Yarning about oral health: perceptions of urban Australian Aboriginal and Torres Strait Islander women.

BACKGROUND: Many factors influence how a person experiences oral health and how such experiences may facilitate supportive oral health behaviours. Women in particular face different challenges due to their environment, responsibilities and physiological differences to men. Within Australia, Aboriginal and Torres Strait Islander women are reported to have poorer oral health and are faced with additional barriers to supporting their oral health compared with non-Indigenous women. The objective of this paper is to report the experiences and perceptions of oral health from the perspective of urban, Aboriginal and Torres Strait Islander women. METHODS: The present data derive from a descriptive study that used yarning circles and face-to-face interviews with women who were mothers/carers of urban, Aboriginal and/or Torres Strait Islander children. This was a qualitative study to investigate the impact of child oral health on families. Participants used the opportunity to share their own personal experiences of oral health as women, thus providing data for the present analyses. Information collected was transcribed and analysed thematically. RESULTS: Twenty women shared their personal narratives on the topic of oral health which were reflective of different time points in their life: growing up, as an adult and as a mother/carer. Although women are trying to support their oral health across their life-course, they face a number of barriers, including a lack of information and the costs of accessing dental care. The teenage years and pregnancy were reported as important time periods for oral health support. CONCLUSIONS: To improve the oral health of Indigenous Australian women, policymakers must consider the barriers reported by women and critically review current oral health information and services. Current oral health services are financially out of reach for Indigenous Australian women and there is not sufficient or appropriate, oral information across the life-course.

Amoxicillin-clavulanate versus azithromycin for respiratory exacerbations in children with bronchiectasis (BEST-2): a multicentre, double-blind, non-inferiority, randomised controlled trial.

BACKGROUND: Although amoxicillin-clavulanate is the recommended first-line empirical oral antibiotic treatment for non-severe exacerbations in children with bronchiectasis, azithromycin is also often prescribed for its convenient once-daily dosing. No randomised controlled trials involving acute exacerbations in children with bronchiectasis have been published to our knowledge. We hypothesised that azithromycin is non-inferior to amoxicillin-clavulanate for resolving exacerbations in children with bronchiectasis. METHODS: We did this parallel-group, double-dummy, double-blind, non-inferiority randomised controlled trial in three Australian and one New Zealand hospital between April, 2012, and August, 2016. We enrolled children aged 1-19 years with radiographically proven bronchiectasis unrelated to cystic fibrosis. At the start of an exacerbation, children were randomly assigned to oral suspensions of either amoxicillin-clavulanate (22·5 mg/kg, twice daily) and placebo or azithromycin (5 mg/kg per day) and placebo for 21 days. We used permuted block randomisation (stratified by age, site, and cause) with concealed allocation. The primary outcome was resolution of exacerbation (defined as a return to baseline) by 21 days in the per-protocol population, with a non-inferiority margin of -20%. We assessed several secondary outcomes including duration of exacerbation, time to next exacerbation, laboratory, respiratory, and quality-of-life measurements, and microbiology. This trial was registered with the Australian/New Zealand Registry (ACTRN12612000010897). FINDINGS: We screened 604 children and enrolled 236. 179 children had an exacerbation and were assigned to treatment: 97 to amoxicillin-clavulanate, 82 to azithromycin). By day 21, 61 (84%) of 73 exacerbations had resolved in the azithromycin group versus 73 (84%) of 87 in the amoxicillin-clavulanate group. The risk difference showed non-inferiority (-0·3%, 95% CI -11·8 to 11·1). Exacerbations were significantly shorter in the amoxicillin-clavulanate group than in the azithromycin group (median 10 days [IQR 6-15] vs 14 days [8-16]; p=0·014). Adverse events were attributed to the trial medication in 17 (21%) of 82 children in the azithromycin group versus 23 (24%) of 97 in the amoxicillin-clavulanate group (relative risk 0·9, 95% CI 0·5 to 1·5). INTERPRETATION: By 21 days of treatment, azithromycin is non-inferior to amoxicillin-clavulanate for resolving exacerbations in children with non-severe bronchiectasis. In some patients, such as those with penicillin hypersensitivity or those likely to have poor adherence, azithromycin provides another option for treating exacerbations, but must be balanced with risk of treatment failure (within a 20% margin), longer exacerbation duration, and the risk of inducing macrolide resistance. FUNDING: Australian National Health and Medical Research Council.

Impact of oral health on Australian urban Aboriginal and Torres Strait Islander families: a qualitative study.

BACKGROUND: The oral health of a child not only impacts the physical well-being of the child, but can have quality of life implications for parents and families as they endeavour to provide care and support their child's oral health needs. Within Australia, Aboriginal and Torres Strait Islander children are thought to experience a disproportionate burden of poor oral heath compared to non-Indigenous children. Despite the prevalence of oral health challenges, there are limited qualitative studies investigating the oral health experiences of families. The objective of the study was to explore 'from the perspective of urban, Aboriginal and Torres Strait Islander parents and carers' the impact child oral health has on families. METHODS: Yarning circles and face-to-face interviews were used to document the experiences of (N = 20) parents of urban, Aboriginal and Torres Strait Islander children. Participants were recruited from an Aboriginal-owned and operated primary health clinic in northern Brisbane, Australia and through word of mouth. Information collected was transcribed and analysed thematically. Codes and themes were confirmed by the researcher and two participants. RESULTS: The findings indicate that oral health is an important issue for urban Indigenous families and maintaining oral health to a desired standard is having emotional, physical and financial impacts. Themes identified were financial concerns, worry about the future and juggling multiple priorities, all of which were inter-related and cyclical. CONCLUSIONS: Families in this study have demonstrated that with the current policy arrangements, oral health is impacting their quality of life, contributing to stress, financial challenges and at times affecting their physical health. To address these challenges, oral health education and promotion needs a multidisciplinary approach that reaches families before children are school-aged.

Paediatric and adult bronchiectasis: Vaccination in prevention and management.

Bronchiectasis has received increased attention recently, including an emphasis on preventing infective exacerbations that are associated with disease progression and lung function decline. While there are several bacteria and viruses associated with bronchiectasis, licensed vaccines are only currently available for Streptococcus pneumoniae, Haemophilus influenzae (H. influenzae protein D as a conjugate in a pneumococcal vaccine), Mycobacterium tuberculosis, Bordetella pertussis and influenza virus. The evidence for the efficacy and effectiveness of these vaccines in both preventing and managing bronchiectasis in children and adults is limited with the focus of most research being on other chronic lung disorders, such as chronic obstructive pulmonary diseases, asthma and cystic fibrosis. We review the existing evidence for these vaccines in bronchiectasis and highlight the existing gaps in knowledge. High-quality experimental and non-experimental studies using current state-of-the-art microbiological methods and validated, standardised case definitions are needed across the depth and breadth of the vaccine development pathway.

Burden and emergency department management of acute cough in children.

AIM: In children presenting to an emergency department (ED) with an acute coughing illness, the aims of this study were to: (i) describe the frequency of doctor visits and medication use; and (ii) describe management and relate it to current evidence-based guidelines. METHODS: This was a cross-sectional study in ED of a major teaching hospital (Royal Children's Hospital, Brisbane, Australia). Participants included 537 children (<15 years) presenting with acute (<2 weeks) cough, with a median age of 2.2 years (interquartile range 1.0-4.0); 61.5% were boys. Hospitalised children and those with asthma, pneumonia or chronic illnesses were excluded. Main outcome measures were: (i) frequency of pre-ED doctor visits and medication use; and (ii) comparison of management to current evidence-based recommendations related to four discharge diagnoses: bronchiolitis, 'wheeze/reactive airway disease (RAD)', croup and 'non-specific acute respiratory illness'. RESULTS: A total of 300 children (55.9%) had seen a doctor prior to their ED presentation, and use of medications pre-ED was high (53.4%). While 93.4% of children with croup were treated in accordance with guidelines, concordance was lower for children with bronchiolitis or 'wheeze/RAD'. The majority of children with a discharge diagnosis of 'wheeze/RAD' (95.6%) received bronchodilators, and 72.7% also received oral corticosteroids but were not diagnosed with asthma. More than half (55.1%) of the children with non-specific acute respiratory illness received medication(s) either prior to or during their ED presentation. CONCLUSIONS: The burden of acute cough-related illnesses in children is high, and there is a need for improved uptake of evidence-based guidelines. In addition, the large number of children diagnosed with 'wheeze/RAD' suggests asthma is likely under-diagnosed in this setting.

Health-resource use and quality of life in children with bronchiectasis: a multi-center pilot cohort study.

BACKGROUND: Bronchiectasis in children is an important, but under-researched, chronic pulmonary disorder that has negative impacts on health-related quality of life. Despite this, it does not receive the same attention as other chronic pulmonary conditions in children such as cystic fibrosis. We measured health resource use and health-related quality of life over a 12-month period in children with bronchiectasis. METHODS: We undertook a prospective cohort study of 85 children aged < 18-years with high-resolution chest computed-tomography confirmed bronchiectasis undergoing management in three pediatric respiratory medical clinics in Darwin and Brisbane, Australia and Auckland, New Zealand. Children with cystic fibrosis or receiving cancer treatment were excluded. Data collected included the frequency of healthcare attendances (general practice, specialists, hospital and/or emergency departments, and other), medication use, work and school/childcare absences for parents/carers and children respectively, and both parent/carer and child reported quality of life and cough severity. RESULTS: Overall, 951 child-months of observation were completed for 85 children (median age 8.7-years, interquartile range 5.4-11.3). The mean (standard deviation) number of exacerbations was 3.3 (2.2) per child-year. Thirty of 264 (11.4%) exacerbation episodes required hospitalization. Healthcare attendance and antibiotic use rates were high (30 and 50 per 100 child-months of observation respectively). A carer took leave from work for 53/236 (22.5%) routine clinic visits. Absences from school/childcare due to bronchiectasis were 24.9 children per 100 child-months. Quality of life scores for both the parent/carer and child were highly-correlated with one another, remained stable over time and were negatively associated with cough severity. CONCLUSIONS: Health resource use in this cohort of children is high, reflecting their severe disease burden. Studies are now needed to quantify the direct and societal costs of disease and to evaluate interventions that may reduce disease burden, particularly hospitalizations.

Longitudinal study of quality of life among children with acute respiratory infection and cough.

PURPOSE: Acute respiratory infections (ARIs), and associated symptoms such as cough, are frequently experienced among children and impose a burden on families (e.g., use of medical resources and time off work/school). However, there are little data on changes in, and predictors of, quality of life (QoL) over the duration of an ARI with cough (ARIwC) episode. We therefore aimed to determine cough-specific QoL and identify its influencing factors among children with ARIwC, at the time of presentation to a pediatric emergency department (ED), and over the following 4 weeks. METHODS: Data from 283 children aged < 15 years were included in our analyses. We used the validated parent-proxy children's acute cough-specific QoL questionnaire (PAC-QoL) at each time-point. Linear regression and mixed effect modeling were used to identify factors influencing QoL at baseline and over the follow-up period. RESULTS: Median PAC-QoL at baseline was 2.7 (IQR 2.1-3.6) and significantly improved by Day-7 (4.9, IQR 3.8-6.1) and Day-14 (6.59, IQR 5.1-7.0), both p < 0.001. The improvements in median PAC-QoL between Days-14, -21, and -28 were not significant. Regression modeling identified that day-cough severity, night-cough severity, and financial concerns had the highest impact on both baseline, and follow-up, PAC-QoL scores. There were five additional independent significant factors at baseline and six at follow-up. CONCLUSIONS: Quality of life is considerably impaired at presentation to ED, but improves significantly by Days-7 and -14. As cough severity and financial concerns had the highest impact on QoL, effectively managing cough to reduce the clinical and financial burden on children and families is important.

Health service utilisation amongst urban Aboriginal and Torres Strait Islander children aged younger than 5 years registered with a primary health-care service in South-East Queensland.

AIM: The majority of Australia's Aboriginal and/or Torres Strait Islander children live in urban areas; however, little is known about their health service use. We aimed to describe health service utilisation amongst a cohort of urban Aboriginal and/or Torres Strait Islander children aged <5 years. METHODS: We analysed health service utilisation data collected in an ongoing prospective cohort study of children aged <5 years registered with an Aboriginal-owned and operated primary health-care service. Enrolled children were followed monthly for 12 months, with data on health service utilisation collected at baseline and at each monthly follow-up. Health service utilisation rates, overall and by service provider and reason for presentation, were calculated and reported as incidence rates per 100 child-months with the corresponding 95% confidence intervals (CIs). RESULTS: Between February 2013 and November 2015, 180 children were enrolled, and 1541 child-months of observation were available for analysis. The overall incidence of health service utilisation was 52.5 per 100 child-months (95% CI 48.7-56.5); 81% of encounters were with general practitioners. Presentation rates were the highest for acute respiratory illnesses (30.7/100 child-months, 95% CI 27.8-33.9). CONCLUSIONS: In this community, acute respiratory illnesses are predominant causes of health service utilisation in young children. The health-care utilisation profile of these children presents important opportunities for health promotion and intervention.

Upper airway viruses and bacteria in urban Aboriginal and Torres Strait Islander children in Brisbane, Australia: a cross-sectional study.

BACKGROUND: Respiratory morbidity in Australian Indigenous children is higher than their non-Indigenous counterparts, irrespective of urban or remote residence. There are limited studies addressing acute respiratory illness (ARI) in urban Indigenous children, particularly those that address the upper airway microbiome and its relationship to disease. We aimed to describe the prevalence of upper airway viruses and bacteria in symptomatic and asymptomatic urban-based Australian Indigenous children aged less than 5 years. METHODS: A cross-sectional analysis of data collected at baseline in an ongoing prospective cohort study of urban Aboriginal and Torres Strait Islander children registered with a primary health care service in the northern suburbs of Brisbane, Australia. Clinical, demographic and epidemiological data and bilateral anterior nasal swabs were collected on enrolment. Polymerase chain reaction was performed on nasal swabs to detect 17 respiratory viruses and 7 bacteria. The primary outcome was the prevalence of these microbes at enrolment. Logistic regression was performed to investigate differences in microbe prevalence between children with and without acute respiratory illness with cough as a symptom (ARIwC) at time of specimen collection. RESULTS: Between February 2013 and October 2015, 164 children were enrolled. The median age at enrolment was 18.0 months (IQR 7.2-34.3), 49.4% were boys and 56 children (34.2%) had ARIwC. Overall, 133/164 (81%) nasal swabs were positive for at least one organism; 131 (79.9%) for any bacteria, 59 (36.2%) for any virus and 57 (34.8%) for both viruses and bacteria. Co-detection of viruses and bacteria was more common in females than males (61.4% vs 38.6%, p = 0.044). No microbes, alone or in combination, were significantly associated with the presence of ARIwC. CONCLUSIONS: The prevalence of upper airways microbes in asymptomatic children is similar to non-Indigenous children with ARIwC from the same region. Determining the aetiology of ARIwC in this community is complicated by the high prevalence of multiple respiratory pathogens in the upper airways. STUDY REGISTRATION: Australia New Zealand Clinical Trial Registry Registration Number: 12,614,001,214,628. Retrospectively registered.

Characteristics and respiratory risk profile of children aged less than 5 years presenting to an urban, Aboriginal-friendly, comprehensive primary health practice in Australia.

AIM: There are no published data on factors impacting on acute respiratory illness (ARI) among urban Indigenous children. We describe the characteristics and respiratory risk profile of young urban Indigenous children attending an Aboriginal-friendly primary health-care practice. METHODS: We conducted a cross-sectional analysis of data collected at baseline in a cohort study investigating ARI in urban Indigenous children aged less than 5 years registered with an Aboriginal primary health-care service. Descriptive analyses of epidemiological, clinical, environmental and cultural factors were performed. Logistic regression was undertaken to examine associations between child characteristics and the presence of ARI at baseline. RESULTS: Between February 2013 and October 2015, 180 Indigenous children were enrolled; the median age was 18.4 months (7.7-35), 51% were male. A total of 40 (22%) children presented for a cough-related illness; however, ARI was identified in 33% of all children at the time of enrolment. A total of 72% of children were exposed to environmental tobacco smoke. ARI at baseline was associated with low birthweight (adjusted odds ratio (aOR) 2.54, 95% confidence interval (CI) 1.08-5.94), a history of eczema (aOR 2.67, 95% CI 1.00-7.15) and either having a family member from the Stolen Generation (aOR 3.47, 95% CI 1.33-9.03) or not knowing this family history (aOR 3.35, 95% CI 1.21-9.26). CONCLUSIONS: We identified an urban community of children of high socio-economic disadvantage and who have excessive exposure to environmental tobacco smoke. Connection to the Stolen Generation or not knowing the family history may be directly impacting on child health in this community. Further research is needed to understand the relationship between cultural factors and ARI.

Acoustic and Perceptual Profiles of Swallowing Sounds in Children: Normative Data for 4-36 Months from a Cross-Sectional Study Cohort.

Limited data on cervical auscultation (CA) sounds during the transitional feeding period of 4-36 months in healthy children exist. This study examined the acoustic and perceptual parameters of swallowing sounds in children aged 4-36 months over a range of food and fluid consistencies. Using CA, swallowing sounds were recorded from a microphone as children ate or drank. Acoustic parameters of duration, peak frequency and peak intensity were determined. Perceptual parameters of swallowing/breath sounds heard pre-, during and post-swallow were rated ('present', 'absent', 'cannot be determined') for each texture. 74 children (35 males; mean age = 17.1 months [SD 10.0]) demonstrated mean swallow durations of <1 s. Increasing age correlated to reduced peak frequency on puree (r = -0.48, 95 % CI -0.66, -0.24). Age correlated to peak amplitude when swallowing puree (r = 0.27, 95 % CI 0.02, 0.49), chewable solids (r = 0.31, 95 % CI 0.02, 0.56) and thin fluids (r = 0.48, 95 % CI 0.27, 0.64). The bolus transit sound was present in all swallows. A majority of children had normal breathing sounds and coordinated swallows. A swallow duration of <1 s and the presence of a quick bolus transit sound with normal breathing sounds were found in healthy children. The normative data reported in this study provide a platform for future comparison to abnormal swallowing sounds in children.

Immunisation timeliness in a cohort of urban Aboriginal and Torres Strait Islander children.

BACKGROUND: To evaluate immunisation coverage, timeliness and predictors of delayed receipt in urban Australian Indigenous children during the first 18 months of life. METHODS: Cross-sectional retrospective analysis of data collected from 140 Australian Indigenous children aged < 5 years at the time of enrolment in a prospective cohort study on respiratory illness between 14 February 2013 and 28 January 2015. Children were recruited through an urban community primary health care centre in the Northern suburbs of Brisbane, Queensland. RESULTS: The proportion of children with completed immunisation schedules was 50 of 105 (47.6%) at 7 months, 30 of 85 (35.3%) at 13 months and 12 of 65 (18.5%) at 19 months. Timely receipt of diphtheria-tetanus-pertussis decreased from 78.4% at 2 months of age to 63.7 and 59.3% at 4 and 6 months respectively. Amongst the 105 parents/guardians with children ≥7 months at enrolment, 71 (67.6%) incorrectly reported their child's immunisation status. Delayed vaccine receipt was significantly associated (p ≤0.05) with having multiple children in the household, mother's unemployment and premature birth. CONCLUSIONS: Coverage and timeliness among this population is suboptimal and decreases as children age. Parent/guardian reporting of vaccination status was unreliable. Children of unemployed mothers and those with multiple siblings should be targeted to improve community immunisation timeliness due to a greater risk of vaccination delay. High quality trials, conducted in several settings to account for the diversity of Australian Indigenous communities are urgently needed to identify culturally appropriate, effective and sustainable strategies to improve immunisation targets in children.

The Use of Cervical Auscultation to Predict Oropharyngeal Aspiration in Children: A Randomized Controlled Trial.

In this study, we aimed to determine if the use of cervical auscultation (CA) as an adjunct to the clinical feeding evaluation (CFE + CA) improves the reliability of predicting oropharyngeal aspiration (abbreviated to aspiration) in children. The design of the study is based on open label, randomized controlled trial with concealed allocation. Results from children (<18 years) randomized to either CFE or CFE + CA were compared to videofluoroscopic swallow study (VFSS), the reference standard data. Aspiration was defined using the Penetration-Aspiration Scale. All assessments were undertaken at a single tertiary pediatric hospital. 155 children referred for a feeding/swallowing assessment were randomized into the CFE n = 83 [38 males; mean age = 34.9 months (SD 34.4)] or CFE + CA n = 72 [43 males; mean age = 39.6 months (SD 39.3)] group. kappa statistic, sensitivity, and specificity values, area under receiver operating curve (aROC). No significant differences between groups were found, although CFE + CA (kappa = 0.41, 95 % CI 0.2-0.62) had higher agreement for aspiration detection by VFSS, compared to the clinical feeding exam alone (kappa = 0.31, 95 % CI 0.10-0.52). Sensitivity was 85 % (95 % CI 62.1-96.8) for CFE + CA and 63.6 % (95 % CI 45.1-79.6) for CFE. aROC was not significantly greater for CFE + CA (0.75, 95 % CI 0.65-0.86) than CFE (0.66, 95 % CI 0.55-0.76) across all age groups. Although using CA as an adjunct to the clinical feeding evaluation improves the sensitivity of predicting aspiration in children, it is not sensitive enough as a diagnostic tool in isolation. Given the serious implications of missing the diagnosis of aspiration, instrumental assessments (e.g., VFSS), remain the preferred standard.

An acute cough-specific quality-of-life questionnaire for children: Development and validation.

BACKGROUND: Patient-relevant outcome measures are essential for high-quality clinical research, and quality-of-life (QoL) tools are the current standard. Currently, there is no validated children's acute cough-specific QoL questionnaire. OBJECTIVE: The objective of this study was to develop and validate the Parent-proxy Children's Acute Cough-specific QoL Questionnaire (PAC-QoL). METHODS: Using focus groups, a 48-item PAC-QoL questionnaire was developed and later reduced to 16 items by using the clinical impact method. Parents of children with a current acute cough (<2 weeks) at enrollment completed 2 validated cough score measures, the preliminary 48-item PAC-QoL, and 3 other questionnaires (the State Trait Anxiety Inventory [STAI], the Short-Form 8-item 24-hour recall Health Survey [SF-8], and the Depression, Anxiety, and Stress 21-item Scale [DASS21]). All measures were repeated on days 3 and 14. RESULTS: The median age of the 155 children enrolled was 2.3 years (interquartile range, 1.3-4.6). Median cough duration at enrollment was 3 days (interquartile range, 2-5). The reduced 16-item scale had high internal consistency (Cronbach α = 0.95). Evidence for repeatability and criterion validity was shown by significant correlations between the domains and total PAC-QoL scores and the SF-8 (r = -0.36 and -0.51), STAI (r = -0.27 and -0.39), and DASS21 (r = -0.32 and -0.41) scales on days 0 and 3, respectively. The final PAC-QoL questionnaire was sensitive to change over time, with changes significantly relating to changes in cough score measures (P < .001). CONCLUSION: The 16-item PAC-QoL is a reliable and valid outcome measure that assesses QoL related to childhood acute cough at a given time point and reflects changes in acute cough-specific QoL over time.

The respiratory health of urban indigenous children aged less than 5 years: study protocol for a prospective cohort study.

BACKGROUND: Despite the burden of acute respiratory illnesses (ARI) among Aboriginal and Torres Strait Islander children being a substantial cause of childhood morbidity and associated costs to families, communities and the health system, data on disease burden in urban children are lacking. Consequently evidence-based decision-making, data management guidelines, health resourcing for primary health care services and prevention strategies are lacking. This study aims to comprehensively describe the epidemiology, impact and outcomes of ARI in urban Aboriginal and Torres Strait Islander children (hereafter referred to as Indigenous) in the greater Brisbane area. METHODS/DESIGN: An ongoing prospective cohort study of Indigenous children aged less than five years registered with a primary health care service in Northern Brisbane, Queensland, Australia. Children are recruited at time of presentation to the service for any reason. Demographic, epidemiological, risk factor, microbiological, economic and clinical data are collected at enrolment. Enrolled children are followed for 12 months during which time ARI events, changes in child characteristics over time and monthly nasal swabs are collected. Children who develop an ARI with cough as a symptom during the study period are more intensely followed-up for 28 (±3) days including weekly nasal swabs and parent completed cough diary cards. Children with persistent cough at day 28 post-ARI are reviewed by a paediatrician. DISCUSSION: Our study will be one of the first to comprehensively evaluate the natural history, epidemiology, aetiology, economic impact and outcomes of ARIs in this population. The results will inform studies for the development of evidence-based guidelines to improve the early detection, prevention and management of chronic cough and setting of priorities in children during and after ARI. TRIAL REGISTRATION: Australia New Zealand Clinical Trial Registry Registration Number: 12614001214628 . Registered 18 November 2014.

Medically-attended respiratory illnesses amongst pregnant women in Brisbane, Australia.

There are limited community-based data on the burden of influenza and influenza-like illnesses during pregnancy to inform disease surveillance and control. We aimed to determine the incidence of medically-attended respiratory illnesses (MARI) in pregnant women and the proportion of women who are tested for respiratory pathogens at these visits. We conducted a nested retrospective cohort study of a non-random sample of women aged 18 years or over who had a live birth in maternity units in Brisbane, Queensland, from March 2012 to October 2014. The primary outcomes were self-reported doctor visits for MARI and laboratory investigations for respiratory pathogens. Descriptive analyses were performed. Among 1,202 participants, 222 (18.5%, 95%CI 16.3%-20.7%) self-reported MARI during their pregnancy. Of those with an MARI, 20.3% (45/222) self-reported a laboratory test was performed. We were able to confirm with health service providers that 46.7% (21/45) of tests were undertaken, responses from providers were not received for the remainder. Whilst one in 5 women in this population reported a MARI in pregnancy, only 3.7% (45/1,202) reported a clinical specimen had been arranged at the consultation and the ability to validate that self-report was problematic. As the focus on maternal immunisation increases, ascertainment of the aetiological agent causing MARI in this population will be required and efficient and reliable methods for obtaining these data at the community level need to be established.

Indigenous Respiratory Outreach Care: the first 18 months of a specialist respiratory outreach service to rural and remote Indigenous communities in Queensland, Australia.

OBJECTIVE: Respiratory diseases are a leading cause of morbidity and mortality in Indigenous Australians. However, there are limited approaches to specialist respiratory care in rural and remote communities that are culturally appropriate. A specialist Indigenous Respiratory Outreach Care (IROC) program, developed to address this gap, is described. METHODS: The aim of the present study was to implement, pilot and evaluate multidisciplinary specialist respiratory outreach medical teams in rural and remote Indigenous communities in Queensland, Australia. Sites were identified based on a perception of unmet need, burden of respiratory disease and/or capacity to use the clinical service and capacity building for support offered. RESULTS: IROC commenced in March 2011 and, to date, has been implemented in 13 communities servicing a population of approximately 43000 Indigenous people. Clinical service delivery has been possible through community engagement and capacity building initiatives directed by community protocols. CONCLUSION: IROC is a culturally sensitive and sustainable model for adult and paediatric specialist outreach respiratory services that may be transferrable to Indigenous communities across Queensland and Australia.

Mailed versus frozen transport of nasal swabs for surveillance of respiratory bacteria in remote Indigenous communities in Australia.

BACKGROUND: Surveillance programs and research for acute respiratory infections in remote Australian communities are complicated by difficulties in the storage and transport of frozen samples to urban laboratories for testing. This study assessed the sensitivity of a simple method for transporting nasal swabs from a remote setting for bacterial polymerase chain reaction (PCR) testing. METHODS: We sampled every individual who presented to a remote community clinic over a three week period in August at a time of low influenza and no respiratory syncytial virus activity. Two anterior nasal swabs were collected from each participant. The left nare specimen was mailed to the laboratory via routine postal services. The right nare specimen was transported frozen. Testing for six bacterial species was undertaken using real-time PCR. RESULTS: One hundred and forty participants were enrolled who contributed 150 study visits and paired specimens for testing. Respiratory illnesses accounted for 10% of the reasons for presentation. Bacteria were identified in 117 (78%) presentations for 110 (79.4%) individuals; Streptococcus pneumoniae and Haemophilus influenzae were the most common (each identified in 58% of episodes). The overall sensitivity for any bacterium detected in mailed specimens was 82.2% (95% CI 73.6, 88.1) compared to 94.8% (95% CI 89.4, 98.1) for frozen specimens. The sensitivity of the two methods varied by species identified. CONCLUSION: The mailing of unfrozen nasal specimens from remote communities appears to influence the utility of the specimen for bacterial studies, with a loss in sensitivity for the detection of any species overall. Further studies are needed to confirm our finding and to investigate the possible mechanisms of effect. CLINICAL TRIAL REGISTRATION: Australia and New Zealand Clinical Trials Registry Number: ACTRN12609001006235.

The development of chronic cough in children following presentation to a tertiary paediatric emergency department with acute respiratory illness: study protocol for a prospective cohort study.

BACKGROUND: Acute respiratory illness, a leading cause of cough in children, accounts for a substantial proportion of childhood morbidity and mortality worldwide. In some children acute cough progresses to chronic cough (>4 weeks duration), impacting on morbidity and decreasing quality of life. Despite the importance of chronic cough as a cause of substantial childhood morbidity and associated economic, family and social costs, data on the prevalence, predictors, aetiology and natural history of the symptom are scarce. This study aims to comprehensively describe the epidemiology, aetiology and outcomes of cough during and after acute respiratory illness in children presenting to a tertiary paediatric emergency department. METHODS/DESIGN: A prospective cohort study of children aged <15 years attending the Royal Children's Hospital Emergency Department, Brisbane, for a respiratory illness that includes parent reported cough (wet or dry) as a symptom. The primary objective is to determine the prevalence and predictors of chronic cough (≥4 weeks duration) post presentation with acute respiratory illness. Demographic, epidemiological, risk factor, microbiological and clinical data are completed at enrolment. Subjects complete daily cough dairies and weekly follow-up contacts for 28(±3) days to ascertain cough persistence. Children who continue to cough for 28 days post enrolment are referred to a paediatric respiratory physician for review. Primary analysis will be the proportion of children with persistent cough at day 28(±3). Multivariate analyses will be performed to evaluate variables independently associated with chronic cough at day 28(±3). DISCUSSION: Our protocol will be the first to comprehensively describe the natural history, epidemiology, aetiology and outcomes of cough during and after acute respiratory illness in children. The results will contribute to studies leading to the development of evidence-based clinical guidelines to improve the early detection and management of chronic cough in children during and after acute respiratory illness.

Barriers and facilitators of physical activity in children with bronchiectasis: Perspectives from children and parents.

Background: Current bronchiectasis management guidelines recommend regular physical activity but a large proportion of children with bronchiectasis do not meet public health recommendations which call for 60 min or more of moderate-to-vigorous intensity physical activity daily. Knowing the factors that influence physical activity in children with bronchiectasis is necessary for the development of effective interventions to increase physical activity in this patient group. The objective of this study was to identify facilitators and barriers to physical activity in children with bronchiectasis unrelated to cystic fibrosis (CF) from the perspectives of children and their parents. Materials and methods: This was a qualitative study informed by the theoretical domains framework (TDF). Children aged 7-15 years (8.8 years, 8.4-11.0) (median, interquartile range) and parents (45.8 years, 39.7-48.3) completed separate, semi-structured interviews (n = 21). Recordings were transcribed verbatim, and barriers and facilitators related to each TDF domain deductively coded. Emergent themes were inductively derived via consensus moderation. Results: From the perspectives of children, fun with friends, organized sport and activities, and family co-participation in physical activity emerged as facilitators. Inability to keep up with their peers and time on technology emerged as barriers. From the perspectives of parents, instrumental and logistic support for physical activity and supportive social and physical activity environments emerged as facilitators, while management of symptoms associated with bronchiectasis emerged as a barrier. Conclusion: Programs to increase physical activity in children with bronchiectasis should be fun, accessible, provide opportunities for social interaction and address barriers related to exercise tolerance, perceived competence, and presence of respiratory symptoms.