The prevalence and clinical associations of HTLV-1 infection in a remote Indigenous community.

OBJECTIVE: Hospital and laboratory data indicate that human T-lymphotropic virus type 1 (HTLV-1) is endemic to central Australia, but no community-based studies of its prevalence or disease burden have been reported. We determined the prevalence rates of HTLV-1 infection and of HTLV-1-associated diseases in a remote Indigenous community. SETTING: A remote Northern Territory community. DESIGN: All residents were asked to complete a health survey and offered a limited clinical examination, together with serological tests for HTLV-1 and Strongyloides, and HTLV-1 proviral load (PVL) assessment. MAIN OUTCOME MEASURES: HTLV-1 seropositivity rates; HTLV-1 PVL (copies/105 peripheral blood leucocytes [PBL]); presentation with HTLV-1-related clinical disease. RESULTS: HTLV-1 serostatus was determined for 97 of 138 residents (70%). The prevalence of HTLV-1 infection was significantly higher among adults (30 of 74 people tested) than children (1 of 23; P = 0.001). Nine of 30 HTLV-1-positive adults had a clinical syndrome that was potentially attributable to HTLV-1 infection (chronic lung disease, seven; symptomatic strongyloidiasis, two). The median HTLV-1 PVL was significantly higher for adults with chronic lung disease than for those who were asymptomatic (chronic lung disease, 649 copies/105 PBL [IQR, 162-2220]; asymptomatic adults, 40 copies/105 PBL [IQR, 0.9-229]; P = 0.017). Ten of 72 adults tested were seropositive for Strongyloides (six of 28 HTLV-1-positive participants and four of 44 HTLV-1-negative participants; P = 0.17), as were three of 15 children tested; the three children were HTLV-1-negative. CONCLUSION: The prevalence of HTLV-1 infection and the rate of disease potentially attributable to HTLV-1 were high among adults in this remote community.

Self-discharge by adult Aboriginal patients at Alice Springs Hospital, Central Australia: insights from a prospective cohort study.

OBJECTIVE: To determine rates and risk factors for self-discharge by Aboriginal medical inpatients at Alice Springs Hospital. METHODS: Prospective cohort study. Interviews were conducted in primary language by Aboriginal Liaison Officers, from July 2006 to August 2007. Topics included understanding of diagnosis, satisfaction with services and perceptions of staff and environment. Risk factors for self-discharge were then determined prospectively. RESULTS; During the study period 202 (14.7%) of 1380 patients admitted to general medical units at Alice Springs Hospital, were interviewed. Self-discharge rates for all admissions were significantly lower during the study period than they had been previously (pre-study, mean 22.9±standard error 0.3%; study, 17.0±0.2%) (P<0.001). Most interviewees (73.4%) did not know their reason for admission (73.4%) or estimated length of stay (82.3%). Forty interviewees (19.8%) self-discharged. Mean monthly self-discharge rates differed between the three medical units (Unit A, 13.9±0.3%; Unit B, 17.3±1.37%; Unit C, 20.0±0.4%) (P=0.005). Multivariable predictors of self-discharge included male sex (hazard ratio (HR) 2.4; 95% confidence interval (CI) 1.1, 5.2), a past history of self-discharge (HR 3.2; 95%CI 1.5, 6), planned transfer to a tertiary referral centre (HR 3.8; 95%CI 1.3-7.4) and a desire to drink alcohol (HR 4.5; 95%CI 1.8-10.2). CONCLUSIONS: Physician, institutional and patient factors all contribute to self-discharge. Improving cultural safety may be the key to lowering self-discharge rates. WHAT IS KNOWN ABOUT THE TOPIC? Rates of self-discharge by Aboriginal adults in Central Australia are the highest reported worldwide. Previous studies have been retrospective and focussed on patient demographics without addressing the environmental and cultural contexts in which self-discharge occurs. WHAT DOES THIS PAPER ADD? In this acute care setting, we found a pervasive failure to communicate effectively with Aboriginal patients. Consequently, most patients were unaware of their diagnosis or length of stay. Self-discharge was a common practice; nearly half of all previously admitted patients had self-discharged in the past. We demonstrate that physician, hospital and patient factors all contribute to this practice. Prospectively determined risk factors included the treating medical team, the need for transfer outside Central Australia, and patient factors such as male gender and alcohol dependence. Self-discharge rates fell significantly with Aboriginal Liaison involvement. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS? Cross-cultural communication skills must be markedly improved among medical staff caring for this marginalised population. Critical to reducing rates of self-discharge are improvements in institutional cultural safety by involving Aboriginal Liaison Officers and family members. However, persistently high self-discharge rates suggest a need to redirect medical services to a more culturally appropriate community-based model of care.

Seroprevalence of Strongyloides stercoralis in a South Australian Vietnam veteran cohort.

OBJECTIVES: Strongyloides stercoralis is a parasitic roundworm causing chronic infection that is endemic in Southeast Asia. Vietnam veterans are considered to be at high risk of Strongyloides infection. The prevalence of persistent infection in this group is unknown. This study aimed to establish the seropositivity rate of Strongyloides antibodies in South Australian Vietnam veterans and to identify the most reported symptoms within the seropositive group. METHOD: This cross-sectional study recruited 309 veterans who had served in Vietnamese territory between 1962 and 1975 and were currently resident in South Australia. Participants completed a self-administered questionnaire examining demographics, deployment, somatic symptoms and depression. Venous blood was collected for Strongyloides serology and eosinophil count. Participants who demonstrated positive Strongyloides serology underwent faecal microscopy for parasites. RESULTS: A total of 309 participants were recruited and 256 completed the questionnaire. Strongyloides seropositivity was demonstrated in 29 of 249 participants (11.6%). No participant had Strongyloides larvae detected by faecal microscopy. On multivariate analysis, only dermatological symptoms were associated with positive serology (OR 4.84, 95%CI 1.31-17.92, p-value 0.01). CONCLUSIONS: This study found a high seroprevalence (11.6%) of Strongyloides antibodies within the Vietnam veteran community in South Australia. Seropositivity was associated with increased likelihood of dermatological symptoms. IMPLICATIONS: Post-deployment screening and eradication therapy for Strongyloides should be offered to ADF staff after service in Strongyloides-endemic areas. This should include those veterans who left the service many years ago.

Two nations: racial disparities in bloodstream infections recorded at Alice Springs Hospital, central Australia, 2001-2005.

OBJECTIVE: To compare bloodstream infection (BSI) rates, pathogens and mortality among Indigenous and non-Indigenous adults in central Australia. DESIGN, PARTICIPANTS AND SETTING: Retrospective study of adult patients (aged > or = 15 years) admitted to Alice Springs Hospital (ASH) between 1 January 2001 and 31 December 2005. Patients were followed up until 30 June 2008. MAIN OUTCOME MEASURES: Admission-based and population-based BSI rates and mortality rates for Indigenous and non-Indigenous adults. RESULTS: During the study period, there were 824 BSI episodes (Indigenous, 753; non-Indigenous, 71). The admission-based BSI rate for Indigenous patients was 26.5 (95% CI, 26.4-26.6) per 1000 adult admissions, compared with 5.2 (95% CI, 5.1-5.2) per 1000 adult admissions for non-Indigenous patients (infection rate ratio [IRR], 5.13 [95% CI, 5.10-5.18]). The population-based BSI rate was 1354.7 (95% CI, 1256.3-1460.8) per 100 000 persons per year among Indigenous patients and 69.9 (95% CI, 55.1-88.6) per 100 000 persons per year among non-Indigenous patients (IRR, 19.4 [95% CI, 15.1-24.9]). These differences were not explained by higher comorbidity levels among Indigenous patients. Human T-cell lymphotropic virus type 1 and Strongyloides stercoralis infected 43% and 35%, respectively, of Indigenous patients tested. The risk of death during the follow-up period was 32.1% for Indigenous and 13.4% for non-Indigenous patients (hazard ratio [HR], 2.69 [95% CI, 1.38-5.25]; P = 0.004). Mortality rates were higher among Indigenous patients who had more than a single BSI (HR, 1.86 [95% CI, 1.32-2.62]; P < 0.001). The mean age at death was 48.5 years (SD, 16.2 years) for Indigenous patients and 75.1 years (SD, 18.7 years) for non-Indigenous patients (P < 0.001). CONCLUSION: Indigenous adults living in central Australia experience BSI rates that are among the highest reported in the world. These are associated with a high risk of death, and are a likely consequence of the poor socioeconomic circumstances of Indigenous people.

Racial disparities in infection-related mortality at Alice Springs Hospital, Central Australia, 2000--2005.

OBJECTIVE: To compare infection-related mortality rates and pathogens isolated for Indigenous and non-Indigenous adult patients at Alice Springs Hospital (ASH). DESIGN, PARTICIPANTS AND SETTING: Retrospective study of inhospital deaths of adults (patients aged > or = 15 years) associated with an infection during a medical or renal admission to ASH between 1 January 2000 and 31 December 2005. MAIN OUTCOME MEASURES: Admission- and population-based infection-related mortality rates and mortality rate ratios (MRRs) for Indigenous versus non-Indigenous adults. RESULTS: There were 513 deaths, of 351 Indigenous and 162 non-Indigenous patients. For Indigenous patients, 60% of deaths were infection-related, compared with 25% for non-Indigenous patients (P < 0.001). The admission-based infection-related MRR for Indigenous versus non-Indigenous adults was 2.2 (95% CI, 1.6-3.1) (15.3 v 6.8 deaths per 1000 admissions; P < 0.001). After adjusting for age and year of death, the population-based infection-related MRR was 11.3 (95% CI, 8.0-15.8) overall (351 v 35 deaths per 100,000 population; P < 0.001) and 31.5 (95% CI, 16.1-61.8) for patients aged < 60 years. The median age of patients who died with an infection was 49 (interquartile range [IQR], 38-67) years for Indigenous and 73 (IQR, 58-80) years for non-Indigenous patients (P < 0.001). For Indigenous patients, 56% of infection-related deaths were associated with bacterial sepsis, with half of these due to enteric organisms. Other deaths followed chronic hepatitis B infection, invasive fungal infections and complications of strongyloidiasis. CONCLUSION: Indigenous patients at ASH are 11 times more likely than non-Indigenous patients to die with an infectious disease. This racial disparity reflects the ongoing socioeconomic disadvantage experienced by Indigenous Australians.