Indigenous health

Objective: To compare the clinical effectiveness of single-dose azithromycin treatment with 7 days of amoxycillin treatment among Aboriginal children with acute otitis media (AOM) in rural and remote communities in the Northern Territory. Design, setting and participants: Aboriginal children aged 6 months to 6 years living in 16 rural and remote communities were screened for AOM. Those diagnosed with AOM were randomly allocated to receive either azithromycin (30 mg/kg as a single dose) or amoxycillin (50mg/kg/day in two divided doses for a minimum of 7 days). We used a double-dummy method to ensure blinding. Our study was conducted from 24 March 2003 to 20 July 2005. Main outcome measures: Failure to cure AOM by the end of therapy; nasal carriage of Streptococcus pneumoniae and non-capsular Haemophilus influenzae (NCHi). Results: We followed 306 of 320 children (96%) allocated to the treatment groups. Single-dose azithromycin did not reduce (or increase) the risk of clinical failure (50% failure rate [82/165]) compared with amoxycillin (54% failure rate [83/155]) (risk difference [RD], – 4% [95% CI, – 15% to 7%]; P = 0.504). Compared with amoxycillin, azithromycin significantly reduced the proportion of children with nasal carriage of S. pneumoniae (27% v 63%; RD, – 36% [95% CI, – 47% to – 26%]; P < 0.001) and NCHi (55% v 85%; RD, – 30% [95% CI, – 40% to – 21%]; P < 0.001). Nasal carriage of S. pneumoniae with intermediate or full resistance to penicillin was lower (but not significantly so) in the azithromycin group (10% v 16%), but this group had significantly increased carriage of azithromycin-resistant S. pneumoniae (10% v 3%; RD, 7% [95% CI, 0.1% to 12%]; P = 0.001). Carriage of β-lactamase-producing NCHi was about 5% in both groups. Conclusion: Although azithromycin reduced nasal carriage of S. pneumoniae and NCHi, clinical failure was high in both treatment groups. The possibility of weekly azithromycin treatment in children with persistent AOM should be evaluated. Trial registration: Australian Clinical Trials Registry ACTRN 12609000691246.

Peter S Morris MB BS, PhD, FRACP · Gaudencio Gadil MD · Gabrielle B McCallum BNurs, MPH · Cate A Wilson EN, BPsych(Hons) · Heidi C Smith-Vaughan BAppSci, PhD · Paul Torzillo MB BS, FRACP, JFICM · Amanda J Leach BAgSc(Hons), MAgSc, PhD

Conference delegates workshopped a realistically staged disaster scenario in which they were completely isolated from outside resources If you have to have a disaster, Broome, on the remote Kimberley coast of Western Australia, seems a good place to be; that is, until you take a closer look at what it would be like at the centre of the action. And this is exactly what delegates did during the inaugural conference on Tropical, Emergency and Disaster Medicine (TED-MED), held in Broome on 22–24 May 2009. The conference was attended by 81 delegates, including 28 general practitioners, eight tropical medicine specialists, six emergency medicine specialists and five disaster medicine specialists, plus representatives of government agencies, rural and remote nurse paramedics, clinical laboratory scientists and environmental health and industry participants. In this conference, we used the scenario of a tropical cyclone to move conference attendees outside their comfort zones and draw them into the reality of health crisis management in regional Australia. As it happened, Broome turned out to be an excellent location for the TED-MED conference because of a series of recent events, including the explosion of a refugee boat off the north-west coast of Australia and a tourist vehicle rollover on the Mitchell Plateau to the north-east. To add further realism to the program, there was severe wind damage caused by storms hitting Perth the day before visiting speakers flew into Broome, and the nation was on the verge of moving from the “Delay” phase to the “Contain” phase of the response to pandemic (H1N1) 2009 influenza. There were two triggers for a broad-based conference such as this. One was a renewed emphasis on regional development, particularly in WA’s north-west, where the expansion of the Ord River Irrigation Scheme, mining and petrochemical industries, and tourism are expected to drive a threefold to fourfold expansion of the regional population over the next decade. The second trigger was the Government of WA’s Royalties for Regions policy, under which some of the revenue generated by the mining and resources industry is returned to regional WA in the form of infrastructure funding, and is expected to add impetus to the population growth in the north of the state. In his opening address, WA Director General of Health Peter Flett emphasised the challenges of providing health care to such a thinly spread population in a tropical environment. He said that there was an urgent need to tackle the declining professional population as the baby boomer generation goes into retirement. David Atkinson, from the Kimberley Aboriginal Medical Service Council, compared his extensive experience in remote Aboriginal communities with indigenous communities in remote Canada. The extremes of hot and cold were explored further by retired remote and rural general surgeon Val Lishman AM, who spoke on his work in northern Australia and as an Australasian Antarctic Expedition doctor. Val’s moving snapshot of wilderness medicine in extreme environments was a profound reminder of the importance of resourcefulness and unquenchable optimism in the face of adversity. At the centre of the conference program was a carefully researched disaster scenario (Cyclone TED). Delegates prepared for an extended problem-solving activity through a series of lectures. Major-General Paul Alexander (Australian Defence Force [ADF] Surgeon General) gave the initial plenary session on ADF health capability, reflecting on the role Defence personnel often play in disaster response. He usefully clarified what the Defence Force can do and under what circumstances they would be tasked to assist. Highlights of subsequent parallel sessions were a vivid description by plastic surgeon Fiona Wood of the management of patients with burns who were injured in the Bali bombing, the challenges to medical evacuation from a combat zone by David Werda (former ADF paramedic during United Nations deployment to Somalia), and tag-team presentations on snakebite and emergency resuscitation by George Jelinek and Steve Dunjey (both from the Emergency Department at Sir Charles Gairdner Hospital). Steve’s recent high-profile resuscitation success in outback WA led him to comment that medicine is full of surprises. “You can see unexpected survival in patients under 50 after over 20 minutes’ resuscitation.” The closing straight was led by a relay team of experts. Juliet Hubbard, speaking for Indigenous communities, advocated much wider training of health professionals in cultural safety, particularly in managing major community crises. Alison McMillan (Department of Human Services, Victoria), speaking on the Victorian bushfire disaster, reminded us how quickly local emergency services can be overwhelmed. She gave delegates a sense of the confusion that arises as responding agencies piece together a picture of a disaster. Finally, Brad Santos, a severe-weather expert from the Bureau of Meteorology, left the storm damage in Perth behind him and showed how cyclones behave, with specific reference to their severity and time course. Having given us a taste of what to expect, he introduced the disaster scenario with a scene-setting severe-weather warning. Unlike in many tabletop exercises that aim to advertise the capabilities of host agencies, the details of the scenario were not disclosed to participating agencies. Michael Watson (Clinical Microbiologist, Perth), who led the team of scenario writers, said that he wanted a realistic challenge. As it happened, the date of the conference coincided with peak high tides, enabling Michael and his team to design a realistic scenario in which cyclonic winds caused a storm surge and significant flooding. They envisaged power, telecommunications, the airport, and road links being out of action for 48 hours. To the frustration of health administrators, there was no phone-a-friend-in-Perth option. Police, fire and emergency services, ambulance services, the Royal Flying Doctor Service, the Water Corporation, the Department of Housing and the Department for Child Protection (which is responsible for resettling displaced people) had to rely on what was available locally. There was a lot of tension in the room in the early stages of the disaster scenario as participants grappled with conflicting priorities. In the wrap-up session, table after table recounted tales of resources they discovered when they started to reach out to other groups. Some discovered leadership skills they didn’t know they had. Others showed a natural talent for critical thinking under pressure. One of the conference highlights was a vivid description by Phil Kuhne (Department for Child Protection) of what it would be like in an overcrowded cyclone shelter, and why there wouldn’t be any cyclone parties on his watch. Adding a little realism to the scenario, television crews from two competing channels arrived to interview organisers and speakers just after the scenario started, diverting critical expertise when it was most needed. Cyclone TED was full-on; a draining experience for all those involved. However, there was little rest for the delegates. While the lessons of the disaster scenario were still fresh in their minds, participants split into three parallel skills-development workshops on practical aspects of disaster response, life support with particular emphasis on failed intubation drills, and deployable molecular diagnostic laboratories. Ronan Murray brought the more esoteric aspects of laboratory diagnostic support down to earth by reminding participants of the potential role of the molecular diagnostics laboratory in assisting with front-line clinical decision making in remote or rural regions. The Australasian College of Tropical Medicine took the opportunity to consult on the practical needs of health practitioners in tropical Australia, convening a small group to write up the lessons learned and condense them into a regional development framework — as one delegate put it, the “where we are, where we need to be and how we’re going to get there” of health care in tropical Australia. This process generated the action statement that was presented at the conclusion of the conference. The document, known as the Broome Declaration (Box), captured the spirit of the meeting and provided a sense of direction. In the final discussion of the conference, converting the Declaration into action was debated. There was uncertainty over where resources could be found for infrastructure development, and some scepticism over anything resembling a centrally driven capital project, but there was considerable enthusiasm for local ownership of the process from local delegates. The TED-MED Conference demonstrated that there are people who work at the hot and dusty end of health care who are willing to provide professional leadership. The Broome Declaration represents a benchmark for health development in tropical and regional Australia. It remains to be seen whether there is a substantive political commitment to support front-line health care professionals in developing health capability for regional Australia. The Broome Declaration 1. On this day, 24th May 2009, in Broome, Western Australia, we, the participants in the first consultative tropical medicine summit convened under the auspices of the Australasian College of Tropical Medicine, hereby recognise that the following 10 themes are essential to the development of tropical health: holistic, one health;* collaborative intersectoral partnership; primacy of prevention, early intervention; cultural safety;† subsidiarity;‡ leadership development; proximity of services; immediate availability; effective communication; and strategic urgency. 2. Recognising the current shortfall in health capability in this region as typical of many parts of the tropics, we commit to: establishing tropical health development priorities based on the above themes; informing health authorities of our conclusions; and working toward practical development outcomes within our immediate areas of professional influence. 3. We therefore propose the following specific priorities for north-west Australia: developing a remote access tropical medicine training program; establishing a regional development centre for all stakeholder groups in the Kimberley and the rest of the north-west; and forming a steering group to identify governance and resource support for these outcomes. * A reference to the concept of health as a state of physical, mental and social wellbeing, rather than an absence of disease, first articulated in the Declaration of Alma-Ata.1 † Achieved in a health care setting when carers and providers are attuned to the cultural context of the individuals and communities, and are sensitive to culture-specific vulnerability. ‡ The principle of devolving responsibility for decision making to as close as possible to the level of community at which action is taken.

Timothy J J Inglis DM, FRCPA, FACTM · Ronan J Murray FRCPA, FRACP, FACTM · Michael Watson FRCPA, FRACP, FACTM

A child is born to be cared for, loved and nurtured. However, the hope that birth brings is not to be taken for granted. Where, and in what circumstances, the new life takes hold is a lottery that some win and others lose. I have worked for some years in both East Timor and Central Australia. I find the burden of despondency and disease heavier in my own country than in East Timor. Non-Aboriginal Australia is tired of hearing of the problems of Aboriginal Australia. A culture, they say, of handouts and victimisation — why can’t they just get over it like every other ravaged and decimated people? The domino effect is in play — one generation is knocked out and the effects are felt in subsequent generations. Try to imagine losing your land, your language, your way of life, your mother and father. I reflected on all of this when I went out to a mission settlement, Kumanjai Creek (near Tennant Creek, in the Barkly region of the Northern Territory), with three sisters, Connie, Joyce and Theresa. We stood on slabs of cement as the women explained: This was the “half-caste” dormitory; this was the kitchen; this is where we were locked in; this is where the boys slept. We had to carry out toilet buckets past the boys in the mornings and they mocked us. The old women swept away the dirt to reveal a date — 1945 — that they knew was scrawled in the cement. We sat around a camp fire under an ancient gum tree, which stood as a silent witness to past events, and ate kangaroo tails, witchetty grubs and seeds the women had collected. They told stories of the day Joyce was taken away. I tried to imagine: being a child who had to run away with my family for hundreds of kilometres because a white man was killed and I might be killed in retaliation; landing at a mission, being locked in at night, being beaten, eating only flour, rice and goats milk, eating no fruits or bush tucker, and little meat or vegetables; being that “half-caste” child separated from those I loved and locked up with others of lighter skin in a separate dormitory; being sent away because of my colour, while those who remained banged their heads with rocks as if in mourning for the dead. In the last century, a large percentage of the women’s kinsmen were killed or displaced. The old people had mastery of the language of the land, but it was hard to regroup in a new and alien world. They were powerless, landless and their ancient skills were not valued. The keepers and owners of country became outcasts and margin dwellers. They knew each plant, animal and water soakage. They knew medicinal bark, the goanna holes, bush raisins and tomatoes, and the roots that harbour witchetty grubs. They survived in one of the harshest environments in the world. They are resilient people whose roots tap deep into the red soil. The old people of Central Australia still remember how to survive. They also remember what happened to their people. The wheel keeps turning. Now the old people can’t sleep at night because younger people are drinking too much alcohol. What can be done? They don’t know; no one knows. They care for others’ children because part of a generation is lost. What will happen when they are gone? A 3-week-old baby, his mother, father and sister, his grandmother and 89-year-old great-grandmother live in a tin shed without power, water or sanitation. That newborn doesn’t have a fair chance. Too many children in Central Australia struggle as no child should have to. A child has a right not to be blighted with fetal alcohol syndrome, not to have rheumatic fever, not to have kidneys destroyed by glomerulonephritis, not to suffer intractable otitis media, not to have scabies so badly that to walk or make a fist is nearly impossible. Children deserve to hear, to be sent to school and to live in safe and clean environments. A young woman is angry because she needs to nurture her child, and yet her future is uncertain — like many others, she has end-stage renal failure. In her early twenties, she is facing a long period of exile in Alice Springs (the nearest major town to Tennant Creek about 500 km away) because of a shortage of dialysis beds where she lives. In our town, you often see wheelchairs used by people missing limbs because of diabetes, or by children with congenital abnormalities. There is a high rate of substance misuse, with all its consequences for the individual and their family. We hope there will be funding for ear, nose and throat surgeons to visit regularly so that the hundreds of children of the Barkly needing surgery will be spared the long waiting lists and midnight bus trips to Alice Springs. We hope for more dialysis beds so that the incoming wave of patients with renal failure will not be faced with the choice between exile in Alice Springs or death. We hope for more public health staff to tackle scabies, strongyloidiasis, alcoholism, diabetes and the other medical curses of the inland. We hope for more social workers and child protection officers to help and follow up children at risk. I have worked in East Timor,1 where, despite enormous poverty, the people are rebuilding their communities after a long period of destruction (related to the Indonesian occupation and resulting civil conflict). They have regained their sovereignty, and preserved their language and beliefs. They retain their hope while many of our own people do not. In East Timor, the thread of culture is not broken. The spirit and structure of society survives. The indigenous people still plant their corn, tend their caribou and thatch their houses as before. There are changes at the margin but the fabric of their society is not torn asunder. Many towns in East Timor now have “sister cities” in Australia. There is contact and connection between East Timorese and Australian communities. What stops similar connections being forged within Australia itself, between coastal communities and the outback? Should we not face our history a little more squarely and admit that the atrocities were real, and not a delusion perpetuated by the “black-armband set”? Could a new understanding be reached between Aboriginal and non-Aboriginal Australians, who for too long have sat in opposing camps? The welfare of the people of Central Australia has been thought of as a “government issue” that the ordinary citizen, business sectors and non-government organisations have stayed out of, but this is changing. No one knows the way forward. It is a way we need to forge together. There is anger and suspicion to overcome; people have been hurt and damaged. Nothing will be easy. The problems of the outback are social, but the consequences are medical. People need suitable housing, but ideally they should be involved in their design and construction and so have pride and personal investment in the buildings. They need support to maintain their buildings. Education is offered as a way out of the poverty trap of “sit-down money”, but still many children attend school irregularly and leave as soon as they can. Traineeships and apprenticeships are few, and work in general is scarce. Poor physical health is a symptom of a deeper illness at the heart of Australia. Change will take a long time, but a groundswell of support and small projects may do more than top-down intervention. To paraphrase Marcus Aurelius: to work for change and stay on our feet, we don’t need the fancy footwork of the dancer, but the determination of the wrestler. If enough people, both Aboriginal and non-Aboriginal, stay engaged, we can work together towards healing. Then, perhaps, love will be reborn in the heart of our country. “They told stories of the day Joyce was taken away.” “Children deserve to hear, to be sent to school and to live in safe and clean environments.” “They are resillent people whose roots tap deep into the red soil.” Indigenous women, Kumanjai Creek, NT Tilling the field, East Timor School children, East Timor

Colette L Livermore MB BS(Hons), FRACGP, MPH

We were cruising at 5000 feet, enjoying beautifully clear winter weather, just south of Tennant Creek in the Northern Territory. My friend Don and I were flying in his Cessna 182 and about to turn east and follow the Barkly Highway to a large cattle property known as “Avon Downs”. We were planning to visit an old patient — let’s call her Claire. Originally from England, she was working for the South Australian Government in the NT looking after Aboriginal children in a kindergarten. The story began when a letter arrived from Claire asking if I would make a flying visit to her “back country” village. She heard that I had taken up private flying and had an interest in visiting the bush. My friend Don was a novice private pilot like myself, and we were both very keen to take the opportunity to test our wings on a long flight to the country. Claire lived alone in a large caravan that could accommodate four adults. It was grouped in a large, protected area with three other similar caravans: one served as the ablution block for the children, another was for their changing and rest rooms, and the third was a large classroom where lessons were conducted. Claire was endeavouring to help with training in health and education for young Indigenous children from deprived areas. The excitement was immense as we landed in a cloud of dust on the bush airstrip. We taxied up to Claire, who was surrounded by dancing and shouting children. It was not long before we were chatting about bygone years and about how Claire was coping with the various demands while attempting to introduce Western culture into the Aboriginal community. Claire described her disappointment with the lives of some of her former pupils — for example, girls aged 10 or 12 who, on returning to their Aboriginal communities, were allocated as wives to elders of the tribe. She was anxious to visit some of these older children, who now lived on the coast at Borroloola, about 500 km north of Avon Downs. Why not make a flying visit to Borroloola? It was soon decided that we should. We quickly cleared the aircraft of unwanted gear so that Claire would be able to join us on the flight. We took off early the next morning and arrived at Borroloola after about two and a half hours. Claire was very excited to see her former pupils and learn about their lifestyle and activities in the years since leaving school at Avon Downs. We spent a happy day meeting all the young mothers and their children, and the time passed very quickly. Then we suddenly remembered that the airstrip at Avon Downs did not have landing lights! We realised we had to leave quickly because the calculated flying time would only just allow us to arrive home before last light. When I turned to walk to our aircraft, I met the anxious gaze of the hospital matron: “Could you possibly help with a desperately ill little Aboriginal baby? The Flying Doctor can’t come till tomorrow and this wee child is seriously distressed and unfortunately the hospital sisters can’t help.” I looked across to Don and Claire as I followed the matron running to the sick child’s bedside. He was seriously ill from dehydration after protracted vomiting and diarrhoea and needed an intravenous saline drip. So a small baby with collapsed veins set the challenge for time and urgency. Naturally, my flying companions were a bit anxious about the prospect of delaying our departure. However, the nursing staff were all very grateful for my help. After some effort, the needle entered the vein of this brave little boy, who began to improve with the added fluid. I stood back with relief, which was shared by us all. After a quick farewell we went out to the aircraft. We checked the seatbelts, oil and fuel, then warmed up the engine and leapt into the air on track for Avon Downs. We checked our calculation on the time for last light for Avon Downs with a radio call to Mt Isa traffic control. Our calculations were correct — we would be 25 minutes late for last light on arrival! There were no options at this stage, so we pressed on, hoping the last light of the sunset on the flat landscape would give us sufficient vision. But look! What was that unusual glow ahead on the track near the horizon? That must be close to the Avon Downs airstrip! As we flew nearer to this bright area, while the natural light was failing rapidly, we saw we were being welcomed by numerous cars that had their headlights lighting up the airstrip to guide our return. It seemed the hospital staff from Borroloola had called the folk at Avon Downs and told them about our problem and why we had a delayed departure. Claire was sad to say goodbye to us but, happily, she wrote to say what fun our visit had been and that the little boy had recovered and was doing well. North-eastern region of the Northern Territory

Anthony H T Hodgkinson FRCS, FRACS, FAOrthA

Objectives: To examine patterns of nicotine dependence, the value of the Fagerström Test for Nicotine Dependence (FTND) and its correlation with self-reported tobacco use and urinary cotinine concentrations among pregnant Indigenous women in Townsville.Design, participants and setting: Cross-sectional study of 201 consecutive women who self-reported tobacco use at their first antenatal visit to Townsville Aboriginal and Islander Health Service (TAIHS) between 1 November 2005 and 31 October 2007. All smokers were to be assessed by FTND, and 108 women participating in the Tilly’s Tracks project (a randomised trial of an intervention to reduce smoking in pregnant Aboriginal and Torres Strait Islander women) were to have a comprehensive smoking history taken and urinary cotinine samples collected.Main outcome measures: Self-reported smoking status, FTND scores and urinary cotinine concentrations.Results: Of 302 Indigenous women presenting to TAIHS, 201 (66.6%) identified as current tobacco users at their first antenatal visit; this proportion rose to 79.6% in women aged < 20 years. An FTND was completed for 152 women (75.6%), with a median score of 4, and 40.1% scoring 3 or less, indicating low levels of nicotine dependence. There were significant correlations between the FTND and number of cigarettes smoked (ρ = 0.56; P < 0.001) and urinary cotinine concentrations (ρ = 0.25; P = 0.030). Of those who provided comprehensive smoking histories, the median age of starting smoking was 15 years, with a median of two previous quit attempts; 71.4% reported partners who smoked and 27.3% reported smoking occurred inside the house.Conclusion: The use of the FTND in Indigenous pregnant women may assess physical nicotine dependence, thus providing information that will help in preparing quit-smoking plans, including tailoring of pharmacological support to individual need. Quit-smoking programs that better address the behavioural and psychological aspects of smoking within the Indigenous community in Australia are needed.

Kathryn S Panaretto MB BS, FAFPHM · Melvina R Mitchell EN · Lynette Anderson EN · Conor Gilligan BPsych, PhD · Petra Buettner PhD · Sarah L Larkins MB BS, MPH · Sandra Eades MB BS, PhD

To the Editor: Bronchiolitis, most often associated with respiratory syncytial virus (RSV), is a major cause of hospitalisation in young children. Those with chronic lung and congenital heart disease (the latter affecting about 192 births annually in Western Australia) are at particularly high risk.2 Immunoprophylaxis with the RSV monoclonal antibody palivizumab is effective in reducing severe RSV-related hospitalisations, and monthly immunoprophylaxis is recommended in high-risk children.2,3 Monthly immunoprophylaxis is costly; therefore, the most cost-effective schedule follows the times of peak RSV activity4 — usually the winter months, May to October. Using the Western Australian Data Linkage System,5 we investigated the seasonality of bronchiolitis hospitalisations (International Classification of Diseases-10 code J21) from 1996 to 2005 as a proxy for RSV-related illness. Data specifically for RSV-related illness were considered unreliable because some children may not have been tested for RSV, test results may not have been documented on hospital discharge notes, or RSV immunofluorescence tests may have given false negative results. Furthermore, RSV codes (B97.4, J12.1, J20.5, J21.0) were not used by hospitals in WA until July 1999. We identified 11 988 hospitalisations for bronchiolitis throughout WA among 245 249 births. Most bronchiolitis admissions (81%) were in children younger than 12 months. In the Perth metropolitan region, there was a clear winter seasonal pattern, with hospitalisations peaking in July. However, in the Kimberley region in northern WA, there was a sustained bimodal seasonality, with a peak in April and second peak in August (Box). Moreover, only 51.5% (469) of bronchiolitis admissions in the Kimberley and 61.5% (444) in the Pilbara–Gascoyne (located in mid-north WA) occurred between May and October, as opposed to 84.3% (6354) in the metropolitan region. These data support an earlier implementation and longer dosing schedule with palivizumab for high-risk children in the Kimberley and Pilbara–Gascoyne than for those in Perth. Our study has some limitations. Not all bronchiolitis hospitalisations may be caused by RSV. However, when we investigated only those hospitalisations with a specific RSV code, the monthly distribution showed a similar pattern. Additionally, timing of RSV activity, and therefore bronchiolitis, may vary from year to year. Although the numbers were too small to allow separate analysis by calendar year, bronchiolitis hospitalisations in the Kimberley showed extended seasons in 8 of the 10 years. Our findings support the need for each jurisdiction to know its seasonal pattern of bronchiolitis and RSV hospitalisations, and to implement recommended palivizumab schedules accordingly. Such use of extended prophylactic regimens may well require its cost-effectiveness to be reconsidered. Our analysis highlights the relevance of population-based data linkage studies to clinical care policy. Monthly distribution of bronchiolitis hospitalisations by region of child’s birth, 1996–2005

Hannah C Moore · Anthony D Keil · Peter C Richmond · Deborah Lehmann

To the Editor: More than 30 years ago, I was employed by the Commonwealth Government’s Maternal Mortality Committee to identify and evaluate factors contributing to maternal and infant mortality among Aboriginal Queenslanders. At that time, government policy was to transfer all pregnant Aboriginal women from their rural communities or missions to Cairns Base Hospital at 32 weeks’ gestation until 7–10 days after birth. Findings I presented in a report to Queensland Health in 19771 and at the Australian College of Paediatrics Annual Meeting in 19792 included: Babies of women who were compulsorily transferred at 32 weeks’ gestation to Cairns Hospital had lower neonatal death rates. It was assumed that — as Aboriginal women had unreliable gestational age assessments, antenatal care was irregular, and birthweights were lower than for other races3 — the risk of premature deliveries could be avoided by early transfer. There was a lower rate of breastfeeding among mothers transferred to Cairns, largely because if they opted to bottle-feed they could return home after 3–4 days (rather than waiting 7–10 days in Cairns to ensure breastfeeding was established).1 Growth failure was common in the month after weaning.4 Bottle-fed babies experienced slower weight gain and higher rates of illness.5 Suboptimal growth in bottle-fed babies during the early postnatal months predisposed babies to poor growth patterns during infancy6 and increased death rates.7 Women returning to their communities took with them infections acquired during the hospital stay in Cairns. Separation anxiety or maternal deprivation was common among children left in their communities. There was decreased family bonding (eg, between the father and the new child) and sibling resentment at maternal separation. There was unquantifiable resentment at having babies born away from the ancestral lands. Women delayed admitting their pregnancies in an attempt to remain in their communities, resulting in fewer antenatal visits. The antenatal transfer policy has been in effect for 30 years, despite conflict between those who were predominantly concerned with maternal and perinatal mortality (who favoured compulsory delivery in Cairns Base Hospital), and those (myself included) who were concerned about the effects on children’s growth and development. During this time, I have observed weakening family and community bonds, increasing alcohol and substance misuse and sexual abuse, low school attendance, poor employment records and domestic violence. My studies of Aboriginal and non-Aboriginal children born in Cunnamulla in western Queensland followed the same cohort of children from birth8 for 20 years.9 The presence of a father who was employed at the time of the child’s birth acted as a role model for the future and was more effective than all other social interventions with respect to the child’s successful education or employment 20 years later, irrespective of race or subsequent social support or interventions offered to the child during school years.9,10 Arnold and colleagues’ recent article in the Journal records a situation almost unchanged from 30 years ago, with the exception that antenatal ultrasounds have allowed transfer to occur at 36 weeks’ instead of 32 weeks’ gestation.11 Enormous resources of goodwill, effort and money have been spent in these communities over 30 years, yet the family disruption, unemployment and abuse statistics remain at variance with the Queensland norm. Perhaps the time has come to allow low-risk births to occur in selected towns, where the mother can be surrounded by her friends and relations, and be in closer contact with her ancestral land. I endorse the article by Arnold et al and hope they are more successful in implementing change than I have been.

John W Cox

To the Editor: A letter by Scrimgeour1 in the 18 May 2009 issue of the Journal praised an earlier study by Andreasyan and Hoy2 for adding to the evidence that Indigenous people living in small communities (known as “outstations” or “homelands”) in very remote areas are healthier than those living in larger settlements. I believe this was an error. The study found that mortality was lower in both outer regional areas and very remote areas than in remote areas.2 But, unfortunately, this tells us nothing about outstations. The Accessibility/Remoteness Index of Australia (ARIA) classification used by the authors groups larger remote communities and their outstations together — categorising both as “very remote”. Scrimgeour is not alone in overstating the evidence for better health among Indigenous people living in smaller communities. The possible health benefits associated with living in outstations has become a major argument against the Australian Government’s plan to create 26 remote “hubs” that will receive improved services (to the likely detriment of smaller communities)3 and the related plan of the Northern Territory Government to develop 20 larger remote communities.4 For example, Tom Calma, Aboriginal and Torres Strait Islander Commissioner at the Australian Human Rights Commission, was reported as saying that there was “a strong body of research showing that people on homelands lived longer, healthier lives”.5 Calma seriously overstated the evidence we have to date, which consists of two studies from Utopia in central Australia and one study of land management practices in an Arnhem Land community.6-8 Although this research is encouraging, we are a long way from determining the causes of better health among sections of those two communities, and whether residence at outstations/homelands or land management practices are associated with better health in other communities as well. There are many reasons for supporting the growth of outstations, and health may be one of them, but it is crucial that those in the field of Indigenous health get this right. Rather than jumping the gun, we need more research into the effects of outstation life on health and wellbeing.

Emma E Kowal

To the Editor: In an article about Indigenous mortality in the Northern Territory, Andreasyan and Hoy1 concluded that Indigenous residents in very remote areas (VRAs) had a better health status than those in remote areas (RAs) and outer regional areas (ORAs). This result is inconsistent with previous reports and prompted us to examine the authors’ outcome. A central problem with the authors’ analysis lies in the identification of “usual residence” for death registration. The usual residence is defined by the Australian Bureau of Statistics as the dwelling at which a person spends or intends to spend 6 months or more in the year in which the question is asked.2 This definition limits its usefulness for the authors’ purpose, but is further compromised by the common practice by certifying doctors of simply using the last known address as a proxy for usual residence. In either case, the address recorded at death registration may differ from the location where a person lived for the majority of his or her life. The latter is the location more closely associated with health risks, particularly for chronic disease. As a test, we investigated changes of residence for all NT public hospital inpatients who died within a 7-year period by linking multiple hospitalisations between 1 January 2001 and 31 December 2007. We found that 26% of inpatients classified as residents of RAs at the time of death were previously usual residents of VRAs. This “unhealthy migrant” effect can be readily recognised as people relocate due to illness from VRAs, which have limited health services, to RAs or ORAs to access secondary and tertiary health care. The likelihood of inconsistent classification of usual residence in mortality data can also be tested demographically. Assuming the authors’ mortality ratios were correct for a stable population, we estimate that the Indigenous life expectancy at birth in VRAs would be 72.3 years, or 23 years longer than the life expectancy at birth in RAs (49.1 years). Such a large discrepancy is implausible. The age structure of a stable population is determined by fertility and mortality,3 and reported NT Indigenous fertility rates show a lack of substantial variation across regions.4 If the life expectancy at birth in VRAs was significantly longer than the life expectancy in RAs, VRAs would have about five times more elderly people (aged over 75 years) than the current estimates.5 The mobility of residence shown by hospital data and the absence of a substantial elderly population in VRAs suggest that the reported differential mortality rates between VRAs and RAs are the result of misidentification of “usual residence”.

Yuejen Zhao · Steve Guthridge · Shu Q Li · Christine Connors

In reply: We thank Zhao and colleagues for their interest in our study.1 The main issue they raise is misclassification of deaths by remoteness of residence. In our article, we acknowledged the role of migration to larger urban centres to access health services and raised the issue of unhealthy lifestyle and its flow-on effects on mortality. If we were to assume that 26% of deaths in hospital in remote areas were deaths of people who previously lived in very remote areas (as Zhao and colleagues suggest), regional variation in the disparity between Indigenous and total Australian all-cause mortality would narrow but would still remain. A re-analysis of our data based on this assumption1 shows that standardised mortality ratios in remote areas would drop from 875% (95% CI, 799%–956%) to 646% (95% CI, 582%–717%) in 1998–2000 and from 731% (95% CI, 665%–801%) to 540% (95% CI, 484%–601%) in 2001–2003. In very remote areas, the standardised mortality ratios would increase from 214% (95% CI, 193%–236%) to 281% (95% CI, 258%–306%) in 1998–2000 and from 208% (95% CI, 189%–228%) to 264% (95% CI, 242%–286%) in 2001–2003. Furthermore, in our article we stressed the importance of examining Indigenous migration to enable more accurate interpretation of our findings and called for future studies to “clarify the reasons for these differences in mortality by remoteness, with a particular focus on migration”. Our studies of Queensland data and national data (unpublished) have shown a similar pattern of higher Indigenous mortality in remote areas than in very remote areas, but the difference in mortality rates between these areas is highest in the Northern Territory. Thus, the phenomenon of the “methodological” error applies to all of these studies. We propose to undertake a prospective study of Indigenous mortality that will overcome some study design problems inherent in a cross-sectional study.

Karen Andreasyan · Wendy E Hoy

To the Editor: We commend the Indigenous Health issue of the Journal (18 May 2009). Its editorial emphasis — that partnerships with and continued leadership by Aboriginal and Torres Strait Islander peoples will be key to closing the gap between Indigenous and non-Indigenous Australians1 — is supported by preliminary, unpublished findings from our research into improving mainstream general practice care of Indigenous patients. Couzos and Thiele emphasised that closing the gap in health and life expectancy between Indigenous and non-Indigenous Australians depends on Aboriginal community controlled health services (ACCHSs).2 By virtue of their governance structure and focus, these services deliver culturally safe and appropriate primary health care to Indigenous Australians, while addressing issues of Indigenous autonomy and other social determinants of health.2 However, although not all general practices see Indigenous patients, 0.9% of general practice encounters (range, 0.7%–1.6%) are with Indigenous patients, equating to about one million consultations a year. Indigenous Australians present to general practitioners with essentially the same range of clinical conditions as do non-Indigenous Australians, although consultation rates for diabetes and circulatory conditions are higher for Indigenous patients.3 Most Indigenous Australians (76%) live in urban and regional areas, and are widely spread through the general population. They are likely to need mainstream services including general practice and primary care services, at least some of the time and for the foreseeable future. There is clearly a need for initiatives beyond support for ACCHSs, Indigenous workers and communities, to improve mainstream services for Indigenous Australians in a culturally sensitive and appropriate manner.4 Better sociocultural education for health care providers, trainees and students is required to close the gap that exists in mainstream understanding and acceptance of Indigenous cultures and aspirations. The Inala Indigenous Health Service in Brisbane is an example of a mainstream practice successfully developing into an accessible service.5 Our research aims to improve mainstream general practice care for Indigenous Australians with diabetes who live in urban areas of Victoria. As the following statement made by Indigenous participants in focus groups for our research indicated, health services must be patient-centred: We need to hold the health system — and that includes GPs — accountable for delivering help to Aboriginal people. The best one to do that is the consumer. Focus group participants also highlighted the importance of working together: I think we need to take some responsibility ourselves as (Indigenous) workers in organisations and go to these mainstream services. Whether it’s diabetes or drugs and alcohol, we need to say look, you get funded to look after everybody, and we want to come here and tell you how to look after our people when they come to your centres.

Siaw-Teng Liaw

In reply: It is unclear how many mainstream general practice consultations involve Aboriginal and Torres Strait Islander patients. Of 485 300 patient encounters attributed to general practices in the BEACH study (2003–2008), 7292 were with Indigenous patients, but 2906 of these encounters took place in Aboriginal community controlled health services (ACCHSs) rather than in general practices.1 If funding to close the gap in Aboriginal disadvantage is being channelled to general practice and the Divisions of General Practice (through recent measures of the Council of Australian Governments), then the Indigenous health outcomes of mainstream services must be carefully attributed.2 The ACCHS sector agrees there is a need to make general practices culturally secure for Indigenous Australians. For example, the Aboriginal Health Council of Western Australia has developed modules for cultural safety training, which are accredited by the Royal Australian College of General Practitioners for GPs’ professional development.3 The National Health and Hospitals Reform Commission report recommends that health services be required, by accreditation processes, to meet specific standards of cultural safety for Indigenous patients to ensure high-quality care.4 Within a quality assurance framework, systematic reforms such as these can potentially improve mainstream services, while supporting Indigenous workers who face unrealistic pressures to improve their local services. As Liaw points out, these initiatives are in addition to the vital role of ACCHSs in closing the health disparity gap.

Sophie Couzos · Dea D Thiele

Incorrect graph and wording: In “Avoidable hospitalisation in Aboriginal and non-Aboriginal people in the Northern Territory” in the 18 May 2009 issue of the Journal (Med J Aust 2009; 190: 532-536), there was an error in Box 4 (Li et al). In the panels headed “25–44 years” and “45 years and over”, the lines representing Aboriginal and non-Aboriginal rates were transposed. The correct version of Box 4 appears here. In addition, in the second paragraph of the results section, the wording was potentially misleading. The paragraph should have read: “Although total average avoidable hospitalisation rates were higher in Aboriginal than non-Aboriginal people in the NT, the largest differences were observed in the age groups 25–44 and 45–64 years (Box 1).” 4 Trends in age-adjusted, avoidable hospitalisation rates by Aboriginality and age group, Northern Territory, 1998–99 to 2005–06

Shu Q Li MPH, MB, BNursing · Natalie J Gray MIPH(Hons), MB BS(Hons), BSc/LLB(Hons) · Steve L Guthridge MB BS, MPH, FAFPHM · Sabine L M Pircher MPH, BNutrDiet

Otitis media in Australia, particularly among Indigenous children, has not received the attention that other less common but more emotive diseases attract. However, this condition, with its significant impact on hearing, language development and learning in the vulnerable early childhood years, has been commented on since early European settlement in Australia.1 The end result of recurrent acute otitis media — chronic suppurative otitis media — is uncommon in most developed countries, but Indigenous Australian children account for the highest prevalence of chronic suppurative otitis media in the world (70% in some remote communities). The World Health Organization regards a prevalence of chronic suppurative otitis media of over 4% in a defined population of children as a massive public health problem requiring urgent attention.2 John Ah Kit, Minister for Community Development from the Northern Territory, described the situation of Indigenous children as A spiral of being ill before birth, of being poorly fed in childhood, of being deaf at school. Of a life without work that would be cut short by a litany of disease and violence.3 What has happened in the 13 intervening years since the last Medical Journal of Australia supplement on otitis media was published?4 In some areas (described further in this supplement), our understanding of pathogenesis, new concepts of biofilm and intracellular infection, and the importance of nasopharyngeal carriage, we have progressed significantly. Likewise, new research — into the genetics of recurrent acute otitis media, the immunological responses of children to these infections, and the impact of antibacterial vaccines — is contributing to our knowledge about this condition. New social and medical interventions, such as the swimming pool project,5 building new housing, and the controversial Northern Territory Intervention, with new guidelines on the use of antibiotics in otitis media and its sequelae in children, have been partially successful in ameliorating the burden of otitis media in Indigenous (and non-Indigenous) children.6 Yet, in this time of financial constraint, the necessary programs to implement change in the fundamental and underlying causes of otitis media and its complications are not being provided. Chronic suppurative otitis media is a disease of poverty, and without actions to lessen overcrowding and provide appropriate housing and water supply, education of parents and adequate access to medical care, progress to improvement will be slow.7 In addition, throughout urban, rural and remote Australia, we must increase awareness about otitis media, and the ramifications of neglect of this silent epidemic, among parents, teachers, community leaders, and health workers. We must train more Aboriginal health workers specialising in ear conditions (and possibly also eye conditions and dental health), perhaps with support from ear nurse specialists (this has been very successful in the government-funded Variety Club ear buses program in New Zealand), and ensure there is an adequate workforce of audiologists, speech pathologists and teachers of the deaf to provide the necessary ancillary support services for children with impaired hearing and speech delays. The recent publication The cost burden of otitis media in Australia brings to light the pervasive nature and community costs of otitis media and its sequelae. Admission for insertion of grommets is the second major cause of surgical admission to hospital in Australia for children. Over 650 000 Australians had otitis media in 2008; 9.9% of these were Indigenous. For 2008, the estimated health system costs of otitis media range from $85.6 million to $163.2 million, and the net cost of lost wellbeing due to otitis media is estimated at between $1.05 billion and $2.6 billion.8 So where to next? Governments must advocate for otitis media prevention programs, improve living standards for socially disadvantaged families, ensure adequate medical and paramedical resources, and continue to fund basic and outcomes-based research into otitis media. As otitis media is, in part, a vaccine-preventable disease, attention to considering the newer vaccines available for invasive and otitis media infections in children for the immunisation schedule should be a priority.

Harvey L C Coates AO, MS, FRACS

Otitis media remains a major health problem in Australia, with an unacceptably great dichotomy of incidence and severity of otitis media and its complications between Indigenous and non-Indigenous Australians. Among most children with acute otitis media, infection resolves rapidly with or without antibiotics, with ongoing middle ear effusion the only sequela. Overcrowding, poor living conditions, exposure to cigarette smoke, and lack of access to medical care are all major risk factors for otitis media. Estimates of the number of cases of otitis media in 2008 vary between 992 000 and 2 430 000 Australians, with a total estimated cost of $100 – $400 million.

Kelvin Kong BSc, MB BS, FRACS · Harvey L C Coates AO, MS, FRACS

Otitis media typically presents as either acute otitis media (AOM), with symptoms including fever, otalgia, otorrhoea or irritability and short duration; or as otitis media with effusion (OME), which is often asymptomatic and characterised by accumulation of fluid in the middle ear. Diagnostic certainty of otitis media is challenging, given the young age of patients and variability of symptoms. Otitis media predominantly occurs as coincident to viral upper respiratory tract infections and/or bacterial infections. Common viruses that cause upper respiratory tract infection are frequently associated with AOM and new-onset OME. These include respiratory syncytial virus, rhinovirus, adenovirus, parainfluenza and coronavirus. Predominant bacteria that cause otitis media are Streptococcus pneumoniae, Moraxella catarrhalis, and non-typeable Haemophilus influenzae. Antibiotic therapy does not significantly benefit most patients with AOM, but long-term prophylactic antibiotic therapy can reduce the risk of otitis media recurrence among children at high risk. In Australia, 84% of AOM is treated with antibiotic therapy, which contributes to development of antibiotic resistance. Vaccine development is a key future direction for reducing the world burden of otitis media, but requires polymicrobial formulation and ongoing monitoring and modification to ensure sustained reduction in disease burden.

Helen M Massa PhD · Allan W Cripps PhD · Deborah Lehmann MB BS, MSc

Otitis media is a common childhood illness associated with hearing loss, social disadvantage and medical costs. Prevalence and severity are high among Indigenous children. Respiratory bacterial and viral pathogens ascend the eustachian tube from the nasopharynx to the middle ear, causing inflammation, fluid accumulation, and bulging of the tympanic membrane, with or without pain. Among Australian Indigenous children, ear disease commences earlier in life, and involves multiple strains of bacterial pathogens at high density that persist longer. Persistent nasal discharge, overcrowded living conditions (particularly exposure to many children) and poor facilities for washing children perpetuate a vicious cycle of transmission and infection. Risk factors include environmental tobacco smoke, season, lack of breastfeeding, younger age and immature immune system, and possibly genetic factors. The innate immune system is a critical first response to infection, particularly as passive maternal antibodies decline and during the maturation of the infant adaptive immune response. The relative contributions of innate factors to protection from otitis media are currently not well understood. A diversity of antibodies that target strain-specific and conserved antigens are generated in response to natural exposure to otitis media pathogens (or to vaccines). Deficiencies in these antibodies may explain susceptibility to recurrent infections. Incremental contributions from all these elements are likely to be important in otitis media susceptibility versus protection. Effective medical and social strategies to prevent early age of onset are urgently needed.

Selma P Wiertsema PhD · Amanda J Leach PhD

Acute otitis media (AOM) is diagnosed on the basis of acute onset of pain and fever; a red, bulging tympanic membrane; and middle ear effusion. AOM is managed with analgesia (paracetamol or non-steroidal anti-inflammatory drugs). Antibiotic therapy is minimally effective for most patients; it is most effective for children < 2 years with bilateral otitis media and for children with discharging ears. National guidelines recommend antibiotic therapy for Indigenous children with AOM. Evidence for corticosteroids, topical analgesia and xylitol are scant. Otitis media with effusion (OME) is diagnosed as the presence of middle ear effusion (type B tympanogram or immobile tympanic membrane on pneumatic otoscopy) without AOM criteria. Well children with OME with no speech and language delays can be observed for the first 3 months; perform audiological evaluation and refer to an ear, nose and throat (ENT) specialist if they have bilateral hearing impairment > 30 dB or persistent effusion. Children with effusions persisting longer than 3 months can benefit from a 2–4-week course of amoxycillin. Chronic suppurative otitis media is a chronic discharge through a tympanic membrane perforation. It is managed with regular ear cleaning (dry mopping or povidone–iodine [Betadine] washouts) until discharge resolves; topical ear drops (eg, ciprofloxacin); audiological evaluation; and ENT review.

Hasantha Gunasekera DCH, FRACP, MIPH(Hons) · Tony E O’Connor AFRCSI, FRCS(ORL-HNS) · Shyan Vijayasekaran MB BS, FRACS · Christopher B Del Mar MD, FRACGP

In Australia, three to five children die each year because of otitis media complications, and 15 children will suffer permanent hearing loss each year as a result of otitis media. Extracranial complications occur most commonly, and include mastoiditis, cholesteatoma and otitis media with perforation. Intracranial complications are less common, and include meningitis, brain abscess and lateral sinus thrombosis. In Australia, approximately 60% of extracranial and intracranial complications of otitis media occur in children. The contrasting rates of childhood otitis media among Indigenous and non-Indigenous children have implications for the frequency and types of complications occurring in both groups. Otitis media with effusion and acute otitis media predominate among non-Indigenous children, whereas chronic suppurative otitis media (CSOM) occurs most commonly among Indigenous children. The incidence of mastoiditis in Australia is low by international standards (2/100 000 children), but cholesteatoma rates among Indigenous children in Australia are higher than previously estimated (up to 10% in CSOM). A high rate of chronic tympanic membrane perforation occurs among Indigenous children, estimated to be as high as 80%. Intracranial complications of otitis media are uncommon, but are potentially life-threatening and are more likely to occur among Indigenous than non-Indigenous children. Reduced access to medical care, lower socioeconomic status and remote living conditions mean that levels of early childhood hearing loss among Indigenous children are likely to be underestimated. This has implications for early childhood speech and language development and education.

Tony E O’Connor AFRCSI, FRCS(ORL-HNS) · Christopher F Perry MB BS, DTM · Francis J Lannigan MD, FRCS(ORL)(Ed), FRACS

Otitis media with effusion and recurrent acute otitis media are ubiquitous among Indigenous children. Otitis media causes conductive hearing loss that may persist throughout early childhood and adversely affect social interactions, language acquisition and learning. Control of otitis media usually restores hearing to adequate levels. Surgery is to be considered when otitis media has not responded to medical treatment. In non-Indigenous populations, tympanostomy tubes (“grommets”), with or without adenoidectomy, can control otitis media; how these findings relate to Indigenous Australians is not known. Tympanic membrane perforation is a frequent sequela of early childhood otitis media among Indigenous children. It occurs as early as 12 months of age and causes conductive hearing loss. Perforation is associated with recurrent aural discharge, particularly in the tropics and in desert regions. Medical and public health management is required until a child is old enough to undergo surgical closure of the perforation, usually by an age of 7–10 years. Surgical closure of the tympanic membrane stops the aural discharge and improves the hearing sufficiently to avoid the need for hearing aids in most cases. The success rate of surgery conducted in rural and remote Australia is below urban benchmarks; improving this will probably require funding for community-based follow-up.

Stephen J O’Leary BMedSc, PhD, FRACS · Ross D Triolo BSc(MedSci), MB BS

Otitis media is a common disease in childhood that can adversely affect cognitive and educational outcomes. The literature in this area is equivocal, and findings may be influenced by research design. The impact of otitis media on individual children’s development appears to depend on the inter-relationship between several factors. Children who have early-onset otitis media (under 12 months) are at high risk of developing long-term speech and language problems. Otitis media has been found to interact negatively with pre-existing cognitive or language problems. For biological or environmental reasons, some populations have a pattern of early onset, higher prevalence and episodes of longer duration; this pattern leads to a higher risk of long-term speech and language problems. These factors suggest that Indigenous children may be at higher risk of cognitive and educational sequelae than non-Indigenous children.

Corinne J Williams PhD · Ann M Jacobs BAppSc(Speech and Hearing)

Objective: To identify individual and household factors associated with violence among Australian Indigenous women with dependent children.Design and participants: Univariate and multivariable analysis of data from the 2002 National Aboriginal and Torres Strait Islander Social Survey, stratified by area.Main outcome measure: Self-reported experience of being a victim of violence in the previous year.Results: One in four Indigenous women living with dependent children younger than 15 years reported being victims of violence in the previous year; this corresponds to an estimated 24 221 Indigenous mothers (95% CI, 21 507–26 935) nationwide. Violence was more prevalent in regional areas and cities than remote areas. In remote areas, mothers who had been removed from their natural families during childhood had nearly threefold greater odds of being victims of violence (odds ratio [OR], 2.90; 95% CI, 1.82–4.61); in non-remote areas, the odds were 72% greater (OR, 1.72; 95% CI, 1.23–2.39). Older maternal age (≥ 45 years) was associated with lower odds of experiencing violence in both non-remote areas (OR, 0.39; 95% CI, 0.25–0.60) and remote areas (OR, 0.46; 95% CI, 0.30–0.70). Women with partners residing in the household faced lower odds of violence in both non-remote areas (OR, 0.54; 95% CI, 0.41–0.72) and remote areas (OR, 0.46; 95% CI, 0.32–0.67).Conclusions: The prevalence of violence against Indigenous mothers with young children is alarmingly high across remote and non-remote areas. This study identified distinctive characteristics of victims, but further research is needed to assess potential risk factors, such as history of removal from natural family.

Kyllie Cripps BA(Hons), PhD · Catherine M Bennett PhD, MAppEpid · Lyle C Gurrin PhD · David M Studdert LLB, ScD

Otitis media affects nearly all children worldwide. Despite an enormous amount of research, our understanding of this common condition continues to be challenged. New pathogens involved in otitis media are still being identified. The importance of interactions between viral and bacterial infection and the role of new vaccines need to be clarified. The proposal that bacteria can become more resistant to therapy through biofilm formation and intracellular infection could have important implications for treatment. The most important clinical research findings have been summarised in systematic reviews. In developed countries, research supporting “watchful waiting” of otitis media with effusion and acute otitis media have had most impact on evidence-based clinical practice guidelines. Indigenous Australian children remain at risk of more severe otitis media. Research programs targeting this population have been well supported. Unfortunately, interventions that can dramatically improve outcomes have remained elusive. For children at high risk of otitis media, health care services should concentrate on accurate diagnosis, antibiotic treatment of suppurative infections, and scheduled follow-up of affected children. Despite the lack of recent studies, strategies to minimise the impact the hearing loss associated with otitis media are important. Improvements in education, hygiene practices, and living conditions are likely to reduce the incidence and severity of otitis media. Studies of these types of interventions are needed.

Peter S Morris MB BS, FRACP, PhD · Peter Richmond MB BS, FRACP · Deborah Lehmann MB BS, MSc · Amanda J Leach MAgSci, PhD · Hasantha Gunasekera DCH, FRACP, MIPH(Hons) · Harvey L C Coates AO, MS, FRACS

Objective: To describe a prolonged outbreak of mumps in the Kimberley region of Western Australia in 2007–2008.Design: Descriptive analysis of all mumps cases notified to the WA Notifiable Infectious Diseases Database for the period 1 July 2007 to 30 June 2008.Main outcome measures: Notified cases of mumps by patients’ place of residence, age, Indigenous or non-Indigenous ethnicity, vaccination status and method of diagnosis.Results: 84% (153/183) of mumps notifications in WA over the study period occurred in the Kimberley region or were directly linked to Kimberley cases. Median age of patients was 18 years (range, 2–63 years), and 54% of patients were aged less than 20 years. Almost all (92%) were Australian Aboriginal people; 67% (102/153) had received at least one dose of mumps vaccine, and 52% had received two doses. The highest notification rate (1816 cases per 100 000 population) was in the Aboriginal 15–19-years age group, and 92% of these patients had received at least one dose of mumps vaccine. Almost all outbreak cases (94%) were laboratory confirmed. Genotyping was performed on 20 mumps virus isolates: all were genotype J.Conclusion: A prolonged outbreak of mumps occurred in a well defined, highly vaccinated, predominantly young Aboriginal population in the remote Kimberley region of WA. This outbreak raises questions about the effectiveness and scheduling of the current vaccine (which is genotype A-derived), especially for Aboriginal people. Surveillance of circulating mumps virus genotypes and neutralisation studies will help in evaluating the protection provided by the current vaccine against genotypically different strains.

Revle D Bangor-Jones MB BCh, MRCGP, MPH · Gary K Dowse BMedSc(Hons), MSc, FAFPHM · Carolien M Giele BSc(Hons), MPH, GradDipClinEpi · Paul G van Buynder MB BS, MPH, FAFPHM · Meredith M Hodge MB BS, MPHTM, FRACP · Mary M Whitty RN, RM, ChildHlthCert

I am an Aboriginal Kuku Yalanjii and Birri Gubba man. My Yalanjii people are from north of Mareeba, near Cairns, and my Birri Gubba connection is in Proserpine, right next to the beautiful Whitsunday Islands. My family grew up in Inala, on the outskirts of Brisbane, where we have lived for over 25 years. I come from a family of eight children. My mother is from Woorabinda and my father is from Proserpine and they are both Aboriginal. I have always heard about Aboriginal and Torres Strait Islander men having heart attacks at a young age and in higher proportions than non-Indigenous men. I have lost a number of uncles from heart disease, through not eating right, hereditary factors, high alcohol consumption and lack of exercise. In terms of my own health, I thought I was fine because I was always physically active, playing rugby league and touch football and being very involved in the community. I would never have believed it possible that at 34 years of age I could suffer a heart attack. I am sharing this story with other Aboriginal and Torres Strait Islander people around Australia in the hope that it will make some kind of impact on their lives. My story demonstrates how working in the Aboriginal and Torres Strait Islander community can have both a positive and a negative impact on yourself, your family and your community. I started working in the Inala Indigenous Health Service in 2001 as a research assistant and then moved to the role of community health worker. Before this, I’d had no experience in the areas of health or education. The main experience I’d had in community work was as a youth worker with the Queensland Department of Family, Youth and Community Care and as a teacher aide at the Glenala State High School. I’d also had experience as a volunteer coach of a Junior Rugby League side at Inala that has a high proportion of young Aboriginal and Torres Strait Islander people, parents and families involved. Working in the service gave me valuable experience under the guidance of our Aboriginal doctor Noel Hayman and Aboriginal nurse manager Nola White. Together, they gave me the confidence to undertake a Bachelor of Applied Health Science in Indigenous Primary Health Care at the University of Queensland in Brisbane. It took me 5 years to complete the course, while simultaneously juggling commitments to my family, community and employer. All I ever wanted to do was give back to the community that I grew up in, and working at the Inala Indigenous Health Service has given me that opportunity. In the 8 years I have worked at the Health Service, I have been involved in all areas of Indigenous health, including hearing health; drugs and alcohol; health status research; mental health; nutrition; counselling; transport; Indigenous leadership; youth issues; youth and adults incarceration; and health promotion. A major role I shared with my mentor Matilda Bani (Indigenous Service Officer with Centrelink) was coordination of the Inala Aboriginal and Torres Strait Islander Interagency Forum. This forum, which has been going for over 12 years, promotes information-sharing between departments and other agencies working with the Inala Aboriginal and Torres Strait Islander community. Shared Responsibility Agreement: making a differencePerhaps one of the biggest achievements in my life (besides having children) was being involved in establishing a Shared Responsibility Agreement (SRA) between my community and the federal government in 2006 (Box 1). The central aim of the SRA was to improve the health and wellbeing of Aboriginal and Torres Strait Islander men in our community via their engagement in rugby league. Rugby league has been an institution within our community, particularly among Aboriginal and Islander boys and men. For 5 years prior to the SRA, there was no opportunity for men in Inala to play rugby league, due to a lack of activities and sporting programs for Aboriginal and Torres Strait Islander men, and few Aboriginal and Torres Strait Islander men were likely to go outside the community to play rugby league. Without football in the community, few men played sport, and this contributed to many problems such as boredom, poor health, low self-esteem, and high intake of drugs and alcohol — all of which can lead to incarceration. Through conversations with the federal government, I developed a proposal to get a group of respected Aboriginal and Torres Strait Islander men to look at ways of getting our brothers involved in sport, employment and healthy living for themselves and their families. The federal government agreed to fund two open rugby league sides at Inala, on the condition that men in the community participated in health, employment, education and mentoring opportunities within the community. My role as the Community Health Worker was to encourage Aboriginal and Torres Strait Islander men to come to the Inala Indigenous Health Service for adult health assessments, and to participate in other health promotion activities such as the Inala Indigenous Health Calendar (Box 2) and workshops on nutrition and physical activity. The men were also enlisted to participate in mentoring activities, such as coaching, refereeing, volunteering with junior teams, participating in local training and employment initiatives (if they were unemployed), promoting healthy lifestyles, and demonstrating positive behaviour on the sporting field and in the community. Through this process, many local men also participated in training that saw them become qualified referees, coaches and first aid officers. Since being involved with the SRA in Inala, I have seen some great success stories. Seeing other young Aboriginal and Torres Strait Islander men putting their hand up to be involved in rugby league as coaches, referees, first aid officers and volunteers at the club has really built the self-confidence of men in our community. The pressures of community work, family and volunteering: my healthDuring this time, I was so passionate about my work that I forgot who I was. I was doing this as part of my role as Community Health Worker, but was also a volunteer. I was so busy taking care of everyone else that I forgot to take care of myself. I was at the club nearly 7 days a week with the junior and senior teams, feeling constantly stressed, spending a lot of time away from my family, and not taking time out for myself. Because I was always on the go, I was not eating healthily. I just wanted the SRA to succeed and be sustainable, so that Inala Aboriginal and Torres Strait Islander men could be strong, self-reliant, and able to source other avenues such as sponsorship and fundraising. I was also a rugby league player at the time, so I was heavily involved in the game, both on and off the field. Rugby league has always been my passion and, although I would go to games to help with strapping and make sure everything was taken care of, I would often jump on the field and play if the team were short of players. It was towards the end of the 2008 season that I put on the jersey for Inala, like so many times before. But during this particular game, I started experiencing dizziness, came off the field and collapsed. Although I didn’t know it at the time, I had just had a heart attack. Fortunately, the coach of the team (one of my closest friends and a participant in a first aid course delivered under the SRA) and the registered first aid officer kept me alive until an ambulance arrived. It was only their quick actions that saved my life. All I remember is drinking a sports drink and then waking up in the ambulance. When I asked the ambulance officer if I had been knocked out on the field, he told me I’d had a cardiac arrest and said that, if it wasn’t for the coach and first aid officer, I wouldn’t be alive. Since then, I have had three operations on my heart and am now fitted with a defibrillator in my chest in case a similar episode happens again. At 34 years of age, I am very lucky to be alive, and to this day I feel enormous gratitude to the coach and first aid officer to whom I owe my life. There is an irony in the fact that the very thing that caused so much stress in my life was also the very thing that led to my life being saved. My illness also made a big impact on the Inala Aboriginal and Torres Strait Islander community in the south of Brisbane. There has been an increase in the number of people attending the Inala Indigenous Health Service, and the number of health checks has doubled. Many Aboriginal and Torres Strait Islander people aged 35 years and over are now attending the health service. I’m glad that some good has come out of my heart attack, not only for me and my family, but also for the community as a whole. It has changed my life dramatically — I thought I was OK, and then all of a sudden my whole life was turned upside down. Lessons I have learntAfter having all the operations and undergoing mainstream cardiac rehabilitation at a hospital in Brisbane, I started to get my confidence up with doing exercise such as walking and playing tennis and doing things around the house with my family. Back at work a month after having surgery, I am slowly easing my way back into work, eating more healthily, and getting lectures from family and community members about taking it easy in the community. I am doing OK now and just taking life one day at a time. I am grateful to everyone for their support — my family, my work colleagues and my community. There is much good that is happening, and Inala is continuing to grow and develop into a really great community. After all the operations and cardiac rehabilitation, I decided to get married to my lovely partner of many years. I put the pain behind me to set up a new chapter in the lives of me and my family. At times I don’t think about the heart attack, I just think every day what I can do to get my kids out of the house and do something active. My family is my life, my community is my strength, and my work keeps me active. I share my story with people who are reluctant to go for a heart operation and encourage them to have it done so they will be able to live longer and see their children and grandchildren grow up. Today I am enrolled in a Master of Philosophy by research at the University of Queensland, while working as a research fellow with the Inala Indigenous Health Service and at the George Institute for International Health in Sydney. This will broaden my role in my line of work and will enhance my capacity to be a good role model and mentor for my community. I feel very passionate about working in Indigenous health, especially in the field of heart disease, kidney disease and diabetes, with the support of the Inala Indigenous Health Service and the George Institute’s Kanyini program. Rugby league is continuing to thrive in Inala with the keen involvement of other Aboriginal and Torres Strait Islander men in the community. They have been playing the game for 3 years now without any funding assistance from the federal government. They won a grand final in 2007, were runners-up in 2008 (Box 3), and are very actively involved in community events and the junior club. I am slowly working my way back into the community, having learnt some valuable lessons from this journey — in particular, the need to balance my family commitments, work and volunteering. I have taken a big step back from being involved in the community in a voluntary capacity. Inala is going forward in a very positive way, and members of the next generation are putting up their hand to give back to the community that has supported them. 1 Some of the people involved in our Shared Responsibility Agreement Left to right: John Brady, Tricia Button (State Manager, Indigenous Coordination Centre), Mal Brough (former Minister for Families, Community Services and Indigenous Affairs), Robert Duncan (Junior Club President). 2 Health messages from the Inala Indigenous Health Calendar 3 Inala rugby league team members and young supporters

John P Brady BAppHlthSc