2 0 19 Vo lum e 43

DOI:10.33321/cdi.2019.43.5

Paediatric Active Enhanced Disease Surveillance

(PAEDS) annual report 2016: Prospective hospital-
based surveillance for serious paediatric conditions
Jocelynne E McRae, Helen E Quinn, Gemma L Saravanos, Alissa McMinn,
Philip N Britton, Nicholas Wood, Helen Marshall and Kristine Macartney on behalf
of the PAEDS network
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Annual Report

Paediatric Active Enhanced Disease Surveillance

(PAEDS) annual report 2016: Prospective
hospital-based surveillance for serious
paediatric conditions
Jocelynne E McRae, Helen E Quinn, Gemma L Saravanos, Alissa McMinn, Philip N Britton,
Nicholas Wood, Helen Marshall and Kristine Macartney on behalf of the PAEDS network

Abstract

Introduction

The Paediatric Active Enhanced Disease Surveillance (PAEDS) network is a hospital-based active
surveillance system employing prospective case ascertainment for selected serious childhood condi-
tions, particularly vaccine preventable diseases and potential adverse events following immunisation
(AEFI). PAEDS data is used to better understand these conditions, inform policy and practice under
the National Immunisation Program, and enable rapid public health responses for certain conditions
of public health importance. PAEDS enhances data available from other Australian surveillance sys-
tems by providing prospective, detailed clinical and laboratory information on children with selected
conditions. This is the third annual PAEDS report, and presents surveillance data for 2016.

Methods

Specialist nurses screened hospital admissions, emergency department records, laboratory and other
data, on a daily basis in 5 paediatric tertiary referral hospitals in New South Wales, Victoria, South
Australia, Western Australia and Queensland to identify children with the conditions under sur-
veillance. Retrospective data on some conditions was also captured by an additional hospital in the
Northern Territory. Standardised protocols and case definitions were used across all sites. Conditions
under surveillance in 2016 included acute flaccid paralysis(AFP) (a syndrome associated with polio-
virus infection), acute childhood encephalitis (ACE), influenza, intussusception (IS; a potential AEFI
with rotavirus vaccines), pertussis, varicella-zoster virus infection (varicella and herpes zoster), inva-
sive meningococcal and invasive Group A streptococcus diseases. Most protocols restrict eligibility to
hospitalisations; ED only presentations are also included for some conditions.

Results

In 2016, there were 673 cases identified across all conditions under surveillance. Key outcomes of
PAEDS included: contribution to national AFP surveillance to reach World Health Organization
(WHO) reporting targets; identification of the leading infectious causes of acute encephalitis which
included human parechovirus, influenza, enteroviruses, Mycoplasma pneumoniae, and bacterial

health.gov.au/cdi Commun Dis Intell 2019;43(DOI:10.33321/cdi.2019.43.5) Epub 1/2/2019 1 of 15

meningo-encephalitis; demonstration of high influenza activity with vaccine effectiveness (VE)
analysis demonstrating some protection offered through vaccination. All IS cases associated with
vaccine receipt were reported to the relevant state health department. Varicella and herpes zoster case
numbers increased from previous years associated with suboptimal vaccination in up to 40% of cases
identified. Pertussis surveillance continued in 2016 with the addition of test negative controls cap-
tured for estimating vaccine effectiveness. Surveillance for invasive meningococcal disease showed
predominance for serotype B in absence of immunisation, and new invasive group A streptococcus
surveillance captured severe disease in children.

Conclusions

PAEDS continues to provide unique policy-relevant data on serious paediatric conditions using
hospital-based sentinel surveillance.

Keywords: paediatric, surveillance, child, hospital, vaccine preventable diseases, adverse event
following immunisation, acute flaccid paralysis, encephalitis, influenza, intussusception, pertussis,
varicella zoster virus, meningococcal, group A streptococcus.

Introduction
During 2016, the PAEDS network consisted of 6
This is the third annual report of the Paediatric participating hospitals: The Children’s Hospital
Active Enhanced Disease Surveillance (PAEDS) at Westmead (CHW), Sydney, New South Wales
network and summarises data collected in 2016. (NSW); Royal Children’s Hospital (RCH),
Previous years PAEDS data can be found in Melbourne, Victoria; Women’s and Children’s
the 2015 annual report1 and historical data for Hospital (WCH), Adelaide, South Australia;
2007–2014, including impacts and outcomes, in Princess Margaret Hospital (PMH), Perth,
the PAEDS 2014 inaugural report.2 Western Australia; and Lady Cilento Children’s
Hospital (LCCH), Brisbane, Queensland. The
PAEDS is a hospital-based active surveillance sixth hospital: Royal Darwin Hospital (RDH),
system for serious childhood conditions of Darwin, Northern Territory joined PAEDS in
public health importance, particularly vac- early 2017 and participated in retrospective data
cine preventable diseases (VPDs) and adverse collection from July 2016 on some conditions.
events following immunisation (AEFI). PAEDS, PAEDS is coordinated by the National Centre
through prospective case identification and for Immunisation Research and Surveillance
ascertainment, collects timely and detailed (NCIRS) based at CHW in Sydney.
clinical data on children requiring hospitalisa-
tion for the select conditions under surveillance. PAEDS activities are substantially sup-
In some instances, emergency department (ED) ported through funding from the Australian
presentations are also included. PAEDS data Government Department of Health and the
is used to better understand these conditions, 6 participating states’ health departments. In
inform policy and practice under the National addition, the Australian Paediatric Surveillance
Immunisation Program (NIP) and enable rapid Unit (APSU) and the Influenza Complications
public health responses for certain conditions Alert Network (FluCAN) collaborate with
of public health interest. PAEDS is well posi- PAEDS on specific conditions. PAEDS produces
tioned compared to other passive surveillance monthly data reports for all funding bodies and
programs that are usually less able to adequately collaborators.
capture such timely and comprehensive data.3

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Methods to identify any serious acute neurologic events
(SANE) that occurred within 6 weeks of receipt
Active case ascertainment of a seasonal influenza vaccine.

Under PAEDS, specialist surveillance nurses in Collection of biological samples

each hospital identified children diagnosed with
the conditions under surveillance, as defined in Surveillance nurses facilitated collection of
Table 1, by reviewing admission and emergency samples in line with public health requirements
department databases, clinical records, labora- and condition protocols. For example, children
tory logs and through liaison with medical, hospitalised with AFP require collection of 2
laboratory and nursing staff. 1,2 stool samples for enteric virus identification by
the National Enterovirus Reference Laboratory
For 2016, all 6 of the PAEDS participating hos- (NERL) in Melbourne as part of the Global Polio
pitals were approved by their respective Human Eradication Initiative.4,5 For other conditions,
Research Ethics Committees to operate under samples were collected for virus genotyping (e.g.
a waiver of consent model for surveillance of VZV) or for additional pathogen characterisa-
all conditions. Surveillance nurses collected tion (e.g. ACE, IGAS).
detailed clinical information from the medi-
cal records and vaccination history from the Quality assurance and ICD-10-AM audits
Australian Childhood Immunisation Register
(ACIR). Information not available in the medi- To check for completeness of case ascertain-
cal record was obtained by contacting the child’s ment, PAEDS nurses at each site conducted
parent/guardian; participation was voluntary. In regular retrospective audits of hospitalisation
some cases, the parent/guardian was approached records by searching for primary and second-
for consent to their child’s participation in addi- ary ICD-10-AM codes ascribed to the relevant
tional research studies, involving elements such conditions (e.g. K56.1 for IS). Cases ascertained
as long-term follow-up or non-routine specimen through these audits were compared with the
collection. In this instance, a patient informa- cases ascertained prospectively by PAEDS for
tion sheet and consent form was provided to the same period. Additional cases identified by
facilitate participation (Figure 1). the ICD-10-AM audit process were retrospec-
tively included into PAEDS. As an additional
Conditions under surveillance quality assurance measure, periodic audits were
undertaken by investigators of case medical
In 2016, there were 7 conditions under surveil- records to assess accuracy of data collected.
lance at all PAEDS sites: acute flaccid paralysis
(AFP), acute childhood encephalitis (ACE), Data management
intussusception (IS), pertussis, and varicella-
zoster virus infection (VZV; varicella and herpes PAEDS utilises a web-based data management
zoster), with the addition of 2 new conditions system called ‘WebSpirit’6 which enables online
commenced at all sites: invasive meningococcal data entry by surveillance nurses at each site and
disease (IMD) and invasive group A streptococ- centralised data extraction. Data is held securely
cus (IGAS). Surveillance for influenza (in col- and exported on a regular basis by staff at the
laboration with FluCAN) was undertaken at 2 PAEDS coordinating centre for clinical review,
PAEDS sites: CHW (Sydney) and PMH (Perth). monthly quality checks, analysis and reporting.
In addition, in 2016, data collected from surveil- Data for 2 specific study arms: FluCAN and
lance of 2 PAEDS conditions in children aged IGAS are also recorded on a separate secure
<5 years, AFP and ACE, were analysed monthly system, Redcap.

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Figure 1: PAEDS method for surveillance using the waiver of consent model plus opt-in consent
for additional research of specific study arms

Daily search for potential cases – Review of ED and inpatient databases, laboratory logs, and contact with key clinicians

Meets case definition criteria?

NO

YES
No further follow-up

+/– Consent for additional

Consent waived for surveillance research
(All study arms) (Specific study arms)

Patient data collection: history, Sample Salvaged Consent sought for participation in
immunisation status, presentation, biological sample additional research for specific
treatment and outcome from clinical collection for PAEDS conditions
notes further pathogen This may include:
Results
analysis (e.g. viral, • Collection or salvage of biological
bacterial analysis), samples not currently considered
dispatch to relevant as part of routine surveillance
laboratory (e.g. • Longer-term patient follow-up
VIDRL*) and follow- outside of the acute event with
Incomplete up of results hospitalisation
data • Detailed family/contact history

Data entry Incomplete data: contact treating clinician (if

still an inpatient) or parent/guardian directly if
patient discharged

De-identified data – entered directly into

a web-based data management system
(Webspirit)

Data extraction and analysis

Reports and publications

* VIDRL = Victorian Infectious Diseases Reference Laboratory

5
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Table 1: PAEDS conditions under surveillance, case definitions and rationale, 2016

Condition and case definition Rationale

Acute flaccid paralysis (AFP) WHO requires active national surveillance for cases of AFP in children aged <15
Case definition: years in order to monitor for potential cases of paralytic poliomyelitis. PAEDS
Any child aged birth to <15 years and collaborates with the APSU in nationwide surveillance in an effort to meet the
presenting with acute flaccid paralysis: target enrolment of 1 non-polio AFP case / 100,000 children aged <15 years
onset of flaccid paralysis in one or more per year. Data collected on AFP also contributes to separate analysis for SANE*.
limbs or acute onset of bulbar paralysis.

Acute childhood encephalitis (ACE) Encephalitis is a critical condition that is considered a marker syndrome for
Case definition: emerging infectious diseases. It is most often caused by viruses (including
Any child aged birth to <15 years AND those which are or potentially will be vaccine preventable). It can also be
hospitalised with acute encephalopathy immune-mediated, and uncommonly can be associated with vaccine receipt.
AND who has one or more of the following: As there is limited epidemiologic data on encephalitis, PAEDS is uniquely
fever, seizures, focal neurological placed to undertake active, syndromic surveillance and can collect biological
findings, at least one abnormality of specimens. Enrolment of participants into comprehensive follow-up studies
cerebrospinal fluid, or EEG/neuroimaging to improve understanding of long-term neuropsychological sequelae also
findings consistent with infection-related occurs.7 Data collected on ACE also contributes to separate analysis for SANE*.
encephalitis.
Influenza – FluCAN The emergence of H1N1-09 influenza in 2009 demonstrated the importance
(Seasonally: April–October) of enhanced influenza surveillance in children.8 PAEDS provides unique timely
Case definition: sentinel data from 2 sites (Sydney and Perth) on influenza hospitalisations,
Any child aged birth to <18 years who is including complications and deaths, which can be used to inform public health
hospitalised, clinically suspected of having response and policy. The data on children supplements adult data from 15
influenza (respiratory symptoms +/- fever) other FluCAN sites. Information on influenza test-negative (control) patients
and confirmed influenza PCR-positive. with acute respiratory illness (ARI) is also collected and allows calculation of
vaccine effectiveness to be performed.
Intussusception (IS) Intussusception is the most common cause of bowel obstruction in infants and
Case definition: young children and was associated with a previous rotavirus vaccine in the
Any child aged <9 months presenting USA which was withdrawn in 1999. Timely, active and systematic surveillance
with a diagnosis of acute intussusception of IS cases is important and has identified a temporal but low incidence
confirmed using the Brighton Collaboration association with the rotavirus vaccines currently available under the NIP (since
clinical case definition (Level 1 or 2). July 2007).10 Surveillance also aims to describe the epidemiology, aetiology and
Includes hospitalised or ED only.9 severity of IS.11,12

Pertussis Despite immunisation coverage approaching 93%, pertussis continues to

Case definition: cause significant morbidity and mortality, particularly in very young Australian
Hospitalised pertussis - Any child aged birth children.13 The aims of this surveillance are to determine the burden of
to <15 years hospitalised with laboratory disease from hospitalised pertussis, with special emphasis on the duration of
confirmed pertussis. hospitalisation, use of intensive care, death and disability. Possible sources of
Pertussis vaccine effectiveness study – Any infection and co-morbidities to severity of pertussis are examined. The adjunct
child aged from birth to <6 months with study seeks to estimate the effectiveness of pertussis vaccination (either
laboratory-confirmed pertussis identified in infancy or maternal) against pertussis hospitalisations and emergency
from either the “Hospitalised Pertussis” department presentations by comparing pertussis vaccination status in infants
study (above) or from the emergency with pertussis <6months of age and test-negative controls. These surveillance
department. data will assist in optimising pertussis prevention strategies.
Varicella–Zoster Virus (VZV) Infection Complications of varicella or herpes zoster requiring hospitalisation provide
Case definition: a measure of disease burden and severity. Ongoing surveillance aims to
Any child aged birth to <15 years show trends in incidence and severity of both varicella and herpes zoster
hospitalised for varicella or herpes zoster related to the varicella vaccination program and allow vaccine effectiveness
with or without complications. estimations.14 The timely collection of vesicle samples and genetic subtyping
of varicella-zoster virus infection allows for identification of vaccine failures in
immunised children and genotypes associated with severe complications or
derived from the live attenuated vaccine.

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 Condition and case definition Rationale

Invasive Meningococcal Disease (IMD) Invasive Meningococcal Disease (IMD) causes death in young healthy children
Any child aged birth to <18 years who is and adolescents in 5-10% of cases.15-17 No other infectious disease has
hospitalised with laboratory confirmed such debilitating consequences following resolution of the infection, with
invasive meningococcal disease. 20-57% of surviving children developing long term complications including
amputation, cerebral infarction and severe skin scarring.18-20 Surveillance
of IMD will enable identification of serogroup/genotypes causes and any
associations between severity of disease and sequelae. This study also seeks to
estimate vaccine effectiveness against Men B infection and disease severity in
IMD cases pre and post introduction of Men B vaccine in Australia.
Invasive Group A Streptococcus (IGAS) The group A beta-haemolytic streptococcus is a common infective agent in
Any Child aged birth to <18 years children and adults that causes the widest range of clinical disease in humans
hospitalised with laboratory confirmed of any bacterium. Invasive disease (IGAS identified in a sterile site) is less
invasive group A streptococcus disease. common, but has high rates of mortality and long-term morbidity. Group
A streptococcal toxin mediated diseases include streptococcal toxic shock
syndrome (STSS), which is usually found in association with invasive disease
and has a case fatality rate over 50%.21,22 There is no vaccine currently available
for prevention of streptococcal infection although research is underway.
Further epidemiological data on incidence, severity, clinical features and
pathogen characteristics (genotype) are warranted.
*SANE – Serious acute neurological event

Results under FluCAN surveillance. Since PAEDS

inception in 2007 a total of 5,570 cases (exclud-
In 2016, there were 174,840 admissions at the 6 ing controls) have been recruited.
participating PAEDS sites (Table 2). There were
673 cases identified across all PAEDS conditions Surveillance results for 2016
under surveillance and sites in 2016 (Table 3).
Data on an additional 227 control cases (influ- Table 3 shows case numbers for all 8 conditions
enza test-negative ARI cases) were collected in 2016 and details of auditing and ICD-coded
hospital discharge data.

Table 2: Total hospital admissions and ED presentations (inclusive of admitted patients) for the 6
hospitals participating in PAEDS in 2016E

Total PAEDS cases all conditions

PAEDS site Hospital admissions ED presentations
(% hospital admissions)*

CHW, Sydney‡ 32,834 57,379 245 (1.0)

RCH, Melbourne 47,624 87,806 85 (0.2)

WCH, Adelaide 21,921 46,175 42 (0.2)

PMH, Perth‡ 27,571 62,474 192 (1.0)

LCCH, Brisbane 39,945 65,713 105 (0.3)
RDH, Darwin† 4,945 14,440 4 (0.02)
Total 174,840 333,987 673 (0.4)

Denominator used is hospitalisations. Some cases of intussusception, pertussis (< 6months of age for VE study) or AFP (though rarely), may not
*

be included as they may be treated in ED only.

†
RDH case numbers pertain to recruitments from the second half of 2016 only, total hospital admission and ED numbers represent the full
calendar year.
‡
CHW (Sydney) and PMH (Perth) attained higher case numbers as they were the only PAEDS hospitals involved in influenza surveillance in 2016.

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Table 3: Number of cases captured by PAEDS in 2016 by condition and method of case
ascertainment
Case identification methods
Total captured
Number captured cases (surveillance
Condition Total cases Number captured
retrospectively and ICD-10 audit
captured by active by PAEDS only, not
following ICD-10 combined)
surveillance ICD-coded*
audit
Acute flaccid paralysis† 51 29 2 53

Acute childhood encephalitis 156 72 6 162

Influenza‡ 229 – – 229

Intussusception 50 6 2 52

Pertussis§ 58 7 2 60

Varicella or Herpes Zoster 57 9 5 62

Invasive Meningococcal
7 0 7 14
Disease||
Invasive Group A
23 3 18 41
Streptococcus||
Total 631 126 42 673

*
These cases did not have an ICD-10 code for this hospitalisation that was consistent with the condition diagnosed.
†
AFP numbers may differ from those published in APSU and/or VIDRL reports due to differences in surveillance systems.
‡
Influenza – an additional 227 control cases were captured at CHW (Sydney) and PMH (Perth). No ICD audit was carried out on
this condition.
§
Pertussis VE study commenced 1 July 2016 - an additional 29 control cases were captured across all sites.
||
Invasive Meningococcal and Invasive Group A Streptococcus diseases commenced 1 July 2016 with a large proportion from retrospective
recruitment via ICD audit due to staggered commencement from participating PAEDS sites.

Acute flaccid paralysis unknown causes. The leading infectious causes

were human parechovirus, influenza, enterovi-
PAEDS reported 53 cases of AFP to the NERL ruses, Mycoplasma pneumoniae, and bacterial
in 2016, meeting the surveillance target of one meningo-encephalitis.
non-polio AFP case per 100,000 children aged
<15 years4 (estimated Australian population in Serious acute neurological events (SANE)
this age group is 4.58 million).23 Of the 53 cases, following influenza immunisation
at least one stool sample was collected within 2
weeks of onset of paralysis for 38 cases (72%), Vaccine data from AFP and ACE surveillance
and 2 stool samples were collected for 28 cases was reviewed in combination. During 2016, 43
(53%). The most common diagnoses associated SANE in children aged <5 years were identified
with AFP were Guillain-Barré syndrome (GBS; (23 confirmed and 7 probable encephalitis, 3
26%), transverse myelitis (26%) and acute demy- GBS, 2 ADEM, one acute cerebellar ataxia; and
elinating encephalomyelitis (ADEM; 15%). 4 undiagnosed acute flaccid paralysis). Only one
of the 43 children had received an influenza
Acute childhood encephalitis vaccine; and this child had been vaccinated
within 42 days of symptom onset. She presented
PAEDS identified 162 cases of suspected ACE in to hospital with progressive proximal weak-
2016. Amongst these cases were 89 (55%) with ness in her lower legs and an inability to walk
confirmed encephalitis. Amongst these were 7 days following receipt of influenza vaccine.
46 (52%) with infectious causes, 32 (36%) with She was diagnosed with transverse myelitis and
immune-mediated causes and 11 (12%) with had adenovirus detected in a stool specimen.

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SANE cases were reported via AusVaxSafety this included an additional 3 cases identified
influenza monthly and annual reports to the from the emergency department. For this study
Commonwealth Department of Health. component, 29 controls were also enrolled.

Influenza Varicella and Herpes Zoster

There were 229 children with laboratory-con- In 2016, 62 cases of varicella-zoster virus infec-
firmed influenza admitted to CHW (n=124) tion were identified (40 varicella; 22 herpes zos-
and PMH (n=105) in the 2016 season (April – ter). Of these, vesicular fluid or vesicle scraping
October). Of these, 201 children were aged ≥ 6 samples were obtained from 27 (44%); in many
months and 28 were aged < 6 months. In addi- children sampling was difficult as vesicles had
tion, 227 influenza test-negative controls were crusted over by the time the child was identi-
enrolled in order to calculate vaccine effective- fied. Of the 62 children, 43 (69%) were eligible
ness. Of all influenza confirmed cases, 16 (7%) for NIP-funded varicella vaccination but only 26
were admitted to the intensive care unit, and (60%) had been vaccinated.
106 (46%) had underlying medical conditions.
In children aged ≥ 6 months, influenza vaccina- Invasive Meningococcal Disease
tion status was ascertained in 192 cases with 17
(9%) vaccinated. Of 166 controls, 23 (14%) were From July 2016, 14 cases of IMD were identi-
reported to be vaccinated. In infants under 6 fied across the PAEDS network. Nine (64%)
months maternal vaccination status was ascer- cases were aged less than 5, of which 3 were <
tained in 19 paired mothers with 3 (16%) being 12 months of age. Four (29%) cases were aged
vaccinated for influenza. There were 63 controls between 5 and 10, and 1 (7%) was aged > 10. Of
aged < 6 months and maternal vaccination sta- all cases, serogroup B was the predominating
tus was ascertained in 40 mothers. Of these, 9 strain with 9 cases overall, 7 (78%) of these were
(23%) were vaccinated during their pregnancy. in children aged less than 5. Serogroup W was
identified in 4 cases; for one case serogroup/
Intussusception genotype was not able to be determined. All
children were of eligible age for vaccination,
Of the 52 cases of IS identified, 37 (71%) met with 10 (71%) vaccinated for meningococcal C.
level 1 Brighton Criteria.9 Nine cases (24%) had No children were vaccinated for meningococcal
received a rotavirus vaccine in the preceding B. Seven cases (50%) exhibited meningitis on
21 days: one after their first dose of vaccine, 3 after presentation and 8 (57%) were septicaemic. Two
their second dose, and 5 after their third dose. of these children had both meningitis and septi-
Three (33%) of the 9 children required surgery to caemia. The most common reported symptoms
correct the IS and 6 (67%) children were success- on presentation were fever 13 (93%), lethargy 13
fully treated with air enema. Among all 37 cases (93%), rash 12 (86%) and vomiting 11 (79%).
of level 1 IS, 12 (32%) children required surgery
and 25 (68%) resolved following air enema. Invasive Group A Streptococcus

Pertussis For the period 1 July to 31 December 2016, there

were 45 children hospitalised with laboratory
There were 57 children hospitalised with labora- confirmed Invasive Group A streptococcus
tory-confirmed pertussis in 2016. Thirteen chil- identified across all PAEDS sites. Thirty-one
dren (23%) required admission to the intensive (69%) cases were male, and 31 (69%) were under
care unit; 23% (n=13) were <3 months of age. the age of 5-years. Nineteen children (42%) were
For the adjunct vaccine effectiveness study, 8 admitted to ICU, 14 within the first 24hrs of
infants aged less than 6 months were enrolled, presentation to hospital. Eight children (18%)
were classed as severe disease (intubated with

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mechanical ventilation or inotropic support) rary causes and consequences of this challeng-
and 2 (4%) classed as very severe disease (extra- ing condition. Preliminary data from this cohort
corporeal membrane oxygenation (ECMO)). has been presented at the Infectious Diseases
The average duration of antibiotics (both IV and Society of America ID Week in 201625 and the
oral) was 26 days (range 1-79 days). The mean European Congress of Clinical Microbiology
number of days spent in ICU was 4 days (range and Infectious Diseases in 2017.26 In a combined
1-13), with a mean of 9 days (range 1-27) spent analysis of PAEDS-ACE surveillance data and
on the ward. PAEDS-FluCAN surveillance data, the con-
tribution of seasonal influenza to neurological
Discussion disease in children in Australia was estimated
and the clinical features and outcome of influ-
PAEDS provides novel and unique data on enza associated encephalopathy/encephalitis
hospitalisations due to uncommon serious described.27,28 PAEDS-ACE investigators are
childhood conditions, particularly VPDs and currently seeking to continue ACE surveillance,
potential AEFI. Active case finding by specialist but reduce the burden of detailed data collec-
surveillance nurses and collection of detailed tion for research, and improve efficiency of case
clinical and laboratory information provides review and reporting.
comprehensive and timely data not available
from other surveillance systems. The waiver Surveillance of serious acute neurological events
of consent framework for surveillance allows following influenza vaccination offers confidence
vitally important information to be captured in the influenza vaccines of 2016, with only one
from otherwise hard-to-reach groups, such as noted to be proximate to an acute flaccid paraly-
those who are critically ill, lost to follow-up, sis episode (diagnosis: transverse myelitis). Due
or from a non-English speaking background to low number of cases ascertained an associa-
(NESB), thereby obtaining more complete data tion cannot be determined. However, developing
from the broader population. Quality assurance this novel methodology to monitor for severe
processes such as ICD-10-AM audits, periodic and infrequent vaccine adverse events supports
case reviews and continued data management Australia’s existing suite of influenza vaccine
have enhanced both the yield and quality of the safety monitoring, and could be expanded to
data captured. other vaccine types such as pertussis booster
vaccination, human papillomavirus vaccine etc.
PAEDS surveillance for AFP continues to pro-
vide the majority of cases for national surveil- PAEDS contributes important paediatric data
lance, enabling Australia to meet the WHO to national influenza surveillance in collabora-
AFP surveillance target4 for 2016. Achieving tion with FluCAN.29 Influenza vaccines are
the WHO stool collection target of 2 stool adjusted each year to provide optimal coverage
samples within 2 weeks remains challenging in against circulating influenza strains, so ongoing
the context of a modern health system where a surveillance is critical to understanding disease
non-polio AFP diagnosis is rapidly available24; burden, vaccine efficacy and evaluate vaccina-
however, PAEDS nurses facilitated collection of tion program strategies. In 2016, a quadrivalent
at least one stool sample in 71% of PAEDS AFP influenza vaccine was made available under
cases ascertained in 2016. the National Immunisation Program follow-
ing a higher than usual presence of influenza
PAEDS encephalitis surveillance is realising its B in 2015.30,31 Despite this, data collected from
potential to support early detection of epidemic PAEDS showed that vaccine uptake in children
infectious diseases in children. In addition, aris- ≥ 6months was extremely low at 11% (across
ing out of the surveillance is the largest cohort cases and controls) and similarly for infants <
of all-cause childhood encephalitis cases in the 6 months; where maternal vaccination could
world that will be used to define the contempo- be ascertained, uptake was only 20%. In 2016,

health.gov.au/cdi Commun Dis Intell 2019;43(DOI:10.33321/cdi.2019.43.5) Epub 1/2/2019 9 of 15

influenza A was the predominating strain in for one dose of vaccine against hospitalised vari-
circulation and the available vaccine was con- cella to be 64.6% (95% CI: 46.1–76.7%); adjusting
sidered to have been a good match. Estimates of for immunocompromised children and time
vaccine effectiveness from FluCAN used PAEDS since vaccination did not significantly alter VE
data and additional paediatric data from other estimates.38 Despite a moderate VE, Australia’s
hospitals, providing a point estimate of 36% program has impacted on varicella and zoster
(95% CI: -27%, 68%) in children aged 6 months virus disease burden. Continued surveillance
and older, and a maternal vaccination effective- through the PAEDS network provides the only
ness assessment of 44% (95% CI:-50%, 66%) for nationally consistent, verified source of data
infants < 6 months.32 PAEDS FluCAN surveil- for severe varicella and herpes zoster, enabling
lance for 2016 was restricted to 2 sites (WA and ongoing evaluation of varicella vaccination
NSW). As of 2017, an additional 4 sites have now under the NIP.
engaged in active influenza surveillance. These
data obtained now nationally from the PAEDS Clinical features of meningococcal disease are
network on paediatric influenza requiring not captured in adequate detail in current IMD
hospitalisation are important to inform future surveillance programs. PAEDS offers the abil-
policy and practice. ity to monitor changes in clinical presentation
and sequelae which may relate to changes in the
PAEDS data has been instrumental in quanti- epidemiology of disease such as with the recent
fying the association between IS and rotavirus increase in serogroup W disease in Australia.
vaccine when given to infants.11,12,33 Given the As many states have now introduced meningo-
documented but low vaccine-associated risk, IS coccal ACWY vaccine programs, monitoring
surveillance continues. Analysis of the >500 IS the impact of these programs including sever-
cases for which PAEDS holds detailed clinical ity of disease and any vaccine failures is an
data is underway to compare the clinical char- important priority.
acteristics of vaccine proximate cases with non-
vaccine proximate cases. The results obtained for IGAS across the PAEDS
network over 6 months are similar to that found
Pertussis continues to be one of the least well in the 2-year pilot data at RCH Melbourne (28
controlled VPDs in Australia.34 Infants too cases).39 Due to our strict inclusion of cases from
young for vaccination, or those for whom vac- sterile sites only, a number of seriously ill chil-
cination is delayed, are at the highest risk of dren who had Group A Streptococcus isolated
severe morbidity and mortality.13,35 Since 2015, from ‘non-sterile’ sites such as abscesses or deep
early infant protection via maternal vaccina- wounds had to be excluded. This may need to
tion during each pregnancy has been recom- be revised in future surveillance to ensure all
mended.35-37 The expansion of the pertussis severe cases are able to be captured. There is
surveillance in 2016, through an NHMRC part- increasing awareness about this important inva-
nership grant (ID1113851) to collect controls sive infection. IGAS is currently only notifiable
and undertake maternal vaccine effectiveness in Queensland and the Northern Territory and
analysis will provide an important contribution ongoing data collection is imperative in provid-
in understanding the role of this strategy in the ing an evidence base to support its recognition
Australian context. as a potentially national notifiable disease. The
in-depth clinical data we collect will also be par-
PAEDS VZV data from 2016, shows an increase ticularly important in supporting the potential
in case numbers from previous years1,2 and the introduction of a vaccine for group A strepto-
proportion of children vaccinated was 60%. coccus disease in the near future.
This is similar to 2015 (64%)1, though decreased
from earlier years (2007-2014 78%)2. Analysis of From 2016, PAEDS activities have expanded
2007-2015 data with controls has estimated VE to incorporate social research which is also

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supported through the NHMRC partnership politan centres, limiting surveillance coverage
grant. This component seeks to use captured to populations served by these hospitals. In 2017,
cases and conduct detailed research into the a seventh hospital: Monash children’s Hospital
knowledge and attitudes of families of children will join the network and engage in surveillance
hospitalised with influenza and pertussis, with activities for a number of PAEDS conditions.
the aim of developing improved strategies to
better protect young infants. Following ethics PAEDS continues to be an important capacity-
approval attained late 2016, recruitment is set to building initiative to enhance existing public
commence in 2017. health surveillance for serious childhood
conditions, particularly VPDs and AEFIs, with
In 2016, PAEDS was operational across 6 ter- the overarching aim of improving child health
tiary paediatric hospitals based in large metro- outcomes. This unique surveillance platform

Table 4. Table of Acronyms

Acronym Definition
ACE Acute Childhood Encephalitis
ACIR Australian Childhood Immunisation Register
ADEM Acute Demyelinating Encephalomyelitis
AEFI Adverse events following immunisation
AFP Acute Flaccid Paralysis
APSU Australian Paediatric Surveillance Unit
ARI Acute Respiratory Illness
CHW The Children’s Hospital at Westmead
ED Emergency department
FluCAN Influenza Complications Alert Network
FS Febrile Seizures
GBS Guillain Barre Syndrome
ICD International Classification of Diseases
IMD Invasive Meningococcal Disease
IGAS Invasive Group A Streptococcus
IS Intussusception
LCCH Lady Cilento Children’s Hospital Brisbane
NCIRS National Centre for Immunisation Research and Surveillance
NERL National Enterovirus Reference Laboratory
NESB Non-English Speaking Background
NHMRC National Health and Medical Research Council
NIP National Immunisation Program
NSW New South Wales
PAEDS Paediatric Active Enhanced Disease Surveillance
PMH Princess Margaret Hospital Perth
RCH The Royal Children’s Hospital Melbourne
SANE Serious Acute Neurological Event
VE Vaccine Effectiveness
VIDRL Victorian Infectious Diseases Reference Laboratory
VPD Vaccine Preventable diseases
VZV Varicella Zoster Virus
WCH The Women’s and Children’s Hospital Adelaide
WHO World Health Organisation

health.gov.au/cdi Commun Dis Intell 2019;43(DOI:10.33321/cdi.2019.43.5) Epub 1/2/2019 11 of 15

also has the potential to be used for other urgent Author details
or research-focused studies for which active
surveillance is optimal. More information on Ms Jocelynne E McRae1
PAEDS is available at www.paeds.edu.au. Dr Helen E Quinn2,3
Ms Gemma L Saravanos4
Acknowledgements Ms Alissa McMinn5
Dr Philip N Britton6
We thank all PAEDS investigators, collabora- A/Prof Nicholas Wood7,8
tors, surveillance nurses and laboratory teams, A/Prof Helen Marshall9
who contributed to PAEDS in 2016. Prof Kristine Macartney10,11,12

The PAEDS network: Elliott E, McIntyre P, 1. PAEDS Network Manager, Clinical Nurse
Macartney K, Booy R, Wood N, Britton P, Quinn Consultant, National Centre for Immunisa-
H, Jones C, Rost L, Meredith K, Saravanos G, tion Research and Surveillance (NCIRS),
Dinsmore, Buttery J, Crawford N, McMinn A, Kids Research Institute, The Children’s Hos-
Lee D, Gibson M, Richmond P, Blyth C, Snelling pital at Westmead, New South Wales
T, Finucane C, West R, Kent J, Clark J, Kynaston
A, Dougherty S, Gold M, Marshall H, Walker M 2. Senior Research Fellow, National Centre for
and Heath C. Immunisation Research and Surveillance,
Kids Research Institute, The Children’s Hos-
We would also like to thank: Cheng A and pital at Westmead, New South Wales
Garlick J (FluCAN), Kesson A, Leung K,
Grote D and Stewart G (CHW Laboratory), 3. Lecturer, Child and Adolescent Health, Uni-
Lopez C (RCH laboratory), Clark E (Pathology versity of Sydney, New South Wales
Queensland), Sammels L, Lindsey K, Levy A,
Wuillemin J (Pathwest, WA), Hobday L and 4. Research Nurse, National Centre for Im-
Thorley B (VIDRL), Toi C (ICPMR). munisation Research and Surveillance, Kids
Research Institute, The Children’s Hospital at
PAEDS and this paper would not have Westmead, New South Wales
been possible without their important and
sustained contributions. 5. Research Manager, Registered Nurse
SAEFVIC, Infection & Immunity Murdoch,
We also thank the Australian Government Children’s Research Institute, The Royal Chil-
Department of Health and Departments of dren’s Hospital, Victoria
Health in the participating jurisdictions (New
South Wales, Victoria, South Australia, Western 6. Staff Specialist, Department of Infectious Dis-
Australia and Queensland) for funding sup- eases & Microbiology, The Children’s Hospi-
port. Funding for PAEDS participation in tal at Westmead, Sydney, New South Wales
FluCAN comes via the Australian Government
Department of Health and ACE surveillance has 7. Clinical fellow, National Centre for Immuni-
been supported by the Australian Government sation Research and Surveillance (NCIRS)
Department of Health (Surveillance Branch),
Arkhadia Fund/Norah Therese Hayes- 8. Post-graduate coordinator, Clinical school,
Ratcliffe Fellowship, Marie Bashir Institute, Child and Adolescent Health, University of
Sydney Medical School Dean’s fellowship, Sydney, New South Wales
the Shepherd Foundation, NHMRC partner-
ship grant (APP1113851) and other NHMRC 9. Senior Medical Practitioner and Direc-
(various sources). tor, Vaccinology and Immunology Re-
search Trials Unit, Women and Children’s

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 Hospital, Adelaide 2013;49(7):588-594.

10. Director, National Centre for Immunisation 4. Roberts J, Hobday L, Ibrahim A, Aitken T,
Research and Surveillance, Kids Research In- Thorley B. Australian National Enterovirus
stitute, The Children’s Hospital at Westmead, Reference Laboratory annual report, 2014.
New South Wales Commun Dis Intell Q Rep 2017;41(2):E161-
e180.
11. Professor, Discipline of Child and Adoles-
cent Health, University of Sydney, New South 5. World Health Organization. Global Polio
Wales Eradication Initiative, Surveillance. Accessed
on 24.10.17. Available from: http://polio-
12. Staff Specialist, Department of Microbiol- eradication.org/who-we-are/strategy/surveil-
ogy and Infectious Diseases, The Children’s lance/
Hospital at Westmead, New South Wales
6. Paediatric Trials Network Australia. Web-
Corresponding author: Ms Jocelynne E McRae, Spirit. 2013. Accessed on 24 October 2017.
PAEDS Network Manager, Clinical Nurse Available from: http://www.ptna.com.au/
Consultant, National Centre for Immunisation index.php/webspirit
Research and Surveillance (NCIRS), Kids
Research Institute, The Children’s Hospital 7. Britton PN, Dale RC, Booy R, Jones CA.
at Westmead, Locked Bag 4001, Westmead Acute encephalitis in children: Progress and
NSW 2145. priorities from an Australasian perspective. J
Telephone: +61 2 98453024 Paediatr Child Health 2015;51(2):147-158.
Email: [email protected]
8. Elliott EJ, Zurynski YA, Walls T, Whitehead
References B, Gilmour R, Booy R. Novel inpatient sur-
veillance in tertiary paediatric hospitals in
1. McRae J, Quinn HE, Macartney K. Paedi- New South Wales illustrates impact of first-
atric Active Enhanced Disease Surveillance wave pandemic influenza A H1N1 (2009)
(PAEDS) annual report 2015: Prospective and informs future health service planning.
hospital-based surveillance for select vaccine Journal of Paediatrics and Child Health
preventable diseases and adverse events fol- 2012;48(3):235-241.
lowing immunisation. Communicable Dis-
eases Intelligence 2017;41(3). 9. Bines JE, Kohl KS, Forster J, Zanardi LR, Da-
vis RL, Hansen J, et al. Acute intussusception
2. Zurynksi YA, McRae J, Quinn HE, Wood NJ, in infants and children as an adverse event
Macartney K. Paediatric Active Enhanced following immunization: case definition and
Disease Surveillance (PAEDS) inaugural guidelines of data collection, analysis, and
report 2014: Prospective hospital-based presentation. Vaccine 2004;22(5-6):569-574.
surveillance for select vaccine preventable
diseases and adverse events following immu- 10. Buttery JP, Danchin MH, Lee KJ, Carlin JB,
nisation. Communicable Diseases Intelligence McIntyre PB, Elliott EJ, et al. Intussusception
2016;In press. following rotavirus vaccine administration:
post-marketing surveillance in the National
3. Zurynski Y, McIntyre P, Booy R, Elliott EJ, Immunization Program in Australia. Vaccine
on behalf of the PAEDS Investigators Group. 2011;29(16):3061-3066.
Paediatric Active Enhanced Disease Surveil-
lance: a new surveillance system for Aus- 11. Carlin JB, Macartney KK, Lee KJ, Quinn
tralia. Journal of Paediatrics and Child Health HE, Buttery J, Lopert R, et al. Intussuscep-

health.gov.au/cdi Commun Dis Intell 2019;43(DOI:10.33321/cdi.2019.43.5) Epub 1/2/2019 13 of 15

 tion risk and disease prevention associated 19. Davis KL, Misurski D, Miller J, Karve S.
with rotavirus vaccines in Australia’s Na- Cost impact of complications in meningo-
tional Immunization Program. Clin Infect Dis coccal disease: evidence from a United States
2013;57(10):1427-1434. managed care population. Human vaccines
2011;7(4):458-465.
12. Quinn HE, Wood NJ, Cannings KL, Dey A,
Wang H, Menzies RI, et al. Intussusception 20. Wang B, Clarke M, Thomas N, Howell S,
after monovalent human rotavirus vaccine in Afzali HH, Marshall H. The clinical burden
Australia: severity and comparison of using and predictors of sequelae following invasive
healthcare database records versus case con- meningococcal disease in Australian chil-
firmation to assess risk. The Pediatric infec- dren. The Pediatric infectious disease journal
tious disease journal 2014;33(9):959-965. 2014;33(3):316-318.

13. Pillsbury A, Quinn HE, McIntyre PB. 21. Hoge CW, Schwartz B, Talkington DF, Brei-
Australian vaccine preventable disease epi- man RF, MacNeill EM, Englender SJ. The
demiological review series: Pertussis, 2006– changing epidemiology of invasive group A
2012. Communicable Diseases Intelligence streptococcal infections and the emergence
2014;38(3):E179-194. of streptococcal toxic shock-like syndrome.
A retrospective population-based study.
14. Marshall H, Quinn H, Gidding H, Rich- Journal of the American Medical Association
mond P, Crawford N, Gold N, et al. Severe 1993(269):384-389.
and complicated varicella in the post-vari-
cella vaccine era and associated genotypes. 22. Steer AC, Danchin MH, Carapetis JR.
Presented at: 15th National Immunisation Group A streptococcal infections in children.
Conference; 7–9 June 2016; Brisbane. Journal of Paediatrics and Child Health.
2007(43):203-213.
15. Bilukha OO, Rosenstein N. Prevention and
control of meningococcal disease. Recom- 23. Australian Bureau of Statistics (ABS). Popu-
mendations of the Advisory Committee on lation by age and sex, regions of Australia,
Immunization Practices (ACIP). MMWR 2016. (Cat. No. 3235.0). . Canberra: ABS,
Recommendations and reports : Morbidity 2017.
and mortality weekly report Recommenda-
tions and reports 2005;54(Rr-7):1-21. 24. Desai S, Smith T, Thorley BR, Grenier D,
Dickson N, Altpeter E, et al. Performance of
16. Peltola H. Meningococcal disease: still acute flaccid paralysis surveillance compared
with us. Reviews of infectious diseases with World Health Organization stand-
1983;5(1):71-91. ards. Journal of Paediatrics and Child Health
2015;51(2):209-214.
17. Trotter CL, Chandra M, Cano R, Larrauri
A, Ramsay ME, Brehony C, et al. A surveil- 25. Britton P, Dale R, Blyth C, Clark J, Crawford
lance network for meningococcal disease N, Marshall HS, et al. The Causes and Clini-
in Europe. FEMS microbiology reviews cal Features of Childhood Encephalitis in
2007;31(1):27-36. Australia: A Multicentre, Prospective, Co-
hort Study. Open Forum Infectious Diseases,
18. Borg J, Christie D, Coen PG, Booy R, Viner 2016;3(Suppl_1,1).
RM. Outcomes of meningococcal disease in
adolescence: prospective, matched-cohort 26. Britton P, Dale R, Clarke J, Crawford
study. Pediatrics 2009;123(3):e502-509. N, Marshall H, Elliott E, et al. Emerging
epidemic viruses are an important cause of

14 of 15 Commun Dis Intell 2019;43(DOI:10.33321/cdi.2019.43.5) Epub 1/2/2019 health.gov.au/cdi

 encephalitis in infants and children: findings following rotavirus vaccine administration:
from Australian cohort (ACE) study (2013- post-marketing surveillance in the National
2016). Presented at: European Congress of Immunization Program in Australia. Vaccine
Clinical Microbiology and Infectious Dis- 2011;29(16):3061-3066.
eases (ECCMID).
34. NNDSS Annual Report Working Group.
27. Britton PN, Blyth CC, Macartney K, Dale Australia’s notifiable disease status, 2014: An-
RC, Li-Kim-Moy J, Khandaker G, et al. The nual report of the National Notifiable Dis-
Spectrum and Burden of Influenza-Associat- eases Surveillance System. Commun Dis Intell
ed Neurological Disease in Children: Com- 2016;40(1):E48-E145.
bined Encephalitis and Influenza Sentinel
Site Surveillance From Australia, 2013-2015. 35. Australian Technical Advisory Group on
Clin Infect Dis 2017;65(4):653-660. Immunisation (ATAGI). The Australian im-
munisation handbook. 10th. Canberra: Aus-
28. Britton PN, Dale RC, Blyth CC, Macartney tralian Government Department of Health
K, Crawford NW, Marshall H, et al. Influ- and Ageing; 2013.
enza-associated Encephalitis/Encephalopa-
thy Identified by the Australian Childhood 36. Amirthalingam G, Andrews N, Campbell
Encephalitis Study 2013-2015. The Pediatric H, Ribeiro S, Kara E, Donegan K, et al. Ef-
infectious disease journal 2017;36(11):1021- fectiveness of maternal pertussis vaccination
1026. in England: an observational study. Lancet
2014;384(9953):1521-1528.
29. Blyth CC, Macartney KK, Hewagama S,
Senanayake S, Friedman ND, Simpson G, et 37. Quinn HE, Snelling TL, Habig A, Chiu C,
al. Influenza epidemiology, vaccine coverage Spokes PJ, McIntyre PB. Parental Tdap boost-
and vaccine effectiveness in children admit- ers and infant pertussis: a case-control study.
ted to sentinel Australian hospitals in 2014: Pediatrics 2014;134(4):713-720.
the Influenza Complications Alert Network
(FluCAN). Eurosurveillance In press. 38. Quinn H, Gidding H, Marshall H, Booy R,
Elliott E, Richmond P, et al. Varicella vaccine
30. Australian Government Department of effectiveness over 10 years in Australia. (Pa-
Health. Australian influenza surveillance re- per in progress: Planned submission to Journal
port 2015;10(Reporting Period 25 September of infection 2018).
to 9 October 2015).
39. Ching NS, Crawford N, McMinn A, Baker
31. Australian Technical Advisory Group on C, Azzopardi K, Brownlee K, et al. Prospec-
Immunisation. ATAGI Bulletin 58th Meeting tive surveillance of paediatric invasive group
15 and 16 October 2015. In: Department of A streptococcal infection. Journal of the Pedi-
Health: Immunisation Branch, editor. Can- atric Infectious Diseases Society In Press.
berra.

32. Blyth C. on behalf of the PAEDS and Flu-

CAN Networks. Influenza. Paediatric Active
Enhanced Disease Surveillance (PAEDS): 10
Year Anniversary Showcase: ; 2017; Mel-
bourne.

33. Buttery JP, Danchin MH, Lee KJ, Carlin JB,

McIntyre PB, Elliott EJ, et al. Intussusception

health.gov.au/cdi Commun Dis Intell 2019;43(DOI:10.33321/cdi.2019.43.5) Epub 1/2/2019 15 of 15