Remote Australia Online

Case presentation: A 16-year-old Australian Indigenous female at 23 weeks of pregnancy (gravida 1, para 0) presented to the emergency department after 3–4 days of fatigue, vomiting and dark-coloured urine. Aside from multiple skin sores present for some months prior, systemic review was unrevealing. She had no previous medical history. Kidney function tests were normal 6 months earlier. There was a maternal history of rheumatic heart disease but none of kidney disease. The patient had received limited antenatal care. She denied smoking or alcohol use. Her only regular medications were multivitamins and iron.

The abuse and mistreatment of older people, or elder abuse, is estimated to affect up to 15.7 percent of community-dwelling older people in high- and middle-income countries and is more often than not perpetrated by a family member. However, true prevalence rates are likely to be higher, as older adults tend to under-report instances of interpersonal violence, especially when perpetrated by family members. There are many factors that amplify an older person’s risk of abuse, including gender, physical and cognitive impairments, past trauma, shared living situations, carer stress, social isolation, language barriers and ageism. Building upon criminological theories and the crime triangle, this chapter explores how older people living in rural and remote areas could be potentially vulnerable due to a lack of protective mechanisms exacerbated by social and geographic isolation and difficulties accessing support and legal services. Incorporating data collected within several studies in the Australian context, this chapter canvasses the distinctive nature of elder abuse in rural, regional and remote locations, also acknowledging the different experiences of older Indigenous people.

There is limited access to life-saving antenatal ultrasound in low-resource rural and remote settings worldwide, including Australia, mainly due to shortages in skilled staff. Point-of-care ultrasound (PoCUS) offers a viable solution to this service deficit, however, rural clinicians face many barriers accessing training and professional development critical to advancing their clinical practice. Standards for PoCUS training and competency assessment are unclear. Regulation is lacking globally, allowing untrained and inexperienced clinicians to practice PoCUS clinically.

Background Teeth affected with enamel defects (EDs) are at an increased risk of dental caries. In spite of improving oral health status overall in Australia, Indigenous Australians still experience higher rates of dental caries than non-Indigenous Australians. This study reports on the prevalence of EDs and dental caries experience among Indigenous children in the Kimberley region of Western Australia. Methods Health status of all the primary teeth (ICDAS II criteria) and the presence of EDs on index teeth (modified Dental Defects of Enamel index; DDE) of young Indigenous children who participated in a 2-arm intervention trial was recorded. Generalized estimating equations were used to estimate the association between EDs and dental caries and effect estimates were presented as odds ratios and associated 95% confidence intervals. Results Person-level prevalence, from 237 children (mean age 3.6 years, standard deviation 1.7) assessed for EDs, was 58% and tooth-level prevalence was 24%. Teeth affected with demarcated or diffuse defects were associated with a twofold higher odds of having caries experience, odds ratio (OR) 2.5, 95% confidence interval (CI) 1.7– 3.7 and OR 2.7, 95% CI 1.7–4.0 respectively. Conclusions The presence of EDs among young Indigenous children was associated with a higher odds of caries experience among affected teeth.

OBJECTIVE: Improving the oral health of Aboriginal children is an Australian priority. Public policy recommends the development of evidence-based, culturally competent oral health promotion programs. Positive health outcomes are more likely for Aboriginal people when programs are co-designed with the community and tailored to local needs. This study aims to determine the impact of a community-led oral health promotion program for Aboriginal children in rural and remote communities. BASIC RESEARCH DESIGN: Consecutive surveys. Baseline data were collected on the oral health of Aboriginal children aged five-12 years in rural and remote communities in Central Northern New South Wales in 2014. Then, an evidence-based oral health promotion program was co-designed with local Aboriginal communities. It included daily toothbrushing, water bottle program, regular application of fluoride varnish, regular distribution of toothbrushes and fluoride toothpaste and dental health education and commenced in 2016 in three schools in the region. In 2018, oral health status and oral hygiene behaviours of participating children were compared against baseline data to evaluate the program. RESULTS: There was a significant reduction in tooth decay, plaque scores and gingivitis. The mean number of teeth affected by tooth decay was 4.13, compared to 5.31 in 2014. An increase was also seen in positive oral hygiene behaviour. CONCLUSIONS: The co-design elements of the program are critical to its success. Engaging local Aboriginal communities to co-design and deliver oral health promotion can reduce the burden of tooth decay experienced by Aboriginal children.

Background: Delivering effective primary care to where it’s needed most – specifically remote Aboriginal communities – is hampered by high turnover and low stability of health centre staff and a lack of evidence about this to inform remote workforce policy making. This research describes the turnover, stability and employment survival patterns over 12 years in remote Northern Territory (NT) health centres. Methods: Descriptive statistics and marginal structural analysis of Department of Health payroll data, 2004-2015, for all staff based at 54 government-run remote NT health centres. Main outcome measures were annual turnover rates, 12-month stability rates and employment survival probabilities. Outcomes were investigated by health centre, calendar year, professional discipline, geographical remoteness and the periods before and after the NT Emergency Response in 2007. Results: Annual turnover rates for all staff combined averaged 118% (95% confidence interval (CI) 113-124%), declining significantly over time (175% in 2004 to 92% in 2015; p<0.05). Turnover rates were significantly lower after the NT Emergency Response (66% lower, 95%CI 48-85%). Stability rates increased for all staff combined (41% in 2004 to 51% in 2015; χ2 =12.5, p<0.001), averaging 49% overall (95%CI 42-56%). The most stable health centre had a mean 12-month stability rate for all staff that was 6 times higher than the least stable health centre (11% versus 66%, χ2 =35.6, p<0.01). Aboriginal Health Practitioners had significantly lower annual turnover rates (53%; 95%CI 46-61%) and higher probability of remaining employed 12 months after commencing employment (0.53; 95%CI 0.46-0.59) compared to other professional groups. Nurses employed directly by the Department of Health had significantly higher annual turnover rates (150%; 95%CI 141-160%) than other professional groups, with no improvement over time. If unit-level agency-employed nurse data were included in turnover calculations, nurse turnover almost certainly would have increased over the study period.

The NSW Ministry of Health commissioned this rapid review to outline the evidence to address the overarching question: What strategies have proven effective or ineffective for increasing the efficacy of allied health recruitment and retention in Australia? The take home message is that while there has been considerable research to identify the factors that influence allied health professional recruitment and retention in rural areas, there is limited quality evidence to demonstrate the impact of recruitment and retention interventions on workforce outcomes across individual professions or the allied health workforce as a whole. This is due to issues with the research design such as small sample size, failure to control for extraneous variables, difficulty establishing a baseline against which to assess results, significant drop out rates in longitudinal studies, and an inability to identify causal relationships between interventions and workforce outcomes. The strongest evidence concerning recruitment of Allied Health Professionals to rural and remote practice relates to: • Rural background • Curriculum that reflects rural health issues • Quality rural placements. Factors that influence retention are broadly categorised as professional and organisational, social (family and personal), and financial. These are modifiable to varying extent. Non-modifiable factors include location and community amenity, modifiable factors include: • Safe and supportive work environments • Career development • Nature of the work and outreach support • Professional networks • Public recognition of the role • Appropriate financial incentives. Rural Pipeline: One of the strongest lines of emerging evidence is the ‘Rural Pipeline’: recruiting students from rural backgrounds, delivering regional training, exposure during training to rural curriculum and placements, and then building opportunities for regional postgraduate training. This has been progressed in medicine and allied health over the last decade. Drawing on published and grey literature and industry knowledge, this rapid review demonstrates many components of a rural allied health pipeline are in place. Further work is required to link the components together to create a comprehensive pipeline. A proposed approach is to cohesively structure interventions to address known determinants of poor retention, create the pipeline, market this effectively and have funding models and mechanisms that create sustainable positions and service delivery. The following summary identifies a range of factors that influence the recruitment and retention of allied health professionals in rural areas across the professional lifespan. It is based on the concept of the ‘Rural Pipeline’ and is informed by the evidence contained in this rapid review.

Objectives The objectives of this qualitative study were to examine local perspectives on the causes of crime and recidivism in two remote Indigenous communities, and provide a series of recommendations regarding more effective responses that could be implemented by way of justice reinvestment. Method This study was coordinated by a multi-disciplinary research team that actively engaged the community in every stage of the research process, through a culturally and ecologically informed participatory action research design. Data was gathered through semi-structured individual and focus group interviews with three cohorts: (a) offenders who had been incarcerated on at least one occasion (n = 20); (b) offenders' families (n = 20); and, (c) service providers working with offenders (n = 20). Data was also gathered through over 40 informal conversations. Data collection occurred over a period of 18 months, with participants recruited by Indigenous researchers and community members. Data Analysis Interviews were transcribed and analysed by NVivo qualitative data processing software in the first instance. The core research team and community members reviewed this analysis in order to collectively identify major themes and patterns in the perspectives of participants. Conclusion People in remote Indigenous communities are aware of the complex issues associated with crime in their community and have clear ideas regarding what can be done. We argue that in order to understand and address Indigenous crime and over-representation in the criminal justice system, the perspective of Indigenous people must be elevated and communities empowered to identify and implement ecologically and culturally informed solutions that will work for them.

INTRODUCTION: Despite a paucity of research, adolescents living in rural areas appear to have a heightened risk for developing a mental health problem compared with their urban counterparts. The main objectives of this study were to contribute to building an evidence base of prevalence rates and determinants of internalising problems of adolescents in rural South Australia. A multidimensional Process Model was used as theoretical framework to enable an investigation of the various determinants from individual, family and community domains; specifically, the contribution of self-esteem, parental acceptance and elements of social capital at an individual level (ie participation in the local community and proactivity in a social context represented structural social capital, and feelings of trust and safety, and neighbourhood connections represented cognitive social capital). METHODS: In this cross-sectional prospective study, a total of 388 Year 9 (2nd year of secondary school) students (208 females, 180 males) aged 13-15 years (mean age = 14.2 years) participated from 11 high schools within the Country Health South Australian area. These adolescents completed a battery of self-reported measures online at school. RESULTS: The results demonstrated that the adolescents experienced a 'normal' level of self-esteem and a 'moderate' level of perceived parental acceptance. The level of social capital was considered 'low' and the adolescents experienced a 'moderate' level of internalising symptoms. Based on the mean score of the Revised Child Anxiety & Depression Scales (RCADS), 25% of the adolescents experienced internalising symptoms ranging in severity from mild to severe, with no significant differences between males and females. Approximately 13% were considered above the clinical threshold, with 4% reporting experiencing severe symptoms. Relationships between all measures were investigated using Pearson product-moment correlations coefficients and associations between self-esteem, parental acceptance, social capital, and internalising problems were assessed using multivariate linear regressions. Both parental acceptance and social capital were found to predict self-esteem. Parental acceptance was also significantly associated with social capital. The linear contribution of self-esteem, parental acceptance and social capital was significantly related to internalising problems. Approximately 33% of the variance in internalising problems could be accounted for by the combination of the three predictors; however, self-esteem and parental acceptance were the significant contributors to the prediction of internalising problems. Social capital was not a significant predictor of internalising problems. CONCLUSIONS: The present study only begins to contribute to the lack of existing data on the mental health status of adolescents from rural areas of South Australia. Greater research is needed to enhance understanding of this overlooked population and also assist in providing evidence-based guidelines in establishing priorities for newly appointed Federally funded youth services in rural Australia. In light of the concerning rates of internalising problems demonstrated by the present study, coupled with the fact that young people from rural areas were not considered in previous National Mental Health Surveys, it seems timely to highlight the importance of including as many Australians as possible from rural and remote areas, in the approaching, subsequent National survey. This will provide a more accurate evidence-based representation of Australia's adolescent population to inform policy and facilitate the implementation of relevant strategies.

Purpose: To report on diabetic retinopathy (DR) and the major causes of vision loss and blindness in Aboriginals in the Eastern Goldfields region of Western Australia between 1995 and 2007. Methods: Aboriginals (>16 years old) diagnosed with diabetes or eye problems from 11 communities in the Eastern Goldfields region of Western Australia were examined annually from 1995 to 2007. Data collected from prospective clinical examination included; visual acuity (VA), causes of vision loss, and whether DR was present. Severity of DR was graded according to the Early Treatment of Diabetic Retinopathy Study modified Airlie House grading system. Results: A total of 920 Aboriginals underwent 1331 examinations over the study period. There were 246 eyes with vision loss (best-corrected VA < 6/12) in 159 Aboriginals, of whom five were bilaterally blind. The four major known causes of vision loss were cataract (n = 53, 30.1%), DR (n = 44, 25.0%), uncorrected refractive error (n = 31, 17.6%) and trauma (n = 19, 10.8%). Aboriginals who had diabetes were far more likely to have vision loss (odds ratio = 8.5, 95% confidence interval 5.7 12.6, P < 0.0001). Of the 329 Aboriginals with diabetes, 82 (24.9%) had DR, and 32 (9.7%) had vision-threatening retinopathy. Of those with diabetes, 94 (42.5%) returned for follow-up examination on an average of 3.2 visits with a median time between visits of 2 years. Conclusion: The four major causes of vision loss in Aboriginals from the Eastern Goldfields are largely preventable and/or readily treated. DR and other diabetes-related eye conditions are a major cause of vision loss in Aboriginals, representing a significant health challenge for health services and clinicians into the future.

INTRODUCTION: Access to surgical specialist services by rural and remote residents in Australia is limited. Little information is available on the cost to rural residents of accessing specialist treatment. The aim of the present study was to define the personal costs incurred by country patients in Western Australia when accessing specialist surgical services in a rural or metropolitan setting. METHODS: A random sample of 50 patients who attended a visiting rural surgical service between December 1998 and February 1999 inclusive was recruited. In a structured telephone interview patients were asked 40 non-clinical questions relating to their recent specialist consultation. The cost of accessing these services was determined from time lost from work, distance and travel expenses. The same formula was then applied to estimate the cost of attending a base metropolitan hospital. The need for an accompanying person was determined from a subset of 16 patients who had transferred to metropolitan specialist consultation in the previous 12 months. Average waiting list times for consultations and common surgical procedures for the visiting service were compared with those for a metropolitan-based service. RESULTS: An estimated saving of AU$1,077 was made per specialist consultation when accessing a local rather than a metropolitan service. Savings were observed in travel time, distance travelled, lost income, provision of an escort and waiting time. CONCLUSION: The present study shows that the personal costs and difficulties incurred by rural and remote residents when accessing specialist treatment can be reduced if a visiting specialist service is available.

This study investigated the perceived impediments that prevent remote agritourism operators in the Northern Territory (NT) Australia from expanding and accessing support from governmental and industry organisations. Five primary themes emerged from 11 in-depth interviews with remote agritourism operators across the NT. These included distance from urban centres, limited human resources, infrastructure gaps, high capital requirements, and difficulties navigating and accessing support organisations. In addition, all businesses acknowledged they required support, the vast distance from urban centres often prevented participation in relevant programs due to a lack of time (for both travel and participation), seasonality and the patchwork range of support resources. A key recommendation is for government and other support organisations, as well as policymakers to improve their engagement with the sector in order to develop appropriate supports.

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

Strongyloides stercoralis is a soil-transmitted helminth (STH) endemic to tropical and subtropical areas. We reviewed the temporal detection trends in patients with S. stercoralis larvae present in faecal samples, in Northern Territory (NT) Government Health facilities, between 2002 and 2012. This was a retrospective observational study of consecutive patients with microbiologically confirmed detection of S. stercoralis in faeces. The presence of anaemia, eosinophilia, polyparasitism, and geographic and demographic data, were included in the assessment. S. stercoralis larvae were present in 389 of 22,892 faecal samples (1.7%) collected across the NT over 11 years, examined by microscopy after formol ethyl acetate concentration. 97.7% of detections were in Indigenous patients. Detections, by number, occurred in a biphasic age distribution. Detections per number of faecal samples collected, were highest in the 0–5 year age group. Anaemia was present in 44.8%, and eosinophilia in 49.9% of patients. Eosinophilia was present in 65.5% of the ≤5 age group, compared to 40.8% of >5 year age (p < 0.0001). Polyparasitism was present in 31.4% of patients. There was an overall downward trend in larvae detections from 2.64% to 0.99% detections/number of faecal samples year between 2002 and 2012, consistent with the trends observed for other local STHs. S. stercoralis remains an important NT-wide pathogen.

On Aug 22, 2022, Togo confirmed that the country had eliminated four neglected tropical diseases (NTDs), the first country to do so. The announcement came after trachoma was declared the latest NTD to be eliminated in Togo. Trachoma—an eye disease caused by the bacterium Chlamydia trachomatis—is the leading infectious cause of blindness worldwide, mainly affecting children in rural communities who do not have access to safe water for face and hand washing. Approximately 90% of cases are from Africa, but Togo is not the only African country to successfully control trachoma, with Morocco (2016), Ghana (2018), Gambia (2021), and Malawi (2022) achieving elimination in recent years. With the past successes in eliminating trachoma in low-resource settings, and its association with poor sanitation, it is surprising that trachoma is still present in Australia, the only high-income country where the disease still exists. Australia committed to eliminate trachoma as part of the WHO Global Alliance for the Elimination of Trachoma by the year 2020. The country did have some success, with the national trachoma prevalence rate in children aged 5–9 years decreasing from 14% in 2009 to 3·3% in 2021; however, the target of elimination by 2020, and the subsequent target for 2022, were ultimately not met. “We need to do far better to meet all conditions for elimination, with endemic levels still existing in some regions,” said a representative from the Australian Government Department of Health and Aged Care (Canberra, ACT, Australia). These regions are primarily remote Indigenous communities in South Australia, Western Australia, and the Northern Territory, with 115 communities identified as being at risk. In April 2020, WHO recommended suspension of mass treatment, screening, and surveys for NTDs because of the COVID-19 pandemic. This suspension affected trachoma programmes worldwide, including in Australia, with the government representative telling The Lancet Microbe that the pandemic “affected trachoma screening and treatment activities in First Nations communities” due to “travel restrictions and the diversion of clinical staff to the COVID-19 public health response”. COVID-19 caused understandable disruption to trachoma control; however, the disease was present in Australia for many years prior to the pandemic. A reason why trachoma has been persisting in Australia is because of the remote location and inequities of the communities it affects. In December 2021, the Australian Government published the National Aboriginal and Torres Strait Islander Health Plan 2021–2031 (Health Plan), which The Lancet Microbe was told: “prioritises the social determinants of health and provides a platform for implementation of cross-jurisdictional action focused on the underlying conditions that give rise to trachoma”. This acknowledgment of the social determinants of trachoma is important. Sightsavers—a non-governmental organisation that works in low-income and middle-income countries to treat and prevent trachoma—has helped several countries eliminate trachoma. Their success has shown that the WHO-endorsed four-part strategy (surgery to treat blinding trichiasis, antibiotics to clear infection, promotion of facial cleanliness, and improving access to water and sanitation) works, but the director of NTDs Simon Bush (Sightsavers, Accra, Ghana) emphasises that understanding social context is crucial. “We can't underestimate the influence of the community volunteers who go out into their villages and win people's trust in [trachoma] treatments”, he told The Lancet Microbe. Culturally informed interventions are outlined as a priority in the Health Plan and the Australian Government representative said that they are working closely with the National Aboriginal Community-Controlled Health Organisation “to explore what role it and its members could play in both the design and implementation of responses to trachoma”. The recognition that local communities need to be involved in trachoma interventions is a step forward to eliminating the disease from Australia, but it also emphasises how these communities have been neglected for years. The health disparities between Indigenous and non-Indigenous communities in Australia are well documented in the Overcoming Indigenous Disadvantage reports, which the Australian Government have commissioned since 2002. The latest report stated that hospitalisation rates for Indigenous people with diseases that are associated with poor environmental health are more than double those of non-Indigenous people, and they are also 1·5-times more likely to die from such a disease. Data on access to safe water and sewerage systems for these communities has not been available since 2006, but the report states that, in 2018–19, one in five Indigenous households lived in housing of an “unacceptable standard”, suggesting that water and washing facilities may also be inadequate to prevent health conditions. Trachoma prevalence in Australia has declined over the past decade and the government has made commitments to improving the health of Indigenous people. However, achieving the last step of elimination will be difficult if data on living conditions are not recorded or improved. In the words of Simon Bush: “trachoma elimination requires leaving no one behind”.

As part of the Commonwealth-funded project, Growing Our Own, Charles Darwin University, in partnership with the Darwin Catholic Education Office, is delivering a preservice education degree program to remote indigenous communities. This paper employs a case study approach to investigate how the program is operating in one of the communities, using examples from the Wadeye local context. In remote community schools, there is a high turnover of staff each year. In addition, there are very few indigenous teachers, although nearly every classroom has an indigenous Teacher Assistant, particularly in the bilingual schools. There are other connected issues, such as school attendance statistics and providing role models for young people. In order to build a more sustainable staff and increase the number of indigenous teachers from within the local community, lecturers from Charles Darwin University travel to five remote communities each week of the school year to deliver preservice teacher education to small groups of teacher assistants. Because they already work in classrooms every day, their ability to take a whole day for their university studies is only possible because of cooperation from their mentor teacher and the school. The program is designed to link closely with the daily work the teacher assistants are already doing in their classrooms. The learning tasks and assessment items are planned to complement and enrich their practice in the local environment, and to reposition them from being seen as teacher assistants to teachers. In this truly work-integrated learning model, the students’ daily work is essential to their studies.

Soil-transmitted helminths include hookworms, threadworms, whipworms and roundworms. These worms may infect different hosts including humans and dogs, and some species are zoonotic, meaning that they are able to transmit between animals and humans. In many Australian Indigenous communities, people remain infected with these worms at high rates compared to other parts of the country despite various control strategies. Resource and health literacy inequalities are primary drivers for these differences. However, the potential for dogs to act as reservoirs for zoonotic worm infections in humans must also be considered. For this reason, it’s important to create a clear picture of the level of infection by location and host. Given that tests used to establish prevalence can produce false positive or negative results, we performed a meta-analysis allowing comparison of true prevalence estimates by location and host, regardless of the test used. This review suggests that threadworm and dog hookworm remain endemic in Australian Indigenous communities, though a gap exists to accurately inform the prevalence of the other worms. It also highlights the need for One Health strategies in research, policy and control where humans, all animal hosts and the environment are considered in a culturally relevant way.

Objective: To describe the clinical and laboratory features and management of Strongyloides stercoralis infection in the Top End of the Northern Territory. Design: A 12-month retrospective review of clinical records of patients confirmed on stool microscopy to be infected with S. stercoralis. Setting: The Royal Darwin Hospital (RDH), a 300-bed referral hospital servicing the tropical areas of the Northern Territory, which have a population of 120 000, 21% of which is Aboriginal. Results: Potentially pathogenic gastrointestinal parasites were identified in 205 patients over the 12 months. Of these, 68 patients had strongyloidiasis - 64 were Aboriginal, three were Caucasian and one was of New Guinean origin. Thirty-seven (54%) were under five years of age. Patients came from all regions served by RDH, including urban Darwin. Seventy-five per cent of adults had chronic underlying disease and 80% of children under five years old were below 80% of standard weight for age. Gastrointestinal symptoms were absent in 28%; occasionally, severe disease occurred. Eosinophilia with greater than 0.7 x 109 cells/L was present in 57% of patients. Only 57% of cases were treated with thiabendazole. Conclusion: In the Top End of the Northern Territory, Strongyloides infection is endemic in Aboriginal communities, but also occasionally occurs in non-Aboriginal people. It is likely that the infection is frequently not recognised. Current community-based anthelmintic regimens have succeeded in reducing the prevalence of hookworm infection, but strongyloidiasis still appears to be a prevalent condition. The possibility of hyper-infection or disseminated strongyloidiasis in immunocompromised patients such as renal transplant recipients and people infected with the human immunodeficiency virus needs consideration in this endemic area. The interaction in northern Australia of S. stercoralis with human T-lymphotropic virus type I and with undernutrition warrants further study.

Strongyloides stercoralis, a nematode parasite, has a well-documented history of infecting human hosts in tropic and subtropic regions mainly through skin contact with inhabited soil. The result is strongyloidiasis, a human parasitic disease, with a unique cycle of auto-infection contributing to a variety of symptoms, of which, hyper-infection causing fatality may occur. In Australia, Indigenous community members often located in rural and remote settings, are exposed to and infected with strongyloides. Previous researchers report strongyloidiasis as a recurrent health issue for Indigenous Australians. This is a systematic review to determine the barriers to control for this pernicious pathogen. Barriers to control can be defined across three key themes: (1) health status, (2) socioeconomic status, and (3) health care literacy and procedure. By conceptualizing these barriers and addressing steps to control as outlined in this study, there is potential for improvement in prevention and treatment outcomes of strongyloidiasis and subsequently, overall health for Australian Indigenous people. This study contributes to furthering prevention and treatment of strongyloidiasis, increasing exposure to the issue of strongyloidiasis in Australian Indigenous people. It is the intent of this paper to express the need to have continued research and further health policy directed specifically to eradicate strongyloidiasis in Australian Indigenous communities.

Background: Strongyloides stercoralis may cause a complicated infection in immunocompromised patients, which has a high case fatality rate. Death generally results from sepsis with enteric pathogens. Globally, infection with the human T-cell lymphotropic virus type 1 (HTLV-1) is a major risk factor for this syndrome. Both S. stercoralis and HTLV-1 are endemic to Central Australia. Aims: The aim of the study was to determine whether complicated strongyloidiasis occurs in association with HTLV-1 infection in Central Australia. Methods: A retrospective audit of all cases of complicated strongyloidiasis presenting to Alice Springs Hospital between January 2000 and December 2006 was carried out. Diagnosis was defined as definite or probable according to whether diagnosis was made by faecal studies or serology respectively. The medical records, investigations and outcomes of patients who met predetermined criteria for a diagnosis of complicated strongyloidiasis were reviewed. Results: Eighteen indigenous patients met the criteria for complicated strongyloidiasis (definite 9, probable 9). Seven of 11 patients tested were HTLV-1 seropositive. At diagnosis, no treatment was documented for nine patients (definite 4, probable 5), three received a single dose of ivermectin and one a single dose of albendazole. Fifteen patients (83%) died because of sepsis (definite 7, probable 8). Pathogens isolated and their foci of infection included Klebsiella pneumoniae pneumonia (4), bloodstream infection with Enterococcus spp. (2), K. pneumoniae peritonitis (1) and streptococcal meningitis (1). Conclusion: Complicated strongyloidiasis occurs in association with HTLV-1 infection in central Australia. This finding has significant implications for the management of S. stercoralis in the region.

A substantial quantity of rock art was produced in central Australia in the period following contact between the Indigenous population and Europeans in the latter part of the nineteenth and early part of the twentieth centuries. An analysis of the post-contact rock art assemblage indicates that, despite the abrupt disruption to traditional hunter-gatherer lifestyles, the Indigenous response to the European invasion in this region was more positive, resilient and creative than early historians assumed. Significantly, many elements of the pre-contact assemblage continued to be produced or reworked whilst the range of production techniques expanded. Innovations emerged with a number of older forms of representation being replaced by newer forms, a range of new subject matter was introduced, and new means of flagging identity were created alongside the old. Analysis of the post-contact rock art assemblage has demonstrated that Aboriginal people in central Australia were active participants in change, mediating their interactions with the intruders in innovative ways.

Strains of meningococci isolated from patients in South Australia (SA) and the Northern Territory (NT) with either bacteremia or meningitis (or both) were serotyped and serosubtyped using monoclonal antibodies in a whole cell ELISA technique. From SA, 144 isolates were examined for the period 1971 through 1989 and from the NT, 38 isolates from 1975 through 1977 and 1983 through 1989 were examined. During the periods of study the principal serogroups were group B in South Australia and group A in the Northern Territory. About 60% of the SA strains were typable and subtypable: the predominant types were 4, 2a, 15 and 14, in that order; the predominant subtypes were P1.2, P1.1 and P1.10, in that order. Of the strains from the NT about 80% were typable, the predominant type was type 4 and all 19 group A strains were identified as type 4, subtype P1.10.

Background: Living in small, isolated groups may promote health for Aborigines if traditional lifestyles are followed, but overall health risks in such communities are inadequately documented. Aim: To document health status of a remote Aboriginal community with reference to nutrition, cardiovascular risks, renal disease and infections and to identify areas where health might be improved. Methods: All residents of a small community in the Great Sandy Desert underwent medical examinations, anthropometry and measurement of blood pressure. Investigations included cholesterol, triglycerides, glucose, insulin, creatinine, lipoprotein (a), apolipoprotein E phenotype, angiotensin-converting enzyme genotype, urinalysis, stool microscopy (children), liver function tests and full blood examination. Results: Children (n=26) were undernourished while 14% of adults (n=51) were underweight, 22% overweight and 40% of women and 13% of men were obese with central obesity in 90% of women and 48% of men. Fifteen per cent of the group were hypertensive. Insulin levels were increased in 55% of subjects, total cholesterol in 21% and triglycerides in 56%, while HDL was decreased in 78%. Angiotensin-converting enzyme and apolipoprotein E typing and lipoprotein (a) did not suggest increased cardiovascular risk. Proteinuria was present in 39% of subjects, haematuria in 49% and definite or possible urinary tract infections in 30%. Faecal parasites were prevalent and a history of infections, including sexually transmitted diseases, was common. Conclusions: Increased cardiovascular risk, nutritional disorders, renal disease and infections are major problems in this community which had relocated several years previously from a mission environment closer to western influences, including alcohol.

Poor-quality and overcrowded housing in remote communities in Australia is widely seen to negatively impact Indigenous children's health and development. Despite widespread reports of, in some instances, quite appalling housing conditions, recent analyses of data from the Longitudinal Study of Indigenous Children (LSIC) found little evidence of adverse housing effects for Indigenous children living in very remote Australia. Given the apparent inconsistency in evidence coming from representative survey data and other accounts, a small-scale case study was conducted in the Kimberley's Fitzroy Valley to gain greater insights into housing in very remote communities for families with school-aged children. The LSIC very remote sample is confirmed to offer a good representation of housing conditions in these communities, based on replication of key housing data items in a small survey of Fitzroy Valley parents. While not apparent in those parent surveys, problems of severe overcrowding were highlighted in interviews with community leaders. Other issues raised included delays in maintenance and repairs and a lack of local input into housing management and associated employment, which was seen to disempower communities.

While many Australians benefit from infrastructure in metropolitan areas, there are up to a million Australians without the luxury of accessible, reliable and safe essential services. These are often the most disadvantaged of Australia’s population, especially Aboriginal and Torres Strait Islander peoples. Infrastructure Partnerships Australia strives to achieve the best policy outcome for remote communities across the country. For the purposes of this report, Infrastructure Partnerships Australia’s definition of what constitutes a ‘remote community’ includes those which are not connected to trunk infrastructure and national or regional networks and systems, instead relying on smaller and standalone services where they exist. Australia already has access to the tools, technology, resources and expertise to improve remote community outcomes. Many solutions have been put in place with great success across all Australian jurisdictions and in other parts of the world. But these often have limited scopes and are not being routinely or consistently applied in all remote communities. The first step must be to address gaps in the service standards governments set for remote infrastructure across the country. These can and should be aligned to the SDGs, which Australia has committed to deliver. By tightening existing gaps, improving clarity and addressing inconsistencies, these standards can act as a minimum expectation for service delivery across the country, for all Australians. These can be agreed by all governments through National Cabinet, with outcomes reported on publicly and transparently.