Infection is the major component of the disease burden in aboriginal and non-aboriginal Australian children: a population-based study

Assessing Inequities in Hospital Outcomes for Australian Children From Underserved Populations

OBJECTIVES

Inequity in health outcomes for children and young people (CYP) from underserved populations (Indigenous, culturally and linguistically diverse, refugee and/or asylum seeking, out-of-home care backgrounds, and National Disability Insurance Scheme participants) persists. We quantify baseline inequities in health outcomes to measure the effectiveness of equity interventions.

METHODS

We analyzed electronic medical records on CYP from the Sydney Children's Hospitals Network between 2015 and 2019. The primary outcome measures were high-acuity presentations, potentially preventable hospitalizations (PPH), chronic condition hospitalizations, discharge against medical advice (DAMA), ward and critical care admission, readmission, and extended length of stay (LOS). We used generalized estimating equation models to examine the relationship between underserved population status and outcomes.

RESULTS

One third of 253 934 inpatient and 446 924 emergency department (ED) encounters were underserved CYP. Compared with nonunderserved populations, there was increased risk of PPH (relative risk [RR], 1.25; 95% CI, 1.23-1.27), chronic conditions (RR, 1.09; 95% CI, 1.07-1.10), DAMA (RR, 1.33; 95% CI, 1.19-1.49), ward admission (RR, 1.16; 95% CI, 1.15-1.18), readmission (RR, 1.48; 95% CI, 1.42-1.53), extended inpatient LOS (RR, 1.21; 95% CI, 1.18-1.24), and ED LOS (RR, 1.11; 95% CI, 1.10-1.12). As an example of cumulative risk, Indigenous CYP living with a disability had a 239% higher risk of readmission than CYP without these risk factors (RR, 3.39; 95% CI, 2.92-3.93).

CONCLUSIONS

Interventions are required to reduce health inequities for underserved CYP. We present strategies that include improved patient identification, enhanced service access, and system-wide culture change within an equity learning health system.

Providing Enhanced Access to Child Health Services (PEACH) at Sydney Children's Hospital Network: a study protocol

INTRODUCTION

Children and young people (CYP) from priority populations in Australia have inequities in accessing healthcare, health outcomes and opportunities to lead healthy lives. Priority populations include CYP who are Aboriginal and/or Torres Strait Islander, culturally and linguistically diverse (born in a country where English is not an official language and/or speak a language other than English at home), with experience of being a refugee or asylum seeker, living in out-of-home care or with a disability. Providing Enhanced Access to Child Health Services (PEACH) is an organisation-wide quality improvement project that aims to achieve equivalent health outcomes in CYP from priority populations compared with their non-priority population peers.

METHODS AND ANALYSIS

PEACH creates an equity-focused learning health system using electronic medical record (eMR) patient data and qualitative methodology exploring staff and service user experiences. Five priority population advisory groups, consisting of staff and priority population service users, guide the research at the Sydney Children's Hospitals Network (SCHN), Australia's largest tertiary paediatric health service. Interviews, surveys and co-design workshops with service users (CYP and/or their parent/carer) and staff describe existing health inequities and inform the design and implementation of interventions to improve identification, provision of earlier and supported access to services and effect cultural change. The impact of PEACH on reducing inequity in care and outcomes will be measured by comparing data during and after implementation (2020-2027) with baseline data before implementation (2015-2019) and with national controls, controlling for potential confounding factors. Health access and outcome measures, including emergency and preventable hospitalisations, critical care admission, discharge against medical advice, readmission and extended length of stay, will be analysed and drawn into dashboards, driving continuous learning and improvement.

ETHICS AND DISSEMINATION

The SCHN Human Research Ethics Committee (2022/ETH00145) and Aboriginal Health and Medical Research Council (1920/22) have granted ethics approval. Research findings will be shared with service users, staff advisory groups and the wider children's healthcare sector through presentations, conferences and peer-reviewed journals.

Risk of pneumonia among children with cleft palate before and after palatoplasty: a population-based study

Pneumonia remains the primary cause of mortality among children under age 5. Cleft palate (CP) poses various challenges including velopharyngeal disfunction, potentially increasing rates of pneumonia. However, clinical evidence linking pneumonia to defect is lacking. This study aims to assess the prevalence of pneumonia and lower respiratory tract infections (LRTI) among CP patients through a population-based approach. This retrospective cohort study was conducted using medical records from Clalit Health Services in Israel, 2013-2022, encompassing population of 138,261 infants, including 166 with CP. We investigated the prevalence of pneumonia and other infectious diseases before and after palatoplasty, employing Poisson regression models adjusted for multiple demographic and clinical variables. A sibling comparison study was also conducted, analyzing 129 preoperative and 55 postoperative pairs. The preoperative analysis revealed an increased risk of pneumonia (relative risk [RR]: 5.8, 95% confidence interval (CI): 3.93-8.19), lower respiratory tract infections (LRTI) (RR: 1.55, 95% CI: 1.12-2.06), and urinary tract infections (UTI) (RR: 5.27, 95% CI: 3.23-8.03) in children with CP compared to controls. Following surgical repair, a statistically significant but reduced risk for pneumonia persisted up to 5 years (RR: 2.55, 95% CI: 1.59-3.84). Sibling comparison analyses underscored an elevated pneumonia risk compared to CP siblings preoperatively (RR: 7.07, 95% CI: 2.48-29.8). Postoperatively, the RR decreased and was no longer statistically significant (RR: 1.44, 95% CI: 0.49-4.75).

CONCLUSION

Patients with CP are at higher risk for pneumonia, and the magnitude of risk may be reduced after palatoplasty.

WHAT IS KNOWN

• Cleft palate (CP) disrupts the separation of the nasal and oral cavities, leading to food regurgitation into the nasal cavity and theoretically may lead to respiratory tract infections. • The association between CP and respiratory tract infections has yet to be assessed thoroughly.

WHAT IS NEW

• This population-based study has shown that CP is an independent risk factor for pneumonia. • The risk for pneumonia among CP patients is lowered after surgical repair of the defect.

Cohort profile: Understanding the influence of early life environments and health and social service system contacts over time and across generations through the Western Australian Aboriginal Child Health Survey (WAACHS) Linked Data Study

PURPOSE

Despite the volume of accumulating knowledge from prospective Aboriginal cohort studies, longitudinal data describing developmental trajectories in health and well-being is limited. The linkage of child and carer cohorts from a historical cross-sectional survey with longitudinal health-service and social-service administrative data has created a unique and powerful data resource that underpins the Western Australian Aboriginal Child Health Survey (WAACHS) linked data study. This study aims to provide evidence-based information to Aboriginal communities across Western Australia, governments and non-government agencies on the heterogeneous life trajectories of Aboriginal children and families.

PARTICIPANTS

This study comprises data from a historical cross-sectional household study of 5289 Aboriginal children from the WAACHS (2000-2002) alongside their primary (N=2113) and other (N=1040) carers, and other householders. WAACHS data were linked with Western Australia (WA) government administrative datasets up to 2020 including health, education, child protection, police and justice system contacts. The study also includes two non-Aboriginal cohorts from WA, linked with the same administrative data sources allowing comparisons of outcomes across cohorts in addition to between-group comparisons within the Aboriginal population.

FINDINGS TO DATE

Linked data coverage rates are presented for all WAACHS participants. Child health outcomes for the WAACHS children (Cohort 1) are described from birth into adulthood along with other outcomes including child protection and juvenile justice involvement.

FUTURE PLANS

Analysis of data from both the child and carer cohorts will seek to understand the contribution of individual, family (intergenerational) and community-level influences on Aboriginal children's developmental and health pathways, identify key developmental transitions or turning points where interventions may be most effective in improving outcomes, and compare service pathways for Aboriginal and non-Aboriginal children. All research is guided by Aboriginal governance processes and study outputs will be produced with Aboriginal leadership to guide culturally appropriate policy and practice for improving health, education and social outcomes.

Respiratory carriage of hypervirulent Klebsiella pneumoniae by indigenous populations of Malaysia

Klebsiella pneumoniae is a Gram-negative Enterobacteriaceae that is classified by the World Health Organisation (WHO) as a Priority One ESKAPE pathogen. South and Southeast Asian countries are regions where both healthcare associated infections (HAI) and community acquired infections (CAI) due to extended-spectrum β-lactamase (ESBL)-producing and carbapenem-resistant K. pneumoniae (CRKp) are of concern. As K. pneumoniae can also exist as a harmless commensal, the spread of resistance genotypes requires epidemiological vigilance. However there has been no significant study of carriage isolates from healthy individuals, particularly in Southeast Asia, and specially Malaysia. Here we describe the genomic analysis of respiratory isolates of K. pneumoniae obtained from Orang Ulu and Orang Asli communities in Malaysian Borneo and Peninsular Malaysia respectively. The majority of isolates were K. pneumoniae species complex (KpSC) 1 K. pneumoniae (n = 53, 89.8%). Four Klebsiella variicola subsp. variicola (KpSC3) and two Klebsiella quasipneumoniae subsp. similipneumoniae (KpSC4) were also found. It was discovered that 30.2% (n = 16) of the KpSC1 isolates were ST23, 11.3% (n = 6) were of ST65, 7.5% (n = 4) were ST13, and 13.2% (n = 7) were ST86. Only eight of the KpSC1 isolates encoded ESBL, but importantly not carbapenemase. Thirteen of the KpSC1 isolates carried yersiniabactin, colibactin and aerobactin, all of which harboured the rmpADC locus and are therefore characterised as hypervirulent. Co-carriage of multiple strains was minimal. In conclusion, most isolates were KpSC1, ST23, one of the most common sequence types and previously found in cases of K. pneumoniae infection. A proportion were hypervirulent (hvKp) however antibiotic resistance was low.

Socioeconomic circumstances, health-related behaviours and paediatric infections: a mediation analysis

OBJECTIVE

To examine how the effect of disadvantaged socioeconomic circumstances on the risk of paediatric infections is mediated by pregnancy smoking, excess weight during pregnancy and breast feeding in children under 5 years of age.

DESIGN

A population-level, retrospective cohort study. The Swedish Medical Birth Register was combined with the National Patient Register, the longitudinal integration database for health insurance and labour market studies, the Cause of Death Register and a local register held by the Child Health Care Unit in Uppsala Region.

SETTING

Uppsala Region, Sweden.

PATIENTS

63 216 term and post-term singletons born to women who resided in Uppsala Region, Sweden between 1997 and 2015.

MAIN OUTCOME MEASURES

Number of hospital admissions for infectious diseases. Secondary outcomes were the number of hospitalisations for respiratory and enteric infections, respectively.

RESULTS

The effect of disadvantaged socioeconomic circumstances, that is, low maternal education on the overall risk of paediatric infections was mediated to a considerable (33%-64%) proportion by pregnancy smoking, excess weight during pregnancy and breast feeding.

CONCLUSIONS

Pregnancy smoking, excess weight during pregnancy and breast feeding mediate a considerable proportion of the association between deprived socioeconomic circumstances and paediatric infectious diseases. Therefore, inequalities in paediatric infectious diseases may be reduced by public health policies addressing these health-related behaviours.

Population-based birth cohort study on diabetes in pregnancy and infant hospitalisations in Cree, other First Nations and non-Indigenous communities in Quebec

OBJECTIVES

Diabetes in pregnancy, whether pre-gestational (chronic) or gestational (de novo hyperglycaemia), increases the risk of adverse birth outcomes. It is unclear whether gestational diabetes increases the risk of postnatal morbidity in infants. Cree First Nations in Quebec are at high risk for diabetes in pregnancy. We assessed whether pre-gestational or gestational diabetes may increase infant hospitalisation (an infant morbidity indicator) incidence, and whether this may be related to more frequent infant hospitalisations in Cree and other First Nations in Quebec.

DESIGN

Population-based birth cohort study through administrative health data linkage.

SETTING AND PARTICIPANTS

Singleton infants (≤1 year) born to mothers in Cree (n=5070), other First Nations (9910) and non-Indigenous (48 200) communities in rural Quebec.

RESULTS

Both diabetes in pregnancy and infant hospitalisation rates were much higher comparing Cree (23.7% and 29.0%) and other First Nations (12.4% and 34.1%) to non-Indigenous (5.9% and 15.5%) communities. Compared with non-diabetes, pre-gestational diabetes was associated with an increased risk of any infant hospitalisation to a greater extent in Cree and other First Nations (relative risk (RR) 1.56 (95% CI 1.28 to 1.91)) than non-Indigenous (RR 1.26 (1.15 to 1.39)) communities. Pre-gestational diabetes was associated with increased risks of infant hospitalisation due to diseases of multiple systems in all communities. There were no significant associations between gestational diabetes and risks of infant hospitalisation in all communities. The population attributable risk fraction of infant hospitalisations (overall) for pre-gestational diabetes was 6.2% in Cree, 1.6% in other First Nations and 0.3% in non-Indigenous communities.

CONCLUSIONS

The study is the first to demonstrate that pre-gestational diabetes increases the risk of infant hospitalisation overall and due to diseases of multiple systems, but gestational diabetes does not. High prevalence of pre-gestational diabetes may partly account for the excess infant hospitalisations in Cree and other First Nations communities in Quebec.

Burden of paediatric hospitalisations to the health care system, child and family: a systematic review of Australian studies (1990-2022)

Background

Paediatric hospitalisations represent a significant cost to the health system and cause significant burden to children and their families. Understanding trends in hospitalisation costs can assist with health planning and support strategies across stakeholders. The objective of this systematic review is to examine the trends in costs and burden of paediatric hospitalisations in Australia to help inform policy and promote the well-being of children and their families.

Methods

Electronic data sources (Embase, Medline, Web of Science, PSYCH-Info, CINAHL and Scopus) were searched from 1990 until December 2022. Any quantitative or qualitative studies conducted in Australian tertiary hospitals were included in the review. Eligible studies were those that included paediatric (<18 years) hospitalisations and reported on economic and/or non-economic costs for the child, family unit and/or health system. Study quality and risk of bias for each study were assessed with the Joanna Briggs Critical Appraisal Tools. We present a summary of the findings of the hospitalisation burden across major diagnostic admission categories and for the child and family unit. The systematic review was registered with Prospero (ID: CRD42021276202).

Findings

The review summarises a total of 88 studies published between 1990 and December 2022. Overall, the studies identified that paediatric hospitalisations incur significant financial costs, which have not shown significant reductions over time. In-patient direct hospital costs varied depending on the type of treatment and diagnostic condition. The costs per-case were found to range from just below AUD$2000 to AUD$20,000 or more. The financial burden on the family unit included loss of productivity, transport and travel costs. Some studies reported estimates of these costs upward of AUD$500 per day. Studies evaluating 'hospital in the home' options identified significant benefits in reducing hospitalisations and costs without compromising care.

Interpretation

Increasing focus on alternative models of care may help alleviate the significant costs associated with paediatric hospitalisation.

Funding

This research was supported by Hospitals United for Sick Kids (formerly Curing Homesickness).

Non-tuberculous mycobacterial skin and soft tissue infections in the Northern Territory, Australia, 1989-2021

BACKGROUND

A previous review demonstrated that the majority of NTM infections in the Northern Territory (NT) are pulmonary in nature [1], however skin and soft tissue (SST) are likely the next most common sites of disease. The current epidemiology of NTM SST infections across the NT is not known. We aimed to establish the current and historical incidence rates, and the organisms involved.

METHODS

All NTM cases reported to the Centre for Disease Control in Darwin from 1989-2021 were retrospectively reviewed.

RESULTS

226 NTM notifications were reviewed. 73 (32%) cases were SST infections. The incidence of SST cases increased over the study period. Female cases were more common (p=0·002). Disease occurred across a wide age range (1-85 years). Only 16% of cases occurred in Aboriginal individuals which may reflect immunological factors requiring further investigation. Many cases had no clear provocation, but localised skin trauma was the most common risk factor. The most common organism identified was M. fortuitum (41%). Diagnosis was often delayed, with a median time to diagnosis of 69 days (IQR=31-149). Most cases (60%) underwent surgical intervention with adjunctive anti-mycobacterial medical therapy.

CONCLUSION

NTM SST incidence rates increased over the study period. NTM SST infections are a rare but important differential diagnosis for non-healing cutaneous wounds.

Influenza-associated hospitalisation and mortality rates among global Indigenous populations; a systematic review and meta-analysis

BACKGROUND

More than 50 million influenza infections and over 100,000 deaths from influenza occur annually. While Indigenous populations experience an inequitable influenza burden, the magnitude of this inequity has not previously been estimated on a global scale. This study compared rates of influenza-associated hospitalisation and mortality between Indigenous and non-Indigenous populations globally.

METHODS

A systematic review and meta-analysis was conducted including literature published prior to 13 July 2021. Eligible articles either reported a rate ratio (RR) comparing laboratory-confirmed influenza-associated hospitalisation and/or mortality between an Indigenous population and a corresponding benchmark population, or reported sufficient information for this to be calculated using publicly available data. Findings were reported by country/region and pooled by country and period (pandemic/seasonal) when multiple studies were available using a random-effects model. The I2 statistic assessed variability between studies.

RESULTS

Thirty-six studies (moderate/high quality) were included; all from high or high-middle income countries. The pooled influenza-associated hospitalisation RR (HRR) for indigenous compared to benchmark populations was 5·7 (95% CI: 2·7-12·0) for Canada, 5·2 (2.9-9.3) for New Zealand, and 5.2 (4.2-6.4) for Australia. Of the Australian studies, the pooled HRR for seasonal influenza was 3.1 (2·7-3·5) and for pandemic influenza was 6·2 (5·1-7·5). Heterogeneity was slightly higher among studies of pandemic influenza than seasonal influenza. The pooled mortality RR was 4.1 (3·0-5.7) in Australia and 3·3 (2.7-4.1) in the United States.

CONCLUSIONS

Ethnic inequities in severe influenza persist and must be addressed by reducing disparities in the underlying determinants of health. Influenza surveillance systems worldwide should include Indigenous status to determine the extent of the disease burden among Indigenous populations. Ethnic inequities in pandemic influenza illustrate the need to prioritise Indigenous populations in pandemic response plans.

Perspectives of health service providers in delivering best-practice care for Aboriginal mothers and their babies during the postnatal period

BACKGROUND

Evidence suggests that Aboriginal babies in Western Australia are not receiving adequate primary health care in their first 3 months of life, leading to questions about enablers and constraints to delivering such care. This paper presents findings from a qualitative research project investigating health providers' perceptions and experiences of best and current practice in discharge planning, postnatal care and health education for Aboriginal mothers and their newborn babies.

METHODS

Constructivist grounded theory guided this research involving 58 semi-structured interviews conducted with health providers who deliver care to Aboriginal mothers and infants. Participants were recruited from hospital-based and primary health sites in metropolitan Perth, and regional and remote locations in Western Australia.

RESULTS

Structural factors enabling best practice in discharge planning, postnatal care, and health education for mothers included health providers following best practice guidelines and adequate staffing levels. Organisational enablers included continuity of care throughout pregnancy, birth and postnatally. In particular, good communication between services around discharge planning, birth notifications, and training in culturally respectful care. Structural and organisational constraints to delivering best practice and compromising continuity of care were identified as beyond individual control. These included poor communication between different health and social services, insufficient hospital staffing levels leading to early discharge, inadequate cultural training, delayed receipt of birth notifications and discharge summaries received by Aboriginal primary health services.

CONCLUSION

Findings highlight the importance of examining current policies and practices to promote best practice in postnatal care to improve health outcomes for mothers and their Aboriginal babies.

Epidemiology of early and late-onset neonatal sepsis in an Australian regional special care nursery with a high proportion of Aboriginal and Torres Strait Islander births

AIM

To describe the incidence and aetiology of early and late-onset neonatal sepsis and compare rates in Aboriginal and Torres Strait Islander infants against non-Indigenous infants in the Top End of the Northern Territory.

METHODS

This was a retrospective case series of infants with positive blood or cerebrospinal fluid cultures at Royal Darwin Hospital between 2012 and 2016. Cultures from infants during initial hospital admission up to 120 days of age were included for analysis. Demographic, clinical, laboratory and treatment data were collected from medical records. Published definitions of sepsis and criteria for organism pathogenicity and were used to determine cases of sepsis.

RESULTS

There were 52 episodes of sepsis in 45 infants. There were eight cases of early onset sepsis, with an incidence of 0.51 per 1000 live births. The incidence was similar for Aboriginal and non-Indigenous infants. The case fatality rate was 25%. Late-onset sepsis occurred in 44 cases, comprising 1.3% of all infants admitted to the special care nursery. Coagulase-negative Staphylococcus was the most frequently cultured organism. Case fatality rate was 11%. Aboriginal and Torres Strait Islander infants had a five-time higher risk of late-onset sepsis compared with non-Indigenous infants; however, their increased risk was not independent of other sepsis risk factors of low rates and prematurity.

CONCLUSIONS

The incidence of culture-confirmed early and late-onset sepsis was low, but case fatality was high. Bacteraemia is an important contributor to neonatal and infant mortality in our setting.

Interrupted time-series analysis showed unintended consequences of non-pharmaceutical interventions on pediatric hospital admissions

OBJECTIVE

COVID-19-associated non-pharmaceutical interventions (NPI) have disrupted respiratory viral transmission. We quantified the changes in pediatric hospital admissions in 2020 from five different NPI phases in Western Australia for acute lower respiratory infections (ALRI) in children in the context of all-cause admissions.

STUDY DESIGN AND SETTING

We assessed anonymised hospitalization data from Perth Children's Hospital (Jan 2015-Dec 2020) for all-cause admissions, ALRI, febrile illnesses and trauma (negative control) in those <17 years. We evaluated absolute changes in admissions and the weekly change estimated from interrupted time-series models.

RESULTS

The absolute number of admissions was comparable in 2020 (15,678) vs. 2015 to 2019 average (15,310). Following the introduction of strict NPIs, all-cause admissions declined by 35%, recovered to pre-pandemic levels, then increased by 24% following NPI cessation. ALRI admissions in children <5 years initially declined by 89%, which was sustained throughout the gradual easing of NPI until an increase of 579% (997% in <3 months) following the final easing of NPI. Admissions for trauma showed minimal changes in 2020 compared to preceding years.

CONCLUSION

COVID-19-associated NPI had significant unintended consequences in health service utilization, especially for ALRI and infants <3 months, prompting the need to understand viral transmission dynamics in young children.

The familial risk of infection-related hospitalization in children: A population-based sibling study

Objective

To assess the risk of severe childhood infections within families, we conducted a sibling analysis in a population-based cohort study with genealogical linkage. We investigated the sibling risk of hospitalization with common infections, a marker of severity. We hypothesized that having siblings hospitalized for infection would increase the proband’s risk of admission with infection.

Study design

We used population data on Western Australian live-born singletons and their siblings between 1980 and 2014. Measures of infection were infection-related hospitalizations from discharge diagnostic codes. Exposure was having a sibling who had an infection-related hospitalization. Outcomes were infection-related hospitalizations in the child/proband. Probands were followed until an infection-related hospitalization admission (up to the first three), death, 18th birthday, or end of 2014, whichever occurred first. Infection risks were estimated by adjusted Cox proportional hazard models for multiple events.

Results

Of 512,279 probands, 142,915 (27.9%) had infection-related hospitalizations; 133,322 (26.0%) had a sibling with a previous infection-related hospitalization (i.e. exposed). Median interval between sibling and proband infection-related hospitalizations was 1.4 years (inter-quartile range 0.5–3.7). Probands had a dose-dependent increase in risk if sibling/s had 1, 2, or 3+ infection-related hospitalizations (adjusted hazard ratio, aHR 1.41, 95% CI 1.39–1.43; aHR 1.65, 1.61–1.69; aHR 1.83, 1.77–1.90, respectively). Among siblings with the same clinical infection type, highest sibling risks were for genitourinary (aHR 2.06, 1.68–2.53), gastrointestinal (aHR 2.07, 1.94–2.19), and skin/soft tissue infections (aHR 2.34, 2.15–2.54). Overall risk of infection-related hospitalization was higher in children with more siblings and with older siblings.

Conclusion

In this population-based study, we observed an increased risk of infection-related hospitalization in children whose siblings were previously hospitalized for infection. Public health interventions may be particularly relevant in families of children hospitalized with infection.

Burden of infection in Australian infants

AIM

To determine the incidence, risk factors and health service utilisation for infection in the first 12 months of life in a population-derived Australian pre-birth cohort.

METHODS

The Barwon Infant Study is a population-derived pre-birth cohort with antenatal recruitment (n = 1074) based in Geelong, Victoria, Australia. Infection data were collected by parent report, and general practitioner and hospital records at 1, 3, 6, 9 and 12 months of age. We calculated the incidence of infection, attendance at a health service with infection and used multiple negative binomial regression to investigate the effects of a range of exposures on incidence of infection.

RESULTS

In the first 12 months of life, infections of the upper and lower respiratory tract (henceforth 'respiratory infections'), conjunctivitis and gastroenteritis occurred at a rate of 0.35, 0.04 and 0.04 episodes per child-month, respectively. A total of 482 (72.4%) infants attended a general practitioner with an infection and 69 (10.4%) infants attended the emergency department. Maternal antibiotic exposure in pregnancy and having older siblings were associated with respiratory infection. Childcare attendance by 12 months of age was associated with respiratory infections and gastroenteritis. Breastfeeding, even if less than 4 weeks in total, was associated with reduced respiratory infection.

CONCLUSION

Infection, especially of the respiratory tract, is a common cause of morbidity in Australian infants. Several potentially modifiable risk factors were identified, particularly for respiratory infections. Most infections were managed by general practitioners and 1 in 10 infants attended an emergency department with infection in the first year of life.

Impact of Rotavirus Vaccines on Gastroenteritis Hospitalizations in Western Australia: A Time-series Analysis

Background

Rotavirus vaccination was introduced into the Australian National Immunisation Program in mid-2007. We aimed to assess the impact of the rotavirus vaccination program on the burden of hospitalizations associated with all-cause acute gastroenteritis (including rotavirus gastroenteritis and non-rotavirus gastroenteritis) in the Aboriginal and non-Aboriginal population in Western Australia.

Methods

We identified all hospital records, between July 2004 and June 2012, with a discharge diagnosis code for all-cause gastroenteritis. Age-specific hospitalization rates for rotavirus and non-rotavirus acute gastroenteritis before and after the introduction of the rotavirus vaccination program were compared. Interrupted time-series models were used to examine differences in the annual trends of all-cause gastroenteritis hospitalization between the two periods.

Results

Between July 2004 and June 2012, there were a total of 106,974 all-cause gastroenteritis-coded hospitalizations (1,381 rotavirus-coded [15% among Aboriginal] and 105,593 non-rotavirus gastroenteritis-coded [7% among Aboriginal]). Following rotavirus vaccination introduction, significant reductions in rotavirus-coded hospitalization rates were observed in all children aged <5 years (up to 79% among non-Aboriginal and up to 66% among Aboriginal). Among adults aged ≥65 years, rotavirus-coded hospitalizations were 89% (95% confidence interval, 16–187%) higher in the rotavirus vaccination program period. The time-series analysis suggested reductions in all-cause gastroenteritis hospitalizations in the post-vaccination period among both vaccinated and unvaccinated (age-ineligible) children, with increases observed in adults aged ≥45 years.

Conclusions

Rotavirus vaccination has been associated with a significant decline in gastroenteritis hospitalizations among children. The increase in the elderly requires further evaluation, including assessment of the cost-benefits of rotavirus vaccination in this population.

Epidemiological trends in notified influenza cases in Australia's Northern Territory, 2007-2016

BACKGROUND

The Northern Territory (NT) of Australia has a mix of climates, sparsely distributed population and a large proportion of the populace are Indigenous Australians, and influenza is known to have a disproportionate impact upon this group. Understanding the epidemiology of influenza in this region would inform public health strategies.

OBJECTIVES

To assess if there are consistent patterns in characteristics of influenza outbreaks in the NT.

METHODS

Laboratory confirmed influenza cases in the NT are notified to the NT Centre for Disease Control. We conducted analyses on notified cases from 2007-2016 to determine incidence rates (by age group, Indigenous status and area), seasonality of cases and spatial distribution of influenza types. Notified cases were linked to laboratory datasets to update information on influenza type or subtype RESULTS: The disparity in Indigenous and non-Indigenous notification rates varied by age group, with rate ratios for Indigenous versus non-Indigenous ranging from 1.58 (95% CI:1.39, 1.80) for ages 15-24 to 5.56 (95% CI: 4.71, 6.57) for ages 55-64. The disparity between Indigenous and non-Indigenous notification rates appeared higher in the Central Australia region. Indigenous versus non-Indigenous hospitalisation and mortality rate ratios were 6.51 (95% CI: 5.91, 7.18) and 5.46 (95% CI: 2.40, 12.71) respectively. Inter-seasonal peaks during February and March occurred in 2011, 2013 and 2014, and were due to influenza activity in the tropical north of the NT.

CONCLUSIONS

Our results highlight the importance of influenza vaccination across all age groups for Indigenous Australians. An early vaccination campaign targeted against outbreaks in February-March would be best focused on the tropical north.

Managing haematology and oncology patients during the COVID-19 pandemic: interim consensus guidance

Introduction

A pandemic coronavirus, SARS‐CoV‐2, causes COVID‐19, a potentially life‐threatening respiratory disease. Patients with cancer may have compromised immunity due to their malignancy and/or treatment, and may be at elevated risk of severe COVID‐19. Community transmission of COVID‐19 could overwhelm health care services, compromising delivery of cancer care. This interim consensus guidance provides advice for clinicians managing patients with cancer during the pandemic.

Main recommendations

During the COVID‐19 pandemic:

In patients with cancer with fever and/or respiratory symptoms, consider causes in addition to COVID‐19, including other infections and therapy‐related pneumonitis.

For suspected or confirmed COVID‐19, discuss temporary cessation of cancer therapy with a relevant specialist.

Provide information on COVID‐19 for patients and carers.

Adopt measures within cancer centres to reduce risk of nosocomial SARS‐CoV‐2 acquisition; support population‐wide social distancing; reduce demand on acute services; ensure adequate staffing; and provide culturally safe care. Measures should be equitable, transparent and proportionate to the COVID‐19 threat.

Consider the risks and benefits of modifying cancer therapies due to COVID‐19. Communicate treatment modifications, and review once health service capacity allows.

Consider potential impacts of COVID‐19 on the blood supply and availability of stem cell donors.

Discuss and document goals of care, and involve palliative care services in contingency planning.

Changes in management as a result of this statement

This interim consensus guidance provides a framework for clinicians managing patients with cancer during the COVID‐19 pandemic. In view of the rapidly changing situation, clinicians must also monitor national, state, local and institutional policies, which will take precedence.

Endorsed by

Australasian Leukaemia and Lymphoma Group; Australasian Lung Cancer Trials Group; Australian and New Zealand Children's Haematology/Oncology Group; Australia and New Zealand Society of Palliative Medicine; Australasian Society for Infectious Diseases; Bone Marrow Transplantation Society of Australia and New Zealand; Cancer Council Australia; Cancer Nurses Society of Australia; Cancer Society of New Zealand; Clinical Oncology Society of Australia; Haematology Society of Australia and New Zealand; National Centre for Infections in Cancer; New Zealand Cancer Control Agency; New Zealand Society for Oncology; and Palliative Care Australia.

The Impact of Pneumococcal Vaccination on Bacterial and Viral Pneumonia in Western Australian Children: Record Linkage Cohort Study of 469589 Births, 1996-2012

Background

Pneumococcal conjugate vaccine (PCV) was included in Australia's National Immunisation Program for all children from 2005. We assessed the impact of PCV on all-cause and pathogen-specific pneumonia hospitalizations in Western Australian (WA) children aged ≤16 years.

Methods

All hospitalizations with pneumonia-related International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification diagnosis codes occurring in WA-born children (1996-2012) were linked to pathology records. Age-specific incidence rate ratios and temporal trends for all-cause and pathogen-specific pneumonia hospitalizations were calculated before and after PCV introduction.

Results

Among 469589 births, there were 15175 pneumonia-related hospitalizations. Hospitalization rates were 6.7 (95% confidence interval, 6.4-6.9) times higher in Aboriginal than in non-Aboriginal children. Following PCV introduction, all-cause pneumonia hospitalizations showed significant declines across all age groups. A pathogen was identified in 2785 of 6693 (41.6%) pneumonia hospitalizations that linked to a pathology record. Respiratory syncytial virus (RSV) was most frequently identified, with RSV-associated pneumonia hospitalization rates of 89.6/100000 child-years in Aboriginal and 26.6/100000 child-years in non-Aboriginal children. The most common bacterial pathogen was Streptococcus pneumoniae in Aboriginal children (32.9/100000 child-years) and Mycoplasma pneumoniae in non-Aboriginal children (8.4/100000 child-years). Viral pneumonia rates declined in all children following PCV introduction, with the greatest declines seen in non-Aboriginal children; declines in bacterial pneumonia were observed in non-Aboriginal children.

Conclusions

Based on our ecological analyses, PCV seems to have had an impact on hospitalizations for pneumonia, suggesting that the pneumococcus is likely to play a role in both bacterial and viral pneumonia. Respiratory viruses remain an important pathogen in childhood pneumonia. Vaccines targeting respiratory viruses are needed to combat the residual burden of childhood pneumonia.

Predictors of In-Hospital Mortality in Aboriginal Children Admitted to a Tertiary Paediatric Hospital

Background: Aboriginal Australian children have higher rates of mortality at younger ages than non-Aboriginal Australian children. We aimed to (i) calculate the case fatality rate (CFR) for Aboriginal and non-Aboriginal children admitted to children's hospitals in New South Wales (NSW) and (ii) identify predictors of CFR. Methods: We used a retrospective cross-sectional analysis of data from electronic medical records for in-patient admissions to the Sydney Children's Hospitals Network (SCHN) over five years (2011-2015). Logistic regression analysis was used to identify predictors of mortality and excess deaths in Aboriginal children were calculated. Results: There were 241,823 presentations over the 5-year period. The CFR for Aboriginal children was double that of non-Aboriginal children (0.4% vs. 0.2%, p = 0.002), with Aboriginal children under 2 years and from remote and regional Australia at highest risk of excess mortality. Predictors of death for all children in order of significance were: Circulatory disorders (Odds Ratio (OR) 17.16, p < 0.001), neoplasm/blood/immune disorders (OR 2.77, p < 0.001), emergency admissions (OR 1.94, p < 0.001), aboriginality (OR 1.73, p = 0.005) and longer length of stay (OR 1.012; p < 0.001). Conclusions: Our data show that Aboriginal children are almost twice as likely to die than non-Aboriginal children. In particular, excess deaths in Aboriginal children are most commonly from outer regional and remote areas and children aged under 2 years with perinatal or circulatory conditions.

High burden of infectious disease and antibiotic use in early life in Australian Aboriginal communities

OBJECTIVE

To quantify the childhood infectious disease burden and antibiotic use in the Northern Territory's East Arnhem region through synthesis and analysis of historical data resources.

METHODS

We combined primary health clinic data originally reported in three separate publications stemming from the East Arnhem Healthy Skin Project (Jan-01 to Sep-07). Common statistical techniques were used to explore the prevalence of infectious conditions and the seasonality of infections, and to measure rates of antibiotic use.

RESULTS

There was a high monthly prevalence of respiratory (mean: 32% [95% confidence interval (CI): 20%, 34%]) and skin (mean: 20% [95%CI: 19%, 22%]) infectious syndromes, with upper respiratory tract infections (mean: 29% [95%CI: 27%, 31%]) and skin sores (mean: 15% [95%CI: 14%, 17%]) the most common conditions. Antibiotics were frequently prescribed with 95% (95%CI: 91%, 97%) of children having received at least one antibiotic prescription by their first birthday, and 47% having received six antibiotic prescriptions; skin sores being a key driver.

CONCLUSIONS

Early life infections drive high antibiotic prescribing rates in remote Aboriginal communities. Implications for public health: Eliminating skin disease could reduce antibiotic use by almost 20% in children under five years of age in this population.

Perinatal Risk Factors Associated With Gastroenteritis Hospitalizations in Aboriginal and Non-Aboriginal Children in Western Australia (2000-2012): A Record Linkage Cohort Study

BACKGROUND

Gastroenteritis is a leading cause of childhood morbidity worldwide. We aimed to assess the maternal and infant characteristics and population attributable fractions associated with childhood gastroenteritis-related hospitalizations.

METHODS

We conducted a whole-of-population retrospective birth cohort study of 367,476 children live-born in Western Australia 2000-2012. We identified hospital admissions up to <15 years of age pertaining to these children, with a principal diagnosis code for infectious gastroenteritis. Cox regression was used to obtain the adjusted hazard ratios with 95% confidence intervals and the population attributable fractions associated with each risk factor in Aboriginal and non-Aboriginal children for their first gastroenteritis-related hospital admission.

RESULTS

There were a total of 15,888 gastroenteritis-related hospital admissions (25.7% occurring among non-Aboriginal children). The overall gastroenteritis hospitalization rate for children <15 years of age was 4.6/1000 child-years for non-Aboriginal children and 21.5/1000 child-years for Aboriginal children. Male gender, <20 years of maternal age, preterm birth, low birth weight, residence in remote regions of Western Australia and birth in the pre-rotavirus vaccine era were significant independent risk factors for gastroenteritis hospitalization in both Aboriginal and non-Aboriginal children. Additionally, birth by caesarean section and low socioeconomic status were identified as being associated with gastroenteritis hospitalization in non-Aboriginal children. Population attributable fractions suggest that 39% of all gastroenteritis hospitalizations in non-Aboriginal children (38% in Aboriginal children) could be averted if all children receive the rotavirus vaccine.

CONCLUSIONS

Given the beneficial effect of infant rotavirus vaccination in preventing all-cause gastroenteritis hospitalization, efforts should be taken to optimize rotavirus vaccine coverage in those at highest risk.

How differing methods of ascribing ethnicity and socio-economic status affect risk estimates for hospitalisation with infectious disease

Significant ethnic and socio-economic disparities exist in infectious diseases (IDs) rates in New Zealand, so accurate measures of these characteristics are required. This study compared methods of ascribing ethnicity and socio-economic status. Children in the Growing Up in New Zealand longitudinal cohort were ascribed to self-prioritised, total response and single-combined ethnic groups. Socio-economic status was measured using household income, and both census-derived and survey-derived deprivation indices. Rates of ID hospitalisation were compared using linked administrative data. Self-prioritised ethnicity was simplest to use. Total response accounted for mixed ethnicity and allowed overlap between groups. Single-combined ethnicity required aggregation of small groups to maintain power but offered greater detail. Regardless of the method used, Māori and Pacific children, and children in the most socio-economically deprived households had a greater risk of ID hospitalisation. Risk differences between self-prioritised and total response methods were not significant for Māori and Pacific children but single-combined ethnicity revealed a diversity of risk within these groups. Household income was affected by non-random missing data. The census-derived deprivation index offered a high level of completeness with some risk of multicollinearity and concerns regarding the ecological fallacy. The survey-derived index required extra questions but was acceptable to participants and provided individualised data. Based on these results, the use of single-combined ethnicity and an individualised survey-derived index of deprivation are recommended where sample size and data structure allow it.

Ascertaining infectious disease burden through primary care clinic attendance among young Aboriginal children living in four remote communities in Western Australia

Infectious diseases contribute a substantial burden of ill-health in Australia's Aboriginal children. Skin infections have been shown to be common in remote Aboriginal communities, particularly in the Northern Territory, Australia. However, primary care data on skin and other infectious diseases among Aboriginal children living in remote areas of Western Australia are limited. We conducted a retrospective review of clinic presentations of all children aged 0 to 5 years presenting to four clinics located in the Western Desert region of Western Australia between 2007 and 2012 to determine this burden at a local level. Infectious diseases accounted for almost 50% of all clinic presentations. Skin infections (sores, scabies and fungal infections) were the largest proportion (16%), with ear infections (15%) and upper respiratory infections (13%) also high. Skin infections remained high in all age groups; 72% of children presented at least once with skin infections. Scabies accounted for only 2% of all presentations, although one-quarter of children presented during the study for management of scabies. Skin sores accounted for 75% of the overall burden of skin infections. Improved public health measures targeting bacterial skin infections are needed to reduce this high burden of skin infections in Western Australia.

Antenatal influenza and pertussis vaccine uptake among Aboriginal mothers in Western Australia

BACKGROUND

Antenatal influenza and pertussis vaccination prevent serious disease in mothers and infants. Aboriginal individuals are at increased risk of infection yet little is known about vaccine coverage among Aboriginal mothers.

AIMS

To estimate the uptake of influenza and pertussis vaccination among pregnant Aboriginal women in Western Australia and identify barriers and enablers to vaccination.

MATERIALS AND METHODS

Four hundred Aboriginal women, aged ≥18 years, who gave birth to a live infant between April and October 2015, were randomly selected and invited to participate in telephone interviews. Of the 387 women who did not decline, 178 had a functioning phone number and 100 completed the survey. Analyses were weighted by maternal residence.

RESULTS

During pregnancy the majority of Aboriginal mothers were recommended influenza (66%; unweighted, 65/96 = 68%) and pertussis (65%; unweighted, 62/94 = 66%) vaccines, with 62% (unweighted, 56/94 = 56%) and 63% (unweighted, 60/93 = 65%) receiving the vaccinations, respectively. Almost all vaccinated women (98%) reported wanting to protect their baby as the reason for immunisation. Rural mothers were more likely than metropolitan mothers to have been vaccinated against influenza (odds ratio (OR) 4.1, 95% CI 1.7-10.2) and pertussis (OR 3.1, 95% CI 1.2-7.6). Recommendation by a healthcare provider was strongly associated with vaccine uptake (influenza: OR 15.6, 95% CI 4.9-49.5; pertussis: OR 13.3, 95% CI 4.6-38.0).

CONCLUSION

Vaccination uptake among Western Australian Aboriginal mothers is comparable with rates reported for non-Aboriginal populations worldwide. Provider recommendation is the single most important factor associated with vaccination uptake, underlining the importance of integrating vaccination into routine antenatal care.

Staphylococcus aureus colonisation and its relationship with skin and soft tissue infection in New Zealand children

New Zealand children suffer from high rates of skin and soft tissue infection (SSTI). Staphylococcus aureus colonisation is known to increase the risk of nosocomial infection. We aimed to determine whether S. aureus colonisation also increased the risk of community-onset SSTI. This study, performed within the Growing Up in New Zealand cohort, used interview and administrative data, and bacterial culture results from the nose, throat, and skin swabs collected at 4½ years of age. Multivariable log-binomial regression was used to derive adjusted risk ratios. S. aureus was isolated from 2225/5126 (43.4%) children. SSTI affected 1509/5126 (29.4%) children before age five. S. aureus colonisation at any site was associated with SSTI (aRR = 1.09, 95%CI 1.01-1.19), particularly in the year prior to swab collection (aRR = 1.18, 95%CI 1.02-1.37). The strongest association was between skin colonisation and SSTI within the year prior to swab collection (aRR = 1.47, 95%CI 1.14-1.84). Socioeconomic and ethnic variables remained independent determinants of SSTI. S. aureus colonisation was associated with an increased risk of community-onset SSTI. Socioeconomic and ethnic factors and eczema had independent effects on SSTI risk. Interventions which reduce the prevalence of S. aureus colonisation may be expected to reduce the incidence of community-onset SSTI.

Housing conditions associated with recurrent gastrointestinal infection in urban Aboriginal children in NSW, Australia: findings from SEARCH

OBJECTIVE

To examine the associations between housing and gastrointestinal infection in Aboriginal children in urban New South Wales.

METHODS

A total of 1,398 Aboriginal children were recruited through four Aboriginal Community Controlled Health Services. Multilevel regression modelling of survey data estimated associations between housing conditions and recurrent gastrointestinal infection, adjusting for sociodemographic and health factors.

RESULTS

Of the sample, 157 children (11%) had recurrent gastrointestinal infection ever and 37 (2.7%) required treatment for recurrent gastrointestinal infection in the past month. Children in homes with 3+ housing problems were 2.51 (95% CrI 1.10, 2.49) times as likely to have recurrent gastrointestinal infection ever and 6.79 (95% CrI 2.11, 30.17) times as likely to have received recent treatment for it (versus 0-2 problems). For every additional housing problem, the prevalence of recurrent gastrointestinal infection ever increased by a factor of 1.28 (95% CrI 1.14, 1.47) and the prevalence of receiving treatment for gastrointestinal infection in the past month increased by a factor of 1.64 (95% CrI 1.20, 2.48).

CONCLUSIONS

Housing problems were independently associated with recurrent gastrointestinal infection in a dose-dependent manner. Implications for public health: The role of housing as a potential determinant of health in urban Aboriginal children merits further attention in research and policy settings.

Hospital admissions for skin infections among Western Australian children and adolescents from 1996 to 2012

The objective of this study was to describe the occurrence of skin infection associated hospitalizations in children born in Western Australia (WA). We conducted a retrospective cohort study of all children born in WA between 1996 and 2012 (n = 469,589). Of these, 31,348 (6.7%) were Aboriginal and 240,237 (51.2%) were boys. We report the annual age-specific hospital admission rates by geographical location and diagnostic category. We applied log-linear regression modelling to analyse changes in temporal trends of hospitalizations. Hospitalization rates for skin infections in Aboriginal children (31.7/1000 child-years; 95% confidence interval [CI] 31.0-32.4) were 15.0 times higher (95% CI 14.5-15.5; P<0.001) than those of non-Aboriginal children (2.1/1000 child-years; 95% CI 2.0-2.1). Most admissions in Aboriginal children were due to abscess, cellulitis and scabies (84.3%), while impetigo and pyoderma were the predominant causes in non-Aboriginal children (97.7%). Admissions declined with age, with the highest rates for all skin infections observed in infants. Admissions increased with remoteness. Multiple admissions were more common in Aboriginal children. Excess admissions in Aboriginal children were observed during the wet season in the Kimberley and during summer in metropolitan areas. Our study findings show that skin infections are a significant cause of severe disease, requiring hospitalization in Western Australian children, with Aboriginal children at a particularly high risk. Improved community-level prevention of skin infections and the provision of effective primary care are crucial in reducing the burden of skin infection associated hospitalizations. The contribution of sociodemographic and environmental risk factors warrant further investigation.

Disparities in infant hospitalizations in Indigenous and non-Indigenous populations in Quebec, Canada

BACKGROUND

Infant mortality is higher in Indigenous than non-Indigenous populations, but comparable data on infant morbidity are lacking in Canada. We evaluated disparities in infant morbidities experienced by Indigenous populations in Canada.

METHODS

We used linked population-based birth and health administrative data from Quebec, Canada, to compare hospitalization rates, an indicator of severe morbidity, in First Nations, Inuit and non-Indigenous singleton infants (< 1 year) born between 1996 and 2010.

RESULTS

Our cohort included 19 770 First Nations, 3930 Inuit and 225 380 non-Indigenous infants. Compared with non-Indigenous infants, all-cause hospitalization rates were higher in First Nations infants (unadjusted risk ratio [RR] 2.05, 95% confidence interval [CI] 1.99-2.11; fully adjusted RR 1.43, 95% CI 1.37-1.50) and in Inuit infants (unadjusted RR 1.96, 95% CI 1.87-2.05; fully adjusted RR 1.37, 95% CI 1.24-1.52). Higher risks of hospitalization (accounting for multiple comparisons) were observed for First Nations infants in 12 of 16 disease categories and for Inuit infants in 7 of 16 disease categories. Maternal characteristics (age, education, marital status, parity, rural residence and Northern residence) partly explained the risk elevations, but maternal chronic illnesses and gestational complications had negligible influence overall. Acute bronchiolitis (risk difference v. non-Indigenous infants, First Nations 37.0 per 1000, Inuit 39.6 per 1000) and pneumonia (risk difference v. non-Indigenous infants, First Nations 41.2 per 1000, Inuit 61.3 per 1000) were the 2 leading causes of excess hospitalizations in Indigenous infants.

INTERPRETATION

First Nations and Inuit infants had substantially elevated burdens of hospitalizations as a result of diseases of multiple systems. The findings identify substantial unmet needs in disease prevention and medical care for Indigenous infants.

Using record linkage to validate notification and laboratory data for a more accurate assessment of notifiable infectious diseases

BACKGROUND

Infectious disease burden is commonly assessed using notification data. Using retrospective record linkage in Western Australia, we described how well notification data captures laboratory detections of influenza, pertussis and invasive pneumococcal disease (IPD).

METHODS

We linked data from the Western Australian Notifiable Infectious Diseases Database (WANIDD) and the PathWest Laboratory Database (PathWest) pertaining to the Triple I birth cohort, born in Western Australia in 1996-2012. These were combined to calculate the number of unique cases captured in each dataset alone or in both datasets. To assess the impact of under-ascertainment, we compared incidence rates calculated using WANIDD data alone and using combined data.

RESULTS

Overall, there were 5550 influenza, 513 IPD (2001-2012) and 4434 pertussis cases (2000-2012). Approximately 2% of pertussis and IPD cases and 7% of influenza cases were solely recorded in PathWest. Notification of influenza and pertussis cases to WANIDD improved over time. Overall incidence rates of influenza in children aged <5 years using both datasets was 10% higher than using WANIDD data alone (IRR = 1.1, 95% CI = 1.1-1.2).

CONCLUSIONS

This is the first time WANIDD data have been validated against routinely collected laboratory data. We anticipated all cases would be captured in WANIDD but found additional laboratory-confirmed cases that were not notified. Studies investigating pathogen-specific infectious disease would benefit from using multiple data sources.

The impact of health promotion on trachoma knowledge, attitudes and practice (KAP) of staff in three work settings in remote Indigenous communities in the Northern Territory

Background

Globally, trachoma is the leading cause of infectious blindness and Australia is the only developed country with endemic trachoma. It is found in remote Indigenous communities burdened with poverty, overcrowding and poor hygiene. Lack of culturally appropriate health promotion, a small trachoma workforce and lack of awareness and support for trachoma elimination in general, were early barriers.

Methods

A cross-sectional pre-post study using a convenience sample, was conducted in clinics, schools and community work-settings from 63 of the 82 remote Aboriginal communities identified as being at risk of trachoma in the Northern Territory (NT). The study assessed the effect of a multi-component health promotion strategy aimed at increasing knowledge, attitude and practice amongst health, education and community support settings staff. Data were collected between 2010 and 2012. The health promotion initiatives were introduced in communities in staggered delivery over a one-year period; 272 participants were surveyed at baseline and 261 at follow-up.

Results

Trachoma related knowledge, attitudes and practice increased across all settings and for all primary outcome measures. Across all settings, there was a significant increase in the proportion of participants reporting the most important thing to do if a child has a ‘dirty’ face is to ‘wash it every time its dirty’ (61.6% cf 69.7%; X²p = 0.047), a significant reduction in the proportion of respondents answering ‘no’ to the question “Is it normal for kids to have dirty faces in your community’ (40.5% cf 29.6%; X²p = 0.009) and a significant increase in reported capacity to teach others about trachoma prevention (70.8% cf 83.3%; X²p <0.001).

Conclusion

Health promotion was associated with increased trachoma knowledge, attitude and practice amongst health, education and community support staff working with children and in remote NT communities. In the early stages of the trachoma health promotion program, this increased trachoma awareness and improved local workforce capacity and support for trachoma elimination in three health promotion settings in remote communities in the NT.

Australia is the only high-income nation with endemic trachoma. It is prevalent in remote Indigenous communities, although it was eliminated from wider society in Australia over one hundred years ago. Trachoma elimination across vast areas of remote Australia is an enormous challenge. Community members are highly mobile, English may be the second, third or fourth language in multiple Indigenous language groups, and trachoma is merely one of many complex health and social issues. A small number of trachoma program staff and frequent staff turnover in all work settings also limit progress. Trachoma elimination has focused on the Surgery & Antibiotic elements of the SAFE strategy. However, Facial cleanliness & Environmental improvements are critical for sustained progress towards elimination. Health promotion offers multiple, engaging approaches to help increase awareness that trachoma is simple to treat and that clean faces and improved hygiene practices help children be healthy and strong. In addition, safe and working bathroom (washing) facilities are needed to carry out hygiene practices. The two target groups for trachoma health promotion were staff who work in remote communities, and children and their carers (mothers, aunties, grandmothers, or other family members). The participants in this study, in the early stages of the health promotion program provides evidence that health promotion made a contribution to improved trachoma knowledge, attitudes and to a lesser extent practices in staff who provided education and support to children and families in trachoma endemic communities. This was achieved in a relatively short time despite high levels of staff turnover. Health promotion for hygiene related behaviour change requires multiple-sector support crucial to operationalise clean faces/hygiene practices more widely and to provide safe and working bathroom facilities in homes, schools, clinics and community work settings. This paper adds to the literature by illustrating some success achieved in a trachoma health promotion strategy in the Northern Territory and may support trachoma elimination in Australia and globally.

Ethnic disparities in infectious disease hospitalisations in the first year of life in New Zealand

AIM

Infectious disease (ID) hospitalisation rates are increasing in New Zealand (NZ), especially in pre-school children, and Māori and Pacific people. We aimed to identify risk factors for ID hospitalisation in infancy within a birth cohort of NZ children, and to identify differences in risk factors between ethnic groups.

METHODS

We investigated an established cohort of 6846 NZ children, born in 2009-2010, with linkage to a national data set of hospitalisations. We used multivariable logistic regression to obtain odds ratios (OR) for factors associated with ID hospitalisation in the first year of life, firstly for all children, and then separately for Māori or Pacific children.

RESULTS

In the whole cohort, factors associated with ID hospitalisation were Māori (OR: 1.49, 95% CI: 1.17-1.89) or Pacific (2.51; 2.00-3.15) versus European maternal ethnicity, male gender (1.32; 1.13-1.55), low birthweight (1.94, 1.39-2.66), exclusive breastfeeding for <4 months (1.22, 1.04-1.43), maternal experience of health-care racism (1.60, 1.19-2.12), household deprivation (most vs. least deprived quintile of households (1.50, 1.12-2.02)), day-care attendance (1.43, 1.12-1.81) and maternal smoking (1.55, 1.26-1.91). Factors associated with ID hospitalisation for Māori infants were high household deprivation (2.16, 1.06-5.02) and maternal smoking (1.48, 1.02-2.14); and for Pacific infants were delayed immunisation (1.72, 1.23-2.38), maternal experience of health-care racism (2.20, 1.29-3.70) and maternal smoking (1.59, 1.10-2.29).

CONCLUSIONS

Māori and Pacific children in NZ experience a high burden of ID hospitalisation. Some risk factors, for example maternal smoking, are shared, while others are ethnic-specific. Interventions aimed at preventing ID hospitalisations should address both shared and ethnic-specific factors.

Childhood Infections, Socioeconomic Status, and Adult Cardiometabolic Risk

BACKGROUND AND OBJECTIVES

Socioeconomic disadvantage throughout the life course is associated with increased risk of cardiometabolic diseases, but traditional risk factors do not fully account for the social gradient. We investigated the interactions between low socioeconomic status (SES) and infection in childhood and adverse cardiometabolic parameters in adulthood.

METHODS

Participants from the Cardiovascular Risk in Young Finns Study, a cohort well phenotyped for childhood and adulthood cardiometabolic risk factors and socioeconomic parameters, were linked to lifetime hospitalization data from birth onward available from the Finnish National Hospital Registry. In those with complete data, we investigated relationships between infection-related hospitalization in childhood, SES, and childhood and adult cardiometabolic parameters.

RESULTS

The study cohort consisted of 1015 participants (age range 3-18 years at baseline and 30-45 years at follow-up). In adults who were raised in below-median income families, childhood infection-related hospitalizations (at age 0-5 years) were significantly associated with higher adult BMI (β ± SE comparing those with 0 vs ≥1 hospitalizations 2.4 ± 0.8 kg/m(2), P = .008), waist circumference (7.4 ± 2.3 cm, P = .004), and reduced brachial flow-mediated dilatation (-2.7 ± 0.9%, P = .002). No equivalent associations were observed in participants from higher-SES families.

CONCLUSIONS

Infection was associated with worse cardiovascular risk factor profiles only in those from lower-SES families. Childhood infection may contribute to social gradients observed in adult cardiometabolic disease risk factors. These findings suggest reducing childhood infections, especially in socioeconomic disadvantaged children, may reduce the cardiometabolic disease burden in adults.

Predictors of Outcome in Pediatric Osteomyelitis: Five Years Experience in a Single Tertiary Center

BACKGROUND

Acute haematogenous osteomyelitis is a bacterial infection of bone, which occurs most frequently in children. Outcomes are excellent for the majority of children, but a minority develop complicated osteomyelitis. Predicting which children will develop complicated osteomyelitis remains a challenge, particularly in developed countries where most patients are discharged home after a relatively short period in hospital.

METHODS

We conducted a 5-year retrospective case note review of all children aged 3 months to 16 years admitted with a diagnosis of acute haematogenous osteomyelitis. We compared standardized clinical and laboratory parameters in those who developed simple and complicated osteomyelitis.

RESULTS

Of the 299 children who met inclusion, 241 (80.6%) had simple and 58 (19.4%) had complicated osteomyelitis. The major predictors of complicated disease were older age, a temperature greater than 38.5°C and a higher C-reactive protein at admission.

CONCLUSIONS

A risk prediction model, utilizing information available shortly after hospitalization, allows early identification of children at greatest risk of developing complicated osteomyelitis.

Improving access to primary care for Aboriginal babies in Western Australia: study protocol for a randomized controlled trial

BACKGROUND

Despite a decade of substantial investments in programs to improve access to primary care for Aboriginal mothers and infants, more than 50% of Western Australian Aboriginal babies are still not receiving primary and preventative care in the early months of life. Western Australian hospitals now input birth data into the Western Australian electronic clinical management system within 48 hours of birth. However, difficulties have arisen in ensuring that the appropriate primary care providers receive birth notification and clinical information by the time babies are discharged from the hospital. No consistent process exists to ensure that choices about primary care are discussed with Aboriginal families.

METHODS/DESIGN

We will undertake a population-based, stepped wedge, cluster randomized controlled trial of an enhanced model of early infant primary care. The intervention is targeted support and care coordination for Aboriginal families with new babies starting as soon as possible during the antenatal period or after birth. Dedicated health professionals and research staff will consult with families about the families' healthcare needs, provide information about healthcare in the first 3 months of life, offer assistance with birth and Medicare forms, consult with families about their choice for primary care provider, offer to notify the chosen primary care provider about the baby's health needs, and offer assistance with healthcare coordination at the time of discharge from the hospital. We will evaluate this model of care using a rigorous stepped wedge approach. Our primary outcome measure is a reduced hospitalization rate in infants younger than 3 months of age. Secondary outcome measures include completed Aboriginal and Torres Strait Islander child health screening assessments, immunization coverage, and satisfaction of the families about early infant primary care. We will also assess the cost effectiveness of the model of care.

DISCUSSION

This study will be conducted over a 4-year period in partnership with birthing hospitals and primary care providers including Western Australian Aboriginal Community Controlled Health Services and the new Primary Health Networks. The results of our trial will be used to develop improved primary care models and to improve health outcomes for all Aboriginal infants. These are vital steps toward more equitable health service delivery for the Aboriginal and Torres Strait Islander children in Australia.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry Registration number: ACTRN12615000976583 Date registered: 17 September 2015.

Comparing risks of cerebral palsy in births between Australian Indigenous and non-Indigenous mothers

AIM

To compare proportions of live births subsequently described as having cerebral palsy (CP), the distributions of associated impairments, and the causes of postneonatal CP between Aboriginal and Torres Strait Islander (Indigenous) and non-Indigenous populations in Australia.

METHOD

Data from statutory birth records and CP registers for the 1996 to 2005 birth cohort in Queensland, Western Australia, and the Northern Territory were stratified by Indigenous status and whether the CP was acquired pre/perinatally or postneonatally. Relative risks associated with Indigenous status were estimated and the distributions of causes of postneonatal CP compared.

RESULTS

Indigenous births had a relative risk of 4.9 (95% confidence interval [CI] 3.0-7.9) for postneonatal CP but only of 1.42 (95% CI 1.2-1.7) for pre/perinatal CP. Almost half of postneonatal CP in Indigenous infants resulted from infection, whereas for non-Indigenous infants the most frequent cause was cerebrovascular accident. The impairments of Indigenous CP and of postneonatally acquired CP tended to be more numerous and more severe.

INTERPRETATION

Indigenous children are at significantly greater risk of CP, particularly postneonatal CP. The predominant cause of postneonatal CP in non-Indigenous children has shifted to cerebrovascular accident over time; however, infections followed by head injury are still the most frequent causes in Indigenous infants.

A systematic review of the evidence that swimming pools improve health and wellbeing in remote Aboriginal communities in Australia

OBJECTIVE

To provide an overview of the evidence for health and wellbeing benefits associated with swimming pools in remote Aboriginal* communities in Australia.

METHODS

Peer-reviewed and grey literature from 1990 to 2014 was searched to identify studies set in remote Australia that evaluated health and wellbeing benefits that have been associated with swimming pools. Studies were categorised using an evidence classification scale.

RESULTS

Twelve studies met our search criteria. All prospective studies that collected data on skin infections found access to swimming pools to be associated with a drop of skin sore prevalence and -where measured- severity. Studies documenting ear and eye infections showed mixed outcomes. Many wider community and wellbeing benefits were documented in various studies, although many of these were primarily anecdotal in nature.

CONCLUSIONS

Although a case can be made regarding skin infections and the broader wellbeing benefits that swimming pools may bring to remote Aboriginal communities, the benefit to ear and eye health remains unresolved.

IMPLICATIONS

The decision to provide swimming pools to remote Aboriginal communities should not hinge on the demonstration of direct health benefits alone. Equity considerations and the potential broader benefits such amenities may entail are equally important.

Childhood metabolic syndrome, inflammation and carotid intima-media thickness. The Aboriginal Birth Cohort Study

BACKGROUND/OBJECTIVES

We evaluated whether atherosclerotic changes associated with MetS in Australian Aboriginals are reversible in childhood. In addition, we investigated whether heightened inflammation is mediating the adverse effects of MetS.

METHODS

The study cohort comprised of 351 children from the Aboriginal Birth Cohort Study (a longitudinal study based in the Northern Territory of Australia) aged 9-13 years at baseline examination who were followed up 6 years later. MetS was defined by at least three of the following parameters within the extreme sex- and age-specific quartile: highest quartile for waist circumference, blood pressure, triglycerides, and glucose, and lowest quartile for HDL-cholesterol. Carotid intima-media thickness (IMT) and C-reactive protein (CRP) were assessed at follow-up.

RESULTS

Individuals with MetS at baseline or follow-up had increased carotid IMT at follow-up (mean ± SEM 539 ± 3 vs. 561 ± 8 μm, P=0.007; and 537 ± 3 vs. 567 ± 8 μm, P<0.0001 respectively). In combined analyses from baseline and follow-up studies, those individuals with MetS only at baseline had partially improved vascular status; their IMT was not significantly increased compared to those without MetS at both time-points (534 ± 3 vs. 550 ± 10 μm, P=0.09). At the follow-up examination, MetS status was associated with increased IMT levels only among individuals with CRP levels above the median (≥ 2.1mg/l) (536 ± 5 vs. 573 ± 9 μm, P<0.0001, P for interaction 0.01).

CONCLUSIONS

MetS in childhood is associated with subclinical atherosclerosis in an Australian Aboriginal population and the effects appear to be mediated by increased inflammation. The extent of atherosclerosis was partially reduced if metabolic status improved during the follow-up.

Infection-Related Hospitalization in Childhood and Adult Metabolic Outcomes

BACKGROUND AND OBJECTIVES

Identifying childhood determinants of adult cardiometabolic disease would facilitate early-life interventions. There are few longitudinal data on the contribution of childhood infections. Therefore, we investigated whether hospitalization with childhood infection is associated with adult anthropometric and metabolic outcomes in a large, well-phenotyped longitudinal cohort.

METHODS

A total of 1376 subjects from the Cardiovascular Risk in Young Finns Study, aged 3 to 9 years at baseline (1980), who had lifetime data from birth onward on infection-related hospitalization (IRH) had repeated assessments through childhood and adolescence and at least once in adulthood (age 30-45 years in 2001-2011). Early childhood (<5 years), childhood/adolescence (5-18 years), adult (>18 years), and total lifetime IRHs were related to adiposity, BMI, and metabolic syndrome in adulthood. Analyses were adjusted for childhood and adulthood risk factors and potential confounders.

RESULTS

Early-childhood IRH correlated with adverse adult but not childhood metabolic variables: increased BMI (P = .02) and metabolic syndrome (risk ratio: 1.56; 95% confidence interval: 1.03-2.35; P = .03), adjusted for age, gender, birth weight, childhood BMI and other risk factors, and family income. The age at which differences in adult BMI became persistent was related to age of IRH in childhood. The greatest increase in adult BMI occurred in those with >1 childhood IRH.

CONCLUSIONS

Childhood IRH was independently associated with adverse adult metabolic variables. This finding suggests that infections and/or their treatment in childhood may contribute to causal pathways leading to adult cardiometabolic diseases.

Association of Gestational Age at Birth with Reasons for Subsequent Hospitalisation: 18 Years of Follow-Up in a Western Australian Population Study

Background

Preterm infants are at a higher risk of hospitalisation following discharge from the hospital after birth. The reasons for rehospitalisation and the association with gestational age are not well understood.

Methods

This was a retrospective birth cohort study of all live, singleton infants born in Western Australia between 1^st January 1980 and 31^st December 2010, followed to 18 years of age. Risks of rehospitalisation following birth discharge by principal diagnoses were compared for gestational age categories (<32, 32–33, 34–36, 37–38 weeks) and term births (39–41weeks). Causes of hospitalisations at various gestational age categories were identified using ICD-based discharge diagnostic codes.

Results

Risk of rehospitalisation was inversely correlated with gestational age. Growth-related concerns were the main causes for rehospitalisation in the neonatal period (<1 month of age) for all gestational ages. Infection was the most common reason for hospitalisation from 29 days to 1 year of age, and up to 5 years of age. Injury-related hospitalisations increased in prevalence from 5 years to 18 years of age. Risk of rehospitalisation was higher for all preterm infants for most causes.

Conclusions

The highest risks of rehospitalisation were for infection related causes for most GA categories. Compared with full term born infants, those born at shorter GA remain vulnerable to subsequent hospitalisation for a variety of causes up until 18 years of age.

Long-term trends in invasive Haemophilus influenzae type B disease among indigenous Australian children following use of PRP-OMP and PRP-T vaccines

BACKGROUND

Among indigenous populations with high incidence and early onset of invasive Haemophilus influenzae type b (Hib) disease, PRP-OMP vaccines are used in the United States and PRP-T vaccines in Canada. In Australia, PRP-OMP vaccines were exclusively used in indigenous children from 1993 until they were replaced by PRP-T between late 2005 and 2009.

METHODS

Analytic descriptive study of 20 years of enhanced surveillance data (1993-2013) for invasive Hib disease in Australian children <10 years of age was conducted.

RESULTS

Of 579 Hib cases under 10 years of age reported from vaccine introduction in 1993 to 2013, 78 (13%) were in indigenous children, 47 (60%) of whom lived in regions with high prevaccine incidence. In this population, incidence per 100,000 declined from 18.1 (95% confidence interval [CI]: 10.4, 29.4) in the early PRP-OMP period (1993-1996) to 6.2 (95% CI: 4.0, 9.2) and 4.7 (95% CI: 1.7, 10.3) in the later PRP-OMP (1996-2009) and PRP-T periods (2009-2013), respectively. The indigenous:nonindigenous incidence rate ratio increased to 43 (95% CI: 16, 145) and 58 (95% CI: 7, 2660) in the later PRP-OMP and PRP-T periods, respectively, more than 10-fold higher than in lesser-incidence Australian regions.

CONCLUSIONS

We found no change in Hib incidence among indigenous Australian children living in high-incidence regions in the first 4 years following a change to PRP-T-containing combination vaccines. This may be of relevance to North American indigenous populations characterized by suboptimal living conditions and young age of onset for whom PRP-OMP continues to be recommended, such as Alaska Natives.

Childhood hospitalisation with infection and cardiovascular disease in early-mid adulthood: a longitudinal population-based study

Background

Pathogen-specific and overall infection burden may contribute to atherosclerosis and cardiovascular disease (CVD), but the effect of infection severity and timing is unknown. We investigated whether childhood infection-related hospitalisation (IRH, a marker of severity) was associated with subsequent adult CVD hospitalisation.

Methods

Using longitudinal population-based statutorily-collected administrative health data from Western Australia (1970-2009), we identified adults hospitalised with CVD (ischaemic heart disease, ischaemic stroke, and peripheral vascular disease) and matched them (10:1) to population controls. We used Cox regression to assess relationships between number and type of childhood IRH and adulthood CVD hospitalisation, adjusting for sex, age, Indigenous status, socioeconomic status, and birth weight.

Results

631 subjects with CVD-related hospitalisation in adulthood (≥ 18 years) were matched with 6310 controls. One or more childhood (< 18 years) IRH was predictive of adult CVD-related hospitalisation (adjusted hazard ratio, 1.3; 95% CI 1.1-1.6; P < 0.001). The association showed a dose-response; ≥ 3 childhood IRH was associated with a 2.2 times increased risk of CVD-related hospitalisation in adulthood (adjusted hazard ratio, 2.2; 95% CI 1.7-2.9; P < 0.001). The association was observed across all clinical diagnostic groups of infection (upper respiratory tract infection, lower respiratory tract infection, infectious gastroenteritis, urinary tract infection, skin and soft tissue infection, and other viral infection), and individually with CVD diagnostic categories (ischaemic heart disease, ischaemic stroke and peripheral vascular disease).

Conclusions

Severe childhood infection is associated with CVD hospitalisations in adulthood in a dose-dependent manner, independent of population-level risk factors.

The pattern of pediatric respiratory illnesses admitted in ebonyi state university teaching hospital South-East Nigeria

Background:

Reports from the developed nations reveal respiratory tract infections as the leading cause of childhood hospital admissions. Children may be admitted for a variety of respiratory illnesses. Data on the spectrum of pediatric respiratory illnesses admitted in the hospital is scarce.

Aim:

To determine the pattern of pediatrics respiratory illness admissions, seasonal frequency, underlying risk factors and outcome.

Subjects and Methods:

A retrospective assessment of respiratory cases admitted in the pediatric ward from 2005 to 2010 was conducted using case notes. Parameters considered included month of presentation, age, sex, immunization and nutritional status, tools of diagnosis and patient outcome. Results were analyzed using the Statistical Package for the Social Sciences with the level of significance P ≤ 0.05.

Results:

Of the 239 cases admitted, there were more males than females (1.4:1). The commonest case was Bronchopneumonia, 71.6% (171/239 out of which 161 were uncomplicated, 5 had effusions and 6 were associated with measles). Other cases were Pulmonary Tuberculosis, 10.9% (26/239), Lobar pneumonia 8.8% (21/239), Bronchiolitis, 5% (12/239), Aspiration pneumonitis 2.1% (5/239) and Bronchial asthma, 0.8% (2/239). Mortality was 7.5% (18/239) mostly from Bronchopneumonia amongst the 1–5 years old. Mortality was significantly associated with malnutrition (P < 0.001) and poor immunization status (P < 0.01).

Conclusion:

Bronchopneumonia was found to be the commonest illness with significant mortality and peak occurrence in the rainy season. More emphasis must be laid on anticipatory guidance and prevention by encouraging the immunization, good nutrition and increased attention on children even after 1 year of age.