Cultivating a Healthier Policy Landscape: The Building Healthy Communities Initiative.

OBJECTIVE: To identify effective methods for local public health departments to secure policy and systems changes that will achieve health equity and improve health outcomes across diverse populations. METHODS: We reviewed 220 documents from a philanthropic initiative that funded collaborative efforts to improve conditions for health and equity in 14 California communities from 2010 to 2020. We examined the role of factors associated with movement-building approaches-such as organizing, base-building, investing in organizational capacity, and forming alliances-in securing policy and systems changes that foster more equitable community conditions. RESULTS: All 14 sites made progress in implementing policies and systems to improve the social determinants of health, including neighborhood conditions and the built environment, health care access, social and community context, economic stability, and education access. All 14 also shifted processes to be more inclusive of and responsive to community members, who in turn gained capacity to advocate for change and build collective power. CONCLUSION: Local public health leaders can make progress toward health equity by drawing on movement-building approaches to change policies and systems that affect social determinants of health.

Management of Gastroschisis: Results From the NETS2G Study, a Joint British, Irish, and Canadian Prospective Cohort Study of 1268 Infants.

OBJECTIVE: In infants with gastroschisis, outcomes were compared between those where operative reduction and fascial closure were attempted ≤24 hours of age (PC), and those who underwent planned closure of their defect >24 hours of age following reduction with a pre-formed silo (SR). SUMMARY OF BACKGROUND DATA: Inadequate evidence exists to determine how best to treat infants with gastroschisis. METHODS: A secondary analysis was conducted of data collected 2006-2008 using the British Association of Pediatric Surgeons Congenital Anomalies Surveillance System, and 2005-2016 using the Canadian Pediatric Surgery Network.28-day outcomes were compared between infants undergoing PC and SR. Primary outcome was number of gastrointestinal complications. Interactions were investigated between infant characteristics and treatment to determine whether intervention effect varied in sub-groups of infants. RESULTS: Data from 341 British and Irish infants (27%) and 927 Canadian infants (73%) were used. 671 infants (42%) underwent PC and 597 (37%) underwent SR. The effect of SR on outcome varied according to the presence/absence of intestinal perforation, intestinal matting and intestinal necrosis. In infants without these features, SR was associated with fewer gastrointestinal complications [aIRR 0.25 (95% CI 0.09-0.67, P = 0.006)], more operations [aIRR 1.40 (95% CI 1.22-1.60, P < 0.001)], more days PN [aIRR 1.08 (95% CI 1.03-1.13, P < 0.001)], and a higher infection risk [aOR 2.06 (95% CI 1.10-3.87, P = 0.025)]. In infants with these features, SR was associated with a greater number of operations [aIRR 1.30 (95% CI 1.17-1.45, P < 0.001)], and more days PN [aIRR 1.06 (95% CI 1.02-1.10, P = 0.003)]. CONCLUSIONS: In infants without intestinal perforation, matting, or necrosis, the benefits of SR outweigh its drawbacks. In infants with these features, the opposite is true. Treatment choice should be based upon these features.

Viral hepatitis in correctional facilities in the Northern Territory of Australia 2003-2017.

BACKGROUND: The demographic of Northern Territory prison population differs than elsewhere in Australia and the prevalence of hepatitis B and hepatitis C may therefore be somewhat different from other jurisdictions. There has been no study which has specifically described the serological results of a large proportion of prisoners in Northern Territory correctional facilities over an extended period of time. METHODS: This retrospective longitudinal study reviewed serological results and testing rates for hepatitis B, and hepatitis C performed in correctional facilities in the Northern Territory of Australia between July 1st, 2003 and June 30th, 2017. RESULTS: The proportion of positive records over 14 years for hepatitis B surface antigen (HBsAg) was 641/12,066 (5.3, 95% CI 4.9-5.7), for hepatitis B core antibody (anti-HBc) 4937/12,138 (40.1, 95%CI 39.8-41.6), for hepatitis B surface antibody (anti-HBs) 6966/13,303 (52.4, 95% CI 51.5-53.2), and for hepatitis C antibody 569/12,153 (4.7, 95% CI 4.3-5.1). The proportion of prisoners tested for hepatitis B and hepatitis C has decreased since 2015, while a high proportion of prisoners remain non-immune to hepatitis B. CONCLUSION: There is a relatively high proportion of positive serological markers of hepatitis B, and a lower proportion of positive hepatitis C serology in the Northern Territory's correctional facilities compared to overall Australian rates. As the proportion of prisoners tested for hepatitis B and C has decreased recently, and a high proportion of prisoners remain non-immune to hepatitis B, there are opportunities to increase testing and vaccination rates in this population.

Invasive salmonellosis in paediatric patients in the Northern Territory, Australia, 2005-2015.

AIM: To describe the epidemiology of invasive Salmonella disease in children in the Northern Territory, Australia. METHODS: Design: A retrospective review of invasive salmonellosis cases identified by pathology records and the Northern Territory Notifiable Disease Surveillance System. Case definitions: Those aged 18 years or under, with Salmonella cultured from a usually sterile site, collected in the Northern Territory between 1 July 2005 and 30 June 2015. OUTCOME MEASURES: The primary outcome measure was the annual incidence rate of invasive salmonellosis, comparing rates between Indigenous and non-Indigenous children. RESULTS: There were 86 cases of invasive Salmonella infection in children over the 10-year period; an annual incidence of 14.1 per 100 000 population, in those aged less than 18 years. Gastrointestinal Salmonella notifications were similar between Indigenous and non-Indigenous children. In children aged less than 15 years, the rate of invasive salmonellosis was higher in Indigenous children compared to non-Indigenous children (23.4 per 100 000 compared with 11.6 per 100 000); rate ratio 2.0 (95% confidence interval 1.3-3.3, P = 0.002). Indigenous children with invasive salmonellosis had a median hospital stay of 8 days, which was compared to 5 days for non-Indigenous children (P = 0.015). The highest incidence rate of invasive salmonellosis occurred in Indigenous patients less than 12 months of age (138 per 100 000). CONCLUSION: The Northern Territory of Australia has high rates of invasive salmonellosis in children. Indigenous and non-Indigenous children experience similar rates of Salmonella gastroenteritis but Indigenous children experience higher rates of invasive salmonellosis.

Temporal trends in paediatric bacterial meningitis in a tropical Australian region: 1992-2014.

AIM: The epidemiology of community-acquired bacterial meningitis has changed following the introduction of routine immunisation against common causative organisms. Indigenous children living in the Northern Territory, Australia, have high rates of bacterial infections. This study describes changes in the epidemiology of childhood bacterial meningitis and the distribution of the burden of disease in the Top End. METHODS: A retrospective review of cases derived from hospital medical records and laboratory data was performed. Inclusion criteria were children aged 3 months to 14 years of age, admitted to Royal Darwin Hospital between 1992 and 2014 and diagnosed with bacterial meningitis. Annual incidence of bacterial meningitis and the distribution of causative pathogens are described. Demographic data, investigations, treatment and outcomes were compared between Indigenous and non-Indigenous children. RESULTS: There were 137 cases of childhood bacterial meningitis identified over the 23-year period. The incidence reduced from 21 per 100 000 children per year for 1992-2002 to 11 per 100 000 per year for 2003-2014 (P = 0.0025). Haemophilus influenzae type b, Streptococcus pneumoniae and Neisseria meningitidis were the most common causative organisms, with a reduction in cases for each pathogen observed across the study period. Indigenous children were over-represented (104/137, 76%). Case fatality rate was 8% (11/137); 91% of fatal cases presented to a remote facility. CONCLUSIONS: The incidence of childhood bacterial meningitis has declined in the Northern Territory of Australia, but Indigenous children are disproportionately affected. Routine immunisation is beneficial for all, although further efforts to 'Close the Gap' between health outcomes in Indigenous and non-Indigenous Australians is required.

Combination of Vancomycin and ß-Lactam Therapy for Methicillin-Resistant Staphylococcus aureus Bacteremia: A Pilot Multicenter Randomized Controlled Trial.

BACKGROUND: In vitro laboratory and animal studies demonstrate a synergistic role for the combination of vancomycin and antistaphylococcal ß-lactams for methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. Prospective clinical data are lacking. METHODS: In this open-label, multicenter, clinical trial, adults with MRSA bacteremia received vancomycin 1.5 g intravenously twice daily and were randomly assigned (1:1) to receive intravenous flucloxacillin 2 g every 6 hours for 7 days (combination group) or no additional therapy (standard therapy group). Participants were stratified by hospital and randomized in permuted blocks of variable size. Randomization codes were kept in sealed, sequentially numbered, opaque envelopes. The primary outcome was the duration of MRSA bacteremia in days. RESULTS: We randomly assigned 60 patients to receive vancomycin (n = 29), or vancomycin plus flucloxacillin (n = 31). The mean duration of bacteremia was 3.00 days in the standard therapy group and 1.94 days in the combination group. According to a negative binomial model, the mean time to resolution of bacteremia in the combination group was 65% (95% confidence interval, 41%-102%; P = .06) that in the standard therapy group. There was no difference in the secondary end points of 28- and 90-day mortality, metastatic infection, nephrotoxicity, or hepatotoxicity. CONCLUSIONS: Combining an antistaphylococcal ß-lactam with vancomycin may shorten the duration of MRSA bacteremia. Further trials with a larger sample size and objective clinically relevant end points are warranted. Australian New Zealand Clinical Trials Registry: ACTRN12610000940077 (www.anzctr.org.au).

Melioidosis diagnostic workshop, 2013.

Melioidosis is a severe disease that can be difficult to diagnose because of its diverse clinical manifestations and a lack of adequate diagnostic capabilities for suspected cases. There is broad interest in improving detection and diagnosis of this disease not only in melioidosis-endemic regions but also outside these regions because melioidosis may be underreported and poses a potential bioterrorism challenge for public health authorities. Therefore, a workshop of academic, government, and private sector personnel from around the world was convened to discuss the current state of melioidosis diagnostics, diagnostic needs, and future directions.

Decreasing prevalence of Trichuris trichiura (whipworm) in the Northern Territory from 2002 to 2012.

OBJECTIVE: To observe the prevalence, disease associations, and temporal trends in Trichuris trichiura (whipworm) infection in the Northern Territory between 2002 and 2012. DESIGN, PARTICIPANTS AND SETTING: Retrospective observational analysis of consecutive microbiologically confirmed cases of T. trichiura infection among members of the NT population from whom a faecal sample was obtained for testing by NT Government health care facilities between 1 January 2002 and 31 December 2012. MAIN OUTCOME MEASURES: Annual prevalence of T. trichiura infection; age, sex, Indigenous status and place of residence of infected patients; percentage of infected patients with anaemia (haemoglobin level, ≤ 110 g/L) and eosinophilia (eosinophil count, ≥ 0.5 × 10(9)/L). RESULTS: 417 episodes of T. trichiura infection were identified over the 11 years from 63 668 faecal samples. The median age of patients was 8 years (interquartile range [IQR], 3-36 years). Patients were predominantly Indigenous (95.3%; P = 0.001) and from three main geographical areas (Victoria Daly, East Arnhem Land and West Arnhem Land). Infections were associated with anaemia (40.2%) and eosinophilia (51.6%). There was a downward trend in the prevalence of T. trichiura infection diagnosed at NT Government health care facilities, from 123.1 cases (95% CI, 94.8-151.3 cases) per 100,000 Indigenous population in 2002 to 35.8 cases (95% CI, 21.8-49.9 cases) per 100,000 Indigenous population in 2011. CONCLUSIONS: T. trichiura is the most frequently identified soil-transmitted helminth infecting patients in NT Government health care facilities. Cases are identified predominantly in Indigenous patients in remote communities. We have observed a declining prevalence of whipworm infection in the NT.

Comprehensive observational study evaluating the enduring effectiveness of 4CMenB, the meningococcal B vaccine against gonococcal infections in the Northern Territory and South Australia, Australia: study protocol.

INTRODUCTION: The effectiveness of antibiotics for treating gonococcal infections is compromised due to escalating antibiotic resistance; and the development of an effective gonococcal vaccine has been challenging. Emerging evidence suggests that the licensed meningococcal B (MenB) vaccine, 4CMenB is effective against gonococcal infections due to cross-reacting antibodies and 95% genetic homology between the two bacteria, Neisseria meningitidis and Neisseria gonorrhoeae, that cause the diseases. This project aims to undertake epidemiological and genomic surveillance to evaluate the long-term protection of the 4CMenB vaccine against gonococcal infections in the Northern Territory (NT) and South Australia (SA), and to determine the potential benefit of a booster vaccine doses to provide longer-term protection against gonococcal infections. METHODS AND ANALYSES: This observational study will provide long-term evaluation results of the effectiveness of the 4CMenB vaccine against gonococcal infections at 4-7 years post 4CMenB programme implementation. Routine notifiable disease notifications will be the basis for assessing the impact of the vaccine on gonococcal infections. Pathology laboratories will provide data on the number and percentage of N. gonorrhoeae positive tests relative to all tests administered and will coordinate molecular sequencing for isolates. Genome sequencing results will be provided by SA Pathology and Territory Pathology/New South Wales Health Pathology, and linked with notification data by SA Health and NT Health. There are limitations in observational studies including the potential for confounding. Confounders will be analysed separately for each outcome/comparison. ETHICS AND DISSEMINATION: The protocol and all study documents have been reviewed and approved by the SA Department for Health and Well-being Human Research Ethics Committee (HREC/2022/HRE00308), and the evaluation will commence in the NT on receipt of approval from the NT Health and Menzies School of Health Research Human Research Ethics Committee. Results will be published in peer-reviewed journals and presented at scientific meetings and public forums.

Characterisation of Corynebacterium diphtheriae isolates in the Northern Territory of Australia.

This article summarises our review of 41 Corynebacterium diphtheriae wound swab isolates from the tropical Northern Territory of Australia. On polymerase chain reaction and whole genome sequencing, no isolates were toxigenic strains.

Group B streptococcus in the Northern Territory in 2023: clindamycin down but not out.

Group B streptococcus (GBS) is a significant cause of perinatal morbidity and mortality; prophylactic antibiotics in the obstetric population can mitigate the risk of neonatal infection. The antibiotic of choice is penicillin; however, in women who have a penicillin hypersensitivity, clindamycin is the preferred agent. Worldwide resistance to clindamycin is rising in GBS isolates. In the Top End of the Northern Territory of Australia, we reviewed 113 GBS isolates in 2023. These GBS isolates revealed a 30% resistance to clindamycin. This rate has considerably increased since the Australia-wide survey published in 2011 where GBS resistance to clindamycin was quoted at 4.2%. As a result of this study, we are advocating for a change in practice in patients with known GBS resistance with penicillin hypersensitivity.

Neonatal Group B Streptococcal Infection in Australia: A Case-control Study.

BACKGROUND: To determine maternal and neonatal risk factors for, and incidence of, neonatal early-onset group B streptococcus (EOGBS) and late-onset (LOGBS) infection in South Australia (SA) and the Northern Territory (NT). METHODS: A case-control study with 2:1 matched controls to cases. The study included tertiary hospitals in South Australia and the Northern Territory, Australia. Retrospective data were collected from a 16-year epoch (2000-2015). RESULTS: Of a total of 188 clinically suspected or confirmed cases, 139 were confirmed, of which 56.1% (n = 78) were EOGBS and 43.9% (n = 61) were LOGBS. The incidence of clinically suspected and confirmed cases of EOGBS was 0.26/1000 live births in SA and 0.73/1000 live births in the NT, and the incidence of confirmed cases was 0.19/1000 for SA and 0.36/1000 for the NT. The incidence of clinically suspected or confirmed LOGBS was 0.18/1000 live births in SA and 0.16/1000 for the NT. The majority of infants with GBS presented with sepsis, pneumonia, or meningitis. Developmental delay was the most commonly recorded long-term complication at 1 year old. Risk factors for EOGBS included maternal GBS carriage, previous fetal death, identifying as Aboriginal and/or Torres Strait Islander, and maternal fever in labor/chorioamnionitis. CONCLUSIONS: GBS remains a leading cause of neonatal morbidity and mortality. Adding previous fetal death to GBS screening guidelines would improve GBS prevention. The introduction of maternal GBS vaccination programs should be guided by country-specific disease epidemiology.

The COVID-19 laboratory response in Timor-Leste; a story of collaboration.

Timor-Leste is a small nation of 1.3 million people which shares a land border with Indonesia and is 550 km from Darwin, Australia. It is one of the poorest nations in Asia. The National Health Laboratory (NHL) and its network of smaller laboratories in Timor-Leste had limited capacity to perform molecular diagnostic testing before the coronavirus disease 2019 (COVID-19) pandemic began. With the support of international development partners, the NHL rapidly expanded its molecular testing service. From March 2020 to February 2022, over 200,000 molecular tests were performed; COVID-19 testing sites were established in hospital and community health center laboratories and all 13 municipalities, and the number of scientists and technicians at the molecular diagnostic laboratory at the NHL increased from five to 28 between 2019 and 2022. Molecular diagnostic testing for COVID-19 was successfully established at the NHL and in the municipalities. The molecular diagnostic laboratory at NHL is now equipped to respond to not only large-scale COVID-19 testing but also laboratory detection of other infectious diseases, preparing Timor-Leste for future outbreaks or pandemics.

Epidemiological and clinical characteristics of legionellosis in Northern Australia, 2010-2021.

Objective: This study describes characteristics of the legionellosis cases occurring between 2010 and 2021 in the Northern Territory (NT), Australia. Methods: We retrospectively reviewed 53 cases of legionellosis during the defined period and documented patient and clinical characteristics, diagnostics, and seasonality of infection. Results: All cases were sporadic. The incidence rate in the NT was higher than the Australian median rate (2.1 and 1.5 per 100,000 population per year respectively). Aboriginal and Torres Strait Islander patients presented at a younger age than did non-Indigenous patients (median 41 and 60 years of age respectively), and overall there was a male preponderance. There was a higher proportion of legionellosis in the months with increased humidity, with a greater number of L. longbeachae infections detected overall (59%) than of L. pneumophila (41%). The majority of cases were diagnosed serologically (57% of L. pneumophilia and 93% of L. longbeachae ). Conclusions: Legionellosis in the NT is more common, seasonal, and may be underreported due to current reliance on serological testing for diagnosis. The higher incidence of legionellosis, and the younger age of Aboriginal and Torres Strait Islander patients of the NT, have public health implications, given that the clinical presentation of legionellosis is indistinguishable from other forms of pneumonia.