Volume 217 Issue 1

First Nations Yol?u women are speaking up to reclaim control and return of childbirth services

Sarah Ireland · Yvette Roe · Suzanne Moore · Elaine Ḻäwurrpa Maypilama · Dorothy Yuŋgirrŋa Bukulatjpi · Evelyn Djota Bukulatjpi · Sue Kildea

The convergence of excessive heat, poor housing, energy insecurity and chronic disease has reached critical levels

Simon Quilty · Norman Frank Jupurrurla · Ross S Bailie · Russell L Gruen

The current lack of a national strategy for Indigenous adolescent health in Australia is a glaring gap

Seth Westhead · Quinton Appleby · Brittney Andrews · Tina Brodie · Alex Brown · Karla Canuto · Josh Cooke · Mahlia Garay · Thomas Harrington · Djai Hunter · Corey Kennedy · Jaeda Lenoy · Olivia Lester · Hannah McCleary · Odette Pearson · Lorraine Randall · Rachel Reilly · Hamish Rose · Daniel Rosendale · Jakirah Telfer · Peter Azzopardi

No consensus on research skills in medical curricula perpetuates the unmet need for clinician researchers

Diann S Eley · Wendy Hu · Nicholas J Talley

A 42-year-old man presented with elevated alanine aminotransferase and aspartate aminotransferase on a blood test screening for viral hepatitis

William Luu · Joanne Sy · Queenie Luu

A 40-year-old man was referred with left- sided abdominal pain radiating across his abdomen, arthralgias and a mild ileitis endoscopically

Annabelle Faint · A James M Daveson

Flesh made new: the unnatural history and broken promise of stem cells

Megan Munsie

Increasing the visibility of Aboriginal and Torres Strait Islander peoples will ensure that the MJA enhances its commitment to inclusivity and health equity

Nicholas J Talley · Elizabeth Zuccala · Francis Geronimo · Tania Janusic · Elmer V Villanueva

Progress has been sluggish, and social factors and access to major health service schemes need much more attention

Ian T Ring · Kalinda Griffiths

Emergency department presentations are opportunities to discuss cardiovascular risk factors while the patient’s awareness of their importance is heightened

Christopher Zeitz · Angus Baumann

Life expectancy increased more rapidly for Indigenous than non-Indigenous people but the gap remains considerable

Yuejen Zhao · Shu Qin Li · Tom Wilson · C Paul Burgess

Our multicomponent intervention is a highly translatable primary care approach to reducing smoking by pregnant Indigenous women

Gillian S Gould · Nicole M Ryan · Ratika Kumar · Leah C Stevenson · Kristin V Carson‐Chahhoud · Christopher Oldmeadow · Joley Foster · Simon Deeming · Katherine Boydell · Christopher M Doran · Andrew Searles · Joerg Mattes · Louise Atkins · Marilyn Clarke

The prevalence of SARS-CoV-2 antibodies in children and adolescents in early 2021 was very low

the PAEDS Serosurvey Group

About two in three of participating urban Aboriginal infants had mild or moderate hearing loss at twelve months of age

Tamara Veselinović · Sharon A Weeks · Valerie M Swift · Deborah Lehmann · Christopher G Brennan‐Jones

Aboriginal and Torres Strait Islander people may benefit from culturally appropriate cardiac risk factor management

Jaimi H Greenslade · Sara Berndt · Laura Stephensen · Katrina Starmer · Greg Starmer · William Parsonage · Victor Lau · Tileah Drahm‐Butler · Tania Davis · Virginia Campbell · Richard Stone · Robert Bonnin · Sarah Ashover · Tanya Milburn · Elizabeth Mowatt · Karlie Proctor · Anthony Brazzale · Louise Ann Cullen

We need intellectual investment that prioritises Indigenous ways of knowing, being and doing, and acknowledges the historical and contemporary colonisation, dispossession and racism that continue to have an impact on health outcomes today

Michelle Kennedy · Jessica Bennett · Sian Maidment · Catherine Chamberlain · Kate Booth · Romany McGuffog · Bree Hobden · Lisa J Whop · Jamie Bryant

To the Editor: The impetigo burden for Australian Aboriginal children living in remote areas is the highest in the world, affecting 45% at any one time.1 This unacceptable public health crisis contributes to ongoing high rates of rheumatic fever and glomerulonephritis, both sequelae of Streptococcus pyogenes or group A streptococcus (GAS) infection.2 GAS infection is the key immediate driver of impetigo.3 Colonisation, social determinants and inadequate housing are overarching drivers.4 To reduce the skin infection burden, the See, Treat, Prevent (SToP) Trial (registered with the Australian New Zealand Clinical Trials Registry, ACTRN12618000520235) was funded as a stepped wedge, cluster randomised trial in partnership with Aboriginal service providers and communities to see, treat and prevent skin infections.1 Before commencing, a situational analysis5 was performed in 2017 to describe trends, driving forces and conditions related to skin infections. The situational analysis5 identified the complex, courageous yet under‐resourced environmental health and health promotion activities in the Kimberley that could be included as prevention aspects in the SToP Trial1 and found: • a well established program of health advocacy and collaboration integrating public and environmental health which prioritises prevention; • remote Aboriginal populations remain relatively stable with predictable mobility between communities, in contrast to the high turnover of the predominantly non‐Aboriginal health workforce; and • access to household maintenance throughout Kimberley communities, necessary to prevent skin infections, remains limited and frequently under‐resourced. Despite this need, the resourcing required for this sector to deliver on these services has not occurred.6 Before the SToP Trial, prior skin infection studies focused on biomedical treatments as short term solutions to improve skin health.1 Integration of diagnosis, treatment and prevention activities in a single trial to inform skin disease control is novel and needful. Aboriginal communities and health care organisations highlighted the urgent need to incorporate prevention to reduce the inequitable burden of skin infections. The key findings of the situational analysis are as follows:5 • services are working together to combat the high burden of skin infections in the Kimberley; • the immediate environment continues to contribute to poor skin health and is an area for intervention; • addressing the social determinants of health is critical to reducing skin infections; • partnerships are required to appropriately achieve the healthy living practices; and • the Kimberley has led the way with the development of the environmental health referral form. The SToP Trial includes clinic and school staff training modules for the identification and treatment of skin infections. These include online options to overcome the logistic challenges limiting face‐to‐face professional development in isolated locations and to support continuous training of new staff. The stability of the community is a strength and community requests have led to the incorporation of family training packages. Partnerships between primary health care and environmental health service providers are allowing for the better integration of prevention measures within communities. Capitalising on the advocacy and collaboration demonstrated by Aboriginal leaders across the region has aided SToP Trial initiatives, with results expected in 2023.

Frieda McLoughlin · Vicki O’Donnell · Asha C Bowen

To the Editor: Wu and colleagues1 describe a case of congenital syphilis where the mother had no apparent risk factors and a single negative syphilis serology collected in early pregnancy. The father had an identifiable risk factor. In metropolitan Perth, Western Australia, infectious syphilis among women of reproductive age is rising, with an over 18‐fold increase from 2015 to 2021 (Box). During this period, most cases (229, 74.1%) were non‐Indigenous women. This growth has been accompanied by cases in pregnancy and, concerningly, neonates with congenital syphilis. The authors1 observed that identifying risk factors during pregnancy is challenging. They may be absent, difficult to ascertain, subject to change during the pregnancy, and are dependent on the pregnant woman and her sexual partners, whose risks she may not know. Identification relies on health care providers checking the risk throughout pregnancy and on whether the woman recognises, discloses or feels safe to discuss a risk factor. In Perth, syphilis diagnoses among pregnant women are occurring across cultural backgrounds. While some women have additional risks such as insecure housing or illicit drug use, this is not the norm. Consequently, and because we have likewise observed neonates with congenital syphilis born to women who screened negative early in pregnancy, routine syphilis serology at initial visit and at 28 and 36weeks (or delivery, if earlier) is now recommended for all pregnant women in metropolitan Perth as per the WA sexual health guidelines2 and local obstetric guidelines.3 This was achieved through the collaboration of clinical and public health staff under the Antenatal and Postnatal Working Group of the WA Syphilis Outbreak Response Group, where a decision was made that monitoring risk factors throughout pregnancy has limitations. Three‐test syphilis screening for all pregnant women minimises the risk of congenital syphilis occurring because of an unrecognised risk factor, ensures emerging risk factors are not missed, helps normalise testing and reduce stigma, and recognises that women remain sexually active while pregnant. Notably, screening is not a replacement for good history taking and clinical examination, but syphilis can present in subtle and unusual ways that can be overlooked. Routine syphilis testing at the first antenatal visit is advised by the Australian sexually transmissible infections guidelines.4 A test early in the third trimester is recommended depending on local guidelines.4 As syphilis rates grow in many parts of Australia,5 other jurisdictions should consider adopting additional routine syphilis screening for all pregnant women. Box – Infectious syphilis cases among women of reproductive age, 2015–2021 Data sources: The number of cases were obtained from the Western Australian Notifiable Infectious Diseases Database, Department of Health Western Australia (Jan 2022); and the rate of cases were obtained from the Australian Bureau of Statistics census‐derived population data from the Epidemiology Branch, Public and Aboriginal Health Division, Western Australia Department of Health (Dec 2021).

Hannah MacKenzie · Suzanne McEvoy · Michelle Porter

To the Editor: In Australia, up to 40% of women have experienced an unintended pregnancy,1 which can be associated with suboptimal pre‐conception health behaviour and reproductive health care engagement and adverse maternal and neonatal outcomes.1 Aboriginal and Torres Strait Islander women experience higher rates of pregnancy risk factors, adverse perinatal outcomes, and adolescent pregnancy compared with non‐Indigenous women.2 However, little is known about the prevalence and impact of unintended pregnancy among Aboriginal and Torres Strait Islander women. While two related national studies have been undertaken over the past decade, Aboriginal and Torres Strait Islander people were underrepresented1 or Indigeneity was unreported.3 Access to sexual and reproductive health care is a government priority,4 but without adequate data, dealing with issues or evaluating change will be impossible. This knowledge gap must be addressed. We need to better understand the prevalence, experiences and outcomes of unintended pregnancy for Aboriginal and Torres Strait Islander people (acknowledging that unintended does not necessarily mean unwanted), including issues relating to pregnancy intentions, decision making, and health care access. Meaningful engagement and collaboration with Aboriginal and Torres Strait Islander communities and researchers are required to confirm priority issues, design culturally appropriate data collection processes, and achieve a nationally representative sample. Data sources such as those held by primary health care providers and Aboriginal Community Controlled Organisations have an untapped potential to highlight the needs and priorities of Aboriginal and Torres Strait Islander people, should they be used with appropriate consultation and respect for Indigenous data sovereignty. Furthermore, knowledge gained must inform the national policy gap that exists in the area of holistic reproductive health. A national reproductive health policy and an implementation plan that address unintended pregnancy, decision making and management are urgently needed. These must be developed with due consideration to the needs of Aboriginal and Torres Strait Islander peoples from a strengths‐based paradigm and a decolonising approach that recognises historical reproductive rights violations.5 Data collection within a supportive policy framework will inform service provision, education and health promotion initiatives to improve maternal and infant outcomes and support Aboriginal and Torres Strait Islander women and families in choosing whether and when they have children.

Jessica Botfield · Emma Griffiths · Faye McMillan · Danielle Mazza