Jiunn-Yih Su

Echocardiographic Screening for Rheumatic Heart Disease in High and Low Risk Australian Children

Background— Echocardiographic screening for rheumatic heart disease (RHD) is becoming more widespread, but screening studies to date have used different echocardiographic definitions. The World Heart Federation has recently published new criteria for the echocardiographic diagnosis of RHD. We aimed to establish the prevalence of RHD in high-risk Indigenous Australian children using these criteria and to compare the findings with a group of Australian children at low risk for RHD. Methods and Results— Portable echocardiography was performed on high-risk Indigenous children aged 5 to15 years living in remote communities of northern Australia. A comparison group of low-risk, non-Indigenous children living in urban centers was also screened. Echocardiograms were reported in a standardized, blinded fashion. Of 3946 high-risk children, 34 met World Heart Federation criteria for definite RHD (prevalence, 8.6 per 1000 [95% confidence interval, 6.0–12.0]) and 66 for borderline RHD (prevalence, 16.7 per 1000 [95% confidence interval, 13.0–21.2]). Of 1053 low-risk children, none met the criteria for definite RHD, and 5 met the criteria for borderline RHD. High-risk children were more likely to have definite or borderline RHD than low-risk children (adjusted odds ratio, 5.7 [95% confidence interval, 2.3–14.1]; P<0.001). Conclusions— The prevalence of definite RHD in high-risk Indigenous Australian children approximates what we expected in our population, and no definite RHD was identified in the low-risk group. This study suggests that definite RHD, as defined by the World Heart Federation criteria, is likely to represent true disease. Borderline RHD was identified in children at both low and high risk, highlighting the need for longitudinal studies to evaluate the clinical significance of this finding.

Epidemiology of chlamydia and gonorrhoea among Indigenous and non-Indigenous Australians, 2000-2009.

Objectives: To assess notification trends for chlamydia and gonorrhoea infections in Indigenous Australians compared with non‐Indigenous Australians in 2000–2009.

Identifying national health research priorities in Timor-Leste through a scoping review of existing health data

Health research is crucial to understand a country’s needs and to improve health outcomes. We conducted a scoping review and analysis of existing health data in Timor-Leste to identify the health research priorities of the country. Published and unpublished health research in Timor-Leste from 2001 to 2011 that reported objectives, methods and results were identified. Key findings were triangulated with data from national surveys and the Health Management Information System; 114 eligible articles were included in the analysis, the leading topics of which were communicable (malaria, tuberculosis, HIV and sexually transmitted diseases and dengue) and non-communicable (eye and mental health) diseases. There were 28 papers (25%) on safe motherhood, child health and nutrition, of which 20 (71%) were unpublished. The review of national indicators showed high infant, under-five and maternal mortality rates. Burden of disease is greatest in young children, with respiratory infections, febrile illnesses and diarrheal disease predominating. There is poor access to and utilization of health care. Childhood malnutrition is an important unresolved national health issue. There are several obstacles leading to under-utilization of health services. The following topics for future health research are suggested from the review: nutrition, safe motherhood, childhood illness (in particular identifying the causes and cause-specific burden of severe respiratory, febrile and diarrheal diseases) and access to and use of health services.

Effectiveness of using Grindr to increase syphilis testing among men who have sex with men in Darwin, Australia

Darwin is the capital city of the Northern Territory (NT), Australia, with a population of 127,532 in 2013.1 Diagnosis of locally acquired infectious syphilis had been rare in Darwin in the past three years. Only five cases were diagnosed in 2010-12 (three or fewer each year), and all except one were diagnosed at the only sexual health clinic in Darwin, Clinic 34. However, with five new locally acquired cases diagnosed at Clinic 34 between February and July 2013, a local outbreak of infectious syphilis was suspected. All these cases were non-Indigenous MSM and some had multiple anonymous contacts impossible to trace. Therefore, the NT Centre for Disease Control collaborated with NT AIDS and Hepatitis Council (NTAHC) to launch a social media campaign to control the suspected outbreak.

Exploring the Benefits of Molecular Testing for Gonorrhoea Antibiotic Resistance Surveillance in Remote Settings

Background Surveillance for gonorrhoea antimicrobial resistance (AMR) is compromised by a move away from culture-based testing in favour of more convenient nucleic acid amplification test (NAAT) tests. We assessed the potential benefit of a molecular resistance test in terms of the timeliness of detection of gonorrhoea AMR. Methods and Findings An individual-based mathematical model was developed to describe the transmission of gonorrhoea in a remote Indigenous population in Australia. We estimated the impact of the molecular test on the time delay between first importation and the first confirmation that the prevalence of gonorrhoea AMR (resistance proportion) has breached the WHO-recommended 5% threshold (when a change in antibiotic should occur). In the remote setting evaluated in this study, the model predicts that when culture is the only available means of testing for AMR, the breach will only be detected when the actual prevalence of AMR in the population has already reached 8 – 18%, with an associated delay of ~43 – 69 months between first importation and detection. With the addition of a molecular resistance test, the number of samples for which AMR can be determined increases facilitating earlier detection at a lower resistance proportion. For the best case scenario, where AMR can be determined for all diagnostic samples, the alert would be triggered at least 8 months earlier than using culture alone and the resistance proportion will have only slightly exceeded the 5% notification threshold. Conclusions Molecular tests have the potential to provide more timely warning of the emergence of gonorrhoea AMR. This in turn will facilitate earlier treatment switching and more targeted treatment, which has the potential to reduce the population impact of gonorrhoea AMR.

An assessment of the effectiveness of the Tiwi Sexual Health Program 2002-2005.

Objectives: To describe the key elements of a comprehensive sexual health program implemented between 2002 and 2005 in remote Indigenous communities on the Tiwi Islands and to assess its effectiveness in reducing rates of bacterial sexually transmitted infections (STIs).

Molecular antimicrobial resistance surveillance for Neisseria gonorrhoeae, Northern Territory, Australia

Neisseria gonorrhoeae antimicrobial resistance (AMR) is a globally recognized health threat; new strategies are needed to enhance AMR surveillance. The Northern Territory of Australia is unique in that 2 different first-line therapies, based primarily on geographic location, are used for gonorrhea treatment. We tested 1,629 N. gonorrhoeae nucleic acid amplification test–positive clinical samples, collected from regions where ceftriaxone plus azithromycin or amoxicillin plus azithromycin are recommended first-line treatments, by using 8 N. gonorrhoeae AMR PCR assays. We compared results with those from routine culture-based surveillance data. PCR data confirmed an absence of ceftriaxone resistance and a low level of azithromycin resistance (0.2%), and that penicillin resistance was <5% in amoxicillin plus azithromycin regions. Rates of ciprofloxacin resistance and penicillinase-producing N. gonorrhoeae were lower when molecular methods were used. Molecular methods to detect N. gonorrhoeae AMR can increase the evidence base for treatment guidelines, particularly in settings where culture-based surveillance is limited.

Trends in testing and notification for genital gonorrhoea in a northern Australian district, 2004-2008.

BACKGROUND The study aimed to examine the trends in notification and testing for genital gonorrhoea (Neisseria gonorrhoeae) in the Darwin Remote District of Northern Territory, Australia, between 2004 and 2008. METHODS Using laboratory testing data and notification data, we calculated the annual sex- and age-specific notification rates, testing rates and positivity rates, and examined their trends. A deterministic matching method was used to identify unique individuals tested in order to estimate the number of years out of five in which each individual was tested. The correlation between testing rates and notification rates was calculated. RESULTS The notification rates for the 15-24 year age group increased sharply from 2004 to 2005, and then trended downwards between 2005 and 2008, with a decrease of 48.2% in females and 59.9% in males. No evident trends were found in testing rates. The positivity rates for this age group decreased by 46.3% in females (from 8.9% to 4.8%), and by 70.4% in males (from 10.8% to 3.2%) between 2004 and 2008. Over 76% of the population in this age-group had been tested at least once during the study period. A moderate correlation was found between notification rates and testing rates in both sexes. CONCLUSIONS There was a significant decreasing trend in the notification rate of gonorrhoea between 2005 and 2008, which was most probably due to a decrease in prevalence. This study demonstrates the importance and utility of population-level testing data in understanding the epidemiology of common bacterial sexually transmissible infections such as gonorrhoea.

HIV incidence in Indigenous and non-Indigenous populations in Australia: a population-level observational study

BACKGROUND Australia has set a national target of ending HIV by 2020, achieving this will require the inclusion of priority populations (eg, Indigenous Australians) in strategies to reach elimination. To assist in evaluating the target of elimination, we analysed HIV notification data for Indigenous and non-Indigenous Australians. METHODS Using the National HIV Registry at The Kirby Institute at UNSW, Sydney, NSW, Australia, we collated and analysed annual HIV notification data for 1996-2015. Patients who were not born in Australia were excluded. We calculated the rates of HIV diagnoses with annual trends in notification rates for Indigenous versus non-Indigenous Australians by demographic characteristics, exposure categories, and stage of HIV at diagnosis. For missing data, assumptions were made and verified through sensitivity analyses. Annual rate ratio (RR) and 4 year summary rate ratio (SRR) trends were calculated to determine patterns of HIV diagnosis in the two populations. FINDINGS Between Jan 1, 1996, and Dec 31, 2015, 11 492 people born in Australia were reported with a diagnosis of HIV, of whom 461 (4%) were recorded as Indigenous Australians and we classified the remaining 11 031 (96%) as non-Indigenous Australians. For exposure to HIV, among Indigenous Australians a higher proportion of diagnoses occurred among women, and through injecting drug use and heterosexual sex than among non-Indigenous Australians (p<0·0001). Among Indigenous Australians, we found a significantly higher SRR of HIV diagnoses among men in the period 2012-15 than in previous periods (SRR 1·53, 95% CI 1·28-1·83; p<0·0001), and significantly higher diagnosis among Indigenous women (4·92, 4·02-6·02; p<0·0001) for the entire study period than among non-Indigenous women. Concurrently, a decrease in HIV diagnoses of 1% per annum (RR 0·99, 95% CI 0·98-0·99; p<0·0001) across the study period was seen among non-Indigenous people. Indigenous Australians were more likely to be diagnosed at an advanced stage of HIV infection than non-Indigenous Australians (20·8% vs 15·1%; p=0·0088). INTERPRETATION Greater efforts should be made to include Indigenous people in prevention strategies, particularly newer biomedical interventions, such as scale up of pre-exposure prophylaxis and treatment as prevention initiatives in Australia. More involvement of Indigenous Australians in these approaches is also required to prevent widening of the gap in HIV diagnosis rates between non-Indigenous and Indigenous Australians. FUNDING None.

Community and clinic-based screening for curable sexually transmissible infections in a high prevalence setting in Australia: a retrospective longitudinal analysis of clinical service data from 2006 to 2009

UNLABELLED Background In response to the high prevalence of sexually transmissible infections (STIs) in many central Australian Aboriginal communities, a community-wide screening program was implemented to supplement routine primary health care (PHC) clinic testing. The uptake and outcomes of these two approaches were compared. METHODS Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) community and clinic screening data for Aboriginal people aged 15-34 years, 2006-2009, were used. Regression analyses assessed predictors of the first test occurring in the community screen, positivity and repeat testing. RESULTS A total of 2792 individuals had 9402 tests (median: four per person) over 4 years. Approximately half of the individuals (54%) were tested in the community and clinic approaches combined, 29% (n=806) in the community screen only and 18% (n=490) in the clinic only. Having the first test in a community screen was associated with being male and being aged 15-19 years. There was no difference between community and clinic approaches in CT or NG positivity at first test. More than half (55%) of individuals had a repeat test within 2-15 months and of these, 52% accessed different approaches at each test. The only independent predictor of repeat testing was being 15-19 years. CONCLUSIONS STI screening is an important PHC activity and the findings highlight the need for further support for clinics to reach young people. The community screen approach was shown to be a useful complementary approach; however, cost and sustainability need to be considered.