Predicting child development and school readiness, at age 5, for Aboriginal and non-Aboriginal children in Australia's Northern Territory.

BACKGROUND: Positive early development is critical in shaping children's lifelong health and wellbeing. Identifying children at risk of poor development is important in targeting early interventions to children and families most in need of support. We aimed to develop a predictive model that could inform early support for vulnerable children. METHODS: We analysed linked administrative records for a birth cohort of 2,380 Northern Territory children (including 1,222 Aboriginal children) who were in their first year of school in 2015 and had a completed record from the Australian Early Development Census (AEDC). The AEDC measures early child development (school readiness) across five domains of development. We fitted prediction models, for AEDC weighted summary scores, using a Partial Least Square Structural Equation Model (PLS-SEM) considering four groups of factors-pre-pregnancy, pregnancy, known at birth, and child-related factors. We first assessed the models' internal validity and then the out-of-sample predictive power (external validity) using the PLSpredict procedure. RESULT: We identified separate predictive models, with a good fit, for Aboriginal and non-Aboriginal children. For Aboriginal children, a significant pre-pregnancy predictor of better outcomes was higher socioeconomic status (direct, ß = 0.22 and indirect, ß = 0.16). Pregnancy factors (gestational diabetes and maternal smoking (indirect, ß = -0.09) and child-related factors (English as a second language and not attending preschool (direct, ß = -0.28) predicted poorer outcomes. Further, pregnancy and child-related factors partially mediated the effects of pre-pregnancy factors; and child-related factors fully mediated the effects of pregnancy factors on AEDC weighted scores. For non-Aboriginal children, pre-pregnancy factors (increasing maternal age, socioeconomic status, parity, and occupation of the primary carer) directly predicted better outcomes (ß = 0.29). A technical observation was that variance in AEDC weighted scores was not equally captured across all five AEDC domains; for Aboriginal children results were based on only three domains (emotional maturity; social competence, and language and cognitive skills (school-based)) and for non-Aboriginal children, on a single domain (language and cognitive skills (school-based)). CONCLUSION: The models give insight into the interplay of multiple factors at different stages of a child's development and inform service and policy responses. Recruiting children and their families for early support programs should consider both the direct effects of the predictors and their interactions. The content and application of the AEDC measurement need to be strengthened to ensure all domains of a child's development are captured equally.

An evaluation of the quality of ear health services for Aboriginal children living in remote Australia: a cascade of care analysis.

BACKGROUND: In the Northern Territory (NT) the prevalence of otitis media (OM) in young Aboriginal children living in remote communities has persisted at around 90% over the last few decades. OM-associated hearing loss can cause developmental delay and adversely impact life course trajectories. This study examined the 5-year trends in OM prevalence and quality of ear health services in remote NT communities. METHODS: A retrospective analysis was performed on de-identified clinical data for 50 remote clinics managed by the NT Government. We report a 6-monthly cascade analysis of the proportions of children 0-16 years of age receiving local guideline recommendations for surveillance, OM treatment and follow-up at selected milestones between 2014 and 2018. RESULTS: Between 6,326 and 6,557 individual children were included in the 6-monthly analyses. On average, 57% (95%CI: 56-59%) of eligible children had received one or more ear examination in each 6-monthly period. Of those examined, 36% (95%CI: 33-40%) were diagnosed with some type of OM, of whom 90% had OM requiring either immediate treatment or scheduled follow-up according to local guidelines. Outcomes of treatment and follow-up were recorded in 24% and 23% of cases, respectively. Significant decreasing temporal trends were found in the proportion diagnosed with any OM across each age group. Overall, this proportion decreased by 40% over the five years (from 43 to 26%). CONCLUSIONS: This cascade of care analysis found that ear health surveillance and compliance with otitis media guidelines for treatment and follow-up were both low. Further research is required to identify effective strategies that improve ear health services in remote settings.

Pathways to school success: Self-regulation and executive function, preschool attendance and early academic achievement of Aboriginal and non-Aboriginal children in Australia's Northern Territory.

BACKGROUND: With the pending implementation of the Closing the Gap 2020 recommendations, there is an urgent need to better understand the contributing factors of, and pathways to positive educational outcomes for both Aboriginal and non-Aboriginal children. This deeper understanding is particularly important in the Northern Territory (NT) of Australia, in which the majority of Aboriginal children lived in remote communities and have language backgrounds other than English (i.e. 75%). METHODS: This study linked the Australian Early Development Census (AEDC) to the attendance data (i.e. government preschool and primary schools) and Year 3 National Assessment Program for Literacy and Numeracy (NAPLAN). Structural equation modelling was used to investigate the pathway from self-regulation and executive function (SR-EF) at age 5 to early academic achievement (i.e. Year 3 reading/numeracy at age 8) for 3,199 NT children. RESULT: The study confirms the expected importance of SR-EF for all children but suggests the different pathways for Aboriginal and non-Aboriginal children. For non-Aboriginal children, there was a significant indirect effect of SR-EF (ß = 0.38, p<0.001) on early academic achievement, mediated by early literacy/numeracy skills (at age 5). For Aboriginal children, there were significant indirect effects of SR-EF (ß = 0.19, p<0.001) and preschool attendance (ß = 0.20, p<0.001), mediated by early literacy/numeracy skills and early primary school attendance (i.e. Transition Years to Year 2 (age 5-7)). CONCLUSION: This study highlights the need for further investigation and development of culturally, linguistically and contextually responsive programs and policies to support SR-EF skills in the current Australian education context. There is a pressing need to better understand how current policies and programs enhance children and their families' sense of safety and support to nurture these skills. This study also confirms the critical importance of school attendance for improved educational outcomes of Aboriginal children. However, the factors contributing to non-attendance are complex, hence the solutions require multi-sectoral collaboration in place-based design for effective implementation.

A community-based service enhancement model of training and employing Ear Health Facilitators to address the crisis in ear and hearing health of Aboriginal children in the Northern Territory, the Hearing for Learning Initiative (the HfLI): study protocol for a stepped-wedge cluster randomised trial.

BACKGROUND: Almost all Aboriginal children in remote communities have persistent bilateral otitis media affecting hearing and learning throughout early childhood and school years, with consequences for social and educational outcomes, and later employment opportunities. Current primary health care and specialist services do not have the resources to meet the complex needs of these children. METHOD/DESIGN: This stepped-wedge cluster randomised trial will allocate 18 communities to one of five 6-monthly intervention start dates. Stratification will be by region and population size. The intervention (Hearing for Learning Initiative, HfLI) consists of six 20-h weeks of training (delivered over 3 months) that includes Certificate II in Aboriginal Primary Health Care (3 modules) and competencies in ear and hearing data collection (otoscopy, tympanometry and hearScreen), plus 3 weeks of assisted integration into the health service, then part-time employment as Ear Health Facilitators to the end of the trial. Unblinding will occur 6 months prior to each allocated start date, to allow Community Reference Groups to be involved in co-design of the HfLI implementation in their community. Relevant health service data will be extracted 6-monthly from all 18 communities. The primary outcome is the difference in proportion of children (0 to 16 years of age) who have at least one ear assessment (diagnosis) documented in their medical record within each 6-month period, compared to control periods (no HfLI). Secondary outcomes include data on sustainability, adherence to evidence-based clinical guidelines for otitis media, including follow-up and specialist referrals, and school attendance. Structured interviews with staff working in health and education services, Ear Health Trainees, Ear Health Facilitators and families will assess process outcomes and the HfLI broader impact. DISCUSSION: The impact of training and employment of Ear Health Facilitators on service enhancement will inform the health, education and employment sectors about effectiveness of skills and job creation that empowers community members to contribute to addressing issues of local importance, in this instance ear and hearing health of children. TRIAL REGISTRATION: ClinicalTrials.gov NCT03916029 . Registered on 16 April 2019.

The impact of hearing impairment on early academic achievement in Aboriginal children living in remote Australia: a data linkage study.

BACKGROUND: The prevalence of otitis media (OM) and related hearing loss has remained persistently high among some groups of Australian Aboriginal children who are also reported to have poor academic outcomes. The general literature remains inconclusive about the association between OM-related hearing loss and academic performance in primary school. This study aimed to investigate this association in Aboriginal children living in the Northern Territory (NT) of Australia. METHODS: A retrospective, observational cohort study was conducted for 2208 NT Aboriginal children, aged about 8 years, living in remote and very remote communities. The explanatory variable was audiometrically determined hearing level as recorded in the Remote Hearing Assessment dataset. The outcome variable consisted of scale scores in the five domains of the National Assessment Program - Literacy and Numeracy (NAPLAN) for Year 3. Other linked datasets used in the study included school attendance records, perinatal records and community level information on relative remoteness, socioeconomic disadvantage and housing crowdedness. Fixed effects linear regression models were used for statistical analyses. RESULTS: Compared with children with normal hearing and after controlling for a range of covariates, children with mild hearing impairment (HI) scored lower in Writing and Spelling by 15.0 points (95% CI: - 22.4 to - 7.6, p < 0.0005) and 5.0 points (95% CI: - 9.6 to - 0.3, p = 0.037), equivalent to 7.3 and 2.1% of the mean score, respectively. Children with moderate or worse HI scored lower in Writing and Numeracy by 13.4 points (95% CI, - 24.8 to - 1.9, p = 0.022) and 15.2 points (95% CI, - 27.6 to - 2.7, p = 0.017), both equivalent to 6.3% of the mean score the respective domain. Other factors associated with poorer NAPLAN results included being male, lower Year 2 school attendance, low birthweight, average household size> 5 persons, living in a very remote community and speaking English as a second language. CONCLUSIONS: OM-related HI was independently associated with poorer early year academic achievement in Aboriginal children living in remote NT communities. Interventions to improve academic outcomes for Aboriginal children must incorporate actions to address the negative impact associated with HI through early detection, effective treatment and ongoing support for affected children.

Impact of hearing impairment on early childhood development in Australian Aboriginal children: A data linkage study.

AIM: To investigate the association between hearing impairment (HI) and measures of early childhood development in Aboriginal children at age 5 years. METHODS: An observational cohort study (n = 1037) of children aged 4.0-7.3 years (median 5.4 years), living in remote Northern Territory (NT) communities, was conducted using multiple linked administrative datasets, including the NT Perinatal Data Register, Remote Hearing Assessment records (2007-2015) and Australian Early Development Censuses (AEDC, 2009, 2012 and 2015). Outcome measures were summary and domain-specific AEDC results using both dichotomous and continuous variables (domain scores). RESULTS: Compared with normal hearing children, after adjustment for selected confounding factors, those with moderate or worse HI had an adjusted odds ratio of 1.69 (95% confidence interval (CI), 1.03-2.77) for being developmentally vulnerable in two or more of the five AEDC domains. Children with mild HI and those with moderate to worse HI had lower domain score sum by -1.60 (95% CI, -3.02 to -0.18) and - 2.40 (95% CI, -4.50 to -0.30), respectively. There was also evidence for an association between HI and poorer outcomes in the 'language and cognitive skills', 'communication skills and general knowledge' and 'physical health and wellbeing' domains. CONCLUSIONS: Otitis media-related HI is associated with increased risk for poorer outcomes in early childhood development and this risk appears to increase with higher levels of HI. Prevention and early treatment of otitis media will reduce both the disease and the associated negative impact on early child development, especially the development of language, cognitive and communication skills and physical health and wellbeing.

Data linkage and computerised algorithmic coding to enhance individual clinical care for Aboriginal people living with chronic hepatitis B in the Northern Territory of Australia - Is it feasible?

BACKGROUND: Chronic hepatitis B (CHB) is endemic in the Aboriginal population of Australia's Northern Territory (NT). However, many people's hepatitis B virus (HBV) status remains unknown. OBJECTIVE: 1. To maximise the utility of existing HBV test and vaccination data in the NT by creating a linked dataset and computerised algorithmic coding. 2. To undertake rigorous quality assurance processes to establish feasibility of using the linked dataset and computerised algorithmic coding for individual care for people living with CHB. METHODS: Step 1: We used deterministic data linkage to merge information from three separate patient databases. HBV testing and vaccination data from 2008-2016 was linked and extracted for 19,314 people from 21 remote Aboriginal communities in the Top End of the NT. Step 2: A computerised algorithm was developed to allocate one of ten HBV codes to each individual. Step 3: A quality assurance process was undertaken by a clinician, using standardised processes, manually reviewing all three databases, for a subset of 5,293 Aboriginal people from five communities to check the accuracy of each allocated code. RESULTS: The process of data linking individuals was highly accurate at 99.9%. The quality assurance process detected an overall error rate of 17.7% on the HBV code generated by the computerised algorithm. Errors occurred in source documentation, primarily from the historical upload of paper-based records to electronic health records. An overall HBV prevalence of 2.6% in five communities was found, which included ten cases of CHB who were previously unaware of infection and not engaged in care. CONCLUSIONS: Data linkage of individuals was highly accurate. Data quality issues and poor sensitivity in the codes produced by the computerised algorithm were uncovered in the quality assurance process. By systematically, manually reviewing all available data we were able to allocate a HBV status to 91% of the study population.

The link between hearing impairment and child maltreatment among Aboriginal children in the Northern Territory of Australia: is there an opportunity for a public health approach in child protection?

BACKGROUND: International studies provide evidence of an association between child disabilities, including hearing impairment (HI), and child maltreatment. There are high prevalences of ear disease with associated HI, and child maltreatment among Australian Aboriginal children, but the link between HI and child maltreatment is unknown. This study investigates the association between HI and child maltreatment for Aboriginal children living in the Northern Territory (NT) of Australia. METHODS: This was a retrospective cohort study of 3895 Aboriginal school-aged children (born between 1999 and 2008) living in remote NT communities. The study used linked individual-level information from health, education and child protection services. The outcome variables were child maltreatment notifications and substantiations. The key explanatory variable, HI, was based on audiometric assessment. The Kaplan-Meier estimator method was used in univariate analysis; Cox proportional hazards regression was used in multivariable analysis. RESULTS: A majority of the study cohort lived in very remote (94.5%) and most disadvantaged (93.1%) regions. Among all children in the study cohort, 56.1% had a record of either HI or unilateral hearing loss (UHL), and for those with a history of contact with child protection services (n = 2757), 56.7% had a record of HI/UHL (n = 1564). In the 1999-2003 birth cohort, by age 12 years, 53.5% of children with a record of moderate or worse HI had at least one maltreatment notification, compared to 47.3% of children with normal hearing. In the 2004-2008 cohort, the corresponding results were 83.4 and 71.7% respectively. In multivariable analysis, using the full cohort, children with moderate or worse HI had higher risk of any child maltreatment notification (adjusted Hazard Ratios (adjHR): 1.16, 95% CI:1.04-1.30), notification for neglect (adjHR:1.17, 95% CI:1.04-1.31) and substantiation (adjHR:1.20, 95% CI:1.04-1.40), than children with normal hearing. In the 2004-2008 birth cohort, children with moderate or worse HI had higher risk of a substantiated episode of physical abuse (adjHR:1.47, 95% CI:1.07-2.03) than children with normal hearing. CONCLUSION: Our findings demonstrate the urgent need for HI and child maltreatment prevention strategies through raised community awareness and inter-agency collaboration. Effective information-sharing between service providers is a critical first step to a public health approach in child protection.

The Impact of Hearing Impairment on the Life Trajectories of Aboriginal Children in Remote Australia: Protocol for the Hearing Loss in Kids Project.

BACKGROUND: Previous studies have reported a high prevalence of chronic otitis media (OM) and hearing impairment (HI) in Aboriginal children in the Northern Territory (NT) of Australia. Children affected by these disorders are believed to be at increased risk for adverse outcomes in early childhood development, school attendance, academic performance, and child maltreatment and youth offending. However, to date, there have been no studies quantifying the association between HI and these outcomes in this population. OBJECTIVE: This study will investigate the association between HI and the 5 outcomes in Aboriginal children living in remote NT communities. METHODS: Individual-level information linked across multiple administrative datasets will be used to conduct a series of retrospective observational studies on selected developmental and school outcomes. The predictor variables for all studies are the results from audiometric hearing assessments. The outcome measures are as follows: Australian Early Development Census results, representing developmental readiness for school, assessed around 5 years of age; Year 1 school attendance rates; Year 3 school-based academic performance, assessed in the National Assessment Program-Literacy and Numeracy; incidence of child maltreatment events (including both notifications and substantiated cases); and incidence of a first guilty verdict for youth offenders. Confounding and moderating factors available for the analysis include both community-level factors (including school fixed effects, socioeconomic status, level of remoteness, and housing crowdedness) and individual-level factors (including maternal and perinatal health and hospital admissions in early childhood). RESULTS: The study commenced in 2018, with ethics and data custodian approvals for data access and linkage. This has enabled the completion of data linkage and the commencement of data analysis for individual component studies, with findings expected to be published in 2019 and 2020. CONCLUSIONS: This study will provide first evidence of the impact of OM-related HI on the developmental, educational, and social outcomes of Australian Aboriginal children. The findings are expected to have significant implications for policy development, service design, and resource allocation. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/15464.

Hearing and justice: The link between hearing impairment in early childhood and youth offending in Aboriginal children living in remote communities of the Northern Territory, Australia.

BACKGROUND: High prevalence of chronic middle ear disease has persisted in Australian Aboriginal children, and the related hearing impairment (HI) has been implicated in a range of social outcomes. This study investigated the association between HI in early childhood and youth offending. METHOD: This was a retrospective cohort study of 1533 Aboriginal children (born between 1996 and 2001) living in remote Northern Territory communities. The study used linked individual-level information from health, education, child protection and youth justice services. The outcome variable was a youth being "found guilty of an offence". The key explanatory variable, hearing impairment, was based on audiometric assessment. Other variables were: child maltreatment notifications, Year 7 school enrolment by mother, Year 7 school attendance and community 'fixed- effects'. The Cox proportional hazards model was used to estimate the association between HI and youth offending; and the Royston R2 measure to estimate the separate contributions of risk factors to youth offending. RESULTS: The proportion of hearing loss was high in children with records of offence (boys: 55.6%, girls: 36.7%) and those without (boys: 46.1%; girls: 49.0%). In univariate analysis, a higher risk of offending was found among boys with moderate or worse HI (HR: 1.77 [95% CI: 1.05-2.98]) and mild HI (HR: 1.54 [95% CI:1.06-2.23]). This association was attenuated in multivariable analysis (moderate HI, HR: 1.43 [95% CI:0.78-2.62]; mild HI, HR: 1.37 [95% CI: 0.83-2.26]). No evidence for an association was found in girls. HI contributed 3.2% and 6.5% of variation in offending among boys and girls respectively. Factors contributing greater variance included: community 'fixed-effects' (boys: 14.6%, girls: 36.5%), child maltreatment notification (boys: 14.2%, girls: 23.9%) and year 7 school attendance (boys: 7.9%; girls 12.1%). Enrolment by mother explained substantial variation for girls (25.4%) but not boys (0.2%). CONCLUSION: There was evidence, in univariate analysis, for an association between HI and youth offending for boys however this association was not evident after controlling for other factors. Our findings highlight a range of risk factors that underpin the pathway to youth-offending, demonstrating the urgent need for interagency collaboration to meet the complex needs of vulnerable children in the Northern Territory.

The impact of hearing impairment on Aboriginal children's school attendance in remote Northern Territory: a data linkage study.

OBJECTIVE: To investigate the association between hearing impairment (HI) and Year 1 school attendance in Aboriginal children in the Northern Territory (NT) of Australia. METHODS: Observational cohort study (n=3,744) by analysing linked individual-level information for Aboriginal children from the NT Government school attendance records, NT Perinatal Register and Remote Hearing Assessment dataset, and community level data for relative remoteness, socioeconomic disadvantage and housing crowdedness. RESULTS: Children with unilateral hearing loss, mild HI and moderate or worse HI had significantly lower Year 1 attendance than those with normal hearing, attending 5.6 (95%CI, -9.10 ∼-2.10), 4.0 (95%CI, -7.17 ∼-0.90) and 6.1 (95%CI, -10.71 ∼-1.49) days fewer, respectively. Other variables that yielded significant association were: male gender, having attended preschool less than 20% of available days, speaking English as second language, twin birth and average household size >5. CONCLUSIONS: Aboriginal children with any level of HI are likely to have lower school attendance rates in Year 1 than their peers with normal hearing. Implications for public health: In this population, where the prevalence of otitis media and accompanying HI remains extremely high, the early detection and management of hearing loss on entry into primary school should be included in the measures to improve school attendance.

HIV incidence in Indigenous and non-Indigenous populations in Australia: a population-level observational study.

BACKGROUND: Australia has set a national target of ending HIV by 2020, achieving this will require the inclusion of priority populations (eg, Indigenous Australians) in strategies to reach elimination. To assist in evaluating the target of elimination, we analysed HIV notification data for Indigenous and non-Indigenous Australians. METHODS: Using the National HIV Registry at The Kirby Institute at UNSW, Sydney, NSW, Australia, we collated and analysed annual HIV notification data for 1996-2015. Patients who were not born in Australia were excluded. We calculated the rates of HIV diagnoses with annual trends in notification rates for Indigenous versus non-Indigenous Australians by demographic characteristics, exposure categories, and stage of HIV at diagnosis. For missing data, assumptions were made and verified through sensitivity analyses. Annual rate ratio (RR) and 4 year summary rate ratio (SRR) trends were calculated to determine patterns of HIV diagnosis in the two populations. FINDINGS: Between Jan 1, 1996, and Dec 31, 2015, 11 492 people born in Australia were reported with a diagnosis of HIV, of whom 461 (4%) were recorded as Indigenous Australians and we classified the remaining 11 031 (96%) as non-Indigenous Australians. For exposure to HIV, among Indigenous Australians a higher proportion of diagnoses occurred among women, and through injecting drug use and heterosexual sex than among non-Indigenous Australians (p<0·0001). Among Indigenous Australians, we found a significantly higher SRR of HIV diagnoses among men in the period 2012-15 than in previous periods (SRR 1·53, 95% CI 1·28-1·83; p<0·0001), and significantly higher diagnosis among Indigenous women (4·92, 4·02-6·02; p<0·0001) for the entire study period than among non-Indigenous women. Concurrently, a decrease in HIV diagnoses of 1% per annum (RR 0·99, 95% CI 0·98-0·99; p<0·0001) across the study period was seen among non-Indigenous people. Indigenous Australians were more likely to be diagnosed at an advanced stage of HIV infection than non-Indigenous Australians (20·8% vs 15·1%; p=0·0088). INTERPRETATION: Greater efforts should be made to include Indigenous people in prevention strategies, particularly newer biomedical interventions, such as scale up of pre-exposure prophylaxis and treatment as prevention initiatives in Australia. More involvement of Indigenous Australians in these approaches is also required to prevent widening of the gap in HIV diagnosis rates between non-Indigenous and Indigenous Australians. FUNDING: None.

An audit on the management and outcomes of infants at risk of congenital syphilis in the Top End of the Northern Territory, Australia, 2005-2013.

INTRODUCTION: Congenital syphilis (CS) remains a condition of serious clinical and public health importance, particularly in the Aboriginal populations of northern Australia, which have seen a recent resurgence in cases. In 2005, the Northern Territory (NT) Centre for Disease Control (CDC) published guidelines for management of infants at risk of CS. We audited the management and outcomes of infants at risk of CS who were born between 2005 and 2013 in the Darwin and Katherine regions of the NT. METHODS: Data, including serology, clinical examination, treatment, follow-up and infant outcomes at 12 months, were extracted from the Syphilis Register, medical and pathology records to assess clinician compliance with the CDC guidelines. RESULTS: Thirty-three infants were identified as being at risk of CS, 26 low risk and 7 high risk. Hospital management at birth conformed well with the guidelines, with 85% of low risk, and 100% of high risk infants receiving treatment and 92% of low risk and 86% of high risk having appropriate serology. Follow-up was poorly compliant, with only 48% of infants completing serological follow-up and less than 15% undergoing clinical examination. No definitive case of CS was identified among the at-risk children. CONCLUSIONS: Overall, peri-natal management of infants was performed well, but follow-up was poor. Effective systems to transfer care from hospitals to primary care are required to improve this. The fact that no infant had direct evidence of syphilis infection suggests consideration should be given to modifying the Australian surveillance case definition.

Molecular Antimicrobial Resistance Surveillance for Neisseria gonorrhoeae, Northern Territory, Australia.

Neisseria gonorrhoeae antimicrobial resistance (AMR) is a globally recognized health threat; new strategies are needed to enhance AMR surveillance. The Northern Territory of Australia is unique in that 2 different first-line therapies, based primarily on geographic location, are used for gonorrhea treatment. We tested 1,629 N. gonorrhoeae nucleic acid amplification test-positive clinical samples, collected from regions where ceftriaxone plus azithromycin or amoxicillin plus azithromycin are recommended first-line treatments, by using 8 N. gonorrhoeae AMR PCR assays. We compared results with those from routine culture-based surveillance data. PCR data confirmed an absence of ceftriaxone resistance and a low level of azithromycin resistance (0.2%), and that penicillin resistance was <5% in amoxicillin plus azithromycin regions. Rates of ciprofloxacin resistance and penicillinase-producing N. gonorrhoeae were lower when molecular methods were used. Molecular methods to detect N. gonorrhoeae AMR can increase the evidence base for treatment guidelines, particularly in settings where culture-based surveillance is limited.

Primary health clinic toilet/bathroom surface swab sampling can indicate community profile of sexually transmitted infections.

BACKGROUND: The microbiome of built environment surfaces is impacted by the presence of humans. In this study, we tested the hypothesis that analysis of surface swabs from clinic toilet/bathroom yields results correlated with sexually transmitted infection (STI) notifications from corresponding human populations. We extended a previously reported study in which surfaces in toilet/bathroom facilities in primary health clinics in the Australian Northern Territory (NT) were swabbed then tested for nucleic acid from the STI agents Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalis. This was in the context of assessing the potential for such nucleic acid to contaminate specimens collected in such facilities. STIs are notifiable in the NT, thus allowing comparison of swab and notification data. METHODS: An assumption in the design was that while absolute built environment loads of STI nucleic acids will be a function of patient traffic density and facility cleaning protocols, the relative loads of STI nucleic acids from different species will be largely unaffected by these processes. Another assumption was that the proportion of swabs testing positive for STIs provides a measure of surface contamination. Accordingly, "STI profiles" were calculated. These were the proportions that each of the three STIs of interest contributed to the summed STI positive swabs or notifications. Three comparisons were performed, using swab data from clinics in remote Indigenous communities, clinics in small-medium towns, and a single urban sexual health clinic. These data were compared with time and place-matched STI notifications. RESULTS: There were significant correlations between swab and notifications data for the both the remote Indigenous and regional data. For the remote Indigenous clinics the p values ranged from 0.041 to 0.0089, depending on data transformation and p value inference method. Further, the swab data appeared to strongly indicate known higher relative prevalence of gonorrhoeae in central Australia than in northern Australia. Similarly, the regional clinics yielded p values from 0.0088-0.0022. In contrast, swab and notifications data from the sexual health clinic were not correlated. DISCUSSION: Strong correlations between swab and notifications were observed. However, there was evidence for limitations of this approach. Despite the correlation observed with the regional clinics data, one clinic yielded zero positive swabs for C. trachomatis, although this STI constituted 25.1% of the corresponding notifications. This could be ascribed to stochastic effects. The lack of correlation observed for sexual health clinic data was also likely due to stochastic effects. It was concluded that toilet/bathroom surface swab sampling has considerable potential for public health surveillance. The approach may be applicable in situations other than primary health clinics, and for targets other than STIs.

The Molecular Epidemiology and Antimicrobial Resistance of Neisseria gonorrhoeae in Australia: A Nationwide Cross-Sectional Study, 2012.

BACKGROUND: Antimicrobial resistance (AMR) by Neisseria gonorrhoeae is considered a serious global threat. METHODS: In this nationwide study, we used MassARRAY iPLEX genotyping technology to examine the epidemiology of N. gonorrhoeae and associated AMR in the Australian population. All available N. gonorrhoeae isolates (n = 2452) received from Australian reference laboratories from January to June 2012 were included in the study. Genotypic data were combined with phenotypic AMR information to define strain types. RESULTS: A total of 270 distinct strain types were observed. The 40 most common strain types accounted for over 80% of isolates, and the 10 most common strain types accounted for almost half of all isolates. The high male to female ratios (>94% male) suggested that at least 22 of the top 40 strain types were primarily circulating within networks of men who have sex with men (MSM). Particular strain types were also concentrated among females: two strain types accounted for 37.5% of all isolates from females. Isolates harbouring the mosaic penicillin binding protein 2 (PBP2)-considered a key mechanism for cephalosporin resistance-comprised 8.9% of all N. gonorrhoeae isolates and were primarily observed in males (95%). CONCLUSIONS: This large scale epidemiological investigation demonstrated that N. gonorrhoeae infections are dominated by relatively few strain types. The commonest strain types were concentrated in MSM in urban areas and Indigenous heterosexuals in remote areas, and we were able to confirm a resurgent epidemic in heterosexual networks in urban areas. The prevalence of mosaic PBP2 harboring N. gonorrhoeae strains highlight the ability for new N. gonorrhoeae strains to spread and become established across populations.

Why are men less tested for sexually transmitted infections in remote Australian Indigenous communities? A mixed-methods study.

Gender disparities in testing rates for sexually transmitted infections (STIs) have been identified as one potential factor sustaining high rates of STIs and repeat infections in the Northern Territory of Australia, especially in remote Indigenous communities. The study aimed to investigate the reasons for these disparities utilising a mixed-method study design. We conducted an audit on client information at a remote community health clinic, focus-group discussions with young men in the same community and interviews with experienced remote area clinicians. The clinic audit found a significantly higher proportion of female residents of the community than males visited the clinic (72.8 versus 55.3%, p < 0.005). Women were also more likely to be tested for STIs than men when visiting the clinic (49.7 versus 40.3%, p = 0.015). Major barriers to men's seeking STI testing included a sense of shame from being seen visiting the clinic by women, men's lack of understanding of STIs and the need for testing, and inadequate access to male clinicians. Increasing men's access to healthcare and STI testing requires offering testing at a gender-sensitive and separate locations, and community-based sexual health promotion to increase knowledge of STIs.

Community and clinic-based screening for curable sexually transmissible infections in a high prevalence setting in Australia: a retrospective longitudinal analysis of clinical service data from 2006 to 2009.

UNLABELLED: Background In response to the high prevalence of sexually transmissible infections (STIs) in many central Australian Aboriginal communities, a community-wide screening program was implemented to supplement routine primary health care (PHC) clinic testing. The uptake and outcomes of these two approaches were compared. METHODS: Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) community and clinic screening data for Aboriginal people aged 15-34 years, 2006-2009, were used. Regression analyses assessed predictors of the first test occurring in the community screen, positivity and repeat testing. RESULTS: A total of 2792 individuals had 9402 tests (median: four per person) over 4 years. Approximately half of the individuals (54%) were tested in the community and clinic approaches combined, 29% (n=806) in the community screen only and 18% (n=490) in the clinic only. Having the first test in a community screen was associated with being male and being aged 15-19 years. There was no difference between community and clinic approaches in CT or NG positivity at first test. More than half (55%) of individuals had a repeat test within 2-15 months and of these, 52% accessed different approaches at each test. The only independent predictor of repeat testing was being 15-19 years. CONCLUSIONS: STI screening is an important PHC activity and the findings highlight the need for further support for clinics to reach young people. The community screen approach was shown to be a useful complementary approach; however, cost and sustainability need to be considered.

Notification and management of congenital syphilis in the Northern Territory 2009 to 2014.

OBJECTIVE: To determine whether cases of congenital syphilis in the Northern Territory between 2009 and 2014 were correctly notified based on probable or confirmed case criteria stipulated by the Communicable Diseases Network Australia (CDNA). METHODS: Pregnant women with positive syphilis serology defined as reactive treponemal test and rapid plasma reagin titre ≥1:8 were identified from the Northern Territory Syphilis Register Information System. Risk classification was performed based on local guidelines, and CDNA criteria for probable/confirmed cases of congenital syphilis were applied to determine whether cases were appropriately notified. RESULTS: Thirty-four cases of positive maternal syphilis serology in pregnancy were identified from 31 women; all were Indigenous. Twenty-one cases fulfilled criteria for probable congenital syphilis; 1 case was formally notified to the Centre for Disease Control. Twenty cases (95%) fulfilling CDNA criteria for probable congenital syphilis were not notified over the study period. CONCLUSIONS: Application of standard case definitions significantly increases the rate of congenital syphilis cases in the Northern Territory. Improved education regarding CDNA criteria for notification of congenital syphilis is necessary for clinicians and public health staff. Emerging evidence has supported the recent simplification of CDNA criteria for notification of congenital syphilis, effective 1 July 2015.

Exploring the Benefits of Molecular Testing for Gonorrhoea Antibiotic Resistance Surveillance in Remote Settings.

BACKGROUND: Surveillance for gonorrhoea antimicrobial resistance (AMR) is compromised by a move away from culture-based testing in favour of more convenient nucleic acid amplification test (NAAT) tests. We assessed the potential benefit of a molecular resistance test in terms of the timeliness of detection of gonorrhoea AMR. METHODS AND FINDINGS: An individual-based mathematical model was developed to describe the transmission of gonorrhoea in a remote Indigenous population in Australia. We estimated the impact of the molecular test on the time delay between first importation and the first confirmation that the prevalence of gonorrhoea AMR (resistance proportion) has breached the WHO-recommended 5% threshold (when a change in antibiotic should occur). In the remote setting evaluated in this study, the model predicts that when culture is the only available means of testing for AMR, the breach will only be detected when the actual prevalence of AMR in the population has already reached 8 - 18%, with an associated delay of ~43 - 69 months between first importation and detection. With the addition of a molecular resistance test, the number of samples for which AMR can be determined increases facilitating earlier detection at a lower resistance proportion. For the best case scenario, where AMR can be determined for all diagnostic samples, the alert would be triggered at least 8 months earlier than using culture alone and the resistance proportion will have only slightly exceeded the 5% notification threshold. CONCLUSIONS: Molecular tests have the potential to provide more timely warning of the emergence of gonorrhoea AMR. This in turn will facilitate earlier treatment switching and more targeted treatment, which has the potential to reduce the population impact of gonorrhoea AMR.