Effect of COVID-19 pandemic restrictions on chlamydia and gonorrhoea notifications and testing in Queensland, Australia: an interrupted time series analysis

OBJECTIVE

To investigate trends in testing and notifications of chlamydia and gonorrhoea during the COVID-19 pandemic in Queensland, Australia.

METHODS

Statewide disease notification and testing data between 1 January 2015 and 31 December 2021 were modelled using interrupted time series. A segmented regression model estimated the pre-pandemic trend and observed effect of the COVID-19 pandemic response on weekly chlamydia notifications, monthly gonorrhoea notifications and monthly testing figures. The intervention time point was 29 March 2020, when key COVID-19 public health restrictions were introduced.

RESULTS

There were 158 064 chlamydia and 33 404 gonorrhoea notifications and 2 107 057 combined chlamydia and gonorrhoea tests across the 72-month study period. All three studied outcomes were increasing prior to the COVID-19 pandemic. Immediate declines were observed for all studied outcomes. Directly after COVID-19 restrictions were introduced, declines were observed for all chlamydia notifications (mean decrease 48.4 notifications/week, 95% CI -77.1 to -19.6), gonorrhoea notifications among males (mean decrease 39.1 notifications/month, 95% CI -73.9 to -4.3) and combined testing (mean decrease 4262 tests/month, 95% CI -6646 to -1877). The immediate decline was more pronounced among males for both conditions. By the end of the study period, only monthly gonorrhoea notifications showed a continuing decline (mean decrease 3.3 notifications/month, p<0.001).

CONCLUSION

There is a difference between the immediate and sustained impact of the COVID-19 pandemic on reported chlamydia and gonorrhoea notifications and testing in Queensland, Australia. This prompts considerations for disease surveillance and management in future pandemics. Possible explanations for our findings are an interruption or change to healthcare services during the pandemic, reduced or changed sexual practices or changed disease transmission patterns due to international travel restrictions. As pandemic priorities shift, STIs remain an important public health priority to be addressed.

A population-level application of a method for estimating the timing of HIV acquisition among migrants to Australia

INTRODUCTION

Australia has set the goal for the virtual elimination of HIV transmission by the end of 2022, yet accurate information is lacking on the level of HIV transmission occurring among residents. We developed a method for estimating the timing of HIV acquisition among migrants, relative to their arrival in Australia. We then applied this method to surveillance data from the Australian National HIV Registry with the aim of ascertaining the level of HIV transmission among migrants to Australia occurring before and after migration, and to inform appropriate local public health interventions.

METHODS

We developed an algorithm incorporating CD4⁺ T-cell decline back-projection and enhanced variables (clinical presentation, past HIV testing history and clinician estimate of the place of HIV acquisition) and compared it to a standard algorithm which uses CD4⁺ T-cell back-projection only. We applied both algorithms to all new HIV diagnoses among migrants to estimate whether HIV infection occurred before or after arrival in Australia.

RESULTS

Between 1 January 2016 and 31 December 2020, 1909 migrants were newly diagnosed with HIV in Australia, 85% were men, and the median age was 33 years. Using the enhanced algorithm, 932 (49%) were estimated to have acquired HIV after arrival in Australia, 629 (33%) before arrival (from overseas), 250 (13%) close to arrival and 98 (5%) were unable to be classified. Using the standard algorithm, 622 (33%) were estimated to have acquired HIV in Australia, 472 (25%) before arrival, 321 (17%) close to arrival and 494 (26%) were unable to be classified.

CONCLUSIONS

Using our algorithm, close to half of migrants diagnosed with HIV were estimated to have acquired HIV after arrival in Australia, highlighting the need for tailored culturally appropriate testing and prevention programmes to limit HIV transmission and achieve elimination targets. Our method reduced the proportion of HIV cases unable to be classified and can be adopted in other countries with similar HIV surveillance protocols, to inform epidemiology and elimination efforts.

The improving state of Q fever surveillance. A review of Queensland notifications, 2003-2017

Q fever is a notifiable zoonotic disease in Australia, caused by infection with Coxiella burnetii. This study has reviewed 2,838 Q fever notifications reported in Queensland between 2003 and 2017 presenting descriptive analyses, with counts, rates, and proportions. For this study period, Queensland accounted for 43% of the Australian national Q fever notifications. Enhanced surveillance follow-up of Q fever cases through Queensland Public Health Units was implemented in 2012, which improved the data collected for occupational risk exposures and animal contacts. For 2013-2017, forty-nine percent (377/774) of cases with an identifiable occupational group would be considered high risk for Q fever. The most common identifiable occupational group was agricultural/farming (31%). For the same period, at-risk environmental exposures were identified in 82% (961/1,170) of notifications; at-risk animal-related exposures were identified in 52% (612/1,170) of notifications; abattoir exposure was identified in 7% of notifications. This study has shown that the improved follow-up of Q fever cases since 2012 has been effective in the identification of possible exposure pathways for Q fever transmission. This improved surveillance has highlighted the need for further education and heightened awareness of Q fever risk for all people living in Queensland, not just those in previously-considered high risk occupations.

Structure-Guided In Vitro to In Vivo Pharmacokinetic Optimization of Propargyl-Linked Antifolates

Pharmacokinetic/pharmacodynamic properties are strongly correlated with the in vivo efficacy of antibiotics. Propargyl-linked antifolates, a novel class of antibiotics, demonstrate potent antibacterial activity against both Gram-positive and Gram-negative pathogenic bacteria, including multidrug-resistant Staphylococcus aureus. Here, we report our efforts to optimize the pharmacokinetic profile of this class to best match the established pharmacodynamic properties. High-resolution crystal structures were used in combination with in vitro pharmacokinetic models to design compounds that not only are metabolically stable in vivo but also retain potent antibacterial activity. The initial lead compound was prone to both N-oxidation and demethylation, which resulted in an abbreviated in vivo half-life (∼20 minutes) in mice. Stability of leads toward mouse liver microsomes was primarily used to guide medicinal chemistry efforts so robust efficacy could be demonstrated in a mouse disease model. Structure-based drug design guided mitigation of N-oxide formation through substitutions of sterically demanding groups adjacent to the pyridyl nitrogen. Additionally, deuterium and fluorine substitutions were evaluated for their effect on the rate of oxidative demethylation. The resulting compound was characterized and demonstrated to have a low projected clearance in humans with limited potential for drug-drug interactions as predicted by cytochrome P450 inhibition as well as an in vivo exposure profile that optimizes the potential for bactericidal activity, highlighting how structural data, merged with substitutions to introduce metabolic stability, are a powerful approach to drug design.

Impact of participation in a surgical site infection surveillance network: results from a large international cohort study

BACKGROUND

Surveillance of surgical site infections (SSIs) is a core component of effective infection control practices, though its impact has not been quantified on a large scale.

AIM

To determine the time-trend of SSI rates in surveillance networks.

METHODS

SSI surveillance networks provided procedure-specific data on numbers of SSIs and operations, stratified by hospitals' year of participation in the surveillance, to capture length of participation as an exposure. Pooled and procedure-specific random-effects Poisson regression was performed to obtain yearly rate ratios (RRs) with 95% confidence intervals (CIs), and including surveillance network as random intercept.

FINDINGS

Of 36 invited networks, 17 networks from 15 high-income countries across Asia, Australia and Europe participated in the study. Aggregated data on 17 surgical procedures (cardiovascular, digestive, gynaecological-obstetrical, neurosurgical, and orthopaedic) were collected, resulting in data concerning 5,831,737 operations and 113,166 SSIs. There was a significant decrease in overall SSI rates over surveillance time, resulting in a 35% reduction at the ninth (final) included year of surveillance (RR: 0.65; 95% CI: 0.63-0.67). There were large variations across procedure-specific trends, but strong consistent decreases were observed for colorectal surgery, herniorrhaphy, caesarean section, hip prosthesis, and knee prosthesis.

CONCLUSION

In this large, international cohort study, pooled SSI rates were associated with a stable and sustainable decrease after joining an SSI surveillance network; a causal relationship is possible, although unproven. There was heterogeneity in procedure-specific trends. These findings support the pivotal role of surveillance in reducing infection rates and call for widespread implementation of hospital-based SSI surveillance in high-income countries.

Potential Exposures to Australian Bat Lyssavirus Notified in Queensland, Australia, 2009-2014

Background

Australian bat lyssavirus (ABLV) belongs to the genus Lyssavirus which also includes classic rabies virus and the European lyssaviruses. To date, the only three known human ABLV cases, all fatal, have been reported from Queensland, Australia. ABLV is widely distributed in Australian bats, and any bite or scratch from an Australian bat is considered a potential exposure to ABLV.

Methodology/Principal Findings

Potential exposure to ABLV has been a notifiable condition in Queensland since 2005. We analysed notification data for potential exposures occurring between 2009 and 2014. There were 1,515 potential exposures to ABLV notified in Queensland, with an average annual notification rate of 5.6 per 100,000 population per year. The majority of notified individuals (96%) were potentially exposed to ABLV via bats, with a small number of cases potentially exposed via two ABLV infected horses and an ABLV infected human. The most common routes of potential exposure were through bat scratches (47%) or bites (37%), with less common routes being mucous membrane/broken skin exposure to bat saliva/brain tissue (2.2%). Intentional handling of bats by the general public was the major cause of potential exposures (56% of notifications). Examples of these potential exposures included people attempting to rescue bats caught in barbed wire fences/fruit tree netting, or attempting to remove bats from a home. Following potential exposures, 1,399 cases (92%) were recorded as having appropriate post-exposure prophylaxis (PEP) as defined in national guidelines, with the remainder having documentation of refusal or incomplete PEP. Up to a quarter of notifications occurred after two days from the potential exposure, but with some delays being more than three weeks. Of 393 bats available for testing during the reporting period, 20 (5.1%) had ABLV detected, including four species of megabats (all flying foxes) and one species of microbats (yellow-bellied sheathtail bat).

Conclusions/Significance

Public health strategies should address the strong motivation of some members of the public to help injured bats or bats in distress, by emphasising that their action may harm the bat and put themselves at risk of the fatal ABLV infection. Alternative messaging should include seeking advice from professional animal rescue groups, or in the event of human contact, public health units. Further efforts are required to ensure that when potential exposure occurs, timely reporting and appropriate post-exposure prophylaxis occur.

Australian bat lyssavirus (ABLV), closely related to classic rabies virus, is widely distributed in bats in Australia. So far, the only three known human ABLV cases, all fatal, have been reported in Queensland, Australia. Any Australian bat-related injury (bite or scratch), or contact of bat saliva/neural tissue with eyes, mouth, nose, or broken skin of humans, is considered a potential exposure to ABLV. Use of timely, appropriate rabies vaccine and human rabies immunoglobulin is recommended to prevent fatal human ABLV disease. Based on notification data for potential exposures to ABLV in Queensland, we found that intentional handling of bats by the general public was the major cause of bat-related injuries; for example, people reported attempting to rescue bats caught in barbed wire fences or fruit tree netting, or attempting to remove bats from a home. This highlights a need to address the strong motivation of some members of the public to help injured bats or bats in distress and the lack of awareness of the risks of contact with or handling of bats, underscoring the importance of avoidance of bat handling by contacting vaccinated, experienced, and well-equipped professional animal rescue groups to deal with bats. There is a need to improve timeliness of notification to ensure immediate post-exposure management. Queensland Health bat testing results revealed the detection of ABLV in four common species of megabats (all flying foxes) and one species of microbats (yellow-bellied sheathtail bat), further reinforcing the message of avoiding all bat-related injuries. Once a potential exposure to ABLV occurs, immediate cleansing of wound (with soap and water for at least 5 minutes and application of povidone-iodine or alcohol) is required; and appropriate and timely rabies vaccine and human rabies immunoglobulin should be administered.

Characterising health care-associated bloodstream infections in public hospitals in Queensland, 2008-2012

OBJECTIVE

To describe the epidemiology and rates of all health care-associated bloodstream infections (HA-BSIs) and of specific HA-BSI subsets in public hospitals in Queensland.

DESIGN AND SETTING

Standardised HA-BSI surveillance data were collected in 23 Queensland public hospitals, 2008-2012.

MAIN OUTCOME MEASURES

HA-BSIs were prospectively classified in terms of place of acquisition (inpatient, non-inpatient); focus of infection (intravascular catheter-associated, organ site focus, neutropenic sepsis, or unknown focus); and causative organisms. Inpatient HA-BSI rates (per 10,000 patient-days) were calculated.

RESULTS

There were 8092 HA-BSIs and 9418 causative organisms reported. Inpatient HA-BSIs accounted for 79% of all cases. The focus of infection in 2792 cases (35%) was an organ site, intravascular catheters in 2755 (34%; including 2240 central line catheters), neutropenic sepsis in 1063 (13%), and unknown in 1482 (18%). Five per cent (117 of 2240) of central line-associated BSIs (CLABSIs) were attributable to intensive care units (ICUs). Eight groups of organisms provided 79% of causative agents: coagulase-negative staphylococci (18%), Staphylococcus aureus (15%), Escherichia coli (11%), Pseudomonas species (9%), Klebsiella pneumoniae/oxytoca (8%), Enterococcus species (7%), Enterobacter species (6%), and Candida species (5%). The overall inpatient HA-BSI rate was 6.0 per 10,000 patient-days. The rates for important BSI subsets included: intravascular catheter-associated BSIs, 1.9 per 10,000 patient-days; S. aureus BSIs, 1.0 per 10,000 patient-days; and methicillin-resistant S. aureus BSIs, 0.3 per 10,000 patient-days.

CONCLUSIONS

The rate of HA-BSIs in Queensland public hospitals is lower than reported by similar studies elsewhere. About one-third of HA-BSIs are attributable to intravascular catheters, predominantly central venous lines, but the vast majority of CLABSIs are contracted outside ICUs. Different sources of HA-BSIs require different prevention strategies.

Surgical site infections following coronary artery bypass graft procedures: 10 years of surveillance data

BACKGROUND

Surgical site infections following coronary artery bypass graft (CABG) procedures pose substantial burden on patients and healthcare systems. This study aims to describe the incidence of surgical site infections and causative pathogens following CABG surgery over the period 2003-2012, and to identify risk factors for complex sternal site infections.

METHODS

Routine computerised surveillance data were collected from three public hospitals in Queensland, Australia in which CABG surgery was performed between 2003 and 2012. Surgical site infection rates were calculated by types of infection (superficial/complex) and incision sites (sternal/harvest sites). Patient and procedural characteristics were evaluated as risk factors for complex sternal site infections using a logistic regression model.

RESULTS

There were 1,702 surgical site infections (518 at sternal sites and 1,184 at harvest sites) following 14,546 CABG procedures performed. Among 732 pathogens isolated, Methicillin-sensitive Staphylococcus aureus accounted for 28.3% of the isolates, Pseudomonas aeruginosa 18.3%, methicillin-resistant Staphylococcus aureus 14.6%, and Enterobacter species 6.7%. Proportions of Gram-negative bacteria elevated from 37.8% in 2003 to 61.8% in 2009, followed by a reduction to 42.4% in 2012. Crude rates of complex sternal site infections increased over the reporting period, ranging from 0.7% in 2004 to 2.6% in 2011. Two factors associated with increased risk of complex sternal site infections were identified: patients with an ASA (American Society of Anaesthesiologists) score of 4 or 5 (reference score of 3, OR 1.83, 95% CI 1.36-2.47) and absence of documentation of antibiotic prophylaxis (OR 2.03, 95% CI 1.12-3.69).

CONCLUSIONS

Compared with previous studies, our data indicate the importance of Gram-negative organisms as causative agents for surgical site infections following CABG surgery. An increase in complex sternal site infection rates can be partially explained by the increasing proportion of patients with more severe underlying disease.

Evaluating the effectiveness of a multifaceted, multilevel continuous quality improvement program in primary health care: developing a realist theory of change

Background

Variation in effectiveness of continuous quality improvement (CQI) interventions between services is commonly reported, but with little explanation of how contextual and other factors may interact to produce this variation. Therefore, there is scant information available on which policy makers can draw to inform effective implementation in different settings. In this paper, we explore how patterns of change in delivery of services may have been achieved in a diverse range of health centers participating in a wide-scale program to achieve improvements in quality of care for Indigenous Australians.

Methods

We elicited key informants’ interpretations of factors explaining patterns of change in delivery of guideline-scheduled services over three or more years of a wide-scale CQI project, and inductively analyzed these interpretations to propose fine-grained realist hypotheses about what works for whom and in what circumstances. Data were derived from annual clinical audits from 36 health centers operating in diverse settings, quarterly project monitoring reports, and workshops with 12 key informants who had key roles in project implementation. We abstracted potential context-mechanism-outcome configurations from the data, and based on these, identified potential program-strengthening strategies.

Results

Several context-specific, mechanism-based explanations for effectiveness of this CQI project were identified. These were collective valuing of clinical data for improvement purposes; collective efficacy; and organizational change towards a population health orientation. Health centers with strong central management of CQI, and those in which CQI efforts were more dependent on local health center initiative and were adapted to resonate with local priorities were both favorable contexts for collective valuing of clinical data. Where health centers had prior positive experiences of collaboration, effects appeared to be achieved at least partly through the mechanism of collective efficacy. Strong community linkages, staff ability to identify with patients, and staff having the skills and support to take broad ranging action, were favorable contexts for the mechanism of increased population health orientation.

Conclusions

Our study provides evidence to support strategies for program strengthening described in the literature, and extends the understanding of mechanisms through which strategies may be effective in achieving particular outcomes in different contexts.

Preparation of evodiamine solid dispersions and its pharmacokinetics

In order to increase the dissolution rate and bioavailability, solid dispersions of evodiamine in PVP K₃₀ with different enriched samples of evodiamine to PVP K₃₀ ratios were prepared by solvent method. Our studies showed that the dissolution rate of evodiamine was significantly higher in the solid dispersion system in comparison with that in enriched samples of evodiamine or physical mixtures. The increase of the dissolution rate was evidently related to the ratio of evodiamine to PVP K₃₀. The solid dispersion system (enriched samples of evodiamine/PVP K₃₀= 1/6, w/w) gave the highest dissolution rate: about 27.7-fold higher than that of enriched samples of evodiamine in hard capsules. Powder X-ray diffraction studies showed that enriched samples of evodiamine presented a total chemical stability after its preparation as solid dispersions. In vivo administration studies indicated that solid dispersions of evodiamine in hard capsules had a higher C_max and a shorter T_max than those of physical mixture in hard capsules, and the differences of C_max and T_max between them were significant. These results suggest that solid dispersions of evodiamine in hard capsules has a notably faster and greater absorption rate than enriched samples of evodiamine in physical mixture hard capsule and corresponds with the in vitro dissolution.

Variation in quality of preventive care for well adults in Indigenous community health centres in Australia

BACKGROUND

Early onset and high prevalence of chronic disease among Indigenous Australians call for action on prevention. However, there is deficiency of information on the extent to which preventive services are delivered in Indigenous communities. This study examined the variation in quality of preventive care for well adults attending Indigenous community health centres in Australia.

METHODS

During 2005-2009, clinical audits were conducted on a random sample (stratified by age and sex) of records of adults with no known chronic disease in 62 Indigenous community health centres in four Australian States/Territories (sample size 1839).

MAIN OUTCOME MEASURES

i) adherence to delivery of guideline-scheduled services within the previous 24 months, including basic measurements, laboratory investigations, oral health checks, and brief intervention on lifestyle modification; and ii) follow-up of abnormal findings.

RESULTS

Overall delivery of guideline-scheduled preventive services varied widely between health centres (range 5-74%). Documentation of abnormal blood pressure reading ([greater than or equal to]140/90 mmHg), proteinuria and abnormal blood glucose ([greater than or equal to]5.5 mmol/L) was found to range between 0 and > 90% at the health centre level. A similarly wide range was found between health centres for documented follow up check/test or management plan for people documented to have an abnormal clinical finding. Health centre level characteristics explained 13-47% of variation in documented preventive care, and the remaining variation was explained by client level characteristics.

CONCLUSIONS

There is substantial room to improve preventive care for well adults in Indigenous primary care settings. Understanding of health centre and client level factors affecting variation in the care should assist clinicians, managers and policy makers to develop strategies to improve quality of preventive care in Indigenous communities.

Indigenous community care -- documented depression in patients with diabetes

AIM

This article reports on documented levels of depression among people with diabetes attending indigenous primary care centres.

METHOD

Between 2005 and 2009, clinical audits of diabetes care were conducted in 62 indigenous community health centres from four Australian states and territories.

RESULTS

The overall prevalence of documented depression among people with diabetes was 8.8%. Fourteen (23%) of the 62 health centres had no record of either diagnosed depression or prescription of selective serotonin reuptake inhibitors among people with diabetes. For the remaining 48 centres, 3.3-36.7% of people with diabetes had documented depression.

DISCUSSION

The results of this study are inconsistent with the evidence showing high prevalence of mental distress among indigenous people. A more thorough investigation into the capacity, methods and barriers involved in diagnosing and managing depression in indigenous primary care is needed.

Delivery of maternal health care in Indigenous primary care services: baseline data for an ongoing quality improvement initiative

Background

Australia's Aboriginal and Torres Strait Islander (Indigenous) populations have disproportionately high rates of adverse perinatal outcomes relative to other Australians. Poorer access to good quality maternal health care is a key driver of this disparity. The aim of this study was to describe patterns of delivery of maternity care and service gaps in primary care services in Australian Indigenous communities.

Methods

We undertook a cross-sectional baseline audit for a quality improvement intervention. Medical records of 535 women from 34 Indigenous community health centres in five regions (Top End of Northern Territory 13, Central Australia 2, Far West New South Wales 6, Western Australia 9, and North Queensland 4) were audited. The main outcome measures included: adherence to recommended protocols and procedures in the antenatal and postnatal periods including: clinical, laboratory and ultrasound investigations; screening for gestational diabetes and Group B Streptococcus; brief intervention/advice on health-related behaviours and risks; and follow up of identified health problems.

Results

The proportion of women presenting for their first antenatal visit in the first trimester ranged from 34% to 49% between regions; consequently, documentation of care early in pregnancy was poor. Overall, documentation of routine antenatal investigations and brief interventions/advice regarding health behaviours varied, and generally indicated that these services were underutilised. For example, 46% of known smokers received smoking cessation advice/counselling; 52% of all women received antenatal education and 51% had investigation for gestational diabetes. Overall, there was relatively good documentation of follow up of identified problems related to hypertension or diabetes, with over 70% of identified women being referred to a GP/Obstetrician.

Conclusion

Participating services had both strengths and weaknesses in the delivery of maternal health care. Increasing access to evidence-based screening and health information (most notably around smoking cessation) were consistently identified as opportunities for improvement across services.

Assessing quality of diabetes care and its variation in Aboriginal community health centres in Australia

BACKGROUND

Examining variation in diabetes care across regions/organizations provides insight into underlying factors related to quality of care. The aims of this study were to assess quality of diabetes care and its variation among Aboriginal community health centres in Australia, and to estimate partitioning of variation attributable to health centre and individual patient characteristics.

METHODS

During 2005-2009, clinical medical audits were conducted in 62 Aboriginal community health centres from four states/territories. Main outcome measures include adherence to guidelines-scheduled processes of diabetes care, treatment and medication adjustment, and control of HbA(1c), blood pressure, total cholesterol and albumin/creatinine ratio (ACR).

RESULTS

Wide variation was observed across different categories of diabetes care measures and across centres: (1) overall adherence to delivery of services averaged 57% (range 22-83% across centres); (2) medication adjustment rates after elevated HbA(1c): 26% (0-72%); and (3) proportions of patients with HbA(1c) < 7%:27% (0-55%); with blood pressure < 130/80 mmHg: 36% (0-59%). Health centre level characteristics accounted for 36% of the total variation in adherence to process measures, and 3-11% of the total variation in patient intermediate outcomes; the remaining, substantial amount of variation in each measure was attributable to patient level characteristics.

CONCLUSIONS

Deficiencies in a range of quality of care measures provide multiple opportunities for improvement. The majority of variation in quality of diabetes care appears to be attributable to patient level characteristics. Further understanding of factors affecting variation in the care of individuals should assist clinicians, managers and policy makers to develop strategies to improve quality of diabetes care in Aboriginal communities.

Incidence of type 2 diabetes in Aboriginal Australians: an 11-year prospective cohort study

BACKGROUND

Diabetes is an important contributor to the health inequity between Aboriginal and non-Aboriginal Australians. This study aims to estimate incidence rates of diabetes and to assess its associations with impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) among Aboriginal participants in a remote community.

METHODS

Six hundred and eighty six (686) Aboriginal Australians aged 20 to 74 years free from diabetes at baseline were followed for a median of 11 years. During the follow-up period, new diabetes cases were identified through hospital records. Cox proportional hazards models were used to assess relationships of the incidence rates of diabetes with IFG, IGT and body mass index (BMI).

RESULTS

One hundred and twenty four (124) new diabetes cases were diagnosed during the follow up period. Incidence rates increased with increasing age, from 2.2 per 1000 person-years for those younger than 25 years to 39.9 per 1000 person-years for those 45-54 years. By age of 60 years, cumulative incidence rates were 49% for Aboriginal men and 70% for Aboriginal women. The rate ratio for developing diabetes in the presence of either IFG or IGT at baseline was 2.2 (95% CI: 1.5, 3.3), adjusting for age, sex and BMI. Rate ratios for developing diabetes were 2.2 (95% CI: 1.4, 3.5) for people who were overweight and 4.7 (95% CI: 3.0, 7.4) for people who were obese at baseline, with adjustment of age, sex and the presence of IFG/IGT.

CONCLUSIONS

Diabetes incidence rates are high in Aboriginal people. The lifetime risk of developing diabetes among Aboriginal men is one in two, and among Aboriginal women is two in three. Baseline IFG, IGT and obesity are important predictors of diabetes.

Comparison of diabetes management in five countries for general and indigenous populations: an internet-based review

Background

The diabetes epidemic is associated with huge human and economic costs, with some groups, such as indigenous populations in industrialised countries, being at especially high risk. Monitoring and improving diabetes care at a population level are important to reduce diabetes-related morbidity and mortality. A set of diabetes indicators has been developed collaboratively among the Organisation for Economic Co-operation and Development (OECD) countries to monitor performance of diabetes care. The aim of this review was to provide an overview of diabetes management in five selected OECD countries (Australia, Canada, New Zealand, the US and the UK), based on data available for general and indigenous populations where appropriate.

Methods

We searched websites of health departments and leading national organisations related to diabetes care in each of the five countries to identify publicly released reports relevant to diabetes care. We collected data relevant to 6 OECD diabetes indicators on processes of diabetes care (annual HbA1c testing, lipid testing, renal function screening and eye examination) and proximal outcomes (HbA1c and lipid control).

Results

Data were drawn from 29 websites, with 14 reports and 13 associated data sources included in this review. Australia, New Zealand, the US and the UK had national data available to construct most of the 6 OECD diabetes indicators, but Canadian data were limited to two indicators. New Zealand and the US had national level diabetes care data for indigenous populations, showing relatively poorer care among these groups when compared with general populations. The US and UK performed well across the four process indicators when compared with Australia and New Zealand. For example, annual HbA1c testing and lipid testing were delivered to 70-80% of patients in the US and UK; the corresponding figures for Australia and New Zealand were 50-60%. Regarding proximal outcomes, HbA1c control for patients in Australia and New Zealand tended to be relatively better than patients in the US and UK.

Conclusions

Substantial efforts have been made in the five countries to develop routine data collection systems to monitor performance of diabetes management. Available performance data identify considerable gaps in clinical care of diabetes across countries. Policy makers and health service providers across countries can learn from each other to improve data collection and delivery of diabetes care at the population level.

Catalytic activities of human cytochrome P450 2C9*1, 2C9*3 and 2C9*13

Cytochrome P450 2C9 (CYP2C9) is a geneticly polymorphic enzyme responsible for the metabolism of some clinically important drugs. CYP2C9*13 is an allele identified in a Chinese poor metabolizer of lornoxicam which has a Leu90Pro amino acid substitution. This paper reports on a study aimed at comparing the catalytic properties of CYP2C9*13 with those of the wild-type CYP2C9*1 and mutant CYP2C9*3 (Ile359Leu) in the COS-7 expression system using various substrates. CYP2C9*3 and *13 produced far lower luminescence than CYP2C9*1 in luciferin H metabolism. CYP2C9*13 exhibited an 11-fold increase in Km but no change in Vmax with tolbutamide as the substrate, a five-fold increase in Km and an 88.8% reduction in Vmax with diclofenac. These data indicate that CYP2C9*13 exhibits reduced metabolic activity toward all studied CYP2C9 substrates. The magnitude of the CYP2C9*13-associated decrease in intrinsic clearance (Vmax/Km) is greater than that associated with CYP2C9*3.

Study protocol: Audit and Best Practice for Chronic Disease Extension (ABCDE) Project

BACKGROUND

A growing body of international literature points to the importance of a system approach to improve the quality of care in primary health care settings. Continuous Quality Improvement (CQI) concepts and techniques provide a theoretically coherent and practical way for primary care organisations to identify, address, and overcome the barriers to improvements. The Audit and Best Practice for Chronic Disease (ABCD) study, a CQI-based quality improvement project conducted in Australia's Northern Territory, has demonstrated significant improvements in primary care service systems, in the quality of clinical service delivery and in patient outcomes related to chronic illness care. The aims of the extension phase of this study are to examine factors that influence uptake and sustainability of this type of CQI activity in a variety of Indigenous primary health care organisations in Australia, and to assess the impact of collaborative CQI approaches on prevention and management of chronic illness and health outcomes in Indigenous communities.

METHODS/DESIGN

The study will be conducted in 40-50 Indigenous community health centres from 4 States/Territories (Northern Territory, Western Australia, New South Wales and Queensland) over a five year period. The project will adopt a participatory, quality improvement approach that features annual cycles of: 1) organisational system assessment and audits of clinical records; 2) feedback to and interpretation of results with participating health centre staff; 3) action planning and goal setting by health centre staff to achieve system changes; and 4) implementation of strategies for change. System assessment will be carried out using a System Assessment Tool and in-depth interviews of key informants. Clinical audit tools include two essential tools that focus on diabetes care audit and preventive service audit, and several optional tools focusing on audits of hypertension, heart disease, renal disease, primary mental health care and health promotion. The project will be carried out in a form of collaborative characterised by a sequence of annual learning cycles with action periods for CQI activities between each learning cycle. Key outcome measures include uptake and integration of CQI activities into routine service activity, state of system development, delivery of evidence-based services, intermediate patient outcomes (e.g. blood pressure and glucose control), and health outcomes (complications, hospitalisations and mortality).

CONCLUSION

The ABCD Extension project will contribute directly to the evidence base on effectiveness of collaborative CQI approaches on prevention and management of chronic disease in Australia's Indigenous communities, and to inform the operational and policy environments that are required to incorporate CQI activities into routine practice.

Delivery of child health services in Indigenous communities: implications for the federal government's emergency intervention in the Northern Territory

OBJECTIVES

To describe delivery of child health services in Australian Aboriginal communities, and to identify gaps in services required to improve the health of Aboriginal children.

DESIGN

Cross-sectional baseline audit for a quality improvement intervention.

SETTING AND PARTICIPANTS

297 children aged at least 3 months and under 5 years in 11 Aboriginal communities in the Northern Territory, Far West New South Wales and Western Australia in 2006.

MAIN OUTCOME MEASURES

Adherence to guideline-scheduled services including clinical examinations, brief interventions or advice on health-related behaviour and risks, and enquiry regarding social conditions; and recorded follow-up of identified problems.

RESULTS

Documentation of delivery of specific clinical examinations (26%-80%) was relatively good, but was poorer for brief interventions or advice on health-related behaviour and risks (5%-36%) and enquiry regarding social conditions (3%-11%). Compared with children in Far West NSW and WA, those attending NT centres were significantly more likely to have a record of growth faltering, underweight, chronic ear disease, anaemia, or chronic respiratory disease (P < 0.005). Only 11%-13% of children with identified social problems had an assessment report on file. An action plan was documented for 22% of children with growth faltering and 13% with chronic ear disease; 43% of children with chronic respiratory disease and 31% with developmental delay had an assessment report on file.

CONCLUSION

Existing systems are not providing for adequate follow-up of identified medical and social problems for children living in remote Aboriginal communities; development of systems for immediate and longer-term sustainable responses to these problems should be a priority. Without effective systems for follow-up, screening children for disease and adverse social circumstances will result in little or no benefit.

Describing and analysing primary health care system support for chronic illness care in Indigenous communities in Australia's Northern Territory - use of the Chronic Care Model

Background

Indigenous Australians experience disproportionately high prevalence of, and morbidity and mortality from chronic illness such as diabetes, renal disease and cardiovascular disease. Improving the understanding of how Indigenous primary care systems are organised to deliver chronic illness care will inform efforts to improve the quality of care for Indigenous people.

Methods

This cross-sectional study was conducted in 12 Indigenous communities in Australia's Northern Territory. Using the Chronic Care Model as a framework, we carried out a mail-out survey to collect information on material, financial and human resources relating to chronic illness care in participating health centres. Follow up face-to-face interviews with health centre staff were conducted to identify successes and difficulties in the systems in relation to providing chronic illness care to community members.

Results

Participating health centres had distinct areas of strength and weakness in each component of systems: 1) organisational influence – strengthened by inclusion of chronic illness goals in business plans, appointment of designated chronic disease coordinators and introduction of external clinical audits, but weakened by lack of training in disease prevention and health promotion and limited access to Medicare funding; 2) community linkages – facilitated by working together with community organisations (e.g. local stores) and running community-based programs (e.g. "health week"), but detracted by a shortage of staff especially of Aboriginal health workers working in the community; 3) self management – promoted through patient education and goal setting with clients, but impeded by limited focus on family and community-based activities due to understaffing; 4) decision support – facilitated by distribution of clinical guidelines and their integration with daily care, but limited by inadequate access to and support from specialists; 5) delivery system design – strengthened by provision of transport for clients to health centres, separate men's and women's clinic rooms, specific roles of primary care team members in relation to chronic illness care, effective teamwork, and functional pathology and pharmacy systems, but weakened by staff shortage (particularly doctors and Aboriginal health workers) and high staff turnover; and 6) clinical information systems – facilitated by wide adoption of computerised information systems, but weakened by the systems' complexity and lack of IT maintenance and upgrade support.

Conclusion

Using concrete examples, this study translates the concept of the Chronic Care Model (and associated systems view) into practical application in Australian Indigenous primary care settings. This approach proved to be useful in understanding the quality of primary care systems for prevention and management of chronic illness. Further refinement of the systems should focus on both increasing human and financial resources and improving management practice.

Quality improvement in Indigenous primary health care: History, current initiatives and future directors

This paper addresses the question: "What is the current situation for Aboriginal primary health care services in relation to continuous quality improvement (CQI) in clinical care and what is needed for sustainable practice to be achievable five years from now?" The paper describes a number of recent CQI initiatives that evolved within an accountability framework, the origins of which are based on a top-down government approach to performance measurement. Over the last decade there has been a shift to a more negotiated approach and most recently to an emerging agenda that focuses more on systems to support CQI at the primary care coalface. Further development should aim to capitalise on the synergies between different CQI-related initiatives and effectively align quality improvement with performance measurement. Principles of CQI and key challenges for the future are identified.

Indigenous health: effective and sustainable health services through continuous quality improvement

The Australian government's Healthy for Life program is supporting capacity development in Indigenous primary care using continuous quality improvement (CQI) techniques. An important influence on the Healthy for Life program has been the ABCD research project. The key features contributing to the success of the project are described. The ABCD research project: uses a CQI approach, with an ongoing cycle of gathering data on how well organisational systems are functioning, and developing and then implementing improvements; is guided by widely accepted principles of community-based research, which emphasise participation; and adheres to the principles and values of Indigenous health research and service delivery. The potential for improving health outcomes in Aboriginal and Torres Strait Islander communities using a CQI approach should be strengthened by clear clinical and managerial leadership, supporting service organisations at the community level, and applying participatory-action principles.

Improving organisational systems for diabetes care in Australian Indigenous communities

BACKGROUND

Indigenous Australians experience disproportionately high prevalence of, and morbidity and mortality from diabetes. There is an urgent need to understand how Indigenous primary care systems are organised to deliver diabetes services to those most in need, to monitor the quality of diabetes care received by Indigenous people, and to improve systems for better diabetes care.

METHODS

The intervention featured two annual cycles of assessment, feedback workshops, action planning, and implementation of system changes in 12 Indigenous community health centres. Assessment included a structured review of health service systems and audit of clinical records. Main process of care measures included adherence to guideline-scheduled services and medication adjustment. Main patient outcome measures were HbA1c, blood pressure and total cholesterol levels.

RESULTS

There was good engagement of health centre staff, with significant improvements in system development over the study period. Adherence to guideline-scheduled processes improved, including increases in 6 monthly testing of HbA1c from 41% to 74% (Risk ratio 1.93, 95% CI 1.71-2.10), 3 monthly checking of blood pressure from 63% to 76% (1.27, 1.13-1.37), annual testing of total cholesterol from 56% to 74% (1.36, 1.20-1.49), biennial eye checking by a ophthalmologist from 34% to 54% (1.68, 1.39-1.95), and 3 monthly feet checking from 20% to 58% (3.01, 2.52-3.47). Medication adjustment rates following identification of elevated HbA1c and blood pressure were low, increasing from 10% to 24%, and from 13% to 21% respectively at year 1 audit. However, improvements in medication adjustment were not maintained at the year 2 follow-up. Mean HbA1c value improved from 9.3 to 8.9% (mean difference -0.4%, 95% CI -0.7;-0.1), but there was no improvement in blood pressure or cholesterol control.

CONCLUSION

This quality improvement (QI) intervention has proved to be highly acceptable in the Indigenous Australian primary care setting and has been associated with significant improvements in systems and processes of care and some intermediate outcomes. However, improvements appear to be limited by inadequate attention to abnormal clinical findings and medication management. Greater improvement in intermediate outcomes may be achieved by specifically addressing system barriers to therapy intensification through more effective engagement of medical staff in QI activities and/or greater use of nurse-practitioners.

On the human CYP2C9*13 variant activity reduction: a molecular dynamics simulation and docking study

Cytochrome P450 2C9 (CYP2C9) plays a key role in the metabolism of clinical drugs. CYP2C9 is a genetically polymorphic enzyme and some of its allelic variants have less activity compared to the wild-type form. Drugs with a narrow therapeutic index may cause serious toxicity to the individuals who carry such allele. CYP2C9*13, firstly identified by some of the present authors in a Chinese poor metabolizer of lornoxicam, is characterized by mutation encoding Leu90Pro substitution. Kinetic experiments show that CYP2C9*13 has less catalytic activity in elimination of diclofenac and lornoxicam in vitro. In order to explore the structure-activity relationship of CYP2C9*13, the three-dimensional structure models of the substrate-free CYP2C9*1 and its variant CYP2C9*13 are constructed on the basis of the X-ray crystal structure of human CYP2C9*1 (PDB code 1R9O) by molecular dynamics simulations. The structure change caused by Leu90Pro replacement is revealed and used to explain the dramatic decrease of the enzymatic activity in clearance of the two CYP2C9 substrates: diclofenac and lornoxicam. The trans configuration of the bond between Pro90 and Asp89 in CYP2C9*13 is firstly identified. The backbone of residues 106-108 in CYP2C9*13 turns over and their side chains block the entrance for substrates accessing so that the entrance of *13 shrinks greatly than that in the wild-type, which is believed to be the dominant mechanism of the catalytic activity reduction. Consequent docking study which is consistent with the results of the kinetic experiments by Guo et al. identifies the most important residues for enzyme-substrate complexes.

Aboriginal health workers and diabetes care in remote community health centres: a mixed method analysis

OBJECTIVE

To assess the effect of employing Aboriginal health workers (AHWs) on delivery of diabetes care in remote community health centres, and to identify barriers related to AHWs' involvement in diabetes and other chronic illness care.

DESIGN, SETTING AND PARTICIPANTS

Three-year follow-up study of 137 Aboriginal people with type 2 diabetes in seven remote community health centres in the Northern Territory.

MAIN OUTCOME MEASURES

Delivery of guideline-scheduled diabetes services; intermediate outcomes (glycated haemoglobin [HbA(1c)] and blood pressure levels); number and sex of AHWs at health centres over time; barriers to AHWs' involvement in chronic illness care.

RESULTS

There was a positive relationship between the number of AHWs per 1000 residents and delivery of guideline-scheduled diabetes services (but not intermediate health outcomes). Presence of male AHWs was associated with higher adherence to the guidelines. Barriers to AHWs' involvement in chronic illness care included inadequate training, lack of clear role divisions, lack of stable relationships with non-Aboriginal staff, and high demands for acute care.

CONCLUSIONS

Employing AHWs is independently associated with improved diabetes care in remote communities. AHWs have potentially important roles to play in chronic illness care, and service managers need to clearly define and support these roles.

Assessing health centre systems for guiding improvement in diabetes care

Background

Aboriginal people in Australia experience the highest prevalence of diabetes in the country, an excess of preventable complications and early death. There is increasing evidence demonstrating the importance of healthcare systems for improvement of chronic illness care. The aims of this study were to assess the status of systems for chronic illness care in Aboriginal community health centres, and to explore whether more developed systems were associated with better quality of diabetes care.

Methods

This cross-sectional study was conducted in 12 Aboriginal community health centres in the Northern Territory of Australia. Assessment of Chronic Illness Care scale was adapted to measure system development in health centres, and administered by interview with health centre staff and managers. Based on a random sample of 295 clinical records from attending clients with diagnosed type 2 diabetes, processes of diabetes care were measured by rating of health service delivery against best-practice guidelines. Intermediate outcomes included the control of HbA1c, blood pressure, and total cholesterol.

Results

Health centre systems were in the low to mid-range of development and had distinct areas of strength and weakness. Four of the six system components were independently associated with quality of diabetes care: an increase of 1 unit of score for organisational influence, community linkages, and clinical information systems, respectively, was associated with 4.3%, 3.8%, and 4.5% improvement in adherence to process standards; likewise, organisational influence, delivery system design and clinical information systems were related to control of HbA1c, blood pressure, and total cholesterol.

Conclusion

The state of development of health centre systems is reflected in quality of care outcome measures for patients. The health centre systems assessment tool should be useful in assessing and guiding development of systems for improvement of diabetes care in similar settings in Australia and internationally.

A multifaceted health-service intervention in remote Aboriginal communities: 3-year follow-up of the impact on diabetes care

OBJECTIVE

To examine the trends in processes of diabetes care and in participant outcomes after an intervention in two remote regions of Australia.

DESIGN

Follow-up study over 3 years.

SETTING

Seven health centres in the Tiwi Islands and the Katherine West region of the Northern Territory.

PARTICIPANTS

137 Aboriginal people with type 2 diabetes.

INTERVENTION

Implementation of a multifaceted trial, including transfer of purchasing and planning responsibility to local health boards, the development and dissemination of clinical guidelines supported by electronic registers, recall and reminder systems and associated staff training, and audit and feedback.

MAIN OUTCOME MEASURES

Trends in the proportion of Aboriginal people receiving services in accordance with clinical guidelines and in the proportion for whom specified levels of blood pressure and glycosylated haemoglobin (HbA(1c)) were achieved; health staff perceptions of barriers to effective service delivery.

RESULTS

An initial improvement in overall service levels from 40% to 49% was not fully sustained over the 3-year period. The overall proportion of services delivered varied from 22% to 64% between communities and over time. The proportion of participants whose most recent HbA(1c) level was less than 7% improved from 19% to 32%, but there was little change in blood pressure control. Perceived barriers to service delivery included discontinuities in staffing, lack of work-practice support and patients' acceptance of services.

CONCLUSIONS

Multifaceted interventions can improve quality of care in this environment, but achieving sustainable, high-quality care in a range of services and local conditions presents particular challenges. Developing and testing strategies for consistent and sustained improvement should be a priority for service providers and researchers.

Preventive medical care in remote Aboriginal communities in the Northern Territory: a follow-up study of the impact of clinical guidelines, computerised recall and reminder systems, and audit and feedback

BACKGROUND

Interventions to improve delivery of preventive medical services have been shown to be effective in North America and the UK. However, there are few studies of the extent to which the impact of such interventions has been sustained, or of the impact of such interventions in disadvantaged populations or remote settings. This paper describes the trends in delivery of preventive medical services following a multifaceted intervention in remote community health centres in the Northern Territory of Australia.

METHODS

The intervention comprised the development and dissemination of best practice guidelines supported by an electronic client register, recall and reminder systems and associated staff training, and audit and feedback. Clinical records in seven community health centres were audited at regular intervals against best practice guidelines over a period of three years, with feedback of audit findings to health centre staff and management.

RESULTS

Levels of service delivery varied between services and between communities. There was an initial improvement in service levels for most services following the intervention, but improvements were in general not fully sustained over the three year period.

CONCLUSIONS

Improvements in service delivery are consistent with the international experience, although baseline and follow-up levels are in many cases higher than reported for comparable studies in North America and the UK. Sustainability of improvements may be achieved by institutionalisation of relevant work practices and enhanced health centre capacity.

Biflavonoids from the aerial part of Stephania tetrandra

Investigation of the aerial part of Stephania tetrandra led to the isolation of two biflavonoids, stephaflavone A and stephaflavone B, with a 3-6" linkage pattern, together with beta-sitosterol. Their structures were established on the basis of their spectroscopic data and their physicochemical properties.

Two butylated aminooligosaccharides isolated from the culture filtrate of Streptomyces luteogriseus

Two novel aminooligosaccharides, butytatins M03 and M13 were isolated and purified from the culture filtrate of Streptomyces luteogriseus. Analysis by liquid chromatography coupled to electrospray ionization mass spectrometry indicated their resemblance to isovalertatin, with a four-carbon acyl group. Their structures were established by NMR as aminooligosaccharide derivatives possessing a butylated side chain.

Profiling of isovalertatin family aminooligosaccharides extracted from the culture of Streptomyces luteogriseus by using liquid chromatography/electrospray ionization mass spectrometry

A rapid and novel procedure using the liquid chromatography coupled to an electrospray ionization ion trap mass spectrometry technique was applied for the profiling of isovalertatin-family aminooligosaccharides in the extract from the culture filtrate of Streptomyces luteogriseus. The aminooligosaccharides were separated on a C-8 reversed-phase column with an acetonitrile-alkaline water gradient. The desired homologues were detected using the multiple reaction monitoring mode, and the chemical structures were confirmed by analyzing the characteristic fragment ions in their collision-induced dissociation spectra. This facile procedure led to the identification of all the five known aminooligosaccharides, isovalertatins M03, M13, M23, D03, and D23, in addition to the characterization of at least 41 novel isovalertatins, the molecular weights of which ranged from 729 to 2,793. This kind of assay should be intended as a simple and convenient way for the high-throughput analysis of screening aminooligosaccharides and potentially other structural families of natural products.

Structural revision of isovalertatins M03, M13, and M23 isolated from the culture of Streptomyces luteogriseus

Three aminooligosaccharides, isovalertatins M03 (1), M13 (2), and M23 (3) were isolated and purified from the culture filtrate of Streptomyces luteogriseus. Their physicochemical properties, liquid chromatographic behavior, and spectroscopic data were in full accordance with the reported compounds [Xu, Q.; Wang, Q.; Lu, D. CN Patent 1100756, 1995; Chem. Abstr. 1995, 123, 110278n], but their structures were reinvestigated and revised by spectroscopic methods, including ESI multistage mass spectrometry and 2-dimensional NMR techniques.

[Trend and causes of injury deaths among children in Macheng city of Hubei province during 1969 through 1998]

OBJECTIVES

To describe time trend of mortality and proportional mortality of injury and to determine the characteristics of distribution of injury deaths in children aged 0 - 14 in Macheng city during 1969 to 1998.

METHODS

Data were collected from Notification System for Deaths of Macheng City during 1969 to 1998. Injury claimed 14,510 deaths caused by injury in children in total during these years. Changes in mortality and proportional mortality for injury were fitted with log-linear and simple linear regression models to compare their difference in children with different gender and ages.

RESULTS

Both injury mortality and proportional mortality in infants declined during the past 30 years, and injury mortality dropped but proportional mortality due to injury increased gradually in children aged 1 - 14 years old. From 1984 to 1998, the average injury mortality was 81.36 per 100,000 children of 0 - 14 of age, with a potential years of life lost rate was 57.92 per 1,000 children. Boys had higher injury mortality than girls. Injury mortality in infants reached 560.15 per 100,000, and mechanical suffocation was the leading cause of injury deaths in infants. Injury mortality was 95.48 per 100,000 in children aged 1 - 4 years. Injury deaths in children aged 0 - 4 accounted for 73.2 percent of total injury deaths. And, drowning was the leading cause of injury deaths in children aged 1 - 14 years.

CONCLUSION

Children under five years old were the vulnerable population for injury death needed for special care and strategy and measures should be taken to control injury in children in the rural areas.

[Germination temperature of seeds of medicinal plants]

According to our experiments in the last ten years, the germination behaviour of the seeds of medicinal plants may be classified into five types by different temperature requirements for germination: (1) low temperature type; (2) middle temperature type; (3) high temperature type; (4) alternating temperature type; (5) wide ranging temperature type. This classification is helpful for cultivators to determine the time of sowing.