The epidemiology and clinical features of rickettsial diseases in North Queensland, Australia: Implications for patient identification and management.

BACKGROUND: Rickettsial infections are a common cause of hospitalization in tropical settings, although early diagnosis is challenging in the rural locations where these infections are usually seen. METHODS: This retrospective, clinical audit of microbiologically-confirmed cases of scrub typhus or spotted fever group (SFG) rickettsial infection between 1997 and 2016 was performed a tertiary referral hospital in tropical Australia. Clinical, laboratory and radiological findings at presentation were correlated with the patients' subsequent clinical course. RESULTS: There were 135 locally-acquired cases (95 scrub typhus, 37 SFG, 3 undifferentiated). There were nine hospitalizations during the first 5 years of the study period and 81 in the last 5 years (p for trend = 0.003). Eighteen (13%) of the 135 cases required ICU admission, all of whom were adults. A greater proportion of patients with SFG infection required ICU support (8/37 (22%) compared with 10/95 (11%) scrub typhus cases), although this difference did not reach statistical significance (p = 0.10). Three (8%) of the 37 patients with SFG infection had severe disease (1 died, 2 developed permanent disability) versus 0/95 scrub typhus patients (p = 0.02). Adults with a high admission qSOFA score (≥2) had an odds ratio (OR) of 19 (95% CI:4.8-74.5) for subsequent ICU admission (p<0.001); adults with a high NEWS2 score (≥7) had an OR of 14.3 (95% CI:4.5-45.32) for ICU admission (p<0.001). A patient's respiratory rate at presentation had strong prognostic utility: if an adult had an admission respiratory rate <22 breaths/minute, the negative predictive value for subsequent ICU admission was 95% (95% CI 88-99). CONCLUSIONS: In the well-resourced Australian health system outcomes are excellent, but the local burden of rickettsial disease appears to be increasing and the clinical phenotype of SFG infections may be more severe than previously believed. Simple, clinical assessment on admission has prognostic utility and may be used to guide management.

Implications of male circumcision for women in Papua New Guinea: a transformational grounded theory study.

BACKGROUND: Male circumcision reduces the risk of female-to-male transmission of human immunodeficiency virus (HIV) and is being explored for HIV prevention in Papua New Guinea (PNG). PNG has a concentrated HIV epidemic which is largely heterosexually transmitted. There are a diverse range of male circumcision and penile modification practices across PNG. Exploring the implications of male circumcision for women in PNG is important to inform evidence-based health policy that will result in positive, intended consequences. METHODS: The transformational grounded theory study incorporated participatory action research and decolonizing methodologies. In Phase One, an existing data set from a male circumcision study of 861 male and 519 female participants was theoretically sampled and analyzed for women's understanding and experience of male circumcision. In Phase Two of the study, primary data were co-generated with 64 women in seven interpretive focus group discussions and 11 semi-structured interviews to develop a theoretical model of the processes used by women to manage the outcomes of male circumcision. In Phase Three participants assisted to refine the developing transformational grounded theory and identify actions required to improve health. RESULTS: Many women know a lot about male circumcision and penile modification and the consequences for themselves, their families and communities. Their ability to act on this knowledge is determined by numerous social, cultural and economic factors. A transformational grounded theory was developed with connecting categories of: Women Know a Lot, Increasing Knowledge; Increasing Options; and Acting on Choices. Properties and dimensions of each category are represented in the model, along with the intervening condition of Safety. The condition of Safety contextualises the overarching lived realty for women in PNG, enables the inclusion of men in the transformational grounded theory model, and helps to explain relationships between men and women. The theory presents the core category as Power of Choice. CONCLUSIONS: This transformational grounded theory provides a means to explore how women experience male circumcision and penile modification in PNG, including for HIV prevention. Women who have had opportunities for education have a greater range of choices and an increased opportunity to act upon these choices. However, women can only exercise their power of choice in the context of safety. The concept of Peace drawn from the Social Determinants of Health is applied in order to extend the explanatory power of the transformational grounded theory. This study shows that women's ambivalence about male circumcision is often related to lack of safety, a consequence of gender inequality in PNG.

Weighing up the costs of seeking health care for dengue symptoms: a grounded theory study of backpackers' decision-making processes.

Dengue fever, a mosquito-borne virus, is an ongoing public health issue in North Queensland. Importation of dengue fever by travellers visiting or returning to Australia can lead to epidemics. The mosquito can acquire the virus in the symptomatic viraemic phase, so timely recognition of cases is important to prevent epidemics. There is a gap in the literature about backpackers' knowledge of dengue fever and the decision-making process they use when considering utilising the Australian health-care system. This study uses grounded theory methods to construct a theory that explains the process backpackers use when seeking health care. Fifty semi-structured interviews with backpackers, hostel receptionists, travel agents and pharmacists were analysed, resulting in identification of a core category: 'weighing up the costs of seeking health care'. This core category has three subcategories: 'self-assessment of health status', 'wait-and-see' and 'seek direction'. Findings from this study identified key areas where health promotion material and increased access to health-care professionals could reduce the risk of backpackers spreading dengue fever.

General practitioners' patterns of treatment of febrile travellers in north Queensland: an exploratory study.

In north Queensland, recurring epidemics of dengue fever are a public health concern. Each epidemic is initiated by an index case: an infected person arriving from an endemic country or region with dengue activity who then transmits the disease to local mosquitoes. A timely diagnosis of dengue in an index case and notification to public health services is essential to prevent epidemics. This qualitative study explores north Queensland general practitioners' experiences and patterns of treatment of febrile travellers. Individual, semi-structured interviews with 50 general practitioners working in north Queensland were conducted. Analysis of the data resulted in four themes for discussion: characteristics of febrile travellers presenting to local general practitioners, the cost of pathology tests as a barrier to diagnosis, appropriate pathology testing, and notifying tropical public health services. Recommendations from this study point to a need for ongoing education and training for general practitioners in best practice with regards pathology testing for suspected dengue fever cases. As well, there is a need to provide clearer guidelines to general practitioners on when to notify tropical public health services of suspicious diagnoses of dengue.