Department of Health and Human Services

Abstract Objective : To compare the relative risks of serious gastrointestinal complications reported with individual non-steroidal anti-inflammatory drugs. Design : Systematic review of controlled epidemiological studies that found a relation between use of the drugs and admission to hospital for haemorrhage or perforation. Setting : Hospital and community based casecontrol and cohort studies. Main outcome measures : (a) Estimated relative risks of gastrointestinal complications with use of individual drugs, exposure to ibuprofen being used as reference; (b) a ranking that best summarised the sequence of relative risks observed in the studies. Results : 12 studies met the inclusion criteria. 11 provided comparative data on ibuprofen and other drugs. Ibuprofen ranked lowest or equal lowest for risk in 10 of the 11 studies. Pooled relative risks calculated with exposure to ibuprofen used as reference were all significantly greater than 1.0 (interval of point estimates 1.6 to 9.2). Overall, ibuprofen was associated with the lowest relative risk, followed by diclofenac. Azapropazone, tolmetin, ketoprofen, and piroxicam ranked highest for risk and indomethacin, naproxen, sulindac, and aspirin occupied intermediate positions. Higher doses of ibuprofen were associated with relative risks similar to those with naproxen and indomethacin. Conclusions : The low risk of serious gastrointestinal complications with ibuprofen seems to be attributable mainly to the low doses of the drug used in clinical practice. In higher doses ibuprofen is associated with a similar risk to other non-steroidal anti-inflammatory drugs. Use of low risk drugs in low dosage as first line treatment would substantially reduce the morbidity and mortality due to serious gastrointestinal toxicity from these drugs. Key messages Because there are no important differences in efficacy, choice of first line treatment with these drugs should be based on their relative toxicity Meta-analysis of the available epidemiological studies shows wide differences between individual drugs in the risk of inducing gastrointestinal bleed- ing and ulcer perforation Of the drugs in common use, ibuprofen and diclofenac rank low in toxicity whereas azapropa- zone, ketoprofen, and piroxicam rank high Some of the differences between drugs may be explained by dose, and the advantage of “low risk” drugs may be lost once their dose is increased

BACKGROUND: Overweight and obesity are global health problems which are increasing throughout the industrialised world. If left unchecked, they will continue to contribute to the ever increasing noncommunicable disease burden. OBJECTIVES: To assess the effects of psychological interventions for overweight or obesity as a means of achieving sustained weight loss. SEARCH STRATEGY: Studies were obtained from searches of multiple electronic bibliographic databases. The date of the latest search was June 2003. SELECTION CRITERIA: Trials were included if the fulfilled the following criteria: 1) they were randomised controlled clinical trials of a psychological intervention versus a comparison intervention, 2) one of the outcome measures of the study was weight change measured by any method, 3) participants were followed for at least three months, 4) the study participants were adults (18 years or older) who were overweight or obese (BMI > 25 kg/m(2)) at baseline. DATA COLLECTION AND ANALYSIS: Two people independently applied the inclusion criteria to the studies identified and assessed study quality. Disagreement was resolved by discussion or by intervention of a third party. Meta-analyses were performed using a fixed effect model. MAIN RESULTS: A total of 36 studies met the inclusion criteria and were included in the review. Overall, 3495 participants were evaluated. The majority of studies assessed behavioural and cognitive-behavioural weight reduction strategies. Cognitive therapy, psychotherapy, relaxation therapy and hypnotherapy were assessed in a small number of studies. Behaviour therapy was found to result in significantly greater weight reductions than placebo when assessed as a stand-alone weight loss strategy (WMD -2.5 kg; 95% CI -1.7 to -3.3). When behaviour therapy was combined with a diet / exercise approach and compared with diet / exercise alone, the combined intervention resulted in a greater weight reduction. Studies were heterogeneous however the majority of studies favoured combining behaviour therapy with dietary and exercise interventions to improve weight loss. Increasing the intensity of the behavioural intervention significantly increased the weight reduction (WMD -2.3 kg; 95% CI -1.4 to - 3.3). Cognitive-behaviour therapy, when combined with a diet / exercise intervention, was found to increase weight loss compared with diet / exercise alone (WMD -4.9 kg; 95% CI -7.3 to - 2.4). No data on mortality, morbidity or quality of life were found. AUTHORS' CONCLUSIONS: People who are overweight or obese benefit from psychological interventions, particularly behavioural and cognitive-behavioural strategies, to enhance weight reduction. They are predominantly useful when combined with dietary and exercise strategies. The bulk of the evidence supports the use of behavioural and cognitive-behavioural strategies. Other psychological interventions are less rigorously evaluated for their efficacy as weight loss treatments.

OBJECTIVES: The International Classification of Disease, 10th Revision (ICD-10) was introduced worldwide beginning in the late 1990s. Because there have been no published data on the quality of coding using ICD-10, the aim of our analysis is to assess the quality of ICD-10 coding in routinely collected hospital discharge data from Australia, which began using ICD-10 in 1998. METHODS: Audit data from the years 1998-1999 (n = 7004) and 2000-2001 (n = 7631), excluding same-day chemotherapy and dialysis cases, were used in data analysis. Quality measures included prevalence comparisons, sensitivity, positive predictive value (PPV), and the kappa statistic. RESULTS: Comparison of the audit sample to public hospital discharges showed little difference in age and gender, with audited cases more likely to be overnight stays. There was no difference in the median number of hospital assigned diagnosis and procedure codes per discharge. Agreement of the principal diagnosis code was 85% at the 3-digit level and 79% at the 4-digit level in 1998-1999; this rate had improved to 87% and 81% in 2000-2001. Principal procedure code agreement was 85% in 1998-1999 and 83% in 2000-2001 at the 5-digit level, and 81% and 80% at the 7-digit level, respectively. Specific major diagnoses, comorbid diagnoses, major procedures, and minor procedures showed good-to-excellent coding quality. CONCLUSIONS: The transition to ICD-10 has occurred with no loss of data quality, with data showing a high level of reliability and adherence to coding standards. When consideration is given to the nature of the analysis, administrative data can provide highly reliable population-based estimates of hospitalization rates.

Importance: Emerging evidence suggests that risk of bacterial sexually transmitted infections (STIs) increases among gay and bisexual men following initiation of HIV preexposure prophylaxis (PrEP). Objective: To describe STI incidence and behavioral risk factors among a cohort of predominantly gay and bisexual men who use PrEP, and to explore changes in STI incidence following PrEP commencement. Design, Setting, and Participants: The Pre-exposure Prophylaxis Expanded (PrEPX) Study, a multisite, open-label intervention study, was nested within the Australian Collaboration for Coordinated Enhanced Sentinel Surveillance (ACCESS) clinic network. A total of 4275 participants were enrolled (July 26, 2016-April 1, 2018) in Victoria, Australia. Of these, 2981 enrolled at 5 ACCESS clinics (3 primary care, 1 sexual health, and 1 community-based HIV rapid testing service), had at least 1 follow-up visit, and were monitored until April 30, 2018. Exposures: Upon enrollment, participants received daily oral tenofovir disoproxil fumurate and emtricitabine for HIV PrEP, quarterly HIV and STI testing, and clinical monitoring. Main Outcomes and Measures: The primary outcome was incidence of chlamydia, gonorrhea, or syphilis. Incidence rates and hazard ratios describing behavioral risk factors of STI diagnosis were calculated. Incidence rate ratios (IRRs), adjusted for change in testing frequency, described changes in STI incidence from 1-year preenrollment to study follow-up among participants with preenrollment testing data (n = 1378). Results: Among the 2981 individuals (median age, 34 years [interquartile range, 28-42]), 98.5% identified as gay or bisexual males, 29% used PrEP prior to enrollment, 89 (3%) withdrew and were censored at date of withdrawal, leaving 2892 (97.0%) enrolled at final follow-up. During a mean follow-up of 1.1 years (3185.0 person-years), 2928 STIs were diagnosed among 1427 (48%) participants (1434 chlamydia, 1242 gonorrhea, 252 syphilis). STI incidence was 91.9 per 100 person-years, with 736 participants (25%) accounting for 2237 (76%) of all STIs. Among 2058 participants with complete data for multivariable analysis, younger age, greater partner number, and group sex were associated with greater STI risk, but condom use was not. Among 1378 participants with preenrollment testing data, STI incidence increased from 69.5 per 100 person-years prior to enrollment to 98.4 per 100 person-years during follow-up (IRR, 1.41 [95% CI, 1.29-1.56]). After adjusting for testing frequency, the increase in incidence from 1 year preenrollment to follow-up was significant for any STI (adjusted IRR, 1.12 [95% CI, 1.02-1.23]) and for chlamydia (adjusted IRR, 1.17 [95% CI, 1.04-1.33]). Conclusions and Relevance: Among gay and bisexual men using PrEP, STIs were highly concentrated among a subset, and receipt of PrEP after study enrollment was associated with an increased incidence of STIs compared with preenrollment. These findings highlight the importance of frequent STI testing among gay and bisexual men using PrEP.

This paper addresses a fundamental question in evidence based policy making--can scientists and policy makers work together? It first provides a scenario outlining the different mentalities and imperatives of scientists and policy makers, and then discusses various issues and solutions relating to whether and how scientists and policy makers can work together. Scientists and policy makers have different goals, attitudes toward information, languages, perception of time, and career paths. Important issues affecting their working together include lack of mutual trust and respect, different views on the production and use of evidence, different accountabilities, and whether there should be a link between science and policy. The suggested solutions include providing new incentives to encourage scientists and policy makers to work together, using knowledge brokers (translational scientists), making organisational changes, defining research in a broader sense, re-defining the starting point for knowledge transfer, expanding the accountability horizon, and finally, acknowledging the complexity of policy making. It is hoped that further discussion and debate on the partnership idea, the need for incentives, recognising the incompatibility problems, the role of civil society, and other related themes will lead to new opportunities for further advancing evidence based policy and practice.

AIMS: To investigate the extent to which emotional labour and emotional intelligence are associated with well-being and job-stress among a group of Australian community nurses. The moderating role of emotional intelligence was evaluated as a key factor in the rescue of healthcare workers from job-stress, thus increasing job retention. BACKGROUND: Although emotional labour has been broadly investigated in the literature, the contribution of emotional labour and emotional intelligence to the well-being and experience of job-stress in a community nursing setting requires further exploration. DESIGN: This study used a cross-sectional quantitative research design with data collected from Australian community nurses. METHODS: Australian community nurses (n = 312) reported on their perceived emotional labour, emotional intelligence and their levels of well-being and job-stress using a paper and pencil survey in 2010. RESULTS/FINDINGS: Results from structural equation modelling support the hypothesis that both emotional labour and emotional intelligence have significant effects on nurses' well-being and perceived job-stress. Emotional intelligence plays a moderating role in the experience of job-stress. CONCLUSION: These findings provide additional evidence for the important effects that emotional labour and emotional intelligence can have on well-being and job-stress among community nurses. The potential benefits of emotional intelligence in the nurses' emotional work have been explored.

BACKGROUND: A multidisciplinary collaboration investigated the world's largest, most catastrophic epidemic thunderstorm asthma event that took place in Melbourne, Australia, on Nov 21, 2016, to inform mechanisms and preventive strategies. METHODS: Meteorological and airborne pollen data, satellite-derived vegetation index, ambulance callouts, emergency department presentations, and data on hospital admissions for Nov 21, 2016, as well as leading up to and following the event were collected between Nov 21, 2016, and March 31, 2017, and analysed. We contacted patients who presented during the epidemic thunderstorm asthma event at eight metropolitan health services (each including up to three hospitals) via telephone questionnaire to determine patient characteristics, and investigated outcomes of intensive care unit (ICU) admissions. FINDINGS: ). At 1800 AEDT, a gust front crossed Melbourne, plunging temperatures 10°C, raising humidity above 70%, and concentrating particulate matter. Within 30 h, there were 3365 (672%) excess respiratory-related presentations to emergency departments, and 476 (992%) excess asthma-related admissions to hospital, especially individuals of Indian or Sri Lankan birth (10% vs 1%, p<0·0001) and south-east Asian birth (8% vs 1%, p<0·0001) compared with previous 3 years. Questionnaire data from 1435 (64%) of 2248 emergency department presentations showed a mean age of 32·0 years (SD 18·6), 56% of whom were male. Only 28% had current doctor-diagnosed asthma. 39% of the presentations were of Asian or Indian ethnicity (25% of the Melbourne population were of this ethnicity according to the 2016 census, relative risk [RR] 1·93, 95% CI 1·74-2·15, p <0·0001). Of ten individuals who died, six were Asian or Indian (RR 4·54, 95% CI 1·28-16·09; p=0·01). 35 individuals were admitted to an intensive care unit, all had asthma, 12 took inhaled preventers, and five died. INTERPRETATION: Convergent environmental factors triggered a thunderstorm asthma epidemic of unprecedented magnitude, tempo, and geographical range and severity on Nov 21, 2016, creating a new benchmark for emergency and health service escalation. Asian or Indian ethnicity and current doctor-diagnosed asthma portended life-threatening exacerbations such as those requiring admission to an ICU. Overall, the findings provide important public health lessons applicable to future event forecasting, health care response coordination, protection of at-risk populations, and medical management of epidemic thunderstorm asthma. FUNDING: None.

This study explored the effects of occupational exposure to solvents and noise on hearing. Interviews and hearing tests were conducted for printing and paint manufacturing workers. The experimental groups included unexposed (N = 50) workers and workers exposed to noise (N = 50), noise and toluene (N = 51), or an organic solvent mixture (N = 39). The risk of hearing loss was greater for the exposed groups than for the unexposed group. The adjusted relative risk estimates were four times greater [95% confidence interval (95% CI) 1.4-12.2] for the noise group, 11 times greater (95% CI 4.1-28.9) for the noise and toluene group, and five times greater (95% CI 1.4-17.5) for the solvent-mixture group. The findings suggest that exposure to the studied solvents had a toxic effect on the auditory system and that an interaction between noise and toluene took place. The audiological results of the noise and toluene group suggest a central auditory pathway involvement in the hearing losses observed.

Cockayne syndrome is an autosomal recessive multisystem disorder characterized principally by neurological and sensory impairment, cachectic dwarfism, and photosensitivity. This rare disease is linked to mutations in the CSB/ERCC6 and CSA/ERCC8 genes encoding proteins involved in the transcription-coupled DNA repair pathway. The clinical spectrum of Cockayne syndrome encompasses a wide range of severity from severe prenatal forms to mild and late-onset presentations. We have reviewed the 45 published mutations in CSA and CSB to date and we report 43 new mutations in these genes together with the corresponding clinical data. Among the 84 reported kindreds, 52 (62%) have mutations in the CSB gene. Many types of mutations are scattered along the whole coding sequence of both genes, but clusters of missense mutations can be recognized and highlight the role of particular motifs in the proteins. Genotype-phenotype correlation hypotheses are considered with regard to these new molecular and clinical data. Additional cases of molecular prenatal diagnosis are reported and the strategy for prenatal testing is discussed. Two web-based locus-specific databases have been created to list all identified variants and to allow the inclusion of future reports (www.umd.be/CSA/ and www.umd.be/CSB/).

In most cases of schizophrenia the onset of frank psychosis is preceded by a period of prodromal features. This period has been relatively neglected by researchers and is potentially important in promoting early intervention. The prevalence of DSM-III-R schizophrenia prodrome symptoms was assessed as part (n = 657) of a large (n = 2525) questionnaire-based survey of high school students. Individual symptoms were highly prevalent and the prevalence of DSM-III-R prodromes ranged from 10 - 15% to 50%. Despite methodological weaknesses, the data suggest that DSM-III-R prodromal features are extremely prevalent among older adolescents and unlikely to be specific for subsequent schizophrenia. Clinically these features cannot be regarded as sufficient evidence of early schizophrenia and more accurate predictors of incipient schizophrenia need to be defined.

Abstract Genomic sequencing has significant potential to inform public health management for SARS-CoV-2. Here we report high-throughput genomics for SARS-CoV-2, sequencing 80% of cases in Victoria, Australia (population 6.24 million) between 6 January and 14 April 2020 (total 1,333 COVID-19 cases). We integrate epidemiological, genomic and phylodynamic data to identify clusters and impact of interventions. The global diversity of SARS-CoV-2 is represented, consistent with multiple importations. Seventy-six distinct genomic clusters were identified, including large clusters associated with social venues, healthcare and cruise ships. Sequencing sequential samples from 98 patients reveals minimal intra-patient SARS-CoV-2 genomic diversity. Phylodynamic modelling indicates a significant reduction in the effective viral reproductive number ( R e ) from 1.63 to 0.48 after implementing travel restrictions and physical distancing. Our data provide a concrete framework for the use of SARS-CoV-2 genomics in public health responses, including its use to rapidly identify SARS-CoV-2 transmission chains, increasingly important as social restrictions ease globally.

BACKGROUND: Although allied health clinicians play a key role in the provision of healthcare, embedding a culture of research within public and private health systems remains a challenge. In this rapid review we critically evaluate frameworks for embedding research into routine allied health practice, as the basis for high quality, safe, efficient and consumer-focused care. METHODS: A rapid review (PROSPERO: CRD42017075699) was conducted to evaluate frameworks designed to create and embed research in the health sector. Included were full-text, English-language, peer-reviewed publications or Government reports of frameworks that could inform the implementation of an allied health research framework. Eight electronic databases and four government websites were searched, using search terms such as models, frameworks and research capacity-building. Two independent researchers conducted all review stages and used content and thematic analysis to interpret the results. RESULTS: Sixteen framework papers were finally included. Content analysis identified 44 system and regulatory level items that informed the research frameworks, 125 healthcare organisation items and 76 items relating to individual clinicians. Thematic analysis identified four major themes. Firstly, sustainable change requires allied health research policies, regulation, governance and organisational structures that support and value evidence-based practice. Secondly, research capability, receptivity, advocacy and literacy of healthcare leaders and managers are key to successful research implementation. Third, organisational factors that facilitate a research culture include dedicated staff research positions, time allocated to research, mentoring, professional education and research infrastructure. When healthcare agencies had strong partnerships with universities and co-located research leaders, research implementation was strengthened. Finally, individual attributes of clinicians, such as their research skills and capabilities, motivation, and participation in research teams, are essential to embedding research into practice. CONCLUSION: Theoretical frameworks were identified that informed processes to embed a culture of allied health research into healthcare services. Research-led and evidence-informed allied health practice enables optimisation of workforce capability and high-quality care.

BACKGROUND: The need for healthcare strengthening to enhance equity is critical, requiring systematic approaches that focus on those experiencing lesser access and outcomes. This project developed and tested the Ophelia (OPtimising HEalth LIteracy and Access) approach for co-design of interventions to improve health literacy and equity of access. Eight principles guided this development: Outcomes focused; Equity driven, Needs diagnosis, Co-design, Driven by local wisdom, Sustainable, Responsive and Systematically applied. We report the application of the Ophelia process where proof-of-concept was defined as successful application of the principles. METHODS: Nine sites were briefed on the aims of the project around health literacy, co-design and quality improvement. The sites were rural/metropolitan, small/large hospitals, community health centres or municipalities. Each site identified their own priorities for improvement; collected health literacy data using the Health Literacy Questionnaire (HLQ) within the identified priority groups; engaged staff in co-design workshops to generate ideas for improvement; developed program-logic models; and implemented their projects using Plan-Do-Study-Act (PDSA) cycles. Evaluation included assessment of impacts on organisations, practitioners and service users, and whether the principles were applied. RESULTS: Sites undertook co-design workshops involving discussion of service user needs informed by HLQ (n = 813) and interview data. Sites generated between 21 and 78 intervention ideas and then planned their selected interventions through program-logic models. Sites successfully implemented interventions and refined them progressively with PDSA cycles. Interventions generally involved one of four pathways: development of clinician skills and resources for health literacy, engagement of community volunteers to disseminate health promotion messages, direct impact on consumers' health literacy, and redesign of existing services. Evidence of application of the principles was found in all sites. CONCLUSIONS: The Ophelia approach guided identification of health literacy issues at each participating site and the development and implementation of locally appropriate solutions. The eight principles provided a framework that allowed flexible application of the Ophelia approach and generation of a diverse set of interventions. Changes were observed at organisational, staff, and community member levels. The Ophelia approach can be used to generate health service improvements that enhance health outcomes and address inequity of access to healthcare.

< 0.001) positive relationship between the concentrations of SARS-CoV-2 in wastewater and the levels found on the passive samplers, indicating that with further evaluation, these devices could yield semi-quantitative results in the future. Passive samplers have the potential for wide use in WBE with attractive feasibility attributes of cost, ease of deployment at small-scale locations, and continuous sampling of the wastewater. Further research will focus on the optimization of laboratory methods including elution and extraction and continued parallel deployment and evaluations in a variety of settings to inform optimal use in wastewater surveillance.

Recent high-profile outbreaks such as Ebola and Zika have illustrated the transnational nature of infectious diseases. Countries that are most vulnerable to outbreaks may be higher priorities for technical support. RAND's Infectious Disease Vulnerability Index should help U.S. government and international agencies identify these countries and inform programming to preemptively mitigate the spread and effects of potential transnational outbreaks.

The Common Rule — the set of federal regulations for ethical conduct of human-subjects research — has finally been updated. A long process of deliberation and discussion has resulted in a final rule that differs significantly from what was initially proposed.

OBJECTIVE: To assess from a health sector perspective the incremental cost-effectiveness of interventions for generalized anxiety disorder (cognitive behavioural therapy [CBT] and serotonin and noradrenaline reuptake inhibitors [SNRIs]) and panic disorder (CBT, selective serotonin reuptake inhibitors [SSRIs] and tricyclic antidepressants [TCAs]). METHOD: The health benefit is measured as a reduction in disability-adjusted life years (DALYs), based on effect size calculations from meta-analyses of randomised controlled trials. An assessment on second stage filter criteria ("equity", "strength of evidence", "feasibility" and "acceptability to stakeholders") is also undertaken to incorporate additional factors that impact on resource allocation decisions. Costs and benefits are calculated for a period of one year for the eligible population (prevalent cases of generalized anxiety disorder/panic disorder identified in the National Survey of Mental Health and Wellbeing, extrapolated to the Australian population in the year 2000 for those aged 18 years and older). Simulation modelling techniques are used to present 95% uncertainty intervals (UI) around the incremental cost-effectiveness ratios (ICERs). RESULTS: Compared to current practice, CBT by a psychologist on a public salary is the most cost-effective intervention for both generalized anxiety disorder (A$6900/DALY saved; 95% UI A$4000 to A$12 000) and panic disorder (A$6800/DALY saved; 95% UI A$2900 to A$15 000). Cognitive behavioural therapy results in a greater total health benefit than the drug interventions for both anxiety disorders, although equity and feasibility concerns for CBT interventions are also greater. CONCLUSIONS: Cognitive behavioural therapy is the most effective and cost-effective intervention for generalized anxiety disorder and panic disorder. However, its implementation would require policy change to enable more widespread access to a sufficient number of trained therapists for the treatment of anxiety disorders.

There has been increasing emphasis on the use of patient satisfaction surveys in publicly funded health services to assess elements of quality of care. However, how these surveys are used to change policy and services has received less attention. This paper reports on two different surveys conducted in Victoria, Australia and how these have developed and been used at a policy level. One is a survey of recent mothers, repeated three times over the course of the decade. The other is an inpatient survey developed over the past 5 years. The results of the surveys are publicly available and arc one means of obtaining consumer views, influencing health care quality and reporting to the public.

ABSTRACT The availability of different types of wound dressings has increased in the last decade. Wound care practitioners have at their disposal an extensive range of dressings. Emerging dressing types include interactive/bioactive dressings and tissue‐engineered skin substitutes. There is no one dressing that is suitable for the management of all types of chronic wounds and few are suited for the treatment of a single wound during all stages of the healing cycle. Successful wound management depends on an understanding of the healing process combined with knowledge of the properties of the various dressings available. Without such knowledge and careful assessment of all the factors that effect healing, dressing selection is likely to be arbitrary and ineffective, wasteful both in terms of time and physical resources. This article is an overview of some of the first‐line and second‐line interactive/bioactive dressings available. A synopsis of wound assessment and wound bed preparation will aid in choosing the appropriate dressings. It will also touch on advanced technologies including tissue‐engineered skin substitutes.

OBJECTIVE: To report outcomes from the first 2 years of the National Hand Hygiene Initiative (NHHI), a hand hygiene (HH) culture-change program implemented in all Australian hospitals to improve health care workers' HH compliance, increase use of alcohol-based hand rub and reduce the risk of health care-associated infections. DESIGN AND SETTING: The HH program was based on the World Health Organization 5 Moments for Hand Hygiene program, and included standardised educational materials and a regular audit system of HH compliance. The NHHI was implemented in January 2009. MAIN OUTCOME MEASURES: HH compliance and Staphylococcus aureus bacteraemia (SAB) incidence rates 2 years after NHHI implementation. RESULTS: In late 2010, the overall national HH compliance rate in 521 hospitals was 68.3% (168,641/246,931 moments), but HH compliance before patient contact was 10%-15% lower than after patient contact. Among sites new to the 5 Moments audit tool, HH compliance improved from 43.6% (6431/14,740) at baseline to 67.8% (106,851/157,708) (P < 0.001). HH compliance was highest among nursing staff (73.6%; 116,851/158,732) and worst among medical staff (52.3%; 17,897/34,224) after 2 years. National incidence rates of methicillin-resistant SAB were stable for the 18 months before the NHHI (July 2007-2008; P = 0.366), but declined after implementation (2009-2010; P = 0.008). Annual national rates of hospital-onset SAB per 10,000 patient-days were 1.004 and 0.995 in 2009 and 2010, respectively, of which about 75% were due to methicillin-susceptible S. aureus. CONCLUSIONS: The NHHI was associated with widespread sustained improvements in HH compliance among Australian health care workers. Although specific linking of SAB rate changes to the NHHI was not possible, further declines in national SAB rates are expected.