Stephen Brady

Influenza vaccine effectiveness against hospitalisation with confirmed influenza in the 2010-11 seasons: a test-negative observational study.

Immunisation programs are designed to reduce serious morbidity and mortality from influenza, but most evidence supporting the effectiveness of this intervention has focused on disease in the community or in primary care settings. We aimed to examine the effectiveness of influenza vaccination against hospitalisation with confirmed influenza. We compared influenza vaccination status in patients hospitalised with PCR-confirmed influenza with patients hospitalised with influenza-negative respiratory infections in an Australian sentinel surveillance system. Vaccine effectiveness was estimated from the odds ratio of vaccination in cases and controls. We performed both simple multivariate regression and a stratified analysis based on propensity score of vaccination. Vaccination status was ascertained in 333 of 598 patients with confirmed influenza and 785 of 1384 test-negative patients. Overall estimated crude vaccine effectiveness was 57% (41%, 68%). After adjusting for age, chronic comorbidities and pregnancy status, the estimated vaccine effectiveness was 37% (95% CI: 12%, 55%). In an analysis accounting for a propensity score for vaccination, the estimated vaccine effectiveness was 48.3% (95% CI: 30.0, 61.8%). Influenza vaccination was moderately protective against hospitalisation with influenza in the 2010 and 2011 seasons.

Effectiveness of H1N1/09 monovalent and trivalent influenza vaccines against hospitalization with laboratory-confirmed H1N1/09 influenza in Australia: A test-negative case control study

We aimed to estimate the effectiveness of H1N1/09 containing influenza vaccines against hospitalization from influenza in Australia. We performed a test-negative case control study in patients hospitalized in 15 sentinel Australian hospitals between March and November 2010, comparing influenza vaccination (H1N1/09 monovalent or 2010 seasonal trivalent) in hospitalized patients with PCR-confirmed influenza compared to PCR-negative controls. Between March and November 2010, 1169 hospitalized patients were tested for suspected influenza, of which influenza vaccine status was ascertained in 165/238 patients with H1N1/09 influenza, 40/64 with seasonal influenza and 558/867 test negative controls; 24% of H1N1/09 cases, 43% of seasonal influenza cases and 54% of controls were vaccinated. VE against hospitalisation with H1N1/09 influenza after adjusting for age, medical comorbidities and pregnancy status was estimated at 49% (95% CI: 13%, 70%). Influenza vaccination was associated with a reduction in hospitalisation caused by H1N1/09 influenza in the 2010 southern hemisphere winter season.

Case series of four patients with strongyloides after occupational exposure.

TO THE EDITOR: Strongyloidosis in Australia has been reported in Indigenous Australians, war veterans who have served in South-East Asia and travellers and immigrants from regions in which strongyloidosis is endemic.1,2 The condition is caused by Strongyloides stercoralis, and chronic infection with the nematode is maintained by an autoinfective life cycle. The consequences of infection range from asymptomatic minor infection to chronic symptomatic strongyloidosis. In immunocompromised people, lifethreatening dissemination can occur3 with a mortality of nearly 90%.2 In the past 8 years at Alice Springs Hospital, four people have presented with strongyloidosis, in whom the only identifiable exposure was their occupation. Work-related exposure resulting in S. stercoralis infection has been documented previously in healthy Australian medical professionals volunteering in the Solomon Islands.4 In our series, Patient 1 was a middle-aged white man who had previously worked as a teacher in an Indigenous school. He had documented Still’s disease treated with prednisolone, methotrexate and hydroxychloroquine, and presented with urticaria, diarrhoea and a cough. Patient 2 was a child care worker with rheumatoid arthritis, treated with methotrexate and hydroxychloroquine. She presented with a rash, cough, wheezing and eosinophilia. Patient 3 was a middle-aged ex-nurse treated with methotrexate for rheumatoid arthritis, who presented with recurrent epigastric pain. Patient 4 was a paediatrician with systemic lupus erythematosis, who developed abdominal pain, nausea, diarrhoea and eosinophilia after commencing prednisolone for worsening arthralgia and vasculitis. All four patients tested positive for S. stercoralis in serological tests. The “gold standard” for diagnosis of strongyloides infection is finding typical larvae in stool samples or biopsies, but the strongyloides serological test has a sensitivity of 97% and a specificity of 100%.5 Symptoms for all four patients resolved with two doses of ivermectin 200 mg/kg, spaced 2 weeks apart. Follow-up serological tests performed 6 months later showed an adequate reduction in titres. This case series describes four individuals who were exposed to strongyloides at work, and highlights the importance of considering strongyloidosis in patients with possible occupational exposure, especially in those on immunosuppressive therapy.3 Whether professionals with occupational exposure to strongyloides should be routinely screened for infection, or should receive regular empirical ivermectin treatment, is of potential debate.

Community‐acquired pneumonia in the central desert and north‐western tropics of Australia

Background: Community‐acquired pneumonia (CAP) results in significant morbidity in central and north‐western Australia. However, the nature, management and outcome of CAP are poorly documented. The aim of the study was to describe CAP in the Kimberley and Central Desert regions of Australia.

Pattern and Outcome of Heart Failure-Related Hospitalization Over 5 Years in a Remote Australian Population: A Retrospective Administrative Data Cohort of 617 Indigenous and non-Indigenous Cases

OBJECTIVEnThe aim of this work was to understand the pattern and outcomes for heart failure (HF)-related hospitalization among Indigenous and non-Indigenous patients living in Central Australia.nnnMETHODS AND RESULTSnA retrospective analysis of administrative data for patients presenting with a primary or secondary diagnosis of HF to Central Australias Alice Springs Hospital during 2008-2012 was performed. The population rate of admission and subsequent outcomes (including mortality and readmission) during the 5-year study period were examined. A total of 617 patients, aged 55.8u2009±u200917.5 years and 302 (49%) female constituted the study cohort. The 446 Indigenous patients (72%) were significantly younger (50.8u2009±u200915.9 vs 68.7u2009±u200914.9; Pu2009<u2009.001) and clinically more complex compared with the non-Indigenous patients. Annual prevalence of any HF hospitalization was markedly higher in the Indigenous population (1.9%, 95% CI 1.7-2.1) compared with the non-Indigenous population (0.5%, 95% CI 0.4-0.6); the greatest difference being for women. Overall, non-Indigenous patients had poorer outcomes and were significantly more likely to die (Pu2009<u2009.0001), but this was largely driven by age differences. Alternatively, Indigenous patients were significantly more likely to have a higher number of hospitalizations, although indigeneity was not a predictor for 30- or 365-day rehospitalization from the index admission.nnnCONCLUSIONnThe pattern of HF among Indigenous Australians in Central Australia is characterized by a younger population with more clinically complex cases and greater health care utilization.

The epidemiology of gonococcal arthritis in an Indigenous Australian population

Background Disseminated Gonococcal Infection (DGI) is caused by Neisseria gonorrhoeae bacteraemia. Typically the primary source is a sexually acquired mucosal infection. If not recognised and treated promptly DGI can be associated with significant morbidity and, in rare cases, death. Central Australia has one of the highest rates of gonococcal notifications in Australia. Despite this, the nature and prevalence of complications arising from gonococcal infections within this at-risk population is unknown. Methods Enhanced surveillance and audit of patients with DGI discharged from Alice Springs Hospital between 2003 and 2012. Patient demographics and clinical management data were extracted from healthcare records and investigation databases. Results DGI cases were significantly more likely to present in young (≤29u2005years) Indigenous women compared with young Indigenous men (χ2, p=0.020). Overall Indigenous women had nearly twice the risk of DGI compared with men (relative risk 1.92 (95% CI 1.45 to 2.53)). The incidence of DGI per all gonococcal notifications on average was 911/100u2005000 (95% CI 717 to 1142) gonococcal notifications. Conclusions DGI represents a severe complication of N. gonorrhoeae infection. In Central Australia DGI is not a rare oddity but rather an important differential when dealing with patients with undefined sepsis and associated joint disease.

Northern Territory Perspectives on Heart Failure with Comorbidities – Understanding Trial Validity and Exploring Collaborative Opportunities to Broaden the Evidence Base

Congestive Heart Failure (CHF) is an ambulatory care sensitive condition, associated with significant morbidity and mortality, rarely with cure. Outpatient based pharmacological management represents the main and most important aspect of care, and is usually lifelong. This narrative styled opinion review looks at the pharmacological agents recommended in the guidelines in context of the Northern Territory (NT) of Australia. We explore the concept of validity, a term used to describe the basis of standardising a particular trial or study and the population to which it is applicable. We aim to highlight the problems of the current guidelines based approach. We also present alternatives that could utilise the core principles from major trials, while incorporating regional considerations, which could benefit clients living in the NT and remote Australia.

Pulmonary Hypertension in Central Australia: A Community-Based Cohort Study

BACKGROUNDnThe burden of pulmonary hypertension (PHT) in Central Australia has not been previously studied. Our aim is to characterise the prevalence, clinical classification, and long-term survival of individuals with PHT in Central Australia.nnnMETHODSnA community-based cohort study of all individuals diagnosed with PHT in Central Australia between 2005 and 2016 was undertaken. We estimated PHT prevalence using population data, describe clinical PHT classification, and characterised long-term survival using Kaplan-Meier approaches.nnnRESULTSnA total of 183 patients were identified (mean age 52±16years, 63% female). Of these individuals, 149 (81.4%) were of Aboriginal and Torres Strait Islander (ATSI) descent. The prevalence per 100,000 of any PHT was significantly higher In ATSI (723 [95% CI 608-839] compared to non-ATSI individuals (126 [95% CI 84-168], p<0.001). Furthermore, ATSI individuals were diagnosed at younger ages compared to non-ATSI individuals (49±15 vs 64±16years, p<0.001). Median estimated pulmonary artery systolic pressure (ePASP) was higher in patients with pulmonary arterial hypertension (PAH) compared to other causes (62 [IQR 54-69] vs 50 [IQR 44-58] mmHg, p<0.01). The median survival rate from diagnosis was 9 years (IQR 7.2-13.2). Age and ePASP were significant predictors of mortality (HR 1.05 [95% CI 1.02-1.07] and HR 1.56 [95% 1.00-2.42] respectively).nnnCONCLUSIONSnIn this community based study, we found a high burden of PHT in Central Australia. The prevalence of PHT is greater in ATSI individuals and is diagnosed at younger ages compared to non-ATSI individuals. Together with other cardiovascular diseases, PHT may be in-part contributing to the gap in life expectancy between ATSI and non-ATSI individuals.