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Controlling Communicable Diseases in Rural New South Wales: Epidemiological Research for Directing Health Policy and Practice

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Controlling Communicable Diseases in Rural New South Wales: Epidemiological Research for Directing Health Policy and Practice ResearchOnline@JCU This file is part of the following reference: Massey, Peter D. (2011) Controlling communicable diseases in rural New South Wales: epidemiological research for directing health policy and practice. Professional Doctorate (Research) thesis, James Cook University. Access to this file is available from: http://researchonline.jcu.edu.au/31902/ The author has certified to JCU that they have made a reasonable effort to gain permission and acknowledge the owner of any third party copyright material included in this document. If you believe that this is not the case, please contact [email protected] and quote http://researchonline.jcu.edu.au/31902/ Controlling communicable diseases in rural New South Wales - epidemiological research for directing health policy and practice Peter D Massey July 2011 A thesis submitted in partial fulfilment of the requirements of the degree of Doctor of Public Health within the School of Public Health and Tropical Medicine, James Cook University. Statement of access I, the undersigned author of this work, understand that James Cook University will make this thesis available for use within the university library and via the Australian Digital Thesis Network, for use elsewhere. I understand that, as an unpublished work, a thesis has significant protection under the Copyright Act and I do not wish to place any further restriction on access to this work. __ 7 / 8 / 2011 Signature Date i Statement of sources I declare that this thesis is my own work and has not been submitted in any form for another degree or diploma at any university or other institution of tertiary education. Information derived from the published or unpublished work of others has been acknowledged in the text and a list of references is given. _________________________ 7 / 8 / 2011 Signature Date ii Electronic Copy I, the undersigned, the author of this work, declare that the electronic copy of this thesis provided to the James Cook University Library is an accurate copy of the print thesis submitted, within the limits of the technology available. _________________________ 7 / 8 / 2011 Signature Date iii Declaration on Ethics The research presented and reported in this thesis was conducted within the guidelines for research ethics outlined in the National Statement on Ethics Conduct in Research Involving Humans (1999), the Joint NHMRC/AVCC Statement and Guidelines on Research Practice (1997), the James Cook University Policy on Experimentation Ethics, Standard Practices and Guidelines (2001), and the James Cook University Statement and Guidelines on Research Practice (2001). Specific ethics approval details are provided in each publication. _________________________ 7 / 8 / 2011 Signature Date iv Summary The overall aim of this body of work was to expand the evidence base for controlling communicable diseases in regional and rural Australia, specifically conducting epidemiological research for directing health policy and practice. The diseases investigated are diverse but the setting and the risks are common, that is the Hunter New England area of New South Wales (NSW) and the people who live and work in this regional part of Australia. The vision for health in rural, regional and remote Australia as articulated in the Healthy Horizons framework is: “People in rural, regional and remote Australia will be as healthy as other Australians and have the skills and capacity to maintain healthy communities ” [1]. Within the context of this vision for equitable health experience there is only a limited understanding of the epidemiology and impact of prevention strategies on communicable diseases in rural, regional and remote Australia. Of particular focus in this thesis were those communicable diseases that affect Aboriginal and Torres Strait Islander people, and people in close contact with livestock and feral animals. An operational research approach was used to better understand the epidemiology and control of pandemic influenza; rural communicable disease outbreaks; invasive meningococcal and pneumococcal diseases in Aboriginal and Torres Strait Islander people; tuberculosis; brucellosis; Q fever; and malaria in rural New South Wales communities. The studies into pandemic influenza mainly used qualitative methods. Focus groups and in- depth interviews were used to explore Aboriginal and Torres Strait Islander people’s experiences with the pandemic and to investigate more appropriate control strategies. This investigation occurred within a Participatory Action Research method that enabled communities to benefit through action and understanding. Structured interviews and focus groups were also used in the study into the prevention strategies for Brucellosis. Other studies conducted within this thesis used quantitative methods including a cohort study, descriptive and analytical studies, and evaluation of outcomes. Structured surveys and medical record reviews were also used to explore the control of some communicable diseases. v This thesis presents a number of studies that display lateral and original approaches to communicable disease control. The use of a Participatory Action Research method, that included research capacity building with Aboriginal communities, and the qualitative work with feral pig hunters are unique methods in the development of communicable diseases control strategies in rural areas. In addition, the novel epidemiological approach in the submitted manuscript in Chapter 6, has not been reported elsewhere in the literature. Pandemic influenza A careful analysis of influenza pandemic epidemiology found that in New South Wales, Aboriginal and Torres Strait Islander people were four times more likely to be admitted to hospital with A(H1N1)pdm09 pandemic influenza than non-Aboriginal people. Working within a Participatory Action Research framework, overseen by the Hunter New England Aboriginal Health Partnership, an interactive process of research engagement and negotiation with Aboriginal communities yielded pandemic influenza control strategies that were based on community understanding and recognition of the importance of families in the life of Aboriginal and Torres Strait Islander communities. Strategies included: • the need for health services to undertake respectful engagement with communities; • modifying home isolation and quarantine policies; • family centred prevention; and • communicating with and through grandmothers. Prior to the 2009 pandemic considerable preparatory work was conducted in the Hunter New England regional area. Pandemic exercises were conducted and these included careful evaluation to inform a future response. The need to modify mass vaccination plans, particularly in rural areas, to effectively engage community partners was a major finding from a mass vaccination clinic exercise. A large-scale surveillance and response exercise clearly demonstrated the capacity of senior nursing staff to perform a surge function during a protracted public health response to pandemic influenza. The epidemiological situation at the time that pandemic containment was discontinued suggests that during future events more thought should be given to the heterogeneity of disease occurrence across a state or nation. In addition the capacity of regional areas to respond needs to be considered before altering pandemic response phases. vi Learning from outbreaks Boarding schools, where people live in close proximity, are vulnerable to outbreaks of respiratory illness. A cluster of twenty-five community acquired pneumonia (CAP) in previously well adolescents attending a boarding school in rural New South Wales led to an epidemiological investigation of the outbreak. Strategies for improving influenza surveillance and control in this setting were identified. Clusters of pneumonia in boarding schools should alert clinicians to the possibility of Streptococcus pneumoniae complicating influenza infection and prompt appropriate laboratory investigations with notification to public health authorities. The outbreak in 2006 provided an excellent opportunity to test the newly set up Public Health Real-time Emergency Department Surveillance System (PHREDSS). This investigation found that using the current thresholds, PHREDSS would have trigged a signal for pneumonia syndrome in children aged 5-16 years four days earlier than the notification by the clinicians involved. Early notification of outbreaks can lead to reduction of the impact of an outbreak if control strategies can be applied. Aboriginal and Torres Strait Islander status of people notified with invasive meningococcal and pneumococcal diseases In New South Wales, Aboriginal and Torres Strait Islander children were not considered a particular high risk group for invasive bacterial disease. Careful analysis of invasive meningococcal disease notifications, between 1991 and 2005, found that Aboriginal and Torres Strait Islander children 0–4 years of age had a significantly higher risk when compared with non-Aboriginal children (relative risk 3.31, 2.35-4.68, 95%CI). Similarly, Aboriginal and Torres Strait Islander children aged 0-4 years had a two-to three-fold higher rate of invasive pneumococcal disease than non-Indigenous children (relative risk 2.68, 1.02–7.09, 95%CI). Linking notification data with routine hospital admission data proved a useful and time efficient surveillance strategy to increase the proportion of notifications with Aboriginal and Torres Strait Islander status recorded. Tuberculosis (TB) and country of birth TB rates in NSW
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