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High rates of STDs in Australian Aboriginal communities point to limitations in current surveillance and control methods
MJA 1997; 166: 456
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Our information on the extent of STD in the population is largely
derived from a passive notification system. Sentinel sites that
routinely screen their client population for STDs and community
surveys supplement the data from notification systems. Sentinel
surveillance for HIV is conducted at urban sexual health clinics and
data are collated nationally by the National Centre for HIV
Epidemiology and Clinical Research, but there is no national
collection of sentinel data for STD outside sexual health clinics.
Our understanding of the epidemiology of STD outside the cities and
towns is incomplete.
At present, notifications are more often received from communities
that recognise STD as an important health issue. Thus, communities
that act on their responsibility for sexual health and STD control run
the risk of being denigrated because of their apparently high rates of
STD, while other communities not active in sexual health may have
similar or bigger problems that remain largely hidden.
The problem of detecting cases of STD is also an issue in evaluating the
extent of their complications, which often form the greatest burden
of disease. As shown in the report by Mein and Bowden (page 464 of this issue of the Journal),3 this burden falls heavily
upon women in Aboriginal communities. What is perhaps most alarming
in their case review is that only 45% of patients admitted to a
gynaecological ward with suspected pelvic inflammatory disease
were tested appropriately for STD (by endocervical swab). The rates
of infection calculated by Mein and Bowden are therefore only the
minimum estimate of gonococcal and chlamydial infection in pelvic
inflammatory disease.
The effort to control STD in Aboriginal communities can be
facilitated by using new technology. In particular, tests based on
the polymerase chain reaction (PCR) can diagnose chlamydia and
gonorrhoea from urine samples. Such samples can be collected and
processed more easily than swabs, and the procedure is more
acceptable to Aboriginal people.
This application of PCR technology is still in its infancy, and there
may be some interpretation problems. The PCR test detects DNA or RNA,
but does not tell us if the material comes from an infectious organism
or from non-infectious remnants of a resolving infection. Another
problem is that PCR testing does not allow the determination of
antibiotic sensitivity patterns. Sentinel surveillance
activities (involving culture for gonorrhoea to determine trends in
antimicrobial resistance) must continue so that control efforts are
not frustrated by drug resistance.
A second application is through increased opportunistic testing by
health care workers at consultations unrelated to sexual health.
This approach is not necessarily easier than community surveys and
represents a challenge to Aboriginal communities with limited
access to health resources and a different cultural perspective on
sexual matters. Opportunistic testing cannot be undertaken without
prior consultation with the community and the development of
guidelines on who should be tested and when. The risk of acquiring an
STD is not evenly distributed within Aboriginal communities and a
better understanding of social and sexual networks is needed.
Mechanisms will need to be in place to inform people of test results and
to ensure their treatment, and that of their contacts. The provision
of adequate and acceptable community-based health services
that recognise the importance of STD and have the capacity and will to
detect, follow up and treat cases should be a priority. This will
involve the active participation of the communities concerned and is
perhaps the biggest challenge facing funders and providers of health
services.
HIV is already present in Aboriginal communities but its extent is
limited at present.6
Experience in Africa (where the main focus of successful prevention
programs is the provision of quality STD health services,
encouragement of early presentation and availability of effective
treatment) suggests that our ability to control bacterial STD will be
a major determinant in controlling the spread of HIV.7
The two reports published in this issue of the Journal2,3 suggest that we have a long way to go
in controlling STD in remote communities. We have the technology to
enable non-invasive testing for gonorrhoea and chlamydia. We now
have to use it effectively to detect, treat and reduce the level of
endemic disease. The challenge is there for public health
professionals and involved communities.
Russell G Waddell
<URL: http://www.mja.com.au/>
© 1997 Medical Journal of Australia.
A recent MJA editorial recognised Australia's achievements
in controlling sexually transmitted disease (STD), but emphasised
that the necessary aim must be "striving to eliminate endemic
disease".1 Two articles in
this issue of the Journal2,3
highlight the problems in the path of this objective -- and some of the
potential solutions.
What you test for is what you see, and
our passive notification systems may be blind to much STD in the
community
Nationally, notifications of gonorrhoea and syphilis have declined
in recent years,4 but
celebration may be premature. The community-based survey reported
in this issue by Skov et al. demonstrates that our
notification systems may not provide an accurate picture of STD
distribution in Australia.2
Their study found a far higher rate of gonorrhoea and chlamydia than
would have been expected from previous notification data.
Notifications made as a result of their community screening were
responsible for a significant part of the 59% increase in
notifications of gonorrhoea in South Australia in 1995.5 What you test for is what you see, and
our passive notification systems may be blind to much STD in the
community.
PCR technology can be used in two ways in STD control. Firstly, in
community surveys, such as that described by Skov et al.2 This survey, a collaborative effort
between Aboriginal and government health services, required
considerable infrastructure and community consultation, which
were facilitated by the TriState STD/HIV Project (funded by the
Western Australian, South Australian, Northern Territory and
Commonwealth health departments). The collaborative approach of
the TriState STD/HIV Project offers a model for undertaking surveys
of this nature.
Clinic Manager, STD Control Branch
South Australian Health Commission
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