Introduction: Healthcare professionals' pivotal role in delivering quality care necessitates their continuous updating with the latest advancements through Continuing Medical Education (CME). Traditional CME methods, though valuable, have limitations. Aim: This article investigates how innovative CME approaches can enhance engagement and clinical competence among healthcare professionals. Methods: A review of the literature and analysis of various resources, guidelines and reports summarized by adding authors' personal perspectives. Results: Immersive virtual reality facilitates realistic simulations, enhancing clinical skills and reducing errors, but challenges include initial costs and ethical considerations. Personalized mobile learning apps offer flexible learning experiences tailored to individual needs, but face challenges like requirement of digital literacy, and content quality assurance. Incorporating game elements boosts engagement and knowledge retention, with challenges involving balancing gaming and learning. Blended learning, combining online modules with in-person experiences, bridges theory and practice but faces technological hurdles, and reduced face-to-face interaction. Personalized feedback and content delivery enhance engagement but encounter challenges like needing an algorithm design, data privacy and development costs. Conclusion: Innovative CME approaches are reshaping medical education, offering the potential to improve patient care outcomes. Addressing challenges and embracing these innovations is essential for healthcare professionals to excel in their fields and deliver high-quality care.

Background: COVID-19 vaccine booster dose hesitancy amongst the Saudi Arabia population is a concern. The objectives of the study were to explore the Saudi public’s willingness to receive a COVID-19 vaccine booster dose and identify the factors affecting their willingness. Methods: From December 2021 to March 2022, an online cross-sectional survey using an anonymous, structured, and self-administered questionnaire was conducted among members of the Saudi public aged ≥18 years who did not receive a COVID-19 vaccine booster dose. Results: Of the 2101 respondents, 86.8% expressed a willingness to receive a COVID-19 vaccine booster dose. Multiple logistic regression analysis showed that age (18 to 25 years) (adjusted odds ratio [aOR] = 2.54; 95% confidence interval [95% CI] = 1.14–5.74), being single (aOR = 2.85; 95% Cl = 1.42–5.72), and prior receipt of an influenza vaccine (aOR = 2.45; 95% Cl = 1.80–3.34) were significantly associated with participants’ willingness to receive the COVID-19 vaccine booster dose. Having a bachelor’s degree or above (aOR = 0.95; 95% CI = 0.81–0.99) and not following COVID-19 news (aOR = 0.70; 95% CI = 0.52–0.89) were associated with a significant likelihood of having no intention to receive the COVID-19 vaccine boosters. Conclusions: Most Saudi people were willing to have the COVID-19 vaccine booster dose, with age and prior influenza vaccination as the predictors; paradoxically, a university-level qualification was a barrier.

Backgroundand objectives: Although several vaccines have been produced and administered around the world, new SARS-CoV-2 worsened the COVID-19 infection risk and impacted the initial vaccine dosage effectiveness. Based on studies indicating that the third and fourth COVID-19 vaccine doses significantly reduced COVID-19 transmission, Saudi Arabia has been administering COVID-19 booster vaccine doses to its citizens. The purpose of this study was to evaluate the uptake of the COVID-19 vaccine booster in relation to the socio-demographic characteristics and other associated factors among the Saudi population. Materials and Methods: This study was an online analytical cross-sectional study using a self-administered questionnaire. Pearson Chi-square test and multiple logistic regression analyses were used to determine factors associated with the uptake of COVID-19 booster dose vaccines. Results: A total of 2332 responded to our study. Overall, 527 (22.6%) participants had received a booster dose. An age of 55 and above (aOR: 5.415; 95% CI: 2.719–10.783), Eastern region (aOR: 2.513; 95% CI: 1.566–4.033), history of influenza vaccination at annual intervals (aOR: 2.387; 95% CI: 1.730–3.293), the first dose of Moderna vaccine (aOR: 1.324; 95% CI: 1.160–1.510), and cancer (aOR: 2.161; 95% CI: 1.218–3.879) were independent factors most associated with a higher uptake of the COVID-19 vaccine booster dose. In contrast, the second dose of Moderna vaccine (aOR: 0.794; 95% CI: 0.683–0.922), AstraZeneca vaccine (aOR: 0.691; 95% CI: 0.509–0.939), strong symptoms from side effects after the second dose of the COVID-19 vaccine (aOR: 0.615; 95% CI: 0.404–0.935) were independent factors most associated with a lower uptake of the COVID-19 vaccine booster dose. Conclusions: Our findings indicate low COVID-19 vaccine booster uptake. This necessitates the need for strategies to address discouraging factors of the COVID-19 vaccine booster dose uptake and engage the Saudi population to raise awareness about the importance of the booster dose.

The role of public health preparedness at mass gatherings (MGs) and a framework to ensure a safe and healthy mass gathering are provided in this chapter. The unique aspects of Hajj and Umrah events, including their massive size and the interplay of environmental conditions with the international nature of attendees, require proper and thorough public health preparation. The key aspects of a framework designed to promote public health at mass gatherings are also outlined in this chapter. The key aspects include risk assessment, public health surveillance; regulations, legislation and policy; emergency planning and response; environmental health; public health awareness; strengthening communication; and internal organizational and capacity building. Our search evaluates literatures pertaining to the frameworks of public health concerns at mass gatherings and analyzes the preparedness and effectiveness of such regulations and projections in current models of disaster preparedness and public health promotion. Such a model is crucial for setting the stage for decision-making and ensuring the safety of attendees; it should be implemented before the commencement of the event. Further, the health risks associated with attending a mass gathering such as Hajj/Umrah are discussed. Clinicians and attendees have specific roles to play in ensuring good public health during these pilgrimages. Clinicians have a role in ensuring attendees are well equipped with the knowledge and resources to stay healthy during Hajj/Umrah, which helps to protect the public from infectious disease transmission. Attendees have a role in ensuring personal health and maintaining hygiene standards. Infectious diseases of concern at such mass gatherings include Middle East respiratory syndrome-coronavirus (MERS-CoV), meningococcal disease, diarrheal disease and seasonal influenza. Other diseases of concern include the potential for pilgrims to contract Zika due to local populations of Zika vectors. Specific vaccine requirements and knowledge regarding health warnings are crucial to Hajj attendees when traveling to the Kingdom of Saudi Arabia (KSA). In addition, pilgrims are encouraged to seek accurate information related to travel and visas and requirements of Hajj-specific travel visas.

Dear Editor,We read the intriguing editorial titled, ‘Restoring confidence in vaccines in the COVID-19 era’ by Verger and Dube [1]. Buttressed by examples from mainstream populations and healthcare...

Background: Data on long-term antibody responses to pneumococcal vaccines in the elderly, especially the frail elderly at greatest risk of severe disease, are limited. We followed up participants in a randomised trial of the immunogenicity of 23-valent polysaccharide vaccine (23vPPV) and 7 valent pneumococcal conjugate vaccines (PCV7) in hospitalised older adults. Methods: We measured antibody to vaccine serotypes by standardised enzyme-linked immunosorbent assay (ELISA) and opsonophagocytic (OPA) assays. A follow up study was conducted six years after vaccination with 23vPPV alone or with PCV7 followed by 23vPPV six months later. Results: Of 215 surviving trial participants, 136 (63%) completed follow up; 62 received 23vPPV and 74 received PCV7 + 23vPPV. There was no significant difference in death and readmission between arms. Antibody levels by ELISA and OPA did not differ significantly between the two study arms at 72 months post-vaccination. ELISA and OPA antibody remained higher than baseline except for OPA antibody to 4, 6A, 6B, 9v, 19F and 23F, including in subjects with undetectable immunity at baseline. Discussion: While ELISA responses in both study arms remained high 6 years post-vaccination, considerable waning was observed by OPA in both study arms, which should be considered given the current single-dose recommendation in Australia. Further research is needed to inform pneumococcal vaccine recommendations in people over the age of 65. (C) 2019 Elsevier Ltd. All rights reserved.

The burden of pneumococcal disease at Hajj has not been precisely evaluated through a systematic review. To this end we have conducted a systematic review on the burden of clinical infections due to Streptococcus pneumoniae among Hajj pilgrims.

Background The aim of this study was to estimate the prevalence of pneumonia and secondary bacterial infections during the pandemic of influenza A(H1N1)pdm09. Methods A systematic review was conducted to identify relevant literature in which clinical outcomes of pandemic influenza A(H1N1)pdm09 infection were described. Published studies (between 01/01/2009 and 05/07/2012) describing cases of fatal or hospitalised A(H1N1)pdm09 and including data on bacterial testing or co-infection. Results Seventy five studies met the inclusion criteria. Fatal cases with autopsy specimen testing were reported in 11 studies, in which any co-infection was identified in 23% of cases ( Streptococcus pneumoniae 29%) . Eleven studies reported bacterial co-infection among hospitalised cases of A(H1N1)2009pdm with confirmed pneumonia, with a mean of 19% positive for bacteria ( Streptococcus pneumoniae 54%) . Of 16 studies of intensive care unit (ICU) patients, bacterial co-infection identified in a mean of 19% of cases ( Streptococcus pneumoniae 26%) . The mean prevalence of bacterial co-infection was 12% in studies of hospitalised patients not requiring ICU ( Streptococcus pneumoniae 33%) and 16% in studies of paediatric patients hospitalised in general or pediatric intensive care unit (PICU) wards ( Streptococcus pneumoniae 16%) . Conclusion We found that few studies of the 2009 influenza pandemic reported on bacterial complications and testing. Of studies which did report on this, secondary bacterial infection was identified in almost one in four patients, with Streptococcus pneumoniae the most common bacteria identified. Bacterial complications were associated with serious outcomes such as death and admission to intensive care. Prevention and treatment of bacterial secondary infection should be an integral part of pandemic planning, and improved uptake of routine pneumococcal vaccination in adults with an indication may reduce the impact of a pandemic.

The burden of pneumococcal disease at Hajj has not been precisely evaluated through a systematic review. To this end we have conducted a systematic review on the burden of clinical infections due to Streptococcus pneumoniae among Hajj pilgrims. Major electronic databases including OVID Medline, Web of Science, OVID Embase, Social Sciences Citation Index, Google Scholar and relevant websites (e.g., online Saudi Epidemiology Bulletin) were searched by using MeSH terms and text words containing but not limited to 'Hajj', pneumonia and S. pneumoniae. This was buttressed by hand searching of reference lists of identified studies. Of 21 full text papers reviewed, nine articles were included in this review. Seven studies reported the burden of pneumococcal pneumonia and the other two reported the burden of invasive pneumococcal diseases including meningitis and sepsis. The proportion of pneumonia that was pneumococcal ranged from 1% to 54% of bacteriologically confirmed pneumonias. The pneumococcus accounted for 2/3rd of bacteriologically diagnosed meningitis cases, and 1/3rd of confirmed cases of sepsis. Case fatality rate of pneumococcal pneumonia was recorded in only two studies: 33.3% and 50%. Only one study provided data on antimicrobial susceptibility of S. pneumoniae isolates, reporting 33.3% to be penicillin resistant. None of the included studies provided data on serotype distribution of S. pneumoniae. This systematic review highlights the significance of pneumococcal disease during Hajj, and demonstrates paucity of data on its burden particularly on disease-causing serotype.

Haematopoietic stem cell transplant (HSCT) and bone marrow transplant (BMT) recipients are at increased risk of developing infections, including invasive pneumococcal disease (IPD) (Kulkarni et al, 2000; Johnston & Conly, 2002). The use of conjugate vaccine is recommended in HSCT recipients, as a series of three doses at 6, 8 and 12 months, followed by 23-valent pneumococcal polysaccharide vaccine (PPV23) at 24 months, irrespective of previous immunisation history (Australian Government Department of Health, 2016). We conducted a clinical trial to determine the immune responses of a two- versus three-dose schedule of PCV7 followed by a dose of PPV23 in adult HSCT/BMT recipients. A randomised, clinical trial was conducted in a large tertiary referral hospital in Sydney, Australia from April 2006 to October 2007. We aimed to recruit 10 subjects per vaccine group for the pilot study (30 patients). Eligible participants were those aged ≥18 years undergoing allogeneic or autologous HSCT or BMT. Thirty-one patients were recruited before transplantation and randomized into arm A (n = 15) and arm B (n = 16). Participants in arm A received three doses of PCV7 (Prevenar, Wyeth Pharmaceuticals Inc., Collegeville, PA, USA) at 3, 6 and 12 months after HSCT/BMT and a dose of PPV23 at 18 months following transplant. Participants in arm B received two doses of PVC7 at 3 and 6 months post-transplantation, with a dose of PPV23 at 12 months following transplantation. A systematically selected control arm (n = 10) was included to compare against the two different schedules of PCV7. Participants in the control arm were 12 months post-BMT and were scheduled to have routine vaccine (a single dose of PPV23) (Fig 1). Blood samples were collected at baseline (pre-vaccination), immediately prior to vaccination and also 1 month after each vaccine dose except after first dose (Fig 1). Baseline and 3-month post-vaccination serological testing was also conducted among the controls as per hospital protocols. Anti-pneumococcal polysaccharide (PnPs) antibody concentration for each of the seven individual polysaccharide serotypes common to PCV7 were measured by enzyme-linked immunosorbent assay (ELISA) (Quataert et al, 2001). The bactericidal activities of the samples were evaluated by opsonophagocytic assay (OPA) (Cooper et al, 2011). Testing of serum samples was conducted at Pfizer Vaccine R&D (Pearl River, NY, USA). All antibody titres were log transformed and then the antilog of the means were calculated to obtain the geometric mean concentration (GMC, μg/ml) and that of the OPA (/titre). SAS version 9.4 (SAS Institute Inc., Sydney, Australia) was used for statistical analysis. The characteristics of participants were similar across the study arms (Table SI). No significant differences were observed between Arm A and Arm B in PnPs immunoglobulin G (IgG) titres measured by ELISA at any time point. By OPA testing, the only significant differences were seen for serotype 9V and 23F at 13 months post-transplant and following a 12-month dose of PPV23 (Table 1). The intervention arms (A and B) had significantly higher baseline IgG titres for serotypes 3, 4, 6A, 14, 19A and 19F compared to controls. After receiving PCV7 doses at 6 months, participants in the intervention arms had significantly higher GMC values for serotypes 14 and 19A versus controls. OPA was not significantly different between the study arms and the control for most of the serotypes except for 14 at baseline. No significant differences were seen for the ten serotypes tested by OPA between the study arms and controls at 6 month (Table SII). In the intervention arms, GMCs of serotypes 4, 14 and 18C were significantly higher at 6 and 13 months, and 9V ad 19F at 13 months compared to baseline (Table SIII). After the first dose of PCV7, five participants reported local adverse events– four in Arm B and one in Arm A. Three participants in Arm B reported local adverse events after the second dose of PCV. Four participants reported local reactions after the third dose of PCV – two each in Arms A and B. Systematic adverse events were not reported by any participant. The data suggested a benefit of boosting with PPV23 following two doses of PCV7, consistent with our previous study of PCV7 versus PPV23 in frail elderly adults, which also showed a benefit of PCV7 followed by PPV23 (Macintyre et al, 2014). A number of trials have demonstrated immunogenicity of the conjugate vaccine in HSCT recipients (Cordonnier et al, 2009, 2015), however there are limited data on optimal dosing and timing of vaccination in immunosuppressed patients. Limitations of this study include the small sample size, high dropout rate, and the current use of PCV10 and PCV13 in most countries. In conclusion, vaccination with two or three doses of conjugate vaccine 3 months after HSCT was non-inferior to vaccination at 12 months with PPV23. Given the high risk of infections in transplant patients, earlier vaccination may improve the potential to prevent infections in this vulnerable group. The study adds evidence in favour of a mixed conjugate and polysaccharide vaccination schedule to improve boosting of the immune response. The Authors wish to thank head of departments, their staff to allow us approach patients, the participants and Ms. Sue Campbell Lloyd for providing the vaccines, and Dr. Zhanhai Gao for his contribution to the statistical analysis. We also would like to thank all participants who were involved in the study. CRM has received in-kind support and funding for investigator-driven research from GlaxoSmithKline, Pfizer, Merck, and bioCSL, and has sat on advisory boards for Merck, GlaxoSmithKline and Pfizer. IR has received grant funds for investigator-driven research from GSK, Pfizer and for consultation from Merck. The other authors declare that they have no competing interests and have no non-financial interests that may be relevant to the submitted work. CRM: lead investigator, conception and design of the study, manuscript revision; ALK, IR, AM, MK, KB: contributed to study design and acquisition of data and manuscript revision; AAC, MB: contributed to data management, data analysis and drafting the manuscript. All authors approved the final version to be submitted. This investigator-driven and designed research was funded by the National Health and Medical Research Council of Australia (NHMRC Project Grant ##352337). The laboratory testing was conducted and funded by Pfizer, USA. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Table SI. Comparison of participants’ characteristics between treatment groups at baseline (n = 41). Table SII. Comparison of IgG (GMC, µg/ml) and OPA (GMT, /titer) between A and B and control. Table SIII. Comparison of ELISA (GMC, µg/ml) between A and B 6 at baseline, 6 and 13 months. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

The role of social distancing measures in mitigating pandemic influenza is not precisely understood. To this end, we have conducted a systematised review, particularly in light of the 2009 pandemic influenza, to better inform the role of social distancing measures against pandemic influenza. Articles were identified from relevant databases and the data were synthesised to provide evidence on the role of school or work place-based interventions, case-based distancing (self-isolation, quarantine), and restriction of mobility and mass gatherings. School closure, whether proactive or reactive, appears to be moderately effective and acceptable in reducing the transmission of influenza and in delaying the peak of an epidemic but is associated with very high secondary costs. Voluntary home isolation and quarantine are also effective and acceptable measures but there is an increased risk of intra-household transmission from index cases to contacts. Work place-related interventions like work closure and home working are also modestly effective and are acceptable, but likely to be economically disruptive. Internal mobility restriction is effective only if prohibitively high (50% of travel) restrictions are applied and mass gatherings occurring within 10 days before the epidemic peak are likely to increase the risk of transmission of influenza.

Studies to determine the effectiveness of facemasks in preventing influenza have been inconclusive, largely due to small sample size. The Hajj pilgrimage, where the incidence of influenza and other respiratory infections is high, provides an excellent opportunity to test the effectiveness of facemasks against syndromic and laboratory-confirmed infections. Hence, a pilot study was conducted among Australian pilgrims to assess the feasibility of such a large-scale trial in the coming years. At the 2011 Hajj, tents were randomised to 'supervised mask use' versus 'no supervised mask use'. Pilgrims with ILI symptoms for ≤3 days were recruited as 'cases' and those who slept within 2 meters of them as 'contacts'. Surgical facemasks were provided to cases and contacts in the 'mask' tents, but not in the 'control' tents. Pilgrims in both groups were given diaries to record their respiratory symptoms. Nasal or pharyngeal swabs were collected from the cases and contacts with ILI for point-of-care and nucleic acid tests. A total of 22 tents were randomised to 'mask' (n=12) or 'control' (n=10). There were 164 pilgrims recruited; 75 in 'mask' and 89 in 'control' group. Mask use compliance was 76% in the 'mask' group and 12% in the 'control' group. Based on developing syndromic ILI, less contacts became symptomatic in the 'mask' tents compared to the 'control' tents (31% versus 53%, p= 0.04). However, laboratory results did not show any difference between the two groups. This pilot study shows that a large trial to assess the effectiveness of facemasks use at Hajj is feasible.

Pertussis seroepidemiology and associated factors in older adults aged ≥40 years with and without acute myocardial infarction (AMI) were studied to investigate whether unrecognised pertussis may precipitate AMI. Sera were obtained from a previous case-control study investigating the role of influenza in precipitating AMIs. Baseline sera were considered pertussis toxin (PT) IgG seropositive at levels ≥5 IU/mL. Levels ≥v62.5 IU/mL were considered indicative of infection in the previous year, and recent infection was indicative at levels ≥125 IU/mL. Of the serum samples tested, 55% (122/222) were seropositive for PT IgG, 5% (11/222) had evidence of infection in the past year and 1.4% (3/222) had evidence of recent infection. Evidence of infection in the past year was found in 3.2% of those aged 65-74 years. Overall, 47.8% of 40-64 year olds and 43.2% of those aged ≥65 years were seronegative for pertussis. Serological evidence of pertussis was not associated with AMI (46/92, 50.0% cases vs. 76/130, 58.5% controls, p=0.2). After adjusting for age, AMI and self-reported pertussis and GP verified influenza vaccination, females (OR = 2.2, 95% CI = 1.1-4.1, p=0.02) were more likely to be seronegative. Just under half of participants had no detectable pertussis immunity and are therefore susceptible to infection. Our study supports the need for an adult pertussis booster to supplement current recommendations.

INTRODUCTION:With the availability of newer conjugate vaccines, immunization schedules have become increasingly complex due to the potential for unpredictable immunologic interference such as 'carrier priming' and 'carrier induced epitopic suppression'. Carrier priming refers to an augmented antibody response to a carbohydrate portion of a glycoconjugate vaccine in an individual previously primed with the carrier protein. This review aims to provide a critical evaluation of the available data on carrier priming (and suppression) and conceptualize ways by which this phenomenon can be utilized to strengthen vaccination schedules. METHODS:We conducted this literature review by searching well-known databases to date to identify relevant studies, then extracted and synthesized the data on carrier priming of widely used conjugate polysaccharide vaccines, such as, pneumococcal conjugate vaccine (PCV), meningococcal conjugate vaccine (MenCV) and Haemophilus influenzae type b conjugate vaccines (HibV). RESULTS:We found evidence of carrier priming with some conjugate vaccines, particularly HibV and PCV, in both animal and human models but controversy surrounds MenCV. This has implications for the immunogenicity of conjugate polysaccharide vaccines following the administration of tetanus-toxoid or diphtheria-toxoid containing vaccine (such as DTP). CONCLUSION:Available evidence supports a promising role for carrier priming in terms of maximizing the immunogenicity of conjugate vaccines and enhancing immunization schedule by making it more efficient and cost effective.

People with dementia are at a greater risk of complications from respiratory infections therefore can benefit from vaccinations against influenza, pneumococcal disease and pertussis. This review aimed to evaluate the uptake and impact of vaccination in older adults with dementia against respiratory infections and identify knowledge gaps. Key databases were explored, search results were assessed, relevant studies identified, and data were synthesised and summarised. Most available data suggest that older adults with dementia are less likely to receive influenza or pneumococcal vaccine while a few studies indicate an increase in vaccination uptake but poor immunogenicity. Among dementia patients, community dwellers have a lower vaccination rate than home care residents. However, vaccinations against influenza and pneumococcal disease can benefit individuals with dementia by reducing both mortality and morbidity. Health professionals caring for patients with dementia could play a role in fostering vaccination of these individuals.

The uptake of the pneumococcal vaccine is suboptimal in Australia and remains unknown among Australian Hajj pilgrims, many of whom are eligible because of age or underlying disease and at particular risk because of travel and activities at Hajj. Pneumococcal vaccination uptake was examined over three consecutive years (2011 to 2013) through anonymous self-administered cross sectional surveys among Australian pilgrims who assembled in Mina valley, Mecca, Saudi Arabia. Respectively, 158, 513 and 219 pilgrims were recruited in 2011, 2012 and 2013; their mean ages were 43.8 (SD±13), 43 (SD±13.5) and 42.6 (SD±12.3) years; males accounted for 67 (42.4%), 325 (63.4%) and 172 (78.5%). Pneumococcal vaccine uptake rates were 28.5% (45/158), 28.7% (147/513) and 14.2% (31/219); among the pilgrims with 'at risk' conditions the pneumococcal vaccine uptake rates were 15 (30.6%), 43 (45.3%) and 9 (29%) respectively. According to our surveys, the pneumococcal vaccine uptake among Australian pilgrims is low. Further research is needed to explore the reasons through a validated study.

BACKGROUNDHajj is the largest annual mass gathering where the risk of respiratory infection is high. Although the Saudi Arabian authority recommends influenza vaccination for Hajj pilgrims, the uptake is variable. Influenza vaccine uptake data among Australian Hajj pilgrims is not readily available. Therefore, we aimed to estimate the influenza vaccination uptake rate and identify both attitudes and barriers to vaccine uptake from two consecutives surveys at Hajj in 2011 and 2012.METHODSUsing an anonymous self-administered questionnaire, surveys were conducted in Mecca, Saudi Arabia, among Hajj pilgrims from Australia in 2011 and 2012. Pilgrims staying in "Australian" tents were recruited serially.RESULTSIn 2011, 431 Australian pilgrims completed the survey-median age was 42 (range 7-86) years, 55% were male; 65% reported receiving influenza vaccine. In 2012, 535 pilgrims of median age 43 (range 12-83) years completed the survey, 62% were male; 89% reported receiving the vaccine. Both in 2011 and 2012, common reasons for not receiving the vaccine were the pilgrims' reliance on their "natural immunity" (33 and 26%, respectively, p = 0.4) and believing that they would rarely catch influenza or come in contact with influenza patients (18 and 29%, respectively, p = 0.1). In 2012, when asked why they had received the vaccine, 65% pilgrims responded that it was because of the tour group leaders' recommendation.CONCLUSIONInfluenza vaccine uptake among Australian Hajj pilgrims seems satisfactory and increasing but could be better because many pilgrims have misconceptions about vaccines. Tour operators may play a greater role in promoting vaccination.

BACKGROUND:Cost-effective interventions are needed to control the transmission of viral respiratory tract infections (RTIs) in mass gatherings. Facemasks are a promising preventive measure, however, previous studies on the efficacy of facemasks have been inconclusive. This study proposes a large-scale facemask trial during the Hajj pilgrimage in Saudi Arabia and presents this protocol to illustrate its feasibility and to promote both collaboration with other research groups and additional relevant studies.METHODS/DESIGN:A cluster-randomised controlled trial is being conducted to test the efficacy of standard facemasks in preventing symptomatic and proven viral RTIs among pilgrims during the Hajj season in Mina, Mecca, Saudi Arabia. The trial will compare the 'supervised use of facemasks' versus 'standard measures' among pilgrims over several Hajj seasons. Cluster-randomisation will be done by accommodation tents with a 1:1 ratio. For the intervention tents, free facemasks will be provided to be worn consistently for 7days. Data on flu-like symptoms and mask use will be recorded in diaries. Nasal samples will be collected from symptomatic recruits and tested for nucleic acid of respiratory viruses. Data obtained from questionnaires, diaries and laboratory tests will be analysed to examine whether mask use significantly reduces the frequency of laboratory-confirmed respiratory viral infection and syndromic RTI as primary outcomes.CONCLUSIONS:This trial will provide valuable evidence on the efficacy of standard facemask use in preventing viral respiratory tract infections at mass gatherings. This study is registered at the Australian New Zealand Clinical Trials Registry (ANZCTR), ACTRN: ACTRN12613001018707 (http://www.anzctr.org.au).

Objective. We compared the efficacy of medical masks (MM) and N95 respirators (N95) in preventing bacterial colonization/infection in healthcare workers (HCWs).Methods. A cluster randomized clinical trial (RCT) of 1441 hospital HCWs randomized to medical masks or N95 respirators, and compared to 481 control HCWs, was performed in Beijing, China, during the winter season of 2008-2009. Participants were followed for development of clinical respiratory illness (CRI). Symptomatic subjects were tested for Streptococcus pneumoniae, Bordetella pertussis, Chlamydia pneumoniae, Mycoplasma pneumoniae or Haemophilus influenza type B by multiplex polymerase chain reaction (PCR).Results. The rate of bacterial colonization was 2.8% in the N95 group (p = 0.02), 53% among medical mask users (p < 0.01) and 7.5% among the controls (p = 0.16). N95 respirators were significantly protective (adjusted RR 0.34, 95% CI: 0.21-0.56) against bacterial colonization. Co-infections of two bacteria or a virus and bacteria occurred in up to 3.7% of HCWs, and were significantly lower in the N95 arm.Conclusions. N95 respirators were significantly protective against bacterial colonization, co-colonization and viral-bacterial co-infection. We showed that dual respiratory virus or bacterial-viral co-infections can be reduced by the use of N95 respirators. This study has occupational health and safety implications for health workers. (C) 2014 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-SA license (http://creativecommons.org/licenses/by-nc-sa/3.0/).