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AIM To investigate the association between hearing impairment (HI) and measures of early childhood development in Aboriginal children at age 5 years. METHODS An observational cohort study (n = 1037) of children aged 4.0-7.3 years (median 5.4 years), living in remote Northern Territory (NT) communities, was conducted using multiple linked administrative datasets, including the NT Perinatal Data Register, Remote Hearing Assessment records (2007-2015) and Australian Early Development Censuses (AEDC, 2009, 2012 and 2015). Outcome measures were summary and domain-specific AEDC results using both dichotomous and continuous variables (domain scores). RESULTS Compared with normal hearing children, after adjustment for selected confounding factors, those with moderate or worse HI had an adjusted odds ratio of 1.69 (95% confidence interval (CI), 1.03-2.77) for being developmentally vulnerable in two or more of the five AEDC domains. Children with mild HI and those with moderate to worse HI had lower domain score sum by -1.60 (95% CI, -3.02 to -0.18) and - 2.40 (95% CI, -4.50 to -0.30), respectively. There was also evidence for an association between HI and poorer outcomes in the 'language and cognitive skills', 'communication skills and general knowledge' and 'physical health and wellbeing' domains. CONCLUSIONS Otitis media-related HI is associated with increased risk for poorer outcomes in early childhood development and this risk appears to increase with higher levels of HI. Prevention and early treatment of otitis media will reduce both the disease and the associated negative impact on early child development, especially the development of language, cognitive and communication skills and physical health and wellbeing.

Background Almost all Aboriginal children in remote communities have persistent bilateral otitis media affecting hearing and learning throughout early childhood and school years, with consequences for social and educational outcomes, and later employment opportunities. Current primary health care and specialist services do not have the resources to meet the complex needs of these children. Method/design This stepped-wedge cluster randomised trial will allocate 18 communities to one of five 6-monthly intervention start dates. Stratification will be by region and population size. The intervention (Hearing for Learning Initiative, HfLI) consists of six 20-h weeks of training (delivered over 3 months) that includes Certificate II in Aboriginal Primary Health Care (3 modules) and competencies in ear and hearing data collection (otoscopy, tympanometry and hearScreen), plus 3 weeks of assisted integration into the health service, then part-time employment as Ear Health Facilitators to the end of the trial. Unblinding will occur 6 months prior to each allocated start date, to allow Community Reference Groups to be involved in co-design of the HfLI implementation in their community. Relevant health service data will be extracted 6-monthly from all 18 communities. The primary outcome is the difference in proportion of children (0 to 16 years of age) who have at least one ear assessment (diagnosis) documented in their medical record within each 6-month period, compared to control periods (no HfLI). Secondary outcomes include data on sustainability, adherence to evidence-based clinical guidelines for otitis media, including follow-up and specialist referrals, and school attendance. Structured interviews with staff working in health and education services, Ear Health Trainees, Ear Health Facilitators and families will assess process outcomes and the HfLI broader impact. Discussion The impact of training and employment of Ear Health Facilitators on service enhancement will inform the health, education and employment sectors about effectiveness of skills and job creation that empowers community members to contribute to addressing issues of local importance, in this instance ear and hearing health of children. Trial registration ClinicalTrials.gov NCT03916029. Registered on 16 April 2019.

Additional file 1: Table 1. Demographic and selected health characteristics of the study cohort, by levels of hearing impairment (HI). Table 2. Cumulative incidence (95% confidence interval) of the first child maltreatment notification or substantiation, by type, for NT-born Aboriginal children in NT Remote Hearing Dataset (1999–2003 and 2004–2008 birth cohorts) at age 12 years, by levels of hearing impairment (HI). Table 3. Cumulative incidence (95% confidence interval) of first child maltreatment notification or substantiation by type, for NT-born Aboriginal children in NT Remote Hearing Dataset (1999–2003 birth cohort) at age 17 years, by levels of hearing impairment (HI). Table 4. Multivariable regression (fixed effect model) for child maltreatment notifications and substantiations, by type, for levels of hearing impairment (HI), NT-born Aboriginal children, 1999–2008 birth cohort, Northern Territory.

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.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.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 (p0·0001). 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; p0·0001), and significantly higher diagnosis among Indigenous women (4·92, 4·02-6·02; p0·0001) 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; p0·0001) 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).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.None.

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

Background International studies provide evidence of an association between child disabilities, including hearing impairment (HI), and child maltreatment. There are high prevalences of ear disease with associated HI, and child maltreatment among Australian Aboriginal children, but the link between HI and child maltreatment is unknown. This study investigates the association between HI and child maltreatment for Aboriginal children living in the Northern Territory (NT) of Australia. Methods This was a retrospective cohort study of 3895 Aboriginal school-aged children (born between 1999 and 2008) living in remote NT communities. The study used linked individual-level information from health, education and child protection services. The outcome variables were child maltreatment notifications and substantiations. The key explanatory variable, HI, was based on audiometric assessment. The Kaplan–Meier estimator method was used in univariate analysis; Cox proportional hazards regression was used in multivariable analysis. Results A majority of the study cohort lived in very remote (94.5%) and most disadvantaged (93.1%) regions. Among all children in the study cohort, 56.1% had a record of either HI or unilateral hearing loss (UHL), and for those with a history of contact with child protection services (n = 2757), 56.7% had a record of HI/UHL (n = 1564). In the 1999–2003 birth cohort, by age 12 years, 53.5% of children with a record of moderate or worse HI had at least one maltreatment notification, compared to 47.3% of children with normal hearing. In the 2004–2008 cohort, the corresponding results were 83.4 and 71.7% respectively. In multivariable analysis, using the full cohort, children with moderate or worse HI had higher risk of any child maltreatment notification (adjusted Hazard Ratios (adjHR): 1.16, 95% CI:1.04–1.30), notification for neglect (adjHR:1.17, 95% CI:1.04–1.31) and substantiation (adjHR:1.20, 95% CI:1.04–1.40), than children with normal hearing. In the 2004–2008 birth cohort, children with moderate or worse HI had higher risk of a substantiated episode of physical abuse (adjHR:1.47, 95% CI:1.07–2.03) than children with normal hearing. Conclusion Our findings demonstrate the urgent need for HI and child maltreatment prevention strategies through raised community awareness and inter-agency collaboration. Effective information-sharing between service providers is a critical first step to a public health approach in child protection.

Background High prevalence of chronic middle ear disease has persisted in Australian Aboriginal children, and the related hearing impairment (HI) has been implicated in a range of social outcomes. This study investigated the association between HI in early childhood and youth offending. Method This was a retrospective cohort study of 1533 Aboriginal children (born between 1996 and 2001) living in remote Northern Territory communities. The study used linked individual-level information from health, education, child protection and youth justice services. The outcome variable was a youth being “found guilty of an offence”. The key explanatory variable, hearing impairment, was based on audiometric assessment. Other variables were: child maltreatment notifications, Year 7 school enrolment by mother, Year 7 school attendance and community ‘fixed- effects’. The Cox proportional hazards model was used to estimate the association between HI and youth offending; and the Royston R2 measure to estimate the separate contributions of risk factors to youth offending. Results The proportion of hearing loss was high in children with records of offence (boys: 55.6%, girls: 36.7%) and those without (boys: 46.1%; girls: 49.0%). In univariate analysis, a higher risk of offending was found among boys with moderate or worse HI (HR: 1.77 [95% CI: 1.05–2.98]) and mild HI (HR: 1.54 [95% CI:1.06–2.23]). This association was attenuated in multivariable analysis (moderate HI, HR: 1.43 [95% CI:0.78–2.62]; mild HI, HR: 1.37 [95% CI: 0.83–2.26]). No evidence for an association was found in girls. HI contributed 3.2% and 6.5% of variation in offending among boys and girls respectively. Factors contributing greater variance included: community ‘fixed-effects’ (boys: 14.6%, girls: 36.5%), child maltreatment notification (boys: 14.2%, girls: 23.9%) and year 7 school attendance (boys: 7.9%; girls 12.1%). Enrolment by mother explained substantial variation for girls (25.4%) but not boys (0.2%). Conclusion There was evidence, in univariate analysis, for an association between HI and youth offending for boys however this association was not evident after controlling for other factors. Our findings highlight a range of risk factors that underpin the pathway to youth-offending, demonstrating the urgent need for interagency collaboration to meet the complex needs of vulnerable children in the Northern Territory.

Congenital syphilis (CS) remains a condition of serious clinical and public health importance, particularly in the Aboriginal populations of northern Australia, which have seen a recent resurgence in cases. In 2005, the Northern Territory (NT) Centre for Disease Control (CDC) published guidelines for management of infants at risk of CS. We audited the management and outcomes of infants at risk of CS who were born between 2005 and 2013 in the Darwin and Katherine regions of the NT.Data, including serology, clinical examination, treatment, follow-up and infant outcomes at 12 months, were extracted from the Syphilis Register, medical and pathology records to assess clinician compliance with the CDC guidelines.Thirty-three infants were identified as being at risk of CS, 26 low risk and 7 high risk. Hospital management at birth conformed well with the guidelines, with 85% of low risk, and 100% of high risk infants receiving treatment and 92% of low risk and 86% of high risk having appropriate serology. Follow-up was poorly compliant, with only 48% of infants completing serological follow-up and less than 15% undergoing clinical examination. No definitive case of CS was identified among the at-risk children.Overall, peri-natal management of infants was performed well, but follow-up was poor. Effective systems to transfer care from hospitals to primary care are required to improve this. The fact that no infant had direct evidence of syphilis infection suggests consideration should be given to modifying the Australian surveillance case definition.

BACKGROUND Antimicrobial resistance (AMR) by Neisseria gonorrhoeae is considered a serious global threat. METHODS In this nationwide study, we used MassARRAY iPLEX genotyping technology to examine the epidemiology of N. gonorrhoeae and associated AMR in the Australian population. All available N. gonorrhoeae isolates (n = 2452) received from Australian reference laboratories from January to June 2012 were included in the study. Genotypic data were combined with phenotypic AMR information to define strain types. RESULTS A total of 270 distinct strain types were observed. The 40 most common strain types accounted for over 80% of isolates, and the 10 most common strain types accounted for almost half of all isolates. The high male to female ratios (>94% male) suggested that at least 22 of the top 40 strain types were primarily circulating within networks of men who have sex with men (MSM). Particular strain types were also concentrated among females: two strain types accounted for 37.5% of all isolates from females. Isolates harbouring the mosaic penicillin binding protein 2 (PBP2)-considered a key mechanism for cephalosporin resistance-comprised 8.9% of all N. gonorrhoeae isolates and were primarily observed in males (95%). CONCLUSIONS This large scale epidemiological investigation demonstrated that N. gonorrhoeae infections are dominated by relatively few strain types. The commonest strain types were concentrated in MSM in urban areas and Indigenous heterosexuals in remote areas, and we were able to confirm a resurgent epidemic in heterosexual networks in urban areas. The prevalence of mosaic PBP2 harboring N. gonorrhoeae strains highlight the ability for new N. gonorrhoeae strains to spread and become established across populations.

Gender disparities in testing rates for sexually transmitted infections (STIs) have been identified as one potential factor sustaining high rates of STIs and repeat infections in the Northern Territory of Australia, especially in remote Indigenous communities. The study aimed to investigate the reasons for these disparities utilising a mixed-method study design. We conducted an audit on client information at a remote community health clinic, focus-group discussions with young men in the same community and interviews with experienced remote area clinicians. The clinic audit found a significantly higher proportion of female residents of the community than males visited the clinic (72.8 versus 55.3%, p0.005). Women were also more likely to be tested for STIs than men when visiting the clinic (49.7 versus 40.3%, p = 0.015). Major barriers to men's seeking STI testing included a sense of shame from being seen visiting the clinic by women, men's lack of understanding of STIs and the need for testing, and inadequate access to male clinicians. Increasing men's access to healthcare and STI testing requires offering testing at a gender-sensitive and separate locations, and community-based sexual health promotion to increase knowledge of STIs.

BackgroundChronic hepatitis B (CHB) is endemic in the Aboriginal population of Australia's Northern Territory (NT). However, many people's hepatitis B virus (HBV) status remains unknown.Objective1. To maximise the utility of existing HBV test and vaccination data in the NT by creating a linked dataset and computerised algorithmic coding. 2. To undertake rigorous quality assurance processes to establish feasibility of using the linked dataset and computerised algorithmic coding for individual care for people living with CHB.MethodsStep 1: We used deterministic data linkage to merge information from three separate patient databases. HBV testing and vaccination data from 2008-2016 was linked and extracted for 19,314 people from 21 remote Aboriginal communities in the Top End of the NT. Step 2: A computerised algorithm was developed to allocate one of ten HBV codes to each individual. Step 3: A quality assurance process was undertaken by a clinician, using standardised processes, manually reviewing all three databases, for a subset of 5,293 Aboriginal people from five communities to check the accuracy of each allocated code.ResultsThe process of data linking individuals was highly accurate at 99.9%. The quality assurance process detected an overall error rate of 17.7% on the HBV code generated by the computerised algorithm. Errors occurred in source documentation, primarily from the historical upload of paper-based records to electronic health records. An overall HBV prevalence of 2.6% in five communities was found, which included ten cases of CHB who were previously unaware of infection and not engaged in care.ConclusionsData linkage of individuals was highly accurate. Data quality issues and poor sensitivity in the codes produced by the computerised algorithm were uncovered in the quality assurance process. By systematically, manually reviewing all available data we were able to allocate a HBV status to 91% of the study population.

BackgroundPrevious studies have reported a high prevalence of chronic otitis media (OM) and hearing impairment (HI) in Aboriginal children in the Northern Territory (NT) of Australia. Children affected by these disorders are believed to be at increased risk for adverse outcomes in early childhood development, school attendance, academic performance, and child maltreatment and youth offending. However, to date, there have been no studies quantifying the association between HI and these outcomes in this population.ObjectiveThis study will investigate the association between HI and the 5 outcomes in Aboriginal children living in remote NT communities.MethodsIndividual-level information linked across multiple administrative datasets will be used to conduct a series of retrospective observational studies on selected developmental and school outcomes. The predictor variables for all studies are the results from audiometric hearing assessments. The outcome measures are as follows: Australian Early Development Census results, representing developmental readiness for school, assessed around 5 years of age; Year 1 school attendance rates; Year 3 school-based academic performance, assessed in the National Assessment Program—Literacy and Numeracy; incidence of child maltreatment events (including both notifications and substantiated cases); and incidence of a first guilty verdict for youth offenders. Confounding and moderating factors available for the analysis include both community-level factors (including school fixed effects, socioeconomic status, level of remoteness, and housing crowdedness) and individual-level factors (including maternal and perinatal health and hospital admissions in early childhood).ResultsThe study commenced in 2018, with ethics and data custodian approvals for data access and linkage. This has enabled the completion of data linkage and the commencement of data analysis for individual component studies, with findings expected to be published in 2019 and 2020.ConclusionsThis study will provide first evidence of the impact of OM-related HI on the developmental, educational, and social outcomes of Australian Aboriginal children. The findings are expected to have significant implications for policy development, service design, and resource allocation.International Registered Report Identifier (IRRID)RR1-10.2196/15464

Objectives: The objective of this study was to develop a real-time PCR assay targeting the gonococcal porB gene (PorB-PCR) for predicting susceptibility of Neisseria gonorrhoeae to penicillin. This complements a previously described PCR assay for detecting penicillinase-producing N. gonorrhoeae (PPNG) developed by our laboratory (PPNG-PCR). Methods: The PorB-PCR assay was designed using six probes to characterize various combinations of amino acids at positions 101 and 102 of the PorB1b class protein, including the WT G101/A102 and mutant G101K/A102D, G101K/A102N and G101K/A102G sequences, as well as the PorB1a sequence. The ability of these sequences to predict penicillin susceptibility was initially assessed using 2307 N. gonorrhoeae isolates from throughout Australia for which phenotypic susceptibility data were available. The assay was then applied to N. gonorrhoeae-positive clinical specimens (n = 70). Specificity was assessed by testing commensal Neisseria strains (n = 75) and N. gonorrhoeae-negative clinical specimens (n = 171). Results: Testing of the 2307 N. gonorrhoeae isolates using PorB-PCR to detect G101/A102 and PorB1a sequences identified a total of 78.4% (61.2% and 17.2%, respectively) of penicillin-susceptible isolates with specificities of 97.4% and 99.3% and positive predictive values of 98.8% and 98.9%, where PPNG strains were simultaneously identified and excluded. Similar performance data were obtained when the PorB-PCR assay was applied to the N. gonorrhoeae-positive clinical specimens. No false-positive results were observed for the N. gonorrhoeae-negative samples and no cross-reactions were observed with the non-gonococcal species. Conclusions: When used in parallel with the previously described PPNG-PCR, the PorB-PCR approach has the potential to facilitate individualized treatment of gonorrhoea using penicillin.

To assess notification trends for chlamydia and gonorrhoea infections in Indigenous Australians compared with non-Indigenous Australians in 2000-2009.We assessed trends in national notification rates using univariate Poisson regression and summary rate ratios.Crude notification rates and summary rate ratios, by Indigenous status, sex, age and area of residence.Over the 10-2012 period studied, chlamydia notification rates per 100,000 increased by 80% from 1383 in 2000 to 2494 in 2009 among Indigenous people, and by 335% from 51 in 2000 to 222 in 2009 among non-Indigenous people. The Indigenous versus non-Indigenous summary rate ratio was 23.92 (95% CI, 23.65-24.19; P0.001). Gonorrhoea notification rates per 100,000 increased by 22% from 1347 in 2000 to 1643 in 2009 among Indigenous people, and by 70% from 10 in 2000 to 17 in 2009 among non-Indigenous people. The gonorrhoea summary notification rate ratio in Indigenous compared with non-Indigenous people was 173.78 (95% CI, 170.81-176.80; P0.001). In Indigenous people, the highest chlamydia and gonorrhoea notification rates were in women, 15-19-2012-olds, and those living in remote areas.Chlamydia and gonorrhoea notification rates have increased in both populations but were higher among Indigenous people. Our findings highlight the need for targeted prevention programs for young people, especially Indigenous Australians residing in remote areas.

Objective: To identify risk factors and associations for sexually transmitted infections (STI) in young Aboriginal women presenting to an ED for non-genitourinary reasons, in order to better target opportunistic screening in this group. To determine the prevalence of chlamydia and gonorrhoea in women presenting to the Alice Springs Hospital ED. Methods: A cross-sectional study involving STI screening and participant interview between January 2007 and September 2007 was used. The participants were a convenience sample of Aboriginal women aged 16–35 years presenting to the Alice Springs Hospital ED for non-genitourinary reasons. The main outcome measures were the prevalence of gonorrhoea and chlamydia and significant associations for STI. Results: A total of 213 women were included in the study. The prevalence rates of women screened were 8.9% for chlamydia, 9.4% for gonorrhoea and 16.0% for gonorrhoea or chlamydia. Identified objective associations for positive STI diagnosis included presenting with an injury due to an assault (odds ratio [OR], 3.56), self-reported past history of an STI (OR, 2.53) and leucocytes on urinalysis (OR, 2.19). Conclusion: The prevalence of STI is high in young Aboriginal women presenting to Alice Springs Hospital ED. Screening is acceptable to these patients using low vaginal swabs, and may be targeted at those women with the identified associations. The results of the present study may have relevance to other hospital ED in areas with a high prevalence of STI. A prospective study is needed to confirm these findings.

Objective: To describe the impact of pandemic (H1N1) 2009 influenza (nH1N1) on Indigenous people in the Top End of the Northern Territory at community, hospital and intensive care unit (ICU) levels. Design, setting and participants: We analysed influenza notifications for the Top End from 1 June to 31 August 2009, as well as data on patients admitted through Top End emergency departments with an influenza-like illness. In addition, data on patients with nH1N1 who were admitted to Royal Darwin Hospital (RDH) and the RDH ICU were prospectively collected and analysed. Main outcome measures: Age-adjusted notification rates for nH1N1 cases, Top End hospital admission rates for patients with nH1N1 and RDH ICU admission rates for patients with nH1N1, stratified by Indigenous status. Results: There were 918 nH1N1 notifications during the study period. The age-adjusted hospital admission rate for nH1N1 was 82 per 100 000 (95% CI, 68–95) estimated resident population (ERP) overall, with a markedly higher rate in the Indigenous population compared with the non-Indigenous population (269 per 100 000 versus 29 per 100 000 ERP; adjusted incidence rate ratio, 12 [95% CI, 7.8–18]). Independent predictors of ICU admission compared with hospitalisation were hypoxia (adjusted odds ratio [aOR], 4.5; CI, 1.5–13.1) and chest x-ray infiltrates (aOR, 4.3; CI, 1.5–12.6) on hospital admission. Conclusions: Pandemic (H1N1) 2009 influenza had a disproportionate impact on Indigenous Australians in the Top End, with hospitalisation rates higher than those reported elsewhere in Australia and overseas. These findings have implications for planning hospital and ICU capacity during an influenza pandemic in regions with large Indigenous populations. They also confirm the need to improve health and living

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). Methods: A descriptive study using STI notification and laboratory testing data to analyse the occurrence of STI diagnoses overtime compared to nearby similar regions. Results: Over the four years’ of program implementation, the numbers of tests and individuals tested increased substantially and were sustained. The notification rate of chlamydia decreased from 1,581.3 to 80.0 per 100,000, that of gonorrhoea from 2,919.2 to 1,159.7 and that of syphilis from 1,743.4 to 200.0, representing a decrease of 94.9%, 60.2% and 88.5%, respectively. No similar trends in notification rates were observed in nearby regions. During the same time, the positivity rate (the number of positive tests divided by the total number of tests) of nucleic acid tests for gonorrhoea decreased from 5.9% (56/952) to 3.9% (39/1,004), and that for chlamydia decreased from 5.2% (38/1,003) to 0.3% (3/1,007), representing a decrease of 33.9% and 94.2%, respectively. Conclusion and implications: The Tiwi Sexual Health Program was accompanied by a significant reduction in STI rates between 2002 and 2005. This model of a comprehensive sexual health program with a dedicated co-ordinator located within a Primary Health Care service can be recommended as an effective approach to address high rates of STIs in remote Indigenous community settings.

To determine whether cases of congenital syphilis in the Northern Territory between 2009 and 2014 were correctly notified based on probable or confirmed case criteria stipulated by the Communicable Diseases Network Australia (CDNA).Pregnant women with positive syphilis serology defined as reactive treponemal test and rapid plasma reagin titre ≥1:8 were identified from the Northern Territory Syphilis Register Information System. Risk classification was performed based on local guidelines, and CDNA criteria for probable/confirmed cases of congenital syphilis were applied to determine whether cases were appropriately notified.Thirty-four cases of positive maternal syphilis serology in pregnancy were identified from 31 women; all were Indigenous. Twenty-one cases fulfilled criteria for probable congenital syphilis; 1 case was formally notified to the Centre for Disease Control. Twenty cases (95%) fulfilling CDNA criteria for probable congenital syphilis were not notified over the study period.Application of standard case definitions significantly increases the rate of congenital syphilis cases in the Northern Territory. Improved education regarding CDNA criteria for notification of congenital syphilis is necessary for clinicians and public health staff. Emerging evidence has supported the recent simplification of CDNA criteria for notification of congenital syphilis, effective 1 July 2015.

Objectives: The objective of this study was to develop a real-time PCR method for specific detection of the gonococcal GyrA amino acid 91 locus directly in clinical samples so as to predict Neisseria gonorrhoeae ciprofloxacin susceptibility. Methods: The real-time PCR assay, GyrA91-PCR, was designed using two probes, one for detection of the WT S91 sequence and the other for detection of the S91F alteration. The performance of the assay was initially assessed using characterized N. gonorrhoeae isolates (n = 70), a panel of commensal Neisseria and Moraxella species (n = 55 isolates) and clinical samples providing negative results by a commercial N. gonorrhoeae nucleic acid amplification test (NAAT) method (n = 171). The GyrA91-PCR was then applied directly to N. gonorrhoeae NAAT-positive clinical samples (n = 210) from the year 2014 for which corresponding N. gonorrhoeae isolates with susceptibility results were also available. Results: The GyrA91-PCR accurately characterized the GyrA 91 locus of all 70 N. gonorrhoeae isolates (sensitivity = 100%, 95% CI = 94.9%-100%), whereas all non-gonococcal isolates and N. gonorrhoeae NAAT-negative clinical samples gave negative results by the GyrA91-PCR (specificity = 100%, 95% CI = 98.4%-100%). When applied to the 210 N. gonorrhoeae NAAT-positive clinical samples, the GyrA91-PCR successfully characterized 195 samples (92.9%, 95% CI = 88.5%-95.9%). When compared with the corresponding bacterial culture results, positivity by the GyrA91-PCR WT probe correctly predicted N. gonorrhoeae susceptibility to ciprofloxacin in 161 of 162 (99.4%, 95% CI = 96.6%-99.9%) samples. Conclusions: The use of a PCR assay for detection of mutation in gyrA applied directly to clinical samples can predict ciprofloxacin susceptibility in N. gonorrhoeae.

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.

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 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.

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 noncommunicable (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. Refereed/Peer-reviewed

The Northern Territory of Australia has an exceptionally high prevalence of sexually transmitted infections (STIs), particularly in remote areas. In contrast there are few notified cases of HIV at present. This study describes HIV testing rates in both primary care and sexual health clinics in the Top End region. In 2010, medical records were reviewed for a random sample of patients from a sexual health clinic and three remote primary care clinics. Among sexual health clinic patients 51.4% overall, and 59.7% of those with an STI, were tested for HIV. In people diagnosed with an STI in remote primary care clinics 19.1 % were tested for HIV. HIV testing rates in the Top End of the Northern Territory do not meet the standard of national and international guidelines, with implications both for the early initiation of therapy and the accuracy of surveillance in a region with very high rates of STIs.

To identify risk factors and associations for sexually transmitted infections (STI) in young Aboriginal women presenting to an ED for non-genitourinary reasons, in order to better target opportunistic screening in this group. To determine the prevalence of chlamydia and gonorrhoea in women presenting to the Alice Springs Hospital ED.A cross-sectional study involving STI screening and participant interview between January 2007 and September 2007 was used. The participants were a convenience sample of Aboriginal women aged 16-35 years presenting to the Alice Springs Hospital ED for non-genitourinary reasons. The main outcome measures were the prevalence of gonorrhoea and chlamydia and significant associations for STI.A total of 213 women were included in the study. The prevalence rates of women screened were 8.9% for chlamydia, 9.4% for gonorrhoea and 16.0% for gonorrhoea or chlamydia. Identified objective associations for positive STI diagnosis included presenting with an injury due to an assault (odds ratio [OR], 3.56), self-reported past history of an STI (OR, 2.53) and leucocytes on urinalysis (OR, 2.19).The prevalence of STI is high in young Aboriginal women presenting to Alice Springs Hospital ED. Screening is acceptable to these patients using low vaginal swabs, and may be targeted at those women with the identified associations. The results of the present study may have relevance to other hospital ED in areas with a high prevalence of STI. A prospective study is needed to confirm these findings.

Enterococcal infections at the Chang Gung Memorial Hospital, Taiwan, have increased significantly in recent years, accompanied by a significant growth of vancomycin resistance from1% to 3.8%. However, the significant increase in vancomycin resistance was only found in Enterococcus faecium (from 0.5% to 17.4%).A total of 172 patients infected with vancomycin-resistant enterococci (85 E. faecium and 87 E. faecalis) during 1998-2004 were retrospectively studied. Clinical and laboratory features were analyzed using Stata for Windows (version 8.2). Genotypes of the isolates were determined by infrequent-restriction-site polymerase chain reaction.Multivariate analysis revealed that prior use of imipenem (odds ratio [OR], 30.1; 95% confidence interval [CI], 4.2-215.9) or clindamycin (OR, 6.5; 95% CI, 1.5-28.1), positive urine cultures (OR, 6.1; 95% CI, 2.1-17.8) and penicillin resistance (OR, 55.9; 95% CI, 18.5-168.3) were significantly associated with the infections caused by vancomycin-resistant E. faecium. Genotyping analysis demonstrated a predominant genotype in 71 (83.5%) of the E. faecium isolates, while diverse genotypes were found among the E. faecalis isolates. No apparent correlation between genotype and any specific ward was found. Up to the end of 2005, primary efforts to restrict imipenem usage and reinforce infection control measures have reduced by half the infections caused by vancomycin-resistant E. faecium.Multiple factors were associated with the unusual increase of vancomycin-resistant E. faecium infections in this hospital. Continuous monitoring of appropriate antimicrobial usage and stringent compliance to infection control measures are required to control the increase of such infections.

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. Copyright

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.

Objective To systematically review evaluations of the impact of sexually transmissible infection (STI) programs delivered by primary health care services in remote Aboriginal communities. Methods: PubMed, Google Scholar, InfoNet, Cochrane Controlled Trials Register, Australian New Zealand Clinical Trial Registry, conference proceedings and bulletins were searched to April 2011 using variations of the terms ‘Aboriginal’, ‘programs’ and ‘STI’. The primary outcome of interest in the review was the change in bacterial STI infection prevalence in the target age group assessed through cross-sectional screening studies over a 5-year period or more. The characteristics of the primary health care service, STI programs and other clinical service outcomes were also described. Results: Twelve reports described four distinct STI programs in remote communities and their impact on STI prevalence. In the Anangu Pitjantjatjara Yankunytjatjara (APY) lands of northern South Australia, there was a reduction in the age-adjusted chlamydia and gonorrhoea prevalence by 58% and 67%, respectively (1996–2003). In the Tiwi Islands of Northern Territory (NT), chlamydia and gonorrhoea positivity decreased by 94% and 34%, respectively (2002–2005). In the Ngaanyatjarra Lands of Western Australia, crude chlamydia and gonorrhoea prevalence decreased by 36% and 48%, respectively (2001–2005), and in the central Australian region of NT, there was no sustained decline in crude prevalence (2001–2005). Conclusion: In three of the four programs, there was some evidence that clinical best practice and well coordinated sexual health programs can reduce STI prevalence in remote Aboriginal communities.