Remote Australia Online

Background: A widespread G2P[4] rotavirus epidemic in rural and remote Australia provided an opportunity to evaluate the performance of Rotarix and RotaTeq rotavirus vaccines, ten years after their incorporation into Australia’s National Immunisation Program. Methods: We conducted a retrospective case-control analysis. Vaccine-eligible children with laboratory-confirmed rotavirus infection were identified from jurisdictional notifiable infectious disease databases and individually matched to controls from the national immunisation register, based on date of birth, Aboriginal status and location of residence. Results: 171 cases met the inclusion criteria; most were Aboriginal and/or Torres Strait Islander (80%) and the median age was 19 months. Of these cases, 65% and 25% were fully or partially vaccinated, compared to 71% and 21% of controls. Evidence that cases were less likely than controls to have received a rotavirus vaccine dose was weak, OR 0.79 (95% CI, 0.46–1.34). On pre-specified subgroup analysis, there was some evidence of protection among children <12 months (OR 0.48 [95% CI, 0.22–1.02]), and among fully vs. partially vaccinated children (OR 0.65 [95% CI, 0.42–1.01]). Conclusion: Despite the known effectiveness of rotavirus vaccination, a protective effect of either rotavirus vaccine during a G2P[4] outbreak in these settings among predominantly Aboriginal children was weak, highlighting the ongoing need for a more effective rotavirus vaccine and public health strategies to better protect Aboriginal children.

Perspectives: Leadership in rural health through policy generation: attraction and recruitment in rural Australia

People with chronic diseases are likely to require some form of domestic care, however their care needs acquire low visibility in housing policy frameworks. Amongst Yolngu (Indigenous Australians from north-east Arnhem Land), high rates of kidney disease reinforce needs for housing and care. I consider how access to housing shapes relations and practices of care in the families of Yolngu renal patients in Darwin, Australia; and how Yolngu relations and practices of care are implicated in housing policy. Through an ethnographic case study approach, I show that in Yolngu families, practices of extending shelter to kin are care practices fundamental to the performance of domestic labour. I argue that while housing policy frameworks rely on familial relations and practices of care to reduce rough sleeping and achieve other policy objectives, Yolngu relations and practices of care are also marginalised through the governance of public housing. The politics of care that play out in their places of residence reproduce housing precarity.

The burden of chronic kidney disease in Indigenous Australians is 7.3 times higher than that of non–Indigenous Australians. If chronic kidney disease is detected early and managed, deterioration in kidney function can be reduced. Urine albumin to creatinine ratio is a key marker of early renal damage.To report on 16 years of analytic quality of urine albumin to creatinine ratio testing on Siemens DCA devices enrolled in the national Quality Assurance for Aboriginal and Torres Strait Islander Medical Services point-of-care testing program.Quality Assurance for Aboriginal and Torres Strait Islander Medical Services participants are required to test 2 quality assurance samples each month across two 6-monthly testing cycles per year. Participants also test 2 quality control samples monthly.The percentage of urine albumin, creatinine, and albumin to creatinine ratio results for quality assurance point-of-care testing that were within assigned allowable limits of performance averaged 96.9%, 95.9%, and 97.5%, respectively. The percentage acceptable quality control results for urine albumin and creatinine averaged 93.5% and 86.8%. The median imprecision for urine albumin, creatinine, and albumin to creatinine ratio quality assurance testing averaged 5.5%, 4.1%, and 3.3%, respectively, and the median within-site imprecision for quality control testing averaged 5.4%, 4.3%, and 5.7%, respectively, for the low sample and 4.0%, 4.1%, and 4.5%, respectively, for the high sample.For 16 years the DCA system has proven to be reliable and robust and operators at Aboriginal medical services have demonstrated they are able to conduct point-of-care testing for urine albumin to creatinine ratio that consistently meets analytic performance standards.

This study evaluated a community-driven animal health and management program in the remote community of Wadeye, Northern Territory. This evaluation used a pre-post design to assess changes in animal and human health outcomes over a 12-month period of program implementation, from June 2018 to June 2019. The evaluation assessed the program by comparing animal health outcomes before versus one year after program implementation and comparing human health outcomes before versus during the first 12 months of the program. Outcome measures included the desexing status of dogs and cats, body condition and hair score of dogs, and rates of people presenting to the health clinic for a dog bite. Animal health outcomes significantly improved after program implementation. From pre to post program, there was a 77% increase in the prevalence of good body condition score among dogs and a 9% increase in the prevalence of good hair score among dogs, and the prevalence of desexed dogs and cats more than doubled. There was no significant change in the number of people presenting to the health clinic for a dog bite. Consideration on how to further incorporate human and environmental health aspects into the program could be useful for future One Health programs.

Objective Recent literature has highlighted a link between hearing loss as a result of otitis media in the early years of life and impacted binaural processing skills in later childhood. Such findings are of particular relevance to Indigenous Australian children, who tend to experience otitis media earlier in life and for longer periods than their non-Indigenous counterparts. There is also growing interest in the effects of reduced auditory processing ability on a child's early learning of language and, specifically, on phonological awareness that contributes to word reading skills. The aim of the present study was to determine the association between hearing thresholds, dichotic listening skills and phonological awareness in children with pervasive otitis media (OM) from remote Indigenous communities of Australia who generally do not speak English as a first language. Methods Participants included one hundred and one children between the ages of 4.8–7.9 years (mean 6.1 years) from three separate remote Northern Territory communities. Evaluations included otoscopy, air conduction PTA, and tympanometry. All children were also assessed on the Dichotic Digits difference test (DDdT) and the Foundations of Early Literacy Assessment (FELA), assessing children's dichotic listening and phonological awareness respectively. Results The results showed that 56% of the children had middle ear dysfunctions (type B and type C on tympanometry results) in at least one ear on the day. Partial correlation showed a significant correlation, between dichotic scores and FELA with age as covariate (r = 0.45, p < 0.001). One way ANOVA showed females exhibited a significantly higher performance compared to males on FELA [F (1, 99) = 5.47, p = 0.021]. The overall regression model was found to be significant in predicting total FELA scores [F (7, 77) = 7.56, p < 0.0005]. Age and gender as well as dichotic listening scores explain 40.7% of the variance. Conclusions The results reinforce the importance of managing the ear health of Indigenous children, clarifying the impact this has on listening and phonological awareness. These findings highlight the importance of evaluating children's listening abilities, and how poor listening can impact phonological awareness. The findings have important implications for ensuring optimal listening and learning conditions in schools in remote NT communities.

This commentary article describes the clinical context in the Northern Territory, Australia, and the concerns and changes in practice brought forth by COVID-19. We provide an overview of the local response, which has included a shift to telepractice, and discuss the merits and potential issues of telepractice service provision in remote and very remote Australia.

The prevalence of otitis media (OM) and related hearing loss has remained persistently high among some groups of Australian Aboriginal children who are also reported to have poor academic outcomes. The general literature remains inconclusive about the association between OM-related hearing loss and academic performance in primary school. This study aimed to investigate this association in Aboriginal children living in the Northern Territory (NT) of Australia.

Identifying and removing access barriers to the timely provision of comprehensive health care is increasingly important for the wellbeing of Australia's rapidly ageing and frail populations, particularly those in non-metropolitan settings. This study has examined if current general practice (GP) locations in non-metropolitan South Australia and Western Australia (WA) are geographically accessible to the rapidly growing frail and prefrail populations known to have a high level of health service use and reduced mobility. Geospatial analysis linking 60-kilometre GP service catchments, 2016 population counts, and 2027 population projections has estimated that the size of the frail and prefrail population that live outside these GP service catchments will double, reaching 7,800 people by 2027. The maldistribution of GP locations was most evident in WA. As regional and remote populations continue to age, the challenge of health service provision, including geographic access to care, must be resolved to ensure that populations in these areas have the best opportunity to age well. Geospatial methods linking service and demographic information, such as the approach used in this analysis, can aid in planning the equitable provision of health care for older Australians.

Background There is strong evidence from many settings that tobacco tax rises which increase prices reduce tobacco consumption, but only limited evidence from Indigenous settings.Methods We analysed 3 years (2016–2018) of weekly sales data from 32 stores in remote Aboriginal communities. We used interrupted time series analysis to estimate the immediate impact of the price rice following annual 12.5% tobacco tax rises on sales on (A) stick equivalents of tobacco and (B) fruit and vegetables (kg) per $A1000 of grocery sales, and on the trend in sales between price rises.Results We detected 5.8% and 8.2% immediate declines in tobacco sales following the price rises associated with annual 12.5% tax rises in 2016 and 2018, and a non-significant decline (1.6%) following the 2017 tax rise. Decreased sales were mainly driven by declines in mainstream and premium factory-made cigarettes. Fruit and vegetable sales did not change at the time of tobacco price rises.Conclusion For the first time, we demonstrated evidence of price-sensitivity and the immediate impact of price rises from tobacco tax rises on tobacco sales in remote Aboriginal communities. We acknowledge that Australia already has very high tobacco taxation and prices, but recommend further increases to the taxation of roll-your-own (RYO) tobacco to prevent smokers and industry using cheaper RYO cigarettes to undermine this impact of high tobacco taxes and prices.

Stories matter: as powerful frames for policy and public understanding, but the current narratives about Outback Australia are both confused and often negative. We illustrate this power of stories, including how deliberate framing and story-telling to create a better narrative on some rangeland issues has had positive policy outcomes. Moving to a more intuitive name is one key issue – we suggest that talking of the ‘Modern Outback’ is a powerful change in this regard. We then draw on discussions to provide a set of guiding principles for how to frame writings about the Outback, and give an example of their use.

This report identifies trends and differences in alcohol and other drug use, harms and treatment in Major cities and Regional and remote Australia. The consumption of alcohol at levels placing people at risk of alcohol-related harm was higher for clients in Regional and remote Australia compared with those in Major cities. While the consumption of illicit drugs was similar for clients in Major cities and Regional and remote areas, the type of illicit drug used varied. Clients in Regional and remote areas were more likely than those in Major cities to travel 1 hour or longer to access services.

Introduction The management of patients who need chronic and complex care is a focus of attention internationally, brought about by an increase in chronic conditions, requiring significantly more care over longer periods of time. The increase in chronic conditions has placed pressure on health services, financially and physically, bringing about changes in the way care is delivered, with hospital avoidance and home-based care encouraged. In this environment, nurses play an important role in co-ordinating care across services. This review formed one part of a funded project that explored the nurse navigator role within a proposed 24-hour telephone-call service in one regional area that has a diverse population in terms of cultural identity and geographical location in relation to service access. Aim The review reports on the extant literature on the nurse’s role in the provision of afterhours telephone services for patients with chronic and complex conditions. The specific aim was to explore the effectiveness of services for patients in geographically isolated locations. Methods The methodological approach to the review followed the Preferred Reporting System for Meta-Analyses (PRISMA) guidelines. A thematic analysis was used to identify themes with chronic care models underpinning analysis. Results Three themes were identified; nurse-led decision making; consumer profile; and program outcomes. Each theme was divided into two sub-themes. The two sub-themes for decision making were: the experience of the staff who provided the service and the tool or protocol used. The two sub-themes for consumers profile were; the geographic/demographic identity of the consumers, and consumer satisfaction. The final theme of outcomes describes how the effectiveness of the service is measured, broken into two sub-themes: the economic/workforce outcomes and the consumer outcomes. Discussion The provision of an after-hours telephone service, in whatever model used should align with a Chronic Care Model. In this way, after-hours telephone services provided by experienced nurses, supported by ongoing professional development and relevant protocols, form part of the ongoing improvement for chronic and complex care management as a health priority.

Background This study evaluated the acceptability of real-time video counselling compared to a) telephone counselling and b) written materials in assisting rural and remote residents to quit smoking. Methods Participants were recruited into a three-arm, parallel group randomised trial and randomly allocated to either: a) real-time video counselling; b) telephone counselling; or c) written materials. At 4-months post-baseline participants completed an online survey that examined self-reported acceptability and helpfulness of the support. Results Overall, 93.5% of video counselling participants and 96.2% of telephone counselling participants who received support thought it was acceptable for a smoking cessation advisor to contact them via video software or telephone respectively. There were significant differences between video counselling and telephone counselling groups on three of 10 acceptability or helpfulness measures. Video counselling participants had significantly lower odds of reporting the number of calls were about right (OR 0.50, 95% CI 0.27- 0.93), recommending the support to family and friends (OR 0.18, 95% CI 0.04-0.85) and reporting the support helped with motivation to try quitting (OR 0.24, 95% CI 0.07-0.76) compared to telephone counselling participants. Video counselling participants had significantly greater odds than written materials participants of rating the support favourably on all seven acceptability and helpfulness items compared. Conclusions Real-time video counselling for smoking cessation is acceptable and well-received by those living in rural and remote locations. Further research is required to enhance the three attributes that were less acceptable for video counselling than telephone counselling.

Between 2010 and 2013, an outbreak of serotype-1 sequence type 306 (ST306) invasive pneumococcal disease (IPD) occurred primarily in remote locations of Northern and Central Australia. This is a descriptive study of the epidemiology of the outbreak using nationwide IPD surveillance data, sup-plemented with more detailed data held by affected jurisdictions, and of the response to the outbreak, including vaccination strategies. In the year the outbreak peaked (2011), serotype-1 IPD incidence was over 30-fold higher in the affected regions than in the rest of Australia (incidence rate ratio: 30.7 [95% CI 20.1–48.9]). The study includes 245 cases of serotype-1 IPD from the outbreak regions, with 75.5% identified as Indigenous.No reported cases of serotype-1 IPD occurred in young children who had completed either a 10- or 13-valent pneumococcal conjugate vaccine schedule. However serotype-1 IPD did occur in older chil-dren who had previously received 23-valent pneumococcal polysaccharide vaccine.Development of public-health-focused national IPD management guidelines, including suitable vac-cine strategies for consistent use nationwide, could potentially decrease the duration and intensity of similar outbreaks in the future.

The human T-cell leukaemia virus type 1 (HTLV-1) subtype c is endemic to central Australia. We report the first large-scale, community-based, health survey of HTLV-1 and its disease associations in this setting.Aboriginal community residents aged >2 years in seven remote communities were invited to do a health survey that included a questionnaire, spirometry and clinical examination by a physician blinded to HTLV-1 status, clinical records and spirometry results. Blood was drawn for HTLV-1 serology and proviral load (PVL). Pulmonary disease was assessed clinically and spirometrically and, where records were available, radiologically after the clinical assessment. Associations between specific diseases and HTLV-1 status were determined using logistic regression, adjusting for available confounders.Overall, 579 residents (children aged 3-17, 164; adults, 415) were examined (37.7% of the estimated resident population). HTLV-1 prevalences for children and adults were 6.1% and 39.3%, respectively. No associations were found between HTLV-1 and any assessed clinical condition among children. Chronic pulmonary disease and gait abnormalities were more common among adults with HTLV-1 infection. Adjusted odds ratios (aOR)(95% CI) among participants with PVL ≥ 1000 per 10 5 PBL were 7.08 (2.67, 18.74; p<0.001), 9.81 (3.52, 27.35; p<0.001) and 14.4 (4.99, 41.69; p<0.001) for clinically defined chronic pulmonary disease, moderate-severe expiratory airflow limitation and radiologically determined bronchiectasis/bronchiolitis, respectively, and 5.21 (1.50, 18.07; p=0.009) for gait abnormalities.In the first study of HTLV-1 disease associations based on community recruitment and blinded assessment, HTLV-1 infection was strongly associated with pulmonary disease and gait abnormalities.

There is a palpable fear that COVID-19 will devastate Aboriginal populations in remote communities in Northern Australia. For example, there are over 45,500 Aboriginal people in the ‘Outback’ of the Northern Territory alone, and a quarter of these are children under 14 years of age (ABS, 2020). This population is highly vulnerable as a result of systemic and long-term neglect. Sadly, overcrowding, high rates of chronic disease, comorbidity, poor water security, high rates of unemployment, substance abuse and mental health issues are well established realities of the socioeconomic condition in remote communities. Add to this low levels of English literacy, mass returns to country from cities like Darwin–heightening community stressors and increasing overcrowding–a highly mobile population and communal cultural mores (social distancing will not work in these places – full stop) and you do not have to be an epidemiologist to be concerned about the impact COVID-19 might have. These communities are not cut off from the world or safe havens from the virus. As I write this, hundreds of fly-in fly-out workers are landing in communities with mining operations and the Kimberley in Western Auatralia has ust had two confirmed cases. So, while the Minster for Indigenous affairs, the Hon. Ken Wyatt,and the Minister for Health, the Hon. Greg Hunt, are taking advice from an appointed Indigenous leadership about community lock-downs, there is a risk that the horse, as they say, may have already bolted (Hunt & Wyatt, 2020).

Evidence for cross-cultural response biases is now relatively ubiquitous in psychological research, however the idea that cultural differences might influence neurocognitive performance remains relatively underexplored. We objectively measured different response strategies of Indigenous and non-Indigenous children using signal detection theory to examine whether the way they responded (measured as response bias) might affect their perceived visual working memory ability (measured as detection sensitivity). We conceptualised response bias as whether children responded more liberally or conservatively when determining whether they observed a change in temporally-presented change-detection stimuli. We present quantitative evidence that remote Indigenous children employ more conservative decision making strategies than non-Indigenous children when completing visual working memory tasks. Evidence presented here of cross-cultural differences in decision-making during cognitive performance highlights the importance of considering cross-cultural differences when conducting cognitive research, and suggests a need to evaluate whether such differences may affect task performance. This evidence also highlights the need to evaluate whether such differences may affect task performance in applied settings, for example within the domain of literacy acquisition.

The aims of this article are to comment on pre–coronavirus disease 2019 (COVID-19) mental health activity in rural and remote Australia, including related air medical retrievals; to discuss how the current pandemic is likely to impact on this vulnerable population's mental health; and to provide potential solutions. The COVID-19 pandemic has resulted in significant air medical activity from rural and remote Australia. COVID-19 and the necessary public health and socioeconomic interventions are likely to significantly compound mental health problems for both the general public and the mental health workforce servicing rural and remote communities. However, the COVID-19 crisis provides a window of opportunity to develop, support, and build novel and sustainable solutions to the chronic mental health service vulnerabilities in rural and remote areas in Australia and other countries.

Based on an evaluation of the inDigiMOB project, auspiced by First Nations Media Australia, this article examines the role of a programme designed to improve digital inclusion for people living in town camps and remote communities of central Australia. Increasingly, Australians are expected to use technology to access health, government, utility, and education services. Over the last three years, inDigiMOB has been testing a model using local “Digital Mentors” to support a transfer of essential digital skills and knowledge to community members. The evaluation identified a number of enabling mechanisms that have led to several important outcomes. These outcomes are employability skills, essential access to technology, and basic literacy, as well as maintaining language and culture, which are supported through organisational structures and relationships. The article concludes by responding to the question: Does the “place” of central Australia change how digital inclusion should be pursued as an outcome?

Epidemiological surveillance of Shigella spp. in Australia is conducted to inform public health response. Multi-drug resistance has recently emerged as a contributing factor to sustained local transmission of Shigella spp. All data were collected as part of routine public health surveillance, and strains were whole-genome sequenced for further molecular characterisation. 108 patients with an endemic regional Shigella flexneri strain were identified between 2016 and 2019. The S. flexneri phylogroup 3 strain endemic to northern Australia acquired a multi-drug resistance conferring blaDHA plasmid, which has an IncFII plasmid backbone with virulence and resistance elements typically found in IncR plasmids. This is the first report of multi-drug resistance in Shigella sp. in Australia that is not associated with men who have sex with men. This strain caused an outbreak of multi-drug-resistant S. flexneri in northern Australia that disproportionality affects Aboriginal and Torres Strait Islander children. Community controlled public health action is recommended.

Introduction Aboriginal and Torres Strait Islander Australians living in remote locations suffer disproportionately from chronic hepatitis B (CHB). Defining the temporospatial epidemiology of the disease—and assessing the ability of local clinicians to deliver optimal care—is crucial to improving patient outcomes in these settings. Methods The demographic, laboratory and radiology findings in all patients diagnosed with CHB after 1990, and presently residing in remote Far North Queensland (FNQ), tropical Australia, were correlated with their management and clinical course. Results Of the 602 patients, 514 (85%) identified as Aboriginal and Torres Strait Islander Australians, 417 (69%) of whom had Torres Strait Islander heritage. Among the 514 Aboriginal and Torres Strait Islander Australians, there were only 61 (12%) born after universal postnatal vaccination was introduced in 1985. Community CHB prevalence varied significantly across the region from 7/1707 (0.4%) in western Cape York to 55/806 (6.8%) in the Eastern Torres Strait Islands. Although 240/602 (40%) are engaged in care, with 65 (27%) meeting criteria for antiviral therapy, only 43 (66%) were receiving this treatment. Among 537 with complete data, 32 (6%) were cirrhotic, of whom 15 (47%) were engaged in care and 10 (33%) were receiving antiviral therapy. Only 64/251 (26%) in whom national guidelines would recommend hepatocellular carcinoma (HCC) surveillance are receiving screening, however, only 20 patients have been diagnosed with HCC since 1999. Conclusion Vaccination has had a dramatic effect on CHB prevalence in FNQ in only a generation. However, although engagement in care is the highest in Australia, this is not translating into initiation of antiviral therapy in all those that should be receiving it, increasing their risk of developing cirrhosis and HCC. New strategies are necessary to improve the care of Indigenous Australians living with CHB to reduce the morbidity and mortality of this preventable disease.

The urban focus of crime has dominated the attention of criminologists. Although images of idyllic, crime-free areas beyond the cityscape persist, there is scant academic consideration of the realities and variances of crime across regional, rural and remote Australia. Contributors to Locating Crime explore the nexus between crime and space, examining the complexities that exist in policing, prosecuting and punishing crime in different zones. The various authors draw upon original knowledge and insight and utilise innovative research and an interdisciplinary approach to their work. The broad theme of Locating Crime is centred on ‘context, place and space’, but several sub-themes emerge too. Contributors grapple with a number of issues: contextualisations of rurality; notions of ‘access to justice’; the importance of building ‘social capital’; the role of history; and of proactively addressing offending rates with crime prevention measures. This original research adds significantly to criminological understandings of crime in different spaces and offers novel insights of the impact upon victims and communities affected by crime in non-urban environments. Twelve scholarly chapters are grounded in criminological, legal and socio-legal frameworks and incorporate theoretical and practical knowledge from other fields such as history, sociology, cultural geography, media, cultural studies and Indigenous studies. The contributions from four professionals with expert knowledge of specific facets of criminal justice systems in Australia offer evaluations often absent from scholarly criminological literature. By melding both academic and practitioner discourse into the same work, this book allows a greater appreciation of the nexus between thought and practice. PART A: LOCATING CRIME 1. An Interpretive Approach to Understanding Crime in Rural Australia John Scott and Dean Biron 2. Placing Crime: The Failings of Urban-Centric Environmental Criminology Murray Lee and Garner Clancy 3. Development of Crime and the Criminal Justice System in Australia Jenny Wise and David Andrew Roberts 4. Crime Patterns: Measurement and Evaluation of Crime and Deviance in Rural and Regional Australia Frank Morgan PART B: CRIMINAL JUSTICE ISSUES AND RESPONSES 5. The Place of Indigenous People: Locating Crime and Criminal Justice in a Colonising World Chris Cunneen 6. Violent Landscapes: A Spatial Study of Family Violence Bridget Harris 7. Policing of Protest in Rural and Regional Contexts David Baker 8. Farm Crime: The Forgotten Frontier? Alistair Harkness 9. Accessing Justice in Regional Australia: Evolving Perspectives and Contexts Richard Coverdale 10. Witness, Judge or Watchdog?: Journalism and Regional Courts Kristy Hess and Lisa Waller 11. Penology from City to Country: Rurality and Penality in Australia Russell Hogg 12. Crime Prevention in Varied Settings Anthony Morgan PART C: PRACTITIONER PERSPECTIVES 13. Broadmeadows to the Bush: A Policing Perspective Robert Haldane 14. Law and True Justice: A Perspective from the Top End Jonathon Hunyor 15. Bush Courts and Beyond Jenny Blokland 16. Lawmaking or Making Justice?: Foundations for Criminal Justice Responses in Rural and Regional Communities Rob Hulls 17. Conclusion: The State of Play David Baker

Objective: The purpose of this double-blind, randomised, placebo-controlled, adaptive design trial with frequent interim analyses is to determine if Australian Indigenous children, who receive an additional (third) dose of human rotavirus vaccine (Rotarix, GlaxoSmithKline) for children aged 6 to < 12 months, would improve protection against clinically significant all-cause gastroenteritis. Participants: Up to 1000 Australian Aboriginal and Torres Strait Islander (hereafter Indigenous) infants aged 6 to < 12 months will be recruited from all regions of the Northern Territory. Interventions: The intervention is the addition of a third scheduled dose of human monovalent rotavirus vaccine. Co-primary and secondary outcome measures: ORVAC has two co-primary outcomes: (1) anti-rotavirus IgA seroconversion, defined as serum anti-rotavirus IgA ≥ 20 U/ml 28 to 55 days post Rotarix/placebo, and (2) time from randomisation to medical attendance for which the primary reason for presentation is acute gastroenteritis or acute diarrhoea illness before age 36 months. Secondary outcomes include (1) change in anti-rotavirus IgA log titre, (2) time from randomisation to hospitalisation with primary admission code presumed or confirmed acute diarrhoea illness before age 36 months, (3) time from randomisation to hospitalisation for which the admission is rotavirus confirmed diarrhoea illness before age 36 months and (4) time from randomisation to rotavirus infection (not necessarily requiring hospitalisation) meeting the jurisdictional definition before age 36 months. Discussion: A detailed, prospective statistical analysis plan is presented for this Bayesian adaptive design. The plan was written by the trial statistician and details the study design, pre-specified adaptative elements, decision thresholds, statistical methods and the simulations used to evaluate the operating characteristics of the trial. As at August 2020, four interim analyses have been run, but no stopping rules have been triggered. Application of this SAP will minimise bias and supports transparent and reproducible research.

Substantial government funding has been invested to support the training of General Practitioners (GPs) in Australia to serve rural communities. However, there is little data on the impact of this expanded training on smaller communities, particularly for smaller rural and more remote communities. Improved understanding of the impact of training on underserved communities will assist in addressing this gap and inform ongoing investment by governments and communities.