We thank Schultz for her stimulating correspondence in response to our article1 and the accompanying editorial2 on invasive infections in critically ill Indigenous children. Schultz highlights that the assessment of life-threatening infections as defined and analysed in the article may not adequately reflect the wider social, emotional and cultural aspects of wellbeing.
Marmot recently advocated for shifting discussions on a global scale from economic growth alone towards an increased focus on human development3 as a prerequisite to fundamentally address inequities in health care. We agree that while our study attempts to assess the direct burden of invasive infections in critically ill children, the data do not permit us to draw conclusions on the wider impact of severe infections. Nonetheless, the study highlighted the increased risk for Indigenous children to suffer from life-threatening infections, which is one of several factors contributing to excess childhood mortality in this vulnerable patient group. This finding will hopefully prompt further research into effective interventions. For example, the severity of paediatric sepsis, such as the degree of organ failures, is closely related to the time to initiation of antimicrobial treatment and fluid resuscitation. While sepsis bundles commonly focus on the recognition of deteriorating patients within health care settings,4 education to increase community awareness of the disease in high income countries to facilitate early medical treatment has received less attention.
Importantly, the impact of socio-economic status on morbidity and premature mortality has been demonstrated to be comparable with that of other major health risk factors such as smoking, insufficient physical activity, hypertension and alcohol consumption.5 Rather than considering socio-economic circumstances as a non-modifiable risk factor, they may provide opportunities for improved strategies to address disease burden and improve the wellbeing and health of the population. Indeed, one of the strongest determinants of mortality among children aged under 5 years in communities is maternal education.6 In addition to the wider components of a holistic perspective on human health proposed by Schultz, maternal education may therefore represent one of several key strategies to close the gap on paediatric sepsis.
- 1. Ostrowski JA, MacLaren G, Alexander J, et al. The burden of invasive infections in critically ill Indigenous children in Australia. Med J Aust 2017; 206: 78-84. <MJA full text>
- 2. Palasanthiran P, Bowen A. The excess burden of severe sepsis in Indigenous Australian children: can anything be done? Med J Aust 2017; 206: 71-72. <MJA full text>
- 3. Marmot M. The health gap: the challenge of an unequal world. Lancet 2015; 386: 2442-2444.
- 4. Schlapbach LJ, Javouhey E, Jansen NJG. Paediatric sepsis: old wine in new bottles? Intensive Care Med 2017; doi: 10.1007/s00134-017-4800-6 [Epub ahead of print].
- 5. Stringhini S, Carmeli C, Jokela M, et al. Socioeconomic status and the 25 x 25 risk factors as determinants of premature mortality: a multicohort study and meta-analysis of 1.7 million men and women. Lancet 2017; 389: 1229-1237.
- 6. Gakidou E, Cowling K, Lozano R, Murray CJ. Increased educational attainment and its effect on child mortality in 175 countries between 1970 and 2009: a systematic analysis. Lancet 2010; 376: 959-974.
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