Invasive pneumococcal disease in Australia, 2001.

There were 1,681 cases of invasive pneumococcal disease (IPD) notified to the National Notifiable Diseases Surveillance System in Australia in 2001; a rate of 8.6 cases per 100,000 population. The notification rate varied between states and territories and by geographical region with the highest rates in the north of the country. Pneumococcal disease was reported most frequently in children aged less than 5 years (47.3 cases per 100,000 population). Enhanced surveillance for IPD was carried out in the Northern Territory, Western Australia, South Australia, Victoria, Tasmania and metropolitan areas of New South Wales, encompassing 72 per cent of the population and providing additional data on 86 per cent of all notified cases. Enhanced surveillance data revealed high rates of pneumococcal disease in Indigenous Australians. Rates of IPD in Indigenous children aged less than 5 years were as high as 483 cases per 100,000 population in the Northern Territory. The clinical presentation of IPD was most commonly pneumonia (56%) and bacteraemia (36%). There were 125 deaths attributed to IPD resulting in an overall case fatality rate of 8.6 per cent. More than half (54%) of all cases had a recognised risk factor for IPD. Eighty-six per cent of serotypes identified in non-indigenous children compared with only 55% of serotypes in Indigenous children were in the 7-valent vaccine. Antibiotic susceptibility testing showed reduced susceptibility to penicillin in 12 per cent, and to third generation cephalosporins in 5 per cent of isolates. These are the first national data available on IPD in Australia and will assist in evaluating the impact of the newly introduced conjugate vaccine and guide overall pneumococcal vaccine strategies.     

Laboratory surveillance of invasive pneumococcal disease in Australia in 2001 to 2002--implications for vaccine serotype coverage.

This paper reports the results of comprehensive laboratory surveillance of invasive pneumococcal disease (IPD) in Australia during 2001 and 2002. The 7-valent conjugate pneumococcal vaccine was introduced for high risk paediatric groups, including Indigenous children, in late 2001. Of 1,355 isolates from non-Indigenous children, 86 per cent belonged to serotypes and 93 per cent to serogroups represented in the 7-valent pneumococcal conjugate vaccine. Thirteen per cent and 24 per cent of isolates had reduced susceptibility to penicillin and erythromycin, respectively and of these, more than 99 per cent belonged to serogroups represented in the 7-valent vaccine. Of the 1,504 isolates from non-Indigenous adults, 96 per cent belonged to serotypes included in the 23-valent polysaccharide vaccine; 14 per cent and 15 per cent had reduced susceptibility to penicillin and erythromycin, respectively and more than 95 per cent of these belonged to serotypes included in the 7-valent conjugate vaccine. In Western Australia and the Northern Territory (the only states for which Indigenous status was consistently available), there were 29 cases of IPD in Indigenous children, of which 21 were due to 7-valent vaccine serotypes in 2001, compared with 24 cases, including 10 due to vaccine serotypes, in 2002. This represents a statistically significant increase in the proportion of total isolates due to non-vaccine serotypes (chi2 = 3.93, p = 0.048) following the introduction of the 7-valent conjugate vaccine, principally due to serotypes 7F and 12F. The number of episodes due to penicillin resistant isolates decreased from nine in 2001 to two in 2002. Ninety per cent of isolates from Indigenous adults were included in the 23-valent polysaccharide vaccine and six per cent and five per cent had reduced susceptibility to penicillin and erythromycin, respectively. Conjugate pneumococcal vaccines can be expected to reduce the incidence of IPD due to vaccine serotypes in vaccinated children and potentially, their adult contacts. It may also impact favourably on the incidence of IPD due to penicillin and erythromycin resistant strains. Continued surveillance of both serotype distribution and antibiotic susceptibility are required to identify serotype replacement by non-vaccine serotypes and to monitor the overall impact of current and future vaccine programs on invasive pneumococcal disease in Australia.     

A community-based study of respiratory episodes in Melbourne, Australia

OBJECTIVE: To provide recent data regarding the epidemiology of community-based respiratory infections in Australia. METHODS: A longitudinal study between 1997-99 involving collection of a health diary from 600 families in Melbourne. RESULTS: More than 80% of study participants reported at least one respiratory episode over 15 months. An average of 2.2 respiratory episodes per person per year was reported, with a mean episode duration of 6.3 days. On average, subjects were symptomatic for 4.2% of the study days. Compared with other age groups, children aged less than two years were most likely to have at least one respiratory episode, a greater number of episodes per person and the longest episode duration (6.8 days). Approximately, one in three (28.7%) respiratory episodes were associated with a doctor's visit, and one in four (23%) necessitated time off school or work. Exposure to other people with respiratory symptoms was commonly reported. CONCLUSIONS: Respiratory infections are common, cause a significant amount of morbidity, and are major contributors to the total community health burden. IMPLICATIONS: The direct and indirect costs of respiratory infections to the community are substantial.     

Trends in neural tube defects in Western Australia in Indigenous and non-Indigenous populations

Neural tube defects (NTD) were 43% more common in Indigenous than in non-Indigenous infants in Western Australia in the 1980s, and there has been a fall in NTD overall in Western Australia since promotion of folate and voluntary fortification of food has occurred. In order to investigate whether the fall had occurred in both indigenous and non-Indigenous infants, data on NTD (births and terminations) were obtained from the WA Birth Defects Registry, and on all births from the Maternal and Child Health Research Data Base. Knowledge of folate was asked in a survey of indigenous women interviewed postpartum. Before the promotion of folate (1980-92), there has been a 42% increase in NTD in Indigenous compared with non-Indigenous infants (prevalence ratio (PR)=1.42 [95% confidence interval (CI) 1.04, 1.94]); while in the most recent period (1996-2000), the prevalence in Indigenous infants was almost twice that of non-Indigenous infants (PR 1.98 [CI 1.25, 3.15]). Fifty-five per cent of Indigenous women knew about folate in pregnancy. Similar to sudden infant death syndrome, this study has highlighted health promotion that has been successful in reducing the risk of a childhood condition overall, but has failed to be effective for Indigenous children.     

Infections associated with severe malnutrition among hospitalised children in East Africa

Severe protein-energy malnutrition (PEM) predisposes affected children to various infections, which either worsens their nutritional status or causes malnutrition, hence complicating their management and outcome. This study was carried out to determine the infections associated with severe malnutrition among children admitted at Kilifi District Hospital (KDH) in Kenya and Muhimbili National Hospital (MNH) in Dar es Salaam, Tanzania. Data was collected from hospital register books and online system database. A total of 1121 children with severe malnutrition were admitted during a period of one year (2004-2005) (MNH = 781; KDH = 340). The proportion of male children with malnutrition was higher than that of female children. Non-oedematous malnutrition was more prevalent at MNH (N = 504; 64%) than KDH (N = 130; 38%). Conversely, oedematous was more prevalence than non-oedematous malnutrition among children admitted at KDH (N = 2 10; 61.7%). More than 75% of all patients with severe PEM were children < 2 years old. Thirty-six per cent of all severe PEM cases had malaria in both hospitals. Forty-five per cent of all admitted patients with severe PEM at KDH had diarrhoea. Two hundred twenty two (28%) and 64 (19%) of the children with severe malnutrition died at MNH and KDH, respectively. Oedematous PEM was associated with a higher case fatality rate than non-oedematous one (P < 0.05). At MNH, 86% of the patients who died with severe malnutrition had other co-morbidities. More (46%) oedematous malnourished patients with co-infections died at MNH than non-oedematous malnourished patients (19%). At KDH, septicaemia was the leading cause of death (55%) among severely malnourished patients. In conclusion, coinfections complicate the management of severe malnutrition and are associated with higher death rate. Management of such infections is of paramount importance to reduce case fatality rates.     

Reduction in malformation-related early mortality--a possibility for modifying perinatal mortality

From 1980 to 1996 1.8% of all births died as a result of malformations during the first week of life. This rate has been declining significantly after 1992. Congenital malformations of the heart have increased significantly because of improved diagnostic methods. From 1980 to 1996 0.67/1000 of all children died of vitium cordis during the first week of life. From 1992 to 1996 this group of malformations increased the perinatal mortality rate by 0.4/1000. There is a decreased mortality rate of neural tube defects by 0.25/1000 1980 to 1986 and by 0.08/1000 1992 to 1996. Trisomy 21: the early mortality rate decreased from 0.07/1000 to 0.03/1000. The number of non-deceased children with Down's syndrome remains constant, even though 40 per cent of all cases with trisomy 21 were prenatal. 3 per cent of all malformed newborn died during the first week of life as a result of their congenital malformations. The possibility of primary prevention of malformations with folic acid has not been sufficiently utilised.     

Measuring the impact of conjugate vaccines on invasive Haemophilus influenzae type b infection in Western Australia

Abstract: Haemophilus influenzae type b (Hib) causes serious infections in 26–59 per 100 000 non–Aboriginal Australian children under five years of age. Aboriginal children suffer much higher rates of infection (≥ 150 per 100 000), and at an earlier age, and have a greater risk of death and disability due to Hib infection. In 1992 and 1993, four conjugate Hib vaccines were introduced in Australia, and a nationally funded program of infant vaccination was begun in July 1993. This study aimed at evaluating the effectiveness of Hib vaccination in Aboriginal and non–Aboriginal children in Western Australia using a population–based active surveillance system for non–Aboriginal children and a case control study for Aboriginal children. The incidence of invasive Hib disease in non–Aboriginal children fell from 30.9 per 100 000 before vaccination was available to 6.3 per 100 000 in the second year after its introduction. The vaccine efficacy was estimated to be 80 per cent for Aboriginal children (odds ratio 0.20, 95 per cent CI 0.01–2.76) and, after adjustment for confounders, 75 per cent (odds ratio 0.25, CI 0.02–3.66). Based on the adjusted value (75 per cent), and using a Bayesian approach, we estimate that the posterior probability was 0.55 that the true vaccine efficacy is greater than 70 per cent, and 0.69 that the efficacy is greater than 50 per cent. We conclude that Hib vaccination is effective in preventing invasive Hib disease in Aboriginal and non–Aboriginal children in Australia. Aust N Z J Public Health 1998; 22: 67–72)     

The epidemiology and management of self-harm amongst adults in England

BACKGROUND: Previous research into the epidemiology and management of self-harm has been largely based in centres with a special interest in this behaviour or focused on hospital admissions only. There are no national data on the characteristics and management of people presenting to hospital following self-harm. METHODS: Data were collected from 8-week service audits carried out in a stratified random sample of 31 general hospitals in England. RESULTS: 4033 episodes of self-harm resulting in presentation to Accident and Emergency Departments were identified. Overdose alone accounted for 79 per cent of episodes, 80 per cent of presentations were outside normal office hours (9 am - 5 pm, Monday to Friday) and the peak period of attendance was from 8 pm to 2 am. In only 56 per cent of episodes was a specialist psychosocial assessment conducted prior to discharge and less than half (46 per cent) led to admission to a hospital bed. Psychiatric admission occurred in 10 per cent. Episodes involving older subjects (>45 years) and those using methods other than laceration or overdose were the most likely to lead to assessment and admission. CONCLUSIONS: Non-fatal self-harm is one of the strongest predictors of suicide, yet nearly half of all hospital attendances in England following self-harm do not lead to a specialist assessment. Patterns of service provision should take account of the observation that most self-harm attendances occur outside normal working hours and those at greatest risk of repetition are the least likely to receive assessments.     

The association of infant feeding with parent-reported infections and hospitalisations in the West Australian Aboriginal Child Health Survey

OBJECTIVE: To examine infant feeding associations with parent-reported infections and hospitalisations in Western Australian Aboriginal infants and children. METHOD: Families in Western Australia with children under 18 years of Aboriginal or Torres Strait Islander descent were included. A stratified multi-stage sample using an area-based sampling frame was compiled. Survey weights produced unbiased estimates for the population of families with Aboriginal children. Data were collected on demographic variables, maternal and infant characteristics and parent-reported recurring chest, ear and gastrointestinal infections. The data were linked to the Hospital Morbidity System to identify hospitalisations for infections for the same children. RESULTS: Twenty-seven per cent of Aboriginal children were breastfed for less than three months. Parent-reported recurring chest, ear and gastrointestinal infections were reported in 47% of the 0-3 age group. Hospitalisations due to upper respiratory and gastrointestinal infections were most common in the older children, but wheezing lower respiratory infections were most common in younger children. Breastfeeding for less than three months and birth weight less than 2,500 g were risk factors for parent-reported chest infections and hospitalisations for upper and wheezing lower respiratory infections (p<0.05). CONCLUSION: Rates of parent-reported chest infections and hospitalisations due to these infections continue to be high in Aboriginal infants and children. Because breastfeeding for less than three months and low birth weight are risk factors for these infections, interventions to reduce the prevalence of low birth weight and to increase breastfeeding rates should be primary health goals in Aboriginal communities for the benefits of Aboriginal infants and children.     

Persistent diarrhoea in a rural area of Bangladesh: a community-based longitudinal study

As part of a health impact evaluation of a water supply and sanitation project in a rural area of Bangladesh, diarrhoeal morbidity was recorded in children 0-4 years of age using weekly recall in household interviews, during the period March 1984 to December 1987. During the baseline year, 1984, the incidence rate of all diarrhoea episodes (3.8 episodes per child per year), and those defined as persistent, duration greater than 14 days (0.6 episodes per child per year), showed a similar age distribution, peaking in the 12-23 month age group. Sixteen per cent of all episodes were classified as persistent, and this proportion was greatest in the 0-5 month age group (25%). Children suffering at least one episode of persistent diarrhoea in 1984 also experienced a higher incidence of acute diarrhoea (less than = 14 days duration) than those suffering acute diarrhoea only (4.2 versus 3.7 episodes per child per year). Persistent diarrhoea showed a similar seasonal pattern to that of all episodes. Rates of abdominal pain, isolation of Shigella spp and a diagnosis of dysentery were significantly higher in persistent episodes than in acute episodes. Closer follow-up of children during 1986 and 1987, through the recording of all periods of absence of the child from the home, showed that overall diarrhoea incidence rates were little affected when absence was taken into account, but that the incidence of persistent diarrhoea and the proportion of episodes classified as persistent were significantly reduced. The implications of this methodological problem are discussed.     

Epidemiology of otitis media: a community study.

A community study of the incidence of clinically diagnosed otitis media and middle ear effusions was undertaken in the City of Galveston, Texas, based on a random sample of records of patients aged 0-8 years receiving medical care from four major sources during 1975. No overall sex or ethnic differences were observed in association with otitis media. Thirty-five per cent of the sample had at least one episode of otitis media during 1975 and, of these, one-third had two or more episodes, yielding a conservative annual incidence rate of 55.1 per cent for this age group. The overall age-specific incidence pattern indicated the highest rates for the 0-2 year age group (71 to 114 episodes per 100 children) with a steady decline in risk with increasing age. Infants who received an initial diagnosis within the first 12 months of life experienced significantly more episodes of otitis during a two-year period than did children who received an initial diagnosis after one year of age. Seasonal patterns of otitis media were comparable with those reported in other studies. Analysis by birth month of children who experienced repeated episodes of otitis indicated an increased number of children born in the late summer and fall.     

Diphtheria-tetanus-pertussis immunization and sudden infant death syndrome.

We compared the recency of diphtheria-tetanus-pertussis (DTP) immunization in healthy children with birthweights greater than 2500 gms who died of sudden infant death syndrome (SIDS) to that of age-matched reference children, using a modified case-control analysis. Focusing on very narrow time intervals following immunization, we found the SIDS mortality rate in the period zero to three days following DTP to be 7.3 times that in the period beginning 30 days after immunization (95 per cent confidence interval, 1.7 to 31). The mortality rate of non-immunized infants was 6.5 times that of immunized infants of the same age (95 per cent CI, 2.2 to 19). The latter result and to some extent the former appear to be ascribable to known risk factors for SIDS. Although the mortality ratios for SIDS following DTP, as estimated from this study, are high the period of apparently elevated risk was very short, so that only a small proportion of SIDS cases in infants with birthweights greater than 2500 gms could be associated with DTP.     

Survival of infants born with Down's syndrome: 1980-96

The improved life expectancy of people with Down's syndrome as a result of the greater availability of surgery and advances in medical care has been widely documented. However, there has been no evaluation of survival in the Australian Down's syndrome population since the 1980s. This study aimed to evaluate the changes in survival from birth in cases of Down's syndrome notified to the Birth Defects Registry in Western Australia. Babies born with Down's syndrome between 1980 and 1996 (inclusive) and registered with the Birth Defects Registry were studied. Survival status was obtained in several ways. Cases were stratified into three cohorts for comparison. Survival curves were constructed using the methods of Kaplan and Meier. For infants born during 1980-96, survival to 1 year is now > 91%, and 85% can expect to survive until the age of 10 years. Although survival in those with heart disease showed improvement over the period studied, overall this was still a strong predictor of mortality. Survival in Aboriginal children with Down's syndrome was significantly poorer than in non-Aboriginal children, mirroring the pattern in the general population. Mortality was greater in females and in those with a low birthweight. There was no statistically significant difference in the survival between those born in metropolitan and in rural areas. There has been a considerable improvement in survival of infants born with Down's syndrome in Western Australia. This improvement is similar to findings in recent international studies. The difference in survival between Aboriginal and non-Aboriginal children is particularly disturbing. These findings are useful for both clinicians and families who need to plan for the long-term care of these children.     

Episodes of angioedema in children with C1 esterase inhibitor deficiency

A 6-year-old boy and a 3.5-year-old girl presented with unexplained episodes of angioedema without urticaria. Low serum C1 esterase inhibitor activity was found in both children. Family history revealed autosomal dominant inheritance in the girl. The boy had a negative family history for angioedema. C1 esterase inhibitor deficiency is a rare but serious condition that may cause oedema of the upper respiratory tract and death by asphyxiation. Episodes of angioedema occur spontaneously, usually subsiding within 48-72 h. Between episodes, the patients are symptom free. Treatment consists of substitution of synthetic C1 esterase inhibitor during episodes of edema carrying a risk of upper airway obstruction. In patients who have more than one episode of severe angioedema per month, daily treatment with tranexamic acid should be considered. Both of these patients were not receiving daily treatment.     

The use of tobacco, alcohol and other drugs by young Aboriginal people in Albany, Western Australia

Abstract: This paper describes patterns of tobacco, alcohol and other drug use among Aboriginal people aged 8 to 17 years in the town of Albany, Western Australia. Of a total of 110 young Aboriginal people residing in the town at the time of the study, 105 were interviewed by two trained Aboriginal research assistants using interview schedules that included questions based on the national guidelines for the comparability of studies of drug use among young people. The most commonly used drugs were tobacco, alcohol and cannabis. Use of other substances was usually experimental. The majority (57 per cent) of this population had not used any drugs, 13 per cent made some use of alcohol and/or tobacco, 15 per cent were polydrug users, and 15 per cent were frequent poly–drug users. Use of drugs increased with age: 48 per cent of those aged 15 to 17 were frequent polydrug users. Tobacco consumption was greater and alcohol use less than that reported among Western Australian secondary school children of comparable age.     

The epidemiology of recurrent otitis media.

Nearly one-half of 165 children with episodes of acute otitis media had at least one recurrent acute episode within the year. Males had significantly more recurrences. Most (60 per cent) of the recurrent episodes occurred within four months of the index episode. Hearing loss persisted beyond two weeks in 8 per cent of testable children. This experience suggests that prophylactic antibiotic use within the first few months after an episode of acute otitis media in young children should be evaluated.     

Catheter thrombosis and superior/inferior vena cava syndrome are rare complications of long term parenteral nutrition

The objective of this study was to determine the incidence of catheter thrombosis and superior/inferior vena cava (SVC IVC ) syndrome in a large population of patients receiving home total parenteral nutrition (TPN), using retrospective data collection and analysis. 527 patients including 138 children who were discharged on home TPN and followed in the UCLA home TPN program for a minimum of one week between April, 1973 and October, 1991. There was a total of 1154 years of patients follow-up, including 241 years in children. Fifty-seven patients (11%) developed 81 episodes of catheter thrombosis excluding SVC IVC syndrome with an incidence of 0.07 episodes per catheter year. The median catheter duration prior to thrombosis was 7 months. Twenty-one thromboses occured in children with an incidence of 0.09 per catheter year. Eleven percent of thrombotic episodes were associated with catheter sepsis. Thirty-nine percent of patients had a PTT less than control values. Twenty-two patients including 6 children developed SVC IVC syndrome with an incidence of 0.02 per catheter year. SVC IVC syndrome was not associated with catheter sepsis in any patient. Sixty-eight percent of patients had catheter thrombosis at some point prior to developing SVC IVC syndrome. It is concluded that catheter-related thrombotic events are rare complications of home TPN and are uncommonly associated with infection. However, we recommend warfarin anticoagulation following an initial thrombotic event, in the absence of catheter malposition, for all such patients as long as they maintain a central venous catheter.     

Trends in the hospitalization for acute childhood asthma, 1970-84

Data from the 1970 through 1984 National Hospital Discharge Surveys indicate that the rate of hospitalization for children under 15 years old with asthma has increased at least 145 per cent while the average length of stay for children with asthma decreased by 26 per cent from 5 days in 1970 to 3.6 days in 1984. Over an analogous period (1970 to 1980), data from the National Health Interview Survey indicate that the prevalence of childhood asthma has increased by approximately 28 per cent for children 6 to 16 years of age. Several potential explanations for the hospital trend are discussed, including changes in the disease classification and information system, criteria for admission, organizational factors, changes in therapy, and changes in morbidity.