to the notion of workforce surge needs. historically, many governments have restricted funding for telehealth to non-primary care doctors, such as referred specialist medical services which are the least accessible medical service in rural areas. however, new government policies during the covid- pandemic in australia and canada started to fund rural phc teams to use telephone and video consultations. this funding is in recognition of the role that telehealth plays in phc in non-contact healthcare for protecting health workers and the community from infection. in rural settings, it has also provided a potential option to surge rural workers to overcome staff shortages, staff isolation (due to exposure) and border closures. telehealth availability, funded in phone and video formats, has provided for unprecedented capacity to grow and diversify models of phc services fit for rural communities, using a wider choice of platforms of choice. further, the flexibility to deliver services via video-or -phone assists to deliver consultations through a simple base of interaction where this is a better fit. as a model, telehealth, and the blend of phone and video used, still requires evaluation within the rural context to establish where it offers the most utility for providers and patients. this is because its long-term use may require a significant change in management effort and the redesign of existing models of care. it is imperative that such models do not add excessive demand for mobile technology and at-home medical devices that rural and remote people and rural phc teams may find hard to access. more work is needed to determine the proportion and nature of phc services that fit telehealth delivery and how these are optimally complemented with in-person consultations. rural phc teams and rural health services researchers are possibly best placed to explore this topic given they have the most in-depth knowledge of the dynamic and complex environment of rural and remote settings. in the rural system, the capacity to overlay telehealth largely depends on the stability of a trained phc workforce in rural areas, their equipment and adequate broadband internet services. one national cross-sectional survey during covid- identified that gps in the most disadvantaged areas, and gps in rural areas used less telehealth. this perhaps reiterates the imperative of understanding the context of use in rural areas. like in urban areas, telehealth is a potential adjunct service in rural areas. but it may have less capacity or more dire consequences if replacing face-to-face services for disadvantaged and socially isolated groups in the community. this is because in rural settings, there are likely to be differences in the patient's approachability and acceptability of online health services including for aged, disadvantaged, culturally diverse and first peoples and seeing the doctor may provide better quality of care and social contact (and therefore health benefit). the potential for digital inequalities (at the supply and demand side) is an important issue for rural communities to adopt technology-based healthcare solutions. many rural places continue to lack stable internet service networks, particularly when more people may be working or self-isolating at home during pandemic periods. a high proportion of rural areas may experience broadband connectivity issues resulting in weak or no access to the internet meaning that phone-calls remain a central back up system. , further, some rural communities may incur high costs associated with high-speed broadband internet use as another limitation. in conclusion, the specific needs of rural communities may inadvertently be overlooked within rapid mainstream pandemic planning. however, these communities have widely different contexts from urban settings. this commentary highlights that specific preparation is needed for addressing nuanced rural risks, building community resilience, and fostering a coordinated and supported rural phc response. critically pandemics present an enormous risk to a small critical mass of rural phc teams, and the communities they serve. this is particularly in relation to their smaller staffing and infrastructure, serving a diverse population with higher pre-existing healthcare needs. this perspective identifies clear opportunities to continue to future-proof rural phc systems for surge events. this article did not require ethical review as it used available published literature. the authors report no conflicts of interest for this work. risk management and healthcare policy is an international, peerreviewed, open access journal focusing on all aspects of public health, policy, and preventative measures to promote good health and improve morbidity and mortality in the population. the journal welcomes submitted papers covering original research, basic science, clinical & epidemiological studies, reviews and evaluations, guidelines, expert opinion and commentary, case reports and extended reports. the manuscript management system is completely online and includes a very quick and fair peer-review system, which is all easy to use. visit http://www.dovepress.com/testimonials.php to read real quotes from published authors. contribution of primary care to health systems and health. millbank quarterly sustainable development goals redesign of a rural emergency department to prepare for the covid- pandemic world health organization. rapid risk assessment of acute public health events australia's influenza pandemic preparedness plans: an analysis united nations department of economic and social affairs population division. the world's cities in -data booklet global evidence on inequities in rural health protection: new data on rural deficits in health coverage for countries australian institute of health and welfare. rural and remote health experiences of nurses on the critical shortage of medical equipment at a rural district hospital in south africa: a qualitative study recruitment and retention of general practitioners in rural canada and australia: a review of the literature australian institute of health and welfare. rural, regional and remote health: indicators of health status and determinants of health first nations information governance centre. national report of the first nations regional health survey phase : volume two house of representatives standing committee on regional australia. cancer of the bush or salvation for our cities? fly-in, fly-out and drive-in, drive-out workforce practices in regional australia. canberra: the parliament of the commonwealth of australia impact of fly-in fly-out/drive-in drive-out work practices on local government. sydney: australian centre of excellence for local government rural outreach by specialist doctors in australia: a national cross-sectional study of supply and distribution reviewing reliance on overseas-trained doctors in rural australia and planning for selfsufficiency: applying years' mabel evidence international mobility of health professionals and health workforce management in canada: myths and realities: oecd health working paper no. . france: oecd world health organization the role of the sharing economy for a sustainable and innovative development of rural areas: a case study in sardinia (italy) an overview of commuting in canada: with special emphasis on rural commuting and employment labour markets for rural population: commuting and migration abroad do you have a right to go to the cottage during the coronavirus pandemic? in: the conversation. the conversation media group ltd melbourne grey nomads travelling in queensland, australia: social and health needs housing as a social determinant of first nations, inuit and métis health. british columbia: nccfah mobility of aboriginal people in rural and remote australia. australian housing and does health literacy mediate the relationship between socioeconomic status and health disparities? integrative review placing hiv beyond the metropolis: risks, mobilities, and health promotion among gay men in the halifax models of care involving district hospitals: a rapid review to inform the australian rural and remote context what primary health care services should residents of rural and remote australia be able to access? a systematic review of "core" primary health care services issues for nurses in rural and remote canada thesis: future of smaller rural public hospitals aeromedical evacuations from an east arnhem land community - : the impact on a primary health care centre frequent users of the royal flying doctors service primary clinic and aeromedical services in remote new south wales: a quality study rural and remote community health care in canada: beyond the kirby panel report, the romanow report and the federal budget of the impact of covid- on gps and non-gp specialists in private practice. melbourne: anz-melbourne institute health government bodies and their influence on the h n health sector pandemic response in remote and isolated first nation communities of sub-arctic ontario estimating the burden of united states workers exposed to infection or disease: a key factor in containing risk of covid- infection rural and remote communities: unique ethical issues in the covid- pandemic helping rural, remote and indigenous communities respond to covid- geographical mobility of general practitioners in rural australia patterns of resident health workforce turnover and retention in remote communities of the northern territory of australia how do rural gps' workloads and work activities differ with community size compared with metropolitan practice? always one doctor away from a crisis! rural remote health evaluation of microwave steam bags for the decontamination of filtering facepiece respirator a community-based participatory approach and engagement process creates culturally appropriate and community informed pandemic plans after the h n influenza pandemic: remote and isolated first nations communities of sub-arctic ontario pandemic influenza and critical infrastructure dependencies: possible impact on hospitals primary care integration in rural areas: a community-focused approach enhancing chemotherapy capabilities in rural hospitals: implementation of a telechemotherapy model (qrecs) in north queensland, australia telehealth for global emergencies: implications for coronavirus disease (covid- ) patient-centred access to health care: conceptualising access at the interface of health systems and populations digital inequalities in rural australia: a double jeopardy of remoteness and social exclusion digital divides and the 'first mile': framing first nations broadband development in canada a jurisdictional scan of the programs and services available to support the community reintegration of ircs youth in northern saskatchewan. saskatoon: university of saskatchewan centre for forensic behavoural science and justice studies key: cord- -kq s authors: squire, michele m.; carter, glen p.; mackin, kate e.; chakravorty, anjana; norén, torbjörn; elliott, briony; lyras, dena; riley, thomas v. title: novel molecular type of clostridium difficile in neonatal pigs, western australia date: - - journal: emerg infect dis doi: . /eid . sha: doc_id: cord_uid: kq s clostridium difficile causes neonatal enteritis in piglets; strains of pcr ribotype are most commonly identified. we investigated c. difficile prevalence in piglets in australia and isolated a novel strain with a unique pathogenicity locus. in a mouse infection model, this strain produced more weight loss than did a ribotype strain. c lostridium difficile is the causative agent of severe enteritis ("scouring") in neonatal piglets - days of age throughout canada, the united states, and europe ( ) . although deaths attributable to c. difficile infection (cdi) generally are low because of good stockmanship, piglets that survive cdi remain %- % underweight on average and take additional time to wean ( ) . colonization frequency of c. difficile in scouring piglets is as high as %; this rate declines to % by months of age ( ) . c. difficile is also commonly found in feces from apparently healthy piglets, which contributes to environmental contamination. widespread air and surface contamination of the piggery environment with c. difficile, presumably in the form of long-surviving spores, may play a role in the epidemiology of cdi in pigs and subsequent community-acquired infection in humans ( ) . in europe and the united states, the genotypes of c. difficile isolates that cause disease in humans and production animals overlap, particularly pcr ribotype , which predominates in pigs worldwide. this ribotype is increasing in prevalence and associated with severe communityacquired cdi in humans geographically located near pig farms ( ). c. difficile has also been found in retail food, including meat products, seafood, and vegetables ( ) . c. difficile in piglets in australia has not been systematically investigated, despite reports of idiopathic enteritis nationwide. it is likely that that c. difficile strains in piglets in australia are different from those found in the rest of the world because of australia's geographic isolation, strict quarantine laws regarding importation of livestock, and low human population and pig density. we studied c. difficile prevalence in scouring neonatal piglets and evaluated a novel strain of c. difficile isolated from these piglets by using multiple identification methods. rectal swab specimens were collected during july-november from neonatal piglets on farms that were experiencing scouring problems. the farms were located at geographic locations in western australia ( km apart) and were owned by a commercial farrow-tofinish operation. at the time of the study, %- % of litters were scouring, with death rates of %- %. the sick piglets had early-onset, nonhemorrhagic, yellow, pastyto-watery diarrhea; disease course without treatment was ill-thrift, anorexia, dehydration, and death. healthy piglets were treated prophylactically at - days of age with amoxicillin or penicillin. of the piglets, were on farms at the same geographic location that had the most severe scouring problems. the remaining piglets were on a high biosecurity farm at a separate location with a variable scouring problem; of these animals were asymptomatic. test results for escherichia coli, rotavirus, and c. perfringens were negative for all animals; we did not test for porcine reproductive and respiratory syndrome virus or transmissible gastroenteritis coronavirus because they are considered exotic (i.e., no reported outbreaks) in australia. samples were cultured directly onto cycloserine cefoxitin fructose agar and incubated anaerobically at °c for h. the swabs were then inoculated into a robertson's cooked-meat selective enrichment broth and incubated anaerobically at °c for days; spores were then selected by alcohol shock ( : with anhydrous ethanol). the spores were then cultured onto cycloserine cefoxitin fructose agar with . % taurocholic acid added. putative c. difficile colonies were subcultured onto prereduced blood agar and identified by gram stain, characteristic colony morphology, and smell. toxin profiling was by pcr detection of the toxin a (tcda), toxin b (tcdb), and binary toxin (cdt) genes ( , ) . isolates underwent pcr ribotyping and were compared with human reference c. difficile strains from australia and international ribotypes from the anaerobe reference laboratory (cardiff, wales, uk) ( ) . genome shotgun sequencing of a representative isolate (designated strain ai ) was performed by using the illumina hiseq platform ( ). toxin b quantitation was performed by using a vero cell cytotoxicity assay ( ) . vero cells were exposed to serial -fold dilutions of c. difficile cell-free culture supernatants from a ribotype human strain (m ), a ribotype animal strain (jgs ), and strain ai . c. difficile strain , a recognized low-toxin producer, was included as a control. after the cultures were incubated overnight at °c in % co , morphologic changes were examined by microscopy. the endpoint was scored as the last dilution at which % cytopathic effect was observed. assays were performed in triplicate on independent culture supernatants. in vivo virulence was assessed by using a mouse model of cdi ( ) . specifically, - -week-old male c /b mice ( mice per strain) were force-fed × spores of the same c. difficile strains used in the vero cell assays. mice were housed in separate cages to avoid cross-contamination and monitored daily for weight loss and signs of disease. of the piglets tested, c. difficile was isolated from ( %): ( %) of piglets from the herds with severe scouring, ( %) of piglets from the herd with variable scouring, and ( %) of asymptomatic piglets. isolates were clonal; all were novel pcr ribotype and had a toxin profile of tcda -tcdb + cdta + cdtb + . genome sequencing of strain ai showed a novel pathogenicity locus (paloc) structure (figure ) . a large deletion had removed the tcda and tcdc genes and a portion of the adjacent cdd gene located outside the paloc. strain ai also encoded a variant tcde. the ai binary toxin locus was complete and contained an intact copy of cdtr, unlike ribotype isolates, which encode a cdtr with a premature stop codon. strain ai may therefore be a more proficient binary toxin producer than ribotype strains. despite these variations, multilocus sequence typing showed that strain ai belongs to the same clade (clade ) and sequence type ( ) as ribotype strains [strain ai in the report by stabler et al. ( ) is the same ribotype as ai ]. in vitro testing showed ai produced » -fold less toxin b than did the ribotype (p = . by t test) and ribotype (p = . by t test) isolates, but ai showed similar toxin levels to the low toxin producing strain . ai -mediated cytopathic effect on vero cells was similar to that reported for the lethal toxin of c. sordellii and c. difficile strain , a toxin a -b + human strain with mutations affecting its glucosylation substrate specificity ( ) . strain m (ribotype ) was significantly more virulent than strain ai (p = . by log-rank [mantel cox] test) and strain jgs (p = . by log-rank [mantel cox] test). all mice infected with strain m died (figure , panel a), but mice infected with strains ai and jgs survived ( figure , panel a) . still, despite low toxin production, ai caused significantly greater weight loss in mice than did the ribotype strain jgs (p = . by analysis of variance) (figure , panel b) . this difference may be the result of production of a variant toxin; similar toxins were -fold more toxic to mice than was toxin b produced by strain vpi ( ) . our results show that a toxigenic c. difficile strain circulating in piglets in australia is of a different ribotype, , than that commonly found in other parts of the world. the strain we found contained a unique paloc and produced more weight loss in mice than did the more common ribotype animal strain. identifying this strain is the first step in detecting and responding to this emerging disease in piglets in australia. future studies in swine will focus on nationwide prevalence, laboratory detection, and epidemiologic investigation to understand the transmission cycle in pigs and any relationship between animal and human disease. ms squire is a phd student in microbiology at the university of western australia, nedlands. her current research focuses on c. difficile infection in neonatal piglets. clostridium difficile: an important pathogen of food animals clostridial enteric infections in pigs longitudinal investigation of clostridium difficile shedding in piglets acquisition of clostridium difficile by piglets emergence of clostridium difficile infection due to a new hypervirulent strain, polymerase chain reaction ribotype clostridium difficile infection in humans and animals, differences and similarities pcr targeted to the s- s rrna gene intergenic spacer region of clostridium difficile and construction of a library consisting of different pcr ribotypes production of actin-specific adp-ribosyltransferase (binary toxin) by strains of clostridium difficile identification of toxin a-negative, toxin b-positive clostridium difficile by pcr velvet: algorithms for de novo short read assembly using de bruijn graphs toxin b is essential for virulence of clostridium difficile a mouse model of clostridium difficileassociated disease macro and micro diversity of clostridium difficile isolates from diverse sources and geographical locations genetic rearrangements in the pathogenicity locus of clostridium difficile strain -implications for transcription, expression and enzymatic activity of toxins a and b characterization of a toxin a-negative, toxin b-positive strain of clostridium difficile key: cord- -v mz d authors: shearer, freya; walker, james; tellioglu, nefel; mccaw, james m; mcvernon, jodie; black, andrew; geard, nicholas title: assessing the risk of spread of covid- to the asia pacific region date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: v mz d during the early stages of an emerging disease outbreak, governments are required to make critical decisions on how to respond appropriately, despite limited data being available to inform these decisions. analytical risk assessment is a valuable approach to guide decision-making on travel restrictions and border measures during the early phase of an outbreak, when transmission is primarily contained within a source country. here we introduce a modular framework for estimating the importation risk of an emerging disease when the direct travel route is restricted and the risk stems from indirect importation via intermediary countries. this was the situation for australia in february . the framework was specifically developed to assess the importation risk of covid- into australia during the early stages of the outbreak from late january to mid-february . the dominant importation risk to australia at the time of analysis was directly from china, as the only country reporting uncontained transmission. however, with travel restrictions from mainland china to australia imposed from february , our framework was designed to consider the importation risk from china into australia via potential intermediary countries in the asia pacific region. the framework was successfully used to contribute to the evidence base for decisions on border measures and case definitions in the australian context during the early phase of covid- emergence and is adaptable to other contexts for future outbreak response. on december , , chinese authorities reported a cluster of cases of atypical pneumonia in the city of wuhan, hubei province, later identified to be caused by a novel coronavirus, sars-cov- [ ] . the disease caused by this virus is now known as coronavirus disease or covid- [ ] . the number of confirmed cases and geographical extent of covid- has increased significantly since december . as of february , , , cases had been confirmed in mainland china, including , deaths. a further , cases and deaths had been reported outside of china -and more than half of these cases had been reported in the asia pacific region. multiple countries outside of china had reported sustained local transmission [ ] . when a novel pathogen such as covid- emerges, governments are required to make critical decisions on how to respond appropriately, despite limited data being available to inform d r a f t these decisions. the extent of transmission of covid- in mainland china changed rapidly during the first month of the epidemic. from january , chinese authorities progressively implemented strict mobility restrictions on the people of wuhan, and on travel out of the a↵ected area to other parts of china. internationally, border screening measures were implemented, and travel restrictions were imposed by both governments and airlines [ ] . for example, australian authorities placed restrictions on all travel to australia from mainland china on february , in order to reduce the risk of importation of the virus. only australian citizens and residents (and their dependants) were permitted to travel from china to australia [ ] . these restrictions remained in place at the time of writing. the day before australia imposed these restrictions (january ), , cases of covid- had been reported in mainland china. australia had detected and managed imported cases, all with recent travel history from or a direct epidemiological link to wuhan [ , ] . a further cases had been confirmed outside of china, including cases in countries of the south east asia and western pacific regions [ ] . at that time (january ), models estimated that , individuals ( % cri , - , ) had been infected in greater wuhan up to january (with who reporting , confirmed cases for the same time period) and projected that the epidemic could peak in wuhan as early as late february [ ] . before the restrictions, australia was expecting to receive approximately , air passengers from mainland china during february [ ] . travel numbers fell dramatically following the imposed travel restrictions. prior models suggest that travel restrictions are unable to completely prevent the international transmission of viral respiratory illnesses [ , ] . screening methods are unable to identify all cases, due to limitations in the sensitivity and specificity. exposed travellers can complete a journey during the incubation period when they are undetectable, and some exposed travellers may never show symptoms at all [ , ] . furthermore, when applied early in an epidemic, screening methods that rely on detecting fever will identify many more cases of other respiratory diseases such as influenza than the target disease. while travel restrictions are highly unlikely to prevent the ultimate importation of covid- [ ] , they can reasonably be anticipated to delay the establishment of an epidemic in a country, buying valuable time for health authorities to establish response measures. analytical risk assessment is a valuable approach to guide decision-making on travel restrictions and border measures during the early phase of an outbreak [ , , ] . while importation risk into a country of interest from a source country is a general problem for emerging diseases, the specifics of risk assessment should consider the status of both the evolving epidemic and the local and global public health response. here, we consider the covid- importation risk to australia from countries other than china at a time when china was the only country reporting uncontained local transmission and limited cases had been reported in other countries. with air-travel restricted from china, and strict quarantine measures in place for those allowed to return, a key concern for australia was the epidemic status of other countries with large (and unrestricted) travel volumes to australia. we introduce a modular framework for assessing the risk of covid- being imported from a source country (here china) to a country of interest (here australia) via other intermediary countries in the region. we have focused on the risk of (potentially undetected) spread to countries in the south east asia and western pacific regions because they are highly connected to both china and australia, relative to the rest of the world. our analysis takes into account the covid- epidemiological situation and mobility restrictions imposed as of mid-february but is adaptable to the analyses required during later phases of the outbreak. the framework was developed to provide a rational basis for decision-making on border measures and case definitions in australia at a time when global transmission of covid- was not yet established, which was no longer the case at the time of writing. while the detailed analysis presented here is specific to australia and the south east asia and western pacific regions during the early phase of covid- emergence, the framework itself is adaptable to other contexts for future outbreak response. a framework was developed to assess the risk of covid- infections being imported by passengers travelling on flights from the south east asia and western pacific regions to australia as of february , . the framework includes a series of analyses based on current epidemiological evidence, patterns of air travel, and model components described in de salazar and colleagues ( ) [ ] and developed by the authors. our framework considered a single point of origin for all exported infections, as china was the only country reporting uncontained transmission at the time of analysis. each step of the analysis is outlined in figure and described in more detail below. probability of an outbreak outbreak size importation risk to australia step step step step step -importation risk from china to intermediary countries sars-cov- first emerged in china [ ] and hence the risk of importation for countries in the south east asia and pacific regions, in the early stages of the outbreak, was primarily dependent on travel from china. the expected numbers of imported cases in each intermediary country was estimated using an approach proposed by de salazar and colleagues ( ) based on air travel volume estimates from china since covid- emergence [ ] . their model estimates the expected number of imported cases in countries by regressing the number of imported cases reported by each country against their relative incoming travel volumes from china (under unrestricted travel). they assume that the expected case count would be linearly proportional to air travel volume. bootstrap sampling was used to estimate % confidence intervals. we fitted the model to reported cumulative case counts for each country extracted from who situation reports , , , , and (i.e., one per week from january ). step -number of potentially undetected cases in intermediary countries the number of potentially undetected introductions in each intermediary country was based on the discrepancy between expected (step ) and reported cases (noting that cases due to local transmission were excluded from these counts). under the assumption that all reported cases were e↵ectively isolated ( hours after symptom onset) with reduced risk to onward transmission, the di↵erence between the expected and reported numbers of cases per country provided a crude estimate of the number of unreported cases. we assumed unreported cases were undetected and therefore more likely to contribute to local transmission and potentially a large outbreak. step -probability of an outbreak in intermediary countries a branching process model was used to generate stochastic projections of the initial stages of an outbreak for each country. this model incorporates country-specific rates of covid- importation (as estimated in step ) and country-specific detection probabilities based on the ratio of reported cases to expected cases (with a maximum detection probability of ). we assumed an r of . (within the range estimated for covid- in wuhan in early january [ ] ), no individual-level variation in transmission and independence of all undetected introductions [ ] . the probability of local transmission was defined as the proportion of simulations with no locally transmitted cases weeks after simulation commenced (i.e., february ). details of this branching process model are provided in the supplement. step the stochastic transmission model described in step was also used to estimate the likely number of locally transmitted cases in each intermediary country, conditional on local transmission occurring. this model assumed no public health intervention, and that both importation rate and detection probability were constant over time. the transmission model was run from january , with epidemic curves (separated by imports and local transmission) projected forward by one week beyond the last data collection date (february ). step -importation risk from intermediary countries to a country of interest the likelihood that a passenger arriving in australia from a country in the south east asia or western pacific region would be infected by covid- will depend on the prevalence in that country, and the travel volume from there to australia. given the wide confidence intervals on estimated prevalence, and the multiple stochastic factors, there is considerable uncertainty involved in such estimates. for the purpose of this initial risk assessment exercise, we simply provided the prevalence estimates and travel volumes. travel volumes from countries within the south east asia and western pacific regions to australia were extracted from the australian bureau of statistics [ , ] . we present a ranked table of aggregate risk of covid- infections being imported into the country of interest (australia), based on sustained transmission occurring in the source country (china) by originating country of travel ( figure ). the table includes key quantities estimated . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint at steps to of the analysis outlined in the methods and depicted in figure . the potential number of undetected imported cases (as of february , ) in each country of the south east asia and western pacific regions (intermediary countries) is displayed in figure . projected epidemic curves for selected countries are shown in figure (curves for all countries considered are provided in the appendix), with reported imported and local cases also shown for context. all four countries shown have high levels of expected imported cases ( figure ). thailand and indonesia have fewer reported cases than expected, and hence a higher estimated number of undetected cases (figure ), leading to projection of considerable undetected local transmission. in contrast, malaysia and singapore both reported a number of cases equal to or greater than expected, and hence have a lower estimated number of undetected cases, leading to projection of more modest levels of local transmission. note that the projected levels of transmission in singapore are lower than the actual reported cases. these known local cases were not further incorporated into our analysis, but rather signalled to decision makers that the likelihood of further undetected transmission was relatively low. ( − ) ( − ) . ( − ) < . myanmar . ( − ) ( − ) . ( − ) < . laos . ( − ) ( − ) . ( − ) < . we developed a framework to assess the importation risk of covid- into australia during the early phase of the epidemic, from late january to mid-february . the dominant importation risk to australia at the time of analysis was directly from china, as the only country reporting uncontained transmission. with travel restrictions from mainland china to australia imposed from february , our framework was designed to consider the importation risk from china (source country) into australia (country of interest) via potential intermediary . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. countries. we focused on countries in the south east asia and western pacific regions as potential intermediary countries since they are highly connected to both china and australia, relative to the rest of the world. intuitively, intermediary countries that pose the highest overall risk of importation to a country of interest are those with high connectivity to both the source country and country of interest. high connectivity to china increases the probability of an outbreak of covid- in an intermediate country, and consequently, someone resident in that intermediate country and travelling to the country of interest has a higher likelihood of being exposed. the risk table (figure ) was developed for two purposes. first, to provide evidence of likely exposure over the preceding week to inform the epidemiological case definition, tailored to the source country and for use in near patient decision making for practitioners in the country of interest (here australia) caring for returned travellers. second, projection of the likely future epidemic course helped to inform travel advisories and the likely utility of border restrictions. the framework we have developed provides a risk assessment from solely from an epidemiological perspective. it does not consider the potential social, political and economic implications of future border measures and mobility restrictions which are both substantial [ ] and will exert an influence on epidemiology as people change their behaviour [ ] . this framework is therefore only one key element to be considered by decision-makers contemplating possible border policies and mobility restrictions, which are ultimately a political determination. a significant strength of our approach is in its transparency with respect to both individual factors that contribute to overall risk and the relationship between model projections and the reported epidemiology. this enables decision-makers to incorporate their own expertise when interpreting the outputs. even if limited or highly uncertain data is available to inform absolute estimates of risk associated with plausible importation routes, comparisons of relative risk using our approach are still possible and valuable. in addition, each analysis component has modest . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. data requirements and low computation cost, making rapid preliminary assessment across a range of countries feasible. as the outbreak progressed, mismatches between model projections and observed epidemiology could be readily observed and incorporated into decision making. a strength of our modular approach is that it enables individual components to be adapted as new data and models become available, or as information needs change in response to the evolving situation. the breakdown of our workflow (figure ) provides clear guidance on how . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint d r a f t to adjust the method. importantly, the framework itself still applies, but components of the analysis would need to be adapted. as implemented, our estimates of importation rates into countries only consider air travel (step ). several countries/regions have high volumes of land travel, for example mainland china and hong kong. not accounting for these would lead to an underestimate of importation risk to these countries/regions. furthermore, the estimated importation rates are relative to global reports of imported cases of covid- . if there was systematic under-detection of covid- across all countries at the time of analysis [ ] , this would lead to a systematic underestimation of importation rates. our approach was not able to estimate rates of import prior to january nd when case counts for countries started being reported by the who. our analysis framework is specific to a scenario in which a dominant source of infection is mitigated by border measures. once established outbreaks occur in countries other than the primary source, assessing importation risk becomes more complex. further to this, we primarily focused on identifying undetected epidemics -over the course of time emerging observed data from many countries became more influential in the risk appraisal. thus, as it stands, our analysis is only applicable in the early stages of an outbreak, a feature shared with many other models of global infection links. in detail, by the time of writing, substantial transmission has been reported in a number of additional countries, in particular iran, italy and south korea [ ] . in order for our tool's risk assessment to reflect the true risk of importation to the country of interest, components of the analysis, specifically steps and , would need to be adapted to account for high levels of known local transmission in countries other than the source country. returning to the exemplar study that motivated the development of our framework (risk of importation of covid- into australia), should a large outbreak occur in one or more countries in the south east asia and western pacific regions, additional intra-regional transport connections would be associated with importation risk to countries in the region. more detailed modelling that incorporates intra-regional travel and information on known local transmission could then be included (at steps and ) and updated to reflect emerging epidemic intelligence. this would allow the framework to be applied during such a phase of the outbreak. a further strength of our approach is its use of a stochastic model, including control e↵orts, for early epidemic response in intermediate countries. here, without access to detailed additional information on intermediate country's capacity to respond, we used a simple model of country response capacity. as outbreaks progress, di↵erences in how e↵ectively countries are able to respond, both in terms of their health system capacity, and their ability to implement population-based measures such as social distancing may introduce systematic e↵ects that are not captured by the framework. with additional information or dedicated further research in anticipation of future global events, this additional information could be incorporated into the framework (at steps and ) to improve predictive capabilities. it is also worth noting that here we used a stringent definition of outbreak control (truly no cases) compared to other approaches in the literature, which may define control as a substantially smaller number of cases compared to baseline [ ] . in conclusion, by developing a modular framework that describes not only the underlying mathematical models of transmission and control, but how each component integrates with the next to generate an overall assessment of importation risk of an emerging disease, we have provided a decision-making tool that is flexible to the analysis requirements at di↵erent phases of an outbreak. the framework provides an evidence base for decisions on border measures and case definitions, and it has been successfully used during the early phase of the covid- response in the australian context, when limited cases had been reported outside of mainland china. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint step -importation risk from china to intermediary countries sars-cov- first emerged in china [ ] and hence the risk of importation for countries in the south east asia and pacific regions, in the early stages of the outbreak, was primarily dependent on travel from china. the expected numbers of imported cases in each intermediary country was estimated using an approach proposed by de salazar and colleagues ( ) [ ] , based on air travel volume estimates from china since covid- emergence. full details are provided in [ ] . briefly, their model estimates the expected number of imported cases in countries by regressing the number of imported cases reported by each country against their estimated incoming travel volumes from china. they assume that the expected case count would be linearly proportional to air travel volume. bootstrap sampling was used to estimate % confidence intervals. for our analysis, the model was fitted to reported cumulative case counts for each country extracted from who situation reports , , , , and (i.e., one per week from january ) and incoming air travel volumes as estimated by lai and colleagues [ ] . we fitted the model in r (version . . ) using the glm function from the base stats package. for who situation reports , , and , the cumulative case counts for countries outside of china are separated by whether the likely site of exposure was within china or elsewhere. for our analysis, reported cumulative case counts were extracted from the column 'total cases with travel history to china' in table of who situation reports and , and the sub-column 'china' under 'likely place of exposure' in table of who situation report . we used estimates of incoming air travel volumes for each intermediary country extracted from lai and colleagues' global risk analysis, which accounts for changes in air travel volumes following travel restrictions within china and internationally imposed in late-january. full details are provided in [ ] . briefly, their analysis considered (i) internal travel from wuhan to other cities/regions in china, based on location-based mobility data; and (ii) international travel from mainland china to other countries, based on travel volume from wuhan and other high-risk chinese cities over the period from february to april, based on international air transport association data. travel volume was weighted over time to capture the impact of travel restrictions after lunar new year, following which there was assumed to be no further travel from wuhan and a % reduction in travel from remaining cities. the number of potentially undetected introductions in each intermediary country was based on the discrepancy between expected (step ) and reported cases (noting that cases due to local d r a f t transmission were excluded from these counts). under the assumption that all reported cases were e↵ectively isolated ( hours after symptom onset) with reduced risk to onward transmission, the di↵erence between the expected and reported numbers of cases per country provided a crude estimate of the number of unreported cases. we assumed unreported cases were undetected and therefore more likely to contribute to local transmission and potentially a large outbreak. step -probability of an outbreak in intermediary countries a branching process model was used to generate stochastic projections of the initial stages of an outbreak for each country. the model assumes individuals can be either exposed (e), infectious (i), recovered (r), or isolated (v ). the exposed and infectious classes are split into two compartments (giving them an phase-type distribution) and symptom onset is taken to correspond to the transition between exposed and infectious states (see figure ). imported cases are assumed to be in the first exposed class. at the time on symptom onset there is a probability, p(t), that the individual is detected (either from direct contact tracing e↵orts or enhanced case finding) and hence with probability p(t), the case is missed. this probability depends on the current workload and hence time. once the case is detected there is a -hour period before they are completely isolated during which it is possible for them to infect others. the probability of detection is related to the workload, x(t), by where p is the baseline probability of detection and w c is the workload capacity. so while the workload is less than the capacity, the probability of detection remains high, but decreases once the capacity is exceeded. other model parameters and assumptions: • mean incubation period is . days (time in e and e ) [ ] ; • infectious period is . days (time in i and i ) [ ] ; cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint • r is taken to be . based on estimates from the early epidemic phase in wuhan, china [ ] ; • no variation in individual-level transmission. model simulations (n= ) were performed in r (version . . ) [ ] using the gillespie algorithm [ ] for each country, the import rate is calculated as the weighted mean of daily expected cases, with weights set according to the time intervals between data points. the initial detection probability (p ) of each country was calculated as the mean of the ratio of cumulative reported cases to the cumulative expected cases starting from january . the maximum value of p was . . the workload capacity w c , used for updating the detection probability, was set to infected people/day. the probability of local transmission was defined as the proportion of simulations with more than zero daily locally transmitted cases weeks after simulation commenced (i.e., february ). step -estimated size of an uncontained outbreak in intermediary countries the stochastic transmission model described in step was also used to estimate the likely number of locally transmitted cases in each intermediary country, conditional on local transmission occurring. this model assumed no public health intervention, and importation rate was constant over time. the detection probability was calculated by using workload capacity w c and p at each time increment. if the workload w (the number of people currently being isolated) was smaller than w c , then the detection probability was equal to p . if the w exceeded w c , the health system was deemed to be under strain, and the detection probability was set to (p ⇥ w c )/w c . the transmission model was run from january , with epidemic curves (separated by imports and local transmission) projected forward by one week beyond the last data collection date (february ). manuscript figure was generated in r (version . . ) using functions from the package gridextra. manuscript figure was generated in r with % quantile bounds smoothed using functions from the package ggplot . projected epidemic curves for all intermediary countries are shown in figures , and , with reported imported and local cases also shown for context. step -importation risk from intermediary countries to a country of interest travel volumes from countries within the south east asia and western pacific regions to australia were taken from australian bureau of statistics arrivals data for march [ , ] . values shown are a sum of visitors arriving from each intermediary country, and australian residents returning from each intermediary country. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. figure : imported cases (left panels) and epidemic curves (right panels) from january using who data up to february , and projecting forward to march , for selected countries in the western pacific region. lines and shaded regions in each panel show median and % quantiles for the cumulative number of cases (imported or locally transmitted). black points show cumulative imported cases (left panels) and cumulative local cases (right panels) for each country, as reported by who. note that the decrease in cumulative local cases in japan from february to is due to a change in reporting formats within the who situation reports between these dates. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. figure : imported cases (left panels) and epidemic curves (right panels) from january using who data up to february , and projecting forward to march , for selected countries in the western pacific region. lines and shaded regions in each panel show median and % quantiles for the cumulative number of cases (imported or locally transmitted). black points show cumulative imported cases (left panels) and cumulative local cases (right panels) for each country, as reported by who. world health organization. novel coronavirus ( -ncov) situation report - . available at world health organization. novel coronavirus ( -ncov) situation report - . available at world health organization world health organization. novel coronavirus ( -ncov) situation report - . available at australian government department of health. australian health protection principal committee (ahppc) novel coronavirus statement on australian government department of health. -ncov acute respiratory disease world health organization. novel coronavirus ( -ncov) situation report - . available at nowcasting and forecasting the potential domestic and international spread of the -ncov outbreak originating in wuhan, china: a modelling study short-term movement, visitors arriving -selected countries of residence: original', time series spreadsheet e↵ectiveness of traveller screening for emerging pathogens is shaped by epidemiology and natural history of infection. elife, :e estimated e↵ectiveness of symptom and risk screening to prevent the spread of covid- . elife using predicted imports of -ncov cases to determine locations that may not be identifying all imported cases. medrxiv assessing spread risk of wuhan novel coronavirus within and beyond china preparedness and vulnerability of african countries against importations of covid- : a modelling study short-term movement, residents returning -length of stay and main reason for journey: original', time series spreadsheet an integrative review of the limited evidence on international travel bans as an emerging infectious disease disaster control measure nine challenges in incorporating the dynamics of behaviour in infectious diseases models quantifying bias of covid- prevalence and severity estimates in wuhan, china that depend on reported cases in international travelers. medrxiv the royal children's hospital world health organization. novel coronavirus ( -ncov) situation report - . available at using predicted imports of -ncov cases to determine locations that may not be identifying all imported cases. medrxiv assessing spread risk of wuhan novel coronavirus within and beyond china early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia nowcasting and forecasting the potential domestic and international spread of the -ncov outbreak originating in wuhan, china: a modelling study r: a language and environment for statistical computing. r foundation for statistical computing a general method for numerically simulating the stochastic time evolution of coupled chemical reactions short-term movement, visitors arriving -selected countries of residence: original', time series spreadsheet short-term movement, residents returning -length of stay and main reason for journey: original', time series spreadsheet appendix to manuscript 'assessing the risk of spread of covid- to the asia pacific region' key: cord- -h u atf authors: prentice, catherine; chen, jinyan; stantic, bela title: timed intervention in covid- and panic buying date: - - journal: journal of retailing and consumer services doi: . /j.jretconser. . sha: doc_id: cord_uid: h u atf abstract in view of outbreak of the pandemic covid- , the paper examines the relationship between government measures for combating the pandemic and their side effects. panic buying is identified as one such side effect. among various models and measures undertaken by government to manage the pandemic, timed-intervention policy is commonly practiced by most countries. this paper examines the timing effect between government measures and panic buying. three studies were undertaken to understand the timing effect and identify a connection between timed measures and consumer behaviours. semantic analysis, secondary data search, and big data analytics were deployed to address the research aim. although claiming a causal relationship is cautioned, the findings reveal a connection between timing of government measures and panic buying. these findings are discussed with the support of real-life evidence. implications for researchers and practitioners conclude this paper. the pandemic covid- that originated from wuhan city in china in december has dramatically changed the world at almost every aspect of life for individuals, businesses, industries, and countries. various but similar measures were taken to prevent the spread of covid- infections including travel bans, lockdowns or curfews, quarantine measures, and social distancing. bin et al. ( ) classify these measures as the lock-down policy (ldp) and the timed intervention policy (tip). ldp refers to total lockdown, which can be effective in controlling the spread of the virus in a shorter period, during which time mitigation strategies (e.g. vaccine, increases in the capacity of virus combat facilities) can be developed. however, this policy can result in substantial and unintentional financial, economic, and social consequences at both macro and micro levels (ozili and arun, ) . tip is manifested through phased lockdown and social distancing measures at different times based on the virus-status within the community. the first stage of lockdown normally takes place at the epicentre the place of the outbreak of the virus. the second stage is closure of institutions such as universities, schools, and places where there may be large gatherings. the third stage is home quarantine with limited mobility and access only to essential activities. the final stage is largescale lockdown with complete restrictions on mobility. social distancing measure changes in accordance with different stages of lockdown (from allowing individuals to gather to , , , then down to individuals). tip is regarded as a demand-management policy (bin et al., ) . the main purpose of this type of policy is to minimise negative impacts caused by the pandemic as well as to manage healthcare system so that there are sufficient facilities, equipment, and resources to treat infected patients. this model has been implemented by most countries and regarded as being more realistic (e.g. australia, usa, and uk). however, bin et al. indicate that the timing of the implementation of this model is critical. implementing the policy too early or too late may result in severe negative consequences. timing is considered a relative concept, especially in the case of covid- , as the incubation period varies between individuals (e.g. days, days or up to days has been reported) and exponential growth rate of the virus is rapid. the timing within this model is critical in managing the virus and its related impacts, as it triggers other undesirable consequences or side effects. the phenomenon of panic buying is just one of the outcomes associated with the implementation of tip. panic buying is often a consequence of a large scale, severe disaster (e.g. hurricanes, snowstorms) or pandemics such as covid- . consumers tend to stockpile staples (e.g. rice, pasta, flour) and other essential items that they perceive may help them sustain themselves through the crisis period and in anticipation of supply shortages (yoona et al., ) . some may simply fear a significant price increase caused by the disaster (su, ) . previous research has attempted to understand the causes and behaviours of panic buying (e.g. wang et al., ; xu et al., ; zheng et al., ) . from a social learning perspective, zheng et al. ( ) pointed out that consumers tend to mimic others who are physically (in person) and virtually (online) influential and social media posts can play a significant role in the proliferation of mimicking and purchase behaviours. fan indicates that panic buying is a psychological reaction to a current crisis and the fear of an interruption to the supply chain. however, very few studies have been undertaken to examine the relationship between government crisis intervention measures and panic buying. therefore, understanding this relationship has implications for policy makers, the relevant authorities, and marketers to identify the most appropriate measures and strategies to mitigate the undesirable consequences and minimise the potential side effects. consistent with foregoing discussion, this paper uses a mixed method approach to understand how government's timed interventions, manifested by tips, are related to the panic buying, witnessed during the covid- pandemic. the primary measures taken were timed lockdowns and social distancing. this research intends to address the effectiveness of these measures and reveal the timing effect on consumer behaviours with regard to panic buying. to achieve this aim, three studies were undertaken in sequence. first, a semantic analysis was performed to examine whether there was a link between covid- and panic buying. second, secondary data analysis was conducted to identify the timing of government measures and panic buying with the intention to establish a connection between the two. third, big data analytics were used to understand the timing effect of government measures and panic buying through sentimental analysis. the study is focused on the relationship between interventions associated with covid and consumer behavioural response, rather than on the pandemic per se. the rationale for the three studies is to progressively demonstrate the connection between the government staged interventions and panic buying. semantic analysis has the merit of establish the association between the key variables of interest. secondary data research provides objective information to support this association. the sentiment analysis in study address the core research question. the sample frame is limited to australia. similar to other countries, australia adopted tip to manage or combat covid- . panic buying has been a puzzling phenomenon during the pandemic in australia and seemingly corresponded with government timed measures. this option can be a reference to countries that undertake tip and are evident in panic buying. for the purpose of this study, twitter posts were used to examine whether there was a link between government covid- measures and panic buying. twitter was chosen since it has public application programming interface api, which allows access to all tweets and wide opinion of people. tweets can be used to access individuals' opinions toward the government measures. first, a list of related keywords that reflect the research aims were identified to search relevant posts. we initially searched keywords such as "coronavirus" and "covid" using twitter public api. in order to capture all relevant traffic, we extended the scope of the keywords to include government measures such as "lockdown", "social distancing", and "panic buying". however, the volume of posts from the entire country was too large and unmanageable in this instance. we decided to include posts from one region only -queensland. preliminary analysis showed that this score was adequate to capture a baseline of pandemic related discussions over time but also provided a predefined set of tweets related to government measures. the social media data presented in this work covers the period from march to april , as shown in fig. . suitable keywords were identified by mapping assessments of sample tweets that were part of existing posts and by looking into the most commonly mentioned words in relevant topics. drawing on these initial posts, more terms were added that formed part of relevant posts (e.g. "corona virus", "pandemic", etc). to capture posts that indicated government measures, we noted the occurrence of commonly used words, such as "social distancing", "quarantine", "buying", "panic", etc. the filtering process in most cases included words with leading and ending space. to ensure the capture of all relevant posts we relaxed the rule and selected all possible relevant words, for example if we searched for "frustrat" with no space at the end, words like 'frustrated' or 'frustration' were also collected. the full list of keywords were: "coronavirus", "corona virus", "covid", "pandemic", "sars", "border", "face mask", "hand sanitiser", "panic buying", "toilet paper", "lost job", "job loss", "unemployed", "jobkeeper", "jobseeker", "travel ban", "travelban", "lockdown", "quarantine", "social distancing", "shop", "coles", "woolworths", "isolation", "sacked", "centrelink", "landlord", "rent", "repayment", "closure", "closedown". semantic analysis is specifically undertaken to identify key topics and themes. a semantic network analyses the relationship of words in twitter posts. first, the node in the network represents a word and the links among nodes are the connections and represent how many times both words are present in posts. if a word is used frequently, the size of the node is bigger. the thickness of the connection between words also reflects the number of connections the two words have in the twitter posts. semantic network analysis involves identifying the frequency and associative patterns between words in the text. fig. shows the semantic analysis of tweets relating to panic buying, which has been identified through the filtering of relevant keywords ("panic buying", "toilet paper", "shop", "coles", "buy", and "woolworths"). the sematic network was processed in gephi (https://gephi.org/). the colour of the nodes was based on a modularity calculation in gephi, which clusters nodes to the one community with the same colour. modularity is designed to measure the communities of division of a network into a module. in this analysis, if the words are often used together, they will be assigned to the same community with the same colour. as shown in fig. , people, "panic buying" and "toilet paper", rather than specific government measures and "panic buying" stand out as three major communities. however, the results (see fig. ) from the concept map that intended to identify the most popular topics in the posts, show that "shop" and "buying" overlap with "coronavirus". this finding indicates correlation and relevance in the same posts. panic buying therefore can be seen as a subset of buying. the topics related to covid stand alone and could be comments from media. toilet paper, despite being most often mentioned in posts, has no connection with other topics. this study intended to identify whether there is link between australia's timed measures for combating covid- and panic buying. secondary data was searched to identify changes to government measures at different times, and whether these changes correspond to the evidence of consumer behaviour. panic buying within this research is manifested by the stockpiling and hoarding of essential items, measured by degree of change in retail revenues during the pandemic. we intended to identify how government measures are related to this panic buying. secondary data were primarily sourced from reliable e-news and websites (e.g. the guardian, abc, channel , , and ), official reports and government records. the first covid- case in australia was diagnosed on january , . by april, there were nearly cases confirmed, with the highest number of cases in new south wales, with (worldometers, ) . the total number of new cases initially grew exponentially in march, levelling out to about per day around march , and with figures starting to fall at the beginning of april. for this reason, the secondary data search focused on the period from march to early april when the research was conducted. the pandemic is still going on and the situation may change in the near future. for the purpose of this study, we focused on the key dates that pandemic was announced, key government interventions were enforced. the commencement date in march was the day when the who announced covid- as a pandemic. the following section presents the primary government measures and panic buying following a time sequence. australia has passed through a number of stages of lock down, inter alia, including national and state border closures at different times, closure of various institutions, and the banning of cruise ships. on march , australians were also urged not to travel overseas amid coronavirus (covid- ) fears (abcnews, b). "we now advise all australians to reconsider your need to travel overseas at this time, regardless of your destination, age or health", "if your travel is not essential, consider carefully whether now is the right time", the prime minister said (abcnews, b). on march , the government advised all australians not to travel overseas at this time. this is the highest advice level (level of ). if anyone already overseas wishes to return to australia, the government recommended they do so as soon as possible by commercial means (smarttraveller, ) . on march , australian states closed their borders, except to residents and essential workers, to slow the spread of the virus and all interstate arrivals were required to self-isolate for days (sbs, b) . for instance, on march , the south australian chief public health officer stated: "all of the cases we have investigated thus far have acquired the virus overseas, interstate or have been close contact with a known case. …… there is no known community-acquired transition at this stage in south australia, but we are still conducting contact tracing in-vestigations…. it is a very serious situation we are now in, we have advanced our emergency declaration as a state and we are placing restriction on interstate travel" (wills et al., ) . western australia also introduced border control on march , with the premier announcing: "we will be introducing new border controls for western australia. these strict new border controls will apply to all access points; roads, rail, air, and sea. …. unless exempted, arrivals from inter-state will be ordered to self-isolate for days. exemptions will apply for essential services and essential workers. we are looking at acquiring very soon some hotels for self-isolation zones so that we can have places to quarantine people who have difficulty self-isolating or who will not self-isolate" (mercer, ) . following the closing of national borders on march , schools commenced moving towards online learning but remained open for students whose parents were essential workers. on march , nonessential services such as clubs, hotels, and casinos were required to shut down (knaus et al., ) . on march , a ban on australian citizens travelling overseas came into force. "no-one should be getting on a plane and going overseas" the prime minister said (abcnews, a). social distancing corresponds to the lockdown measure. on march , all public events with more than attendees were cancelled (australian associated press, ). the order was enforceable by the police. violations of the order would carry a prison term of six months and/or an $ , fine (australian associated press, ). on march , the government introduced a ban on non-essential gatherings of more than people in indoor areas. in outdoor areas the ban remained for non-essential gatherings of more than people (fraser, ) . on march , a social distancing rule of square metres ( sq ft) per person in any enclosed space was imposed by the australian government (burke, ) . on march , the prime minister addressed a press conference following a national cabinet meeting and announced that public gatherings would be limited to two people, while also urging australians over the age of , those with chronic illness over the age of , and indigenous australians over the age of to stay at home and self-isolate (mcgowan and doherty, ). the prime minister also clarified the only four acceptable reasons for australians to leave their houses: shopping for essentials; for medical or compassionate needs; exercise in compliance with the public gathering restriction of two people; and for work or education purposes (abcnews, c). these measures were slightly different in the different states, but the two-person limit and . m distancing were universally applied (dakin, ) . fines would be applied to those going out without acceptable reasons (white and stackpool, ) . in response to these measures, the virus has been reasonably well managed as shown in the fig. . although the number of infected cases peaked towards the end of march, the confirmed cases had been decreasing. however, in line with the timing of the different measures, the phenomenon of panic buying emerged. since intensification of the lockdown and social distancing fig. . concept map of panic buying, generated by leximancer measures in mid-march, panic buying had increased. panic buying and stock piling commenced in early march and increased sharply towards the end of the month when the lockdown scale was extended, and social distancing was tightened. the anz reported that the supermarket spend was up % from the same week ending march the previous year. fig. shows how the weekly spend on essential items increased in relation to the changes in government measures over the period. items that were most popular were toilet paper, staples (e.g. rice, pasta), flu related medicine, long-life products, canned and frozen food, and consumer electronics. there was a % increase in retail food spending, a % jump in the pharmacy and toiletry spend, and a % rise in electronic purchases. figs. and show how these items changed dramatically in march when government measures changed. among the items stockpiled, toilet paper was the common and greatest stockpiled item. this finding is consistent with that in the semantic analysis from study . a few incidences occurred relating to this item. figs. and demonstrate humorous examples of how toilet paper became the dominant panic buying item. this study applied big data analytics to understand the connection between government measures and panic buying by analysing consumers' responses and sentiments towards government measures. the same data collection procedure in study was undertaken for big data analytics. data from study were stored for processing in a local mongodb database located at the in-house big data cluster at griffith university. to ensure the privacy of users, only date and location, when the account was opened, number of likes and retweets, along with the actual text from the posts were stored for data analysis. twitter posts were downloaded including the date of posting. this option enables the analysis of activities over time. data were collected from march to mid-april . this period shows posts over this time, the topic trends, and the key dates of events, such as policy updates by the government. as shown in fig. , there was a sharp increase in posts about the topic, which is in line with the government strict social distancing policy (mcgowan and doherty, ), as well the australian government announcing the wage subsidy program to support economically impacted sectors on march and . sentiment analysis on twitter posts was performed to assess the tweets and mine the opinions of individuals towards the topic. sentiment analysis basically refers to the use of computational linguistics and nlp to analyse text and identify its subjective information. different sentiment analysis methods have been developed in various domains becken et al., ) . in this paper, a dictionary-based system, which relies on the use of comprehensive sentiment lexicon and sets of fine-tuned rules were applied. a sentiment lexicon can be created either by humans, by machine, or by both (semi-automatically). for instance, a dictionary may contain words such as "good", "fantastic," "bad", or "ugly," with their associated values of polarity. few methods have been published for dictionary-based approaches and we relied on and extended the work of the valence aware dictionary for sentiment reasoning (vader) method, which has been tested and developed (hutto and gilbert, ) . vader combines a lexicon and a series of intensifiers, punctuation transformation, and emoticons, along with heuristics to compute sentiment polarity of text. the positive sentiment is reflexed by - while negative sentiments were from - to . the results, also presented in fig. , include the number of posts and sentiment over the time to show a comparison between them. fig. shows that the number of posts increased towards the end of march and beginning of april, nevertheless, the sentiment towards government measures decreased during the same period. this finding may indicate that people in queensland were very concerned about coronavirus (covid- ) as the number of infected cases peaked towards the end of march and also implied there were very controversial attitudes towards the government polices related to covid . in order to assess individuals' attitudes towards to panic buying, we again calculated the sentiment analysis for the dataset that was only related to panic buying (based on the filtering key words mentioned earlier). the sentiment score presented in fig. shows how sentiment changed over time and attitudes towards the panic buying. it is interesting to see that the distribution of the sentiment shows a negative average sentiment at the beginning, when individuals tended to blame others for hoarding. however, latter sentiment showed an increasing trend, which could indicate more acceptance of panic buying behaviour as the evidence shows that the process might go up or have gone up on items in shortage. geographically, when looking into all comments related to coronavirus , the number of posts from certain area is directly correlated with the population density. however, this is not the case in panic buying dataset. the findings indicate that the panic buying related posts mostly only occurred in areas with higher density of population, for example from brisbane, the gold coast, and the sunshine coast region in queensland as is shown in fig. . in view of the current covid pandemic crisis, the paper deploys a mixed method approach to examine the relationship between government measures on managing the crisis and possible undesirable consequences. the models that have been generally utilised to manage such pandemics across the globe are the lock-down policy (ldp) and/or the timed intervention policy (tip). the latter was adopted by many countries to minimise the severe economic impact from a complete lockdown policy. despite similar inventions and measures being taken by different countries, the outcomes vary in relation to the increase in the number of infected cases and the number of deaths. for instance, italy, spain, and the usa have been significantly affected; whereas other countries (e.g. australia, china, india) have (at time of publication) managed the spread of the virus reasonably well. the different outcomes are largely accounted for by the timing of the interventions. whilst the focus of these interventions is on controlling spread of the virus, the side effects from macro and micro levels such as economic, social, and individual impacts emerged. inter alia, the phenomenon of panic buying stands out as an impact associated with timed intervention measures. the paper examines how tip is related to panic buying in terms of timing effect with a focus on australia. the findings from a range of methods including semantic analysis, secondary data, and big data analytics show that the timing of interventions corresponds with the scenario of panic buying. australia has undertaken different stages and levels of lockdown and social distancing measures to manage and control of spread of covid- . the findings from the semantic analysis show that government measures associated with covid- are related to panic buying. the secondary data analysis also demonstrated that when these measures had a smaller scope, focusing on travel bans and scaled quarantine in january and february , australian consumers engaged in their normal shopping and consumption routine. panic buying then commenced in mid to late march when lock down was extended and social distancing was tightened. this phenomenon peaked in late march and early april when social distancing measures limited to a maximum of two people being able to gather in public, however panic buying appeared to slow in april. this may be accounted for by repeated assurances from government and the interventions practised by retailers or supermarkets. for instance, in late march, australia prime minister asserted that the army could be used to help with food deliveries, if necessary, and stated: "absolutely, of course it will. i've already had the defence forces being deployed into the states to assist with medical check-ups and chase-ups, contact tracing. because some states, particularly new south wales, have become overwhelmed. now, it's important that we provide that support and we're there to help, and the defence forces are turning up, now, just like they were during the bushfires. but it's a very different need." prime minister said (knaus et al., ; march ) . supermarkets were also urging australians to stop their stockpiling behaviours. the retail giants, coles, woolworths, aldi, and iga indicated that they would do everything to ensure availability of stock (sbs, a). some pharmacies mitigated panic buying by increasing the price of face masks and hand sanitiser (haggan, ) . supermarkets and chemists also placed purchase limits on panic buying items (gillespie, ). the sentiment analysis from the big data analytics revealed a number of findings: ) the number of posts and comments on panic buying peaked in late march and early april; ) sentiments were negative toward tightened social distancing and lockdown measures in the same period but improved towards the mid of april; and ) sentiments towards panic buying were positive and high in that period, then turned to be negative and minor. before mid-march while government measures were less strict, with a small number of infected cases, australians may have appreciated that these measures were adequate to manage spread of the virus, but not so much that they would limit their daily life. when these measures were expanded and tightened toward the end of march with increased social distancing requirements, australians did not appear to respond positively to these interventions, as was shown by the negative sentiments in social media posts. the expanded lockdown measure resulted in income reduction or job losses. in particular, significant fines and penalties were enforced for those violating the policies. however, the sentiments in relation to government interventions appear to have been perceived more positively from early to mid-april. this may be accounted for by increased government support through financial subsidies and employment assistance and more transparent communication. towards the end of march, the australian government had also launched an app offering up-to-date advice and information on the covid- pandemic. the coronavirus australia app, available on the apple app store and google play, was released alongside a new whatsapp messaging feature (mubin et al., ) . the features of the app include a symptoms checker, register of isolation, the current status of the virus, advice, resources, news and media, and contacts and settings. a hotline was also established to help people seeking information on covid- , with the line operating h a day, seven days a week (department of health, b). the government also sent a sms/text message to remind residents of control measures and information on covid- . the government frequently held press conferences (the guardian, ) and provided updates with information relating to the virus on a daily basis (department of health, a). these initiatives were informative in nature and allowed australians a degree of foreseeability in relation to future measures and their timing. additionally, the government released an economic stimulus package to support those who had lost positions through the jobseeker payment. during mid-march, the government also announced a a$ . billion stimulus package. the package consisted of a one-off a$ payment to welfare recipients, , grants capped to $ , , and a % wage subsidy for , apprentices or trainees for up to months. in addition, billion dollars was allocated to support economically impacted sectors, regions and communities, $ million to increase tax write-offs, and $ . billion to provide short-term small and medium-sized business investment (prime minister of australia, ). on march , the government also announced a second stimulus package worth a$ billion, increasing the financial support to a$ billion. this increase was used to double income support for individuals on the jobseeker allowance, grants of a$ , to small and medium-sized businesses, and a$ million to australian airports and airlines. individuals affected by the pandemic were also allowed to access up to a$ , of their superannuation and with the option to take the same amount again in the following year. in contrast, the sentiment towards panic buying was negative before the end of march, then appeared to turn positive during the time when sentiment towards the government measures were negative. these findings indicate that panic buying appears to correspond to changes in government interventions and measures. initially, australians appeared to view such phenomenon as positive or "normal" in relation to the pandemic crisis. however, negative sentiment may have been triggered by the consequences of panic buying. these consequences included the shortage of essential items in the supermarkets and by retailers, erratic behaviour from panic buyers, such as brawling over toilet paper in supermarkets, excessive pricing of essential items for sale on e-bay, social media jokes in relation to panic buying. however, sentiments turned positive again towards mid-april, most likely as a result of supermarket interventions. this study examines the possible link between pandemic management and consumer behaviours with a focus on the timing effect. the findings show timing consistency between changes to government interventions and panic buying. this study contributes to crisis management and public policy literature, as well as consumer behaviour research. previous research on pandemic crises is primarily approached from medical, economic, and political perspectives, and has focused on the effectiveness of various interventions and measures. this research provides a fresh perspective and integrates pandemic crisis management and consumer behaviour to understand the side effects of pandemic interventions and offers a potential measure to assess the effectiveness of government interventions. this study extends consumer behaviour research from the scope of business and marketing management to crisis management and public policy realm. traditionally consumer behaviour study is embedded in the marketing discipline and approached from the organisational level (meso level). this research demonstrates that such research can be escalated to the macro level to understand the impact of national and/or international public policies on consumer behaviour. the study therefore has practical implications for policy makers and marketers. the findings show that the relevant authorities must be aware of the side effects of their policies and interventions that are intended to focus on the pandemic crisis per se. whilst focusing on the effectiveness of managing issues relating to a pandemic, other measures and contingent plans must be in place to minimise side effects such as panic buying and its related consequences. for practitioners, panic buying may bring instant benefits for supermarkets, retailers, manufacturers of stockpiled goods, and other related businesses (e.g. transportation). however, the marketers for these businesses must be aware of the immediate and long-term consequences of such behaviours. the immediate consequences may be a shortage of supplies and essential items. the long-term effects may include a decrease in revenue and unpredictable sales as a result of stockpiling and hoarding. businesses and marketers must identify appropriate marketing strategies to manage panic buying and develop contingency plans that address erratic consumer behaviour. organisations must work closely with the relevant authorities to mitigate aberrant consumer behaviour during pandemic or natural crises. additionally, research undertaken by mckinsey & company (june , ) shows that consumer sentiment is evolving along with the changes of covid status quo. their sentiments are related to their choice of purchase items and shopping channels. those who remain pessimistic may continue stockpiling essential items and may prefer online shopping; whereas others who are optimistic may opt for nonessential goods and services through various commerce channels. hence, it is imperative to understand and analyse consumer sentiment for marketers to develop a more accurate forecast for future sales. despite best efforts and the application of a range of methods within this paper, some limitations must be acknowledged. first, the research has focused on the australian experience, therefore, interpretation and generalisation of the findings must be cautioned. further research, including other countries and through comparison would add greater insights into the phenomenon. second, whilst the study had intended to establish a link between timed-intervention policies and panic buying, we must emphasise that a causal relationship is not guaranteed based on the findings from secondary data and big data analytics. these findings on the claimed relationships can be used as a reference for practitioners and researchers. future research may be able identify more appropriate methods to establish the existence of a causal relationship. third, the sentiment analysis from the big data analytics was based on twitter responses. the findings therefore may be biased and have limited generalisability. including other social media and online platforms would provide greater insight to address the research questions. in view of the current covid pandemic crisis, the paper deploys a few methods including semantic analysis, big data analytics and secondary data research to examine the relationship between government measures on managing covid and panic buying behaviours. the study provides a fresh perspective on the unintentional consequences of timed interventions practiced by the government. this paper contributes to public policing and consumer behaviour research, as well as practical implications for the relevant authorities and marketers. coronavirus-driven ban on australian citizens travelling overseas comes into force at midday gatherings of more than people to be cancelled, australians urged not to travel overseas amid coronavirus fears scott morrison has announced the two-person rule on gatherings in the fight against coronavirus, but what does it actually mean? retrieved from sentiment analysis in tourism: beginning of a new research paradigm? panic buying or the essentials intensifies nsw coronavirus cases spike to monitoring the environment and human sentiment on the great barrier reef: assessing the potential of collective sensing on fast multi-shot epidemic interventions for post lock-down mitigation australia closes borders to stop coronavirus woolworths in need of , new workers amid coronavirus crisis department of health, b. australian government secures additional million face masks to contain coronavirus outbreak australian government bans gatherings of more than people, international travel woolworths, iga introduce shopping hour for elderly to combat coronavirus panic buying face mask pricing referred to accc vader: a parsimonious rule-based model for sentiment analysis of social media text pm announces pubs, clubs and cinemas to close, schools stay open in stage one measures -as it happened coronavirus australia latest: at a glance australian states close borders as covid- threat intensifies the government's coronavirus mobile app is a solid effort, but it could do even better spillover of covid- : impact on the global economy economic stimulus package it's un-australian, and it must stop': scott morrison tells australians to cease panic buying wa to close borders as covid- cases across australia surge coronavirus and international cruises the guardian, . pm announces pubs, clubs and cinemas to close, schools stay open in stage one measures -as it happened dynamic graph cnn for learning on point clouds timeline of coronavirus measures v. daily case count now you can't even go for a drive: top cop says australians will be fined for 'blatantly' being on the road in coronavirus lockdown even if they don't set foot outside premier steven marshall will isolate sa as coronavirus surges the seroprevalence of pandemic influenza h n ( ) virus in china retailer's sourcing strategy under consumer stockpiling in anticipation of supply disruptions supply disruption management under consumer panic buying and social learning effects the project is funded by inspector general emergency management queensland, australia. supplementary data to this article can be found online at https://doi. org/ . /j.jretconser. . . key: cord- -apb l tq authors: ward, m.p.; kelman, m. title: companion animal disease surveillance: a new solution to an old problem? date: - - journal: spat spatiotemporal epidemiol doi: . /j.sste. . . sha: doc_id: cord_uid: apb l tq infectious disease surveillance in companion animals has a long history. however, it has mostly taken the form of ad hoc surveys, or has focused on adverse reactions to pharmaceuticals. in a blue ribbon panel was convened by the u.s. white house office of science and technology policy to discuss the potential utility of a national companion animal health surveillance system. such a system could provide fundamental information about disease occurrence, transmission and risk factors; and could facilitate industry-supported pharmaco-epidemiological studies and post-market surveillance. disease watchdog, a prospective national disease surveillance project, was officially launched in january to capture data on diseases in dogs and cats throughout australia. participation is encouraged by providing registrants real-time disease maps and material for improved communication between veterinarians and clients. from january to mid-november , an estimated % of veterinary clinics australia-wide joined the project. over disease cases – including canine parvovirus (cpv), canine distemper, canine hepatitis, feline calicivirus, feline herpesvirus, and tick paralysis – were reported. in new south wales alone, cpv cases in dogs were reported from postcode locations. new south wales data was scanned using the space–time permutation test. up to clusters (p < . ) were identified, occurring in all months except march. the greatest number of clusters (n = ) were identified in april. the most likely cluster was identified in western sydney, where cases of cpv were reported from a postcode in february. although the project is still in its infancy, already new information on disease distribution has been produced. disease information generated could facilitate targeted control and prevention programs. surveillance of infectious diseases in companion animals has a long history. this surveillance has mostly taken the form of ad hoc surveys, or has focused on adverse reactions to vaccines and other pharmaceuticals. most of these activities have not included an ongoing measurement of the population using comparable methods, so strictly do not meet our current understanding of disease surveillance. a notably exception is surveillance for rabies, for which passive surveillance systems exist (for example, see blanton et al., ; tenzin et al., tenzin et al., , . an example of using secondary data sources for surveillance is research on the recent epidemic of canine leptospirosis in north america (for details, see ward et al., ward et al., , a ward, a,b) . this research program was initiated using data from the veterinary medical database (vmdb). the vmdb was established in north america in by the national cancer institute to collect, store, and retrieve veterinary clinical information (hayes et al., ; priester, ) . it contains a standardized abstract of every animal examined at participating veterinary teaching hospitals in the united states and canada. at the time of initiation of this study, veterinary teaching hospitals in the united states and canada had contributed data (ward et al., ) . results showed a clear trend in increasing diagnoses of canine leptospirosis, suggesting this to be a re-emerging zoonosis. however, because the vmdb is a secondary data source, data analysis was limited to those covariates recorded in the vmdb, and results might be subject to diagnostic bias and might not necessarily represent the target population. for spatial analyses (ward, a) , research was limited to the location of the hospitals reporting the cases. later, data generated within a specific veterinary teaching hospital data management system was integrated (using a geographic information system) with data generated from a state veterinary laboratory accession management system to conduct more focused research on spatial distribution and risk factors (ward et al., a,b) . this allowed recommendations to be made to reduce the impact of this epidemic of leptospirosis. however, integrating databases and data cleaning, error checking and validation consumed a considerable amount of time, and the system could not identify new trends in near-real time. a critical gap identified was database integration and analytical methodologies that could be applied routinely. most research in the area of companion animal disease surveillance has focused on systems to detect adverse vaccine and other drug reactions. for example, moore et al. ( a) developed a surveillance system that utilized electronic medical records from a large corporate small animal general practice in the united states, in which each of more than hospital locations in this system used the same computerized medical record system. records of dogs receiving a range of vaccines (including for bordetella, coronavirus, multivalent distemper-adenovirus-parainfluenza-parvovirus-leptospirosis, giardia and rabies) were extracted and searched for adverse reactions. using the collective data recording of these hospitals, adverse events were identified during a -year period, representing , , doses of vaccine administered to , , dogs. the use of veterinary practice databases to complement spontaneous reporting systems for vaccine safety is one example of recent advances in companion animal disease surveillance (moore et al., b) . this system has also been used as a research tool to identify space-time clusters of adverse events associated with canine rabies vaccine (moore et al., ) . in september , a blue ribbon panel was convened on behalf of the u.s. white house office of science and technology policy to discuss the potential utility and possible strategies for design and implementation of a national companion animal health surveillance system (stone and hautala, ) . a goal of such a system is improved veterinary care, and it could be also used to develop evidence-based veterinary practices. data derived from a surveillance system could provide fundamental information regarding disease incidence, prevalence, transmission, and risk factors. such an enhanced understanding of disease epidemiology would enable practitioners to evaluate the effectiveness of treatments and intervention programmes. such a system could also facilitate industry-supported pharmaco-epidemiological studies and post-market surveillance, which would enable the development of safer and more effective veterinary products. as stated by the blue ribbon panel, a companion animal surveillance system should ideally be a public/private partnership involving representatives from the veterinary community and the veterinary products industry who are involved in the design of the system in order to promote compliance and leverage resources. in january , virbac animal health in australia launched disease watch-dog, a prospective national disease surveillance project, to capture data on communicable disease cases and outbreaks, with the ultimate aim of the reduction and control infectious diseases in cats and dogs. this project is unique as it involves a growing number of participants, and as well as gathering data, encourages participation by providing benefits to registrants including real-time maps of disease occurrences and outbreaks, material for improved communication between veterinarians and clients, and empowerment of staff. from january to mid-november, an estimated % of veterinary clinics australia-wide have joined the project, with > cases of disease reported. while the project is still in its infancy, the analysis of initial data is demonstrating some important findings with respect to disease distributions in space and time and risk factors, and there is considerable potential to gather vital information that could lead to targeted vaccination and treatment efforts which could be the key to the control of various diseases. in this paper we report details of this surveillance tool and illustrate its utility with a case study of canine parvovirus (cpv) occurrence and distribution during a -month period in the state of new south wales. the purpose of this paper is to demonstrate the feasibility of surveillance in pet animal populations, and to highlight the value of spatial analysis of such surveillance data. disease watchdog was created out of the need for better epidemiological data on current and emerging companion animal diseases. despite significant advances in technology, veterinary science is lacking recent studies on the occurrence and distribution of diseases that affect the lives of millions of animals worldwide. incidence of common infectious diseases such as canine parvovirus (cpv), canine distemper virus (cdv), feline calicivirus (fcv), feline rhinotracheitis virus (fvr), feline immunodeficiency virus (fiv), and feline leukemia virus (felv) are largely unknown. with comprehensive data and a better understanding of the epidemiology of these diseases, solutions to problems such as how to formulate best practice vaccination protocols during disease outbreaks or how to strategically address endemic disease with preventive and treatment techniques can be proposed. as a national disease surveillance system, disease watchdog was developed to gather epidemiological data and to provide real-time mapping that demonstrates disease occurrences at suburb level. data needs were based on the following considerations: fields in which data could be recorded were then assembled into a web-based system and the website interface carefully designed to maximize compliance from users. estimated time to enter a case of disease is currently s. features to improve compliance include a ''litter'' checkbox where multiple affected littermates can be simultaneously entered into the database, reducing repetitive data entry. a chart can be downloaded from the website so that users can record cases on paper as an interim measure, then enter cases in a batch if this is easier for the user. to maximize accuracy, user access to submit data is limited to registered veterinarians and veterinary nursing staff of veterinary clinics. veterinary clinics register for access to the disease watchdog site at www.diseasewatchdog.org and once approval is granted, an email provides username and password. there is no charge for using disease watchdog. once a month, all registered users are sent an email reminder to enter cases for the previous month if they have not already done so. the monthly email also provides an opportunity to communicate with users, updating them on improvements to the system and how best to use the program. when a user registers, a pack of resources is sent to the clinic to which they belong, to help communicate their involvement to their staff and clients. an emphasis on empowerment of staff to be involved in the program aims at encouraging participation and collegiality. the message behind the program is that together, the veterinary profession has the power to control diseases through participation in the program, data collection, analysis and then strategic disease prevention and treatment. a benefit for veterinary clinics of participating in disease watchdog is the ability to view maps of disease cases and outbreaks in real-time. data entered via the website is immediately visible on the disease maps that any registered participant can view. maps can then be used to show clients where at-risk areas for disease exist, highlight the importance of disease prevention, and to monitor disease outbreaks in their local area. measurement of disease cases and recording of outbreaks also provides strong data that can also be communicated through channels such as the australian veterinary association's media office, to allow alerts to be transmitted to the general public via local and national media. never before in australia has accurate recording of disease outbreaks been available on this scale for this number of diseases. a feature of disease watchdog is the role of disease surveillance champions. these are individuals within veterinary practices that are responsible for data entry. these individuals routinely update data within the system, for their practice, on a monthly basis. they act as the primary contact point within each practice, and promote the advantages of the disease watchdog surveillance system to colleagues and clients. disease watchdog was upgraded to version . in september , partly in response to suggestions and ideas for improvements from contributors. this upgrade provided both contributors and analysts with a number of additional features and benefits for better searching and display of disease cases and outbreaks, and improved recording of information. some of the important news features include: . allowing the graphing feature to be controlled by disease surveillance champions. this feature displays disease cases and outbreaks -enabling the diseases, locations and timeframes that are displayed to be personally selected, for better representation of disease outbreaks relevant to a local community. disease watchdog users can adjust the graph that displays on the home page, to suit the needs of their individual clinic. the graph of current outbreaks of disease defaults to the last months. . a new facility to search by radius around a suburb, providing more relevant information on the diseases in the user's area and allowing improved mapping. this facility could also be useful for research studies to identify risk factors for disease occurrence. . a feature to allow multiple diseases to be displayed by assigning different colors to each disease, so that multiple diseases can be shown simultaneously. more information on diseases in a suburb can be obtained by the user simply by clicking on a colored flag placed at the suburb location. displaying multiple diseases allows practices and their clients to visualize which diseases are prevalent in their specific area. . tick paralysis data has been added to disease watch-dog. tick paralysis is an acute, progressive ascending motor paralysis. it is caused by a salivary neurotoxin produced by some species of ticks. in australia ixodes holocyclus is the principle cause of cases of tick paralysis in domestic animals. this tick species can be found on native animals along the east coast of australia. reported distribution of tick paralysis has previously been mostly anecdotal. inclusion of tick paralysis in disease watchdog allows for the first time the spatial and temporal distribution of this important disease to be monitored in australia. recording tick paralysis cases will enable veterinarians to alert clients to the dangers of ticks in specific areas, and also whether tick paralysis is seasonal in their area and the importance of tick prevention and awareness. . two more infectious diseases were added to the disease watchdog list; the distribution of felv and feline infectious peritonitis (fip) can now be monitored. these diseases were chosen as the next additions because of their apparent lower prevalence, but higher mortality. felv is caused by a retrovirus that can be transmitted between cats via saliva or nasal secretions, and can be fatal. fip, caused by a coronavirus, is incurable and generally fatal. other diseases will be added to disease watchdog in the future, based on the perceived health importance and ability of veterinarians to detect and diagnose the health condition. the development and maintenance of disease watch-dog to date has been funded entirely by virbac animal health. awareness of the disease watchdog initiative is being achieved within the veterinary community via the support of the australian veterinary association (which represents most veterinarians within australia), idexx laboratories (a company that develops and markets diagnostics within australia; http://www.idexx.com.au/), vetnostics (part of a network of pathology laboratories operating throughout australia; http://www.vetnostics.com.au/), and gribbles veterinary (a veterinary pathology organization providing veterinary diagnostic and analytical services throughout australia and new zealand; http://www.gribblesvets.com.au/info/general/home/get/ / /). between january and november , registrants joined disease watchdog across australia (a small number are non-veterinary registrants and do not record disease cases), representing approximately % of veterinary clinics australia-wide. based on estimates of veterinary clinic numbers across the states of australia, participation levels range from % in victoria ( ) to % in new south wales ( ). to demonstrate the utility of the disease watchdog system, data analysis focused on reports of cpv in the state of new south wales. cpv is an infectious disease of dogs caused by cpv type . it is highly contagious and is spread via direct contact or indirectly via fecal contaminated environments and fomites. this disease is often diagnosed in puppies unprotected by maternal antibodies or vaccination. although cpv first appeared in the late s as a pandemic (johnson and spradbrow, ; walker et al., ) and other epidemics have been reported (sabine et al., ) , the spatial distribution, seasonality and risk factors for cpv are not well understood. in a questionnaire survey of veterinary practitioners in australia and new zealand seeking details of their experience with cpv infections in , sabine et al. ( ) found that explosive outbreaks of disease had occurred in most parts of australia in that year. no obvious pattern of spread over the continent could be detected. an overall mortality rate of % was estimated. in a serological survey, smith et al. ( ) found that cpv was generally a disease of dogs less than months of age. the current analysis focuses on the spatial distribution of this disease, as a case study of the application of the disease watchdog surveillance system. data extracted from disease watchdog included date of diagnosis and the residential postcode. for the purposes of demonstration, data selected was restricted to reported cases occurring between january and september, in the state of new south wales. all data was joined to a postcode shapefile (gda , new south wales lambert conformal conic projection) in arcgis v. . (esri inc., redlands ca). the lambert conformal conic projection system is one of the best for 'middle' latitudes. the state of new south wales lies between latitudes and °s. spatial relationships were measured on the scale of meters. only cases which had valid data entered for location (postcode) and diagnosis date (day, month) were included in spatial analyses. for all postcodes included in the study, the postcode centroid was calculated (arctools, arcgis . ). most postcode polygons in new south wales are relatively small: % of the postcodes cover a land area of km . data were scanned using the space-time permutation test (satscan v. . kulldorff m. and information management services, inc. satscantm v . : software for the spatial and space-time scan statistics. http://www.satscan.org/, ). the permutation test was used because the number of dogs at-risk of cpv per postcode is unknown. however, it was assumed that during the -month study period the distribution of the population of dogs would have remained stable across postcodes. future research using disease watchdog will include estimation of the dog and cat population at-risk within suburbs and postcodes. this might be achieved by annual surveys of disease watchdog participants, or by estimations based on reported disease cases. based on a maximum period of infectiousness for cpv of up to - weeks (goddard and leisewitz, ) , the temporal scanning window was restricted to days, with windows of , , and days used. the spatial scanning window was restricted to km, with windows of , , and km used in a series of separate analyses. the analytical approach, recognizing that it was a demonstration of the application of the disease watchdog surveillance system, was exploratory and attempted to provide insights into the epidemiology of cpv in the new south wales dog population -a subject on which no peer-reviewed information has previously been published. the selection of scanning windows was motivated by an assumed level of clustering that might occur within an area covered by up to - postcodes (in urban and semi-urban areas of new south wales) within a relatively short timeframe, i.e., potential local outbreaks of cpv. an additional exploratory analysis was performed using the scan statistic bernoulli model. for these analyses, cases were reports of cpv in which the affected dogs had been vaccinated and controls were those dogs diagnosed with cpv that reportedly had not been vaccinated. the results of such an analysis might reveal clusters of cpv disease associated with vaccine failure. in all scan statistic analyses, permutations were performed and significant (p < . ) clusters were identified and mapped. clusters were interpreted based on the ratio of observed to expected cases occurring within the cluster. data was exported from disease watchdog, processed within arcgis v. . (esri inc., redlands ca) and then exported to satscan v. (kulldorff m. and information management services, inc. satscan™ v . : software for the spatial and space-time scan statistics. http:// www.satscan.org/, ) for analysis. between january and september, , there were reports submitted to disease watchdog, representing disease cases. only one case of fip, and two cases each of cdv and chv, were reported. a total of and cases of fcv and fhv were reported, respectively. tick paralysis was added to disease watchdog in september, and cases were reported during this month. all reports contained valid data for diagnosis and postcode. during the study period, cases of cpv were reported from new south wales ( cases/ reports), queensland ( / ). victoria ( / ), western australia ( / ), the northern territory ( / ), south australia ( / ) and tasmania ( / ). in new south wales, most cpv reports ( ; %) consisted of only one case. reports with , , , , and cases were made on , , , , and occasions. most of the cases were male ( ; %). a total of breeds were reported to be affected. the following breeds accounted for > % of cases: australian cattle dog ( ; %), staffordshire terrier ( ; %), jack russell terrier ( ; %), bull terrier ( ; %), mastiff ( ; %), maltese ( ; %) and fox terrier ( ; %). the mean ( % confidence interval) and median (interquartile range) ages were ( - ) and ( - ) months, respectively. the minimum age of cases was months. the most common methods of diagnosing cpv were the elisa snap ( ; %) and clinical signs ( ; %). immunofluorescence and pcr were rarely used ( and , respectively). outcome was reported for cases, with treatment ongoing at the time of reporting for a further cases. of those cases with a final outcome reported, ( %) died, ( %) were euthanized, and ( %) recovered. vaccination status was reported for cases, of which ( %) cases were vaccinated. no significant association was found between survival status (recovered versus died or euthanized) and gender (male versus female, odds ratio (or) . ; p = . ), method of diagnosis (clinical versus test, or . ; p = . ) or vaccination status (unvaccinated versus vaccinated, or . ; p = . and unknown versus vaccinated, or . ; p = . ). dogs that survived were older ( weeks) than those that died ( weeks), p = . . the greatest number of cases of cpv were reported in the months of february and april ( % each). half of all cases were reported between march and june. the data entry screen in disease watchdog (www.diseasewatchdog.org) is shown in fig. . examples of the reports that can be generated and viewed on the disease watchdog website are shown in fig. . reports include histograms showing the frequencies of diseases reported during a given period, and maps of the distribution of cases. an example of the spatial search capacity of disease watchdog is shown in fig. . cpv cases were reported from postcodes. only one case was reported from postcodes; or more cases were reported from the following postcodes: , , , , , , , , (fig. ) . only of these ( and ) were in areas of substantial human population. regardless of the size of the scanning window used (all combinations of , , and km and , , and days), the most likely cluster was identified in western sydney, in which clinics reported cases of cpv on february (observed Ä expected . ). depending on the scanning window used, between and significant (p < . ) additional clusters were detected. at larger spatial scanning windows, fewer clusters were detected. the size of the temporal scanning window had little influence on the number of clusters detected. clusters were detected in every month except march. the most clusters were identified in april. twelve of these clusters were only of one day duration; the other clusters lasted from to days (median days). the clusters (fig. ) were distributed throughout most of the state, excluding the southeast and the far west. all but two of these clusters were located outside the metropolitan area of sydney. using reports of cpv in which the affected dogs had been vaccinated as cases and controls as those dogs diagnosed with cpv that reportedly had not been vaccinated, the same location in western sydney was identified as the primary cluster, although the observed Ä expected ratio was less ( . ). in contrast, in this analysis no significant (p < . ) secondary clusters were detected. surveillance of small animal populations for infectious diseases has been rare. almost all examples of surveillance systems focus on the detection of rabies cases. for example, in the united states the system for rabies surveillance is well-developed and based on the reporting of cases (usually accompanied by submission of diagnostic samples) to the centres for disease control and prevention. however, even in this system, the focus is cases in wildlife, rather than companion animals (for example, in approximately % of the cases were in wildlife, and % were in domestic animals; blanton et al., ) . other studies have used a surveillance-like design. for example, biggeri et al. ( ) used a -stage sampling design, with first stage transects, to study the risk of dog parasitic infections in the city of naples, italy, during - . this system focused on zoonotic parasitic diseases, including infections with trichuris, isospora, toxascaris, ancylostoma and toxocara. however, the study apparently was driven by a research goal and not as an ongoing effort, thus, not strictly matching the definition of surveillance. other initiatives have used existing hospital management systems as a secondary data source for monitoring diseases in companion animal populations. for example, moore et al. ( ) used databases complied by banfield, the pet hospital corporation in the united states to describe several diseases. development of a disease surveillance system for companion animal disease as a primary objective apparently has not been successfully undertaken previously. the blue ribbon panel convened on behalf of the u.s. white house office of science and technology policy in to discuss the potential utility and possible strategies for design and implementation of a national companion animal health surveillance system (stone and hautala, ) stressed the importance of consultation with end-users: ''the type of information collected, the frequency with which it is collected, and the format in which it is disseminated should be determined in accordance with user goals''. disease watchdog is unique in its flexibility and ability to be modified in response to suggestions by those who use the system. for example, the upgrade of the system in september included several features identified as important by end-users, such as graphing and displays capabilities, and the addition of new diseases such as tick paralysis. the blue ribbon panel also identified four fundamental principles relevant to the design of a companion animal surveillance system: syndromic versus disease-specific surveillance; the ability to leverage existing systems; predefined response protocols; and integration with other health surveillance systems. syndromic surveillance involves collection of information on clinical syndromestwo or more characteristic clinical signs. disease watchdog is based on the diagnosis and reporting of specific disease, rather than syndromes. expansion of disease watchdog to include syndromes (for example, vomiting and diarrhea) could be implemented with comparative ease. however, such a modification would need to be driven by the endusers, which are primarily veterinary practices. in the case of cpv, a substantial proportion ( %) of cases was diagnosed using the snap elisa. in this situation, reporting cases based on syndrome might not provide additional benefit to the end-user. in contrast, cases of tick paralysis are generally diagnosed based on clinical signs (for exam-ple, between and september the reported cases of tick paralysis were diagnosed based on clinical presentation ( %), tick found ( %) or tick crater only found ( %)). tick paralysis was added to disease watchdog in september in response to requests from end-users of the system. for an applied surveillance system such as disease watchdog, the usefulness of syndromic surveillance needs to be assessed in partnership with the enduser. acute cpv enteritis can reportedly occur in dogs of any breed, age, or sex. however, puppies between weeks and months of age appear to be more susceptible (goddard and leisewitz, ). in the current study the median (interquartile range) age of reported cases was ( - ) months. this finding was unexpected, based on previous statements regarding the age pre-disposition for cpv. of those cases with reported vaccination status, only % of cases were vaccinated. this might, in part, explain a higher age of cases than expected. however, the common belief amongst veterinarians that cpv is a disease of puppies may need revision, following further research using data generated by disease watchdog. some breeds -mostly large breeds such as rottweiler, doberman pinscher, labrador retriever and german shepherd dog -have been reported to be more at risk for severe cpv enteritis (goddard and leisewitz, ) . none of these breeds were commonly reported to be cases in the current study. however, the proportion of a breed in a population -and the proportion that are presented at veterinary clinics -needs to be taken into account before breed predisposition can be determined. goddard and leisewitz ( ) state that the risk of cpv in sexually intact males is twice that of sexually intact females. in the current study more reported cases were male than female, but the difference was small ( % versus %). half of all cases were reported between march and june, which represents the autumn months. generally cpv is considered to peak in summer (goddard and leisewitz, ) . as more data is accumulated in disease watchdog, a more accurate description of seasonality can be made. many clusters of cpv were identified during the short -month study period in new south wales. such a spatial distribution of cases is likely to indicate that local factors are important, generating local epidemics. follow-up studies, using larger datasets, might be able to identify some of these factors. based on preliminary analysis, apparently vaccination practice is unlikely to explain most of these clusters. there are three specific design elements for a companion animal surveillance system (stone and hautala, ) : target population; data collection, analysis and standards; and mechanisms for dissemination of results. the system must have a clearly defined target population. this is necessary so that the disease frequency estimated can be referred to a defined population. in disease watchdog, the target population is comprised of veterinary practices that report disease cases. this is a subset (currently nearly onethird) of all practices in australia, the reference population. 'all practices in australia' is a well-defined population, since practices need to be licensed by the relevant state or territory authority where they operate. a current gap in disease watchdog is that the population of dogs and cats (and their demographics -such as age, breed and gender distributions) -is unknown. such data -when available -is for specific locations only (toribio et al., ) . this information could potentially be collected within the disease watchdog system, for example by having contributors annually describe their practice caseload during the previous months, or by estimating the likely population at-risk based on the proportions of cases reported, and potentially informed by known covariates (for example human population size and socioeconomic status) within the practice area. variable disease watch-dog adoption proportions for different australian statescurrently ranging from % in victoria to % in new south wales -means that inferring the impact of disease in different areas needs to be done with caution. a companion animal disease surveillance system should collect a comprehensive data set comprising both clinical and epidemiological data (stone and hautala, ) . disease watchdog collects spatial information via the postcode of the owner's address. it is assumed that this is the area in which the animal has spent most time during the short period preceding disease diagnosis, and assumed to be the area that other animals are at risk of the same disease. the actual date of diagnosis is reported in disease watchdog. diseases currently reported in this system can be diagnosed on the basis of clinical presentation, diagnostic test (including elisa snap, immunofluorescence, pcr) or other. other information collected includes animal name, suburb, state, postcode, species and breed, age (years/months/weeks), sex, neuter status, whether a litter was affected and if so, the number of animals in the litter and the total number affected, case outcome (recovered, died, euthanized, treatment ongoing) and vaccination status and date. a unique case identification number is generated by the system, and the case is linked to the clinic name and the veterinarian's name. finally, within a surveillance system, each user should define triggers for implementing responses and identify data that will support specific responses (stone and hautala, ) . within disease watchdog, the response to perceived clusters of disease rests with the end-user, the veterinary clinic. a feature of this system is the ability for practices to conduct spatial searches within their local area. this allows veterinarians and veterinary assistants to promote disease control and prevention based on empirical data. this might be one reason why the adoption of disease watchdog has been high during its first months of operation. two tasks that could facilitate major advances in the surveillance of companion animal populations are standardization of data captured within such systems, and the development of a set of core analytical tools. a current barrier to disease surveillance is an inability to rapidly and validly integrate different surveillance systems. the barrier is usually a lack of consistency in the scale (spatial, temporal) at which data is recorded, a lack of standard case definitions (e.g. method of diagnosis, method of measurement) and differences in which auxiliary data is recorded (e.g. animal data such as age, gender, breed and population demographic data -the 'population at-risk'). identifying key surveillance systems and key individuals, an agreement on standards that should be used could be reached. an analogy is the recent development of the reflect statement: methods and processes of creating reporting fig. . the distribution of spatio-temporal clusters of cases of canine parvovirus reported in the disease watchdog surveillance system between january and september in new south wales, australia. clusters were detected using the scan statistic permutation test, with spatial scanning windows up to km radius and temporal scanning windows up to days in length. guidelines for randomized control trials for livestock and food safety (o'connor et al., ) . an array of analytical tools are available for detecting trends and clusters in disease surveillance data (for example, see ward and carpenter, a,b; ward, ) . there is a lack of consistency regarding which tools should be applied routinely, and also a lack of knowledge of the performance of the different tools applied to different types of surveillance data. as above, agreement is needed in order to correctly evaluate the results of analysis of surveillance data. to our knowledge, results of the analysis of the spatial distribution of cpv cases have not been published in the peer-reviewed literature. a likely barrier is the lack of large, good quality surveillance datasets. disease watch-dog fills that gap: in new south wales alone, cases were reported during just months. considering the lack of knowledge of spatial distribution of cpv and the lack of knowledge of the population at-risk within each postcode, we used the permutation model. the model does not require any assumptions to be made with respect to how the population at-risk is characterized. the only assumption is that the population at-risk remains relatively stabile during the study period. as more analyses are undertaken of the spatial distribution of diseases in pet populations, analytical approaches are likely to be refined. during a short period of operation, disease watchdog has been adopted by nearly one-third of australian veterinary clinics. epidemiologic data, including location and date, are providing new insights into the distribution of diseases of dogs and cats in australia. ability of end users to produce disease maps is one likely explanation of its success to date. disease mapping in veterinary epidemiology: a bayesian geostatistical approach rabies surveillance in the united states during canine parvovirus the veterinary medical data program (vmdp): past, present, and future isolation from dogs with severe enteritis of a parvovirus related to feline panleucopaenia virus a space-time cluster of adverse events associated with canine rabies vaccine postmarketing surveillance for dog and cat vaccines: new resources in changing times adverse events diagnosed within three days of vaccine administration in pet dogs the reflect statement: methods and processes of creating reporting guidelines for randomized control trials for livestock and food safety multiple primary tumours in domestic animals. a preliminary view with particular emphasis on tumors in dogs canine parvovirus infection in australia during canine parvovirus-five years later serological observations on the epidemiology of parvovirus enteritis of dogs meeting report: panel on the potential utility and strategies for design and implementation of a national companion animal infectious disease surveillance system reemergence of rabies in chhukha district re-emerging rabies in dogs and other domestic animals in eastern bhutan demographics and husbandry of pet cats living in sydney, australia: results of cross-sectional survey of pet ownership a serological survey of canine parvovirus infection in new south wales clustering of leptospirosis among dogs in the united states and canada seasonality of canine leptospirosis in the united states and canada and its association with rainfall spatio-temporal analysis of infectious disease outbreaks in veterinary medicine: clusters, hotspots and foci analysis of time-space clustering in veterinary epidemiology techniques for analysis of disease clustering in space and in time in veterinary epidemiology prevalence of and risk factors for leptospirosis among dogs in the united states and canada: cases ( - ) serovar-specific incidence of and risk factors for leptospirosis among dogs presented to a veterinary teaching hospital geographical risk factors for leptospirosis among indiana dogs key: cord- -np b a o authors: mardani, karim; noormohammadi, amir h.; ignjatovic, jagoda; browning, glenn f. title: naturally occurring recombination between distant strains of infectious bronchitis virus date: - - journal: arch virol doi: . /s - - -z sha: doc_id: cord_uid: np b a o new variants of infectious bronchitis virus (ibv) have emerged in australia despite its geographical isolation and intensive vaccination programs. in the present study, the ′ terminal . kb of the genome of a recently isolated variant of ibv (n / ) was sequenced and compared with the sequences of classical and novel strains of ibv, the two main groups of these viruses in australia. the comparison revealed that recombination between classical and novel ibvs was responsible for the emergence of the new variant. it was concluded that novel ibvs, which have not been detected since , and which are phylogenically more distant from classical ibvs than turkey coronaviruses, might still be circulating and contributing to the evolution of ibv in australia. infectious bronchitis virus (ibv), the prototype of the family coronaviridae, is an important pathogen in chickens and infects the respiratory tract, kidneys and oviduct, causing reduced performance, reduced egg quality and quantity, increased susceptibility to infection with other pathogens and increased mortality [ ] . the genome of ibv is single-stranded, positive-sense rna of about . kb, encoding four structural proteins, including the spike glycoprotein (s), the membrane glycoprotein (m), the phosphorylated nucleocapsid protein (n) and the small membrane protein (e). new serotypes and genotypes of ibv emerge frequently in different parts of the world [ , , , , , , , ] . a number of factors, including mutation and recombination, and the widespread use of live attenuated vaccines, play an important role in increasing the number of new genetic variants [ , , , , ] . recombination and mutation are two major forces in coronavirus evolution, and polymerase jumping during coinfection may promote recombination events between coronaviruses [ ] . molecular characterization using sequencing and phylogenetic analysis are effective methods for detection and characterization of recombination events among rna viruses [ ] . n / , a nephropathogenic strain of ibv, was the first isolate of ibv obtained in australia, in [ ] . since , a number of distinct strains of ibv have been isolated, including a group of strains that were found to have no epitopes in common with other ibv strains on either their n or m proteins [ ] . in a study on the pathogenicity of australian strains of ibv, a change was detected in the prevalence of ibv strains, from highly nephropathogenic strains in the s and s to strains predominantly pathogenic for the respiratory tract in the s and early s, indicating that ibv strains in australia have undergone a significant change since [ ] . ibv strains in australia have been classified into two groups, classical and novel [ ] , based on their genotypes. the novel ibvs are phylogenetically distant from the classical ibvs, and in fact, classical ibvs and turkey coronaviruses are more similar to each other than they are to the novel ibvs. recently, the isolation of a new variant of ibv in australia, from broiler farms located in new south wales, that had low s gene identity to those of classical and novel ibvs but n gene and untranslated region sequences similar to those of classical ibvs, suggested the emergence of a new subgroup of ibvs in australia [ ] . in this study, the new variant of ibv that circulated in nsw during and was further analysed by comparing the terminal . kb of its genome (all the structural protein genes) with those of the other two ibv groups in australia. the ibv strain n / used in this study has been described previously [ ] . virus propagated in allantoic fluid was used for rna extraction. extraction of rna was performed using an rneasy kit (qiagen, hilden, germany) according to the manufacturer's instructions. approximately ll of allantoic fluid was used for each extraction, and rna was eluted in ll of elution buffer. the extracted rna was used as template in a reverse transcription reaction. for synthesis of cdna, ll of extracted rna was denatured at °c for min, cooled by placing on ice for min, and then mixed with ll of reaction buffer containing ll of diethylpyrocarbonate-treated water, . lm oligo (dt) (promega, madison, wi, usa), . u of rnaguard (amersham pharmacia biotech, sydney, australia), lm each of datp, dttp, dgtp and dctp, ll of reaction buffer (promega), and u of moloney murine leukaemia virus reverse transcriptase (promega). the reaction mixture was incubated at °c for h and subsequently incubated at °c for min to inactivate the reverse transcriptase. the resultant cdna was immediately used or stored at - °c for later use. for the amplification reaction, two primers, poly-f (gattgtgcatggtggacaatg) and utr-r (ctgt accctcgatcgtactc), binding to the end of the polymerase gene (nucleotides , - , , beaudette strain, genbank accession number nc_ ) and the untranslated region (nucleotides , - , , beaudette strain) of the ibv genome, respectively, were used to amplify a . -kb fragment of the ibv genome that contains all of the genes for the structural proteins. the pcr reaction was carried out in -l mixtures containing lm each of datp, dttp, dgtp and dctp, . lm of each primer, ll of high fidelity pcr buffer (invitrogen, carlsbad, ca, usa), mm magnesium sulfate, . u platinum taq high fidelity dna polymerase (invitrogen) and ll of cdna as template. amplification was performed using cycles of incubation at °c for s, °c for s and °c for min, with a final extension at °c for min. the resultant pcr products were separated in a . % agarose gel, and the gel was photographed. pcr product was purified using a pcr purification kit (ultra clean pcr clean-up, mo bio laboratories, solana beach, ca, usa) according to the manufacturer's instructions. the . -kb pcr product from ibv strain n / was cloned in the pgem-t plasmid using a pgem-t vector system cloning kit (promega). the cloned pcr product was sequenced using a big dye terminator v . cycle sequencing kit (applied biosystems), and the reaction products were sent to the australian genomic research facility, walter and eliza hall institute of medical research, melbourne, for analysis on an abi prism genetic analyzer. sequences of different genes of n / were aligned with the same genes from other australian ibvs and the beaudette strain (table ) using clustalw [ ] . evolutionary relationships between australian ibv genes were inferred using the neighbour-joining method [ ] . the evolutionary distances were computed using the maximum composite likelihood method [ ] and measured as the number of base substitutions per site. phylogenetic analyses were conducted in mega [ ] . the -terminal . kb of the genomes of the representative classical and novel australian ibv strains were aligned with the sequences from the same region of the n / isolate, and the multiple alignment results were introduced into simplot version . . to identify likely recombination sites [ ] . bootscanning analysis was performed in simplot to identify and map the putative recombinant ibv genome [ ] . this program was also used to find phylogenetically informative sites, as described previously by robertson et al. [ ] . statistical analysis of the distribution of phylogenetically informative sites was performed using minitab version (minitab inc, us). a two-proportion comparison was performed, and a p value of less than . was considered significant. amplification, sequencing and analysis of the . -kb region of n / the . kb of the n / genome was amplified, cloned and sequenced successfully and compared with the same region of a number of classical and novel strains. phylogenetic trees were constructed for each gene. analysis of the s gene sequences of australian ibv strains showed that, among classical strains, they differed by - . % and, among novel strains, by . - . %. the classical and novel ibvs differed by . - . %, indicating a major difference between the s genes of these two groups of ibvs. interestingly, the s gene sequence of strain n / differed from those of both classical and novel ibvs by . - %. phylogenetic analysis of the s gene grouped n / in a separate cluster from classical and novel ibvs (fig. ) . e gene sequences of classical strains differed by - . %, and those of novel strains by - %. the difference between classical and novel ibvs ranged from . to . %. more interestingly, the e gene sequence of n / was very similar to those of the classical strains (differences of . - . %) and very different from those of novel ibvs (differences of . to . %). in the e gene phylogenetic tree, n / clustered with the classical ibvs (fig. ) . m gene sequences of classical strains differed by - . %, and those of novel ibvs differed by - . %. the m gene sequences of classical and novel ibvs differed by . - . %. the n / m gene clustered with the classical strains (differences of . - . %) (fig. ) . the n gene of classical ibvs differed by . - . %, and those of novel ibvs differed by . - . %. the n gene sequences of classical and novel ibvs differed by . - . %. the n gene of n / was more similar to the n genes of the classical ibvs (differences of . - . %) than of novel ibvs (differences of . - . %) and clustered with the classical strains in phylogenetic analyses (fig. ) . to identify the region likely to have been involved in recombination in n / , similarity plots and bootscan analysis were performed using strains vics and n / as representatives of the two main groups of ibv in australia and the armidale strain as a query. in both the similarity plots and the bootscan graph, n / had greater similarity to n / (a novel ibv strain) in its s gene region (almost kb), while the reminder of the -terminal . -kb region had greater similarity to vics (a classical ibv strain) (fig. , ). data from phylogenetic analyses also suggested that n / had sequence similarity to both main groups of australian ibvs. these findings suggested that there had been a recombination event with a crossover point at the end of the s gene (base number ) of n / (fig. , ) . to obtain a precise picture of this possible crossover point, the distribution of phylogenetically informative sites along the -terminal . -kb sequences of n / and vics were examined. using simplot, informative sites were found that could support one of three possible trees. for almost % of the s gene ( kb), informative sites were found, and % of these informative sites supported a tree clustering n / with the novel ibv strain n / . in contrast, only % of the informative sites supported each of the other two possible trees in this region (p \ . ). for the rest of sequences ( , - , bp), informative sites were found, with % supporting the tree clustering n / with vics and only % supporting the tree clustering n / with n / (p \ . ). this indicated that n / clustered with the classical ibv strain vics throughout the -terminal . kb of its genome and confirmed that a recombination event had occurred at the end of the s gene region (at around position ) and that n / is a recombinant virus that emerged from recombination between these two groups of ibvs in australia. new ibv isolates have been reported in recent years in australia and have been classified as subgroup viruses. the emergence of these new isolates was considered to be unexplained, as was the earlier emergence of subgroup , or novel viruses. n / is one of these new viruses, which have been isolated from broiler farms using one of the four commercial ibv vaccines [ ] . this study was undertaken to explore the mechanism behind the emergence of the subgroup ibvs in australia. based on phylogenetic analysis of the complete . -kb region of the genome, n / was distinct from both classical and novel ibvs. however, the s gene sequence of fig. evolutionary relationships between n genes of australian ibv strains inferred using the neighbour-joining method. the evolutionary distances were computed using the maximum composite likelihood method and are given in the number of base substitutions per site n / was equally different from both the classical and novel ibvs, while the rest of the -terminal . -kb region of the genome clustered closely with those of the classical ibvs and was very different from those of the novel ibvs. the similarity of the n / e, m and n genes to those of classical ibvs suggested that this isolate was closely related to the most commonly used australian ibv vaccine strains. as these strains have been used for a long time in australia, it is possible that they have contributed to the emergence of variant ibvs in the field. the s gene of n / clustered more closely with the novel ibvs, and similarity plotting and bootscan analysis confirmed the close relationship between the s genes of n / and the novel ibvs and suggested that the crossover event occurred near the end of this gene. these analyses provide convincing evidence that recombination has occurred between classical and novel ibvs, leading to emergence of variant ibvs in the field. novel ibvs have not been isolated since , but this finding suggests that novel ibvs are still circulating in the field in australia. the failure to detect them since may be a result of the relatively slow growth of these viruses [ ] . these results confirm the hypothesis of ignjatovic et al. [ ] that recombination may have played a role in the emergence of this new variant of ibv in australia. recombination between ibvs and its role in emergence of new ibv variants has been reported previously [ , , , ] and may occur at multiple sites [ , ] , although crossover events occur more frequently at the end of the s gene [ , , ] , as seen in this study. however, it is particularly notable here because of the very significant phylogenic distance between the novel and classical australian strains of ibv. indeed, the novel strains of ibv are more distinct from the classical strains than is turkey coronavirus, and they lack several of the smaller nonstructural genes found in classical strains. in conclusion, this study showed that the recombination was involved in the emergence of the new variant of ibv in australia and that a rapid and reliable technique is needed to determine whether the novel ibvs are still circulating in poultry farms. it would be appropriate to sequence and analyse the polymerase genes of classical, novel and new variant strains of ibv to obtain further information about the relationships between the different australian ibvs. isolation and characterization of new infectious bronchitis virus variants in hungary comparisons of envelope through b sequences of infectious bronchitis coronaviruses indicates recombination occurs in the envelope and membrane genes recent advances in avian virology severe acute respiratory syndrome vaccine development: experiences of vaccination against avian infectious bronchitis coronavirus identification of taiwan and china-like recombinant avian infectious bronchitis viruses in taiwan isolation of a new serotype of infectious bronchitis-like virus from chickens in england infectious avian nephrosis (uraemia) in australia a recombination event, induced in ovo, between a low passage infectious bronchitis virus field isolate and a highly embryo adaptedvaccine strain variant serotypes of infectious bronchitis virus isolated from commercial layer and broiler chickens a 'new' strain of infectious bronchitis virus infecting domestic fowl in great britain bioedit: a user-friendly biological sequence alignment editor and analysis program for windows / /nt a long-term study of australian infectious bronchitis viruses indicates a major antigenic change in recently isolated strains pathogenicity of australian strains of avian infectious bronchitis virus isolation of a variant infectious bronchitis virus in australia that further illustrates diversity among emerging strains a novel variant of avian infectious bronchitis virus resulting from recombination among three different strains sequence evidence for rna recombination in field isolates of avian coronavirus infectious bronchitis virus evidence of genetic diversity generated by recombination among avian coronavirus ibv a new genotype of nephropathogenic infectious bronchitis virus circulating in vaccinated and nonvaccinated flocks in china fulllength human immunodeficiency virus type genomes from subtype c-infected seroconverters in india, with evidence of intersubtype recombination infectious bronchitis viruses with a novel genomic organization genotypic and phenotypic characterization of the california (cal ) variant of infectious bronchitis virus coronavirus replication and pathogenesis: implications for the recent outbreak of severe acute respiratory syndrome (sars), and the challenge for vaccine development recombination in aids viruses the neighbor-joining method: a new method for reconstructing phylogenetic trees identification of breakpoints in intergenotypic recombinants of hiv type by bootscanning prospects for inferring very large phylogenies by using the neighbor-joining method mega : molecular evolutionary genetics analysis (mega) software version . evidence of natural recombination within the s gene of infectious bronchitis virus evolutionary aspects of recombination in rna viruses characterization of three infectious bronchitis virus isolates from china associated with proventriculus in vaccinated chickens avian infectious bronchitis: characterization of new isolates from italy acknowledgments the senior author would like to thank the department of education, employment and workplace relations of australia for providing him with an endeavour research fellowship award, which enabled this work to be completed. he also thanks urmia university, iran, for granting him leave to go to australia to undertake this work. key: cord- - fmbs authors: nan title: news date: - - journal: aust vet j doi: . /j. - . .news_v _i .x sha: doc_id: cord_uid: fmbs nan the conference was hosted by australian cattle veterinarians (acv), australian sheep veterinarians (asv) and australian reproduction veterinarians (arv), and nearly delegates from across australia and around the world took part. "we hosted qualified speakers coming from across the globe to arm australia's livestock vets with the latest developments in reproduction research, " dr andrew hoare, acv president said. "this is crucial because livestock vets are at the frontline of the country's critical industries for food production. with climate change becoming a growing global problem, its potential to impact agricultural industries is quite high. long-term food security is now a global concern and australian agriculture will play its part in feeding communities here and overseas, " he said. "looking at ways to increase the quantity and quality of animals we produce now is one way we can ensure australia continues to lead the way in reducing that risk. a conference like this one to tackle this issue at its core will help australian vets meet the challenges of sustainable food production. " the conference was held at the marriot hotel, gold coast from - july, and where else but at a megarepro conference could delegates be welcomed by sammie and ashleigh the metre maids. three awards were given during the conference, all of which are tied to the acv strategic objective of encouraging young veterinarians towards a career in rural cattle practice. these were the acv norbrook bovine champions award, which was given to one winner from each of university of queensland, sydney, melbourne and murdoch. this award, for current acv student members, focuses on the applicant's desire and potential capability for a career in cattle practice. the george osborne memorial speakers award, was given for young veterinarians who had to give a presentation at the conference, and the rural practice scholarship was open to students and newer graduate cattle veterinarians who are current members of acv, to enable the successful applicant to further their career in bovine practice. the major prize for this can be attendance at an overseas conference, a study tour to the us or uk, or another project as selected by the entrant. speakers at the conference ranged from john aitken talking about causes and strategies for embryonic losses, ian lean on the nutritional basis of livestock reproductive success, to dave beggs who gave a most entertaining and thought provoking session on how to market your practice. herman raadsma gave a surprisingly understandable (for non-geneticists) talk on the genetic aspects of livestock reproduction, and the meeting concluded with the great sperm debate, and a panel discussion on livestock reproduction stargazing led by john haslep and jeremy thompson. in the wrap up, peter chenoweth noted the international quality of the meeting, with its mix of basic and applied science, networking, stimulation, motivation, economics, prophesy, sperm, oocytes, embryos, toxicology and marketing. high praise is due to the members who have been involved in the development of these workshops and the materials and momentum that they have produced. in particular, i would like to thank sue fowkes, andrew easton, bruce pott and robert hedlefs along with the eva and queensland division. i would also like to acknowledge the support of the queensland department of primary industries and fisheries and workplace health and safety queensland in these initiatives. hendra has been one of the stimuli for these workshops, developed to focus on biosecurity in veterinary practice and a reinvigorated need to raise the bar with infection control. this is especially timely following the recent and tragic death of alister rodgers, from hendra virus. there has never been a more important time to further progress the great work that has been done to stimulate changes in practice. this is a critical story that needs to be read, remembered and put into practice and the ava will continue to communicate with members nationally as well as through our sig's, divisions and branches. we do need government and industry to help us get this message out with support for education and training. cultural change does not come easy but it must come and we must all play our part whether working in teaching, industry, government or private practice. we can become champions in biosecurity, we have to become champions, our lives depend on it. along with cultural change in the horse and veterinary industries there must be investment in research (prevention, treatment and diagnosis) into hendra. we called early for a fast tracking of the development of an equine vaccine, along with other strategies. it is of amazing credit to alister's family that they quickly saw this need and have set up a research fund in his memory at the university of queensland. this noble act in their loss and grief symbolises the community input that veterinarians have. the story of alister's life and work is clear testimony to this. we have implemented structural change at a divisional level with the establishment of executive officers and this has been well received in queensland (and the other divisions) and is progressing with a feeling that there is an opportunity to take some of the heavy load off the president and committee, and this is delivering outcomes in the sunshine state. we have changed our policy on vaccinations. this is a complicated issue and not everyone will be happy, but this is something that was important for us to progress. we need to embrace the principles of this policy while supporting the relationship of the veterinarian and the client/patient to deliver the right outcome in varied circumstances. we will continue to work with the profession on this. i have encouraged younger members to nominate for positions on divisional and special interest group committees and will continue to do so. i have great respect for the committee volunteers of our divisions and sig's, and mean no disrespect to them, but we do need to engage our future leaders as part of our changing demographics. another issue that has been brought to the fore by the current hendra outbreak is the state of our veterinary capacity in emergency response. onl y dur am une adu lt ® vac cine is regi ster ed for yea rs pro tect ion from we eks of age . proh eart ® sr- injec tion for heart worm preve ntion and/o r annu al vacci natio ns for canin e coug h, coron aviru s and lepto spiro sis will comp leme nt annu al healt h chec ks. it's a simple -step implemen tation phase: Ê decide which vaccinatio n protocol will best suit your practice Ë communi cate and train all your staff Ì communi cate the benefi ts to your clients call to book a clinic training session, to order customer relations tools or for advice on vaccinatio n protocols . call to book a clinic training session, to order an information pack or for advice on vaccination protocols. n news e arlier this year we told ava members about the outcomes of a membership review, and subsequent changes to our fee structure. from january , all eligible membership concessions will be at a standard % of the full ava member fee. we have reinstated a category of 'spouse membership' that grants a concession to the second ava member in a couple, and at the last agm members voted to remove the affiliate category to leave a single category of associate for nonveterinarians who want to become a part of the ava. we also ceased charging fees for ava branch membership in , and continue to discuss other options for fee reform with special interest groups. the proposed changes to life membership at the agm didn't achieve the necessary % majority vote of members, so the status quo remains for the time being. our modelling indicates that this approach is simply not sustainable however, so we expect further initiatives about this to come before the membership in the future. generally speaking, my discussions with members suggest that most acknowledge the need for change. interestingly, as we look at possible changes to fee structures, we are starting to hear an increasing number of suggestions for new categories of fees. these take a variety of forms, but basically propose that various cohorts within the membership should be charged a smaller fee as they don't use the full range of ava services. while it would seem a simple equation of 'what you use is what it costs the ava' , this is not actually the case. the ava has lots of fixed costs that need to be met regardless of the number of current members or what member benefits they take advantage of. this includes many activities, like advocacy, media or policy development that are critical to the profession as a whole and that many members value highly. the production and mailing of printed material is actually now only a very small proportion of what it costs the ava to fulfil our role and service members. this is another reason behind the move at this year's agm to charge new life members % of the full ava member fee -it recognises that demands tend to be lower on our variable costs, but that fixed costs still need to be covered. this is just like a veterinary practice. you can't only charge clients for the variable costs involved in each consult, but must cover the fixed costs involved in running the business as a whole. you always have the option of discounting, but if you discount below a level where both fixed and variable cost are covered, you'll quickly go broke. understanding fixed and variable costs is critical to business and we are currently doing some work to more clearly define what it costs the ava to recruit, service and retain our members. we don't have exact figures yet, but it is clear that the cost of servicing each ava member is significantly higher than our membership fees and these are heavily subsidised by other income sources. the same applies to sig members -the cost of servicing sig members is subsidised both through direct income sources (conferences, sponsorship) and the costs borne by the national office such as membership, event and corporate services. just like any business we must recognise the need to discount. the point that retired members and others may not use many ava services is still valid, and we do take this into account in trying to determine fees relative to the costs of services. we are also mindful of the need to build relationships with the next generations of veterinarians and to provide an incentive for new graduates to join their association. the value of the contribution made by an ava member over years, through both subscriptions and more intangible contributions like volunteerism, is something we don't take lightly. our challenge lies in getting the balance right, and recognising this contribution while ensuring the ongoing sustainability of the association for future generations. the quality you expect the efficacy you demand the value you have come to expect a nyone visiting the gungahlin veterinary hospital (gvh) in the act is struck by the bright and airy reception area, but the real focal point is barry the budgie, who is adored by all. in the gvh opened its doors as a small house-based clinic in canberra's growth area, gungahlin. in the purpose-built, centrally located hospital opened. "we are committed to excellence in patient care. our facilities are first-rate and we are continuously updating equipment such as high-end anaesthetic monitoring with great attention to pain relief, " dr michael hayward, one of gvh's practice principals, said. "in this busy practice, we try to select staff with the right attitude as well as skills. every team member has a passion for pets and a genuine interest in people. "communication is respectful, caring, sincere, and informative. we have more than medical, surgical, and behavioural information handouts as well as a quarterly newsletter, website, sms updates to clients, and colourful waiting room displays. staff have morning tea together every day, protocols are regularly reviewed, and conflict is handled upfront by meeting or mediation. this challenged, happy and fulfilled team promotes great customer service. "we believe over % of problems are due to system rather than personal error. no blaming means the practice enjoys a culture of collaborative problem-solving. "our staff have undertaken extensive training in customer service, and our success in fostering positive, long-term relationships with clients rests on every team member's passion and genuine interest in pets and people. " gvh has always recognised the importance of pet behaviour to owners, the community, and the animals themselves. "more than puppies have graduated from our puppy classes, which now run four nights a week. "we also offer beyond puppy classes for puppy class graduates and training for older dogs on sundays, " dr hayward said. dr sarah webb, the only specialist small animal surgeon in the act region, provides specialist surgical practice on the premises. operating separately from gvh, she is able to give informal advice and accept same-day surgical referrals within the same building. a culture of continuous improvement, continuing professional development and giving back to the profession are also important features of the practice. pfizer vaccines. all round support for you and your patients. with only % of our total cat and dog population being regularly vaccinated, you need more than just a vaccine. that's why pfizer animal health has a proven annual vaccination protocol to protect against the major diseases and the largest field force in australia to support you. every pfizer vaccine comes with professional in-field support, a hour technical support line and a range of tools to help you educate your customers about the importance of regular vaccination. n news s mall enough to care, experienced enough to trust, is the service philosophy of this busy veterinary clinic located in the sydney suburbs. james thompson, principal veterinarian at turramurra veterinary clinic, works with three experienced part-time veterinarians and four support staff in a clinic which pairs old fashioned personal service with the best in modern veterinary practice. "we aim for the highest standards of patient care, customer communication, cleanliness, and community services. "we believe small things countstaff carry goods to the car and open the door for clients if they have their hands full. "one simple effective policy that we have is the 'any room, any time' rule. staff know that clients can be expected in any room at any time, and so we make sure the clinic is spotless % of the time. "longer half hour appointments reduce stress and crowding, free coffee vouchers are offered with every consultation. new pets receive complimentary puppy or kitten packs. we also provide bravery award stickers to cheer up young children who may be upset, " dr thompson said. many of their australian clients grew up in country nsw, and a landscape painting depicting the area is reassuring. the chinese community appreciate feng shui in the clinic design. the phone number -( ) , includes many number 's, and this is considered fortuitous by the chinese. located in a region with a significant south african community, many clients appreciate the large photo of an elephant in the waiting room. "our flag pole usually flies the australian flag, but during special events we fly sydney swans, socceroos or wallaby flags", he said. "we support four major australian charities, offer pet safety talks (based on ava's petpep) and sponsor eight local schools. "our vets are serious about mentoring vet students. they can always approach us for career guidance or study help during exams, " dr thompson said. the practice strives to be at the forefront of technology, being one of the few veterinary clinics in sydney with a high energy particle arrestor (hepa) filter for the surgery, minimising particulate contamination. the award acknowledges excellence and encourages veterinary practices australia-wide to further improve their customer service techniques and overall practice management. nominations are accepted from any practice in australia provided that the principal veterinarians of the practice are all ava members. previous winners of this award are not eligible to reapply for a period of three years, however previously unsuccessful applicants are encouraged to apply again. to maintain the high professional standard of the awards, the selection committee will include senior representatives of the wide diversity of practice types in australia as well as the veterinary industry. once the policy was finalised, a survey was conducted with members of the asava about their current practices and asked for information about the best way to communicate with them about important changes like this one. the policy was then distributed directly to members to help them respond to any enquiries they might receive from members of the public. the asava launched the new policy and some new client information resources at its christchurch conference in august. the information for veterinary clients focuses on the need for regular preventive health care for pets, and is available for purchase through the asava office. electronic versions are available for download from the ava website. ava met with the australian pesticides and veterinary medicines authority (apvma) to clarify the new ava vaccination policy and discuss issues of off-label usage of medications. scientific information was provided to support the policy, and the policy was well received by the apvma. the ava website has been updated with frequently asked questions for veterinarians, information for pet owners, and advice for kennels and catteries about the new policy and its implications. ava comment on the introduction of h n influenza into australian piggeries assured the public that the situation was being dealt with appropriately by the authorities. the other important message was that pork remained safe to eat. local stories included a parvovirus outbreak in launceston, with comments from angela offord on behalf of the tasmanian division. the story was covered by media in both launceston and hobart. bill harkin in victoria was on to a big winner with an interview on how to keep the costs of pets down while still looking after them well. the interview appeared in six community newspapers across melbourne. two media releases were distributed to promote pet dental health month, and these received coverage in local and regional newspapers. the australian land transport standards and guidelines of animals, were approved by the primary industries ministerial council (pimc) and will be enacted in february or march . representative stakeholders, however, were still unable to reach agreement on the transport of bobby calves ( to days old). pimc has instructed that a science-based standard for maximum allowable time off-feed be prepared within months, through animal health australia, for consideration by the primary industries standing committee. the ava attended this meeting to relay information from the association and australian cattle veterinarians to help finalise the standards. the ava attended a meeting of the live export industries consultative committee to assist in the development of an export industry animal welfare module. a summary of the 'hot stuff' model, which helps to anticipate climatic conditions during transport at various times of the year was presented. the ava is continuing discussions with agrifood skills australia to have further input into the development of the certificate iv training package for equine dental providers, including the proposed diploma course which recognises a higher skill set. the views of ava equine dental experts were tabled. the meeting was also attended by representatives of the australasian association of equine dentistry inc. the ava is continuing discussions with the australian chief veterinary officer, dr andy carroll about veterinary workforce arrangements for emergencies. further representations will be made to the animal health committee to obtain agreement on veterinarian employment contracts before private practitioners are faced with further emergency animal disease demands. important issues, including professional indemnity and public liability insurance cover and practice support payments will be discussed. our mortgage products provide flexibility for owner occupiers to borrow up to % of the purchase price, or up to % of the purchase price for investment properties, without lender's mortgage insurance. there is also plenty of room to tailor loans to accommodate your individual circumstances -such as a unique, fixed rate offset account. in addition, all of our products combine the benefits of competitive interest rates, dedicated expert finance consultants and a quick and easy approval process. make your move and contact the specialists committed to providing innovative financial solutions to healthcare professionals. all finance is subject to our credit assessment criteria. terms and conditions, fees and charges apply. deposit products are issued by investec bank. before making any decision to invest in these products, please contact experien, a division of investec bank, for a copy of the product disclosure statement and consider whether these products suit your personal financial and investment objectives and circumstances. we reserve the right to cease offering these products at any time without notice. income protection/life insurance is distributed by experien insurance services pty ltd (experien insurance services) which is an authorised representative of financial wisdom limited afsl (ar no. ). experien insurance services is part owned by investec experien pty ltd. so who should attend? the conference will have something for both women and men. for female veterinarians, it will be a unique opportunity to participate in discussions on your past, present and future. sessions will also cover topics specifically relevant to women, such as coaching staff, negotiation skills and life balance. for male veterinarians, the ever increasing feminisation of the profession will have the greatest impact on you, so it's essential that you join in the discussions. professional management sessions are relevant to all and will give you a much better understanding of the issues that are faced by your female colleagues and will improve your working relationship with them. for veterinarians in industry, the demographics of your customers are going to change over the next few years and understanding these issues will be essential. all veterinarians are also invited to contribute to a collection of short essays relating to women in the veterinary profession. suggested topics include: • pioneering women in the profession • adversity overcome • female veterinarians in diverse careers • advice for future female veterinarians • amusing stories. essays should be no more than words and will be reviewed and selected by the avpma to form part of a book on the outcome of the panel/forums held at the conference. essays can be sent to avpma@ava.com.au with a subject line of women's essay. elephants are used to transport goods, from the forest and farms to neighbouring villages and to the closest town, sen monorom. one elephant is usually shared between two owners and up to ten users. as a consequence, there is a high rate of abuse, lack of dietary knowledge, poor living standards and inadequate resting time in the surrounding forests for these elephants. eighteen elephants have so far been saved and rehabilitated by the project. some have survived atrocious conditions, chained and hobbled in one place for - hours a day with no access to food or water. overall, there are about working elephants in the region, at least of which desperately require assistance. and these are only the ones we know about. princess, a -year-old female asian elephant, is a true success story. despite suffering a dislocated hip in a terrible logging accident over a decade ago, she was forced to continue working, malnourished and dehydrated, pulling huge loads while suffering great pain. although permanently lame and scarred from her injuries, she is slowly regaining health and vigour. elephants frequently suffer from deep cuts, lacerations and abscesses and working elephants also develop wounds on the chest, abdomen or back from straps or chairs (howdahs), as well as wounds from the improper use of guide devices (ankus or ear ropes sometimes used with a metal hook placed in or around the ear to control the elephant). these can rapidly become secondarily infected. elephants in these parts are also plagued by parasites, especially flies. having access to mud and water is essential to minimise fly irritation. at the river the elephants would wash and time loofah themselves against tree trunks, then paint themselves with thick layers of mud. this behaviour is essential for them to maintain healthy skin and ward off parasites. they use trees and large branches to fend off flies. flies deposit their eggs in decaying flesh and invade wounds. when the larva is mature, the fly exits, leaving a small hole in the skin which often becomes secondarily infected. such nodules were apparent in virtually all elephants at the project. sunburn is also a common problem for elephants that are not afforded adequate shade and access to river mud. there was a continual debate between the manager and the mahouts about the treatment of wounds, neither would give way, which was very frustrating. as a veterinarian, i could see that they each had some points which would work far better in combination. the mahouts provided an endless source of knowledge about the medicinal properties of plants we encountered in the jungle, although all communication was via sign language as they knew no english. a fun aspect of my volunteer work was riding the elephants into the jungle so they could relearn how to browse. this was an important lesson as it would help prevent them from raiding neighbouring farms. if you're looking for a truly unique experience and really want to make a difference, then consider volunteering at the elephant valley project. it's an experience you will never forget. i would like to thank cenvet for providing a generous hamper which was raffled off to raise funds for the project and also for their donation of syringes and needles that are so difficult to source in cambodia. i would also like to thank auschrichter, who donated products which we sold to raise funds and the wonderful clients from the grange veterinary clinic. their enthusiastic support, participation in our raffles and competitions and generous donations enabled me to purchase and take over much needed supplies. check pipi's inflamed ear from morning bush walk. breakfast on the go. at guild, our focus on vets and their practices means we offer a very specific product, developed together with the profession and referred by the australian veterinary association. individually tailored, our veterinarians insurance covers the specific risks you face, in your profession. our guildwatch risk management guide provides specific guidance on how to reduce risk within your practice and our online tools help you assess which areas of your practice may be leaving you exposed. after all, helping vets reduce their risk exposure means less hassle, better business and happier owners. we've built our business on the highest levels of customer service. when you need us, you will deal directly with your local guild office, not a corporate call centre. our local offices are there to lend an extra hand at all times and we understand your practice, so when the time comes to offer a helping hand, we know exactly what you need. so with guild, you will always get the service you want, the assistance you need and enjoy the freedom to focus on your practice. all shelters conduct animal birth control (abc) programs, and jaipur was the first city in india to have no incidence of human rabies due to the his abc program. his also has projects to improve veterinary and management care of elephants, camels and horses. his and associated shelters need your help. the work is varied and interesting and placements can be for a month or more. we are looking for volunteer veterinarians who are skilled in spaying dogs and cats. accommodation (single room with an attached bathroom) and vegetarian meals are provided. the square metre facility was officially opened by the minister for trade, the hon. mr simon crean, and now stands as one of the few plants in the world that is licensed to manufacture highly potent sterile injectables for sale in the european and united states markets. parnell has recently increased turnover through the launch of estroplan, a reproductive hormone for cattle into the us market. they are also looking for a global co-marketing partner for zydaz, a product that treats osteoarthritis in dogs and horses. the state-of-the-art therapeutic goods administration in australia (tga) and food and drug administration (fda) standard plant has been a significant investment for parnell. it has the capacity to manufacture millions of doses of its estroplan and zyadax medications annually, and has been designed to have the capacity for contract manufacturing possibilities. parnell chief executive officer, mr robert joseph, said "our international expansion was dependent on the construction of a world leading pharmaceutical manufacturing facility and it will become a key pillar in our global expansion". since inception nearly years ago, parnell has developed and launched over products for companion, production and performance animals, across key therapeutic areas, including reproductive hormones, osteoarthritis, anaesthesia and anti-infectives. parnell anticipates that there will be an opportunity to explore contract manufacturing relationships allowing other companies to benefit from the use of its manufacturing facility. city public relations whether you are farming pigs, poultry, cattle, horses (or any other species) or you have pets or wildlife, there is an application for protexin. all animals have the same need for a stable healthy digestive system to ensure good health and nutrition, positive growth and viable productive capacity. for more than years protexin has gained the support of veterinarians, nutritionists, farmers, horse owners, trainers and studs, wildlife carers and pet owners who have discovered a multitude of ways to maximise the health and wellbeing of their animals. more productive farm animals more productive farm animals and healthier, happier pets. and healthier, happier pets. • establishes beneficial microflora • suppresses e. coli, salmonella & aeromonus spp • treats and controls scours • improves digestibility of feed • improves growth and feed conversion • reduces digestive upsets • enhances animal health • re-establishes gut microflora following antibiotics, worming or vaccination • reduces stress (stress disrupts normal intestinal balance) • safe to use, non-toxic and residue free whether you are farming pigs, poultry, cattle, horses (or any other species) or you have pets or wildlife, there is an application for protexin. all animals have the same need for a stable healthy digestive system to ensure good health and nutrition, positive growth and viable productive capacity. nutrition, positive growth and viable productive capacity. for more than years protexin has gained the support of veterinarians, nutritionists, farmers, horse owners, trainers and studs, wildlife carers and pet owners who have discovered a multitude of ways to maximise the health and wellbeing of their animals. animals. this is the ava's most prestigious award for outstanding service by a member or a non-member to veterinary science in australia. nominees that were unsuccessful from the previous two years are automatically included. issued jointly with the australian college of veterinary scientists, the kesteven medal is awarded to members for distinguished contributions to international veterinary science through technical and scientific assistance to developing countries. nominees that were unsuccessful from the previous two years are automatically included. awarded to members for outstanding service to the association. awarded to ava members or non-members (who are not eligible for membership of the association), but have delivered meritorious service to the ava. these awards recognise special or long-term service to the ava, its divisions, branches or special interest groups. awarded to eminent non-veterinarians for services to the ava or the veterinary profession. submissions in support of nominations for the latest round of awards should be made in writing to the ceo at ava national office, via your division or special interest group. all submissions must be received no later than friday november . for more information about the award categories, please contact national office on or secretariat@ava.com.au. cannon netting is just one of the techniques used by the national wild bird surveillance program for collecting samples from wild birds to test for avian influenza in australia. the birds are not harmed and are released after the samples are taken. no highly pathogenic avian influenza (hpai) has been identified by the program so far, but there remains a possibility of avian influenza viruses being introduced into australia by migratory birds such as rednecked stints and red knots, and mutating into hpai if introduced to poultry. james wallner has participated in sampling wild birds for the program but still talks about past cannon netting trips with awe, "the wader survey is quite a spectacular thing, because the beach is covered with millions of birds, weighing as little as a grams or less, and they're all frantically feeding after a long flight from siberia. " while quick to admire the beauty of the wild bird habitats, he also points out that cannon netting is hot, heavy and intensive work, and that he and his co-workers have been eyed speculatively by crocodiles at night. "we bury the cannon nets in the late afternoon so that we're ready to net and bleed the birds early in the day, before it's too hot to work in the afternoon. the nets have to buried and hidden because the birds are quite inquisitive. " "each net has three or four cannons attached, so they're quite heavy. a cartridge is packed with gun-powder, the charge throws the projectiles attached ropes and net out when it's fired. you might get as many as birds in one catch. " to protect wild birds, training and accreditation are required for the use of cannon netting. teams hide in bushes with a detonator, fire the net and then quickly retrieve the birds out of the nets to place them in holding cages to protect them from the heat prior to sampling. "with a larger bird like a duck you just tuck it under your arm and take a cloacal swab, " says james. he admits it's a messy job that requires gloves, uncomfortable given the heat, to protect against scratches. the data collected is used to understand what types of virus spread in australia, how they circulate and what the risk is of introduction of avian influenza (both h n and other subtypes) through wild bird migration from other countries. samples are submitted to state or university laboratories for preliminary testing for ai, and positive samples forwarded to the csiro australian animal health laboratory for further testing to determine the virus gene subtype. the ocvo, which works closely with all states and some universities to ensure national coverage and coordination of wild bird surveillance activities, reports the national findings to industry and states. the program is so far providing valuable information about circulating ai virus subtypes. " kununurra t he creative nonfiction journal is compiling an issue about the bonds -emotional, ethical, biological, physical, or otherwise -between humans and animals. they are looking for stories that illustrate the way animals (wild and domestic) affect, enrich, or otherwise have an impact on our daily lives. essays must be unpublished and no more than words. submissions close on november. creative nonfiction editors will award a $ prize for the best essay and a $ prize for the runner-up. for more information visit www.creativenonfiction.org/ thejournal/subscribe.htm or email questions to information@ creativenonfiction.org. here is some advice about what to do (and what not to do) when dealing with client complaints. when dealing with a complaint, no matter how trivial, time is of the essence. an irate client who does not receive a prompt response may feel ignored and be more likely to take matters further. we recommend the following: • you or another senior person (such as the proprietor of the practice) should handle the matter. this should convey the message that it is being taken seriously. • contact the client as soon as possible. make it clear that this matter concerns you and listen to what they have to say. it is important to remain calm but firm -there is no point getting involved in a slanging match, but you also should not put up with any abuse. • do not offer compensation or mention your insurance cover. this may encourage further pursuit of a claim. simply inform the client that you will investigate the matter and provide a response as soon as possible. • notify your professional indemnity insurer of the incident, even if a formal claim has not been made. guild insurance will retain guild lawyers and a solicitor will contact you to provide advice. if it is obvious that an error has occurred, in most situations it is appropriate to apologise. in the past there has been some reluctance to offer an apology on the basis that it may be misconstrued as an admission of fault. however, recent legislative reform across all states has confirmed that an apology is not an admission of liability. the effect of an apology should not be underestimated. our experience has been that many civil claims for damages would not eventuate if a carefully worded, timely and sincere apology had been provided to a client. often a client may feel wronged and want acknowledgement. if ignored they will often take matters further. another reason to apologise is that registration boards tend to take this into account when determining an outcome. assume a client arrives at your veterinary practice complaining that their pet has not improved following treatment that you provided. in these circumstances, you would examine the patient to asses their present condition. it would also be appropriate to let the client know that you are sorry the treatment has not aided in their pet's recovery, by saying something like: "i am sorry to hear your pet is still unwell. i will investigate this and review what happened during the consultation. i will get back to you as soon as i can but in the meantime i am concerned about your pet's wellbeing. would it be okay for me to re-examine your pet and consider a different treatment plan?" this acknowledges the complaint and shows sympathy without making an admission of liability. clients need to know that complaints concerning the treatment of their pets are recognised and taken seriously. a prompt response and an apology without admitting liability can go a long way towards avoiding an expensive and potentially damaging claim. for more information contact guild insurance on . n news a n increasing number of businesses are employing workers as independent contractors. however, it is important that you are aware of the differences between being classified as a contractor or an employee. a contractor relationship is almost like a relationship between two businesses. a contractor is not considered an employee and is not entitled to minimum standards such as shift loadings, minimum wages or leave entitlements. the independent contractors act does not give a straight forward answer to this question. the court uses the common law 'multiple factor' test which operates by looking at the whole relationship between the parties, not just the written contract. factors used to determine if a person is a contractor or an employee include: • does the person trade as themselves or a company? • do you have the ultimate right of control to direct how the work is to be done by the worker? • how are they paid for the services they provide? • do they provide and maintain their own equipment? • is there an obligation for them to work at times and dates specified by the organisation? • does the worker only take leave or re-arrange their hours of work when they have your permission? • does the organisation provide payment to them while they are on holidays? • does the organisation deduct income tax from the payments made to them? • do you pay the worker on submission of an invoice with gst payable? • how does the organisation delegate work? there is no one factor that classifies a worker as a contractor. describing the relationship as a contractor relationship or having the employee provide an abn does not automatically mean the worker can be classified as an independent contractor, even if a written contract is present. for a more in-depth analysis of your specific circumstances speak to your solicitor or accountant. employees are protected under the fair work act and state legislation from being incorrectly deemed a contractor. under the fair work act an employer cannot: • disguise an employment relationship as an independent contracting arrangement • dismiss or threaten to dismiss an employee to re-engage them as a contractor • knowingly make a false statement to persuade or influence an employee to become an independent contractor. fair work australia inspectors may take an employer to court if they find the employer is breaching the act and penalties of up to $ , can be imposed. if a contractor is found to be an employee, then the employer, could also be liable for unpaid wages and leave entitlements. there is even the potential for the australian tax office to investigate for unpaid income tax and unpaid superannuation entitlements. employers should undertake a review of the independent contractor arrangements in their business and consider the validity of their arrangements. in particular, each contract must be examined to ensure that the correct classification (contractor or employee) has been used. if in doubt, seek the advice of specialists such as an accountant, insurer and a solicitor. for more information and assistance, call the ava members hr advisory service on or email us at avahrhotline@ whr.com.au between . am and pm aest. ava members practical advice for employees and employers from experts who know the needs of veterinarians answers cover human resource management and industrial relations questions i think it is important to clarify that intensive 'factory' farming was introduced in western society to increase economic efficiencies in farming, not in order to reduce the risk of human starvation. intensive farming may result in more available and cheaper meat for an already overfed western population, but it does not increase the total amount of food available globally for human consumption. in fact, studies suggest the opposite is true. intensive farming is sometimes called 'a protein factory in reverse' , because large amounts of protein and energy in the form of grain or soybeans are channeled through animals, ending up with a much smaller output of protein and energy. for instance it takes up to kgs of grain to produce kg of beef, kgs of grain to produce kg of pork, chickens are less inefficient but even so the grain-to-meat conversion is about to . the entire process is an inefficient way of feeding humans (it would be far more efficient to use the croplands to grow protein crops for humans to eat). and, rather than contributing to feeding the world, intensive farming is contributing to inflating grain prices so that grain is less affordable for the poorer nations. intensive farming also places greater demands on the environment in terms of energy and water than other forms of farming, in addition to the recognised animal welfare issues. i do agree with mark that there are lots of positive things happening on the animal welfare front and it is great to see increased veterinary involvement and interest in this area. as veterinarians i think animal welfare should be our foremost concern, and we should also be aware of the broader issues of food production, population and the environment. fresh opportunity for struggling regional communities an enormous new opportunity is being presented to rural and regional australia, one which will bring enthusiastic young professionals into many struggling communities. the brolga project places final-year university students into shortterm work experience positions with rural and regional host agencies, businesses, government departments and non-profit organisations. it's about building regional opportunities, leveraging from graduates in australia (brolga), with the goal of the project to provide an opportunity for the urban-orientated students to try life 'in the country' for a short period of time -work experienceas part of their studies. hopefully many will enjoy the experience enough to return to the regional or rural community when they've completed their degree. with a presence in a dozen universities from south australia to north queensland, up to five students a day are expressing a willingness to participate. with such strong student response, a s we've previously reported, the ava formed a taskforce of veterinarians to develop a submission for the australian industrial relations commission (airc) about the affect the award modernisation process would have on the veterinary profession. our initial advice was that as the profession was so small that we would probably lose any awards that applied directly to our profession. we invited input from members and found that both members and the taskforce were overwhelming in favour of fighting for a stand alone veterinary practice award.. the ava has been in negotiations with the various unions, employer groups and the veterinary nurses council of australia (vnca) to ensure the best outcomes for the profession. we are excited to report that the airc now has recognised a category called 'animal care and veterinary services' . at present this category includes the veterinary surgeons award, all the state veterinary nursing awards, the zookeeper awards and the institutional animal welfare awards. the ava was recently represented at a hearing by the airc in melbourne where we were able to discuss the possible structure of the award with the commission. representation was also put by the unions, vnca and employer groups. the commissioner seemed very interested in the ava's point of view on the new modern award being developed. the commission will now draft an 'exposure' award that we will be able review and put forward further submissions if necessary. for more information please contact avpma@ava.com.au. ethics of what we eat libby lynch, winner of the acv rural practice scholarshipyoung members at the outback spectacular event prior anderson. all journals are normally despatched direct from the country in which they are printed by surface air-lifted delivery. journal compi-lation© australian veterinary association. all rights reserved. no part of this publication may be reproduced, stored or transmitted in any form or by any means without the prior permission in writing from the copyright holder. this consent does not extend to other kinds of copying such as copying for general distribution, for advertising or promotional purposes, for creating new collective works or for resale. authorisation to photocopy items for internal and personal use is granted by the copyright holder for libraries and other users registered with their local reproduction rights organisation (rro), eg. the publisher, the australian veterinary association and editors cannot be held responsible for errors or any consequences arising from the use of information contained in this journal; the views and opinions expressed do not necessarily reflect those of the publisher, the australian veterinary association and editors, neither does the publication of advertisements constitute any endorsement by the publisher, the australian veterinary association and editors of the products advertised. submission of photographs for publication will be held to imply that permission for publication has been obtained from the photographer and from the subject(s) of the image.avj.pi.jan trademarks ava and the ava logo are registered trademarks of the australian veterinary association limited.project managers are looking for more host agencies to offer student placements.placements may be as short as a week of unpaid experience, or as long as four months paid, each placement is unique and is negotiated via internet teleconference after an initial introduction.it is a st century solution to the age-old problem of rural drift.there is enormous scope within the project, for example an organic produce group could use a marketing student to help promote their product, nonprofit organisations could use an it student to streamline online programs, and family businesses like accountants and lawyers can tap straight into a pool of potentially hundreds of employees.host agencies interested in finding out more about the project are encouraged to contact the office or complete an online expression of interest, available at www.brolgaproject.com.au and project management will get back in contact. manager the brolga project dear editor, tom hart in his letter to avj vol no made some very valid points that were apparent in western australia several years ago including the fact that that some recent graduates were unable to perform recovery surgery on patients in practice. they were in fact learning their craft on paying clients animals.the western australian solution was to develop relationships with various animal welfare organisations who consented to supply patients for sterilisation operations. murdoch university veterinary students now have access to live cats and dogs on which they learn asceptic surgery using the ochidectomy and ovarohysterectomy as the surgical model.the program is now in its fourth year and builds through the fourth and fifth years of the course. there is a maximum of seven, three person groups, operating at the one time in the fourth year with one surgeon, one assistant and one anaesthetist in each group. these groups are supervised by at least two experienced veterinary surgeons, two veterinary nurses and one specialist anaesthetist.the feedback being received is very positive from all parties. it is saving the welfare organisations money, patients get the best care and treatment, the students learn from a real life situation and veterinary clients are not having to pay for recent graduates to learn on their beloved pets.i would commend the program to all veterinary schools and welfare organisations in other states. life member north fremantle western australia key: cord- -s kqfz a authors: tribe, john title: recreation, leisure and tourism organizations date: - - journal: the economics of recreation, leisure and tourism doi: . /b - - - - . -x sha: doc_id: cord_uid: s kqfz a nan public-sector organizations are those owned by the government. this can be national government or local government. leisure and tourism provision in the local government sector may include: it should be noted that sometimes services are free, sometimes they are subsidized and sometimes they are provided at full commercial rates. for example, charges for swimming pools are often subsidized but sometimes cover the full cost of provision. on the other hand, in order to analyse and understand the behaviour of organizations in the recreation, leisure and tourism sector, we need to be able to clarify their aims and objectives. an important initial question is whether the organization is in the private sector or government-run. for most private-sector organizations such as the walt disney corporation, profits are the main objective. on the other hand, tourism concern is a not-for-profit organization and exists to encourage ethical and sustainable tourism. organizations run by government were traditionally set up to provide services such as parks, museums and swimming pools that were desirable but not commercially profitable. but attitudes to the extent of government provision and use of subsidies vary across countries according to which party holds political power. by studying this chapter students should be able to: l distinguish between private-and public-sector organizations; l understand the differences in finance, control, structure and objectives of organizations; l understand ways in which capital can be raised; l analyse movements in share prices; l analyse the effects of different organizational structures on organizational behaviour. organizations and markets facilities such as parks, libraries and children's playgrounds are generally provided without charge. the finance of these organizations comes from: in essence, local government organizations are owned by the local population. policy decisions or decisions of strategic management are taken on their behalf by the local council. each local government area elects councillors or members to represent them. the political party which holds the majority of seats on the council will generally be able to dictate policy and such policy will be determined through a series of committees such as: the planning and resources committee is a particularly powerful one as it determines the medium-to long-term strategy of the council and thus provides the financial framework within which the other committees must operate. the day-to-day or operational management of local government-run services depends on the nature of the service being provided. council employees are responsible for overall management and services which are spread out across a local government area, such as parks, will be run from the council offices. larger services such as leisure centres will have their own management which in turn will be responsible to a service director at the council offices. the aims of local government and its organizations are largely determined by the political party or coalition of parties who hold the majority. this often means that leisure provision, for example, will vary between neighbouring local authorities which have different political parties in power. administrations to the right of the political spectrum favour lower local taxes and market-driven provision. those to the left favour public provision financed out of tax revenues and offered free or at subsidized prices. to determine the differing aims of political parties we need to consult their manifestos as well as review their actual provision. however, political parties do not operate in a vacuum. they will be influenced by: l pressure groups l trade unions l local press l national government. edgecombe ( ) examined a major dilemma facing local government leisure facility managers in australia -that of providing recreation services, whilst at the same time minimizing financial deficits and avoiding significant negative impacts on private enterprises providing similar services. national government-owned organizations can be further subdivided into public corporations, government departments and other government agencies. public corporations are sometimes known as nationalized or state-run industries. they generally supply goods or services to the public. examples of these include: but the extent of nationalization of recreation, leisure and tourism industries depends on the politics of individual countries. so in the usa, most television stations and airlines are in the private sector, and in the uk, railways are run by private-sector organizations. government departments perform an executive role on behalf of governments in implementing policy. there are a number of government departments which impinge on the recreation leisure and tourism sector of the economy. examples include: organizations and markets and tourism sectors. it also develops and delivers policies to increase australia's international competitiveness, consistent with the principles of environmental responsibility and sustainable development. other government agencies tend to work at a smaller level than government departments and provide more specific services. examples include: l tourism australia l visit britain. the aims of nationalized industries vary from country to country. in some cases, public corporations aim for public service provision without the limitations imposed by the profit motive and are able to provide services that are loss making. in these instances, the rigours of efficiency and private-sector management styles may not be apparent. in other parts of the world (notably in the uk and in the usa) public corporations have been subjected to efficiency targets, performance indicators and target rates of return on investment, all of which have made them more closely mimic private-sector organizations. nationalized industry's aims are generally contained within their charters or constitutions. the aim of government departments is to carry out the policy of the government of the day and includes planning, monitoring and reviewing of provision and legislation. exhibit . illustrates the aims of the government department of resources, energy and tourism in australia. this department covers the three areas of energy, resources and tourism. from the exhibit it can be seen that this department, as with other similar departments worldwide, is to provide both policy advice and implement programme-delivery services. sometimes air india, originally known as tata airlines, started life with two planes, one palm-thatched shed, one full-time pilot, one part-time engineer and two apprentice-mechanics. in its first full year of operations ( ), it flew , miles, carrying passengers and . tonnes of mail. tata airlines was converted into a public company and renamed air india in august . however, by the early s the financial condition of airlines operating in india had deteriorated so that the government made the decision to nationalize the air transport industry. on august , indian airlines was formed with the merger of eight domestic airlines to operate domestic services and air india international was established to operate the overseas services. leisure, tourism and recreation fall under the same government department, but sometimes as in this case they are separated. the aims of other government agencies are specific to each organization and are generally targeted to a quite narrow field. this department covers the following areas: l resources l energy l tourism. we enhance australia's economic prosperity by improving productivity, competitiveness, security and sustainability of the resources, energy and tourism sectors through the provision of high-quality policy advice and programme-delivery services for the australian government. minister: we are responsive to our minister in delivering apolitical, honest and frank policy advice and in implementing the government's policies and programmes. we focus on achieving constructive and collaborative relationships with our stakeholders including portfolio agency partners and other government departments, underpinned by genuine consultation, feedback and robust service delivery. policy: we provide high-quality evidence-based advice, through informed judgement and prudent risk management. people: we encourage a positive workplace and display high levels of personal leadership and integrity. we are results focussed and continuously strive to learn and innovate. resources: the australian government is committed to creating a policy framework to expand australia's resource base, increase the international competitiveness of our resources sector and improve the regulatory regime, consistent with the principles of environmental responsibility and sustainable development. energy: the australian government is committed to the provision of adequate, reliable and affordable energy to meet future energy consumption needs and to underpin strong economic growth, consistent with the principles of environmental responsibility and sustainable development. tourism: the australian government is committed to maximizing tourism's net economic contribution to the australian economy and to fostering an industry that promotes the principles of environmental responsibility and sustainable development. organizations and markets national government organizations in the public sector are financed in the main from: l taxes l trading income. the dependence on tax funding can mean that public-sector organizations are very sensitive to the changing priorities of the government of the day. equally if the state of the economy as a whole is unhealthy, spending cuts will generally be imposed through the public sector. national government organizations are owned by the government on behalf of the population at large. however, each type of organization is controlled in a different way. l nationalized industries are typically given some autonomy and generally have a legal identity separate from the government. at the point of nationalization a law is passed outlining the aims, organization and control mechanism for each industry. a typical structure is one where a board of directors is established responsible for the day-to-day running of the industry. the chair of the board and its other members are appointed by an appropriate government minister and strategic decisions will be taken by the minister in consultation with the government. l government departments are headed by a minister and staffed by government employees. their actions are directly accountable through a minister to the national assembly such as parliament. the offices of government departments are generally located close to the national assembly. the degree of political control exerted over government departments is thus more direct than for nationalized industries. private-sector organizations are those which are non-governmentowned. they can be further subdivided into profit-making organizations and non-profit-making organizations. profit-making private-sector organizations consist of those with unlimited liability, those with limited liability and companies which are quoted on the stock exchange. unlimited liability means that the owners of such companies face no limit to their contribution should the organization become indebted. most of their personal assets can be used to settle debts should the business cease trading. this includes not only the value of anything saleable from the business, but also housing, cars, furniture and stereos. because of the discipline that unlimited liability brings, there are often very few formalities required to start trading as this form of business. sole proprietorships and partnerships are examples of this type of business organization and advantages include: in contrast, the formation of a limited liability company enables its owners to create a separate legal identity and this enables them to limit their exposure and liability in the case of company failure. incorporation confers separate legal identity on the company. this may be contrasted with the position of unlimited liability organizations where the owners and the organization are legally the same. limited liability places a limit to the contribution by an investor in an organization to the amount of capital that has been contributed. should one of these organizations cease trading with debts, an investor may well lose the original investment, but liability would cease there and personal assets would not be at risk. the benefits of the limited liability company mean that they are bound by closer rules and regulations than are unlimited liability organizations. typically such companies need to provide details of: limited liability companies are further subdivided into private companies and public companies. it is the latter's shares which are freely tradable on the stock exchange. there are benefits and drawbacks of moving from a private limited company to a public limited company. ability to raise more capital is a key advantage of becoming a public limited company as the stock exchange provides access to thousands of potential investors. on the other hand, there are considerable extra costs associated with flotation. these include the costs of bringing a company to the market as well as the costs of reporting and more burdensome governance requirements. also there is a constant need to perform and produce high profits in the short term as a public limited company, and the risk of loss of control. the free access to share ownership and lack of control on transfer of shares mean that it is more difficult to retain control of public than private limited companies as groups of shareholders can build up controlling interests. exhibit . provides an illustration of a company flotation in the travel industry. amadeus, a leading travel it company, was refloated on the madrid stock exchange in meaning its shares were made available to the public and that the owners of the company were able to raise a large amount of capital. amadeus, the spanish travel reservations firm, has achieved a position as a leading transaction processor for the global travel and tourism industry. it provides transaction processing to both travel providers (including airlines, hotels, railways, cruise lines, ferries, car rental companies and tour operators) and travel agencies. amadeus' distribution and it systems cover itinerary planning, fare-searching, reservations, ticketing, airlines schedule and inventory control, passenger check-in and departure control. it earned a . billion in revenues in . the company which was originally listed on the madrid stock exchange was delisted in when bc partners and cinven bought their stake from airlines air france, lufthansa and iberia for a . billion. this effectively meant that the company was taken into the ownership format of a private limited company. however, amadeus returned to the spanish stock exchange in to become one of europe's largest flotations in that year. according to the prospectus lodged with stock market regulator comisión nacional del mercado de valores (cnmv), amadeus offered . million shares in a primary offering and . million existing shares to institutional investors. this share offer represented about per cent of the firm. the price range expected for the listing was estimated at between a . and a . per share. in the event it raised over a . billion in the listing which meant it had a market capitalization of around. a . billion. on the day of the flotation the share price rose by . per cent by midday to reach a figure of a . . exhibit . examines the case of the qantas group -the major national and international airline operating in australia. as the exhibit explains qantas was formerly a nationalized industry run by qantas is australia's largest domestic and international airline. it employs around , staff and serves destinations in countries (including those covered by its codeshare partners) in australia, asia and the pacific, the americas, europe and africa. the qantas group's main brands are: the qantas group's long-term vision is to operate the world's best premium airline, qantas, and the world's best low-fares carrier, jetstar. qantas is a public limited company listed on the australian stock exchange. however, qantas was at one stage a nationalized industry owned by the australian government. but in the s, the government moved to privatize the airline. a public share offer was launched on june . the privatization was completed and qantas shares listed on the australian stock exchange on july with a float price of aus$ . . since then key variations in its share price have included: organizations and markets the australian government and this was the case for many airlines. government ownership meant that the airline was funded mainly from taxes. some governments still maintain ownership of national airlines since it is believed that they play a strategic role in the economy. additionally, airlines need to make very large capital purchases and these can be difficult to finance in the private sector. however, nationalization often means that competition and enterprise are stifled resulting in a poorer service for air travellers. also as air travel is still something of a luxury it is argued that the state should not sub sidize this sector out of taxes. finally, state-run industries can be run on bureaucratic lines meaning that they are inefficient and inflexible. since these sources generally are only available to supply limited funds, this is a key reason why small firms remain small. on the other hand limited liability, incorporated firms are able to raise capital through the additional routes of: l shares (equity) l debentures. a share, or equity or stock (usa), represents a small portion of ownership of a company that is sold. the company issues shares certificates in return for capital. the price of shares goes up and down according to relative demand and supply in the market place -in this case a stock exchange. shares can be seen from the perspective of a shareholder and of a company. from the company's point of view, share capital is generally of low risk since if the company does not make any profits then no dividends are paid. so unlike with bank loans a company is not saddled with the need to make payments if it is going through an unprofitable period. shareholders are attracted to shares by the prospect of dividend payments (related to the level of company profits) as well as growth in the capital value of shares. of course, there is some risk as there is no guarantee of dividend payments and the value of shares can go down as well as up, indeed the value of shares in failing companies will often become worthless. debentures can be seen as a form of loan as they carry a fixed rate of interest. thus to the company they pose a problem when profits are low because they still have to pay out the fixed interest, but their fixed interest rate is attractive when profits are high as the company will retain more of its profits. debenture holders get a guaranteed rate of return and are paid before shareholders so they are generally less risky than shares. on the other hand, there is no opportunity to benefit from higher dividends when a company is growing and making good profits. table . illustrates many of the aspects of financing mentioned earlier through the case of eurotunnel. eurotunnel is the name given to the rail tunnel that was built between england and france in the s. of course, a massive amount of capital was required to finance this project. several points emerge from table . which illustrates the financing of eurotunnel. first, eurotunnel's capital represents a mixture of loans from banks which carry interest payments until they are repaid, and share issues which will not pay dividends until profits are earned. if profits from the tunnel are insufficient to repay loans and interest, the company may be forced into liquidation by the banks. the assets of the company would then be sold to repay the banks. under this scenario, shareholders would get nothing. this is because shareholders are assigned a lower priority than loan providers. however, because their liability is limited, neither would they stand to lose any personal assets, just the value of their shares. under a more optimistic, high-profit scenario, payments to the banks are limited to previously negotiated rates, leaving substantial profits to be distributed in the form of high dividends to shareholders. second, three different forms of share issue are illustrated by this case: l a placing in : this is where eurotunnel's shares were placed directly with institutions such as pension funds and insurance companies. this represents a direct negotiation between the merchant bank selling the shares and the target groups they wish to sell to. organizations and markets l an offer for sale in : this is where shares are advertised and offered to the public. this is a more open and competitive market, but there is a risk that not all the offer will be taken up or that the price offered will be lower than anticipated. l a rights issue in and : this is where existing shareholders are able to buy new shares at a discount. their right to buy new shares is related to the size of their existing shareholding. finally, the underwriting of share issues means that insurance has been taken out against the eventuality of shares remaining unsold. should this be the case the underwriting firm would purchase the unsold shares at a pre-agreed price. shares which are sold on the stock market are second-hand shares and thus their purchase does not provide new capital to companies. prices of shares are determined by supply and demand. the stock market approximates to a perfect market (see chapter ) and thus prices are constantly changing to bring supply and demand into equilibrium. the demand for and the supply of shares depend upon the following: the main aim for organizations in the private sector is generally to maximize profits. for example, exhibit . illustrates the objectives of 'the walt disney company' where it can be seen that maximizing long-term shareholder value is a prime concern. the private sector consists of both small-and medium-sized enterprises (smes) and large corporations. these have previously been classified as sole proprietors and partnerships and limited liability corporations. understanding small-business organizations is straightforward. the owner is the manager and this can act as a strong incentive to maximize profits. however, it may also mean that profit maximization is subject to personal considerations such as environmental concerns or hours worked. indeed, the term 'lifestyle entrepreneur' has been used to describe small-business owners who construct a business around a hobby that enables them to earn an income whilst pursuing their interest. for corporations, size of operations and number of shareholders make the picture more complex. companies are run along standard lines: the managing director is responsible for directing managers in the day-to-day running of the organization. the board of directors is responsible for determining company policy and for reporting annually to the shareholders. this can lead to a division between ownership (shareholders) and control (managers) and a potential conflict of interests. shareholders generally wish to see their dividends and capital gains, and thus company profits, maximized. managers will generally have this as an important objective since they are ultimately answerable to shareholders. however, they may seek other the walt disney company, together with its subsidiaries and affiliates, is a leading diversified international family entertainment and media enterprise with four business segments: media networks parks and resorts studio entertainment and consumer products. the walt disney company's objectives is to be one of the world's leading producers and providers of entertainment and information, using its portfolio of brands to differentiate its content, services and consumer products. the company's primary financial goals are to maximize earnings and cash flow, and to allocate capital toward growth initiatives that will drive long-term shareholder value. organizations and markets objectives -in particular, maximizing personal benefit -which may include kudos from concluding deals, good pension prospects and a variety of perks such as foreign travel, well-appointed offices and high-specification company cars. non-profit organizations in the private sector vary considerably in size and in purpose. they span national organizations with large turnovers, smaller special interest groups, professional associations and local clubs and societies, and include: l the national trust (uk): this is a charity trust and independent from the government. it derives its funds from membership subscriptions, legacies and gifts, and trading income from entrance fees, shops and restaurants. it is governed by an act of parliament -the national trust act . its main aim is to safeguard places of historic interest and natural beauty. l surf life saving australia (slsa): this is australia's major water safety and rescue authority and one of the largest volunteer organizations in the world. their mission is 'to provide a safe beach and aquatic environment throughout australia'. slsa provides lifesaving patrol services on most of australia's populated beaches in the swimming season. l indigenous tourism rights international (usa): this is an indigenous peoples' organization collaborating with indigenous communities and networks to protect their territories, rights and cultures. their mission is to exchange experiences in order to understand, challenge and take control of the ways in which tourism affects our lives. l tourism concern (uk): the vision of tourism concern is 'a world free from exploitation in which all parties involved in tourism benefit equally and in which relationships between industry, tourists and host communities are based on trust and respect'. tourism concern's mission is to ensure that tourism always benefits local people. tourism concern works with communities in destination countries to reduce social and environmental problems connected to tourism and with the outgoing tourism industry in the uk to find ways of improving tourism so that local benefits are increased. the aims and missions of voluntary groups are generally not profit driven. they include protection of special interests, promotion of ideas and ideals, regulation of sports and the provision of goods and services which are not catered for by the free market. andersson and getz ( ) offered a helpful examination of the differences between private, public and not-for-profit concepts with using festivals as their context. plate shows tourists (including the author on the right of the photo) at the david sheldrick wildlife trusts' orphans' project in nairobi, kenya. this is a charity organization which depends entirely on donations. it has the specific aim of rehabilitating orphaned elephants. identify the different aspects of the mission agenda that are evident for each of the above organizations using figure . , and discuss these differences. which aspects of the mission agenda are most likely to be found for (a) a private sector corporation (b) a not-for-profit organization (c) a local government organization. why is it important for economists to identify organizational type if they are to understand the pricing policy of recreation, leisure and tourism organizations? this was the beginning of the virgin empire which demonstrated its maturity when branson floated the company on the london stock exchange. however, in his autobiography, 'losing my virginity', branson explains why he changed his mind about the benefits of being a public company so that the company's management executed a management buyout to take virgin private again. he particularly pointed to the 'onerous obligations' which included the duty of appointing and working with outside directors. he also felt that he had lost the ability to make quick decisions: 'our business was not one that could be boxed into a rigid timetable of meetings. we had to make decisions quickly, off-the-cuff: if we had to wait weeks for the next board meeting before authorizing simon to sign ub , then we would probably lose them altogether'. branson found the british tradition of paying a large dividend difficult to fit with his business philosophy which was to reinvest profits to increase the company's value and stated that the one year when virgin was quoted on the stock exchange was the company's least creative year because the executives were taken away from management and strategy by the need to explain their business to fund managers and financial advisers. virgin launched its low-cost carrier virgin blue in australia in . from that year to the end of march the airline had made a pretax profit of aus$ million on revenues of aus$ million and it is expected to report profits of about aus$ million for - . its owner richard branson has announced plans to float the company on the stock market by christmas . virgin blue was originally expected to come to the market in summer but a listing was postponed because of the adverse effects on the aviation sector from the impact of the severe acute respiratory syndrome (sars) outbreak and the war in iraq. the float valued the group at around aus$ billion (£ million). the airline raised about aus$ million from the flotation on the australian stock exchange. one of the principal reasons for the strategy is to give the company enough cash to expand internationally without having to obtain the money from existing shareholders. the airline wanted to use the cash raised to help fund its plans to launch a lowcost airline in the usa and virgin blue was also planning new routes to new zealand, papua new guinea and the polynesian islands. the group was also looking at speeding up the expansion of its virgin mobile operations in the usa. commenting on the float, grant williams of brokerage firm reynolds & co said, 'there seems to be a strong interest in virgin blue's float but this is not a lot of money and there won't be much around for the retail market'. a virgin spokesman said the money from virgin blue could be used to increase the virgin group's 'war chest'. plans for a low-cost carrier in the usa are described as 'quite advanced'. launched in august with initial funding of $ million, virgin america is one of the best funded start-up airlines in history according to the wall street journal. virgin america positioned itself as a new, california-based airline. its competitive edge is honed around a package that includes brand new planes, attractive fares, service excellence, in-flight internet, mood-lit cabins, leather seats and on-demand menus. the virgin group has grown to become a leading global company operating in businesses in sectors ranging from mobile telephony to transportation, travel, financial services, media, music and fitness. it has created more than branded companies worldwide, employing approximately , people, in countries. global branded revenues in exceeded £ . billion (approximately us$ billion). its portfolio includes: (a) a firm can be sued for damages. (b) a firm's owner is liable for all of its debts. they find that the solution is to set up their own business. this desire for quality of life merged with running a business means that lifestyle enterprises can allow for flexible hours, or a favoured location, or the specializing is certain products or services (often developing out of a passionate interest or hobby) or a particular stance with regard to ethical practices. examples of such businesses include small accommodation providers, yoga retreats, specialized restaurants and organizers of leisure pursuits. ateljevic and doorne noted that the long-term survival of lifestyle entrepreneurs in tourism has been cited as a possible constraint on regional economic development. their research is based on a cohort of lifestyle entrepreneurs in the new zealand tourism sector. they focus on the values that motivate lifestyle entrepreneurs finding that typically the conscious rejection of economic and business growth opportunities is an expression of a specific, personal sociopolitical ideology. the authors found that this rejection of profit as an over-riding motive does not necessarily result in financial difficulties or a stagnation in the development of the business. rather new opportunities are created to engage with niche consumers who portray common values. their research also concluded that lifestyle entrepreneurs can be associated with the creation of innovative services and products and that this business format can make an important contribution to sustainability, the developing of a sense of place and community and be a point of stimulation for regional development. recap questions what particular issues of expansion and growth are pertinent to lifestyle enterprises? how do aims, mission, ownership and control differ between lifestyle enterprises and profit-maximizing businesses? what factors are likely to influence the business decisions of lifestyle entrepreneurs? why would lifestyle entrepreneurs be unlikely to float their business on the stock exchange? locate, read and critique this article. british tourist authority: www.visitbritain.com department for culture, media and sport: www.culture.gov.uk department of resources, energy and tourism: www.ret.gov.au department of the interior surf life saving australia: www the british broadcasting corporation: www.bbc.co.uk the national trust: www (d) a firm may be sued for libel. tourism concern is:(a) a non-profit-making organization.(b) a local government organization.(c) a nationalized industry.(d) quoted on the stock exchange. which of the following is a valid reason for holding shares:(a) a chance to benefit from a company's profit. key: cord- -yuh rwkt authors: burgner, david; richmond, peter title: the burden of pneumonia in children: an australian perspective date: - - journal: paediatr respir rev doi: . /j.prrv. . . sha: doc_id: cord_uid: yuh rwkt the burden of pneumonia in australian children is significant with an incidence of – per person-years. pneumonia is a major cause of hospital admission in children less than years of age. indigenous children are at particular risk with a – -fold higher risk of hospitalisation compared to non-indigenous children. they also have longer admissions and are more likely to have multiple admissions with pneumonia. there are limited data on pathogen-specific causes of pneumonia, however streptococcus pneumonia is the most common bacterial cause in children under years of age and respiratory syncytial virus (rsv) and influenza are the predominant viral causes in young children. pneumonia due to haemophilus influenza type b (hib) has been virtually eliminated by the introduction of universal hib immunisation. further studies are needed to accurately define the epidemiology of pneumonia due to specific pathogens to help target treatment and immunisation strategies. the burden of respiratory and other infections in australian children reflects the demography of the population, the variations in climate, patterns of migration and the proximity of countries from which less common pathogens may be imported. australia is relatively unique amongst developed industrialised nations: it is comparatively sparsely populated, with the majority of the population concentrated around the southern and eastern seaboard. the total australian population is approximately . million, predominantly urban and the majority descended from the european migration in the last years. indigenous australians (aboriginal australians and torres strait islanders) have inhabited the continent for at least years and comprise . % of the total population. the majority of indigenous australians live in deprived socio-economic circumstances, often in remote rural locations. indigenous australians have some of the worst health indicators in the industrialised world. they bear a disproportionate burden of infectious diseases in childhood -and pneumonia is no exception. australia has a large migrant population with over . million individuals born overseas, equivalent to almost one quarter of the population. the majority of migrants are from other industrialised nations and the epidemiology of infectious diseases in these migrants is likely to be similar to that in non-indigenous australians. in addition, australia currently accepts refugees under a humanitarian program and many more from refugee-like backgrounds under family reunification programs. the epidemiology of respiratory infections in this population is related to the country of origin or transit, paediatric respiratory reviews ( ) summary the burden of pneumonia in australian children is significant with an incidence of - per person-years. pneumonia is a major cause of hospital admission in children less than years of age. indigenous children are at particular risk with a - -fold higher risk of hospitalisation compared to non-indigenous children. they also have longer admissions and are more likely to have multiple admissions with pneumonia. there are limited data on pathogen-specific causes of pneumonia, however streptococcus pneumonia is the most common bacterial cause in children under years of age and respiratory syncytial virus (rsv) and influenza are the predominant viral causes in young children. pneumonia due to haemophilus influenza type b (hib) has been virtually eliminated by the introduction of universal hib immunisation. further studies are needed to accurately define the epidemiology of pneumonia due to specific pathogens to help target treatment and immunisation strategies. ß elsevier ltd. all rights reserved. previous limited access to adequate health care and the potentially poor vaccination coverage in refugee children. the climate of australia ranges from temperate in the south to large areas of desert in the interior and tropical conditions in the north. the epidemiology of childhood respiratory infections partly reflects these differences, with familiar pathogens occurring frequently throughout the country, but with high incidences of bacterial pneumonia amongst indigenous australians and less familiar pathogens, such as meliodosis, occurring in the northern territory. the close proximity to south-east asia has led to concern (to date largely unfulfilled) of the potential spread to australia of 'new' respiratory diseases, such as avian influenza and severe acute respiratory syndrome (sars). as in other industrialised nations, there has been a substantial decline in infectious disease mortality in australia throughout the twentieth century. in the mortality rate across all ages from all infectious diseases was . per population; years later it was . per . similar trends are evident in children and are attributed to improvements in sanitation, vaccination and the introduction of antibiotics. in communicable diseases accounted for % of the total disease burden in australia. however, in children infections contribute significantly more to the burden of childhood diseases, although there are no national data. respiratory infections have also declined substantially over the same time period. australia (particularly in western australia) has an impressive resource of linked health-related databases, which provide detailed data on the overall epidemiology of children hospitalised with pneumonia. clearly any data relating to the aetiology of pneumonia should be interpreted with a certain degree of caution, as the discharge diagnosis of pneumonia is usually made on clinical and/or radiological grounds, without microbiological confirmation of the aetiology. much of the australian epidemiological data spans a period where rapid diagnosis of respiratory viral pathogens was not available and diagnostic labels such as 'bronchitis' were more commonly applied than they are currently. however these studies provide useful insights into the overall burden of pneumonia in australian children. in a study of all western australian live births in , % of non-indigenous and % of indigenous children were admitted to hospital with a diagnosis of pneumonia in the first two years of life. of the indigenous children, % had repeated admissions with pneumonia. for all children, low or high birth weight, male sex and measures of social disadvantage (young or unmarried mothers or rural location) were significant risk factors for admission. between and in western australia, there were admissions to hospital with respiratory diseases in children aged up to years, of which ( . %) were for pneumonia (table ). pneumonia was second only to asthma as the most frequent admission diagnosis in children beyond one year of age. in indigenous children, the rate of pneumonia was - times higher than non-indigenous children (table ) . more recent and partially overlapping data from western australia have examined the burden of childhood pneumonia in the first two years of life in all children born between and (k. carville, d. lehmann, r. richmond, n. de klerk and d. burgner, unpublished results). in this cohort of singleton live births ( indigenous births, non-indigenous births), pneumonia accounted for hospital admissions, equivalent to . % of all admissions with an infectious diagnosis. almost half of admissions with pneumonia in the first two years of life were in indigenous children, in whom pneumonia accounted for . % of all infectious diagnoses. not only was pneumonia far more common in indigenous children ( fig. ), these children were three times more likely than non-indigenous children to have multiple admissions with this diagnosis. indigenous children with pneumonia also had a longer hospital stay than non-indigenous children, possibly reflecting more severe disease and logistic difficulties with returning families to their remote locations. a retrospective study from suburban sydney assessed the incidence and risk factors for all-cause pneumonia in in this predominantly non-indigenous population the estimated incidence of pneumonia was . per personyears. this is comparable to the rate of . per person-years reported in non-indigenous children of the same age in western australia. in the former study over % of children received antibiotic therapy and % were hospitalised. there appeared to be an association with a preceding diagnosis of asthma and increased risk of pneumonia. with some notable exceptions, there is a lack of data on the epidemiology of pneumonia due to specific pathogens in australian children. however, given the ethnic make-up of the australian population, the climate and clinical experience, cautious generalisation of data from other countries is possible. there is increasing awareness that mixed infections, with more than one pathogen, may be important in the aetiology of childhood pneumonia, although this has not been investigated in australia. as in other industrialised countries, group b streptococcus (gbs) is the leading cause of early-onset neonatal infection. pneumonia is the principal clinical manifestation, in contrast to late-onset gbs infection, when meningitis predominates. the incidence of early-onset gbs infection has fallen from per live births in non-indigenous australians in - , to . per in - . the burden of early-onset gbs disease in indigenous neonates was - times higher and also showed a similar decline. the fall in the incidence of gbs is due to the increasing introduction of universal screening late in the third trimester and widespread antibiotic prophylaxis, in accordance with international guidelines. interestingly, although only % of neonatal gbs occurs in preterm infants, they carry about % of the mortality and will not benefit from the screening that occurs in the last few weeks of the third trimester. the pneumococcus is recognised as the most common bacterial cause of community-acquired pneumonia in children, responsible for approximately one third of cases. , exact estimates of the burden of disease are hampered by lack of sensitive and specific diagnostic methods in children who have negative blood cultures. the highest incidence of pneumococcal pneumonia is common in children under years of age although a significant proportion of cases occur in older children. in australia, the majority of data relates to pneumococcal pneumonia with bacteraemia in children from the national enhanced invasive pneumococcal disease (ipd) surveillance program. introduction of pneumococcal conjugate vaccine (pcv) was . per population, representing % of cases of ipd in this age group. the proportion of ipd associated with pneumonia in indigenous children was much higher ( %) compared to non-indigenous children ( %). the overall incidence of bpp in indigenous children was approximately -fold higher than in non-indigenous children under years of age. the serotypes responsible for ipd were more varied in indigenous children, with approximately % being due to the seven serotypes in the licensed pneumococcal conjugate vaccine (prevnar tm ) compared to % in non-indigenous children under years of age. bpp figures clearly underestimate the true burden of pneumococcal pneumonia. in undertaking a cost-effectiveness analysis of pcv in australian children, butler and colleagues estimated the incidence of moderate or severe pneumococcal pneumonia to be per persons in children under years. vaccine efficacy studies also provide an estimate of the burden of disease. in the pcv efficacy study in northern california, the incidence of chest x-ray proven pneumonia was reduced by . % ( % confidence interval (ci) = . - . %) in the intention to treat analysis and a similar level of efficacy was seen in a study of -valent pcv in south africa ( % in hiv negative children). the impact of universal pcv in both indigenous and non-indigenous australian children is awaited with interest. the burden of pneumonia due to haemophilus influenzae in australia has not been well defined. the majority of data relates to bacteraemic pneumonia due to haemophilus influenzae type b (hib) in the prevaccination era. hib pneumonia represented - % of invasive hib disease in non-indigenous children in southeastern australia , but up to % of invasive hib disease in indigenous children from the northern territory. the age of onset of bacteraemic pneumonia was much earlier in indigenous children (majority < months of age). the epidemiology of bacteraemic hib pneumonia in indigenous children is similar to that in developing countries suggesting that hib was responsible for approximately % of severe pneumonia in indigenous children prior to hib vaccination. following the introduction of conjugate hib vaccines, the incidence of bacteraemic hib pneumonia has dramatically decreased in both populations. there are few specific australian data relating to the burden of m. pneumoniae respiratory infection in children. studies from european countries indicate that this pathogen may be responsible for almost one-third of childhood admissions with pneumonia in finland but is much less commonly identified in the uk and the usa. anecdotally m. pneumoniae is thought to be one of the commonest causes of pneumonia in school-age australian children and empiric macrolide antibiotics are widely used in this setting, but this is not evidence-based. interestingly, an australian study suggested that asymptomatic carriage of m. pneumoniae is widespread in children admitted to hospital with non-pneumonic diagnoses, although whether there is significant nosocomial transmission is unknown. similarly, there are no specific studies of c. pneumoniae in australian children. european data suggest this pathogen may be an important cause of pneumonia, especially in children > years. a small study of pneumonia in both adults and children from northern australia failed to identify c. pneumoniae. it is likely that this pathogen is underestimated as a cause of pneumonia in australian children. this is an important cause of severe pneumonia, particularly in indigenous children. in one study, from western australia, cases were admitted over a year period, with a decreasing but significant mortality over the study period. there is an increasing prevalence of methicillin-resistant s. aureus (mrsa: both 'local' strains and 'imported' multiresistant strains), particularly in indigenous children, , which has clear implications for antibiotic therapy for this pathogen. although tuberculosis (tb) is the world's most prevalent infectious disease, australia has continued to have one of the world's lowest rates. the majority of tb disease occurs in migrants and less commonly in indigenous australians and is predominantly a disease of the aged. tb is reported in few australian children but this is likely to represent a gross under-estimate, given the extreme difficulties in confirming the diagnosis microbiologically in paediatric patients. the prevalence of latent tb, as measured by positive mantoux reactivity, is high, especially in migrants from countries where tb is endemic. in a study of - year-old sydney children, % of the australianborn and % of the overseas-born children had a positive mantoux test. the risk of developing tb disease following latent infection may be extremely high in early childhood and remains significant through later childhood and adulthood. active identification of latent tb in recent migrants to australia, especially in children, although not universally performed, would seem prudent. , other bacterial pathogens this is a prevalent pathogen in indigenous children from northern australia, who have some of the highest rates of rheumatic fever in the world. , streptococcus pyogenes may, therefore, represent a more common cause of pneu-monia in this population than appreciated, although there are no epidemiological studies of its role in pneumonia. melioidosis is an important pathogen in south-east asia and northern australia. in the northern territory the incidence is . per population, increasing to . per in indigenous australians. it causes pneumonia and septicaemia, together with abscesses in a variety of organs, including the lungs. most infections occur in those with predisposing risk factors, such as diabetes, but it is reported in children from tropical northern australia. the epidemiology of the major paediatric respiratory viruses is generally similar in australian children to that observed in europe and the usa. in industrialised nations, respiratory syncytial virus (rsv) is the predominant cause of viral lower respiratory tract infection in infancy. studies , and clinical experience suggest that the same is true in australia. the primary pathology is bronchiolitis, rather than pneumonia. rsv infection is associated with considerable morbidity and mortality, especially in high-risk groups. the epidemiology of rsv appears to be related to meteorological conditions in australia and in neighbouring south-east asian countries. influenza is an important cause of lower respiratory tract infection in australian children, although precise data regarding the size of the problem are lacking. retrospective data suggest that the pattern of epidemics do not necessarily correlate closely with european and usa epidemiology. australia is part of the who global influenza surveillance network (flunet: http://rhone.b e.jussieu.fr/ flunet/www/), which tracks influenza activity from active reporting from sentinel general practices and publishes regular local and national updates. , a recent london study indicated that influenza a caused one-third of viral community-acquired pneumonia and % of all community-acquired pneumonia. an australian paediatric study suggested that influenza is also an important cause of hospital admission and morbidity and that influenza a affected younger children, whereas influenza b tended to affect those with underlying medical problems. 'new' viral infections -severe acute respiratory syndrome (sars) and avian influenza the proximity of australia to the epicentres of newly recognised viral infections (severe acute respiratory syn-drome (sars) and avian influenza), has created considerable concern that these infections may become major public health issues in australia. sars is a newly described coronavirus infection, with a high mortality rate. active sars surveillance has been undertaken in australia since . of the individuals in australia investigated during this period, had 'suspect' and 'probable' infection; five of the latter group were reported to the who as likely cases, after other diagnoses were excluded. none of these were children, but given the significant paediatric morbidity reported from neighbouring countries, there is the potential for sars becoming a significant paediatric infection in australia. avian influenza, a viral infection spread from infected birds and poultry, has caused significant morbidity and mortality in asian countries. to date no human cases have been reported in australia but there is considerable potential risk through migration and, to a lesser extent, through adoption of children from overseas. pneumonia is a common disease in australian children and a frequent cause of admission to hospital. whilst australian children suffer from a range of pathogens similar to those experienced by children in industrialised countries in the northern hemisphere, there are several important caveats. in tropical australia, unusual pathogens are encountered and there is the additional risk posed by imported respiratory infections from neighbouring countries. indigenous australians bear a hugely disproportionate burden of many diseases and have a much higher incidence of pneumonia compared to non-indigenous children. the introduction of conjugate hib vaccines decreased the burden of hib pneumonia in both indigenous and non-indigenous children highlighting the importance of vaccination in reducing the burden of pneumonia. the important issues in reducing the burden of pneumonia in australia relate to ( ) the impact of newly introduced vaccines, such as the conjugate pneumococcal vaccine, ( ) the development of novel vaccines and therapies, especially against common viral pathogens and ( ) understanding the causal pathways (and in particular the gene -environment interactions) that underlie the differential severity of essentially ubiquitous pathogens. australia has an impressive epidemiological infrastructure and surveillance networks that will be crucial in addressing these key questions. australian aboriginal child health an issue of access: delivering equitable health care for newly arrived refugee children in australia comprehensive health assessment for newly arrived refugee children in australia severe acute respiratory syndrome surveillance in australia trends in mortality rates for infectious and parasitic diseases in australia: - problems in determining the etiology of community-acquired childhood pneumonia hospital admissions for lower respiratory tract illness before the age of two years in western australia hospitalization of aboriginal and nonaboriginal patients for respiratory tract diseases in western australia, - mixed microbial aetiology of community-acquired pneumonia in children intrapartum antibiotics and early onset neonatal sepsis caused by group b streptococcus and by other organisms in australia, australasian study group for neonatal infections intrapartum antibiotics for group b streptococcal colonisation prevention of perinatal group b streptococcal disease. revised guidelines from cdc group b streptococci during pregnancy and infancy differentiation of bacterial and viral pneumonia in children etiology and treatment of community-acquired pneumonia in ambulatory children community-acquired pneumonia in children invasive pneumococcal disease in australia the cost-effectiveness of pneumococcal conjugate vaccination in australia efficacy, safety and immunogenicity of heptavalent pneumococcal conjugate vaccine in children. northern california kaiser permanente vaccine study center group a trial of a -valent pneumococcal conjugate vaccine in children with and those without hiv infection epidemiology of haemophilus influenzae type b disease in australia and new zealand clinical manifestations and outcome of haemophilus influenzae type b disease the epidemiology and prevention of haemophilus influenzae infections in australian aboriginal children the gambian haemophilus influenzae type b vaccine trial: what does it tell us about the burden of haemophilus influenzae type b disease? the decline of haemophilus influenzae type b disease in australia incidence of communityacquired pneumonia in children caused by mycoplasma pneumoniae: serological results of a prospective, population-based study in primary health care community acquired pneumonia--a prospective uk study a survey of nosocomial respiratory viral infections in a children's hospital: occult respiratory infection in patients admitted during an epidemic season chlamydia pneumoniae is an important cause of communityacquired pneumonia in school-aged children: serological results of a prospective, population-based study community acquired pneumonia in north eastern australia--a hospital based study of aboriginal and non-aboriginal patients primary staphylococcal pneumonia in childhood: a review of cases the continuing evolution of methicillin-resistant staphylococcus aureus in western australia emergence of community-acquired methicillin-resistant staphylococcus aureus (mrsa) infection in queensland tuberculosis in australia: bacteriologically confirmed cases and drug resistance tuberculosis notifications in australia diagnosis and treatment of tuberculosis in children the prevalence of tuberculosis infection among year schoolchildren in inner sydney in inconspicuous consumption: disseminated tuberculosis following untreated latent infection incidence of tuberculosis among a cohort of tuberculin-positive refugees in australia: reappraising the estimates of risk missed opportunities for prevention of tuberculosis in victoria multiple strains of streptococcus pyogenes in skin sores of aboriginal australians clinical and epidemiological features of group a streptococcal bacteraemia in a region with hyperendemic superficial streptococcal infection melioidosis in northern australia childhood infections in the tropical north of australia respiratory syncytial virus: a continuing culprit and conundrum clinical severity of respiratory syncytial virus group a and b infection in sydney respiratory syncytial virus: a report of a -year study at a children's hospital seasonal trends of viral respiratory tract infections in the tropics influenza epidemics in the united states, france, and australia, - the influenza surveillance program in western australia annual report of the national influenza surveillance scheme influenza a community-acquired pneumonia in east london infants and young children comparison of influenza a and influenza b virus infection in hospitalized children molecular epidemiology of the novel coronavirus that causes severe acute respiratory syndrome severe acute respiratory syndrome among children confronting the avian influenza threat: vaccine development for a potential pandemic emerging infectious disease issues in international adoptions: severe acute respiratory syndrome (sars), avian influenza and measles key: cord- -ldkjqco authors: nan title: news date: - - journal: aust vet j doi: . /avj. sha: doc_id: cord_uid: ldkjqco nan r eports of psychological distress, occupational stress and burnout and an increased risk of suicide in the veterinary profession are urgent reminders that veterinary schools, professional organisations and also employers should continue to address these issues. , managerial aspects of the job, long working hours, heavy workload, poor work-life balance, difficult client relations and performing euthanasias have been consistently associated with increased levels of occupational stress. chronic work stress can lead to emotional exhaustion and burnout. female veterinarians, younger veterinarians and those working on their own are at greatest risk of stress and mental health difficulties. , results from a recent observational study conducted at veterinary practices in canada suggest that team effectiveness can improve an individual team member's job satisfaction and offer protection against stress and burnout. the study found that % of veterinary team members were considered to be at a high risk of burnout. the study recommendations are that practice managers: • ensure all team members are kept abreast of changes in the clinic and given opportunities to provide suggestions to improve patient care and client service • recognise team members for their contributions • provide all staff with adequate resources and guidance to complete their jobs in a meaningful fashion and provide opportunities for growth and professional development • ensure all team members have clearly defined roles and are given autonomy to make decisions consistent with their position in the practice • encourage colleagues and supervisors to provide guidance and social support to help team members develop coping skills • take steps to create and maintain a positive work environment -this may include addressing conflicts among co-workers, ensuring all employees are treated equally and fairly, promoting civility and collegiality • consider current staff numbers and individual workloads to prevent excessive workload. providing communication and coping skills training and improving cognitive skills for young professionals may also help to decrease depression, anxiety, stress and burnout. if you are concerned that a colleague, close friend or family member is experiencing mental health difficulties, try talking to them in a supportive manner and encourage them to consult their gp or mental health professional. a -hour telephone counselling service is available for ava members on . this service can also arrange a counsellor to attend veterinary workplaces to help support staff after a traumatic incident. lifeline is another excellent support option: . dogs suffering from osteoarthritis need proven relief from pain and infl ammation. julia nicholls, president a s i write, our policy advisory council (pac) is voting on policies that are under review or newly drafted. so it may be a good time to reflect on why we have these polices and how they are written, as there has also been some debate about the function and process of the pac. ava policies are used as a reference point for the public, the media and members. many of our members sit on external boards and committees and the policies are key documents in these forums. i recently had to respond to a good question as to why our policy on equine dentistry did not completely align with the recommended key principles for veterinary practice acts in australia, which were recently circulated to members (www.ava.com.au/node/ ). the crux of this is that the policy reflects an ideal world, but the veterinary practice acts, which are written for the protection of the public, reflect current reality. we have other policies that do not align with those of key stakeholders or with current legislation. this is healthy and reflects our independence and the democratic process. the ava has approximately policies and position statements. subjects range from live animal export to genetic defects in domestic animals, and from puppy socialisation to cane toad euthanasia. position statements replace policies where there is a significant diversity of opinion among members. many policies reflect our stance on animal welfare issues and this is something to be proud of. the pac consists of a representative from every division and special interest group and meets once a year face-to-face but engages in healthy debate online all year. the full process of policy development may seem long-winded to an outsider. an initial draft is created by a working group and is then discussed by all the councillors until the majority are happy that the policy is suitable to go to all members for comment. members have a chance to comment on draft policies twice each year. the councillors work very hard to gain consensus from the members and to work with each other to get a policy ready for the vote. the october voting round is an electronic vote for policies that have been discussed online or have been out for general member comment. councillors vote whether to move each policy to the next stage in the process, send it back to a working group or abandon it altogether. anything requiring more debate is referred to the face-to-face meeting in may. the final sign off is by the ava board. the structure of the ava's policies is important. they should start with a short statement suitable for a media release or sound bite and then have a section on the underlying philosophy, the evidence and some scientific references. operational matters or procedures linked to the policy are usually included as guidelines. each policy undergoes regular review to maintain currency. some are deleted and others added as the environment changes. the policy compendium is a living document and something that is the envy of other veterinary associations. it is hard to see any shortcuts that would improve the process for member involvement. yet situations occur where we have no policy to fall back on. in the world of the -hour news cycle, topics arise that require an immediate response or at least one faster than the formal policy development process. the changes to higher education funding are a case in point. we do not have a policy on this, but it was clear that the proposed changes pose a threat to the future viability of our profession. we believe that we have to oppose this government policy shift, so we are, hopefully with your support. another example is where we have a policy but it is silent on the particular aspect of the topic under debate. in these circumstances, the board or a consultative group delegated by the board will arrive at an official position in keeping with the spirit of our policies. ideally, a policy will eventually flow from experiences like these. members and board directors have asked a range of questions about our policy development process in recent years: • should there be more scanning and identification of futureproofing policies? pet insurance is an increasingly important element of economic sustainability for many members. it means that clinical veterinarians can provide the best care for their patients and clients, regardless of the cost. unfortunately, there have been a number of teething problems with policies and claims, which led us to form a pet insurance taskforce in . the taskforce's role is to work with the profession and pet insurance companies to identify and then address issues of concern for veterinarians, pet owners and the insurance companies. our ultimate goal is to ensure that pet owners and veterinarians have confidence in pet insurance as a trustworthy and valuable element of pet care. one of the key activities the taskforce has undertaken is to develop a veterinarians guide to pet health insurance. the guide includes: • general information on what pet insurance is (and isn't) • useful facts about the australian market • reasons why more clients don't use pet insurance • techniques for making pet insurance work in your practice and for your clients. it also includes our guidelines for promoting pet insurance, your legal obligations, and what you can and can't say when talking to clients. we've heard from many members who are confused about this area, and the guidelines provide some much needed clarity. a veterinarians guide to pet health insurance is available for download now from the ava website: www.ava.com.au/node/ . on the back of member a survey conducted earlier this year, the taskforce is now gathering more detailed feedback including case studies from members at conferences and other forums. the feedback highlights several areas we believe could be addressed to remove barriers to take-up of pet insurance in australia, including: • the need for a cooling off period so that the pet owner can withdraw from an insurance policy if they are dissatisfied with the exclusions • the need for clearer terms and conditions, and explanations of any exclusions at the time of policy uptake • removing policy exclusions for pre-existing conditions based on entire body systems and unrelated to previous conditions -for example, removal of a toe lump cannot be considered a pre-existing condition just because a dog had a superficial skin infection a year before • making it easier for clients to know if their policy provides cover for particular treatments and diagnostic tests • an improved review of disputed claims by australianregistered veterinarians -we think that an industry review panel of ava members would offer an alternative pathway for appeal to the financial industry ombudsman • moving to electronic submission of claims, and making interactions with the insurers more efficient for veterinarians. we're looking forward to engaging with the insurance companies over these and other issues in the coming weeks. we'll keep you up-to-date with any new developments, and we also plan to develop some more educational resources for veterinarians shortly. with changes to the way the insurance policies and claims process works, we anticipate that more and more pet owners will choose to insure their pets, resulting in more treatment options. it will also mean that veterinarians are working with a system that supports good outcomes for all involved -pets, owners and veterinarians. fun is like life insurance; the older you get, the more it costs. international veterinary, biomedical and business journals at your fingertips vet ed library: www.ava.com.au/library as a vet, you are used to handling your patients with care and understanding, (especially if their bite is worse than their bark). at boq specialist, we adopt the same approach. we've spent nearly years working closely with vets and we've come to know your world as well as we do our own. we know your idiosyncrasies and we can anticipate your needs. so, unlike a conventional bank, we've developed products and services that are carefully designed to meet your business and personal banking requirements. when you call us, you'll always feel you are dealing with one of your own breed. crayfish plague is caused by a water mould, aphanomyces astaci. its native hosts are north american freshwater crayfish and although it produces some minor pathology, does not usually cause death. however, in naïve crayfish (never exposed to the pathogen), the disease causes death and effectively exterminates native crayfish from infected waters in as little as a couple of weeks. historically, north american crayfish were first introduced into europe in the late s for culture and fishery purposes. they carried crayfish plague with them. crayfish plague travelled around europe, with american crayfish that were translocated into european waterways. however, once crayfish plague was introduced to a country, it would also spread rapidly via contaminated fishing gear and water. crayfish plague continues to spread to previously unaffected areas of europe. the effect was severe in areas with a culture of consuming crayfish, particularly scandinavia. national declines in crayfish populations vary from % to % and lakes where crayfish were eliminated became overgrown with aquatic plants. in finland, the estimated cumulative direct loss from crayfish plague over the past years is € million. australia's freshwater crayfish fauna is diverse, with over described species, including a large number that are rare and endangered. crayfish play a crucial role as predators, herbivores and in breaking down detritus in freshwater ecosystems, and are often the largest animals in australian mountain streams. australian crayfish can be split into two broad groups: spiny and smooth-shelled crayfish. spiny crayfish are slow growing, have very large claws and usually prefer clear, cool water. because of their low meat yield and slow growth, they are not farmed. they are important fauna of streams where habitat is suitable, and many have highly restricted distributions, low fecundity and are listed as endangered. the best known of the spiny crayfish is the murray river cray (euastacus armatus). smooth-shelled crayfish include commercially and recreationally important species such as marron (cherax cainii), redclaw crayfish (cherax quadricarinatus), and the ubiquitous 'yabby' (cherax spp.). marron, redclaw and yabbies are farmed in queensland, new south wales, south australia and western australia. marron are primarily farmed in western australia and south australia. annual production varies, but in - it was valued at a$ . million and a$ , , respectively. redclaw production in queensland has declined over the past years and is now valued at a$ , . yabby production for food is limited, mainly from farms in western australia ($ , ) and new south wales ($ , ). redclaw and yabbies have been translocated (legally and illegally) for recreational fishing. many species have substantial cultural importance, and have been a source of food for indigenous people for millennia. crayfish are 'keystone species' in aquatic environments, acting as major processors of organic materials, facilitating the release of energy and nutrients, turning over substrates and aerating soil, and can reach very high biomasses in some systems. some smooth-shelled crayfish are remarkably persistent in dry environments and can survive drought in deep burrows for extended periods. aphanomyces astaci spreads by means of motile zoospores released from mature filaments in infected crayfish. the zoospores are attracted to crayfish cuticle, and the filaments penetrate immediately. zoospores can remain motile for up to days and cysts can survive for weeks (in distilled water). zoospores can re-encyst three times if they do not encounter a host. it is recommended to wait months before attempting to re-stock waters in which crayfish have been killed by crayfish plague, to allow all zoospores to die out. crayfish plague is also spread via contaminated fishing equipment or zoospores in water. american crayfish, including red swamp crawfish (procambarus clarkii) and signal crayfish (pacifastacus leniusculus) are tolerant of infection. they can remain carriers for life, and may exhibit little or no sign of infection. until recently, crayfish plague was only known in temperate to cool climates, but a spanish strain is active at temperatures of - °c. the strain that affects the invasive red swamp crawfish can sporulate at temperatures up to . °c. red swamp crawfish have established in japan, china and taiwan, and populations are sometimes maintained in ornamental fish outlets in the region. thus there is potential for spread of the pathogen throughout the region, either in contaminated water or with live or dead crayfish. freshwater crabs are susceptible to crayfish plague and may act as reservoirs for the pathogen. the chinese mitten crab (eriocheir sinensis) and the european crab (potamon potamios) are both susceptible to infection with crayfish plague. the chinese mitten crab is listed as one of the most invasive species on the planet and has established successfully in europe and north america. australia has very rich and diverse freshwater crab fauna. if infected chinese mitten crabs established in australia, their extensive migration habits (migrating upstream from estuary spawning grounds) could spread crayfish plague inland to crayfish and crab populations. australian crayfish are known to be highly susceptible to crayfish plague. eight species of four genera (including yabbies, cherax destructor) of australian crayfish were experimentally exposed to zoospores of a. astaci. they showed limited or little effective host response to invading filaments. the usual response of crayfish to infection is encapsulation and melanisation of invading filaments. redclaw crayfish and marron have been introduced into many countries for farming purposes. in late , crayfish plague was detected in farmed redclaw crayfish in taiwan. it was detected in five widely spread locations, four of which experienced % mortality, while one experienced % mortality and % morbidity. pathology was not described in the report. as demonstrated by its ability to infect multiple crayfish species, chinese mitten crabs and european crabs, crayfish plague is not very species-specific and could potentially infect most or all australian freshwater crayfish and crab species. it can cause disease and death in crabs, although the effects are not as immediate or dramatic as in crayfish. often the first sign of crayfish plague is the sudden mass death of crayfish in a water body. however, some symptoms do appear, including behavioural changes and external signs. affected crayfish may become active in the day and appear uncoordinated and lethargic. whitish areas in the muscle may be visible through the cuticle under the tail. at very low temperatures (< °c) effects may be slower to emerge, and the disease may be chronic rather than lethal in susceptible species. when american crayfish species (i.e. tolerant of infection but carry it) become infected, the shell may develop dark patches, as the reaction by crayfish to damage is to lay down melanin around the pathogen. these patches are easiest to see on the underside along the abdomen. the identification field guide to aquatic animal diseases of significance to australia provides details of clinical signs and diagnosis for crayfish plague. the aquavetplan disease strategy manual for crayfish plague provides details on gross and clinical signs of the disease. crayfish plague should be differentiated from other possible causes of mass death, such as insecticide poisoning. pcr techniques for detection of the pathogen have been developed. there is an australian and new zealand standard diagnostic procedure detailing methods for diagnosing crayfish plague. the oie manual of diagnostic tests for aquatic animals also provides details on diagnostics to confirm the presence of the pathogen. australian freshwater crayfish are known to be susceptible to crayfish plague fungus. freshwater crayfish are important and dominate in many australian ecosystems, and many species are rare or threatened. many species have restricted distributions, so could become extinct very rapidly if exposed to the disease. crayfish are the basis of an aquaculture industry, as well as supporting recreational and cultural fisheries. the potential consequences of entry of this disease into australia could be severe. the outbreak in taiwan is the first reported case of australian native crayfish being naturally infected by a. astaci and demonstrates the high susceptibility of this tropical crayfish to the pathogen. it caused very high mortalities, suggesting that a similar outbreak in australia could have devastating consequences. some strains of crayfish plague fungus are temperate but others transmit in temperatures up to . °c, suggesting that crayfish plague could infect large areas of australia. american crayfish are widespread in asia. they are regarded as pests in some countries, and until recently crayfish plague had not been reported from asia. the report from taiwan indicates that plague is present and could, potentially, be widespread in the region in feral populations of north american crayfish or chinese mitten crabs. australia has import conditions to restrict the entry of freshwater crayfish or crabs for both environmental and biosecurity reasons. these conditions limit the risk of entry of crayfish plague into australia. however, vigilance for diseases should always be maintained. if an exotic disease is suspected, please call the disease watch hotline for advice and assistance. brett herbert australian government department of agriculture comment on this article at www.ava.com.au/ r abies is present in more than countries across the world, causing more than , human deaths each year, almost all of them in africa and asia and many of them young children. although rabies can infect all warm-blooded animals, the most important source of human infection around the world is an infected dog bite or scratch. australia is one of the few countries that claims freedom from the disease, but as the rabies virus spreads in nearby countries, it is becoming more likely that it will eventually reach our shores. honorary associate professor at the university of sydney, dr helen scott-orr, has been involved in rabies programs in flores, as well as early response and control programs when rabies was first diagnosed in bali in . "rabies is a terrible and terrifying disease when it occurs. it exists in canine populations on several indonesian islands close to our northern shores. in recent years there have been outbreaks on eastern islands, including bali, flores, ambon and the tanimbar islands, which have increased the risk of the disease entering australia. "if it were to reach our border, the most likely place for an incursion is northern australia and the most likely scenario is an illegally imported, infected animal arriving by boat, " dr scott-orr said. dr ted donelan is president of animal management in rural and remote indigenous communities (amrric), which delivers animal health programs in rural and remote aboriginal and torres strait islander communities. dr donelan says that people in isolated indigenous communities are most at threat from a rabies outbreak. "large portions of the northern australian coastline are very sparsely populated. there are significant populations of semi-free-ranging camp dogs, dingos and other wild dogs in and around these communities. if these dogs became infected, they would pose a huge threat to the health and safety of the aboriginal and torres strait islander people living in those areas, " dr donelan said. the australian government has been active in rabies preparedness and prevention. the minister for agriculture, barnaby joyce, recently said, "the work offshore, at our borders and on shore -including the department's engagement with indigenous communities in northern australia as part of the northern australia quarantine strategy (naqs) -is vitally important to ensuring australia maintains its freedom from rabies and other exotic diseases. " since , the department of agriculture has been working in partnership with the indonesian ministry of agriculture to improve the management of emerging infectious diseases. the australia indonesia partnership for emerging infectious diseases is funded by the australian government, with a$ million allocated to developing a more integrated veterinary service capable of preventing, detecting and controlling important endemic and emerging infectious diseases. dr scott-orr and dr donelan agree that the naqs is doing a great deal of work on rabies surveillance, education and preparedness to prevent its introduction to australia. they also believe that australia's ongoing work with neighbouring countries is playing an important part in our protection from the deadly disease. "spending resources on helping our neighbours control rabies helps reduce the risk to australia. it also helps build the pool of professionals with experience in fighting an outbreak, " dr donelan said. preventing the spread of rabies is best achieved through vaccination. dr scott-orr says the most universal knee-jerk reaction from authorities is to kill dogs, but this has proven to be ineffective in containing the virus. "in new incursions, it often spreads insidiously for several months in the dog population before one or more human deaths occur, causing panic. the way to control rabies is to vaccinate dogs. the target for control is at least % of dogs vaccinated every year with a vaccine that has a -year duration of immunity. in addition to this, preventing rapid turnover of the dog population by fertility control is strongly advisable, " dr scott-orr said. • rabies is a vaccine-preventable viral disease that occurs in more than countries and territories. • infection causes tens of thousands of deaths every year, mostly in asia and africa. • % of people who are bitten by suspect rabid animals are children under years of age. • dogs are the source of the vast majority of human rabies deaths. • immediate wound cleansing and immunisation within a few hours after contact with a suspect rabid animal can prevent the onset of rabies and death. • every year, more than million people worldwide receive a post-exposure vaccination to prevent the disease -this is estimated to prevent hundreds of thousands of rabies deaths annually. within australia, dr donelan is encouraging veterinary practitioners who regularly visit remote communities to provide dog health programs to be more proactive in rabies preparedness. "relationships are everything in working with indigenous communities and people who are known, trusted and respected by the locals are far more likely to be given information about sick dogs and gain their cooperation with control measures and vaccination programs, than are outsiders. there is often a healthy mistrust of authority, stemming from experience that usually the prime goal of dog 'management' is to kill the dogs, " dr donelan said. both dr scott-orr and dr donelan advise veterinarians to consider getting vaccinated against rabies for personal protection and to enable them to assist in an outbreak if one was to occur. amrric is currently establishing a register of rabies-vaccinated practitioner members currently servicing or prepared to volunteer in northern australia. "the prevalence of the closely related australian bat lyssavirus (ablv) in both flying foxes and some insectivorous bats, with three human and two equine fatalities recorded, presents another reason for australian vets to consider being vaccinated against rabies. ablv has been found in all states except tasmania and the act, " dr scott-orr said. the media space is becoming more competitive, with more pressure on fewer journalists to file stories in a shorter space of time and when big stories overtake the news, such as the recent terrorist threat, these pressures intensify. total times the ava and its spokespeople feature in the media each year. ava news is not only covered in print, radio and television but increasingly online as well. in fact, between january and september this year, % of our media coverage appeared in online news sites. this reflects people's demand for immediate, up-to-date news and growing preferences to receive information from online sources. you can view some of the online news coverage we've received on the ava website at www.ava.com.au/news- . the ava media program involves identifying and telling positive stories to raise the ava's profile and promote the veterinary profession. the topics we cover include topical policies, response to disease outbreaks and the advocacy work the ava does to support our five strategic priorities. an example of coverage from our advocacy work is the higher education reforms campaign where media coverage has supported our efforts to communicate our position to decision makers in person. significant media coverage was received on this issue. julia nicholls conducted several interviews about the impact the reforms would have on veterinary students and the profession. the story was covered in the sun herald, the sunday age and the sunday canberra times. flow on coverage included wsfm, ue in sydney, ec bega and pr perth, as well as the rural report on abc online. a successful program of stories throughout the year for many of our special interest groups has helped maintain our media profile. these stories have covered heat waves, tick paralysis, parvovirus, behavioural issues, farm safety, dental health, distemper, heartworm, parvovirus, horse heart murmurs, hendra virus, bvdv, pollen, snake bites and swooping magpies. you can view all the ava media releases on the website at www.ava.com.au/mediareleases. ava members also have regular pet advice columns in the west australian and the adelaide advertiser, and a weekly pet radio segment on nm muswellbrook. although stories focussing on companion animals tend to be popular with the media, we continue to increase our influence in the rural media and promote the great work veterinarians do with producers and livestock.  % pets  % livestock  % equine  % legislation / advocacy  % other media releases have been distributed throughout the year to promote sig and division conferences. the publicity program for the ava annual conference was a great success this year and generated media hits. one of the biggest drawcards was the media conference on antimicrobial resistance, which generated more than media hits alone, including radio national and abc radio stations around australia. a panel of experts, who presented papers on the topic at the conference, spoke at the media conference about the facts on antimicrobial resistance in animals and the potential impact on people. although the situation in australia is better than in many other parts of the world, the take home message was that we can't be complacent. australia needs a long-term national surveillance program of antibiotic resistance before any problems get out of hand. you can view some of the coverage at yahoo news (aap) and abc rural. this year's asava conference resulted in a tv news piece on nbn and an interview with david neck on abc brisbane. several media releases to support the world buiatrics congress delivered media impressions in queensland country life, abc rural, the veterinarian and southern cross radio among others. every year the ava conducts media training sessions using professional media trainers to ensure we have a pool of spokespeople to cover every division, sig and potential topic of media interest. we have been very fortunate with the calibre of ava volunteer spokespeople over the years and they have been instrumental in helping us to achieve such excellent exposure for the profession and the ava in the media. comment on this article at www.ava.com.au/ protection against hendra at equestrian events e quine veterinarians australia (eva) has recently advised members on the best-practice approach to managing hendra risk at equestrian events. "managing hendra biosecurity risk at events is extremely challenging due to the nature of the disease and the large number of horses and people intensively interacting, " said nathan anthony, president of eva. "event organisers have a responsibility to ensure a safe environment for horses and people. however, not all event organisers are willing or able to implement and adhere to hendra biosecurity essentials during an equestrian event, " dr anthony said. veterinarians providing services at equestrian events have obligations in relation to work health and safety, and they are expected to provide accurate advice on biosecurity threats. eva has provided recommendations and resources to help veterinarians meet these obligations. "for events in queensland and new south wales, eva advises organisers to implement a mandatory hendra vaccination requirement for all event participants. this is to protect both people and horses from the extremely serious effects of an outbreak at an event, " dr anthony said. "for events in other states and territories, we advise event organisers to require horses travelling from queensland or new south wales to be vaccinated against hendra virus. "eva has developed resources to help vets communicate this advice and to ensure that event organisers acknowledge their responsibility to manage the risk of a hendra outbreak, " he said. a ntimicrobial resistance threatens human and animal health worldwide. antibiotic awareness week australia ( - november) forms part of a global campaign to increase awareness of antimicrobial resistance and to promote responsible use of antimicrobials. the veterinary profession is involved this year through the ava's strategic priority program 'fighting antimicrobial resistance' . the veterinary profession has adopted the one health concept of expanding interdisciplinary collaboration and communications in all aspects of health care for humans and animals. veterinarians are seen by other health professions and the public as key players in the responsible use of antimicrobials, because of our stewardship over a considerable amount of antimicrobial use in companion and food animal species. participating in antibiotic awareness week alongside human health professionals is a key way for veterinarians to demonstrate their commitment to working with others to help solve this global crisis. the focus on antimicrobial resistance and use in humans and animals is increasing around the world, and both the world health organization and world organisation for animal health (oie) are leading policy to extend the useful life of antimicrobials. here in australia, the departments of agriculture and health are developing a national strategy on antimicrobial resistance similar to canada, the united states and the united kingdom. resistance to antibiotics is found in australian hospitals and increasingly in the community. multidrug-resistant bacterial pathogens are becoming more prevalent. patients with resistant infections experience delayed recovery and treatment failure and are more likely to die than patients with non-resistant infections. the profession and the ava have been proactive in addressing antimicrobial resistance concerns, naming 'fighting antimicrobial resistance' as one of the ava's five strategic priorities. recent new resources have included simple one-page guidelines on the principles of responsible prescribing of antimicrobials by veterinarians and a client fact sheet on safe handling of animals being treated with antibiotics. the ava is also currently exploring options to develop new national guidelines to help veterinarians ensure they're making the best decisions when prescribing antibiotics. the australian veterinary journal has recently published several articles on antimicrobial resistance and its effect on our patients and ourselves, including articles on methicillin-resistant staphylococcus aureus (mrsa) in horses, vet hospitals and its carriage by veterinarians. australia is in an enviable position with regard to antimicrobial resistance -we have never allowed the use of fluoroquinolones in food-producing animals, and a recent survey by meat and livestock australia showed low levels of resistance in australian beef. over time, the one health focus on antimicrobial resistance will increase and it's important that veterinarians are proactively involved and informed of their responsibilities when using antimicrobials in all areas of practice, both companion and food animals. in the future, veterinarians may well be more involved in human cases of antimicrobial resistance. for example, family pets may be identified as reservoirs of infection. veterinarians may have to make decisions on whether to use the newest 'big gun' antimicrobial or more conservative treatment. off-label prescribing and compounding practices in food-producing animals may also come under increasing scrutiny. these challenges will provide an opportunity to underscore the importance of veterinary science to the overall health of both humans and animals. veterinarians are not unique in facing this challenge. more than health professionals have already taken a pledge to support the mind me principles: microbiology guides therapy wherever possible indications should be evidence based narrowest spectrum required dosage appropriate to the site and type of infection minimise duration of therapy ensure monotherapy in most cases. indeed, clients may come to expect this approach from all health professions, veterinarians included. jonathan taylor amrric is an independent group of veterinarians, academics and health professionals, both indigenous and non-indigenous, working in the one health framework to improve the health and well-being of companion animals and their communities. since its inception, amrric has focused on developing and implementing sustainable, culturally-sensitive programs in rural and remote aboriginal and torres strait islander communities. this program has seen dozens of veterinarians, nurses and other volunteers from around australia and overseas donate their time and skills in desexing, worming and treating animals in some of the country's most remote communities. the conference, held in darwin in conjunction with the international fund for animal welfare (ifaw), attracted over delegates from australia and around the world. following a welcome to country by larrakia elder bilawara lee, amrric president ted donelan and ifaw regional director, isabel mccrea, opened proceedings. keynote speakers included kate nattrass atema, ifaw's program director companion animals, who discussed the logistics of animal welfare programs in countries ranging from bosnia to bali. dr frank ascione, from the university of denver, has performed extensive research on the link between animal abuse and interpersonal violence. he discussed the relationship between mental health and animal abuse, as well as animal abuse as an indicator of family violence. he also discussed initiatives that had been developed as a result of this research, including pet-friendly shelters for victims of domestic violence. with the threat of a rabies incursion into northern australia presenting a real risk to remote communities, the topic of rabies detection and control was a key theme of the conference. a panel of experts, including nt chief veterinary officer dr malcolm anderson, nt centre for disease control public health physician dr charles douglas, northern australia quarantine strategy veterinary officer joe schmidt and former nsw chief veterinary officer helen scott-orr, participated in a simulated rabies incursion to assess australia's preparedness for such an outbreak. issues raised included the number of vaccinated veterinarians available to assist in such an event, the need for existing relationships with and experience with communities, and understanding of dog population dynamics in remote communities. above all, the conference provided an opportunity for those working at the coalface to connect with others in academia and government and ensure that community animal health and welfare are on the agenda. "what i have learnt there was very motivating and made me see my community from another perspective, " said torres strait island regional council animal management worker, william bero. "it has motivated me to continue in promoting healthy and happy animals equals healthy and safe community. " the study reaffirms much of what we already know, but it is an australian study -which is important, as we don't have much local data, " said dr andrew carter, ava sa division president. "interestingly, the study also noted that two-thirds of incidents involved the dog being provoked. this is significant, as it again points to the need for children to be taught about appropriate interaction with pets, but also highlights the need for adults to step in, " dr carter said. in regard to breed, the study finds that breed-specific legislation is not necessarily effective and proposes the development of a set of well-defined criteria that enables early identification of dangerous dogs on an individual basis. "this is very much in line with our own ava research, which emphasises the importance of education coupled with identification and control of individual 'potentially dangerous' dogs along with 'dangerous' dogs, " dr carter said. the results mirror another recent study of dog bite-related fatalities in the united states. that study, released late last year, looked at fatalities from to . although calculated risk factors could not be specified by the study, the key factors that were found to be present in fatal attacks were: • absence of someone to intervene • the dog and victim were unknown to each other • the dog was not desexed • compromised ability of victims to interact appropriately with dogs • the dogs were isolated from regular positive human interactions (possibly kept outside) • owners' prior mismanagement of dogs • owners' history of abuse or neglect of dogs. importantly, in the majority of fatalities at least four of these factors were in place. the study reinforced other findings relating to breed, stating that dog bite-related fatalities "were characterized by coincident, preventable factors; breed was not one of these. " the paper also notes that although desexing appeared to be a factor, it is uncertain whether this is causal or coincidental. they note that past research "…suggests that owner failure to have their dog spayed or castrated may co-occur with other factors that more directly influence a dog's social competence. " executive officer -sa and nt division comment on this article at www.ava.com.au/ the results support the existing understanding of dog bite incidents: dog bites are most likely to involve children aged - years, who are bitten on the face by a familiar dog and in a familiar environment. esutures is a discount distributor of ethicon, covidien, synthes, bard and arthrex suture, mesh and surgical devices. we specialize in selling brand name products at below market prices in quantities you decide. we stock thousands of surgical devices available by the box or by the individual item, and ready to ship today! no contracts. no minimum orders. fast shipping. all orders ship global priority from the u.s. at a flat rate. order today: info@esutures.com www.esutures.com use promo code: avj for $ off your next order of $ or more.* a ccording to the food and agriculture organisation of the united nations (fao), a recent strain of avian influenza virus in poultry in southeast asia needs to be closely monitored. known as a(h n ), the fao says it represents a new threat to animal health, with recent detection in poultry in the lao pdr and vietnam after first being reported in poultry in china in april . it also represents a threat to the poultry-related livelihoods that contribute to the incomes of hundreds of millions of people in the region. fao's chief veterinary officer, dr juan lubroth, said that influenza viruses are constantly mixing and recombining to form new threats. "h n is particularly worrisome as it's been detected in several places so far from one another. and because it's so highly pathogenic, meaning infected poultry become sick and, within hours, death rates are very high, " dr lubroth said. the world health organisation for animal health (oie), which works together with the fao and the world health organization (who) to support countries' responses to animal and human disease threats, is also monitoring the situation closely. only one case of h n has been reported in humans after contact with exposure to poultry shortly after its detection in china. the person later died. according to the who, although the dynamics of the new strain are still not fully understood, it's unlikely that h n represents an immediate and significant threat to human health. both the who and fao have advised that even if the public health risks posed by h n currently appears to be low, it is still of concern and they recommend that consumers follow appropriate hygiene, food preparation and food safety guidelines. these include washing hands often, cleaning utensils and surfaces used during food preparation and eating only well-cooked poultry meat products. people should also avoid handling sick birds or those that have died of illness. the fao is also urging countries to remain vigilant to prevent further spread of the virus and is recommending that governments in the area support poultry producers in following essential biosecurity measures and standard hygiene precautions. this includes early detection, immediate reporting and rapid response. comment on this article at www.ava.com.au/ d r russell dickens oam is a trailblazer and mentor to countless young and now a bit older veterinarians. dr robert johnson suggested we shine the avj member spotlight on his mentor, dr dickens, so we can share his story with ava members. dr dickens started a veterinary practice in western sydney in and has been protecting australian wildlife and caring for animals, farmers and pet owners ever since. he has seen western sydney transition from a rural, farming community to a burgeoning, densely-populated metropolis and has evolved his practice to meet the changing needs of his community. beyond his practice and research work, dr dickens is a primary producer of angus beef at cullen bullen and has also placed his considerable energy into community activities. he has been a councillor at blacktown council for over years, served as mayor and is currently deputy mayor, while still working at his practice. he is a foundation member of the animal ethics committee at westmead hospital and millennium institute, a rotary paul harris fellow, on the salvation army's advisory board and this year was lauded with the university of sydney's alumni award, which places him among some of the sharpest minds in australia. dr johnson recounted a recent saturday afternoon, when he thought he'd done a stellar day's work after a full week. he finished by pm and thought he'd pop in to visit dr dickens' practice. "i found a packed waiting room with russ methodically managing the clients by himself. when he saw the look on my face, he smiled and said, 'i'm also acting mayor today' , " dr johnson recalled. he also still -almost exclusively -runs his practice's out-of-hours service and has done so since the s. "age is a matter of mind. if you don't mind it doesn't matter, " he quipped. when asked to recall a time he had shared with his mentor that had a particular effect on him, robert chose to share the aftermath of being sent to help a friesian cow with a dislocated hip, some years ago. "russ sent me out to attend to a large heifer and i managed to sedate her, get her to lie down and with the farmer's help and some impressive force, to reduce the dislocation. triumphant, i headed back to the practice where russ looked at me with some surprise. i asked, "why the funny look?" russ said that he had expected me to be covered from head to toe in mud and to provide him with his entertainment for the afternoon. like most other days, we laughed. "russ has taught me the two most important things in my career: that it's fun to be a veterinarian and you should always be prepared to laugh at yourself, " dr johnson said. e ach year the ava recognises those who contribute to and serve the veterinary profession or the association. nominations are now open for the following prizes and awards: this is the ava's most prestigious award for outstanding service by a member or a non-member to veterinary science in australia. nominees who were unsuccessful from the previous two years are automatically included. issued jointly with the australian college of veterinary scientists, the kesteven medal is awarded to members for distinguished contributions to international veterinary science through technical and scientific assistance to developing countries. nominees who were unsuccessful from the previous two years are automatically included. awarded to members for outstanding service to the association. the award is given either to members who have rendered meritorious service to the association, regional divisions, branches or special interest groups, or to persons who are not eligible for membership of the association but have clearly provided meritorious service to those bodies. awarded to eminent non-veterinarians for services to the ava or the veterinary profession. animal health australia, the australian veterinary association and guild insurance have put together a unique framework to cover private practising vets like you to assist in an emergency animal disease response. no other insurer offers this unique cover. for leading veterinary business insurance and professional indemnity insurance call us today for a quote. insurance issued by guild insurance ltd (gil) abn , afsl and subject to terms, conditions and exclusions. gil supports your association through the payment of referral fees. gil will assess an eadr outbreak and make a decision to provide cover on a case by case basis. gil will need to be contacted for the cover to be activated. additional premiums may apply depending on existing cover with gil. for information on the guild veterinary business insurance policy, refer to the product disclosure statement (pds) and policy wording. you can get a copy of the pds by calling . gld avj eadr ad / while you're taking care of an emergency, who's taking care of you? make the right choice. freecall guildinsurance.com.au/eadr d r alex rosenwax from waterloo in sydney, reports that he has had five unrelated unusual cases of rabbit deaths over the past few weeks. all presented with gastrointestinal stasis and were febrile with anorexia. the signs appeared to be consistent with calicivirus and all died within - hours, despite intensive treatment. all came from one general area of sydney, and they had been vaccinated in the past. "i have contacted the dpi and they have confirmed that a new strain of calicivirus has been documented in sydney by elizabeth macarthur agricultural institute (emai) in the past year. that strain is resistant to the vaccine. their signs were similar to the ones in the rabbits we have seen, " said dr rosenwax. rabbit haemorrhagic disease virus (rhdv) is a calicivirus that usually kills % of susceptible adult rabbits within hours, but the molecular mechanisms for this virulence are unknown. it has been used in australia as a biological control agent to reduce rabbit numbers since it was released in . there is also an endemic non-pathogenic australian rabbit calicivirus, rcv-a , that is known to provide some cross-protection to lethal infection with rhdv, and pet rabbits are usually vaccinated against the endemic strain to protect them. australia's chief veterinary officer, dr mark schipp, notified oie of the new strain in january this year. the notification related to the outbreak in sydney where sudden deaths occurred in show rabbits of various ages and both sexes. there were very few clinical signs prior to death. the rabbits had previously been in good health and were vaccinated against the endemic strain of rabbit calicivirus. of the susceptible rabbits, there were cases, and deaths, equating to an apparent morbidity rate of . %, mortality rate of . %, and case fatality rate of . %. gross necropsy findings showed little signs of the heavy haemorrhage usually seen with rhdv. they had more cranial changes. emai reported that the normal elisa test for calicivirus was negative whereas pcr was positive. some of the rabbits were presented to dr rosenwax because they were apparently having seizures. he noted that although his cases were highly suspicious of calicivirus, as the appropriate samples had not been taken, the cases could not be confirmed. a nonformalin-fixed, frozen -g liver sample is required for submission to emai to confirm the presence of the virus. tracing and surveillance of the new strain is underway to determine how many rabbits have been exposed and how widespread the virus is. this may have implications for pet rabbits, as evidence suggests the current vaccine may not be effective against this new strain. this new strain also has implications for rabbit control. the invasive animal cooperative research centre (ia crc) research shows that australian native vegetation is very sensitive to rabbit damage, and as few as . rabbits per hectare can remove all seedlings of the more palatable native trees and shrubs, so delaying natural regeneration. rabbits are australian agriculture's most costly pest animal with the annual cost of over $ million. according to the ia crc, the use of myxomatosis and calicivirus is still limiting rabbit numbers and without them, the annual cost to agriculture from the imported pest would exceed $ billion. however, they report that rabbit numbers are increasing, with research also showing there are a number of rabbit colonies that are immune to the calicivirus. without this virus, other control techniques would need to be tried, including warren ripping, fumigating, shooting and baiting. the ia crc is now involved in studies to evaluate other rhdv strains, mainly because there is increasing genetic resistance in the rabbits to current rhdv strains and young rabbits are acquiring immunity. dr rosenwax reports that in the absence of a definitive diagnosis, his practice has instituted quarantine for all rabbits with suspicious clinical signs. we heard about the contrasting aspects of rural practice in three different areas of australia. all seemed to share similar problems of beef and dairy profitability, increased numbers of graduating veterinarians, competition from paraprofessionals, the cost of travel and the loss of populations from rural towns. david petersen from deniliquin, told us about his practice in the dairy area of the riverina in victoria. there is no water except for irrigation -the gates on the channels are opened at the top levels, and the water 'wooshes' down for about hours per day. they see american holstein cattle, which are big cows with lots of milk, that have poor reproductive function, in an area where daytime temperatures are regularly between and ºc, and ºc at am. the veterinarians keep temperature logs in their cars, and have to throw away medications if they get too hot. sam mcmahon told us of her experiences in setting up the northern territory veterinary services in katherine. with an area of . million km , slightly bigger than nz, uk, ireland and france combined, but with a population of only , , they need a fleet of wd to cover the area. their practice includes going out to stations and indigenous communities and their new branch in alice springs is a . hour road trip away from their main centre. brahman cattle are most common in the humid katherine, and british cattle breeds in the drier alice springs area. comment on this article at www.ava.com.au/ workshop host bill tranter's practice covers km to the north, south and west, with two small animal and equine practices in mareeba. they cover extensive beef in the west of the region as well as herd health management for the more intensive dairy industry. the practice is an integral part of clinical training at james cook university. our first visit was to a relatively small feedlot, with heat-tolerant brahman-cross cattle. the property has . metres of rain annually, and also produces silage. the next stop was at a dairy of between and holstein cows. the tropical grasses grow very slowly except for a flush when it rains in december. they have a year-round calving pattern, and have to produce the same amount of milk throughout the year. their best conception rates are in the cooler winter months, and they also produce silage and grow ryegrass to boost production at that time. bull and heifer reproductive examination was next, with andrew hoare demonstrating the ultrasound probe and showing us ovarian anatomy, and enoch bergman demonstrating the intimacies of bull examination. andrew hoare multitasking i wasn't the only one taking photos communicationthe essential ingredient w ith the increasing amount of technology changing the way we communicate, it can be difficult to find the best medium to engage with all of your stakeholders. despite all these advancements, in particular the role of the internet, text messaging and social media in our lives, there is still no replacement for verbal communication in a work environment. it is verbal communication that is the essential ingredient in building an efficient and harmonious workplace. the key to an efficient workplace is to create an environment that is conducive to open and honest communication. this creates a positive relationship between employee and employer and while this relationship remains positive, then the workplace will usually stay productive. most issues with employees can be resolved through a face-to-face discussion where both parties are able to voice concerns, resolve misunderstandings and get a clear understanding of each party's motivations and the solutions required to overcome any grievances. communication is a two-way process. it involves both the dissemination of information, but even more importantly, the receipt of information through genuine listening. both are equally important for the employee and the employer. firstly, managers need to explain to employees what is expected of them and not simply rely on job descriptions to explain this. employees also have an obligation to ask questions if they are unsure about work requirements and advise managers of any changes that may affect the way they perform the job, or improve the process to deliver expected outcomes. it has often been said that the employment relationship is similar to a marriage. both parties enter into the relationship with the best of intentions, but throughout the relationship there will be good and bad times, which put the relationship to the test. once communication becomes difficult, or either party looks for ways to avoid verbal communication, it is a strong sign that there is a problem. the only way to resolve these problems is to address them as soon as the issue is identified and do this face-to-face. just because an employee chooses to communicate via text, it is never a good idea for a manager to start texting anything more than confirming receipt of the message. it is always best to make a phone call and talk to the employee directly. there can never be too much communication. managers do not have to wait for that annual review, or monthly meeting, to raise a concern or discuss a matter with their employees on any matter. frequent communication on any matter will assist in building relationships. communication must be kept simple and relevant with employees -don't start communicating information that does not affect the employee. importantly, effective communication does not mean gossiping about an employee's personal life; it simply means communicating what is expected of employees and issues that might be affecting their performance and the effect on other stakeholders. in summary, there are three things that are critical to build an efficient workplace ... communication, communication, communication. if you do this well, you will reduce and avoid most workplace relations issues. michelle eamer ava hr advisory service comment on this article at www.ava.com.au/ the material contained in this article is general comment and is not intended as advice on any particular matter. no reader should act or fail to act on the basis of any material contained herein. the material contained in this publication should not be relied on as a substitute for legal or professional advice on any particular matter. suicidal behaviour and psychosocial problems in veterinary surgeons: a systematic review veterinary surgeons and suicide: a structured review of possible influences on increased risk the role of veterinary team effectiveness in job satisfaction and burnout in companion animal veterinary clinics references . nobanis. invasive alien species fact sheet: -aphanomyces astaci. www.nobanis.org the effects of crayfish plague on finland's crayfish economy australian fisheries statistics manual of diagnostic tests for aquatic animals cultured aquatic species information programme: procambarus clarkii (girard, ) the crayfish plague pathogen can infect freshwater-inhabiting crabs defence reactions in and susceptibility of australian and new guinean freshwater crayfish to european-crayfish-plague fungus event summary: crayfish plague (aphanomyces astaci) australian government department of agriculture, fisheries and forestry. identification field guide to aquatic animal diseases of significance to australia. th edn. www.daff.gov.au/animal-plant-health/pests-diseases-weeds/ aquatic-animal-diseases-significant-to-australia-identification-field-guide australian government department of agriculture, fisheries and forestry. aquavetplan disease strategy manual for crayfish plague world organisation for animal health. oie manual of diagnostic tests for aquatic animals. www.oie.int/international-standard-setting/aquaticmanual/access-online/ accessed conservation of freshwater crayfish in australia australian commission on safety and quality of health care. antibiotic awareness week australian veterinary association. fighting antimicrobial resistance international organisation for animal health, oie. managing antimicrobials use in animals emergence of multi-resistant pseudomonas aeruginosa in a western australian hospital methicillin-resistant staphylococcus aureus in a population of horses in australia methicillin-resistant staphylococcus aureus: an issue for veterinary hospitals carriage of methicillin-resistant staphylococcus aureus by veterinarians in australia antimicrobials and the cattle industry methicillin-resistant staphylococcus aureus in a family and its pet cat nps medicinewise: resistance fighter pledge first-time study of women's and children's hospital bite victims shows that nine in attacks is by a familiar dog retrospective review of dog bite injuries in children presenting to a south australian tertiary children's hospital emergency department policy and model legislative framework co-occurrence of potentially preventable factors in dog bite-related fatalities in the united states rabbit haemorrhagic disease invasive animals cooperative research centre. landscape control -rabbits prices include delivery of print journals to the recipient's address. delivery terms are delivered at place (dap); the recipient is responsible for paying any import duty or taxes. title to all issues transfers fob our shipping point, freight prepaid. we will endeavour to fulfil claims for missing or damaged copies within six months of publication, within our reasonable discretion and subject to availability. ltd. all journals are normally despatched direct from the country in which they are printed by surface air-lifted delivery. copyright © australian veterinary association. all rights reserved. no part of this publication may be reproduced, stored or transmitted in any form or by any means without the prior permission in writing from the copyright holder. this consent does not extend to other kinds of copying such as copying for general distribution, for advertising or promotional purposes, for creating new collective works or for resale. authorisation to photocopy items for internal and personal use is granted by the copyright holder for libraries and other users registered with their local reproduction rights organisation (rro), eg. copyright clearance center (ccc), rosewood drive, danvers, ma , usa (www.copyright.com), provided the appropriate fee is paid directly to the rro. this consent does not extend to other kinds of copying such as copying for general distribution, for advertising or promotional purposes, for creating new collective works or for resale. special requests should be addressed to permissionsuk@wiley.com disclaimer the publisher, the australian veterinary association and editors cannot be held responsible for errors or any consequences arising from the use of information contained in this journal; the views and opinions expressed do not necessarily reflect those of the publisher, the australian veterinary association and editors, neither does the publication of advertisements constitute any endorsement by the publisher, the australian veterinary association and editors of the products advertised. submission of photographs for publication will be held to imply that permission for publication has been obtained from the photographer and from the subject(s) of the image.avj.pi.feb trademarks ava and the ava logo are registered trademarks of the australian veterinary association limited. key: cord- -ko bdvo authors: vasilakis, nikos; tesh, robert b.; popov, vsevolod l.; widen, steve g.; wood, thomas g.; forrester, naomi l.; gonzalez, jean paul; saluzzo, jean francois; alkhovsky, sergey; lam, sai kit; mackenzie, john s.; walker, peter j. title: exploiting the legacy of the arbovirus hunters date: - - journal: viruses doi: . /v sha: doc_id: cord_uid: ko bdvo in recent years, it has become evident that a generational gap has developed in the community of arbovirus research. this apparent gap is due to the dis-investment of training for the next generation of arbovirologists, which threatens to derail the rich history of virus discovery, field epidemiology, and understanding of the richness of diversity that surrounds us. on the other hand, new technologies have resulted in an explosion of virus discovery that is constantly redefining the virosphere and the evolutionary relationships between viruses. this paradox presents new challenges that may have immediate and disastrous consequences for public health when yet to be discovered arboviruses emerge. in this review we endeavor to bridge this gap by providing a historical context for the work being conducted today and provide continuity between the generations. to this end, we will provide a narrative of the thrill of scientific discovery and excitement and the challenges lying ahead. almost years have passed since walter reed, james carroll, aristides agramonte, and jesse lazear established that yellow fever is caused by a filterable infectious agent which is transmitted by the bite of a mosquito, then known as stegomyia fasciata (aedes aegypti). lazear, who like his colleagues, had been stationed by the us army in cuba to study the disease, died of yellow fever in september after being exposed experimentally to mosquitos that had fed on sick patients. at about the same time in south africa, james spreull and sir arnold theiler demonstrated that bluetongue disease of sheep is caused by an "ultravisible" agent that could be transmitted by the injection of an infected serum. epidemiological evidence suggested that the agent was vector-borne, and it was subsequently shown by r.m. du toit that the disease occurred in sheep inoculated experimentally with suspensions of wild-caught biting midges (culicoides imicola). these and other seminal discoveries precipitated a century of research into vector-borne and zoonotic viral diseases, resulting in the discovery and isolation of many hundreds of novel viruses from insects or vertebrate hosts. some were identified as important human or veterinary pathogens. many other viruses were archived in reference collections, with only basic characterization of their biological or molecular properties. in recent years, the advent of next generation sequencing (ngs) has transformed this situation. complete genome sequences are now available for many of the archived isolates, allowing more accurate taxonomic assignments, analysis of their phylogenetic and evolutionary relationships with other viruses, and evaluation of the potential risks they may present to humans and wild or domestic animal populations. ngs has also opened the door to viral metagenomics, which has greatly increased the pace of new virus discovery from a wide range of hosts, usually with complete or near-complete viral coding sequences, but no virus isolate and minimal biological data. this has presented both opportunities and challenges for virologists and epidemiologists, as well as viral taxonomists, evolutionary biologists, and bioinfomaticians. sadly, this technological revolution has been accompanied by a period of progressive disinvestment in training in classical virology. in this review, we recall the rich history of the discovery of arboviruses and other zoonotic viruses in various settings around the world and the many outstanding scientists who have contributed to the endeavour. we also consider the impacts of ngs and metagenomic analysis, and the implications of these new technologies for the future of this important field of research. the rockefeller foundation (rf) was organized in for "the well-being of mankind throughout the world" [ ] . at the time, yellow fever was still epidemic in many tropical and subtropical regions of africa and the americas, so in , the rf established the yellow fever commission, with the lofty goal of eradicating yellow fever from the world. during the next years, the rf supported an international group of scientists working on yellow fever in new york city in the united states (u.s.); rio de janeiro and salvador in brazil; bogota, colombia; yabba, nigeria; and entebbe, uganda [ , ] . much of the work and accomplishments of rf-funded personnel during this period was described in strode's classic book, entitled "yellow fever" [ ] . the major accomplishments included: confirmation of earlier work by the reed commission in cuba, demonstrating that yellow fever was caused by a filterable agent, yellow fever virus (yfv), that was transmitted by the bite of infected mosquitoes, aedes aegypti; . discovery that the rhesus monkey and the white mouse are susceptible to infection with yfv, providing models for subsequent studies on the pathogenesis, transmission, epidemiology, and control of the disease; . demonstration that convalescent sera of humans and animals infected with yfv neutralize the virus. this discovery led to the development of the mouse neutralization test, which allowed investigators to map the geographic distribution of the virus; . discovery of the forest or sylvan cycle of yfv and the importance of mosquitoes other than ae. aegypti in the transmission and maintenance of the virus; . development of the d vaccine strain of yfv and its first human trials. max theiler, son of south african bluetongue researcher sir arnold theiler, received a nobel prize in for this work. as a by-product of the overseas yellow fever investigations, rf-funded researchers also isolated a number of other previously unknown arboviruses, including west nile, zika, semliki forest, bunyamwera, bwamba, uganda s, ilheus, and anopheles a and b viruses [ ] . the threat and onset of world war ii changed the priorities of the rf, and most of its overseas yf research activities ceased during this period. many of the former american rf staff became involved in studies of diseases of military importance, such as typhus, malaria, sandfly fever, and dengue, some as civilians and others as members of the u.s. armed forces. in , after the end of the war, the rf decided to develop a major new program to study arthropod-borne viruses and to discover "what might be out there", as well as their disease associations, life cycles, and vectors. this led to the development of the rockefeller foundation virus program, a world-wide virus discovery program that was funded from to [ ] . over the next several years, field laboratories staffed by both rf and local scientists were established with foreign governments in pune, india; port of spain, trinidad; belem, brazil; johannesburg, south africa; ibadan, nigeria; cali, colombia; and cairo, egypt [ ] . in egypt, the cairo laboratory was associated with the u.s. naval medical research unit no. . scientists in these field laboratories were involved in the detection and investigation of human diseases in their respective geographic regions, surveying human and animal populations for serologic evidence of past viral infection, and searching for viruses in a wide variety of arthropods, mammals, birds, reptiles, and amphibians [ ] . all virus isolations were done on site, using the classic technique of intracranial inoculation of newborn white mice, but later, as vertebrate cell cultures became available, inoculation of cell cultures was also used. in addition, sentinel animals, such as non-human primates, mice, and hamsters, were also used in the field to detect virus activity. viruses isolated in the overseas laboratories were initially characterized locally, lyophilized for preservation and storage, and then aliquots of each new virus were shipped back to the rf central virus laboratory in new york for further characterization and study. it was during this period that jordi casals, delphine clarke, loring whitman, and others developed the sucrose-acetone method for preparation of viral antigens and began to adapt the hemagglutination inhibition (hi) and complement fixation (cf) tests to identify and group arboviruses [ ] [ ] [ ] . the rf virus program was extremely productive and many novel arboviruses, as well as non-arthropod-borne viruses (i.e., hantaviruses and arenaviruses), were discovered by rf-funded investigators during this period. the productivity of this search strategy in detecting novel viruses affecting humans was recently reviewed by rosenberg et al. [ ] . the virus discovery rate was highest in the period - , which coincided with the rf virus program. a similar approach was also practiced by the institut pasteur and other international groups involved in virus discovery during this period, as described in this article and in other publications [ ] [ ] [ ] [ ] [ ] [ ] , resulting in the detection of a high proportion of pathogenic arboviruses. the second advantage of the strategy was that it yielded actual virus isolates, whose pathogenesis could be studied experimentally in vivo and in vitro in vertebrate and arthropod models. in contrast, current search methods for new viruses, which generally use metagenomics and other sophisticated genetic techniques to detect novel viral agents, do not usually yield live viruses, only their nucleotide sequences. a complete or partial genetic sequence alone rarely provides insight into the epidemiology and ecology, host range, pathogenesis and disease potential, or transmission modes of the new viruses. in , the rf made a decision to phase-out its virus program and to devote more of its efforts and resources to other projects, such as population control and increasing food production ("the green revolution"). over the next years, the rf-funded investigators working in overseas laboratories were withdrawn and the respective laboratories were turned over to local institutions or governments. in , the rf made arrangements with yale university to transfer its arbovirus group to new since the establishment of the institut pasteur in paris in , louis pasteur sent collaborators to various countries, mainly in the french colonies of indochina and africa. in that early time, pasteur wanted to set up rabies centers where the disease was highly and dramatically prevalent; naturally, the research potential of these centers was rapidly extended to tropical infectious diseases [ ] . currently, spread among countries on five continents, there are institutions, of which bear the name of "institut pasteur" (ip). altogether, these institutions constitute a structure long called the "institut pasteur d'outre-mer", which in became the international network of pasteur institutes (réseau international de l'institut pasteur, riip) and associated institutes. from this emerging network, the first african laboratory for microbiology was created in saint louis, senegal in , and then transferred to dakar to become the pasteur institute of dakar (institut pasteur de dakar, ipd yellow fever was to play a key role in the research at ipd. in the s, ipd had developed a vaccine against yellow fever (strain fnv) and produced it commercially. the re-emergence of yellow fever in africa in the s occurred mainly in the savannah zone and revealed the lack of knowledge about the natural maintenance of the virus during the inter-epidemic period. a large study to understand the emergence and re-emergence of sylvatic yellow fever was established between the ipd, institute pasteur abidjan (ipa) in côte d'ivoire, and institute pasteur bangui (ipb) in the central african republic, in order to detect the circulation of the yfv and map its emergence in the different ecozones. permanent research stations were developed in rain forests and savannas to detect virus circulation in vectors and hosts from the tree canopies to the savanna ground. year-round mosquito and monkey sampling over a period of more than years made possible the detection of yfv in various monkey and mosquito species (e.g., aedes africanus, aedes opok, aedes furcifer-taylori, and aedes luteocephalus), thus elucidating the mechanism of yfv maintenance in nature. epidemiological observations during this period allowed max germain to formulate the concept of a "yellow fever zone of emergence" in west and central africa [ ] . these ecological transition zones constitute ecotones adjacent to sylvatic environments, where prevailing ecological conditions, such as vector abundance, presence of non-human primates, and closeness for human contact, enable the cross-species transmission of viruses into humans-a "zone of emergence", which clearly appeared as the main source of epidemics in west africa [ ] . thus, this specific ecosystem constitutes an ideal transition ecotype, where vaccination campaigns for the containment of epizootics and ultimately eradication ought to concentrate [ ] . lastly, virus isolation in male mosquitoes (ae. furcifer-taylori) allowed the documentation of vertical transmission, allowing for virus maintenance in the inter-epidemic periods [ ] . in the early s, research laboratories focusing broadly on arboviruses were established under the umbrella of the collaborating center for reference and research on arboviruses (crora), led by paul brés. crora laboratories were created at various ips throughout africa, including ipd, ipa, and ipb, as well as ip yaoundé (cameroon), and ip tananarive (madagascar). one of the major activities was to establish an inventory of arboviruses circulating in various ecosystems. although virus isolations were made at various ips, virus characterization and identification were carried out at the crora reference center at ipd, followed by confirmation at yaru, with final registration in the international arbovirus catalogue [ ] . at the end of the s, following an outbreak of the ebola epidemic in zaire in , ipb set up a research program on viral hemorrhagic fevers that lasted until [ ] . this research program was the result of an important collaboration between the various pasteur institutes in africa and researchers of orstom. in , orstom extended its field of research and expertise to tropical medical virology, thus supporting teams from the riip. the partnership between riip and ostrom was instrumental in expanding the scope of field research in africa, with seminal studies on the vertical transmission of arboviruses in mosquitoes [ ] or the role of environmental factors, such as climate and latitude, in arbovirus transmission from arthropod to vertebrate hosts, using yfv [ , ] and dengue virus (denv) [ ] [ ] [ ] as models. research at ipb was also critical in elucidating the etiology of exanthematous fevers, coined "congolese red fevers", that have long been attributed to rickettsia. a total of arboviruses (chikungunya, igbo-ora, o'nyong nyong, sindbis, bouboui, yellow fever, wesselsbron, west nile, zika, ilesha, bwamba, dugbe, tataguine, nyando, bangui, and rift valley fever viruses) were associated with these syndromes. symptoms, consisting of fever, diffuse pain, and exanthem, were present in more than % of the cases, with etiology dominated by four viruses-chikungunya, ilesha, bwamba, and tataguine [ , ] . between and , two field research stations were established in the central african republic, one located adjacent to the forest (bouboui) and the other in the wooded savanna (bozo) (figure ). during this period, more than , mosquitoes of identified species in , pools were preserved for virus isolation. the most common anthropophilic mosquitoes caught were aedes (stegomiya) africanus and ae. (st.) opok, inside the forest gallery, aedes vittatus, in the savannah, and anopheles gambiae and an. funestus, in the houses of the village of bozo. a total of viruses were isolated and assigned to different species. these included chikungunya, bagaza, bouboui, bozo, bwamba, ilesha, kamese, kedougou, middleburg, mossuril, m'poko, nyando, orungo, pata, pongola, simbu, sindbis, tataguine, wesselsbron, west nile, yellow fever, and zika viruses. altogether, six arboviruses were found in the forest gallery, including bouboui, bozo, chikungunya, orungo, yellow fever, and zika viruses, vectored primarily by ae. africanus. research at ipd and ipb was also instrumental in demonstrating the expanded range of the crimean-congo hemorrhagic fever virus (cchv) in west and central africa [ ] [ ] [ ] , followed by repeated isolation of the virus. this allowed a clear understanding of its eco-epidemiology in the region, including north-south migration of the infected ticks through the cattle traffic migration patterns in the sahel [ , ] . likewise, active circulation of the rift valley fever virus (rvfv) was also demonstrated in senegal [ ] , mauritania [ ] , upper volta (present day burkina faso) [ , ] , and the central african republic [ ] . support for riip laboratories located in africa was provided by the ipp and ostrom teams, as well as through collaboration with various research centers in the u.s., such as harvard university, supporting the initial study on yellow fever and fnv vaccine; yaru, as a partner for new arbovirus classification; the centers for diseases control (cdc) at fort collins colorado, for the study of arboviruses; the cdc in atlanta and the u.s. army medical research institute of infectious diseases (usamriid), for the initiation of viral hemorrhagic fever research in central and west africa. the era of virus discovery in australia can be traced to the summer of - , when a major epidemic of encephalitis swept through southeastern australia. there were clinical cases reported in victoria, new south wales, and south australia, of which ( %) were fatal [ ] . a similar epidemic of unknown etiology (named australian x disease) had occurred in eastern australia from until , with almost reported cases and an average case/fatality rate of % [ , ] . surprisingly, no further cases were reported in the intervening years. amongst those investigating the - epidemic were john a.r. miles and colleagues at the institute of medical and veterinary science in adelaide, and eric l. french of the walter and elisa hall institute of medical research in melbourne who, almost simultaneously, reported the isolation of a virus from the brain tissue of clinical cases [ , ] . the virus, named murray valley encephalitis virus (mvev), was shown to be closely antigenically related to japanese encephalitis virus (jev), a flavivirus (then designated group b arbovirus) known to cause fatal encephalitis in east and southeast asia [ ] . the subsequent development of arbovirology and the pathway to virus discovery in australia were linked intimately with the establishment of the queensland institute of medical research (now the qimr-berghofer institute) at herston in brisbane ( figure ). ralph l. doherty joined the staff and, in , established a program of virus isolation from mosquitoes, based at a field station at innisfail in the far north queensland. in , doherty isolated the ross river virus (rrv) from aedes vigilax mosquitoes collected in townsville [ ] . he subsequently showed that rrv neutralizing antibodies occurred commonly in human sera in eastern australia [ ] . he also showed that individuals suffering from a severe debilitating syndrome, known as epidemic polyarthritis, had high antibody titres to rrv, suggesting a causal relationship [ , ] . in , doherty and his colleagues isolated the virus from a boy from the edward river mission aboriginal settlement in cape york [ ] . rrv and the related alphavirus, the barmah forest virus (see below), are now recognized as important public health problems in much of australia and the pacific islands, causing arthritis, myalgia, and fatigue for six months or longer. several thousand cases of the disease are notified annually [ ] . , normanton, and cairns in far north queensland. these included four novel flaviviruses (kunjin, kokobera, edge hill, and stratford), three orthobunyaviruses (koongol, wongal, and maputta) and one orbivirus (corriparta) [ ] . the study also identified two alphaviruses previously unknown in australia (sindbis and getah) and the first isolations of mvev from mosquitoes [ ] . with support from the rockefeller foundation, a field station was established at kowanyama and further expeditions were undertaken to collect arthropods and potential mammalian hosts throughout queensland. anopheline mosquitoes and a swamp pheasant (centropus phasianinus) collected at kowanyama from to yielded three novel viruses (kowanyama, trubanaman, and alfuy viruses) [ ] . in - , three novel viruses were isolated at kowanyama (wongorr and mitchell river viruses from mosquitoes and the ngaingan virus from biting midges), three novel viruses were isolated from mosquitoes collected near charleville in western queensland (charleville, warrego, and wallal viruses) and two viruses (belmont and d'aguilar viruses) were isolated from mosquitoes and biting midges, respectively, collected near brisbane [ , ] . further expeditions to charleville to collect mosquitoes resulted in the isolation of two novel viruses in (facey's paddock and murweh viruses) and two novel viruses in (parker's farm and little sussex viruses) [ ] . leanyer virus was also isolated in from mosquitoes collected near darwin in the northern territory [ ] . viruses were also isolated from wildlife hosts; the almpiwar virus was isolated from a skink (cryptoblepharus virgatus) at kowanyama in [ ] and the mossman virus was first isolated from a rodent (rattus leucopus) captured near mossman in [ ] . in collaboration with doherty and his qimr team, expeditions were also conducted to isolate viruses from ticks associated with sea birds. in , harald n. johnson from yaru collected soft ticks (ornithodoros capensis) from sooty tern (onychoprion fuscatus) colonies on the great barrier reef near cairns, from which two viruses (upolu and johnston atoll viruses) were isolated [ ] . the saumarez reef virus was subsequently isolated by toby d. st. george and colleagues from australia's commonwealth scientific and industrial research organization (csiro) in , from the same species of ticks associated with sooty terns on a coral cay in the southern coral sea [ ] . in , m. durno murray from csiro undertook an expedition to the australian territory of macquarie island in the southern ocean to collect hard ticks (ixodes uriae) associated with sea birds, resulting in the isolation of two novel viruses (nugget and taggert viruses) [ ] . a second csiro expedition to macquarie island in yielded two additional novel viruses (gadget's gully and precarious point viruses) from hard ticks collected in royal penguin (eudyptes chrysolophus schlegeli) rookeries [ ] . other research groups in australia also joined the hunt for arboviruses during the late s and early s, including ian d. marshall at the australian national university in canberra and neville f. stanley at the university of western australia. from to , marshall and his colleagues conducted surveys for arbovirus activity, particularly rrv and mvev, in coastal regions of new south wales and in the murray river valley. in addition to these and other known arboviruses, marshall and colleagues isolated several novel arboviruses from mosquitoes, including gan gan, yacaaba, tilligerry and termeil, paroo river, picola, and barmah forest viruses [ , ] and a novel reovirus, nelson bay virus, from a fruit bat (pteropus poliocephalus) [ ] . like the related alphavirus rrv, the barmah forest virus was subsequently shown to be a cause of epidemic polyarthritis in humans [ , ] , with infections occurring commonly throughout australia [ ] . the gan gan virus also infects humans and is suspected of an association with epidemic polyarthritis [ ] . marshall also conducted a number of collecting trips to papua new guinea from to funded by the rockefeller foundation. during an expedition to the sepik river district of papua new guinea in - , he isolated the joinjakaka virus from a mixed pool of culicine mosquitoes and the japanaut virus from both culicine mosquitoes and a fruit bat (syconycteris crassa). in western australia, stanley and colleagues surveyed for arbovirus activity in the ord river valley from to [ , ] . from , mosquitoes of species, virus isolates were recovered, including isolates of mvev and isolates of the kunjin virus from cx. annulirostris, suggesting the region may be an endemic focus in australia [ ] . the study also identified eight novel viruses, including kimberly, parry's creek, ord river, and kunnanurra viruses, as well as four unknown isolates (or , or , or , and or ), which have yet to be characterized [ , ] . continuing surveillance in western australia by others has continued to reveal novel arboviruses, including oak vale, stretch lagoon, parry's lagoon, and fitzroy river viruses [ ] [ ] [ ] [ ] . in , csiro established a new virology laboratory at long pocket in brisbane, headed by toby d. st. george, to investigate endemic diseases of livestock in northern australia. in , doherty and colleagues had isolated bovine ephemeral fever virus (befv) from cattle during a major epizootic in queensland [ ] but, despite epidemiological evidence suggesting vector-borne transmission, the virus had never been isolated from insects. this led st. george and colleagues to attempt virus isolations from a location in northern australia, where serological monitoring of a sentinel herd of cattle indicated that befv was likely to be enzootic. for a continuous period from october until may , insect collections for virus isolation were conducted at beatrice hill southeast of darwin. from the , mosquitoes and , biting midges processed, one isolate of befv was recovered (from a mosquito pool). however, the collection also yielded other virus isolates from different serological groups, including four novel viruses (csiro village, marrakai, beatrice hill, and humpty doo virus) [ ] . most significantly, the collection also yielded a single isolate of a novel serotype of bluetongue virus (btv serotype , btv- ), a major pathogen of sheep and goats that had previously been regarded as exotic to australia [ ] . the isolation of btv- and the consequences for international trade dramatically changed the landscape with respect to virus discovery and characterization in australia. an immediate consequence was the approval of government expenditure for the establishment of the $ million csiro australian animal health laboratory (aahl) in geelong, victoria, providing high-level biosecure containment for laboratory work and live animal studies. the discovery also led to the establishment of a permanent veterinary virology capability at the berrimah veterinary laboratory in darwin under geoff p. gard, and a national program for serological monitoring of sentinel cattle herds and the collection of insect vectors. efforts to isolate viruses from arthropods and livestock intensified. in the northern territory, a second novel serotype of bluetongue virus (btv- ) was isolated from a healthy sentinel cow at victoria river station in [ ] , and four other novel arboviruses (coastal plains, berrimah, adelaide river, and koolpinyah viruses) were isolated from healthy cattle between and [ ] [ ] [ ] [ ] . in queensland, eight novel arboviruses were first isolated between and from biting midges (tibrogargan, tinaroo, peaton, wongabel, and walkabout creek viruses), healthy sentinel cattle (the douglas virus), and soft ticks (argas robertsi) (vinegar hill and lake clarendon viruses) [ , [ ] [ ] [ ] [ ] [ ] . surveillance activities by the berrimah veterinary laboratory have continued to the present, with regular reports of the isolation of novel arboviruses. continuing surveillance by others in northern australia has also resulted in the isolation from mosquitoes of the bamaga virus and new mapoon virus from cape york [ , ] . the s also saw several significant disease emergence events in australia, which drew particular attention to bats as reservoir hosts of highly pathogenic viruses. in september , an outbreak of a severe respiratory disease occurred in horses at a stable in brisbane. of the affected horses were euthanized or died of the disease. one of two severely affected humans who had contact with the horses also died. cooperation between the queensland government, the newly established csiro australian animal health laboratory, and others resulted in rapid isolation of the hendra virus, a novel paramyxovirus [ ] , and the identification of fruit bats as reservoir hosts [ , ] . the hendra virus has since re-emerged regularly in australia, with more than confirmed cases in horses and seven infected humans, four of whom have died. in , an injured female fruit bat (pteropus alecto) was found at ballina in new south wales. tissue homogenates from the euthanized bat were injected into mice, resulting in the isolation of a novel lyssavirus, subsequently named australian bat lyssavirus (ablv) [ ] . three fatal human cases of ablv infection have subsequently been reported [ ] [ ] [ ] . the virus is now known to occur at low prevalence in five of six families of bats endemic to the northern territory, queensland, and western australia [ ] . in april , another novel paramyxovirus, the menangle virus, emerged at a commercial piggery in new south wales, causing stillbirths with abnormalities of the brain, spinal cord, and skeleton [ ] . two humans exposed to the pigs also developed an influenza-like illness [ ] . fruit bats were again implicated as reservoir hosts [ ] . the role of bats in the ecology and emergence of pathogenic viruses has been a major focus of study in australia since that time, primarily involving research teams led by hume e. filed and linfa wang. in all, more than novel rna viruses representing families and genera have been isolated from humans, livestock, wildlife, and arthropods in australia and papua new guinea, and reported in the literature (table s ). many others have been isolated but remain uncharacterized and/or unreported. more complete characterization of these viruses will be facilitated greatly by the use of ngs. south and southeast asia have also been a fertile area for virus discovery, particularly novel mosquito-borne and tick-borne flaviviruses and viruses with reservoirs in bat species. early studies in india, partly funded by the rockefeller foundation, by telford work and his indian colleagues from the virus research centre in pune, including d.p. murthy, p.n. bhatt, h. trapido and k. pavri, led to the discovery of the kyasanur forest disease (kfd) virus [ ] . the virus was isolated from sera and tissues collected from a moribund black-faced langur (presbytis entellus). this followed reports of an epizootic of unknown etiology causing large numbers of deaths in non-human primates and a number of cases of severe febrile illness in villages close to forested areas where dead monkeys had been found. the virus was shown to be closely related to the russian spring-summer encephalitis (rsse) serocomplex of flaviviruses, now known as the tick-borne encephalitis (tbe) serocomplex of flaviviruses. the virus was also isolated from some larvae and nymphs of hemaphysalis spinigera ticks [ ] . kfd in humans followed a biphasic course, not unlike tbe, but with some hemorrhagic manifestations not seen in tbe, and without either meningitis or encephalitis. another tick-borne virus related to the rsse serocomplex, langat virus, had been isolated two years earlier from a pool of hard ticks, ixodes granualtus, collected from forest rats caught near kuala lumpur, malaysia, by c.e. gordon smith, then working at the institute for medical research in kuala lumpur [ ] , but it is not known to be a human pathogen. a number of mosquito-borne flaviviruses were first isolated in southeast asia. the most important with respect to human disease are three of the four dengue serotypes. although dengue serotype had been first isolated independently by hotta in japan in [ ] , and shortly after by sabin in cincinnati in with material collected in hawaii [ ] , the other three serotypes were first isolated from material collected in southeast asia. dengue serotype was also isolated by sabin in from material obtained from new guinea [ ] and dengue serotypes and were first isolated in from human sera and aedes aegypti and culex tritaeniorhynchus mosquitoes collected during a major outbreak of epidemic hemorrhagic fever in manila, philippines, by w.m. hammon, a. rudnick, and colleagues at the university of pittsburgh [ ] . other novel flaviviruses have been isolated in malaysia, thailand, and papua new guinea [ ] . the tembusu (tmuv) virus was isolated in kuala lumpur in from various mosquito species [ ] and was the first of several closely related viruses, including the thcar virus, which was isolated from a pool of cx. tritaeniorhynchus mosquitoes collected in chiang mai, thailand, in [ ] ; the sitiawan virus, from sick broiler chicks in malaysia [ ] ; and the duck tembusu virus, an infection of ducks and geese causing an egg-drop syndrome in china and southeast asia [ , ] . neutralising antibodies were found in humans in malaysia [ ] but the virus has not been implicated in human disease. two other mosquito-borne flaviviruses have been described, jugra virus and sepik virus. little is known about the jugra virus, which was isolated from aedes spp. and uranotaenaia spp. mosquitoes and from the blood of a cynopterus brachyotis fruit bat [ ] . the sepik virus was isolated in by ian d. marshall and colleagues from a pool of mansonia septempunctata mosquitoes collected in the sepik district of papua new guinea [ ] . it was associated with a hospitalized case of febrile illness of unknown origin, with rising neutralising antibody to the virus. the sepik virus is particularly interesting, as its nucleotide sequence analysis shows it to be the closest known flavivirus to yellow fever virus [ ] . a novel lineage of the west nile virus was isolated in sarawak, east malaysia, by d.i.h. simpson, e.t.w. bowen, and colleagues, from cx. pseudovishnui group mosquitoes [ ] . initially called kunjin virus, it was shown to differ significantly in genomic sequence from the australian kunjin viruses, which have been shown to comprise west nile lineage b viruses, and have been described as west nile lineage virus [ ] . two flaviviruses with no known vector have been isolated in southeast asia, both from cy. brachyotis fruit bats: the carey island virus was isolated from a bat in the jugra forest, malaysia, in by a. rudnick and colleagues from the institute of medical research, kuala lumpur and the international center for medical research, university of california [ ] , and the phnom penh virus was isolated by j.j. salaun and colleagues in from the salivary glands and brown of bats [ ] . a closely related virus, the batu cave virus, is considered to be a variant of phnom penh virus. a considerable number of novel bunyaviruses have been isolated from south and southeast asia, particularly by scientists from the national institute of virology (formerly the virus research centre) in pune, including p.n. bhatt, k. pavri, k.r. singh, c.n. dandawate, f.m. rodrigues, d.t. mourya, p.d. yadev, a.c. mishra, and many others. recently reviewed in [ ] , these viruses include the orthobunyaviruses, umbre, kaikalur, thimiri, and sathuperi viruses; a nairovirus, ganjam virus; phleboviruses, bhanja, and malsoor viruses; a hantavirus, thottapalayam virus; and two uncharacterized viruses, kaisodi and wanowrie viruses. additionally, novel bunyaviruses, batai and oya viruses, have been isolated in malaysia, the former from cx. gelidus mosquitoes [ ] and the latter from pigs [ ] , and the kaeng khoi virus was isolated from tadarida plicata bats in thailand. novel orbiviruses from south and southeast asia include the sathuvachari virus, isolated from starlings (brahminy myna) collected in vellore, tamil nadu, india, and most closely related to the mosquito-borne orbiviruses [ ] ; and the japanaut virus, isolated from a mixed pool of culicine mosquitoes from papua new guinea [ ] . new rhabdoviruses first isolated in south asia include the chandipura virus and joinjakaka virus-the former, a major human pathogen in india, was isolated from a human infection in near nagpur city [ ] , whereas the latter, isolated in from a mixed culicine pool in the sepik district of papua new guinea, is not associated with disease in humans or animals. chandipura infection is characterized by fever, chills, arthralgia, myalgia, vomiting, and weakness. two novel alphaviruses were reported in kuala lumpur-bebaru and getah viruses. bebaru was first isolated from cx. (lophoceraomyia) spp. collected in , but although neutralising antibodies have been found in human sera, it has not been associated with human disease [ ] . getah virus was first isolated from cx. gelidus mosquitoes collected in near kuala lumpur [ ] . it causes a mild disease in horses, characterized by pyrexia, edema of the hind limbs, swelling of the submandibular lymph nodes, and urticarial rash. it also causes a mild disease in pigs, with occasional reproductive problems, including abortion and neonatal infections. neutralising antibodies have been found in a number of animals and in humans. the important role of bats as reservoirs of a wide range of viruses was underlined by a number of the viruses described above, and particularly by the discovery of their role as the reservoir of the nipah virus in malaysia in [ ] and subsequently their probable role as the origin of severe acute respiratory syndrome coronavirus (sars-cov) [ , ] . the nipah virus, a virus closely related to the hendra virus in australia, was first isolated k.b. chua and s.k. lam during an outbreak of severe disease of humans and pigs in - in peninsula malaysia [ ] , resulting in human cases with a mortality of %, and the culling of over million pigs. transmission to humans was from infected pigs. the disease in humans was a rapidly progressive encephalitic syndrome, with a significant pulmonary syndrome in some patients [ ] . in pigs, the disease was spread via the respiratory tract, and the symptoms were either neural or pulmonary, or both. subsequent epidemics in bangladesh and india have substantially expanded our knowledge of the nipah virus, and have demonstrated that direct transmission of the virus from bats to humans can occur through the consumption of date palm juice, and possibly by other routes, and that mortality rates may often be significantly greater than in malaysia [ ] . furthermore, evidence of nipah-like and hendra-like viruses have been detected either by isolation or serology from other pteropid bats across the geographic range of the genus, and related viruses may be carried by other bat species on other continents. sars-cov was first isolated by m. peiris and colleagues in hong kong [ ] , and contemporaneously in the u.s. [ ] and europe [ ] . it was shown to be unrelated to other coronaviruses. transmission to humans is believed to have been via an intermediate host, such as the himalayan palm civets (paguna larvata), through wet markets in southern china. continued studies of the nipah virus in malaysia, and subsequently in bangladesh and india, and investigations of sars-cov in bats have resulted in an enormous explosion of knowledge of viruses carried by bats, with many examples from most viral families, although in many cases the information is from genomic fragments [ ] . virus isolations have been made from bats, especially frugivorous bats, from india and malaysia. one of the earliest isolations was a paramyxovirus of the genus rubulavirus, which was isolated from a rousettus leschenaultia bat collected near pune in india [ ] . a novel adenovirus from the genus mastadenovirus was also isolated from the same fruit bat species caught in maharashtra state [ ] . a number of viruses have been isolated from fruit bats in malaysia by k.b. chua, s.k. lam, l.f. wang, and their colleagues-tioman virus, a paramyxovirus in the genus rubulavirusi, isolated from pteropus hypermelanus and related to the australian menangle virus, but not known to cause human disease [ ] ; pulau virus, an orthoreovirus related to the nelson bay virus of australia, and not associated with human or animal disease [ ] ; melaka virus, an orthoreovirus, causing acute respiratory disease in humans [ ] ; and kampar virus, an orthoreovirus related to the melaka virus, and also causing acute respiratory disease [ ] . the importance of orthoreoviruses originating in pteropid bats was assessed in an outpatient clinic, where it was found that pteropine orthoreoviruses are among one of the common causative agents of acute upper respiratory tract infection (urti), with a cough and sore throat as the most common presenting clinical features [ ] . the history of arbovirus research in the ussr began in , when an expedition under the leadership of lev a. zilber (at the time, the head of central virological laboratory of narkomzdrav ussr in moscow) went to the russian far east to study seasonal epidemic encephalitis. this disease with high mortality rates affected forest workers and soldiers stationed in the taiga, mainly those who came from other regions of the ussr. the disease had a pronounced seasonality-the cases started being recorded at the beginning of may, reached the peak in early june, and declined by august. local doctors designated the disease "spring-summer encephalitis" (sse) and assumed that it had been caused by some kind of virus. it has also been suggested that there were some similarities between sse and "summer encephalitis" (japanese b encephalitis and st. louis encephalitis) described at the time, it was also assumed to be a toxic form of influenza [ ] . however, the etiology and transmission routes of sse remained unclear. during summer of , zilber and colleagues isolated at least strains of a new virus from the blood and cerebrospinal fluid of sick people, and from brain tissues of dead patients. the isolated virus had a weak antigenic relationship (in complement fixation tests) with japanese b encephalitis virus [ ] . based on comparative analysis of epidemiologic data and the seasonal abundance of ixodes persulcatus ticks in the taiga, zilber assumed that sse was transmitted by ticks, in contrast to "summer encephalitis", which is transmitted by mosquitoes [ ] . several strains of the virus were isolated from the ix. persulcatus ticks, and their ability to transmit the virus by biting laboratory animals was shown experimentally [ ] . one of the first isolated strains (sofjin) was used for infecting rhesus macaques, which developed the clinical symptoms with signs of central nervous system (cns) impairment, similar to those in sick people [ , ] . so, the etiological agent of sse, which was subsequently given the name tick-borne encephalitis, was discovered and is now known by the name tick-borne encephalitis virus (tbev). in - , subsequent expeditions under the leadership of pavlovsky and smorodintsev studied in detail various aspects of the ecology, epidemiology, and pathogenesis of tbev, as well as the protective properties of the first anti-tbe vaccine, obtained from the brain tissue of mice infected by the tbev strain sofjin [ ] [ ] [ ] . further studies showed that tbev is also prevalent in other regions of the ussr, including the european part, where the main vector of the virus is ix. ricinus ticks. at the same time, it was found that tbev is also an etiological agent of some seasonal encephalitis or febrile illnesses, such as central european encephalitis or biphasic milk fever [ ] [ ] [ ] . the strains of tbev were initially divided into two geographical subtypes ("far eastern" and "central european"). these subtypes differed in severity of the illness and had antigenic differences in virus neutralization tests with serum of convalescents [ ] . a third subtype of tbev ("west siberian") was described by pogodina and her colleagues in [ ] . genetic data that has been accumulating since the late s confirms the existence of three main tbev subtypes (or genotypes). the nucleotide difference between genotypes reaches - % when comparing complete genomes [ ] [ ] [ ] . tbe is the most important arboviral infection in russia. despite significant progress in the development of anti-tbev vaccines, thousands of cases are recorded annually in russia, mainly in siberian and far eastern regions [ ] . in the modern classification, tbev belongs to the species tick-borne encephalitis virus of the genus flavivirus (flaviviridae) [ ] . tbev is widely distributed within the area of its main arthropod vector-ix. persulcatus and ix. ricinus ticks, including russia, eastern and central europe, baltic and scandinavian countries [ , ] . the discovery of tbev as a causative agent of sse gave an impetus to studies of similar diseases throughout the ussr. during subsequent years, the major virological centres were established as parts of the academy of medical science of the ussr (ams ussr), such as the department of neurovirology at the institute of neurology ( ), the institute of virology ( ), the institute of poliomyelitis and viral encephalitis ( ), as well as departments of virology at regional medical institutes in siberia and the far east. scientists from these centres were actively involved in the study of various zoonotic viral infections distributed in the ussr. many participants of the first expeditions subsequently became famous virologists. one of the most notable ones is michael p. chumakov, who later headed the institute of virology ams ussr ( ) ( ) ( ) ( ) ( ) and the institute of poliomyelitis and viral encephalitis ams ussr ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) in moscow. chumakov organized numerous expeditions that aimed to study the etiology of zoonotic human infections. in the s, outbreaks of the disease, designated by local doctors as "atypical tularemia", "anicteric leptospirosis", and "omsk spring-summer fever", were recorded in several rural regions of the omsk district in western siberia. clinicians from the omsk medical institute, under the leadership of ahrem-akhremovich, described the disease in detail and named it omsk hemorrhagic fever (ohf), as the patients often developed hemorrhagic diathesis. they also suggested that ohf was transmitted by dermacentor reticulates ticks, which are highly prevalent in the region [ , ] . in , chumakov and colleagues investigated the blood of patients with ohf and isolated strains of a new virus, which was similar but different from tbev in serologic tests. the virus was named omsk hemorrhagic fever virus (ohfv). several strains of ohfv were also isolated from de. reticulates ticks collected in the natural foci of ohf [ , ] . in subsequent years, the ecology of ohfv was extensively studied by scientists from the omsk medical institute and the institute of poliomyelitis and viral encephalitis ams ussr. the de. reticulatus ticks and their host, a narrow-headed vole (microtus gregalis), are considered an original natural reservoir of ohfv. the european water vole (arvicola amphibius), the tundra vole (microtus oeconomus), and some species of shrews are also involved in the circulation of ohfv [ ] . however, the emergence of ohf outbreaks in the s was presumably a consequence of the introduction by humans of muskrats (ondatra zibethicus) to this region in - [ ] . muskrats are highly susceptible to ohfv and serve as an extremely effective amplifying host. the appearance and growth of the muskrat population in the natural foci of ohf led to an increase in infection rates in other animals and ticks [ , ] . in addition to transmission of ohfv by ticks, humans can get infected while hunting and skinning, by direct contact with blood and excretions of infected animals. such "muskrat outbreaks" among hunters and their family members have been registered in the region at different times of the year, including winter, which is the season of active hunting for muskrats [ , ] . based on antigenic relationships, ohfv was assigned to the tbe antigenic complex [ ] , and later was classified as a separate species, omsk hemorrhagic fever virus of the genus flavivirus (family flaviviridae) [ ] . genome sequence analysis confirmed the close evolutionary relationships of ohfv with tbev [ ] [ ] [ ] . in , virologists led by chumakov studied the etiology of an outbreak of a febrile illness which was accompanied with hemorrhagic manifestations ("acute infectious capillary toxicoses") in a rural area in the northwest part of the crimean peninsula. they designated the disease as crimean hemorrhagic fever (chf) and suggested that is transmitted by hyalomma (plumbeum) marginatum ticks. despite the absence of virus isolates from specimens from chf patients or from ticks, the viral etiology of chf and its zoonotic nature were proven experimentally by infecting volunteers with the blood of chf patients or a filtered suspension of ticks collected from a hare caught in the focus of the disease [ ] . sporadic cases and outbreaks of chf were subsequently recorded almost annually in southern regions of the european ussr and central asian soviet republics. the first strains of the chf virus were isolated by alexander m. butenko from chumakov's team in , from sera of chf patients and from hy. marginatum nymphs isolated in southern russia [ , ] . later, the chf virus was shown to be identical to the congo virus isolated from a patient with hemorrhagic fever in zaire (present day democratic republic of congo) and the virus received its present name, the crimean-congo hemorrhagic fever virus (cchfv) [ ] . cchfv is a one of the prototypic nairoviruses and today is assigned to the species crimean-congo hemorrhagic fever virus, of the genus orthonairovirus (nairoviridae: bunyavirales). during spring and summer , chumakov, together with libíková from the institute of virology in bratislava (former cžechoslovakia), investigated an outbreak of fibrile illness in the kemerovo district in western siberia. initially, it was assumed that the patients were affected by tbe, but the sera of the patients did not react with tbev-specific antigen in serological tests. on the contrary, a new virus, named the kemerovo virus (kemv), was isolated from the blood of patients. several strains of kemv were also isolated from ix. persulcatus ticks collected in the region where the outbreak occurred [ , ] . similar to kemv, the tribeč virus and lipovníc virus were isolated from ix. ricinus ticks in czechoslovakia in [ , ] . based on morphological studies, kemv was classified to the genus orbivirus (family reoviridae) [ ] . the ecology of kemv in russia has not been studied sufficiently, but recent research has shown that its prevalence in ix. persulcatus, ix. ricinus, ix. pavlovsky, and de. reticulatus ticks varies from zero to . % in different regions of the country [ , ] . from the above, it follows that in the period - , arboviruses in the ussr were studied mostly as causative agents of human disease. examinations of arthropods and vertebrates in the natural foci of important human disease often led to exploring some other arboviruses. for example, butenko isolated the west nile virus (wnv) and dhori virus (dhov) from hy. marginatum ticks for the first time in the ussr while studying the natural foci of cchfv in the southern region of russia in [ ] . in the late s, there was an ecological trend in virology developing in the ussr. the founder of the ecological approach to virology in the ussr was dmitry k. lvov, who established the department of the ecology of viruses at the d.i. ivanovsky institute of virology in moscow ( ) , and later headed the institute ( - ). under his leadership, an ecological and virological survey was organized, aimed to identify the arboviral diversity in hematophagous arthropods and wild animals of the entire ussr. the survey included collecting and examining mosquitoes, ticks, and vertebrate animals (mostly rodents and birds), as well as samples from humans, in different types of biocenoses located in different climatic zones of the ussr. lvov and colleagues isolated more than strains of different mosquito-borne viruses, including viruses of the california encephalitis antigenic group (species california encephalitis orthobunyavirus) and batai and batai-like viruses (species bunyamwera orthobunyavirus) in the genus orthobunyavirus, family peribunyaviridae [ ] [ ] [ ] [ ] . the other mosquito-borne viruses whose circulation was discovered and studied extensively, are the sindbis virus (sinv) and getah virus (getv) (genus alphavirus, family togaviridae) [ ] [ ] [ ] . one of the important subjects of d. lvov's research was ix. uriae ticks, which parasitize on colony-nesting sea birds. in - , more than virus strains were isolated from ix. uriae ticks collected in the nests of sea birds on the coasts and islands in the sea of okhotsk, the bering sea, and the barents sea [ ] . the isolated strains were mostly classified as novel bunyaviruses, flaviviruses, and orbiviruses, often based on morphological studies of the virion structure only, because their antigenic relationships with other viruses were not known at the time. among them, the sakhalin virus (sakhv) and paramushir virus (prv) were described as a novel bunyaviruses and later classified to the species sakhalin orthonairovirus (genus orthonairovirus, family nairoviridae) [ ] . several other new viruses (zaliv terpenia, comandory, and rucutama viruses) were discovered and now belong to the species uukuniemi phlebovirus (genus phlebovirus, family phenuiviridae) [ ] . the tyuleniy virus (tyuv) was isolated for the first time, which is one of the prototypic viruses of seabird tick-borne flaviviruses group (genus flavivirus, family flaviviridae) [ ] . the prevalence of the okhotsky virus (okhv) and aniva virus (aniv), two newly described viruses belonging to the species great island virus (genus orbivirus, family reoviridae), have been studied in detail [ , , ] . many new viruses were discovered by lvov and his colleagues while exploring the territories of central asia and transcaucasia. they isolated and studied the issyk-kul virus (iskv), which is associated with bats of the family vespertionidae and their argasid ticks [ , ] . new viruses, tamdy (tamv) and burana (burv), were isolated from hyalomma spp. ticks collected from sheep or cows in pasture lands [ ] . some novel viruses (artashat, chim, and geran viruses) were isolated from argasid ticks collected in rodent burrows [ ] . morphological studies of these viruses by electron microscopy identified them as bunyaviruses. recently, they were classified as different species of the genus orthonairovirus (family nairoviridae) [ ] . in total, during the ecological and virological surveys of the s to s, thousands of strains of different arboviruses were isolated, some of which remain to be classified. based on the studies conducted by soviet and russian virologists, we now know that at least zoonotic viruses, assigned to eight viral families, circulate on the territories of the former ussr [ ] . does this number reflect the true diversity of viruses circulating in the vast territory of northern eurasia? this question can only be answered by additional research aimed at finding new viruses, using new methods and approaches. the concept of viruses developed from the observations of ivanovsky and beijerinck of "filterable agents", with the discovery of the causative agent of tobacco mosaic in the s. yellow fever virus and dengue virus were the first two arboviruses to be isolated early in the th century [ , ] . the pioneering work of alexis carrel on the development of many cell and tissue culture methods in the s at the rockefeller institute, and later refinements by maitland, eagle, and enders, led to the widespread use of various culture systems as indispensable tools for virus studies [ ] [ ] [ ] . although these tools have since been used extensively for the in vitro characterization of viruses, they were inadequate for the identification and classification of a flood of novel viruses collected through the yfv surveillance program supported by the rockefeller foundation. jordi casals, among others, led the use of the complement fixation (cf) test in order to study viruses affecting the central nervous system. the cf test exploits the unique affinity of complement for antigen-antibody complexes. the original assay was developed in the s for the serologic study of yfv, was improved in the s [ , ] , and its sensitivity and specificity improved again in the s [ ] . using cf tests, casals and his colleagues were able to classify viruses into antigenic groups. however, the inherent complexity and labour consuming aspects of the assay (titrations of antigen, complement, and hemolysin for optimal outcomes), technical demands (accurate interpretation of outcomes) and the development of alternative assays (see below), have restricted its applicability in laboratories worldwide. hirst observed in that chicken erythrocytes agglutinated in the presence of the influenza a virus and that virus-specific antibodies inhibited agglutination, forming the foundation for the hemagglutination inhibition (hi) test [ ] . a decade later and on theiler's suggestion, casals showed that many arboviruses also agglutinated erythrocytes, establishing the hi test as a diagnostic tool for arbovirus infection and identification [ ] . the gold standard for arbovirus identification, the plaque reduction neutralization test (prnt), has its origins in the observations of stokes and colleagues, dating back in the s when monkeys could be protected against yfv by the inoculation of convalescent sera from patients who had recovered from the disease [ ] . by the early s, max theiler had adapted the assay for use in mice, in which mixed serum and virus was inoculated intracerebrally [ ] . the cell culture adaptation of the test was first demonstrated by itoh and melnick in for studying the seroconversion of chimpanzees infected with echoviruses [ ] , and a year later by henderson and taylor to detect antibodies to the eastern equine encephalitis virus [ ] . versions of this assay are now widely used, including the microprnt [ ] , the virus reduction neutralization test (vrnt) [ ] , the focus reduction neutralization test (frnt) [ ] , the rapid fluorescent inhibition test (rffit) [ ] , the flow-cytometry neutralization [ , ] , the colorimetric micro-neutralization assay (cmnt) [ ] , and the reporter virus particle-based neutralization assays [ ] [ ] [ ] [ ] . historically, these methods (virus isolation, hi, cf, and neutralization tests) served as the basis of arbovirus diagnosis for many years, augmenting electron microscopy (see section below), which allowed the visualization of viruses in infected tissues and cell cultures. however, an inherent limitation of the serology-based assays has been their inability to determine whether antibodies in the examined serum were the result of a recent or past infection. this conundrum was solved by determining whether antibodies were igm (recent infection) or igg (past infection), using the enzyme-linked immunosorbent assay (elisa) [ ] . the introduction of elisa revolutionized the field by also offering increased specificity and sensitivity for the accurate detection of many viruses. overall, although identification of pathologic agents through serologic assays is quite straightforward, there are instances where accurate identification may not be possible due to cross-reactivity. for example, cross-reactivity among flaviviruses poses a challenge in their identification, even when the "gold standard" of prnt for arbovirus detection is applied, especially in hyper-endemic settings of flavivirus circulation. several diagnostic labs faced this challenge during the recent emergence and explosive spread of the zika virus in the americas. a similar challenge is also common for the serologic diagnosis of bunyavirus infections, which is attributed to their ability to reassort. in this scenario, a novel bunyavirus may be misidentified as a known pathogen due to the presence of the m segment (contributed by the known pathogen), which encodes the immune-reactive envelope proteins (reviewed in [ ] ). since the beginning of modern virology in the s, transmission electron microscopy (tem) has been one of the most important and widely used techniques for the identification and characterization of new viruses. two tem techniques are usually used for this purpose: negative staining on an electron microscopic grid coated with a support film and (ultra) thin section tem of infected cells, fixed, pelleted, dehydrated, and embedded in epoxy plastic. negative staining can be conducted on highly concentrated suspensions of purified virus or cell culture supernatants. for some viruses, tem can be conducted on contents of skin lesions (e.g., poxviruses and herpesviruses) or concentrated stool material (rotaviruses and noroviruses). for successful detection of viruses in ultrathin sections of infected cells, at least % of cells must be infected, and so either high multiplicity of infection (moi) or rapid virus multiplication is required. viruses can be differentiated by their specific morphology (ultrastructure): shape, size, intracellular location or, for some viruses, from the ultrastructural cytopathology and specific structures forming in the host cell during virus replication. usually, ultrastructural characteristics are sufficient for the identification of a virus at the level of a family. in certain cases, confirmation can be obtained by immuno-em performed either on virus suspension before negative staining or on ultrathin sections. this requires virus-specific primary antibodies, which might be not available in the case of a novel virus. for on-section immuno-em, oso post-fixation must be omitted and the partially dehydrated sample must be embedded in a water-miscible acrylic plastic (usually lr white). the ultrastructure of most common viruses is well documented in good atlases and book chapters [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] and many classical publications of the s, s, and s. several excellent reviews were recently published on the use of tem in the detection and identification of viruses [ ] [ ] [ ] . the advent of next generation sequencing (ngs) has expanded the tool kit of the virus hunter. for many years, sanger-based sequence analysis has been employed in the identification and characterization of viruses [ ] [ ] [ ] [ ] . however, with the completion of the human genome sequence, the necessity for a high throughput approach that provided a massively-parallel sequencing strategy was fully apparent [ , ] . the automated sanger method was considered a first-generation technology and newer methods are referred to as next generation sequencing (ngs). commercially available technologies from roche/ , illumina, life technologies/apg, oxford nanopore, and pacific biosciences offer unique ngs platforms, and all have been extensively reviewed [ ] [ ] [ ] [ ] [ ] . unlike sanger sequencing, ngs does not require prior knowledge of the viral sequence and thus can be used for viruses of unknown sequence. many viruses cannot be cultured in the cell culture systems currently in use. ngs has shifted the paradigm by removing the need for cell culture and so opening the door to the discovery of many new viruses. the first instruments for ngs were developed in the s and commercialized in the early s, and they were quickly adopted for the identification of novel viruses from a wide range of sources. the number of known viruses increased from about , in to approximately , viruses in [ ] , and that number has since increased dramatically. the technology has also been applied to sequence analysis of many previously known but poorly characterized viruses. this has significantly expanded the known virosphere and assisted in understanding the diversity and evolutionary relationships of viruses. the expansion of the known virosphere has also allowed the taxonomic assignment of an increasing number of viruses, with a total of orders, families, genera, and species of viruses currently approved by the international committee on taxonomy of viruses (ictv) [ ] [ ] [ ] [ ] [ ] [ ] . ngs has also allowed sequence analysis of hundreds or thousands of isolates known pathogenic viruses, facilitating epidemiological studies at scales extending from very local to global. this has generated a trove of new knowledge of significant public health importance. however, without the availability of isolates, ngs has not necessarily increased our understanding of the ecology of novel viruses, their host range, and the risks they may pose to public, veterinary, agricultural, or environmental health. the application of ngs to the unbiased mass sequencing and bioinformatic analysis of total nucleic acids extracted from biological samples obtained from a wide range of sources has led to an explosive increase in the number of complete or near-complete viral genomes. for example, a recent study using ngs to sequence the transcriptomes of arthropods representing species from four classes (insecta, arachnida, chilopoda, and malacostraca) identified novel viruses, many of which are represented by complete or near-complete genomes [ ] . the novel viruses encompass the entire taxonomic diversity of previously known families and/or genera of (-) ssrna viruses and include divergent viruses with entirely novel and unusual genome architecture. similarly, sequence analysis of the transcriptomes of animals of more than species sampled across nine metazoan phyla (arthropoda, annelida, sipuncula, mollusca, nematoda, platyhelminthes, cnidaria, and echinodermata), as well as chordates of the subphylum tunicata (salps and sea squirts), resulted in the discovery of rna viruses, mostly represented by complete or near-complete genomes [ ] . based on phylogenetic analysis of rna polymerase (rdrp) domain sequences, the novel viruses included clades representing many established families of plant and animal rna viruses, as well as at least five clades that are so divergent that they are considered as likely new virus families or orders. also, the sequencing of transcriptomes of gut, liver, and lung or gill tissue of fish, reptiles, amphibians, and birds identified novel vertebrate-associated viruses, representing every family or genus of rna virus associated with vertebrate infection, including those containing important human pathogens (orthomyxoviruses, arenaviruses, and filoviruses) [ ] . these and other similar studies have heralded a new era in virology, revealing new dimensions in viral biodiversity and providing largely unexpected insights into the deep evolutionary history of viruses. however, only a minor subset of newly discovered viruses has been subject to full phenotypic characterization which can provide critical and fundamental insights into their biology and virus-host interactions, ultimately transforming our understanding of the evolutionary forces that shape the virosphere and disease emergence. realistically, as important as these discoveries are to the advancement of science, very few of the viruses will ever cause human disease or influence the global economy. this mass sequencing approach, which has been called viral metagenomics, can also be applied in a more targeted way to identify viruses in clinical cases of diseases of unknown etiology or to survey for potentially novel zoonotic viruses that may represent a significant risk of transmission to humans. indeed, ngs is being used increasingly in conjunction with real-time pcr as a front-line tool in medical and veterinary settings for rapid detection and identification of exotic or unknown emerging viruses. for example, in , an outbreak of acute hemorrhagic fever occurred in mangala, democratic republic of congo (drc), involving three human cases, two of which were fatal. as no positive diagnosis was obtained using real-time pcr for known viral hemorrhagic fevers in africa, ngs was conducted on acute phase serum collected from the surviving patient, revealing the near-complete sequence of a novel rhabdovirus, bas-congo virus (basv; species bas congo tibrovirus) [ ] . although the disease was attributed by the investigators to the novel virus, no isolate was obtained and there was no evidence of neutralising antibodies in serum samples from undiagnosed hemorrhagic fever cases or random serum donors from the drc. subsequently, ngs of blood collected from healthy individuals from nigeria identified two related viruses, ekpoma virus (ekv- ; species ekpoma tibrovirus) and ekpoma virus (ekv- ; species ekpoma tibrovirus), and a serological survey indicated that antibodies to these or similar viruses occur commonly in healthy humans in nigeria [ ] . however, once again, neither virus was isolated. interestingly, several other tibroviruses had previously been isolated from healthy cattle or biting midges (culicoides spp.) in australia and florida [ , , , ] . none have been associated with either disease in livestock or the infection of humans [ , ] . these and other studies raise important issues regarding the significance of ngs data, even when providing complete or near-complete viral genome sequences, when investigating disease etiology. most viruses can cause asymptomatic infections and many newly discovered viruses may be benign in their natural host. therefore, in the absence of a virus isolate which can be used for experimental studies, establishing a causal association with disease based only on detection of the viral genome should be approached cautiously. the availability of a rapidly expanding number of novel viral genomes identified by metagenomic studies has also presented challenges for virus taxonomy-a system for classification of viruses that is administered by the international committee on taxonomy of viruses (ictv). should viruses detected only by their nucleotide sequence be classified and assigned to species and other higher taxa (genus, family order, etc.) alongside viruses for which we have a viable isolate? the ictv (then the international committee on nomenclature of viruses) was established in at the ninth international congress for microbiology in moscow, publishing its first report in [ ] . it operates under the auspices of the international union of microbiological societies (iums), with the authority to develop, refine, and maintain a universal virus taxonomy. historically, the description and classification of a new virus by the ictv required significant information, such as host range, serology, replication cycles, and structure, aspects that could be determined from the study of isolates. on the other hand, sequences alone provide a trove of information, including evolutionary relationships (e.g., phylogeny), genome organization (e.g., the number of genes and their order), presence or absence of distinctive motifs (e.g., protein cleavage sites, terminal sequences, internal ribosome entry sites), as well as genome composition (e.g., codon usage, gc content), which of course could be used to inform classification into species. these concerns framed the contents of a workshop of experts and members of the ictv, resulting in a seminal consensus statement in which viruses identified only from metagenomic data are considered to be bona fide viruses and thus candidates for taxonomic assignment [ ] . the expanding diversity of the known virosphere also presented challenges. a recent analysis of metagenomes of geographically and ecologically diverse samples led to the discovery of , new partial dsdna viral genomes encoding more than . million proteins, % of which had no sequence similarity to proteins from known virus isolates [ ] . other metagenomic studies have revealed similar diversity in ssdna and rna viruses, particularly in marine ecosystems [ ] . this has led ictv to consider a far broader framework for taxonomic assignment of viruses, recently approving the establishment of a taxonomic hierarchy that includes ranks (realm, subrealm, kingdom, subkingdom, phylum, subphylum, class, subclass, order, suborder, family, subfamily, genus, subgenus, and species), thus expanding the range even beyond those currently available for other organisms [ ] . the sheer volume of new virus genomes identified by metagenomic studies has also led to the development of new bioinformatic tools, that are increasingly being applied for automated virus classification of viruses, based almost exclusively on nucleotide sequence data [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . while the classic tools of virus discovery and characterization (e.g., em, serology, and tissue culture) are still widely used, ngs allowed for the rapid identification of an enormous repertoire of viruses, thus exponentially expanding the boundaries of the known virosphere. the resultant genomic sequences allowed for their accurate taxonomic assignments, analysis of their phylogenetic and evolutionary relationships with other viruses, and evaluation of the potential risks they may present to humans and wild or domestic animal populations. below are a few representative examples of how ngs transformed the known relationships of arboviruses within their respective families. rhabdoviruses contain negative-sense (-) single-stranded rna (ssrna) genomes. they are amongst the most numerous and diverse of rna viruses, naturally infecting mammals, birds, fish, reptiles, and amphibians, as well as insects, arachnids, crustaceans, nematodes, and a wide range of plants [ , ] . most (but not all) rhabdoviruses that infect vertebrates are transmitted by hematophagous arthropods. the rhabdoviridae currently comprises genera containing species and one unassigned species [ ] . of these, viruses assigned to seven of the genera (vesiculovirus, ephemerovirus, tibrovirus, hapavirus, ledantevirus, curiovirus, and sripuvirus) are considered to be arboviruses. viruses assigned to the newly characterized genus almendravirus appear to be insect-specific [ ] . viruses assigned to the genus tupavirus have been isolated only from vertebrates but may possibly have arthropod vectors. complete coding sequences are now available for more than other rhabdoviruses, many of which have been isolated from or detected in arthropods, but they have not yet been formally classified. while the classic tools of viral discovery (e.g., em, serology, and tissue culture) are still widely used, ngs has played a central role in recent genome sequencing efforts, revealing diversity, not only in the ecology of rhabdoviruses but also in the structural diversity of genome architecture [ , [ ] [ ] [ ] [ ] [ ] [ ] . in addition to the five canonical rhabdovirus structural protein genes (n, p, m, g, and l), it is now recognized that rhabdoviruses commonly contain multiple long open reading frames encoding putative accessory proteins, mostly of unknown function. ngs has also facilitated studies of the evolution of rhabdovirus genome organization [ ] and revealed the importance of arthropods in the evolutionary history of rhabdoviruses [ ] . according to the current international committee on taxonomy of viruses (ictv), classification of the order bunyavirales encompasses families of segmented (-) ssrna viruses-arenaviridae, hantaviridae, nairoviridae, peribunyaviridae and cruliviridae, mypoviridae, fimoviridae, wupedeviridae, phasmaviridae, and phenuiviridae-a classification based on structural, genetic, and antigenic characteristics [ ] . bunyavirales is a diverse order with a large number of viruses associated with human, veterinary, and plant disease, as well as being vectored by arthropods (mosquitoes, ticks, sandflies, and thrips) and infecting a wide range of other invertebrates. the recent discovery of gouléako (golv) [ ] and cumuto (cumv) [ ] viruses (the latter with ngs) which are evolutionarily related to but distinct from viruses in the genus phlebovirus, family phenuiviridae, suggesting they are to be assigned to the new genus goukovirus. in the past five years, ngs has revolutionized understanding of the vast diversity of this order, by allowing genetic identification of previously uncharacterized and unassigned bunyaviruses, which in turn provided a complimentary approach to the gold standard of classification (structural, genetic, and antigenic characteristics) for a more refined taxonomic classification. combined, these approaches will be instrumental for enhancing our understanding of their ecologic and geographic distribution, as well as public health impact. the family flaviviridae comprises positive-sense (+) ssrna viruses. the family contains several serious human pathogens, including dengue, yellow fever, zika, japanese encephalitis, west nile, and tick-borne encephalitis viruses (all arboviruses in the genus flavivirus) and the hepatitis c virus (a member of the genus hepacivirus). members of the genus flavivirus, like the alphaviruses (see section . ), are a diverse group of arthropod-borne viruses that are found on every continent except antarctica. several flaviviruses have been discovered and characterized recently, mainly through chance or increased surveillance efforts, and facilitated through ngs. newly characterized viruses include the mercadeo virus (mecdv), from pools of culex species mosquitoes in panama [ ] , sabethes flavivirus (sbfv), from sabethes belisarioi in brazil [ ] , the la tina virus (ltnv), from aedes scapularis in peru [ ] , the long pine key virus (lpkv), from anopheles crucians in the florida everglades, and the kampung karu virus (kpkv), from anopheles tesselatus in borneo [ ] , aedes flavivirus (aefv), from aedes albopictus laboratory colony that originated in thailand [ ] , xishuangbanna flavivirus (xfv), from aedes albopictus in china [ ] , and the cuacua virus (cucuv), from mansonia ssp. in mozambique [ ] . one unexpected finding was the discovery of segmented viruses that grouped in the family flaviviridae and were more closely related to flaviviruses than members of other established genera. the jingmen tick virus (jmtv) is unique in the family flaviviridae with a four segment positive-sense genome [ ] . traditional sanger sequencing generated the ns and ns gene sequences but could not connect these within a single genome segment. phylogenies based on either ns -like or ns -like sequences, which are encoded on two of the four segments, showed jmtv falling basal on the flavivirus tree and clearly distinct from the other viruses in this genus. the remaining two segments did not appear to have a flavivirus origin. jmtv has been isolated from cattle, monkeys, and ticks (rhipicephalus and haemaphysalis spp.) [ ] . this prototype virus has lent its name to the newly identified segmented flaviviruses, and other viruses have recently populated the jingmenvirus clade. similarly, the guaico culex virus (gcxv) consists of five segments, and initial studies suggested gcxv is insect-specific, based on its isolation from culex ssp. mosquitoes [ ] . additional potentially insect-specific four-segmented viruses include shuangao insect virus (saiv ), the wuhan flea virus (whfv), wuhan aphid virus (whav ), wuhan aphid virus (whav ), and the wuhan cricket virus (whcv) [ ] . interestingly, sequences that are similar to toxocara canis, a larva roundworm, and tentatively named t. canis larva agent virus (tclav), are distantly related to jmtv and appear to be the first evidence of a flavivirus-line organism in a member of the phylum nematoda [ ] . the discovery and characterization of a segmented genome flavivirus has significant implications, as it reveals that rna virus segmentation is an evolutionary process that has occurred in previously unanticipated circumstances. the alphaviruses are a diverse group of (+) ssrna arthropod-borne viruses that are found on every continent except antarctica [ ] . there were no known mosquito-only alphaviruses until , when analysis by ngs of a mosquito-pool from the negev desert in israel showed the presence of an alphavirus, the eilat virus (eilv) [ ] . further analysis showed that, although eilv could infect mosquito cells, it was unable to replicate in vertebrate cells [ ] . eilv is considered a vaccine candidate, as it can produce immunity without replication in the vertebrate host, illustrating the importance of such discoveries, which can lead to novel platforms for the prevention and/or treatment of disease [ ] . reoviruses are a diverse family of double-stranded rna (dsrna) viruses that infect a wide range of hosts and have a wide range of characteristics. of the genera, there are only three for which novel viruses have been described using ngs, and the majority of these are in the genus orbivirus. interestingly, because of the structure of the genomes of reoviruses and the conserved sequences at the ' and ' ends of the segments [ ] , it is relatively simple to sequence segments of reoviruses using more traditional techniques. this may be why there are so few novel reoviruses determined by ngs. novel viruses identified using ngs have been assigned to four other genera (seadornavirus, orthoreovirus, dinovernavirus, and cypovirus), all of which are shown in table . refers to year of the publication and not of the isolation of the virus. *not yet formally classified. newly recognized viruses containing a (+) ssrna genome have been proposed to form a new genus negevirus, related to genera of mite-infecting plant viruses (blunervirus, cilevirus, and higrevirus) in the new family kitaviridae [ , ] . originally, six viruses with restricted host range in insects (isvs), designated as negev (negv), ngewotan (nwtv), piura (piuv), loreto (lorv), dezidougou (dezv), and santana (sanv), were identified in and isolated from mosquitoes and phlebotomine sandflies, collected in brazil, the ivory coast, israel, indonesia, peru, and the usa, [ ] . their widespread geographic distribution was documented by several other groups, who reported the isolation and characterization of related viruses in the philippines (tanay virus; tanav) [ ] , trinidad and tobago (wallerfield virus; walv) [ ] , côte d'ivoire (goutanap virus; ganv) [ ] , portugal (ochlerotatus caspius negevirus; ocnv and culex univittatus negevirus; cunv) [ ] , brasil (brajeira and wallerfield viruses), colombia, and nepal. collectively, the close relationship of negeviruses with plant viruses of the genera cilevirus, higrevirus, and blunervirus, coupled with their heterogenous genome organization and architecture, provides support for the possibility that negeviruses are plant-like viruses that could eventually anchor a new virus family [ ] . members of the family mesoniviridae, a newly discovered family of (+) ssrna viruses assigned to the order nidovirales [ , ] , appear to have an extensive geographic distribution but a restricted host range within members of the family culicidae (flies) [ , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . the mesoniviridae comprise of a single genus alphamesonivirus with nine recognized species: alphamesonivirus , including nam dinh (ndiv) [ ] , cavally (cavv) [ ] , ndiv a . [ ] , ndiv ngewotan, and ndiv houston [ ] viruses; alphamesonivirus , including the single isolate of the karang sari (ksav) virus, and the four bontag baru (bbav) isolates sampled in the early s in indonesia, but only recently characterized [ ] ; alphamesonivirus , including the dak nong virus (dknv), the three isolates of kamphaeng phet (kphv), sampled in indonesia and thailand in the mid- s [ , ] ; alphamesonivirus , including the casuarina virus (casv), isolated in australia from coquillettidia xanthogaster mosquitoes [ ] ; alphamesonivirus , the african hana virus (hanav) [ ] ; alphamesonivirus and , including ofaie (ofav) and kadiweu (kadv) viruses, isolated in the pantanal of brasil from mansonia sp. mosquitoes, respectively [ ] ; and alphamesonivirus- and , including the african nse (nsev), and meno (menov) viruses [ ] ; and the distinct yet unassigned species, the yichang virus [ ] , isolated from culex sp. mosquitoes in china. across several generations, virus hunters have left a profound legacy, both to science and to the broader global community. in the field, their work has often been conducted in difficult, demanding, and sometimes dangerous circumstances. in the laboratory, they have developed and applied tools and methodologies that led to improved diagnosis, prevention, and treatment of viral disease, and still lie at the center of virology today. others working at more fundamental scientific levels have used their virus isolates as scientific models, opening the door to a revolution in molecular and cellular biology. yet, their work continues. viral disease emergence remains one of the most serious threats to humanity, with potentially devastating social and economic consequences. recent examples, such as sars, mers, henipa-, ebola, and zika viruses, illustrate the threat that unidentified or poorly characterized viruses can, and almost certainly will, continue to present. equally devastating emerging diseases of livestock, fisheries, and crops threaten food production and livelihoods. as history has repeatedly shown us, technological revolutions have been often accompanied by periods of progressive disinvestment in training for the eclipsed technologies of the past, and in our case, classical virology. the recent emergence of the zika virus in the americas has reinforced the notion that traditional methods of virus discovery and new technologies offer a complimentary toolkit, especially in resource-poor settings that can be seamlessly integrated in the service of public health. it is our hope and expectation that new generations of virus hunters will appreciate the legacy of their predecessors and complement the power of ngs, metagenomics, and bioinformatics, not only to advance viral evolutionary biology, but to understand and limit the potential impacts of emerging viral disease. funding: this work was supported in part by nih grants r ai and u ai . the funding agencies had no involvement in the writing of the report or in the decision to submit this article for publication. the rockefller foundation virus program: - with update to the arthropod-borne viruses of vertebrates. an account of the rockefeller foundation virus program techniques for hemagglutination and hemagglutination-inhibition with arthropod-borne viruses a new antigenic group of arthropod-borne viruses: the bunyamwera group antigenic classification of arthropod-borne viruses search strategy has influenced the discovery rate of human viruses the history of arbovirology at instituto evandro chagas, belem, para, brazil from to . revista pan-amazonica de saude epidemiology and control of mosquito-borne arboviruses in california lifting the impenetrable veil: from yellow fever to ebola hemorrhagic fever and sars the hunt for caribbean viruses. a history of the trinidad regional virus laboratory; caribbean epidemiology centre (carec/paho/who): port of spain bulletin de la société de pathologie exotique filiales years of tropical medicine research: a history of the gorgas memorial institute of tropical and preventive medicine, inc. and the gorgas memorial laboratory opportunities and responsibilities of the reference center emerging infections. microbial threats to health in the united states global climate change and infectious diseases yale arbovirus team heads south les instituts pasteur d'outre-mer-cent vingt ans de microbiologie francaise dans le monde isolements du virus de la fievre jaune a partir d' aedes du groupe a. africanus (theobald) en republique central africaine. importance des savanes humides et semi-humides en tant que zone d'emergence du virus amaril. cahiers orstom série entomologie médicale et parasitologie recent advances in research regarding sylvatic yellow fever in west and central africa yellow fever in senegal from to données bio-écologiques sur les vecteurs potentiels de virus amaril. cahiers orstom série entomologie médicale et parasitologie in international catalogue of arboviruses, including certain other viruses of vertebrates antibody prevalence against haemorrhagic fever viruses in randomized representative central african populations isolation in east senegal of a yellow fever virus strain from a pool of aedes belonging to the subgenus diceromyia. comptes rendus hebdomadaires des séances de l'académie des sciences d surveillance for yellow fever virus in eastern senegal during the yellow fever epidemic in burkina faso dengue in eastern senegal: serologic survey in simian and human populations. - . bulletin de la société de pathologie exotique filiales isolation of dengue and dengue viruses from patients in senegal circulation selvatique du virus dengue , en , dans les savanes subsoudaniennes de côte d'ivoire. cahiers orstom série entomologie médicale et parasitologie epidemiological study of arboviruses in the central african republic: demonstration of chikungunya virus during and . bulletin de la société de pathologie exotique filiales arbovirosis from central african republic: incidence, diagnosis in human pathology apropos of a case with hemorrhagic manifestations in mauritania. bulletin de la société de pathologie exotique filiales haemorrhagic fever caused by crimean congo haemorrhagic fever virus in mauritania bulletin de la société de pathologie exotique filiales crimean-congo hemorrhagic fever in senegal. latest data on the ecology of the cchf virus prevalence of antibodies against rift valley fever virus in sheep and goats in senegal epidemiology of rift valley fever in western africa. i. serologic survey in domestic ruminants of burkina faso. bulletin de la société de pathologie exotique filiales rift valley fever virus and haemorrhagic fever in the central african republic murray valley encephalitis and australian x disease australian x disease, murray valley encephalitis and the french connection isolation of a virus from encephalitis in south australia: a preliminary report murray valley encephalitis isolation and characterization of the aetiological agent the isolation of a third group a arbovirus in australia, with preliminary observations on its relationship to epidemic polyarthritis studies of arthropod-borne virus infections in queensland. iii. isolation and characterization of virus strains from wild-caught mosquitoes in north queensland epidemic polyarthritis epidemic polyarthritis in eastern australia, - isolation of ross river virus from man the risk of ross river and barmah forest virus disease in queensland: implications for new zealand studies of the epidemiology of arthropod-borne viru infections at mitchell river mission, cape york peninsula, north queensland. ii. arbovirus infections of mosquitoes, man and domestic fowls isolation of arboviruses from mosquitoes, biting midges, sandflies and vertebrates collected in queensland virus strains isolated from arthropods during an epizootic of bovine ephemeral fever in queensland isolation of virus strains from mosquitoes collected in queensland, - isolation of sindbis (alphavirus) and leanyer viruses from mosquitoes collected in the northern territory of australia, . aust genomic characterisation of almpiwar virus, harrison dam virus and walkabout creek virus; three novel rhabdoviruses from northern australia mossman virus, a paramyxovirus of rodents isolated in queensland isolation of viruses from ornithodoros capensis neumann from a tern colony on the great barrier reef, north queensland the isolation of saumarez reef virus, a new flavivirus, from bird ticks ornithodoros capensis and ixodes eudyptidis in australia isolation of arboviruses (kemerovo group, sakhalin group) from ixodes uriae collected at macquarie island, southern ocean the isolation of arboviruses including a new flavivirus and a new bunyavirus from ixodes (ceratixodes) uriae (ixodoidea: ixodidae) collected at macquarie island, australia, - annually recurrent epidemic polyarthritis and ross river virus activity in a coastal area of new south wales. ii. mosquitoes, viruses, and wildlife viruses recovered from mosquitoes and wildlife serum collected in the murray valley of southeastern australia archiv fur die gesamte virusforschung barmah forest virus infections in humans in new south wales illness caused by a barmah forest-like virus in new south wales ross river virus and barmah forest virus infections: a review of history, ecology, and predictive models, with implications for tropical northern australia. vector borne zoonotic dis arbovirus infection in humans in nsw: seroprevalence and pathogenicity of certain australian bunyaviruses ord river arboviruses-isolations from mosquitoes isolation of murray valley encephalitis virus and other arboviruses in the ord river valley - identification of very small open reading frames in the genomes of holmes jungle virus, ord river virus, and wongabel virus of the genus hapavirus genetic characterization of k , a strain of oak vale virus from western australia genetic and epidemiological characterization of stretch lagoon orbivirus, a novel orbivirus isolated from culex and aedes mosquitoes in northern australia a new orbivirus isolated from mosquitoes in north-western australia shows antigenic and genetic similarity to corriparta virus but does not replicate in vertebrate cells characterization of fitzroy river virus and serologic evidence of human and animal infection adaptation to mice of the causitive virus of ephemeral fever of cattle from an epizootic in queensland isolation of arboviruses from insects collected at beatrice hill, northern territory of australia the isolation of a bluetongue virus from culicoides collected in the northern territory of australia the isolation of two bluetongue viruses from healthy cattle in australia isolation of a new rhabdovirus in australia related to tibrogargan virus the isolation in australia of a new virus related to bovine ephemeral fever virus the isolation of a fourth bovine ephemeral fever group virus koolpinyah: a virus related to kotonkan from cattle in northern australia isolation of tibrogargan virus, a new australian rhabdovirus, from culicoides brevitarsis the isolation of three simbu group viruses new to australia genomic characterisation of wongabel virus reveals novel genes within the rhabdoviridae genomic characterisation of vinegar hill virus, an australian nairovirus isolated in from argas robertsi ticks collected from cattle egrets isolation of a new arbovirus from the tick argas robertsi from a cattle egret (bubulcus ibis coromandus) colony in australia a newly discovered flavivirus in the yellow fever virus group displays restricted replication in vertebrates identification of new flaviviruses in the kokobera virus complex a morbillivirus that caused fatal disease in horses and humans serologic evidence for the presence in pteropus bats of a paramyxovirus related to equine morbillivirus isolation of hendra virus from pteropid bats: a natural reservoir of hendra virus encephalitis caused by a lyssavirus in fruit bats in australia a human case of encephalitis due to a lyssavirus recently identified in fruit bat australian bat lyssavirus infection: a second human case, with a long incubation period australian bat lyssavirus in a child: the first reported case evidence of australian bat lyssavirus infection in diverse australian bat taxa an apparently new virus (family paramyxoviridae) infectious for pigs, humans, and fruit bats probable human infection with a newly described virus in the family paramyxoviridae. the nsw expert group evidence of bat origin for menangle virus, a zoonotic paramyxovirus first isolated from diseased pigs summary of preliminary report of investigations of the virus research centre on an epidemic disease affecting forest villagers and wild monkeys of shimoga district, mysore russian spring-summer virus in india: kyasanur forest disease a virus resembling russian spring-summer encephalitis virus from an ixodid tick in malaya experimental studies on dengue. i. isolation, identification and modification of the virus production of immunity to dengue with virus modified by propagation in mice viruses associated with epidemic hemorrhagic fevers of the philippines and thailand the zoonotic flaviviruses of southern, southeastern and eastern asia, and australasia: the potential for emergent viruses federation of malaya: kuala lampur, malaya identification of a flavivirus isolated from mosquitos in chiang mai thailand encephalitis and retarded growth of chicks caused by sitiawan virus, a new isolate belonging to the genus flavivirus duck egg-drop syndrome caused by byd virus, a new tembusu-related flavivirus an infectious disease of ducks caused by a newly emerged tembusu virus strain in mainland china activity of jugra and umbre viruses in a malaysian community in international catalogue of arboviruses, including certain other viruses of vertebrates characterization of sepik and entebbe bat viruses closely related to yellow fever virus arbovirus infections in sarawak: the isolation of kunjin virus from mosquitoes of the culex pseudovishnui group a new virus, phnom-penh bat virus, isolated in cambodia from a short-nosed fruit bat, cynopterus brachyotis angulatus miller a mini-review of bunyaviruses recorded in india characterization and identification of oya virus, a simbu serogroup virus of the genus bunyavirus, isolated from a pig suspected of nipah virus infection a novel mosquito-borne orbivirus species found in southeast asia a new arbovirus isolated in india from patients with febrile illness nipah virus infection in bats (order chiroptera) in peninsular malaysia severe acute respiratory syndrome coronavirus-like virus in chinese horseshoe bats bats are natural reservoirs of sars-like coronaviruses nipah virus: a recently emergent deadly paramyxovirus fatal encephalitis due to nipah virus among pig farmers in malaysia nipah virus outbreaks in bangladesh: a deadly infectious disease coronavirus as a possible cause of severe acute respiratory syndrome a novel coronavirus associated with severe acute respiratory syndrome identification of a novel coronavirus in patients with severe acute respiratory syndrome bats as viral reservoirs isolation of a new parainfluenza virus from a frugivorous bat, rousettus leschenaulti, collected at poona, india. am isolation of a novel adenovirus from rousettus leschenaultii bats from india tioman virus, a novel paramyxovirus isolated from fruit bats in malaysia pulau virus; a new member of the nelson bay orthoreovirus species isolated from fruit bats in malaysia a previously unknown reovirus of bat origin is associated with an acute respiratory disease in humans identification and characterization of a new orthoreovirus from patients with acute respiratory infections pteropine orthoreovirus infection among out-patients with acute upper respiratory tract infection in malaysia clinic of spring-summer encephalitis. nevropaologia i psichiatria etiology of the spring-summer encephalitis vernal (verno-aestival) endemic tick-borne encephalitis the ixodes persulcatus tick as vector of the spring-summer encephalitis far eastern tick-borne spring-summer (spring) encephalitis years study of soviet medicine in spring-summer encephalitis experimental contributions to active immunization of mice against the spring-summer (tick-borne) encephalitis by means of preparations of live and killed virus experimenteller und epidemiologischer beitrag zur aktiven immunisierung gegen die frühling-sommer-zecken-encephalitis tick-borne human encephalitis in the european part of the ussr and siberia the geographical distribution and epidemiological characteristics of tick-borne encephalitis in european part of the soviet union, siberia and kazachstan. nevropaologia i psichiatria epidemiology of tick-borne encephalitis (tbe) in europe and its prevention by available vaccines strain properties of the aina/ serotype of the tick-borne encephalitis virus tick-borne encephalitis virus genome. the nucleotide sequence coding for virion structural proteins nucleotide sequence of the genome region of the tick-borne encephalitis virus coding for structural proteins of virion nucleotide sequence of the genome and complete amino acid sequence of the polyprotein of tick-borne encephalitis virus tick-borne encephalitis in the russian federation: state-of-the-art and prevention policy in virus taxonomy. th international committee taxonomy of viruses zoonotic viruses of northern eurasia. taxonomy and ecology tick-borne encephalitis: etiology, epidemiology and prophylactics in siberia materials for epidemiology, etiology and prophylaxis of spring-summer fever in some districts of omsk region spring-summer fever in omsk region results of a study made of omsk hemorrhagic fever by an expedition of the institute of neurology isolation and studying of strains of causative agent of omsk hemorrhagic fever the omsk hemorrhagic fever: research results omsk hemorrhagic fever-current status of the problem omsk hemorrhagic fever in human subjects and musk rats during the winter period ondatra as the source of infection of laboratory personnel with omsk haemorrhagic fever and its role in the epidemiology of this disease the flaviviruses (group b arboviruses): a cross-neutralization study analysis of the complete genome of the tick-borne flavivirus omsk hemorrhagic fever virus nucleotide and deduced amino acid sequence of the envelope glycoprotein of omsk haemorrhagic fever virus; comparison with other flaviviruses the deduced evolution history of omsk hemorrhagic fever virus a new tick-borne virus disease-crimean hemorrhagic fever drozdov") of crimean hemorrhagic fever virus and data on serodiagnostics of this infection isolation and study of the virus from crimean hemorrhagic fever patient in samarkand region of uzbek sss, strain khodzha antigenic similarity between the virus causing crimean hemorrhagic fever and congo virus identification of the virus of kemerovo tick-borne fever. evidence of the antigenic independence of this virus isolation from ixodes persulcatus ticks of cytopathic agents (kemerovo virus) differing from tick-borne encephalitis virus and some of their properties viruses related to the kemerovo virus in ixodes ricinus ticks in czechoslovakia isolation of tribec virus from the blood of sentinel pastured goats in tribec region (slovakia) physicochemical and morphological relationships of some arthropod-borne viruses to bluetongue virus-a new taxonomic group. physiocochemical and serological studies prevalence of kemerovo virus in ixodid ticks from the russian federation first detection of kemerovo virus in ixodes pavlovskyi and ixodes persulcatus ticks collected in novosibirsk region, russia. ticks tick-borne dis isolation of a new for ussr arbovirus astra from ticks hy. plumbeum and mosquitos an. hyrcanus in astrakhan district isolation of tahyna virus (california antigenic group, family bunyaviridae) from the blood of febrile patients in the tadzhik ssr isolation of viruses of antigenic complexes of california encephalitis and bunyamwera (family bunyaviridae, genus bunyavirus) from mosquitoes in northeast asia the circulation of viruses of the california encephalitis and bunyamwera groups (family bunyaviridae, genus bunyavirus) on the northeastern russian plain distribution of viruses from the californian encephalitis serogroup (family bunyaviridae, genus bunyavirus) in the northern expanses of russia kyzylagach virus (family togaviridae, genus alphavirus), a new arbovirus isolated from culex modestus mosquitoes trapped in the azerbaijani ssr isolation of getah virus (family togaviridae, genus alphavirus) strains in north-eastern asia identity of karelian fever and ockelbo viruses determined by serum dilution-plaque reduction neutralization tests and oligonucleotide mapping ecology of tick-borne viruses in colonies of birds in the ussr sakhalin virus-a new arbovirus isolated from ixodes (ceratixodes) putus pick.-camb. collected on tuleniy island, sea of okhotsk zaliv terpeniya virus, a new uukuniemi group arbovirus isolated from ixodes (ceratixodes) putus pick.-camb. on tyuleniy island (sakhalin region) and commodore islands (kamchatsk region) isolation of tyuleniy virus from ticks ixodes (ceratixodes) putus pick.-camb. collected on the commodore islands okhotskiy virus, a new arbovirus of the kemerovo group isolated from ixodes (ceratixodes) putus pick.-camb. in the far east issyk-kul virus, a new arbovirus isolated from bats and argas (carios) vespertilionis (latr., ) in the kirghiz ssr. archiv fur die gesamte virusforschung issyk-kul virus disease tamdy virus-a new arbovirus, isolated in the uzbee ssr and turkmen ssr from ticks hyalomma asiaticum asiaticum schulee et schlottke, , and hyalomma plumbeum plumbeum panzer investigations on the structure and morphogenesis of some arboviruses isolated in the ussr complete genome coding sequences of artashat experimental investigations regarding the etiology of dengue fever experimental transmission of yellow fever to laboratory animals cultivation of vaccinia virus without tissue culture nutrition needs of mammalian cells in tissue culture cultivation of the lansing strain of poliomyelitis virus in cultures of various human embryonic tissues complement fixation in yellow fever in monkey and in man antigens and methods for performing the complement fixation test for yellow fever laboratory branch complement fixation method. in standardized diagnostic complement fixation method and adoptation to micro test the quantitative determination of influenza virus and antibodies by means of red cell agglutination yellow fever protectiontest in mice by intracerebral injection the infection of chimpanzees with echo viruses arthropod-borne virus plaques in agar overlaid tube cultures japanese encephalitis vaccine (inactivated, biken) in u.s. soldiers: immunogenicity and safety of vaccine administered in two dosing regimens virus reduction neutralization test: a single-cell imaging high-throughput virus neutralizationa ssay for dengue potential of ancestral sylvatic dengue viruses to re-emerge a rapid fluorescent focus-inhibition test for determining dengue neutralizing antibody and for identifying prototype dengue viruses comparison of plaque-and flow cytometry-based methods for measuring dengue virus neutralization measuring antibody neutralization of dengue virus (denv) using a flow cytometry-based technique high throughput quantitative colorimetric microneutralization assay for the confirmation and differentiation of west nile virus and st. louis encephalitis virus dengue reporter virus particles for measuring neutralizing antibodies against each of the four dengue serotypes a novel reporter system for neutralizing and enhancing antibody assay against dengue virus a rapid zika diagnostic assay to measure neutralizing antibodies in patients high-throughput neutralization assay for multiple flaviviruses based on single-round infectious particles using dengue virus type reporter replicon the enzyme-linked immunosorbent assay (elisa)-a new serodiagnostic method for the detection of parasitic infections laboratory diagnosis of arboviruses the foundations of virology-discoverers and discoveries, inventors and inventions, developers and technologies electron microscopy of viral infections diagnosis of viral infections by electron microscopy hsiung's diagnostic virology as illustrated by light and electron microscopy atlas of invertebrate viruses electron microscopy in viral diagnosis an atlas of mammalian viruses electron microscopy in diagnostic virology: a practical guide and atlas the atlas of insect and plant viruses: including mycoplasmaviruses and viroids ultrastructure of animal viruses and bacteriophages: an atlas atlas of anatomy and ontogenesis of human and animal viruses virus morphology modern uses of electron microscopy for detection of viruses cell culture and electron microscopy for identifying viruses in diseases of unknown cause morphologic differentiation of viruses beyond the family level dna sequencing with chain-terminating inhibitors fluorescence detection in automated dna sequence analysis capillary gel electrophoresis for rapid, high resolution dna sequencing dna sequencing using capillary array electrophoresis finishing the euchromatic sequence of the human genome the sequence of the human genome applications of next-generation sequencing technologies in functional genomics the challenges of sequencing by synthesis sequencing technologies-the next generation high-throughput dna sequencing-concepts and limitations next generation sequencing technology: advances and applications fruits of virus discovery: new pathogens and new experimental models negevirus: a proposed new taxon of insect-specific viruses with wide geographic distribution evolution of genome size and complexity in the rhabdoviridae genetic characterization of goutanap virus, a novel virus related to negeviruses, cileviruses and higreviruses gouleako virus isolated from west african mosquitoes constitutes a proposed novel genus in the family bunyaviridae evolutionary and phenotypic analysis of live virus isolates suggests arthropod origin of a pathogenic rna virus family discovery of a unique novel clade of mosquito-associated bunyaviruses unprecedented genomic diversity of rna viruses in arthropods reveals the ancestry of negative-sense rna viruses redefining the invertebrate rna virosphere the evolutionary history of vertebrate rna viruses a novel rhabdovirus associated with acute hemorrhagic fever in central africa discovery of novel rhabdoviruses in the blood of healthy individuals from west africa newly characterized arboviruses of northern australia bivens arm virus: a new rhabdovirus isolated from culicoides insignis in florida and related to tibrogargan virus of australia seroepidemiology of bivens arm virus infections of cattle in florida, st. croix and puerto rico years of the international committee on taxonomy of viruses: progress and prospects consensus statement: virus taxonomy in the age of metagenomics uncovering earth's virome ecogenomics and potential biogeochemical impacts of globally abundant ocean viruses additional changes to taxonomy ratified in a special vote by the international committee on taxonomy of viruses evaluation of the genomic diversity of viruses infecting bacteria, archaea and eukaryotes using a common bioinformatic platform: steps towards a unified taxonomy the genomic underpinnings of eukaryotic virus taxonomy: creating a sequence-based framework for family-level virus classification virus classification-where do you draw the line? methods for virus classification and the challenge of incorporating metagenomic sequence data toward genetics-based virus taxonomy: comparative analysis of a genetics-based classification and the taxonomy of picornaviruses partitioning the genetic diversity of a virus family: approach and evaluation through a case study of picornaviruses pairwise sequence comparison (pasc) and its application in the classification of filoviruses improvements to pairwise sequence comparison (pasc): a genome-based web tool for virus classification rhabdoviruses: molecular taxonomy, evolution, genomics, ecology, host-vector interactions vector-borne rhabdoviruses ictv virus taxonomy profile: rhabdoviridae almendravirus: a proposed new genus of rhabdoviruses isolated from mosquitoes in tropical regions of the americas a proposed new genus in the rhabdoviridae has a strong ecological association with bats koolpinyah and yata viruses: two newly recognised ephemeroviruses from tropical regions of australia and africa kolente virus, a rhabdovirus species isolated from ticks and bats in the republic of guinea characterization of farmington virus, a novel virus from birds that is distantly related to members of the family rhabdoviridae genomic characterisation of cuiaba and charleville viruses: arboviruses (family rhabdoviridae, genus sripuvirus) infecting reptiles and amphibians niakha virus: a novel member of the family rhabdoviridae isolated from phlebotomine sandflies in senegal taxonomy of the family arenaviridae and the order bunyavirales: update characterization of a novel negevirus and a novel bunyavirus isolated from culex (culex) declarator mosquitoes in trinidad mercadeo virus: a novel mosquito-specific flavivirus from panama identification of insect-specific flaviviruses in areas of brazil and paraguay experiencing endemic arbovirus transmission and the description of a novel flavivirus infecting sabethes belisarioi characterization of three new insect-specific flaviviruses: their relationship to the mosquito-borne flavivirus pathogens insect-specific viruses detected in laboratory mosquito colonies and their potential implications for experiments evaluating arbovirus vector competence complete genome sequence of xishuangbanna flavivirus, a novel mosquito-specific flavivirus from china discovery of novel viruses in mosquitoes from the zambezi valley of mozambique a tick-borne segmented rna virus contains genome segments derived from unsegmented viral ancestors characterisation of divergent flavivirus ns and ns protein sequences detected in rhipicephalus microplus ticks from brazil. memórias do instituto oswaldo cruz a multicomponent animal virus isolated from mosquitoes divergent viruses discovered in arthropods and vertebrates revise the evolutionary history of the flaviviridae and related viruses genome-scale phylogeny of the alphavirus genus suggests a marine origin eilat virus, a unique alphavirus with host range restricted to insects by rna replication eilat virus host range restriction is present at multiple levels of the virus life cycle a chikungunya fever vaccine utilizing an insect-specific virus platform nucleotide sequences of double-stranded rna segments from a hypovirulent strain of the white root rot fungus rosellinia necatrix: possibility of the first member of the reoviridae from fungus genomes of viral isolates derived from different mosquitos species a novel bluetongue virus serotype strain in tunisia changuinola virus eerogroup, new genomes within the genus orbivirus (family reoviridae) isolated in the brazilian amazon region mobuck virus genome sequence and phylogenetic analysis: identification of a novel orbivirus isolated from a white-tailed deer in missouri genetic characterization of tribec virus and kemerovo virus, two tick-transmitted human-pathogenic orbiviruses isolation of a novel fusogenic orthoreovirus from eucampsipoda africana bat flies in south africa novel reovirus associated with epidemic mortality in wild largemouth bass (micropterus salmoides) the plasma virome of febrile adult kenyans shows frequent parvovirus b infections and a novel arbovirus (kadipiro virus) a newly isolated reovirus has the simplest genomic and structural organization of any reovirus identification and characterization of two novel rna viruses from anopheles gambiae species complex mosquitoes tanay virus, a new species of virus isolated from mosquitoes in the philippines negeviruses found in multiple species of mosquitoes from southern portugal: isolation, genetic diversity, and replication in insect cell culture genetic characterization, molecular epidemiology, and phylogenetic relationships of insect-specific viruses in the taxon negevirus discovery of the first insect nidovirus, a missing evolutionary link in the emergence of the largest rna virus genomes an insect nidovirus emerging from a primary tropical rainforest identification and characterization of genetically divergent members of the newly established family mesoniviridae a new nidovirus (nam dinh virus ndiv): its ultrastructural characterization in the c / mosquito cell line characterization of dak nong virus, an insect nidovirus isolated from culex mosquitoes in vietnam a new species of mesonivirus from the northern territory, australia genome sequences of five arboviruses in field-captured mosquitoes in a unique rural environment of south korea isolation and characterization of a novel mesonivirus from culex mosquitoes in china mesoniviruses are mosquito-specific viruses with extensive geographic distribution and host range novel viruses isolated from mosquitoes in pantanal, brazil the authors thank ashley rhame and dora salinas for excellent help in preparation of the manuscript. the authors declare no conflict of interest. key: cord- - t g u authors: wintle, brendan a.; legge, sarah; woinarski, john c.z. title: after the megafires: what next for australian wildlife? date: - - journal: trends ecol evol doi: . /j.tree. . . sha: doc_id: cord_uid: t g u the – megafires in australia brought a tragic loss of human life and the most dramatic loss of habitat for threatened species and devastation of ecological communities in postcolonial history. what must be done now to keep impacted species from extinction? what can be done to avoid a repeat of the impacts of such devastating bushfires? here, we describe hard-won lessons that may also be of global relevance. the - megafires in australia brought a tragic loss of human life and the most dramatic loss of habitat for threatened species and devastation of ecological communities in postcolonial history. what must be done now to keep impacted species from extinction? what can be done to avoid a repeat of the impacts of such devastating bushfires? here, we describe hard-won lessons that may also be of global relevance. despite the familiarity of australia with fire, the timing, ferocity, and extent of the - fires was shocking. by area burnt, it was the largest fire season in eastern australia since european occupation. the total area burnt in eastern australia from august to march was almost km or . million hectares, almost the area of england ( million ha) ( figure ). megafires have occurred intermittently in australia over the past years, possibly facilitated by the removal of traditional land practices of indigenous people. for example, in , fires in eastern australia burnt an area b % of the most recent fires, killing people and destroying n dwellings. however, this most recent fire season was unprecedented in geographical scale, duration, and intensity, and has had major impacts on species and ecosystems that were already under immense stress from prolonged drought. the comprehensiveness of the destruction is striking. postfire aerial reconnaissance revealed vast landscapes of grey ash extending as far as the eye can see: grey, not a hint of green, bounded only by the blue of sea and sky ( figure ). the full impacts on biodiversity will not be fully understood for years to come as extinction debts are realised. some coarse surrogates paint a stark picture: ( plants, and animals, including five invertebrates) of the~ listed threatened species in australia had a significant portion (n %) of their known distribution within the fire footprint i , of which were already critically endangered. among the significantly impacted species, have lost at least half of their habitat and have lost over %. although these numbers are still being refined, this is likely to result in significant population losses. the conservation status of many species [e.g., gang gang cockatoo (callocephalon fimbriatum) and yellow-bellied glider (petaurus australis)] previously considered secure, will now need to be reconsidered. impacts will be long-lasting, because many of the fire-affected species were dependent upon long-unburnt habitats that take decades to re-establish and many have slow reproductive output and, thus, it will take many years for populations to re-establish. thousands of less wellknown species, including invertebrates and plants, many yet to be described and many with very localised distributions, will have suffered dramatic impacts. some may even have become extinct before being discovered or named. most fires leave a scattering of unburnt patches within the fire footprint, often in small topographical features such as sheltered, wetter gullies, but sometimes also due to the vagaries of sudden windshifts that send the fire in a different direction. although a comprehensive analysis of the spatial variation in fire intensity across the entire fire-affected areas is yet to be done, it appears that, at least in some regions, the - fires burnt extraordinarily thoroughly, even burning through landscape features such as deep gullies, rainforest edges, rocky outcrops, and riparian strips, that have acted as fire refuges in past fire events (figure ). this creates a new and more serious challenge for the recovery of species. immediately following fire, animals that survived the blaze by sheltering underground, in water, or in rocks are faced with the challenge of finding food and avoiding predation in a moonscape environment. many will perish due to lack of food and shelter. animals able to find the rare patches of unburnt vegetation will likely find it to be suboptimal habitat or the territory of another animal. plants regenerating after fire are vulnerable to herbivores and desiccation. fish die in warm, deoxygenated water caused by heavy loads of sediment and ash following the first post-fire rains. a particular challenge of megafires is that, as the bushland slowly recovers, the prospects for recolonisation by dispersal-limited species is greatly diminished due to the larger distances over which species need to travel to recolonise suitable habitat. in many cases, those dispersal pathways are now interrupted by cleared land and human settlements or dams and weirs on rivers. recovery will also be stymied if, as is likely, the interval between successive fires decreases. in the midst of emergency, the response was, understandably, almost solely about human life and property. unfortunately, there was little strategic priority in fire control operations for the protection of key populations of threatened species, critical habitats, and threatened ecological communities. thus, aside from a small number of exceptional cases, biodiversity destruction was unabated by human intervention. in the immediate aftermath of fires, the wildlife response focussed primarily on animal welfare. the triage effort by veterinarians was impressively rapid, with significant government support. images of koalas (phascolarctos cinereus) in bandages being offered water by fire fighters resulted in~$au million being donated to animal welfare organisations. one of only a few pre-emptive responses aimed at species conservation was for the critically endangered wollemi pine (wollemia nobilis), a highly restricted species of great antiquity: the species was saved by an air operations crew who deposited fire retardant on the ridge-lines surrounding the few populations, and by conservation managers setting up irrigation systems around trees. this was a wonderful, but sadly exceptional, proactive nature conservation success. the absence of strategic protection targeting the protection of threatened species, ecosystems, and iconic places is disappointing, given that we know how much harder it is to restore or repair nature than it is to avoid its loss or damage. (i) (ii) (iii) (i) (ii) (iii) (a) (b) by contrast, the postfire response of agencies has been energetic, focussed, and adept. before the fires were out, federal and state governments pledged nearly $au million for conservation. expert panels were formed, impacts on species and ecosystems were analysed with support from science and nongovernment organisations. experts salvaged birds, plants and their seed, and fish species that faced postfire demise or were in imminent danger from further fire. actions included targeted control of feral herbivores and predators, erection of artificial nest boxes, and supplementary feeding of endangered macropods. for the most part, it was an impressive start to the long journey of postfire conservation. at the time of writing, the australian government and civil society organisations continue to allocate significant resources to support the recovery of fireaffected species and environments. such actions include postfire reconnaissance to quantify impacts on species and ecosystems, to manage postfire threats, and to monitor changes in species and ecosystems following fire and in response to recovery actions. some of the most widely deployed actions have included aerial culling of feral herbivores (mostly deer) that threaten the regeneration of sensitive forest and alpine ecosystems, and intensified baiting of introduced predators (mostly foxes) in fire-affected areas and fire fringes where they hunt native wildlife more intensively and successfully [ ] . compared with the limited consideration of biodiversity protection in preparatory fire management plans and during the fire emergency, the immediate postfire response was generally well organised, science based, and relatively well resourced. the increased attention given to the plight of wildlife during the fires in the media has created momentum around postfire biodiversity conservation. given that recovery efforts may need to be sustained for years, even decades, a key challenge will be to maintain support for those efforts as the collective memory of the fire fades and governments and society now grapple with another disaster, covid- . monitoring the outcomes of recovery efforts and tracking the fate of species after the fires is crucial, not only to inform where ongoing investment of conservation effort is most needed and which recovery actions are working best, but also for public engagement [ ] . numerous challenges remain; systematic prioritisation is required to determine where spending and conservation efforts, such as predator and herbivore control, are most beneficial, and to correctly time and implement the re-introduction of species that were rescued during and immediately following the fire. translocations will also be needed to 'rescue' or bolster populations, and to re-establish populations in areas from which they were extirpated. reassessment of conservation status will be required to identify and list species that now face a palpable risk of extinction. active restoration, including seed harvesting and aerial sowing of some forest ecosystems, will be needed if they are to persist following repeated recent fires [ ] . there is a significant opportunity to couple postfire forest restoration efforts with carbon sequestrationfunding initiatives to leverage biodiversity conservation. however, most of these actions must be deployed under imperfect knowledge, making rigorous monitoring of the outcomes crucial for improving understanding and maximising ongoing effectiveness in an adaptive management framework [ ] . avoidance of damaging postfire 'salvage' logging is key to the survival of many species, such as the threatened greater glider (petauroides volans) and sooty owl (tyto tenebricosa) [ ] . protecting residual oldforest habitats is one of the most crucial but politically challenging postfire actions to achieve because conserving habitat for threatened species competes with economic considerations. unfortunately, each new fire confers greater importance on the diminishing old-forest habitats that remain, making their protection ever more critical to the survival of old-forest-dependent species. careful analysis of the importance of remaining habitats for the survival of species, based on population viability analysis, provides evidence to support their protection in the face of economic pressures [ , ] . consistent with an escalating global trend of warming and drying, was the hottest and driest year on record in australia ii . national annual rainfall was % lower than the long-term average and maximum temperatures were, on average . °c above the long-run average maxima. the forest fire index in december was the highest on record for almost all of eastern australia [ ] . these conditions will increase in frequency with a changing climate, and catastrophic fire events will also become more frequent. there is little joy to be derived from reflecting on the ever-increasing size of fires and the ever-diminishing interval between them. however, it drives home the importance of learning from each experience and doing better next time, for there will be lots of next times. clear guidance on how to most effectively organise species and ecosystem conservation activities before, during, and immediately following a major fire event can be helpful (figure ). reflecting on the recent fire season, we failed nature, both in the heat of the moment and beforehand. precautionary precatastrophe actions should include: the establishment of more insurance populations (which can be used as sources after such extensive fires); translocations to better allow risks to be spread; more effective, sustained, and extensive control of other threats that can compound fire impacts; and collection of baseline monitoring and survey data to help identify places critical to protect, prioritise emergency responses, and provide clarity around what has been lost immediately following a fire event. most of the - fires were ignited by lightning strike, and little can be done to stop this. however, many fires are anthropogenic in origin [ ] . reducing anthropogenic ignitions and providing more effective suppression before fires get out of control could both be helpful. as a society, we could make the choice to invest more in early-strike fire suppression capacity. there is also a need for strategy, planning, and a greater recognition in fire control centres of the importance of protecting natural assets during fire. at present, natural assets feature only in some of the plans that form the basis for fire-fighting strategy. in most fire management and control plans, there is little spatial information on the occurrence of critical biodiversity features that must be protected, acknowledging that it is impossible to replace millions of years of evolution. it may be unrealistic to expect critical habitats of our most precarious species to compete for fire-fighting resources with houses and farms. we are far too self-interested. however, could we imagine the last remaining habitat for a brush-tailed rock-wallaby (petrogale penicillata) might feature as an asset for protection in a fire that is burning through a wilderness area? surely that needs doing. it will require prioritisation, mapping habitats of precious fire-sensitive species, and a signal to the fire controller that these maps should sit alongside critical human infrastructure maps in the fire room. inclusion of biodiversity assets in fire management plans and fire control operations also needs to be complemented by increased recognition of the risks of wildfire within conservation management and recovery planning: very few of such existing plans for threatened species anticipated such catastrophes or provided useful guidance on how to respond. we should learn from what went well this past fire season and ensure that successful responses are hardwired for next time, here in australia and in comparable biomes elsewhere in the world. the rapid production of spatial statistical summaries activities are organised according to the relevant timing (columns) and under broad families of activities (rows). crucial elements in the preparatory phase 'before the fire' that were not adequately addressed before the - australian megafires include analysis and synthesis of species sensitivity to fire, monitoring, surveying, and mapping to delineate critical habitats for protection and emergency postfire action. undertaking adequate preparation will help ensure that, during and immediately post fire, actions will be efficiently deployed to protect sensitive and critical biodiversity assets and rapidly drive their recovery. many of the medium-long-term postfire activities support preparation for the next fire event, such as policy and management changes, to reduce the likelihood and minimise the impacts of future events. identifying species that were most impacted facilitated prioritisation of immediate care, and what form that care should take; these actions probably saved species. fortunately, some of those processes have been documented and made publicly available i . there is a role for everyone in reducing risks of fire, minimising losses during fire, and recovery after fire. we have focussed here primarily on the role of land managers, wildlife rescue, policy makers, and ecologists. however, the most crucial role may reside in the media and social sciences. there is a significant risk that mega-fires will be attributed to the occurrence of natural vegetation. we need to better understand these perceptions and design messages that dampen the desire to punish the bush for what happened to rural communities and avoid an outbreak of illegal or statesanctioned land clearing in the name of fire prevention. it is vital to communicate the awe and wonder of our species and ecosystems, and the message that, while we will always live with the risk of fire in our landscapes, those risks to people and property can be managed and mitigated without the need for further sacrifice of nature. extraterritorial hunting expeditions to intense fire scars by feral cats monitoring threatened species and ecological communities aerial sowing stopped the loss of alpine ash (eucalyptus delegatensis) forests burnt by three short-interval fires in the alpine national park towards adaptive management of native vegetation in regional landscapes salvage logging in the montane ash eucalypt forests of the central highlands of victoria and its potential impacts on biodiversity ranking conservation and timber management options for leadbeaters possum in southeastern australia using population viability analysis modelling human impacts on the tasmanian wedge-tailed eagle (aquila audax fleayi) unprecedented burn area of australian mega forest fires spatial patterns of wildfire ignitions in south-eastern australia thanks to many people who contributed knowledge, ideas, and data. thanks to natasha cadenhead and casey visintin for assistance with editing and figures. thanks to the community and many agencies for their extraordinary efforts to recover biodiversity. key: cord- -xxku q f authors: hess, kristy; waller, lisa jane title: local newspapers and coronavirus: conceptualising connections, comparisons and cures date: - - journal: nan doi: . / x sha: doc_id: cord_uid: xxku q f within weeks of the nation-wide covid- shutdown, more than regional and community newspapers across australia announced they could no longer keep their presses running due to the unprecedented crisis. a drain in advertising spend, a broken business model and the refusal of digital behemoths to pay for content were blamed for their collapse, ironically as audiences’ demand for credible news and information soared across the globe. there is no doubt the covid- crisis has widened existing, deep cracks in the news media industry. in response this article sets out to explore possible solutions and strategies for local newspapers in the post-pandemic media landscape. we take an analogical approach to argue some of the issues that emerged during covid- and strategies used to fight the global health pandemic also present valuable lessons for the preservation of public interest journalism and news at the local level. we conceptualise five coronavirus-related themes that resonate with a much-needed innovations agenda for local newspapers in australia: ( ) support for essential services, ( ) warnings of complacency against an evolving biological threat, ( ) appreciating the power of the social ( ) coordinated government/policy responses and ( ) ‘we are all in this together’. in april , at the height of the covid- lockdown in australia, university of sydney emeritus professor of public health simon chapman wrote a piece of media commentary highlighting the power of analogy in countering cognitive dissonance, a term that describes the ability of people to sustain particular beliefs or behaviours in the face of overwhelming evidence that could shatter their views. he argued that during his work as a public health advocate, analogy had proved to be a useful tool for dismantling steadfast beliefs in the interests of positive social change. the story included a graphic of the following analogy to describe sections of australian society's eagerness to ease covid- social distancing restrictions: the curve is flattening, we can start lifting social restrictions now = the parachute has slowed our rate of descent, we can take it off now? (chapman, , n.p) an area of society that has taken a major nosedive during the global pandemic, and according to a chorus of media reports requires a parachute for safe landing, is the news industry itself (see meade, ) . despite a sharp rise in demand for reliable and relevant news and information due to the virus (park et al., ) , there were more than regional newspaper closures in australia and/or temporary suspensions of the printed publications (public interest journalism initiative, ) between january and june . some of these publications including the yarram standard in victoria, which first rolled off the press more than years ago, survived the spanish flu of - and flourished for decades afterwards. however, the australian media's underlying health issues meant these newspapers had little or no immunity when the acute economic downturn that accompanied covid- infected their life blood. newspapers' deteriorating state of wellbeing-with symptoms including shrinking readerships and weakening advertising revenue-has been charted by media watchers dating back to the advent of radio and then television (temple, ) . the decline of print was declared to have entered a more acute phase in the early s when web . revolutionised the way digital information is created, shared, stored, distributed, and manipulated. the enduring discourses of 'crisis' and 'digital disruption' that emerged have contributed not only to how journalism is perceived, but also have shaped its reality (zelizer, ) . for example, both industry and academics have been in a perpetual state of anxiety over the 'future of journalism', with countless conferences, summits, roundtables, industry and government reports, policy overhauls and literally thousands of academic papers and books dedicated to the topic. there have also been many experiments in the search for a 'cure' -from enterprises including aol's failed hyperlocal experiment patch, to local news outlets recruiting 'citizen journalists' to provide content or seeking philanthropic partnerships to underwrite public interest journalism (hess and waller, ) . one of the most remarkable aspects of covid- has arguably been how rapidly it overwhelmed the dominant discourses of 'crisis' and 'digital disruption' in journalism studies and practice. this special issue of media international is one of many such themed editions throughout the world with a strong focus on viewing journalism through the lens of the pandemic. as researchers working on a project that will gauge the civic value of australia's country press and develop an innovation model for the sector, we have made the case for an approach to media innovation that does not simply reinforce the 'crisis' discourse (hess and waller, ) or pin small newspaper closures like butterflies to a google map of pandemic despair (see https://piji.com.au). instead, we set out to learn from the unexpected within scholarship, industry and policy arenas and how responses to the current health crisis might inform new directions for achieving and maintaining a safe and sustainable local newspaper sector. in the sections that follow we will first provide some context around the state of local newspapers prior to the onset of covid- . we look to interdisciplinary scholarship on analogy to argue the pandemic can play a heuristic role in developing fresh approaches related to local journalism practice, policy and theory. examining some of the strategies and tactics used to tackle covid- through the conceptual framework of five pandemic-related themes presents valuable lessons and synergies in the fight to preserve the health of public interest journalism in australia. when covid- virus hit australia's shores, it circulated predominantly in the nation's major metropolitan areas, leaving rural areas largely unscathed. however, long-serving rural newspapers were arguably hardest hit by the sudden decline in media advertising revenue (see e.g. meade, ) . dozens of vulnerable small independent and australian community media publications had little choice but to temporarily freeze their operations and put their cadet journalists on the government's jobkeeper scheme. the nation's media juggernaut news corporation soon followed with the announcement it would close more than suburban and country newspapers, or shift them to a digital-only format (mason, ). our research, along with studies produced internationally, highlights that local news matters to audiences and a healthy democracy (see ali et al., ; hess and waller, ) . the vast geographic distances between australia's towns and cities, however, generated challenges and opportunities for local media before covid- (hess and waller, ) . issues facing the sector range from internet connectivity (freeman, ) to the rise of news gaps in remote areas, or on the periphery of established news circulation or broadcast licencing areas. the overarching policy challenge for australia's federal government has been to how best to serve the news and information needs of all australians, especially when it is well established that the availability of local news and information is considered vital for enhancing civic life and social capital (richards, ) . it is important to note that australia's local newspaper sector has been a tale of mixed fortunes since the rise of digital platforms and social media giants like facebook more than a decade ago. while many newspapers are in decline, some have been in a holding pattern with circulation and revenue across print and digital platforms (see https://countrypressaustralia.com.au). increasingly australia is also witnessing an increase in the number of new start-up ventures emerging to fill news gaps or serve communities (see https://papernews.com.au/). most experts agree, nonetheless, that a comprehensive reassessment is needed, along with innovative strategies for the longterm sustainability of the sector (see australian consumer and competition commission (accc), ). there have been two national media policy developments in recent years that have sought to define the problems besetting the country newspaper sector and generate solutions and these have evolved or been refined during covid- . the first was the federal government's innovation fund for rural and regional publishers that followed a series of senate inquiries into public broadcasting and public interest journalism between - (australian government, b) . the $ million, three-year regional and small publishers innovation fund (australian government, a) was developed to support '. . . the continuation, development, growth and innovation of australian journalism that investigates and explains public policy and issues of public significance, engages citizens in public debate, and informs democratic decision-making' (australian government, a) . it adopted a technological determinist approach to innovation (zelizer, (zelizer, , by providing support for equipment, software, training and some funds to employ cadet journalists. during the pandemic, the fund was partially repackaged into a $ million public interest news gathering programme open to most news providers in the country beyond the rural and regional and a $ million regional and small publishers innovation fund to target small newspaper proprietors (see acma, ). the second development was the accc inquiry into the impact of digital platforms, including google and facebook, on australian news and society (australian government, b) . the biggest proposed shake-up of the sector-to be discussed later in this essay-came in may, when the federal government announced plans to force facebook and google to share its advertising revenue to create a more level playing field with news providers (taylor, ) . the accc has since been given responsibility for developing a mandatory bargaining code to structure the sharing of advertising revenue among australia's media players. other actors have also had influence on supporting local journalism at the local level, from philanthropists to academics and union bodies, which we will also return to soon. our approach to exploring the relationship between covid- and the future of local newspapers in australia is a novel one because we extend upon a framework for analogising in a way that appreciates its imaginative, sensemaking and sensibility dimensions (see schwartz plaschg, ). importantly, this perspective acknowledges the argumentative and persuasive power of analogy. in our broader scholarship, we are also interested in teasing out how analogies can be exploited and strategized by those in positions of influence and power, including academic researchers. in the sections that follow analogy is employed as a heuristic device to aid discovery, innovation, exploration and clarification (bartha, ) . in other words, it provides a conceptual shortcut in an attempt to develop, and begin to explore, a new set of arguments about the complex problems and issues facing local journalism. such analogising, or analogical reasoning, has resulted in major breakthroughs in other disciplines from philosophy to science, law, mathematics, organisation studies, design, cognitive psychology, bio sciences, bioethics, business and creative entrepreneurship (see steadman, ) . in this case, we draw inspiration from the imaginative and sensibility dimensions of analogic reasoning as conceptualised by claudia schwartz plaschg ( ) to help envisage or reimagine how existing structures and thinking around local newspapers might be renewed, reformed or rejected. this approach acknowledges the imaginative function of analogy as the 'power of the possible' (ricoeur, ) that can assist in exploring the potentialities of reality, while acknowledging that the 'imaginative' needs to be balanced with examining those in positions of privilege and power who utilise analogies for their advantage. persuasive analogies are often built from a common knowledge source with which both speakers and audience are familiar. schwartz plaschg ( ) reminds us that such analogies enact power by evoking widely shared interpretations in their audiences. analogising therefore calls for researchers, policymakers and industry to practice reflexivity; that is, to deliberately and consciously examine our own motives, practices and positions of power in using analogies to influence society. we acknowledge that elsewhere we have drawn analogies between hyperlocal journalism ventures and organic mushrooms and asked other journalism academics and policymakers to consider australia's three-tiered political system in terms of layers of a wedding cake to foreground more complex theoretical ideas waller, , ) . by so doing, we have influenced academic understanding and further research on local journalism. we are not alone in using analogy to define the terms of discussion in our field. journalism as both culture and practice has been analogised in terms of ecosystems, woven fabric, pens and swords. however, the use of the analogy in journalism studies is often adopted with little reflexivity or thought about its purpose or value as a specific research approach, rather adopted instinctively as a strategy to help unpack complex theoretical ideas. this article contributes to our wider project on the future of country newspapers in australia and in being reflexive, we appreciate that we hold an immediate bias in that our research aims to not only investigate, but also develop innovative approaches that can help to ensure the sustainability of these local news outlets. in doing so, we openly declare we have an agenda and therefore analogies are a tactic we use to discuss the unexpected in our attempt to shift away from the dominant techno-determinist and 'public interest journalism' discourses that currently dominate industry, public and policy understanding of the issues at stake (hess and waller, ) . we are eager to move beyond discussions of 'crisis in the age of covid- ' by employing analogy to develop, and begin to explore, a new set of arguments generated by how other powerful institutions have responded to the pandemic and the key challenges and issues that arose in debate about the news. we take five analogies associated with the pandemic to address the future of country newspapers, drawing on media coverage of key themes that emerged during the height of the crisis in march to june . they are: ( ) support for essential services, ( ) warnings of complacency against an evolving biological threat, ( ) appreciating the power of the social ( ) the need for coordinated government/policy responses and : we are all in this together. 'essential service' was arguably one of the most commonly used and somewhat confusing keywords to emerge from australian leaders' daily press conferences and news media coverage. it took on new significance and was repurposed in particular ways. for example, there was public debate over whether hairdressing and personal training were 'essential services', while according to prime minister scott morrison everyone with a job was performing an essential service (no author, a) . during the pandemic, local newsrooms shut down throughout the world. in australia, they were eligible for the jobkeeper scheme, but it did not stop hundreds of newspapers (largely news corp and acm) from temporarily or permanently suspending their printed publications and shifting to digital, bringing local journalism into national and international conversations that defined journalism as an 'essential service' (gorman, ) . there is no doubt that country newspapers have been undergoing digital transformations that affect many aspects of their operations. here we argue that it is important to look beyond the role of journalism itself as an essential service to the communities and broader society it serves to also consider the 'essential service' role that the printed newspaper plays in rural and regional australia within a digital world. this factor sets country mastheads apart from many of their national and metropolitan cousins, for whom print is no longer the main game. journalism scholars, immersed in the increasing scholarship around platformatization, could be forgiven for missing this crucial point as print is fast becoming redundant in much international research on media innovation (hess and waller, ) . positioning the printed newspaper as an essential service in is context specific and in response to existing demographics and media-related practices. elsewhere we have emphasised the continuing importance of the printed newspaper in times of crisis (freeman et al., ) . online content about covid- is not a service for those with poor connectivity or limited socio-economic circumstances (such as constraints related to age, income and literacy levels) in rural and regional areas. in these places, local journalists are best placed to provide accessible news and information and contextualise global and national stories for their audiences; and significantly, to report how a crisis like covid- is affecting their own institutions, businesses and people. it provides a record of history in these times as well as in everyday life, especially when digital archiving of rural and regional publications are inconsistent and often incomplete in libraries and across archiving platforms. connectivity challenges also inhibit alternative sources like hyperlocal community media (that are often dependent on more cost effective blog platforms) from reliably enhancing local media responses to crisis. there is also limited scholarly research on the news needs of ageing residents in rural and regional australia. while there was intense focus on the health and wellbeing of elderly people during covid- (with early research pointing to the ageing as most susceptible to the virus), the wellbeing of older residents is lacking in academic discussions about the future of local newspapers. an industry survey of more than , elderly residents by national seniors australia ( ) revealed diversity in terms of ability, comfort and attitudes to overall digital literacy and engagement in an online world. when it comes to news use, however, several studies show older residents continue to have an affinity with traditional news sources, especially local press (barnes, ; nossek et al., ; park et al., ) . barnes ( ) , for example, argues older australians continue to rely on 'traditional' media for their news and informational needs more than any other information source. the reasons for this include a lack of digital literacy, as well as other exclusion issues including access and cost. she also highlighted other barriers for engagement such as the design and usability of news websites to ensure these are perceived as relevant and usable for older readers. covid- has sharpened public awareness that many once taken-for-granted services are 'essential', with supermarket workers and cleaners celebrated as national heroes alongside medical workers. recognition of news media as an essential service has provided a strong rationale for policy interventions to support journalism. at the rural and regional level, the discussion has underlined the importance of the printed product in serving the public interest function of serving all sectors of the community which warrants its place as an essential service as an issue of equity during this period of digital transformation. nations throughout the world have scrambled to gather the resources necessary to respond to covid- and the race to find vaccines and treatments is difficult. critics say there should have been better preparations and resources in place as scientists have been warning for years about an imminent biological threat (dulaney, ) . there are parallels here with society's complacency about the failing health of small newspapers, and then panic, to rescue them amid the pandemic. sociologist robert park -a founder of local journalism studies-drew an analogy between newspapers and evolutionary adaptation in the s by comparing their evolving norms to the features of a 'surviving species' (park, , see nadler, for full discussion). he contended the history of the newspaper 'is the history of the surviving species. it is an account of the conditions under which the existing newspaper has grown up and taken form" (park, : np) . in this article we compare social media giants such as google and facebook to a bacterial infection in australia's mediated democracy that are proving a threat to the species' survival. policymakers, industry and academics (including ourselves) have all argued during the pandemic that local mastheads are a threatened species that warrants protection as they continue to evolve in the digital era. bacteria is a useful analogy for social media because it can be understood to be both dangerous and beneficial and can cause infection if left untreated. the benefit of social media platforms such as twitter and facebook to advanced liberal democracies is the subject of much scholarship and debate. on the one hand, societal and political significance of social media, bloggers and the internet more broadly has been celebrated as part of a new fifth estate (dutton and dubois, ; jerico, ) . the bacteria is perceived in some quarters, however, to be dangerous to democracy with google and facebook in particular considered to be no 'friend' of public interest journalism. government inquiries across the globe into the platform's handling of fake accounts, advertising, privacy, and hate speech has revealed how social media sites pillage and plunder the information highway once dominated by traditional mainstream outlets (accc, ; halpern, ) . analogising tech giants as bacteria shifts the discussion from the rise of digital technology to one that considers the makeup and environmental conditions in which it flourishes or damages healthy mediated discussion. treatments and vaccines (such as an accc bargaining code discussed earlier) are being developed to ensure that the healthy bacteria social media does contribute to public debate in the form of free speech and social connection is not overrun by the kind that is toxic (think misinformation, trolls, fake news) (tandoc et al., ) . we should not, however, overlook the role that news media and journalism studies scholars play in feeding the bacteria that facebook has become. if we wind the clock back just a decade, it's easy to forget that the relationship between journalism and facebook wasn't all bad. while the shift to digital classifieds had started eating into traditional media advertising during the early s, mainstream news media was still arguably in control of the public conversation. back then, scholars and industry were fascinated by facebook as a 'new play thing' in the digital sphere. both journalists and facebook positioned the platform as a relatively harmless phenomena, given its links to notions of 'friending', 'liking', and building 'community'. journalists began using facebook to share and promote stories, to find news sources, and to move audiences connected to shared geographical spaces into easily accessible online communities. almost all local news outlets across australia now have facebook pages to promote content. the idea that facebook could, however, exploit the symbolic power of news media and set journalism aside as a social force just wasn't a key part of the initial discussion (gutsche and hess, ) . the directive for entire populations to stay confined to their homes for weeks on end during the covid- pandemic highlights the basic-yet often taken for granted-importance of social interaction and connection. the early collapse of event businesses, cafes and restaurants quickly demonstrated how economies are built around our very desire to be social and the freedom to engage in ritualistic practices such as weddings, celebrations and funerals. global tech companies with the software and capabilities to connect people socially in a virtual world have been the big winnerssites like zoom, house party and live streaming companies, have enjoyed early spikes in usability and profits (no author, b) . the ability to capitalise on our desire for social connection in a mediated world is perhaps best illustrated by the rise of facebook. at a time when local news media profits have slumped, the company recorded a per cent increase for the first quarter of and a rise in the number of users (horwitz, ) -a point we shall return to soon. the focus on the social dimension of our everyday lives provides a powerful reminder of its importance to the future of local newspapers. yet far too often the 'social' dimensions of journalism have been set apart or 'distanced' from its revered fourth estate function where journalists serve a public sphere and hold power to account. by social we mean the information relevant to the realm of our everyday lives, which helps us make sense of who we are as individuals and collectives (hess and gutsche, ) . such information may be referred to as stories recognising the success, milestones, tragedy, despair, honour of individuals (human interest stories), solutions journalism that brings people together to advocate social change, curated and contextualised weather and traffic and transport reports/incidents, reporting and synthesis of events, obituaries, feature articles, travel and lifestyle content. instead, within journalism practice, the social has become synonymous with social media and social networking, as if sites such as facebook are now the legitimate sphere for our everyday social needs. terms such as social journalism (hermida, ) , social news (goode, ) , and the sociability of news (phillips, ) have been coined to explore how social networking is shaping journalism, from its celebrated fifth estate function (jerico, ) to audience and journalistic engagement and participation. there is a need to engage with innovative strategies that enhance, critique and/or extend the role of the news media and its connection to the social. political scientist robert putnam used an analogy at the turn of the century to explain the role of social capital in society. he defined social capital as connections among individuals, networks and the norms of reciprocity and trustworthiness that arises from them, and argued such a resource served like a social glue to hold societies together and a form of social wd that lubricated connections and networks (putnam, ) . researchers adopting a putnam approach have highlighted the role of local newspapers especially as providing the information that connects people, generating social capital or 'sense of community'. we have adopted social capital theory more broadly to focus on the role and power of local news media to connect people with each other, a practice that builds a local journalist and newspaper's legitimacy while also enhancing community social capital, identity and progress (hess, ) . ideas around membership building, facilitating community conversations to inform and generate meaningful social connections, solutions and advocacy journalism all fit within this framework because it focuses on the brokerage role journalists play in connecting everyday people with each other, or facilitating connections with those in positions of power. james carey's ritualistic view of communication (carey, ) also offers important wisdom to journalism academics that 'the subject matter of journalism is the conversation the public is having with itself'. those conversations can be public and social, but what is more important is how local media develop strategies to reclaim their centrality to such conversations by ensuring and creating a constructive space for them to occur in both physical and digital settings. in other words, being able to connect people socially -through the ability to generate a sense of community, bring people together and link them to those in positions of power in the interests of change and progress are powerful tools for news media. local news outlets which outsource the 'social' dimensions of news to facebook, in our view play a very dangerous game (hess and gutsche, ) . the power of collective, coordinated responses to covid- -from the healthcare sector through to politics, neighbourhoods and schools-has been celebrated across australia. the pandemic has led to dramatic overhauls of decision-making structures at the highest levels. on may , , prime minister scott morrison announced that the council of australian government (coag) would cease (https://www.coag.gov.au). as the peak intergovernmental forum established in , its role was to manage matters of national significance, from climate policy to healthcare and education. coag membership included the prime minister, state and territory first ministers and australian local government association president. it attracted criticism nonetheless because it met irregularly and was considered too bureaucratic. officials and commentators have used the analogy of the cemetery to describe coag as a 'graveyard of good proposals for reform' (pelly, ) ; or as the pm stated in april, a place where 'good ideas went to die' (prasser, ) . instead a covid- legacy will be the creation of a national cabinet -devised to develop timely, more effective and collaborative decision making involving the pm, premiers and territory leaders. it is not our intention to endorse or criticise this response, but it does highlight the need for a reassessment and realignment of existing power structures and the value of a more coordinated response to sustaining local journalism. there are a range of initiatives, administrative bodies, policy think tanks, philanthropic grants, industry and academic research on local news all being circulated without regular collaboration or coordination between key stakeholders. as we highlighted earlier, the federal government is administering a $ million public interest journalism fund, while the australian communication and media authority is responsible for a $ million scheme to support regional publishers. the judith neilson institute is allocating millions of dollars to support journalism projects, as the accc is developing a bargaining code to tackle the social media giants (judith nielson, ). the dismantling of coag also resonates with another key challenge in debates about the future of news-the most powerful voices tend to dominate discussion. the local government association, for example, lost its seat at the table of the national cabinet, prompting concern that rural and regional voices would be lost in future decision making discussions (vogler, ) . in media policy debates, there too is concern that news corp, acm and nine will drown out the voices of small town proprietors and community newspapers. scholars elsewhere have suggested that covid- highlights the important need for a new collaborative funding model to support local news -one that draws on a mix of subscription fees, social media subsidies, advertising revenue and government support to sustain news (see especially olsen et al., ) . such an approach is a useful one, providing we do not overlook issues of power in these debates and that there are mechanisms to ensure those who receive such a mix of support are held accountable to local audiences -in other words, the need for someone to watch the watchdogs (finkelstein & ricketson, ) there too remains a serious structural imbalance and lack of coordination in the way different states and territories support local journalism beyond the metropole through government advertising revenue. victoria is arguably the most committed state, ensuring departments and agencies spend at least % of their campaign advertising expenditure on rural and regional media (victorian . during the pandemic the premier, daniel andrews, also announced a $ . million advertising support package for struggling country papers (andrews, ) . however, as recently as south australia announced legislation that provided freedom for states and local governments to publish information on their own websites, removing their requirement to report public notices in local newspapers, (government of south australia, ) . from 'we're all in this together' posters on shop doors and restaurant windows (pelly, ) rainbow signs on front fences and balconies, to teddy bears in windows, ordinary citizens around the world have joined the world health organisation and government leaders in reminding each other 'we are all in this together'. local expressions of universal solidarity appeared to 'go viral' as people took it upon themselves to act on behalf of others in need (abc news, ). at an institutional level, covid- has had the same effect, with medical researchers involved in a world-first collaboration to test experimental treatments for covid- (world health organization (who), ) and grocery giants who usually compete ferociously uniting in a taskforce for the common good and to ensure social order (powell, ) . in his work on the concept of solidarity, german philosopher kurt bayertz ( ) traces its roots to the roman law of obligations, defining it as a mutual attachment between individuals and groups that operates on two levels. the first is the 'factual' plane of actual common ground between people; the second is the 'normative' level of mutual obligations to aid each other, 'as and when should be necessary' (bayertz, : ) . he uses the term 'universalistic solidarity' to describe this, suggesting all human beings have a moral duty to work together for the benefit of all. this is what 'we're all in this together' implies. during times of crisis this can be in the interests of preserving social order, rather than the kind of 'political solidarity' that is often formed to enact change or challenge the status quo. but as bayertz ( ) emphasises, 'universalistic solidarity' also ignores differences in power, and potential conflict between the needs and values of different groups. it overshadows how the impact of a crisis is not equal among groups in society, a point emphasised in our earlier discussion of 'essential services'. elsewhere we have argued that there are certain individuals/institutions that are expected to perpetuate moral universalism when it matters most and that people turn to journalism -especially at the local level-for this very purpose (hess, ) . this approach provides scope to consider how institutions themselves can unite in the interests of and perpetuate what bayetrz refers to as solidarity while reinforcing their own self-interest. australia's supermarkets found themselves in uncharted waters when panic buying gripped the nation. coles and woolworths have described how they were 'moving fast but flying blind' individually, with no chapters in their crisis handbooks on how to deal with a global pandemic (powell, ) . with the support of the government, they joined forces with aldi and iga to form the first ever supermarket taskforce to focus on cross-industry collaboration. powell ( ) explained that while the taskforce was strictly prohibited by the accc from discussing issues such as product pricing, the group shared their plans and best practices across issues like in-store cleaning, social distancing and set the same limits on buying certain products. at the height of the panic buying, the big four supermarkets took out full-page advertisements in major newspapers in an attempt to quell the unrest among shoppers. woolworths chief brad banducci explained how the usually fierce rivals decided the order in which the four companies' logos would be displayed on the ad: 'of course there was only one answer: alphabetically', he laughs. 'but that move set a really important tonality that we were all in it together'. (in powell, ) as the crisis deepened, the supermarket taskforce faced some fundamental issues that resonate with bayetrz's ( ) observations about the challenges of universal solidarity when it comes to social inequality. they had to find a way to ensure two million vulnerable australians had food and essential provisions if they were unable to leave the house. their online delivery systems were illsuited to the task, so they collaborated with australia post and logistics business dhl to organise delivery for an $ box of essentials. they also instigated a shopping hour for the elderly and vulnerable. there are lessons here for the legacy media companies who have united on what bayertz ( ) termed 'the factual plane of actual common ground' in the fight against the digital techs, for example, in the accc bargaining code framework. their approach remains disjointed and there are concerns that big players like acm, news corp and nine will drown out the interests of smaller players like small independent newspapers (www.vcpa.com.au). while there is of course selfinterest at play here, the supermarket taskforce provides an example of competitors working together in the interests of not only wider society, but those in most need, which has taken them into the realm of universal solidarity. they have done this by renegotiating their terms of engagement, the policy frameworks they operate within, and by reaching outside their patch to enlist other collaborators who can help deliver essential services to communities in danger of being severely disadvantaged. as we have discussed previously, the pandemic has crystallised the understanding of country newspapers as 'essential services' opening the possibility of developing new approaches to cross-industry collaboration. on another level, some scholars promote a 'we are all in this together approach' by advocating for more collaboration between journalism institutions in the production of good quality and investigative journalism involving public broadcasters, not-for profits and mainstream commercial providers (jenkins and graves, ) . there remains issues around who ultimately benefits from the production of news content, nonetheless. in advancing a local newspaper innovations agenda, an approach inspired by systems thinking resonates with the overarching analogy of the covid- response explored here. systems thinking conceptualises the material world as a network of inseparable relationships, patterns and contexts. it accounts for how living networks continually create or recreate themselves by transforming or replacing their components -undergoing continual structural changes while preserving their weblike patterns of organisation. as covid- reminds us, the coexistence of stability and change is one of the key characteristics of life. a system thinking approach can therefore be used to challenge the idea that the most urgent problems facing regional newspapers can be understood as a product of the covid- pandemic, or in isolation from other environmental, political, cultural, social, technological and economic concerns. the problems facing local newspapers require a systemic solution. elsewhere we have outlined a six-dimensional model that complements this approach to examine media innovation-a model that acknowledges and calls for a critical engagement of these various factors (see hess and waller, ) . scientists are looking for innovative ways to protect society from a viral pandemic and are drawing on existing and new treatment options. we too seek new ways of protecting the health of local newspapers while appreciating that not all that is new is innovative and there may be tried and true structures and practices that are fundamental to the future of local news. we are optimistic that taking a fresh conceptual approach to media innovation can generate rich empirical findings and inform the rural news sector for the betterment of society according to james ( ) , systems thinking helps us understand that all parts of a business or a process are connected and to focus on interrelatedness. it involves cooperation, pooling or combining ideas and experience, and can improve innovation, efficiency and performance. in the context of regional and rural newspapers, systems thinking calls for deep engagement with readers and non-readers, as well as those working in the industry and related areas including the businesses that advertise. there are often too many disparate and disconnected voices in the debate about the future of local news who should be brought together, encouraged and supported to work together regularly and constructively. as we have witnessed from the collaborative coordinated response from supermarkets during the pandemic, self-interest can work alongside the greater good, but issues of power must always be examined in the process. one strategy that emerged from the pandemic that merits further investigation is the value of an independent national cabinet-style body to examine the future and ongoing sustainability of local news. key stakeholders would include the federal communications department, accc, acma, philanthropic organisations, community newspaper representatives, key industry representatives, the abc and academic experts on local media. while the australian local government association lost it place at the table upon the disbandment of coag, it most certainly warrants a place within a national consultative body on local media, given it plays an integral and symbiotic role in the survival of local news and a healthy mediated democracy at the grassroots level. in a submission to the accc bargaining code in june, , we argued for a digital transition fund to support local newspapers. an administrating body would be needed to fairly divide and allocate any advertising revenue shared by google and facebook into the future. like the national cabinet established in the midst of the pandemic, a national body for local news would help ensure a more streamlined, effective and targeted approach to supporting rural and regional newspapers into the next decade. this essay has argued there is value in analogising as a way of generating fresh perspectives in the debate about the future of local news in australia. analogies can be a useful way of ordering and explaining complex ideas and thoughts, and are often adopted by the powerful to outline a point of view. we have begun to map an approach to analogising in media and communication research that focuses on its broader sense-making role, ultimately to help to envisage or reimagine what local journalism might be. in doing so, we acknowledge that the 'imaginative' needs to be balanced with a critical examination and reflexive approach to those in positions of privilege who utilise analogies for their advantage. positioning the future of news against broader societal responses to covid- provides interesting insight. first, we suggest that we must look beyond the normative role of journalism as 'an essential service' to more specifically understand the importance of the printed product in nonmetropolitan areas due to demographics and a continuing digital divide. ' we are all in this together', meanwhile, has been a powerful reminder of the importance of solidarity in times of crisis. the supermarket taskforce offers inspiration for a national body whose mission is not only to ensure local newspapers survive, but to serve the news needs of geographically marginalised audiences. much of our research over the past decade has focused on everyday people's media-related practices to explore the reasons they engage with local news-beyond engagement with matters of politics or a public interest. over time we have understood the power of the social and the benefits and advantages of those who are central to the social realms that connect with our everyday lives. facebook and google position themselves as merely hosts in which harmful bacteria can thrive. within immunobiology for example, only when the innate host's own defences are bypassed, evaded, or overwhelmed is an induced immune response required. covid- also tells us that if a host becomes overwhelmed with contagious toxins, they must be isolated and treated as part of the problem. the author(s) received financial support for the research, authorship, and publication of this article: the author received financial support from the australian research council linkage scheme lp . kristy hess https://orcid.org/ - - - lisa jane waller https://orcid.org/ - - - emergency support to help regional papers survive, victorian government premier's office media statement innovation fund a boost for regional and small publishers senate select committee on the future of public interest journalism final report. parliament of australia digital news and silver surfers an examination of older australians engagement with news online analogy and analogical reasoning distinction: a social critique of the judgment of taste mass communication and cultural studies it's time for a parachute analogy the practice of everyday life (trans. s rendall the next pandemic is coming: and sooner than we think, thanks to changes in the environment the fifth estate: a rising force of pluralistic accountability report of the independent inquiry into media and media regulation digital civic participation in australian local governments: everyday practices and opportunities for engagement communication life line? abc emergency broadcasting in rural/ regional australia social news, citizen journalism and democracy journalism is an essential service during the pandemic. we must fund it as one. local news lab, april development (public notification) variation regulation geographies of journalism mark zuckerberg's plans to capitalise on facebook's failures. the new yorker social journalism: exploring how social media is shaping journalism making connections: mediated social capital and the small town press shifting foundations: journalism and the common good journalism and the social sphere rethinking news media and local government: journalism, politics and symbolic power community and hyperlocal journalism: a 'sustainable' model? hyperlocal journalism charting the media innovations landscape for rural and regional newspapers facebook shares soar as adsales stabilise thinking in the future tense: a workout for the mind oxford: reuters institute for the study of journalism the rise of the fifth estate: social media and blogging in australian politics hundreds of jobs go as news corp confirms restructure more than australian newsrooms shut since nature's economy and news ecology no author ( a) scott morrison's statement on the new national coronavirus restructures no author ( b) zoom boom as teleconferencing company profits from coronavirus crisis is print really dying: the state of print media use in communal news work: covid- calls for collective funding of journalism the natural history of the newspaper we are all in this together: the phrase uniting toronto. cbc news, march lawyers fear for class action reform sociability, speed and quality in the changing news environment inside story: how woolworths and coles joined forces to avert covid- disaster nothing new under the sun in morrison's new federalism. the canberra times bowling alone: the collapse and revival of american community differences over difference: journalism beyond the metropolis oneself as another the power of analogies for imagining and governing emerging technologies the evolution of designs: biological analogy in architecture and the applied arts man vs. machine? the impact of algorithm authorship on news credibility google and facebook could be forced to share advertising revenue. the guardian the rise and fall of the british press ensuring we reach all victorians with our communications. victorian government of australia local government must retain a seat at the national cabinet. local government association of queensland, may public statement for collaboration on covid- vaccine development terms of choice: uncertainty, journalism, and crisis why journalism is about more than digital technology . we are cis on the australian rresearch council linkage project "media innovation and the civic future of australia's country press. [lp ] . we follow de certeau ( ) here to define strategies as measures enacted by the powerful from a position of advantage whereas tactics are used by those of us in everyday society to manage our way around or through strategies imposed by institutions. we also acknowledge we are always tied to our lived experiences and histories in such processes (see bourdieu, ) . abc news ( ) coronavirus pandemic sparks outpouring of kindness, community spirit and pickled carrots. available at: https://www.abc.net.au/news/ - - /coronavirus-community-response-to-covid / australian communications and media and authority ( ) regional and small publishers innovationfund. available at: https://www.acma.gov.au/regional-and-small-publishers-innovation-fund ali c, radcliffe d, schmidt tr, et al. ( ) searching for sheboygans: on the future of smallmarket newspapers. journalism ( ): - . key: cord- -axio zna authors: van, debbie; mclaws, mary-louise; crimmins, jacinta; macintyre, c raina; seale, holly title: university life and pandemic influenza: attitudes and intended behaviour of staff and students towards pandemic (h n ) date: - - journal: bmc public health doi: . / - - - sha: doc_id: cord_uid: axio zna background: in a pandemic young adults are more likely to be infected, increasing the potential for universities to be explosive disease outbreak centres. outbreak management is essential to reduce the impact in both the institution and the surrounding community. through the use of an online survey, we aimed to measure the perceptions and responses of staff and students towards pandemic (h n ) at a major university in sydney, australia. methods: the survey was available online from june to september . the sample included academic staff, general staff and students of the university. results: a total of surveys were completed. nearly all respondents ( . %, / ) were aware of the australian pandemic situation and . % ( / ) reported either "no anxiety" or "disinterest." asian-born respondents were significantly (p < . ) more likely to believe that the pandemic was serious compared to respondents from other regions. . % ( / ) of respondents had not made any lifestyle changes as a result of the pandemic. most respondents had not adopted any specific behaviour change, and only . % ( / ) had adopted the simplest health behaviour, i.e. hand hygiene. adoption of a specific behaviour change was linked to anxiety and asian origin. students were more likely to attend the university if unwell compared with staff members. positive responses from students strongly indicate the potential for expanding online teaching and learning resources for continuing education in disaster settings. willingness to receive the pandemic vaccine was associated with seasonal influenza vaccination uptake over the previous years. conclusions: responses to a pandemic are subject to change in its pre-, early and mid-outbreak stages. lessons for these institutions in preparation for a second wave and future disease outbreaks include the need to promote positive public health behaviours amongst young people and students. in april , severe cases of pneumonia preceded by influenza-like illness were noted to occur in mexico and then north america. a novel influenza a (h n ) virus was identified as the cause and it rapidly evolved into a pandemic. cases of the strain were first identified in australia in early may and soon appeared across the country [ ] . as of february , there have been , confirmed cases and deaths in australia. while this pandemic has been moderate or milder than previous pandemics such as the spanish flu of - , similarities can be drawn between the two in regards to the median age of cases. in australia, the median age of confirmed cases is years [ ] universities therefore have the potential to become explosive, centrifugal outbreak centres due to their large young adult population, high levels of close social contact and permeable boundaries. during a pandemic or disease outbreak, the proportion affected may exceed the seasonal norm of one-third of the student population [ ] . as sites of transmission, they may have a negative impact on the larger communities in which they are embedded. additionally, student behaviour is often divergent from non-student adult populations [ ] . hence, understanding of and outbreak management in such institutions are essential to minimise the impact of pandemic influenza in both the institution and its surrounds. university settings are unique given the permeability of their boundaries and the groups, and the activities within the institution that affect social contact between its members. both of which have the potential to affect behaviours and perceptions. this survey was conducted to examine the understanding of and attitudes towards pandemic (h n ) amongst students and staff at the university of new south wales (unsw), sydney, australia and their behavioural intentions during this pandemic. the cdc recommends that institutions of higher education balance the goals to minimize morbidity and mortality from pandemic influenza with the goal of minimising educational and social disruption [ ] . between april th and september th , ten broadcast emails were sent out by the director of the university health service to staff and students. contained in the emails was information on the: ( ) h n situation; ( ) modes of spread and common symptoms; ( ) recommended health advice consistent with both the who and national recommendations; and ( ) contact information for the relevant health departments [ ] . posters developed by the commonwealth department of health and ageing and unsw were placed in high traffic areas and focused on: ( ) encouraging faculty, staff and students to stay at home if symptomatic (i.e. with a fever, cough, and runny nose) and to protect each other; ( ) cough/sneeze etiquette (i.e. "cover your mouth and nose when you cough and sneeze" and "dispose of used tissues in the bin) and ( ) hand hygiene (i.e. "wash your hands properly and regularly"). data was collected from the june - september, coinciding with the peak of the pandemic in australia. an anonymous online survey was designed to assess the knowledge, attitudes and perceptions of pandemic (h n ) , which was referred to by its vernacular alternative, "swine flu". the survey was piloted on june th with three students and three staff, representative of the members of the study population, and modified accordingly. the final version assessed: ( ) demographic characteristics; ( ) awareness, perceived personal risk and anxiety; ( ) recent influenza-related behaviours changes; ( ) intended behaviour in the event of various scenarios at unsw and ( ) compliance with different community interventions. in regards to the behaviour changes, we included four changes (cancelling social plans, avoiding busy public places, cancelling/postponing travel plans and not using public transport) that were related to avoidance behaviour and not recommended by the government and five changes (buying hygiene products, receiving the seasonal influenza vaccine, using online resources for teaching and learning and stockpiling necessities) that were related to recommended behaviours. the recommended behaviours questions were adapted with permission from a study undertaken by rubin et al [ ] . the sample comprised of both academic and non-academic staff (i.e. administration, it and other support staff) and students at unsw in sydney, australia. participants accessed the final questionnaire via a link on an online newsletter available to all unsw staff and students, and via an online information gateway. emails were also sent to the heads of each faculty, informing them of the survey. consent was implied upon completion and submission of the questionnaire. submitted surveys were collated in a directory and deidentified prior to analysis. participants were offered the chance to win a $ cash prize upon completing the survey. ethics approval was granted by the university of new south wales human research ethics committee. the quantitative data on the completed survey was collected in microsoft excel. openepi (version . ) was used to calculate [ ] , proportions, % confidence intervals and χ tests for significance. alpha was set at the % level. we used logistic regression to compute odds ratios to evaluate the association of demographic variables and attitudes and beliefs. a total of unsw staff and students aged ≥ years completed the online survey between the june and september . the overall response rate was . % ( / ) and most respondents were young ( - years, . %, / ) and born in australia ( . %, / ) ( table ). academic and general staff members were both overrepresented in our sample ( . %, / , x = . , p < . ; . %, / , x = , p < . respectively) compared to the actual proportions employed at unsw ( . %, / and . %, / respectively). students were underrepresented ( . %, / , x = , p < . ) compared to the proportion of internal students at unsw ( . %, / ). most respondents ( . %, / ) reported that they had heard about the australian pandemic situation. whilst . % ( / ) believed that it was serious, . % ( / ) said that they were "not anxious" (figure ) and a further . % ( / ) reported "disinterest". of the respondents who felt they were likely to contract pandemic influenza ( . %, / ), . % ( / ) believed the infection would adversely affect their health. towards the end of the survey period and the end of winter, the percentage reporting "no anxiety" increased and the proportion of respondents who believed that the pandemic was "serious" significantly decreased (or, . [ % ci, . - . ); p < . ) ( figure ). perceptions of susceptibility significantly decreased with the decline of laboratory-confirmed cases in australia (or, . [ % ci, . - . ]; p = . ). asian-born respondents were significantly more likely to believe that the pandemic was serious (or, universities are not immune to natural or manmade disasters, and past experience with these have illustrated the importance of continuity during and after these events [ , ] . in an influenza pandemic, such institutions must maintain a balance between academic continuity, with infection control and minimising morbidity [ ] . in contrast to pre-pandemic and early pandemic findings in australian communities [ , ] , most of the university population surveyed were not anxious about the australian pandemic situation nor did they think it was serious. younger respondents (aged - ) were most likely to believe they were not susceptible to pandemic h n , despite being the most affected group in previous influenza pandemics. following the resurgence of media coverage of "swine flu" in australia, we did measure a significant rise in anxiety, perceived susceptibility and seriousness. this however declined with the approach of spring and the decline of laboratory confirmed cases of influenza a (h n ) in nsw [ ] . this illustrates that public perception of a pandemic is unstable, especially when the severity and natural progression cannot be accurately predicted. if requested by authorities, most respondents in our cohort were willing to undergo isolation if suffering from influenza-like-illness (ili). of concern was the high proportion of students who indicated that they would still attend university with symptoms. in the event of an exam or assessment deadline, their proportion tripled. such behaviour is detrimental for both students and the community, for in addition to spreading the pandemic virus, students with ili are also likely have reduced academic performance by up - % [ ] . absenteeism from university was higher in respondents who had indicated making a lifestyle change, implying the practicality of encouraging general positive health behaviour in this population. along with encouraging students to self-isolate in the case of illness, there must be ongoing education about the importance of infection control, especially when anxiety rates and risk perceptions are low. health messages need to educate students about the impact of the illness on their studies, and universities should emphasise their illness/misadventure assessment policies during disease outbreaks. online resources such as lecture recordings and forum tutorials allow for off-campus education, and can provide continuity of learning for students undergoing isolation. however in our study, few respondents had adopted the use of online teaching or learning resources as a result of pandemic influenza (h n ). this may be due to a number of factors including: ( ) the apparent mildness of the pandemic; and/or ( ) the lack of promotion by the university to use these resources. it was encouraging to see that students were very willing to continue university schooling via online resources, indicating the potential for expanding the existing unsw online teaching resources. while it was encouraging that students would undertake online courses, we found very little support for an online teaching method among the academic staff members. reluctance to use online resources was associated with increased age, and may be due to unfamiliarity with or resistance to technology. in preparation for an outbreak, universities should focus on creating additional support for technologies that allow faculty and students to continue their teaching and learning activities which minimise disruption. online recordings, virtual learning environment, blogs, web conferencing and discussion forums should all be utilised to assist in the delivery of lessons. having a contingency and communication plan for teaching key sections may provide the needed continuity for students and faculty. training must be provided in the pre-pandemic periods to minimise disruption. we found that most respondents had not made any lifestyle changes or undertaken any specific behaviour change despite receiving information from the university. this may be attributed to the mildness of pandemic (h n ) . this finding supports both the pre-pandemic and post-sars findings on the dose-response relationship between outbreak severity and the responses to it [ , ] . of the respondents who did indicate behaviour change, increased hand hygiene was the most common. it would therefore be beneficial and at minimal cost for institutions such as universities to provide extra hand-washing facilities and posters encouraging compliance in communal areas and computer labs. universities could also boost hygienic practices by openly distributing small bottles of hand gels or tissue packets to staff and students on campus. close to % of our respondents stated that they were 'very willing' to receive a hypothetical pandemic vaccine. as the survey period ended before the vaccine became available, we were unable to follow up participants to ascertain if they did receive the vaccine. in australia, the h n vaccine was not released until september , by which time, virus activity was very low. a recent national survey [ ] , found that although % of the australian cohort was aware of an available pandemic vaccine, less than % had received the vaccine. we can therefore expect similarly low vaccination rates in our cohort. the survey also identified that uptake of the h n vaccine was three times as high in those aged years and over ( %) than in those aged - years ( %), with no statistically significant difference between males and females [ ] . we found that respondents who had received seasonal influenza vaccinations in the past were significantly more likely to accept the pandemic vaccine then their non-vaccinated counterparts. these findings are consistent with several recent studies on pandemic vaccine uptake [ , ] . providing the vaccine through clinics or university health facilities should help bolster vaccine uptake, especially for international students, who may not have access to free healthcare. of the participants surveyed, asian-born respondents were the most likely to be anxious about the australian pandemic situation, rate the situation as serious, undertake specific behavioural changes and comply with public health measures. it could be hypothesised that these respondents, their families, friends or members of their communities may have been exposed to previous infectious disease situations such as sars and avian influenza [ , ] . if not exposed, at the least these respondents have lived in countries where their governments have had to deal with these situations, leading to stricter infection control standards and higher levels of media exposure. interestingly, asian born respondents who have been settled in australia for longer periods were less likely to have made any lifestyle changes compared to their counterparts who have been in the country for only short amount of time. it would appear that living in australia dilutes the tendency to adopt behavioural changes, and it would be beneficial for future studies to identify aspects of australian culture which influence health behaviours. we acknowledge that this study has several limitations. these include: ( ) the survey was restricted to the unsw student, general and faculty staff, mostly highly educated sydney residents; ( ) the electronic format of the survey may have excluded persons without internet access; ( ) we did not defin what "requested by the authorities meant" so it was open to the respondents interpretation and ( ) the survey was not translated into other languages. however, english is the dominant language used in both teaching and communication and unsw relies heavily on electronic communication with its campus population to disseminate other unrelated information in english. there was no established measure of influenza protective behaviour, as most of the survey items were developed prior to the publication of the cdc guidance for responses to influenza for institutions of higher education [ ] . the declining number of participants who accessed the online survey towards the end of the survey period likely restricted analysis of how responses to the pandemic change over time. from the study results, several key messages should be drawn. firstly, risk perceptions and anxiety are low and will remain so unless there is a major shift in the virus. this will continue to impact on compliance or uptake of mitigation strategies. secondly, more effective health communication and management is needed to promote self-isolation and infection control in the event of illness especially amongst students. these students are unlikely to adopt behaviours that are unknown to them. therefore the focus should be on handwashing and cough etiquette. lastly, universities must invest in online teaching resources and training during inter-pandemic periods. there also needs to be greater recognition for the need for online assignment submission and examinations to ensure minimal disruption to the students. national centre for immunisation research and surveillance of vaccine preventable diseases (ncirs), the children's hospital at westmead and discipline of paediatrics and child health australian government department of health and ageing: pandemic (h n ) australian department of health and ageing: australian influenza surveillance report no colds and influenza-like illnesses in university students: impact on health, academic and work performance, and health care use on the use of college students in social science research: insights from a second-order meta-analysis cdc guidance for responses to influenza for institutions of higher education during the - academic year public perceptions, anxiety, and behaviour change in relation to the swine flu outbreak: cross sectional telephone survey openepi: open source epidemiological statistics for public health pandemic policy and planning considerations for universities: findings from a tabletop exercise. biosecurity and bioterrorism: biodefense strategy, practice, and science pandemic influenza in australia: using telephone surveys to measure perceptions of threat and willingness to comply the community's attitude towards swine flu and pandemic influenza australian government department of health and ageing: pandemic (h n ) predicting the anticipated emotional and behavioral responses to an avian flu outbreak longitudinal assessment of community psychobehavioral responses during and after the outbreak of severe acute respiratory syndrome in hong kong adult vaccination survey provisional topline results for h n vaccination uptake. canberra: australian government department of health and ageing acceptance of pandemic (h n ) pandemic influenza vaccination by the australian public does receipt of seasonal influenza vaccine predict intention to receive novel h n vaccine: evidence from a nationally representative survey of world health organisation: avian influenza: assessing the pandemic threat. world health organisation severe acute respiratory syndrome (sars) pre-publication history the pre-publication history for this paper can be accessed here submit your next manuscript to biomed central and take full advantage of: • convenient online submission • thorough peer review • no space constraints or color figure charges • immediate publication on acceptance • inclusion in pubmed, cas, scopus and google scholar • research which is freely available for redistribution authors' contributions dv/hs participated in the design of the study and survey, undertook the distribution and collection, performed the analysis and drafted the manuscript. mlm participated in the design of the study and survey, assisted with the analysis and reviewed the manuscript. jc/crm participated in its design and coordination and helped to draft the manuscript. all authors read and approved the final manuscript. raina macintyre receives funding from influenza vaccine manufacturers gsk and csl biotherapies for investigator-driven research. these payments were not associated with this study. the remaining authors have no competing interests. key: cord- - zalzk authors: looke, david f m; gottlieb, thomas; jones, cheryl a title: the global challenges of infectious diseases date: - - journal: med j aust doi: . /mja . sha: doc_id: cord_uid: zalzk nan i n , on behalf of the australasian society for infectious diseases (asid), we reported in the journal on the infectious diseases challenges for australia in the coming decade. we identified antimicrobial resistance (amr) as a public health crisis requiring global professional and political action, and reflected on how the spread of infectious diseases and amr is affected by interconnected factors including mass transportation, climate change, environmental perturbations and mass food production. we also noted how enhanced molecular capabilities in therapeutics and diagnostics provide new opportunities for detection and containment. "just over months ago, no one could have foreseen the global ramifications of the ebola virus epidemic" in this article, we take stock on the progress and changes in the global landscape since our previous report. the past years have seen increased global recognition of amr. an ambitious strategy has been launched by the world health organization, which convened a ministerial conference on antibiotic resistance in june and published a draft global action plan. government policies for combating amr have also been developed in , such as the national strategy in the united states and the -year plan in the united kingdom. these provide blueprints for action, as shown by the inclusion of $ . billion funding for amr in the us budget. the australian government has also provided international leadership by taking a strong one health approach to its national amr strategy. it has established a highlevel steering group chaired jointly by the heads of the department of health and department of agriculture, supported by the australian strategic and technical advisory group on amr, which has highlighted the need for data on antibiotic usage and resistance to increase understanding of the drivers of amr. the australian commission on safety and quality in health care (acsqhc) is setting up comprehensive surveillance of amr and consumption through the antimicrobial use and resistance in australia project, and a similar exercise is planned for animals and agriculture. one way to measure success of programs to limit amr is through reduction of health care-associated infections (hais). the annual costs of hais in the us alone have been estimated at $ billion, with deaths per year. in australia, the acsqhc has been instrumental in efforts to reduce hais, largely via hospital accreditation. the acsqhc has championed hand hygiene initiatives, national infection control standards and mandatory antimicrobial stewardship programs in all australian hospitals. these efforts promise significant benefits, as shown by a recent report of a significant reduction of staphylococcus aureus bloodstream infections in australian institutions. despite the advances in combating amr, we remain vulnerable to outbreaks. in his natural history, pliny the elder ( - ad) wrote, "there is always something new out of africa". the same applied in . just over months ago, no one could have foreseen the global ramifications of the ebola virus epidemic. a few isolated cases quickly led to epidemic spread in impoverished urban centres of sierra leone, liberia and guinea that rapidly overwhelmed local health systems. this outbreak has highlighted not only our global vulnerability to epidemics, but also the immense value of traditional strict infection control practices, which when applied have resulted in a marked diminution in the projected size of the epidemic. new technologies have enabled development of novel rapid diagnostics and candidate vaccines which provide enormous hope for future epidemics. vaccines against dengue virus and clostridium difficile are two other examples where there is promise for future advances. however, possession of effective vaccines is not sufficient for control. infrastructure for delivery needs to be present, and consumers must have confidence in vaccine safety and efficacy. controlled pathogens can re-emerge when this framework breaks down, as shown by the resurgence of poliomyelitis in war-torn syria and outbreaks in pakistan after the murder of vaccine volunteers, and the recent measles outbreak in the us linked to disneyland in california. the latter shows that electronic media can be a powerful tool for consumer education but also a means to spread misinformation. the recent dramatic outbreaks of disease caused by ebola virus, hendra virus and middle east respiratory syndrome coronavirus overshadow many advances in management of endemic infections previously thought to be incurable. hepatitis c infection can now be cleared in a high proportion with antiviral agents, and prospects for a vaccine have never looked better. hiv has now become a long-term chronic viral illness for those infected who have access to newer, better tolerated antiretroviral agents. if longer-acting agents in clinical trials prove effective, further advances may be made, including control of hiv in marginalised groups and more effective prevention. research into the role of human microbiota in the pathogenesis of both communicable and non-communicable diseases may provide further therapeutic advances. faecal microbiota transplantation has now been proven to be an effective therapy for relapsing c. difficile infection and may have other future applications. these advances have been enabled by the revolution in molecular techniques, including rapid diagnostics such as matrix-assisted laser desorption ionisation time of flight mass spectroscopy, multiplex polymerase chain reaction, and whole-genome sequencing for outbreak investigation. further advances are expected when they become more widely available in microbiology laboratories. however, technological advances may not always bring benefits. robotisation of specimen handling is fuelling the creation of remote, -hour automated laboratories, with downsizing or closure of on-site hospital laboratories and loss of well trained laboratory scientists. this could see clinicians being given more complex data (eg, on a new obscure organism), without the ability to interpret their significance if there is a lack of available microbiological expertise. compounding this is the decline in understanding of basic microbiology, infections and antibiotic use in newly graduated junior doctors in australia. the end results may be increased inappropriate testing, antibiotic overprescribing and errors in prescribing, which would be counterproductive to our national quality and stewardship aims. this knowledge gap needs to be addressed as a priority by australian medical schools. in the field of infectious diseases, every year is replete with surprises. the asid annual scientific meeting (to be held in in auckland on - march) is a testament to this, presenting both new research and clinical experiences from across the globe. asid recognises that global strategies to reduce amr, coupled with the extraordinary advances in molecular diagnostics, are essential for outbreak preparedness and to advance control of endemic pathogens. however, to attempt to see beyond the present to the next years in infectious diseases would be audacious. as niels bohr is believed to have said, "prediction is very difficult, especially about the future". australian commission on safety and quality in health care. antimicrobial use and resistance in australia (aura) project surveillance and reporting of antimicrobial resistance and antibiotic usage in animals and agriculture in australia for the emerging infections program healthcare-associated infections and antimicrobial use prevalence survey team. multistate pointprevalence survey of health care-associated infections a major reduction in hospital-onset staphylococcus aureus bacteremia in australia - years of progress: an observational study a monovalent chimpanzee adenovirus ebola vaccine -preliminary report analysis of knowledge and attitude surveys to identify barriers and enablers of appropriate antimicrobial prescribing in three australian tertiary hospitals key: cord- - pfww l authors: fleet, graham h; heiskanen, paul; reid, iona; buckle, ken a title: foodborne viral illness - status in australia date: - - journal: int j food microbiol doi: . /s - ( ) -x sha: doc_id: cord_uid: pfww l norwalk-like virus contamination of oysters and orange juice, and hepatitis a virus contamination of oysters have been responsible for large outbreaks of foodborne viral disease in australia. rotavirus, adenovirus, astrovirus, parvovirus and other enteroviruses also contribute to the incidence of gastroenteritis in this country but the role of foods and waters in transmitting these viruses is unclear. protocols for the investigation, surveillance and reporting of foodborne viral illness require further development to enable a more accurate description of the problem. few laboratories have the capability to analyse foods for viruses and specific training in this technology is needed. management of food safety in australia largely relies on the implementation of haccp principles, but these need to be adapted to address the specific risks from viruses. government regulatory sectors. to achieve this safety, both sectors closely follow recommendations of the food industry is one of the largest manufactur-the codex alimentarius commission by implementing and service sectors in australia. it employs about ing appropriate quality assurance, haccp, and risk individuals and has an annual turnover value management programs, and ensuring that products of approximately $us billion (anonymous, conform to appropriate microbiological specifications a). because it has a strong focus on export, it is and standards (fleet, ; jouve, ; peters, intimately linked with international trade. the suc- the suc- , hathaway, ) . cess of the industry depends on production, mana-as a nation, australia is comprised of six states gerial and regulatory practices that ensure high and two territories. food safety is regulated by quality, safe products. microbiological safety com-legislation that is administered through each state mands high priority by both the industry and the and territory, using a common policy that has been developed at the national level by the australia new zealand food authority (anzfa) (anonymous, *corresponding author. food safety standards based on haccp principles - / / $ -see front matter © elsevier science b. v. all rights reserved. pii: s - ( ) -x that will also be administered at the state and attempts to collate the data of these reports at the territory level. foods for export are regulated separ-national level, but these initiatives have been ad hoc ately by the australian quarantine inspection service and irregular (murrell, a,b; crerar et al., ) . (aqis) which is an agency of the national govern-in , the australian government established the ment but, in essence, follows the safety policies of national notifiable diseases surveillance system anzfa. imported foods are also monitored by (nndss) to compile national statistics on com-aqis which administers the imported food inspec-municable diseases including foodborne diseases. it tion program based on policies developed by receives data from the state and territory notifica-anzfa (fleet, ; oram-miles, ) . tion programs, as well as other voluntary reporting in addition to the general requirements for due schemes such as the recently established national diligence and good manufacturing practice, the mi-enteric pathogen surveillance scheme (nepss), the crobiological safety of foods in australia is regulated australian paediatric surveillance unit (apsu), the through a series of microbiological standards that are escherichia coli reference laboratory and the virolpublished in the australian food standards code ogy and serology laboratory reporting scheme (anonymous, a). currently, these standards are (labvise). the nepss collates reports on the based on bacteriological and fungal criteria. virologi-isolation of pathogenic organisms from foods and cal criteria are not part of these standards, mainly other environmental sources and the apsu monitors because little information is known about the occur-disease outbreaks in children. labvise collates data rence of viruses in local foods and because of the on virus diseases as diagnosed in sentinel labtechnical difficulties associated with analysis of oratories operating throughout australia. one objecviruses in foods. nevertheless, as will be discussed tive of the nndss is to provide information that will in the following sections, australia has a significant assist in developing a uniform, national policy history of food and waterborne viral diseases. the towards management of food safety (anonymous, incidence of these outbreaks appear to be on the b, a). reports of the nndss are published increase which, combined with newer methods that in the communicable diseases intelligence, through enable the analysis of foods for viruses, are increas-the department of health and family services of the ing demands for greater quality assurance and regu-australian government. lation of this problem. as a basis for developing according to data compiled by the nndss, future programs for prevention and management, this notification of foodborne microbial diseases in ausarticle examines the past and current status of food tralia increased from approximately cases in and waterborne viral diseases in australia. to cases in . hepatitis a, the only notifiable virus disease, represented about - % of the cases over this period. however, it is generally . surveillance systems and epidemiological accepted that these statistics are a substantial underestatistics stimation of the real incidence of foodborne disease, and highlight major limitations of the surveillance each state and territory within australia has system (crerar et al., ; hellard and findlay, public health legislation that requires official notifi- ; anonymous, a) . many cases of foodborne cation of communicable diseases. notification simply illness remain unreported or not diagnosed and, means that clinical diagnosis of the disease or consequently, are not notified. also, the notification isolation of the causative organism must be reported system does not include illness caused by many to the appropriate department of health or equiva-foodborne pathogens, such as staphylococcus aulent. communicable foodborne diseases that are reus, bacillus cereus, clostridium perfringens or listed for notification are campylobacteriosis, sal-viruses other than hepatitis a. for example, orange monellosis, shigellosis, yersiniosis, typhoid, lis-juice contaminated with norwalk virus was responteriosis and hepatitis a. annual reports of these sible for over cases of gastroenteritis in ausnotifications are published by each state and territ-tralia in , but these data are not included in the ory and have been accessed for the purposes of this official notifiable statistics. based on the data availcontribution. over the years, there have been various able and the limitations inherent in the existing surveillance system, several groups have indepen-causing disease. eyles ( , ) and grohmann dently estimated that the true incidence of foodborne ( ) have made passing references to outbreaks of microbial illness in australia is about . - . mil-foodborne viral disease in australia as part of more lion cases per year. about - % of these cases are general discussions of viruses in foods. the followprobably attributable to viruses (anonymous, b, ing sections provide a more detailed discussion of a). this proportion of foodborne viral illness, viruses associated with or thought to be associated relative to the total, is similar to that reported for the with outbreaks of foodborne disease in australia. usa (anonymous, b) . as in other countries, significant outbreaks of poliomyelitis occurred in australia during the early . rotavirus part of the twentieth century, and foods and waters were frequently suspected as being involved in rotaviruses were first discovered in australia in transmitting the disease (eyles, ) . however, , and were found in the faeces and duodenal genuine interest in food or waterborne viral diseases mucosal epithelial cells of children who had been did not develop in australia until when oysters hospitalised with acute, non-bacterial gastroenteritis were found to be responsible for a very large (bishop et al., ) . these viruses are now recogoutbreak of gastroenteritis caused by norwalk-like nised as a major cause of gastroenteritis in children agents. table shows the range of viral diseases that throughout the world. rotaviruses belong to the have the potential to be food or waterborne and are family of reoviridae, and infect the epithelial cells now routinely monitored throughout the country by of the small intestine (christensen, ; dessel-labvise. the values in table do not represent the berger, ). illness becomes evident after - true incidences of each of the viral diseases since days incubation and is characterised by the sudden they are compilations of reports from only onset of acute, watery diarrhoea and vomiting, often sentinel laboratories. however, based on compari-accompanied by fever. the symptoms persist for sons with nndss data for hepatitis a virus, a fully several days or longer, leading to dehydration which, notifiable viral disease, the values in table proba-in severe cases, can cause death. high levels of bly represent an approximate five-fold underestima-infectious virus particles are excreted with the tion of the real incidence. nevertheless, the data of faeces. transmission of the disease from person to table are significant in showing annual trends and person occurs mostly via the faecal-oral route, the relative frequency of the different viruses in because the virus is highly infectious. however, , ) . a national rotavirus reference centre survival rate in the environment (christensen, ; has recently been established to improve surveillance hedberg and osterholm, ; bishop, ) . and management of the disease (masendycz et al., in australia, gastroenteritis caused by rotaviruses ). is responsible for the annual hospitalisation of about children under the age of years. this represents about % of all children hospitalised . norwalk or norwalk-like viruses with gastroenteritis and is estimated to cost the nation about $us million annually (bishop and the norwalk or norwalk-like viruses belong to a barnes, ; carlin et al., ; group generally called the small round structured ). outbreaks of the disease are mostly associ-viruses (srsvs) because of their morphology. their ated with child care centres, pre-schools and other genome consists of single stranded rna, the sesituations where there are large numbers of children quence of which corresponds with their classification (hanna, ; hanna and brookes, ; ferson, in the family caliciviridae (appleton, ; de- ) . however, outbreaks in adults, especially at sselberger, ; anonymous, a). they have nursing homes for the elderly, can occur (bishop, been a major cause of food or waterborne gastroen- ). while person to person contact is considered teritis in australia (eyles, ; grohmann, ; to be the principal mode for spread of the virus in marshall and wright, ) . characteristic sympthese situations, the involvement of faecally contami-toms of nausea, vomiting and diarrhoea generally nated water and foods is often suspected, but re-appear after - h of incubation and last about quires more specific investigation. crerar et al. - h. ( ) refer to one outbreak, involving indi- the first evidence of a problem with these viruses viduals, where salad vegetables were considered to occurred in , when oysters harvested from have transferred the virus. diagnosis of the disease georges river, sydney, caused outbreaks of gasgenerally relies on the symptoms it causes and troenteritis in the uk. the oysters had been opened detection of the virus in faecal specimens by and frozen in the half shells before export. the serological and electron microscopic techniques. frozen oysters conformed to escherichia coli stan-the epidemiology of the illness has been exten-dards ( , . e. coli / g) as tested by exporting sively monitored over the last years by serotyping authorities in australia and importing authorities in and electrophoretic differentiation of the viral rna the uk. no bacterial pathogens were detected in the (rodger et al., ; barnes et al., ; diwarkala oysters at levels that would cause gastroenteritis. and . the incidence of outbreaks subsequent investigations revealed that the implifollows a seasonal pattern, predominating in mid to cated oysters had been harvested from georges river late winter months, but minor variations in this at a time during rainfall and that unfrozen batches of pattern occur across the country. in tropical regions, the oysters had exhibited counts exceeding the e. peak times of infection may occur in summer months coli standard. evidently, freezing of the oysters (bishop and barnes, ) . different states within killed the e. coli but not the suspected virus. the australia also have different rotavirus notification same batch of frozen oysters caused gastroenteritis rates, ranging from . per to . per more than months after storage (fleet, unpublished children under the age of years (carlin et al., data) . although oysters and specimens from victims ). similar serotype patterns are observed in of the outbreaks were not examined for viruses, the different cities, emphasising the endemic nature of symptoms of gastroenteritis were characteristic of rotavirus infection in the population. the majority of norwalk or norwalk-like viruses. moreover, oysters the outbreaks are caused by group a rotavirus, harvested from the same location several months serotype g (about % of cases), but epidemics later in caused outbreaks of similar gastroencaused by serotypes g , g , g , g and g have teritis in australia affecting over consumers. occurred (palombo and bishop, ) . substantial these outbreaks have been extensively studied, and heterogeneity occurs in the rna electrophoretic norwalk virus was detected by electron microscopy, profiles of the serotypes, and suggests the continual immunoelectron microscopy and reverse transcrip-tion (rt)-pcr in faeces of many of the affected faecal specimens from affected individuals by directconsumers (murphy et al., ; and immuno-electron microscopy did not give con- ; linco and moe et al., ) . clusive evidence of virus presence, but elisa unfortunately, norwalk virus could not be detected testing of sera as well as epidemiological data in oysters implicated in these outbreaks, although suggested the occurrence of norwalk-like agents. echovirus type and reovirus were isolated, but not private hospitals, hostels, parenting centres, and considered responsible for the gastroenteritis (eyles nursing homes are often involved in outbreaks of et al., ). these outbreaks resulted in major norwalk-like gastroenteritis (oliver et al., ; changes to the regulation of oyster production in the selden et al., ; taylor and murphy, ; wilby state of new south wales (nsw) of australia and, and ferriera, ; ; marshall subsequently, it became mandatory for all oysters to and wright, ) . transmission of the disease by be subjected to a process of depuration before sale mechanisms other than food or water seems to have (souness and fleet, ; ayres, ) . while occurred in these outbreaks but, generally, the source depuration combined with quality assurance pro-of the virus and its mode of transfer were not grams have managed to prevent further major out-thoroughly investigated. breaks of oyster associated norwalk virus, some wright et al. ( ) have completed a major authors have questioned the efficacy of depuration in retrospective study of the incidence of norwalk-like eliminating the virus (eyles, (eyles, , gastroenteritis in australia, principally the state of et al., ; grohmann, ) . oysters harvested victoria, by examining for the virus in faecal specifrom an estuary in northern nsw and supposedly mens that had been submitted for suspected viral depurated were suspected of causing an outbreak of gastroenteritis over the period - . faecal cases of norwalk virus gastroenteritis in . samples were screened for presence of the virus by the virus could not be detected in faecal specimens electron microscopy. positive samples were further but was detected in one sample of oysters by rt-examined by rt-pcr followed by partial sequenc-pcr (stafford et al., ) . further research is being ing of the amplified dna. of the samples conducted at the university of new south wales to examined, about . % were positive for presence of determine the kinetics of virus depuration from local norwalk-like virus with the majority ( %) represhellfish, and to evaluate the use of bacteriophages as senting submissions from adults or elderly persons. potential indicators of estuary and shellfish contami-of the positive samples, % were submissions from nation with human viruses such as the norwalk or hospitals, % were from nursing homes, % were norwalk-like viruses. associated with outbreaks related to a restaurant or the largest outbreak of norwalk virus associated reception, % from camp, chalet or child-care setgastroenteritis involved over individuals who tings, and % were from family or uncertain had consumed orange juice that was largely served to origins. outbreaks were more common in late winter passengers on domestic airline flights during august and early summer months. based on dna se- . extensive surveying of passengers as to what quences, the viruses were classified into genogroups they had consumed, enabled identification of the and , with most cases of gastroenteritis being causative food, in this case orange juice which was associated with genogroup . while the source of the traced to one manufacturer. inspection of the pro-virus was not reported in this study, epidemiological duction facilities identified several areas where con-data suggested a significant involvement of foods or tamination of the juice could have occurred. the waters. a recent report has suggested that norwalk virus was not detected in the juice but the outbreak and norwalk-like viruses probably account for the terminated when the juice was withdrawn from the greatest incidence of foodborne disease in australia market. faecal specimens from affected individuals (anonymous, a) . showed the presence of characteristic norwalk-like particles (lester et al., ) . sewage contaminated drinking water was suspect- . hepatitis a ed to be the cause of an outbreak of norwalk-like gastroenteritis in several hundred guests at a caravan hepatitis a virus (hav) is classified in the family park in nsw (mcanulty et al., ) . analysis of picornaviridae which also includes the poliovirus and enterovirus groups. their genome consists of tected in the sera of affected individuals (dienstag et single stranded rna which, in the case of hav, is al., ; locarnini and gust, ) . a dredge, highly conserved, giving only four genotypes and discharging untreated sewage into the water near one serotype (white and fenner, ) . spread of where the mussels were growing, was thought to be the virus occurs by the faecal-oral route, where the source of the virus. the largest outbreak of hav contaminated foods and waters can be significant in australia occurred over several months during vectors. after ingestion, the virus multiplies within - after consumption of oysters harvested the intestinal epithelium, passes into the blood from the wallis lakes region in northern nsw. stream and then attacks liver cells. onset of the almost individuals were affected and one person disease occurs after an incubation period of - died as a result of the disease. analysis of samples of weeks and is evidenced by symptoms of malaise, oysters collected from the region during the time of anorexia, nausea, lethargy, jaundice, pale faeces, the outbreak were positive for the presence of hav dark urine and liver pain. illness may last - as determined by a pcr method. the oysters also weeks, after which full recovery is usual. however, tested positive for the presence of adenoviruses and shedding of the virus in the faeces can extend for enteroviruses but not norwalk viruses. however, - months and some individuals experience re-they conformed to bacteriological standards (less lapses of the disease. death due to liver failure may than . e. coli / g) and, supposedly, had been subject occur, but is rare (white and fenner, ; anony- to depuration according to legislative requirements of mous, b). the state government. a subsequent coronial enquiry statistics on hav infection in australia have been into the outbreak revealed numerous sources by reviewed and discussed by several authors (scott and which untreated sewage could contaminate the lake sheridan, ; selden et al., ; ferson et al., and oyster cultivation areas (e.g. no reticulated ; merritt et al., ; amin et al., ) . as sewage systems in nearby villages, leaking public noted already, hav infection is a notifiable disease toilets, caravan parks, and recreation water craft) in australia. data from the nndss indicate - (anonymous, c; grohmann, ; wilcox, cases per year over the period - . ). more stringent quality assurance programs for notification statistics vary between states and ter-oyster cultivation and processing have been imritories, and range from . to . cases / plemented to avoid future problems of this nature individuals. significant outbreaks of hav infection (wilcox, ) . however, the question as to whether have been reported in homosexual men (ferson et hav is effectively eliminated from oysters after al., ), individuals within institutions (hanna and commercial depuration processes remains unresolved brookes, ; bell et al., ) , child care centres and requires research. another concern arising from ( ferson et al., ; tallis et al., ) , in lower this outbreak was the failure of e. coli standards to socioeconomic communities or families (dick et al., reliably indicate oyster contamination by viruses. ) and after consumption of foods (dienstag et sporadic outbreaks of foodborne hav occur al., ; anonymous, c,d) . apart from the well throughout the country and generally involve foods described foodborne outbreaks, person to person served at restaurants. one such outbreak involved contact is considered to be the main mode for spread cases and was traced to the consumption of imported of the virus. however, poor hygiene and faecal frozen, fresh water prawns. pcr testing of leftover contamination of foods and waters may be respon-prawns failed to detect hav and blood samples taken sible for spread of the virus in institutional and child from restaurant staff all tested negative for recent care settings. hav infection (anonymous, d). the first documented foodborne outbreak of hav in australia was attributed to the consumption of incompletely cooked mussels that had been harvested . astroviruses from faecally contaminated waters in the state of victoria. seven out of the individuals who astroviruses contain single-stranded rna within a consumed the mussels developed symptoms of hepa-capsid that has a characteristic star-shaped appeartitis a. antibodies to hav were subsequently de-ance when visualised by electron microscopy. they cause gastroenteritis, especially in young children, serotype (less than %). seasonal patterns of the giving symptoms similar to those caused by rotavir-virus genotypes were evident, with type being uses, but generally, are less severe. transmission of prevalent in late autumn and type remaining the virus occurs by the faecal-oral route (lew et al., prevalent year-round. the source of the virus and its ; appleton, ) . very little has been reported mode of transmission were not examined in these about the occurrence of this virus in australia. using studies. a specific dna probe, astrovirus was detected in . % of faecal specimens from children who were hospitalised with gastroenteritis in the state of . human calicivirus or sapporo-like viruses victoria during . incidence of the virus was greatest during winter months and in infants of - human caliciviruses (hcvs), also known as sapmonths of age (palombo and bishop, ) . the poro-like viruses, are a subgroup of the caliciviridae epidemiological significance of these findings was and cause gastroenteritis similar to that caused by not reported. clearly, astrovirus-associated gastroen-norwalk or norwalk-like viruses. the first reported teritis does occur in australia (table ) but the role outbreak in australia attributed to hcv occurred in a of food or water in its transmission needs further day care centre in . fifty-three people were investigation. the specific role of shellfish in its affected, with hcv being found in % of faecal transmission would be worthy of more thorough samples from symptomatic adults and children, and investigation, because of their previous association in % of asymptomatic individuals. the outbreak, with outbreaks of hav and norwalk-like viruses in which affected young children more severely, lasted this country and overseas reports of shellfish-associ-more than weeks due to the number of asymptoated outbreaks of astrovirus gastroenteritis (ap-matic individuals and the prolonged excretion of pleton, ). virus particles. the outbreak persisted despite taking many control measures such as closing the central kitchen, encouraging handwashing, and modifying . adenovirus diaper changing practices (grohmann et al., ) . since , the cases of hcv in australia have adenoviruses contain double stranded dna with-remained sporadic and rare (table ) . a study of in an icosahedral capsid. many of the or more faecal samples from patients with gastroenteritis known adenovirus serotypes can multiply in the during - found that only . % of cases small intestine, but only types and have been were due to hcv, compared with . % of cases due associated with gastroenteritis (grimwood et al., to norwalk and norwalk-like viruses (wright et al., ) . the most common method of transmission is ). via the faecal-oral route, with food and water as possible vectors (mickan and kok, ) . illness lasts slightly longer than rotavirus infections, but the . other viruses symptoms of diarrhoea, vomiting and fever are milder (christensen, ) . parvovirus-like particles were responsible for an several studies covering the analysis of about outbreak of gastroenteritis involving children faecal specimens during the period [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] and teachers at a primary school in sydney, nsw, in indicate that adenoviruses contribute - % of the , but the source of the virus was not determined gastroenteritis cases admitted to australian hospitals (christopher et al., ) . although these viruses (pitson et al., ; mickan and kok, ; grim- contribute significantly to the sporadic incidence of wood palombo and bishop, ) . gastroenteritis (table ) , their transmission in foods diagnosis of the virus is generally based on its is not reported. coronaviruses have been detected in detection in faecal samples by electron microscopy the faeces of adults in australia (marshall et al. , and enzyme immunoassay. the majority of the cases ), including aborigines where the excretion rates are associated with young children and involve were higher than those for non-aboriginals (schnagl serotype ( - %) and to a lesser extent, et al., ) . while the standard of hygiene is thought to relate to the incidence of this virus, foods (armon and kott, ) . with the absence of evidence of a direct role of foods in its transmission analytical monitoring, management of foodborne is not clear (caul, ) . coxsackie, echo and other viral disease largely relies upon the proper imenteroviruses have been detected in oysters harvested plementation of haccp principles. however, it is from nsw estuaries (eyles et al., ; imperative that these be adapted to account for ) but not implicated in outbreaks of gastroen-specific viral hazards. teritis. nevertheless, these viruses have been connected with numerous cases of gastroenteritis, the causes of which were not reported (table ) eration and action to improve the surveillance, anonymous, a. food safety standards, costs and benefits. monitoring and control of viruses in foods. com-australia -new zealand food authority, commonwealth government of australia, canberra, pared with bacteria, epidemiological investigation anonymous, b. discussion paper on viruses in food. cx / fh and reporting of foodborne viral illnesses were outbreak of human calicivirus gastroenteritis in a day-care - . sation for acute gastroenteritis in young children in australia norwalk virus gastroenteritis in volcrobiol parvovirus gastroenteritis -a new entity for australia an endemic of rotavirus diarrhoea in far north absenteeism from a child day-care foodborne disease: current trends and future surveillance needs centre during a rotavirus outbreak some occupational exposures to dis. , - . hepatitis a persisting hepatitis a hathaway, s., . management of food safety in international infection in a central queensland town mussel-associated viral hepatitis, type a: serological - , variation of capsid protein vp of serotype g human rotavirus - . isolates principles of food safety legislation accumulation and elimination of viruses by travel-associated gastroenteritis outbreak viruses direct and indirect costs of an outbreak of . rotavirus in a child-care centre food and hepatitis a. food ferson hepatitis a outbreak in a preschool in eastern sydney changing epigastroenteritis associated with contaminated drinking water at a demiology of hepatitis a in the s in sydney microbiological methods -the australian seah coronavirus-patients with enteric adenovirus gastroenteritis admitted to an like particles in adults in melbourne norwalk-like viruses: prevalence grohmann foodborne microorganisms of public health signifi-rotavirus diversity: what surveillance will tell us limitations of molecular biological tech-dis. int. , - . niques for assessing the virological safety of foods molecular epidemiology of human rotaviruses in mel stine, electrophoresis of genome ribonucleic acid review of hepatitis a in queensland an australia-wide outbreak coronavirus-like particles in aboriginals and non-aboriginals in of gastroenteritis from oysters caused by norwalk virus an outbreak microbial safety of food in australia: a of gastroenteritis at a brownie camp the epidemiology of critical overview. part beard, outbreak of norwalk gastroenteritis in an isolated guest house bacterial agents in shellfish food aust. , - . depuration terization of a serotype g human rotavirus isolated in raton - . distribution, and genetic diversity of human astrovirus isolates an outbreak of gastroenteritis at a reassortants responsible for an outbreak of gastroenteritis in hostel for the aged and at a private hospital caused by a central and northern australia nsw district registry, federal court of aus-peters, r.e., . developing and implementing haccp certifitralia. cation in australia comcal human caliciviruses in southeastern australia, - . parison between children treated at home and those requiring key: cord- -h ins a authors: coombe, j.; kong, f.; bittleston, h.; williams, h.; tomnay, j.; vaisey, a.; malta, s.; goller, j.; temple-smith, m.; bourchier, l.; lau, a.; hocking, j. s. title: the impact of covid- on the reproductive health of people living in australia: findings from an online survey date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: h ins a introduction: australia introduced lockdown measures to control covid- on march . for two months, australians were asked to remain at home and only leave for essential activities. we investigate the impact this had on sexual and reproductive health (srh). methods: australians aged + were eligible to participate in an online survey from april- may . questions included contraceptive use, pregnancy intentions and access to srh services. we report on the experiences of female participants aged < years. pregnancy intentions and contraceptive use were analysed using descriptive statistics. odds ratios and % confidence intervals were calculated to investigate difficulty accessing srh products and services. qualitative data were analysed using descriptive thematic analysis. results: most participants ( . %, / ) were aged - years. most ( . %, / ) indicated they were trying to avoid pregnancy. the oral contraceptive pill was the most common single method used ( . %; / ). nearly % ( / ) reported they were not using contraception. older women (or= . ; %ci: . , . for - vs - years) and those employed (or= . ; %ci: . , . ) had less trouble accessing contraception during lockdown. women aged - (or= . ; %ci: . , . ) or - years (or= . ; %ci: . , . ) were less likely to experience difficulty accessing feminine hygiene products. qualitative analysis suggested that covid- affected pregnancy plans, with participants delaying childbearing, or deciding to remain childfree. conclusion: covid- lockdown impacted the srh of australian women. findings highlight the importance of continued access to srh services and products during global emergencies. in response to rising covid- cases, the australian government implemented a country-wide lockdown extending from march to may . during this time, people were asked to remain in their homes and only leave to access essential goods and services, to receive or provide care, to exercise, or to attend work or education where these activities could not take place at home. this approach was largely successful; at the end of the lockdown period, australia had recorded , cases and deaths [ ] , numbers that pale in comparison with those recorded elsewhere [ ] . however, australia is not immune to the social and economic hardships the pandemic caused, nor the impact on the provision of and access to sexual and reproductive health (srh). in march, one of the largest condom producers in the world warned of a global shortage [ ] , potentially impacting the sexual health of millions. domestic travel restrictions in australia exacerbated an already complicated abortion care system with patients and providers unable to travel to seek or provide care [ ] . marie stopes australia warned of an increased risk of unplanned pregnancy and sexually transmissible infections (stis) as contraception and abortion, as well as pregnancy and sti tests become less accessible [ ] . plan international reported on the impact on menstrual hygiene, highlighting the significant impact of the pandemic on the ability of menstruating people to manage their periods safely and hygienically [ ] . news outlets reported predictions of a falling fertility rate as couples reassessed desires to reproduce during a health crisis and amidst the resulting social and economic hardships [ ] . we are conducting serial cross-sectional surveys to investigate the impact of covid- on the srh of people living in australia. in this paper, we report on the results from the first survey and explore the impact of australia-wide lockdown on reproductive health including pregnancy intentions and contraception access. data reported here were collected as part of the sexual and reproductive health during covid- survey open from april- may . people aged + who were living in australia were eligible to participate. repeat waves will be conducted throughout , and a cohort analysis undertaken for participants who respond to multiple surveys. the survey comprises three sections: demographics, sexual practices and reproductive health. in this paper we report on data pertaining only to the baseline survey and for those participants who completed the reproductive health section. the study was approved by the university of melbourne human research ethics committee (id: ). participants were asked about changes in sexual practices, intimate relationships, contraceptive use and access, pregnancy intention and access to and use of srh services. several questions investigated whether during lockdown, participants had difficulty accessing contraception, srh products like pregnancy tests, lubrication and feminine hygiene products. they were also asked about their healthcare access during lockdown, including whether restrictions had impacted their ability to access emergency contraception or termination of pregnancy. free-text responses to a question regarding the impact of covid- on pregnancy plans were also collected. analysis was limited to reproductive aged women (< years). descriptive statistics were used to describe socio-demographic characteristics, pregnancy intentions and contraception use. odds ratios and % confidence intervals were calculated to investigate factors associated with healthcare access and difficulty in accessing contraception, srh products and feminine hygiene products. as this was an explorative analysis, regression modelling to examine the impact of confounding on associations was not undertaken. chi square tests and t tests (where appropriate) were used to investigate factors associated with providing free-text responses. as not everyone completed all questions, missing data were excluded, but denominators are provided to place missing data in context. responses to the free-text question were imported into nvivo qualitative analysis software [ ] . utilising thematic analysis [ ] , we took a largely descriptive and semantic approach to the data, looking for the overt meaning of the comments. patients and the public were not involved in the development of this study; however, the survey was pilot tested with several people not involved with the study and their feedback incorporated into the final survey. a lay summary will be available to participants on our website [ ] upon publication of our results. a total of people consented to participate of whom ( . %) answered the questions on sexual practices and ( . %) answered questions on reproductive health. of these , ( . %) reported that they were female and aged < years and were included in the analysis. there was no difference in average age between those who completed the reproductive health questions and those who did not ( . vs . years, p= . ). among participating women, . % ( / ) were aged - years, . % ( / ) were in a cohabitating relationship and . % ( / ) reported being single. overall, ( . %) were living in urban areas of australia and . % ( / ) were employed at the time of the survey. a small proportion reported that they or their partner was pregnant ( . %, / ) and most ( . %, / ) indicated that they were trying to avoid pregnancy. nearly % ( / ) reported they were not using any contraception, with the oral contraceptive pill being the most common single method used ( . %; / ) and condoms and the pill ( . %; / ) being the most common dual method used (table ) . . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted august , . . https://doi.org/ . / . . . doi: medrxiv preprint is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted august , . *metropolitan: major cities of australia; rural/regional: inner regional, outer regional, remote & very remote australia (using the australian statistical geography standard-remoteness area geographical classification); †employed on a full time, part time, or casual basis, and/or self-employed; ‡in a relationship' includes those who selected married/de facto/boyfriend/girlfriend/lat (living apart together) or long distance relationship; 'cohabitating' defined as living with partner/s; 'single' includes those who selected single/divorced/widowed (and did not select another relationship); 'other' includes people who selected polyamorous or multiple partners (and did not select another relationship option, such as single), and those who indicated in comments that they were casually dating, but not exclusive; ¶contraception being used by respondent or partner of respondent, excluding respondents who said they are unable to get pregnant; **including combined pill and progesterone only pill; † †intrauterine device, including hormonal iud and copper iud when asked about the ease of access to srh products and services during lockdown, . % ( / ) reported that they had trouble accessing contraception, . % ( / ) had trouble accessing srh products like pregnancy tests and lubrication and . % ( / ) had trouble accessing their usual feminine hygiene products. of those who experienced difficulty accessing feminine hygiene products, nearly half ( . %, / ) said that they changed their use of products as a consequence. univariate analysis found that women aged - years (or= . ; %ci . , . ) compared with women aged - years and those employed (or= . ; %ci . , . ) had less trouble accessing contraception during lockdown. no factors were associated with accessing srh products. women aged - years (or= . ; %ci . , . ) or - years (or= . ; %ci . , . ) were less likely to experience difficulty accessing feminine hygiene products than those aged - years. those in a non-cohabitating relationship (or= . ; %ci . , . ) and those living with parents (or= . ; %ci . , . ) were more likely to have difficulty accessing feminine hygiene products than those in a cohabitating relationship (table ) . when asked about their access to health services, . % ( / ) reported that they had needed to access healthcare services for reasons related to their sexual or reproductive health during lockdown, . % ( / ) had accessed an online health service (although this may have been . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted august , . . https://doi.org/ . / . . . doi: medrxiv preprint for reasons other than srh), and . % ( / ) had needed to access emergency contraception or termination of pregnancy services for themselves, or for their partner. there were no significant differences between women living in metro versus rural/regional areas. univariate analysis found that women aged - years (or= . ; %ci: . , . compared with women aged - years were more likely to have accessed healthcare for their srh reasons, and single women (or= . ; %ci: . , . ) were less likely to have accessed services compared to women in a cohabitating relationship. women aged - years were more likely to have accessed online healthcare services than women aged - (or= . , %ci: . , . ). no factors were associated with accessing emergency contraception or termination of pregnancy services (table ) . . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted august , . . https://doi.org/ . / . . . doi: medrxiv preprint ) / ( . ) . ( . , . ) * excludes those who reported that they do not access or use any of the products; † products such as pregnancy tests and lubrication; ‡ products such as tampons and sanitary pads; ¶ any missing values due to participants skipping question/s; ** metropolitan: major cities of australia; rural/regional: inner regional, outer regional, remote & very remote australia (using the australian statistical geography standard-remoteness area geographical classification); † † in a relationship' includes those who selected married/de facto/boyfriend/girlfriend/lat (living apart together) or long distance relationship; 'cohabitating' defined as living with partner/s; 'single' includes those who selected single/divorced/widowed (and did not select another relationship); 'other' includes people who selected polyamorous or multiple partners (and did not select another relationship option, such as single), and those who indicated in comments that they were casually dating, but not exclusive; ‡ ‡ employed on a full time, part time, or casual basis, and/or self-employed . ( . , . ) *including abortion services and emergency contraception; †including general practice, specialist sexual or reproductive health provider, pharmacy, hospital, and counselling/psychology services; ‡including online pharmacy, online sti testing, and seeing a general practitioner via telephone/internet (telehealth); †any missing values due to participants skipping question/s; ** metropolitan: major cities of australia; rural/regional: inner regional, outer regional, remote & very remote australia (using the australian statistical geography standard-remoteness area geographical classification); † † in a relationship' includes those who selected married/de facto/boyfriend/girlfriend/lat (living apart together) or long distance relationship; 'cohabitating' defined as living with partner/s; 'single' includes those who selected single/divorced/widowed (and did not select another relationship); 'other' includes people who selected polyamorous or multiple we also explored the impact of covid- on plans for pregnancy, and participants were asked to respond to a free-text question about this (has the covid- (coronavirus) pandemic impacted your future plans for pregnancy? please tell us about it in the box below). in total, participants provided a comment. participants who chose to respond to the free-text question were older than those who did not provide a response ( . years vs. . years; p< . ). they were also more likely to be in a cohabitating relationship than those who did not provide a response ( . % vs. . %; p< . ). participants who responded to the free-text question were more likely to be trying to get pregnant ( . % vs . %; p< . ), or at a stage where they did not mind getting pregnant ( . % vs . %; p< . ) than those who did not respond to the free text question. participant responses largely fell into one of four key themes. these themes are presented below, and illustrative quotes can be found in table . most participants reported no impact on their future plans for pregnancy, reporting variations of 'no' or 'no impact'. others were more expansive in their responses, noting that covid- has not changed their plans for pregnancy, largely because these plans are in the distant, hopefully covid free future, or because they do not want to have children. for some, covid- had not impacted plans to conceive, with a few indicating that they will continue to try to conceive this year. some participants reported delaying or avoiding pregnancy due to covid- . these participants cited concerns about pregnancy care during the pandemic, not putting undue strain on the healthcare system, and concerns about the impact of the virus on pregnant women and newborns. other participants reported a delay in plans for pregnancy due to their changing life circumstances. although these participants had not planned to conceive in , because of delayed travel, delayed marriage, career interruptions, changing financial situations, and an inability to meet a partner due to lockdown restrictions, these plans are delayed further into the future and, for some, indefinitely. finally, a group of participants reported that earlier in the year they had been actively trying to conceive or were planning to conceive this year. these participants reported putting these plans on hold, either because they were unable to continue trying to conceive due to the cancellation of ivf and other reproductive services, or because they had made the decision to stop actively trying during the pandemic. . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted august , . . https://doi.org/ . / . . . doi: medrxiv preprint for a small number of participants, covid- had provided favourable circumstances for conception. for some changing life plans, like an inability to travel overseas, had led them to move their plans to conceive earlier. others reported being able to save more money due to the covid- restrictions, also facilitating earlier conception than otherwise planned. in contrast to those questioning or deciding not to have children due to the pandemic, some participants said that the pandemic had increased their desire for children. these comments were often framed within the isolation of lockdown. . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted august , . . https://doi.org/ . / . . . doi: medrxiv preprint cancelled ivf cycle ( yrs, metro) well, we're actually saving money due to covid, so we might be able to afford another baby sooner than we thought. ( yrs, metro) being completely alone has made me want a baby more ( yrs, metro) the covid- pandemic and the resulting restrictions have clearly impacted the ability of australian women to access reproductive healthcare and products. while most participants reported little difficulty in accessing their usual contraceptive methods and appeared to continue to access healthcare as needed, nearly a third reported difficulties accessing their usual feminine hygiene products. many also reported delaying plans for pregnancy due to the pandemic. although our findings should be considered within their limitations, namely the homogeneity of our sample, our findings offer unique insight into the srh impact of covid- on australian women. our findings show that most participants were able to continue to access their usual contraceptive method during the first lockdown in australia. however, of those reporting difficulties accessing their usual contraceptive method, younger women, and women who were unemployed were more likely to report difficulties. recent analysis examining those hardest hit by the economic fall-out from covid- show that women and young people are most adversely affected, largely due to their disproportionate representation in industries adversely impacted by the pandemic to-date [ ] . while there are many contraceptive options available on the australian market, the most effective methods require a prescription by a healthcare provider and out-of-pocket costs from the user to purchase [ ] . while switching to a different, potentially cheaper method sounds feasible, in practice, women often spend a significant amount of time finding a suitable contraceptive method, and even switching between different brands of the oral contraceptive pill can bring new, unwanted side effects [ ] . accessing one's preferred contraceptive method is also essential to the prevention of unintended pregnancy. most participants in our study reported intentions to avoid pregnancy, with few reporting actively trying to conceive. importantly, many reported delaying or indefinitely putting plans for pregnancy on hold due to the pandemic. the impact of covid- on pregnant and birthing women has been profound. while the limited research thus far suggests that pregnant women are not at increased risk of contracting covid- or experiencing more severe symptoms [ ] , the increased stress and anxiety experienced by these women as they navigate care under strict covid- regulations is becoming clear [ ] [ ] [ ] . it is perhaps unsurprising then that women are delaying plans for pregnancy in the current environment. what impact this might have on the australian fertility rate in the future is unclear although, at least for the participants in our study, it seems that a post lockdown baby-boom is unlikely. finally, nearly a third of participants who reported usually accessing feminine hygiene products reported difficulties in accessing their usual products, and nearly half of these reported changing . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted august , . . https://doi.org/ . / . . . doi: medrxiv preprint their use as a result. during the first phase of the pandemic australians were repeatedly reassured by the australian government and large supermarkets that there was no shortage of supplies of essential goods, and that the lack of toilet paper, tissues, flour, eggs and pasta (among other things) was a consequence of the panic buying that typified the first phase of the pandemic. this behaviour did not go unnoticed by the prime minister, who asked australian's to "just stop it" [ ] . while this shortage may indeed have been inadvertently caused by the panic buying of panicked australian's, the lack of feminine hygiene products, combined with difficulties accessing contraception and delayed plans to conceive are clear examples of the gendered impact of covid- . although evidence regarding the gendered impact of the pandemic, including but not limited to srh is mounting, the australian government continues to largely ignore this in their pandemic response. recent examples include changes to telehealth services that now require patients to have an existing relationship with a general practitioner providing the service [ ] , a move widely criticised by the srh sector [ ] , and the removal of financial support for the childcare sector [ ] , the only sector to have their support removed thus far and a move that clearly disproportionally impacts women [ ] . the covid- pandemic is clearly impacting the srh of women in australia. availability of all forms of contraception and srh products and services are essential for reproductive planning, and it is vital that all who need these services continue to be able to access them as the pandemic continues. . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted august , . . https://doi.org/ . / . . . doi: medrxiv preprint and did not select another relationship option, such as single), and those who indicated in comments that they were casually dating employed on a full time, part time, or casual basis, and/or self-employed australian government department of health. coronavirus (covid- ) at a glance - world health organisation. who coronavirus disease (covid- ) dashboard. [date accessed: th global condom shortage looms as coronavirus shuts down production. the guardian situational report: sexual and reproductive health rights in australia periods in a pandemic: menstrual hygine management in the time of demographer warns of coronavirus 'ripple effects', predicts drop in birthrate and taxpayers. australian broadcasting company (abc) news (online) qsr international pty ltd, nvivo qualitative data analysis software thematic analysis, in qualitative research in clinical and health psychology, p. rohleder and a.c. lyons sexual and reproductive health during covid- (coronavirus). [date accessed: th who's hit hardest by the economic effects of covid- ? examining long-acting reversible contraception non-use among australian women in their 's: findings from a qualitative study the royal australian and new zealand college of obstetricians and gynaecologists. a message for pregnant women and their families. [date accessed australian broadcasting company (abc) news. scott morrison says panic buying driven by coronavirus lockdown fears is 'ridiculous' and 'un-australian'. wednesday media statement: continuous care with telehealth stage seven medicare rollback will limit sexual & reproductive health access australian government department of education skills and employment. early childhood education and care covid- frequently asked questions ~:text=the% early% childhood% education% and% care% relief% package % (relief% package the case for maintaining free childcare -australia's "pink collar recession". the canberra times we would like to thank everyone who generously gave their time to complete our survey. jh is supported by a national health and medical research council fellowship ( ). the other authors report no competing interests. this study did not receive any external funding. all authors contributed to the design and development of the survey. jc was responsible for administering the survey. hb, jh and jc conducted the analysis. jc, hb and jh interpreted the results and drafted the manuscript. all authors contributed to the revision of draft iterations of the manuscript prior to submission. key: cord- -u t mgi authors: chin, ken lee; ofori-asenso, richard; jordan, kaylee a.; jones, daryl; liew, danny title: early signs that covid- is being contained in australia date: - - journal: j infect doi: . /j.jinf. . . sha: doc_id: cord_uid: u t mgi • the covid- pandemic is overwhelming many national healthcare networks. • case fatality from covid- infection in australia is between . % to . %. • strict public health measures were enforced to control this outbreak in australia. • australia is on its way joining china and south korea in ‘flattening the curve’. the covid- pandemic is overwhelming many national healthcare networks and crippling many economies. as of april ( : am gmt), a total of , , confirmed cases, , deaths and , recovered cases have been recorded in over countries. to date, the reported case-fatality varies from . % (in china) to . % (in italy), with substantially higher fatality among older populations, and those with co-morbidities. australia has a population of approximately million, of whom . % are aged years and above. the first case of covid- infection was reported on january . as of april , there were , known cases, and deaths. both the federal and state/territory governments have enforced strict public health measures to control this outbreak. in the present study, we report on the epidemiology of the covid- outbreak in australia observed thus far, as well as the predicted future numbers of cases, deaths and icu admissions, and associated icu costs. in - , total icu capacity across public and private hospitals in australia comprised , beds, and the mean cost of each icu bed-day was aud $ . , we forecasted the number of beds required for covid- patients over time and its associated costs by applying the following conditions: (i) allocation of %, % and % of icu beds for covid- ; (ii) % (as currently observed in australia), % (china) and % (italy) of confirmed cases requiring intensive care ; (iii) mean icu stay between and days; and (iv) mean hospital stay prior to intensive care between and days. evaluation of temporal changes in trend and dynamic time series forecasting were performed by box-jenkins autoregressive integrated moving average and regression models. predicted models were validated by review of mean absolute percentage errors and r-squared values. we estimated the mortality rate by dividing the number of deaths on a given day by the number of patients with confirmed covid- infection (i) on the same day and (ii) seven days before, given that patients who die on any given day were infected much earlier. on this basis, case fatality from covid- infection in australia is presently between . % to . %. australia all reporting less new cases in the three to five days prior (supplement figures a and b) . hence the rate of rise in incidence has slowed, mindful of the limitations of applying trends to short periods of time. based on extrapolation of trends prior to march , the australian healthcare system would have been over-run by over , confirmed cases by april (supplement figure c) . furthermore, icu capacity would have been exceeded by mid to end april (supplement figure d) . the associated icu costs would have amounted to between aud $ . million and $ . million if capped at the current maximum number of icu beds. notably, australia has successfully averted these outcomes through timely implementation and strict enforcement of bans on travel and social gatherings, as well as concerted diagnostic and management strategies. the results of our analysis suggest that australia is on its way joining china and south korea in 'flattening the curve'. klc designed the study and performed the analysis. all authors contributed to manuscript preparation and revision for intellectual content. all authors approved final manuscript version prior to submission. none coronavirus covid global cases case-fatality rate and characteristics of patients dying in relation to covid- in italy population by age and sex, australia, states and territories australian department of health. coronavirus (covid- ) health alert national pricing model: technical specifications - australian and new zealand intensive care society. centre for outcome and resource evaluation critical care utilization for the covid- outbreak in lombardy, italy: early experience and forecast during an emergency response jama clinical course and risk factors for mortality of adult inpatients with covid- in wuhan, china: a retrospective cohort study figure . public health measures undertaken to contain covid- in australia none key: cord- -h v nmx authors: bagust, t. j. title: a review of viral infections of horses date: - - journal: aust vet j doi: . /j. - . .tb .x sha: doc_id: cord_uid: h v nmx nan viruses are classified on the possession of a core of either desoxyribose or ribosenucleic acid, the symmetry and structure of the outer protein coat of the virus particles, biophysical and biochemical properties and serological identity. viruses can only be grown in living cells and early investigations of equine viral infections were hampered by the need for the work to be done in horses. developments in the technique of in vitro cultivation of monolayers of living cells (cell or tissue culture) in the last years have greatly aided the isolation of viruses infecting horses. at least viruses are now known to infect horses (scott ) . some of these viruses have been found to cause clinical disease, and for the other viruses serological evidence only of infection of horses is available. in this article, viruses infecting horses ( table ) are reviewed with special reference to those viruses now known to infect horses in australia. equine rhinopneumonitis virus, doll et a ), by two serotypes of equine rhinoviruses and also by parainfluenza virus and equine influenza a virus, of which antigenically separate sub-types and are known to infect horses independently. a coronavirus, of similar morphology to avian infectious bronchitis virus, has also been isolated from a thoroughbred with upper respiratory disease in canada (ditchfield ). the clinical differential diagnosis of equine upper respiratory disease has been outlined by both blood ( ) and lewis ( ) , the latter also emphasising epidemiological differences for these viruses. in australia, extensive investigation of respiratory diseases seen in horses in victoria and queensland have shown that equine herpesvirus type (rhinopneumonitis) is the most common aetiological agent (duxbury and oxer ; bagust and pascoe , ) . this virus is widespread in australia, % of adult horses having detectable serum antibodies as a result of prior infection (turner and studdert ; equine virus infechm and disease virus infections of horses will be considered in relation to body systems commonly affected. as similar clinical signs may be produced in response to infection by several different groups of viruses, identification of an aetiological agent may also require virological examination. exotic viruses infecting horses are not discussed in this article, because they are to be considered in detail in publications by the exotic diseases sub-committee of the australian commonwealth and states veterinary committee. the upper respiratory disease complex is commonly seen in foals and young horses, both overseas and in australia. it is characterised by a transitory pyrexia and anorexia, slight swelling of the lymph nodes of the throat and serous nasal discharge, which becomes mucopurulent after a few days. these clinical signs may be produced by any of several groups of viruses (studdert ) , including equine herpesvirus type (previously called equine influenza virus, then *this is the third article in a series of reviews on viral diseases of animals. previous articles in the series were published in the august (page ) and february (page ) issues of the journal. bagust et a ) . acute upper respiratory infection by equine herpesvirus type is usually seen only in young horses in their first infection with this virus, and older horses with antibody show only mild clinical signs on re-infection, usually by respiratory droplet spread of infection from young horses. viruses other than equine herpesvirus type have not been isolated from respiratory disease in horses in australia, except €or slowly cytopathic herpesviruses, which have been obtained from both clinically normal and diseased horses in australia and overseas (studdert et bodies to the chlamydia (psittacosis) group of organisms detected in the serums of australian horses by studdert ( ) is not clear. at least viruses, mainly arthropod-borne, infect the equine central nervous system (scott ) and include the classic encephalomyelitides produced by western, eastern, venezuelan and japanese b encephalitis viruses. equine herpesvirus type has also been associated with lumbar paralysis in stallions (saxegaard ) . in australia, virus infection of the equine nervous system has not yet been reported, although murray valley encephalitis virus has been suspected to infect horses (hungerford , and antibodies to this arbovirus have been detected in the serums of horses in south australia, western australia and queensland (spradbrow ) . equine coital exanthema, long recognised in europe and the usa (lieux ) , is manifested by the formation of papules, pustules and ulcers on the genitalia of horses. in several countries, including australia, this disease is considered to be caused by a herpesvirus (pascoe et a (pascoe et a , , which may be aided by trauma of the genital mucosa at coitus and the presence of pyogenic bacteria on the niucosal surfaces (pascoe et uf ). turner rt a ( ) have reported that an australian strain of equine herpes-virus type can also produce a vulvo-vaginitis after experimental intra-vestibular infection. equine herpesvirus type is known to be a cause of both sporadic and widespread equine abortion in many countries, but coital exanthema herpesvirus is not abortigenic (bryans ). foetuses are aborted by equine herpesvirus type from - months of gestation, and gross and histopathological lesions on autopsy are characteristic (doll ) . although infection with this virus is widespread in australia, the virus has not yet been isolated from aborted foals in this country. turner et a ( ) have shown that a strain of equine herpesvirus type isolated from respiratory disease of horses in australia was abortigenic when inoculated directly into the gravid uterus. a picornavirus has been isolated from an aborted equine foetus in germany (bohm ) , but the significance of this isolation is still not known. the role of natural predators in hindering disease investigations of aborted foetuses in australia (bain ) , as well as the heat-lability of viruses, should not be overlooked. virus diseases of the skin of horses in australia have not been investigated in detail, but there is ample clinical evidence for the occurrence of equine cutaneous papillomatosis (warts), caused by a host-specific papovavirus and appearing approximately - months after infection. papular drrmatitis, which may be viral in aetiology, has been reported to occur annually in yearlings in training in the sydney area as firm multiple papular swellings, which form scabs and recede after - weeks (hutchins ) . greasy heel conditions and the transplantable cutaneous fibrosarcoma of equine sarcoid may also be of viral aetiology. horsepox virus, which produces nodules, vesicles, then pustules and scabs on the limbs, lips and buccal mucosa, has been reported in europe (blood and henderson ), but not in australia. with the exception of a chronic diarrhoea, which may be of viral aetiology (rooney ) , virus infections directly involving the equine alimentary system are not common. however, a secondary effect of many virus infections is to cause functional disorders of this system. equine infectious anaemia is a virus infection characterised by an acute initial attack, then a long chronic illness, and was diagnosed as present in australia by brooks et a ( ) and winter ( ) . invasion by this virus causes damage to the vascular system, particularly the intima of small blood vessels, and excessive destruction of erythrocytes. inflammatory changes are produced in the parenchymatous organs, especially in the liver, and mares may also abort. infected horses should be destroyed, because present therapy is ineffective and transfer to uninfected horses may occur by contaminated discharges or by a common syringe needle. equine viral arteritis has not been detected in australian horses, but the disease is important in that clinical signs of acute infection (fever, depression, ocular and nasal discharges, oedema of the eyelids, limbs and abdomen, coughing and difficulty in breathing, colic, enteritis, jaundice, abortion) could be confused with infection by several viruses previously discussed. in the usa, equine viral arteritis is also seen as abortion in mares following a mild non-specific febrile illness (rooney ). the pathognomonic lesion of equine arteritis virus infection is degeneration and necrosis of the media of small arterioles throughout the body. outbreaks of this virus infection have been reported to occur only sporadically, virus being spread in the discharges of infected animals. the virus has been isolated only in the usa and switzerland to date. virological diagnosis is made on the isolation of viruses from infected animals and on serological evidence of infection, and these two methods are best used in conjunction where possible. freshly-collected swabs or washings for virus isolation should be stored in a transport medium (burrows ), which will protect the virus from heat-inactivation, and transported to the laboratory as quickly as possible on wet ice. viruses are grown in the laboratory in susceptible cell cultures, and isolates are identified by pathological effects on cell monolayers, by specific tests, and by serological relationships with antiserums to known groups of viruses. direct visualisation of virus particles by the electron microscope (spradbrow and francis ) and fluorescent labelling of antibodies to specific viruses can allow the more rapid identification of viruses. serological demonstration of the absence of serum neutralising or complement fixing antibody to a viral agent in a serum sample collected from a horse at the time of acute clinical disease, and detection of antibody in another serum collected - weeks later strongly indicates a relationship between the virus infection and disease. serological studies of the age incidence and spread (the epizootiology) of a virus may also be of value in interpreting the extent of disease caused by a virus in a horse population. viral infections of horses may be complicated by bacterial diseases if an inadequate period is allowed for convalescence, or if horses are stressed and fatigued when infected. specific antiviral chemotherapeutic agents are not yet available for use in equine virus infections, but antibiotic therapy may aid healing of the lesions by controlling secondary bacterial infection, such as therapy suggested by pascoe ( ) for equine herpesvirus type i infection of horses occurring under australian conditions. apart from the classical control measures of segregation of affected animals and disinfection (benyon and miller ) , prophylactic vaccination where merited is the main practical means of control. satisfactory vaccines are not available for several equine viruses (scott ) , but efficient vaccines containing live attenuated viruses are in use overseas for viruses spread by contagion, such as equine herpesvirus type and equine influenza a viruses. a vaccine of cell culture origin for equine arteritis virus has been favourably recommended (anon ). tnactivated vaccines for eastern and western equine encephalomyelitis are in use in the usa (anon ), and recent japanese work has indicated the possibility of immunising horses against equine infectious anaemia using a live attenuated virus (kono et af ) . vaccines for virus infections of horses are not currently used in australia, there being little justification for their use on present evidence of disease losses to the horse breeding industry. the future accidental introduction and establishment of equine influenza a virus in the australian horse population would probably result in an explosive spread of infection (lewis ) , and necessitate the use of prophylactic vaccination in this country. in the event of an introduction of a pathogenic equine virus at present exotic to australia, slaughter of affected horses and "ring" vaccination of horses with inactivated vaccines would probably be necessary control measures. valewith volume , spring , the journtrl of tlrc roycrl a r m y veterinary c o r p s comes to an end, victim of rising costs. its passing is much regretted, but the ravc is still active and is capable of adding to the sum of veterinary knowledge, and in the final issue of the journal the colonel commandant exhorts members of the corps to continue to publish the results of their observations and experimentsin other journals. the director regrets the death of the joiirnal but says, "death. we must remember with bacon. although very sad, opens the gate to great fame and extinguishes envy", the final issue has papers on sensitivity of lymphocyte chromosomes irradiated in vitro and in viva, observations on gastric activity in adult alsatian dogs, a i i~t t d i u n vetcrinurv journul, vol. , september. transport of mules by air from cyprus to hong kong. management colic ( a case), small animal "immobilon" and "revivon". a specially interesting article entitled hearts and minds in the sand gives an interesting commentary on the dhofar province of the sultanate of aman and the activities of the veterinary officerincluding his embarrassment on being presented with a woman for wife in return for treating some sick camels, and further when "four women were led forward who 'wished to carry the tabib al haiwan's (vet's.) chicks in their tummy' ". there is news from many units in great britain and overseas, poems on boar hunting, some reminiscences and a final editorial. vale! hugh mcl. gordon anon ( i )-j. a m . it/. r w d . a s s . : i arr.s/. vet yic,t. i~o t . proc ) -z~n t h l . vc%bfrd. b: , abstr proc american veterinary publications diseases of livestock" p ) in "equine medicine and surgery" pp. and american veterinary publications control and therapy in general practice. no. i . post graduate committee in veterinary science vc,tmcd ) -a u s t . w t c o r r i~i v e t . : . : key: cord- -zol k p authors: hill-cawthorne, grant; negin, joel; capon, tony; gilbert, gwendolyn l; nind, lee; nunn, michael; ridgway, patricia; schipp, mark; firman, jenny; sorrell, tania c; marais, ben j title: advancing planetary health in australia: focus on emerging infections and antimicrobial resistance date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: zol k p with rising population numbers, anthropogenic changes to our environment and unprecedented global connectivity, the world economic forum ranks the spread of infectious diseases second only to water crises in terms of potential global impact. addressing the diverse challenges to human health and well-being in the st century requires an overarching focus on ‘planetary health’, with input from all sectors of government, non-governmental organisations, academic institutions and industry. to clarify and advance the planetary health agenda within australia, specifically in relation to emerging infectious diseases (eid) and antimicrobial resistance (amr), national experts and key stakeholders were invited to a facilitated workshop. eid themes identified included animal reservoirs, targeted surveillance, mechanisms of emergence and the role of unrecognised human vectors (the ‘invisible man’) in the spread of infection. themes related to amr included antimicrobial use in production and companion animals, antimicrobial stewardship, novel treatment approaches and education of professionals, politicians and the general public. effective infection control strategies are important in both eid and amr. we provide an overview of key discussion points, as well as important barriers identified and solutions proposed. with rising population numbers, anthropogenic changes to our environment and unprecedented global connectivity, the world economic forum ranks the spread of infectious diseases second only to water crises in terms of potential global impact. addressing the diverse challenges to human health and well-being in the st century requires an overarching focus on 'planetary health', with input from all sectors of government, non-governmental organisations, academic institutions and industry. to clarify and advance the planetary health agenda within australia, specifically in relation to emerging infectious diseases (eid) and antimicrobial resistance (amr), national experts and key stakeholders were invited to a facilitated workshop. eid themes identified included animal reservoirs, targeted surveillance, mechanisms of emergence and the role of unrecognised human vectors (the 'invisible man') in the spread of infection. themes related to amr included antimicrobial use in production and companion animals, antimicrobial stewardship, novel treatment approaches and education of professionals, politicians and the general public. effective infection control strategies are important in both eid and amr. we provide an overview of key discussion points, as well as important barriers identified and solutions proposed. the st century confronts us with profound global challenges such as food, water and energy security, reduced resilience of our planet's life-giving ecosystems and threats from emerging and antimicrobial-resistant infections. according to the world economic forum, the spread of infectious diseases is now ranked second only to water crises as the global risk with the greatest likelihood and potential impact, while the one world one health concept recognises that human and animal health are intimately linked and ultimately dependent on healthy ecosystems. in , the rockefeller foundation invested us$ million to establish the pillars of a new discipline called planetary health, which identifies the need for integration of social, economic, environmental and health knowledge. in a similar vein, the wellcome trust launched the our planet, our health initiative, investing £ million over years to explore the link between human health and environmental change. the united nations' sustainable development goals (sdgs) also emphasise the dependence of human health on the resilience of the planet's ecosystems, with specific targets that prioritise and focus global action. within australia, the 'foundations for the future: a long-term plan for australian ecosystem science' report, published in , stated that: 'our natural and managed ecosystems form the world we live, play and work in; the settings for our industry; and the distinctive natural heritage that characterises the australian nation. they are the basis of our current and future prosperity, and our national well-being'. however, a national summary box ► the emergence and spread of infectious diseases, including antimicrobial-resistant infections, pose a major health security threat. ► a more holistic approach to emerging infectious diseases (eid) and antimicrobial resistance (amr) is essential to encourage 'resilience thinking'. the main themes identified were: animal reservoirs of emerging human pathogens, pathogen surveillance, mechanisms of disease emergence and disease spread by asymptomatic individuals (the so-called 'invisible man'). tables and summarise relevant participant responses. the severe acute respiratory syndrome coronavirus (sars-cov) outbreak in highlighted the importance of animal reservoirs as a source of human infection. henipavirus outbreaks, including hendra on the australian eastern seaboard and nipah in malaysia and bangladesh, demonstrated the importance of bats as viral reservoir species and of domestic animals (horses and pigs, respectively) as amplifying hosts. for the middle east respiratory syndrome coronavirus (mers-cov), domestic camels have been implicated as the likely amplifying hosts. fortunately, serological testing of camels in australia, which is home to the largest population of wild camels in the world, has revealed no evidence of mers-cov infection to date. bats may also carry ebolavirus, but its environmental reservoirs remain uncertain. in general, the inter-relationships between animal reservoirs and amplifying hosts, as well as the circumstances that lead to pathogen overspill or backspill between wildlife, livestock and humans are poorly characterised. in the absence of systematic pathogen surveillance in wildlife and domestic animals, human cases often act as bmj global health across the usa. the risk of infections spreading from wildlife reservoirs into human populations is exacerbated by the expansion of agriculture and mining into natural environments, road infrastructure, deforestation, subsistence hunting and co-location of wild and domestic animals in so-called wet markets. strategically, targeted surveillance of the environment, domestic and wild animals, infection vectors and vulnerable human populations will facilitate early detection and better control of disease emergence risk. the importance of pathogen surveillance has been emphasised by both the ebola interim assessment panel chaired by dame barbara stocking and the independent panel on the global response to ebola chaired by professor peter piot. the stocking report recognised poor implementation of international health regulations (ihr), which were approved by the world health assembly in , as well as the need for global solidarity to build local capacity, which has been incorporated in target .d of the sdgs: 'strengthen the capacity of all countries, in particular developing countries, for early warning, risk reduction and management of national and global health risks'. ihr implementation requires strong government commitment to establish and maintain public health laboratory and service provider capacity. the us committed us$ billion towards the global health security agenda, while the uk created a £ billion fund in partnership with the bill and melinda gates foundation to tackle malaria and other infectious diseases. the australian government committed $a million over years - to the indo-pacific centre for health security, assisting core capacity strengthening and complementing who's regional strategy for emerging diseases and public health emergencies in the asia-pacific (asia pacific strategy for emerging diseases; apsed iii ). the synthesis of data on the ecology and evolutionary biology of various organisms provide enhanced understanding of pathogen emergence, but information on the social mechanisms that underpin disease outbreaks and persistence remains rudimentary. for example, the reasons for increasing rates of human non-typhoidal salmonellosis in australia (noted at the workshop), at a time when rates were falling in most comparable countries, were poorly understood. integration of food, animal and human surveillance data could provide the insight needed to improve control of these infections. the impact of climate change, particularly on water and vector-borne diseases, was highlighted as a key concern. viruses spread by aedes aegypti and a. albopictus mosquitoes (zika, dengue and chikungunya) pose a significant risk to global health. so far, australia has successfully restricted these mosquito populations, but the likelihood of their permanent establishment will increase with climate change. mosquito surveillance in australia is undertaken on a state-by-state basis with coordination by the national arbovirus and malaria advisory committee. more comprehensive and better standardised surveillance programmes will facilitate accurate mapping of mosquito populations and better tracking of endemic and imported viruses. the 'invisible man' presymptomatic or asymptomatic individuals can unwittingly spread infection. salient examples include the spread of hiv from asymptomatically infected individuals, the hours presymptomatic period during which patients with influenza are infectious and unrecognised colonisation with multidrug-resistant organisms. outbreak control strategies usually depend on syndromic diagnosis and cluster identification to guide intervention strategies. when outbreaks are fuelled by unrecognised human vectors, the importance of routine infection control precautions becomes evident and pre-emptive control measures such as quarantine of high-risk individuals or large-scale social distancing may be appropriate. such measures are difficult to implement. risk assessment and modelling to predict the most likely eventualities in advance and develop realistic scenarios to aid public health response preparedness are important to guide mitigation strategies. strengthening of public health systems, especially in low-income and middle-income countries, is essential to achieve core ihr capacities. the australian government's health for development strategy - articulated most of the important elements required for a comprehensive regional response, but australia's bmj global health international aid budget has declined to its lowest level in many decades; falling well short of international targets. effective implementation of the joint external evaluation process in the asia-pacific region has provided a valuable overview of country-level preparedness, but it needs to be combined with the world organisation of animal health (oie) evaluation of performance of veterinary services assessment to improve one health surveillance, while ongoing monitoring is essential to ensure that identified capacity gaps are addressed and best practices shared. it is predictable that eids will escalate in frequency. although much effort has been expended in developing pandemic preparedness policies, recent experiences with sars and mers-cov demonstrated that even the most advanced medical systems require continued vigilance linked to careful scenario response planning. [ ] [ ] [ ] epidemic outbreaks, or even the perceived threat of an epidemic, usually lead to a flurry of activity, but lessons learnt and interim policies developed are rarely consolidated during interepidemic periods. successful policy implementation requires an expert panel that represents all relevant disciplines, to work with the commonwealth office of health protection to draft national guidelines and monitor implementation of actions to reduce the likelihood and negative impact of eids. it could also oversee the drafting of generic research proposals to test interventions and generate enhanced insight during epidemic outbreaks. methodologies for better decision-making during emergencies require refinement. [ ] [ ] [ ] the rockefeller-lancet commission identified three important strategies, adopting a threshold approach, scenario planning and resilience thinking. these require pre-emptive scoping of relevant risks, as well as possible scenarios and outcomes associated with identified courses of action. effective public communication in times of uncertainty poses a major challenge. the australian media were more measured than media outlets in the usa during the ebola virus outbreak, but news reports still generated considerable public anxiety. detailed scenario planning will help to identify priority actions and communication strategies to reassure the public that the situation is under control and that perceived risks are manageable. optimal communication will require close liaison between researchers, public health officials (for human, animal and environmental health), policymakers and the media. within australia, there is no formal framework within academic institutions or government to facilitate and support cross-disciplinary collaboration, although the national framework for communicable disease control does encourage a one health approach to pandemic preparedness. increased amr awareness has been encouraging, but like climate change progress is slow, given the multiple vested interests and differences in risk/benefit perception. much can also be learnt from the roadmap developed by the us centers for disease control and prevention (cdc) to assist one health operationalisation. the australian national antimicrobial resistance strategy - , jointly developed by the departments of health and agriculture and water resources, represents an example of how these silos can be linked, but implementation remains challenging. table summarises participant responses to open-ended questions focused on amr. the main discussion themes included antimicrobial use in production animals, amr in companion animals, antimicrobial stewardship and public education. table provides an overview of key barriers and potential solutions identified. the ecological effects of antimicrobial selection pressure, including its effects on the human and animal microbiome, are poorly understood. antimicrobial use in production animals has been restricted in australia following the recommendations of the swann report. when avoparcin use in feedlot cattle was shown to increase the prevalence of enterococcus faecium resistance to vancomycin (a glycopeptide antibiotic used for the treatment of human infections), it was voluntarily withdrawn from the australian market. fluoroquinolones were never approved for use in production animals in australia, which probably explains the low levels of fluoroquinolone resistance observed in campylobacter, salmonella and escherichia species compared with other countries where agricultural use is unrestricted. globally, the pork and chicken industries are the biggest users of antimicrobials. recent descriptions of highly resistant bacteria found on chicken and swine farms in china, linked to outbreaks of human infection with bacteria containing similar plasmid-mediated resistance, offer a stark example of the health risks associated with unregulated antimicrobial use in production animals. however, it was acknowledged that the responsible use of antimicrobials to address concerns about food security and animal welfare require careful consideration. companion animals are important to australians; % of households own pets and the pet industry contributes nearly us$ . billion to the australian economy, employing people. the health benefits of pet ownership are estimated to save the healthcare system approximately us$ . billion per year. despite the intensity of interaction, there has been surprisingly little research into the transmission of amr between pathogens of humans and their pets. a better understanding of antimicrobial use in companion animals is needed, since there is no regulatory guidance and pets fall outside the agriculture and health portfolios. australian doctors prescribe more than twice the amount (in defined daily doses per population per day) of antibiotics compared with their counterparts in the bmj global health table responses to open-ended questions on antimicrobial resistance (amr) nightmare scenario ► global spread and dominance of totally antimicrobial resistant pathogensreturning to the preantibiotic era priorities for future research/policy ► environmental impact of antimicrobial use in humans, animals and crops ► emerging bacterial resistance to biocides and disinfectants. ► amr transmission from and to companion animals. ► balancing food production capacity with amr concerns. ► need for comprehensive amr surveillance; understanding the selection, expansion and spread of multidrug-resistant mobile genetic elements (mapping the mobile gene pool). ► antibiotic stewardship-understanding why doctors prescribe and patients demand, antimicrobials inappropriately. ► better infection control within health and aged care facilities. ► point-of-care diagnostics (including rapid species identification and drug susceptibility testing). ► use of highly selective bacteriophage therapy. ► adaptive clinical trial designs for rapid assessment of multidrug regimens ► alternative drug development funding models that considers the public good. ► non-antimicrobial approaches to controlling infections. ► are there effective treatment strategies that will reduce selective pressure and on-going evolutionary 'escape', such as increasing bacterial susceptibility to immune attack or reducing the risk/impact of invasive bacterial infection only? ► what are the key characteristics of a healthy microbiome and the short and long term impacts of antimicrobial induced changes? issues that require public consultation ► restricting antimicrobial access to reduce inappropriate use, for example stronger regulation or increases in price ► how best to educate the general public and prescribers about the dangers (personal and environmental) of inappropriate antimicrobial use. ► balancing animal and human welfare considerations. ► balancing distributive justice and community versus individual cost-benefit. amr, antimicrobial resistance. netherlands. at least % of prescriptions are judged by experts to be clinically inappropriate, inadequate or unnecessary. litigation risk aversion, diagnostic uncertainty, time pressure and perceived patient demand are among the reasons why doctors overprescribe antibiotics. evidence of previously unrecognised harm related to impacts on the human microbiome, as well as the social and ecological harm from amr, should inform development of novel strategies to optimise antimicrobial use. a public policy research agenda, informed by social scientists and psychologists, should explore how best to reform policy settings, devise appropriate incentives and disincentives, develop innovative public and professional education programmes and use social media to improve public understanding and influence responsible regulation expectations. both the general public and professional groups require an enhanced appreciation of basic infection control principles. based on scenarios of increasing amr prevalence for six pathogens, it has been estimated that by , million lives per year and trillion usd of economic output may be lost due to amr infections. a divisive debate has focused on the relative impacts of human versus animal or agricultural use of antimicrobials, but constructive collaboration is essential to elucidate and mitigate the key drivers of amr. a major advance in promoting a one/eco health approach to amr in australia was achieved through the joint support of the australian chief medical and veterinary officers to develop and implement a national amr strategy. this is the first joint ministerial initiative between the australian government departments of health and of agriculture and water resources. the who's antimicrobial resistance: global report on surveillance ( ) identified a policy package with broad goals that included strengthened surveillance and laboratory capacity. however, without adequate funding and accountability measures, such farsighted policies will continue to fall short, especially in the asia-pacific region where antimicrobial use is essentially unregulated and strong financial incentives exist to retain the status quo. the who western pacific region's action agenda is a step towards tackling these problems, but the agenda includes no plans for bmj global health lack of funding for cross-disciplinary research was identified as a significant barrier; participants believed that this was exacerbated by the separation of the two major australian public research funding bodies-the national health and medical research council (medical) and the australian research council (non-medical). breaking down traditional medical, veterinary and biological research silos is crucial, with dedicated funding to support cross-disciplinary initiatives. few new antimicrobials have been developed in recent years, as antimicrobials do not deliver attractive returns on investment. private-public partnerships have been used with success to develop vaccines for neglected diseases, but this requires generous philanthropic support. new economic models should reward antimicrobial discovery (or novel non-antibiotic approaches to reducing amr) as a public good, delinking the return on investment from the volume of sales. the association of british pharmaceutical industries antibiotics network has suggested an insurance-based model that guarantees an annual license fee, providing a more predictable return on investment. while the development of new antimicrobial drugs is important in the short term, history has shown that resistance will develop frameworks for the optimal and ethical application of new technologies, such as social network surveillance and advanced pathogen genomics. provide leadership within the asia pacific region and link with international efforts ► strengthen linkages with and support of regional who offices (western pacific and southeast asia), especially the 'health security and emergencies' and 'communicable diseases' sections and other regional mechanisms and forums, including the south pacific commission, the east asia summit and the asia pacific economic cooperation, as well as global initiatives such as global health security agenda and the development banks. ► encourage adequate funding of dfat's regional health security strategy. ► link with one/eco/planetary health communities in other countries, encourage a 'united front' and support international efforts *this was recently completed, but many of the core elements remain to be executed. develop in response to selection pressure and spread without appropriate infection control measures. alternative therapeutic strategies, such as bacteriophage treatment may be successful if linked to rapid and accurate pathogen identification. attempts to reduce selection pressure fuelled by indiscriminate microbial killing, includes highly targeted bacteriophage-based approaches, modification of disease causing microbes to make them more susceptible to immune attack and developing strategies that prevent or selectively treat invasive disease only. rapid point-of-care tests that differentiate viral and bacterial infections, and provide antimicrobial susceptibility profiles, would assist more targeted use of conventional antibiotics. the challenge posed by eids and amr requires careful consideration of effective mechanisms for prevention and response. table summarises the processes and activities identified for a coordinated australian response to the threat of eids, supported by the recently released national action plan for health security. while the national amr strategy emphasises bmj global health the need for a coordinated one health approach, implementation within existing government structures remains challenging without significant internal reform. public education should also target politicians and key decision-makers, since implementation requires strong political will and requisite funding. global risks one world, one health: beyond the millennium development goals influenza coordination, unicef, the world bank safeguarding human health in the anthropocene epoch: report of the rockefeller foundation-lancet commission on planetary health wellcome trust launches our planet, our health initiative sustainable development goals [internet]. sust aina bled evel opment. un. org foundations for the future: a long-term plan for australian ecosystem science from public to planetary health: a manifesto ecological dynamics of emerging bat virus spillover antibodies against mers coronavirus in dromedary camels absence of mers-cov antibodies in feral camels in australia: implications for the pathogen's origin and spread a new approach for monitoring ebolavirus in wild great apes emerging infectious diseases of wildlife--threats to biodiversity and human health west nile virus: success of public health response underlines failure of the system ecology of zoonoses: natural and unnatural histories who. stocking b. final report of the ebola interim assessment panel will ebola change the game? ten essential reforms before the next pandemic. the report of the harvard-lshtm independent panel on the global response to ebola fact sheet: the global health security agenda chancellor george osborne and bill gates to join forces to end malaria aspx? w= tb cagpkpx% fls k% bg zkeg% d% d pacific strategy for emerging diseases and public health emergencies (apsed iii): advancing implementation of the international health regulations dengue and climate change in australia: predictions for the future should incorporate knowledge from the past australian department of foreign affairs and trade a new strategy for global development improving emergency preparedness and response in the asia-pacific public health measures to control the spread of the severe acute respiratory syndrome during the outbreak in toronto mers-cov outbreak following a single patient exposure in an emergency room in south korea: an epidemiological outbreak study developments in non-expected utility theory: the hunt for a descriptive theory of choice under risk an axiomatic approach to choice under uncertainty with catastrophic risks decision-making under great uncertainty: environmental management in an era of global change national framework for communicable disease control department of health. uk five year antimicrobial resistance strategy tackling drug-resistant infections globally one health": a policy perspective commonwealth of australia. responding to the threat of antimicrobial resistance report of the joint committee on the use of antibiotics in animal husbandry and veterinary medicine avoparcin used as a growth promoter is associated with the occurrence of vancomycin-resistant enterococcus faecium on danish poultry and pig farms low-level fluoroquinolone resistance among campylobacter jejuni isolates in australia control of fluoroquinolone resistance through successful regulation global trends in antimicrobial use in food animals emergence of plasmid-mediated colistin resistance mechanism mcr- in animals and human beings in china: a microbiological and molecular biological study species shift and multidrug resistance of campylobacter from chicken and swine, china, - australian companion animal council health benefits and health cost savings due to pets: preliminary estimates from an australian national survey australian commission on safety and quality in health care. antimicrobial prescribing practice in australia cultures of resistance? a bourdieusian analysis of doctors' antibiotic prescribing antimicrobial resistance: global report on surveillance . who. world health organization action agenda for antimicrobial resistance in the western pacific region s partnership model association of the british pharmaceutical industry. antimicrobial resistance. house of commons science and technology select committee australia's national action plan for health security aust-nat-action-plan-health-security- - . pdf . marais bj. ethics; the third dimension acknowledgements the authors would like to thank kerri anton for developing and designing the layout and structure of the workshop, and christine aitken for event organisation. we also thank participants from all the different sectors that took part, including martin kirk (national centre for epidemiology & population health at the australian national university, canberra, australia), elizabeth harry (the ithree institute, the university of technology sydney, australia) and ben howden (microbiological diagnostic unit public health laboratory, the doherty institute for infection and immunity, melbourne, australia) who contributed to the closed group discussion. the meeting was supported by the university of sydney contributors bm and gh-c conceptualised the manuscript and led the workshop. all authors contributed to the workshop and assisted with the development of the content and review of the manuscript.funding the authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. competing interests none declared.patient consent for publication not required.provenance and peer review not commissioned; internally peer reviewed. open access this is an open access article distributed in accordance with the creative commons attribution non commercial (cc by-nc . ) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. see: http:// creativecommons. org/ licenses/ by-nc/ . /. key: cord- -s aorzi authors: leow, lowell; ng, calvin s h; mithiran, harish title: surgery beyond covid‐ date: - - journal: anz j surg doi: . /ans. sha: doc_id: cord_uid: s aorzi nan text covid- has changed the world as we know it and the practice of medicine forever. past pandemics may have primed us but covid- unfolded on a scale not seen in modern history with many likening it to the spanish flu. fortunately, medicine has progressed since then, and the response to covid- in countries like australia, new zealand, singapore, hong kong and taiwan has been robust. the aggressive stance adopted by australia and new zealand in travel bans, social distancing and active quarantine and surveillance has flattened the curve, curtailed the spread and prevented overwhelming of healthcare systems by covid- patients. this has helped keep the case-fatality rate to near % . despite healthcare systems coming under siege from the surge, inspirational stories surface each day on how healthcare workers support each other and continue to deliver excellent care. as surgeons, we pride ourselves in our kinaesthetic ability and physical stamina in service of our patients. however, this crisis has forced many of us to adapt to new roles and redefine our practices , . proud custodians of tradition have been compelled to adopt new technology and function within the confines of lockdowns and social distancing. with the advent of a vaccine or herd immunity, we will eventually overcome this pandemic but the landscape of surgery will be transformed. how do we navigate what is to come? as countries learn to live with covid- , with a flattened curve and limited outbreaks that can be controlled by quarantine and case contacting, coming out of a lockdown presents equal challenge to entering one. across the world, countries lifting restrictions are being hit by a second wave of infections and have reinstated lockdowns . to reduce this impact, countries such as australia and singapore have adopted three phase plans to guide the re-opening , . as the final line of defence, healthcare institutions are expected to unwind restrictions within the workplace slower compared to the rest of society. this means many of our services will continue to function in a pandemic mode until the crisis within our countries are truly over. mass testing of healthcare workers may expedite this reversal process and mitigate the risk of workplace transmission . ramping back up of services will be required despite personnel still recovering from the exhaustion of such a prolonged heightened accepted article posture. having prioritized surgeries and displaced most benign and non-emergent cases, surgeons will be faced with a backlog of anxious patients . we need to anticipate this by reprioritizing surgeries and progressively performing more elective cases where resources allow . in this globalized age, spread between countries as borders reopen may cause the pandemic to be further protracted. we this episode reminds us that behind the scalpel, we need to continually update our knowledge and maintain relevance as clinicians first. medicine has always been slow to adapt, perhaps due to the nature of our training to be only convinced by hard evidence before adopting an idea. surgery, where the outcomes of our patients are directly and immediately apparent from our actions, carries even higher thresholds. this pandemic has forced us to catch up with the rest of the world in the adoption of technology in our daily practice. online platforms such as zoom have radically changed the way we practice multidisciplinary boards, hold department meetings and conduct teaching sessions , , . we believe this transition will eventually be permanent. even if physical meetings resume, there will have to be provisions made for participants to join via these platforms . this is especially beneficial for surgeons as we often shuttle between these meetings and the operating theatre. such accessibility exists though, as a double-edged sword. "zoom fatigue", a lower threshold for excessive meetings, potential security breaches and an invasion of home privacy may create more problems . we need to remain cognisant of these pitfalls and utilize technology responsibly and rationally. teleconsultation has also seen a resurgence in this pandemic. we feel this event will serve as an impetus for healthcare systems to develop information accepted article this article is protected by copyright. all rights reserved. technology infrastructure and expand on existing programmes that bring healthcare more conveniently to patients. newer technology conceptualized only for the distant future, such as remote robotic surgery, hybrid "one stop" theatres or bespoke d printed ppe may get a much-needed kick-off in the name of infection control. training programmes will need to embrace virtual reality and simulation training as norm , . however, technology cannot fully replace the physical aspect of medicine and surgery. patients still require the "human touch" and we must continue to respect and uphold this therapeutic privilege that they entrust us with. beyond the scope of our own institutions, conferences will also benefit from this transition. we are seeing record number of attendees on streamed webinars hosting international panellists despite ongoing travel restrictions. the resources and logistics associated with organizing a conference has been greatly reduced both for participants and faculty . it is likely that future conferences will have to incorporate live stream access and remote participation. clinical immersion programmes also now come at a fraction of the cost for the visiting surgeons . technology as a tool should be used to encourage international collaboration and the exchange of ideas and information within our surgical fraternity. compared to , we as a community have collectively responded better to covid- . an explosion of ideas, research and clinical practices have surfaced and been exchanged rapidly via webinars and international conferences. whilst we remain vigilant against the propagation of misleading information, we have witnessed the sharing of ideas between national health ministries, hospitals down to medical professionals in combating this disease . such efforts should persist beyond this pandemic to resolve universal problems like wound care and cancer therapy. against the ever-evolving diseases in modern medicine, we can achieve so much more as a united global front. at the essence of it, this pandemic has reminded us that wherever we may be, we are unified by a common desire to do good for our patients. this article is protected by copyright. all rights reserved. https://www.health.gov.au/news/australian-health-protection-principal-committee-ahppc-statementon-restoration-of-elective-surgery this article is protected by copyright. all rights reserved. how new zealand and australia are tackling covid- . world economic forum lessons already learnt from the covid- pandemic covid- outbreak in northern italy: viewpoint of the milan area surgical community risk of new lockdowns rises with fear of second covid- ending circuit breaker: phased approach to resuming activities safely special feature australian government department of health. -step framework for a covidsafe australia the past, present, and future of orthopaedic education: lessons learned from the covid- pandemic here's why you're feeling zoom fatigue. forbes a midpoint perspective on the covid- pandemic accepted article this article is protected by copyright. all rights reserved. key: cord- - gqn z authors: watkins, rochelle e; cooke, feonagh c; donovan, robert j; macintyre, c raina; itzwerth, ralf; plant, aileen j title: influenza pandemic preparedness: motivation for protection among small and medium businesses in australia date: - - journal: bmc public health doi: . / - - - sha: doc_id: cord_uid: gqn z background: community-wide preparedness for pandemic influenza is an issue that has featured prominently in the recent news media, and is currently a priority for health authorities in many countries. the small and medium business sector is a major provider of private sector employment in australia, yet we have little information about the preparedness of this sector for pandemic influenza. this study aimed to investigate the association between individual perceptions and preparedness for pandemic influenza among small and medium business owners and managers. methods: semi-structured face-to-face interviews were conducted with small and medium business owners or managers in new south wales and western australia. eligible small or medium businesses were defined as those that had less than employees. binomial logistic regression analysis was used to identify the predictors of having considered the impact of, having a plan for, and needing help to prepare for pandemic influenza. results: approximately per cent of participants reported that their business had a plan for pandemic influenza, per cent reported that they had not thought at all about the impact of pandemic influenza on their business, and over per cent stated that they required help to prepare for a pandemic. beliefs about the severity of pandemic influenza and the ability to respond were significant independent predictors of having a plan for pandemic influenza, and the perception of the risk of pandemic influenza was the most important predictor of both having considered the impact of, and needing help to prepare for a pandemic. conclusion: our findings suggest that small and medium businesses in australia are not currently well prepared for pandemic influenza. we found that beliefs about the risk, severity, and the ability to respond effectively to the threat of pandemic influenza are important predictors of preparedness. campaigns targeting small and medium businesses should emphasise the severity of the consequences to their businesses if a pandemic were to occur, and, at the same time, reassure them that there are effective strategies capable of being implemented by small and medium businesses to deal with a pandemic. since late the risk of pandemic influenza and the need for preparedness have featured reasonably frequently in the news media in australia, often associated with overseas reports of large outbreaks of infection among birds or small clusters of infection among humans. strategic plans have been prepared for an outbreak of pandemic influenza associated with human avian influenza infection at national and global levels [ , ] . many of these plans include mechanisms to facilitate and manage community-wide responses in recognition of the likelihood that pandemic response requirements will exceed the response capacity of health authorities and governments. preparation by the business community for an influenza pandemic is encouraged by governments, but much of the onus is on businesses to inform themselves about the threat posed by pandemic influenza and develop their own plans. as such, large corporations often have detailed plans, but less is known about pandemic preparedness in small and medium sized businesses. small and medium businesses are a major employer in australia, accounting for approximately half of all private sector employees [ ] . small businesses, which include businesses with less than employees, were alone estimated to employ almost . million people in australia in [ ] . pandemic influenza is likely to have a major impact on businesses, yet little is known about the needs and preparedness of small and medium sized businesses. government and health authorities in australia and overseas have recommended that businesses, community organisations and individuals implement a range of strategies to prepare for pandemic influenza, and an increasing number of resources are being produced to provide guidance on pandemic preparedness and business continuity planning [ ] [ ] [ ] [ ] . a resource specific to pandemic preparedness planning among small businesses in australia is also available [ ] . pandemic planning resources generally describe the nature of the anticipated threat, highlight the role of government and health authorities, outline essential business continuity planning and response requirements, and describe specific measures that may be implemented to limit or prevent disease spread. specific strategies recommended to limit disease spread within the workplace include promoting improved hygiene and infection control practices, using social distancing measures and flexible work arrangements to minimise contact between individuals within the workplace and the community, using personal protective equipment, restricting workplace entry and isolating individuals who may be infectious [ ] . a greater understanding of the factors associated with planning for pandemic influenza among small and medium businesses is required to inform communication strategies that promote improved preparedness for a pandemic. protection motivation theory [ ] is a commonly used framework for fear-appeal research [ ] . protection motivation theory conceptualises an individual's acceptance of advice on how to protect themselves from a health threat as primarily a function of four specific beliefs: the perceived severity or seriousness of the threat and the likelihood of the threat occurring (which together constitute 'threat appraisal'); and the perceived effectiveness of actions to avoid the threat and the individual's perceived self-capacity to implement those actions (which together constitute 'coping appraisal'). if a sufficient level of threat is perceived to exist, and coping appraisal is high, then the individual will take appropriate action. however, where a threat appraisal is high but coping appraisal is low, the individual is unlikely to take appropriate action. protection motivation theory suggests that campaigns using threats must include information about how to avert the threat, and ensure that members of the target audience have the skills and resources necessary to adopt the recommended actions. investigations of the effectiveness of health threat communications are supportive of the protection motivation theory framework [ ] , finding that communication effectiveness is associated with the extent to which the communications present real but controllable threats [ ] . the health belief model [ , ] also conceptualises behaviour as dependent upon individual perceptions including the perceived likelihood and severity of the potential health threat, and the perceived effectiveness of responses to the threat. similarly, research has supported the importance of health belief model constructs in behaviour change [ ] , particularly where illness avoidance and perceived threat are of central importance [ , ] . among health behaviour theories that identify similar constructs as important determinants of health behaviour, current research provides no clear indication of the superiority of any single approach [ ] . guided by the concepts considered to be of importance in these health behaviour theories, and the protection motivation theory framework in particular, we aimed to investigate the association between selected beliefs and preparedness for pandemic influenza among small and medium business owners and managers. between may and july , structured face-to-face interviews were conducted with either the owners or managers of small or medium businesses in australia. eligible businesses were defined as businesses which have less than employees [ ] . participating businesses were recruited from new south wales ( ) and western australia ( ), with approximately per cent of the sample in each state being selected from businesses located in the capital cities (n = ), per cent being recruited from large satellite cities (n = ), and the remaining per cent from rural centres (n = ). participating businesses in western australia were randomly sampled from a membership database of businesses obtained from the local chambers of commerce and industry. in new south wales businesses were randomly sampled from a purchased list of businesses stratified by industry type. in both instances the lists of businesses were checked to ensure that the sampling frames included only businesses which operated in the eligible study areas prior to recruitment. a flow chart was used to guide the recruitment of interviewees in both states to ensure recruitment processes were standardised, including gaining confirmation that the business had less than employees, ensuring that a minimum of three attempts were made to establish contact with each business to be recruited, and ensuring that an appropriate person was interviewed. face to face interviews with business owners or senior managers were administered by trained interviewers from a market research firm in new south wales, and by trained interviewers contracted by the local chambers of commerce and industry in western australia. prior to the study interview verbal consent to participate was obtained following the provision of, and discussion of, a study information sheet. study procedures were approved by the human research ethics committee of curtin university of technology. focus group discussions with business owners and managers in perth and sydney were used to inform and develop the structured interview schedule. the interview schedule was pre-tested among a small sample of business owners to ensure the questions were acceptable, understandable, unambiguous, and that open ended questions elicited the expected type of response. basic characteristics of the participating businesses assessed included the job classification of the interviewee (owner, chief executive officer/managing director, senior manager), main business location (capital city, satellite city, rural centre), industry type, business size (number of employees), average number of customers per day, and the educational level of employees (proportion of employees who attended university). the response categories for industry type were pre-coded based on the divisions in the australian and new zealand standard industrial classification [ ] . for analysis purposes, businesses operating in the primary and secondary industry sectors (i.e., businesses engaged in production and manufacturing) were aggregated; and classifications for tertiary industry businesses (i.e., businesses operating within the service sector) were aggregated according to the following three industry type categories: property and business services; retail trade; and other tertiary. the following beliefs about pandemic influenza were each assessed by a single question: the perceived severity of the threat; the risk of the threat; and the ability to respond effectively to the threat. the general belief about the severity of the threat was operationalised as the perceived proportion of people that could become sick if pandemic influenza were to affect the local community. the perceived risk of the threat was operationalised as the likelihood that pandemic influenza would become a significant health issue in australia in the near future, and assessed on a four point scale (very unlikely, unlikely, likely, very likely). an additional business-specific indicator of risk, the perceived level of risk that pandemic influenza poses to the interviewee's business, was also rated on a four-point scale (no risk, some risk, moderate risk, high risk). a dichotomous indicator of coping appraisal was derived from the open-ended question: "can you think of any steps you can take to protect your business from pandemic influenza?" responses were independently reviewed by two coders, and participants who were unable to identify any potentially useful steps that could be taken to protect their business or limit disease spread were classified as having low coping appraisal. a small proportion of participants nominated the responses 'don't know' and 'no idea' to represent their beliefs about the risk and severity of pandemic influenza (table ) . when dichotomous indicators of risk and severity were used in the analysis, these responses were aggregated with the other low risk or low severity responses for analysis purposes on the basis that these responses indicated an absence of perceptions of high risk or high severity. this coding did not significantly affect the findings of the analysis. three dependent variables in the analysis provide different indicators of engagement in adaptive processes associated with the threat of pandemic influenza. participants were asked "before being contacted about this study, how much have you thought about the impact of pandemic influenza on your business?" (not at all, a little, a lot). the need for help with planning for pandemic influenza, which can be considered an indicator of an adaptive response to the threat of pandemic influenza, was assessed using the following open-ended question: "is there anything you need to help you prepare for pandemic influenza?" responses were dichotomised into a variable which indicated whether help was or was not required. lastly, the presence of a plan for pandemic influenza was assessed by the single question "has your business made any specific plans should pandemic influenza arise?" (yes, no, unsure). the chi-square test of independence was used to test for associations between categorical study variables, and the independent samples t-test was used to test for differences between groups on continuous variables. phi, which is a measure based on the chi-square test of association, is used to assess the strength of association between two dichotomous variables, and indicates the amount of total variance explained by the association between the variables. binomial logistic regression analysis was used to identify the significant independent predictors of the health behaviour theory-based belief variables and the three main dependent variables: having considered the impact of, hav- ing a plan for, and needing help to prepare for pandemic influenza. dependent variables were dichotomised for analysis due to skewed distributions and the small sample size. initial model development included entry of variables into a forward stepwise model, with the probability criterion for entry set at . and exit at . . the final models were developed manually to allow exploration of alternative model forms. a main effects model was initially determined. effect modification was also explored, and the inclusion of interactions was determined by the significance of the change in log likelihood of the model. crude odds ratios (cor), adjusted odds ratios (aor) adjusted for the other variables in each model, and % confidence intervals ( %ci) are used to summarise the magnitude of association found between variables. all analyses were performed using spss version . (spss inc., ) and the significance level was set at p ≤ . . in total, eligible businesses were contacted and interviews were completed, producing an overall response rate of per cent. the response rate of per cent ( / ) for new south wales (nsw) was considerably lower than the per cent ( / ) achieved for western australia (wa), but consistent with the different sampling methods used. there was no significant difference between participating and non-participating businesses in wa according to business size (p = . ) or industry type (p = . ). similar data on the characteristics of non-participating businesses in nsw were not available for analysis. nonparticipation was most frequently associated with the business owner or manager being either too busy or unavailable during the interview period, explaining per cent and per cent of refusals in the wa and nsw samples respectively. the characteristics of participating businesses are summarized in tables and by state. most participating busi-nesses had less than employees and more than half of the individuals interviewed were business owners. business owners were significantly more likely to be interviewed in wa than nsw ( table ) . most of the participating businesses operated within the tertiary or service sector. the representation of businesses from different industry types was significantly different by state, with the wa sample having a higher proportion of retailers (table ) and reporting a significantly lower proportion of university educated staff compared with the nsw sample (table ) . approximately per cent of participants believed that pandemic influenza was likely or very likely to become a significant health issue in australia in the near future (table ) , and, on average, participants believed per cent of people in affected communities would become sick ( table ). around per cent of participants reported that they had not spent any time thinking about the impact of pandemic influenza on their business, and over per cent could not identify any steps that they could take to protect their business (table ). only per cent of participants reported having a pandemic influenza plan for their business ( per cent were unsure), and over per cent of participants reported needing help to prepare for pandemic influenza (table ) . beliefs about the risk and severity of pandemic influenza and the amount of time spent considering the impact of pandemic influenza on the business did not differ significantly between states. beliefs about being able to respond to the threat and perceptions about the need for help did differ between states, with businesses in wa having a significantly lower level of response efficacy and being less likely to need help to prepare than businesses in nsw (table ) . businesses in nsw were also significantly more likely to have a plan for pandemic influenza than businesses in wa (table ) ; however, the difference in response rate for the two states renders the generalisability of such differences as tenuous. beliefs about the perceived severity of pandemic influenza and the perceived risk of pandemic influenza to the business were not significantly associated with any business characteristics. business characteristics which were significant predictors of beliefs about the perceived risk of pandemic influenza and coping appraisal are summarized in table . the perceived risk of apandemic in australia was significantly associated with the role of the person interviewed, with non-owners being about twice as likely to consider pandemic influenza as a likely or very likely risk than business owners. both state and the role of the individual interviewed were significantly associated with response efficacy, with businesses in nsw and non-owners being about twice as likely to be able to identify actions which could protect their business in the event of a pandemic than businesses in wa and owners. each of the significant predictors of beliefs identified only explained a small proportion (less than per cent) of the overall variance associated with the belief variables. bivariate associations between beliefs and the dependent variables (table ) indicate that almost all beliefs and dependent variables assessed were significantly associated. the high correlation between the general belief about the risk of pandemic influenza and the specific belief about the risk of pandemic influenza to the business, which explained over per cent of the total variance in responses (equivalent to a pearson correlation coefficient of approximately . ), was among the strongest associations found. there was no significant association between having a plan and the need for help, and coping appraisal was independent of perceptions of severity. logistic regression models were used to determine the significant independent predictors of having considered the impact of, having a plan for, and needing help to prepare for a pandemic. all models were tested for interaction terms and no significant effect modification was found. the significant independent predictors of dependent variables, based on the inclusion of both belief variables and business characteristics, are summarised in table . thinking a lot (versus a little or not at all) about the impact of pandemic influenza on the business was most strongly associated with the perceived risk of pandemic influenza, with participants who perceived a pandemic as likely or very likely to be a health issue in australia in the near future being approximately times more likely to have reported thinking a lot about the impact of a pandemic on their business. businesses that were located in the capital city were about three times more likely to have spent a lot of time thinking about the impact of a pandemic compared with businesses in satellite city or rural locations. these same factors were also significant predictors of having considered the impact of a pandemic on the business when this variable was dichotomised as thought at all (a little or a lot) versus not at all. the perceived need for help was most strongly associated with the perceived risk of pandemic influenza to the business, with participants who perceived the risk of a pandemic to the business as moderate or high being approximately times more likely to report needing help to prepare. state was a significant independent predictor of the perceived need for help, with businesses in nsw more likely to report needing help than those in wa. the perceived need for help was also significantly associated with industry type, with businesses in the property and business services and retail trade sectors being significantly less likely to need help than other service sector businesses. industry type was not significantly associated with perceptions about the risk or severity of a pandemic, but was significantly associated with coping appraisal (χ = . , p = . ), with per cent of retailers unable to think of steps to protect their business as opposed to per cent of other service sector businesses and per cent of production and manufacturing businesses. the presence of a specific plan for pandemic influenza was significantly and independently associated with both perceived severity of a pandemic and coping appraisal. participants who believed that per cent or more of the local community would become sick were over times more likely to have a plan, and participants who were able to identify steps that could be taken to protect their business were over times more likely to have a plan for pandemic influenza. there is a lack of empirical data to inform public health response strategies for pandemic influenza. to our knowledge this study provides the first systematically collected information on preparedness among small and medium businesses in australia, and is among only a few studies in the field worldwide. we found that only a small proportion of businesses studied had thought a lot about how pandemic influenza may impact on their business, that few had made any specific plans to protect their staff or their business in the event of pandemic influenza, and that over per cent state they need help to prepare for pandemic influenza. these findings suggest that additional strategies are required to promote increased awareness of the threat of pandemic influenza in the community, to promote the resources available to assist with preparedness, and to facilitate engagement in preparedness planning. behaviour change is a process, and time is required to initiate and establish new behaviours. according to the protection motivation theory, coping appraisal responses which lead to the establishment of protection motivation occur after the threat-appraisal process, as a threat needs to be identified before coping options can be evaluated [ ] . as such, and as has already been highlighted by others, occasional media reports are insufficient to adequately inform individuals about pandemic influenza, and interventions are required before a pandemic occurs to improve public awareness, build mutual trust, promote effective coping responses and assist in the successful implementation of plans when they are required [ ] . national influenza plans require collective communitywide efforts for an effective response to pandemic influenza. however, they lack information relating to strategies to enable the effective dissemination of this information beyond the availability of these plans on websites [ ] . given that the strategy for response to pandemic influenza in australia is based on containment and reducing transmission of the virus [ ] , and that key response strategies such as isolation, social distancing, and improved personal hygiene which have been supported by mathematical modelling studies [ ] depend on community-wide behaviour modification, additional strategies are required to enable an effective shared response. our findings suggest that the beliefs of small and medium business owners and managers are likely to have important consequences for preparedness. beliefs about the risk of and severity of pandemic influenza were the most important independent predictors of having thought about, and having a plan for pandemic influenza respectively. the perceived risk of pandemic influenza to the business was also the most important predictor of needing help to prepare. these findings are consistent with the relationships proposed by prominent theories of health behaviour, including the protection motivation theory [ , ] , and suggest that these theories provide a useful model for understanding preparedness behaviours among small and medium businesses in australia and elsewhere. protection motivation theory and health belief model concepts have been found to be valuable for understanding and promoting a variety of health-related behaviours [ , , , ] , including the performance of protective behaviours during the outbreak of the severe acute respiratory syndrome in hong kong [ ] . the importance of perceptions about risk and severity in understanding preparedness behaviour suggests that health behaviour theories provide a useful framework for the design of communication strategies that aim to promote preparedness for pandemic influenza among the business community. based on the temporal relations identified in these theoretical frameworks, our results suggest that communications containing information about risk and severity are likely to promote both threat appraisal and coping appraisal processes, and can motivate protective behaviours given a perceived ability to implement recommended actions. promotion of the ability to respond effectively to the threat of pandemic influenza appears to be an important factor associated with protective responses to the threat of pandemic influenza. this finding is consistent with research findings based on other health threats which indicates that low levels of self efficacy and response efficacy provide a barrier to action [ , ] . the high proportion of participants reporting needing help with preparation indicates that self efficacy may be an important factor limiting planning for pandemic influenza, which is consistent with the findings of recent research in europe and asia [ ] . individual business characteristics were relatively unimportant among the predictors of having thought about or planned for pandemic influenza. apart from beliefs about risk, the only other significant predictor of having considered the impact of pandemic influenza on the business was whether the business operated within or outside a capital city. it is possible that this association reflects a factor which can modify the perceived threat of pandemic influenza based on understandings about population density and the probability of exposure to infection. in contrast, individual business characteristics were more important predictors of needing help to prepare, with industry type and state being significant predictors in addition to beliefs about risk. retail traders and businesses that provide property and business services were less likely to report the need for help. differences in the need for help by industry type, given the significant association between industry type and coping appraisal, suggests that some businesses may have difficulty identifying effective protection strategies that are appropriate for specific high-risk business environments, such as retail outlets. this finding highlights the importance of providing support to identify effective response strategies and overcome response difficulties within all business environments. furthermore, our finding that the need for help was not significantly related to whether a plan for pandemic influenza exists appears to highlight the difficulties associated with planning for pandemic influenza, even among those businesses that have already made specific plans for pandemic influenza. our finding of a difference in the need for help by state is likely to be associated with the different sampling and recruitment processes used in the two study locations. in wa the local chambers of commerce was directly contracted to supply the business contact details and conduct the interviews. thus, the existing relationship with the businesses sampled is likely to explain the higher response rate in wa, why a higher proportion of owners were interviewed, and provide a sample which may be less biased in terms of either having a specific interest in pandemic influenza or time or resource pressures than the nsw sample. selection bias associated with the different recruitment strategies may explain why participants from nsw were more likely to have a plan, were more likely to need help and reported lower response efficacy. alternatively, these findings may be due to real differences in beliefs and behaviour between states, which may for example be associated with differences in media exposure or other local influences. regardless of the cause, these differences did not significantly influence the associations found between beliefs and preparedness. due to the cross-sectional study design we are limited in the type of conclusions that we can draw about causality based on the associations observed. for example, having prepared a pandemic influenza plan is likely to result in improved levels of coping appraisal. however, experimental research [ ] has provided support for the impact of beliefs on protection motivation and current behaviour. the associations found in this study explained a low proportion of variance in preparedness behaviour, although the magnitude of the associations found is similar to those reported for protection motivation theory concepts and other health-related behaviours [ , ] . several factors could have contributed to the low explanatory power in the present study, including the assessment of a limited number of theory-based belief constructs, the use of single-item and thus limited operationalisations of the key belief and outcome variables which have unknown reliability, and the use of dichotomous indicators due to the small sample size. also we did not assess behavioural intentions. further work is required to extend the scope of this study and considered other relevant constructs including social norms and response costs. the non-random nature of the sampling frames used to recruit study participants and the small scale of the study limits the generalisability of the study findings. it is also likely that response bias associated with the low response rate may have resulted in an overestimation of the proportion of businesses that have a plan for pandemic influenza, particularly in nsw. the use of financial or other incentives for participation is recommended in future studies to facilitate improved response rates, particularly where industry partners are not used. the findings of this study may also be limited in that self-report methods were used to assess whether the business had a pandemic influenza plan. responses may have been biased in favour of reporting the presence of a plan or having considered the impact of pandemic influenza on the business associated with social desirability bias. there is a shortage of data available to guide public health policy and practice in pandemic influenza planning and response [ ] . current guidance for pandemic influenza preparedness appears to have had little impact on preparedness among the small and medium business sectors in australia. our findings suggest that further investment by governments is required to improve both the specification of and utilisation of available planning resources, as has been highlighted previously [ ] . further work is required to underpin both the design of communication strategies to promote behavioural change, as well as the feasibility and effectiveness of strategies for disease control, which also support beliefs about being able to respond effectively to the threat of pandemic influenza. the findings of this study should be interpreted alongside more in-depth knowledge about the beliefs of business owners and managers that underlie the protection motivation theory constructs, as has been illustrated elsewhere [ ] . in this way, a greater understanding about beliefs to be reinforced or changed, and responses to specific strategies can be gained, helping to promote improved effectiveness of the communication strategies developed. also, particularly in the small and medium business sectors that may have significant resource constraints, the presence of alternative adaptive responses to the threat of pandemic influenza require further investigation. we found that only a small proportion of small and medium sized businesses in australia have made formal plans to guide their response in the event of pandemic influenza. effective communication strategies and support structures to promote preparedness for pandemic influenza are essential to facilitate large-scale community involvement in response efforts. findings from this study provide knowledge which can be used in the preparation of strategies to enable the effective delivery of information on preparedness for businesses. our results indicate that to motivate improved planning among the small and medium business sector, campaigns targeting small and medium businesses should emphasise the severity of the consequences to their businesses if a pandemic were to occur, and, at the same time, reassure them that there are effective strategies capable of being implemented by small and medium businesses to deal with a pandemic. world health organization: epidemic and pandemic alert and response: avian influenza the australian response: pandemic influenza preparedness australian government department of industry tourism and resources: business continuity guide for australian businesses australian government department of health and ageing: australian health management plan for pandemic influenza interim pre-pandemic planning guidance: community strategy for pandemic influenza mitigation in the united states -early targeted layered use of nonpharmaceutical interventions new zealand government ministry of economic development: influenza pandemic planning: business continuity planning guide australian government department of industry tourism and resources: being prepared for an influenza pandemic: a kit for small businesses a protection motivation theory of fear appeals and attitude change protection motivation theory and skin cancer risk: the role of individual differences in responses to persuasive appeals a meta-analysis of research on protection motivation theory a meta-analysis of fear appeals: implications for effective public health campaigns the health belief model and personal health behaviour the health belief model: a decade later a meta-analysis of studies with the health belief model with adults psychosocial factors influencing the practice of preventive behaviours against the severe acute respiratory syndrome among older chinese in hong kong health behaviour theory and cumulative knowledge regarding health behaviors: are we moving in the right direction? australian bureau of statistics: australian and new zealand standard industrial classification (anzsic) preparing for an influenza pandemic: ethical issues using mathematical models to assess responses to an outbreak of an emerged viral disease. final report to the department of health and ageing. canberra, national centre for epidemiology and population health effects of a psychosocial intervention on breast self-examination attitudes and behaviours adolescents' cognitive appraisals of cigarette smoking: an application of the protection motivation theory avian influenza risk perception prediction and intervention in health-related behaviour: a meta-analytic review of protection motivation theory people at risk of flooding: why some residents take precautionary action while others do not world health organization writing group: nonpharmaceutical interventions for pandemic influenza, national and community measures managing fear in public health campaigns: a theory-based formative evaluation process the research was funded by the national health and medical research council of australia (project grant number ) and the australian biosecurity cooperative research centre for emerging infectious disease. the authors would also like to thank the local chambers of commerce and industry in east victoria park for their assistance with and support of the research. the author(s) declare that they have no competing interests. ajp, rew and crm conceived, designed and supervised the study; fcc and ri entered the data; rew and fcc analyzed the data; rew drafted the manuscript; and rjd, ajp, crm and fcc provided feedback on the interpretation of results and editorial comments on the manuscript. we wish to dedicate this paper to the memory of our colleague and much loved friend professor aileen joy plant who died suddenly on the th of march while on an avian influenza mission for the world health organization. this work would not have been possible without her leadership. her outstanding vision for and contribution to the advancement of global public health will be greatly missed. the pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/ - / / /pre pub key: cord- -c af ip authors: kelly, jaimon t.; allman‐farinelli, margaret; chen, juliana; partridge, stephanie r.; collins, clare; rollo, megan; haslam, rebecca; diversi, tara; campbell, katrina l. title: dietitians australia position statement on telehealth date: - - journal: nutr diet doi: . / - . sha: doc_id: cord_uid: c af ip it is the position of dietitians australia that clients can receive high‐quality and effective dietetic services such as medical nutrition therapy (mnt) delivered via telehealth. outcomes of telehealth‐delivered dietetic consultations are comparable to those delivered in‐person, without requiring higher levels of additional training nor compromising quality of service provision. dietitians australia recommends that policy makers and healthcare funders broaden the recognition for telehealth‐delivered dietetic consultations as a responsive and cost‐effective alternative or complement to traditional in‐person delivery of dietetic services. the successful implementation of telehealth can help to address health and service inequalities, improve access to effective nutrition services, and support people with chronic disease to optimise their diet‐related health and well‐being, regardless of their location, income or literacy level, thereby addressing current inequities. nutrition-related chronic diseases are the leading cause of ill health in australia. within the next years, it is estimated that over % of australian adults will be living with overweight or obesity. one in two australian adults have a chronic disease, with over seven million ( % of the australian population) living with nutrition-related chronic disease, including type diabetes, cardiovascular disease, obesity, diet-related cancer, chronic kidney disease and mental health conditions. , australia, like many developed countries, has an ageing population, which presents a significant challenge for the healthcare system. together these will drive up healthcare expenditure and present a multitude of additional societal, geographical and workforce challenges for the healthcare system to manage. telehealth-delivered nutrition consultations offer a flexible modality to provide effective and cost-effective medical nutrition therapy (mnt), regular monitoring and support to the large numbers of people in the community requiring dietetic services, in particular those with obesity and nutrition-related chronic disease. , according to the world health organisation, the term "telehealth" refers to the remote delivery of health services using information and communication technologies to exchange health information, either synchronously authors are members of the dietitians australia telehealth working group (ie, two-way communication in real time; e.g. telephone and videoconference consultations) and/or asynchronously (ie, one way communication at any time; e.g. text-messaging and web-portals). digital health modalities (encompassing telehealth) also include the remote delivery of nutrition interventions via electronic health (ehealth) modes, such as webbased programs, software programs and a range of mobile health (mhealth) options, such as smartphone applications (apps), text messaging programs and wearable devices. many australians cannot access dietetic services due to economic, geographic and sociographic barriers. there is a high concentration of dietitians located in urban, affluent areas while communities experiencing high rates of people living with overweight and obesity and type diabetes mellitus are located in more disadvantaged urban suburbs and rural areas. furthermore, one in four people with or at risk of chronic disease fail to attend in-person consultations in community-based and outpatient clinics, contributing to substantial healthcare resource waste. some of the major reasons people fail to keep appointments in the community are incurring high indirect costs associated with inclinic consultations (e.g. time away from work, travel and costs of parking), cancellations and re-bookings, and frustrations associated with lengthy waiting times. , innovative health solutions can be used to create proactive, effective and sustainable services to suit growing needs and demands on the healthcare system. while these needs are recognised, historically models of care have fallen short with meeting these needs. in march , the australian government temporarily expanded access to accredited practising dietitians (apd) for medicare benefits schedule (mbs) items to deliver telehealth services to australians with an eligible chronic disease management plan, including videoconference and telephone consultations, in response to the covid- pandemic. these changes have encouraged a reframe of traditional models of healthcare delivery into virtual modalities delivered remotely that can continue well after the immediate covid- crisis. the aim of this position statement is to outline the clinical-and cost-effectiveness of telehealth-delivered dietetic consultations, and to translate this evidence to practice and policy recommendations. this position statement is informed by a review of the existing literature reporting the effectiveness of telephone and videoconference-delivered consultations by dietitians. the literature appraised includes recent systematic reviews where the effect of telehealth-delivered consultations by a dietitian could be defined and compared to either a control group or a face-to-face consultation , - , including cost-modelling studies. [ ] [ ] [ ] further, an updated search (to april ) using the search terms reported in kelly et al screened against additional criteria, including (a) telephone or videoconference diet intervention and (b) delivered by a dietitian. a meta-analysis was performed on selected dietary outcomes. the effect of telehealth-delivered dietetic services is arranged into five sections: (i) weight management for people who are overweight or obese; (ii) chronic disease populations; (iii) malnutrition; (iv) emerging technologies; and (v) cost-effectiveness. there is a growing evidence base supporting the effect of telephone-delivered weight management services for people who are overweight or obese (body mass index (bmi) ≥ kg/m ). two randomised controlled trials (rcts) ( , n = participants ; and , n = participants ) showed that weight loss in people with overweight and obesity is similar regardless of whether the dietetic consultation is delivered by inperson mode, ad-hoc or via telehealth. compared to traditional care, a recent systematic review with meta-analysis ( , n = rcts) concluded that telephone-delivered weight management interventions resulted in a significant decrease in bmi for people with overweight or obesity of − . kg/m ( % ci − . , − . ). recent rcts and other study designs yield additional evidence. an rct ( , n = participants) in people with overweight or obesity, referred by their primary care physician, found that weekly telephone lifestyle counselling by dietitians for months, and second weekly calls for the following months, resulted in significant weight loss. at months, . % of patients in the treatment group had lost % of their body weight vs . % in the control group (p < . ). the treatment group also significantly increased their moderate to vigorous physical activity compared with the control group (+ . minutes vs + . minutes). while weight regain was observed in the months after counselling stopped, physical activity was maintained. telephone-delivered nutrition care is effective for improving dietary behaviour of people with chronic diseases. half of the existing telephone programs published in the literature are conducted in diabetes, and osteoarthritis. telephone-delivered consultations are as effective as inperson consultations in clinic settings. , a -month rct ( , n = participants) focused on improving type diabetes mellitus self-management behaviours, which included nutrition education once a month, led to significant improvements in glycosylated haemoglobin (hba c), cardiovascular disease risk and overall wellbeing compared to in-person delivery. of note, diet quality and reduction in bmi was significant in both the telephone coaching and traditional face-to-face rehabilitation. similarly, a -month rct ( , n = participants) in breast cancer survivors led to a significant improvement in dietary intake of fruits, vegetables, fibre and a reduction in fat intake with a corresponding increase in activity levels and weight loss. in this study, the in-person weight management program was as effective, and both the in-person and telephone coaching arm were more effective compared to traditional care. in an updated search (april , n = rcts) of telephone-delivered dietetic services, a meta-analysis was performed that showed that telephone-delivered consultations by dietitians was a superior intervention compared to traditional care (including those with ad hoc nutrition care) for improving a range of important dietary intake measures, including fruit, vegetable, fibre and fat intake per day (see table ). telephone-delivered consultations also significantly improved physical activity levels, reduced body weight and waist circumference, and improved cardiovascular disease risk compared to traditional care modes (see table ). table summarises the results of the individual meta-analysis performed. combining telephone with one or more other methods of service delivery (eg, face to face; online resources, text messages, videoconferencing) produces similar outcomes to that reported in telephone-only programs. , , , , there is conflicting evidence reported in telephonedelivered dietetic consultations studies for some dietrelated outcomes, including diet quality , , [ ] [ ] [ ] and sodium intake, , , and changes in clinical variables including hba c, , , - blood pressure, , , , , , lipid profiles , [ ] [ ] [ ] , and quality of life. , , larger rcts are needed to confirm the effect of telephonedelivered dietetic consultations for these outcomes. telephone-delivered dietetic counselling has been shown to be an effective method to deliver malnutrition-related care to older adults. malnutrition has been shown to affect up to % of the residential aged care population and up to % of hospitalised older patients. [ ] [ ] [ ] in a systematic review ( , n = rcts), clinical improvements following telephone-delivered consultation cardiovascular disease risk study, participants the cardiovascular disease risk reduced in telephone group, but rose in control patients (d = . ) abbreviations: md, mean difference; smd, standardised mean difference. compared with in-person dietetic care or no intervention included significantly increased protein intake, improved quality of life, and (nonsignificant) trends towards improvements in overall nutrition status, physical function, energy intake, reduced hospital readmission rates and mortality. | videoconference-delivered dietetic services for chronic disease management videoconference modalities to deliver nutrition care are less frequently utilised in the published literature, however, appear to be effective for managing diabetes and obesity. an australian review ( , n = dietetic studies) of videoconference dietetic consultations concluded that these appear to be feasible and well accepted. videoconference-delivered nutrition care is as effective as similar programs conducted in-person. two of the non-rcts included in the review by raven and bywood reported on dietary outcomes, compared inperson vs videoconference methods in people with diabetes and found clinical outcomes to be similar for a group-based program ( , n = participants), and for a multidisciplinary (including a dietitian) individual counselling program ( , n = participants). both these studies reported high levels of patient satisfaction, improvements in diet adherence and enhanced self-efficacy, with improvements found in biomarkers, including hba c, ldl cholesterol and blood pressure. in clients with type diabetes, videoconference interventions to deliver mnt have been shown to be more effective than traditional care (including ad hoc nutrition care), for improving a range of important diet and clinical variables. for example, the ideatel project was an rct ( , n = participants) which provided years of mnt and showed the group receiving videoconference counselling to have significant improvements in diet and exercise knowledge (+ . points compared to the control group). however, while there was significant improvement in waist circumference (by . cm over years) for women, bmi and waist circumference were not significant when males were included in the overall analysis. in the only other identified rct ( , n = participants), people with obesity received weeks of telehealth nutrition coaching (which included combined videoconference and telephone consultations), resulting in significant reductions in body weight (− . kg), waist circumference (− . cm), and energy intake (− kj/day) and improved diet quality (+ points) from baseline. however, the enhanced usual care (which included brief dietitian counselling) also experienced significant improvements in these measures, albeit on a smaller magnitude. therefore, the only difference at follow up was body weight, where % of the intervention group lost % of their body weight, compared to % of the control arm. australian dietitians incorporate ehealth and mhealth technologies into their practice and patient care. , the potential of digital health to support dietitians in the nutrition care process and delivery of nutrition interventions for patients requiring weight and chronic disease management has been outlined previously. in general, patients report high acceptability, feasibility and usability for mhealth interventions targeting chronic disease management, though the technologies and implementation are not without limitations. , positive effects for food and nutrition outcomes have been observed when mhealth modalities are used for treatment and preventative service delivery. systematic reviews report that app-based mhealth interventions can improve dietary behaviours and intake of specific nutrients and foods, such as sodium ( , n = rcts), vegetables, fruit, fast food or takeaway and sugar sweetened beverage intake, as well as snacking behaviours ( , n = studies). another systematic review ( , n = studies) compared mhealth programs to either a nonintervention control or traditional dietary management and concluded that mobile apps and wearable devices are effective tools in facilitating clinically important weight loss of % over the duration of treatment, but these effects were not maintained at to months. however, overall, the evidence was limited due to only three of the studies reporting results compared to a true nonintervention control group. many interventions reported in the literature are multicomponent combining health practitioner counselling with the addition of technology such as text messaging. a metaanalysis ( , n = rcts) delivered via text message demonstrated significantly greater weight loss (− . kg) in the intervention group compared to control. the evidence-base supporting the effectiveness of mhealth technologies in diabetes management is growing. a recent meta-analysis ( , n = studies) showed a mean difference in hba c of − . % ( % ci: − . % to − . ; i = %) in groups receiving smartphone technology consultations compared with control. another review ( , n = rcts) showed favourable glycaemic control regardless of whether the mobile app intervention was delivered by the health professional physically or remotely. in cardiovascular disease specific literature, a systematic review ( , n = studies) of mhealth interventions identified three studies which included diet outcomes found improvements in nutrition knowledge and dietary choice with interventions that were delivered via apps, text messages and web-based platforms. another systematic review ( , n = studies) examined the effects of health interventions on weight loss among patients with cardiovascular disease reporting favourable outcomes for trials using web-based platforms(− . kg; % ci - . to − . ; i = %; n = studies), telemedicine (− . kg; % ci − . to − . ; i = %; n = ) and text messaging (− . kg; % ci − . to − . ; i = %; n = ). telephone-delivered nutrition programs are also costeffective. when compared to the same weight management program delivered face-to-face over months, telehealth-delivered programs were more cost effective ( , n = participants). further, an in-person group-based obesity management rct in rural settings ( , n = ) showed telephone counselling resulted in a lower cost per kilogram weight loss (aud . /kg) vs face-to-face (aud . /kg). an rct ( , n = participants) in a brisbane hospital outpatient setting found individual telephone counselling was more effective than a group based in-person program and the cost per healthy life year gained was aud and aud , for the telephone and group program, respectively. in chronic disease studies specifically, comparing telephone-delivered nutrition consultations to usual care (including those with ad hoc nutrition care), four of five interventions were found to be cost-effective , [ ] [ ] [ ] in people with diabetes, hypertension, chronic kidney disease and people undergoing cardiac rehabilitation. however, the intervention in one of the five studies conducted in osteoarthritis patients was not cost-effective when compared with usual care. for cost-effectiveness of emerging telehealth interventions, a systematic review ( , n = studies) in type diabetes reported mhealth interventions were highly costeffective, with cost per quality adjusted life years (qaly) gained ranging from . % to . % of gdp per capita. the costs varied depending on the number and type of technologies employed that ranged from one technology to three. an existing practice-based evidence in nutrition (pen) knowledge pathway is available for apds, which includes practice points for delivering telephone consultations for adults with chronic disease, non-chronic disease management telephone programs and telephone interventions for improving nutrition outcomes in infants and new mothers. one of these pen knowledge pathways highlights the lack of evidence for call centre support for public health nutrition interventions and government policy implementation, which is due to a lack of evaluation studies in the published literature. however, there are existing telehealth programs with nutrition components in australia, but these are not always specific to dietetic services. for example, since nsw health has offered the community get healthy coaching and information service which provides telephone-delivered coaching sessions over months aiming to improve nutrition, physical activity and, if desired, weight loss. the first evaluation of the service ( , n = participants) revealed significant weight loss of . kg, increased fruit and vegetable intakes and physical activity with decreased intake of take-away meals and sugar sweetened beverages. since then, there have been telephone coaching services offered to different population groups that have been evaluated including aboriginal and torres strait islander people ( , n = participants) showing a significant mean weight loss of . kg, those at risk of type diabetes (mean weight loss of . kg, p < . , n = ), and a pilot program ( , n = participants) in pregnant women to avoid excessive weight gain, showing a nonsignificant difference of . % in the coaching program vs . % in the control meeting recommended weight gain. conceptual models for effective telehealth within chronic disease management have been proposed. success factors in implementing a telehealth model identified by o'cathain and colleagues include ensuring that both the human and technical aspects of telehealth operate well. these implementation considerations are summarised in table s . dietitians australia has highlighted suitable candidates for telehealth dietetic services. these suitable candidates and practical strategies to be considered for optimising telehealth outcomes are also summarised in table s . by considering factors specific to delivery of virtual nutrition care by videoconference, dietitians can use their expertise to deliver services that complement, rather than compete with existing and emerging technologies. issues specific to using videoconference in dietetic service delivery can be addressed through use of a checklist to support them during delivery of mnt in order to facilitate effective and efficient virtual nutrition care. substituting telehealth services for standard consultations covered by mbs item would be cost neutral for the consultation. advice from the department of health is that patients accessing chronic disease management mbs items claim an average . allied health (not dietetic-specific) items per year. expanding access to telehealth-delivered dietetic consultations will result in improved outcomes which would reduce expenditure on medications and decrease hospital costs as demonstrated by the pilot of the diabetes care project. any increase in the number of consultations for dietitians may not require an increase in the health budget but more sophisticated analysis of the current pattern of usage of chronic disease management mbs item numbers to allow modelling of potential changes in its usage. appropriate and effective use of technology within practice is a key competency standard outlined in national competency standards for dietitians in australia. dietitians possess all the skills required to provide mnt using telehealth. taking courses in ehealth either as part of dietetic training, or as continuing professional development for apds, can improve the understanding of concepts essential for using telehealth and ehealth technologies. key components include definitions of ehealth terms and concepts related to telehealth and mhealth technologies; and knowledge and skills related to (i) use of telehealth equipment, (ii) comparison of dietetic consultation components completed in person vs remotely via video call, (iii) quality assessment of mobile apps and (iv) exploration of advantages and disadvantages, and the ethical, security and privacy issues relating to use of ehealth technologies in dietetic practice. this training and professional development in delivery of nutrition and dietetic consultations using telehealth results in improved knowledge, skills and competence in using these technologies. , | future research opportunities there are a number of opportunities for further research concerning telehealth-delivered consultations. specifically, clinical trials are needed to evaluate the implementation of telehealth consultations delivering group-based interventions in populations with chronic disease, and improving access and outcomes for vulnerable populations groups, including those in regional and remote areas through telehealth-delivered consultations. there is also a need to understand the challenges of completing some components of nutrition care via telehealth (e.g. physical measures) and evaluate alternative or modified measures to recommend as suitable proxies. robust economic evaluations are needed across different chronic disease populations and demographics which are most likely to benefit from wider access to dietary services under medicare, including rural/remote areas and house-bound individuals. an economic evaluation should also consider and evaluate the societal benefits of telehealth-delivered consultations that cannot always be captured by typical economic analysis using a healthcare perspetive, , including willingness-to-pay (ie, evaluating the monetary value on the benefit associated with a service, from a societal perspective), and any unintentional consequences that new dietitian delivered telehealth consultations may potentially have (e.g. consequences which may arise from unexpected uptake, creating inequity for populations that may not have access to technology hardware or reliable phone or internet service due to financial disadvantage, which substantially increases costs, unexpected workload changes or other unforeseen factors). finally, it will also become important to evaluate the effectiveness of emerging technologies including mhealth and ehealth nutrition programs alone, in combination with telephone or videoconference programs, or when combined with in-person delivery to reduce the number of counselling sessions required. these evaluations, in addition to addressing the evidence gaps mentioned above, will allow decision makers to make informed, evidence-based decisions on telehealth-delivered dietetic consultations. the summary of results presented in this position statement support the evidence-based recommendations summarised in table . evidence-based recommendations for telehealth-delivered consultations weight management • telephone counselling is effective for management of overweight and obesity in primary care. chronic disease management • telephone and videoconference nutrition consultations improves diet, physical activity levels and reduces body weight in people with chronic conditions. • telephone and videoconference consultations are just as effective as in-person delivered mnt. • telephone counselling is effective for the prevention and management of malnutrition in the community. digital health • digital health solutions (including ehealth (e.g. web platforms) and mhealth (e.g. smartphone applications)) can support traditional in-person or telephone and videoconference delivered nutrition care, but their effectiveness as a delivery modality exclusively requires further research. funding for telehealthdelivered dietetic services • government policy makers and healthcare funders should broaden remuneration benefits for telephone and videoconference-delivered consultations provided by apds, as these are cost-effective and low cost for apds to operate. • expanded telehealth access under medicare and private health payers addresses health and service inequalities, improves access to effective nutrition services, and supports people with chronic conditions to optimise their diet-related health and well-being, regardless of their location, income or literacy level. • mnt delivered via mhealth and ehealth should be considered eligible for medicare or private health rebates when they are used alongside telephone or video conferencing modalities or in-person delivery. abbreviations: apd, accredited practising dietitian; mnt, medical nutrition therapy. australian institute of health welfare. australia's health . australia's health series no. future predictions of body mass index and overweight prevalence in australia primary health care advisory group. primary health care advisory group final report: better outcomes for people with chronic and complex health conditions. australia: department of health, commonwealth of australia expanding access to accredited practising dietitians under medicare. canberra: dietitians association of australia ehealth interventions for the prevention and treatment of overweight and obesity in adults: a systematic review with meta-analysis telehealth methods to deliver dietary interventions in adults with chronic disease: a systematic review and meta-analysis telephone-delivered interventions for physical activity and dietary behavior change: an updated systematic review global diffusion of ehealth: making universal health coverage achievable: report of the third global survey on ehealth the dietetic workforce distribution geographic atlas provides insight into the inequitable access for dietetic services for people with type diabetes in australia non-attendance in chronic disease clinics: a matter of non-compliance? why do patients not keep their appointments? prospective study in a gastroenterology outpatient clinic future of health: shifting australia's focus from illness treatment to health and wellbeing management australian government department of health. the australian health system. australia: commonwealth of australia covid- : whole of population telehealth for patients, general practice, primary care and other medical services: a joint media release with professor michael kidd am digital mental health and covid- : using technology today to accelerate the curve on access and quality tomorrow allied health video consultation services interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults the effectiveness of telemedicine on body mass index: a systematic review and meta-analysis cost evaluation of providing evidence-based dietetic services for weight management in adults: in-person versus ehealth delivery the breakeven point for implementing telehealth economic evaluation strategies in telehealth: obtaining a more holistic valuation of telehealth interventions equivalent weight loss for weight management programs delivered by phone and clinic comparative effectiveness of weight-loss interventions in clinical practice a randomized clinical trial of a tailored lifestyle intervention for obese, sedentary, primary care patients impact of enhanced (dietitians helping patients care for diabetes) telemedicine randomized controlled trial on diabetes optimal care outcomes in patients with type diabetes telephone-delivered lifestyle support with action planning and motivational interviewing techniques to improve rehabilitation outcomes telephone counseling for physical activity and diet in primary care patients living well with diabetes: -month outcomes from a randomized trial of telephone-delivered weight loss and physical activity intervention to improve glycemic control long-term lifestyle intervention lowers the incidence of stroke impact of a goal setting and decision support telephone coaching intervention on diet, psychosocial, and decision outcomes among people with type diabetes using telehealth to provide diabetes care to patients in rural montana: findings from the promoting realistic individual selfmanagement program telemedicine intervention effects on waist circumference and body mass index in the ideatel project group diabetes education administered through telemedicine: tools used and lessons learned a dietary intervention in urban african americans: results of the "five plus nuts and beans" randomized trial salt and fluid restriction is effective in patients with chronic heart failure coaching patients on achieving cardiovascular health (coach): a multicenter randomized trial in patients with coronary heart disease randomized trial comparing telephone versus in-person weight loss counseling on body composition and circulating biomarkers in women treated for breast cancer: the lifestyle, exercise, and nutrition (lean) study a coaching program to improve dietary intake of patients with ckd: entice-ckd telephone-based weight loss support for patients with knee osteoarthritis: a pragmatic randomised controlled trial feasibility and acceptability of telehealth coaching to promote healthy eating in chronic kidney disease: a mixed-methods process evaluation a pilot randomized controlled trial of a telenutrition weight loss intervention in middle-aged and older men with multiple risk factors for cardiovascular disease a coaching program to improve dietary intake of patients with ckd: entice-ckd setting single or multiple goals for diet and physical activity behaviors improves cardiovascular disease risk factors in adults with type diabetes: a pragmatic pilot randomized trial salt and water restriction is effective in patients with chronic heart failure malnutrition prevalence and nutrition issues in residential aged care facilities recognition by medical and nursing professionals of malnutrition and risk of malnutrition in elderly hospitalised patients nutritional status and length of stay in patients admitted to an acute assessment unit prevalence of malnutrition in adults in queensland public hospitals and residential aged care facilities is telehealth effective in managing malnutrition in community-dwelling older adults? a systematic review and meta-analysis ehealth readiness of dietitians the use of smartphone health apps and other mobile h ealth (mhealth) technologies in dietetic practice: a three country study smartphone apps and the nutrition care process: current perspectives and future considerations mobile health applications in weight management: a systematic literature review impact of mhealth chronic disease management on treatment adherence and patient outcomes: a systematic review application of mobile health technologies aimed at salt reduction: systematic review efficacy of interventions that use apps to improve diet, physical activity and sedentary behaviour: a systematic review efficacy and external validity of electronic and mobile phone-based interventions promoting vegetable intake in young adults: systematic review and meta-analysis frequent nutritional feedback, personalized advice, and behavioral changes: findings from the european food me internetbased rct can mobile technology improve weight loss in overweight adults? a systematic review a systematic review and meta-analysis of interventions for weight management using text messaging effectiveness of smartphone technologies on glycaemic control in patients with type diabetes: systematic review with meta-analysis of trials efficacy of mobile apps to support the care of patients with diabetes mellitus: a systematic review and meta-analysis of randomized controlled trials effect of mobile health interventions on the secondary prevention of cardiovascular disease: systematic review and meta-analysis digital health interventions for the prevention of cardiovascular disease: a systematic review and meta-analysis comparing costs of telephone vs face-to-face extended-care programs for the management of obesity in rural settings feasibility, effectiveness and cost-effectiveness of a telephone-based weight loss program delivered via a hospital outpatient setting cost-effectiveness of a population-based lifestyle intervention to promote healthy weight and physical activity in non-attenders of cardiac rehabilitation cost-effectiveness of a telephone-delivered intervention for physical activity and diet a comparison of the cost-effectiveness of two pedometer-based telephone coaching programs for people with cardiac disease economic evaluation of telephone-based weight loss support for patients with knee osteoarthritis: a randomised controlled trial cost and costeffectiveness of mhealth interventions for the prevention and control of type diabetes mellitus: a systematic review practice-based evidence in nutrition (pen) the nsw get healthy information and coaching service: the first five years enhancing the get healthy information and coaching service for aboriginal adults: evaluation of the process and impact of the program telephone based coaching for adults at risk of diabetes: impact of australia's get healthy service piloting a telephone based health coaching program for pregnant women: a mixed methods study telehealth in chronic disease: mixed-methods study to develop the tech conceptual model for intervention design and evaluation dietitians association of australia. telehealth/technology-based clinical consultations video consultations and virtual nutrition care for weight management evaluation report of the diabetes care project dietitians association of australia. national competency standards for dietitians in australia evaluation of the introduction of an e-health skills component for dietetics students. telemed e-health impact of training and integration of apps into dietetic practice on dietitians' self-efficacy with using mobile health apps and patient satisfaction this position paper was commissioned, funded and endorsed by dietitians australia. funding supported the lead author to conduct the literature searches and draft the paper.kc and td are members of the dietitians australia board. neither received any specific funding from dietitians australia throughout this project. key: cord- -sqc x c authors: hamilton, kyra; smith, stephanie r.; keech, jacob j.; moyers, susette a.; hagger, martin s. title: application of the health action process approach to social distancing behavior during covid‐ date: - - journal: appl psychol health well being doi: . /aphw. sha: doc_id: cord_uid: sqc x c background: this study examined the social cognition determinants of social distancing behavior during the covid‐ pandemic in samples from australia and the us guided by the health action process approach (hapa). methods: participants (australia: n = , . % women; us: n = , . % women) completed hapa social cognition constructs at an initial time‐point (t ), and one week later (t ) self‐reported their social distancing behavior. results: single‐indicator structural equation models that excluded and included past behavior exhibited adequate fit with the data. intention and action control were significant predictors of social distancing behavior in both samples, and intention predicted action and coping planning in the us sample. self‐efficacy and action control were significant predictors of intention in both samples, with attitudes predicting intention in the australia sample and risk perceptions predicting intention in the us sample. significant indirect effects of social cognition constructs through intentions were observed. inclusion of past behavior attenuated model effects. multigroup analysis revealed no differences in model fit across samples, suggesting that observed variations in the parameter estimates were relatively trivial. conclusion: results indicate that social distancing is a function of motivational and volitional processes. this knowledge can be used to inform messaging regarding social distancing during covid‐ and in future pandemics. the covid- pandemic has had unprecedented global effects on mortality, way of life, national economies, and physical and mental health not previously experienced in modern times. it has presented governments, healthcare services, and education facilities with wide-scale and complex logistical challenges on how to manage the rapid spread of the disease and minimise the projected human and economic costs. given that, to date, there is no vaccine to protect against covid- , non-pharmacological intervention is the only currently available means to reduce the spread of sars-cov- , the virus that causes covid- , and "flatten the curve" of infection rates. in response, national and statewide governmental measures aimed at minimising transmission of the virus including "stay at home" orders, closure of businesses and places of congregation, and travel restrictions have had a substantive impact on mortality rates (worldometer, ) . as rates of infection dissipate in some countries, particularly in countries like australia that have relatively low rates of daily infections, governments are now beginning to ease restrictions. however, preventive behaviors aimed at reducing infection rates remain highly pertinent given concerns over the potential for infection rates to rise again and fears of a "second wave". furthermore, some countries who are easing lockdown measures, such as some states in the us, still have high localised rates of infection, highlighting the imperative of ongoing performance of preventive behaviors to manage infection transmission. based on world health organization (who) recommendations (world health organization, ) and previous research on behaviors known to reduce virus transmission (jefferson et al., ; rabie & curtis, ; smith et al., ) , two key sets of covid- -related behaviors that may apply to the population as a whole have been proposed . the first set is "personal protective behaviors" that are aimed at the individual in order to protect themselves or others (e.g. washing hands frequently, practicing respiratory hygiene). the second set involves behaviors aimed at ensuring physical distance between people (e.g. social distancing, stay at home orders). despite knowledge of these key behaviors in the prevention of virus transmission (e.g. islam et al., ) , there is a relative dearth of information on the determinants and mechanisms of action that underpin these preventive behaviors and how to strengthen individuals' capacity to adopt them. in the absence of direct evidence, knowledge to inform practice guidelines that governments and organisations can use to mobilise individuals into performing covid- preventive behaviors has been gleaned from applying general principles from behavioral science and the models of behavior that underpin them (lunn et al., ; michie et al., ; british psychological society, ; west et al., ) as well as findings of previous empirical investigations in the psychological literature on similar health and risk behaviors (e.g. face mask use, handwashing, distancing; chu et al., ; reyes fern andez et al., ; zhang, chung, et al., ; zhang et al., ) . although this approach is potentially useful in structuring thinking and recommendations in urgent times, there is a pressing need for direct evidence that identifies the key determinants of these covid- preventive behaviors and the processes involved. this knowledge can then be used to inform development of effective interventions to promote uptake and adherence to these behaviors. this is especially important given that individuals' beliefs may affect their adoption of non-pharmacological measures to prevent virus transmission (teasdale et al., ) . prominent among social cognition theories are dual-phase models which aim to provide a comprehensive theoretical account of health behavior uptake and participation, and the processes involved (hagger, cameron, hamilton, hankonen, & lintunen, ; hagger, smith, keech, moyers, & hamilton, ) . one such dual-phase theory that has been frequently applied to predict multiple health behaviors is the health action process approach (hapa; schwarzer, ; schwarzer & hamilton, ) . the hapa is an integrated model that combines features of stage, continuum, and dual-phase social cognition models. a key feature of the model is the distinction made between motivational (where an individual is in a deliberative mindset while setting a goal/forming an intention) and volitional (where an individual is in an implementation mindset while pursuing their goal) phases involved in behavioral enactment. in the motivational phase, intentions are conceptualised as the most important determinant of behavior. intentions are proposed to be a function of three sets of belief-based constructs: outcome expectancies (beliefs that the target behavior will lead to outcomes that have utility for the individual, conceptually identical to an individual's attitudes toward the behavior), self-efficacy (beliefs in personal capacity to successfully perform the target behavior and overcome challenges and barriers to its performance), and risk perceptions (beliefs in the severity of a health condition that may arise from not performing the target behavior and personal vulnerability toward it). in the volitional phase of the hapa, planning and action control strategies are important self-regulatory strategies that determine subsequent enactment of the target behavior (schwarzer, ; schwarzer & hamilton, ) . two forms of planning are proposed: action planning, a task-facilitating strategy that relates to how individuals prepare themselves in performing a behavior, and coping planning, a distraction-inhibiting strategy that relates to how individuals prepare themselves in avoiding foreseen barriers and obstacles that may arise when performing a specific behavior, and potentially competing behaviors that may derail the behavior. in addition, action control, a self-regulatory strategy for promoting behavioral maintenance through the monitoring and evaluation of a behavior against a desired behavioral standard, is also an important direct determinant of behavior (hamilton et al., ; reyes fern andez et al., ) . behavioral intention operates as a "bridge" between the motivational and volitional phases, while planning serves to link intentions with behavior. previous research has provided support for the hapa constructs in predicting health preventive behaviors, with prominent roles for outcome expectancies, forms of selfefficacy, planning and action control, with risk perceptions only relevant in certain contexts (see schwarzer & hamilton, ; . furthermore, the model has been used as a basis for effective behavior change interventions aimed at promoting increased participation in health-related behaviors (schwarzer & hamilton, ) . given that social distancing is a key evidence-based behavior that will minimise transmission of sars-cov- if performed consistently at the population level, the aim of the present study was to apply the hapa to identify the social cognition and self-regulatory determinants of this preventive behavior in samples of adults from two countries, australia and the us. these two countries provided an opportunity to examine the determinants of social distancing because they experienced rapid increases in covid- cases at relatively similar times during the pandemic and introduced public health advice as well as "lockdown" measures and "shelter-in-place" orders to minimise transmission, including social distancing. specifically, the current research aimed to identify potentially modifiable determinants that are reliably related to social distancing intentions and behavior, which may form targets of behavioral interventions to reduce covid- infection rates, and, going forward, other communicable diseases transmitted through person-to-person contact. the value of applying the hapa is that it provides information on phase-relevant constructs in determining this important behavior. proposed predictions among model constructs are summarised diagrammatically in figures and . figure presents the hapa predictions excluding effects of past social distancing behavior. intention to perform social distancing was expected to be predicted by attitude (as a proxy for outcome expectancies), self-efficacy, and risk perceptions, and social distancing behavior was expected to be predicted by self-efficacy, intentions, action planning, coping planning, and action control. intention was proposed to mediate effects of attitude, self-efficacy, and risk perceptions on behavior. in addition, intention was expected to predict action planning and coping planning such that the planning constructs mediate the intention-behavior relationship. action control was proposed to predict behavior directly. although it is strictly a self-regulation technique aimed at facilitating better behavioral enactment, as proposed by the original hapa (e.g. schwarzer, ) , individuals who are effective at action control (i.e. self-monitoring) may also more likely form strong intentions. action control implies not only the recall of behavior but also the recall of intentions. self-monitoring of the concurrent behavior, therefore, may make the individual aware of their intention as well as their behavior, focusing on possible discrepancies between the two. it is plausible, then, that action control can be specified as a predictor of both intention and behavior. the coexistence of intention and action control within the same dataset allows this key question to be tested; which of the two factors may be more proximal to the behavioral outcome? action control might not be a time-specific variable, and individuals may self-monitor their behaviors at any point in time (see zhou et al., ) , even before goal setting. actions can be monitored before making intentions, while doing so, or afterwards. thus, examining the indirect (via intention) and direct effects of action control on behavior is intuitively meaningful, although not supported by the original hapa, and tested in the present study. figure outlines the inclusion of past behavior in the model to test its sufficiency. although model effects were expected to hold with the inclusion of past behavior, it was expected to attenuate the size of the proposed effects consistent with previous studies (brown et al., ; hagger et al., ) . this was expected to be the case in the current study due to the relatively brief one-week follow up. the attenuation effect was proposed to model past decision making and effects of other unmeasured constructs on behavior. a sample of australian (n = , . % women) and us (n = , . % women) residents were recruited via an online research panel company. to be eligible for inclusion, participants needed to be aged years or older and were required to not be subject to formal quarantine for covid- . in addition to the inclusion criteria, participants were screened on the demographic characteristics of age, gender, and geographical region and quotas were imposed to ensure that the sample comprised similar proportions of these characteristics to the national population of each country. sample characteristics are presented in table s . data were collected in april and may during which time residents throughout australia and all states in the us were subject to "stay at home" orders to reduce transmission of the coronavirus. the study adopted a prospective correlational design with self-report measures of hapa constructs (attitudes, self-efficacy, risk perceptions, intentions, action planning, coping planning, and action control) and past engagement in social distancing behavior administered at an initial time-point (t ) in a survey administered using the qualtrics tm online survey tool. participants were informed that they were participating in a survey on their social distancing behavior and were provided with an information sheet outlining study requirements. they were also provided with a consent form to which they had to affirm before proceeding with the survey. participants were also provided with an information sheet providing instructions on how to complete the study measures. in addition, they were provided with a definition of the target behavior: "the following survey will ask about your beliefs and attitudes about 'social distancing'. what do we mean by social distancing? social distancing (also known as 'physical distancing') is deliberately increasing the physical space between people to avoid spreading illness. the world health organization and other world leading health authorities suggest that you should maintain at least a - m ( - feet) distance from other people to lessen the chances of getting infected with covid- . when answering the questions in this survey, think about your social distancing behavior (i.e. maintaining at least a - m ( - feet) distance from other people)." one week later (t ), participants were contacted a second time by the panel company and were asked to self-report their social distancing behavior over the previous week using the same behavioral measure administered at t . participants received a fixed sum of money for their participation based on expected completion time consistent with the panel company's published rates. approval for study procedures was granted prior to data collection from the griffith university human research ethics committee. study measures were carried out on multi-item psychometric instruments developed using published guidelines and adapted for use with the target behavior in the current study (schwarzer, ) . participants provided their responses on scales with -point response options. complete study measures are provided in table s . social cognition constructs. measures of attitudes, self-efficacy, risk perceptions, intentions, action planning, coping planning, and action control from the hapa were developed according to guidelines (schwarzer, ) . attitude was measured using three semantic differential items in response to a common stem: "my maintaining social distancing in the next week would be...", followed by a series of bi-polar adjectives (e.g. ( ) worthless -( ) valuable). self-efficacy was measured using four items (e.g. "i am confident that i could maintain social distancing", scored ( ) strongly disagree to ( ) strongly agree). risk perception was measured using two items (e.g. "it would be risky for me to not maintain social distancing", scored ( ) strongly disagree to ( ) strongly agree). intention was measured using three items (e.g. "i intend to maintain social distancing", scored ( ) strongly disagree to ( ) strongly agree). action planning was measured using four items. participants were required to respond to the stem: "in the next week, i have made a plan regarding...", followed by the four items of the scale (e.g. ". . .when to maintain social distancing") on likert scales ranging from strongly disagree ( ) to strongly agree ( ). coping planning was measured using four items. participants were required to respond to the stem: "to keep my intention to maintain social distancing in the next week in difficult situations, i have made a plan...", followed by the four items of the scale (e.g. ". . .what to do if something interferes with my goal of maintaining social distancing") on likert scales ranging from strongly disagree ( ) to strongly agree ( ). action control was measured using three items (e.g. "i have consistently monitored when, how often, and how to maintain social distancing"), scored ( ) strongly disagree to ( ) strongly agree). past behavior and behavior.participants self-reported their participation in the target behavior maintaining social distancing in relation to others to minimise transmission of the coronavirus that causes covid- . the measure comprised two items prompting participants to report their frequency of social distancing behavior in the previous week: "in the past week, how often did you maintain social distancing?", scored ( ) never to ( ) always and "in the past week, i maintained social distancing", scored ( ) false to ( ) true. demographic variables. participants self-reported their age in years, gender, employment status (currently unemployed/full time caregiver, currently full-time employed, part-time employed, on leave without pay/furloughed), marital status (married, widowed, separated/divorced, never married, in a de facto relationship), annual household income stratified by income levels based on australia and us national averages, and highest level of formal education (completed junior/lower/primary school, completed senior/high/secondary school, postschool vocational qualification/diploma, further education diploma, undergraduate university degree, postgraduate university degree). binary income (low income versus middle/high income), highest education level (completed school education only versus completed post-school education), and ethnicity (white/ caucasian versus non-white) variables were computed for use in subsequent analyses. hypothesised relations among hapa constructs in the proposed model were tested in the australia and us sample separately using single-indicator structural equation models implemented in the lavaan package in r (r core team, ; rosseel, ) . we opted for single-indicator models over a full latent variable structural equation model due to the complexity of the model and the large number of parameters. the single-indicator approach utilises scale reliabilities to our cut-off for low vs. medium-to-high income was based on national income data for citizens on low incomes in the us (for a family of four, the low income threshold is us$ , per year; semega et al., ) and australia (for a family of four, the low-income average is $ per week; aihw ). participants reporting incomes of $ -$ per week ($ , -$ , per year) or below were classified as low income. provide an estimate of the measurement error of each variable in the model. specifically, each variable in the model was indicated by its averaged composite with the error variance fixed at a value based on the reliability estimates using the formula: -reliability*scale variance. simulation studies have demonstrated that parameter estimates and model fit of single-indicator models compare very favorably with full latent variable structural equation models, particularly when sample sizes are small (savalei, ) . we freed parameters between the single-indicator latent variables according to our proposed model. two models were estimated, one excluding effects of past social distancing behavior (model , figure ) and one which controlled for past behavior (model , figure ) by freeing parameter estimates from past behavior on each construct in the model. we also controlled for effects of the following demographic variables in each model by freeing paths from each variable to all other model variables: gender, age, ethnicity, income, and education level. missing data were handled using the full information maximum likelihood (fiml) method. the fiml approach is a preferred approach to handling missing data as simulation studies indicate that it leads to unbiased parameter estimates in structural equation modeling (enders & bandalos, ; wothke, ) . model comparisons across the australia and us samples were conducted using multigroup analyses. an initial configural multisample model for the model excluding past behavior was estimated (model ), which provided evidence for the tenability of the model in accounting for the data across both samples. this was followed by a restricted model in which the parameter estimates representing proposed relations among the hapa constructs and behavior were constrained to equality across the two samples (model ). the fit of the constrained model did not differ significantly from the configural model across the two samples, which provided evidence that model parameters did not differ substantially. this was established using a formal likelihood ratio test of the goodness-of-fit chi-square for the configural and constrained models (byrne et al., ) . we also examined differences in the cfi; differences of less than . between values for the configural and constrained models have also been proposed as indicative of invariance of parameters (cheung & rensvold, ) . the configural (model ) and constrained (model ) multisample analyses were repeated for the model including past behavior. models were implemented using the maximum likelihood estimator with bootstrapped standard errors with , bootstrap replications. goodness of fit of the models with the data was evaluated using multiple criteria comparing the proposed model with the baseline model including the goodness-of-fit chi-square (v ), the comparative fit index (cfi), the standardised root mean-squared of the residuals (srmr), and the root mean square error of approximation (rmsea) and its % confidence interval ( % ci). since the chi-square value is often statistically significant in complex models and has been shown to lead to the rejection of adequate models, we focused on the incremental fit indices. specifically, values for the cfi should exceed . , values for the srmr should be less than or equal to . , and values for the rmsea should be below . with a narrow % confidence interval (hu & bentler, ) . data files, analysis scripts, and output are available online: https://osf.io/mrzex/ attrition across the two data collection occasions resulted in final sample sizes of (m age = . , sd = . ; . % women; attrition rate . %) and (m age = . , sd = . ; . % women; attrition rate = . %) participants retained at follow-up in the australia and us samples, respectively. there were no missing data for the social cognition and behavior variables as participants could not advance through the survey without providing a response. there were a few instances of missing data for the demographic variables ranging from . per cent to . per cent in the australia sample, and . per cent to . per cent in the us sample as participants could opt not to respond to these items as they represented personal data. missing data are reported in table s . sample characteristics at follow-up are presented in table s , and comparisons on study variables between those retained in the study at follow-up and those lost to attrition are presented in table s . attrition analyses in the australia sample revealed that participants lost to attrition were younger and were more likely to be non-white. however, there were no differences in proportion of gender, income, and education level. a manova with the social cognition constructs and past behavior as dependent variables and attrition status (lost to attrition vs. included at follow-up) revealed no differences (wilks' lambda = . , f( ) = . , p = . , partial g = . ). attrition analyses in the us sample also indicated that participants lost to attrition were younger, and more likely to be men, non-white, and lower educated, and have low income, than those remaining in the study at follow-up. the manova testing for differences on social cognition and past behavior variables among participants lost to attrition and those included at follow-up revealed statistically significant differences (wilks' lambda = . , f( ) = . , p < . , partial g = . ). follow-up tests revealed that mean values for past behavior, attitudes, intentions, and self-monitoring with respect to social distancing were significantly lower among participants lost to attrition compared to those retained at follow-up. however, effect sizes for these differences were small (ds < . ). the total effect is computed as the sum of the indirect effects of the independent variable on the dependent variable through all model variables plus the direct effect. descriptive statistics for study variables are presented in table s . participants reported high levels of intention (australia sample, m = . , sd = . ; us sample, m = . , sd = . ) and behavior (australia sample, m = . , sd = . ; us sample, m = . , sd = . ) with respect to social distancing. internal consistency of the social cognition constructs was estimated using revelle's ( ) omega and internal consistency of the behavior variables and risk perception was estimated using the spearman-brown as they comprised two items each. results are presented in table s . all constructs in both samples exhibited acceptable internal consistency, and these data were used to estimate measurement error in subsequent single-item structural equation models. scale variance, descriptive statistics, and computed error variance terms used in structural equation models are also presented in table s . correlations among the model constructs and behavior and socio-demographic variables are presented in table s . the single-indicator structural equation models that excluded (model ) and included (model ) past behavior exhibited adequate model fit with the data for both the australia and us samples (see table s ). standardised parameter estimates and distribution statistics for each model in the australia and us samples are presented in tables and , respectively. focusing first on the models excluding past behavior, intention and action control were statistically significant predictors of social distancing behavior in both samples, with no significant effects for self-efficacy, action planning, and coping planning. there were also no significant effects of intention on action planning or coping planning in the australia sample, while intention predicted both planning constructs in the us sample. self-efficacy and action control were significant predictors of intention in both samples, with attitudes predicting intention in the australia sample only and risk perceptions predicting intention in the us sample, although the effect in the australia sample fell short of statistical significance by a trivial margin (p = . ). there were significant indirect effects of self-efficacy on behavior mediated by intention in both samples, and significant indirect effects of risk perceptions and action control on behavior mediated by intentions in the us sample only. intention and action control had significant total effects on behavior in both samples, with a further total effect of self-efficacy in the us sample. inclusion of past behavior led to an attenuation of model effects, consistent with previous research (brown et al., ; hagger et al., ) . notably, effects full parameter estimates for the models in the australia and us samples are provided in tables s and s , respectively. of all hapa constructs on behavior were reduced to a trivial size and were not statistically significant. effects of constructs on intentions remained with the same pattern as those in the model excluding past behavior for both samples, albeit with smaller effect sizes. the only exception was the action control-intention effect, which was reduced to a trivial size and non-significance in the us sample. past behavior predicted all model constructs with medium-to-large effect sizes in both samples. comparisons of model fit across the australia and us samples revealed adequate fit of the configural models excluding (model ) and including (model ) past behavior, lending support for the tenability of the proposed pattern of model effects across the samples (table s ). constraining regression coefficients to be invariant for the models including (model ) and excluding (model ) past behavior resulted in no significant change in model fit according to the goodness-of-fit chi-square and the cfi with differences in the cfi across models less than . (table s ). these findings suggested that any observed differences in the parameter estimates of the models across the australia and us samples were relatively trivial. this is consistent with the highly consistent pattern of effects in the models in each sample with relatively minor sample-specific variation. the empirical literature has highlighted the imperative of non-pharmacological interventions in reducing the transmission of communicable viruses and preventing infection (jefferson et al., ; rabie & curtis, ; smith et al., ) . in the context of the covid- pandemic, participation in behaviors that prevent virus transmission is essential given the absence of a vaccine or clinically proven pharmacological therapy. sustained, population-level participation in such behaviors is not only important to reduce infections in the current pandemic phase, but also in the phases of easing restrictions to avoid a potential "second wave" of infections. there is a pressing need for evidence of potentially modifiable determinants of covid- preventive behaviors, such as social distancing, the social distancing behavior and past behavior variables were associated with large skewness and kurtosis values. we checked to see whether the skewness and kurtosis values affected findings. so, we re-estimated our structural equation models using a square root transformation of these variables. the reanalysis revealed virtually identical coefficients and the exact pattern of effects found for the analysis using the untransformed behavior variables. analysis scripts and output for this auxiliary analysis are available online: https://osf.io/mrzex/?view_only= ae e fa c c e d f b on which to base interventions promoting population level participation in these behaviors. the current study aimed to address this need by identifying the theory based social cognition determinants of social distancing behavior, and the processes involved, in samples from australia and the us. the study adopted a correlational prospective survey design guided by the hapa. consistent with hapa predictions, intention and action control were identified as significant direct predictors of social distancing behavior in both samples, while intention predicted action planning and coping planning in the us sample. further, self-efficacy and action control were identified as significant predictors of intention in both samples. attitudes and risk perceptions were additional predictors in the australia and us samples, respectively. significant indirect effects were also observed; self-efficacy predicted behavior mediated by intention in both samples, and risk perceptions and action control were found to predict behavior mediated by intentions in the us sample only. despite these limited differences, it should be noted that comparisons of the models across the australia and us samples suggested that observed differences in parameter estimates across the samples were relatively trivial. findings are consistent with the auxiliary assumption promulgated in the hapa, and social cognition theories more generally, that the effects of the belief-based constructs reflect generalised processes that have a consistent pattern of effects across contexts, populations, and behaviors. in sum, the current findings indicate that individuals' social distancing behavior is a function of both motivational and volitional processes, and this provides formative data on potential targets for behavioral interventions aimed at promoting participation in this preventive behavior. results of this study provide qualified support for the application of the hapa, with its focus on constructs that represent dual phases of action. findings demonstrate a prominent role for self-efficacy as the key determinant of intentions, and intentions as the key determinant of behavior across both samples. these findings are in line with applications of the hapa in multiple health behavioral contexts , as well as research on social cognition constructs more broadly (hamilton, van dongen, & hagger, ; mceachan et al., ) . confidence in engaging in health behaviors and capacity to overcome setbacks and barriers have been consistently linked with future behavioral performance (warner & french, ) . the pervasive effect of intention on behavior is also aligned with a substantive literature on social cognition theories demonstrating intentions as the pre-eminent determinant of behavior (hamilton, van dongen, et al., ; mceachan et al., ) . overall, these effects suggest that social distancing behavior should be conceptualised as a reasoned action. however, the current study also demonstrated a prominent role for constructs representing volitional processes in the enactment of behavior. in particular, action control, a construct reflecting individuals' application of key self-regulatory skills to enact behavior, was a consistent predictor of both intentions and behavior across the samples. individuals possessing these skills are not only more likely to form intentions to perform social distancing behaviors, but are also more likely to engage in the behavior through, for example, an automatic process. specifically, the direct effect not mediated by intentions suggests that individuals with good action control might be more effective in structuring their environment or forming habits that promote enactment of social distancing without the need for extensive deliberation or weighing up of options. over time, these individuals are likely to form habits, that is, performance of behaviors that are activated through cues and contexts independent of the goals and intentions that originally gave rise to them (aarts et al., ; hagger, ; verplanken & orbell, ; wood, ) . research has suggested that individuals possessing these skills are effective in controlling their actions more broadly, but also that such skills can be acquired or learned (gardner, ; gardner et al., ) , which provides a potential avenue for intervention: training people to be more effective in regulating their own actions. interestingly, current research shows that risk perceptions have small effects on intentions and subsequent behavior. risk perceptions had small but significant effects in the us sample, and a small effect which fell short of statistical significance in the australia sample. this pattern of effects is consistent with applications of the hapa and other social cognition models like protection motivation theory, which found relatively modest or null effects of risk perceptions on intentions and behavior (zhang, chung, et al., ) . in the context of covid- prevention and social distancing behavior, it is common knowledge that the infection will not have serious consequences for the majority of the population, and is likely only to be serious for those with underlying conditions or impaired immunity, or the elderly. as a consequence, perceived risk may not be a major influence on decisions to act. instead, it seems that self-efficacy and action control are more pervasive and consistent determinants of behavior, and these may be more pertinent targets for intervention. action and coping planning were expected to mediate intention-behavior effects in the current model, such that planning is an important part of the process of intention enactment for social distancing. however, findings indicated that neither form of planning mediated intention effects on behavior, contrary to hapa predictions. these findings are not, however, unique, and previous research has demonstrated considerable variability in the role of planning in intention enactment, and effect sizes are often small (rhodes et al., ; . taken together, it seems that volitional processes such as action control are far more pervasive in promoting social distancing intentions and behavior. introduction of past behavior in the current model had marked influences on the size of model effects, rendering effects of almost all model constructs on intentions and behavior trivial and not statistically significant. one interpretation of these findings is that the current model is not sufficient in accounting for social distancing over time. however, it was not unexpected that past behavior would have pervasive effects on subsequent behavior over such short range prediction and, given the high stability of social distancing behavior, it is unsurprising that it accounts for model effects over time. it must also be stressed that past behavior alone is not a construct and does not, therefore, offer any information other than on the stability of social distancing behavior (ouellette & wood, ) . some have proposed that past behavior is indicative of habitual influences on behavior, but research examining habit as a construct suggests that it is more than performing a behavior frequently, and that the quality of the behavioral experience, such as experiencing it as automatic or without explicit thought, better characterises habitual processes (aarts et al., ; hagger, ; verplanken & orbell, ) . nevertheless, the residual effect of past behavior may provide some indication of unmeasured constructs on subsequent behavior, particularly those that bypass effects of intentions and are more likely rooted in non-conscious processes that lead to behavior, such as implicit attitudes or motives. research applying social cognition models like the hapa provides useful guidance for the development of future behavioral interventions aimed at promoting social distancing behaviors. although participants' intentions toward, and actual participation in, social distancing behavior were relatively high, scores and variability estimates suggested that some participants were reporting lapses in their social distancing behavior. such lapses present considerable risks to coronavirus transmission, particularly in areas of high prevalence where the likelihood of contact with infected persons is substantially elevated. our research provides some indication of the constructs that should be targeted for change and also the types of behavior change techniques that make up the content of interventions (hagger, cameron, et al, ; hagger, smith, et al., ; kok et al., ) . based on current findings, strategies to promote self-efficacy should be foremost in potential targets of interventions to promote intentions and behavior. interventions that have manipulated mastery experience (i.e. practicing a behavior) and vicarious experience (i.e. observing a model performing the behavior) have been shown to be successful in strengthening self-efficacy, as have interventions that provide feedback on past or others' performance (warner & french, ) . tailoring of these strategies could also be considered and targeted at uptake of the behavior for those that have not already adopted the behavior (e.g. demonstration of appropriate social distance when in line to purchase goods) or at maintenance of the behavior (e.g. developing a rule of thumb on keeping an appropriate social distance every time when in line to purchase goods). action control was another key determinant of intentions and behavior. this suggests that it is important that individuals acquire monitoring and self-regulatory strategies with respect to their social distancing behavior. for example, action control involves consistent monitoring as to whether an individual follows through on their intentions for the target behavior (schwarzer & hamilton, ) . monitoring helps identify discrepancies in behavior (e.g. not being at an appropriate social distance when in line to purchase goods), and noting a discrepancy can trigger taking additional action to ensure goals are achieved (e.g. adjusting the distance) or for disengaging from the goal (e.g. abandoning the goods and leaving the shop) (webb & de bruin, ) . in order to promote better action control, interventions may prompt self-monitoring (e.g. through selfobservation of social distancing behavior) or be monitored by others (e.g. shop attendant prompts an individual to increase their social distance). given that constructs such as attitudes and risk perceptions were not strong, consistent determinants of social distancing behavior, strategies targeting change in these constructs may not be at the forefront of behavioral interventions to promote social distancing. however, context-specific interventions that target change in attitudes for individuals in australia and risk perceptions, particularly for individuals in the us, may assist in promoting stronger intentions. strategies aimed at promoting attitude change and increased risk perceptions usually involve information provision (e.g. providing information about health consequences, highlighting the pros over the cons of social distancing) and communication-persuasion (e.g. using credible sources to deliver messages, using framing/reframing methods) about the importance of maintaining social distancing (hamilton & johnson, ) . however, reviews suggest that such strategies relate more to short-term change rather than sustained, longer-term impact on behavior (jepson et al., ) . another approach could be the use of fear appeals which seek to arouse negative emotional reactions in order to promote self-protective motivation and action (kok et al., ) . however, caution is needed when using fear appeals to attempt to change behavior as excessively heightened fear may be counter-productive in motivating individuals to engage in preventive behaviors (kok et al., ; lin, ) , and may even be counter-productive because they are responses aimed at mitigating fear, such as avoidance or denial, neither of which may manage the risk itself (hagger et al., ; leventhal et al., ) . there is evidence that messages that highlight risk but also provide coping information to increase self-efficacy (kok et al., ) and that use positive prosocial language (heffner et al., ) may be effective because they are more readily accepted and prevent defensive and avoidant reactions. however, current evidence suggests that interventions targeting change in attitudes and risk perception are unlikely to be enough to promote social distancing. the present research has a number of strengths including focus on social distancing, a key preventive behavior aimed at reducing transmission of sars-cov- to prevent covid- infections; adoption of a fit-for-purpose theoretical model, the hapa, that provides a set of a priori predictions on the motivational and volitional determinants of the target behavior; recruitment of samples from two countries, australia and the us, with key demographic characteristics that closely match those of the population; and the use of prospective study design and structural equation modelling techniques. a number of limitations to the current data should also be noted. that there was substantive attrition at follow-up in both samples is an important limitation. non-trivial attrition could result in selection bias. for example, participants who are more motivated or engaged may be overrepresented in the sample. in the current study, participants were provided with multiple reminders to complete measures at follow-up, but more intensive recruitment and incentivisation of non-responders may have further minimised attrition rates. it should be noted that participant drop-out affected the demographic profile of the samples, particularly among underrepresented groups. this is particularly relevant to the current context given data indicating that covid- infection and mortality rates are higher in underrepresented minority and socioeconomic groups (cdc, ) . a potential solution would be to oversample in underrepresented groups in which attrition rates are likely to be high and should be considered in future research. furthermore, our recruitment strategy was focused on producing samples with characteristics that corresponded with those of the national population on gender and state. however, the samples were not stratified by salient demographic or socioeconomic variables. the current samples cannot be characterised as representative of the australian or us population. taking these biases into account, the current findings should not be considered directly generalisable to the broader population. in addition, the current study adopted a prospective design, which provided a basis for the temporal ordering of constructs in the model. however, the correlational design of the current study means that inferences of causality are based on theory rather than the data. furthermore, the current design did not permit modeling of the stability or change in model constructs over time. the latter represents an important caveat when utilising current data as a basis for intervention. future research should aim to adopt cross-lagged panel designs that model change in constructs over time, and utilise intervention or experimental designs that target change in model constructs and observe their effects on behavior. also, the study was conducted over a one-week period. although this is a relatively brief follow-up period, it was considered appropriate given the high speed of virus transmission and the need for prompt adoption of social distancing in the population to prevent widespread infection. the current results, however, do not confirm the extent to which model constructs predict social distancing over a longer period, and long-term follow-up would be necessary to support the application of the hapa in accounting for maintenance of social distancing, which is especially important as lockdown restrictions ease in order to prevent a "second wave" of infection. the present study also relied exclusively on self-report measures which may introduce additional error variance through recall bias and socially desirable responding. future studies may consider verification of behavioral data with non-self-report data such as the use of gps mapping of mobile phones or using observation to verify rates of social distancing behavior in particular contexts (e.g. workplaces, grocery stores). it might also be useful for future studies to investigate the role of social factors, as suggested in the hapa, on social distancing behavior. this is particularly important given the considerable potential for "social" influences to affect individuals' behavior in minimising person-to-person contact with others outside the individual's immediate household. precedence for these effects comes from previous research which has found that pressure from important others and moral obligation toward others predicts adherence to covid- preventive behaviors, including social distancing (hagger, cameron, et al, ; hagger, smith, et al., ; lin et al., ) . finally, this research was conducted during a period when it is likely that participants were already engaging in social distancing and, thus, already had substantive experience with the behavior, indicated by the high scale mean scores for past behavior (m = . on a -point scale) in both samples. this likely explains the substantive effect of past behavior in attenuating model effects and the need for longitudinal designs or using methods such as ecological momentary assessment that capture moment-by-moment changes over time in behavior. given the urgent need for populations to adopt covid- preventive behaviors, such as social distancing, the present study applied the hapa to predict key motivational and volitional determinants of social distancing behavior in samples across two different countries, australia and the us. overall, the current findings provide qualified support for some of the core proposed effects among the motivational and volitional factors in the model, as well as their effects on individuals' social distancing behavior. the current study fills a knowledge gap in the literature on the social psychological processes that guide social distancing behavior in an unprecedented context of a pandemic and suggests that the motivational and volitional constructs of self-efficacy, intention, and action control, in particular, may have utility in explaining this important covid- preventive behavior. despite the correlational design, the current findings suggest multiple potential routes to behavioral performance that can serve as a basis for the development of intervention and enable further testing of effects of the techniques on both behavior change and the targeted theory constructs. additional supporting information may be found online in the supporting information section at the end of the article. predicting behavior from actions in the past: repeated decision making or a matter of habit australia's children. canberra: australian institute of health and welfare the mediating role of reasoned-action and automatic processes from past-to-future behavior across three health behaviors testing for the equivalence of factor covariance and means structures: the issue of partial measurement invariance covid- in racial and ethnic minority groups evaluating goodness-of-fit indexes for testing measurement invariance physical distancing, face masks, and eye protection to prevent person-to-person transmission of sars-cov- and covid- : a systematic review and meta-analysis the relative performance of full information maximum likelihood estimation for missing data in structural equation models a review and analysis of the use of "habit" in understanding, predicting and influencing health-related behaviour habit interventions habit and physical activity: theoretical advances, practical implications, and agenda for future research the reasoned action approach applied to health behavior: role of past behavior and tests of some key moderators using metaanalytic structural equation modeling handbook of behavior change the common sense model of self-regulation: meta-analysis and test of a process model predicting social distancing behavior during the covid- pandemic: an integrated social cognition model parental supervision for their children's toothbrushing: mediating effects of planning, self-efficacy, and action control attitude and persuasive communication interventions an extended theory of planned behavior for parent-for-child health behaviors: a meta-analysis emotional responses to prosocial messages increase willingness to self-isolate during the covid- pandemic cutoff criteria for fit indexes in covariance structure analysis: conventional criteria versus new alternatives physical distancing interventions and incidence of coronavirus disease : natural experiment in countries physical interventions to interrupt or reduce the spread of respiratory viruses the effectiveness of interventions to change six health behaviours: a review of reviews a taxonomy of behaviour change methods: an intervention mapping approach ignoring theory and misinterpreting evidence: the false belief in fear appeals self-regulation, health, and behavior: a perceptual-cognitive approach social reaction toward the novel coronavirus (covid- ) using an integrated social cognition model to predict covid- preventive behaviors motivating social distancing during the covid- pandemic: an online experiment prospective prediction of health-related behaviours with the theory of planned behaviour: a meta-analysis reducing sars-cov- transmission in the uk: a behavioural science approach to identifying options for increasing adherence to social distancing and shielding vulnerable people habit and intention in everyday life: the multiple processes by which past behavior predicts future behavior r: a language and environment for statistical computing handwashing and risk of respiratory infections: a quantitative systematic review psych: procedures for psychological social-cognitive antecedents of hand washing: action control bridges the planning-behaviour gap planning and implementation intention interventions lavaan: an r package for structural equation modeling a comparison of several approaches for controlling measurement error in small samples the health action process approach (hapa): assessment tools modeling health behavior change: how to predict and modify the adoption and maintenance of health behaviors changing behaviour using the health action process approach income and poverty in the united states use of non-pharmaceutical interventions to reduce the transmission of influenza in adults: a systematic review public perceptions of non-pharmaceutical interventions for reducing transmission of respiratory infection: systematic review and synthesis of qualitative studies behavioural science and disease prevention: psychological guidance reflections on past behavior: a self-report index of habit strength confidence and self-efficacy interventions monitoring interventions applying principles of behaviour change to reduce sars-cov- transmission habit in personality and social psychology coronavirus disease (covid- ) advice for the public worldometer covid- coronavirus pandemic modeling longitudinal and multiple group data: practical issues, applied approaches and specific examples health beliefs of wearing facemasks for influenza a/h n prevention: a qualitative investigation of hong kong older adults predicting hand washing and sleep hygiene behaviors among college students: test of an integrated social-cognition model a meta-analysis of the health action process approach the role of action control and action planning on fruit and vegetable consumption martin s. hagger's contribution was supported by a finland distinguished professor (fidipro) award (dnro / / ) from business finland. data files and analysis scripts are available online from the open science framework project for this study: https://osf.io/mrzex/?view_only= ae e fa c c e d f b key: cord- -wllc gl authors: kent, katherine; murray, sandra; penrose, beth; auckland, stuart; visentin, denis; godrich, stephanie; lester, elizabeth title: prevalence and socio-demographic predictors of food insecurity in australia during the covid- pandemic date: - - journal: nutrients doi: . /nu sha: doc_id: cord_uid: wllc gl the covid- pandemic has exacerbated economic vulnerabilities and disrupted the australian food supply, with potential implications for food insecurity. this study aims to describe the prevalence and socio-demographic associations of food insecurity in tasmania, australia, during the covid- pandemic. a cross-sectional survey (deployed late may to early june ) incorporated the u.s. household food security survey module: six-item short form, and fifteen demographic and covid-related income questions. survey data (n = ) were analyzed using univariate and multivariate binary logistic regression. the prevalence of food insecurity was %. the adjusted odds of food insecurity were higher among respondents with a disability, from a rural area, and living with dependents. increasing age, a university education, and income above $ , /year were protective against food insecurity. food insecurity more than doubled with a loss of household income above % (adjusted odds ratio (aor): . ; % ci: . , . ; p = . ), and the odds further increased with loss of income above % (aor: . ; % ci: . , . ; p = . ). our results suggest that the prevalence of food insecurity may have increased during the covid- pandemic, particularly among economically vulnerable households and people who lost income. policies that support disadvantaged households and ensure adequate employment opportunities are important to support australians throughout and post the covid- pandemic. food security is achieved "when all people, at all times, have physical, social and economic access to sufficient, safe and nutritious food that meets their dietary needs and food preferences for an active and healthy life" [ ] . this broad definition emphasizes four distinct dimensions of food security [ ] which include the availability, accessibility and utilization of food, in addition to the stability of each of these factors, which refers to an ability to withstand shocks to the broader food system. food insecurity occurs when at least one of these domains are not met, where the experience at a household level may be temporary or longer-term [ ] . access to adequate food is a core social determinant of health, and food insecurity is related to poor nutritional intake and higher mortality the survey used the u.s. household food security survey module: six-item short form (hfssm) to determine the prevalence of food insecurity [ ] . this validated screening tool [ ] sought responses to six questions self-reporting of uncertain, insufficient or inadequate food access, availability and utilization, due to limited financial resources, and the compromised food consumption that may result. the hfssm generally applies a reference timeframe of months; however, it was less applicable for this study which was conducted at the beginning of the covid- pandemic. therefore, the acceptable shorter reference period of days was selected to capture the prevalence of food insecurity during the covid- pandemic only [ ] . responses to the six questions were coded and assessed in accordance with the user notes [ ] , where each affirmative response was assigned a score of , and summed raw scores were used to describe food insecurity at the household level. scores were then used to categorize respondents as having high ( ), marginal ( ), low ( ) ( ) ( ) or very low food security ( ) ( ) . in previous australian studies [ ] , scores of and have been grouped together, while international studies have reported these scores separately. our analyses kept these scores separate, due to the short reference period, and the fact that the majority of respondents who scored reported running out of food and could not afford to buy more. an affirmative response to this question would indicate household food insecurity with other scales, including the single-item measure of food insecurity which is commonly used in australian studies of food insecurity [ ] . fifteen socio-demographic variables were collected, including age (in years), gender (male, female, other), local government area of residence, if they identified as from aboriginal and/or torres strait islander descent, whether they have a health condition or disability that limited their activity, citizenship status (born in australia, australian citizen, permanent resident or temporary resident), the highest level of education, relationship status, household composition, employment status, total household income bracket and whether they were the main shopper for their family. additional questions asked respondents about how the covid- pandemic affected their household finances and job status, including whether the covid- pandemic resulted in a change in their employment and/or a decrease in household income, and whether they were receiving covid- related australian nutrients , , of government benefits (jobkeeper or jobseeker). the study was conducted in accordance with the declaration of helsinki, and the protocol was approved by the university of tasmania's social sciences human research ethics committee (ethics project id: ). data sets were exported from the online survey platforms to ibm spss statistics for windows, version . (ibm corp., armonk, ny, usa), cleaned and prepared for statistical analysis which was performed in stata . (statacorp, ) . all available survey data were used in the analyses. the significance level for all analyses was set at p < . . a binary variable of food security status was generated for application in the univariate and multivariate logistic regression, where food secure was determined by a score of , and food insecure was a score of - on the hfssm. in addition, several of the socio-demographic variables were recoded into a smaller number of categories, due to low cell counts and for ease of interpretation. recoded variables included coding thirty local government areas (lga) of residence categories into three regions (north, south, north-west and west) (see figure for graphical representation) and rurality (urban and rural dwelling regions). age categories were developed from the continuous variable ( - years, - years, - years, - years, - years, + years). disability status was recoded from three options (no, yes a little, yes a lot) to two (yes, no) by collapsing the affirmative responses. relationship status was recoded from seven to four groups (married/de facto, never married, previously married, living apart) by combining widowed, divorced, and separated into previously married. household composition was reduced from ten options to five (couple with no dependents, couple with dependents, single adult with dependents, single person house, other (group/share)). highest education status achieved was recoded from eight options into three (university degree, diploma/technical and further education (tafe) qualification, high school qualification). employment status was recoded from eight options to three (employed [including self-employed]), unemployed and other [which included student, volunteer, retired and other]). household income was recoded into three categories (au$ < , , , - , and , +). all socio-demographic variables were either categorical or ordinal and were cross-tabulated and summarized with frequencies and proportions. cross-tabulations with chi-square statistic were employed to generate descriptive statistics related to food security status, including responses to each of the six food security questions, and with each of the socio-demographic variables. univariate logistic regression was performed individually for each socio-demographic characteristic to generate unadjusted odds ratios for food insecurity. correlation coefficients between all variables were calculated to demonstrate the interrelationships and inform the multivariate analysis. a multivariable logistic regression was performed, including all measured variables to yield adjusted odds ratios (aor) for food insecurity. variables were retained in the final model if any level of the variable had p < . . almost three-quarters of the respondents (n = ) were categorized as having high security (n = , . %), with . % reporting marginal food security (n = ), . % low food security (n = ) and . % (n = ) having very low food security. socio-demographic characteristics of the survey respondents according to food security categories and assessments of the impact of the covid- pandemic on employment and income are presented in table . the majority of respondents were female ( %), and a large proportion ( %) were aged over years. most respondents ( %) were in a married or de facto relationship, and % of respondents had dependents living with them. with regards to income, % of respondents had incomes over au$ , per year, and a majority ( %) had a university education (bachelor's degree or higher). main household shoppers were the predominant survey respondents ( %). the prevalence of household food insecurity ranged from % in the south, to % in the north-west and west regions ( figure ). the greatest proportion of respondents with very low food security were in the north ( %), compared with % in the north-west and west and % in the south. despite a lack of statistically significant regional differences, a larger proportion of respondents residing in rural regions (table ) were classified in the marginal, low and very low food security groups ( %) in comparison to their urban-dwelling counterparts ( %). the proportions of respondents in each food security group who provided affirmative responses to each of the six hfssm questions are represented in table . of the six questions, marginally food secure respondents were most likely to respond affirmatively to the first question: "the food that (i/we) bought just didn't last, and (i/we) didn't have money to get more". however, none of the respondents in the marginally food secure group reported eating less than they wanted or being hungry because there was not enough money for food. in comparison, nearly all respondents ( %) in the very low food security category responded affirmatively to the first question, and a further % reported experiencing hunger. in addition, % of respondents in the low food security category reported they cut down on food or skipped meals for least three days in the past days because they could not afford to buy more, but only % in this group reported experiencing hunger. while the majority of respondents in the low food security group ( %) did not cut down on the size of meals, % reported being unable to afford to eat balanced meals. the proportion of respondents in food secure groups rose with increasing age (table ) . a significantly greater proportion of younger respondents aged - years were classified as having low ( %) or very low food security ( %) over the past month in comparison to older age brackets. while there was no significant difference between men and women in the food secure categories (~ %), a greater proportion of female respondents reported very low food security ( %) in comparison to males ( %). a significantly greater proportion of respondents with a disability reported experiencing low and very low food security ( % and %, respectively) in comparison to respondents without a disability ( % and %). a small proportion of respondents identified as aboriginal and/or torres strait islander ( . %), but less than half of these respondents were food secure, and more than in of these respondents reported experiencing low and very low food security, which was statistically significantly greater than those who did not identify as aboriginal and/or torres strait islander (table ) . a significantly greater proportion of university-educated respondents had high food security ( %) in comparison to smaller proportions of those with a diploma/tafe qualification ( %) and those who obtained a high school qualification ( %). a significantly larger proportion of australian citizens born in australia ( %) and overseas ( %) were classified as having high food security in comparison to permanent residents ( %) and temporary residents ( %). of note, are the high proportions of temporary residents in the marginal ( %), low ( %) and very low ( %) food security groups in comparison to other residents. significantly higher proportions of those respondents who were never married ( %) and separated ( %) were in the very low food security group, and only % of respondents in households of single adults with dependents were classified as having high food security. half ( %) of respondents on the lowest income were classified as having high food security, with a further % in the low food security group and % in the very low food security group, which is much higher than other income brackets (table ) . lga-local government areas. tafe-technical and further education. nutrients , , of similar proportions of respondents who indicated that the covid- pandemic had impacted their job were classified as having marginal food security ( %) in comparison to respondents without a job change. however, a significantly higher proportion of those whose job had been impacted by the pandemic were in the low ( %) and very low ( %) food security groups. fewer respondents who had lost income as a result of the covid- pandemic ( %) had high food security table ). of note, % of respondents who had lost over % of their income reported some degree of food insecurity. interestingly, a similar proportion of respondents receiving the jobkeeper government benefit had high food security, in comparison to less than half ( %) of respondents receiving the lower jobseeker payment ( %), with % of these respondents classified as having marginal food security and a further % in the low and very low food security groups. the prevalence of household food insecurity ranged from % in the south, to % in the north-west and west regions ( figure ). the greatest proportion of respondents with very low food security were in the north ( %), compared with % in the north-west and west and % in the south. despite a lack of statistically significant regional differences, a larger proportion of respondents residing in rural regions (table ) were classified in the marginal, low and very low food security groups ( %) in comparison to their urban-dwelling counterparts ( %). the proportions of respondents in each food security group who provided affirmative responses to each of the six hfssm questions are represented in table . of the six questions, marginally food secure respondents were most likely to respond affirmatively to the first question: "the food that (i/we) bought just didn't last, and (i/we) didn't have money to get more". however, none of the respondents in the marginally food secure group reported eating less than they wanted or being hungry because there was not enough money for food. in comparison, nearly all respondents ( %) in the very low food security category responded affirmatively to the first question, and a further % reported experiencing hunger. in addition, % of respondents in the low food security category reported they cut down on food or skipped meals for least three days in the past days because they could not afford to buy more, but only % in this group reported experiencing hunger. while the majority of respondents in the low food security group ( %) did not cut down on the size of meals, % reported being unable to afford to eat balanced meals. table . distribution of responses to the six-item food insecurity screen across food security status. response the food that (i/we) bought just didn't last, and (i/we) didn't have money to get more. in the last days was this: often true ( . ) ( . ) ( . in the last days, how many days did this happen? in the last days, were you ever hungry but didn't eat because there wasn't enough money for food? table presents crude and adjusted odds ratios of household food insecurity for the variables considered. adjustment for socio-demographic characteristics considered in our multivariable model yielded modest decreases in the strength of some effects, highlighting the co-occurrence of factors associated with elevated risk, especially for income variables. in the multivariate analysis, two demographic variables were removed from the final model, which were also not independently significantly associated with higher food insecurity (main shopper, region). the region was also highly colinear with rurality, which was retained (see table for correlations between variables). as the covid variables were assessing different aspects of the effect of covid- on income, only one (income decrease) was retained in the final model, due to collinearity. the adjusted model had pseudo r = . , and likelihood ratio test statistics χ = . , p < . . the adjusted model indicates that increasing age was protective against food insecurity, with the odds of experiencing food insecurity reducing by % with every decade of life. respondents who identified as aboriginal and/or torres strait islander had more than three-fold greater odds of experiencing food insecurity; however, after adjustment for other household characteristics, this difference did not remain significant despite the aor of . , which may reflect the small proportion of respondents who identified as aboriginal and/or torres strait islander. respondents with a disability had more than two-fold increased odds of experiencing food insecurity compared with those without a disability, which was modestly reduced (aor: . ) after adjusting for other characteristics. an % increase in the odds of experiencing food insecurity was evident for respondents in rural areas after adjusting for other characteristics. higher levels of education were protective against food insecurity, with respondents with a diploma/tafe or high-school qualification showing a two-fold increase in the odds of experiencing food insecurity compared to those with a university-level education (bachelor's degree or higher), which remained significant after adjusting for other characteristics. temporary residents had a four-fold increase in the odds of experiencing food insecurity compared to australian citizens, which was modestly reduced after adjusting for other characteristics and did not remain significant. the multivariate model showed that respondents who were previously married had two-fold higher odds of food insecurity than respondents who were currently married or in a de facto relationship. compared to couple families without dependents, all other household types had increased odds of food insecurity. interestingly, the odds ratio for food insecurity associated with being a single parent household fell from . to . with adjustment for other household characteristics, and this group was no longer statistically significantly different from other household types. household income was independently associated with food insecurity, with incomes above au$ , /year seemingly protective against food insecurity, and income below au$ , per year associated with a two-fold increase in the odds of food insecurity. respondents who reported that the covid- pandemic had resulted in a change in their employment had a % increase in the odds of experiencing food insecurity in comparison to those not impacted. in comparison to those who were employed and not receiving government benefits, respondents who were receiving the jobkeeper government support payment had % higher odds of experiencing food insecurity, and those who were receiving jobseeker support payments (a smaller fiscal amount) had a three and a half-fold increase in the odds of experiencing food insecurity. a gradient was apparent for respondents who had lost income as a result of the covid- pandemic, where an income loss of % or more significantly increased the odds of experiencing food insecurity. independently of other factors, including household income, a loss of more than % of income was associated with a seven-fold increase in the risk of food insecurity. in the adjusted model, similar effects for income decrease were observed, demonstrating that income loss is independently associated with higher odds of food insecurity. this study presents results from a survey of adults in tasmania, australia, assessing the prevalence and socio-demographic predictors of household food insecurity during the covid- pandemic. our results demonstrate that between late april and early june , a time when wide-spread social distancing restrictions were in place, more than in ( %) respondents had experienced food insecurity to some degree. concerningly, % of respondents experienced more severe food insecurity, which meant they were regularly going hungry and were unable to afford balanced meals over the previous month. these statistics are substantially higher than the tasmanian food insecurity prevalence of . %, preceding the covid- pandemic [ ] , and higher than the national reported prevalence of % [ ] . comparable to the results of our study, previous research has shown that food insecurity was highest in the north ( . %) of tasmania, and lower in the south ( . %) and north-west ( . %) [ ] . the tasmanian survey used a single item food insecurity question, meaning these results are not directly comparable to the current study. however, given that more than % of respondents to our survey provided an affirmative response to the equivalent question (see table ), this indicates that the burden of food insecurity in tasmania is substantially higher than pre-covid- levels. there are emerging reports of much higher levels of food insecurity being experienced by populations across the world during the covid- pandemic. a cross-sectional study of low-income adults in the us reported that % of respondents were marginally food insecure, and a further % were food insecure [ ] . however, this study was limited by its focus on low-income households, and the results are, therefore, not generalizable to the wider population. our results demonstrate that the experience of food insecurity was not limited to only those on low incomes, and that loss of income at any level above % contributed to substantially higher odds of experiencing food insecurity. results from a survey in the north-eastern us state of vermont, identified a % increase in food insecurity since the beginning of the pandemic, with % of households experiencing food insecurity (up from %) [ ] . a canadian survey [ ] conducted during april-may found that almost one in seven ( . %) canadians experienced food insecurity to some degree in the previous days, and those who had reduced employment due to covid- , were more likely to be food insecure ( . %) than those who were working ( . %) [ ] . a study in the uk reported that . % of adults had experienced food insecurity since the covid- lockdown began [ ] , up from . % in . interestingly, in this study, a lack of food available in the shops contributed to % of food insecurity experienced, highlighting the importance of stability in the food supply as an overarching domain of food security. the proportions of more severe food insecurity were comparable with our study, where it was reported that % of adults skipped meals, and % regularly went without food [ ] . our study was unable to determine the extent to which food shortages, resulting from food hoarding, impacted food insecure responses. however, it is likely that food-insecure households were left at an extreme disadvantage because of food hoarding. in addition to the wide-spread unavailability of some foods, australian retail outlets and supermarkets placed strict limits on the amount of staple food items that could be purchased in one transaction, which further reduced the ability of households to buy adequate food, especially for larger families living far away from their nearest shop, who need to buy in bulk. while an investigation of the coping strategies adopted by food-insecure households was not a focus of our study, the fact that many respondents reported running out of food, but did not report being hungry shows coping strategies being employed to some degree, especially for those in the marginal and low food security groups ( table ) . such strategies could have included accessing emergency food relief, in addition to restaurants and community groups providing no-cost or low-cost meals and food boxes. our analyses demonstrate that the higher probability of household food insecurity was closely associated with many socio-demographic factors, especially financial factors specific to the covid- pandemic. the most substantial factor in our regression analyses was loss of income related to covid- , with respondents who had lost the majority of their income showing up to a seven-fold increase in the odds of food insecurity. similarly, in the uk, adults reported that loss of income above % resulting from the covid- pandemic were found to be at significantly higher risk of food insecurity, even after accounting for background socio-economic status [ ] . prior to the covid- pandemic, % of tasmanian households were reportedly in financial stress, which means they did not have or could not raise au$ in an emergency [ ] , with this factor closely related to food insecurity in the state. food insecurity has worsened within economically vulnerable populations under covid- conditions, with a loss of income in already low-income households putting individuals at even higher risk of food insecurity. additionally, covid- has also created new economic vulnerability for people were previously food secure and who are now experiencing income losses. previous research has shown that loss of an income or large household bills (also known as bill shock), can require temporary reallocation of financial resources away from groceries, which can result in food insecurity [ ] . previous research during global recessions has shown increased household food insecurity, which can take years to return to pre-recession levels [ ] . our study is limited in that we were unable to control for household savings or other assets, which may explain a large variation in a household's ability to adjust to periods of economic shock in comparison to others. however, low-income households are unlikely to ever accrue substantial savings or assets which could cushion against financial shocks. our analyses demonstrate that a substantial proportion ( %) of our respondents' employment status had been impacted by the covid- pandemic, and that these respondents were at higher risk of moderate to severe food insecurity. positively, government financial support payments were being received by % of our respondents and those receiving the higher jobkeeper payment through their employer showed a similar level of food insecurity to those currently employed. however, approximately half of respondents receiving the lower jobseeker payments reported experiencing food insecurity. this finding is somewhat at odds with national reports of how this new government supplement, which is higher than the usual unemployment benefits, has reduced financial and personal distress, and reduced food insecurity for people who normally access unemployment schemes [ ] . however, the majority of respondents to the national survey had been receiving an income support payment for more than two years, and therefore, our results may reflect the experience of individuals newly claiming this scheme [ ] . in published research, low income is the most consistent and often the strongest predictor of food insecurity [ ] . in our study, those who were food insecure are more highly represented among lower-income brackets, especially for those on incomes lower than au$ , per year. incomes above au$ , per year, which is higher than the median household income in tasmania of approximately au$ , [ ] , were associated with lower odds of food insecurity. low-income households may be larger, and therefore, may be unable to purchase sufficient food to meet their needs, or they may be required to purchase smaller quantities of food, which are sold at a higher unit price, further increasing the prevalence of food insecurity in these households. interestingly, food insecurity was still evident in respondents with the highest incomes (>au$ , per year), indicating that income does not always reflect the economic conditions of the household. of note, the increased food insecurity reported in our study and other studies during the covid- pandemic suggests that the financial impact of covid- on food insecurity is far-reaching in the population, and has affected both households with high socio-economic risk of food insecurity and those not typically perceived to be at risk of food insecurity. in addition, our analyses demonstrate that younger age, rurality, disability, lower education levels, and having dependents were also all independently associated with food insecurity, indicating that the socio-demographic and covid-related factors cannot be explained merely in terms of their association with income. other factors which were associated in the univariate analysis, but not the multivariate, included being of aboriginal/torres strait islander decent, temporary residency, and being single (never married or previously married). for these factors, the relationship with food insecurity may be due to lower-incomes and other factors. in our study, increasing age was protective against food insecurity. these results align with published literature, which demonstrates that even after controlling for economic factors, the probability of moderate or severe food insecurity decreased with age [ , ] . studies of older australians have similarly reported a lower prevalence than in the general population, with prevalence rates of % for australians aged over years [ ] and % of australians aged over years [ ] . compounding this effect, the impact of the covid- pandemic has disproportionately affected younger australians [ ] , due to a large reduction in casual and part-time jobs predominantly held by younger people (e.g., hospitality). interestingly, our study showed that gender was not associated with an increased risk of food insecurity. this is somewhat at odds with the results of other studies, which have explained the increased burden of food insecurity experienced by women to be associated with gender-related economic factors, including lower employment opportunities and child-related duties [ ] . additionally, higher educational attainment was independently associated with lower odds of experiencing food insecurity, which is consistent with other australian research [ , ] , and international studies of food insecurity during the covid- pandemic [ ] . in line with our findings, the greater likelihood of food insecurity among australians from aboriginal and/or torres strait islander descent has been documented previously [ ] , with the prevalence of food insecurity ranging from % in remote areas [ ] to % in the state of victoria [ ] . additionally, respondents reporting health conditions and disabilities that limited their daily activities were more likely to be food insecure than those without a disability and were also shown to experience more severe forms of food insecurity. these results are echoed in previous australian [ ] and international studies [ ] from before the covid- pandemic. while our study did not examine the cause of food insecurity in this group, an uk survey during covid- identified that respondents with a disability had between two and four-fold increased risk of experiencing food insecurity as a result of economic hardship, a lack of food available in shops, and social isolation [ ] . respondents living in rural areas experienced a higher burden of food insecurity in comparison to respondents living in urban areas and were % more likely to be food insecure after accounting for other socio-demographic factors. in rural australia, fresh and healthy food is very expensive in some areas, due to transportation and storage costs [ ] . during the covid- pandemic, reduced access to food and fewer shops in these areas was coupled with media reports of price gouging of foods in response to increased demand [ ] , and these factors may have infringed upon the ability of rural residents to buy enough healthy food to meet their needs. pre-covid- evidence has inconsistently linked immigration status to food insecurity [ , ] . in our study, temporary residents were four times more likely to experience food insecurity compared with australian citizens, which did not remain significant after controlling for other variables. this may either reflect the small number of temporary residents who responded to our survey, or reflect the exacerbated economic hardship experienced by temporary residents during the covid- pandemic. in australia, temporary residents were ineligible for government support payments, and were therefore, at a much higher risk of food insecurity due to loss of income. comparable with published research [ , ] , being married or in a de facto relationship was negatively associated with food insecurity. during the covid- pandemic, this may be related to the increased financial buffer of two potential income streams in comparison to those in single adult households, or that our study investigated household income, not income per-person, so the adjustment for income may be less appropriate for single respondents. additionally, we found that households with dependents were more likely to be food insecure compared with those without dependents. interestingly, households headed by a single parent were at three-fold greater risk of food insecurity. however, after adjustment for other variables, this difference was no longer significant, indicating that other variables, such as lower-income or loss of income accounted for this increased risk during the covid- pandemic. this study has a number of strengths. to our knowledge, this may be one of the few studies that have examined the impact of the covid- pandemic on food insecurity in australia. moreover, we were able to assess the prevalence of food insecurity in a large sample size relative to the population of tasmania, using a multiple item food security tool, which has shown to be more comprehensive than the single item food security question applied in many australian studies [ , ] . despite these strengths, these findings must be considered within the context of a number of potential limitations. our study was cross-sectional in nature, and therefore, our analyses are purely descriptive, and inferences are limited by the design of the study [ ] . importantly, despite the wide recruitment methods used, the likelihood of participating in the survey may be associated with food insecurity (participation bias), and the use of an online survey may have excluded some groups, including those with low literacy or people without internet access. further, our sample may not be representative of the wider tasmanian population [ ] , as our sample contained a higher proportion of female respondents ( . %) compared with the demographic profile of the tasmanian population ( . % female). this over-representation may be explained by the food-based theme of the survey and that women have been reported to predominantly manage household meals [ ] . despite this, our results are supported by reports that women provide more reliable estimates of the food insecurity experiences of a household [ ] . our sample shared similar proportions of married and separated respondents with the tasmanian population ( . % married, . % previously married, and . % never married) [ ] . however, our survey had a lower proportion of respondents who identified as aboriginal and/or torres strait islander ( . %) than the wider tasmanian population ( . %), and a lower proportion of unemployed respondents ( . %), compared to the general tasmanian population ( %). our respondents were overall very highly educated, with % having a university education, compared with . % having tertiary qualifications in the wider tasmanian community [ ] , which may be a result of our convenience sampling methods. as higher education has shown to be protective against food insecurity, actual levels of food insecurity may be higher in the general tasmanian population. lastly, the -item hfssm is slightly less reliable than -item measure, does not measure the most severe levels of food insecurity and does not measure the food security of children in the household [ ]. where to next? as the covid- pandemic continues around the world, it is likely that more severe economic vulnerabilities will emerge towards the end of and beyond. further monitoring of food insecurity across australia and internationally is needed to support the ongoing recovery from the covid- pandemic. prior to the pandemic, food-insecure households have reported numerous coping strategies for making ends meet, including seeking resources from within their social network in addition to emergency food relief. however, social distancing restrictions, business closures and other public health measures may infringe upon these coping strategies, and newly food-insecure households may not have appropriate knowledge of support services. therefore, further australian research is urgently needed to examine the coping strategies that food-insecure households are utilizing during the covid- pandemic, including the appropriateness of income support payments for alleviating more severe food insecurity during the covid- pandemic. our results indicate higher levels of food insecurity in australia during the covid- pandemic and could inform responsive policy interventions. while government support measures, including the jobkeeper and jobseeker payments, appear to be assisting vulnerable australian households, significant financial distress will follow once they are removed or reduced. as loss of income was a major factor in our analyses, effective government responses should center around providing opportunities for secure employment that pays a living wage, rather than a minimum wage. additionally, strengthening social protection mechanisms and emergency food relief programs may protect those at risk of food insecurity. lastly, systems that support the physical access to food, and protect the stability of the food supply must be strengthened. this should involve shortening and localizing food supply chains and bolstering local food systems, where food is grown, packaged, and consumed within the same community. food policy coalitions could provide the mechanism to work at the intersection of health, social justice and environmental sustainability to improve local and regional food systems, positively influencing the food environment [ , ] . given the urgent and widely accepted need to transition to a more circular, just, and sustainable economy, the government in partnership with the community should explore setting up appropriately constituted local food councils in each region. these could support community food hubs to enhance market access for farmers, create jobs, build resilience, promote local and sustainable food procurement, and ultimately improve food security by increasing access to local, healthy food [ , ] . author contributions: conceptualization, k.k., s.m., b.p., s.a., s.g. and e.l.; methodology, k.k., s.m., b.p., s.a., s.g. and e.l.; software, e.l.; formal analysis, d.v. and k.k.; writing-original draft preparation, k.k.; writing-review and editing, all authors; funding acquisition, k.k. all authors have read and agreed to the published version of the manuscript. funding: this research received no external funding and the apc was funded by the university of tasmania's centre for rural health. the food and agriculture organization fao. the state of food insecurity in the what are we assessing when we measure food security? a compendium and review of current metrics the food security continuum: a novel tool for understanding food insecurity as a range of experiences. food secur what does increasing severity of food insecurity indicate for food insecure families? relationships between severity of food insecurity and indicators of material hardship and constrained food purchasing household food insufficiency is associated with poorer health australian bureau of statistics abs. . . . -australian health survey: nutrition-state and territory results severe and moderate forms of food insecurity in australia: are they distinguishable? measuring and understanding food insecurity in australia: a systematic review are low-to-middle-income households experiencing food insecurity in victoria, australia? an examination of the victorian population health survey the association between stressful events and food insecurity: cross-sectional evidence from australia an ecological analysis of factors associated with food insecurity in south australia prevalence of u.s. food insecurity is related to changes in unemployment, inflation, and the price of food restrictions and the 'new normal': documenting life in australia during the coronavirus pandemic australian bureau of statistics abs. . . . -weekly payroll jobs and wages in australia, week ending covid- and consumers: from crisis to recovery online sales halted, supermarket shelves stripped bare as shoppers prepare for coronavirus quarantine restaurants and cafes facing mass closures without more coronavirus support, industry group warns. the money abc news food insecurity and chronic disease validation of a self-reported measure of household food insufficiency with nutrient intake data guide to measuring household food security utilising a multi-item questionnaire to assess household food security in australia food insecurity and covid- : disparities in early effects for us adults food access and security during coronavirus: a vermont study food insecurity during the covid- pandemic vulnerability to food insecurity since the covid- lockdown the impact of the recession on food insecurity among households who were low income: findings from the - national health and nutrition examination surveys survey of people receiving the new rate of jobseeker and other allowances household food security in the united states in prevalence and predictors of food insecurity among older people in canada food insecurity among older australians: prevalence, correlates and well-being food insecurity in community-dwelling older australians. public health nutr gender differences in the prevalence of household food insecurity: a systematic review and meta-analysis. public health nutr understanding food security issues in remote western australian indigenous communities traditional food availability and consumption in remote aboriginal communities in the northern territory inequalities in the social determinants of health of aboriginal and torres strait islander people: a cross-sectional population-based study in the australian state of victoria public health nutrition and food policy disability, food insecurity by nativity, citizenship, and duration national rural health alliance: nhra. food security and health in rural and remote australia coronavirus and price gouging-let's put a stop to it food insecurity and public assistance single-item measure of food insecurity used in the national health survey may underestimate prevalence in australia being honest with causal language in writing for publication development of a food security measurement tool for new zealand households food policy development in the australian state of victoria: a case study of the food alliance the role of a food policy coalition in influencing a local food environment: an australian case study. public health nutr tasmanians seeking more circular and sustainable food systems report of the tasmania project community food hubs: an economic and social justice model for regional australia? this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the authors would like to acknowledge the members of the tasmania project and thank them for their assistance in collecting data for this study, in particular nyree pisanu and ella horton. the authors declare no conflict of interest. key: cord- -qg x pw authors: marshall, andrea p.; austin, danielle e.; chamberlain, di; chapple, lee-anne s.; cree, michele; fetterplace, kate; foster, michelle; freeman–sanderson, amy; fyfe, rachel; grealy, bernadette a.; hodak, alison; holley, anthony; kruger, peter; kucharski, geraldine; pollock, wendy; ridley, emma; stewart, penny; thomas, peter; torresi, kym; williams, linda title: a critical care pandemic staffing framework in australia date: - - journal: aust crit care doi: . /j.aucc. . . sha: doc_id: cord_uid: qg x pw background: pandemics and the large-scale outbreak of infectious disease can significantly impact morbidity and mortality worldwide. the impact on intensive care resources can be significant and often require modification of service delivery, a key element which includes rapid expansion of the critical care workforce. pandemics are also unpredictable, which necessitates rapid decision-making and action which, in the lack of experience and guidance, may be extremely challenging. recognising the potential strain on intensive care units (icus), particularly on staffing, a working group was formed for the purpose of developing recommendations to support decision-making during rapid service expansion. methods: the critical care pandemic staffing working party (n = ), representing nursing, allied health, and medical disciplines, has used a modified consensus approach to provide recommendations to inform multidisciplinary workforce capacity expansion planning in critical care. results: a total of recommendations have been proposed which reflect general recommendations as well as those specific to maintaining the critical care workforce, expanding the critical care workforce, rostering and allocation of the critical care workforce, nurse-specific recommendations for staffing the icu, education support and training during icu surge situations, workforce support, models of care, and de-escalation. conclusion: these recommendations are provided with the intent that they be used to guide interdisciplinary decision-making, and we suggest that careful consideration is given to the local context to determine which recommendations are most appropriate to implement and how they are prioritised. ongoing evaluation of recommendation implementation and impact will be necessary, particularly in rapidly changing clinical contexts. pandemics and the large-scale outbreak of infectious disease can significantly impact morbidity and mortality worldwide with potential to stress intensive care resources [ ] and necessitate change to how services are usually delivered. previous pandemics, such as h n , provide evidence for the need to plan well for increased nursing, allied health, medical, and ancillary staff [ , ] . nevertheless, planning can be challenging owing to the unpredictable and uncertain nature of pandemics [ ] and inability to quickly access skilled staff. we know from experience of respiratory pandemics that pneumonia is a common complication which contributes to the development of critical illness through rapid clinical deterioration [ ] . the impact on intensive care unit (icu) resource can be significant, overwhelming, and unpredictable. with large increases in the number of critically ill patients requiring respiratory support through invasive or noninvasive mechanical ventilation, there will be a concomitant increase in the requirements for nursing, allied health, and medical staff with specific expertise in the management of critical illness. nevertheless, adequate staffing with appropriately trained clinicians who are able to support a surge of critically ill patients can be a major challenge [ ] . this is especially evident in the coronavirus disease (covid- ) pandemic where it has been projected that during maximal surge in australia, an additional registered nursing staff ( % above baseline staffing) and senior medical staff ( % above baseline staffing) may be required [ ] . increases in allied health staffing requirements would also occur, commensurate with service expansion and change in patient profiles. australian federal and state governments' early implementation of travel restrictions and physical distancing measures were initially successful in controlling covid- case numbers [ ] ; however, in the first week of july , nearly new cases of covid- were identified in victoria, almost half of which may indicate community transmission [ ] . while these increases in the rates of transmission are low compared with elsewhere in the world [ ] , the potential for intensive care services to become overwhelmed exists and would require major adjustments in service design and delivery, potentially over a sustained period [ , ] . the purpose of this article is to provide recommendations to inform planning for expansion of multidisciplinary workforce capacity in critical care. the recommendations are provided with the understanding that they will be carefully considered by multidisciplinary teams who take into account local contextual factors and the level of icu surge being experienced. although developed in the context of the covid- pandemic, these recommendations are applicable to most situations in which icu requirements exceed available resources. these recommendations provided herein are underpinned by several tenets: (i) that wherever possible, current staffing recommendations be maintained; (ii) that these recommendations have been developed specifically for the context of critical care practice in australia but may be applicable in other clinical contexts and regions; (iii) that critical care clinical practice in australia has a strong interdisciplinary approach and it is in that spirit that these recommendations have been developed; (iv) that intensive care clinical practice is characterised by rapid changes in response to evidence generation and consequently it is anticipated that these recommendations will be regularly reviewed and updated. updates will be made available on the acccn website (acccn.com.au). an interdisciplinary consultation process was conducted which used a range of methods to engage collaborators who were identified by key nursing, allied health, and medical professional bodies, who comprised the critical care pandemic staffing working party (the working party). at the time of development, we were unable to secure the full range of allied health representation and acknowledge the valuable contributions of social work, occupational therapy and psychology in patient care during, and after recovery from, critical illness. representation and a commitment to securing future input from these groups have been made. recognising the lack of workforce data and research evidence to inform the generation of recommendations, these recommendations are based on both available evidence and expert opinion of a broad interdisciplinary team with experience in both the public and private sectors and expertise in clinical, managerial, and research contexts and built on recommendations in other relevant professional documents (table ) . collaborators contributed to development and iterative refinement of recommendations and, where necessary, consulted more widely within their professional groups. over a -week period in mayejune , collaborators engaged in discipline-specific discussions and wider group consultation through interactive video conferencing telephone consultation written submissions from individuals and organisations. owing to the time-sensitive nature of this exercise, broader consultation was not possible. working party members (n ¼ ) initially developed and contributed recommendations (n ¼ ). these recommendations were reviewed by working party members (n ¼ ) who indicated their level of agreement with each of the recommendations on a -point scale (strongly agree to strongly disagree). a priori, we set the level of agreement to retain a recommendation when % working party members agreed or strongly agreed with the recommendation. recommendations were also iteratively reviewed and refined to achieve clarity, avoid duplication, and determine cross-disciplinary relevance. responses were received from working party members on or before june (response rate: %). working party members' level of agreement was assessed, and all recommendations met the retention criteria of %. however, some duplication was noted and recommendations with a similar focus were grouped, resulting in recommendations; an additional six new recommendations were proposed, and consensus reached for their inclusion, with recommendations included overall. all of the final recommendations met the retention where % working party members agreed or strongly agreed with the recommendation. the majority of recommendations were considered to be broadly applicable across all health professions and were grouped into nine concepts. these included service-level recommendations, maintaining the critical care workforce, expanding the critical care workforce, rostering and allocation of the critical care workforce, nurse-specific recommendations for staffing the icu, education support and training during icu surge situations, workforce support, models of care, and deescalation. specific recommendations for medical practitioners have not been added here and are available within the australian and new zealand intensive care society (anzics) covid- guidelines (version ) [ ] , the minimum standards for intensive care units [ ] , and the statement on managing senior medical workforce in the intensive care during the covid- pandemic [ ] . within the recommendations, critical care nurses refer to registered nurses with experience working in the icu who ideally would also have a postgraduate critical care qualification. allied health professionals are inclusive of, but not limited to, clinical dietitians, clinical pharmacists, physiotherapists, social workers, and speech pathologists. these general recommendations, and the more specific recommendations which follow, are provided with the intent that they be used to guide interdisciplinary decision-making and that careful consideration is given to the local context to determine which recommendations are most appropriate to implement and how they are prioritised. ongoing evaluation of recommendation implementation and impact will be necessary, especially in rapidly changing clinical contexts. . the recommendations outlined in this framework should be considered in conjunction with local, state, and federal emergency response requirements and any recommendations in icuand discipline-specific guidelines to specific pandemics (see table ), which should be monitored frequently for updates. . intensive care services should work collaboratively with hospital-wide services when planning and developing strategies to prepare the broader health service for impact associated with increased icu admissions. . not all recommendations outlined in this document will be universally relevant. when making workforce-related decisions to accommodate anticipated icu surge capacity, the local context should always be considered and multidisciplinary consultation undertaken which examines the potential risk(s) and benefit(s) of each recommendation (acccn workforce standard ) [ ] . . when making any changes to staffing, relevant industrial awards will need to be considered. . health services should consider how they might accommodate redeployment of their critical care nursing and allied health professionals to intrastate or interstate 'hot spots'. . supporting the workforce in surge icus or icus in regional areas could be assisted using new or existing telehealth strategies. these recommendations are made based on the understanding that experienced critical care clinicians who are familiar with their environment will be more confident, adaptable, and able to safely accommodate necessary changes in work practice, including the supervision and support of an expanded critical care workforce, all which contribute to the delivery of safe patient care. . discuss with staff any potential impact they might experience which could influence their ability to attend work. for example, travel restrictions may prevent existing staff from returning to work, or newly appointed staff from travelling to the workplace. existing employees on temporary work visas may need to have visas extended for further work, for example, if they are unable to return home. . review existing and future leave allocations to ensure planned leave is maintained wherever possible to support workforce sustainability. with reference to specific industrial awards, any decisions to change existing and future approved leave should be undertaken in conjunction with the employee and local human resources teams. such decisions should take into consideration icu surge predictions and staffing capacity, the anticipated duration of the pandemic, and need for a sustainable workforce. . where possible, increase the full-time equivalent of parttime staff, ensure all vacancies are filled, revise temporary contracts, and negotiate capacity of casual and agency staff to commit to regular shifts during surge periods. . when planning staffing, consideration should be given for the likely increase in personal, sick, or carer's leave and the potential for some staff to be quarantined. additional strategies to maintain the workforce, such as support with childcare, should be considered. . workforce planning should take into consideration the need to accommodate and support vulnerable staff, for example, by looking after noninfectious critically ill patients who are segregated in a separate clinical area, being deployed to another clinical area or temporary deployment to a nonclinical role. recognising that the degree of vulnerability may vary, such decisions should be made in collaboration with the staff member who should seek independent health advice. it is recognised that icu capacity expansion may be required by using a number of strategies to increase staff members who are able to deliver care to critically ill patients or to support care delivery and logistics in the icu. each strategy will have unique benefits and potential risks, the latter of which should be identified and regularly monitored to optimise patient safety. . expanding the critical care workforce may be achieved through deployment of existing staff with critical care experience from noncritical care to critical care areas. currently employed health professionals with transferrable skills (e.g. those who work in other acute clinical areas with experience in managing patients who require advanced clinical management of complex patients and who are competent in airway management and respiratory support) should be considered for cross-skilling to work in the icu. within health services, early identification of these staff members with critical care experience would be helpful, keeping in mind that deployment to the icu will need to be mutually agreeable [ ] . . health professionals without critical care knowledge and skills could be deployed to support delivery of patient care in the icu under the supervision of a critical care nurse or allied health professional with critical care experience. . strategies to encourage, support, and fast-track health professionals with critical care experience to re-enter the icu workforce should be implemented, for example, the use of flexible education approaches, collaborative organisationwide workforce planning, and streamlined human resource processes. . health professionals without critical care experience who reenter the hospital workforce could be used to support lower acuity patients in the hospital, freeing up staff with acute care experience to support patient care in the icu. . health professionals with critical care experience who are employed external to the health service (e.g,. university partners, private hospitals, industry, armed forces) could be approached to determine their availability to work in either clinical or nonclinical roles. . when expanding the icu workforce, it is essential for the delivery of safe care to determine and communicate to others a clinician's scope of practice. development of a systematic approach to assessment and/or self-assessment of icu capability and competence of newly employed or deployed staff may be helpful. . expansion of nonclinical roles, such as those in education, research, and leadership, may be required to support staff development, service delivery, and data acquisition which are fundamental to the delivery of safe and high-quality clinical care. . where staff members are deployed from nonclinical to clinical roles, the impact on work associated with the nonclinical role should be evaluated and strategies implemented to ensure essential aspects of the role are maintained. . specific to the allied health workforce, each icu should work collaboratively with their allied health departments to review clinical coverage and determine the degree to which expansion and extension of services is required. opportunities exist for allied health workforces to support clinical care requirements and the nursing/medical workforce beyond normal responsibilities but within their scope of practice. we recognise that rostering and allocating the critical care workforce will require careful consideration to minimise risk for staff and patients and to safely achieve optimal patient outcomes. these may assist those responsible for workforce rostering and allocation to make decisions which are in the best interest of patient safety and staff wellbeing. . clearly communicate the processes by which rostering and allocation decisions are made as well as how these will be communicated. the process through which staff members are able to have input into these decisions should also be communicated. . where possible, make informed staffing decisions taking into account the knowledge, skills, experience, strengths, and limitations of individual staff members. knowing the strengths and capabilities of staff will be advantageous when making staffing decisions, specifically when extending icu services beyond what is currently provided (e.g. other areas of the hospital or temporary field hospitals). where possible, try to maintain staff in familiar roles to maintain confidence and minimise uncertainty [ ] . . careful attention to maintaining a balanced skill mix is necessary when allocating staff to rosters. . consider the shift duration and number of consecutive days worked to minimise fatigue. any changes to the usual hours worked, whether this be the number of days or hours per day, should be jointly made with the employee and employer. the aim should be to maximise rest and recuperation times with a view to maintaining the workforce throughout the pandemic. . consider the duration of time health professionals are in personal protective equipment (ppe) and adjust breaks, shifts, or role allocation to minimise physical effects of wearing ppe. following the australian government guidance on the use of personal protective equipment in hospitals during the covid- outbreak is recommended as it relates to the comfortable use of ppe in the icu [ , ] . . use strategies during shifts to minimise staff movement between work areas so that physical distancing and other transmission reduction measures are promoted to reduce the number of staff and patients to which any individual is exposed. . plan rosters and shift duration to take into account prolongation of the shift changeover and breaks owing to the time required to don/doff ppe and debriefing or wellbeing support. registered nurses are responsible for care provision and coordination of critically ill patients. the expectation for : nurse-topatient ratios for critically ill patients means that specific considerations for nurse staffing are required, which may be impacted during a pandemic. . where possible, existing nurse-to-patient ratios and assistance, coordination, contingency, education, supervision, support (access) nurses as recommended in the acccn workforce standards for intensive care nursing [ ] should be maintained. decisions on nurse-to-patient ratios should take into consideration patient safety, acuity, visibility, and staffing skill mix. changes to existing nurse-to-patient ratios should only be considered with maximal surge (tier and of the anzics icu pandemic plan) [ ] . in tier or , the nursing leadership team could consider how nurse-topatient ratios might be maintained with a noncritical care nurse or health professional working under the supervision of a critical care nurse. . the icu patient case mix and unit design (e.g. single rooms) must determine the appropriate nursing service, knowledge, and skills required for the nursing workforce and support staffing of each unit (acccn workforce standard ) [ ] . . any registered nurse who does not have critical care nursing experience should be adequately supported and supervised in the delivery of patient care by a critical care nurse so that patient safety and outcomes are optimised (acccn workforce standard ) [ ] . . staffing models that incorporate direct patient care provided by a nursing student or health professionals other than a registered nurse should only be implemented in extreme situations (tier of the anzics icu pandemic plan) [ ] and should incorporate strategies to ensure effective patient monitoring and review by a critical care nurse. . patient allocation should be done such that there are designated critical care nurses responsible for directing the nursing care of all patients in the icu. where the critical care nurse is responsible for more than one patient, he/she should work in conjunction with, and supervise the care provided by registered nurses without critical care experience, nursing students or other health professionals who are supporting delivery of patient care. such a model of care should be underpinned by clear communication strategies and criteria to escalate concerns to the critical care nurses so that patient safety is maximised (acccn workforce standard ) [ ] . . experienced critical care nurses who routinely undertake collaborative roles such as icu liaison, icu outreach, and/or rapid response maybe required to extend their roles to work more independently in the event of medical shortages. capacity expansion of the icu which may occur during a pandemic will require focused and tailored education, support, and training to maintain high-quality and safe patient care and support optimal organisational performance of the icu. these recommendations are made to assist icu leaders and educators to ensure existing and new staff members are appropriately supported during rapid-learning contexts. . all staff members must have access to and appropriate training in the use of ppe and be aware of strategies being implemented in the workplace to minimise exposure. . alongside review of professional qualifications, assessment of capability and competence should incorporate knowledge, skills, and abilities and be considered across a range of different contexts and not be solely limited to provision of direct patient care. this assessment should subsequently inform decisions about where additional staff members are best placed to support the work of the icu. . situation-specific education and simulation should be provided for existing and newly recruited staff, for example, in preparation for covid- education of health professionals focused on correct use of ppe and patient management strategies including prone positioning. existing staff may also need to assume new and unfamiliar roles for which support and education may be required. . a wide range of education strategies should be used to develop theoretical knowledge, skills, and clinical competency and allow for tailoring of education to individual requirements, which can be informed by self-assessment of individual learning needs. . share high-quality, evidence-based, and peer-reviewed education materials and build on existing education frameworks and learning materials available locally or from regional, state, and national networks, including the use of learning resources from academic and industry colleagues as well as from commercial education providers. . where possible, theoretical education should be supported by supernumerary work to consolidate learning, allow for skill and competency development, and ensure appropriate application of theory to practice. it should be acknowledged that in some instances learning in the workplace without the opportunity for theoretical education or supernumerary support may be required. strategies to maximise learning during supernumerary shifts should be considered. for example, learning may be increased by ensuring exposure to different types of patients, maximising opportunistic learning, and capitalising on 'just-in-time' learning. . when supporting staff to begin or return to work in the icu, consider that longer periods between upskilling and deployment may require staff to be provided opportunities for regular refreshing of newly acquired practices. rapid capacity expansion that may be required during a pandemic will necessitate support of the critical care workforce at the national, state, regional, and local level. support will also be required for health services, hospitals, icus, and specifically for individuals. these recommendations are provided to assist health services, hospitals, icu leaders, and clinicians to consider how organisations, icus, and individuals might be supported to deliver high-quality and safe patient care. . assessment of how changes in staffing, roles, and models of care might disrupt or strain the existing work dynamic may be beneficial to identify areas where additional support may be required. this may be important for staff deployed from the icu to other areas, which may be required for vulnerable staff. assessment should include evaluating the transition experience all staff members undertaking new roles within the icu to determine whether additional support is required. . consider the use of formal and informal debriefing which may be offered at regular intervals (or as required) to all staff members working in the icu during the response to a pandemic; flexibility in when and how debriefing sessions are offered will be needed to maximise participation. staff with debriefing skills should be identified and asked to provide leadership in this area. . as the patient load increases, consideration should be given for simultaneous adjustment to support roles to ensure the ability to maintain services such as, but not limited to, administration, support for patient care, environmental services, and supply of equipment, medications, and consumables (acccn workforce standard ) [ ] . . assess current communication strategies and augment or modify these strategies to accommodate increased frequency of communication to a greater number of staff, ensuring information is able to be easily accessed within or external to the organisation. . streamline communication by providing succinct daily updates to staff which contain key messages specific to the icu as well as that from the broader the health service and the community. in addition to existing infection prevention and control procedures, management of the workspace may be beneficial in promoting adherence to strategies designed to minimise crosscontamination. . review the configuration of shared spaces such as tea rooms, locker areas, and meeting rooms to allow for appropriate physical distancing. for effective implementation, staggered shift start times and breaks might be required. . to minimise potential cross-contamination, consider the use and laundering of hospital-supplied uniforms and access to shower facilities in the workplace. staggered shift finishing times will be required to avoid congestion. existing models of care may require modification to support capacity expansion. it is important that any model of care maintains or improves patient safety and delivery of optimal care while also improving efficiencies. . any proposed changes in models of care should be developed through interdisciplinary collaboration and align with the tiered icu pandemic plan [ ] . . if implementing a team approach to specific tasks, consideration should be given to ensure team members are able to be flexible and provide support in other areas during periods of reduced workload. . team approaches to specific skills or tasks could be considered if there are anticipated gains in efficiencies of care; one example could be the use of proning teams. ensuring that members of the team have the requisite knowledge, skills, and experience to contribute to the collective development of expertise may result in increased efficiency, maximisation of patient safety, and minimisation of risk to the staff. . reconfiguring existing hospital teams (e.g. medical emergency teams or cardiac arrest teams) may be required to minimise workload for icu staff [ ] . where icu expertise is normally provided, this should continue, where possible. . identify models of care delivery that may be implemented to minimise risk and exposure e for example, use of telehealth options or other strategies for collecting information/background history which have normally been done face-to-face. . protocolising the process for transferring patients between departments within the hospital may help ensure appropriately qualified staff members accompany the patient when outside the icu [ ] . . a multidisciplinary team approach to follow up patients recently discharged from the icu should be considered, such as where demand for icu beds is necessitating earlier than anticipated discharge from the icu (acccn workforce standard ) [ ] . this may ensure continuity of specific and/ or complex care such as tracheostomy management, ongoing complex respiratory management, and continuity of rehabilitation and may help to recognise deterioration or prevent readmission to the icu. follow-up of patients discharged to the ward also provides an opportunity for incidental teaching of ward staff. . maintaining a person-centred approach to care delivery, family support, and open communication with families is essential. dedicated support roles such as a family liaison nurse and augmentation of social work support may be helpful strategies to optimise communication with and care of families. telehealth or online collaboration tools (e.g. microsoft teams, zoom, etc) may be effective strategies to connect with families who are either at a distance or unable to visit owing to infection prevention and control measures. decisions to de-escalate from expanded capacity will require careful consideration, particularly where there is potential for fluctuations in capacity which are likely to occur through a pandemic. . retain a portion of the expanded workforce for a period of time to facilitate the ability of staff to access leave or to reduce hours, allowing for rest and recuperation. . as the pandemic eases, identify ways in which staff can be supported through access to leave or reduction in working hours. we recognise the lack of workforce data and research evidence to underpin the development of these recommendations, and this underscores the need for strong interdisciplinary health service research that is specific to the delivery of critical care. a limitation of the study was the inability to gain representation from all allied health professions, for example, by inclusion of occupational therapy, clinical psychology, and social work. however, the role of these professions should similarly be considered alongside other professions contributing to icu management. we attempted to mitigate this limitation by introducing strategies to support the development of recommendations, including the incorporation of current professional and evidence-based guidelines which underpinned some of these recommendations. these strategies include the use of a strong interdisciplinary approach to identify and develop consensus for recommendations, through independent voting, to inform intensive care pandemic staffing that is reflective of the way in which care is delivered in australian icus. in developing these recommendations, we actively engaged the relevant nursing, allied health, and medical professional organisations and ensured the working party members had broad experience in clinical practice, management, education, and research. representation across the public and private sectors, from metropolitan and regional areas, and from a range of states and territories was also ensured. future iterations of this work will be enhanced by broader professional consultation, which is inclusive of consumers. pandemics, which are unpredictable, will continue to be a major global health concern. lessons from past pandemic experiences have helped to inform our preparedness today, and it is important we leverage our learnings from current events to improve future responses. as research and experience continues to inform our understanding of optimal approaches to pandemic management, in particular, how icus can respond to sudden requirements for capacity expansion, it will be important to regularly reflect on, review, and modify these recommendations. covid- : a novel coronavirus and a novel challenge for critical care preparing for the covid- pandemic: our experience in new york the experiences of health care workers employed in an australian intensive care unit during the h n influenza pandemic of : a phenomenological study preparing your intensive care unit for the second wave of h n and future surges influenza epidemiology-past, present, and future preparing icus for pandemics surge capacity of intensive care units in case of acute increase in demand caused by covid- in australia suppressing the epidemic in new south wales coronavirus update for victoria - july melbourne. victoria state government world health organisation. coronavirus disease (covid- ) pandemic geneva. world health organisation covid- bergamo hospital crisis u. adaptations and lessons in the province of bergamo enhancing intensive care capacity: covid- experience from a tertiary center in israel australian college of critical care nurses. workforce standards for intensive care nursing acccn workforce standards for intensive care nursing: systematic and evidence review, development, and appraisal australian and new zealand intensive care society. covid- guidelines. camberwell: vic: anzics; minimum standards for intensive care units covid- critical care coordination collaborative. statement on managing senior medical workforce in intensive care during the covid- pandemic. college of intensive care medicine of australia and new zealand, australian and new zealand intensive care society, australian and new zealand college of anaesthetists facuty of intensive care medicine and the intensive care society. guidelines for the provision of intensive care services physiotherapy management for covid- in the acute hospital setting: clinical practice recommendations nutrition management for critically and acutely unwell hospitalised patients with covid- in australia and new zealand shpa committee of specialty practice in critical care. shpa standards of practice for critical care pharmacy practice speech pathology australia guidance for service delivery, clinical procedures and infection control during the covid- pandemic information/covid- _-_guidance_for_service_delivery/spaweb/about_us/ covid- /guidance_for_service_delivery.aspx?hkey¼fc a -e a - - -a fc d ae royal college of speech language therapists. covid- : maximising the contribution of the speech and langage therapy workforce guidance on the use of personal protective equipment (ppe) in hospitals during the covid- outbreak infection control expert group. the use of face masks and respirators in the context of covid- . canberra: australian government college of intensive care medicine of australia and new zealand. guidelines for transport of critically ill patients. prahran: vic: cicm resources/professional% documents/ic- -guidelines-for-transport-of-critically-ill-patients.pdf we acknowledge the australian college of critical care nurses, the australian and new zealand intensive care society, the college of intensive care medicine, the dietitians association of australia, the society of hospital pharmacists australia, speech pathology australia, and the australian physiotherapy association for providing comment on these recommendations. this document has been reviewed and endorsed by the australian college of critical care nurses, dietitians australia, society of hospital pharmacists australia, and speech pathology australia. the authors have made a commitment to regularly reviewing the recommendations; updates will be available on the australian college of critical care nurses website (acccn.com.au). the authors attest that this work has not been published previously, that it is not under consideration for publication elsewhere, that its publication is approved by all authors and tacitly or explicitly by the responsible authorities where the work was carried out, and that, if accepted, it will not be published elsewhere in the same form, in english or in any other language, including electronically without the written consent of the copyright holder. andrea p marshall, on behalf of all authors, declares that this manuscript is original, has not been published before, and is not currently being considered for publication elsewhere. we confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. we further confirm that the order of authors listed in the manuscript has been approved by all of the authors. we understand that the corresponding author, professor marshall, is the sole contact for the editorial process. she is responsible for communicating with the other authors about progress, submissions of revisions, and final approval of proofs. this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. all persons who meet authorship criteria are listed as authors, and all authors certify that they have participated sufficiently in the work to take public responsibility for the content, including participation in the concept, design, analysis, writing, or revision of the manuscript. furthermore, each author certifies that this material or similar material has not been and will not be submitted to or published in any other publication before its appearance in australian critical care. andrea p marshall is currently editor-in-chief and emma j ridley is an editor of australian critical care. this manuscript has been managed throughout the review process by a consulting editor, professor gavin leslie. this process prevents authors who also hold an editorial role to influence the editorial decisions made. alison hodak is president, australian college of critical care nurses and anthony holley is president of the australian and new zealand intensive care society. key: cord- -azssgdxd authors: brock, tina; vu, thao; kadirvelu, amudha; lee, chooi yeng; kent, fiona title: implementing a collaborative medicine and pharmacy educational activity in two countries date: - - journal: medical education online doi: . / . . sha: doc_id: cord_uid: azssgdxd background: to promote better collaboration for patient care, interprofessional education (ipe) is required in many health professions courses. however, successful ipe implementation at scale can be challenging because of complicated logistics and competing priorities. implementing across multiple geographies adds further complexity. objective: this paper describes the implementation of a full cohort ipe activity for medical and pharmacy students delivered at both the australian and malaysian campuses of monash university. design: we designed a -minute, blended learning activity centred around asthma care for second-year medical and pharmacy students. student perceptions were measured with a pre- and post-activity survey using the validated ten-item, three-factor, spice-r instrument. analysis focused on differences between professions and countries. results: all second-year medicine (n = in australia and n = in malaysia) and pharmacy students (n = in australia and n = in malaysia) participated in the learning activity. a total of / ( %) students participated in the associated research by completing both the pre- and post-activity surveys. the pre-activity survey showed significant differences in four items between medicine and pharmacy students in australia and two items in malaysia. post-activity, we observed significant changes in / items when the two professions were combined. specifically, we noted changes across the countries in perceptions of roles and responsibilities for collaborative practice and patient outcomes from collaborative practice. conclusions: ipe across different professions and countries is feasible. positive outcomes in role understanding and perceived patient outcomes are achievable through a context-sensitive, locally driven approach to implementation. longitudinal experiences may be required to influence perceptions of teamwork and team-based care. to promote better collaboration for patient care, learning about, from, and with other members of the healthcare team is now an accreditation requirement for health professions training courses in many countries [ ] [ ] [ ] [ ] [ ] [ ] . despite this, the operationalisation of interprofessional education (ipe) initiatives varies widely [ ] . this is, in part, because of logistical challenges and competing curricular priorities [ ] . ipe activities involving multiple professions and large cohorts require careful planning and robust evaluation to justify their value and optimise their impact [ ] . this can be even more complicated when designing for and teaching across different countries. in fact, despite globalisation of medical education [ ] [ ] [ ] , most interprofessional investigation has occurred in the context of a single country, most likely a developed country [ ] . this paper presents insights from the first study of its type to implement a co-developed ipe activity based in a developed country, australia, and a developing country, malaysia. this research specifically examines a large-scale instructional activity for second-year medical students and second-year pharmacy students collaborating on a multi-phase asthma-related case at the australian and malaysian campuses of monash university. the structure of the programs at monash university, where both the medicine and pharmacy courses have cohorts based in australia and in malaysia, provides the rare opportunity to develop, implement, and evaluate a similar ipe activity with two professions in these two countries. the research protocol was reviewed and approved (project number: ) by the monash university human research ethics committee, inclusive of both campuses. the design of the ipe activity in this research draws on a collaborative care curriculum (ccc) framework which monash university created in to scaffold the knowledge, skills, behaviours, and attitudes for the health professions represented on its campuses [ ] . the framework was developed with input from academics, practitioners, students, and consumer advocates. it encompasses four key learning themes -person-centred care, role understanding, interprofessional communication, and collaboration within and across teams. it sets learning outcomes for health professionals at the novice (first year), intermediate (middle years), and entry to practice (final years) levels of training. after launching the ccc framework, multiple new ipe activities (such as this one) have been aligned to the framework, to facilitate the educational design of developmentally appropriate content for all participating health professions. there was no intention to combine students from every health professional in every ipe activity. the focus of this ipe activity in this research is the collaborative care for patients with asthma, which allows for authenticity and customisation, two important characteristics of successful ipe initiatives [ ] . in identifying an authentic clinical context, we noted that the care for patients with asthma is suboptimal in many countries [ ] . prior research suggests the need for doctors and pharmacists to work together to improve long-term asthma control [ ] . in both australia and malaysia, a key barrier to effective asthma counselling is a lack of role understanding among health professionals [ , ] . in australia, the national asthma strategy promotes a holistic approach to the care of patients in order to reduce the impact of asthma on individuals, the community, and the economy [ ] . this guidance suggests that initiatives to develop the workforce should include interprofessional training opportunities [ ] . building from this charge, we designed a locally customised activity that required communication between a general practitioner (doctor) and a community pharmacist to optimise the patient care experience. this paper describes and evaluates the implementation of this ipe activity across two professions and two countries. the research findings and lessons learnt from our experience respond to a gap in existing ipe literature, which, according to a review of global health care [ ] , mostly draws on developedworld undergraduate programs and the nursing profession. further, whilst there have been numerous publications about ipe from australia [ ] [ ] [ ] [ ] [ ] and malaysia [ ] [ ] [ ] [ ] [ ] , we identified no published investigations of the overlap of professional and geographical systems with regard to perceptions of collaborative care. further research in this respect is important as the healthcare workforce in many areas is becoming more culturally diverse due, in part, to migration for improved employment opportunities. the design and implementation of the activity were led by a core planning team that included leaders and instructors from both countries to ensure buy-in from the student, instructor, and administrative stakeholders. this team met in person and via zoom® videoconferencing regularly to monitor the project plan which was accessed via a shared google® site. in line with the monash ccc framework, the learning outcomes of the activity were that by completion, active participants would be able to: (a) analyse similarities and differences between professional roles in the management of respiratory illness (b) propose instances where referral to other professions is indicated (c) communicate with other professions in a respectful, responsive, and responsible manner (d) respectfully seek information from and share information with professional colleagues (e) work with other professions to establish a shared vision for care to achieve these learning outcomes, the -minute activity included four phases in a blended design of the individual, large group, and small group work. the sequential discover/explore/apply/reflect format was adapted from the standard instructional model used in the pharmacy course in both countries. ( ) discover | pre-class -this comprised a brief preparatory video and readings about asthma management that were complementary to the programmatic standard (single profession) instruction about asthma diagnosis and treatment. it was delivered online via the university's learning management system. students completed this on their own time prior to the face-to-face activities. this was designed to take about minutes. ( ) explore | face-to-face session -this comprised a large group lecture introducing the ccc framework, explaining the healthcare motivations for collaborative care in asthma, and describing the format for the activity. it was delivered face-to-face by one of the activity leads to a mixed-student group, i.e., medicine plus pharmacy. this was designed to be completed in minutes. ( ) apply | face-to-face session -this comprised a case-based workshop with discussion, handson activities, debrief, and deliverables. the patient case used in australia and malaysia was similar but included contextualisation to reflect local healthcare practices. students were allocated to mixed small groups which were facilitated by practitioners from the fields of medicine and pharmacy, at least one of each profession per room. the facilitators had been trained previously in ipe methods. this was designed to be completed in minutes. ( ) reflect | post-class -this comprised a brief reflection and feedback survey. it was delivered online via the university's learning management system. students completed this on their own time after the face-to-face activities. this was designed to be completed in approximately minutes. the scheduling of the ipe activity was synchronised with the timing of the usual instruction about asthma diagnosis and treatment in both the medicine and pharmacy courses in both countries. we held the face-to-face activities on the same day at the main university campuses in australia and malaysia. the country-based activities were designed to run in parallel (i.e. students in australia were not interacting directly with students in malaysia). within countries, there was no explicit expectation of continued student-student communications following the conclusion of the activity. we measured student perceptions with a pre-and post-activity survey using the validated student perceptions of interprofessional clinical education-revised instrument, version (spice-r ) instrument provided by zorek in based on zorek et al. [ ] . we selected this instrument based on relevance to our goals, soundness (i.e., comparative fit, overall reliability, and factor reliability) and ease of use. the instrument consists of items with a -point likert-type response scale allocated to three factors (interprofessional teamwork and teambased practice, roles/responsibilities for collaborative practice, and patient outcomes from collaborative practice) [ ] . these factors were inspired by the seminal report of north america's interprofessional education collaborative [ ] . students responded to the survey via the university learning management system. we collected student and facilitator feedback on the quality of the experience via separate online surveys. this feedback was for quality improvement and is not detailed in this manuscript. all second-year medicine (n = in australia and n = in malaysia) and pharmacy students (n = in australia and n = in malaysia) participated in the -minute educational intervention as part of their required units. because of an imbalance in the size of the cohorts, in australia, the mixed groups were seated at tables of six with a : ratio of medicine to pharmacy students. in malaysia, the mixed groups were approximately evenly distributed. although all students in all cohorts participated in the ipe activity, participation in the research component was elective. students were provided information about the optional research aspect via the university learning management system and a brief presentation to their class by one of the investigators. consent was implied by completion of the optional surveys in the university learning management system after reading the participant information and consent form. survey data were managed descriptively and analytically. descriptive analysis involved the calculation of means, frequencies, and range of scores on the student survey responses. analytical analysis included a mann-whitney u test to assess between-group differences; wilcoxon signed ranks test to determine pre-to-post change in item scores, and a paired samples t-test to detect changes in perception for each of the three factors within the spice-r tool. engagement in the research portion of the activity varied by profession and country of participation (see figure ) . a total of / ( %) of students participated in the evaluative research by completing both the pre-and post-activity surveys. after the activity, we observed positive changes in most items for both medicine and pharmacy students. in particular, there was a significant increase in medicine students' responses in / items and overall significantly higher responses from the cohort in malaysia. table details the comparative changes in spice-r responses pre-/post-activity across professions and countries. when we looked more specifically at the three factors described in the spice-r survey (i.e., factor = teamwork and team-based practice, factor = roles and responsibilities for collaborative practice, and factor = patient outcomes from collaborative practice), after the activity, we observed significant changes in factors and with moderate to large standardised effects ( . - . ). table details these results. in implementing and evaluating a large-scale learning activity designed for second-year medical students and second-year pharmacy students based in australia and malaysia, we learned several important lessons. first, the activity was logistically challenging but feasible with overall positive outcomes. working from a shared vision (i.e., starting from the learning objectives of the ccc framework), engaging in careful planning (i.e., coordinating frequent video conference calls with the planning teams across two countries), using familiar platforms (e.g., shared learning management system), and incorporating robust evaluation (i.e., using the validated spice-r instrument [ ] ) helped to build community and to justify the value. this is consistent with the intended use of the shared ccc framework [ ] and previous guidance [ ] . the evaluation data and the quality improvement feedback from students/facilitators have been used to improve this activity for subsequent implementations. it has also been used to design subsequent ipe activities involving other health professions in the university. second, the customisation of the activities for different geographies/practice systems/contexts was critical. for example, although instruction on both campuses is in english, the differing healthcare systems in australia and malaysia meant that we sometimes used different terminologies. when describing a specific device for delivering inhaled treatments, we called this a 'puffer' in australia and a 'pump' in malaysia to reflect standard practice. more importantly, we had to acknowledge with great care the potential barriers between healthcare professionals in the public/private sectors. for example, since both general practitioner clinics and pharmacies in malaysia are private businesses, facilitators specifically addressed the potential perception of some competition between professions. the facilitation methods are also likely to have differed somewhat by country, despite using a similar facilitator training process and activity guide. specifically, the shift from didactic teaching methods to active student learning was reported to be more challenging on the campus in malaysia. consistent with the recommendations of lee et al. [ ] and haruta et al. [ ] . ipe should differ across context. this is not only due to the way different health professions interact in practice settings but also to instructor exposure to other health professions and other instructional methods in the academic setting. rather than replicating curriculum across contexts, we acknowledge the need to work towards an equitable, context-sensitive, and locally-driven approach to implementing ipe. [ ] for example, we learned through this activity that it was important to show realistic examples of good practice in a culturally appropriate format. one example of a change we introduced in a subsequent implementation of this activity was to show a video example of a potential phone call between a general practice doctor and a community pharmacist to demonstrate a positive australian interaction. in malaysia, the team chose to demonstrate a similar message via a live role-play of the scenario. third, the variation in improvement across the three factors of the spice-r instrument may have been influenced by the design of the learning activity. one of the tasks included in the workshop was for the medicine/pharmacy small groups to map out the roles and responsibilities of all the health professionals who were providing care to the patient in the case. this task is directly related to factor (roles/responsibilities for collaborative practice) in which we saw significant improvement. another workshop task was for the groups to outline the benefits to the patient of the team working together. this task is directly related to factor (patient outcomes from collaborative practice) in which we saw significant improvement. in comparison, factor focuses on teamwork in practice. in australia, one spice-r item consistently observed little change, i.e., 'participating in educational experiences with students from different disciplines enhances my ability to work on an interprofessional team.' we suggest that this was related to the fact that our intervention was a brief, one-time, classroom-based activity in students who had not previously worked together and who had, at this point, only limited exposure to direct patient care activities. it also supports the need for interprofessionalism to be integrated across the continuum of health professions courses. recent study of nursing and pharmacy students working together through multiple stations of high-and medium-fidelity simulation activities suggests that this intensity influenced their respect for collaboration by healthcare team members to improve outcomes [ ] . still, multiple, contextually relevant, experiential work-based learning activities may be necessary to master the hierarchy of knowledge described in the entry-to-practice level of the curriculum framework. next, we noted that while engagement in the activity was high, participation in the research varied by profession and country. this suggests that the way the program was framed by the instructional leaders for each of the four cohorts (i.e., medicine australia, medicine malaysia, pharmacy australia, pharmacy malaysia) may have differed. one specific difference was that the coordinator of the integrated medical unit in australia was not directly involved with the design, delivery, or evaluation of the activity. although he supported conceptually the implementation of the curriculum, his lack of visibility may have influenced student perceptions of the value of contributing to the research. faculty modelling of the importance of interprofessionalism has been reported to impact on student perceptions in previous studies [ ] [ ] [ ] [ ] . finally, our pre-/post-activity results largely align with previous published use of the spice instruments [ , ] , extending these findings to larger and different cohorts. differences to note include that we did not find a whole of cohort significant prepost difference in the item relating to improved patient satisfaction when care is delivered by a team, although the baseline measures in our study were higher. we did find a whole of cohort significant change in two items that prior study did noti.e., items relating to educating health profession students together to establish a collaborative practice, and involving medical and pharmacy students in teamwork during their education to understand roles. this was the first ipe activity for our students (both campuses) and the carefully constructed addition to the curriculum was positively perceived. our study demonstrates an equitable, contextsensitive, and locally driven approach to implementing ipe that other educators may find useful. still, these results have some limitations. first, we did not collect demographic data from students other than their profession and site. other demographic factors such as gender, previous study, international status, and ratio of medicine to pharmacy students may also have contributed to our outcomes. in addition, the lower participation rate by medical students in australia may influence the representativeness of this information. despite these imperfections, student perceptions about the activity were positive. in particular, participants expressed improved understanding of roles and responsibilities and the potential for better patient outcomes through collaborative care. we capitalised on this when the covid- pandemic of compelled us to redesign the activity quickly for wholly online delivery [ ] . we can also use these results to develop longitudinal activities that bridge from the classroom to health-system settings. furthermore, we highlight the potential influence of the learning activity design on the variation in improvement across the three factors of the spice-r instrument and the need to integrate interprofessionalism across the continuum of health professional courses. in so doing, health professions education can better promote and strengthen collaboration for patient care, learning about, from, and with other members of the healthcare team for better healthcare delivery. world health organization. world health organization framework for action on interprofessional education and collaborative practice _ e n g . p d f ; j s e s s i o n i d = f cbcbf ef d c c ?sequence= standards for assessment and accreditation of primary medical programs by the australian medical council registered nurse accreditation standards [internet]. canberra act: australian nursing and midwifery accreditation council australian pharmacy council. australia/new zealand accreditation processes [internet]. canberra act: australian pharmacy council guidelines on approval and recognition of a pharmacy program guidelines for accreditation of the malaysian undergraduate medical education programme a comparative study of interprofessional education in global health care. a systematic review current trends in interprofessional education of health sciences students: a literature review exploring issues of cost and value in professional and interprofessional education transformative education for health professionals beyond homogenization discourse: reconsidering the cultural consequences of globalized medical education time to chat about globalisation creating a collaborative care curriculum framework effective interprofessional education: development, delivery and evaluation worldwide severity and control of asthma in children and adults: the global asthma insights and reality surveys development and evaluation of an innovative model of inter-professional education focused on asthma medication use pharmacists' perceptions of their role in asthma management and barriers to the provision of asthma services barriers to the provision of asthma services and perceived practice towards asthma management among urban community pharmacists in selangor, malaysia national asthma strategy [internet]. canberra act: national asthma council australia interprofessional education in health sciences: the university of queensland health care team challenge promoting interprofessional understandings through online learning: a qualitative examination interprofessional health education in australia: three research projects informing curriculum renewal and development considerations in the establishment of interprofessional education programs in the workplace the times are changing: workforce planning, new health-care models and the need for interprofessional education in australia the attitudes of medical, nursing and pharmacy students to inter-professional learning together we stand, divided we fall: interprofessional collaborative practice competencies from malaysian medical professionals' perspectives attitudes and readiness of students of healthcare professions towards interprofessional learning. plos one assessment of attitudes for interprofessional team working and knowledge of health professions competencies for final year health professional students. taps acceptance of interprofessional learning between medical and pharmacy students in a prescribing skills training workshop: pre-post intervention study refinement and validation of the student perceptions of physician-pharmacist interprofessional clinical education instrument measuring changes in perception using the student perceptions of physician-pharmacist interprofessional clinical education (spice) instrument interprofessional education collaborative expert panel. core competencies for interprofessional collaborative practice: report of an expert panel interprofessional education collaborative a comparison of the validity of two instruments assessing health professional student perceptions of interprofessional education and practice a plan for embedding an interprofessional education initiative into an existing programme in a southeast asian university translation and cultural adaptation of the japanese version of the interprofessional facilitation scale two heads are better than one" -pharmacy and nursing students' perspectives on interprofessional collaboration utilizing the ripe model of learning attitudes of health sciences faculty members towards interprofessional teamwork and education health science center faculty attitudes towards interprofessional education and teamwork understanding attitude of health care professional teachers toward interprofessional health care collaboration and education in a southeast asian country faculty attitudes about interprofessional education virtual workshops to preserve interprofessional collaboration while physical distancing the authors acknowledge benny efendie, johnson george, jennifer lindley, and sivalal sadasivan for their assistance with the implementation of the activities in australia and malaysia. we also acknowledge kayley lyons and paul white for review and feedback on manuscript drafts. at the time of this work, all authors declare that they had no actual or potential competing financial interests. this project was not supported by external funding. key: cord- -m nepej authors: pham, tien duc; nghiem, son; dwyer, larry title: the determinants of chinese visitors to australia: a dynamic demand analysis date: - - journal: tour manag doi: . /j.tourman. . . sha: doc_id: cord_uid: m nepej although china has progressively become an important inbound tourism market for australia, its demand elasticities have been little studied to date. this study examines the determinants of chinese visitors to australia using a dynamic time-series estimator. interesting findings include a high income elasticity as a source of the continuous doubledigit growth rates in chinese arrivals that australia has experienced over the past two decades, together with relatively high total trip price elasticities for both short run and long run. a trend of chinese outbound to australia is also identified. from a policy perspective, the results confirm that keeping a low cost of visiting australia, both ground and travel costs, is a good strategy to secure greater numbers of chinese tourists. the strong economic growth in china has raised the middleincome class of the country significantly and stimulated substantial growth in outbound tourism to many countries around the world, including australia. the income effects on tourism demand from the middle-income class of china were well observed and documented in literature. earlier, when hong kong was first granted approved destination status, chinese tourists were described as locusts who ravaged hong kong's economic landscape, leaving nothing behind (liu & mckercher, ) . to some extent, adverse impacts of price increases in the destinations on tourism demand from china did not seem to materialise. as its economy has grown, tourism demand from china has impacted on most countries. china has become one of the key inbound markets for australia and has played an increasingly important role in boosting the australian tourism sector. the growth of this market still has much more to offer in the coming years, stemming from the pulse of the middle-income class amongst a large size of the chinese population. despite its increasing importance for many destinations worldwide, very little is known about the sensitivity of chinese demand for tourism to changes in key economic variables, except for destination hong kong (li, song, cao, & wu, ) . the determinants of the chinese market in other destinations have not been examined clearly and specifically. it is imperative for australia's policy makers and the australian tourism industry to understand the determinants of chinese tourists accurately in planning and policy development. in particular, the extent to which chinese visitors are sensitive to price changes is a crucial factor informing tourism policies in australia. if chinese visitors are indeed price inelastic, policy makers could take advantage of this and set the price in favour of the australian tourism industry. in contrast, if they are price sensitive, an increase in prices could result in a substantial loss of tourism revenue from chinese tourists. this paper fills an important gap in the literature to help formulate tourism policies to nurture the growing momentum of the australian tourism industry. it provides timely information, and raises awareness, to better manage an important market. a dynamic demand analysis is undertaken to determine the important factors underpinning inbound tourism to australia from china. the paper begins with a brief overview of important features of the australian tourism industry together with a review of previous australian studies on tourism demand. it then outlines the adopted approach, provides a description of the study methodology and data, and interpretation of the results. the paper concludes with a discussion of the importance of the findings for tourism stakeholders in australia and elsewhere. although set in the china-australia context, the findings in this paper should be of interest and value to those directly involved with the marketing and management of chinese tourists in many other countries. for several decades, tourism has been a key industry contributing to the australian economy through its export capacity. more recently, macro-economic conditions have been conducive for tourism growth, particularly the inbound sector, given the depreciation of the australian dollar, the release of employment from the downturn of the mining boom, and the reduced demands for aeroplane seats by the fly-in fly-out (fifo) workers associated with mining (pham, jago, spurr, & marshall, ) . tourism shares of gross domestic product (gdp) for both domestic and inbound tourism sectors peaked in e (fig. ) , and have settled at slightly lower levels at approximately . per cent and . per cent, respectively, over the last three years. however, it appears that the tourism sector has not been able to accelerate to its full extent to take advantage of the macro-conditions. in e , tourism contributed $ . billion to gdp, with $ . billion from the domestic tourism sector and $ . billion from the inbound sector (the australian bureau of statistics, or abs, ) . of the inbound sector, latest data from tourism research australia (tra) for the past decade show china and india to be the two fastest growing markets (table ) . arrivals from both markets have sustained double-digit growth over an extended period. chinese arrivals growth reached per cent in e , slightly more than two percentage points above that of india ( . per cent). however, from a low base, in e the indian market share reached approximately three per cent of total inbound tourism expenditure, about the same level as that of singapore, malaysia, south korea and hong kong ( table ). the indian market still has much potential in the years ahead, given the rapid development and large population of the indian economy. for china, the expenditure share had expanded from per cent in e to per cent in e , putting china at the top among all inbound markets in australia, driving the australian tourism industry on its trajectory toward the tourism target (tourism australia, ) . given the rapid increase of chinese arrivals in australia, one might have thought australia would be one of the favourite destinations that chinese tourists would go. latest data from the united nations world tourism organisation (unwto, ) in table show the mix of destinations that chinese visitors have travelled. australia was not among the top ten destinations of chinese tourists in . while it is not surprising to see countries in proximity to china such as hong kong, macao, korea, thailand, taiwan and japan on top of the list, it is interesting to see countries including the united states of america, france and russia ranking above australia. this observation highlights a need for australia to formulate tourism policies carefully in such a way to penetrate the chinese market more effectively. thus, it is crucial to understand the determinants of the chinese tourist arrivals to australia. as summarised in lim ( ) , crouch ( ) , song and li ( ) , and peng, song, crouch, and witt ( ) , previous studies on modelling tourism demand and forecasting have typically been based upon fundamental economic theory capturing the effects of income, own-price, cross-price and occasionally some other specific factors included as dummy variables. the determinants reflect the interaction of drivers between the country of origin and the destination country. thus, both sides of 'a trip' can have an influence on the number of arrivals at a destination. from the country of origin e tourism generating region e income is predominantly applied in most of previous tourism demand studies; it is a fundamental concept of the economic demand theory. income is often proxied by gross domestic product (gdp), personal (disposable) income or national income. studies over the past three decades undertaken for many countries reveal that the purchasing power of individuals is an important influence on their decision to travel. an increase in real income provides consumers with greater spending power, resulting in the increased discretionary consumption of many types of products including tourism (crouch, ; peng et al., ) . at the destination country, depending on the study purposes, prices applied in previous studies range from a highly disaggregated commodity level (divisekera, ; wu, li, & song, ) to the national aggregate level (lim & mcaleer, ) . thus, the actual form of prices varies between studies. however, the lack of a tourism price index per se was, and still is, a real challenge in modelling tourism arrivals. individual researchers have adopted various proxies as a result. the most common ones are price-adjusted exchange rates (i.e., real exchange rates), consumer price indexes of destinations and transportation costs. in some cases, cpi and exchange rates have been used in a comprehensive combination to derive own-price and competing prices song, wong, & chon, ) . the use of cpi as a proxy for tourism prices is rather controversial. o' hagan and minnock ( ) argue against the practice, in contrast to the supporting findings in morley ( ) that, since non-fare tourism prices and cpi are highly correlated, the cpi could be used as a proxy for a tourism price index. in such situations, interpretation of the estimated coefficient is problematic, as implicitly visitors were assumed to be in the country already regardless whether or not they could afford to pay for the airfares. for comparing with cpi, morley ( ) derived tourism price indexes directly by combining the individual price indexes of goods that are associated with tourism consumption and the corresponding expenditure shares. this approach coincided with the tourism satellite account (tsa) framework that was introduced by the unwto ( , ) . this approach has inspired and orientated our thinking in this paper. an important observation here is that most studies have applied prices to reflect the cost of living for tourists at the destination (such as cpi or real exchange rate) to measure the own-price effects, with some also adding transportation costs (airfare) to measure the response from tourists when transportation costs change. while table historical annual growth rates of arrivals of australia's top ten international markets (per cent). this separate treatment of transportation cost may be appropriate in some situations (e.g., where countries of origin and destination are close together and particularly where transport substitution is possible (martin & witt, ) ), it may not be practical for the case of australia where airfare can determine whether or not a trip takes place. a bundle approach (i.e., total costs including airfare) to measuring price effects for travelling to australia is probably more realistic (divisekera, ) , since high airfares that require a larger budget to come to australia could deter some visitors, even though they are willing to pay for costs of living while in australia. in that case, the non-airfare spending will never eventuate. alternatively, cheaper airfares during promotion periods, or an introduction of new low-cost carriers, may not suffice to attract additional visitation expenditure in australia if an expensive destination reduces "length of stay". in that case, the airfare spending will also not eventuate. what matters here is the required total budget for travelling, including the cost of travelling (airfares) and the cost of living (accommodation, food and drinks) that simultaneously make a trip affordable and worthwhile for visitors to travel. regarding inbound tourism demand to australia, kulendran ( ) , kulendran and king ( ) , lim and mcaleer ( ) , divisekera ( divisekera ( , , lim, mcaleer, and min ( ) , examined the international short-term tourist flows to australia from japan, new zealand, singapore, the uk, and the us. visitors from those countries of origin were found to be very responsive to changes in tourism prices in australia and changes in their income, indicating that international tourism is a luxury product. seetaram ( seetaram ( , , and seetaram and dwyer ( ) used the dynamic panel data technique to model international arrivals to australia from ten markets, including china, over the period to . seetaram ( ) and seetaram and dwyer ( ) also estimated the relationship between immigration and induced inbound tourism demand. with the panel data, elasticities obtained from seetaram ( seetaram ( , take the form of the aggregate response of the inbound tourism sector across all ten markets. given the fact australia was granted approved destination status in , and china's economic growth has been much faster than any of those selected countries, using the aggregate income and price elasticities from a group of ten markets as a proxy for the chinese market is very likely to under-estimate the response from chinese visitors notwithstanding the fact that the aggregate elasticity estimates are valuable for the policy making process at the aggregate level. to the best of our knowledge, to date there is no published study on tourism demand elasticities for chinese visitors to australia as a destination. this study will fill the gap by estimating those demand elasticities and determinants of chinese tourists to australia. given the available time-series data and our interest in estimating the elasticities of chinese visitors to australia, we specify a dynamic demand relationship in equation ( ). the number of chinese arrivals is chosen as the dependent variable. the independent variables include three main groups of variables: income factor (proxied by gdp per capita), price factor (proxied by the weighted price), and other factors representing changes in the operating environment of tourism as well as migration flows from china to australia. these choices are broadly consistent with most other tourism demand studies over the past five decades as pointed out in crouch ( ) , lim ( ) , dwyer ( ), seetaram ( ) , dwyer, seetaram, forsyth, and king ( ) , and peng et al. ( ) . all variables in equation ( ), except the dummy variables, are implemented in the annual growth form to mitigate effects of possible heteroscedasticity. the advantage of using growth rates is that the marginal effects (i.e., coefficient parameters) can interpreted as elasticities, which is similar to the doublelog form that has been commonly used in previous studies. as the same for the double log form, the elasticities derived from equation ( ) are not changing over time, they are the average elasticities over the whole study period. with the lagged dependent variable incorporated in the model, we argue that chinese visitors could either return to visit australia after the first visit, the kind of habit persistence or stable behaviour patterns as applied in martin and witt ( ) and , or they could promote and convince their neighbours, friends and relatives to visit australia after they return home from their trips. we explicitly emphasise the role of this factor as a determinant of tourism demand. if it is in the form of word of mouth, then this "advertising" should be taken seriously, as in a way it is free publicity. furthermore, it is essential to know how australia is perceived by chinese visitors by the inclusion of this variable, which could be either positive or negative, depending on their experience while they are in australia. from a technical point of view, the lagged dependent variable allows us to examine the effect in the short-run and the long-run explicitly. this study adopted the real gdp per capita as an income measure to explain the movements of chinese visitors. the bundle approach combines the costs of domestic and international travels in a weighted average sum to estimate the price index variable. in particular, we make a slight variation to morley's approach to deriving tourism price index for chinese visitors using the two tourism price indexes published by the australian bureau of statistics (abs), one for domestic and one for international travelling. both contain price movements of airfares and accommodation. the domestic price index is dominated by a large accommodation share. it is what both domestic and foreign visitors face when travelling within australia e the cost of living for tourists at the destination from the perspective of the chinese visitors. the international price index is predominantly represented by the longhaul airfares for the australian outbound. as the international competition will force airfares of all international carriers to move broadly in line with each other, the abs international price index would be the same with the price index that inbound foreign visitors to australia would also have to face e the cost of travel to the destination (martin & witt, ; witt & witt, ) . to combine both airfares and cost of living, the australian tourism satellite account data for inbound tourism expenditure abs ( ) indicate that the long distance transportation cost dominates, accounting for nearly per cent the total. using this ratio ( : ), a tourism price index for chinese visitors was derived using per cent of international price index (airfare) and per cent of the domestic price index (cost of living). this approach is similar to that in kulendran ( ) , in which the ratio of : for transport to accommodation costs was applied for the japanese visitors. the reason for a low accommodation share in tourism expenditure for chinese visitors is probably because the chinese community in australia now is much larger than the japanese community of the s; the free accommodation offered by families and friends could reduce the accommodation expenses for the chinese visitors. the chosen specification presented as equation ( ) does not include the bilateral exchange rate between china and australia, as the exchange rate was found to be statistically insignificant during the model testing. the rationale for not using the exchange rate is that the yuan has been heavily influenced by trade policies to promote exports from china, and is tightly controlled by the chinese government. analysis from fxcm market insights pointed out that the "yuan has not been made fully convertible" (fxcm ). furthermore, the practice of two rates, offshore (cnh) through the bank of china in hong kong, and onshore (cny) in the mainland (desloires, ) , helps to de-associate the link between exchange rate changes and outbound tourism by the chinese. in term of cross-price effects, we share the view of crouch, schultz, and valerio ( ) that since australia is rather distant from all other major destinations, price substitution or price complementary are not influential. in addition, the consistency of price indexes in the bundle approach across all possible countries is a real challenge. thus, the inference of the estimates would not be very accurate if other destinations were to be incorporated as substitutes. hence, equation ( ) does not include cross-price elasticity. the group other factors includes migration flow from china and four dummy variables capturing events that happened during the study period e ( observations), namely the breakout of the severe acute respiratory syndrome (sars) in late , shocks in the domestic travel supply caused by the australian mining boom; the global financial crisis (gfc) ; and a trend in tourism demand for travel by the chinese. chinese migration is expected to have positive effects on tourism via visiting friends and relatives (dwyer, pham, jago, bailey, & marshall, ) . other mechanisms through which migration can affect tourism include: making the destination country more tourism attractive with diverse culture; business networks that connect the destination and an origin country, stimulating business travel (seetaram & dwyer, ) . when sars broke out in guangdong province of china in november , it effectively reduced the number of travellers significantly across many countries, particularly for visitors from china. the event was modelled as an intercept change for . it is expected that sars has a negative effect on tourism (dwyer, forsyth and spurr, ) . in , the mining boom in australia began to absorb a substantial amount of hotel rooms and air transport capacity to facilitate the needs of the fifo mining workers pham et al., ) . the fifo activity imposed a severe constraint on the supply side of the australian tourism sector, at least over the period from to , during which aviation and accommodation services could not be expanded quickly to satisfy the demands from both mining and tourism industries. in this context, the supply constraint is incorporated as a dummy variable for the period e . we expect that this variable has a negative sign due to the supply constraint for both transport and accommodation. the global financial crisis (gfc), starting in , reduced household consumption and created a loss in consumer confidence across many countries. while the gfc effects still linger for many countries, its exact time span for china is not clear-cut, since the economy grew at per cent in , well above the economic growth rates of many other developed and developing countries. however, comparing the performance of the chinese economy before and after the gfc, it is clear that the chinese economy was building growth momentum, rising upward from per cent in to per in , but from , it has actually been trending downward from per cent to just slightly above per cent growth in recent years (the world bank, ; imf ) . for this reason, the gfc dummy variable is adopted for the period from onwards. it is expected that the gfc has a negative effect on tourism via its affects to the budget constraint of travellers (li, blake, & cooper, ) . although the chinese economy has slowed down, the strong long-run growth path of the economy throughout the period since has certainly changed consumer behaviour over the course of time. it is well documented in economic theory that, when growth is continuously strong over a long period, income increases become more permanent and consumer behaviour will move toward the purchase of more luxury goods. tourism is generally perceived as a luxury consumption item (crouch, ) and people might use it to state their social-economic status among friends and relatives. as such, in developing countries like china, demand for travel might be added to the household consumption bundle of the wealthier residents. that this trend is likely to apply to the chinese population is justification for our assumption to include the trend variable. because the trend reflects aspects of economic growth (i.e., increase travel budget) and technological progress (i.e., lower travel costs), we expect that the trend variable has a positive sign. in summary, expected signs for the coefficients are as follows. all data in this study are presented in yearly percentage change format and cover the period of e . due to the yearly data format, we do not need to examine the nature of seasonality in the time series. however, this issue will be examined in the future if monthly or quarterly data sets become available. the time series plot of the main variables in the form of annual growth used in equation ( ) shows no abnormality in the trend and pattern (see fig. ). there is a sharp decline (by . per cent) of tourism arrivals at the outbreak of the sars pandemic in while the global financial crisis only produced a minor fall of . per cent. however, the reductions in these two periods were followed by strong bounce-back corrections, resulting in an average annual growth rate of . per cent in the whole period, which is much faster than the average annual growth rate of gdp per capita ( . per cent) and price index ( . per cent). to check for stationarity of main variables, we use the augmented dickey-fuller test with the null hypothesis that the series have a unit root. the test results rejected the null hypothesis for tourist arrivals (p-value ¼ . ), lag of tourist arrival (p-value: . ), cost index (p-value ¼ . ), and migration flows (pvalue ¼ . ) but failed to reject the null hypothesis for gdp per capita (p-value ¼ . ). despite one of the regressors having a unit root, we can still proceed with the analysis if all regressors are not cointegrated. the johansen trace test for cointegration failed to reject the null hypothesis that the rank of the cointegration matrix is zero (test statistics: . ; critical value at %: . ). thus, we are confident that these variables can be used to estimate the determinants of chinese arrivals in australia as specified in equation ( ). because the lagged dependent variable is included, the error term in equation ( ) may have serial correlation. to mitigate this issue, we firstly applied the prais-winsten regression to take into account possible heteroscedasticity and serial correlation in the error terms. the diagnosis tests show that the regression residuals meet the required criteria. in particular, the durbin h test failed to reject the null hypothesis that the regression residuals do not have autocorrelation (p-value: . ) while the portmanteau test failed to reject the null hypothesis that the residuals are white noise (pvalue: . ). to check for the robustness of results, we then conducted the cochrane-orcutt regression, which is an alternative approach to control for serial autocorrelation in equation ( ). although results from both techniques are similar, the cochrane-orcutt estimator is better for model selection criteria (i.e., akaike information criterion e aic, and bayesian information criterion e bic) are lower (see table ). thus, it is a preferred model in this paper. we now focus on discussing results of the cochrane-orcutt estimator. overall, all coefficients in table have the expected signs. the results confirm a lag effect of the arrivals from the previous year e every one percentage point increase in the number of arrivals in a year is associated with about . percentage points increase in arrivals in the following year. the positive sign for the lagged dependent variable indicates that chinese visitors have a positive perception of australia as a tourist destination. the result is strongly consistent with tra's unpublished data for the period from / to / which show approximately per cent of chinese arrivals are repeat visitors (data provided to authors). while the lagged variable indicates an immediate effect between two consecutive years, the historical data simply recorded the return visitors in general, not specifically referring to those coming back immediately after their visits in the previous year. results show a trend of . per cent growth per year in arrivals to australia from china. by itself, it appears to be rather a strong trend. however, putting this value in the context of the arrival ( ) growth rates with an average of . per cent per annum over two decades (and at times the rates went up to per cent and per cent), the value of the trend coefficient is realistic. understanding the causes of this trend is beyond the scope of this paper. this remains a critical area for further research to explain how the australian marketing agencies can influence such a perception among chinese travellers. also, an important question for future research would be how large are the outbound trends from china to other countries, as compared to the results for australia. results for sars, mining-boom-induced supply constraints and gfc are highly statistically significant. adverse impacts of these events on the number of the chinese arrivals to australia appear to be larger than the changes in the observed historical data. the reason is that, while the observed changes are the net simultaneous results of various factors, the regression parameters isolate and represent the effects of each factor individually without the interactions of the others (i.e. parameters are measured with the "ceteris paribus" or "all else remain constant" assumption). however, when considering all factors together, the net effects of parameters are close to the observed data. for example, the predicted mean effects of all factors in apart from sars is . per cent; hence, the effective impact of sars is only per cent ( . e . ), which is close to the observed change of the per cent reduction in . the growth rate of chinese arrivals to australia has generally increased faster than the gdp per capita growth rate in china. this results in a short-run income elasticity of . per cent, implying a long-run income elasticity of . per cent. the value of the longrun income elasticity is slightly higher than that of japanese tourists ( . %) that kulendran ( ) estimated earlier when japanese tourists were prominent in australia. as demand for necessities will not grow faster than, or even proportional to, income increases, a value greater than unity of the income elasticity in this case reflects the luxury consumption nature of a tourism experience in australia among the chinese. this high income elasticity explains clearly the source of the continuous double-digit growth rates in chinese arrivals that australia has experienced over the past two decades. indeed, in any years without major events, sars for example, the income effect has predominantly driven the total chinese arrivals. with low population growth rates in china (approximately . per cent per annum), the gdp per capita growth rates of the country are nearly the same as the gdp growth rates; this implies the economic impact of china's gdp growth on tourism demand will not be discounted on the per capita basis (gdp divided by the size of the population). even at the projected gdp growth at the low end of per cent for china in the next few years (imf, ) , this high income elasticity will continue to sustain a significant tourism demand for australia. the value of the income elasticity is strongly reinforced, independently, by the projection of the chinese arrivals growth rate of . per cent for e by tra ( ) given a forecast of . per cent growth for china's gdp. it is important to note that the price elasticity in this paper is on the basis of the total trip costs, including the costs of living and costs of airfares (also referred to as travel or transportation in previous studies). thus, a one per cent increase in the price index for chinese visitors used in this paper is equivalent to a combined uniform increase of one per cent for both the costs of living and the airfares simultaneously in other studies which have two separate price components. the estimated short-run price elasticity for chinese visitors is À . % (table ) , with a long-term price elasticity of À . %. this long-run price elasticity is larger than those individual long-run price elasticities for the cost of living (À . %) and the cost of transportation (À . %) that divisekera ( ) estimated earlier for japanese tourists. however, on an equivalent basis, the impacts of per cent increase in the tourism price index in this paper should be compared to the sum of both individual price elasticities, À . plus À . , per cent for japanese tourists. thus, in comparison, japanese tourists back then were even more price responsive than chinese visitors currently, À . per cent as opposed to À . per cent. however, compared to the aggregated long-run elasticities in seetaram ( ) for all inbound markets in australia, the elasticities in this paper for the chinese visitors are higher, at the upper end of the range. again, the long-run price elasticity of À . per cent in this paper should be compared with the sum of both price and airfare elasticities in seetaram ( ) , À . and À . per cent respectively. this difference is expected, as compared to all other regions in seetaram's study, china is the fastest growing economy; thus, the response to price changes are much stronger. it may well be the case that chinese tourists to australia are more price sensitive than other key markets given the large proportion of first time travellers. a study of tourism to malaysia (habibi & rahim, ) estimated a price elasticity of demand for visitors from china of À . , the highest price sensitivity of the ten inbound markets studied. overall, estimated elasticities in this paper are within the range of elasticities estimated in previous studies. together with the income price elasticity, the absolute value greater than one for the price elasticity reinforces the fact that tourism is indeed a luxury consumption for the chinese. the high value of the price elasticity is simply because australia is far from china, airfares are relatively expensive, and in addition to the costs of living in australia, the cost for a trip to australia can take up a large proportion of an average chinese household income. any price changes can lead to changes in the travel decision of chinese visitors. thus, the bundle price elasticity is an important determinant for policy makers in australia to keep in mind when considering policies directly related to the cost of trips as a whole. the effect of migration is significant but with a modest magnitude of . in the short run and . in the long run. our estimated parameter is higher than that of seetaram ( ) with an estimated immigration elasticity of . for the short run and . for the long-run for main tourist markets in the e period. the higher magnitude of migration elasticity in the long run of this study is in line with the finding of dwyer et al. ( ) who found that the elasticity of migration for tourism in was . compared to . in . ideally, the bundle price index could have been estimated using all individual price series associated with chinese tourists' consumption and the expenditure shares that chinese tourists spend in the consumption bundle. unfortunately, the expenditure series of the international visitor survey (ivs) data are only available for the period from to to e (tourism research australia, ) , which severely constrains the number of observations available for this study. technically, data for ivs prior to e could be "backcasted" but results are not guaranteed to produce consistent time series data as the survey methodology has been revised several times. as a result, the direct approach, as outlined in morley ( ) , was not able to be undertaken. the movements of airfares for chinese visitors are then based on the domestic and international holiday travel and accommodation price series (abs, ) . in particular, the airfare price index for chinese visitors is proxied by the australian outbound series as the exact airfare price index for chinese visitors would require the shares of airlines that chinese visitors used and the corresponding average airfares. such information was not available. thus the ratio : was used. this ratio can change over time, as consumption patterns can change over time, resulting in changes in the value of the price elasticity of tourism demand. an important caveat also attaches to the significant economic growth path of china. the size of the chinese economy has grown nearly eight times in real terms from to (the world bank, ), and now is the world's largest economy on a purchasingpower-parity basis (international monetary fund, ) . in such an environment, consumer behaviour is changing so rapidly that longer time series data than the sample size currently available to this study may be required. china's economic growth has become a significant stimulus to many countries, including australia. the sources of stimulus apply across a whole range of industries of australia. the chinese economy is shifting toward more sustainable growth based on consumption and services. thus, growth in chinese outbound tourism demand has played an important role in the australian tourism industry, and is expected to continue to grow in the coming years. tourism is rapidly developing as a luxury consumption item for chinese households. as such, demand for tourism is likely to continue to grow ahead of the chinese gdp growth. on average over the study period, china's gdp per capita grew by per cent, a strong positive influence on the visitor number to australia. gdp growth of china is the main driver for the chinese arrivals in australia. although china's economy has slowed in recent years, the economic growth of the country still generates double-digit growth in its tourist arrivals to australia. chinese visitors are also very responsive to price signals. hence, it is important to keep prices in australia to a minimal level, as the impacts of price increases will be detrimental to the level of inbound demand from china. the australian government has implemented a raft of tourism reforms in recent years including more direct flights between australia and selected markets (china included), simplifying tourist visa applications offering online options for a wide range of countries, granting multiple entry options to key markets (including china), widening criteria for the working holiday maker visas, and adding more occupations to the skilled occupational list (tourism australia, ) . these reforms effectively open up market access for the australian tourism sector, and certainly this is the right direction to boost inbound tourism revenue. the keys to achieving maximum revenue from china tourists are to (a) ensure more convenience for travelling to australia and (b) maintain cost effectiveness so that the high income demand elasticity for travelling to australia of chinese visitors will bring more visitors to australia from china. the present study has major policy implications for destination management. the findings advance our knowledge of the elasticities of demand for tourism arrivals from china, a neglected area of tourism research. as such, they have implications for forecasting tourism arrivals from china as well as policies to maintain high growth from this market. for australia, the combination of high income elasticity with high price elasticity associated with chinese visitors represents a potentially explosive cocktail. a proposal under consideration is to charge a cheaper multiple entry visa fee for tourists from china (pham, son and dwyer, forthcoming) . the potential loss of visa fee revenue will certainly be over-compensated by a large increase in expenditure brought by chinese arrivals. as the chinese economy experiences its expected slowdown into the future, the growth rate of visitors to australia is likely to slow also. in this context, since australia is already a high price destination ranked from countries in world economic forum ( ), any increase in costs could exacerbate this decline. policies to reduce costs or at least to keep it in check, should continue to support healthy tourism flows from china. australian national accounts: tourism satellite accounts effect of income and price on international tourism marketing international tourism to australian -a regression analysis dirty float': how china manages its currency. the sydney morning herald an econometric model of international visitor flows to australia a model of demand for international tourism domestic demand for australian tourism: an almost ieal demand system effects of sars crisis on the economic contribution of tourism to australia modeling the impact of australias mining boom on tourism: a classic case of dutch disease is the migration-tourism relationship only about vfr? a bound test approach to cointegration of tourism demand modelling international short-term tourist flow to australia using the demand function approach. paper presented at the national tourism and hospitality conference modelling quarterly tourist flows to australia using cointegration analysis forecasting international quarterly tourist flows using error-correction and time series models china's tourism in a global financial crisis: a computable general equilibrium approach review of international tourism demand models modelling the determinants of international tourism demand to australia. discussion paper no. armax modelling of international tourism demand how competitive is hong kong against its competitors? an econometric study the impact of visa liberalization on tourist behaviorsethe case of china outbound market visiting hong kong' tourism demand forecasting models -choice of appropriate variable to represent tourists' cost of living the use of cpi for tourism prices in demand modelling the economic significance of tourism within the european community a meta-analysis of international tourism demand elasticities the economic impacts of a higher visa fee for chinese tourists to australia (under review) the dutch disease effects on tourism e the case of australia. tourism management use of dynamic panel cointegration approach to model international arrivals to australia immigration and international inbound tourism: empirical evidence from australia immigration and tourism demand in australia: a panel data analysis tourism demand modelling and forecastingda review of recent research tourism demand modeling: a time-varying parameter approach modelling and forecasting the demand for hong kong tourism tourism tourism forecasts international visitor survey results jointly presented by the united nations statistics division (unsd), the statistical office of the european communities (eurostat), the organisation for international recommendations for tourism statistics data on outbound tourism forecasting tourism demand: a review of empirical research analyzing tourist consumption: a dynamic system-of-equations approach the authors would like to thank associate professor jaume rossell o at universitat de les illes balears and dr jen-je su at griffith business school for their comments and feedback to the paper. key: cord- - qw t s authors: naylor, mj; monckton, rp; lehrbach, pr; deane, em title: canine coronavirus in australian dogs date: - - journal: aust vet j doi: . /j. - . .tb .x sha: doc_id: cord_uid: qw t s objective to estimate the frequency of serum antibodies (igg and igm) to canine coronavirus (ccv) in the australian dog population and evaluate the role of ccv as a causative agent of gastroenteritis. design a serological survey of antibodies to ccv among different dog populations. procedure the development and characterisation of an indirect elisa for the detection of antibodies (igg and igm) to ccv was undertaken. sera collected from both diarrhoeal and non‐diarrhoeal dogs from various populations throughout australia were tested for these antibodies to ccv. results serum samples ( ) collected from to were tested for the presence of igg antibodies to ccv. samples were divided into two categories on the basis of the number of dogs housed together. the groups were either an open population containing dogs housed as groups of three or less, or kennel populations. sera from . % of the open population and . % of kennelled dogs were positive for ccv antibodies. the prevalence of antibodies varied from zero to % in kennelled dogs. about % of dogs positive for igg antibodies to ccv were also positive for igm antibodies to ccv, indicating recent ccv infection. of those dogs that were presented with clinical signs of gastroenteritis such as diarrhoea and vomiting(n = ), % were positive in the igm elisa and . % in the igg elisa for antibodies to ccv. in comparison, for those dogs presented without any history of gastroenteritis only % were positive for igm and % positive for igg. conclusion serological evidence indicates that infection with ccv in dogs is widespread throughout the australian mainland. the prevalence of antibodies varies greatly among different populations, with an average of . % positive in kennelled populations and . % in the open population. c cv was first recovered from the faeces of dogs during an epidemic of diarrhoeal disease in germany. enteritis was subsequently induced in neonatal dogs by oral inoculation of canine coronavirus (strain - ) isolated from the original outbreak. enteritis accompanied by diarrhoea was characterised by atrophy and fusion of intestinal villi. the infection was not fatal and was self-limiting. subsequently ccv has been isolated from other epidemics of canine diarrhoea and has a worldwide distribution. [ ] [ ] [ ] the extent to which ccv is important as a gastroenteric pathogen in the australian dog population is presently unknown, although ccv and cvlp have been previously reported in australia. [ ] [ ] [ ] in these reports, electron microscopy of faecal samples was used as the detection method with a relatively small number of samples. in this study we determine the prevalence of serum igg and igm antibodies to ccv from a larger number of dogs sampled from throughout australia. ccv tn- strain and crfk cell line were obtained from fort dodge laboratories, iowa, usa. crfk cells were propagated in cm cell-culture flasks at o c (corning, australia) in growth medium containing emem (trace biosciences, australia), mm l-glutamine, . % lah and % fbs not heat inactivated (csl ltd, parkville). maintenance medium for maintaining cells without division consisted of emem, mm l-glutamine, . % lactalbumin hydrolysate and % fbs not heat inactivated. positive control serum (pooled sera from dogs inoculated with ccv tn- ) and negative control serum (pooled sera from specific pathogen free dogs) were obtained from fort dodge laboratories, iowa, usa. these serum samples were further verified by serum neutralisation assay as described by mochizuki et al. elisa antigen preparation roller bottles of cm surface area (corning, australia) with crfk cells at % confluency were infected with ccv (tn- ) at a multiplicity of infection of . . after incubation for h at o c, cells were harvested by scraping with a cell scraper and resuspended in ml of pbs. cells were washed three times by centrifugation at g for min and resuspended in ml of pbs containing . % sodium deoxycholate and incubated for min on ice. open population -of the dogs tested, igg antibodies to ccv were detected in ( . %), (table ) . from this group, clinical histories were obtained for dogs. twentyeight of these dogs had signs of gastroenteritis such as diarrhoea, vomiting and weight loss and all dogs were negative for gastroenteric pathogens such as cpv as determined by independent pathology laboratories. twenty-four of the were positive for ccv antibody (igg), with elisa od results equivalent to those obtained from experimentally infected dogs (unpublished data). antibodies (igg) to ccv were detected in of the remaining for which histories were obtained but which did not have diarrhoea or any other signs of gastroenteric infection at the time of presentation. kennel populations -of the group-housed dogs, igg antibodies to ccv were detected in ( . %). ten of the different kennel populations tested contained ccv antibodypositive dogs. the range of od values determined by indirect elisa for serum igg antibodies to ccv varied from . (the cut-off was ultracentrifuged for min at , g ( o c) and the supernatant used as antigen for the elisa. control antigen was prepared in the same manner from uninfected cells. indirect elisas for the detection of serum igg or igm antibodies to ccv were developed on the basis of previously published assay methods. , control and ccv tn- antigens were diluted separately to µg per . ml in carbonate-bicarbonate buffer and incubated overnight ( °c) in -well flat-bottomed immunoplates (nunc, denmark) with . ml per well of diluted antigen. the solution was decanted from the plates and . ml per well of . % skim milk in pbs-blocking agent was added. after incubation for h at o c, plates were washed once with pbs containing . % tween . positive and negative control sera and test sera were serially diluted in pbs containing . % tween with % foetal bovine serum (csl biosciences, australia), inactivated at o c for h and added at a volume of µl per well. dilutions were incubated for a further hour at room temperature before the plates were decanted and washed three times with pbs containing . % tween . fifty µl per well of a : dilution of either hrp-conjugated rabbit anti-dog igg (sigma, australia) or hrp-conjugated goat anti-dog igm (nordic, the netherlands) was added and the plates incubated for h at room temperature. following a further three washes, µl per well of . mg per ml tetramethylbenzidine microwell peroxidase substrate (kirkegarrd & perry laboratory, usa) was added and incubated for min. one hundred µl of . m phosphoric acid was added to stop the reaction and the absorbance was read at nm. each serum dilution was performed in duplicate, with the absorbance value of the control antigen deducted from the ccv tn- antigen absorbance value to give the final value. an absorbance value greater than . was considered a positive reaction. this value was at least two times higher than background values from negative control sera (unpublished data). serum samples (n = ) were collected from dogs in two different housing groups. one group contained dogs housed in groups of no more than three animals (open population) while the other group contained dogs from commercial breeders, rescue shelters and remote settlement colonies where dogs were housed as a group of or more animals (kennel populations) ( table ) . open population -in this group, serum samples were collected from veterinary pathology laboratories, universities and by field sampling from dogs submitted for general pathology, surgery or survey purposes. these dogs were domestic pets from both suburban and rural areas, generally kept singly or in pairs. the sample areas included all the australian states and territories, with sera collected from to . kennel populations -in this group, serum samples were collected from three commercial breeders, a university study, three rescue kennels and four remote settlement colonies. all serum samples were stored at - °c before use. all samples were tested for igg antibodies and randomly selected igg positive sera were tested for igm antibodies to remote settlement colony (nt) . twenty-nine of the ( . %) randomly selected, igg antibody-positive sera were also found to be positive for igm antibodies to ccv. clinical histories were available for of these dogs and ( %) had clinical signs of diarrhoea. among the igg negative sera, fourteen samples were also tested for igm antibodies to ccv. these samples were selected on the basis of a high prevalence of gastroenteric disease in the kennelled population at the time of sampling (breeding colony , nsw, samples) or evidence from clinical records of a recent episode of gastroenteritis in the open population dogs sampled ( samples). seven ( %) of these dogs were positive for anti-ccv igm antibodies. the prevalence of ccv antibodies in different dog populations throughout the world has been found to range from to %, with as high as % reported in kennelled populations. [ ] [ ] [ ] we report the first serological study of canine coronavirus antibodies in the australian dog population. the prevalence of ccv antibody was . % ( to . %) in dogs housed singly or in small groups (open population) but a significantly higher (p < . ) prevalence of . % ( to %) was found among kennelled dogs. ccv has been reported previously in australia based on electron microscopic examination of faeces; these two studies showed . % of dogs positive, and . % of dogs positive. , in the open population of dogs tested we found . % positive for anti-ccv igg antibody, which reflects past exposure and infection with ccv whereas the electron microscopic studies detected only those dogs currently infected and shedding virus in their faeces. dogs positive for ccv antibody were found in every australian state and territory, including remote areas of the northern territory. schnagl and holmes had also previously reported cvlp in remote areas of western australia and northern territory. one dog with antibodies to ccv was found in tasmania, although no other sera were tested from that state. we conclude that ccv exists in dogs throughout australia. in the open populations, most elisa results fell within an od range of . to . (unpublished data). within the kennel populations, approximately % of od readings were greater than . (p > . ). the difference in the occurrence of exposure among dogs from kennel populations and the open population has been observed previously. [ ] [ ] [ ] the higher frequency of exposure found in kennel populations presumably represents the increased opportunity for exposure due to the different housing and social interactions. in the three commercial breeding colonies from nsw examined in this study, severe gastroenteric disease resulting in variable fatality among young pups had been previously observed (m lindsey personal communication). in these cases cpv was reported as the causative agent. the current study identified high titres of ccv antibody in these kennels during the same period. igm antibodies to ccv were also detected in these populations, indicating current ccv infection at the time of the gastroenteritis epidemics. it is probable that a mixed infection of ccv and cpv was occurring and the presence of ccv may have contributed to the severity of the enteritis. appel and brunner and swango demonstrated increased severity of clinical signs of both ccv and cpv in mixed infections, particularly in young and stressed animals. it is therefore difficult to assess the clinical implications of ccv infection alone, because mixed infections or other factors may influence the course of disease. the dogs that were found to be positive for ccv antibody and had signs of gastroenteritis, may represent examples of ccv induced disease as these dogs were also negative for many of the other common gastroenteric pathogens such as cpv (unpublished data). a highly significant correlation (p < . ) was found between the presence of anti-ccv igg antibodies and diarrhoea, with of dogs ( . %) that presented with diarrhoea being igg positive compared with of ( %) dogs that presented without diarrhoea. approximately % of dogs positive for igg antibodies to ccv were also positive for igm antibodies to ccv indicating infection within days of blood samples being collected. seven dogs were identified as igg antibody negative and igm antibody positive to ccv. these dogs represent examples of animals exposed to ccv within to days before blood samples were collected and that had not had time to produce a detectable igg antibody response. all seven of these dogs had signs of gastroenteritis. eighty-five percent of dogs that had clinical signs of gastroenteritis attributed to ccv infection were positive for igg and igm antibody to ccv. in comparison, for those dogs presented without any history of gastroenteritis only % were anti-ccv igm positive (p < . ). our study indicates that ccv is widespread in the australian dog population and suggests that the presence of ccv antibodies is associated with gastroenteritis. in , marjorie was invited back to south australia to organise the brucellosis and t u b e r c u l o s i s eradication scheme in cattle. again true to form, she was the first woman to join the department of agriculture in south australia. due to her efforts and management skills she orchestrated a successful eradication scheme. the effort to coordinate all aspects of the brucellosis campaign, with limited resources in a big state, was a difficult task. marjorie was appointed principal veterinary officer in and deputy chief veterinary officer for south australia in . she retired in to live in the adelaide hills, devoting some of her time on a voluntary basis to the guide dogs for the blind. marjorie was the first woman in many of her appointments and she was able to achieve this due to her strong character, abundant wit and sense of humour. she enjoyed a good argument or discussion and, with her formidable memory for dates and wide reading, she was not an easy person to get the better of. those who tried, felt the sharpness of her wit. an agitated marjorie was a sight to behold. there are still anecdotes circulating around png about marjorie, when someone accidentally locked her in the cold room. in she moved to sydney to be closer to her family and died on june , after a long illness during which she showed her characteristic strength of character. the veterinary profession is very proud of marjorie reid's contribution to the welfare of animals in australia and internationally. m arjorie reid was a remarkable woman who epitomised the wealth and breadth of veterinary training, by successfully accepting challenges that ranged from practice, laboratory, fieldwork and senior veterinary administration. marjorie, who was born in , graduated from the royal veterinary college in and was one of a small, but elite group of women in the veterinary profession in england. she had always had a strong sense of adventure and pioneering spirit and, in , she commenced practice in south africa. later, she moved to kenya and joined the well known veterinary research institute at kabete near nairobi. marjorie enjoyed working in kenya, where there was a constant challenge to use basic veterinary principles to provide a diagnostic service for commercial and wild animals. her two daughters were born during this period in kenya. during she immigrated to australia and became the first female veterinarian at the institute of medical and veterinary science in adelaide. it was during this period she became interested in bacteriology and began to develop her skills in this subject. always seeking adventure, in she joined the department of agriculture, stock and fisheries in papua new guinea and was based at the kila kila veterinary laboratory in port moresby. when she arrived the laboratory was a converted airport control tower from the second world war. this tested her strengths in more ways than one, not only in bacteriology, but also filling in as port moresby's veterinarian on occasions. with her colleagues, ifor owen and noel talbot, she showed a remarkable ability to use good practical commonsense to simplify what seemed to be highly complex issues. when the new laboratory was built, she was able to demonstrate her considerable laboratory skills to all and was a good but firm teacher to many. this was a happy and productive period of her life. marjorie was very good with animals of all species ranging from the usual to exotic species such as crocodiles. because of her combination of ability and character, she was the 'preferred vet' in a strongly male-dominated society, which reflected her high standing in the community. many at first underestimated her strength of character and discipline; everyone soon learnt not to loaf about when marjorie was around. recovery and characterization of a coronavirus from military dogs with diarrhea intestinal infection of neonatal dogs with canine coronavirus - :studies by virologic, histologic, histochemical and immunofluorescent techniques studies of respiratory disease in random source laboratory dogs: viral infections in unconditioned dogs viruses and diarrhoea in dogs infectious disease in the dog and cat coronavirus-like particles in stools from dogs, from some country areas of australia viruses and virus-like particles in the faeces of dogs with and without diarrhoea faecal viruses of dogs -an electron microscope study jw copland dogs in the netherlands studies on the epizootiology of canine coronavirus does canine coronavirus augment the effects of subsequent parvovirus infection canine parvoviral infection: effects on the immune system and factors that predispose to severe disease canine coronavirus infection in the dog following oronasal inoculation micro-neutralization test with canine coronavirus for detection of coronavirus antibodies in dogs and cats enzyme-linked immunosorbent assay for the detection of canine coronavirus and its antibody in dogs the use of an enzyme-linked immunosorbent assay systems for serology and antigen detection in parvovirus, coronavirus and rotavirus infections in dogs in the netherlands van den ingh tsgam. canine viral enteritis: prevalence of parvo the authors would like to thank the various government and university departments, veterinary, private and veterinary pathology organisations for the serum samples and animal histories. we are also grateful to mark lindsey for comments on the manuscript and assistance in obtaining animal sera and case histories. mj naylor was supported by a cooperative education for enterprise development (ceed) grant funded by fort dodge australia pty limited and the university of western sydney, nepean. key: cord- -k y qb c authors: prideaux, bruce title: factors affecting bilateral tourism flows date: - - journal: annals of tourism research doi: . /j.annals. . . sha: doc_id: cord_uid: k y qb c abstract this paper examines the structure of bilateral tourism and identifies five broad categories of factors that may affect the overall size of tourism flows. such analysis of tourism is important because diplomacy and trade continues to be conducted on a nation-to-nation basis despite a growing shift towards multilateralism in free trade blocks such as the european union and the north american free trade agreement. further, bilateralism is important because countries have reduced abilities to control tourism imports in an era of growing globalization. a framework that may be employed to analyze problems in bilateral tourism flows is also outlined. in recent decades, tourism has emerged as one of a small group of service industries that increasingly dominate the post-industrial global economy. because of the volume of funds involved, estimated to be $ billion (wto ) , tourism imports and exports can significantly influence national balance of payments accounts. in , for example, japan and germany recorded net tourism deficits of $ . billion and $ . billion, respectively, while the united states recorded a net tourism balance of $ . billion ( wto ) . as world trade moves towards reducing trading barriers, the ability of countries to unilaterally control tourism exports and imports is becoming increasingly difficult (wanhill ) . there are forced to look for non-regulatory measures to influence flows, such as increasing national attractiveness and competitiveness on a market-by-market or bilateral basis. this paper examines a range of factors that determine the structure of bilateral tourism. the discussion focuses on techniques for identifying underlying demand factors and identifies the role of non-economic factors. increased understanding of these factors will assist policymakers in developing more effective policies to increase destination competitiveness and attractiveness within a bilateral setting. bilateral tourism describes the flow of tourists between two countries, irrespective of proximity, and is measured by actual tourists, their percentage as a proportion of inbound and outbound flows, and the state of the tourism balance of payments. the quantum of the flow between country pairs is a function of a matrix of interrelated factors that includes the public and private sector structures supporting flows, diplomatic relations, and economic and noneconomic factors. countries that have removed barriers to citizens undertaking foreign tourism have limited capability to regulate outbound flows, but still retain significant capacity to increase inbound flows through measures designed to enhance destination competitiveness and encourage citizens to substitute domestic for international tourism. policies designed to alter the level of inbound and outbound flows through nonregulatory measures may become important where countries facing a balance of payments crisis decide to adopt policies designed to increase exports and reduce imports of tourism. however, the recent trend towards multilateralism is a factor that compounds the problems encountered when attempts are made to reduce imbalances. as prideaux and kim ( ) observed, it is unrealistic to expect bilateral tourism to be in balance between countries because of the complexities of the international nature of demand, differences in national income, exchange rates, existing trading relationships, and differences in population size. therefore, the study of bilateral tourism is closely allied to research into competitiveness, flows, and attractiveness, but differs in that it looks at factors that influence the volume and composition of flows in both directions between country pairs. to date a framework for the systematic analysis of bilateral tourism has not been developed. such analysis of the factors underpinning bilateral flows will enable identification of strategies that can be adopted to increase inbound flows, to reduce monetary imbalance, and thus to increase overall destination competitiveness. examples of the types of strategies used were identified by prideaux and kim ( ) , who also noted that one of the major issues in this area may be the desire to maximize opportunities and encourage tourism for the benefits that may accrue in other areas, including cultural exchanges, defense, trade, and international goodwill. the methodology used in this study combined a review of the literature with an analysis of tourist flow data and limited case study bruce prideaux analysis. the steps adopted were: review of the literature to identify factors influencing bilateral flows; examination of models, typologies, and previous research into destination competitiveness to identify economic and noneconomic factors affecting flows; and an analysis of bilateral tourism data and the circumstances governing these flows to identify further factors. based on these findings, the bilateral tourism framework was developed (table ) . to examine the significance of specific factors, australia was used as a case study. the structure and significance of bilateral tourism has received relatively little attention in the literature, although a number of theories have been developed to explain flows between countries. demand factors were the most frequently cited, followed by destination competitiveness (crouch ) . in an analysis of papers examining demand factors, lim ( ) found that the most often cited explanatory variables for demand were income ( %), followed by relative prices ( %), and transport costs ( %). in assessing bilateral tourism from an economic viewpoint, mathieson and wall ( ) discussed the implications of measures designed to regain trade balances, prideaux and witt ( ) examined bilateral flows between countries in the asean group and australia, king and choi ( ) considered the case of south korea and australia, yu ( ) examined flow patterns between china and taiwan, and dwyer ( ) examined a range of issues related to destination competitiveness. a number of researchers have postulated that increasing flows between countries involved in some form of hostility may be a positive force, able to reduce tension and suspicion by influencing national politics, international relations, and world peace (d'amore ; hobson and ko ; jafari ; var, schluter, ankomah and lee ) . other researchers have focused on the role that tourism can play in normalizing relationships between partitioned countries (kim and crompton ; yu ; zhang ; kim and prideaux ) . while usually classified as peace studies, these relationships also describe a specific form of bilateral tourism. butler and mao ( ) , for example, postulated that tourism between politically divided states could assist in reducing tensions and promote greater political understanding. a number of studies have identified specific issues that affect bilateral flows (godfrey ; langlois, theodore and ineson ; murphy and williams ) . culture is one such issue that has been identified by numerous researchers (master and prideaux ; reisinger and turner , ; sussmann and rashcovsky ) . however, research into international flows has generally overlooked the importance of bilateral tourism and focused on issues such as international competitiveness (chon and mayer ; pearce ) and destination choice. mckercher ( ) noted the effect of market access on destination choice, stating that more proximate destinations exhibited a competitive advantage over destinations that offered similar products but were less proximate. while these are significant factors determining the size of flows between countries, these concepts have yet to be integrated into a specific study of bilateral tourism. researchers have also investigated issues of destination competitiveness, including ritchie and crouch ( ) , crouch and ritchie ( , , poon ( ) , kim ( , cited in dwyer , dwyer ( ) , dwyer, forsyth and rao ( a, b) , buhalis ( ) , and hassan ( ) . according to dwyer ''the issue of destination competitiveness is broad and complex: defying attempts to encapsulate it in universally acceptable terms'' ( : ) , because competitiveness is leiper ( ) , pearce ( ) , oppermann ( a), coshall ( ) and thurot ( ) . analysis of cross-border tourism by timothy ( a timothy ( , b timothy ( , timothy ( , found that physical barriers such as fortifications and demarcation markers, the severity of crossing formalities (visas, customs procedures, and quarantine measures), and psychological barriers that include cultural differences, and perceptions of safety and economic factors, all influence bilateral flows. the role of government is a recurrent theme in many studies. geographers have identified distance, demographics, cost, and lack of information as the main variables influencing the volume of flows. geographical concepts used to explain international flows include distance decay, gravity models, spatial hierarchy, origin-destination models (thurot ; lundgren ) , and reciprocity (pearce ) . while these models offer a descriptive primarily spatial analysis of tourism, other issues, including political considerations and economic constraints, are largely ignored. as a consequence, existing models have failed to systematically analyze the entire spectrum of factors involved in the authorization, operation, and conduct of international tourism, particularly from a bilateral perspective. factors contributing to destination choice have received considerable attention in the literature (chon ; mansfeld ; oppermann a) , although the structures that facilitate tourism have received little. mansfeld ( ) suggested a conceptual model of destination choice, while crompton and ankomh ( ) examined the proposition of choice sets in destination selection. other researchers looking at this issue include woodside and lysonski ( ) , um and crompton ( ) , and chon ( ) . furthermore, push and pull factors have been cited as explanations for motivation and destination selection (dann ; laws ; josiam, smeaton and clements ; godfrey ; klenosky ) . as each destination in any bilateral pair will have only a limited number of potential pull factors, individual destinations may encounter difficulties in attracting tourists from the other country in the bilateral relationship. multilateral flows have some implications for understanding bilateral tourism. pearce ( ) referred to this type as circuit tourism, with the concept illustrated in a model developed by thurot ( ) . the extent of circuit tourism is often difficult to estimate, as many countries do not require every country visited on a specific journey to be listed in immigration or visa documentation. the literature review found that demand relies on the interaction of a large range of factors that include price, personal preferences, destination image, government regulations, personal financial capacity to travel, international political/military tensions, health epidemics, concerns for personal safety, and fear of crime. while these issues are explored in some detail in the literature, less research has been undertaken into the structures that facilitate the operation of bilateral tourism. its structure and operation can be explained by two groups of elements. the first includes a number of conceptual processes explained by theories such as push-pull, distance decay, and destination competitiveness. the second centers on the structure of bilateral tourism and includes the public and private sectors, linkages, and economic and noneconomic factors. based on these findings, figure was developed to model the flows and factors involved. table categorizes the major public and private sector factors as well as the economic and noneconomic factors that constitute the structure of bilateral tourism. the categories are not mutually exclusive, because there may be overlaps between the government and private sectors in the provision of tourism specific goods and services and spill over effects among the different categories of factors. in addition, some jurisdictions may choose to enact legislative frameworks to control or regulate specific areas of tourism activity, while others may choose to leave these areas to the market or simply ignore them altogether. it was also apparent that the factors affecting flows from country a to country b might not affect the opposite flow. the range of factors involved is outlined in table . while not exhaustive, it does illustrate their range and complexity. to understand the significance of each of these factors it is necessary to employ evaluative theories including distance decay, push-pull, destination competitiveness, and so on. although not pursued in this paper, theories of this nature clearly do not apply to every factor listed in table . however, it is also apparent that a deeper understanding of the significance and role of these factors will be possible when each is examined by a battery of theories. the manner in which governments manage the domestic economy and external relations may significantly influence the size and structure of bilateral relationships. factors operating at the government level can be subdivided into a number of categories, including diplomatic, policy, marketing, regulatory regimes, and the supply of goods and services. tourism requires diplomatic recognition to facilitate the issue of visas (if required), recognition of passports, operation of transport modes, and recognition of civil rights. deterioration in diplomatic relations between country pairs can reduce tourism, while improvements may have the opposite effect. the significance of diplomatic relations was noted by krohn and o'donnell ( ) and butler and mao ( ) . mok and lam ( ) observed that restoration of diplomatic relations between the united states and vietnam in was regarded by many vietnamese as the return of commerce and tourism. war is also a significant factor and during the falklands war between the united kingdom and argentina in , tourism between the two warring nations ceased and took a long time to return to pre-war levels. deterioration of the united states relations with cuba, after its revolution, reveals the extent to which poor diplomatic relations can affect flows. prior to the revolution about , americans visited cuba anually, but this fell to virtually zero by and has remained at that level to date. the impact of the us embargo devastated the cuban tourism industry for decades, with high spending americans being replaced by a small number of frugal east europeans from the warsaw block (martin de holan and phillips ), before tourism returned to prosperity during the s based on a rising number of european tourists. krohn and o'donnell ( ) have observed that a relaxation of the us embargo would further reinvigorate the cuban industry as well as stabilize tourism in other caribbean countries. government policy may also be a significant factor in restricting both outbound and inbound flows (hall ) . policies to restrict the former may include limiting who can travel (ahmed and krohn ) , limiting the amount of currency taken out of the country (edgell ) , and limiting the value and quantity of goods imported by returning tourists (ascher ) . in a study of restrictions on outbound expenditure, davila, asgary, de los santos and vincent ( ) examined the effects of government restrictions by mexican tourists in the united states and concluded that lowering duty-free limits made little difference. inbound tourism may also be restricted by governments in an effort to prevent overstays by certain groups of tourists. policy measures commonly employed by governments include restrictions on the issue of visas, proof of a return ticket, and evidence of sufficient funds to pay for living expenses while in the country. without government approval, citizens may not be entitled to visit other countries as a matter of right. citizens of north korea, for example, cannot leave the country unless it is for some specifically approved government purpose. in the people's republic of china, many citizens continue to face restrictions without prior government approval. but this restriction is being gradually lifted with the broadening of the approved destination scheme (zhou, king and turner ) . until some classes of citizens of south korea and taiwan (particularly males of military age) were not allowed to leave the country without prior government approval. the impact of these types of policy may be to restrict tourism in one direction only. again citing the people's republic of china, the united states imposes few restrictions on citizens visiting china, but they may not necessarily be granted approval to visit. chinese citizens are neither entitled to visit the united states without some form of chinese government approval nor automatically granted visas to enter. problems resulting from illegal immigration and persons overstaying visas are sometimes cited by governments as reasons for imposing strict entry controls enforced through the selective issuing of visas. in australia, strict entry laws require that applications for visas be approved prior to arrival. to prevent overstaying and illegal immigration, a risk-factor list was established which in listed greek women between and and over , russians, chinese, thai, and indian nationals as having a high risk factor. the effect of this policy is illustrated by the success rate of visa applications in when immigration authorities refused visas to . % of russian applicants compared to only . % from the united kingdom (madigan ) . similar restrictions are not usually applied to australians tourists visiting india, greece, and thailand. bilateral transport policy is also an important factor. it includes the operation of transport modes between countries, operation of terminal facilities, border crossing facilities (timothy ) , and bilateral air service agreements. the latter usually include a number of conditions that impose limits on the ports serviced, service frequencies, and passenger numbers (hanlon ) . pender ( ) observed that the bilateral monopolies of two national airlines at either end of a route could severely curtail competition, unless other airlines can operate th freedom services. conversely, liberalization of air services often stimulates bilateral flows as has occurred within the european community (pender ) . usually employed as a measure to reduce the outflow of foreign exchange, currency restrictions may limit outbound tourism, even in the absence of other restrictions such as passport regulations (bull ) . although there was some relaxation of currency restrictions on chinese citizens after the rmb (national currency) became a convertible currency in (zhou, king and turner ) , they were still restricted to a $ , currency limit in . exchanging rmb for other currencies in hong kong and other centers often circumvents this limit. other countries that retain currency restrictions include north korea and cuba. not all national governments undertake destination marketing, either because of budgetary restrictions or in the belief that promotion is the responsibility of the private sector (chamberlain ) . the us federal government, for example, transferred responsibility for promotion to individual state governments and the private sector after ceasing promotion funding for its travel and tourism administration in , in the belief that promotion should be a function of the private sector. bilateral tourism may reduce the need for extensive promotion if there is already considerable knowledge of the other country as found in north america between canada and the united states and between the latter and mexico. the efficiency and effectiveness of government policy is often an important factor in the development of bilateral and multilateral tourism. casado ( ) noted that there was a need for the mexican government to introduce proactive measures to create conditions of security and safety that would attract foreign tourists. to achieve this, casado recommended pacification of rebellious regions, eradicating narcotic traffic, and suppressing corruption. the role of government includes the organization of government tourism departments, taxation policies, foreign investment and ownership policies, planning policies, law enforcement, and provision of education. government regulatory regimes and their impact on the private sector are also major factors. regulations of this nature include qualitative and quantitative controls over the wide range of private and public sector organizations that supply goods and services to the tourism industry (hall ) . governments also supply a range of goods and services to the tourism industry, including provision of many types of physical infrastructure, maintenance of public health, provision of security, education of the workforce, and, in many countries, the provision of commercial services. tourism may suffer if government funding of these services is insufficient to maintain internationally competitive standards. in india, ragurman ( ) observed the low level of inbound tourism is a direct result of the failure of government to allocate resources to the development of tourism infrastructure, some of which is federally owned. many national governments recognize that economic policy is a significant factor in encouraging international tourism. mexico (casado ) and cuba (martin de holan and phillips ) are two of numerous examples of governments that have allocated scarce financial resources to developing specific infrastructure on the basis of tourism plans incorporating specific economic policies. policy instruments that may affect tourism include interest rates, anti-inflation policies, exchange rate controls, and the impact of indirect taxation. the structure and efficiency of the private sector exert considerable influence over the strength of bilateral flows, in addition to the level of investment in infrastructure and domestic price levels. specialist functions undertaken by the private sector include inbound and outbound travel operations, retail services undertaken by travel agents, wholesale travel services, travel insurance, and transport services in both physical and cyberspace. the structure of this system varies substantially among countries, and both the structure of the national industry and the recommendations of agents (klenosky and gitelson ) can influence bilateral tourism tourism. for example, icoz, var and kozak ( ) observed that inbound flows to turkey vary significantly with the number of travel agents operating in generating countries. in a study of outbound tourism from korea to australia, king and choi ( ) noted that travel agents exerted a strong influence on destination choice by koreans, while oppermann ( b) observed that although a significant component of tourism, the role of travel agents has been largely ignored in the literature. buhalis ( ) noted that access to web travel sources was becoming an important factor in destination selection and inferred that destinations ignoring the internet will suffer a decline in tourism. therefore, it is apparent that for some nations the structure of the marketing infrastructure in generating countries may be the critical factor in increasing the competitiveness of the destination country. domestic price levels are influenced by the efficiency of the private and public sectors, and changes in domestic price levels may reduce a nation's competitiveness and have a flow-on effect. examples include a higher inflation rate than the other country in a bilateral relationship, changes in price levels caused by changes to wage and taxation levels, and changes in exchange rates. in the bilateral relationships between australia and all other countries, the imposition of a % general sales tax in july on most goods and services in australia, but not on overseas airfares, reduced the country's competitiveness. this change may discourage international arrivals because of the increase in price and encourage the substitution of domestic for international tourism to cheaper foreign destinations. factors of this nature can have a significant impact on destination selection (crouch ) . apart from public and private sector considerations, there are a range of factors that relate to the built and natural environments, as well as destination image, lifestyle, barriers to flows, and culture. these are grouped under the heading of intangible factors, a reference to the difficulties often encountered in measuring them. the quality of a country's attractions may stimulate demand by enabling tourists to experience different cultures, participate in new experiences, visit national cultural and heritage icons, view unique flora and fauna, sample exotic cuisine, and shop for products not readily available domestically. national attractiveness is also an important factor, as, in a study of korea, kim ( ) found that the concept of overall destination attractiveness could be a positive motivator in tourism decisions. similarly, authenticity is a significant factor often packaged by tour operators to promote products for specific destinations (silver ) . in a study of destination attractiveness based on australia, greece, hawaii, france, and china, hu and richie ( ) found that scenery ranked first followed by climate, accommodation supply, prices, history, and attractions. icons have a significant role in promoting flows from specific bilateral partners. for example, australia promotes a number of tourism icons, including the great barrier reef, ocean beaches, ayres rock, bruce prideaux unique fauna, the sydney opera house, and aboriginal culture. however, what may be regarded domestically as a national icon may not attract similar interest from international arrivals. thus, while australia's climate and beaches may be highly regarded by japanese, americans can experience similar weather and beaches domestically and may need to be enticed by other experiences and icons. images are also used by national tourism organizations and tour operators as a means of shaping tourism motivations (milman and pizam ) , and according to silver ( ) are also a means of providing tourists with an insight into the places that they are considering visiting. in a study of amsterdam, dahles ( ) observed that image might be a major attraction and notes that amsterdam's recent fall in popularity may require a more process-oriented approach to cultural tourism in the future. in terms of bilateral flows, changing cultural, social, and economic values in each partner country may lead to changes in destination image and affect tourism. deterioration in bilateral relations, discussed previously, may also cause shifts in image from favorable to unfavorable, causing a decline in reciprocal flows that will only be repaired as relations improve. in an examination of disruptions to inbound and outbound tourism to indonesia over the period - , prideaux, laws and faulkner ( noted that a number of barriers could be identified, including inhibiting factors described as events in the generating country which reduce the outflow of tourists to all destinations; diverting factors described as disruptions to existing patterns perhaps by lower prices at competing destinations; and repelling factors described as disasters and crises such as civil unrest and natural disasters that repel arrivals from all origin countries. to these factors can be added other barriers such as war and government restrictions on individuals entering or leaving a country, visa controls applied to specific groups within a society and those created through restrictions imposed on bilateral air service agreements, and other transport agreements. in a study of cross-cultural differences, reisinger and turner ( ) found that cultural differences (including the image of self, personal demeanour, and dietary habits) existed between indonesian tourists and their australian hosts and suggested that these factors should be considered when developing products and services for specific generating countries. a destination's reputation may also be a significant factor in determining the volume of bilateral flows. thailand's reputation as a destination that exhibits an exotic culture and an easygoing lifestyle is attractive to westerners. similarly, australia's reputation, as a friendly country hospitable to international tourists, may be a factor in encouraging tourism; other intangible factors include attitude of hosts, political factors, and the role of the media. a range of economic factors also influence the level of arrivals and departures between bilateral partners. these factors include efficiency of the national economy, competition, exchange rates, national income levels, and elasticity of demand. an efficient economy will result in lower prices for goods and services, while an inefficient economy will produce the opposite effect. measures of national economic efficiency include the cost of utilities, such as communications, energy and water, cost of financial services, domestic transport costs, level of tariff protection, level of government ownership of commercial enterprises, and the level of gdp growth per person per annum. as national economic efficiency improves, the demand of outbound tourism may rise (bull ) . this may also enhance international competitiveness, thereby stimulating inbound flows. the ability of one country to attract tourists from another is often determined by international competitiveness. faulkner, oppermann and fredline ( ) argued that there is increasing recognition of the need to evaluate the competitiveness of destinations as part of strategic positioning and marketing plans. during the asian financial crisis, australian outbound flows to indonesia grew by . % between and when the value of the indonesian rupiah collapsed (prideaux ) . conversely, indonesian arrivals fell by % in the same period (tourism forecasting council ) . hsu ( ) found that arrivals from taiwan to australia remained static between and in spite of an overall substantial rise in taiwanese departures because australia was perceived by taiwanese to be as an expensive destination compared to north america and asia. shifts in exchange rates caused by external factors such as regional or global economic crises and wars can have a significant impact (lim ; tribe ) . the effect of changes to exchange rates is demonstrated by the trends in bilateral flows between australia and thailand during the asian financial crisis. australian arrivals grew by . % in and . % in , while thai arrivals fell by . % in and a further . % in (australian tourist commission ) . shifts in the exchange rate between bilateral partners will influence the volume of flows as illustrated in the preceding example. beyond such national shifts, changes that occur to consumers' personal income may alter their purchasing intentions and/or habits. if the cost of travel to a destination increases without a parallel increase in personal income, there may be a change in consumer purchasing habits and preferences. according to standard economic theory (mctaggart, findlay and parkin a) , if purchasers of services, in this case tourism, have a choice between obtaining domestic services or foreign services, they will compare prices. other things remaining constant, the higher the foreign price or the lower the domestic price the greater is the propensity for the purchaser to purchase domestic goods. this will also occur in a situation where the purchaser is experiencing a depreciation of their currency relative to the currency of the bilateral partner. tourism expenditure is also relatively price sensitive (bull ) and can be measured by expenditure elasticity of demand described as the amount of change in purchasing power of a specific good such as tourism in proportion to the increase in prices charged for that good. bruce prideaux elasticity of demand is another economic factor that may be significant in some bilateral relationships. the higher the rate of change in demand caused by a shift in price the more elastic the product is. the degree of elasticity depends on a number of factors, including the ease one product or service can be substituted for another, the proportion of the consumer's income spent on the product or service, and the elapse of time from the change in price. the substitution effect refers to the tendency of consumers to substitute one product for another, in this case destinations, due to a number of factors that may include changes in the elasticity of demand, shifts in price, and a desire to try new products or experiences (tribe ) . economic theory states that the closer the substitutes are for a service or product, the more elastic is the demand for those services or products (mctaggart, findlay and parkin b) . during the asian financial crisis, the value of the korean won fell in relation to other countries not affected by the crisis. as a consequence, travel to australia, and other countries not affected by the asian financial crisis, became relatively more expensive for korean consumers, who turned to domestic destinations as a substitute causing outbound flows to fall by . % in . conversely, as the value of the korean won fell, overseas consumers were encouraged to substitute korea for other destinations, resulting in a shift from negative growth in (À . %) to positive growth of . % in and . % in . the elasticity of demand and propensity to substitute among destinations are important factors that need to be included in any assessment of bilateral tourism markets. often, political factors arise that are beyond the ability of countries to control. examples include wars, terrorism, and the state of international relations. more recently, in , health emerged as a major factor when there was considerable alarm over the spread of sars (severe acute respiratory syndrome) from china via hong kong to other nations. terrorism presents a major challenge to the tourism industry, because of its vulnerability to political violence (sonmez and graefe ) . in the aftermath of the september , , attack on the united states, international tourism declined between many nations even where they had not been linked to any terrorist threat. following the october terrorist attack in bali, tourism between australia and indonesia fell because of the fear of further attacks. measures to reassure tourists of destination safety will become increasingly important as the perceived level of safety becomes a factor in destination selection. after the bali bombings, australians switched to safe destinations such as fiji, new zealand, and north asia. surprisingly, fiji, only several years before had been subject to adverse australian government travel advisory notices following an attempted coup and had suffered a % decline in australian inbound tourism. but when the advisory notice was lifted, the industry quickly recovered. in a similar observation, bilateral tourism cothran and cothran ( ) noted that the remarkable potential of the mexican tourism industry was at risk because of growing political instability. aside from the strength of bilateral relations at economic, cultural, and diplomatic levels, other events and forces that operate within the international economy can also affect the volume of flows between country pairs. during periods of warfare, international tensions and economic uncertainty, flows may be affected. clements and georgiou ( ) noted the impact of political instability on uk arrivals in the republic of cyprus during the crisis with the turkish republic of northern cyprus in over the purchase of russian-made surfaceto-air missiles. in another example, during the gulf war, , international flights were cancelled in the period january to february (wto . other examples of international uncertainty impacting on flows include the asian economic crisis and the oil shocks of and . similarly, the palestinian uprising against israeli in october resulted in a rapid fall in inbound flows to israel. even the threat of uncertainty can cause difficulties. in the uncertainty of iraq's response to a us led invasion caused a decline in forward bookings from japan to the united states. advances in medicine and improvements to public health in most countries during the th century reduced the danger of many infectious diseases, such as typhus, polio, typhoid, and malaria (prideaux and master ) . dangers from other diseases have been reduced by medical science. however, aids emerged as a pandemic in the later 's and was spread globally by tourists. in , sars, a previously unknown form of flu-like disease, appeared in southern china and spread to hong kong and later canada. widespread and sensationalized publicity of the impact of sars and its comparison to the - spanish flu pandemic which killed an estimated million people (lemonick ) had a significant impact on arrivals and departures in china, hong kong, and other countries where the disease was reported. as a consequence of the uncertainty generated by sars, hong kong hotels experienced a vacancy rate of % in april (carmichael . at its simplest level, bilateral tourism is limited to describing the patterns of departures and arrivals between two countries; however, to gauge its full extent, other measures should be considered. these might include yield expressed as bed nights, revenue flows, and the composition of tourist types. for example, the majority of australian arrivals in korea in were aircrew and apart from limited bed nights, arrivals of this nature have little impact on other sectors of the industry. a further method of analysis, the outbound visitor flow ratio, measures the percentage of a country's population that visit a specific destination in any given year. this is illustrated by comparing the number bruce prideaux of singaporean arrivals in australia as a percentage of its population compared to australian arrivals in singapore measured on a similar basis. in , . % of australia's total population visited singapore while the flow in the other direction was . %. this analysis can be further developed by segmenting arrivals by purpose (including pleasure, business, and education), or by measuring changes longitudinally. taking the example of singapore, it is apparent that australia has been far more successful in attracting singaporeans than the other way around as a percentage of population. further, this analysis may signal that australia could experience future decline in what appears to be a relatively mature market if singaporeans look to new and unfamiliar destinations. for australia, this type of analysis should signal the need to closely examine how sustainable singaporean repeat business will be in the future, as well as indicating the need to develop new australian products and destinations that will encourage a continued high level of singaporean repeat tourism. further understanding of the structure of bilateral tourism might be achieved through the use of appropriately modified models, including butler's ( ) tourism area lifecycle model and prideaux's ( ) resort development spectrum model to identify market profiles and indications of possible future decline in international flows. other ways to measure changes include neo-fordist, post-fordist (torres ) , and postmodernist interpretations (urry ; of possible shifts from standardized production and consumption of mass tourism experiences to mass niche, specialized or individualized tour consumption. when models and interpretations of this type are applied in conjunction with the outbound visitor flow ratios there is scope to develop diagnostic tools for application to tourism policy. the previous illustration of the inability of korea to boost australian arrivals, because of a misunderstanding of the australian market, is another tool. this, combined with a modified tourism area lifecycle model, the resort development spectrum model, or perhaps a post-fordist/postmodernist interpretation of demand, may be used to develop destination marketing strategies and policies. it may also be useful to employ the bilateral framework shown in table to evaluate elements of tourism as illustrated in table . in this example, positive and negative effects of specific factors of government responsibilities are highlighted and possible corrective actions to reduce negative factors are outlined in the australia to indonesia component of their bilateral tourism. while table only considers government responsibilities, any comprehensive analysis must also include all other elements of the bilateral framework as discussed. table is an example of a simple diagnostic test or checklist that may be employed to examine tourism flows. prideaux, laws and faulkner ( ) identified ten major shocks to indonesia's tourism industry during the period to that impacted on the inbound tourism from australia. many of these emanated from difficult internal political and economic conditions in indonesia, which led to severe fluctuations in the level of australian arrivals. the august , terrorist bombing of the jr marriott hotel in central jakarta further illustrates the need for greater security of tourists identified in table . the previous discussion illustrates the relationship among the various factors comprising the structure of the framework outlined in figure . its use for a more detailed analysis will further highlight linkages between specific factors that uniquely influence the pattern of flows between specific country pairs. for example, australians have little difficulty obtaining visas for thailand, but thais face a much more rigorous process because of concern about tourists who overstay or who enter the country to work illegally. in these circumstances, reducing visa restrictions may encourage additional arrivals, although there may be an associated cost of apprehending and deporting thais who overstay. the possible net benefit to australia may be measured by comparing the increase in receipts from additional thai arrivals note: this example only examines the government responsibilities of the bilateral framework outlined in table , whose factors require a comprehensive consideration of all factors outlined in figure . against the cost of enforcing length of stay regulations. similarly, the framework (table ) is a useful tool to broaden the analysis of issues that govern origin-destination studies and when applied as in table may reveal relationships and impediments not previously identified. although a significant component of international arrivals and departures, bilateral tourism has not been studied in detail. given the increasing significance of tourism exports and imports and the reduced ability of governments to unilaterally impose trade barriers, an understanding of the bilateral nature of international flows is important. while this research has been able to develop a clearer understanding of the structure of bilateral flows, the multifaceted and multisector nature of the industry means it is not always possible to clearly delineate responsibility for all factors. understanding the mechanisms that facilitate the flows between country pairs enables the identification of barriers and/or developmental possibilities that may have otherwise been overlooked. moreover, inefficiencies may be identified and remedial action initiated. a further benefit may also be the realization that unequal bilateral flows are not always symptomatic of structural weaknesses in national industries, but may also result from other factors related to population size, national gdp levels, and issues related to destination competitiveness. further research in this area should be directed towards testing the suggested framework by applying it to specific bilateral pairs to identify deficiencies and previously hidden marketing opportunities. this may include application of the tourisim area lifecycle and/or the resort development models and investigating changes in the outbound visitor flow ratio perhaps caused by change in consumer demand from societies entering post-fordist or postmodern periods of development. considerable scope also exists to apply this analysis to multinational tourism structures. reversing the united states' declining competitiveness in the marketing of international tourism: a perspective on future policy obstacles to international travel and tourism australian tourist commission tourism in an era of information technology the concept of a tourist area resort cycle of evolution: implications for management of resources conceptual and theoretical implications of tourism between partitioned states mexico's - tourism plan: implications of internal political and economic stability tourism and hospitality in the st century the role of destination image in tourism: a review and discussion destination competitiveness models and their application in las vegas choice set propositions in destination selection demand elasticities for short-haul versus long-hall tourism destination competitiveness: exploring foundations for a long-term research program destination competitiveness and the role of the tourism enterprise spectral analysis of international tourism flows promise or political risk for mexican tourism redefining amsterdam as a tourist destination tourism-the world's peace industry ego-enhancement and tourism the effects of government restrictions on outbound tourism expenditures destination competitiveness: development of a model with application to australia and the republic of korea. canberra: department of industry science and resources the price competitiveness of travel and tourism: a comparison of destinations sectoral analysis of price competitiveness of tourism: an international comparison international tourism policy destination competitiveness: an exploratory examination of south australia's core attractions attributes of destination choice: british skiing in canada global airlines competition in a transnational industry determinants of market competitiveness in an environmentally sustainable tourism industry tourism and politics: the implications of the change in sovereignty on the future development of hong kong's tourism industry inbound taiwanese tourism in australia measuring destination attractiveness; a contextual approach tourism and peace travel motivation and destination selection perceived attractiveness of korean destinations role of tourism in unifying the two koreas tourism, peace, politics and ideology: impacts of the mt. gumgang tour project in the korean peninsula travel industry structure in fast growing but immature outbound markets: the case of korea to australia travel pull'' of tourism destinations: a means-end investigation travel agents' destination recommendations us tourism potential in a new cuba tourist destination management: issues, analysis and policies main destination ratios, analysis of tourism flows review of international tourism demand models a meta-analysis review of international tourism demand the tourist frontier of nouveau quebec: functions and regional linkages culture and vacation satisfaction: a study of taiwanese tourists in south east queensland tourism economic, physical and social impacts the effect of market access on destination choice micro economics from motivation to actual travel sand and hard cruising tourism in cuba the role of awareness and familiarity with a destination: the central florida case attracting japanese tourists into the rural hinterland: implications for rural development and planning predicting destination choice: a discussion of destination loyalty database marketing for travel agencies tourism today: a geographic analysis competitive destination analysis in south east asia travel trade and transport: an introduction. london: continuum tourism, technology, and competitive strategy. walingford: cab international the impact of the asian financial crisis on bilateral indonesian-australian tourism the role of transport in destination development events in indonesia: exploring the limits to formal tourism trends forecasting methods in complex crisis situations bilateral tourism imbalance: is there a cause for concern: the case of australia and korea health and safety issues effecting international tourists in australia an analysis of tourism flows between australia and asean countries: an australian perspective troubled passage to india cross cultural differences in tourism indonesian tourism in australia cultural differences between asian tourist markets and australian hosts, part the competitive destination: a sustainability perspective influence of terrorism risk on foreign tourism decisions a cross-cultural analysis of english and french canadians' vacation travel patterns political boundaries and tourism: boarders as tourism attractions b international boundaries: new frontiers for tourism research cross-border partnership in tourism resource management: international parks along the us-canada border international boundaries: barriers to tourism capacité de change et production touristique toward a better understanding of tourism and agriculture linkages in the yucatan: tourist food consumption and preferences tourism forecasting council the economics of leisure and tourism environments, markets and impacts attitude determinants in tourism destination choice the tourist gaze consuming places. london: routledge tourism and peace: the case of argentina issues in public sector involvement wto impact of the gulf crisis in international tourism madrid: world tourism organization madrid: world tourism organization travel between politically divided china and taiwan tourism across the taiwan straits the china outbound market: an evaluation of currency constraints and opportunities final version key: cord- -vlxewj k authors: hooker, claire; leask, julie title: risk communication should be explicit about values. a perspective on early communication during covid- date: - - journal: j bioeth inq doi: . /s - - - sha: doc_id: cord_uid: vlxewj k this article explores the consequences of failure to communicate early, as recommended in risk communication scholarship, during the first stage of the covid- pandemic in australia and the united kingdom. we begin by observing that the principles of risk communication are regarded as basic best practices rather than as moral rules. we argue firstly, that they nonetheless encapsulate value commitments, and secondly, that these values should more explicitly underpin communication practices in a pandemic. our focus is to explore the values associated with the principle of communicating early and often and how use of this principle can signal respect for people’s self-determination whilst also conveying other values relevant to the circumstances. we suggest that doing this requires communication that explicitly acknowledges and addresses with empathy those who will be most directly impacted by any disease-control measures. we suggest further that communication in a pandemic should be more explicit about how values are expressed in response strategies and that doing so may improve the appraisal of new information as it becomes available. behavioural responses-both practicing recommended behaviours (such as putting on a mask) and the refusal to do so are reactions to perceive loss of control (jetten et al. ; wong ) . "self-determination" is used in relation to communities as much as to individuals, which may provide new understandings or representations for relations between individual and communal self-shaping in the context of pandemics (eichler ) . given the extensive and growing data that reveals values and ideologies as often the strongest determinants of people's attitudes to health protection behaviours (e.g., dryhurst et al. ; seale et al. ) , we suggest that rich accounts of self-determination, autonomy, and/or freedom beyond "thin" versions of liberty (e.g., to travel or not wear masks) will have much to offer pandemic ethics in future research. in this paper we make a modest beginning on exploring what adding a "values perspective" to risk communication might look like by examining one risk communication principle, "communicate early and often," in the very first stages of the pandemic. our argument is that use of this principle could have minimized some of the negative impacts seen in australia and the united kingdom in february and march . we contend that a hitherto undiscussed reason for why this principle is effective is because it conveys value for people's self-determination, even as this is threatened by both disease and the measures needed to control the disease. we discuss how proactive communication might have improved community preparedness but also suggest that being more explicit about this value should have involved better acknowledgement of, and empathetic engagement with, those who were most directly impacted by control measures at that time. as a result, the australian government could have better addressed stigma, racism, and xenophobia during late january and february and mitigated or avoided food and hygiene product stock-outs in early march. we conclude with a brief discussion of how communication of values might have avoided the loss of trust and misunderstandings associated with the misnamed strategy of achieving "herd immunity" when discussion of this emerged in the united kingdom. we conclude by suggesting that the communication of values can improve the quality of pandemic response and can increase the degree of trust placed in responding authorities. when people face the heightened fear of a novel, uncontrolled, and uncertain risk such as the pandemic of sars-cov_ , self-determination in multiple dimensions is compromised and well-being is reliant on the knowledge and decisions of experts and governments (siegrist and zingg ) . risk communication must connect as much as possible with people's sense of selfdetermination, even (perhaps especially) in contexts where individual liberties may become limited. how c a n t h i s b e d o n e ? t h e p r i n c i p l e s o f r i s k communication-for example communicating early and often, being open and transparent, and not dismissing concerns as "panic"-are all means of affording some sense of control in people facing a situation of high concern and uncertainty. transparency is a core recommendation for pandemic risk communication (van der weerd et al. ) , because it enables citizens' knowledge and confidence (earle, siegrist, and gutscher ; siegrist and zingg ) that the response strategy will occur as expected. because values and moral commitments are intrinsic to all pandemic responses, we argue that true transparency requires that pandemic risk communication is explicit about the values that guide it. further, we suggest that part of the task of managing a pandemic is to cultivate public convergence (kahan ) on the guiding values. this is important because a pandemic response, and communicating about it, are not actually separable: action is, in itself, a very powerful form of communication (amabile and kabat ) , as we discuss below. we suggest that conveying respect for selfdetermination involves early, proactive communication with those who are directly affected by any response strategy. this will involve addressing issues of fairness or justice, since these are present in virtually all ethical frameworks for pandemic response (australian government department of health ; kinlaw, barrett, and levine ; n e w z e a l a n d n a t i o n a l e t h i c s a d v i s o r y committee-kāhui matatika o te motu ; thomas, dasgupta, and martinot ) and have also been shown to strongly influence peoples' perceptions of, and responses to, risk (siegrist, connor, and keller ) . the earliest representations of the new coronavirus in media coverage of the disease in australia and the united kingdom conformed to what priscilla wald has identified as "the outbreak narrative," in which a disease emanating from a non-white, non-western nation is eventually contained as a result of the scientific and technologic prowess of democratic western societies (wald ) . through january and february , health risk communicators from who and government health authorities balanced communication of the potential seriousness of the new disease (clun ; the sydney morning herald ), with caution about acting too strongly or too soon. nonetheless several elements in news media coverage of the novel coronavirus disease in this period together tended to frame the disease as unlikely to significantly threaten australia or the united kingdom (the guardian ). these included comparisons with sars, mers, and ebola, and associations of the new disease with chinese political authoritarianism, which somewhat signalled that these diseases were unlikely to cause widespread disease in western nations (boseley ) . the discourse of "technology as saviour" (hooker, king, and leask ; wald ) , in the form of early and frequent expectation that a vaccine and effective treatment would be rapidly developed by scientists, was prominent (garcia ; mannix ) . media coverage identified that mortality was strongly associated with the elderly and those with comorbidities. media commentators have noted that this reporting often portrayed the elderly, and those with significant health issues, as a passive, vulnerable minority, even one that was expendable or burdensome (ashimoni ). these representations have continued to raise considerable concern (see, for example, people with disability australia (pwda) et al. ) and provides an important context for later discussions of "herd immunity." ii. "communicate early and often" in this discursive media environment, we argue that earlier, proactive communication signalling that nations outside china might become affected and about the possibility of a pandemic was needed. early communication could have supported earlier sense-making, encouraged citizen engagement, and provided potential convergence towards a response strategy. by - february, the who and other health authorities were considering the possibility of a pandemic increasingly likely (callaway ). yet in australia there was little proactive public communication at this time-indeed, australian government websites only contained advice pertinent to travellers. the australian health sector emergency response plan for novel coronavirus (covid- ) was released on february (grattan ) but was accompanied by little transparent communication about what was being done or which elements of the plan were receiving attention. this created a "risk communication vacuum" (leiss ) . in this vacuum, messages came from sources not privy to government planning. one was virologist dr ian mackay, who recognized and attempted to fill the space by publishing an opinion piece in the sydney morning herald (mackay ) . this advised australians to prepare for a pandemic and suggested that australians moderately stock up on basic consumer items and medicine, urging people to "prepare, but do not panic." a steeply-increasing, sometimes harmful, and prolonged period of stockpiling of basic supplies like hand sanitizer, toilet paper, and flour swiftly followed in australia, fed by escalating public anxiety. we contend that earlier and values-oriented communication could have reduced the anxiety that was later expressed in stockpiling behaviours by enabling longer and more moderated preparation for what could be ahead. respect for citizens' complex selfdetermination within the context of potential outbreaks could be conveyed in the cautious communication of concrete scenarios concerning what people might consider in their own family preparation (for example, of how to manage if somebody became sick). this period of sense-making and preparation can allow proactive communication of values around which people might shape their responses, such as providing support for neighbours (e.g., new zealand national ethics advisory committee-kāhui matatika o te motu ). proactive early communication with supermarket managers could have limited or avoided stockpiling (poloyo ) . in attempting to avoid early overreactions, which unintentionally communicates a lack of trust in the public, government effectively intensified a problem, rather than reducing it. early communication centred on ideas of selfdetermination (acknowledging individual and communal aspects of this) could have helped address the challenge that most pandemic response measures affect people unequally (howse et al. ; vaughan and tinker ) . racism and stigmatization have been a feature of almost every epidemic in history (wailoo ) , with anti-asian prejudice and sinophobia widespread during the outbreaks of sars in (leung ) . explicitly confronting this through communication is crucial, not only to reduce violence and injustice but because these issues are entangled in epistemic judgements, as occurred in debates in australia during february, concerning racism in relation to containment measures. as reports of racism and a range of sinophobic behaviours (including avoidance of chinese businesses, suburbs, and people) began to appear in the media from the end of january (vrajlal ; young ), a range of containment measures that primarily, but not exclusively, affected chinese people were enacted. a number of wealthy, independent secondary schools in australia had unilaterally acted to temporarily exclude students who had recently travelled in china (most of whom were chinese), including imposing segregated quarantine, in contravention of commonwealth government health advice (hooker, silva, and anderson ). on february , the australian government announced that foreign national travellers from mainland china would not be allowed entry into australia; australian citizens (most of whom were chinese) returning from china were quarantined in offshore detention facilities notorious for their use with refugees. while it is now generally agreed that early border measures to limit transmission of disease into australia were effective, at the time, school exclusions, selective border controls, and travel-related quarantines in immigration detention camps were questioned as unnecessary and were sometimes perceived as forms of racism (bedo and mcphee ; hooker, silva, and anderson ) . to convey respect for people's self-determination, leaders should reflexively examine how their actions might also be interpreted as disrespectful and discriminatory. actions such as containment (border control) measures are strong forms of communication (sandman and lanard ). while we do not suggest that this was not an important measure at the time, communication needed to address (particular through pre-established two-way channels) those likely to be directly affected by containment measures-in this case, chinese and other asian australians. the predictable harms of stigmatization needed to have been explicitly acknowledged alongside the scientific rationale (major et al. ). risk communication handbooks should urge authorities to be open and honest about the potential for discrimination, in the same way they are encouraged to be explicit about uncertainty. early communication proactively addressing the potential for stigmatization and racism might have not only limited some of the direct racism experienced by asian australians and u.k. nationals but helped to clarify judgements around containment measures by ensuring they were not confused with forms of racism. we note that sometimes violent racism is continuing in australia at the time of writing (fang, yang, and zhou ) . perhaps the most intractable feature of covid- in its early stages was the persistent framing of pandemic response strategies as a choice between "the economy" and "saving lives." this frequently contested (hamilton et al. ; zeballos-riog ) framing exemplified the tendency toward values-based polarization in views about the best response to covid- (kahan ) . early communication with the groups most likely to be affected by any given containment strategy could help with this seemingly incommensurable choice. we discuss how improved communication might have contributed to the pandemic response in the united kingdom when this was first announced on march , the day after the who formally declared a pandemic. a crucial period for communication about covid- in australia and the united kingdom were the first two weeks of march : the period in which the reality and likelihood of a pandemic was dawning, exponential growth feared in both countries (churley ) , and news of crisis from iran and italy were fresh. this period of adjustment was critical for sense-making amid uncertainty, through which convergence on a response strategy could occur. in the united kingdom there was reportedly heated disagreement between members of the scientific advisory group for emergencies over what response strategy to pursue. such disagreement is a predictable but highly confounding feature of emergency response (christensen and painter ) . these differences were epistemic-they involved different appraisals of the evidence available and different assumptions about "herd immunity"-but they were fundamentally driven by different values. how the term "herd immunity" was constructed and interpreted in relation to covid- is worthy of a study in itself. the indirect protection of susceptible individuals resulting from high levels of immunity across a population (d'souza and dowdy ), "herd immunity" is a concept associated most with vaccination (hanage ; macintyre ) . for the first two weeks of march, the u.k. government pursued a "mitigation" (wickham ) strategy with little social restriction under the belief that there was ultimately little the government can do to stop the virus (shipman and wheeler ); social distancing restrictions would incur a high economic cost, be unsustainable for a long period, and would produce a more severe second wave of infection in winter (wickham ) . this approach assumed that reaching "herd immunity" through widespread infection would resolve the pandemic (the times ). this strategy fitted with prime minister boris johnson's values of limiting state intervention and government spending (wickham ) ; we note that it also fitted with the cluster of values termed "hierarchical individualism" in cultural cognition theory (kahan ) . within twenty-four hours of johnson's announcement of this policy on march , outrage was rising as the strategy's scientific credibility was disputed by epidemiologists and others (sandle and boyd ) , who pointed out that the "mitigation" strategy would result in an overwhelmed national health service and that achieving high exposure across the population should not be anticipated to achieve long lasting population immunity and thus conclude the pandemic. the mitigation strategy was perceived as a callous sacrifice of lives, with the media widely reporting that top government aide dominic cummings had told a private meeting that the government's strategy was "herd immunity, protect the economy and if that means some pensioners die, too bad" (buchan ) . a "crisis of trust" (smyth ) followed. even though modelling from imperial college, london (ferguson et al. ) , indicated how swiftly the nhs would be overwhelmed, and convinced the u.k. government to introduce a "suppression" strategy (wickham ) from monday march , doubts remained. the government was urged to "come clean" about the sources of the information on which the mitigation strategy was based (smyth ) , and media investigations followed. earlier communication in this case, where valuesdriven disputes existed between experts (kahan ), likely would not have prevented political crisis, but it would have allowed more time for sense-making processes in scientific, medical, and public communities. we recommend a commitment in pandemic planning documents to sharing sources, models, and evidence at the time of deliberation, and with it, the questions advisors are asking (such as, will the same number of deaths occur regardless of strategy over the long term?) earlier public discussion of these questions might at least have somewhat disrupted simplistic framing and use of "herd immunity," by enabling early and public scientific challenge from epidemiologists, as occurred from mid-march (armitage and hawke ; barr ; macintyre ). we note that the simplistic expectation that "herd immunity" would end the pandemic remains widespread (e.g., hasan ). earlier communication that explicitly discussed values might have enabled better public sense-making about the "mitigation" and "suppression" strategies. because each strategy invoked values differently and prioritized different values, we suggest that better communication is needed to explain how values such as being "proportionate" (australian government department of health ) are expressed in these strategies. because the costs of different strategies tend to fall on different members of the community, valuesexplicit communication could more effectively engage with the concerns and needs of those most affected when a strategy is selected. this paper offers some early thoughts for why the principles of risk communication should include the recommendation to be explicit about values. we are not suggesting that better communication alone can prevent or resolve either epistemic or political disagreements in pandemic management nor alleviate every anxiety nor uncertainty. but we do suggest that, given that disagreements about pandemic responses are very often driven by different value commitments, a "values turn" in risk communication (feinberg and willer ) is likely to produce significant benefits, including clearer communication, with greater impact. with regard to the principle of communicating early, we have shown that this is a means of conveying respect for peoples' threatened sense of self-determination, understood broadly. we suggest that this communication of value offers a richer explanation for why early communication, especially where directed with empathy at those most affected by response measures, is important. values-based risk communication will enable a more effective pandemic response. when self-descriptions contradict behavior: actions do speak louder than words what is herd immunity and could it slow the spread of coronavirus covid- around the world? abc news effective risk communication how coronavirus exposes the way we regard ageing and old people. the conversation australian health management plan for pandemic influenza what is herd immunity and is it a possibility for the uk? the independent stranded chinese students confused and angry over australia's coronavirus travel ban who declares coronavirus a global health emergency the guardian coronavirus: downing street denies claim dominic cummings wanted to protect economy over elderly. the independent time to use the p-word? coronavirus enters dangerous new phase crisis an d emerg ency ris k co mmuni catio n m an ual the politics of sarsrational responses or ambiguity, symbols and chaos? it is a shock to realise everything is not going to be ok. the times health system responds to virus threats. the sydney morning herald best practices in public health risk and crisis communication risk communication-principles, tools, and techniques. paper presented at the presentation for the united states nuclear regulatory commission evaluation and effective risk communication what is herd immunity and how can we achieve it with covid- ? covid- school of public health expert insights risk perceptions of covid- around the world trust, risk perception and the tcc model of cooperation reconciling indigenous peoples' individual and collective rights: participation, prior consultation and selfdetermination in latin america coronavirus has fuelled racism against asian-australians, but why isn't official data showing it? abc news moral reframing: a technique for effective and persuasive communication across political divides impact of non-pharmaceutical interventions (npis) to reduce covid- mortality and healthcare demand risk perception and communication unplugged: twenty years of process political liberty: integrating five conceptions of autonomy an introduction to risk communication we thought we had three years": uq team to fast-track coronavirus vaccine. the sydney morning herald government triggers emergency plan for covid- pandemic, and considers economic assistance. the conversation the guardian. . the guardian view on herd immunity: yes it was "part of the plan open letter from australian economists: don't sacrifice health for "the economy". the conversation . i'm an epidemiologist. when i heard about britain's "herd immunity" coronavirus plan, i thought it was satire. the guardian coronavirus and the threat to south asian democracy. the interpreter journalists' views about reporting avian influenza and a potential pandemic: a qualitative study coronavirus fears can trigger anti-chinese prejudice. here's how schools can help. the conversation chronic disease, health equity and covid- together apart: the psychology of covid- bioethical inquiry cultural cognition as a conception of the cultural theory of risk ethical guidelines in pandemic influenza: recommendations of the ethics subcommittee of the advisory committee of the director the chamber of risks: understanding risk controversies the yellow peril revisited: the impact of sars on chinese and southeast asian communities risk communication in public health risk communication: a handbook for communicating environmental, safety, and health risks busting the myths about covid- herd immunity, children and lives vs jobs. nhmrc centre for research excellence integrated systems for epidemic response. blog you and i may get coronavirus-and live with it: here's how to prepare for a pandemic. the sydney morning herald public health with a punch: fear, stigma, and hardhitting media campaigns csiro to begin testing coronavirus vaccines within weeks. the sydney morning herald national ethnic disability alliance (neda), et al. . statement of concern -covid- : human rights, disability and ethical decisionmaking a toilet paper run is like a bank run. the economic fixes are about the same. the conversation four questions for risk communication: a response to roger kasperson coronavirus: boris johnson warns "many families will lose loved ones" because of virus. the mirror containment as signal: swine flu risk miscommunication. peter sandman risk communication website covid- is rapidly changing: examining public perceptions and behaviors in response to this evolving pandemic crisis communication and the public health coronavirus: ten days that shook britain-and changed the nation for ever trust, confidence, procedural fairness, outcome fairness, moral conviction, and the acceptance of gm field experiments the role of public trust during pandemics: implications for crisis communication perception of risk ministers urged to come clean on model for british response. the times keep coronavirus risk in perspective the theory of self-determination ethics in a pandemic: a survey of the state pandemic influenza plans ethics and risk communication the times. . the times view on boris johnson's handling of the coronavirus crisis: no immunity effective health risk communication about pandemic influenza for vulnerable populations chinese-australians facing racism after coronavirus outbreak stigma, race, and disease in th century america monitoring the level of government trust, risk perception and intention of the general public to adopt protective measures during the influenza a (h n ) pandemic in the netherlands heated" debate between scientists forced the psychology behind why some people refuse to wear face masks communicating risk in public health emergencies: a who guideline for emergency risk communication (erc) policy and practice this is racism": chinese-australians say they've faced increased hostility since the coronavirus outbreak began top economists are deriding the "false choice" between saving lives from coronavirus and maximizing economic growth publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations acknowledgments no funding or conflicts of interest are associated with this manuscript. the authors wish to gratefully acknowledge the very useful feedback provided by two reviewers of this article.author statement all authors contributed to the study conception and design. media analysis and the first draft of the manuscript was written by claire hooker. both authors edited and discussed subsequent versions of the manuscript. claire hooker completed the revisions in response to reviewers. all authors read and approved the final manuscript. key: cord- - vlfc mk authors: colbert, stephanie; wilkinson, claire; thornton, louise; richmond, robyn title: covid‐ and alcohol in australia: industry changes and public health impacts date: - - journal: drug alcohol rev doi: . /dar. sha: doc_id: cord_uid: vlfc mk nan the covid- pandemic is having an unprecedented impact on every aspect of our lives, including the way we drink alcohol. the australian government has implemented strict social distancing measures to contain and prevent the spread of the virus, including requiring all food and drink premises to close or only offer takeaway and home delivery [ ] . new south wales (nsw) liquor and gaming has responded to these measures by temporarily relaxing liquor licensing restrictions to allow any licensed premises, including restaurants, cafes and small bars, which do not usually have the authorisation to sell alcohol for off-premise consumption, to sell alcohol for takeaway and home delivery [ ] . similar measures have also been introduced in south australia [ ] , victoria [ ] , queensland [ ] , the australian capital territory [ ] and western australia [ ] . with families already under financial and psychological stress as a result of the pandemic, increased alcohol use at home has the potential to exacerbate problems further. harmful alcohol use is linked to a range of negative effects in families, from adults modelling poor drinking behaviours to children, to domestic violence and child neglect [ ] . according to data from the nsw bureau of crime statistics and research, around % of recorded domestic violencerelated assaults in were flagged by nsw police as alcohol-related [ ] . harmful alcohol use by carers is also a factor in an estimated - % of child abuse and neglect cases in australia, with alcohol more likely to be involved in more serious cases [ ] . there are reports of increases in purchasing of alcohol by australian consumers [ ] [ ] [ ] , supported by recent credit and debit card data from the commonwealth bank of australia [ ] . the commonwealth bank data shows an overall contraction in spending over the week to march compared to the same week in the previous year, but a % increase in spending on alcohol [ ] . the following week saw a % increase in spending on alcohol compared to the same week in [ ] , although the high spending does appear to be volatile as data from the week ending april shows a % decline in spending on alcohol [ ] . regardless of overall alcohol spending trends, one segment of the market that is undoubtably growing with the current social distancing measures in place is online sales and home delivery. online alcohol sales were experiencing rapid growth in australia before the onset of the covid- crisis [ ] and, according to liquor industry news website 'the shout', there has been a significant boom in sales in recent weeks-some australian online retailers have reported % to % increases in sales compared to the same period in [ ] . data from the united states suggest that similar trends are occurring there, with overall alcohol sales up % in the week ending march compared to the previous year, and sales in the online alcohol delivery subsector up % [ ] . with online sales and home delivery likely to continue to make up a considerable portion of the alcohol market in australia for at least the next - months, it is worth considering the specific issues associated with this mode of alcohol supply. there is a dearth of research in this area, but the limited research we have suggests online retailers are subject to less regulation than 'bricks and mortar' bottle shops [ ] . our recent examination of the delivery practices of the most popular online alcohol retailers in australia found % advertised a willingness to leave alcohol unattended at an address without verifying the purchaser's age [ ] . in addition, only one in five retailers stated anywhere on their website a policy to refuse delivery of alcohol to intoxicated persons [ ] , a low proportion considering it is unlawful in all jurisdictions in australia to sell or supply alcohol to an intoxicated person on a licensed premises [ ] and most jurisdictions require mandatory signage to be displayed to that effect where liquor is being sold on premises [ ] [ ] [ ] [ ] . in a recent survey, one in five on-demand alcohol delivery service users reported that their motivation for using the service was because they were over the blood alcohol limit to drive, and % said that they would have had to stop drinking alcohol if the delivery service was not available [ ] . we are concerned that as the alcohol market shifts online, alcohol will be increasingly available to intoxicated persons and minors. in the midst of the pandemic, 'contactless delivery' is being encouraged by alcohol retailers [ , ] . this reinforces the practice of leaving alcohol unattended without age being verified or consideration taken of whether the customer is intoxicated. harm from alcohol use is a huge burden on the healthcare system in australia [ ] , and practices like these are particularly concerning at a time when the healthcare system is already under pressure due to the covid- pandemic. considering the relationship between alcohol and family violence, and the avoidable burden caused by alcohol on the healthcare system, it is surprising that governments around australia have been so quick to relax liquor licensing restrictions during this pandemic. within hours of the australian government announcing the mandatory closure of all food and drink premises except for takeaway and delivery [ ] , the nsw government had announced a relaxation of liquor licensing restrictions so that any restaurant, cafe, bar, pub or club could sell alcohol for takeaway and home delivery [ ] . so swift was the introduction of these measures that nsw police were even caught offguard, forcing a sydney bar offering home-delivered cocktails to cease trading immediately as they were 'trading outside of their licensing conditions' [ ] . it was reported that several other small bars and restaurants were also forced to stop selling takeaway and home-delivered alcohol due to the confusion caused by rapid change in licensing conditions [ ] . the temporary alcohol policy changes australiawide are unprecedented and vary considerably across states and territories (table ) . for example, while nsw relaxed liquor licensing restrictions for takeaway and home-delivery, the northern territory introduced additional restrictions on the sale of takeaway alcohol at bottle shops. bottle shop attendants in the northern territory are now required to refuse the sale of alcohol to a person that lives outside the region where the purchase is taking place, unless the purchaser is able to satisfy the attendant that they have a lawful place within the region to consume it [ ] . the introduction of these emergency restrictions are intended to discourage groups of people gathering in public to drink [ ] . following reports of alcohol stockpiling among australian consumers [ ] [ ] [ ] and increasing alcohol sales [ ] , retail drinks australia, the organisation representing retail liquor nationally, announced a voluntary initiative by participating liquor retail members to introduce temporary purchase limits (table ) [ ] . however, these limits on purchasing are extremely generous, allowing each customer to purchase two cases of beer and bottles of wine per transaction or the equivalent [ ] . this equates to around standard drinks [ ] or months' supply for someone who is drinking standard drinks per week, the maximum recommended in the revised australian guidelines to reduce health risks from drinking alcohol (currently still in draft form) [ ] . imposing these kinds of purchasing limits could be seen as a deliberate attempt by the industry to make supplies seem scarce to encourage more alcohol purchasing. research into 'scarcity messaging' in advertising has indicated that scarcity of a product can create a sense of urgency among buyers that can result in purchasing greater quantities than they otherwise would [ ] . there has been no shortage of advertising from the alcohol industry during the covid- pandemic, with one major beer brand even taking out full-page newspaper advertisements under the guise of advocating for social distancing [ , ] . the brand name and logo dominated most of the page, with a few lines of social distancing advice-the motivation clearly to promote their products and brands and present themselves as responsible corporate citizens, rather than to actually contribute to reducing the spread of the virus [ , ] . the western australian cancer council has also reported social media advertising from alcohol retailers that promote the stockpiling of alcohol and heavy drinking while in insolation at home [ ] . other alcohol retailers have also been involved in questionable promotional activities, including one offering the 'chance to win your bills paid for a year' with every purchase of a case of beer [ ], clearly targeting those for as long as the public health (covid- places of social gathering) order remains in force. victoria [ ] march business with an existing liquor licence can apply for a temporary limited licence to enable them to sell alcohol for takeaway and home delivery. conditions: • application process: business must apply for a temporary limited licence which will be processed within h. there is no associated application fee for this licence. × ml containers. • purchase with meal: for restaurant, cafe and byo licence holders the supply of liquor for takeaway or by delivery must be with a meal. the earlier of september or the date on which the state of emergency declared in victoria over covid- ceases to be in force. queensland [ ] march temporary conditions depend on the type of licence held: • subsidiary on-premises licence (cafés): allowed to sell takeaway alcohol, limited to a maximum of . l of liquor (total volume) of packaged beer, wine, cider and ready-to-drink beverages, such as premixed spirits. • subsidiary on-premises licence (restaurants): as above but alcohol must be sold with a meal. • commercial other-bar: allowed to sell takeaway alcohol, limited to packaged beer, wine, distilled spirits, cider and ready-to-drink beverages, such as premixed spirits. a maximum of . l of liquor (total volume) per transaction, including a ml limit on distilled spirits within the total volume of any transaction. • community other licence: able to sell takeaway alcohol to members, staff and reciprocal members to allow for disposal of existing stock only. type/volume restrictions the same as for commercial other -bar licence. not specified. south australia [ ] march licensees who hold a restaurant and catering, residential, small venue, club or on-premises licence are able to apply for a short-term licence to enable them to sell alcohol for takeaway or delivery. conditions: • application process: online application for short-term licence with no fee attached. • quantity limits: up to two bottles of wine or one bottle of wine and a six pack of beer, cider or pre-mixed spirits per transaction. • purchase with meal: for this short-term licence the supply of liquor for delivery or takeaway must be with a meal. short-term licences will be valid until the public health emergency relating to covid- concludes. permits issued for months. (continues) covid- and alcohol in australia table . march business that hold an on-premises licence (e.g. restaurants, bars and cafes) can apply for a temporary permit to enable them to sell alcohol for takeaway and delivery. conditions: • application process: licensees must make an application for three-month commercial liquor permit, no fee attached. • quantity limits: no quantity limits specified. • purchase with meal: no requirement to sell alcohol with food. western australia [ ] march business with existing liquor licences are able to apply for an occasional liquor licence to allow for the sale of packaged alcohol with a meal for takeaway or delivery. conditions: • application process: licensees can make an application for an occasional liquor license for up to months. no application fee. • quantity limits: one bottle of wine and a six-pack of beer, cider or pre-mixed spirits per transaction. • purchase with meal: the supply of liquor for takeaway or delivery must be with a meal. occasional licences granted for up to six-months. northern territory [ ] march prior to completing a transaction for the sale of takeaway alcohol bottle shop attendants must check an approved form of identification including details of the customer's address. if a customer presents an identification that indicates that they live outside the region of the northern territory where the purchase is taking place, then the attendant must refuse the sale unless the customer is able to satisfy them that they have a lawful place within the region to consume the liquor. condition remains in place while the northern territory declaration of public health emergency remains in effect. no changes as of april . suffering financial hardship as a result of the pandemic. the western australian cancer council has called on the alcohol industry 'to rein in its opportunistic marketing behaviour during the covid- pandemic' [ ] . we are currently seeing an unprecedented shift towards online purchasing and delivery in the alcohol retail market. even before the covid- crisis, online alcohol sales were averaging over % annual growth in australia in recent years [ ] . as some governments in australia move towards relaxing liquor licensing laws to allow pubs, bars and restaurants the ability to provide takeaway and home delivery, we must consider the risks associated with this and monitor the implications for alcohol-related harm. it will be challenging to untangle the effects of these licensing changes from the broader negative impacts of social distancing, but evidence on this will be critical to the inevitable policy arguments that will arise post-pandemic about whether home delivery of alcohol should continue be to allowed for restaurants, cafés and bars. the harms associated with online alcohol delivery and drinking in the home are not unique to pandemic times, indeed, it has been argued that the covid- pandemic has highlighted weaknesses in existing offpremises liquor licensing in australia in minimising the harms associated with home drinking [ ] . licensing systems should aim to help protect the community from the health and social harms associated with home drinking, both during the covid- pandemic and into the future [ ] . in line with recommendations from the world health organization on alcohol during covid- [ ] , we would advocate against a relaxation of regulations that increase ease of access to alcohol. the world health organization advises that restrictions on access to alcohol should be upheld during the pandemic or even reinforced [ ] , the opposite of what we have chosen to do in australia. at a time when people in the community are feeling anxious, stressed and vulnerable, we need to encourage measures that limit alcohol consumption, not facilitate it. covid- and alcohol in australia update on coronavirus measures: media statement from the prime minister statement of regulatory intent in regards to covid- coronavirus south australian government consumer and business services: liquor licence holders and covid- victorian commission for gambling and liquor regulation: coronavirus (covid- ) information for licensees queensland government liquor and gaming: coronavirus (covid- ) advice for liquor and gaming licensees free permits to support our restaurants, pubs. available at sport and cultural industries: new support for small businesses during liquor restrictions the hidden harm: alcohol's impact on children and families. foundation for alcohol research and education: canberra domestic violence statistics for nsw alcohol's involvement in recurrent child abuse and neglect cases sydney morning herald: loo paper hoarding is over-it's time now for a drink and a new home office dan murphy's and bws introduce product limits to discourage booze hoarding daily news: panic buyers turn to stockpiling grog during coronavirus pandemic cba report reveals what we're buying during pandemic available at commonwealth bank: commbank card data indicates falls in spending are becoming more widespread commonwealth bank: card data indicates massive fall in spending in the lead up to easter wine and liquor sales-australia market research report the shout: online liquor purchases increase by up to per cent online liquor sales up % in the us content analysis of websites selling alcohol online in australia alcohol laws in australia: australian government department of health victorian commission for gambling and liquor regulation: do you have the right liquor signage displayed? gambling & lotteries: key responsibilities of liquor licensees signage that licensed venues must display by law liquor practice manual alcohol home delivery services: an investigation of use and risk winestar: statement on covid- dynamic wines: delivery & shipping australian burden of disease study : impact and causes of illness and death in australia sydney morning herald: police shut down sydney bar over cocktail delivery despite government order northern territory government: director of liquor licensing notice of intention to exercise of emergency powers pursuant to section of the liquor act retail drinks australia: retail drinks announces voluntary national initiative australian governement department of health: standard drinks guide draft australian guidelines to reduce health risks from drinking alcohol scarcity messages: a consumer competition perspective drinks trade: lion launches covid- advertising campaign cancer council wa calls out alcohol industry for opportunistic marketing during covid- pandemic accessibility of 'essential' alcohol in the time of covid- : casting light on the blind spots of licensing? world health organization: alcohol does not protect against covid- ; access should be restricted during lockdown key: cord- - k udppg authors: tisdall, lucas; zhang, yahua title: preparing for ‘covid- ’: lessons in management focus – an australian general aviation perspective date: - - journal: j air transp manag doi: . /j.jairtraman. . sha: doc_id: cord_uid: k udppg this paper considers the observed impacts of covid- on the behaviour of a cross-section of the general aviation (ga) community in australia. it specifically observes the nature of management decision making observed in the sector, and the financial impacts of such choices. this paper highlights a lack of financial acumen in the australian ga community which is likely to inhibit resilience in the sector and limit its ability to learn from the economic shock covid- represents. finally, the paper proposes several initiatives to improve the quality of management decision making in the sector's leadership, with a view to improving its financial outlook and visibility to policy makers. on january , , the first case of what is now termed covid- was reported in australia (hunt, ) . the rapid escalation of the covid- response levels by government agencies across the country was aimed at reducing the spread of an aggressive virus in the majority of the population. to achieve this, a primary target of containment was the free movement of people by means of air transport. on march, qantas announced capacity cuts on international transport of percent before it then rose to percent and flowed over to domestic travel (druce, ) . extensive media reporting highlighted as early as march that an aud$ m airline rescue package was to be launched (karp, ) , followed some days later by an aud$ m fund for regional aviation operators (sullivan, ) . such support was unheralded and welcomed by many airline players despite lobbying positions adopted in support of individual corporate agendas. by contrast, the general aviation (ga) sector was not the beneficiary of specific discussion or fiscal resolve of the same calibre. the federal regulator encouraged aviation operators to reach out to them on march to discuss what regulatory support they might need (casa, a). on march , a series of exemptions were put in place to deal with the practicalities of pilot currency, medical certification, and organisational registration (casa, b) . while these measures have been accepted by industry, the communication of broader management support and strategic direction has been noticeably muted when compared to similar agencies such as the european union aviation safety agency that has adopted a role of stewardship for their respective constituencies (easa, a) . this papers aims to document the impact of covid- on australia's ga sector with a focus on the issues affecting the formulation of government policies, business decisions, and mental health. the next section will give the background of australia's ga industry, followed by the research methods used for this study. section presents the problems that need improving and solving. recommendations are provided in the last section. the australian general aviation sector and its aligned on-demand charter services have long been acknowledged as a disparate subset of the civil aviation industry (btce, ) . the responsible federal department itself states that "there are currently no robust economic datasets compiled for the ga sector, restricting analysis of the impact of the various cost pressures facing ga or the contribution ga makes to the economy (bitre, ) ." the issue is acerbated by a lack of understanding of the key decision-making drivers of the actors within the sector (kivits and charles, ) . the commercial element of the general aviation community has been grappling with structural limitations for many years (mills, ; laird, ) . among their shared concerns have been the capacity to raise capital, access finance, adapt to rapid regulatory change and contain costs in training and operations (aopa, ). the sector, including approximately authorisation holders, has been heavily populated by privately held, thinly capitalised operators who depend on asset utilisation rates to keep ahead of their costs curves with varied degrees of success. representation of the sector has been fragmented, with a heavy policy emphasis on the airline community tending to take away the bandwidth of the smaller players in the aviation industry. the impact of covid- has rapidly exposed the fragility of the ga sector, and the relative immaturity of the business continuity plans nominally held by operators. it has also highlighted the lack of insight that federal policy makers have into the constituency, and the challenge of communicating to operators with varying degrees of commercial acumen across flight training, recreational hire, and on-demand charter alongside maintenance organisations and other supporting businesses. this paper considers the australian experience observed across a range of ga operators in the flight training, maintenance, repair, and operations (mro) and associated on-demand charter spaces in the early months of the covid- pandemic. information gathering for this study involves a review of existing literature produced by academic journals, government organisations, magazines, websites of ga firms, consulting firms and industry bodies. informal interviews with no predetermined question set were carried out with the management of ga operators to understand their concerns, and operational and financial decisions amid the pandemic crisis as well as their future plans. the operators hold either civil aviation safety authority (casa) car or part maintenance regulation approvals, part or training approvals or charter/low capacity rpt operator certificates. the ten businesses observed were located in cairns, archerfield, bankstown and adelaide and are typical in size and scope to the general constituency resident at many ga airports across australia (ditrd&c, ). the rational choice paradigm of decision making suggests that managers will make a choice of alternatives that carries the highest subjective expected value to them, based on logic and data (mcshane et al., ) . however, the rapid onset of covid- and the endless news cycle introduced a level of tension and negative sentiment into the community that excited emotional responses. both information overload and emotion compromise rationality (li et al, ) . numerous operators defaulted to a form of bounded rationality (simon, ) , practicing satisficing rather than maximising potential outcomes and future-proofing their businesses. our interviews reveal that in the early weeks of the pandemic, very few businesses had engaged in scenario planning for exogenous business interruption, despite having had ample examples in sars and mers about the potential for industrial disruption due to global health crises. operators expressed uncertainty about the nature of stand down provisions in minimum wages and national award conditions given that many had never had to consider them. furthermore, the operator principals engaged with were concerned with the capacity of their balance sheets to sustain mass drawings on accrued leave balances while others found a general lack of financial management data to support claims on available federal support like jobkeeper and the various state low-interest term loan schemes, or had difficulty interpreting the qualifying criteria for such assistance. a kind of fight or flight response became amplified across several metropolitan airports. our interviews suggest that key suppliers in the mro space pre-empted business failure by their debtor base and moved to a cash on delivery terms base, withdrawing traditional - days terms for parts consumers. the interviewees admitted that this was largely driven by self-preservation rather than on the basis of creditworthiness and historical character or capacity of the debtor principals. the rushed changes in decision marking principles including the constriction of credit terms by such businesses are likely to result in a shift of clients to those who kept their doors open and who were willing to be pragmatic based on a more in-depth knowledge of end-user consumption rates and ongoing viability. interestingly, it is not all bad news. movement data suggest that flight training organisations took advantage of the exemption of social distancing rules in school classrooms and australia's accommodating autumnal weather conditions to press on with their flying activities (airservices australia, ) . perhaps because of the relatively low levels of initial covid- infection in australia, managers were biased by a representativeness heuristic that compromised the level of investment in virus suppression in favour of throughput. this is also due to a lack of direction from the responsible department of the regulator about what flight activity might continue, which is in contrast to easa who had banned most aspects of visual flight rules (vfr) flight in europe at a very early stage in the pandemic (easa, b). prior to covid- , there has been a noticeable uplift in sentiment among the ga fraternity. the us dollar value was starting to appear manageable, and indication of some consolidation in industry (particularly flight training and mro operations) was in evidence, mirroring international trends (jacobs and goebel, ) . the aircraft broker market had completed higher than expected closures of ga aircraft in the final calendar of calendar , with particular demand in the tourism sector. social capital appeared with industry participants forming networks to try and counter the influence of rpt players coming into the training and charter space, and therefore stymying downstream supply and support players in the ga sector. however, such confidence rapidly evaporated, with various industry participants withdrawing non-binding offers, cancelling aircraft orders and deferring capital projects like hangar expansions and line training for staff (wilson, ) . us manufacturer of advanced private aircraft, cirrus aircraft, laid off staff in just one week in march, for a total of inside one trading year; an example of a global phenomenon of retraction (johnson, ) . in australia, our interviews reveals that one key simulator centre lost % of its income stream almost overnight, with operators taking advantage of relaxations or deferring training for aircraft that will now not arrive on-line in the foreseeable future. given the private nature of many ga entrepreneurs, the true quantum of foregone investment may never be known. during the first six weeks of covid- s presence in australia, ten specific businesses representative of typical airport tenancy mixes were surveyed by the authors to determine the impact of the pandemic on staff wellbeing. research suggests that people have better psychological wellbeing if they have multiple selves; social, professional, personal, and so forth, building to a self-concept that acts as a buffer against any one deleterious impact on one's sense of wellbeing (lester, ) . arguably, the novel coronavirus rapidly stripped people of personal interactions, threatened their professional security and pushed people into isolation without necessarily having the support networks in place to effectively manage it. eighty percent of business owners consulted during the survey process conceded that they had not yet considered this element of their business continuity plan. aviation relies on mentally alert, well-adjusted and fatigue-managed personnel conducting their duties within prescribed standard operating procedures (bendak and rashid, ) . a failure to recognize the mental health impacts on performance of sudden discontinuity may prove costly to capital, compliance, and reputation where no organisation defence is erected to limit human factor or liveware failures in an aviation activity. recognition of the need for authentic leadership and emotional intelligence during periods of organisational stress coupled with their often well-honed cognitive and practical intelligence would enhance the managers ability to role model sound problems solving and provide a frame of reference that can be endorsed by workers who have been suddenly forced outside of their normal operating paradigm. rather than just reflecting fiedleresque contingency theory (fiedler, ) , genuine engagement with the team in a crisis can enhance employee longevity, reduce stress, and promote a sense of unity and purpose that bears long term fiscal benefits. the difficulty in crafting public policy or financial support instruments is clear where the architects have a limited knowledge of the target audience (berg, ) . yet, there are already mechanisms in place that, if reshaped and connected, could do much to alleviate the financial myopia of the general aviation sector evidenced in the preceding observations. to obtain an operator's certificate, the australian federal regulator requires the production of a financial viability statement. once produced and nominally accepted after scant analysis, these rosy projections are unlikely to be revisited as the primary charter of the regulator is deemed to be safety, not fiscal management. the attainment of minimum benchmark ratios and liquidity measures aimed at promoting solvency, depth of balance sheet and sustainable trading terms are often covenanted by financiers and may prove to be of value in maintaining operator focus on key commercial drivers if they were incorporated into the auditable renewal terms of operating approvals. this would conceivably promote sustainable pricing, capacity to reinvest in safety, staff, and equipment, and remove the marginal operators from the marketplace in favour of those more capable of withstanding economic discontinuity. the aforementioned bitre ( ) report highlighted the dearth of performance data to inform public policy. again, the deidentified australian and new zealand standard industrial classification (anzsic) and business activity data held by the ato, in conjunction with some elements of self-reporting as part of the annual general aviation activity survey gathered by bitre should be aggregated to present a macro data set that can be enhanced by an understanding of movement and occupancy data from public and private airports and the risk underwriting information drawn together by insurers every year. this metadata should be sufficient to generate a fuller understanding of a sector that employs more than , people (abs, ) and has (aud) millions invested in plant, equipment, and approvals. further to the ongoing viability of enterprises, enhanced scrutiny should be employed when evaluating those deemed to be "fit and proper" accountable and responsible managers. currently, the validation of such officeholders is based largely on criminal history checks and subjective assessment of familiarity with operating regulations. there is no requirement to demonstrate financial acumen, nor hold any formal or industry recognized business qualification. perhaps by linking the requirement for demonstrating fiscal competency requirements under the australian qualifications framework (promoted in both the vocational education and training (vet) and higher education sectors) to the scope of necessary skills, the calibre of financial management decision makers might be made more robust. extending access to financial literacy programs for licenced personnel as part of their preparation for entering the industry would also do much to the ability for employees to contribute to the financial welfare of the business, and perhaps their own fiscal outcomes. this enhanced source of decision knowledge is likely to improve decision commitment and reduce the risk of conflict in times of external shock. mandating credible financial literacy tuition into existing structures like work health and safety and non-technical skills training would be a small impost but assist all levels of industry to understand their fiscal resilience strategy options and their power to contribute to the bottom line of the businesses they work in. furthermore, such team members are likely to feel empowered about making decisions in difficult circumstances, thereby reducing mental anguish and associated health stressors. finally, in considering targeted financial support for the sector, attention should be given to mechanisms that sure-up the long-term viability of participants. at this stage, the bailout packages available to the airline operators have not been extended to the commercial ga operators (apart from some activity fee waivers or refunds) (nadge, ) . relaxation of pilot currency requirements is a short-term relief, but it must ultimately be redressed in the interests of safety and therefore it is only a deferred cost. generic federal and state loans are to support payroll and cashflow, but not for capital expenditure or acquisition. rather than loan bailouts into already thinly capitalised balance sheets, perhaps the provision of trading line guarantees or rental bonds based on similar low cost terms to encourage the continuance of credit terms and de-risking of tenancies would encourage industry participants to be more supportive of each other during periods of extended duress. likewise, tailored industry finance packages aimed at coupling equipment profiles, attractive depreciation rates and historically low interest rates could be underpinned by government for qualifying candidates to galvanise bank engagement with the sector. numerous options exist to improve the potential for the general aviation sector to meet the challenges that will be presented by 'covid- '. as the example of canada, the us and other international jurisdictions bears out, what is required is the unified presentation of will by the local sector, and an understanding by policy makers of the value and contribution of a resilient and performing ga community in the broader economy. i draw the editor's attention to the fact that the corresponding author is also the managing director of a commercial trading group at brisbane's archerfield airport. i do not believe that this reflects a conflict of interest in the formulation of this submission, and there are no financial implications or considerations for this work that could have influenced its outcome. i confirm that i have given due consideration to the protection of intellectual property associated with this work and that there are no impediments to publication, including the timing of publication, with respect to intellectual property. in so doing i confirm that i have followed the regulations of my institution concerning intellectual property. i understand that the corresponding author is the sole contact for the editorial process (including editorial manager and direct communications with the office). we confirm that we have provided a current, correct email address (as noted below) which is accessible by the corresponding author and which has been configured to accept email from the publishers. lucas tisdall: lucas.tisdall@usq.edu.au. may , . movements at australian airports a plan to revitalise general aviation in australia fatigue in aviation: a systematic review of the literature classical liberalism in australian economics bureau of transport and communications economics (btce), . general aviation flying in australia advice for aviation operators how we're helping you -exemptions being put in place regional development and communications (ditrd&c), . regional aviation policy: issues paper qantas to cut per cent of international flights. the canberra times european union aviation safety agency (easa), a. coronavirus covid- what are the current restrictions all over europe? the contingency model and the dynamics of the leadership process first confirmed case of novel coronavirus in australia the business aviation industry: growth, contraction and consolidation cirrus aircraft slows operations, furloughs employees amid coronavirus disruption australian airline industry to receive $ m rescue package. the guardian aviation planning policy in australia: identifying frames of reference to support public decision making back on track: rethinking transport policy in australia and new zealand a multiple self theory of the mind the rationality of emotions: a hybrid process model of decision-making under uncertainty the reform of australian aviation charter aviation operators feel forgotten with government focus on qantas, virgin and rex. abc news bounded rationality regional aviation receives $ million package to help survive coronavirus an ill wind: covid- and aviation. flight safety australia key: cord- -pi ifpcy authors: chan, raymond javan; emery, jon; cuff, katharine; teleni, laisa; simonsen, camilla; turner, jane; janda, monika; mckavanagh, daniel; jones, lee; mckinnell, emma; gosper, melissa; ryan, juanita; joseph, ria; crowe, bethany; harvey, jennifer; ryan, marissa; carrington, christine; nund, rebecca; crichton, megan; mcphail, steven title: implementing a nurse-enabled, integrated, shared-care model involving specialists and general practitioners in breast cancer post-treatment follow-up: a study protocol for a phase ii randomised controlled trial (the eminent trial) date: - - journal: trials doi: . /s - - - sha: doc_id: cord_uid: pi ifpcy background: due to advances in early detection and cancer treatment, -year relative survival rates for early breast cancer surpass % in developed nations. there is increasing focus on promotion of wellness in survivorship and active approaches to reducing morbidity related to treatment; however, current models of follow-up care are heavily reliant on hospital-based specialist-led care. this study aims to test the feasibility of the eminent intervention for implementing an integrated, shared-care model involving both cancer centre specialists and community-based general practitioners for early breast cancer post-treatment follow-up. methods: we describe a protocol for a phase ii, randomised controlled trial with two parallel arms and : allocation. a total of patients with early-stage breast cancer will be randomised to usual, specialist-led, follow-up care (as determined by the treating surgeons, medical oncologists, and radiation oncologists) or shared follow-up care intervention (i.e. eminent). eminent is a nurse-enabled, pre-specified shared-care pathway with follow-up responsibilities divided between cancer centre specialists (i.e. surgeons and oncologists) and general practitioners. the primary outcome is health-related quality of life as measured by the functional assessment of cancer therapy—breast cancer. secondary outcomes include patient experience, acceptance, and satisfaction of care; dietary, physical activity, and sedentary behaviours; financial toxicity; adherence; health resource utilisation; and adverse events. discussion: the trial is designed to identify the barriers to implementing a shared-care model for breast cancer survivors following treatment. results of this study will inform a definitive trial testing the effects of shared-care model on health-related quality of life of breast cancer survivors, as well as its ability to alleviate the growing demands on the healthcare system. trial registration: australia and new zealand clinical trials registry actrn . registered on november discussion: the trial is designed to identify the barriers to implementing a shared-care model for breast cancer survivors following treatment. results of this study will inform a definitive trial testing the effects of shared-care model on health-related quality of life of breast cancer survivors, as well as its ability to alleviate the growing demands on the healthcare system. the order of the items has been modified to group similar items (see http://www.equator-network.org/reporting-guidelines/spirit- -statement-defining-standardprotocol-items-for-clinical-trials/). in australia, breast cancer is the most common cancer in females with an estimated , new cases annually [ ] . with advances in early detection and cancer treatment, such as surgery, post-operative radiotherapy, and pre-or post-operative systemic therapies including cytotoxic chemo-, endocrine, and anti-her antibody therapies, the -year relative survival rate for breast cancer is estimated at % [ , ] . consequently, in , there were at least , breast cancer survivors living in australia [ ] . despite good survival outcomes, breast cancer survivors require supportive care including prevention of cancer recurrence, surveillance for secondary or new primary cancer, and management of a range of long-term bio-psycho-social effects from their cancer diagnosis and treatment. in addition, many cancer survivors need management of comorbidities as they are . times more likely to develop mental and behavioural problems and almost . times more likely to develop musculoskeletal conditions, circulatory conditions, and endocrine system disorders compared with non-cancer patients [ ] . these health concerns highlight the importance of a comprehensive, well-integrated, patient-centred model of care for people following completion of breast cancer treatment. the current models of post-treatment care in australia are mostly hospital-based and specialist-driven and focus on surveillance for disease recurrence, rather than the holistic care needs of cancer patients. this model of followup care limits the integration between specialist institutions and general practitioners (gps), overloads the specialist system, and is unsustainable to meet the demands of the ever-growing population of cancer survivors. specialist-based follow-up carries the burdens of travel and out-of-pocket costs such as those for parking. those in non-metropolitan areas face more major disruptions to engage in specialist-based follow-up. therefore, there is a strong case for an integrated, shared post-treatment follow-up care model for breast cancer survivors that involves both cancer specialists as well as care provided in the community by gps. such a shared-care model is consistent with cancer australia statements [ ] , the optimal care pathway for breast cancer [ ] , and international guidelines [ ] . in addition, the literature suggests that such a model is feasible, acceptable, safe, and more cost effective and patient-centred than current models used within australia [ , ] . despite the promising evidence base, a shared followup care model in which specialists in the acute cancer care setting and gps collaborate is not routinely implemented across australia and many developed nations. barriers to such shared care include the lack of a coordination between multiple providers, lack of patient and provider knowledge about the benefits of shared care and how to implement it, insufficient or delayed communication between cancer specialists and gps, and lack of awareness of available support such as funding models, tools, and resources [ , ] . these barriers could be overcome if a specialist cancer nurse advises stakeholders (patient and gps) of the benefits of sharedcare, facilitates effective and timely care coordination, and acts as the conduit between the specialist cancer multidisciplinary team and the gps at key transition time points, such as completion of definitive primary and adjuvant treatment [ ] . the objective of the study is to test the feasibility of a prospective, pragmatic randomised controlled trial (rct) of the eminent intervention-a nurse-enabled, integrated, shared-care model involving cancer specialists and gps for early breast cancer post-treatment follow-up. this phase ii pilot rct aims to assess the feasibility of a larger definitive clinical trial. outcome data will be collected at four timepoints (or five if booster nurse clinic is attended): (t ) baseline (at enrolment ± prior to booster nurse clinic, if relevant), (t ) months, (t ) months, and (t ) months. this study is conducted in a large, australian metropolitan tertiary teaching hospital and general practices. the study population consists of patients with earlystage breast cancer (i.e. no-distant metastases) or ductal carcinoma in situ (dcis). patients will be eligible to participate from weeks prior to completion of definitive treatment (surgery or adjuvant chemotherapy) and up to months after completion of treatment. patients meeting all of the following criteria are eligible for inclusion: diagnosis of curable, early breast cancer; receiving care at the princess alexandra hospital; able to speak and read english; years of age or older; ambulatory at the time of recruitment; eastern cooperative oncology group (ecog) performance status or ; able to nominate a gp or gp clinic to be involved in their follow-up; and access to a telephone. patients meeting any of the following criteria are excluded: presence of severe mental, cognitive, or physical conditions that would limit the patient's ability to provide informed consent. potential participants are identified by the research nurse or treating clinician during multidisciplinary team meetings. participants are approached by their treating clinicians to gauge their interest in the study and gain verbal consent to being approached by the research team. participants are then contacted by the research nurse, screened for eligibility, and provided with study information, and after a time of reflection (at least h), they sign the consent form with the research nurse. table outlines the different phases of the study and data collection. consent to access medicare and pharmaceutical benefits scheme (pbs) data on service use that qualifies under the medicare benefits schedule (mbs) will be obtained, including relevant claims details (date of service, medicare item number, and description) and costs details. survivorship care of breast cancer survivors following completion of treatment is an important issue, especially in light of improving survival rates [ ] . the shared-care model between specialists and gps focusses on the complex care needs of breast cancer survivors, rather than solely on disease recurrence, and may influence patient health outcomes and service outcomes [ ] . arm the control group will receive usual follow-up care supplemented with a survivorship booklet on living well after cancer published by cancer council australia [ ] . the usual care follow-up arrangement is a specialist-led model as determined by the treating surgeon, medical oncologist, and radiation oncologist. this specialist-led follow-up care is not standardised and with follow-up activities and schedules depending on individual patient needs and the discretion of the treating clinicians. eminent is a multi-faceted intervention that includes a pre-specified shared-care pathway for post-treatment follow-up. the design of the eminent intervention is informed by a number of cancer australia statements, the optimal care pathway [ ] , the self-efficacy model [ , ] , the capabilities for supporting prevention and chronic condition self-management framework [ ] , and our extensive pilot work including a systematic review [ ] and observational studies [ ] [ ] [ ] [ ] . table outlines the active ingredients of the eminent intervention. after enrolment, participants who have completed chemotherapy and radiotherapy or those who will receive aromatase inhibitor will participate in a -min telehealth cancer pharmacist consultation for medication reconciliation and education prior to specialist nurse consultation. a - -min consultation with a specialist cancer nurse is then conducted to provide a treatment summary, the shared follow-up care appointment schedule, and survivorship patient education (including the survivorship booklet on living well after cancer published by cancer council australia [ ] ) and to codevelop a draft survivorship care plan (scp). the scp includes up to three smart (specific, measurable, achievable, realistic, and timely) goals that are developed by the nurse and patient in partnership using motivational interviewing and self-efficacy techniques. due to the recent covid- pandemic, where there are delays of - months before gp involvement, a second 'booster' specialist cancer nurse consultation is offered to patients to update the scp. the treatment summary and draft scp is provided to the gp. within weeks of the specialist cancer nurse consultation, a - -min case conference between the specialist cancer nurse and the patient's nominated gp is completed to communicate the treatment summary and shared follow-up care schedule and to finalise the scp and negotiate the gp's role in facilitating the scp goals. the gp may propose changes or express if they are not willing to take part in specific care activities outlined in the scp. the finalised scp is then filed in the patient's medical records and provided to the patient and the gp. the shared, follow-up care schedule consists of monthly patient appointments with a cancer centre specialist and annual appointments with the gp for years post-diagnosis. following this, the schedule consists of alternating monthly appointments with a cancer centre specialist and gp for up to years post-diagnosis. at years post-diagnosis, patients are discharged to the care of the gp, as per usual care. the gp appointments will focus on reviewing the scp; promoting general health; primary prevention, screening, and management of comorbidities; psychosocial health; cancer treatment toxicities; cancer-related symptoms; chronic disease management planning; and allied health referrals. the gp has direct telephone access to the specialist cancer nurse in case of concerns or escalation for acute care review. the cancer centre specialist appointments focus on surveillance activities such as physical examination and imaging (i.e. annual mammogram). the presence of any of the following criteria constitutes cause for the withdrawal of the participant: altered mental capacity resulting in inability to provide continuing informed consent, notification from treating oncologist and/or gp that the participant is not deemed to have the capacity to consent, and recurrence or progressive disease or death. fidelity of the intervention will be assessed using the framework for behavioural interventions recommended by the national institute of health (nih) [ , ] as outlined in table . no concomitant care or intervention is prohibited during the trial. there is no ancillary or post-trial care for participants in this trial. however, it is expected that the scp generated will have the value of informing longer term updates of the scp and future survivorship care. the feasibility outcomes are recruitment and acceptability of the intervention. the primary endpoint is healthrelated quality of life (hrqol) as measured by functional assessment of cancer therapy-breast cancer (fact-b) [ ] at baseline, , , and months post-enrollment. the -item fact-b is a valid and reliable tool for use in cancer survivors undergoing as well as beyond treatment and has been demonstrated to be sensitive to changes over time [ ] . a total score as well as scores for each of the five subscales (physical, social/family, emotional, functional wellbeing, additional breast cancer concerns) are calculated, where higher scores indicate higher quality of life. fact-b captures key domains of hrqol and key symptoms that are relevant to the study population and sensitive to the eminent intervention. additional outcomes include a range of patientreported secondary endpoints, and process outcomes related to implementation as shown in table . participants of the intervention group, as well as their nominated carer, breast cancer nurses, gps, and other healthcare providers including other nurses, and hospital-and community-based rehabilitation providers will be invited to participate in a semi-structured interview. open ended questions (online supplementary material ) will explore key factors that facilitate or hinder the implementation of the eminent intervention. in this pilot study, we will recruit patients per arm in order to provide initial insights into the intervention feasibility and protocol as well as preliminary effect size estimates. the aim of this study is not hypothesis testing, and the power level is therefore not a valid consideration for sample size [ , ] . the sample size for this study (n = ) falls within the range of sample size recommendations for pilot studies of this nature [ , ] . participants are recruited through the hospital cancer outpatient clinics and therapy units. research nurses and designated health professionals identify potential participants. potential participants are reviewed by a member of the treating team and asked if they would like to be approached by a research nurse or designated table intervention fidelity strategies (adapted) training providers specialist cancer nurses will be trained to standardise the delivery of the intervention to study participants. training includes provision of study manual containing • generic study information: standard operating procedures, study overview, reporting and documentation guidelines, communication flowchart, rationale for the study treatment, completion of survivorship care plan, self-management goal setting, and health coaching • specialist cancer nurse-specific information: job description, intervention protocol, quality assurance, and monitoring an -h training program will be delivered by experts in cancer survivorship and motivational interviewing. the program includes the national cancer nursing education (edcan) learning module on survivorship, related literature, didactic presentations, and roleplay covering: basic concepts of quality cancer survivorship care, components of a high-quality treatment summary and survivorship care plan; provision of self-management support (including collaborative goal setting; motivational interviewing); and mbs item numbers that facilitate the proposed model of care. intervention procedures are monitored through completion of intervention component checklists to ensure that the intervention is delivered as intended. intervention checklists are completed during clinics and gp case conferences to track protocol deviations across specialist cancer nurses and study arms. the intervention fidelity is closely monitored and discussed during the weekly -min meeting for the first months of the trial between the specialist cancer nurses, research nurses, and investigators. minimising contamination between conditions by training interventionists to address participant questions about randomisation and their assigned condition using non-biased explanations. the scp serves as a resource for a participant to understand and refer to whenever they are unsure of follow-up schedule and collaborative goal setting. enactment of treatment skills enactment of treatment skills includes processes to monitor and improve participant ability to perform treatmentrelated behavioural skills and cognitive strategies in relevant real-life settings as intended. this goal will be achieved by ensuring participants are aware of the follow-up schedules and responsibilities of all health professionals, ensuring participants will have a copy of the completed scp including all care responsibilities and goals set for the individual, and checking in with participants once in the first week into the model, then monthly/bimonthly until the end of the trial period as resources allow. health professionals for consent to participate in the study. participants are given as much time as possible to consider their participation and are encouraged to take the information away and discuss participation in the trial with family, friends, and their gp if they so wish to. participants are also encouraged to ask the research nurses, their treating doctors, or nursing staff any questions in relation to their participation. computer-generated random numbers are used to allocate participants in a : ratio by a researcher not involved in recruitment, intervention implementation, or data collection. randomisation is blocked using random permuted blocks of eight and four to ensure that the groups are balanced periodically within stratification groups. stratification groups include patients who have received ( ) surgery only, ( ) surgery and radiation only, ( ) surgery and chemotherapy ± radiation and are her negative, and ( ) surgery and chemotherapy ± radiation and are her positive. these stratification groups were chosen, with clinician input, to allow learnings for patients with different treatment pathways with different follow-up needs to inform the future definitive trial. allocation sequence is implemented using sequentially numbered opaque, sealed envelopes. envelopes are only accessed by the research nurse to randomise the patient once recruitment and baseline data has been collected. eligibility screen x informed consent x allocation x health-related quality of life x x x x allocation sequence is generated by a researcher not involved in recruitment or data collection. patients are enrolled by a research nurse who collects baseline data prior to randomisation. enrolling nurses assign participants to the intervention after baseline data collection. who will be blinded { a} after assignment to the intervention, only outcome assessors are blinded to group allocation. where participants opt to complete their data collection by phone, they are advised not to reveal their group allocation to the outcome assessor. due to the nature of the intervention, no participants or treating clinicians are blinded. no unblinding procedures required as only outcome assessors and data analysts are blinded. plans for assessment and collection of outcomes { a} patient-reported outcomes are self-administered using online surveys or administered in person or via telephone with an outcome assessor trained in the administration of the study instruments. the description of study instruments is listed in table . the primary outcome is hrqol as measured by functional assessment of cancer therapy-breast cancer (fact-b) [ ] . this validated and reliable instrument is well-used in cancer survivors undergoing and beyond treatment [ ] , and it captures key domains of hrqol and key symptoms that are relevant to the eminent intervention. the secondary outcomes are listed below: patient experience of care as measured by the picker patient experience (ppe- ) questionnaire [ ] . the ppe- highlights aspects of care that need improvement to monitor performance and care. it consists of questions distributed to seven dimensions of care: respect, coordination, information/communication/education, physical comfort, emotional support, involvement of relatives, and transitions to community [ ] . dietary behaviours, specifically usual vegetable intake and usual fruit intake, as measured by two short dietary questions from the national nutrition survey [ ] , which have been validated in the australian population. both questions discriminate between groups with significantly different fruit and vegetable intakes. in administering these questions, information about which foods are included as vegetables and fruits is provided and serve sizes are described. physical activity as measured by the active australia survey [ ] which is designed to measure participation in leisure-time physical activity, and a single item from the international physical activity questionnaire [ ] will be used to measure sedentary behaviours. financial toxicity as measured by the -item comprehensive score for financial toxicity (cost)-functional assessment of chronic illness therapy (facit) tool [ ] . this tool is valid and reliable in measuring financial toxicity in patients with cancer [ ] . adherence to clinical assessments including annual mammography, annual physical examination, and endocrine therapy as measured by hospital records. emergency presentations and hospitalizations as recorded from hospital records. satisfaction of care as measured by a - numerical analogue scale with being the least satisfied and being the most satisfied, supplemented with short, structured qualitative questions. process outcomes, including completion of intervention components, as measured by completion of intervention materials such as scps and checklists, number and length of clinical encounters recorded from mbs data and hospital records, and barriers and facilitators to implementation as explored through semi-structured interviews with patient participants, their nominated carer, breast cancer nurses, gps, and other healthcare providers including other nurses, and hospital-and community-based rehabilitation providers. health resource utilisation assessing both health service use and participant out-of-pocket costs including mbs and pbs administrative data sets. these data inform participants' utilisation of services that qualify under the mbs as well as medications dispensed under the pbs. it is planned that the economic evaluation may be reported separately from the main trial. participants who deviate from the protocol are not withdrawn from the trial. participants who withdraw from the trial nominate the degree to which they withdraw (i.e. whether they withdraw from active data collection ± passive data collection such as mbs/pbs data). all participant characteristic and outcome data are entered directly into redcap (research electronic data capture -vanderbilt university, hosted at queensland university of technology) by the research nurse ± the participants through self-administered online survey. to ensure data quality, the database is designed with branching logic, data validation, and range checks for data values, where possible. all source data, clinical records, and laboratory data relating to the study will be archived at the clinical site as appropriate for years after the completion of the study. all data will be available for retrospective review or audit. no study document will be destroyed without prior written agreement between the responsible organisation and the investigator. if the investigator wishes to assign the study records to another party or move them to another location, he/she must notify the responsible organisation in writing of the new responsible person and/ or the new location. data on potential participants is recorded, including reasons for ineligibility or refusal to participate. participants are only identified by a unique participant study number on the case report forms and other study documents. other study-related documents (e.g. signed consent form, participant log) are kept in strict confidence by the investigator. participants are informed that data is held on file by the responsible organisations and that these data may be viewed by staff including the study project manager and by external auditors on behalf of the responsible organisations and appropriate regulatory authorities (to include reviewing human research ethics committee (hrec) and the research governance officers). participants will be identified in publication and conference presentation reports only in aggregated form. all participant data will be held in strict confidence. plans for collection, laboratory evaluation, and storage of biological specimens for genetic or molecular analysis in this trial/future use { } not applicable. there is no collection of biological specimens in the current trial. descriptive statistics will be used to report on feasibility and process-related elements (e.g. recruitment, intervention, retention rates) as well as clinical and resource outcomes. preliminary effect size estimates for patient and resource use outcomes will be calculated following intention-to-treat principles using generalised linear mixed models. the distribution of the mixed models will be chosen as appropriate for the data, for example, a linear model for scale data or a poisson for count data. models will be adjusted for variables used in stratification of the randomisation process. residuals of all models will be examined for statistical assumptions using descriptive statistics and plots. not applicable. no interim analysis is planned. all qualitative interviews with participants assigned to the eminent intervention are audio-recorded and transcribed verbatim for analysis guided by the consolidated framework for implementation research [ ] . methods in analysis to handle protocol non-adherence and any statistical methods to handle missing data { c} preliminary effect size estimates for patient and resource use outcomes will be calculated following intention-totreat principles using generalised linear mixed models. patterns of missing data will be examined using chisquare and t tests. missing data for the outcomes will be accounted for by using mixed models allowing the use of each available case by computing maximum likelihood estimates. plans to give access to the full protocol, participant leveldata, and statistical code { c} not applicable. there are no plans for granting public access of the full protocol, participant-level dataset, or statistical code. composition of the coordinating centre and trial steering committee { d} the chief investigators are the trial steering committee that will provide all governance to the conduct of the study. composition of the data monitoring committee, its role, and reporting structure { a} not applicable. there is no data monitoring committee established for this pilot trial. an adverse event (ae) is any event, side effect, or other untoward medical occurrences that occur in conjunction with the use of the study intervention in humans, whether or not considered to have a causal relationship to the interventions. an ae can, therefore, be any unfavourable and unintended sign (that could include a clinically significant abnormal laboratory finding), symptom, or disease temporally associated with the use of the study intervention, whether or not considered related to the intervention. conditions recognised as being excluded from ae reporting are as follows: any event, side effect, or other medical occurrences that are anticipated because of the normal course of treatment (standard care). there are no known side effects/adverse events associated with the proposed model of care intervention [ ] . due to the nature of this intervention, there will be no reporting of ae. there are no plans for auditing trial conduct beyond the independent research governance requirements and annual reporting to the hrec. plans for communicating important protocol amendments to relevant parties (e.g. trial participants, ethical committees) { } all agreed protocol amendments are clearly recorded on a protocol amendment form and are signed and dated by the original protocol approving signatories. all protocol amendments will be submitted to the institutional hrec for approval before implementation. the only exception will be when the amendment is necessary to eliminate an immediate hazard to the trial participants. in this case, the necessary action will be taken first, with the relevant protocol amendment following shortly thereafter. once hrec approval has been granted, investigators and the anzctr will be updated. it is intended that the findings from this trial will be disseminated at academic and professional conferences and via a manuscript submission to a peer-reviewed journal. participants will be identified in such reports only in aggregate or by study identification number, gender, and age. there are no publication restrictions. despite the strong case for a shared, follow-up care model for breast cancer survivors involving cancer specialists and gps, barriers to shared care mean that it is not routinely implemented across australia. these include the need for coordination across multiple providers, the need for improved patient and provider knowledge about the benefits of shared care and how to implement it, insufficient or delayed communication between cancer specialists and gps, and lack of awareness of available support such as funding models, tools, and resources [ , ] . the current study aims to address these barriers using a specialist cancer nurse to advise stakeholders of the benefits of shared care (patient and gps), facilitate effective and timely care coordination, and act as the conduit between the specialist cancer multidisciplinary team and the gps. practical issues for this trial include estimating the time required to coordinate the trial across multiple providers including engaging gps and fidelity with the intervention components. the proposed study will provide important information on the feasibility of a definitive phase trial for implementing a nurseenabled, integrated, shared-care model involving cancer specialists and gps for early breast cancer posttreatment follow-up. the information collected through the trial, qualitative interviews, and economic evaluations are crucial in guiding the development of such a trial. the protocol published here is version . dated march . the trial began recruitment on december and is expected to continue until november . trial registration: australia and new zealand clinical trials registry, actrn . registered on november , https://www.anzctr.org.au/trial/ registration/trialreview.aspx?id= &isreview=true. responsible for delivering the pharmacist consult. all authors have provided input and have read and approved the final manuscript. this study is funded by metro south health research support scheme project grant (funded by the metro south study, education and research trust account (serta)). the funding body had no role in the design of the study and will not have a role in the collection, analysis, and interpretation of data or in writing the manuscript. there are no limitations on investigator access to the trial dataset. the datasets generated and/or analysed during the current study are not going to be made publicly available but will be made available from the corresponding author on reasonable request. this study is approved by the metro south hospital and health services human research ethics committee (hrec/ /qms/ ). written informed consent will be obtained from all participants. not applicable. no details, images, or videos relating to an individual person will be published, as all data will be presented in aggregate. australian institute of health and welfare. cancer data in australia. canberra: aihw australian institute of health and welfare australian institute of health and welfare. breastscreen australia monitoring report - australian institute of health and welfare. cancer compendium: information and trends by cancer type comorbidity, physical and mental health among cancer patients and survivors: an australian population-based study cancer australia statement -influencing best practice in breast cancer. surry hills: cancer australia victorian department of health and human services of clinical oncology breast cancer survivorship care guideline randomized trial of long-term follow-up for early-stage breast cancer: a comparison of family physician versus specialist care a new model supporting best practice follow-up care for early breast cancer in australia: shared follow-up care for early breast cancer adult cancer survivors discuss follow-up in primary care: 'not what i want, but maybe what i need oncologists' perceived barriers to an expanded role for primary care in breast cancer survivorship care cancer nurses can bridge the gap between the specialist cancer care and primary care settings to facilitate shared-care models living well after cancer. a guide for people with cancer, their families and friends optimal care pathway for women with breast cancer national inst of mental health. prentice-hall series in social learning theory. social foundations of thought and action: a social cognitive theory cognitive processes mediating behavioral change capabilities for supporting prevention and chronic condition self-management. canberra: department of health and ageing and flinders university models of survivorship care provision in adult patients with haematological cancer: an integrative literature review nurses attitudes and practices towards provision of survivorship care for people with a haematological cancer on completion of treatment oncology practitioners' perspectives and practice patterns of post-treatment cancer survivorship care in the asia-pacific region: results from the step study mapping unmet supportive care needs, quality-of-life perceptions and current symptoms in cancer survivors across the asia-pacific region: results from the international step study provision of survivorship care for patients with haematological malignancy at completion of treatment: a cancer nursing practice survey study enhancing treatment fidelity in health behavior change studies: best practices and recommendations from the nih behavior change consortium ensuring treatment fidelity in a multi-site behavioral intervention study: implementing nih behavior change consortium recommendations in the smart trial reliability and validity of the functional assessment of cancer therapy-breast qualityof-life instrument a systematic review of quality of life instruments in long-term breast cancer survivors considerations in determining sample size for pilot studies sample size of per group rule of thumb for pilot study the picker patient experience questionnaire: development and validation using data from in-patient surveys in five countries properties of the picker patient experience questionnaire in a randomized controlled trial of long versus short form survey instruments evaluation of short dietary questions from the national nutrition survey. canberra: australian government department of health and ageing australian institute of health and welfare. the active australia survey: a guide and manual for implementation, analysis and reporting international physical activity questionnaire: -country reliability and validity the development of a financial toxicity patient-reported outcome in cancer: the cost measure measuring financial toxicity as a clinically relevant patient-reported outcome: the validation of the comprehensive score for financial toxicity (cost) publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations the authors acknowledge the contribution of drs kathryn middleton, wen xu, kate roberts, vladimir andelkovic, margo lehman, and tao supplementary information accompanies this paper at https://doi.org/ . /s - - - .additional file . interview guide for the semi-structured interviews with patients/family members and health professionals. key: cord- - khdh nf authors: munasinghe, sithum; sperandei, sandro; freebairn, louise; conroy, elizabeth; jani, hir; marjanovic, sandra; page, andrew title: the impact of physical distancing policies during the covid- pandemic on health and well-being among australian adolescents date: - - journal: j adolesc health doi: . /j.jadohealth. . . sha: doc_id: cord_uid: khdh nf purpose: physical distancing policies in the state of new south wales (australia) were implemented on march , , because of the covid- pandemic. this study investigated changes in physical activity, dietary behaviors, and well-being during the early period of this policy. methods: a cohort of young people aged – years from sydney (n = ) were prospectively followed for weeks (november , , to april , ). daily, weekly, and monthly trajectories of diet, physical activity, sedentary behavior, well-being, and psychological distress were collected via smartphone, using a series of ecological momentary assessments and smartphone sensors. differences in health and well-being outcomes were compared pre- and post-implementation of physical distancing guidelines. results: after the implementation of physical distancing measures in nsw, there were significant decreases in physical activity (odds ratio [or] = . , % confidence interval [ci] = . –. ), increases in social media and internet use (or = . , % ci = . – . ), and increased screen time based on participants' smartphone screen state. physical distancing measures were also associated with being alone in the previous hour (or = . , % ci: . – . ), decreases in happiness (or = . , % ci = . –. ), and fast food consumption (or = . , % ci = . –. ). conclusions: physical distancing and social restrictions had a contemporaneous impact on health and well-being outcomes associated with chronic disease among young people. as the pandemic evolves, it will be important to consider how to mitigate against any longer term health impacts of physical distancing restrictions. aged children, a move to the online delivery of schooling. authorities requested that people remain in their homes wherever possible and limit their travel to obtaining essential goods and services. this public health strategy was absolutely necessary and appears to be yielding the desired result in terms of "flattening the curve" in the australian context [ ] . there are potential impacts of physical distancing and social isolation, particularly among younger people, where social connection is a key part of psychosocial development. the necessary policy responses to covid- may impact the determinants of poor mental health outcomes, including suicidal behavior [ ] . previous studies have shown psychological and physical health impacts of social isolation during quarantine [ ] , and more generally, social isolation has been shown to be associated with poor mental and physical health outcomes [ ] . in addition, adolescents are likely to have reduced physical activity, particularly incidental physical activity, and increased screen time as a consequence of the physical distancing measures. previous studies have shown the impacts of sedentary behavior on health outcomes in young people [ , ] and interrelated factors of diet, overweight and obesity, and well-being [ , , ] . the impact of the public health interventions in response to covid- to the daily routine of young people in australia on key health and well-being measures known to be associated with chronic disease has not previously been investigated. accordingly, this study investigates whether the physical distancing policies and school closures in the state of new south wales (australia) were associated with changes in physical activity, dietary behaviors, and well-being during the early period of this policy. participants were recruited as part of a broader prospective cohort study of adolescents investigating determinants of health and well-being over time. young people were recruited via social media (instagram and facebook) from the general population aged e years of a sydney population catchment. promotional and recruitment materials were developed and modified by members of a youth advisory group, and the social media strategy targeted those residing in western sydney; however, participants from areas outside of this catchment were not excluded if they enrolled in the study. the western sydney population catchment is a socioeconomically and ethnically diverse population of approximately one million people. participants were followed prospectively over a period of weeks, from november , , to april , , after a social media campaign that ran from november , , to january , . institutional ethics approval for the study was obtained from the western sydney university human research ethics committee (hrec approval number: h ). the total reach of the social media recruitment campaign was , adolescents in the western sydney area, of which % were female (n ¼ , ) and % were male (n ¼ , ). the total number of impressions (i.e., the number of times advertisements were displayed in news feeds) was , , , and this was higher among females (n ¼ , , %) than males (n ¼ , , %). the total number of click-throughs to the study webpage was , , with a higher level of interest among females (n ¼ , , %) than males (n ¼ , , %). of , individuals who clicked through to the study website, a total of , participants enrolled in the study and completed the baseline questionnaire, from which participants were selected who provided one or more responses to follow-up ecological momentary assessment (ema). participants were predominantly female and aged e years (table ) , reflecting the higher engagement in instagram and facebook among females than males more generally [ , ] . the ethica data smartphone app (https://ethicadata.com/ product) was used to collect data from questionnaires, emas, and smartphone sensors. mobile sensor data were collected automatically through the ethica app only from those participants who provided consent and included geolocation information (via gps, wi-fi, and bluetooth), pedometer, motion-based activity recognition (mbar) data, and screen state (whether the screen of the smartphone is "on" or "off"). a baseline questionnaire and a -week schedule of follow-up emas were triggered when participants enrolled in the study, with questions sent directly to each participant's smartphone. there were nine emas relating to psychological distress, well-being, positive emotion, social networks, relationships, diet, physical activity, sleep, and academic behavior. each ema, except psychological distress and well-being, was administered weekly, but on different days. emas relating to psychological distress or well-being were administered monthly. thus, participants received daily emas but received a different ema on each day. emas were sent to participants at random times between a.m. and a.m. or between p.m. and p.m. to avoid notifications during school hours and periods when participants may have been sleeping. the week schedule of emas resulted in weekly or monthly measures for each domain spanning the -week follow-up period. the primary outcome variables for this study included measures of physical activity, sedentary behavior, dietary behavior, and psychological well-being. self-reported physical activity at baseline was based on responses to the pace þ adolescent physical activity measures [ ] , and sedentary behavior was based on the adolescent sedentary activities questions [ ] with the tv and computer items modified to also capture information on internet streaming, mobile phone, tablet, or gaming console use. self-reported physical activity and sedentary behavior relating to the previous -hour period were also collected each week for the - week follow-up period via an ema. questions included: (i) "in the past hours, were you physically active for a total of minutes or more? 'physical activity' is any activity that increases your heart rate and makes you get out of breath some of the time"; (ii) "in the past hours, did you spend any time watching tv?"; and (iii) "in the past hours, did you spend any time on the internet, social media (like instagram, youtube, or facebook), or playing computer games?" for participants who answered "yes" to this question, a follow-up question was asked: "if yes, how long did you spend on the internet, social media, or playing computer games?" additional information on physical activity was collected passively via smartphone sensors, including pedometer, screen state (i.e., whether the phone was "on" or "off"), and mbar. the daily number of steps for each participant was collected via the pedometer. screen state was used as a proxy measure of sedentary behavior, with the assumption that during periods where the phone screen was active, participants were less likely to be engaging in physical activity. mbar is a composite indicator of activity provided by the ethica data app, which combines information from the phone sensors, including accelerometer, gyroscope, gravity, and magnetic field [ ] . the mbar indicator is a categorical variable that divides each moment into an activity type: "on foot," "walking," "running," "on bicycle," "in vehicle," "unknown," "still" (the device is not moving), and "tilting" (the device angle relative to gravity has changed significantly). each categorization is also ascribed a confidence level score between and . in the present study, each participant's mbar category was weighted by this score, such that categories with high confidence level scores were considered a more accurate assessment of the type of activity. self-reported dietary behavior at baseline was measured using questions validated for adolescents by the nsw centre for public health nutrition [ ] to allow comparisons with dietary guidelines for children and adolescents in australia [ ] . selfreported dietary behaviors relating to the previous -hour period were also collected each week for the -week followup period via an ema. questions included: (i) "in the past hours, have you eaten any serves of fruit?" if participants responded "yes," a follow-up question was asked: "how many serves of fruit? (a serve ¼ medium piece or small pieces of fruit or cup of diced pieces)"; (ii) "in the past hours, have you eaten any serves of vegetables?" if participants responded "yes," a follow-up question was asked: "how many serves of vegetables? (a serve ¼ / cup cooked vegetables or cup of salad vegetables)"; and (iii) "in the past hours, have you had any meals or snacks such as burgers, pizza, chicken, or chips from places like mcdonalds, hungry jacks, pizza hut, kfc, red rooster or local takeaway food places?" if participants responded "yes," a follow-up question was asked: "how many meals?" psychological well-being self-reported psychological distress was based on the kessler psychological distress -item scale (k ) [ ] . response options for each k item included "none of the time," "a little of the time," "some of the time," "most of the time," and "all of the time" and were scored in the range of e respectively. a score was used as indicative of probable mental disorder as recommended [ ] ; however, it is important to note that this standard cut point may overlook those with more moderate levels of psychological distress that may still be important [ ] . the engagement, perseverance, optimism, connectedness, and happiness (epoch) measure of well-being was also included in the study to capture information on positive psychological characteristics [ ] using a -point scale from "almost never" to "almost always." the k and epoch questionnaires (supplementary materials) were completed by participants at baseline with follow-ups sent to each participant every weeks and short emas relating to selected epoch items sent weekly [ ] . in addition, social relationships were measured based on the question: "in the past hour, who were you with?" participants could respond to one or more of the following options: "alone," "mother," "father," "sister(s)," "brother(s)," "other relatives," "classmates, peers," "strangers," "boyfriend or girlfriend," "friends," and "other, please specify." for participants who answered "friends," an additional question was asked: "how many friends?" finally, self-reported sleep duration in the previous hours was also collected at baseline via a weekly ema over the -week follow-up period. a range of sociodemographic and other health factors were also collected at baseline. these factors included sex, age, language spoken at home, current year of school and educational achievement, employment status, income, and body mass index (based on self-reported height and weight; table ). the change in measures of physical activity, dietary behavior, and well-being was compared pre-and post-implementation of the nsw guidelines for physical distancing to determine whether this policy resulted in significant changes in these key health behaviors. these guidelines officially came into effect on march , [ ] ; however, physical distancing began in the earlier period of march with the closure of pubs, clubs, gyms, cinemas, places of worship on march , [ ] and evidence of parents keeping children at home from school. accordingly, the period for when physical distancing began to be implemented was defined as march , . analyses were restricted to those participants who completed at least one ema over the follow-up period (n ¼ ; table ). participants were predominantly female, with a median age of years (interquartile range, e ). most participants spoke english at home ( %), were either in their senior year of schooling ( %) or finished school ( %), and almost % worked in a job (mainly part time). these participants contributed , responses to emas over the -week follow-up period, including responses in the period after implementation of physical distancing guidelines ( table ). the mean number of emas per week for this group was . (standard deviation ¼ . ), and the median number of emas per week was (interquartile range ¼ e ). comparisons of participant characteristics between ( ) those who completed baseline and follow-up, ( ) those who completed emas pre-and post-implementation of the physical distancing policy, and ( ) those who provided or did not provide sensor are provided in supplementary tables and descriptive plots of trajectories of physical activity were examined over the -week follow period, based on daily pedometer data, mbar, and weekly self-report emas. trajectories of self-reported fruit, vegetable, and fast food consumption were also examined based on weekly emas, as were trajectories of psychological well-being based on distress, well-being, and sleep duration. multivariate multilevel mixed effect logistic regression models were conducted to investigate associations between the implementation of nsw guidelines (specified as a binary pre-post variable on march , ) and subsequent changes in physical activity, dietary behavior, and well-being measures. there were significant decreases in physical activity in the period after the implementation of physical distancing measures in nsw. adolescents were significantly less likely to report minutes of physical activity in the previous figure a ). declines in physical activity were also evident based on the average number of steps per day and mbar (figure a,b) . there was also a significant increase in sedentary activity postimplementation of physical distancing, with higher social media and internet use (or ¼ . , % ci ¼ . e . ; table , figure a ) and also evidence of increased screen time based on participants' smartphone screen state ( figure c ). the implementation of physical distancing measures was associated with lower levels of happiness (or ¼ . , % ci ¼ . e. ) and positive emotions (or ¼ . , % ci ¼ . e. ), respondents reporting being alone in the previous hour (or ¼ . , % ci ¼ . e . ), and slightly higher increases in psychological distress (or ¼ . , % ci ¼ . e . ; table , figure b ). there were also declines in fast food consumption following implementation of physical distancing (or ¼ . , % ci ¼ . e . ) but no substantial changes in fruit and vegetable consumption, tv watching, or sleep duration (table ; figure c ). this study investigated the impact of physical distancing guidelines implemented in new south wales, australia, on a range of health and well-being outcomes among a cohort of adolescents aged e years in sydney. the implementation of physical distancing interventions was associated with decreases in physical activity and well-being, and increases in being alone and social media and internet use in the weeks after the policy was implemented. there was also a decrease in selfreported fast food consumption in the weeks after the policy was implemented, but little change in fruit or vegetable consumption. these findings suggest that the substantial changes to the way in which communities are currently functioning, particularly for young people, has had a contemporaneous impact on health and well-being outcomes associated with chronic disease. an important finding in the present study were the decreases in happiness reported after the implementation of the physical distancing guidelines and a higher likelihood of being alone during this period. social isolation is an important risk factor for poorer psychological well-being among young people and, conversely, peer-, family-and school-connectedness play key roles as protective factors [ ] . these protective connections may not have been as accessible to young people during the period of physical distancing resulting in lower levels of psychological well-being. it will be important to ensure that protective connections and other strategies to support the well-being of young people are maintained, to mitigate the potential psychological impact on young people. in australia, covid- cases remain low at the time of reporting; however, it is possible that physical distancing restrictions and online education may need to be reinstated if a second or third wave of infections eventuates. the shift to online delivery of education in nsw and the requirement to defer any nonessential travel is reflected in the increase in social media and internet use for the corresponding period in this study. there was also a decrease in physical activity likely related to the suspension of school and community sport and potentially mediated by a lack of access to green space in home environments. recent reviews have suggested both positive and negative impacts of social media, determined by the type of involvement (e.g., passive use, high investment, or support seeking) as well as the amount of time spent on screenbased activity [ , , ] . in addition, some studies have found that screen-based sedentary behavior supplants time spent sleeping or engaged in physical activity [ ] . the present study did not directly examine the association between screen-based sedentary behavior and physical activity, but while the pattern of findings is consistent with the idea of displacement, this may only be relevant when time is constrained (such as during school term or nonholiday periods). the finding that sleep hours did not decline contemporaneously with increased screen time perhaps suggests study participants had more time to engage in sedentary behavior without disrupting sleep duration. it remains to be seen whether sedentary behavior observed during the period of physical distancing will revert back to levels observed before physical distancing measures. this will be an important focus for future research, given the evidence that sedentary habits in adulthood are typically established during adolescence [ ] . an interesting finding was the decrease in fast food consumption in the context of limited changes to fruit and vegetable consumption. this likely reflects a decrease in opportunistic purchases of fast food during the day and traveling either to school or to work. previous research has found increased consumption of this food type among adolescents and young people where there is a high density of fast food outlets located near schools and transport hubs [ , ] . since the initial period of physical distancing, many fast food outlets have moved to take away and home delivery; however, the reduced consumption observed may indicate that fast food consumption was opportunistic and more associated with connecting socially with friends [ ] . future studies could consider the impact of these changes on food delivery on the consumption of fast food among younger people of different ages and with differing discretionary income and access to private transport. the present study also found that consumption of fruit and vegetables did not increase, suggesting either that similar food types were substituted or there was a decrease in overall caloric intake. consumption of calorie-dense foods can be positively associated with feelings of stress, and given the reduction in fast food consumption occurred in the context of increased social isolation and psychological distress, this might explain the lack of nutritional substitution implied in this finding. despite reduced consumption of these food types via fast food outlets, there may have been an overreliance on processed supermarket food during this periodda limitation to this finding was that more specific questions relating to processed or junk food (i.e., not fast food purchases) were not explicitly measured. australia experienced panic buying of processed foods resulting in supermarkets placing limits on a number of food items because of shortages. however, this was not observed for fresh fruit and vegetables. alternatively, it may be that the development of new healthpromoting behaviors takes time to develop, and the observation period of the present study was not long enough for this to emerge. there are a number of methodological limitations to this study. first, although there was a positive response to the study through instagram and facebook, participants who were more likely to engage were overwhelmingly female and more likely to be older in age ( e years). the higher proportion of females may reflect greater engagement in social media among females than males, a phenomenon that has been noted in representative studies of social media use in australia [ , ] . despite the imbalance by sex, the distribution of responses by key dietary behaviors, physical activity, and wellbeing outcomes was not substantially dissimilar to other representative prevalence studies of adolescents [ , ] . the higher proportion of older-age adolescents likely reflects that for those aged e years, parental or guardian consent was required before enrollment in the study. this involved additional steps in making contact with parents or guardians via email and to arrange for links to download the ethica app, which likely discouraged some younger potential participants from enrolling in the study. an additional limitation was the low ema and follow-up survey completion rate. despite the use of an incentive (aud $ giftpay voucher), only % of baseline participants (n ¼ , ) completed one or more subsequent ema, and < % completed all emas over the follow-up period. the weekly schedule of emas may have been too burdensome for participants, and future research may need to consider different schedules or incorporation of personalized feedback to keep young people engaged. there is also the risk of recall bias in this study, given the self-reported nature of the baseline and follow-up questionnaires. however, emas in (near) real time potentially reduce the likelihood or recall bias, in that questions relate to the immediate -hour period. patterns of ema responses relating to physical activity and screen time were also consistent with objective measures of physical activity based on available mobile phone sensor data, and the results were also generally comparable with previous adolescent health surveys for some of the measures [ , ] . smartphone sensor data, collected passively from participants, were also used as proxy measures of physical activity and sedentary behavior. this was an innovative aspect of the study design and allowed comparison with ema responses and investigation of trajectories of spatiotemporal movement among participants. however, a large proportion of participants either did not turn on some smartphone sensors (e.g., geolocation) or there were intermittent trajectories of movement, where sensor data were not collected. this resulted in complete sensor information being available on only participants over the follow-up period, only % of baseline participants (n ¼ , ) . the reasons for participants choosing not to engage in this aspect of the study are unclear but may relate to concerns about individual privacy, among both participants and caregivers (who were required to give parental consent for young people aged < years). there is also likely to be misclassification in smartphone sensor data, where periods between the initiation and cessation of a given state (e.g., "walking" in the mbar sensor) were likely overestimated, as the smartphone did not register the cessation of the state but only the initiation of the subsequent state (e.g., "still" in the mbar sensor). this means that the overall level of activity as measured by the smartphone sensor will be an overestimate; however, relative changes over time are likely to reflect actual declines or increases, and changes in emas appear to be consistent with changes in activities as measured by smartphone sensors. the present study suggests the potential immediate impacts on health behaviors that are intermediary to chronic disease outcomes. however, it is not clear whether there will be longterm psychosocial and health impacts associated with the physical distancing policies. these policies will be slowly wound back over coming weeks, and education and employment experiences will return to a degree of normality. the wider economic impacts associated with physical distancing and other policies relating to the closure of businesses and entertainment precincts on health outcomes are also not known. it is unclear whether the changes in health and well-being documented in the present study will be transient or whether there may be ongoing impacts. additional research needs to establish longer term trends in these outcomes to inform public health policy and intervention responses. this study provided a unique opportunity to measure health behaviors and psychological well-being among australian adolescents during the covid- pandemic. data collection occurred pre-and post-implementation of widespread physical distancing regulations in the community. these public health interventions have successfully "flattened the curve" on covid- to date; however, there have also been important changes among young people on a range of health and well-being outcomes. further research is needed to monitor the longer term trends in these outcomes. as the pandemic evolves, it will be important to consider how best to support psychological and physical wellbeing for young people to mitigate against potential longer term negative impacts. supplementary data related to this article can be found at https://doi.org/ . /j.jadohealth. . . . australian government department of health. coronavirus (covid- ) current situation and case numbers suicide risk and prevention during the covid- pandemic the psychological impact of quarantine and how to reduce it: rapid review of the evidence an overview of systematic reviews on the public health consequences of social isolation and loneliness child and adolescent obesity: part of a bigger picture long-term impact of overweight and obesity in childhood and adolescence on morbidity and premature mortality in adulthood: systematic review the health indicators associated with screen-based sedentary behavior among adolescent girls: a systematic review longitudinal impact of sleep on overweight and obesity in children and adolescents: a systematic review and bias-adjusted meta-analysis office of the esafety commissioner. state of play -youth, kids and digital dangers yellow social media report. melbourne: a sensis company a physical activity screening measure for use with adolescents in primary care the reliability of the adolescent sedentary activity questionnaire (asaq) available at: https://learn.ethicadata. com/documentation/data-sources/motion-sensors recommendations for short questions to assess food consumption in children for the nsw health surveys. sydney: nsw centre for public health nutrition dietary guidelines for children and adolescents in australia. canberra: commonwealth of australia the psychometric properties of the kessler psychological distress scale (k ) in a general population sample of adolescents validity study of the k scale as a measure of moderate mental distress based on mental health treatment need and utilization the epoch measure of adolescent well-being a comparison of affect ratings obtained with ecological momentary assessment and the day reconstruction method please cancel travel to regional nsw coronavirus: australia to close pubs, cafes and places of worship social isolation, psychological health, and protective factors in adolescence social networking sites and associations with depressive and anxiety symptoms in children and adolescentsea systematic review. child adol ment health association between social networks and subjective well-being in adolescents: a systematic review obesogenic neighbourhoods: the impact of neighbourhood restaurants and convenience stores on adolescents' food consumption behaviours overweight/obesity, physical activity and diet among australian secondary students-first national dataset - . cancer forum. the cancer council australia key: cord- - vrw mag authors: liebig, j.; najeebullah, k.; jurdak, r.; el shoghri, a.; paini, d. title: should international borders re-open? the impact of travel restrictions on covid- importation risk date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: vrw mag novel coronavirus disease (covid- ) has spread across the world at an unprecedented pace, reaching over countries and territories in less than three months. in response, many governments denied entry to travellers arriving from various countries affected by the virus. while several industries continue to experience economic losses due to the imposed interventions, it is unclear whether the different travel restrictions were successful in reducing covid- importations. here we develop a comprehensive framework to model daily covid- importations, considering different travel bans. we quantify the temporal effects of the restrictions and elucidate the relationship between incidence rates in other countries, travel flows and the expected number of importations into the country under investigation. as a cases study, we evaluate the travel bans enforced by the australian government. we find that international travel bans in australia lowered covid- importations by . % ( . - . ) between january and june . the presented framework can further be used to gain insights into how many importations to expect should borders re-open. authorities may consider the presented information when planning a phased re-opening of international borders. on th march the world health organisation (who) declared the outbreak of novel coronavirus disease (covid- ) a pandemic . by then over , cases of covid- had been confirmed in countries and territories . the virus with its origin in the chinese city of wuhan , was quickly introduced into other regions and countries through international travel. as a consequence, governments around the world enforced travel restrictions and closed international borders, which resulted in a sharp decrease of passenger flights . while the negative economic effects of the interventions are clearly visible and can for example be measured through financial performance indicators and an increase in unemployment, the societal benefit of restricting international travel has not been quantified. with the growth of outbreaks beginning to slow in some countries, calls to re-open borders are increasing. to assess whether it is feasible to do so, it is important to understand the risks posed by those countries that could act as importation sources. there are two major factors that influence the expected number of covid- importations: incoming traveller volumes, and incidence rates of the disease in source countries. in australia, the border force collects information about every individual entering the country, which is published in anonymised and aggregated form. to assess the travel bans implemented by the australian government, we estimate passenger volumes for the hypothetical scenario that no travel restrictions were implemented, using seasonal auto-regressive integrated moving average (sarima) models . country-level covid- incidence data is available on the website of the european centre for disease prevention and control (ecdc). there is consensus that the ascertainment of covid- cases is extremely low, with some studies claiming that less than % of cases are reported to authorities [ ] [ ] [ ] [ ] . hence, the available incidence data very likely does not reflect the true scale of the pandemic and needs to be adjusted to account for this bias. we perform maximum-likelihood estimations using the observed incidence of the disease in travellers arriving into australia to adjust the data. similarly, to adjust for under-reporting within australia we perform maximum-likelihood estimations using the observed incidence in australian travellers arriving into new zealand. in addition to incoming traveller volumes and adjusted incidence rates, our model considers the time individuals spent overseas as well as possible in-flight transmission. the model presents a flexible framework that can be used to quantify the effects of travel restrictions and to evaluate proposed relaxations. further, it allows the identification of groups of travellers that most likely carry the virus, which can inform strategies for the optimal use of available prevention and control resources. in contrast to other studies that have looked at exportation risk from china - , our model quantifies the expected number of importations for a particular country and is global in scale. we use australia, one of the first countries to report imported cases of the disease , as a case study to demonstrate the model's capabilities. as an island country, nearly all international travel into the country is via air, which allows tighter control of international borders. although partial border closures came into effect as early as one week after the first case was detected on th january, australia experienced an exponential growth in the number of reported imported covid- cases until the end of march . this study sheds light onto the effectiveness and timeliness of the individual travel bans implemented by the australian government. we model the expected number of covid- importations into australia between st january and th june . in particular, we consider two different scenarios. the first considers the actual travel restrictions as implemented by the australian government. the second scenario, which we refer to as open borders, is hypothetical and assumes that no travel restrictions were enforced. figure compares the expected number of importations for the two scenarios. the first travel ban that was implemented by the australian government affected foreign nationals travelling from, and transiting through china within the last days prior to arrival . figure shows a clear reduction in the expected number of importations after this restriction came into effect on st february , compared to the open border scenario. the difference in the expected number of importations for the two scenarios becomes smaller towards the end of the month, which is likely due to china being successful in containing the outbreak. our results indicate that australia was able to lower covid- importations from china by . % ( . - . ) during the studied period. we estimate that approximately , fewer cases were imported from china, out of the total , importations projected for that period with open borders. the arrival card data reveals that the reduction of importations cannot solely be attributed to the travel ban itself, which only affected foreign nationals. during february only . % of the expected number of australian citizens/residents returned from china, thus, contributing to the reduction in importations. the second travel ban affected foreign nationals arriving from iran and came into effect on st march . our results indicate that this restriction was less effective than the travel ban on foreign nationals arriving from china. covid- importations from iran were reduced by . % ( - . ). overall, only fewer cases were imported from iran. presumably, this travel ban was less effective due to the majority of arrivals from iran being australian citizens and residents who were exempt from the ban. on th march australia denied entry to all foreign nationals arriving from south korea , which resulted in a . % ( . - . ) reduction of cases being imported from this source. in contrast to arrivals from iran, arrivals from south korea are dominated by foreign travellers, explaining the high reduction in importations from this country. in addition, only . % of the expected number of citizens/resident arrivals returned to australia during march. overall, we estimate that fewer cases were imported from south korea. six days later, on th march foreign nationals arriving from italy were banned from entering australia . this travel ban reduced the number of covid- importations from italy by . % ( . - . ). in total, fewer cases were imported. however, only . % of the expected number of citizens/resident arrivals returned to australia. the final travel ban enforced by the australian government denied entry to all foreign travellers. this restriction was implemented on th march . figure shows a sharp decrease in the number of importations on this date. we estimate that australia imported on average between and cases a day between st march and th april. during may and june the daily average dropped to three cases a day. our results show that the reduction of covid- importations is partly due to fewer australian citizens and residents returning than expected during non-pandemic conditions. a significant factor underlying this reduction is in reduced flight availability into the country. the reduction of importations directly attributable to the individual travel bans is discussed later in this article. considering the various travel restrictions implemented by the australian government, we estimate that the largest proportion of imported covid- cases were acquired in the united kingdom ( , ( , , , ) cases). the second largest source / . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october , . . was the united states of america with an estimated ( , , ) cases. a full ranking of importation sources is provided in supplementary data file . to better evaluate the individual travel bans, we distinguish between foreign nationals visiting australia and citizens/residents of australia who were exempt from all restrictions. we note that under certain circumstances visitors were allowed to enter the country after the establishment of travel bans, for instance, if they are immediate family members of a citizen or resident. figure shows the estimated number of covid- cases imported by citizens/residents and visitors from the ten largest sources before and after the respective travel restrictions were implemented. in most cases more covid- cases were imported before the implementation of travel bans with italy being the exception. the ban on foreign travellers from italy came into effect on th march . at the same time the government urged citizens and residents to return to australia as soon as possible. the border force recorded an average of citizen/resident arrivals from italy each day until the end of march when the outbreak in italy peaked. the estimated increase in visitor importations from italy is likely due to the increased return of immediate family members of returning citizens/residents who are not citizens or residents themselves. we showed that the overall reduction of covid- importations is not only due to the individual travel restrictions, but can partly be attributed to fewer australian citizens/residents returning from overseas. in this section, we quantify the direct effect of the individual travel restrictions. to do so, we assume that travel bans hinder all visitors who arrive from the corresponding country from entering australia, as was intended by the government. in addition, we assume that all citizens/residents continue to return to australia as usual. our calculations are based on the total number of projected arrivals from each source country during the study period. . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october , . . three respective sources. among the studied countries, the reduction in importations from austria was the lowest. only . % of preventable importations could be averted. the extent of importation reductions (solid vertical lines) are determined by the incidence rate in source countries, the travel volume from that country, and the number of days after the day of first importation from that country. implementing travel bans closer to the date of first importation can further reduce the importations from a source country. to decide whether it is safe to open international borders, governments need to understand the relationship between the number of arrivals, incidence rates in countries that act as importation sources and the expected number of covid- importations. the contour plot in figure visualises this relationship. we assume that arrivals spent an average of days in the source country prior to arrival. stars indicate the expected number of importations during october from the corresponding country if borders re-open and given the country's current reported incidence rates and the expected number of arrivals. the countries referenced in figure were amongst the most frequently cited origins of travellers arriving into australia in . note that the us, uk and indonesia are not shown in figure as the recent daily incidence rates are well above e- . our results indicate that australia can expect less than one importation from malaysia, china, fiji and thailand during october if borders were to re-open. however, there is still a risk of covid- cases being imported. assuming that the number of infected arrivals can be modelled by a poisson process with rate parameter equal to the expected number of importations, the probabilities of importing one or more cases from countries where we expect less than one importation during august, are as follows: china: . %, fiji: . %, malaysia: . %, thailand: . %. . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october , . . https://doi.org/ . / . . . doi: medrxiv preprint we developed a comprehensive framework that models importations of covid- into any given country. the model can be used to quantitatively evaluate existing and proposed border closures and is useful in guiding authorities to decide whether current travel restriction can be relaxed. we applied our model in the context of australia, yet the model is globally applicable to any jurisdiction that tracks the movement of people through its borders. mapping incidence rates and arrivals from source countries to the expected number of importations can underpin a decision support tool to determine the country-specific risk of opening international borders. it is important to note that covid- reporting mechanisms and protocols can vary greatly across countries, and these practices impact the degree to which reported incidence rates are representative in each country. the confidence in reported incidence rates can be used to manage risk through our model, for instance by assigning a source country a confidence range of incidence rates rather than a single value. this helps drive decisions that avoid crossing from one region to another in the contour plot for countries with high uncertainty in their reporting data. another potential source of uncertainty is in estimating incoming travel volumes. australia's geography as an island nation adds confidence that the data used to estimate incoming travel volumes is representative of actual travel volume, which in turn increases confidence in the estimated importations in our model. applying our model to other countries, particularly countries with more porous land borders, needs to consider the greater uncertainty in incoming travel volumes from neighbouring countries. the spatial heterogeneity of covid- in source countries is another important factor in our model. for instance, larger countries such as the us or china have experienced surges of covid- in specific states or regions over time. currently, our model accounts for national incidence rates that cover the entire country. while region-specific incidence rates are available for some countries, incoming travel volumes are reported at country level, which necessitates the averaging of incidence rates across a country. region-specific travel volumes could add to the granularity of our model. we estimate the expected number of arrivals into australia, assuming no travel restrictions were implemented, based on five years of historical data (january -december ). to give the data a normal shape, a box-cox transformation is applied to each individual time-series . we use a seasonal autoregressive integrated moving average (sarima) model that is suitable for forecasting time-series with seasonal variations that are possibly non-stationary . to find the model with the best fit we perform a step-wise search over the model space and chose the model with the lowest akaike information criterion . all calculations have been carried out with python's pmdarima statistical library. we use the monthly number of observed covid- infections amongst travellers arriving into australia from a given country to estimate the country's true incidence rate. we account for australia's ascertainment in a similar way by estimating the true incidence rate with the observed incidence in australian travellers arriving into new zealand. let γ be the true incidence rate of covid- in a given country. then, in a sufficiently large sample of the population, we expect to find nγ infected individuals, where n is the size of the sample, i.e. the arrivals from the given source country. assuming that the number of infected individuals follows a binomial distribution with unknown parameter γ, the maximum-likelihood estimate of γ is given byγ = x/n, where x is the number of infected individuals in the sample population. we construct the % agresti-coull interval to ensure that the interval falls within the parameter space. the estimated incidence rates and their % confidence intervals are shown and compared to those reported by the ecdc in supplementary data file . in addition to adjusting the ecdc data to account for under-reporting, we estimate the disease onset date of all reported cases. from the data published in a recent study , we find that the delay between a case showing symptoms and being reported follows a gamma distribution. to adjust the data we subtract x days from the date of report for each recorded covid- case, where x ∼ gamma ( . , . ). the importation model requires as input the date of arrival into the country under investigation (in our case australia), the duration of the overseas stay, daily incidence rates of covid- in the country of origin and the lengths of the latent and infectious periods. if a traveller is not infected with covid- upon return, the traveller either never contracted the disease or / . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october , . . contracted the disease and recovered. the probability of not contracting the disease is given by where β d = − e −γ d , γ d is the incidence rate of covid- in the country of origin on date d, d d is the departure date of the traveller and d a is the date of arrival into the country under investigation. the probability of recovering before the arrival date is given by where d c denotes the date n − days prior to the arrival date and n is the sum of the latent and the infectious period. the probability of being infected upon arrival is then given by our model also considers in-flight transmission of the disease. to transmit the disease to others, the infected individual must be within the infectious period. if an individual is not infectious while travelling, the individual either never contracted the disease, contracted the disease and recovered or contracted the disease and is within the latent period. the probability of being within the latent period is given by where d l denotes the date l days prior to the arrival date and l is the length of the latent period. the probability of being infectious while travelling is then given by following recent studies of the infectiousness profile of covid- , we set the infectious period to eleven days, beginning three days prior to the onset of symptoms , . the incubation period describes the time between contracting a disease and showing symptoms. there is general agreement that the incubation period of covid- is between five and six days [ ] [ ] [ ] and is approximately three days longer than the latent period . we draw the length of the incubation period from a log-normal distribution with mean equal to . and standard deviation equal to . . to find the latent period we subtract three from the incubation period. the number of individuals that an infectious traveller infects while on a plane is drawn from a poisson distribution with mean λ = tr /s , where r denotes the basic reproduction rate, s is the length of the infectious period and t is the duration of the flight. we set r = . , following the results presented in a study that estimates the basic reproduction rate of covid- on a cruise ship . we assume r on a ship to be similar on a plane where the population is almost fully mixed. the expected number of importations within a given time period is then given by where x ∼ poisson(λ ), p i is the probability that individual i is infected and r i is the probability that individual i is infectious during the flight. the sums run over all individuals who arrive during the period of interest. . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted october , . . https://doi.org/ . / . . . doi: medrxiv preprint the australian arrival card data is available at https://data.gov.au/dataset/ds-dga- a ab -c - ae - d-f a d /details?q=arrival% card% data. covid- data is available at https://www.ecdc.europa.eu/en/publications-data/download-todays-data-geographicdistribution-covid- -cases-worldwide. passenger flows from australia to new zealand are available at https://www.bitre.gov.au/publications/ongoing/international_airline_activity monthly_publications. new zealand covid- importation data is available at https://www.health.govt.nz/our-work/diseases-andconditions/covid- -novel-coronavirus/covid- -current-situation/covid- -current-cases/covid- -current-cases-details#download. covid- importation data for nsw was obtained from nsw health and is not publicly available. world health organisation. coronavirus disease (covid- ) situation report - covid- infection: origin, transmission, and characteristics of human coronaviruses pandemics, tourism and global change: a rapid assessment of covid- time series analysis: forecasting and control correcting under-reported covid- case numbers: estimating the true scale of the pandemic level of underreporting including underdiagnosis before the first peak of covid- in various countries: preliminary retrospective results based on wavelets and deterministic modeling estimating clinical severity of covid- from the transmission dynamics in wuhan, china preliminary estimation of the novel coronavirus disease (covid- ) cases in iran: a modelling analysis based on overseas cases and air travel data the effect of travel restrictions on the spread of the novel coronavirus (covid- ) outbreak assessing the risk of spread of covid- to the asia pacific region impact of international travel and border control measures on the global spread of the novel coronavirus outbreak world health organization. novel coronavirus ( -ncov) situation report - italy added to australia's coronavirus travel ban alongside china australia: epidemiology report an analysis of transformations a new look at the statistical model identification approximate is better than "exact" for interval estimation of binomial proportions open access epidemiological data from the covid- outbreak temporal dynamics in viral shedding and transmissibility of covid- virological assessment of hospitalized patients with covid- incubation period of novel coronavirus ( -ncov) infections among travellers from wuhan, china the incubation period of coronavirus disease (covid- ) from publicly reported confirmed cases: estimation and application incubation period and other epidemiological characteristics of novel coronavirus infections with right truncation: a statistical analysis of publicly available case data the waiting time for inter-country spread of pandemic influenza covid- outbreak on the diamond princess cruise ship: estimating the epidemic potential and effectiveness of public health countermeasures we would like to thank frank de hoog and peter caley for their comments, which greatly helped to improve the manuscript. this work is part of the dinemo project. jl and kn conceived the study and developed the model. jl performed the analysis. kn, rj and dp assisted with the analysis and contributed to the interpretation of the results. aes wrote the code to clean and process the data. all authors edited and approved the final manuscript. key: cord- -vpg sfsk authors: pather, nalini; blyth, phil; chapman, jamie a.; dayal, manisha r.; flack, natasha a.m.s.; fogg, quentin a.; green, rodney a.; hulme, anneliese k.; johnson, ian p.; meyer, amanda j.; morley, john w.; shortland, peter j.; Štrkalj, goran; Štrkalj, mirjana; valter, krisztina; webb, alexandra l.; woodley, stephanie j.; lazarus, michelle d. title: forced disruption of anatomy education in australia and new zealand: an acute response to the covid‐ pandemic date: - - journal: anat sci educ doi: . /ase. sha: doc_id: cord_uid: vpg sfsk australian and new zealand universities commenced a new academic year in february/march largely with “business as usual.” the subsequent covid‐ pandemic imposed unexpected disruptions to anatomical educational practice. rapid change occurred due to government‐imposed physical distancing regulations from march that increasingly restricted anatomy laboratory teaching practices. anatomy educators in both these countries were mobilized to adjust their teaching approaches. this study on anatomy education disruption at pandemic onset within australia and new zealand adopts a social constructivist lens. the research question was “what are the perceived disruptions and changes made to anatomy education in australia and new zealand during the initial period of the covid‐ pandemic, as reflected on by anatomy educators?.” thematic analysis to elucidate “the what and why” of anatomy education was applied to these reflections. about anatomy academics from ten institutions participated in this exercise. the analysis revealed loss of integrated “hands‐on” experiences, and impacts on workload, traditional roles, students, pedagogy, and anatomists' personal educational philosophies. the key opportunities recognized for anatomy education included: enabling synchronous teaching across remote sites, expanding offerings into the remote learning space, and embracing new pedagogies. in managing anatomy education's transition in response to the pandemic, six critical elements were identified: community care, clear communications, clarified expectations, constructive alignment, community of practice, ability to compromise, and adapt and continuity planning. there is no doubt that anatomy education has stepped into a yet unknown future in the island countries of australia and new zealand. australian and new zealand universities commenced a new academic year in february/ march largely with "business as usual." the subsequent covid- pandemic imposed unexpected disruptions to anatomical educational practice. rapid change occurred due to government-imposed physical distancing regulations from march that increasingly restricted anatomy laboratory teaching practices. anatomy educators in both these countries were mobilized to adjust their teaching approaches. this study on anatomy education disruption at pandemic onset within australia and new zealand adopts a social constructivist lens. the research question was "what are the perceived disruptions and changes made to anatomy education in australia and new zealand during the initial period of the covid- pandemic, as reflected on by anatomy educators?." thematic analysis to elucidate "the what and why" of anatomy education was applied to these reflections. about anatomy academics from ten institutions participated in this exercise. the analysis revealed loss of integrated "hands-on" experiences, and impacts on workload, traditional roles, students, pedagogy, and anatomists' personal educational philosophies. the key opportunities recognized for anatomy education included: enabling synchronous teaching across remote universities across australia and new zealand commenced the new academic year in february and march . for most institutions, it was largely business as usual. few realized the extent of disruption and the pace of change that the unfolding covid- global pandemic, caused by the severe acute respiratory syndrome coronavirus (sars-cov- ), would impose upon all higher education (evans et al., ) . the first covid- cases were reported in australia and new zealand at the end of january and february (who, ), respectively, and were related to people travelling for tourism, work or study. even though most universities at first adopted a "watch and wait" approach, it became quickly evident that a higher education sector interruption was imminent (truu, ) . the extent of this disruption was evidenced by an almost immediate restriction on business travel for many university staff, initially to china (perpitch, ) ; and a resulting large number of australian and new zealand anatomy academics cancelled plans to attend international meetings and conferences. as the governments acted to prevent the pandemic spread, some university leaders drew on the experiences and expertise of their faculty, and acted quickly to source equipment, manage logistics, and provide in-time assistance to support the university's continued operations. in the background, core university business appeared to continue as usual. managements' "watch and wait" approach was perceived to be passive, causing some staff and student distress with the apparent lack of decisive action. university leaders, however, were carefully monitoring the situation to delay an inevitable transition to remote learning for as long as possible. at the beginning of march, the signs of higher educations' imminent disruption presented as australia and new zealand entered the "protect" phase of pandemic management learnt from past corona virus experiences (collignon, ; de wit et al., ) . by mid-march, the responsibility fell on academic staff to actively repurpose and redeploy resources, upskill their digital competencies, and develop new material to transition traditionally face-to-face (f f) and blended programs to a remote learning and/or online education delivery mode (johnston, ) . like in many countries, australia and new zealand included, technology-integrated learning has been embedded in medicine and allied health programs for some time (harden, ) . anatomists in this region have been actively involved in the development of digital resources and in curriculum reform (green and whitburn, ; colibaba et al., ; otton et al., ; green et al., ; birbara et al., ; ho et al., ; birbara et al., ; o'rourke et al., ) . anatomy education, however, has never before been delivered solely online or remotely for medicine and allied health programs in these countries. the tertiary education quality and standards agency (teqsa), which is the mandatory independent national quality assurance and regulatory body for higher education in australia (supporting information table ), acted quickly and decisively, enabling rapid educational transformation by announcing to the sector a broad reduction of the regulatory burden for universities managing covid- pandemic challenges (saunders, ) . this deregulation provided universities with approval to effect changes to delivery modes, as well as to provide remote learning to students who were offshore. this last aspect is critical to higher education in australia which serves a large international student body (davies and karp, ) . in , , students enrolled with australian higher education providers were on student visas and comprised a third of the student population (ferguson and sherrell, ) . during march , an overwhelming number of international students were forced to return to their homeland as the pandemic spread. the teqsa caveat, however, was that: "providers should assure themselves that such arrangements [changes to program delivery] maintain assessment and quality standards and are appropriately documented" (saunders, ) . most institutions were, thus able to rapidly initiate a business continuity plan enabling students to continue the academic year, if they chose. in quick succession over the last weeks of march , medicine and science faculties of most universities in australia and new zealand converted to online and/or remote delivery as university staff moved into a new paradigm of "working from home" (wfh) arrangements. defined by simonson et al. ( ) , remote/distance learning refers to institution-based, formal learning, where the learner and instructor are physically separated, and where interactive telecommunications systems are used to connect learners, resources, and instructors. in part, the business continuity plan (especially for medicine faculties) in australia was driven by pragmatism to ensure a functioning health care system in , which relies heavily on graduating medical students entering the system as junior doctors (interns) each year. for the discipline of anatomy, this decision has potentially fundamental consequences. the governments mandated covid- response resulted in restricted movement and physical distancing requirements. the regulations initially constrained anatomy laboratory access, but quickly progressed to a prohibition of students' laboratory access entirely as wfh and remote learning arrangements became the new normal. the initial stage of this transition may be particularly challenging to those in the anatomy discipline as many conventional anatomy education pedagogies rely on "hands-on" practical experience; it is through these small groups that many anatomy educators identify and respond to students' learning needs especially those at-risk of underperforming (kumar ghosh and kumar, ) . furthermore, delivering anatomy education solely online or at a distance, if only for a short period, challenges the long-held educational philosophy of many anatomy educators (pather, ) . additionally, for those who strive to frame their anatomy programs through a lens of ethics and humanism (Štrkalj and pather, ; evans et al., ; hildebrandt, ) , there is a need to work harder to connect students to these paradigms when educating solely within the digital realm, and in the absence of a once-living person (stephens et al., ; kumar ghosh and kumar, ) . notwithstanding these issues, the remarkable mobilization, commitment, speed, and agility of the australian and new zealand anatomy community, including academic and support/technical staff, presents the beginning of a historic bridge into an unknown future. the continuity of anatomy education during the covid- pandemic in australia and new zealand is not "business as usual" and is not likely to return to the pre-pandemic approaches again, given the extent of the present changes. this study, therefore, aimed at documenting the shared experiences of anatomy educators in changing their teaching practice during the early period of the covid- pandemic within australian and new zealand higher education. participants were voluntarily recruited via an email invitation to anatomists serving in leadership roles in the australia and new zealand association of clinical anatomists (anzaca), with snowballing recruitment following. the resultant participant group, and co-authors, included academic anatomists representing ten institutions across these two island countries. in australia, this group represented four of the australian states and territories, and five of the "group of eight" universities (leading eight australian research-intensive universities) (table ) . in new zealand, the participants represented one of the (only) two new zealand universities that teach anatomy. all participants taught anatomy (including neuroanatomy), histology and/or embryology to a variety of student cohorts including science, biomedical science, allied health, and undergraduate and graduate medicine, as well as junior (i.e., resident) and postgraduate (attendings) doctors using multiple approaches before the pandemic (supporting information table ). the research question was "what are the perceived disruptions and changes made to anatomy education in australia and new zealand during the initial period of the covid- pandemic, as reflected on by anatomy educators?." all participants were asked to reflect on the experience of delivering anatomy education from the start of the academic year through to the end of march . this descriptive qualitative account of anatomy education disruption focusses on the early stages of the pandemic within australia and new zealand, with the methodology of adopting a social constructivist lens, wherein the truth is negotiated by those experiencing it (rees et al., ) . thematic analysis to elucidate "the what and why" of anatomy education was applied to these reflections, as outlined by nowell et al. ( ) . the names of institutions were de-identified during thematic analysis. six phases of coding were undertaken with phase ("data familiarization"), phase ("initial coding"), and phase ("theme searching"), carried out by m.d.l. phases and ("theme review" and "naming themes") were carried out separately by two authors (m.d.l., and n.p.). phase ("findings report production") was initially drafted by m.d.l., with n.p. providing feedback, debating, and discussing interpretation discrepancies. while these stages appear linear, each progressive stage was iterative, and thus previous stages were addressed where needed during phase . all analyses were performed in microsoft word (microsoft corp., redmond, wa) as higher order complex coding was not undertaken due to the research question. this approach to thematic analysis included a team-based reflexive exercise (barry et al., ) by those undertaking the analysis (m.d.l., and n.p.). both authors have extensive experience in qualitative research and value grounded theory in answering the research question, but they differ slightly in world views. while one allows the research question to dictate the methods, the other struggles with the idea of quantitative analysis ever being objective, due to inherent complexities of the natural world. both thought the opportunity to reflect, and learn from others' reflections, was a valuable opportunity. the fears expressed in undertaking this study included concern for peer wellness and rapidity of data analysis-but overall, both authors thought the study merits outweighed the risks. this study was approved by the monash human ethics review board research ethics committee (muhrec # ). in australia and new zealand, f f laboratory practical sessions are central to anatomy teaching (table ) . participating anatomy educators' reflections outlined the progressively increasing restrictions placed on f f teaching (e.g., increased physical distancing, cancellation of practical sessions, or complete campus lockdown). these restrictions were coupled with an almost consistent university message: the universities in australia and new zealand are "open for business" with a status of "business as usual." this disconnect between university messaging and imposed social constraints appeared to contribute to at least some of the shared academic anatomists' challenges outlined below. one new zealand academic summed up the higher education pandemic setting concisely in stating: "there is no doubt from our perspective that the world is suddenly a different place." in continuing anatomy education during the initial pandemic period, nearly all universities appeared to employ a mix of synchronous and asynchronous (chen et al., ; watts, ) online activities (table ) , with some institutions having used evidence-based online activities to deliver the curriculum prior to the pandemic. notably, nearly all chose at least some synchronism to mitigate the loss of the practical "hands-on" synchronous live streamed small group sessions a member of the "group of eight" leading australian research-intensive universities. almost all donor programs were suspended in the face of the pandemic. lectures typically relied on prerecorded material, a mix of asynchronous and synchronous teaching was used for practical modification. active learning engaged large group webinars or discussion boards to facilitate class discussion; f f, face-to-face. component of their delivery. of the institutions included, six supported a teaching "pause" (table ) . this provided students a short time to relocate to home, if appropriate. it also, even if notionally, acknowledged the significant work required from academic staff to change the mode of delivery within a limited timeframe, and gave credence to the ubiquitous messaging that the health and well-being of the university community is of primary importance, especially during the covid- pandemic. the urgency of the situation was evident in all narratives. each anatomists' reflection tended to focus on identifying a . many australian and new zealand anatomy educators used digital resources to overcome the legal and ethical limitations related to human donor programs which often prohibit the sharing, photographing or recording of donor material. some institutions were offered a brief ( week) pause to convert a semester of teaching into online approaches, while many others were not. despite typically engaging demonstrators only for f f teaching, many institutions engaged sessional demonstrators in this transition -though their roles changed. while some still led online delivery of material, many were engaged to help develop resources for this pandemic anatomy teaching. dvr, three-dimensional virtual reality. temporary solution, with many also incorporating and planning for future practical laboratory-based intensives ( table ) . the need for a balanced teaching approach, staff adaptability, and well-being support were discussed in nearly all reflections. as expected, some academics found the experience of accelerated change exciting and fruitful, while others found this experience daunting and worrisome. universally, there were shared concerns about the extraordinary workloads this transition required. some academics reported that even when commercially available material was used in teaching, the time spent curating and annotating this to ensure learning outcomes were met, was exorbitant. a reflection from one australian colleague highlights the increased workload: "online teaching extends the working day and the working week (to now include weekend work); the volume of email has increased exponentially." almost all academic anatomists reported that anatomy education is likely to change permanently given the scale of change during the pandemic, with some concerned that this change will call into question traditional laboratory-based approaches, in favor of modern (now trialed) online and remote learning approaches (table ) . this concern was compounded as many academics reflected that these curricular changes, despite attention to quality, were a rapid response to an unprecedented situation, allowing little time for reflection and evidence-based refinement. there were a variety of personnel-and infrastructural-related challenges shared across the australian and new zealand academics' reflections. these challenges fell into four categories: staff (faculty/academic staff and technical/professional staff), students, infrastructure and resources, and curriculum changes to accommodate online and/or remote delivery of anatomy education. with respect to personnel, there were multiple staff categories that were perceived to be affected by the pandemic teaching context; for all staff (regardless of previous role), there was a drastic change in the type of work that they were expected to do. the academic staff appeared to have the least professional role change, as many reported that they were, themselves, still focused on pedagogy; the expectations and skills for executing this new pedagogy, however, was different. a common challenge reflected on was that of information technology (it) skills, and the lack of prior training or knowledge for effective online education delivery practices. technical staff and anatomy sessional staff/demonstrators (defined in supplementary table ) were perceived as having some of the largest role transitions. some anatomy educators noted that demonstrator roles changed from leading f f small group discussions to that of digital media development and/ or to small group instruction via streaming platforms such as zoom ® (zoom video communications, inc., san jose, ca and microsoft teams ® (microsoft corp., redmond, wa) ( table ). in contrast, other anatomists commented on the sudden elimination of the demonstrator role due to the pandemic's impact on university finances. colleagues from one australian university described their experience: "one of our first thoughts went to our casual demonstra-tors…this sudden change would remove their opportunity to extend their teaching experience, develop their knowledge and skills and reduce their income. to rectify this, we immediately instigated mechanisms to involve our demonstrators in the process of developing our remote learning opportunities … for one anatomy practical that required transformation into an online format in less than hours, they [the demonstrators] came into the laboratory after hours to create demonstration videos." technical staff appeared to similarly be learning new skills and pivoting their roles, as illustrated by another australian anatomists' reflection: "our tech [nical] team have been enlisted to create videos of rotating models so that students have at least a visual impression of these resources that are typically available to them in a resource area on each campus." professional and technical staff faced the additional stresses related to job security. initially this stress was related to the seemingly seamless way in which academic staff mobilized to deliver a program of online anatomy education, and was exacerbated when some departments took the strategic decision to temporarily suspend the body donor program due to uncertainty regarding the risk to covid- exposure (table ) . as the pandemic further unfolded, and with increased communications of university budget deficits, the future for professional staff remains tenuous. interestingly, almost universally the academic anatomists' reflections included perceptions that both demonstrators and technical staff appeared to value these new roles and demonstrated skills of adaptability and resilience. the reflective narratives about the academics' own role (and role of their academic team) often also illustrated gratefulness for the flexibility of their peers. a major challenge for all participating academic anatomists was the time investment to support the pandemic's curricular change. there were also many who reflected that the increased workload was not accompanied by the usual rewards of student interaction, a shared sentiment of the anatomy educators expressed in one anatomist's reflection: "we go into these roles because we truly love watching students learn, not being able to see that in a traditional sense does make this workload harder" and this was further explained by an anatomist from another institution: "for some academics the anticipation of contact with students [in the usual f f delivery] is something to look forward to, but this is difficult [during the pandemic] due to the city-wide physical distancing laws." as mentioned, some universities did "pause" teaching to accommodate the transition to online delivery (table ) . this "pause" was for a relatively brief period (< or up to weeks) considering the length of a semester (~ - weeks typically) and the number of learning activities that needed modification for online/remote learning. the challenge was compounded as universities moved to wfh, and with primary and secondary schools increasingly transitioning to home-based learning. this was an unprecedented experience and has meant that academics already working to difficult timelines with a challenging workload were also adjusting to wfh, and for some, with the additional tasks associated with concurrent childcare and home-schooling. the academic reflections included a focus on perceived student-centered challenges. academics expressed awareness of students concerns that centered around future degree and career progression, across the participating universities. according to the academics, students appeared to face financial pressures due to lost income, resulting in concerns about university fees, and for many, a forced intermittence. some of the perceived student challenges included managing student perceptions of "missing out" or "getting what they [the students] paid for." there was an observation that these student concerns were at least, in part, due to the universities' messaging on expectations versus what was achievable by staff in the timeframe available, and within the pandemic education context. also impacting these perceptions may be the pre-pandemic emphasis of anatomy education on, and the now lack of exposure to, human donor material, which is often perceived as a signature experience of the discipline. a colleague summarizes some of the student concerns: "students were concerned about not having access to learning from human donors, which they perceived as the best opportunity to integrate concepts with the 'real' experience. the anatomy lab was where deep understanding of anatomy was achieved. students further reported that they struggled without the f f interaction with academics and tutors in the lectures and labs. in general, the student body was struggling with a lack of motivation without direct teacher interactions.... however, they [students] also highlighted the significant shift that they are making in a short time to adjust from f f to online learning, and without the benefit of physical interactions with peers." academics themselves also had concerns about student learning, specifically around equity and access. this concern was compounded when considering the implementation of synchronous learning activities, and students' repatriating. this enforced geographical distancing meant that students were located across multiple time zones, with some returning to countries with restricted or poor internet access. australia and new zealand also have internet network accessibility and reliability limitations, particularly in rural and remote areas. together, these potential learner challenges were considered in the redevelopment of australian and new zealand anatomy education, and (at least in part) accounts for the suite of synchronous and asynchronous activities (table ). regarding resources and infrastructure, the challenges expressed by anatomy educators are likely globally universal in university programs, including access to software and support for online teaching, technical failures, and network sustainability. however, unique to anatomy education are some of the ethical and medical considerations related to working with human donor resources. multiple state/regional legislations pertain to body donor programs and consent for donation. specifically, the ethical and legal constraints of sharing and displaying digital images of prosected human donor bodies/body parts, increased the challenges to anatomy online education in australia and new zealand; the net result was a reliance on proprietary digital anatomy resources (table ). in addition to the impacts on teaching, reflections communicated concerns about body donor programs sustainability and continued maintenance in the face of the present acute global health crisis. anatomy lectures appeared to be the least complicated of all activities to translate in the pandemic, while anatomy practical experiences and assessments were consistently the most challenging to redesign across these two countries (table ) . lectures. while some anatomy educators chose to livestream lectures on campus and/or from home, most chose prerecorded asynchronous approaches by re-using lecture recordings from previous years or developing new recordings. this decision reportedly allowed academics to focus effort on more complicated curricular translations (i.e., practical sessions and active learning), as noted by one reflection: "in the covid- context, most course conveners released the pre-recorded lectures from the year before. this provided the opportunity for academics to have cognitive capacity to concentrate on upskilling their comfort with other technologies, and to reorganize material for the online space." these prerecorded lectures were reportedly often supplemented with additional lecture material, which included short concept videos and formative assessments ( table ). the sentiments expressed in many reflections was summed up by one colleague: "one strategic decision was to move away from big topics, by encouraging the breakdown of long lecture content into digestible chunks. the organization, search and review for existing digital material on [the] world wide web were additional tasks that were both time consuming and time 'robbing'." some academics incorporated interactive lectures, mirroring some of the active learning principles. active learning, by definition, depends on student interaction to foster learning, and the opportunities for learner reflection (haidet et al., ) . much effort was placed into translating these same principles online using interactive applications like kahoot! © (kahoot! a.s., oslo, norway) and slido © (slido s.r.o., bratislava, slovakia), and incorporating formative quizzes, live streaming, and applied anatomy tasks such as clinical case activities. one academic describes the active learning translation for a medical anatomy curriculum: "our active learning sessions… allow for students' application of learned knowledge in the context of clinical uncertainty. to develop our online learning activities, we first asked ourselves what were core aspects we wanted to reproduce online? for us this included: clinical reasoning, taking chances, and learning from peers. from this, it was decided to develop a series of discussion forums… we gave clear instructions on what was an appropriate approach to responding.... students progression through [clinical] cases required them to work through the previous case, as would happen during the faceto-face active learning session… peers and facilitators were the primary source of feedback and re-direction if a student went off track, again emulating the teamwork needed for successful active learning. once a learner had gone through each case, they were then able to access post-class videos which touched upon key anatomy knowledge." practical experiences. many institutions reflected that student-teacher interaction was a desired attribute of practical sessions and replicating this online required supporting synchronous delivery experiences (table ) . many anatomists reflected a plan for intensive practical experiences postpandemic to make up for the lack of exposure to authentic human donor resources during the remote learning phase ( table ) . some of the shared university practical experiences is represented in one colleague's peer reflection: "for our practical experiences, we decided to focus on two key attributes, the short-term knowledge gains, and opportunities for students to be exposed to experts. we engaged the zoom platform, because of its capacity to allow for user interaction. the medical imaging stayed much the same; herein demonstrators shared curated imaging, allowing students to use zoom's "annotation" function to answer imaging identification questions…tutorials were almost exactly the same with students engaging in presentations related to assigned learning objectives. the dissection component was the area that entirely changed." many institutions integrated practical videos, both prerecorded (pre-pandemic) and novel recordings were developed for supplementing the new synchronous online activities ( table ). the purpose of the videos varied and were highlighted in a colleague's reflection: "explanatory video to describe how and why we were making these changes, and how to use the four (three commercial and one in-house) online anatomy resources… [and] staff prepared additional short videos to emphasize key concepts for each weekly prac[tical] class using these online resources." many used widely available videos from youtube (youtube llc., san bruno, ca) or proprietary anatomy software to minimize "reinventing the wheel," but even this approach resulted in significant workload to both "source appropriate videos" and annotate them, with suggestions ranging from ~ hours for a -hour active learning session to ~ hours for a single practical conversion. for those who had already begun transitioning to technology-enhanced learning before the pandemic, the rapid online transition was perceived as a step backwards in their planned implementation as it was done with limited time for reflection and testing. many also highlighted concerns that this rapid online shift may result in their institutions questioning the role of human donor material altogether. assessments. at the time of writing this report, assessments remained the most complicated and yet to be determined component of australian and new zealand anatomy education. reflections from each university indicated that assessments were to be online. while online practical assessments have previously been effectively trialed (inuwa et al., ) , both the assessment approach and the platform for administration still needed to be determined within a short timeframe. the challenges were summarized in this statement: "we want to ensure that our assessment is a true reflection of learning, remains robust, maintains integrity and is secure." some reflections also outlined a plan to prepare the student body for the anticipated changes to the assessment style: "any assessments that we deliver will be preceded by at least one formative examination in order to familiarize ourselves and the students with the online assessment process." many academics shared awareness of student collusion risks and a difficulty with assessment invigilation; some translated this to developing assessments where collusion became irrelevant using variations of formative assessments or relative grading approaches. other universities reported simply accepting collusion as inevitable in their solutions, as exemplified by one strategy in which assessment incorporated higher order questions: "the questions involve interpretation and analysis rather than recall of information and so whilst we cannot control students cheating, the nature of the questions reduces the likelihood of them locating the answer. if students collaborate then at least they have engaged together in reaching a solution." others modified their assessment approaches to minimize the chances of collusion using, for example, "flag race tests [aka practical exams] … conducted [online with] randomized flags." they report that: "this now effectively becomes an open-book test, so to minimize collusion and maintain some academic rigor, the test will be run at a single time for all students and flags are randomized so that they [students] are not all getting the same question (even if they are sitting side by side.)". one institution had further, in partnership with students in decision-making during the pandemic, implemented pass-fail grading reporting: "students were concerned that others in the student body would resort to extreme measures of colluding or compromise their academic integrity, which would be unfair on those who did not." still others were adjusting assessment weighting to minimize the drive for collusion, and were considering sensitivities around what is being examined: "we are creating our own assessments deploying them [online] as timed low-stakes summative tests. care must be taken to make sure non-sensitive images are used as students may screenshot and distribute questions." even with these mitigating measures, assessment remains challenging-how do we build assessment with constructive alignment for pandemic anatomy education? constructive alignment is based on constructivist theory wherein the learner constructs knowledge through learning activities which are pre-aligned with outcomes and assessment (biggs, ) . adjusting assessments for students with learning disabilities and those requiring extra time for completing assessments further extends the complexity of ensuring a robust assessment practice delivered remotely, within a limited timeframe. this is further compounded when assessing a student body with heightened anxiety due to the constant media reporting and ever-changing circumstances presented by the pandemic. there were also some recognized opportunities that the pandemic presented including as previously noted, the rapid skill acquisition in online pedagogy (schmidt et al., ) and skills in digital media production. with this in mind, and considering the changes already initiated in a short timeframe, the pandemic provided some with an impetus for curriculum review and strategic development of educational resources that would be useful after the pandemic, especially if these further enhance access and equity: "we are developing resources that can be utilized even when we are back to functioning normally. if the resources are aligned with the curriculum content and approach, then they can definitely supplement the practical classes ..." many reflections universally shared benefits such as gratefulness for both peers (staff) and students, and reported enhanced teamwork and skill acquisition of all involved (both staff and students). of note, most participants reported a positive student response, even if this was initially negative. as the pandemic progressed, students increasingly responded to the anatomy learning experience with unsolicited positive feedback, and in some cases also with concern for staff. the timing of the pandemic is of note for the island countries of australia and new zealand. the pandemic's "arrival" coincided with the beginning of the academic year, a very different time to that of their northern hemisphere counterparts (who were nearing the end of the academic year). the implication of this, is that changes to the anatomy education delivery, even if only limited to the first half of , potentially will have knock-on impacts across the entire academic year with respect to both curriculum delivery and assessment. as the covid- pandemic unfolds, and in the face of the significant disruption, the combined experiences and reflections of anatomy academics identify two main contributions to the practice of anatomical education in australia and new zealand. first, there are both opportunities and challenges presented with the rapid change in anatomy education, and there are related significant impacts on workload and professional roles. these were exemplified in the rapid upskilling of human resources, flexibility in redefining roles, and creativeness to enable and support continued learning at a distance. second, there are the perceptions of the impact on pedagogy, technology, higher education institutions, staff, students, and, of course, on personal educational philosophies in both the short and long term. in this domain, concerns on the loss of an integrated "hands-on" laboratory experience, and the lack of being physically present, were raised. the insights into these two areas will have important implications for anyone contemplating anatomy education in the future. while it is an unchartered time in the history of higher education, as always, there are lessons that can be gleaned from disruption, and anatomy education in australia and new zealand to accommodate the acute covid- crisis presents several insights (fig. ) . of primary importance is the care of the whole community. care should be taken to ensure that there is a safe environment. change often creates anxiety for some, and rapid change in response to the covid- pandemic is disruptive for both students and staff. for staff that deal with body donations, the pandemic raised concerns about both job security and risk of exposure if a body donor was a virus carrier. it is imperative that department leaders are aware of these concerns and find means to be "present" to engage in conversations and develop plans to mitigate risk to all constituents of the anatomy community. these concerns whether real or perceived, impact well-being. it is, therefore, imperative for department leaders to act quickly in circumstances where exposure to potential harm (e.g., sars-cov- virus) is unknown and to mitigate any threat to the health of the community, even if it requires temporary suspension of body donor programs. equally, student mental wellness is of concern to the academic anatomist, both prior to, and during the pandemic. while academics grapple with how to deliver anatomy education online, there needs to be an awareness that students who had previously experienced anatomy as a hands-on subject, or had preferred f f learning, require support in the transition to learning remotely (blackley and sheffield, ) . in this remote learning environment, the lack of physically present peers and instructors can lead some to have negative learning experiences. this raises concerns about the cognitive load placed on students through the change of learning environments, and whether the pace of change during the pandemic leaves too little mental capacity to construct knowledge (schwonke, ) . ideally student learning in this new environment requires explicit monitoring of cognitive processes to minimize cognitive overload, as advocated by valcke ( ) . broadbent and poon ( ) highlighted, through systematic review, four strategies students require for online learning: time management, metacognition, effort regulation, and critical thinking. in the short time to transition to remote learning during the pandemic, providing structure was a key element of effective support for managing stress and anxiety, and anatomy educators used a variety of strategies to provide structure like scaffolding learning through structured weekly activities, packaging topics into digestible chunks to reduce cognitive load, the use of short concept videos and quizzes to regulate effort, and interactive synchronous learning to develop critical thinking and social interactions. from the authors experience, students have also been reassured by knowing that hands-on laboratory sessions would be provided post-pandemic to provide opportunities to review cadaveric prosected specimens and surface and living anatomy, and possibly undertake dissection. one of the challenges of the current landscape is that messaging understandably appears changing, unclear and often conflicting. clearly communicating, even when the answer is still being discussed, is essential and will ensure reciprocity and cooperation among students (chickering and gamson, ) . as academics, who were also managing change for students, modelling effective communication strategies and approaches is useful to alleviate any change-induced stress. communication of expectations, as well as simple guidance on managing the online space is of great importance and can make a positive impact on learning (broadbent and poon, ) . some examples of this include clarifying the expectations around the expected daily/weekly progress and assessment criteria, and providing formative assessment opportunities as a preamble to high-stakes assessment tasks, as highlighted by the academics' reflections. in the light of increased student anxiety during the pandemic, communications should be carefully framed within positive messages of support and in a context of open dialogue. useful strategies employed during the pandemic included using anonymous dialogue platforms like slido © to allow students to ask questions in the comfort of anonymity, discussion boards to enable asynchronous student-teacher interactions (green and hughes, ) , and including students in the decision-making process affecting aspects of anatomy delivery, for example, assessments. of note, during this pandemic education delivery, both the academic staff and students described a loss of in person interaction and its impact on their individual motivation. while this has previously been connected to student disengagement in the online learning environment (gillett-swan, ) , the impact of this loss on staff has only recently been reported in the context of embedded-reward systems in higher education (cuseo, ) . as workloads and roles morph, effective change management strategies can be helpful, including clarifying stakeholder expectations. this is especially important given the increasing concern over the last two decades about mental wellness among infographic of shared australian and new zealand anatomy education teaching approaches during the covid- pandemic. scoping implications for this teaching crossed multiple teaching modalities summarized as the six cs, and affected all stakeholders (students and staff) including: change and flexibility, clarify expectations, clear communication, constructive alignment of new material, a focus on community care, and continuity planning in the face of this global health emergency. lectures and active learning tended to engage asynchronous online approaches, using prerecorded videos and discussion boards, while practical activities tended to be synchronous streaming approaches combined with a reliance on future intensive experiences. assessment was the most widely varied aspect across these two countries. all approaches tended to accept collusion as a risk to online assessments, and educators attempted to mitigate this risk by delivering questions with randomized sequencing for each student, decreasing weighting of assessments, making assessments pass or fail, or embracing teamwork as part of the assessment strategy. university academics even in the absence of a crisis (watts and robertson, ; gulliver et al., ; kinman, ) . existing evidence suggests that academics are already overcommitted to their work due to implicit system rewards (hamilton, ) . in the absence of a pandemic, the increase in educators' workloads in developing online resources (green and whitburn, ) and in transitioning to remote and online delivery (kimball, ) is well recognized. managing and supporting students has been identified as the most demanding aspect of digital learning (canninzzo et al., ) . this correlates with the reflections of a large number of participants regarding the increased workload, the extended online work day/week, and the increased student correspondence. regarding the latter, kimball ( ) explains that in remote learning, learners have a perception of a "rolling presence" which can make educators feel pressured to spend large amounts of time interacting with students who perceive online education as "always open" for business. the social and personal impact of the rapid response by anatomy academics to transform to a highly demanding form of delivery (i.e., distance/online) is yet to be determined. it is reasonable to expect that discussions and plans to reset stakeholder expectations will be required, especially if this pandemic continues for an extended period. as workloads explode, there is a need for leaders to provide immediate assurance, acknowledgement of the situation and empathy for the challenges faced with rapid change. those in leadership roles, have the added responsibility to advocate for staff, especially considering high expectations and the complexities of wfh arrangements. clarifying expectations of academics is imperative. for academic colleagues, it is impossible to quantify the time required for repurposing and sourcing resources, but acknowledging this reality is useful, as is acknowledging all who contribute to delivering the learning experience. in good education practice, constructive alignment is paramount. in a pandemic, alignment, if clearly articulated, will potentially aid students in making meaning of the change and will be reassuring and decrease anxiety. in delivering anatomy education remotely and online within a changing pandemic landscape, constructive alignment remains a challenge; a simple effective process to ensure alignment with learning outcomes, activities, and assessment is, however, required. as saunders ( ) posits, distance teaching requires teaching practices to change, and "to change the way in which you teach is a significant undertaking." there are several fundamental elements of effective online pedagogy design (chen et al., ; martin and bolliger, ) employed in delivering anatomy teaching during the pandemic, these elements were variably highlighted and included providing feedback through quizzes, establishing social connections, active facilitation and using a range of technologies. one approach highlighted selecting a pedagogical element to emphasize through the delivery (e.g., active learning) rather than focusing on issues such as infrastructure, policies and budget. even with this foresight, the aspect of remotely delivering assessment requires more deliberation, and institutional resources (kirkwood and price, ) . it is expected that this is an area that australian and new zealand universities will need further investment in. at some stage, once the crisis is over, activities undertaken now will have to be reviewed. for this reason, clear documentation of expectations and modifications made (what, why, and how) will be useful. there is, however, little opportunity with the present pace of change, for an adequate change documentation process. uncertainties also remain around how documentation will be reviewed by professional accreditation bodies, and for australia, teqsa. no doubt there will need to be a targeted program of evaluating competencies and providing in-time education to address any perceived learner knowledge gaps. it is hoped that this compensatory process will also heed the evidence on the benefits of cadaveric-based learning for medical students (estai and bunt, ; flack and nicholson, ) . it will, however, be important to determine what perceived gap, if any, is being addressed before a compensatory activity is planned (wilson et al., ) . at that stage, and with time, there will also be opportunity to evaluate whether other digital resources and immersive learning experiences can be used to address knowledge gaps (doubleday et al., ; losco et al., ; birbara et al., ) . as we cope with this pandemic, being able to compromise, and adapt in practice and curriculum design and teaching delivery is important. anatomy academics' reflections on persevering and adapting to deliver anatomy education amidst constant and daunting change is possibly an indication of a commitment of anatomy educators to the education sector, student body, and discipline. given the limited time available for transition to remote/online delivery, the authors experiences demonstrated an almost consistent strategy of repurposing existing material. this enabled academics to concentrate on redesigning activities related to higher learning outcomes usually attained through the practical components of learning in the anatomy laboratory. some anatomy educators planned later opportunities after the pandemic to address perceived gaps in knowledge. evidence suggests that the quality of remote learning materials needs to be higher than campus-based materials (kimball, ) and this has been corroborated more recently in the practice of developing online content for a blended anatomy course (green and whitburn, ) . however, an important aspect of pandemic change for anatomy academics themselves is to adapt self-imposed standards. it will take confidence to heed calls to compromise self-imposed excellence standards. as saunders ( ) explains, academics incur additional stress in online teaching with the increased pressure that prerecorded videos, case studies, and discussion boards are a permanent record of their knowledge and expertise. given the context of the pandemic, and the speed of change, it befits entire academic community to model self-care and moderation to those around, and to accept that current makeshift resources may not be a true reflection of the educators' abilities, but it will be fit-forpurpose in response to acute transitional change. one of the challenges of change in the paradigm of physical distancing regulations, is that it almost instantly cauterized the existing community of practice academics access in their home departments and institutions. anatomy academics, however, appear to be resourceful in effectively engaging with a wider community of practice to share not just experiences and capabilities but also resources. this was evidenced in the almost immediate role change of technical staff and demonstrators to develop digital resources, and through the sharing of resources and of experiences using social media communities (e.g., twitter inc., san francisco, ca) and by software developers and societies of anatomy (evans et al, ) . smaller communities like local departments of anatomy, have also utilized technologies such as whatsapp © (facebook inc., mountain view, ca), to troubleshoot through challenges, and motivate and aid staff well-being. as in past times of crisis, a positive outcome of the shared challenge is that it unifies communities around common goals. while this is certainly a time of justified anxiety, it is also a time when the positive and resilient aspects of connectedness and community come together to encourage and build each other up-even with physical distance. notwithstanding this, the rapid onset of the covid- pandemic, highlights the need for the discipline and for departments to be proactive in keeping updated with new pedagogies and to be embedded in wider communities of practice outside home institutions. as negative as it sounds, it is essential at this time (as at any) to develop and communicate a continuity plan. in a global health emergency, circumstances are likely to arise that a team member is unable to continue their responsibilities. inevitably, the pandemic highlights to those in leadership roles, the need for contingency planning and investment in staff upskilling. the disruption of anatomy education in response to the pandemic may, however, also be perceived as an opportunity to expand anatomy education more broadly beyond the traditional f f delivery model into the remote learning space. fully online models of anatomy education may have been impeded over the last decade by the lack of acceptance among anatomy educators. the quick response of the anatomy community in australia and new zealand demonstrates their flexibility and potentially enables the discipline to personalize education (gillett-swan, ) and to expand its reach to untapped learner pools, an increasingly important need as institutions enter a post-pandemic financial recovery phase. no doubt that whatever the context, the main inhibitor of remote anatomy education delivery will be the quality of the offering especially if deficient of a hands-on practical experience, time, support, and people capacity. some of the benefits of the pandemic-related disruption are already being recognized and include, for example, using live streaming to deliver lectures to cohorts of students distributed across multiple (sometimes even remote) campuses during clinical placements, thus addressing a challenge experienced by most australian and new zealand anatomy departments. this model could also assist students on extended periods of absence, like for example indigenous students attending community and family ceremonies and funerals. some anatomy academics have, indeed, perceived this rapid change as a novel opportunity to apply newly learnt pedagogies and delve into a freshly acquired space for modern education. there remain several limitations of this current profile of anatomy education during the early stages of the pandemic. while it uniquely captures a cross-section of experiences of delivering anatomy education in australia and new zealand, the reflections were not triangulated, and it does not include all anatomists or all anatomy departments in australia and new zealand. importantly, the participants narratives are a snapshot of their perceptions and views based on a one-off reflection during a period of crisis, and not a longitudinal account of their experiences. the constructivist approach to the study is an appropriate tool to examine anatomy education in the rapidly changing context of the pandemic, as it allows interpretation of experiences at different time points. a follow-up study with the participants post-pandemic would, therefore, provide deeper insights on how academic attitudes in this period of acute change have changed and matured, and how the experience has impacted their personal educational philosophies and their institutional practice of anatomy education. as the covid- pandemic continues to unfold in australia and new zealand, there is no doubt that university leaders and academics deserve recognition for their management and support to all the communities that they serve. their focused efforts in the face of global change, disruption, uncertainty, and potential volatility appears to ensure an effective and safe learning environment, and where possible, serve their nations and their institutions. for anatomy education, these decisions were particularly impactful in that they disrupted access to human donor body resources (a widely utilized discipline pedagogical tool) and forced change to ensure the continued delivery of anatomy teaching. several challenges were recognized by anatomy academics in this period including time, resources, and technical capability. professional and technical staff demonstrated role adaptability and assisted their academic colleagues in meeting teaching obligations. for anatomy academics, flexibility and adaptability enabled the continuity of anatomy education programs which were effectively fit-for-purpose in the pandemic context. interestingly, in person interactions between anatomy academic staff and students, an often-overlooked motivator, was uniquely highlighted as an integral part of the anatomy learning equation. of note, and in a time of crisis and uncertainty, anatomists appear to act and think like leaders-health and safety first, followed by academic standards, and developing flexible solutions for business continuity. there is no doubt that there has been a significant change in the teaching of anatomy in australia and new zealand over the last month. it remains, however, to be seen how the rapid change effected at this time correlates with student performance and satisfaction, and how the bridges that have been built impact on the future of anatomy education. the figure was designed in collaboration with kat orgallo, teaching resource support unit, faculty of medicine, nursing and health sciences at monash university. nalini pather, m.med.sci. (clin. anat.), ph.d., is a professor and the chair of anatomy at the university of new south wales faculty of medicine, sydney, nsw, australia. she teaches anatomy across multiple programs including medicine, allied health, medical science, and biomedical engineering students. her research group focuses on the applications of anatomy, visualization, and immersive technologies to clinical, and imaging specialties, and on medical education. using reflexivity to optimize teamwork in qualitative research constructive alignment in university teaching d modelling and printing technology to produce patient-specific d models virtual reality in anatomy: a pilot study evaluating different delivery modalities digital andragogy: a richer blend of initial teacher education in the st century self-regulated learning strategies and academic achievement in online higher education learning environments: a systematic review moral barriers between work/life balance policy and practice in academia a model for synchronous learning using the internet seven principles for good practice in undergraduate education exploring deep space -uncovering the anatomy of periventricular structures to reveal the lateral ventricles of the human brain swine flu: lessons we need to learn from our global experience student-faculty engagement a downward spiral: coronavirus spins australian universities into economic crisis. the guardian sars and mers: recent insights into emerging coronaviruses the virtual anatomy laboratory: usability testing to improve an online learning resource for anatomy education best teaching practices in anatomy education: a critical view going virtual to support anatomy education: a stop gap in the midst of the covid- pandemic human skills for human[istic] anatomy: an emphasis on nontraditional discipline-independent skills overseas students in australian higher education: a quick guide. parliamentary library research papers series what do medical students learn from dissection? the challenges of online learning: supporting and engaging the isolated learner student outcomes associated with use of asynchronous online discussion forums in gross anatomy teaching impact of introduction of blended learning in gross anatomy on student outcomes the relationship between student engagement with online content and achievement in a blended learning anatomy course university staff mental health literacy, stigma and their experience of students with mental health problems perspective: guidelines for reporting teambased learning activities in the medical and health sciences education literature cash or kudos: addressing the effort-reward imbalance for academic employees international medical education and future directions: a global perspective the role of history and ethics of anatomy in medical education knowledge maps: an online tool for knowledge mapping with automated feedback anatomy practical examinations: how does student performance on computerized evaluation compare with the traditional format? online mass exodus: how australian unis are coping with covid- . itnews managing remote learning: new challenges for faculty effort-reward imbalance in academic employees: examining different reward systems technology-enhanced learning and teaching in higher education: what is 'enhanced' and how do we know? a critical literature review building professionalism in human dissection room as a component of hidden curriculum delivery: a systematic review of good practices effective methods of teaching and learning in anatomy as a basic science: a beme systematic review: beme guide engagement matters: student perceptions on the importance of engagement strategies in the online environment thematic analysis: striving to meet the trustworthiness criteria how can we show you, if you can't see it? trialing the use of an interactive three-dimensional micro-ct model in medical education d printing from cardiovascular ct: a practical guide and review teaching anatomy: prosection and dissection australian broadcasting corporation, government of australia re-visioning academic medicine through a constructionist lens reducing regulatory burden during covid- -important update from teqsa. australian government tertiary education quality and standards agency (teqsa) how faculty learn to teach online: what administrators need to know metacognitive load -useful, or extraneous concept? metacognitive and self-regulatory demands in computer-based learning distance education research: a review of the literature how does donor dissection influence medical students' perceptions of ethics? a cross-sectional and longitudinal qualitative study commemorations and memorials: exploring the human face of anatomy australian universities defer exams, increase response to coronavirus outbreak cognitive load: updating the theory? synchronous and asynchronous communication in distance learning: a review of the literature who. . world health organization. coronavirus disease (covid ) situation report - breaking with tradition: a scoping meta-analysis analyzing the effects of student-centered learning and computer-aided instruction on student performance in anatomy phil blyth, b.h.b., m.b.ch.b., ph.d. (bioeng.) , is a senior lecturer in elearning in medicine in the department of anatomy, school of biomedical sciences, university of otago, dunedin, new zealand. he coordinates the elearning team within the mbchb program and teaches anatomy within the medical and science programs. his research interests include medical education and he has developed orthopedic surgical simulation apps. he practices within the emergency department. jamie a. chapman, ph.d., is a senior lecturer in human anatomy at the tasmanian school of medicine, college of health and medicine, university of tasmania, hobart, tasmania, australia. he coordinates and teaches histology in the first years of the mbbs course and coordinates a first-year, cross-campus human anatomy, and physiology unit. his research is focused on technology-enhanced learning and teaching.manisha r. dayal, ph.d., is a senior lecturer in human anatomy in the school of science at western sydney university, australia. she teaches gross anatomy, embryology, and forensic anthropology to medical and forensic science students including forensic mortuary practice students. her main area of research focuses on retention of anatomical knowledge through kinesthetic learning. , is an associate professor in human anatomy in the department of pharmacy and biomedical sciences, college of science, health, and engineering at la trobe university, bendigo, vic, australia. he is a discipline leader across the university campuses and teaches anatomy to a variety of students including physiotherapy and biomedical sciences. anneliese k. hulme, m.chiro., m.res., is a lecturer in the department of anatomy at the university of new south wales in sydney, australia. she teaches anatomy to medical and science students. her main research interest is in medical education.ian p. johnson, ph.d., is a professor of anatomy in the department of biomedical sciences, faculty of medicine, health and human sciences at macquarie university in sydney, nsw, australia. he is involved in undergraduate science and postgraduate medical education and his research is in neuroscience and medical education.amanda j. meyer, ph.d., is an anatomy lecturer in the school of human sciences at the university of western australia. she teaches neuroanatomy, histology, and gross anatomy to science, biomedical and medical students. her research focuses on the student experience (particularly anxiety and motivation) of anatomy learning. john w. morley, ph.d., is a professor of anatomy and cell biology and the deputy dean in the school of medicine, western sydney university, australia. his main area of teaching is topographical anatomy and neuroanatomy. his research is in sensory neuroscience (vision and touch), cns involvement in duchenne muscular dystrophy, and the development of visual prostheses. peter j. shortland, ph.d., is an associate professor of human anatomy in the school of science at western sydney university, australia. his main area of teaching is neuroanatomy but he also contributes to anatomy courses in musculoskeletal anatomy. his research is on the neuroanatomical plasticity that occurs in the spinal cord following nerve injuries, chemotherapy treatment or ingestion of toxic compounds that contribute to neuropathic pain.goran Štrkalj, ph.d., is an associate professor in the department of anatomy education, school of medical sciences at the faculty of medicine, university of new south wales, sydney, new south wales, australia. he teaches anatomy and biological anthropology to science and medical students. his main research interests are in human variation and evolution, history of science, and medical/science education.mirjana , is an associate professor in the medical school, college of health and medicine at australian national university, canberra, act, australia. she leads the medical school technology-enhanced learning and teaching team. her research encompasses anatomy and its clinical application in a variety of contexts and she teaches anatomy to medical and science students. stephanie j. woodley, b.phty., ph.d., is an associate professor in the department of anatomy, school of biomedical sciences, university of otago, dunedin, new zealand. she teaches anatomy across a variety of undergraduate and postgraduate science and health science programs. her research is focused on musculoskeletal anatomy and imaging, and its application to clinical practice. michelle d. lazarus, ph.d., is an associate professor and deputy head (education) of the department of anatomy and developmental biology at monash university in melbourne, victoria, australia. she is also director of the centre for human anatomy education at monash university. her research focuses on exploring anatomy education curricular impacts on medical student professional identity and role formation. key: cord- - ao rq authors: cossart, yvonne e title: the rise and fall of infectious diseases: australian perspectives, ‐ date: - - journal: med j aust doi: . /mja . sha: doc_id: cord_uid: ao rq australia has been fortunate in its experience with infectious diseases over the past century. by the s, many communicable diseases were controlled through a combination of high living standards, progressive adoption of vaccines and antimicrobial treatment. australian medical scientists have made substantial contributions to the understanding of many historically significant communicable diseases and global initiatives for control. new challenges have emerged as previously unrecognised viral infections have emerged, and microbial resistance to antibiotics has developed in many old pathogens. ongoing evolutionary forces, both environmental and social, change the balance between humans and microbes. the effects of these forces are most sorely felt in poor countries and communities. i n , when the british medical association launched the medical journal of australia, the medical profession and the general public believed that infectious diseases would soon be conquered. acrimonious th century disputes between the contagionists and the sanitarians had given way to an alliance which was steadily improving health. rising living standards reduced infant deaths from gastroenteritis, through better food and water hygiene, and reduced deaths from "consumption" (tuberculosis), because of better nutrition. the success of rat extermination in controlling plague in sydney provided a triumphant validation of new microbiological theories; joseph lister's carbolic spray was adopted by local surgeons; emil von behring's antitoxin treatment reduced mortality from diphtheria; and paul ehrlich's vision of a magic bullet to cure all infections was given credibility by the effi cacy of salvarsan (arsphenamine, an arsenic-containing compound) against syphilis. maritime quarantine provided a signifi cant, if not impregnable, barrier to the introduction of epidemic diseases. the mja refl ected the progressive mentality of australian doctors through reports on new international discoveries and leading articles. in reality though, infection still caused at least a quarter of all deaths, % due to tuberculosis alone. many of the victims were children or young adults. eradication of bovine tuberculosis produced a welcome fall in infant cases, but about cases continued to be notifi ed annually between and . the fi ne sanatorium buildings in "healthy" locations such as the blue mountains are reminders of the desperate attempts to combine sanitary and microbiological principles by isolating patients to prevent spread of the disease while they were treated with rest and diet. , , during world war ii (wwii), intensive screening of australian troops by miniature x-ray was followed up with bacteriological testing to identify patients with active infection, for whom treatment was compulsory. the success of this program prompted a postwar attempt to eradicate the disease from the civilian population, and the advent of streptomycin and sickness benefi t payments made compulsory treatment acceptable to the community. tuberculosis has again become resurgent in many countries. the high expense and long duration of triple therapy test the resources of the poorest countries. undertreatment allows emergence of multidrug-resistant strains for which treatment reverts to pre-antibiotic options. in australia, such strains are, mercifully, still uncommon. syphilis also imposed a high burden of chronic disease on society. in , about % of admissions to mental institutions and % of cases of aortic aneurysm in victoria were due to tertiary syphilis, while % of pregnant women had positive wassermann test results. the social stigma of sexually transmitted diseases and the heroic nature of combined mercurial and salvarsan therapy deterred many asymptomatic patients from seeking treatment. notifi cation of acute cases and compulsory treatment were not successfully implemented, even in the army. in civilian settings, policies of testing only female prostitutes doomed any hope of eradication. many acute infections also remained endemic. there were dedicated wards for patients with typhoid in general hospitals, and the prevalence and mortality of typhoid remained high until the advent of antibiotics. bedside vigils to await the crisis of pneumonia were all too familiar, and childhood infections claimed many young lives. in , gastroenteritis, diphtheria, scarlet fever, whooping cough and measles between them killed one of every live-born children. about as many more died from pneumonia and meningitis. in the interwar decades, diphtheria and pertussis vaccines were produced in the newly established commonwealth serum laboratories and school-based vaccination began. but in , public confi dence was shaken by the bundaberg tragedy, in which a multidose vial of diphtheria toxin-antitoxin became contaminated with staphylococci from the skin of a vaccinee. twelve other children died. this galvanised regulation of vaccine manufacture, safety testing and surveillance for adverse effects. however, almost a century on, the antivaccination movement still opposes mass vaccination of children in early life. during its fi rst few years of publication, the mja reported on mortality due to infection among wwi troops, which exceeded combat deaths. but the battlefi elds were also a clinical laboratory where the effi cacy of tetanus antitoxin was proven and typhoid vaccination was introduced. the mja also reported episodes which, with hindsight, showed that evolutionary forces were altering the balance between microbes and their human hosts. in , infl uenza killed more europeans than had perished in the war. the source of the pandemic strain remains obscure, but there is no doubt about the role of returning troops in its global spread. australia's isolation and its quarantine system protected it for some time, but eventually the country experienced a catastrophic outbreak. australia became an active participant in the subsequent international efforts to maintain surveillance and produce effective infl uenza vaccines. pivotal infl uenza studies led by frank macfarlane burnet at the walter and eliza hall institute were conducted during this period, and the institute's interests soon broadened into basic scientifi c research on many important infections. in the postwar period, the establishment of the australian national university strengthened the national capability in infectious diseases research. poliomyelitis was on the increase in the most "hygienic" countries of scandinavia, north america and australasia: a paradox for an infection spread by the faecal-oral route. this was the penalty for the delay in the average age when infection occurred, which was a consequence of improved hygiene. this in turn increased the numbers of clinical cases because the chance of neurological involvement increased spectacularly with age. the crippling legacy of infection made the sight of children with leg braces all too familiar in schools nationwide, while the invention of the iron lung enabled many patients with respiratory paralysis to survive. norman gregg's pivotal discovery of the role of rubella in causing congenital defects altered scientifi c attitudes to infections during pregnancy. it was almost two decades before cell culture techniques paved the way for vaccines against polio, and then other childhood infections. the growing list of vaccines demanded new combinations to reduce the number of injections needed, and the cost became an issue even in wealthy countries where the plummeting prevalence of vaccine-preventable diseases justifi ed the investment. in the second half of the th century, even the basic triple antigen (diphtheria, tetanus, pertussis) was unaffordable in many developing countries, but international philanthropy plus political support have progressively been mobilised, resulting in signifi cant reduction of vaccine-preventable disease. money is not the only problem. the projected global eradication of polio has stalled because confl icts in africa and pakistan have disrupted infrastructure and fanned ideological doubts about the political motivations of governments and charities. in the optimistic political climate of the post-wwii years, the world health organization undertook an unprecedented program to achieve global eradication of smallpox. frank fenner was chairman of the project's management commission. using edward jenner's th century vaccination technique and an international army of fi eld workers, smallpox eradication was achieved in . it remains the only example of intentional eradication of a human infectious disease. not all microbial evolution resulted in populations of organisms with increased virulence for humans. scarlet fever, after causing devastating epidemics in the late th century, declined in terms of incidence and mortality by the s. this was attributed to the loss of toxin-encoding genes from streptococcus pyogenes. conversely, recent resurgence of severe streptococcal infections underlines the mutability of "old" pathogens. antimicrobial drugs sulfonamides made their spectacular entry into medicine just before wwii and cut the mortality from pneumonia and puerperal fever dramatically. prontosil, a forerunner of all sulfonamide drugs, was not patentable, and manufacturers fl ooded the market with sulfonamide-like drugs. penicillin soon followed -with australian scientist howard florey being a key fi gure in its development -and was quickly adopted in military medicine. the antibiotic era had begun; as discovery followed discovery, it seemed that no bacterial infection would remain untreatable. osteomyelitis, empyema, rheumatic fever and subacute bacterial endocarditis disappeared from the wards, and gonorrhoea and syphilis notifi cations plummeted. patients expected to recover from septicaemia, pneumonia and even meningitis; but it did not take long for the fi rst drug-resistant organisms to appear. sophisticated medical technology has offered unprecedented opportunities to microorganisms. drug resistance has rapidly developed owing to selective pressure resulting from profl igate use of antibiotics in medicine and agriculture. australian hospitals experienced some of the earliest outbreaks of antibiotic-resistant staphylococci, which led to radical improvements in infection control. although most of the resistant organisms were no more (and often less) virulent than the original susceptible strains, their competitive advantage meant that acute urinary infections could no longer be reliably treated with ampicillin, nor gonorrhoea with penicillin, by the mid s. discovery of new antibiotics could not keep pace, and regulatory attempts to restrict their use have proved diffi cult. transfusion-associated hepatitis b infection was discovered during wwii. after the virus was identifi ed in , it was found that about . % of most western populations were chronically infected, but carrier rates of % or more were common in asia and africa. moreover, these rates diptheria* patients expected to recover from septicaemia, pneumonia and even meningitis; but it did not take long for the fi rst drug-resistant organisms to appear were maintained by silent transmission -from mother to infant during delivery, rather than by intravenous drug use or blood transfusion. before blood banks started screening donated blood for hepatitis b, transfusion was a major route of transmission of acute hepatitis b infection in western countries. the need for mass screening prompted development of commercial testing kits, which have revolutionised laboratory diagnostic services. the most concerning feature of hepatitis b infection was the recognition during the s that adult carriers often developed liver cancer, which was then the leading cause of cancer deaths in asia. rather than a rarity, hepatitis b was a major global health problem; this justifi ed universal infant vaccination, which was made possible by recombinant dna technology in the s. the hepatitis b vaccine was the fi rst human recombinant dna vaccine and the fi rst human cancer vaccine. other agents soon emerged from obscurity, often in response to changes in human activity. aids fi rst appeared in the gay communities of "world cities" in the early s -the downside of sexual liberation. the inexorable rise in prevalence and apparently inevitable mortality of hiv infection spurred public health initiatives and scientifi c investigation. in australia, safe-sex campaigns had an almost immediate effect in reducing numbers of new cases, as did controversial needle-exchange and harm-minimisation strategies for injecting drug users. global investment in research led to effective antiviral drugs and greatly extended the healthy lifespan of infected individuals in western countries. however, in the populous countries of africa, south america and asia, heterosexual transmission dominated and led to epidemics of neonatal infection via transplacental transmission. this social and economic catastrophe reawakened respect for infection, and also fuelled fear of nosocomial transmission of bloodborne viruses. the shadowy entity of non-a, non-b hepatitis unexpectedly proved to cause both liver cirrhosis and cancer. acute hepatitis c infection causes only minor symptoms, but the hepatitis c virus often establishes chronic infection with sinister consequences. tests were developed to screen donated blood and it soon became apparent that injecting drug use had silently amplifi ed prevalence of hepatitis c infection in young people in western countries. hepatitis c infection became the commonest indication for liver transplant in australia, and health authorities struggled to fi nd an effective control strategy. treatment was protracted and beset by the adverse effects of interferon, a key component of drug regimens that were initially used. newer drugs achieve high cure rates, but cost puts them out of reach for patients in poor countries, where the reservoir of infection remains high. human papillomavirus was the fourth "new" infection to engage late th century society. genital warts were well known to the ancient romans, and for centuries they were regarded as an embarrassing but harmless sexually transmissible disease. this attitude changed dramatically when their association with cervical cancer was established in the s. the high-risk types of papillomavirus produce "fl at" penile warts which are easily ignored, but results of cervical cytology testing made the cancer connection -it was noted that cells with telltale warty changes were often seen in cervical smears which had malignant or premalignant changes. in australia, preventive human papillomavirus vaccination was pioneered by ian frazer and viral dna detection has been added to screening by pap smear, but neither of these approaches are affordable in poor countries, where death rates from cervical cancer are highest. the challenges of demographic and environmental change in , old infections still lurk, while human and environmental changes create new opportunities. malaria -which depends on humans as a reservoir for the parasite and mosquitoes for transmission -was vulnerable to a combination of treating patients with drugs and spraying the environment with dichlorodiphenyltrichloroethane (ddt) to kill mosquitoes. large areas of the temperate zone and even the tropics became malaria free but, because mosquito eradication measures were inconsistently applied, drug-resistant parasites and ddt-resistant mosquitoes soon emerged. in the absence of an effective vaccine, prevention now relies on avoidance of mosquito bites by use of repellents, protective clothing and screens, plus an ever-diminishing number of effective prophylactic drugs. malaria has been holding its own in many countries, aided by global warming. military deployment of troops in exotic areas and largescale movement of refugees are associated with outbreaks of communicable diseases. cholera has been a recurrent problem when people seek shelter from war or natural disaster, most recently in haiti. hantaan virus caused over cases of korean haemorrhagic fever and almost deaths among american troops during the korean war. the soldiers were exposed through inhalation of aerosolised rodent faeces when camped in wilderness areas. other haemorrhagic fevers -such as ebola virus disease and lassa fever, for which native wildlife act as reservoirs -have caused human outbreaks with high mortality, particularly in sub-saharan africa. australia has several indigenous arboviruses, including murray valley encephalitis, and ross river and barmah forest viruses. as global population pressure drives clearance of forested areas for agriculture, humans have become targets for many infections carried by wild animals. in australia, outbreaks of hendra virus infection and the emergence of the australian lyssavirus have been linked to contact with fl ying foxes. severe acute respiratory syndrome (sars), which caused a deadly outbreak of respiratory disease centred in southern but was transmitted to humans via infected palm civets, which were often for sale in chinese markets. control of sars was achieved through international cooperation in identifying the new coronavirus and applying strict isolation procedures. even so, the high mortality brought home to the world the potential threat of contagious disease. memories of the infl uenza pandemic lent renewed vigour to the who surveillance system for respiratory infections that emerge from reservoirs of infl uenza viruses in pigs, horses, poultry and wild birds (the latter two in particular). alas, the ability to identify novel strains has not been matched by the ability to predict infectivity and severity of disease. intensive agricultural production also provides new routes of infection. mad cow disease resulted from the use of inadequately rendered animal-based food supplements for cattle which allowed the variant creutzfeldt-jakob disease agent to survive. infected cattle often reached maturity and were slaughtered for human consumption before they developed clinical disease, and then humans became infected. the ramifi cations of this outbreak were economic and social. more new infections will undoubtedly emerge as humans change their environment. these pressures also affect old infections such as tuberculosis, malaria, cholera and even plague. the lessons of the past should not be forgotten. for a hundred years, the mja has reported on the overall decline of most infections in our "lucky country" -the result of our high standard of living combined with rational treatment and control measures. aboriginal australians who endure poverty and limited access to medical resources have not shared this luck. this mirrors the disparity in communicable diseases mortality between industrialised and developing countries. abolishing this gap is the immediate priority for the forthcoming century. provenance: commissioned; externally peer reviewed anticontagionism between and the australian mortality decline: all-cause mortality - on the epidemiology of plague the beginning of antiseptic surgery in australia the diphtheria prophylactic of e. von behring sex, disease and society: a comparative history of sexually transmitted diseases and hiv/aids in asia and the pacifi c australian quarantine service. maritime quarantine administration. melbourne: arthur j mullett, government printer tuberculosis in new south wales: a statistical analysis of the mortality from tubercular diseases during the last thirty-three years consumption: report of a conference of principal medical offi cers on uniform measures for the control of consumption in the states of australia tuberculosis: its nature, prevention, and treatment, with special reference to the open air treatment of phthisis the epidemiology, mortality and morbidity of tuberculosis in australia: - health and disease in australia: a history the mortality in australia from measles, scarlatina and diphtheria the hazards of immunization the australian army medical services in the war of - . volume ii. canberra: australian war memorial natural history of infectious disease congenital cataract following german measles in the mother immunisation: a public health success progress toward global polio eradication -africa a successful eradication campaign. global eradication of smallpox severe streptococcal infections in historical perspective history of staphylococcal infection in australia control of fl uoroquinolone resistance through successful regulation jaundice occurring one to four months after transfusion of blood or plasma recent advances in the study of the epidemiology of hepatitis b vertical transmission of hepatitis b antigen in taiwan hepatitis b virus. the major etiology of hepatocellular carcinoma clinical and immunologic sequelae of aids retrovirus infection in and out of africa epidemiology of hepatitis c virus infection among injecting drug users in australia liver transplantation for hepatitis c-associated cirrhosis in a single australian centre: referral patterns and transplant outcomes papillomaviruses and cancer: from basic studies to clinical application hpv immunisation: a signifi cant advance in cancer control global malaria mortality between and : a systematic analysis cholera surveillance during the haiti epidemic -the fi rst years hemorrhagic fever with renal syndrome in korea emerging viral infections in australia bats are natural reservoirs of sars-like coronaviruses world health organization multicentre collaborative network for severe acute respiratory syndrome diagnosis. a multicentre collaboration to investigate the cause of severe acute respiratory syndrome an overview of bovine spongiform encephalopathy (bse) in britain indigenous disparities in disease-specifi c mortality, a cross country comparison: new zealand, australia, canada, and the united states key: cord- -vj o b authors: crous, p.w.; wingfield, m.j.; chooi, y.-h.; gilchrist, c.l.m.; lacey, e.; pitt, j.i.; roets, f.; swart, w.j.; cano-lira, j.f.; valenzuela-lopez, n.; hubka, v.; shivas, r.g.; stchigel, a.m.; holdom, d.g.; jurjević, Ž.; kachalkin, a.v.; lebel, t.; lock, c.; martín, m.p.; tan, y.p.; tomashevskaya, m.a.; vitelli, j.s.; baseia, i.g.; bhatt, v.k.; brandrud, t.e.; de souza, j.t.; dima, b.; lacey, h.j.; lombard, l.; johnston, p.r.; morte, a.; papp, v.; rodríguez, a.; rodríguez-andrade, e.; semwal, k.c.; tegart, l.; abad, z.g.; akulov, a.; alvarado, p.; alves, a.; andrade, j.p.; arenas, f.; asenjo, c.; ballarà, j.; barrett, m.d.; berná, l.m.; berraf-tebbal, a.; bianchinotti, m.v.; bransgrove, k.; burgess, t.i.; carmo, f.s.; chávez, r.; Čmoková, a.; dearnaley, j.d.w.; de a. santiago, a.l.c.m.; freitas-neto, j.f.; denman, s.; douglas, b.; dovana, f.; eichmeier, a.; esteve-raventós, f.; farid, a.; fedosova, a.g.; ferisin, g.; ferreira, r.j.; ferrer, a.; figueiredo, c.n.; figueiredo, y.f.; reinoso-fuentealba, c.g.; garrido-benavent, i.; cañete-gibas, c.f.; gil-durán, c.; glushakova, a.m.; gonçalves, m.f.m.; gonzález, m.; gorczak, m.; gorton, c.; guard, f.e.; guarnizo, a.l.; guarro, j.; gutiérrez, m.; hamal, p.; hien, l.t.; hocking, a.d.; houbraken, j.; hunter, g.c.; inácio, c.a.; jourdan, m.; kapitonov, v.i.; kelly, l.; khanh, t.n.; kisło, k.; kiss, l.; kiyashko, a.; kolařík, m.; kruse, j.; kubátová, a.; kučera, v.; kučerová, i.; kušan, i.; lee, h.b.; levicán, g.; lewis, a.; liem, n.v.; liimatainen, k.; lim, h.j.; lyons, m.n.; maciá-vicente, j.g.; magaña-dueñas, v.; mahiques, r.; malysheva, e.f.; marbach, p.a.s.; marinho, p.; matočec, n.; mctaggart, a.r.; mešić, a.; morin, l.; muñoz-mohedano, j.m.; navarro-ródenas, a.; nicolli, c.p.; oliveira, r.l.; otsing, e.; ovrebo, c.l.; pankratov, t.a.; paños, a.; paz-conde, a.; pérez-sierra, a.; phosri, c.; pintos, Á.; pošta, a.; prencipe, s.; rubio, e.; saitta, a.; sales, l.s.; sanhueza, l.; shuttleworth, l.a.; smith, j.; smith, m.e.; spadaro, d.; spetik, m.; sochor, m.; sochorová, z.; sousa, j.o.; suwannasai, n.; tedersoo, l.; thanh, h.m.; thao, l.d.; tkalčec, z.; vaghefi, n.; venzhik, a.s.; verbeken, a.; vizzini, a.; voyron, s.; wainhouse, m.; whalley, a.j.s.; wrzosek, m.; zapata, m.; zeil-rolfe, i.; groenewald, j.z. title: fungal planet description sheets: – date: - - journal: persoonia doi: . /persoonia. . . sha: doc_id: cord_uid: vj o b novel species of fungi described in this study include those from various countries as follows: antarctica, cladosporium arenosum from marine sediment sand. argentina, kosmimatamyces alatophylus (incl. kosmimatamyces gen. nov.) from soil. australia, aspergillus banksianus, aspergillus kumbius, aspergillus luteorubrus, aspergillus malvicolor and aspergillus nanangensis from soil, erysiphe medicaginis from leaves of medicago polymorpha, hymenotorrendiella communis on leaf litter of eucalyptus bicostata, lactifluus albopicri and lactifluus austropiperatus on soil, macalpinomyces collinsiae on eriachne benthamii, marasmius vagus on soil, microdochium dawsoniorum from leaves of sporobolus natalensis, neopestalotiopsis nebuloides from leaves of sporobolus elongatus, pestalotiopsis etonensis from leaves of sporobolus jacquemontii, phytophthora personensis from soil associated with dying grevillea mccutcheonii. brazil, aspergillus oxumiae from soil, calvatia baixaverdensis on soil, geastrum calycicoriaceum on leaf litter, greeneria kielmeyerae on leaf spots of kielmeyera coriacea. chile, phytophthora aysenensis on collar rot and stem of aristotelia chilensis. croatia, mollisia gibbospora on fallen branch of fagus sylvatica. czech republic, neosetophoma hnaniceana from buxus sempervirens. ecuador, exophiala frigidotolerans from soil. estonia, elaphomyces bucholtzii in soil. france, venturia paralias from leaves of euphorbia paralias. india, cortinarius balteatoindicus and cortinarius ulkhagarhiensis on leaf litter. indonesia, hymenotorrendiella indonesiana on eucalyptus urophylla leaf litter. italy, penicillium taurinense from indoor chestnut mill. malaysia, hemileucoglossum kelabitense on soil, satchmopsis pini on dead needles of pinus tecunumanii. poland, lecanicillium praecognitum on insects’ frass. portugal, neodevriesia aestuarina from saline water. republic of korea, gongronella namwonensis from freshwater. russia, candida pellucida from exomias pellucidus, heterocephalacria septentrionalis as endophyte from cladonia rangiferina, vishniacozyma phoenicis from dates fruit, volvariella paludosa from swamp. slovenia, mallocybe crassivelata on soil. south africa, beltraniella podocarpi, hamatocanthoscypha podocarpi, coleophoma podocarpi and nothoseiridium podocarpi (incl. nothoseiridium gen. nov.) from leaves of podocarpus latifolius, gyrothrix encephalarti from leaves of encephalartos sp., paraphyton cutaneum from skin of human patient, phacidiella alsophilae from leaves of alsophila capensis, and satchmopsis metrosideri on leaf litter of metrosideros excelsa. spain, cladophialophora cabanerensis from soil, cortinarius paezii on soil, cylindrium magnoliae from leaves of magnolia grandiflora, trichophoma cylindrospora (incl. trichophoma gen. nov.) from plant debris, tuber alcaracense in calcareus soil, tuber buendiae in calcareus soil. thailand, annulohypoxylon spougei on corticated wood, poaceascoma filiforme from leaves of unknown poaceae. uk, dendrostoma luteum on branch lesions of castanea sativa, ypsilina buttingtonensis from heartwood of quercus sp. ukraine, myrmecridium phragmiticola from leaves of phragmites australis. usa, absidia pararepens from air, juncomyces californiensis (incl. juncomyces gen. nov.) from leaves of juncus effusus, montagnula cylindrospora from a human skin sample, muriphila oklahomaensis (incl. muriphila gen. nov.) on outside wall of alcohol distillery, neofabraea eucalyptorum from leaves of eucalyptus macrandra, diabolocovidia claustri (incl. diabolocovidia gen. nov.) from leaves of serenoa repens, paecilomyces penicilliformis from air, pseudopezicula betulae from leaves of leaf spots of populus tremuloides. vietnam, diaporthe durionigena on branches of durio zibethinus and roridomyces pseudoirritans on rotten wood. morphological and culture characteristics are supported by dna barcodes. . bayesian posterior probabilities (pp) > . are shown at the nodes and thickened lines represent nodes with pp = . . the scale bar represents the expected changes per site. families and orders are indicated with coloured blocks to the right of the tree. genbank accession and/or fungal planet numbers are indicated behind the species names. the tree was rooted to diaporthe perjuncta (genbank ng_ . ) and the taxonomic novelties described in this study for which lsu sequence data were available are indicated in bold face. the alignment and tree were deposited in treebase (submission id s ). . bayesian posterior probabilities (pp) > . are shown at the nodes and thickened lines represent nodes with pp = . . the scale bar represents the expected changes per site. families and orders are indicated with coloured blocks to the right of the tree. genbank accession and/or fungal planet numbers are indicated behind the species names. the tree was rooted to diaporthe perjuncta (genbank ng_ . ) and the taxonomic novelties described in this study for which lsu sequence data were available are indicated in bold face. the alignment and tree were deposited in treebase (submission id s ). consensus phylogram ( % majority rule) of trees resulting from a bayesian analysis of the lsu sequence alignment ( sequences including outgroup; aligned positions; unique site patterns) using mrbayes v. . . a . bayesian posterior probabilities (pp) > . are shown at the nodes and thickened lines represent nodes with pp = . . the scale bar represents the expected changes per site. families, orders and classes are indicated with coloured blocks to the right of the tree. genbank accession or fungal planet numbers are indicated behind the species names. the tree was rooted to saccharomyces cerevisiae (genbank z . ) and the taxonomic novelties described in this study for which lsu sequence data were available are indicated in bold face. the alignment and tree were deposited in treebase (submission id s ). . bayesian posterior probabilities (pp) > . are shown at the nodes and thickened lines represent nodes with pp = . . the scale bar represents the expected changes per site. families and orders are indicated with coloured blocks to the right of the tree. genbank accession or fungal planet numbers are indicated behind the species names. the tree was rooted to xylaria hypoxylon (genbank ay . ) and the taxonomic novelties described in this study for which lsu sequence data were available are indicated in bold face. the alignment and tree were deposited in treebase (submission id s ). . bayesian posterior probabilities (pp) > . are shown at the nodes and thickened lines represent nodes with pp = . . the scale bar represents the expected changes per site. families and orders are indicated with coloured blocks to the right of the tree. genbank accession and/or fungal planet numbers are indicated behind the species names. the tree was rooted to ramularia endophylla (genbank ay . ) and the taxonomic novelties described in this study for which lsu sequence data were available are indicated in bold face. the alignment and tree were deposited in treebase (submission id s ). notes -phacidiella alsophilae is related to p. podocarpi (conidia -septate, ( -) - (- ) × ( -) . (- ) μm; crous et al. ), although they are morphologically distinct. because the type species of phacidiella, p. salicina (conidia aseptate, on twigs of salix viminalis, finland), is presently not known from culture, the phylogenetic relationships between species in the genus remains unresolved. phacidiella alsophilae and p. podocarpi are thus tentatively retained in phacidiella. based on a megablast search of ncbis genbank nucleotide database, the closest hits using the its sequence had highest similarity to phacidiella podocarpi (strain cbs , genbank nr_ . ; identities = / ( %), gaps ( %)), fitzroyomyces cyperi (strain cbs , genbank mg . ; identities = / ( %), gaps ( %)), and fitzroyomyces cyperacearum (voucher mflu - b, gen-bank mk . ; identities = / ( %), gaps ( %)). closest hits using the lsu sequence were phacidiella podocarpi (strain cbs , genbank ng_ . ; identities = / ( %), gaps ( %)), stictis radiata (voucher palice (ess ), genbank ay . ; identities = / ( %), no gaps), and carestiella socia (strain gg a, genbank ay . ; identities = / ( %), gaps ( %)). (crous) crous, comb. nov. mycobank mb . basionym. phacidiella eucalypti crous, fungal diversity : . . description & illustration - crous et al. ( b) . typus . south africa, western cape province, stellenbosch mountain, on eucalyptus sp., jan. , p.w. crous (holotype cbs h- , cultures ex-type cbs = cpc , cpc , ; its-lsu sequence genbank ef . ). notes -the genus hormodochis was resurrected by crous et al. ( a) to accommodate taxa with erumpent, globose pycni dial conidiomata with aseptate conidia, arranged in cylindrical chains, olivaceous brown, smooth, subcylindrical to somewhat doliiform, with truncate ends. morphologically and phylogene tically, phacidiella eucalypti is better accommodated in hormodochis than phacidiella, as the latter has hyaline conidia (sutton ) . another genus to consider with subhyaline conidia is trullula, which differs in mode of conidiogenesis and conidium morphology (see crous et al. a ). notes -poaceascoma was introduced by phookamsak et al. ( ) to accommodate a genus of saprobic ascomycetes on poaceae with setose ascomata and filiform ascospores. although p. filiforme lacks setae, its spirally twisted, filiform ascospores are a good fit for the genus. based on a megablast search of ncbis genbank nucleotide database, the its sequence had distant, partial hits to poaceascoma taiwanense (strain mflucc - , genbank mg . ; identities = / ( %), gaps ( %)), setoseptoria phragmitis (strain cbs , genbank kf . ; identities = / ( %), gaps ( %)), and setoseptoria englandensis (strain mflucc - , genbank mg . ; identities = / ( %), gaps ( %)). closest hits using the lsu sequence are poaceascoma aquaticum (strain mflucc - , genbank ng_ . ; identities = / ( %), gap ( %)), poaceascoma halophilum (strain mflucc - , genbank mf . ; identities = / ( %) , gaps ( %)), and poaceascoma taiwanense (strain mflucc - , genbank mg . ; identities = / ( %) , no gaps). closest hits using the rpb sequence had highest similarity to poaceascoma aquaticum (strain mflucc - , genbank kt . ; identities = / ( %), no gaps), poaceascoma helicoides (strain mflucc - , genbank kp . ; identities = / ( %), no gaps), and wettsteinina lacustris (strain aftol-id = cbs . , genbank dq . ; identities = / ( %), gaps ( %)). closest hits using the tef sequence had highest similarity to darksidea zeta (strain cbs , genbank kp . ; identities = / ( %), gaps ( %)), darksidea beta (strain cbs , genbank kp . ; identities = / ( %), gaps ( %)), and darksidea gamma (strain cbs , genbank kp . ; identities = / ( %), gaps ( %)). closest hits using the tub sequence had highest similarity to pleurophoma acaciae (strain cpc , genbank ky . ; identities = / ( %), gaps ( %)), crassiclypeus aquaticus (strain kh , genbank lc . ; identities = / ( %), gaps ( %)), and flabellascoma minimum (strain kt , genbank lc . ; identities = / ( %), gaps ( %)). associated with brown leaf spots. conidiomata (on podocarpus leaves and on sna), black, round, flattened, acervular, - μm diam; wall of several layers of brown textura epidermoidea, splitting open all along outer margin, appearing saucer-shaped on leaf. conidiophores reduced to conidiogenous cells, arising from basal layers of stroma, hyaline, smooth, subcylindrical to ampulliform, annellidic, - × . - μm. conidia fusoid, slightly curved, smooth-walled, guttulate, pale brown, unequally -euseptate; basal cell obconic with truncate hilum, hyaline; median cells pale brown; apical cell obtuse, hyaline. apical cell . - μm long; second cell . - μm long; third cell - μm long; fourth cell - μm long; basal cell - μm long; conidia ( -) - (- ) × ( . -) μm; apical appendage filiform, flexuous, unbranched, excentric, - μm long; basal appendage filiform, flexuous, unbranched, excentric, - μm long. culture characteristics -colonies spreading, with moderate aerial mycelium and smooth, lobate margin, covering dish after wk at °c. on mea surface smoke grey, reverse olivaceous grey. on pda surface and reverse olivaceous grey. on oa surface pale olivaceous grey. notes -seimatosporium and allied genera have recently been revised (bonthond et al. , liu et al. , with genera being accepted in sporocadaceae. nothoseiridium podocarpi is allied to seiridium ( -septate, appendaged conidia) and nonappendiculata ( -septate, non-appendaged conidia), but is distinct in having -septate, fusoid conidia with unbranched, excentric apical and basal appendages. nothoseiridium is further characterised by forming submerged acervuli nothoseiridium podocarpi crous, sp. nov. that break through the epidermis with a saucer-like appearance, being associated with prominent leaf spots. it is not possible to distinguish nothoseiridium from seiridium based on lsu sequence data. based on a megablast search of ncbis genbank nucleotide database, the closest hits using the its sequence had highest similarity to seimatosporium lichenicola (as discostroma fuscellum; strain gsaa- , genbank jf . ; identities = / ( %), gaps ( %)), sporocadus rosarum (as seimatosporium pseudorosarum; strain mflucc - , genbank kt . ; identities = / ( %), gaps ( %)), seimatosporium lichenicola (strain cbs . , gen-bank mh . ; identities = / ( %), gaps ( %)) and millesimomyces rhoicissi (strain cpc , genbank nr_ . ; identities = / ( %), gaps ( %)). closest hits using the lsu sequence are seiridium unicorne (strain cbs . , genbank mh . ; identities = / ( %), no gaps), seiridium pseudocardinale (strain cbs , genbank mh . ; identities = / ( %), no gaps), and seiridium phylicae (strain cpc , genbank ng_ . ; identities = / ( %), gap ( %)). closest hits using the rpb sequence had highest similarity to seiridium cardinale (strain cpc , genbank lt . ; identities = / ( %), no gaps), seiridium unicorne (strain cbs , genbank mk . ; identities = / ( %), no gaps), and seiridium aquaticum (voucher mflu - , genbank mn . ; identities = / ( %) , no gaps). closest hits using the tef sequence had highest similarity to seiridium marginatum (strain cbs , genbank lt . ; identities = / ( %), gaps ( %)), seiridium papillatum (strain cbs . , genbank lt . ; identities = / ( %), gaps ( %)), and seiridium podocarpi (strain cbs , genbank lt . ; identities = / ( %), gaps ( %)). closest hits using the tub sequence had highest similarity to seiridium cupressi (strain cbs . , genbank lt . ; identities = / ( %), gaps ( %)), seiridium papillatum (strain cbs . , genbank lt . ; identities = / ( %), gaps ( %)), and seiridium podocarpi (strain cbs , gen-bank lt . ; identities = / ( %), gaps ( %)). associated with prominent brown leaf spots. conidiomata pycnidial, grey-brown, - μm diam, with central ostiole. conidiophores lining the inner cavity, intermingled among paraphyses, - -septate, - × - μm, or reduced to conidiogenous cells, hyaline, smooth, guttulate, doliiform to ampulliform, - × - μm. paraphyses intermingled among conidiophores, hyaline, smooth, cylindrical, aseptate, - (- ) μm diam, up to μm long, with age becoming multiseptate and with intercalary conidiogenous cells. conidiogenous cells hyaline, smooth, guttulate, doliiform to ampulliform, - × - μm, phialidic, with minute periclinal thickening. conidia aseptate, hyaline, smooth, guttulate, subcylindrical to fusoid to irregular, straight to somewhat curved, apex subobtuse, base truncate, ( -) notes -coleophoma includes species that are plant pathogenic or saprobic, occurring on a wide range of plant hosts (crous et al. b (crous et al. , b . the genus was revised by , and shown to reside in the dermateaceae (leotiomycetes), with morphologically similar taxa also clustering in dothideomycetes. based on a megablast search of ncbis genbank nucleotide database, the closest hits using the its sequence had highest similarity to coleophoma parafusiformis (strain cbs , genbank nr_ . ; identities = / ( %), gaps ( %)), coleophoma ericicola ( ( %)). the first of two equally most parsimonious trees obtained from a phylo genetic analysis of the coleophoma its/acta/tef /tub alignment ( strains including the outgroup; characters including alignment gaps analysed: constant, variable and parsimony-uninformative and parsimonyinformative). paup v. . b (swofford ) was used to analyse the data. the novel species was added to the alignment of , where also the genbank accession numbers of the reference sequences can be found. the tree was rooted to two strains of davidhawksworthia ilicicola and the scale bar indicates the number of changes. parsimony bootstrap support values higher than % are shown at the nodes (pbs/njbs) and the novel species is highlighted in bold. type status is indicated in superscript. branches present in the strict consensus tree are thickened. tree statistics: tl = , ci = . , ri = . , rc = . . the alignment and tree were deposited in treebase (submission id s ). notes -the genus chalara as circumscribed by nag raj & kendrick ( ) is polyphyletic and awaits revision. hamatocanthoscypha podocarpi is phylogenetically allied to the type species of hamatocanthoscypha, h. laricionis (svrček ) , and placed in this genus based on dna similarity. several species of 'chalara' have been described from podocarpus, namely c. brevipes (conidia ( -) . (- ) × . - µm), c. novaezelandiae (conidia ( -) . (- ) × - . µm), c. cylindrosperma (conidia ( . -) (- ) × ( . -) . (- . ) µm), c. fusidioides (conidia ( . -) . (- ) × ( . -) . (- . ) µm), c. acuaria (conidia ( -) (- ) × ( -) . (- . ) µm) and c. bicolor (conidia -septate, ( -) - (- ) × . - µm) (nag raj & kendrick ) . of these, h. podocarpi is most similar to c. brevipes, but can be distinguished in having smaller conidiogenous cells, and conidiophores that are aggregated in clusters. based on a megablast search of ncbis genbank nucleotide database, the closest hits using the its sequence had highest similarity to numerous sequences wrongly labelled as 'infundichalara microchona' (e.g., strain krp - , genbank hm . ; identities = / ( %), gaps ( %)), chalara holubovae ( myrmecridium phragmiticola crous & akulov, sp. nov. etymology. name refers to the host genus phragmites from which it was isolated. classification -myrmecridiaceae, myrmecridiales, sordariomycetes. on sna: mycelium consisting of hyaline, smooth, branched, septate, - µm diam hyphae. conidiophores unbranched, erect, straight, medium brown, thick-walled, - -septate, up to µm tall, - . µm diam; basal cell - µm diam. conidiogenous cells terminal, integrated, subcylindrical, - µm long, pale brown, forming a rachis with pimple-shaped denticles less than µm long and . µm diam; slightly thickened. conidia solitary, aseptate, pale brown, thin-walled, smooth, guttulate, with or without a wing-like gelatinous sheath, ellipsoid to fusoid, ( -) - × ( . -) µm; hilum unthickened nor darkened, . µm diam. culture characteristics -colonies flat, spreading, with mo derate aerial mycelium and smooth, lobate margin, reaching mm diam after wk at °c. on mea surface isabelline, reverse hazel. on pda surface and reverse greyish sepia. on oa surface isabelline. notes - arzanlou et al. ( ) established the genus myrmecridium to accommodate taxa with hyaline mycelium, pigmented, solitary conidiophores with pimple-like denticles, and - -septate, ellipsoid conidia with a mucoid sheath. myrmecridium phragmiticola should be compared to m. phragmites (phragmites australis, netherlands), which has - -septate conidia, ( . -) - (- ) × ( . -) (- . ) μm (crous et al. etymology. name refers to the closure or lockdown experienced in many countries during the covid- pandemic. mycelium consisting of branched, septate, hyaline to pale brown, smooth to finely roughened, - µm diam hyphae. conidiophores solitary, erect, flexuous, mostly reduced to a terminal conidiogenous cell. conidiogenous cells pale brown, smooth, subcylindrical to slightly clavate, - × - µm, proliferating via single apical blastic locus, and remaining attached to acropetal chain of conidia that remain attached to one another via narrow isthmus. conidia brown, thin-walled, smooth, guttulate, granular, ellipsoid to obovoid, ( -) - (- ) × ( -) - (- ) µm; conidia remaining attached in chains of - propagules, disarticulating at maturity into single propagules or shorter chains. culture characteristics -colonies flat, spreading, with sparse to moderate aerial mycelium and feathery, lobate margin, reaching mm diam after wk at °c. on mea surface and reverse cinnamon. on pda surface and reverse hazel to brown vinaceous. on oa surface hazel. crous, sp. nov. notes -diabolocovidia is reminiscent of genera such as ampullifera (but conidiophores different and hyphopodia present) and junctospora (but conidiophores sparingly branched, subhyaline; seifert et al. ) . phylogenetically, it is allied to vamsapriya, which is characterised by having brown, synnematous conidiophores, mono-to polytretic conidiogenous cells, and dark brown, septate conidia arranged in acropetal chains (dai et al. ) . based on these differences, diabolocovidia is herewith introduced as a new genus. based on a megablast search of ncbis genbank nucleotide database, the closest hits using the its sequence had highest similarity to vamsapriya khunkonensis (voucher mflu - , genbank nr_ . ; identities = / ( %), gaps ( %)), didymobotryum rigidum (strain jcm , genbank lc . ; identities = / ( %), gaps ( %)), and vamsapriya bambusicola (voucher mflu - , genbank nr_ . ; identities = / ( %), gaps ( %)). closest hits using the lsu sequence are vamsapriya bambusicola (strain mflucc - , genbank ng_ . ; identities = / ( %), no gaps), fasciatispora petrakii (strain hkucc , genbank ay . ; identities = / ( %), gap ( %)), and vamsapriya indica (strain mflucc - , genbank km . ; identities = / ( %), no gaps). crous, sp. nov. notes -juncomyces is closely related to graminopassalora, which was introduced to accommodate passalora graminis, a widespread pathogen occurring on a broad range of grass (poaceae) hosts (videira et al. beltraniella podocarpi crous, sp. nov. etymology. name refers to the host genus podocarpus from which it was isolated. classification -beltraniaceae, xylariales, sordariomycetes. setae solitary to aggregated, erect, flexuous, arising from a lobate basal cell, - µm diam, dark brown, warty, chiefly unbranched, up to -septate, thick-walled with large central guttules, tapering in upper part to acute apex, - × - µm. conidiophores arranged in dense clusters around the base of setae, brown, smooth, subcylindrical, frequently branched at basal cell, - -septate, - × - µm. conidiogenous cells integrated, terminal and intercalary, - × - µm, pale brown, smooth, obclavate, tapering toward - denticulate loci, - . µm long, µm diam. separating cells clavate to fusoid-ellipsoid, pale brown, smooth, finely guttulate, tapering toward long basal stalk and short apical locus, - × - µm. conidia obovoid to narrowly turbinate, tapering toward base, apex rounded to subtruncate, aseptate, finely verruculose, guttulate, pale brown, ( -) - (- ) × ( -) µm. culture characteristics -colonies flat, spreading, with moderate aerial mycelium and feathery, lobate margin, covering dish after wk at °c. on mea surface olivaceous grey, reverse honey with olivaceous grey margin. on pda surface olivaceous grey, reverse iron-grey. on oa surface iron-grey with dirty white margin. notes -beltraniella is characterised by brown, unbranched setae, setiform conidiophores, polyblastic, denticulate conidiogenous cells, and turbinate conidia with a distinct hyaline transverse band (rajeshkumar et al. ) . beltraniella podocarpi is closely related to several species that tend to have some overlap in conidial length, but have narrower conidia (rajeshkumar et al. , crous et al. a ). based on a megablast search of ncbis genbank nucleotide database, the closest hits using the its sequence had highest similarity to beltraniella portoricensis (strain bcrc , genbank gu . ; identities = / ( %), gaps ( %)), beltraniella ramosiphora (strain lcg - , genbank mg . ; identities = / ( %), gaps ( %)), and beltraniella pseudoportoricensis (strain cbs , genbank nr_ . ; identities = / ( %), gaps ( %)). neofabraea eucalyptorum crous, sp. nov. etymology. name refers to the host genus eucalyptus from which it was isolated. classification -dermateaceae, helotiales, leotiomycetes. associated with brown, amphigenous leaf spots, - mm diam. conidiomata - µm diam, acervular, erumpent, associated with dark brown, amphigenous leaf spots. conidiophores hyaline, smooth, branched, septate, subcylindrical, phialidic, up to µm long, - µm diam. conidiogenous cells hyaline, smooth, subcylindrical, terminal and intercalary with visible periclinal thickening, - × - µm. conidia subcylindrical to fusoid-ellipsoid, variously curved, hyaline, smooth, guttulate, apex subobtuse, base with flattened hilum, aseptate, but becoming up to -septate in older cultures, ( -) - (- ) × ( . -) - (- ) notes -the neofabraea generic complex was revised by chen et al. ( ) , and neofabraea eucalypti was subsequently placed in coleophoma . neofabraea eucalyptorum is thus the first confirmed species of the genus associated with leaf spots on eucalyptus (crous et al. b ). based on a megablast search of ncbis genbank nucleotide database, the closest hits using the its sequence had highest similarity to neofabraea alba (strain uasws , genbank hq . classification -ploettnerulaceae, helotiales, leotiomycetes. mycelium consisting of hyaline, smooth, branched, septate, - µm diam hyphae. conidiophores integrated, subcylindrical, hyaline, smooth, septate, sparingly branched, mostly terminal on hyphal ends, - × - µm. conidiogenous cells integrated, terminal and intercalary, subcylindrical, smooth, - × - µm; proliferating sympodially. conidia solitary but aggregating in mucoid mass, y-shaped, smooth, hyaline; central cell obclavate, base with truncate hilum, µm diam, apex subobtuse, - -septate, ( -) - (- ) × ( -) - (- ) µm, with - lateral branches inserted below the median, pointing upwards, aseptate, obclavate, apex subobtuse, ( -) - (- ) × (- . ) µm. culture characteristics -colonies erumpent, spreading, with moderate aerial mycelium and folded surface (on mea), with smooth, lobate margin, reaching mm diam after wk at °c. on mea, pda and oa surface dirty white, reverse ochreous. notes -although the ecology of ypsilina remains unknown, y. graminea has been isolated from freshwater foam, roots and leaves of various plants (descals et al. ) . ypsilina buttingtonensis was isolated from an ancient pedunculate oak quercus robur in buttington, wales (longitude and latitude: . , - . ). the tree, known as the buttington oak, was an open-grown lapsed pollard. at the time when the tree fell in february , it had a trunk girth of . m at breast height and was believed to be the second oldest oak tree in wales. the tree had a . m diam hollow through centre where brown cubical rot could be seen, attributed to fistulina hepatica. the significance of the tree was realised in when it was 'discovered'. cores of wood were extracted from the tree with a . mm increment bore. wood chips were taken from the cm cores at cm intervals and placed on low ph % malt agar petri dishes and incubated at °c in the dark. ypsilina buttingtonensis was cultured from a chip cm into the heartwood. in addition to ypsilina buttingtonensis, fistulina hepatica, and eight species of ascomycete were also cultured from the wood chips including cryphonectria radicalis, a close relative of the aggressive canker pathogen cryphonectria parasitica, responsible for chestnut blight. based on a megablast search of ncbis genbank nucleotide database, the closest hits using the its sequence had highest similarity to helgardia anguioides ( notes -pseudopezicula accommodates two species of apothecial ascomycetes that cause angular leaf scorch on vitis vinifera. an epitype is here designated for one of these, namely p. tracheiphila. in culture they produce phialophora-like asexual morphs (korf et al. ) , that resemble the phialidic asexual morph isolated in the present study. although pseudopezicula betulae was associated with prominent leaf spots, its occurrence was inconsistent, and therefore it is unknown whether it is a primary pathogen. based on a megablast search of ncbis genbank nucleotide database, the closest hits using the its sequence had highest similarity to gyoerffyella entomobryoides (strain cbs . , genbank nr_ . ; identities = / ( %), gap ( %)), gyoerffyella rotula (strain jb , genbank ku . ; identities = / ( %), gap ( %)), and fontanospora eccentrica (strain umb- . , genbank kf . ; identities = / ( %), gaps ( %)). gyrothrix encephalarti crous, sp. nov. etymology. name refers to the host genus encephalartos from which it was isolated. culture sterile, morphology based on sporulation on dead leaf spots. mycelium consisting of brown, smooth, septate, branched, . - µm diam hyphae. setae erect, - µm long, - µm diam, brown, multiseptate, thick-walled, verrucose, subcylindrical with apical taper, base bulbous, - µm diam, apex spirally twisted with twisted lateral branches in apical region. conidiophores reduced to conidiogenous cells around base of setae, ampulliform to subcylindrical, pale brown, smooth, - × - µm, proliferating percurrently at apex. conidia hyaline, smooth, aseptate, fusoid, inaequilateral, inner plane flat, outer plane convex, apex subobtuse, base truncate, ( -) - (- ) × (- . ) µm. culture characteristics -colonies flat, spreading, with moderate aerial mycelium and smooth, lobate margin, reaching mm diam after wk at °c. on mea surface buff, reverse cinnamon. on pda surface buff, reverse rosy buff. on oa surface rosy buff. notes -gyrothrix encephalarti is closely related to g. eucalypti (eucalyptus sp., south africa; conidia ( -) - (- ) × ( -) . μm, setae - μm tall, - μm diam at base; crous et al. c ), but has wider conidia and shorter setae. dna sequences of g. eucalypti and g. encephalarti are related to the type sequence deposited for neoanthostomella viticola (ng_ . ), which has a completely different asexual morph. based on a megablast search of ncbis genbank nucleotide database, the closest hits using the its sequence had highest similarity to neoanthostomella viticola (strain mflucc - , genbank nr_ . ; identities = / ( %), gaps ( %)), gyrothrix eucalypti ( satchmopsis metrosideri crous, sp. nov. etymology. name refers to the host genus metrosideros from which it was isolated. classification -cochlearomycetaceae, leotiales, leotiomycetes. conidiomata cupulate, superficial, - µm diam at apex, - µm deep, dark brown, attached to a basal stroma of dark brown cells that occupy the stomatal chamber; wall consisting of two regions, the lower region having thick-walled dark brown cells up to layers thick; upper region on thin-walled paler cells, cylindrical, - × - µm, with even, smooth flat edge. in culture conidiomata are paler in colour and much larger, flattened, cupulate, and margins have cells that are lobate due to expanding growth (not flat as in vivo). conidiogenous cells restricted to lower part of basal wall, - × - µm, doliiform to lageniform, phialidic with periclinal thickening, hyaline with indistinct collarette. conidia hyaline, smooth, aseptate, guttulate, subcylindrical, predominantly straight with obtuse ends, ( -) - (- ) × - . µm. culture characteristics -colonies flat, spreading, with sparse aerial mycelium and feathery, lobate margin, reaching mm diam after wk at °c. on mea, pda and oa surface umber with patches of sepia, reverse umber. notes -the genus satchmopsis, based on s. brasiliensis (eucalyptus paniculata, brazil; conidia . - . × - . μm) (sutton ) was introduced for a genus of cupulate coelomycetes with aseptate conidia. satchmopsis is commonly isolated from eucalypt leaf litter in south america (crous et al. ). the present collection, from metrosideros excelsa leaf litter collected in south africa, differs from s. brasiliensis in being phylogenetically distinct, and also having longer conidia. based on a megablast search of ncbis genbank nucleotide database, the closest hits using the its sequence had highest similarity to satchmopsis brasiliensis (strain cpc , genbank dq . ; identities = / ( %) satchmopsis pini crous, sp. nov. etymology. name refers to the host genus pinus from which it was isolated. classification -cochlearomycetaceae, leotiales, leotiomycetes. conidiomata cupulate, superficial, - µm diam, and - µm deep, dark brown, attached centrally to a brown stroma via a dark brown stalk, up to µm tall, µm wide; conidiomatal wall of two regions, the lower region of brown cells, the upper region of cylindrical cells with flat to obtuse edge, - × - µm; terminal - cell layers are prominently thick-walled, darker brown, and can give rise to hyphal outgrowths on outside of conidiomatal margin. conidiogenous cells restricted to lower part of basal wall, - × - µm, doliiform to lageniform, phialidic with periclinal thickening, hyaline with indistinct collarette. conidia hyaline, smooth, aseptate, guttulate, subcylindrical, straight with obtuse ends, ( -) - (- ) × - . µm. culture characteristics -colonies flat, spreading, with sparse aerial mycelium and feathery, lobate margin, covering dish after wk at °c. on mea, pda and oa surface umber with patches of sepia, reverse umber. notes -satchmopsis pini is morphologically distinct from s. brasiliensis and s. metrosideri in having cupulate conidiomata with a prominently thick-walled, darker brown upper region, giving rise to hyphal outgrowths on outside of conidiomatal margin. furthermore, conidiomata are centrally attached to a brown stroma via a long, dark brown stalk, which is absent in s. brasiliensis and s. metrosideri. based on a megablast search of ncbis genbank nucleotide database, the closest hits using the its sequence had highest similarity to satchmopsis brasiliensis ( notes -the phylogeny and morphology of torrendiella and hymenotorrendiella was discussed in detail by johnston et al. ( ) . although the name torrendiella eucalypti has commonly been used for the species occurring on eucalyptus leaf litter (crous et al. ) , johnston et al. ( ) showed that the type of t. eucalypti occurred on fallen phyllodes of an acacia sp. (tasmania, australia), which then became the type species of the new genus hymenotorrendiella. however, this resulted in the common endophyte and saprobe occurring on eucalypt leaf litter not having a name. several collections from eucalyptus leaf litter were investigated in the present study, and two taxa were found to be present. the first, described here as h. communis, occurred in a clade with isolates from australia, colombia, spain, and south africa. morphologically, however, the south african isolates differ from others in this clade based on macromorphology. apothecia have shorter stalks, - µm high; setae vary from - per apothecium, but are much shorter, and wider that those from other collections in this clade, being - µm long, with obtuse apices, (- ) µm diam, and slightly inflated bases, - µm diam. asci are similar however, being - × - µm, as well as ascospores, ( -) - (- ) × ( . -) µm. hymenotorrendiella communis can be distinguished from the second species, h. indonesiana (ascospores - × - μm), which occurs in indonesia, by its shorter and wider ascospores. based on a megablast search of ncbis genbank nucleotide database, the closest hits using the its sequence had highest similarity to hymenotorrendiella indonesiana (as torrendiella eucalypti; strain , genbank fr . ; identities = / ( %), gaps ( %)), hymenotorrendiella andina (as torrendiella andina; strain prj sa , genbank kj . ; identities = / ( %), no gaps), and hymenotorrendiella madsenii (as torrendiella madsenii; voucher pdd , genbank ay . ; identities = / ( %), gap ( %)). crous & p.r. johnst., sp. nov. etymology. name refers to indonesia, the country from which it was collected. micromorphology (on malt extract agar; mea): hyphae hyaline to brownish, coenocytic, smooth, finely roughened to definitely roughened near crustaceous, - µm diam. sporangiophores hyaline to brown near dark brown, simple or branched, arising solitarily, occasionally in pairs, never grouped in whorls, arising from aerial hyphae or substrate, most commonly - × - μm; smooth, finely roughened to definitely roughened near crustaceous walls, with a single septum below the sporangium and rarely with additional septum at the base. sporangia hyaline to brown to dark greyish brown, most commonly pyriform, ( -) - (- ) µm diam, smooth-walled. apophyses funnelshaped, smooth-walled. columellae globose, hemispherical, with a short collarette, occasionally with one projection, smoothwalled, ( -) - (- ) µm diam. sporangiospores of two types: sub-globose to globose, hyaline, smooth-walled, and oval, occasionally slightly irregular, brown, rough-walled (formed in the different sporangia), ( . -) . - (- ) × ( . -) . - μm. chlamydospores (terminal and intercalary) occasionally present in the aerial mycelia. zygospores not observed. culture characteristics -(in darkness, °c after d / d): colonies on mea - /> mm diam, cottony, mycelium at first white, then becoming grey to grey-brown (light mouse grey to mouse grey, r ; ridgway ( ) ), abundant sporulation, reverse colonial buff to deep colonial buff (r ), smooth and wavy zonate. colonies on potato dextrose agar (pda - /> mm diam, cottony, mycelium at first white, then becoming grey to grey-brown [r ), very good sporulation, reverse grey to grey with buckthorn brown shades (r ), radially sulcate. colonies on oa - /> mm diam, cottony, mycelium at first white, then becoming light mouse grey to mouse grey (r ), good sporulation. colony diam at °c (in mm after d): . no growth on mea, pda and oa at °°c. typus. usa, new york, jericho, bathroom, air, dec. notes -blast analyses with the its and lsu sequences of a. pararepens showed greatest similarity with a. repens extype cbs (~ % and ~ % similarity, respectively). the american isolates kas (genbank fj ), fsu (genbank ay ), cbs . = fsu (genbank ef ), cbs . = fsu (genbank ef ), nrrl (genbank af ) and a (genbank ay ) also represent a. pararepens, while european isolates cbs (genbank eu , hm ) and fsu (genbank eu ) represent a. repens s.str. however, this geographic pattern should be confirmed by analysis of additional strains. hesseltine & ellis ( ) invalidly designated a neotype for a. repens. in conflict with art. . (turland et al. ) , the authors selected a living culture, nrrl . this culture originated from a collection of a.f. blakeslee, and was probably isolated in america. however, as pointed out by hoffmann et al. ( ) and hoffmann ( ) , there are large genetic differences between european and american isolates of 'a. repens'. consequently, the neotype of a. repens should be selected from among european strains in accordance with the original description of van tieghem ( ), who collected a. repens on fruit of bertholletia excelsa lying on a layer of moist sphagnum in france. the specimen cbs originating from england, uk, was mentioned as isotype of a. repens by hoffmann et al. ( ) and hoffmann ( ) , but formal typification has never been published. to formalize the typification, we designate here a lectotype of a. repens (illustration from the original material): pl. , f. - (not paginated) in p. van tieghem, annales des sciences naturelles botanique ser. , vol. . , vol. . [ . mycobank typification no. is mbt . epitype designated here: specimen cbs (preserved in metabolically inactive state), ex-epitype culture cbs . mycobank typification no. is mbt ). absidia pararepens has on average shorter sporangiophores ( - × - μm), and larger sporangiospores (( . -) . - (- ) × ( . -) . - μm) than the closely related a. repens (( -) - (- ) × . - μm), and ( . - . (- . ) × - μm), respectively. etymology. named after the american bioinformatician john l. spouge who contributed to the discovery of this species, and for his efforts to implement tools for dna barcoding analyses within the genus annulohypoxylon. classification -hypoxylaceae, xylariales, sordariomycetes. stromata glomerate to hemispherical, effused-pulvinate, with perithecial mounds / to / exposed and not covered by the outermost stromatal layer, . - cm long × . - cm broad and - . mm thick; surface dark brown vinaceous, becoming black with reddish brown hues, finally black and shiny; black granules immediately below the surface, koh pigments green olivaceous. perithecia spherical, . - . mm diam. ostioles conical papillate, surrounded by a flattened bovei-type disc, . - . mm diam. asci - × - . µm, the spore bearing parts - µm long with stipes - (- ) µm long, with apical ring bluing in melzer's iodine reagent, discoid . µm high × . - µm broad. ascospores pale brown, unicellular, ellipsoid-inequilateral with narrowly rounded ends, - . × - . (- . ) µm with straight germ slit along the full length of the spore; perispore dehiscent in % koh, epispore smooth. culture characteristics -colonies on potato dextrose agar (pda) covering petri dish in wk, at first white, becoming hazel to dull green, azonate, with diffuse margins, with scattered black patches; reverse dull green to dark brown. conidiogenous structure nodulisporium-like, brown. conidia hyaline, smooth, ellipsoid, . - . × - µm. additional materials examined. herbarium number is indicated, as well as the its, α-actin, β-tubulin and ef -α genbank sequences between brackets, absent sequences are indicated with '-'. annulohypoxylon spougei: thai-notes -during extensive studies of the hypoxylaceae in thailand over a period of almost yr, problems were encountered in the identification of several taxa, especially a. nitens. a previous study on species of hypoxylon and annulohypoxylon using morphology and its nrdna sequences (suwannasai et al. ) indicated that this taxon was not monophyletic but could be separated into a. nitens and another species. twenty-eight fungal specimens of a. nitens and a cryptic species collected from thailand, previously named 'a. nitens' in our study (suwannasai et al. ) , were carefully re-analysed based on morphological and asexual morph characters. the comparison of morphological characters between a. nitens and a cryptic species showed unclear distinction of these species. the cryptic species, here named as a. spougei possesses spherical perithecia ( . - . mm diam), which are slightly narrower than those of a. nitens described by ju & rogers ( ) the ostiolar discs of both species groups are bovei-type and have the same dimensions of . - . mm. ascospore sizes of a. nitens and the cryptic species are . - × . - . µm and - . × - . (- . ) µm, respectively. these are similar to the species description for a. nitens (as h. nitens) ( . - (- ) × - . µm) from ju & rogers ( ) . the cultural and asexual morph characters were observed from both pda and oatmeal agar. colonies of a. spougei are white at first becoming hazel and dull green with scattered black patches. the asexual morph is nodulisporiumlike and conidial size ( . - . × - µm) is similar to a. nitens ( - × . - µm). with those similar features, it is very difficult to separate the a. spougei from a. nitens by using only morphological and asexual morph characters. however, although morphological data for all of the collections initially identified as a. nitens failed to provide clear separation of the two entities, there are clear supporting dna data for their separation. in the present study based on α-actin, β-tubulin and elongation factor -α sequences, we confirm the separation of two taxa mentioned in suwannasai et al. ( ) . colour illustrations. thailand, chaiyaphum province, phu khiao wildlife sanctuary, where the specimens were collected. from top to bottom: stromata with ostiolar discs (swuf-h ); ascospores under sem (swuf-h ); fungal culture on pda (swuf-h ); nodulisporium-like anamorph (swuf-h ); ascospores with apical apparatus (swuf-h ). scale bars = . mm (stromata), µm (ascospores sem), cm (fungal culture), µm (asexual morph), µm ( aspergillus banksianus pitt, sp. nov. etymology. named for the australian endemic tree banksia integrifolia, from the rhizosphere of which this species was isolated. culture characteristics -czapek yeast extract agar (cya), °c, d: colonies - mm diam, low and dense, plane or irregularly wrinkled, with narrow margins of white mycelium; conidiogenesis moderate to heavy, dark grey to dark grey blue (m. - d -e - ); exudate absent, soluble pigment brown; reverse deep green (m. f - ). mea, °c, d: colonies - mm diam, low and plane, with wide uncoloured margins, light to heavily sporing, coloured as on cya or slightly greener (m. d ); exudate and soluble pigment absent; reverse centrally dark green (m. f ), paler towards the margins. % glycerol nitrate agar (g n), °c, d: colonies up to mm diam, of white mycelium. °c, cya, d: colonies - mm diam, heavily sporing, dull green to grey green; reverse dark green, greyish green or black. conidiophores borne from aerial hyphae, sometimes unbranched, and then ( -) - × . - µm, sometimes bearing a short lateral stipe - µm long as well; broadening slowly to spathulate vesicles, - µm diam, fertile area characteristically hemispherical but sometimes asymmetrical to give a 'nodding' appearance. phialides short and stout, . - × . - µm, with narrow bases and very short narrow necks, sometimes almost ellipsoidal. conidia . - µm diam, smooth to finely roughened, borne in short disordered chains, separating in wet mounts. media formulations are from pitt & hocking ( ) ; (m.) colours are from kornerup & wanscher ( notes -aspergillus banksianus clusters in aspergillus subgenus fumigati, in a small clade that includes a. brevipes and a. duricaulis, with which it shares slow growth at °c, green conidial colouration and intermittent production of asymmetrical fruiting structures. colonies of a. banksianus on cya have a deep green reverse colour, in contrast with a. duricaulis, 'colorless to pinkish drab' or a. brevipes 'becoming purple-red' (raper & fennell ) . molecularly, a. banksianus is particularly close to a. quadricinctus, from which the most obvious difference is lack of the neosartorya sexual morph. aspergillus banksianus when grown on agar, liquid media or grain, displays a unique chemotaxonomic profile comprising banksialactones a-i, and banksiamarins a and b, which are not present in the closely related species a. quadricinctus and a. duricaulis (chaudhary et al. ) . aspergillus banksianus also produces known metabolites clearanol and dothideomynone a, together with the pigments endocrocin and questin previously reported from other aspergillus species. colour illustrations. a specimen tree of the endemic species banksia integrifolia, planted on a street in collaroy, nsw, from under which a soil sample included a. banksianus. colonies grown on cya (upper) and malt extract agar (mea) (lower) for d at °c; fruiting structures and conidia. scale bars = µm (fruiting structures) and µm (conidia). classification -aspergillaceae, eurotiales, eurotiomycetes. conidial heads radiate. conidiophores uniseriate. stipes smooth, frequently septate - (- ) × - (- ) μm, sometimes with subterminal branches and mycelial coils occasionally present. vesicles pyriform to subglobose, pigmented, - (- ) × . - (- ) μm (av. ± . × ± . ), phialides - (- ) × - μm (av. ± . × ± . ) covering half to upper half of vesicle. conidia globose to subglobose, - × . - μm (av. ± . × ± . ), brown to greyish brown, with coarsely roughened to echinulate surface, average width/length = ± . , n = . sclerotia observed. culture aspergillus kumbius pitt, sp. nov. etymology. named for the small town of kumbia, south burnett district, queensland, australia, near where this species was collected. conidiophores borne from aerial hyphae, stipes - (- ) × - µm, uncoloured to pale brown, smooth walled. vesicles spherical, - µm diam, fertile over the upper hemisphere or two thirds; metulae - × . - . µm; phialides acerose, - × . - . µm. conidia spherical, . - . µm diam, walls smooth to finally roughened, borne in disordered chains. culture characteristics -czapek yeast extract agar (cya), °c, d: colonies - mm diam, plane, low and relatively sparse, lightly sulcate, velutinous; margins entire, wide; mycelium white to pale yellow; abundant sclerotia borne on the agar surface, white at first, at maturity pale orange to orange grey (m. a-b ), spherical or near, - µm diam; conidial production sparse, pale yellow brown (m. notes -aspergillus kumbius belongs in aspergillus subgenus circumdati sect. circumdati. molecularly, it is very close to aspergillus bridgeri and a, subramanianii. it is distinguished by rapid growth at °c with abundant buff coloured spherical sclerotia. when grown on agar, liquid media or grain, a. kumbius displays a unique chemotaxonomic profile including kumbicins a-d, which are not present in the closely related species a. bridgeri, a. subramanianii, a. salwaensis, a. persii or a. sclerotiorum. aspergillus kumbius also produces known metabolites asterriquinol d dimethyl ether, petromurins c and d, aspochracin, jbir- , and neohydroxyaspergillic acid, compounds previously reported from other aspergillus species. colour illustrations. a scene of pasture near kumbia, queensland, similar to the one from which this species was described. colonies grown on cya (left) and mea (right) for d at °c; fruiting structures and conidia. scale bars = µm (fruiting structures) and µm (conidia). classification -aspergillaceae, eurotiales, eurotiomycetes. conidiophores borne from aerial hyphae, slender, ( -) - (- ) × - . µm, with thin smooth walls, enlarging slowly to very small spathulate vesicles, - (- ) µm diam; bearing few short phialides, - × . - µm. conidia spherical, - . µm diam, smooth-walled, borne in short disordered chains. media formulations are from pitt & hocking ( ) ; (m.) capitalised colours and notation are from kornerup & wanscher ( notes -aspergillus luteorubrus clusters in aspergillus subg. fumigati, near a. fennelliae. this heterothallic species produces cleistothecia and ascospores characteristic of the sexual genus neosartorya. as only a single strain of a. luteobrunneus is known, it is not clear whether this is an asexual species or, perhaps more likely, heterothallic. aspergillus luteorubrus differs from this and other closely related species in colony colours, conidial size, shape and ornamentation. differences also exist in molecular phylogeny and chemistry (unpubl. data). a maximum likelihood tree inferred from the combined bena, cam and actin sequences of taxa within aspergillus sect. fumigati. the combined sequence alignment was partitioned by marker; substitution models for each partition were chosen according to the corrected information criteria using modeltest-ng v. . . (darriba et al. ). the k +g was used for bena sequences, k +g for cam and tpm+i for actin. the tree was constructed using raxml-ng v. . . (kozlov et al. aspergillus nanangensis pitt, sp. nov. etymology. named for the town of nanango, south burnett district, queensland, australia, near which this species was collected. conidiophores borne from surface hyphae, - × - µm, with thick, smooth, pale yellow walls, bearing very small vesicles. vesicles - µm diam, ellipsoidal to somewhat irregular, bearing metulae and phialides over almost all of the vesicle surface, but sometimes bent to form only a hemispherical head; metulae - × . - . µm; phialides ampulliform - × . - . µm. conidia spherical, . - . µm diam, with walls varying from almost smooth to conspicuously spiny, borne in compact spherical heads, even at age. culture characteristics -czapek yeast extract agar (cya), °c, d: colonies growing slowly, - mm diam, rather sparse, lightly floccose; margins narrow and entire; mycelium white to off white; conidial production light, pale greenish grey (m. - c ); exudate and soluble pigment absent; reverse greyish orange (m. b - notes -aspergillus nanangensis clusters in aspergillus clade jani, a small clade within aspergillus subg. circumdati, but is molecularly distinct. it is close to aspergillus janus and aspergillus brevijanus, but differs from both by lack of the larger white conidial heads that characterise these species. culturally, growth rates of a. nanangensis on standard media are much slower. microscopically, a. nanangensis produces smaller vesicles, fertile over a reduced area. when grown on agar, liquid media or grain, a. nanangensis displays a unique chemotaxonomic profile comprising isonanangenine b and d, nanangelenin, nanangenic acid, nanangenines a-h and nanoxepin not present in the closely related species a. janus and a. brevijanus (lacey et al. classification -agaricaceae, agaricales, agaricomycetes. basidiomata growing solitary, epigeous, incrustations in the rooting base, subglobose and - mm wide × - mm high. exoperidium < . mm thin, fragile, slightly tomentose, evanescent, white to yellowish white ( a , a ; kornerup & wanscher ) . mesoperidium < . mm thin, fragile, membranaceous, persistent at the base, smooth with senescence, greyish brown to brown ( c , d , e , f ). endoperidium < . mm thin, fragile and brittle at the apex, resistant and persistent at the base, papyraceous, olive brown to brown ( d , e ). rhizomorphs not seen. subgleba reduced, woolly, compact, brownish beige ( e ). gleba powdery, not persistent, brownish beige, brown to dark brown ( e , e , f ), at maturity. exoperidium hyphalic, . - . µm diam, intertwined, frequent and non-regular septa, double v branching, walls ≤ . µm thin, straight for curves, hyaline, dextrinoid, low reaction and cyanophilic. mesoperidium compacted, collapsed, hyaline, not dextrinoid and cyanophilic. endoperidium apical composed of two layers of hyphae continuous, all brown, not dextrinoid and cyanophilic, hyphae . - . µm diam, frequent and non-regular true septa, double v branching, and mycosclereids globose, subglobose, pyriform, ovoid, ellipsoid, or rectangular, . - . µm high × . - . µm diam, weakly interconnected, branched, breaking in the septa, regular and thick walls ≤ . µm thin and straight for curves. endoperidium basal hyphalic, . - . µm diam, rare and non-regular true septa, v-shaped branches, single and double, and in t, walls < . µm thin, tortuous and regular, brown, dextrinoid, and cyanophilic. subgleba hyphalic, . - . µm diam, rare true septa, branching v, single and double, and t, cyanophilic nodes frequent, regular walls ≤ . µm thin, straight for curves, reddish brown, not dextrinoid and cyanophilic. paracapillitium absent. capillitium calvatia-type, . - . µm diam, hyaline to light brown, dextrinoid and cyanophilic; septa frequent and non-regular, v-branching, single and double, and in t, fragmenting in any part of the capillitium or frequent in the septa; walls ≤ . µm thin and regular, straight, with large and numerous conspicuous pits ( - µm wide). basidiospores globose to subglobose, . - . µm wide × . - . µm high (χ = . ± . × . ± . ; q m (medium coefficient) = . ; n (measurement numbers) = ), verrucose, ornamentation < µm length; pedicels present in some basidiospores ≤ . µm in length. habit & habitat -basidiomata growing solitary on moist soil. notes -calvatia baixaverdensis is morphologically related to species of sect. calvatia: c. craniiformis, c. subtomentosa, c. rugosa, c. nodulata, and c. holothurioides. calvatia craniiformis, c. rugosa and c. subtomentosa have a capillitium with large conspicuous pits ( - µm wide) similar to c. baixaverdensis. however, c. craniiformis presents subglobose to globose basidiospores with punctate ornamentation, and well-developed cellular subgleba. calvatia rugosa has exoperidium granulose, furfuraceous to subvelutinous, endoperidium smooth, membranous, very thin (< . mm), subgleba well-developed and lanose to cellular (reid ) . calvatia subtomentosa has basidiospores . - . µm diam, and capillitium . - . µm, branched, septate, rather short fragments (dissing & lange ) , but is easily distinguished from c. baixaverdensis in the ornamentation of the basidiospores, equinulate, and in the absence of pedicels, besides the absence of large pits in the capillitium and nodules in the hyphae of subgleba in c. subtomentosa. calvatia nodulata and c. holothurioides are other morphologically close species to c. baixaverdensis mainly by the basidiospores - μm diam and capillitium - μm diam; however, c. nodulata has exoperidium granulose to pilose, subgleba occupying half of the basidiomata, and capillitium with spaced nodules (alfredo et al. ) , and c. holothurioides has subgleba prominent, cellular, capillitium with pores up to μm diam (rebriev classification -debaryomycetaceae, saccharomycetales, saccharomycetes. on glucose peptone yeast extract agar (gpya) and % malt extract agar (mea), after d at °c, streak is white-cream, semi-glistening, with a smooth surface and entire margin. cells are ovoid to elongate ( - × - μm) and occur singly or in pairs, dividing by polar and multilateral budding. rare pseudohyphae are produced on potato dextrose agar (pda) and cornmeal agar (cma). ascospores and true hyphae have not been observed during wk at and °c in culture (pure cultures and in mating test) grown on gpya, mea, pda, cma and yeast nitrogen base with . % glucose (ynb) agar. fermentation of glucose, galactose (delayed weak), trehalose and maltose (delayed) are positive, but negative for sucrose, lactose and raffinose. glucose, sucrose, galactose, maltose, cellobiose, trehalose, melezitose, methyl alpha-d-glucoside, dxylose, l-arabinose, d-glucosamine, ethanol, glycerol (weak), ribitol, d-mannitol, d-glucitol, salicin (weak), dl-lactic acid (weak), succinic acid (weak), citric acid, -keto-d-gluconate, arbutin are assimilated; no growth occurs on lactose, melibiose, raffinose, soluble starch, inulin, d-arabinose, d-ribose, l-sorbose, l-rhamnose, galactitol, erythritol, myo-inositol, -keto-d-gluconate, d-glucuronate and methanol. nitrogen compounds: ammonium sulfate, potassium nitrate (weak), creatinine, creatine, l-lysine, d-glucosamine (weak) are assimilated. growth on vitamin-free medium, on mea with % nacl and on % w/w glucose / yeast extract ( . %) agar is positive. growth with . % and . % cycloheximide is weak. (zhai et al. ) , the placement of the new species is demonstrated using the combined its and lsu rdna phylogeny. candida pellucida can be differentiated from the phylogenetically most close species c. viswanathii based on its ability to grow on vitamin-free medium, good growth at the temperature °c, and negative growth on soluble starch. maximum likelihood (ml) tree obtained from the combined analysis of its and lsu sequence data. bootstrap support values above % are shown at the nodes. the alignment included bp and was performed with mafft v. (katoh et al. ) . the general time reversible model (gtr) with gamma distribution and invariant sites (g+i) was used as the best nucleotide substitution model. the phylogenetic analysis was conducted in mega v. (tamura et al. ) . saccharomyces cerevisiae (ab /jq ) was used as outgroup (hidden). © naturalis biodiversity center & westerdijk fungal biodiversity institute fungal planet - june cladophialophora cabanerensis maciá-vicente, sp. nov. etymology. named after the cabañeros national park in central spain, where the soil sample was collected. classification -herpotrichiellaceae, chaetothyriales, eurotiomycetes. mycelium consisting of hyaline, branched, septate hyphae, ( . -) . - . (- . ) µm diam, forming hyphal strands. conidiophores mostly single, sympodial, erect, subcylindrical, hyaline, smooth, bearing one phialide, often reduced to a conidiogenous cell. conidiogenous cells phialidic, hyaline, smooth, fusiform with one locus at the apex that leaves a scar, ( . -) . - . (- . ) × ( . -) . - . (- . ) µm. conidia aseptate, produced in mass, hyaline, smooth, globose with a scar, ( . -) . - . (- . ) µm diam (n = ). chlamydospores absent. sexual morph unknown. culture characteristics -colonies slow-growing, reaching - mm diam on malt extract agar (mea), - mm diam on potato-dextrose agar (pda), and - mm diam on cornmeal agar (cma) after d at °c. colonies velvety, white, becoming light earthy after - wk, with a compact and suede-like surface; reverse white-cream. notes -the three isolates examined have identical morphologies and partial its and lsu sequences. since they originate from the same soil sample, they likely represent clonal isolates. based on a megablast search of ncbis genbank nucleotide database, the its sequence has low similarity with several unidentified chaetothyriales strains (e.g., genbank kx . , identities / ( %), gaps ( %); genbank kf . , identities / ( %), gaps ( %); gen-bank kf . , identities / ( %), gaps ( %)) and with cladophialophora immunda (genbank mh . , identities / ( %), gaps ( %)). however, the low identity values result from a long insert at the ' end of the s rdna gene, similarly to what has been found in other fungi (e.g., tedersoo et al. , cross et al. ), but that is not present in most genbank records. when analysing only the partial its region (nt - ) that is homologous to other sequences in genbank, the megablast search yields highest similarity with environmental sequences originating from a single study (e.g., genbank mf . , identities / ( %), no gaps), and to two unidentified fungi (genbank mg . , identities / ( %), no gaps; genbank gq . , identities / ( %), gap ( %)) and two cladophialophora sp. isolates (genbank lc . , identities / ( %), no gaps; and genbank lc . , identities / ( %), gap ( %)). the closest hits using the lsu sequence are an unidentified fungus (genbank gu . , identities / ( %), gap ( %)), cladophialophora sp. (genbank mf . , identities / ( %), gap ( %)), unidentified chaetothyriales (genbank kf . , identities / ( %), gap ( %)), and cladophialophora carrionii (genbank af . , identities / ( %), gap ( %)). the genus cladophialophora is polyphyletic, including species that are commonly isolated from soil and living plants, but also found as causal agents of human infections. cladophialophora cabanerensis is phylogenetically placed outside the carrionii and bantiana clades defined by badali et al. ( ) that contain most species pathogenic to humans. all the closest hits in the megablast search using the insert-free its sequence originate from fungi associated with plant roots, like the type specimen of c. cabanerensis, suggesting a preference of the species toward this habitat colour illustrations. wet heathland ('trampal') located in the cabañeros national park, ciudad real, spain. seven-day-old colonies growing at °c on pda; from top to bottom, overview of mycelium bearing conidiophores under phase-contrast microscopy; conidiophores under light microscopy; loose conidia under light microscopy. scale bars = µm (mycelium) and µm (conidiophores and conidia). culture characteristics -(after wk at °c in the dark): on potato dextrose agar (pda), colonies reach - mm diam, round shape, flat, dark olive green, dusty, aerial mycelium absent, profuse sporulation, margin white and glabrous, exudates (blackish droplets) produced mainly on the outermost colony surface; reverse olive green to olive black. on malt extract agar (mea), colonies reach - mm diam, irregular flat growth, elevated centre, dusty, olive green to yellowish green, aerial mycelium absent, exudates absent, white filiform margin; reverse, irregular olive-black. on synthetic nutrient-poor agar (sna), colonies reach a - mm diam, irregular flat growth, dusty, olive-green, profuse sporulation mainly in the centre of the colony, exudates absent; reverse olive grey with white filiform margin. on oatmeal agar (oa), colonies reach - mm diam, round shape, flat, olive-green, abundant velvety aerial mycelium, absent on the outermost colony surface, profuse sporulation, exudates absent, margin grey-green, narrow and glabrous. cardinal temperature for growth -optimum °c, maximum °c, minimum °c. notes -based on the combined analysis of its, acta and tef markers, cladosporium arenosum belongs to the c. cladosporioides complex (bensch et al. ) and is phylogenetically related to cladosporium asperulatum. however, c. asperulatum exhibits asperulate surface ornamentation of its conidia, conidiophores and mycelium (bensch et al. ), characters not found in c. arenosum. in addition, c. asperulatum has longer conidiophores (( -) - (- ) × ( -) - (- ) μm) and ramoconidia ( - × - μm)) (bensch et al. ) . finally, c. arenosum produces exudates on pda, limoniform conidia, and its colonies have a characteristic yellowish green colour after wk at °c on mea, characters not found in c. asperulatum (bensch et al. classification -cortinariaceae, agaricales, agaricomycetes. pileus up to mm diam, plano-convex to applanate, slightly glutinous when young, reddish golden to greyish orange ( b - b ); margin smooth or slightly innately fibrillose, incurved. lamellae emarginate, moderately crowded, up to mm broad, greyish when young, later greyish orange ( b - b ), lamellulae present, of various lengths. stipe × mm, cylindrical, with slightly clavate base, up to mm broad, greyish orange to brownish orange ( b - b ). context dull lilac ( c ) to purplish in pileus and in stipe base. odour distinct, earth-like. taste indistinct. spore print light brown ( d ). basidiospores ( . -) . - . (- . ) × ( . -) . - . (- . ) μm, av. = . × . μm, q = ( . -) . - . (- . ), qav = . , n = , amygdaloid, verrucose. basidia -spored, - × - μm, clavate. pileipellis more or less simplex ( -layered); strongly coloured in koh. epicutis at surface of narrow ( - μm wide), loosely erect-entangled, gelatinous, distinctly brownish yellow hyphae (many more or less collapsed); below wider ( - μm wide), parallel hyphae, with yellow thick walls or distinctly zebrastriped, encrusted pigment; the basal part of epicutis of more or less cemented hyphae up to ± μm wide, with distinctly thickened, yellow walls, some filled with dark brown granulate to oleiferous pigment (most pigment in the basal, cemented part). habitat & distribution -solitary, occurring among leaf litter in temperate forests dominated mainly by quercus leuco trichophora and pinus roxburghii. typus. india, uttarakhand, pauri garhwal, teka, m asl, n ° ' " e ° ' ", sept. , k.c. semwal (holotype kcs ; its and lsu sequences genbank mt and mt , mycobank mb ). phlegmacioides based on morphological and molecular (nrdna its and lsu regions) data, belonging to the /balteatocumatilis clade. it forms a well-supported (bs = %) lineage with three sequences known from the americas: usa, tennessee (gen-bank mf ), usa, minnesota (genbank ky ) and mexico (genbank eu ). the closest sequence is the one from minnesota; they differ by nucleotide and indel positions, but only in the its region. further studies are needed to unveil whether this sequence belongs to c. balteatoindicus with such a disjunct distribution. the other north american sequence from tennessee differs by nucleotide and indel positions, so it might well represent a separate species. the phylogenetically more distant european species of this clade have more robust basidiomata too, e.g., c. balteatocumatilis, c. balteatobulbosus, c. pseudonebularis, and the recently described c. hemicaeruleus (brotzu et al. ; its sequence genbank mt ) and have slightly larger spores. the special ecology and the unique its sequence are, however, the best delimiting characters for the time being. classification -cortinariaceae, agaricales, agaricomycetes. pileus up to mm diam, plano-convex to applanate, slightly inflated at centre, surface glabrous, slimy when young, slightly bluish greyish when young, but soon becoming reddish golden to light brown ( c - d ); margin smooth, fairly undulate. lamellae emarginate, crowded, greyish when young, later greyish orange ( b ), brownish orange ( c ) when mature, lamellulae present, of various lengths. stipe - × - mm, prominently clavate at the base, bulb up to mm wide, pale brown, becoming brownish orange to reddish orange ( d , b - b ) with greyish lilac ( b - ) tinge throughout the stipe, especially at apex. context greyish to bluish lilac. odour and taste not recorded. spore print brown ( e ). basidiospores ( . -) . - . (- . ) × ( . -) . - . (- . ) μm, av. = . × . μm, q = ( . -) . - . (- . ), qav = . , n = , amygdaloid, verrucose. basidia -spored, - × - μm, clavate. pileipellis more or less simplex ( -layered); rather weakly coloured in koh. epicutis at surface of narrow, - μm diam, loosely erect-entangled, gelatinous, pale yellow hyphae; below a few layers of slightly wider, - μm diam hyphae with slightly thickened yellow walls, a few with pale, weakly encrusted wall pigment; the basal part of epicutis of hyphae up to approx. μm diam, with distinctly thickened, yellow walls, forming tightly cemented bundles which in surface view forms a zig-pattern. habitat & distribution -caespitose, occurring among leaf litter of quercus leucotrichophora, on humicolous soil, in temperate broadleaved forests dominated by mainly q. leucotrichophora, rhododendron arboreum, and myrica esculenta. typus notes -cortinarius ulkhagarhiensis belongs to sect. phlegmacioides based on both morphological and molecular (nrdna its and lsu regions) data. within the section it belongs to the /daulnoyae clade, where it forms a close sister species of the european c. caesiocolor. they differ by nucleotide and indel positions, and in morphological characters. the spores of c. ulkhagarhiensis are significantly larger than those of c. caesiocolor (av. . × . μm vs . × . μm, respectively), and they are also longer (qav = . vs . ). macromorphologically they are rather similar, with e.g., bluish context. another closely related species is the european c. daulnoyae (syn.: c. chromataphilus and c. sabuletorum) which has a strong earth-like smell, yellowing, never bluish context, and phylogenetically is more distant. morphologically, other species in sect. phlegmacioides might also resemble c. ulkhagarhiensis, but the ecology and its sequence data will be helpful in identification. classification -cortinariaceae, agaricales, agaricomycetes. basidiomata rather small. pileus - (- ) mm diam, at first hemispheric, later convex with a persistent, obtuse, rounded and low umbo; margin first very incurved and highly lobulated and later extended and slightly serrate, retaining whitish veil remnants; surface hygrophanous, smooth to fibrous, dark grey, dark grey-brown (caill. t , t ; cailleux ) to ochraceous, pale ochraceous or reddish brown (caill. m , m , m ) when dry; mature pilei with necropigments. lamellae moderately dense, uncinated, pale ochraceous to beige ochraceous (caill. m , n ); lamellae edges slightly paler, and slightly mustard brown with age; lamellulae present. stipe ( -) - (- ) mm long and - (- ) mm wide, cylindrical to clavate or subglobose at the base; surface white, later pale beige, with universal veil copious towards the base, partial veil fugacious, not forming an annular area. context generally fibrous, pale ochraceous, and brownish in the stipe cortex. taste mild and smell indistinguishable. macrochemical reactions: negative to koh, guaiac tincture, ph.a. and methol. basidiospores broadly ellipsoid in front and side view, ( -) - . - . (- ) × ( . -) - . - . (- ) µm in size, with a q (length/width ratio) = ( . -) . - . - . (- . ), and with a marked apical depression; spore surface densely ornamented with projecting warts of moderate size. basidia - × - µm, -spored; lamellar edge with basidia and some claviform cells, - × - µm. pileipellis a cutis formed by a layer of - µm wide, clamped, more or less cylindrical hyphae, with scattered pale ochraceous incrusted wall pigments; subcutis composed of short and irregularly-arranged, septate hyphae, - × - µm; hyphae of the veil remnants - µm diam. habitat & distribution -restricted to the alpine belt (> m asl) in association with dryas octopetala. so far found in the pre-pyrenees (north-eastern iberian peninsula). the existence of an its sequence in genbank (fr ) identical to the ones obtained in the present study indicates the presence of c. paezii in the hyrcanian forests of iran. notes -cortinarius paezii is a rather small telamonioid species with relatively large spores that we initially considered to conform to the morphological variability of c. casimiri due to the general size, habitat and pigmentation. however, basidiomata of the latter species are in general slenderer than those of c. paezii, and show reddish and somewhat lilaceous tinges, their smell is more or less raphanoid, and the spores are smaller, - . × - µm (brandrud et al. ) . cortinarius paezii produces hygrophanous pilei that are very dark when hydrated, without lilaceous traces, and instead shows pale ochraceous to reddish brown tinges with time. furthermore, c. casimiri distributes preferentially in altimontane-subalpine habitats, and more rarely forms mycorrhizal associations with salix spp. in the alpine belt. considering other species growing in the alpine belt, c. cavipes would share two additional characters with c. paezii: the evident change in colour of pilei after drying and the clavate stipe (favre ) . as indicated by its epithet, however, c. cavipes has a hollow stipe; additionally, it shows lilaceous traces in the stipe apex and context (as in c. casimiri), and produces smaller, less ornamented spores. two additional alpine species described by favre ( ) were c. levipileus and c. rusticellus. the former differs from c. paezii in producing smaller basidiomata, with a finely granulose pileus cuticle, with the surface dark to reddish brown, and by the less abundant veil remnants and the slightly smaller, more ovoid spores (lower q value). lamoure ( ) obtained similar values for spore size in c. levipileus and provided further evidence of its habitat on calcareous soils in the alpine belt. cortinarius rusticellus produces spores more similar in size to those of the new species but has smaller basidiomata, pilei are more umbonate and fibrous to felty, lamellae are darker, and there is an abundant and persistent veil forming an evident annulus on the stipe. the two its sequences obtained for the new species were bp (plus four indels), bp (plus eight indels), and bp (plus six indels) different from those of c. casimiri /subsertipes, c. levipileus and c. rusticellus, respectively. the phylogenetic tree revealed c. tatrensis as a close relative of c. paezii. this species was described from salix and dryas communities in the alpine belt of the belaer tatras, in northern slovakia (fellner & landa ) . apart from the similar habitat, c. paezii and c. tatrensis share the general habitat of basidiomata, the hygrophaneity of pilei and their pigmentation, and the spores, which the authors described as broadly ovoid, ( -) . - . × ( . -) - . µm. however, lilaceous to vinaceous tinges were originally noticed in the surface of the stipe base and in the stipe context of c. tatrensis while these characters are absent in c. paezii. additionally, the stipe in c. tatrensis is described as 'cylindrical, slightly narrowing towards the base', whereas in the new species it is markedly clavate. the its sequence of c. tatrensis is provided for the first time in the present work, and shows five different nucleotides from c. paezii at the its region. classification -cylindriaceae, amphisphaeriales, sordariomycetes. asexual morph: mycelium consisting of smooth hyaline hyphae, branched and septate, - µm diam. conidiomata foliicolous, - wide and - µm tall, often in scattered groups, stromatic, immersed but erumpent when moist after pushing up a flap of host tissue and revealing a whitish jelly content. peridium composed of a single subepidermal inner layer of brown cells arranged as textura angularis, presenting paler pigmentation towards the conidiogenous region. ostiole absent. setae dark brown, - × - µm (length/width), smooth, dichotomously branched at the base, with - transversal septa, tapered towards the apex. paraphyses hyaline, scattered between setae and conidiophores. conidiophores arising from lageniform or cylindrical cells with hyaline or brownish walls at the internal wall of the peridium, formed of - µm long cylindrical cells (tapered towards the apex), septate and branched. conidiogenous cells integrated, hyaline, cylindrical (tapered towards the apex), lageniform, phialidic or percurrent, - × - µm (length/width). conidia hyaline, smooth, falcate, wider in the middle, tapering towards the apex, truncate at the base, measuring - × . - . µm (length/width), completely filled with small droplets. culture characteristics -(day/light °c, after wk): colonies slow-growing, with sparse aerial mycelium, rounded margins, reaching mm in wk. on malt extract agar and potato-dextrose agar white on surface, salmon in reverse. notes -on the basis of a combined phylogeny using its and s nrdna data (available in mycobank mb ), c. magnoliae is probably related with c. aeruginosum, c. algarvense, and c. purgamentum. lombard et al. ( ) proved that c. aeruginosum is phylogenetically related with the type species c. elongatum. crous et al. ( ) created a new family, cylindriaceae to accommodate this genus, proposing c. algarvense and c. purgamentum, and combining c. syzygii. recently, the new species c. grande was added to the genus (crous et al. c) . morphologically, c. magnoliae differs from other species of cylindrium because of its stromatic conidiomata, the specialised method of dehiscence, and the presence of setae and paraphyses. cylindrium magnoliae does not produce a pigmented stipe or sympodial loci and lacks ramoconidia which are present in c. purgamentum . cylindrium grande (crous et al. a ) produces sympodial conidiogenous cells and solitary conidia, features not present in c. magnoliae. colour illustrations. conidiomata on host. section of conidioma with brown setae; conidiophore; conidiogenous cells with successive percurrent proliferations (annellations); conidiogenous cells giving rise to conidia. scale bars = µm (section of conidioma), µm (others). etymology. name refers to the colour of conidial masses produced by conidiomata in culture. classification -erythrogloeaceae, diaporthales, sordariomycetidae, sordariomycetes. conidiomata after wk / h l/d cycles on c. sativa bark strips, pycnidial, separate, globose to subglobose, ( -) (- ) × ( -) (- ) μm with central ostiole, exuding a luteous, pale luteous to hyaline conidial mass. conidiophores reduced to conidiogenous cells, ampulliform to doliiform with prominent taper towards narrow cylindrical apex, enteroblastic, ( -) (- ) × ( -) (- ) μm wide. conidia aseptate, hyaline, smooth, ellipsoid, straight to curved, apex obtuse, smooth, thin-walled, guttules of varying sizes sometimes visible, ( -) (- ) × ( -) (- ) μm. culture characteristics -after mo in the dark at °c. colours determined from rayner ( ) . ex-type culture on potato dextrose agar . × . mm diam. surface undulating, woolly to velvety in texture. centre vinaceous buff, followed by dark mouse grey, hazel, fawn with an irregular pale vinaceous margin. reverse: centre sepia, extending to a mm ring of fuscous black, extending to brick to dark brick. on malt extract agar × mm diam. surface flat, woolly. centre rosy buff, extending to buff, rosy buff, vinaceous, and rosy buff. reverse: centre chestnut extending to flesh coloured. ( ) described four new species of dendrostoma from europe, and also updated the description of d. leiphaemia. on the concatenated lsu, its, tef -a tree, d. luteum was a strongly supported species (maximum parsimony bootstrap support %), sister to d. leiphaemia. morphologically, conidiomata of d. luteum are longer and wider than d. leiphaemia. dendrostoma luteum was consistently associated with branch lesions, but pathogenicity testing on detached c. sativa branches ( cm diam, cm length, n = ) did not produce lesions significantly longer than the control. therefore d. luteum is currently considered as an endophyte of c. sativa. the concatenated phylogenetic tree was inferred using maximum parsimony. * indicates ex-type cultures, with taxonomic novelty in bold. branch supports were determined using maximum parsimony bootstrap replicates. branch support values < % were excluded. scale bar on tree indicates number of changes. etymology. name refers to the host genus durio from which it was isolated. classification -diaporthaceae, diaporthales, sordariomycetes. conidiomata pycnidial, black, globose to subglobose, solitary or aggregated, embedded in tissue, - µm diam; forming up to six well-defined necks that can arise from a single conidioma. conidiophores formed from the inner layer of the conidiomatal wall, reduced to conidiogenous cells, cylindrical, hyaline, - × . - . µm. alpha conidia rare or absent in culture, hyaline, aseptate, biguttulate, ellipsoidal, smooth, ( . -) . - . (- . ) × ( . -) . - . (- ) µm. beta conidia abundant, hyaline, aseptate, hamate, ( . -) . - . (- . ) × . - . (- . ) µm. culture characteristics -on potato dextrose agar (pda), colonies white, fast-growing, covering dish after d at °c, surface buff with patches of purplish grey (rayner ), reverse purplish grey, with patches of dirty white. on malt extract agar (mea) with moderate aerial mycelium, and even, smooth margins; surface dirty white with patches of grey olivaceous, reverse dark mouse grey with patches of greyish sepia. on oatmeal agar (oa) surface dirty white with patches of dark mouse grey. the phylogenetic tree generated by raxml from the combined sequences of three loci demonstrated that the isolates of this study, kcsr . and kcsr . , grouped separately as a novel species. diaporthe ueckerae on cucumis melo has larger alpha conidia (( -) . - . (- . ) × ( -) . - . µm), and lacks beta conidia (udayanga et al. ) . diaporthe miriciae on helianthus annuus has larger alpha conidia, - . (- ) × - . (- ) μm, and longer beta conidia ( - × . - . μm; thompson et al. ) . previously, phomopsis durionis (dna data unavailable), was reported to be the causal agent of the durian leaf spot. however, the original description of p. durionis reports smaller conidioma, - μm diam, smaller alpha conidia ( - . × - . μm), with no beta conidia being observed (sydow ) . based on the characteristically large conidiomata with multiple necks, the canker disease and dieback symptoms, the present collection is herewith introduced as a new species. colour illustrations. dieback symptoms occurring on durio zibethinus at dak lak, central highlands, vietnam. colony on pda; conidioma on a durian twig on water agar; alpha conidia; conidiophores; beta conidia; conidiophores. scale bars: twig = mm, all others = µm. notes -macroscopically elaphomyces bucholtzii closely resembles the e. muricatus group, being differentiated by the variable height of its cortex warts. moreover, a section of the peridium is marbled, forming ellipsoidal (of cerebriform aspect) patches on a purple background, unlike the e. muricatus group that has a peridium marmorised in circles on a light background (white-cream), and the spores are decorated by thick, very curved sticks that usually form loops. a recently described european species e. barrioi (paz et al. ) has a marmorised peridium in red-purple tones forming small ellipses, on a vinous background, a dark brown gleba with red tones and smaller spores than e. bucholtzii. another species of the group is e. decipiens, but its cortex presents flat warts that are slightly oxidised after manipulation, a purple vinous peridium with cream-white veins arranged radially outward from the ascoma (paz et al. ) . elaphomyces violaceoniger has a dark violet peridium and some spores decorated with canes that are joined at maturity by drawing plaits, that clearly distinguishes this species from all the others in the e. muricatus group (paz et al. mycelium on leaves, epiphytic, amphigenous, producing dense, white patches mostly on the upper leaf surfaces. hyphae hyaline, thin-walled, - µm wide; hyphal appressoria mostly simple, nipple-shaped or knob-like, and rarely slightly lobed. conidiophores erect, consisting of a foot-cell, straight or occasionally slightly curved-sinuous at the base, - × - μm, basal septum at the branching point, followed by ( -) - cells up to the same length as the foot-cell. conidia produced singly, mostly cylindrical or ellipsoid-cylindrical, and occasionally doliiform, - × - µm. germ tubes terminal or subterminal, . - (- ) times longer than conidia (longitubus pattern when × longer), terminating in simple, often swollen, or rarely lobed appressoria. sexual morph not observed. notes -erysiphe contains approximately species of powdery mildew (braun & cook ) , including many common, widespread, plurivorous taxa (takamatsu et al. ) . some are taxonomically unresolved species complexes that are difficult to distinguish morphologically. these have similar or identical its sequences, and overlapping, or little-known, host ranges. an example is e. aquilegiae (jankovics et al. , kovacs et al. , takamatsu et al. . powdery mildews with its sequences that were identical or highly similar to e. aquilegiae were recorded on diverse host plants in different parts of the world (takamatsu et al. ) , including australia (cunnington et al. , southwell et al. , and belonged to the e. aquilegiae clade as defined by takamatsu et al. ( ) . phylogenetically, e. medicaginis belongs to a well-defined lineage that is sister to the e. aquilegiae clade. morphologically, it differs from e. aquilegiae, and also from the asexual morphs of other taxa that had its sequences identical, or highly similar, to e. aquilegiae, by having mostly simple, and not lobed or multi-lobed hyphal appressoria. the closest hits using the its sequence of e. medicaginis were two powdery mildew specimens from japan, mumh and mumh , collected from fabaceous hosts, baptisia australis and sophora flavescens, respectively. their its sequences (genbank lc and lc ) were identical to the five e. medicaginis specimens. these two specimens from japan were recognised as representing a distinct lineage, sister to the e. aquilegiae clade, without being identified at the species level (takamatsu et al. ) . erysiphe medicaginis is commonly found on m. polymorpha in queensland, australia. its host plant is a common weed globally, therefore it is likely that e. medicaginis is also widespread on m. polymorpha in different parts of the world, and likely on other fabaceous hosts, as indicated by the two specimens from japan. colour illustrations. medicago polymorpha with powdery mildew-infected older leaves in a weedy area in tipton, queensland, australia. conidiophores; a non-germinating and a germinated conidium; and simple, nipple-shaped and knob-like hyphal appressoria of erysiphe medicaginis. micrographs were taken following rehydration of the powdery mildew mycelium by boiling small pieces of infected plant tissues in lactic acid. scale bars = μm (conidiophores, conidia), μm (hyphal appressoria) the majority rule consensus phylogram inferred from the internal transcribed spacer sequences of the nuclear ribosomal dna and the intervening . s nrdna region using bayesian inference. the analysis was performed using mrbayes v. . . ) based on the gtr+g nucleotide substitution model selected using paup v. . b (swofford ) and mr-modeltest v. . . (nylander mycelium composed of pale olivaceous brown, septate, branched, smooth-and thin-walled hyphae, - μm wide; older hyphae being more strongly pigmented. spirally twisted hyphae present. moniliform cells scarce, globose to ellipsoidal, in short chains (- cells) . conidiophores semi-micronematous, pale olivaceous brown, smooth-and thin-walled, mostly laterally disposed on the vegetative hyphae, sometimes terminally disposed, erect, rarely once branched near the base, cylindrical, with a rounded or pointed apex, - -septate, with a terminal conidiogenous locus, sometimes with additional conidiogenous loci, - × - μm. conidiogenous cells enteroblastic, monoor polyblastic, integrated to the conidiophores, on vegetative hyphae or well-developed, in the latter case ellipsoidal, ovoid or flask-shaped, - × - μm, conidiogenous loci cylindrical or conic-cylindrical, with small percurrent proliferations. conidia aseptate, occasionally -septate, pale olivaceous brown, smooth-and thin-walled, ellipsoidal to reniform, - × - μm, sometimes with a truncate base, solitary. budding cells scarce, ellipsoidal, ovoid or barrel-shaped, - × - μm, in chains up to elements. chlamydospores scarce, olivaceous, globose, - μm diam. culture characteristics -colonies on potato dextrose agar (pda) reaching - mm diam after wk at °c, slightly raised, velvety, margins regular, brownish grey (m. e ; kornerup & wanscher ) , sporulation absent, exudate absent; reverse brownish grey (m. e ), diffusible pigment absent. colonies on oatmeal agar (oa) reaching - mm diam after wk at °c, morphologically similar to those on pda, with sparse sporulation. colonies on malt extract agar (mea) reaching - mm diam after wk at °c, slightly raised, velvety, margins regular, olive brown (m. e ), sporulation absent, exudate absent; reverse olive brown (m. f ), diffusible pigment absent. colonies on potato carrot agar (pca) reaching - mm diam after wk at °c, slightly raised, velvety, margins regular, olive brown (m. e ), sparse sporulation, exudate absent; reverse brownish grey (m. f ), diffusible pigment absent. colonies on pda reaching - mm diam after wk at °c slightly raised velvety, margins regular, brownish grey (m. e ), sporulation absent, exudate absent; reverse brownish grey (m. e ), diffusible pigment absent. minimum, optimal and maximum temperature of growth, °c, °c, and °c, respectively. notes -exophiala frigidotolerans was recovered from a soil sample collected in guayaquil, ecuador. the genus exophiala pertains to a group of fungi known as 'black yeasts', because of the production of yeast-like colonies and budding cells with dark, melanised cell walls. the genus exophiala is characteri sed by an annellidic conidiogenesis and the production of solitary conidia grouping in slimy masses, and its phylogenetic affiliation to the ascomycete order chaetothyriales (de hoog et al. ). this genus contains numerous potential opportunists or pathogens of immunocompetent humans (sudhadham et al. , li et al. and are isolated from a broad spectrum of substrata, environments and geographic areas (de hoog et al. , ferrari et al. . as in e. psychrophila, e. frigidotolerans exhibited the ability to grow at low temperatures. however, e. frigidotolerans presents more developed conidiophores than e. psychrophila (which are reduced to a unique discrete conidiogenous cell in this latter species), and produces shorter chains of moniliform cells (scarce and of up to cells in the former species, and very abundant and of up to several hundred of cells in the latter). based on a megablast search of ncbis genbank nucleotide database, the closest hit using the its sequence is the ex-type strain of exophiala brunnea cbs . (genbank jf ; identities = / ( %), gaps ( %)); and using the lsu sequence the ex-type strain of exophiala brunnea cbs . (genbank mh ; identities = / ( %), gap ( %)). the its-lsu-bena phylogenetic tree corroborated the placement of our isolate as a new species of exophiala, being located phylogenetically close to e. brunnea. exophiala brunnea is easily distinguished from e. frigidotolerans by the production of -celled conidia (mostly -celled in e. frigidotolerans) and absence of budding cells (formed in e. frigidotolerans). maximum likelihood tree obtained from the its-lsu-bena alignment of our isolate and sequences retrieved from genbank. the tree was built by using raxml cipres (http://www.phylo.org/sub_sections/portal/) and the analysis of probability was run in mrbayes v. . . . bootstrap support values ≥ % and bayesian posterior probability values ≥ . are presented at the nodes. fully supported branches ( % bs / pp) are thickened. cyphellophora laciniata cbs . and cyphellophora pauciseptata cbs . were used as outgroup. the new species proposed in this study is indicated in bold. t represents the ex-type strains of the taxa employed in this analysis. etymology. from latin calyx (cup) and coriaceum (leather). in reference to the coriaceous surface of mycelial layer, peeling-off to form a cup under basidiomata. classification -geastraceae, geastrales, agaricomycetes. unexpanded basidiomata epigeous, golden brown ( d , kornerup & wanscher ) to brown ( e ; f ), subglobose to obpyriform, . - × - mm, surface coriaceous, with little triangular processes when young, velutinous to papery with age, slightly encrusted with debris. subiculum white ( a ). expanded basidiomata saccate, - mm high (including peristome) × - mm wide. exoperidium splitting into - triangular rays, revolute or sometimes involute, rolling up under basidiomata, non-hygroscopic. mycelial layer honey yellow ( d ) to brown ( f ), non-persistent, ephemeral, peeling-off forming a cup under basidiomata, surface coriaceous, not encrusted. fibrous layer greyish yellow ( b ) to white orange ( a ), coriaceous. pseudoparenchymatous layer reddish ( e ) when fresh, brownish orange ( c ) to dark brown ( f ) when dried, rimose, persistent or peeling-off in irregular patches, with an inconspicuous collar. endoperidial body greyish brown ( d ) to brownish orange ( c ), subglobose to pyriform, - × - mm, sessile, surface glabrous, non-pruinose. apophysis absent. peristome fimbriate, distinctly delimited by greyish brown ( e ) line, mammiform, lighter than endoperidium, < mm high. gleba greyish brown ( f ). basidiospores brownish, globose to subglobose, . - . × . - . μm (x = . ± . × . ± . µm, q m = . , n = ), ornamentation conspicuous under lm. warts cylindrical ( . - . μm high), sometimes with some confluent tips. apiculous reduced. basidia yellowish, oval, lageniform to clavate, thick walls ( . - . μm), . - . × . - . µm, - sterigmata. eucapillitium pale brown hyphae, . - . μm diam, surface encrusted, covered by warts, thin walls ( . - . μm) and lumen evident. mycelial layer composed of yellowish to hyaline, some sinuous and inflated hyphae, . - . μm diam, surface non-encrusted, some branched, thin-walled ( . - . μm) and lumen evident. fibrous layer composed of yellowish to hyaline hyphae, . - μm diam, surface non-encrusted, non-branched, thin-walled ( . - μm) and lumen evident. pseudoparenchymatous layer composed of yellowish, subglobose, oval to elongated cells, . - . × . - . μm, thick-walled ( . - . μm). rhizomorphs composed of hyaline, thin hyphae, surface covered by acicular crystals, . - . × . - . μm, in an irregular arrangement. notes -geastrum calycicoriaceum is characterised mainly by its ephemeral yellowish mycelial layer with coriaceous surface, peeling-off forming a cup under basidiomata and persistent rhizomorph with acicular crystals, also by distinct delimited peristome and basidiospores with . - . μm diam and small warts (up to . μm high). our phylogenetic analyses (concatenate its and lsu) grouped g. calycicoriaceum in the mycelisotroma section, velutina subsection. this subsection comprises, until now, the species geastrum velutinum, which has some features in common with g. calycicoriaceum: both have a yellowish mycelial layer, delimited and fimbriate peristome and presence of subiculum. however, g. velutinum has lighter colours in peridium layers (yellowish pseudoparenchymatous layer when fresh and pale brown endoperidium) than g. caly cicoriaceum; moreover, g. velutinum lacks an ephemeral, coriaceous mycelial layer (dissing & lange ) . geastrum javanicum is another species which could be grouped in subsect. velutina based on its morphological features. presently there are no molecular data from the type to support g. javanicum as morphologically similar to g. calycicoriaceum, and it is distinct based on its smaller basidiospores ( . - . μm diam), conical peristome and felted endoperidium surface (ponce de leon ). geastrum argentinum is another species morphologically close to g. calycicoriaceum. however, it has a non-delimited peristome, and larger basidiospores ( . - . μm diam) (zamora et al. colour illustrations. woncheon stream, located in namwon city, jeonnam povince, republic of korea. once branched sporangiophore with fertile and sterile sporangium (branch); branched sporangiophore with two branches in whorls of two and columellae; sympodially branched sporangiophore with columellae and sterile sporangia; unbranched sporangiophore with apophysis and columella; giant cells; unbranched sporangiophore with apophysis and columella; sporangiospores. scale bars = μm. etymology. name refers to the isolation site, namwon city, from where the strain was first isolated. classification -cunninghamellaceae, mucorales, mucoromycotina, mucoromycota, mucoromyceta. mycelium hyaline. rhizoids hyaline, coenocytic, branched; stolons hyaline, coenocytic, smooth-walled. sporangiophores mostly arising from stolons or directly from aerial hyphae and stolon-like, erect or slightly recumbent, apophysate, simple or commonly sympodially and/or monopodially branched, smooth-walled, up to mm in length and µm diam, with up to septum (majority) below the sporangium. short and long branches may be found on the same sporangiophore at short or long distances from the main sporangium, and frequently rebranching. branches in whorls of or may be found on some sporangiophores. apophyses globose ( . -) - . (- ) µm, subglobose and ellipsoid, some with a truncated base, . - . × . - µm, smooth-walled. sporangia pale yellow, globose, wall transparent, deliquescent and smooth, up to µm diam. sometimes sterile sporangia are formed. columellae hyaline, globose, subglobose, . - µm diam, hemispherical, . - . × . - . µm, nipple-like, ellipsoidal, - . × - µm. sporangiospores hyaline, reniform, ellipsoidal, some ovoid, . - . × . - . µm, rarely irregular, up to × . µm. giant cells globose, subglobose and branched. chlamydospores mostly globose and subglobose. zygosporangia not observed. culture characteristics & temperature tests -colony white, reverse cream, low to moderate growth, taking the whole petri dish ( cm diam) after d on malt extract agar (mea) at °c; odourless; at °c -lack of growth; at °c -slow growth ( . cm diam after h); at °c -slow growth ( . cm diam after h); at °c -slow growth ( . cm diam after h), better than at °c; at °c -moderate growth ( . cm diam after h); at °c -optimum growth ( cm diam after h); at °c -moderate growth ( cm diam after h); at °cslow growing ( . cm after h). gongronella namwonensis exhibited slightly better growth on mea than on potato dextrose agar (pda) at , , , and °c with similar growth at and °c. the growth was also slightly better on mea than on synthetic mucor agar (sma), except at °c, where g. namwonensis grew . cm after h in sma. typus. south korea, namwon city, jeonbuk province, n ° ' . " e ° ' . ", from freshwater samples, july , h.b. lee (holotype cnufc-ww - ; its and lsu sequences genbank mn and mn , mycobank mb ). notes -gongronella namwonensis differs from other species based on its morphological characters and the phylogenetic relationships established based on the its and lsu rdna regions. morphologically, g. namwonensis differs from the other species by producing concomitantly strongly sympodially and/ or monopodially branched sporangiophores, some showing branches in whorls of , columellae varied (some nipple-like) and apophyses (some with a truncated basis), as well as giant cells. so far, giant cells had only been visualised in g. brasiliensis. sporangiophores of g. namwonensis presents up to one septum below the sporangia and are long (up to mm in length), different from the shorter (up to μm in length) and with up to two septa sporangiophores of g. brasiliensis. the columellae of g. brasiliensis are globose, subglobose and conicalcylindrical, never hemispheric or nipple-like, as observed in g. namwonensis. additionally, as observed in g. brasiliensis, our species produces sporangiospores varied in shape, but they are never falciform or ellipsoid to fusiform like the ones of the brazilian species (tibpromma et al. ). in the its and lsu rdna trees (data not shown) g. namwonensis was placed in a well-supported clade separate from the other species. a more closely related species is g. guangdonguensis. morphologically, both species can be easily distinguished by the shape of sporangiospores, being globose in g. guangdonguensis, as well the fact that it lacks rhizoids and stolons (adamčík et al. ) , both structures which are present in g. namwonensis. phylogenetic tree of gongronella namwonensis cnufc-ww - and cnufc-ww - - based on maximum likelihood analysis of the internal transcribed spacer (its) nrdna region. the numbers at the branches are bootstrap support value (≥ %) from replications. gongronella lacrispora was used as the outgroup. ex-type strains are indicated by t . pathogenic on leaves of kielmeyera coriacea. leaf spots up to cm diam, rather irregular, sometimes confluent and covering almost the whole blade, often at the margins, amphigenous, showing small dark points of conidiomata at the upper side of the leaves. conidiomata acervular at maturity, - µm diam, with brownish wall layers of textura angularis, sub cuticular to intraepidermal, scattered. conidiophores hyaline to pale brown, - -septate, - × . - µm, branched, smooth. vegetative hyphae internal, hyaline to pale brown, smooth, intermingled with the host cells, branched, - μm diam. conidiogenous cells hyaline, phialidic with a conspicuous collarette, - × - . µm, percurrent proliferation with a serrate collarette. conidia hyaline to pale brown, variable, sometimes elongate-fusoid, fusoid to ellipsoidal, aseptate, smooth and thick-walled, attenuate and papillate at the apex, truncate at the base, guttulate, - × - µm, - µm. conidial cirrhi arising from conidiomata on the surface of infected leaves. culture characteristics -colonies on potato dextrose agar (pda), malt agar (ma %) and oatmeal agar (oa) (near-uv light, h photoperiod) with a pale brown centre surrounded by a greyish olivaceous ring containing dark spore masses, followed by a pale brown area with aerial feltose mycelium and irregular margins. a reddish to vinaceous pigment is produced in all media (either side of the plates), more intensely in pda. slow growth on all media, no growth at , , and °c on pda and ma % and at , , and °c on oa. growth / d at °c on pda was . and . mm (for isolates cml and cml , respectively) while on ma % it was . and . mm. growth at °c on pda ( and . mm), on ma % ( . and . mm), on oa ( . and . mm). growth at °c on pda was . mm for both isolates, on ma % was . and . mm and on oa . and . mm. conidia were produced at approximately , and d, respectively on oa, ma % and pda at °c. notes -greeneria kielmeyerae is related to the other species of the genus, g. uvicola (farr et al. ) and g. saprophytica (tangthirasunun et al. ) , but differs from these species in the production of a reddish to vinaceous pigment on plates, for having larger conidia ( × . in g. kielmeyerae, . × . in g. uvicola and × . in g. saprophytica) and a larger length to width ratio of the conidia ( . in g. kielmeyerae, . in g. uvicola and . in g. saprophytica). the closest phylogenetic relative of g. kielmeyerae cml t (accession mn . ) with its sequences was melanconiella spodiaea spod (genbank jq . ; . % identity), it had . % identity with the its sequence of g. uvicola fl (genbank hq . ) and . % identity with the its of g. sapro phytica ntcl - (genbank kj . ). with lsu sequences the closest relative of g. kielmeyerae cml t (genbank mn . ) was g. uvicola usvitis (genbank jn . ; . %) and it was . % identical to the lsu sequence of g. saprophytica ntcl - (genbank kj . ). with ssu sequences, the closest relative of g. kielmeyerae cml t (genbank mn . ) was coryneum heveanum mflucc - (genbank ng_ . ; . % identity), and had . % identity with the ssu sequence of g. saprophytica ntcl - (genbank kj . ). the phylogenetic relationships of the genus greeneria and closely-related genera are not well defined as observed by tangthirasunun et al. ( ) . unrooted maximum likelihood tree obtained by phylogenetic analysis of the combined its and lsu sequences from greeneria kiemeyerae and phylogenetically related species performed in the software mega v. . (tamura et al. ) employing the gtr+g model with bootstrap re-samplings. bootstrap support values > % are presented. the new species is shown in red text ( t = ex-type) and the genus greeneria is delimited in a pale red box. genbank accession numbers are given after each strain (its = blue, lsu= green). hemileucoglossum kelabitense v. kučera, fedosova & sochorová, sp. nov. etymology. name refers to the kelabit highlands where the fungus was collected. classification -geoglossaceae, geoglossales, geoglossomycetes. ascomata scattered to gregarious, capitate, stipitate, - × - . mm, dry, black throughout. ascigerous part capitate or broadly clavate, / - / of the total ascomata length, black, compressed or oval in cross section, sharply delimited from the stipe, smooth both in fresh and dry conditions. stipe terete, cylindrical, oval in cross section, - × . - mm, slender to robust, with dark brown setose hairs in tufts mainly at the upper part of the stipe, rough to squamulose. asci cylindrical-clavate, ( -) - (- ) × . - μm (all measurements of microscopic characters refer to rehydrated material in tap water), q = . - . , unitunicate, inoperculate, -spored, with euamyloid ascoapical apparatus and inamyloid wall in mlz and iki, arising from croziers. ascospores elongate, ellipsoid baculiform, sometimes slightly curved, ( -) - (- ) × - . μm, q = ( -) - , hyaline, finally becoming brown, -septate at maturity, smooth. ascoconidia ellipsoid, ovoid or dacryoid, . - . × . - . μm, q = . - . , brown, aseptate, formed already on ascospores inside the asci, smooth. paraphyses straight, sparsely septate, - μm wide at lower part, hyaline at basal part to pale brown at the apex, agglutinated by dense brown amorphous matter. apical cells of paraphyses usually inflated, clavate to capitate, sometimes constricted and proliferating, - × ( -) - (- ) μm. flesh of the fertile part formed by grey cylindrical cells, - × - μm. flesh of the stipe formed by grey cylindrical cells, - × - μm, oriented with their long axis in the same direction as the stipe. stipe surface squamulose due to tufts of septate dark brown setose hairs, ( -) - (- ) × - μm at the middle part and - μm at the apical part, crumpled, sometimes bifurcated, thick-walled ( . - μm), with rounded apex. habit, habitat & distribution -in small groups on soil among mosses. the species is known only from the type locality. notes -predominantly hyaline ascospores finally becoming brown, paraphyses agglutinated by a dense brown amorphous matter and setose hairs on the stipe (but lacking on the fertile part), as well as the genetic profile rank the new species with the genus hemileucoglossum (arauzo & iglesias ) . hemileucoglossum kelabitense is characterised by the longest ascospores and asci within the genus. morphologically, the most similar species is h. alveolatum, which is alike in number of septa (up to ) in ascospores, but its ascospores are shorter and slightly thinner ( - × - μm). moreover, h. alveolatum prefers very rotten wood and logs (durand (durand , nannfeldt , crous et al. , kučera & fedosova . colour illustrations. tropical rainforest in bario town surroundings, the kelabit highlands. macro-and microscopic structures of holotype: ascomata; ascospores (in tap water); ascospores germinating by ascoconidia inside the ascus (in tap water); amyloid reaction of the ascoapical apparatus (in iki); paraphyses (in % koh); setose hairs of the stipe surface (in tap water). rehydrated material was used for all photos of microscopic characters. scale bars = cm (ascomata), μm (microscopic structures). heterocephalacria septentrionalis kachalkin, m.a. tomashevskaya & t.a. pankratov, sp. nov. etymology. the epithet refers to the species distribution in the northern regions of russia. classification -filobasidiaceae, filobasidiales, tremellomycetes. on glucose peptone yeast extract agar (gpya) and % malt extract agar (mea), after d at °c, streak is cream-coloured, shiny and mucoid, with an entire margin, and flat profile. after a month, the colour of the streak is pinkish cinnamon. cells are globose, ovoid to ellipsoid, - × . - μm, occur singly or in pairs, dividing by polar and multilateral budding. sexual structures, pseudohyphae, true hyphae and ballistoconidia have not been observed during wk at and °c in culture (pure cultures and in mating test) grown on gpya, mea, potato dextrose agar (pda), yeast nitrogen base with . % glucose (ynb) agar and cornmeal agar. glucose is not fermented. glucose, galactose, sucrose, maltose, cellobiose, trehalose, lactose, melibiose, raffinose, melezitose, soluble starch (variable and weak), d-xylose, l-arabinose, d-arabinose, d-ribose, l-rhamnose, d-glucosamine (variable and weak), ethanol (weak), glycerol (weak), ribitol (weak), galactitol, d-mannitol, d-glucitol, methyl alpha-d-glucoside, salicin, d-gluconate, succinic acid, citric acid, -keto-d-gluconate, myo-inositol and arbutin are assimilated; no growth occurs on l-sorbose, inulin, erythritol, dl-lactic acid, methanol. nitrogen compounds: ammonium sulfate, potassium nitrate, l-lysine (variable), d-glucosamine (variable), cadaverine (variable), creatinine (variable), creatine (variable) are assimilated, and no growth occurs on ethylamine. growth on vitamin-free medium is variable. growth on mea with % nacl and on % w/w glucose / yeast extract ( . %) agar is negative. growth with . % and . % cycloheximide is variable. starch-like compounds are produced. diazonium blue b colour and urease reactions are positive. maximum growth temperature is - °c. notes -analysis of the its-d /d regions of the surveyed yeasts suggested that they were conspecific ( subst. between strains from nadym and kandalaksha) and represented a hitherto undescribed species of heterocephalacria. the genus heterocephalacria comprises three sexual mycoparasites of lichens (h. bachmannii and h. physciacearum) and mushrooms (h. solida), and several asexual species of yeasts (kachalkin et al. , kunthiphun et al. , li et al. . two new yeast strains were isolated as a minor component from cladonia lichens whose thallus did not have basidioma-like structures. although no sexual morph was discovered for new species, its mycoparasitic lifestyle cannot be excluded. based on the ncbi genbank database, the best hit using the its and lsu sequences is h. sinensis cbs t (its -genbank mg ; . % similar, subst. and gaps, lsu -gen-bank ky ; . % similar, subst. and gaps), using ssu it is h. bachmannii am (genbank jn ; . % similar, subst. and gap), using tef and rpb the number of nucleotide substitutions was considerable -without hits with heterocephalacria. in compliance with a recent phylogenetic analysis of the genus (kachalkin et al. ) , the placement of the new species is demonstrated using the combined its and lsu rdna phylogeny. heterocephalacria septentrionalis can be differentiated from h. sinensis based on its ability to assimilate galactose, maltose, trehalose, melezitose, l-rhamnose, glycerol, d-mannitol, d-glucitol, citric acid, and negative growth on l-sorbose. notes -kosmimatamyces is a new genus that groups in the capnodiaceae, a family whose members are known as sooty molds whose dark hyphae cover the surface of living leaves and twigs of many plants (hughes , abdollahzadeh et al. . hypersaline soil represents a new ecological niche, reinforcing the hypothesis of crous et al. ( ) and chomnunti et al. ( ) that plant surfaces are not the only environmental niche for this group of fungi. based on a megablast search of ncbis genbank nucleotide database, the closest hit using the its sequence was micro xiphium theae cbs . (genbank mh ; identities = / ( %), gaps ( %)), antennariella placitae as (genbank mg ; identities = / ( %), gaps ( %)), and leptoxyphium kurandae mcc (genbank kf ; identities = / ( %), gaps ( %)); using the lsu sequence the closest hit were capnodium coartatum mflucc - (genbank jn ; identities = / ( %) , no gaps), microxyphium aciculiforme cbs . (gen-bank gu ; identities = / ( %), no gaps), and conidioxyphium gardeniorum cpc (genbank gu ; identities = / ( %) , no gaps). the lsu phylogenetic tree corroborated the placement of our isolate close to the genus leptoxyphium. the species of leptoxyphium are characterised by pycnidial conidiomata with a bulbous swollen base and cylindrical neck that expands at the apex to become funnel-shaped (hughes , chomnunti et al. , whereas kosmimatamyces produces single conidio phores. etymology. from greek αλατος-, salt, and -φιλος, lover, because of the environment from which the fungus was recovered. mycelium consisting of branched, septate, thick-walled, . - . µm wide hyphae. conidiophores solitary, macronematous or semimacronematous, erect, straight to flexuous, from hyaline to dark brown, thick-and smooth-walled to verrucose along its length, branched or unbranched, branches terminal or lateral, in an angle to °, - × . - µm. conidiogenous cells determinate, integrated, terminal or intercalary, pale to dark brown, verrucose, mono-or polyblastic, - × - . µm, scars truncate of - . µm wide. ramoconidia aseptate, pale to dark brown, thick-and smooth-walled to verrucose, subcylindrical, . - × - µm. conidia - -septate, brown to dark brown, thick-walled, with a spinulose, digitate, pustulate to crater-like ornamentation, globose, limoniform to ovoid or ellipsoid, - × - µm, with one or more notorious scars, arranged in branching acropetal chains, of schizolytic secession. culture characteristics -(after wk in darkness at °c). colonies on oatmeal agar (oa) up to mm diam, flat, slightly dusty to floccose, greyish sepia (rayner ) , aerial mycelium scarce, margins entire, exudates as olivaceous brown; reverse black, diffusible pigments absent. colonies on potato dextrose agar (pda) up to mm diam, flat, velvety, radiate and sulcate, greyish sepia at centre, greyish white to the borders, margins regular, scarce droplets of olivaceous exudates; reverse olive black to greyish sepia, diffusible pigments absent. on malt extract agar (mea) up to mm diam, velvety, zonate, radially folded and somewhat elevated, pale olivaceous grey, mostly consisting of vegetative mycelium, margins irregular; reverse greenish black, diffusible pigments absent. on potato carrot agar (pca) up to mm diam, floccose, olivaceous black, radiate, margin filamentous; reverse olivaceous black, diffusible pigments absent. on sna up to mm diam, flat, radiate, olivaceous at the centre and isabelline to the margins, margin entire; reverse olivaceous black at the centre, borders olive, diffusible pigments absent. fungal planet - june kosmimatamyces bianchin., reinoso f., rodr.-andr., cano & stchigel, gen. nov. etymology. from greek κοσμήματα-, jewellery, and -μύκης, fungus, because of the microscopic look of the fungus. classification -capnodiaceae, capnodiales, dothideomycetidae, dothideomycetes. mycelium consisting of branched, septate, pale to dark brown, thick-walled hyphae, sometimes coarsely ornamented. conidiophores solitary, macronematous or semimacronematous, erect, straight to flexuous, from hyaline to dark brown, thick-and smoothto rough-walled, cylindrical, narrow, branched or not, branches terminal and lateral, in angles of to °. conidio genous cells determinate, integrated, terminal and intercalary, monoor polyblastic, pale to dark brown, verrucose, scars truncate. conidia holoblastic, - -septate, brown to dark brown, thickwalled, globose, ovoid or ellipsoid, ornamented with spines and crater-like warts, with dark scars at one or both ends, arranged in branching acropetal chains. lactifluus albopicri t. lebel & l. tegart, sp. nov. etymology. named for the colour and hot taste of the basidiomata, albo = white, picri-= hot. classification -russulaceae, agaricales, agaricomycetes. basidiomata robust, lactarioid. pileus - (- ) mm diam, convex with decurved margin, planoconvex with depressed centre when mature; dry, smooth to very finely tomentose, white becoming very pale yellowish buff to pale honey cream with cream margin and slightly honey coloured centre; context solid, white becoming very pale cream coloured, no staining. lamellae at first broadly adnate, then subdecurrent to decurrent, narrow ( . mm), close (c. - per cm) with some forking, and - rows lamellulae, concolourous with pileus or slightly paler. stipe - (- ) × - (- ) mm, cylindrical or slightly tapered to base in older material, central, smooth, dry, whitish tinged with yellowish buff or hints of pale orange to pinkish buff; context firm, white, unchanging, dry, chalky. basal mycelium white. latex copious, white, unchanging, very hot and peppery. spore deposit white. phenol: rapidly wine red/pink; feso rapidly brown. spores . - . (- . ) × . - . µm (n = , . ± . × . ± . µm), q = . - . , subglobose to broadly ellipsoid, hyaline, asymmetric; ornamentation and spore wall amyloid, up to . - µm high, composed of isolated irregular warts that join together to variable degree in very fine lines to form a very partial reticulum, plage inamyloid. basidia - × . - µm, cylindrical to subclavate, - -spored; sterigmata - µm long. pleuromacrocystidia - × - µm, moderately common to abundant, cylindric to fusiform. pleuropseudocystidia - × - µm, cylindrical, moderately abundant, apices occasionally mucronate. cheilomacrocystidia - × - µm, cylindrical to subclavate with capitate apices, scattered. hymenophoral trama predominantly composed of hyaline hyphae - µm diam, interwoven with abundant sinuous lactifers up to µm broad; subhymenium cellular, - tiers of parenchymatous cells, - × - µm. pileipellis a hyphoepithelium, -layered: subpellis up to µm thick, composed of globose to subglobose cells - (- ) µm diam; suprapellis - µm thick, composed of mostly upright thin-walled hyaline hyphae, - (- ) µm diam, and abundant dermatocystidia - × - µm, cylindrical to clavate, with granular contents. pileus context heteromerous, with abundant sinuous laticiferous hyphae, - µm diam. habit, habitat & distribution -gregarious on soil amongst eucalypt leaf litter in wet sclerophyll forest. widely distributed from cool temperate forest in southern australia (vic, tas) with eucalyptus regnans and nothofagus cunninghamii dominant in canopy, scattered acacia dealbata and a. melanoxylon, with ferny understorey of dicksonia antarctica, blechnum watsii and asplenium sp., up to subtropical eucalypt and lophostemon woodland in northern australia (nt, qld). notes -the overall diversity of lactifluus in australia is poorly known (may et al. ) , perhaps in the order of - species, with only a few sections examined (i.e., gerardii; stubbe et al. ) . the main characters used to distinguish species in lf. sect. piperati are the shape and ornamentation of the spores, the composition of the lamellar edge, the form of the cheilomacrocystidia and the hypoepithelium pileipellis that lacks thick-walled elements (heilmann-clausen et al. , de crop et al. . the majority of other species in lactifluus have pilei with thick-walled elements (verbeken & walleyn ) . two morphologically distinct species are recognised from europe and an additional or so asian species remain to be morphologically documented and described (de crop et al. ) . up until recently, no species of lf. sect piperati were known to occur in south america, africa or australasia. lactifluus albopicri is a widespread species in eastern australia, from tasmania up to subtropical queensland and into the northern territory, occurring in wetter forests in association with eucalyptus and nothofagus. lactifluus albopicri resembles many of the known species from lf. sect. piperati, in the robust, pale coloured basidiomata, hot peppery latex, and spores with fine, low ornamentation. lactifluus albopicri differs from another australian sect. piperati species, lf. austropiperatus, in the typically larger sporocarps, slightly darker yellowish to pale orange pileus and lamellae, larger and subglobose vs broadly ellipsoid spores with finer and lower ornamentation. lactifluus albopicri sits in a well-supported clade with a single sequence from thailand (genbank kf ), amongst other se asian clades. colour illustrations. cool temperate rainforest dominated with eucalyptus regnans and nothofagus cunninghamii with scattered acacia spp. and understorey of dicksonia antarctica (photo g. lay). northern habitat of subtropical lophostemon woodland; basidiomata; section through hypoepithelium pileipellis; sem of spores. scale bars: mm; µm; µm. lactifluus austropiperatus t. lebel & l. tegart, sp. nov. etymology. named for its similarity to lactifluus piperatus from the northern hemisphere and its distribution in australia. basidiomata robust, lactarioid. pileus - mm diam, convex with decurved margin, planoconvex with depressed centre when mature; pileipellis dry, glabrous, azonate, whitish variously tinged with yellowish or hints of pale orange when younger, to pale-biscuit-buff overall in older specimens. lamellae subdecurrent, close (c. - per cm) with some forking closer to margin, and - rows lamellulae, very pale orange, bruising a little darker with handling. stipe - × - mm, cylindrical, whitish tinged with yellowish or hints of pale orange; context white, unchanging, taste hot and peppery. latex copious, white, unchanging or barely yellowing slightly after - min, very hot and peppery. spore print white. spores ( . -) . - . × . - . µm (n = , . ± . × . ± . ), q = . - . ± . , barely globose to subglobose, asymmetric, hyaline; ornamentation amyloid, up to . µm high, composed of irregular warts that join together to variable degree in short thin fine lines; plage inamyloid. basidia - × - µm, cylindrical to subclavate, -spored; sterigmata short, robust. pleuromacrocystidia - × - µm, abundant, narrowly cylindrical to fusiform, with tapering apex. pleuropseudocystidia similar size and shape to pleuromacrocystidia, moderately abundant, sometimes with irregular mucronate apices. cheilomacrocystidia ( -) - (- ) × - . (- ) µm, cylindrical to filiform with acute or capitate apices, with crystalline contents, scattered, more obvious in younger specimens. hymenophoral trama up to µm wide, composed of interwoven hyaline hyphae of - µm diam and abundant sinuous lactifers up to µm thick, sphaerocytes rare; subhymenium layer up to µm thick, parenchymatous, cells - µm diam. pileipellis a hyphoepithelium, -layered: subpellis up to µm thick, composed of globose to subglobose cells - µm diam; suprapellis - µm thick, composed of mostly repent thin-walled hyphae, frequently septate, - (- ) µm broad; context broad, composed of hetero merous tissue, sphaerocytes up to µm diam interwoven with hyaline hyphae - µm diam, and scattered to abundant sinuous laticiferous hyphae of - µm diam. habit, habitat & distribution -in savanna eucalypt woodland with eucalyptus pilularis or e. delegatensis, and e. cypellocarpa near creek lines with syzygium, allocasuarina, acacia spp., with tall grass understorey, rarely in mixed nothofagus moorei forest leaf litter; solitary but common. notes -lactifluus austropiperatus morphologically closely resembles lf. subpiperatus, described from japan (hongo ) ; unfortunately, no sequence data are currently available for comparison. lactifluus dwaliensis, lf. allardii, lf. glaucescens, and lf. subpiperatus grow respectively in association with species of oak in temperate deciduous forests in india, hardwood or pine-oak forests in central to southern usa, mixed deciduous forests in europe, or deciduous oak forest in japan (das et al. , verbeken et al. . lactifluus dwaliensis is a rare all-white species with quite a long stipe, and context and tissue that slowly stains light greenish yellow, while lf. allardii is stockier, with pinkish brown colours and flesh that stains purplish pinkish then green, and white copious latex that slowly turns greenish then brownish (das et al. , de crop et al. . lactifluus glaucescens is an elegant, allwhite species with densely crowded lamellae and latex that turns slowly olive to pastel green. all five species have smallish spores with low ornamentation under . µm high, as isolated warts with scattered connecting lines, grading into a partial reticulum. lactifluus subpiperatus is morphologically most similar to lf. austropiperatus, also having white then patchily pale ochraceous, somewhat stocky basidiomata, forked lamellae, and small subsphaerical spores (hongo ) . however, lf. austropiperatus has sporocarps with more yellowish to pale orange tinges, flesh and latex that does not change colour or only very slowly and slightly, with no green tones, and pleuromacrocystidia are present (de crop et al. ) . lactifluus austropiperatus grows in association with subtropical forest of eucalyptus, and more rarely nothofagus, in northern nsw and southern qld, australia. in our analysis lf. austropiperatus is in a strongly sup ported clade with a specimen from thailand (genbank kf , h.t. le ), however, at this time we maintain the australian material as distinct until further collections from thailand can be examined and sequenced. preliminary morphological examination shows the spores of h.t. le to be slightly smaller, and the ornamentation to be slightly finer than the australian material. lactifluus austropiperatus is sister to l. dwaliensis, a specimen from honduras (lmunah ; no plant associate listed), and an environmental sample from florida, usa associated with pinus clausa. lecanicillium praecognitum gorczak & kisło, sp. nov. etymology. prae (latin: before, ahead of) + cognitum (latin: known, noted; neut. part. adj.); known before; referring to the fact that the species was noted several years before formal description. classification -cordycipitaceae, hypocreales, sordariomycetes. on sabouraud dextrose agar (sda): conidiophores erect, mostly single, sometimes in whorls up to four. unfrequently secon dary phialides arise, sometimes in whorls up to three. phialides . - . (av. = . ) µm long × . - (av. = . ) µm wide. conidia hyaline, smooth, granular, oblong to slightly fusiform, solitary or in small clusters, ( . -) - . (- . ) (av. = . ) µm long × - . (- ) (av. = . ) µm wide, usually trice as long as wide, with one to two guttules. vegetative hyphae smooth, hyaline, regularly septate, . - (av. = . ) µm wide. crystals octahedral, translucent, . - (- . ) (av. = . ) µm long in medium, less regularly in substrate mycelium. culture characteristics -(in darkness, ± °c). colonies cottony, margin even to slightly irregular, with dense and abundant aerial mycelium. on sda and potato dextrose agar (pda) averse white, reverse creamy to yellow, reaching cm in d, . cm in d. octahedral crystals produced in the medium and substrate mycelium. sometimes yellowish droplets of exudate on the surface of older cultures. growth is slow but not arrested in °c. notes -based on a megablast search of ncbis genbank nucleotide database, four similar its sequences were found ( . - . % identity). two of them belongs to strains isolated from wood: historic construction wood in chiloé, chile (genbank kf . ) and picea abies wood from sweden (genbank ay . ) and other two sequences were generated during research on mycorrhizae of ericaceae: pyrola media in scotland, uk (genbank fn . ) and epacris pulchella in south-eastern australia (genbank ay . ). this variety suggests that the species have a global distribution and much wider ecological niche than known strains. however, if l. praecognitum can thrive on frass of minute arthropods as we observed, the actual substratum might have been overlooked in previous cases. no specimens are available from a study in sweden (a. menkis pers. comm.) or study in chile (r. blanchette pers. comm.). lecanicillium longisporum is morphologically most similar to l. praecognitum, but it has longer (up to . µm) and sometimes septate spores (zare & gams ) . other species with similar spores includes akanthomyces muscarius (formerly lecanicillium), which differs in size of conidia and more often has phialides in the whorls; a. attenuatum, which differs in phialide size and has at least some conidia with attenuate base; l. flavidum and l. fungicola which produce spores in slimy heads; l. fusisporium which produces characteristic broad conidia, and l. nodulosum which has characteristic swellings of hyphae. related l. acerosum is most similar when it comes to size of phialides and conidia but it can be easily distinguished by its long, thin, acerose spores. colour illustrations. białowieża primeval forest logging site, poland. fourteen-day-old colonies of l. praecognitum on sda at °c, obverse (left) and reverse (right); solitary phialides; octahedral crystals in medium; conidia; apical hyphae with whorls of phialides and secondary phialides. scale bars = µm. notes -prior to this study, macalpinomyces contained host-specific species restricted to eriachne (poaceae) in australasia (li et al. ) . macalpinomyces collinsiae is the twelfth species, known only from the type specimen on e. benthamii in north-western australia. all species of macalpinomyces are morphologically similar and can only be reliably separated by host range and molecular phylogenetic analysis. phylogram obtained from a maximum likelihood analysis of the its region of rdna in iqtree v. . beta (nguyen et al. ) with a model test for each partition (command -m test -spp) . arlt values (≥ %) (guindon et al. ) and ultrafast bootstrap values (≥ %) (hoang et al. ) from replicates above nodes. minimum spanning network (bandelt et al. ) mallocybe crassivelata ferisin, bizio, esteve-rav., vizzini & dovana, sp. nov. etymology. from the latin crassus (thick) and velatus (with a veil), referring to the presence of a thick, abundant veil on the pileus surface. classification -inocybaceae, agaricales, agaricomycetes. basidiomata stipitate. pileus - mm diam, at first convex, then applanate to plano-convex, without umbo, with an inflexed margin when young, fibrillose-tomentose to woolly-tomentose, sometimes scaly, when moist almost smooth; initially ochraceous yellow (mu yr / ) to ochraceous brown (mu . y / ), brown with an olivaceous tinge when moist, sometimes fulvous orange (mu . yr / ) at disc; in young basidiomes with a thick, white velipellis. lamellae rather crowded to crowded (l = - ), with lamellulae (l = - ), adnexed to arcuate, sometimes subdecurrent, initially pale ochraceous with a faint olivaceous hue, then brown; edge whitish to concolourous, crenulate. stipe - × - mm, cylindrical, solid, then becoming fistulose, pale yellow to concolourous with pileus in aged basidiomes; surface fibrillose, white towards the base for the presence of a white velipellis; white cortina present in young basidiomes. context yellowish in pileus, somewhat and ochraceous brownish in stipe. smell earthy sometimes mixed with a subspermatic component. taste indistinct. basidiospores ( . -) . - . - . (- . ) × ( . -) . - - . (- . ) µm, q = ( . -) . - . - . (- . ), smooth, yellowish, very variable in shape, ellipsoid to subphaseoliform, sometimes amygdaliform in side view with obtuse or sub-ogival apex; presence of anomalous long spores (over μm, probably discharged from bisporic basidia), walls up to . μm thick. ) × ( . -) . - . (- . ) µm, clavate to cylindrical, -spored, sometimes - -spored, with inner olivaceous guttulae and brown necropigment, sterigmata up to µm long; sometimes they are rarely present on lamella edge. hymenophoral trama regular, formed by cylindrical to ellipsoidal, - µm wide elements, with a brownish wall; subhymenium consisting of up to µm long elements, - µm wide. cheilocystidia very numerous, ( . -) - . (- . ) × ( . -) . - . (- . ) µm, hyaline, usually thin-walled, very variable in shape, cylindrical, oblong to clavate, with a few septa; mixed with basidia. pleurocystidia absent. caulocystidia present at stipe apex ( / ), at least partly catenulate with terminal element as true cystidium, from ellipsoid to ovoid, up to µm long. pileipellis an undifferentiated cutis with some ascending hyphae; terminal elements cylindrical to subcylindrical, - × - µm, with ochraceous-brown parietal pigment. clamp-connections present. habitat & distribution -gregarious in deciduous (fagaceae) or coniferous (picea abies, pinus sylvestris) forests. so far known from italy, slovenia and spain. typus. slovenia, pregarje, m asl, under fagus sylvatica, june , g. ferisin (holotype mcve ; its and lsu sequences genbank mn and mn , mycobank mb notes -terminology for descriptive terms is according to kuyper ( ) and vellinga ( ) and colour codes are taken from munsell ( ) . in our phylogeny m. crassivelata belongs to a well-supported clade (bootstrap support value = %) together with m. leucoloma, m. malenconii, m. myriadophylla and three sequences of 'uncultured inocybe sp.' (genbank jx , jx , jx ) from the usa and associated with dryas integrifolia. mallocybe crassivelata shows, as major morphological features, a rather fleshy, predominately ochraceous basidioma, fibrillose-tomentose to woolly-tomentose pileus covered with a thick white velipellis, narrow subphaseoliform spores and an earthy smell (similar to that of inosperma cervicolor) often associated to a subspermatic component, though in some collections (ah ) nearly indistinct. mallocybe leucoloma differs from the new species mainly by a smaller and slender habit, different shape of cheilocystidia (often pyriform), sub-odourless context and being associated with dwarf salix or dryas (kühner ) . mallocybe malenconii can easily be distinguished by its longer spores ( - × - . μm) with mean q-value of c. . (vauras & larsson ) and an indistinct smell (heim ) . compared to m. crassivelata, m. myriadophylla has a pale grey cortina, very narrow and crowded lamellae (- mm wide), smell 'indistinct to somewhat fungoid and slightly metallic' and seems strictly associated with betula pendula (vauras & larsson ) . mallocybe hebelomoides is characterised by a smaller size, broadly elliptical to subovoid spores with q = . - . and habitat under dwarf salix species (kühner classification -marasmiaceae, agaricales, agaricomycetes. basidiomata small to medium sized, collybioid. pileus - (- ) mm, initially hemispherical, convex, becoming plane at maturity, apricot ( ; flora of british fungi chart ), sometimes paler orange ( ) margin, and darker sienna ( ) centre, dry, smooth to finely matt, margin entire, not in-rolled. pileus colours display much variation depending on weather, tending to wash out in rain, and increase in intensity in dry weather. flesh thin, white. lamellae white, margins white or concolourous with pileus, free to adnexed, close, - , - mm deep, with - series of lamellulae, very fine shallow cross-anastomoses, mostly in outer half of cap, and not always present in juveniles. stipe central, cartilaginous, - × - mm, white to cream full length of stipe, or occasionally yellowish brown lower half, smooth, hollow, cylindrical, sometimes bi-tubular; basal hyphae forming a white tuft. spore print white. basidiospores variable between collections, with holotype at lower end of range, ( . -) - . (- . ) × ( . -) - (- . ) μm (av. × . μm, q = . - . , q m = . ± . , n = , s = specimens), slightly curved ellipsoid to elongate, hyaline, inamyloid, with some granular contents. basidia - × - . μm, sterigmata short, rounded, - . μm, - -spored. basidioles - × - μm, clavate. cheilocystidia common, siccus-type broom cells, with short to very long apical divergent projections, main body - × - μm, digits - × - μm, with - (- ) digits, mostly thin-walled, with body also thin-walled except for outer / at base of projections; narrowly to broadly and irregularly cylindrical, clavate, occasionally branched; rare smooth, mucronate cheilocystidia also found, × μm. pleurocystidia absent. pileipellis consists of a hymeniderm of siccus-type broom cells, main body - (- ) × . - . μm, digits . - . × - μm, broadly clavate, cylindrical, ± branching with sparse to common digits, usually thin-walled at base, often thick-walled and refractive in upper two-thirds, and including the digits, which may be bifid; pileal hyphae . - μm. caulocystidia absent. stipitipellis of parallel hyphae, . - μm diam. clamp connections present in all tissues. melzer's reaction -pileal and lamellar trama inamyloid, stipe trama mildly dextrinoid. habit, habitat & distribution -gregarious in habit and at times caespitose, it may also fruit in rings. a terrestrial saprotroph in accumulated leaf litter, the natural habitat in undisturbed sites varies from shaded microsites in tropical savanna woodland, to grassland and margins of tropical rainforest across more than km of northern australia. for approximately yr it has also been found growing in suburban lawns and highly disturbed habitats in florida, usa. typus. australia, queensland, mt carbine, s ° ' . " e ° ' . ", in savanna grassland leaf litter, mar. , f. guard & s. mcmullan-fisher smf (holotype aq ; its and lsu sequences genbank mt and mt , mycobank mb ). notes -marasmius vagus is characterised by a small to medium, orange to apricot, smooth pileus, close gills with cross-anastomoses and an all-white or pale cartilaginous stipe. these characters, with cheilocystidia of siccus-type broom cells, in the absence of pleurocystidia and caulocystidia and a well-developed, non-collariate, non-instititious stipe place this species in sect. globulares (group sicci ) subsect. siccini ser. leonini. marasmius vagus is sister to a well-supported m. hypochroides/ m. vladimiri clade. marasmius hypochroides (berkeley & broome ) described from sri lanka, but found across southern asia, forms more robust, darker basidiomes ( - mm) with longer stipes ( - mm) that have dark reddish brown bases. marasmius vladimiri (crous et al. ) from india, is brighter in colour (orange scarlet with orange chestnut disc), has a coloured stipe with slightly shorter spores and larger basidia ( - μm). marasmius vagus also bears a superficial resemblance to the australian species marasmius elegans (grgurinovic ) that has bicoloured stipes (white above, brown below) and lacks cross-anastomoses in the lamellae. our analyses of its data show that m. elegans and m. vagus are not genetically closely related. marasmius vagus is native to northern australia where it is widely distributed amongst native vegetation in the monsoon tropics; it has been recorded there for more than yr. however, it has also been found in lawns in the tourist mecca, cairns, and several other towns in southeast queensland. in florida this species has been collected almost exclusively in suburban lawns and highly disturbed habitats, with the oldest known observation (mushroom observer, obs. ) from , suggestive of a recent introduction to florida, usa. there are no records that this species was collected by florida mycologists from previous generations, such as william murrill ( - (weber ) or james kimbrough ( - (smith & healy microdochium dawsoniorum c. lock, vitelli, holdom, y.p. tan & r.g. shivas, sp. nov. etymology. named after the dawson family from taunton, queensland, on whose property the fungus was first collected. classification -michrodochiaceae, xylariales, sordariomycetes. conidiophores abundant in a dense compact layer, occasionally branched, mostly reduced to conidiogenous cells. conidiogenous cells cylindrical to irregular, flexuous, - × - μm, narrowed towards the tip, hyaline, smooth. conidia flexuous to falcate, - -septate, sometimes with a geniculation, - × - μm, acute at the tip, narrow at the base. sexual morph not seen. culture characteristics -colonies on oatmeal agar (oa) after wk covering cm diam plates, flat, mycelium in compact irregular to concentric scattered salmon tufts, with abundant slimy apricot sporodochia up to mm arranged in irregular to concentric rings. reverse pale saffron with sporodochia apparent as darker patches. mycelium immersed or superficial, hyphae hyaline, septate, smooth. mollisia gibbospora i. kušan, matočec, pošta, tkalčec & mešić, sp. nov. etymology. named after the protuberances on living, mature ascospores. ascomata apothecial, shallowly cupulate to plate-shaped when young, becoming sub-pulvinate to pulvinate when fully mature, superficial, sessile, ± circular from the top view, * . - (- . ) mm diam, solitary or gregarious (up to few apothecia). hymenium whitish grey to pale lead-grey, not wrinkled but notably finely pruinose; margin slightly irregular, ± sharp, whitish, not concolourous with the hymenium, smooth, entire, finely wavy; excipular surface brownish from base to the upper flank, smooth. basal hyphae macroscopically indistinguishable. asexual morph not seen. hymenium * - µm thick. asci cylindrical with conical-subtruncate apex, * - × ( . -) . - . µm, pars sporifera * - µm, -spored, of which - are gibbose, in living state protruding above ordinary paraphyses up to µm, base cylindrical-truncate, arising from croziers, in lugol's solution (iki) apical ring of medium amyloidity ( bb) of calycina-type. ascospores subscutuloid, with rounded poles, majority of them having lateral or apical protuberation(s) already in *mature asci, -celled, * . - . - . (- . ) × . - . - µm, *q = . - . - . (- . ), - (- ) protuberations per spore, up to . µm high and . - . µm wide, hyaline, smooth, uninucleate, *sporoplasm with one to few non-refractive vacuoles, freshly ejected apically with sheath remnants persisting mostly around protuberations, biseriate inside *asci, lipid bodies scanty, overmatured partly with single septa; in iki unstained, nucleus slightly contrasted, vacuoles hyaline and non-refractive. paraphyses cylindric-obtuse, widest in the subapical or in the middle part, apical cell * - . × ( . -) . - . µm, some far projecting, exceeding living asci ('macroparaphyses'), * - × . - . µm, straight, simple, *containing single cylindrical strongly refractive vacuolar body (vb), wall thin and hyaline; in koh without yellow reaction; in iki vbs not stained, soon collapse. subhymenium * - . µm thick at the middle flank, hyaline, composed of densely packed epidermoid cells * . - . µm wide. medullary excipulum * . - µm thick at the middle flank, reaching µm in the central part, hyaline, composed of textura intricata, cells * . - µm wide, at the border with ectal layer somewhat swollen, reaching . µm in width, thin-walled, koh-soluble globules present, in iki not stained, . - µm wide, devoid of crystals. ectal excipulum * - µm thick at the middle flank, reaching µm in the basal part, composed of textura angularis, cells * . - . × . - . µm, upper flank and inner layers of lower flanks subhyaline and contain refractive koh-soluble and iki unstainable globules, while outer layer of lower flanks tobacco brown with cell walls * . - . µm thick, most of the terminal clavate cells in the cortical layer of upper and middle flank contain single, hyaline and highly refractive vb. marginal tissue very thin, * - . µm thick, composed of several cylindricalclavate cells, * . - . µm wide, thin-walled, each containing short cylindrical or elongated vb. subicular hyphae confined to an apothecial base only, forming plaques, smooth, greyish brown, * . - . µm wide, walls * . - . µm thick. asterisk (*) denotes living material. ascus amyloidity is termed after baral ( ) and spore shape after kušan et al. ( ) . distribution & habitat -sporogenous phases of the species are known so far from the type locality on mt velebit, croatia, and (?)new zealand (unpubl. data). croatian collection is found on a decorticated fallen branch of fagus sylvatica (originally a part of the trunk), lying in a moist litter at the edge of a natural karstic pond in a subalpine type of forest while new zealand collection originates from decorticated wood. notes -tanney & seifert ( ) performed the first multigene analysis of the mollisiaceae s.lat. a detailed polyphasic taxonomic analysis in this group is still missing. according to our analysis of its - . s-its nrdna data (see fp ), m. gibbospora is conspecific with mollisia sp. (genbank mg ) whose dna sequence is derived from germinated ascospores of specimen pdd (unpublished) as well as with ascomycota sp. (genbank kc ) isolated from wooden structures on antarctica (held & blanchette ). several other unidentified sequences from genbank share identities higher than % with m. gibbospora (kauserud et al. , klaubauf et al. ). this group of isolates form the youngest phylogenetic lineage in mollisiaceae among analysed sequences. it is evident that the mollisiaceous group comprises a number of generic representatives whose species, assigned to large genera such as mollisia and pyreno peziza are mixed together thus clearly showing polyphyly in both genera. numerous species attributed to some other genera, such as asexual acidomelania and phialocephala (cf. crous et al. a) , sexual-aquatic loramyces spp. and obtectodiscus aquaticus form phylogenetic groups along with certain members ascribed to the genus mollisia. tanney & seifert ( ) synonymised acidomelania with mollisia, while loramycetaceae falls into synonymy with mollisiaceae, which is supported in our analysis. until now, regularly present lateral and apical protuberations in fully mature, dormant and freshly ejected ascospores were not reported in the genus mollisia. even though m. gibbospora is macroscopically very much alike to a number of species in the genus (including its type m. cinerea), it is readily distinguishable according to the following microscopical differential characters: ) living inner ectal excipular and some medullary excipular cells contain freely floating, hyaline and moderately refractive globules which are not stainable by crb nor by iki, and are soluble in koh; ) living mature asci containing four to eight gibbose ascospores; ) ascospore sheath is fairly longlived after spore ejection but retained around individual spore protuberations; and ) some paraphyses are extremely long, far projecting above living mature asci, giving finely pruinose appearance of hymenial surface on living apothecia. colour illustrations. croatia, mt velebit, subalpine beech forest in javornik area -type locality. *apothecia; vertical median section of the apothecium; upper excipular flank; lower exc. flank; margin; *asci and paraphyses, asci in iki; mature ascospores in *asci; *ascospores; *'macroparaphyses'. scale bars = mm (apothecia), µm (apothecial anatomy) and µm (microscopic elements). fp maximum likelihood phylogenetic tree inferred from the dataset of its - . s-its gene sequences from mollisia gibbospora and related species. classification -didymosphaeriaceae, pleosporales, dothideomycetes. hyphae pale brown to brown, smooth-and thin-walled, septate, - µm wide. conidiomata pycnidial, brown to dark brown, solitary, superficial (on oatmeal agar, oa), globose to subglobose, × - µm, covered by brown, asperulate, septate setae of - µm long and . - µm wide at the base, pycnidial wall of textura angularis, - -layered, - µm thick, composed of brown to dark brown, flattened polygonal cells of - µm diam, neck absent, ostiolate. conidiogenous cells phialidic, ampulliform to doliiform, hyaline, smooth-walled, × . µm. conidia aseptate, hyaline, smooth-and thin-walled, cylindrical, sometimes slightly curved, - × . - µm, guttulate. culture characteristics -colonies on oa reaching mm diam after d at ± °c, flattened, white (m. a ; kornerup & wanscher ( ) notes -this fungus differs from all known species of montagnula by the in vitro formation of a coelomycetous asexual morph, and by the absence of a sexual morph (tennakoon et al. , valenzuela-lopez et al. ). based on a megablast search of ncbis genbank nucleotide database, the closest hit using the lsu sequence is montagnula cirsii strain mflucc - (genbank kx ; identities = / ( %), no gaps). closest hit using its sequence is montagnula scabiosae type strain mflucc - (genbank nr_ ; identities = / ( %), gaps). the closest hit using the tub sequence is montagnula saikhuensis strain mflucc - (genbank ku ; identities = / ( %), no gaps). the closest hit using the rpb sequence is montagnula opulenta strain aftol-id (= cbs . ) (genbank dq ; identities = / ( %), gaps). the closest hit using the tef sequence is bimuria novae-zelandiae type strain aftol-id (= cbs . ) (genbank dq ; identities = / ( %), gaps). maximum likelihood (ml) tree obtained from its of our isolate and sequences retrieved from genbank. alignment and tree building were performed by mega v. . (tamura et al. ). the ml bootstrap support values (≥ %) are provided at the nodes. tremateia arundicola mflucc - and tremateia guiyangensis gzaas were used as outgroup. the new species proposed in this study is indicated in bold. t represents ex-type strains of the species used in this analysis. jurjević, Čmoková & hubka, sp. nov. notes -blast analysis with the its sequences of m. oklahomaensis showed low similarity with members of different genera, including austroafricana parva ( . - %), pseudotaeniolina globosa ( . %) and camarosporula persooniae ( . %), other taxa had similarity lower than %. the lsu nrdna sequence showed - % similarity to a wide variety of genera in the teratosphaeriaceae with devriesia shelburniensis having the highest degree of similarity ( . %). the position of muriphila within teratosphaeriaceae is unresolved. neither lsu nor ssu phylogenetic analyses comprising teratosphaeriaceae genera (quaedvlieg et al. ) were able to resolve its position with satisfactory support. in the resulting phylogenetic trees, the genus muriphila was most commonly placed close to genera batcheloromyces and devriesia (data not shown). muriphila oklahomaensis resembles morphologically meristematic rock-inhabiting fungi that are relatively common in teratosphaeriaceae (egidi et al. mycelium on synthetic nutrient-poor agar (sna) consisting of branched, septate, olivaceous grey (rayner ) , moniliform hyphae with aerial hyphae absent. chlamydospores not observed. conidiophores arising from hyphae occasionally reduced to conidiogenous cells, thick-walled, cylindrical, straight to slightly curved, long, septate, brown with an apical conidiogenous apparatus. conidia smooth, cylindrical, sometimes in acropetal chains, apex and base truncate with one and occasionally two septa, ( . -) . (- . ) × ( . -) . (- . ) μm (n = although morphologically very similar to devriesia it is phylogenetically distinguishable. neodevriesia aestuarina is the first member of the genus isolated from saline water, but other species have been found in a marine environment associated with macroalgae. based on a megablast search of ncbis genbank nucleotide database, the closest hits using the its sequence are neodevriesia capensis (genbank mk ; identities = / ( %), gaps ( %)) and an uncultured marine ascomycete (genbank af ; identities = / ( %), gaps ( %)). closest hits using the lsu sequence had highest similarity to neodevriesia grateloupiae (genbank ku ; identities = / ( %), gaps ( %)), neodevriesia cladophorae (genbank ku ; identities = / ( %), gaps ( %)) and neodevriesia strelitziae (genbank gu ; identities = / ( %), gaps ( %)). conidia subcylindrical, fusoid or ellipsoid to fusoid, individually hyaline, olivaceous green at maturity, with transverse septum, thin-and smooth-walled, ( . -) . - . (- . ) × ( . -) . - . (- . ) µm, mean ± s.d. . ± . × . ± . µm, l/w ratio = . . culture characteristics -colonies on malt extract agar (mea) reaching - cm diam in the dark, at °c, after wk, slow growing, white to dirty white in the first week, becoming yellow-green with pale irregular margin after wk, moderate aerial mycelium, reverse iron-grey to umber, with age. notes -based on a megablast search of ncbi nucleotide database, the closest hits using the its sequence had the highest similarity to neosetophoma aseptata (genbank nr_ . ; identities = / ( %) , no gaps), neosetophoma lunariace (genbank nr_ . ; identities = / ( %) , no gaps) and neosetophoma shoemakeri (genbank nr_ . ; identities = / ( %), gap ( %)). the closest hits using the lsu sequence had the highest similarity to loratospora aestuarii (genbank gu . ; identities = / ( %) , no gaps), ophiosphaerella herpotricha (genbank dq . ; identities = / ( %), gap ( %)) and phoma cladoniicola (genbank jq . ; identities = / ( %), no gaps); closest hits using the rpb sequence are brunneomurispora lonicerae (genbank mk . ; identities = / ( %), no gaps), ophiosphaerella herpotricha (genbank dq . ; identities = / ( %), gaps ( %)) and phaeopoacea festucae (genbank ky . ; identities = / ( %), no gaps). sequences of all known neosetophoma species were retrieved from genbank and aligned with sequences of the isolate obtained in this study. alignments were done with clustalx v. . (thompson et al. ). kimura's two parameter model with gamma distribution (k +g) was used as the best nucleotide substitution model. the maximum likelihood (ml) analysis was performed using mega v. software (kumar et al. ) . the robustness of the ml tree was evaluated by bootstrap replications. maximum likelihood tree obtained from the its and lsu gene sequences of neosetophoma species of our isolates and sequences retrieved from genbank. the tree was built using mega v. . . bootstrap support values above % are shown at the nodes. the species described here is highlighted in bold. the alignment and tree are available in treebase (study s ). conidiophores terverticillate; stipes coarsely roughened, - × - . µm; synnemata up to mm long; branches - µm; metulae - , - × . - . µm; phialides ampulliform, - per metula, - . × - µm. conidia smooth, broadly ellipsoidal, - . × . - µm. culture characteristics -( °c, d) czapek yeast autolysate agar (cya): colonies slightly radially sulcate in centre, low; mycelium white; margins irregular; texture fasciculate; soluble pigments brown, moderately produced; exudate droplets small, copious, brown; sporulation moderate; conidia en masse pale grey-green; reverse brown, dark brown in centre. malt extract agar (mea): colonies plane, elevated in the centre; mycelium white; margins slightly irregular; texture fasciculate; soluble pigments absent; exudate droplets large, pale brown; sporulation strong; conidia en masse dull to grey-green; reverse brown in centre, pale brown at edge. yeast extract sucrose agar (yes): colonies slightly radially sulcate, raised; mycelium white; margins entire; texture floccose; soluble pigment present, brown, weakly produced; exudates absent; sporulation moderate to strong; conidia en masse dull to grey-green; reverse reddish brown (copper). dichloran % glycerol agar (dg ): colonies plane, raised at the centre; margins entire or slightly irregular; mycelium white; texture fasciculate; soluble pigments present, light brown, weak; exudates absent; sporulation strong; conidia en masse dull green; reverse reddish brown (copper) or reddish brown in centre, yellowish brown at edge. oatmeal agar (oa): colonies plane, low; margins regular, thin; mycelium white; texture fasciculate; soluble pigments light brown present, moderately produced; exudates brown present, small; sporulation strong; conidia en masse dark green. notes -a blast search of bena, cam and its sequences of p. taurinense against an in-house reference sequence database containing data of all accepted penicillium species, re trieved the highest similarities with penicillium glandicola, p. geumsanense and p. synnematicola, clearly indicating that the species belongs to penicillium sect. robsamsonia ser. glandicolarum (houbraken et al. unpubl. data) . phylogenetic analyses showed that p. taurinense is sister to a clade containing cbs (ex-type strain of p. synnematicola), cbs . (extype of p. granulatum) and cbs (ex-type of p. granulatum var. globosum). the latter two strains were identified as p. glandicola; however, the ex-type of p. glandicola is more distantly related. frisvad & samson ( ) treated p. granulatum as a synonym of p. glandicola based on morphology and extrolite patterns. however, our phylogenetic analysis shows that p. granulatum is an accepted species, with p. granulatum var. globosum being a synonym of that species. furthermore, p. schneggii is confirmed to be a synonym of p. glandicola. penicillium taurinense is phylogenetically distinct from p. synnematicola and p. glandicola (houbraken et al. , guevara-suarez et al. . penicillium taurinense grows faster than p. synnematicola on cya ( - vs - mm), yes ( - vs - mm) and mea ( - vs - mm) at °c. both grows at °c while p. glandicola is not able to grow at this temperature (frisvad & samson , guevara-suarez et al. . furthermore, p. taurinense produces brown exudates on cya compared to hyaline exudate droplets of p. synnematicola and clear to pale yellow ones of p. glandicola. in addition, p. taurinense has a different colony reverse colour on cya, mea, dg and yes, no acid production on crea and shorter phialides compared to p. synnematicola. a taxonomic study dealing with all accepted species in penicillium ser. glandicolarum is lacking, and could reveal more phenotypic differences. classification -peronosporaceae, peronosporidae, oomycota. hyphae hyaline, aseptate, tortuous, . - µm diam. hyphal swellings absent. sporangia produced abundantly in non-sterile soil extract, noncaducous, papillate, mainly ovoid ( %), globose ( %), limoniform ( %), distorted shapes ( %), other shapes ( %), ( -) . - (- ) × ( -) - (- . ) μm (av. . ± × . ± ), length/breadth ratio . ± . . sporangiophores sympodial. chlamydospores not observed. homothallic, abundant gametangia on % carrot agar with β-sitosterol (cas) after d. oogonia globose, smooth-walled, ( -) - (- . ) μm diam (av. . ± . ), borne laterally and terminally. antheridia amphigynous, -celled, ( . -) . - (- . ) × . - (- . ) μm (av. . ± . × . ± . ). oospores observed after wk on cas, globose, plerotic, ( -) - . (- ) μm diam (av. . ± . ), wall thickness ( . -) - (- ) μm (av. . ± . ). culture characteristics -colonies on cas showed appressed to submerged mycelium, without distinct growth pattern, reaching . ± . mm diam after d at °c in darkness. colonies on corn meal agar (cma) white, with moderate to profuse aerial mycelium, cottoned, reaching . ± . mm diam. © naturalis biodiversity center & westerdijk fungal biodiversity institute fungal planet - june phytophthora personensis z.g. abad, w. gut. & t.i. burgess, sp. nov. etymology. named after person county, north carolina, the location where the first specimen of the species was isolated. classification -peronosporaceae, peronosporidae, oomycota. sporangia produced abundantly in non-sterile soil extract; persistent and produced usually on unbranched sporangiophores, non-papillate, most commonly ovoid ( %), often ellipsoid ( %) and rarely limoniform or obpyriform; . ± . × . ± . µm (overall range . - . × . - . µm), length/ breadth ratio . ± . . sporangial proliferation in chains of internally proliferating sporangia, both nested and extended. hyphal swellings common, catenulate to globose -( . ± . )- . µm. chlamydospores common, globose . -( . ± . )- . µm. gametangia not produced in single culture or when paired with a and a tester strains of p. cinnamomi, p. tropicalis, p. cryptogea and p. cambivora. radial growth rates on v agar at optimum temperature ( - °c) and near the maximum temperature ( . °c), . ± . mm/d and . ± . mm/d, respectively. culture characteristics -submerged colonies with no pattern were produced on malt extract, carrot and v agar. cottony colonies with regular margins were produced on potato dextrose agar. © naturalis biodiversity center & westerdijk fungal biodiversity institute fungal planet - june kiyashko, sp. nov. etymology. name refers to roridomyces irritans, a species which is morphologically similar. classification -mycenaceae, agaricales, agaricomycetes. pileus at first convex, then plano-convex with depressed or subumbilicate centre, up to . mm diam (dried specimens), radially pellucid-sulcate-striate almost up to centre, margin reflexed, crenulate, membranaceous, surface dry, velvety at centre, pallid, greyish orange ( b - , kornerup & wanscher ) , turning yellowish white ( a ) to white towards margin, sometimes with blurred reddish brown ( d - , c - ) spots. lamellae arcuate decurrent, moderately distant ( - reach to the stipe), with - series of lamellulae, thin, whitish to pale greyish orange (like cap centre), sometimes also with spots, edge concolourous, slightly eroded. stipe cylindrical, slightly attenuated towards apex, up to × . mm, shiny, polished, faintly pellucid, whitish at apex, darkening to brownish orange or brownish yellow ( c - ) towards base, covered with thick, glassy glutinous sheath, without strigose hairs at base. context thin, concolourous with cap and stipe surfaces, odour not recorded. basidiospores ellipsoid to oblong, rarely subcylindrical, . - . (- . ) × - . (- . ) mm (x av = . ± . × . ± . mm, q = ( . -) . - . (- . ), q av = . ± . , n = , s = ), with small apiculus, smooth, hyaline, amyloid. clamped, subclavate, . ) × . - mm, thinwalled, inamyloid. basidiolae subclavate or subfusoid, more rarely subutriform, - . × . - mm, thin-walled, inamyloid. lamellar edge sterile. cheilocystidia short and not much exceeding basidia, - . × . - . mm (n = , s = ), mostly clavate to subcapitate, rarely clear capitate, sometimes bifid or septate, thin-walled, occasionally with slightly thickened walls or yellowish content, colourless, smooth, inamyloid. pleurocystidia absent. hyphae of subhymenium cylindrical, smooth, hyaline . - . (- . ) mm diam. pileipellis hymeniform, composed of spheropedunculate (sometimes on very long pedicel) or broadly clavate cells with or without constrictions, . - . × . - . mm, sometimes connected in short chains, smooth, with slightly thickened colourless or brownish walls, sometimes with yellowish content. stipitipellis hyphae - (- . ) mm diam, cylindrical, smooth, uncoloured, thin-walled, parallel, with not abundant caulocystidia. caulocystidia . - . (- . ) × . - . (- . ) mm, narrowly clavate to subcylindrical, rarely more or less capitate, thin-walled, sometimes with slightly thickened walls, smooth, uncoloured, inamyloid. clamp connections on all hyphae. habitat & distribution -gregarious to caespitose on rotten wood in montane mixed forest of broad-leaved trees and pinus kesiya. typus . vietnam, Đắk lắk province, lắk district, chư yang sin national park, ≈ km to the south from krông kmar town, n ° ' . " e ° ' . ", h ≈ m asl, on rotten wood, may , a.a. kiyasko, -ak- (holotype le ; its and lsu sequences genbank mt and mt , mycobank mb ). notes -roridomyces includes species, the most of which are described from the southern hemisphere. morphologically, r. irritans from new caledonia and papua new guinea is the closest to r. pseudoirritans. although they have overlapping spore dimensions, r. pseudoirritans clearly differs from r. irritans by having short cheilocystidia: - . mm vs - mm according to horak ( ) . furthermore, cheilocystidia of r. pseudoirritans are not clearly capitate and may even be bifid or septate. its caulocystidia are also short and narrowly clavate to subcylindrical. among other small-spored species r. lamprosporus and r. pruinosoviscidus both have cheilo-and caulocystidia which are irregularly clavate to bifid with diverticulate projections (horak , chew et al. , mycena yirukensis possesses cylindrical-ventricose, broadly ventricose-rostrate or strangulate cheilocystidia and cylindrical caulocystidia with one or few large branches (grgurinovic ) . roridomyces mauritianus differs in having a dark brown cap and abundant pigmented caulocystidia with flexuous, contorted excrescences (robich & hausknecht ) . roridomyces praeclarus has an orange-red pileus, lageniform cheilocystidia and coralloid caulocystia; r. palmensis and r. subglobosus both are characterised by subglobose spores (rexer , miersch & dähncke . the other species (r. albororidus, r. appendiculatus, r. austrororidus, r. fuscororidus, r. ornatororidus and r. roridus) possess larger spores with no overlapping dimensions (rexer , maas geesteranus & meijer . the majority of roridomyces species from the southern hemisphere still lack dna sequence data, and thus their phylogenetic relationships remain unknown. trichophoma cylindrospora magaña-dueñas, cano & stchigel, sp. nov. notes -based on the phylogenetic analysis of the its, lsu and tef- α combined dataset, the closest relative of t. cylindrospora is forliomyces uniseptata. forliomyces uniseptata differs from t. cylindrospora in producing shorter and broader conidia ( - × - µm vs - × - µm), which are brown-coloured when mature (hyaline in t. cylindrospora) (phukhamsakda et al. ). based on a megablast search of ncbis genbank nucleotide database, the closest hit using the lsu sequence was forliomyces uniseptata mflucc - (genbank ng_ , identities = / ( %), no gaps); the closest hits using its was forliomyces uniseptata mflucc - (genbank nr_ , identities = / ( %), gaps ( %)); and the closest hits using the tef- α sequence was forliomyces uniseptata mflucc - (genbank ku , identities = / ( %), no gaps). etymology. from greek κυλινδρικό-, cylindrical, due to the shape of the conidia. hyphae hyaline to brown, septate, branched, thin-walled, smooth to tuberculate, . - µm wide. conidiomata pycnidial, brown to blackish brown, immersed to semi-immersed, solitary, scattered, subglobose to pyriform, - × - µm, ostiolate, setose. conidioma wall - -layered, - µm thick, covered by a mass of interwoven, brown to dark brown hyphae, followed by an outer layer of textura angularis, composed of brown to dark brown, flattened polygonal cells of - µm diam, incrusted with a dark brown to carbonaceous material around the neck; neck dark brown to carbonaceous, cylindrical, - × - µm, covered by brown to dark brown, septate, erect, nodose, thick-walled setae - × - . µm, tapering towards the apex, mainly disposed around the ostiole. conidiophores absent. conidiogenous cells phialidic, determinate, hyaline, smooth-walled, ampulliform, - × - µm. conidia - -septate, hyaline, smooth-and thin-walled, long cylindrical, - × - µm, guttulate, with a narrowly flattened base and rounded at the end. culture characteristics -( d at °c). colonies on potato dextrose agar (pda) reaching mm diam, flattened, velvety, margins regular, yellowish white to reddish brown (m. a / d ; kornerup & wanscher ) ; reverse reddish brown to dark brown (m. e / f ), exopigment reddish brown to golden yellow (m. d / b ). colonies on oatmeal agar (oa) reaching mm diam, flattened, slightly floccose, margin regular, grey (m. f ); reverse grey (m. f ). colonies on malt extract agar (mea) % reaching - mm diam, flattened, velvety to slightly floccose, margins lobate, dark brown to greyish yellow (m. f / c ); reverse greyish brown to greyish orange, with yellowish brown patches (m. f / b / f ). cardinal temperatures for growing -optimum °c, maximum °c, minimum °c. classification -tuberaceae, pezizales, pezizomycetes. ascomata hypogeous, - cm, subglobose, covered with brown-black pyramidal warts, - -sided, - (- ) mm across, - mm high, often depressed at the apex. peridium - μm thick, pseudoparenchymatous, composed of subglobose, angular cells, - μm diam, pale yellow and thin-walled in the innermost layers, dark red-brown and with thicker walls in the outermost layers. gleba firm, solid, white when immature, becoming dark brown at maturity, marbled with numerous, thin, white, meandering veins that do not change colour when exposed to the air. pleasant odour. asci inamyloid, - × - μm, walls thickened, - μm, ellipsoid to subglobose, with a short stalk, - × - μm, ( -) - (- )-spored. ascospores - × - μm, q = . - . , excluding ornamentation, yellowish, ellipsoid to subglobose, ornamented with a coarse irregular reticulum, - µm high, sometimes bending at the top. meshes variable, usually - across width of spore and often with incomplete secondary crests inside. ascospores from -spored asci - × - μm, -spored asci - × - μm, -spored asci - × - μm, -spored asci - × - μm and -spored asci - × - μm. ecology & distribution -tuber alcaracense grows in mediterranean quercus ilex subsp. ballota forest, in limestone mountains of the southeast of the iberian peninsula, - m alt., from december to february. notes -tuber alcaracense is a black truffle of the aestivum clade characterised by its brown-black warty peridium, brown gleba marbled with thin white veins and reticulate-alveolate spores. it resembles tuber mesentericum, but in addition to genetic differences it differs from t. mesentericum (vittadini ) by having a pleasant odour and lacking a basal cavity. colour illustrations. spain, alcaraz mountain range (albacete), mediterranean quercus ilex subsp. ballota forest. ascocarps; mature ascospores. scale bar = μm. . gtr + g selected as model of evolution for analysis. the sequences obtained in the present study are highlighted in bold. bootstrap support values (≥ %) are indicated at the nodes. tuber macrosporum af was used as outgroup. the scale bar indicates the expected changes per site. classification -tuberaceae, pezizales, pezizomycetes. ascomata hypogeous, - cm, subglobose or irregular in form, sometimes lobed, sometimes with a basal depression, fissured in age, yellow brown to reddish brown, minutely warted with pyramidal, flattened warts. peridium - μm thick, composed of hyaline, agglutinated, interwoven hyphae (intricate texture), becoming pseudoparenchymatous towards the surface and forming pigmented, subangular, thick-walled cells, in a superficial layer - μm thick. gleba firm, solid, whitish at first, becoming light-brown, dark-brown or red-brown at maturity, marbled with numerous, branching, white and dark veins. odour pleasant. asci inamyloid, - × - μm excluding stalk, pyriform to clavate or subglobose, with a long or short stalk arising from a crozier, - μm long, walls - μm thick, - (- )-spored. ascospores - × - μm, q = . - . , excluding ornamentation, at first hyaline, yellowish brown at maturity, ellipsoid to ovoid or subglobose, ornamented with short spines, sometimes curved, - (- ) µm long, often connected by lower ridges, making the ornamentation an irregular and incomplete spiny reticulum. ascospores from -spored asci - × - μm, -spored asci - × - μm, -spored asci - × - μm, -spored asci - × - μm, -spored asci - × - μm. ecology & distribution -tuber buendiae grows in mediterranean quercus ilex subsp. ballota forest, in limestone mountains of the southeast of the iberian peninsula, - m altitude. the species occurs all year; maturing during autumn and winter. notes -tuber buendiae is a reddish brown truffle that clusters in the rufum clade, and is characterised by its minutely warted peridium, brown gleba marbled with white and dark veins and spiny-reticulate spores. healy et al. ( ) previously identified it as a hypothetical undescribed species tuber sp. . tuber buendiae resembles tuber pustulatum, but in addition to genetic differences, it differs from t. pustulatum (leonardi et al. ) , by having a pleasant odour, a gleba with numerous veins and spores with shorter spines. classification -venturiaceae, venturiales, dothideomycetes. lesions on leaves and stems, amphigenous, predominantly adaxial, circular to irregular, pale to dark brown, - mm diam, stem lesions pale to dark brown. mycelium internal, . - mm, subcuticular. stromata oblong to subcircular, ( -) - (- ) × ( -) - (- ) µm, formed by swollen thickwalled cells. conidiophores in loose to dense fascicles on stroma, unbranched, thin-walled, straight to slightly curved, pale brown and lighter towards the apex, occasionally thickened at the base, smooth, ( -) - (- ) × ( -) - (- ) µm, - -septate. conidiogenous cells integrated, terminal, one to several conidiogenous loci, slightly guttulate, proliferating sympodially, loci flat, hila convex and slightly thickened and darkened-refractive. conidia solitary or catenate, fusiform, subcylindrical, obclavate, clavate, straight or slightly curved, ( -) - (- ) × ( -) - (- ) µm, - -septate, slightly or not constricted at the septa, brown to pale brown, smooth to verruculose, thickened, apex obtuse, truncate or papillate. culture characteristics -colonies on potato dextrose agar (pda) flat to slightly raised, aerial mycelium feathery, circular to irregular with entire to undulate margin, mm diam after d at °c under h photoperiod. outer edge of colony grey olivaceous, inner part olivaceous; reverse olivaceous to olivaceous black. notes -based on a megablast search of ncbis genbank nucleotide database, the closest matches for its sequence were venturia oleaginea (genbank mn , identities = / ( %), gaps ( %)), fusicladium phillyreae (gen-bank eu , identities = / ( %), gaps ( %)) and venturia inaequalis (genbank mn , identities = / ( %), gap ( %)). closest similarities using the tef -α partial gene sequence were to venturia polygoni-vivipari (genbank kf , identities / ( %), gaps ( %)), venturia ditricha (genbank kf , identities = / ( %), gaps ( %)) and venturia chlorospora (genbank kf , identities / ( %), gaps ( %)). venturia paralias was shown in pathogenicity tests to cause disease on e. paralias and euphorbia segetalis (unpubl. data). venturia paralias is morphologically similar to fusicladium euphorbiae (schubert et al. ) , which has been recorded from e. amygdaloides, e. cy parissias, e. esula, e. exigua, e. lamprocarpa, e. villosa and e. virgata (schubert et al. ) . we were not able to obtain lectotype material of f. euphorbiae from le for comparison. for taxonomic stability we have therefore described the fungus isolated from e. paralias as v. paralias. fusicladium fasciculatum var. fasciculatum, f. fasciculatum var. didymium and f. fautreyi are also morphologically similar to v. paralias. venturia paralias produces distinctive pale to dark brown elongated stem lesions, dense fasciculate conidiophores with conidiogenous loci that are less conspicuous or prominent than those of f. fasciculatum var. fasciculatum and f. fasciculatum var. didymium (deighton , schubert et al. . venturia paralias is distinguished from f. fautreyi by its pale brown conidiophores, less conspicuous conidiogenous loci and -septate conidia (deighton vishniacozyma phoenicis kachalkin, a.s. venzhik & m.a. tomashevskaya, sp. nov. etymology. name phoenicis refers to the date palm, from which fruits the strains were isolated. dipterocarpaceae forest swuf-h (fn , kp , kp swuf-h (fn , fr , fr swuf-h (fn , kp swuf-h (fn , fr , fr dipterocarpaceae forest sut (dq sut (dq annulohypoxylon nitens: thailand, chiang rai province, dipterocarpaceae forest swuf-h (fm , fr , kp swuf-h (fm , fr , kp blast search of species of macalpinomyces, the its sequence of m. collinsiae differs from the sister species m. vankyi (genbank kx ; identities = / ( %), gaps ( %)), and from m. cookei gaps ( %)). the species of macalpinomyces are further illustrated on the smut fungi of australia lucid key eriachne benthamii tussock grassland, mulga downs station centre for crop health queensland alliance for agriculture and food innovation ecosystem science, department of biodiversity, conservation and attractions fungal planet description sheets © naturalis biodiversity center & westerdijk fungal biodiversity institute fungal planet from the latin nebula, meaning cloud, in reference to the fluffy, white, aerial mycelia. classification -pestalotiopsidaceae, xylariales globose or clavate, scattered or aggregated, semi-immersed, black, up to μm diam; exuding dark brown to black conidial masses. conidiophores reduced to conidiogenous cells. conidio genous cells discrete, ampulliform, hyaline, smooth, - × - μm. conidia fusoid, cylindrical, straight to slightly curved, -septate, - × - μm, basal cell conic, hyaline, smooth and thin-walled, - μm long; three median cells doliiform, - μm long, smooth, versicoloured, septa darker than long, hyaline, conic, thin-walled, smooth °c, margin irregular to undulating, whitish, zonate, with fichera (holotype brip , includes ex-type culture; its, tub and tef a sequences genbank mk , mk and mk notes -the multilocus phylogenetic analysis placed n. nebuloides in a clade with n. asiatica, n. chrysea and n. umbrinospora. blastn searches in genbank, restricted to ex-type strains, showed that n. nebuloides differs from n umbrinospora from unidentified plant material in china sporobolus natalensis infestation near conondale, australia. colony on pda at wk; sporulating conidiomata on pda; conidiogenous cells; conidia. scale bars = μm (conidiomata) and μm (conidiogenous cells and conidia) department of agriculture and fisheries plant pathology herbarium, department of agriculture and fisheries centre for crop health benátská , prague , czech republic and laboratory of fungal genetics and metabolism, institute of microbiology of the cas, v.v.i, vídeňská e-mail: petr.hamal@fnol.cz colour illustrations. human skin. fourteen-day-old cultures of paraphyton cutaneum grown at °c on sga, mea and pda (left to right); conidiophores bearing multi-celled macroconidia and one-celled microconidia, free macroand microconidia, macroconidia in sem. scale bars = µm department of agriculture and fisheries plant pathology herbarium, department of agriculture and fisheries dense infestation of sporobolus natalensis near collection site. conidiomata sporulating on pda analyses were done on the geneious v. . . platform (biomatters ltd.) using raxml v. . . (stamatakis & alachiotis ) and mrbayes v. . . (ronquist & huelsenbeck ), both based on the gtr substitution model with gamma-distribution rate variation. branch lengths are proportional to distance. raxml bootstrap (bs) values > % and bayesian posterior probabilities (pp) > . are given at the nodes (bs/pp). pestalotiopsis camelliae was used as outgroup m. gonzález (holotype rgm , culture extype ccct . ; its, lsu, tub, cox , nad and rps sequences genbank mn , mn , mn , mn , mn and mn , mycobank mb ). additional material examined. chile, aysén, on soil associated with rot of a. chilensis notes -phytophthora aysenensis was isolated for the first time from root and collar rot of aristotelia chilensis, a native chilean plant known as maqui or chilean wineberry. phytophthora aysenensis is a homothallic species, belonging to the waterhouse's group ii, which is characterised by amphigynous antheridia and papillate sporangia p. mengei (genbank jq ; identities = / no gaps) and p. botryosa (genbank jq aristorelia chilensis exhibiting dieback and mortality by phytophthora aysenensis in the collection site (photo credit milixsa gonzález oogonia with amphigynous antheridia; plerotic oospore; papillate sporangia. scale bars = µm (others) and µm (hyphae) unidad de fitopatología e-mail: maria.asenjo@sag.gob.cl & monica.gutierrez@sag.gob.cl maximum likelihood tree inferred from the combined its, lsu, tub, cox , nad and rsp regions for selected phytophthora species. dna sequences were aligned using mafft v. . (katoh & standley ) with automatic strategy. the ml analysis was performed in raxml-hpc black-box v. . . (stamatakis ) via the cipres science gateway v. . (miller et al. ), using a gtr+g+i model of evolution fungal planet description sheets © naturalis biodiversity center & westerdijk fungal biodiversity institute fungal planet mediterranean quercus ilex subsp. ballota forest. the collector and her truffle-hunting dog at the collection site; ascocarps gtr + g selected as model of evolution for analysis. the sequences obtained in the present study are highlighted in bold. bootstrap support values (≥ %) are indicated at the nodes. tuber spinoreticulatum (genbank fj ) was used as outgroup. the scale bar indicates the expected changes per site. species hypotheses for undescribed species (tuber sp ethanol (weak), glycerol, erythritol, ribitol, galactitol, d-mannitol, d-glucitol, myo-inositol, methyl alpha-d-glucoside (weak), salicin, dl-lactic acid (weak), citric acid, succinic acid, d-gluconate, d-glucoronate, d-glucosamine (weak), n-acetyl-d-glucosamine, -keto-d-gluconate, -keto-d-gluconate and arbutin are assimilated (holotype kbp y- preserved in a metabolically inactive state, ex-type cultures vkm y- = dsm = cbs ; ssu, its-d /d domains of lsu nrdna, tef and rpb sequences genbank mn , mn , lr and lr , mycobank mb ). additional material examined. russia, moscow, from dates fruit bought on local market leninskie gory str. / , russia and all-russian collection of microorganisms, g.k. skryabin institute of biochemistry and physiology of microorganisms ras leninskie gory str. / , russia; e-mail: rhysenn skryabin institute of biochemistry and physiology of microorganisms ras, , pushchino, pr. nauki , russia; e-mail: tomkotik@rambler.ru colour illustrations. russia, moscow, dates fruit on local market t (genbank mk ; . % similar, subst. and gaps); using lsu these are v. peneaus cbs t (genbank ng_ ; . % similar, subst.) and some strains genbank fj ); using ssu these are strain v. pseudopenaeus cgmcc . t (genbank mk ; . % similar, subst.) and v. peneaus cbs t in compliance with a recent phylogenetic analysis of the genus (tsuji et al. ), the placement of the new species is demonstrated using the combined its and lsu rdna phylogeny. vishniacozyma phoenicis differs from other species of the genus by good growth (v. taibaiensis with weak growth) on % w/w glucose media. the new species can be also differentiated from v. peneaus based on its ability to assimilate ethanol, creatinine, potassium nitrate, growth on vitamin-free medium and on mea with % nacl, and differ from v. pseudopenaeus by its ability to assimilate dl-lactic acid and soluble starch, production of starch-like compounds and its inability to growth at °c maximum likelihood (ml) tree obtained from the combined analysis of its and lsu sequence data. bootstrap support values above % are shown at the nodes. the alignment included bp and was performed with mafft v pileipellis cutis, consisting of septate and elongate, non-gelatinous, slightly thick-walled hyphae, - μm wide. cheilocystidia numerous, variable in size and shape: predominantly ventricoselageniform, broadly fusiform, more rarely narrowly to broadly clavate or utriform -) -spored, broadly clavate, thickwalled vagayskiy district, near kobjakskaja village, low (minerotrophic) swamp, n ° ' " e ° ' notes -volvariella paludosa is characterised by its rather large basidiospores compared to other known species of volvariella, medium-sized basidiocarps with light grey and hairy pilei, whitish volva and variable hymenial cystidia, and rich fen habitat. the preferred habitat, hairy pileus and spore size are the key characters for separating v. paludosa from other species with grey, fibrillose pilei, such as v. volvacea, v. murinella, v. taylorii. the phylogenetically closest species, shape (justo & castro vagayskiy district, near kobjakskaja village, rich fen, where the holotype was collected. top: mature basidiocarp; median: pileus (view from above); bottom: lamellae and volva; bottom: basidiospores and basidia; on the right: four various cheilocystidia and two various pleurocystidia (all from holotype) tobolsk complex scientific station of the ural branch of the russian academy of sciences, , academic yuri osipov str popov str., saint petersburg, russia; e-mail: e_malysheva@binran.ru best tree from the ml analysis of the nrits dataset for volvariella species with cantharocybe gruberi as outgroup, generated on raxml server v evolution of lifestyles in capnodiales hidden fungal diversity from the neotropics: geastrum hirsutum, g. schweinitzii (basidiomycota, geastrales) and their allies fungal biodiversity profiles - calvatia nodulata, a new gasteroid fungus from brazilian semiarid region la familia geoglossaceae ss. str. en la península ibérica y la macaronesia phylogenetic and morphotaxonomic revision of ramichloridium and allied genera biodiversity of the genus cladophialophora median-joining networks for inferring intraspecific phylogenies lugol's solution / iki versus melzer's reagent: hemiamyloidity, a universal feature of the ascus wall common but different: the expanding realm of cladosporium species and ecological diversity within the cladosporium cladosporioides complex (davidiellaceae, capnodiales) cladosporium species in indoor environments enumeration of the fungi of ceylon, part a global meta-analysis of tuber its rdna sequences: species diversity, host associations and long-distance dispersal seiridium (sporocadaceae): an important genus of plant pathogenic fungi fastgap . . department of bio-sciences phytophthora inundata sp. nov., a part heterothallic pathogen of trees and shrubs in wet or flooded soils taxonomic manual of the erysiphales (powdery mildews) new species from phytophthora clade a: evidence for recent radiation banksialactones and banksiamarins: isochromanones and isocoumarins from an australian fungus, aspergillus banksianus redefining common endophytes and plant pathogens in neofabraea, pezicula, and related genera treedyn: towards dynamic graphics and annotations for analyses of trees bioluminescent fungi from peninsular malaysia -a taxonomic and phylogenetic overview microsporum mirabile and its teleomorph arthroderma mirabile, a new dermatophyte species in the m. cookei clade subgenus mallocybe (inocybe) in the rocky mountain alpine zone with molecular reference to european arctic-alpine material fungal diversity and seasonal succession in ash leaves infected by the invasive ascomycete hymenoscyphus fraxineus fungal planet description sheets they seldom occur alone phylogenetic lineages in the capnodiales the genera of fungi -g : arthrinium, ceratosphaeria, dimerosporiopsis, hormodochis, lecanostictopsis, lembosina, neomelanconium, phragmotrichum, pseudomelanconium, rutola, and trullula fungal planet description sheets eucalyptus microfungi known from culture. . cladoriella and fulvoflamma genera nova, with notes on some other poorly known taxa fungal planet description sheets - fungal planet description sheets foliar pathogens of eucalypts fungal planet description sheets fungal planet description sheets - unexpected ribosomal dna internal transcribed spacer sequence variation within erysiphe aquilegiae sensu lato taxonomy of the onygenales: arthrodermataceae, gymnoascaceae vamsapriya (xylariaceae) re-described, with two new species and molecular sequence data modeltest-ng: a new and scalable tool for the selection of dna and protein evolutionary models new species of lactarius from kumaon himalaya lactifluus piperatus (russulales, basidiomycota) and allied species in western europe and a preliminary overview of the group worldwide toward a novel multilocus phylogenetic taxonomy for the dermatophytes waterborne exophiala species causing disease in cold-blooded animals studies on cercospora and allied genera. ii. passalora, cercosporidium and some species of fusicladium on euphorbia phylogeny.fr: robust phylogenetic analysis for the non-specialist new taxa and combinations of aquatic hyphomycetes gasteromycetes of congo the geoglossaceae of north america muscle: multiple sequence alignment with high accuracy and high throughput phylogeny and taxonomy of meristematic rock-inhabiting black fungi in the dothidemycetes based on multi-locus phylogenies families and genera of diaporthalean fungi associated with canker and dieback of tree hosts greeneria uvicola, cause of bitter rot of grapes, belongs in the diaporthales les champignons supérieurs de la zone alpine du parc national suisse some species of cortinariaceae and russulaceae in the alpine belt of the belaer tatras -i recovering greater fungal diversity from pristine and diesel fuel contaminated sub-antarctic soil through cultivation using both a high and a low nutrient media approach. frontiers in microbiology : . flora of british fungi -colour identification chart polyphasic taxonomy of penicillium subgenus penicillium. a guide to identification of food and air-borne terverticillate penicillia and their mycotoxins mycena in australia: section roridae larger fungi of south australia. the botanic gardens of south australia & state herbarium, and the flora and fauna of south australia handbooks committee new algorithms and methods to estimate maximum-likelihood phylogenies: assessing the performance of phyml . a brief overview of the systematics, taxonomy, and ecology of the tuber rufum clade le genre inocybe, précédé d'une introduction général a l'etude des agarics ochrosporés taxonomic and phylogenetic re-evaluation of microdochium, monographella and idriella species of absidia with ovoid sporangiospores ufboot : improving the ultrafast bootstrap approximation. molecular biology and evolution identification of the genus absidia (mucorales, zygomycetes): a comprehensive taxonomic revision diversity, genotypic identification, ultrastructural and phylogenetic characterization of zygomycetes from different ecological habitats and climatic regions notulae mycologicae. memoirs of the faculty of liberal arts mycena rorida (fr.) quél. and related species from the southern hemisphere new sections in penicillium containing novel species producing patulin, pyripyropens or other bioactive compounds mrbayes: bayesian inference of phylogenetic trees sooty moulds european species of dendrostoma (diaporthales) oidium neolycopersici: intraspecific variability inferred from aflp analysis and relationship with closely related powdery mildew fungi infecting various plant species the phylogenetic relationships of torrendiella and hymenotorrendiella gen. nov. within the leotiomycetes a revision of the genus hypoxylon the genus volvariella in spain: v. dunensis comb. & stat. nov. and observations on v. earlei rare and undersampled dimorphic basidiomycetes mafft online service: multiple sequence alignment, interactive sequence choice and visualization mafft multiple sequence alignment software version : improvements in performance and usability molecular characterization of airborne fungal spores in boreal forests of contrasting human disturbance molecular diversity of fungal communities in agricultural soils from lower austria phytophthora humicola, a new species from soil of a citrus orchard in taiwan pseudopezicula (helotiales, peziculoideae), a new discomycete genus for pathogens causing an angular leaf scorch of grapes variation in the nrdna its sequences of some powdery mildew species: do routine molecular identification procedures hide valuable information? raxml-ng: a fast, scalable and user-friendly tool for maximum likelihood phylogenetic inference first record of hemileucoglossum littorale in slovakia diagnoses de quelques nouveaux inocybes récoltés en zone alpine de la vanoise (alpes françaises) mega : molecular evolutionary genetics analysis version . for bigger datasets heterocephalacria mucosa sp. nov., a new basidiomycetous yeast species isolated from a mangrove forest in thailand biogeographical variability and re-description of an imperfectly known species hamatocanthoscypha rotundispora (helotiales, hyaloscyphaceae) a revision of the genus inocybe in europe i. subgenus inosperma and the smooth-spored species of subgenus inocybe nanangenines: drimane sesquiterpenoids as the dominant metabolite cohort of a novel australian fungus, aspergillus nanangensis agaricales de la zone alpine, genre cortinarius fr., sousgenre telamonia (fr) loud., ème partie partitionfinder : new methods for selecting partitioned models of evolution for molecular and morphological phylogenetic analyses novel and highly di verse fungal endophytes in soybean revealed by the consortium of two different techniques two new species of tuber previously reported as tuber malacodermum heterocephalacria sinensis sp. nov., phaeotremella lacus sp. nov. and solicoccozyma aquatica sp. nov., three novel basidiomycetous yeast species isolated from crater lakes coniosporium epidermidis sp. nov., a new species from human skin exophiala asiatica, a new species from a fatal case in china ten new species of macalpinomyces on eriachne in northern australia sporocadaceae, a family of coelomycetous fungi with appendage-bearing conidia generic concepts in nectriaceae pilzkompendium : - , i-xxxvi mycenae paranaensis. verhandelingen koninklijke nederlandse akademie van wetenschappen, afdeling natuurkunde a multi-locus backbone tree for pestalotiopsis, with a polyphasic characterization of new species pestalotiopsis revisited phytophthora gemini sp. nov., a new species isolated from the halophilic plant zostera marina in the netherlands multiple halophytophthora spp. and phytophthora spp. including p. gemini, p. inun data and p. chesapeakensis sp. nov. isolated from the seagrass zostera marina in the northern hemisphere a combined mitochondrial and nuclear multilocus phylogeny of the genus phytophthora genera of inocybaceae: new skin for the old ceremony interactive catalogue of australian fungi, version . . australian biological resources study mycena palmensis spec. nov., eine neue art der sektion roridae aus spanien creating the cipres science gateway for inference of large phylogenetic trees a restful api for access to phylogenetic tools via the cipres science gateway nag raj tr, kendrick wb. . a monograph of chalara and allied genera the geoglossaceae of sweden (with regard also to the surrounding countries) iq-tree: a fast and effective stochastic algorithm for estimating maximum-likelihood phylogenies mrmodeltest . . program distributed by the author the genus elaphomyces (ascomycota, eurotia ales): a ribosomal dna-based phylogeny and revised systematics of european 'deer truffles poaceascoma helicoides gen et sp. nov., a new genus with scolecospores in lentitheciaceae additions to sporormiaceae: introducing two novel genera, sparticola and forliomyces, from spartium fungi and food spoilage a revision of the family geastraceae introducing the consolidated species concept to resolve species in the teratosphaeriaceae resolving the phylogenetic placement of porobeltraniella and allied genera in the beltraniaceae the genus aspergillus. williams & wilkins a mycological colour chart calvatia holothurioides sp. nov., new species from vietnam. mikologiya i fitopatologiya some gasteromycetes from trinidad and tobago die gattung mycena s.l. studien zu ihrer anatomie, morphologie und systematik mycena mauritiana, a new species of sect antagonistic interactions between garden yeasts and microfungal garden pathogens of leaf-cutting ants mrbayes : bayesian phylogenetic inference under mixed models mrbayes . : efficient bayesian phylogenetic inference and model choice across a large model space an evolutionary perspective on morphology and ecological characters in the mushroom family inocybaceae (agaricomycotina, fungi) polyphasic taxonomy of the heat resistant ascomycete genus byssochlamys and its paecilomyces anamorphs a monograph of fusicladium s.lat. (hyphomycetes) multilocus dna sequencing of the whiskey fungus reveals a continental -scale speciation pattern the genera of hyphomycetes online identification guides for australian smut fungi (ustilaginomycotina) and rust fungi (pucciniales) raxmlgui: a graphical front-end for raxml first conclusive report of an erysiphe sp. causing powdery mildew on moth vine (araujia sericifera) in australia and worldwide raxml-vi-hpc: maximum likelihood-based phylogenetic analyses with thousands of taxa and mixed models raxml version : a tool for phylogenetic analysis and post-analysis of large phylogenies time and memory efficient likelihood-based tree searches on phylogenomic alignments with missing data a fast bootstraping algorithm for the raxml web-servers the australasian species of lactarius subgenus gerardii (russulales) the neurotropic black yeast exophiala dermatitidis has a possible origin in the tropical rain forest eucalyptus microfungi: satchmopsis gen. nov., and new species of coniella, coniothyrium and harknessia the coelomycetes. fungi imperfecti with pycnidia, acervuli and stromata fungi in thailand: a case study of the efficacy of an its barcode for automatically identifying species within the annulohypoxylon and hypoxylon genera new or less known discomycetes paup phylogenetic analysis using parsimony (and other methods). version . sinauer associates novae fungorum species -xxi first comprehensive phylogenetic analysis of the genus erysiphe (erysiphales, erysiphaceae) i. the microsphaera lineage estimation of the number of nucleotide substitutions in the control of mitochondrial dna in humans and chimpanzees mega : molecular evolutionary genetics analysis version . greeneria saprophytica sp. nov. on dead leaves of syzygium cumini from chiang rai mollisiaceae: an overlooked lineage of diverse endophytes response to comment on 'global diversity and geography of soil fungi taxonomy and phylogenetic appraisal of montagnula jonesii sp. nov. (didymosphaeriaceae, pleosporales) the clustal_x windows interface: flexible strategies for multiple sequence alignment aided by quality analysis tools green and brown bridges between weeds and crops reveal novel diaporthe species in australia fungal diversity notes - : taxonomic and phylogenetic contribution to fungal taxa vishniacozyma ellesmerensis sp. nov., a psychrophilic yeast isolated from a retreating glacier in the canadian high arctic international code of nomenclature for algae, fungi, and plants (shenzhen code) adopted by the nineteenth international botanical congress shenzhen, china the diaporthe sojae species complex: phylogenetic re-assessment of pathogens associated with soybean, cucurbits and other field crops coelomycetous fungi in the clinical setting: morphological convergence and cryptic diversity troisième mémoire sur les mucorinées inocybe myriadophylla, a new species from finland and sweden glossary new combinations in lactifluus. . l. subgenera lactifluus and piperati monograph of lactarius in tropical africa additional records of volvariella dunensis (basidiomycota, agaricales): morphological and molecular characterization key to the species of phytophthora de bary on geastrum argentinum, a forgotten species the genera lecanicillium and simplicillium gen candida yunnanensis sp. nov. and candida parablackwelliae sp. nov., two yeast species in the candida albicans/lodderomyces clade lecanicillium cauligalbarum sp. nov. (cordycipitaceae, hypocreales notes -phylogenetically, p. personensis resides in a strongly supported terminal clade and shares a common ancestor with p. inundata (brasier et al. ), p. condilina (burgess et al. ) , p. humicola (ko & ann ) , p. balyanboodja (burgess et al. ) and p. chesapeakensis (man in 't veld et al. ). together with p. gemini (man in 't veld et al. ) these species form a species cluster within clade of the phytophthora phylogeny (burgess et al. ) . in a multigene phylogeny of the its, hsp , bt, nadh and coxi gene regions, p. personensis differs from both p. condilina and p. humicola by . %, p. inundata by . %, p. balyanboodja and p. chesapeakensis by . % and p. gemini by . %. all these species are morphologically similar; they all produce ovoid persistent, nonpapillate sporangia that are borne terminally and they all have high temperature optima and maxima for growth. phytophthora personensis appears to be sterile in culture and thus differs from p. inundata, p. humicola and p. condilina as these three species readily produce homothallic oogonia. phytophthora personensis produces chlamydospores and thus differs from the three other sterile species in the clade, p. balyanboodja, p. chesapeakensis and p. gemini. phytophthora personensis has been recovered from a variety of hosts on two continents, north america and australia, and at this point in time its origin cannot be determined. colour illustrations. grevillia sp., host of the type isolate. typical ovoid and ellipsoid sporangia; proliferation is internal and extended and chlamydospores were common; cottony colony on potato dextrose agar. scale bar = µm.bayesian inference tree based on a concatenated its, ß-tubulin, hsp , coxi and nadh sequence alignment showing the placement of p. personensis in phytophthora clade a generated in mrbayes v. . . (ronquist & huelsenbeck ) as a plugin in geneious prime® . . (biomatters ltd.) using the gtr substitution model. the posterior probability values are shown at the nodes. the tree was rooted to p. rosacearum (not shown) and the novel species is shown in bold font.colour illustrations. vietnam, southern annamite range, chư yang sin national park, montane mixed forest from broad-leaved trees and pinus kesiya at the type locality. in situ basidiomata; spores; basidiae and basidiolae; cheilocystidia; cells of pileipellis; caulocystidia. scale bars = cm (basidio mata), µm (all others).anna kiyashko, komarov botanical institute of russian academy of sciences (bin ras), saint petersburg, professora popova str., , russia; e-mail: anna.kiyashko@binran.ru classification -thermoascaceae, eurotiales, eurotiomycetes.micromorphology (on malt extract agar; mea): hyphae hyaline to pale yellow-brown, . - µm diam, conidiophores borne on the surface or from aerial hyphae, commonly - × ( . -) - μm diam; with smooth walls, bearing terminal whorls of verticillately arranged branches. phialides - per branch, cylindrical, occasionally flask shaped, - (- ) × . - . (- ) μm diam, tapering abruptly toward a long cylindrical collula, up to μm long and - μm diam, solitary phialides rarely present. conidia in long divergent chains, ellipsoidal or cylindrical with conspicuously truncated ends, rarely subglobose, - (- ) × - . (- ) μm diam. chlamydospores very rare, smooth. sexual morph was not observed even after prolonged incubation at °c.cultural characteristics -(in darkness, °c after d): colonies on mea > mm diam, colony texture, floccose, mycelium white to yellow-brown (deep colonial buff to honey yellow, r ; ridgway ( ) ), sporulation very good, conidia en masse light-buff to warm-buff (r ), exudate absent, soluble pigments absent, reverse mustard yellow to primuline yellow (r ). colonies on czapek yeast autolysate agar (cya) - mm diam, colony texture floccose, mycelium white yellow ochre (r ), sporulation good, conidia en masse light buff to warm buff (r ), exudate absent, soluble pigments absent, reverse light buff to warn buff (r ). colonies on potato dextrose agar (pda) > mm diam, colony texture floccose, mycelium deep colonial buff to honey yellow (r ), sporulation very good, conidia en masse light-buff to warm-buff (r ), exudate absent, soluble pigments absent, reverse amber yellow to primuline yellow (r ). colonies on czapek yeast agar with % sucrose, (cy s) - mm diam, colony texture floccose, mycelium white yellow ochre (r ), sporulation good, conidia en masse light buff to warm buff (r ), exudate absent, soluble pigments absent, reverse light buff to warm buff (r ). colonies on dichloran glycerol agar (dg ) - mm diam, colony texture light floccose, sporulation very good, mycelium white to cream colour (r ), reverse warm buff (r ). no growth on cya supplemented with % (w/v) nacl (cyas). colonies on oa - mm diam, colony texture floccose, mycelium white to honey yellow (r ), sporulation very good, conidia en masse light-buff to warm-buff (r ), exudate absent, soluble pigments absent. colonies on creatine sucrose agar (crea) - mm diam, poor growth, no acid production, mycelium white, colony subsurface to submerged into the agar. colony diam (in mm after d) at °c/ °c; mea > / - ; cya - / - ; pda > / - ; cy s - / - ; dg - / - ; oa > / - ; crea - /ng; no growth at °c. a best scoring maximum likelihood tree based on the its region and the β-tubulin gene sequences shows the relationships of p. penicilliformis with other paecilomyces and byssochlamys species. the dataset contained taxa and a total of characters of which were variable and parsimony-informative. partitioning scheme and substitution models for analyses were selected using partitionfinder v. (lanfear et al. ): the gtr+i+g model was proposed for the its , its and β-tubulin gene exons; jc model for the . s region; and k +i model for the β-tubulin gene introns. the tree was constructed with iq-tree v. . . (nguyen et al. ) . support values at branches were obtained from bootstrap replicates. only bootstrap support values ≥ % are shown; ex-type strains are indicated by t and the novel species in bold text. the tree is rooted with sclerocleista ornata nrrl . paecilomyces penicilliformis produces predominantly long cylindrical conidia with conspicuously truncated ends, - (- ) × - . (- ) μm compared to smaller and predominantly globose conidia with flattened base produced by the closely related b. lagunculariae, . - . × . - . μm (samson et al. ). in addition, b. lagunculariae produces a sexual morph in culture (homothallic) and grows faster on mea at °c ( - mm after d) (samson et al. ). paecilomyces penicilliformis is similar to p. dactylethromorphus by its cylindrical or ellipsoidal conidia and regularly branched conidiophores (penicilliumlike). these species can be distinguished by wider conidia, - . (- ) μm produced by p. penicilliformis compared to p. dactylethromorphus, . - . μm wide (samson et al. ). micromorphology (on malt extract agar (mea), °c, wk): mycelium consisting of branched, septate, hyaline, smooth, . - . mm diam hyphae; racquet hyphae, spiral hyphae and peridial hyphae not observed. conidiophores simple, usually poorly differentiated from vegetative hyphae; conidiogenous hyphae unbranched or sparsely laterally branched. microconidia sessile, borne laterally or terminally, clavate or pyriform, truncate, aseptate, smooth-walled, . - . × . - . μm (mean ± standard deviation: . ± . × . ± . μm), l/w . - . . macroconidia borne singly or on sparsely and irregularly branched conidiophores, fusiform or clavate with rounded apex (less frequently slightly acuminate) and truncate base, straight or slightly to strongly curved, multi-celled, thick-walled, usually with - (- ) septa (median = ), smooth-walled, hyaline to pale yellow en masse, - (- ) × - μm ( ± . × . ± . μm), l/w . - . . chlamydospores globose, subglobose to irregular, usually - μm diam. sexual morph unknown.culture characteristics -colonies on sabouraud glucose agar (sga) at °c - mm diam after wk, covering dish after wk, flat, centrally raised to umbonate, granular, pale yellow ( a ; kornerup & wanscher ) to yellowish white ( a ), margins filamentous, reverse light brown ( d ) to orange yellow ( b ). colonies on mea at °c - mm diam after wk, covering dish after wk, flat with elevated centre, granular (with or without cottony centre), pale yellow ( a ) to pinkish white ( a ), pink ( a ) sectors or concentric zone may be present in old cultures, margins filamentous, serrate to irregular, reverse greyish orange ( b ) to orange white ( a ), bright red pigment inconstantly exuded into the medium. colonies on potato dextrose agar (pda) at °c - mm diam after wk, - mm diam after wk, centrally raised to raised, downy to delicately granular, pale yellow ( a ) to yellowish white ( a ), margins filamentous, reverse light brown ( d ) to greyish yellow ( b ). colonies on mea at °c after wk - mm diam, covering dish after wk; no growth on mea °c.typus. south africa, skin scrapings from human patient, before , unknown collector (holotype prm , isotype prm , cultures ex-type uamh = ccf ; its, lsu, β-tubulin and tef α sequences genbank mt , mt , mt and mt , mycobank mb ).additional material examined. czech republic, skin scales, heel, -yr-old woman with suspected dermatophytosis, oct. , p. hamal, culture ccf ; its, lsu, β-tubulin and tef α sequences genbank mt , mt , mt and mt .notes -blast analyses with the its and β-tubulin sequences of paraphyton cutaneum showed the following similarities with currently accepted paraphyton species (de hoog et al. ) : p. cookei ( . % and . %, respectively), p. mirabile ( . % and . %, respectively) and p. cookiellum ( . % and . %, respectively); lsu and tef α sequences are not available for all accepted species.paraphyton cookei and p. cookiellum have echinulate to verrucose macroconidia and can be easily distinguished from p. cutaneum having smooth-walled macroconidia. additionally, macroconidia of p. cookiellum are oval ( - × - μm) and predominantly -celled (currah ) . paraphyton mirabile is a slow-growing species compared with p. cutaneum; its colonies attain approximately mm diam after wk on sga (choi et al. ).both isolates of p. cutaneum were isolated from patients with skin lesions suggestive of dermatophytosis but its pathogenicity is questionable because the detailed anamnestic data are not available. the strain from the czech patient was isolated from a skin lesion on the heel (direct microscopic examination not performed due to insufficient amount of material). a complete clinical healing was observed after mo treatment with topical oxiconazole. the species probably naturally occurs in soil, similarly to the remaining paraphyton species which are also occasionally isolated from clinical material (choi et al. ).classification -pestalotiopsidaceae, xylariales, sordariomycetes.conidiomata pycnidial on / potato dextrose agar (pda), globose or clavate, scattered or aggregated, immersed or semiimmersed, dark brown to black, up to μm diam; exuding dark brown to black conidial masses. conidiophores reduced to conidiogenous cells. conidiogenous cells discrete, cylindrical, hyaline, smooth, - × - μm. conidia fusoid, cylindrical, straight to slightly curved, -septate, - × - μm, basal cell conic, hyaline, smooth and thin-walled, - μm long; three median cells doliiform, - μm long, smooth, concolourous, septa darker than the rest of the cell (second cell from base - . μm long; third cell - . μm long; fourth cell . - μm long); apical cell . - . μm long, hyaline, conic, thin-walled, smooth; with three tubular apical appendages, unbranched, filiform, - μm; basal appendage tubular, centric, - . μm long. sexual morph not seen.culture characteristics -colonies on pda after d cm diam, adpressed with no aerial mycelium, margin entire, dark tan in the centre becoming lighter towards the margin, with dark radial striations in the middle part. notes -the multilocus phylogenetic analysis placed p. etonensis in a well-supported clade with p. parva. based on a blastn search, p. etonensis differs from p. parva in its (gen-bank nr_ ; identities = / ( %), gap ( %)), tub (genbank km ; identities = / ( %), gaps ( %)) and tef a (genbank km ; identities = / ( %), gap ( %)). morphologically, p. etonensis conidia size and shape is indistinguishable from p. parva (fusoid, straight to slightly curved, -septate, - × - μm; maharachchikumbura et al. ) . geographically, p. etonensis is only known from one location in australia, while the origin and distribution of p. parva is unknown (maharachchikumbura et al. ) . pestalotiopsis etonensis has only been isolated from sporobolus jacquemontii in australia, while p. parva is known from delonix regia (caesalpiniaceae) and leucothoe fontanesiana (ericaceae) (maharachchikumbura et al. ) .