Indigenous health

To the Editor: Until recently, detection of locally acquired tox gene carrying diphtheria in Australia was rare. Toxigenic diphtheria had almost disappeared from the Australian landscape, with the widespread uptake of the diphtheria toxoid vaccine. Diphtheria is predominantly caused by toxigenic Corynebacterium diphtheriae and can present as both respiratory and cutaneous diphtheria disease. There have been increasing reports internationally of diphtheria outbreaks primarily in vulnerable migrant populations.1 In Australia, there were 46 diphtheria cases between 1999 and 2019 (eight respiratory diphtheria and 38 cutaneous), with C. diphtheriae accounting for 87% of these cases.2 Since 2020, a genomically linked clone of tox gene carrying diphtheria bacteria has spread across North Queensland. Cases described here are from the Queensland Health's Notifiable Conditions Register. The Townsville Hospital and Health Service Human Research and Ethics Committee provided an ethics exemption (EX/2022/HREC/88895) for this study. Of the 29 linked cases identified between 2020 and 2022, all have had epidemiological links to North Queensland and 23 were notified in 2022. Three of these cases were detected interstate. Clinically, three cases presented with classic diphtheria, four with mild respiratory diphtheria, and 22 with cutaneous diphtheria. The median age was 21 years (range, 2–59 years). Of the 29 cases, 34% (10/29) were aged 11–20 years and 45% (13/29) were older than 20 years. Further, 38% of cases (11/29) were fully vaccinated, 48% (14/29) were partially vaccinated and 10% (3/29), including two of the classic diphtheria cases, were unvaccinated for their age according to the National Immunisation Program Schedule. All were acquired in Australia, and 86% of patients (25/29) identified as Aboriginal and/or Torres Strait Islander. Isolates in the cluster are closely genomically linked, with between zero and 20 single nucleotide polymorphism differences found on whole genome sequencing. All cases were managed with penicillin or azithromycin, vaccination, and diphtheria antitoxin administered when deemed appropriate by infectious disease physician assessment. Azithromycin was given in most cases, as higher minimum inhibitory concentrations to penicillin have been observed with this clone. Household contacts were screened for symptoms, administered chemoprophylaxis with penicillin or azithromycin, and offered a diphtheria‐containing vaccine if due. A North Queensland public health working group has recently been established to develop a consensus on further public health management. This diphtheria outbreak, almost exclusively in Aboriginal and Torres Strait Islander communities, highlights the continuing impact of social determinants on disease in vulnerable populations. We recommend clinicians be aware of these cases and consider diphtheria among their differentials in patients from, or who recently travelled to, North Queensland. Classic diphtheria is characterised by a sore throat, fever, and membrane on the back of the throat, which may cause difficulty in breathing and swallowing. Cutaneous diphtheria usually presents as a non‐healing ulcerative lesion.2 The toxoid vaccine protects against the toxin effects rather than the infection itself. Unvaccinated individuals are therefore at highest risk of severe disease, including classic diphtheria, myocarditis, and neuropathies. Vaccination remains imperative and timely vaccinations are essential. The National Immunisation Program Schedule currently recommends a diphtheria‐containing vaccine for children at two, four, six and 18 months, and four years, and adolescents at 11–13 years. A diphtheria‐containing vaccine booster is recommended for adults at 50 years.3 Clinicians across the state and nation should be vigilant for future cases.

Allison Hempenstall · Jay Short · Tonia Marquardt · Valmay Fisher · Janice Johnson

System-wide racial discrimination and inequitable access to justice impedes Indigenous rights to health and wellbeing

Pat Dudgeon · Abigail Bray · Roz Walker

Indigenous-specific mobile clinics improve access to health care by delivering care to underserviced communities

Deborah A Askew · Ethan Kettyle · Kim Passante · Tamika Campbell · Maree R Toombs

An important aim after critically ill Indigenous people return home is to avoid the need for re-admission to hospital

Dianne P Stephens

When will we see Indigenous Australians move from being the examined to being the examiners?

Candice McKenzie · Lilon G Bandler

Queensland’s approach to Indigenous health equity planning and implementation should align with existing international frameworks

Maree R Toombs · Caitlin Curtis · Claire E Brolan

Elimination programs should be guided by the prevalence of markers of infection, not of disease

Jaki Adams · Sung Hye Kim · Anthony W Solomon

The unacceptably high prevalence among Indigenous people and people who need dialysis warrants a clinical trial of prophylactic antibiotics

Katherine Gibney · Andrew Steer

After adjusting for age and other factors, survival outcomes are poorer for Indigenous than non-Indigenous people admitted to ICUs

Paul J Secombe · Alex Brown · Michael J Bailey · Sue Huckson · Shaila Chavan · Edward Litton · David Pilcher

Barriers that limit the oversight of and participation of Indigenous people in Indigenous health research should be overcome

Luke J Burchill · Aneta Kotevski · Daniel LM Duke · Jeanette E Ward · Megan Prictor · Karen E Lamb · Michelle Kennedy

An intersectoral response to improving the social determinants of skin health is needed, particularly in remote communities

Johanna M Birrell · Rowena Boyd · Bart J Currie · Nicholas M Anstey · Asanga Abeyaratne · Sandawana William Majoni · Vicki L Krause

Assessing progress to trachoma elimination in Australia and elsewhere should therefore incorporate laboratory testing

Kathleen D Lynch · Wendy Morotti · Garry Brian · Lenore Ketchup · Kozue Kingston · Mitchell Starr · Robert S Ware · Beth Everill · Nazihah Asgar · Anne O'Keefe · Lisa J Whop · John M Kaldor · Stephen B Lambert

To the Editor: Zhao and colleagues1 recently published an article highlighting the improved life expectancy for Aboriginal and Torres Strait Islander men in the Northern Territory over the past 20years.1 This is both important and welcomed. It reflects consistent and concerted work of countless individuals and organisations that are contributing to the improved health and wellbeing of Aboriginal and Torres Strait Islander men in the NT, despite limited resources to do so. It makes sense that we are beginning, albeit slowly, to see these inroads. One example of contributing to the positive outcomes for Aboriginal and Torres Strait Islander men’s health in the NT is the evolution of the Darwin Men’s Inter‐Agency Network (DMIAN). DMIAN is a network of men from across government and the non‐government organisation sector to collaboratively advocate for Aboriginal and Torres Strait Islander men in Darwin.2 DMIAN has enabled men’s health researchers to better understand and act on the wants and needs of the Aboriginal and Torres Strait Islander men in the community from the perspective that matters most: their own. As Zhao and colleagues1 point out, there is still a long way to go with improving the life expectancy of Aboriginal and Torres Strait Islander men, which sits 15.4years behind non‐Indigenous men. In addition, as the life expectancy of Aboriginal and Torres Strait Islander men increases, so too does that of non‐Indigenous men.1 So if we are to close the gap, we cannot afford to lose momentum on targeted action, particularly that relating to Aboriginal and Torres Strait Islander male health and wellbeing.3,4 There is still a need for this to be a recognised priority in the NT and nationally, and for primary health care and social services in the NT to be resourced appropriately. In particular, the Aboriginal Community Controlled Health Services and Aboriginal medical services have a key role to play and should be funded to develop, implement and evaluate health and social and emotional wellbeing programs for male clients, as this is severely lacking and is ultimately hampering progress in Aboriginal and Torres Strait Islander male health and wellbeing outcomes.4 While the National Men’s Health Strategy identifies Aboriginal and Torres Strait Islander men as a priority population,5 we also need substantially more investment in research and evaluation to find new innovate solutions.6 We hope the important work being done by individuals in health, justice, education and other social services sectors continues to be enabled to support Aboriginal and Torres Strait Islander men for the benefit of their communities and future generations.

Kootsy Canuto · Karla J Canuto · Jason Bonson · James Smith

Strep A POCT is a critical element in preventing acute rheumatic fever and will contribute to the elimination of rheumatic heart disease in Australia

Dylan D Barth · Gelsa Cinanni · Jonathan R Carapetis · Rosemary Wyber · Louise Causer · Caroline Watts · Belinda Hengel · Susan Matthews · Anna P Ralph · Janessa Pickering · Jeffrey W Cannon · Lorraine Anderson · Vicki Wade · Rebecca J Guy · Asha C Bowen

An Indigenous-led study aims to empower and support Aboriginal and Torres Strait Islander women to be smoke-free

Michelle Kennedy · Hayley Longbottom

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

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

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

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