Susan Vlack

Patterns and determinants of influenza and pneumococcal immunisation among adults with chronic disease living in Queensland, Australia

Using findings from a random, computer assisted telephone survey of households, this paper examines influenza and pneumococcal immunisation coverage and predictors of immunisation in 2203 adults with asthma, diabetes or a cardiovascular condition living in Queensland, Australia. 47% and 31% of high-risk persons were immunised against influenza and pneumococcus respectively. Immunisation coverage varied across chronic conditions and increased with age, being significantly higher for those aged 65 years and older and consequently eligible for free vaccination. Poor self reported health status was an independent predictor of pneumococcal vaccination status for people with asthma, diabetes or a cardiovascular condition; however it was only an independent predictor of influenza immunisation status for people with diabetes. Extending free vaccination to all people at risk may increase immunisation rates for younger people with a chronic condition.

The vaccination status of Aboriginal and Torres Strait Island children in far North Queensland

A survey was undertaken to ascertain the vaccination status of all 773 Aboriginal and Torres Strait Island children who were born and remained in Far North Queensland during the 1993‐94 financial year. Only 42% had received all 15 vaccines scheduled in the first two years of life by their second birthday. More who resided in remote communities were fully vaccinated (64%) by then than those who lived in rural towns (32%) or an urban setting (21%) (p<0.01). The 445 children who were not fully vaccinated required a median of three vaccines to have been fully vaccinated by the second birthday. Of these, 146 (33%) required only one vaccine, nearly 60% of whom would have been fully vaccinated if they had had the fourth (18‐month) dose of diphtheria‐tetanus‐pertussis (DTP) vaccine. Of the 445, 143 (32%) required five or more vaccines to have been fully vaccinated. Only 26% and 36% of the children received all the vaccines scheduled at six and 12 months of age, respectively, on the same day. However, the eventual uptakes of the three vaccines scheduled at six months of age were very similar (‐80%) and simultaneous vaccination with the two vaccines scheduled at 12 months of age would have made a very limited (‐4 percentage points) impact on the overall percentage of fully vaccinated children. Considerably more than simple and apparently logical strategies will be required to ensure that Indigenous children in Far North Queensland are adequately vaccinated. A systematic approach, with a careful understanding of the barriers to routine vaccination and a means of prospectively tracking the vaccination status of each child, will be needed if state and national vaccination goals are to be met.

Stillbirth rates among Indigenous and non-Indigenous women in Queensland, Australia: is the gap closing?

To determine whether the disparity gap is closing between stillbirth rates for Indigenous and non‐Indigenous women and to identify focal areas for future prevention efforts according to gestational age and geographic location.

Immunisation coverage of Queensland Indigenous two‐year‐old children by cluster sampling and by register

Objectives: To obtain, through a survey, estimates of immunisation coverage in a birth cohort of Indigenous children, and to compare survey estimates with those obtained from the Australian Childhood Immunisation Register (ACIR) for the same birth cohort of Indigenous children.

Using Serology to Assist with Complicated Post-Exposure Prophylaxis for Rabies and Australian Bat Lyssavirus

Background Australia uses a protocol combining human rabies immunoglobulin (HRIG) and rabies vaccine for post-exposure prophylaxis (PEP) of rabies and Australian bat lyssavirus (ABLV), with the aim of achieving an antibody titre of ≥0.5 IU/ml, as per World Health Organization (WHO) guidelines, as soon as possible. Methodology/Principal Findings We present the course of PEP administration and serological testing for four men with complex requirements. Following dog bites in Thailand, two men (62 years old, 25 years old) received no HRIG and had delayed vaccine courses: 23 days between dose two and three, and 18 days between dose one and two, respectively. Both seroconverted following dose four. Another 62-year-old male, who was HIV-positive (normal CD4 count), also suffered a dog bite and had delayed care receiving IM rabies vaccine on days six and nine in Thailand. Back in Australia, he received three single and one double dose IM vaccines followed by another double dose of vaccine, delivered intradermally and subcutaneously, before seroconverting. A 23-year-old male with a history of allergies received simultaneous HRIG and vaccine following potential ABLV exposure, and developed rash, facial oedema and throat tingling, which was treated with a parenteral antihistamine and tapering dose of steroids. Serology showed he seroconverted following dose four. Conclusions/Significance These cases show that PEP can be complicated by exposures in tourist settings where reliable prophylaxis may not be available, where treatment is delayed or deviates from World Health Organization recommendations. Due to the potentially short incubation time of rabies/ABLV, timely prophylaxis after a potential exposure is needed to ensure a prompt and adequate immune response, particularly in patients who are immune-suppressed or who have not received HRIG. Serology should be used to confirm an adequate response to PEP when treatment is delayed or where a concurrent immunosuppressing medical condition or therapy exists.

Mild illness during outbreak of Shiga toxin−producing Escherichia coli O157 infections associated with agricultural show, Australia

During a large outbreak of Shiga toxin−producing Escherichia coli illness associated with an agricultural show in Australia, we used whole-genome sequencing to detect an IS1203v insertion in the Shiga toxin 2c subunit A gene of Shiga toxin−producing E. coli. Our study showed that clinical illness was mild, and hemolytic uremic syndrome was not detected.

Potential exposure to Australian bat lyssavirus is unlikely to prevent future bat handling among adults in South East Queensland

Despite ongoing public health messages about the risks associated with bat contact, the number of potential exposures to Australian bat lyssavirus (ABLV) due to intentional handling by members of the general public in Queensland has remained high. We sought to better understand the reasons for intentional handling among these members of the public who reported their potential exposure to inform future public health messages. We interviewed adults who resided in a defined geographic area in South East Queensland and notified potential exposure to ABLV due to intentional handling of bats by telephone between 1 January 2012 and 31 December 2013. The participation rate was 54%. Adults who reported they had intentionally handled bats in South East Queensland indicated high levels of knowledge and perception of a moderately high risk associated with bats with overall low intentions to handle bats in the future. However, substantial proportions of people would attempt to handle bats again in some circumstances, particularly to protect their children or pets. Fifty‐two percent indicated that they would handle a bat if a child was about to pick up or touch a live bat, and 49% would intervene if a pet was interacting with a bat. Future public health communications should recognize the situations in which even people with highrisk perceptions of bats will attempt to handle them. Public health messages currently focus on avoidance of bats in all circumstances and recommend calling in a trained vaccinated handler, but messaging directed at adults for circumstances where children or pets may be potentially exposed should provide safe immediate management options.

THE SOCIAL AND EDUCATIONAL OUTCOME OF A COHORT OF RURAL CHILDREN IN RELATION TO THE RACIAL AND SOCIOECONOMIC GROUPINGS OF THEIR PARENTS

The recent article by JW Cox’ addresses the important issue of the effectiveness of some social and medical interventions in improving outcomes for disadvantaged Aboriginal children in a rural community. The outcome measure he chlose (among many possible choices) was a simple measure of early employment and educational attainment in a small cohort of children born during 1974 and 1975. His conclusion, that ‘for the past 20 years, government and community intervention programmes have failed to achieve their stated objectives’ is extraordinary considering the serious limitations of this study. Although the study claims to test the effectiveness of several interventions (improved housing and childhood nutrition programmes for Aborigines) these are described in a very cursory way in the introduction, with no information about particular services or whether they were actually used by children in the study. Given the history of well-meaning but often inappropriate service provision to Aboriginal communities generally, this is a serious omission. The validity of educational and employment attainment as a measure of outcome in health-related interventions is also highly questionable. We know of very few health service interventions brave enough to claim such heroic effects. The sample size of the original cohort (even assuming 100% follow up) is inadequate for a study such as this. A sample of at least 28 in each group (male and female, Aboriginal, employed Caucasians, unemployed Caucasians) is needed to detect a difference of this magnitude in outcome (with power of 80% and confidence of 95%). With the more than 50% loss to followup in one group and assuming no bias in those followed-up, a much larger sample would be needed. The greater than 50% loss to follow up in the Caucasian group, however, introduces the likelihood of gross selection bias, as the most probable reason for this group moving from the town would be to find employment elsewhere, thereby also increasing the chances of future employment for the children. If only half of this group lost to follow up actually had jobs in their new place of residence, the difference between the UC and EC groups would disappear. Thus the author’s conclusion that interventions aimed at Aborigines are unsuccessful is not supported by the data because: (i) the outcome measure is not appropriate for the intervention; (ii) the intervention is not described in any detail sufficient to judge whether members of the study group were affected by it; (iii) the sample size and statistical methodology is inadequate; and (iv) there is the probability of gross selection bias with respect to the outcome measure in the large proportion lost to follow-up in one group. Our concern is heightened by the recent reporting of the results of this study on the front page of a national newspaper (The Australian, 16 May, 1996) and its conclusions presented (without details of the study) with the imprimatur of scientific validity as a published paper in your (peer-reviewed) journal. In the current climate of political conservatism and social welfare cutbacks in this country, these kinds of articles might falsely give comfort to those who would attack all programmes aimed at reducing Aboriginal disadvantage. We believe these programmes should be evaluated and that resources should be directed to those which are most effective. However, such evaluations should be valid and methodologically sound. This study, unfortunately, is neither.