Health behaviours and outcomes associated with fly-in fly-out and shift workers in Western Australia.

AIMS: To examine the association of health behaviours and outcomes with employment type in the West Australian adult population. METHODS: Cross-sectional study of employed adults aged 16 years and over using self-reported information collected in the WA Health and Wellbeing Surveillance System between 2008 and 2010. A total of 380 fly-in fly-out (FIFO) workers, 913 shift workers and 10 613 workers of other employment types were identified. RESULTS: FIFO workers exhibited similar health behaviours to shift workers but had a different sociodemographic profile. Compared with other employment types, FIFO workers were significantly more likely to be current smokers, drink alcohol at risky levels, and be overweight or obese, after adjusting for age, sex and survey sampling strategies. They were less likely to report current mental health problems. CONCLUSIONS: Self-reported health behaviours of FIFO workers differ from other employment types. FIFO workers are expected to increase in number over the next decade, as the mining and resources sector expands in Australia. Our findings suggest that health interventions, whether in the workplace or clinical settings, need to be informed by the demographic mix of the cohort of workers on entry as they are not a homogenous group, and targeted towards specific employment patterns (length of shifts and type of employment) to improve their current and future well-being.

Epidemiological study of severe febrile reactions in young children in Western Australia caused by a 2010 trivalent inactivated influenza vaccine.

BACKGROUND: The 2010 influenza vaccination program for children aged 6 months to 4 years in Western Australia (WA) was suspended following reports of severe febrile reactions, including febrile convulsions, following vaccination with trivalent inactivated influenza vaccine (TIV). METHODS: To investigate the association between severe febrile reactions and TIV, three studies were conducted: (i) rates of febrile convulsions within 72 h of receiving TIV in 2010 were estimated by vaccine formulation and batch; (ii) numbers of children presenting to hospital emergency departments with febrile convulsions from 2008 to 2010 were compared; and (iii) a retrospective cohort study of 360 children was conducted to compare the reactogenicity of available TIV formulations. FINDINGS: In 2010, an estimated maximum of 18,816 doses of TIV were administered and 63 febrile convulsions were recorded, giving an estimated rate of 3.3 (95% CI 2.6 to 4.2) per 1000 doses of TIV administered. The odds of a TIV-associated febrile convulsion was highly elevated in 2010 (p<0.001) and was associated with the vaccine formulations of one manufacturer-Fluvax and Fluvax Junior (CSL Biotherapies). The risk of both febrile convulsions (p<0.0001) and other febrile reactions (p<0.0001) was significantly greater for Fluvax formulations compared to the major alternate brand. The risk of febrile events was not associated with prior receipt of TIV or monovalent 2009 H1N1 pandemic vaccine. The biological cause of the febrile reactions is currently unknown. INTERPRETATION: One brand of influenza vaccine was responsible for the increase in febrile reactions, including febrile convulsions. Until the biological reason for this is determined and remediation undertaken, childhood influenza vaccination programs should not include Fluvax-type formulations and enhanced surveillance for febrile reactions in children receiving TIV should be undertaken.

Disaster response from Australia: what is the role of Forward Teams?

Large scale Australian civilian medical assistance teams were first deployed overseas in 2004. The deployment of small Forward Teams in the early phase of a health disaster response allows for informed decisions on whether, and in what form, to deploy larger medical assistance teams. The prime consideration is to support the capacity of local services to respond to the specific needs of the affected population. In addition, Australian citizens caught up in large numbers in overseas disasters may need health assistance.

Specialist outreach clinics in primary care and rural hospital settings.

BACKGROUND: Specialist medical practitioners have conducted clinics in primary care and rural hospital settings for a variety of reasons in many different countries. Such clinics have been regarded as an important policy option for increasing the accessibility and effectiveness of specialist services and their integration with primary care services. OBJECTIVES: To undertake a descriptive overview of studies of specialist outreach clinics and to assess the effectiveness of specialist outreach clinics on access, quality, health outcomes, patient satisfaction, use of services, and costs. SEARCH STRATEGY: We searched the Cochrane Effective Practice and Organisation of Care (EPOC) specialised register (March 2002), the Cochrane Controlled Trials Register (CCTR) (Cochrane Library Issue 1, 2002), MEDLINE (including HealthStar) (1966 to May 2002), EMBASE (1988 to March 2002), CINAHL (1982 to March 2002), the Primary-Secondary Care Database previously maintained by the Centre for Primary Care Research in the Department of General Practice at the University of Manchester, a collection of studies from the UK collated in "Specialist Outreach Clinics in General Practice" (Roland 1998), and the reference lists of all retrieved articles. SELECTION CRITERIA: Randomised trials, controlled before and after studies and interrupted time series analyses of visiting specialist outreach clinics in primary care or rural hospital settings, either providing simple consultations or as part of complex multifaceted interventions. The participants were patients, specialists, and primary care providers. The outcomes included objective measures of access, quality, health outcomes, satisfaction, service use, and cost. DATA COLLECTION AND ANALYSIS: Four reviewers working in pairs independently extracted data and assessed study quality. MAIN RESULTS: 73 outreach interventions were identified covering many specialties, countries and settings. Nine studies met the inclusion criteria. Most comparative studies came from urban non-disadvantaged populations in developed countries. Simple 'shifted outpatients' styles of specialist outreach were shown to improve access, but there was no evidence of impact on health outcomes. Specialist outreach as part of more complex multifaceted interventions involving collaboration with primary care, education or other services was associated with improved health outcomes, more efficient and guideline-consistent care, and less use of inpatient services. The additional costs of outreach may be balanced by improved health outcomes. REVIEWER'S CONCLUSIONS: This review supports the hypothesis that specialist outreach can improve access, outcomes and service use, especially when delivered as part of a multifaceted intervention. The benefits of simple outreach models in urban non-disadvantaged settings seem small. There is a need for good comparative studies of outreach in rural and disadvantaged settings where outreach may confer most benefit to access and health outcomes.

Outreach and improved access to specialist services for indigenous people in remote Australia: the requirements for sustainability.

STUDY OBJECTIVE: To examine the role of specialist outreach in supporting primary health care and overcoming the barriers to health care faced by the indigenous population in remote areas of Australia, and to examine issues affecting its sustainability. DESIGN: A process evaluation of a specialist outreach service, using health service utilisation data and interviews with health professionals and patients. SETTING: The Top End of Australia's Northern Territory, where Darwin is the capital city and the major base for hospital and specialist services. In the rural and remote areas outside Darwin there are many small, predominantly indigenous communities, which are greatly disadvantaged by a severe burden of disease and limited access to medical care. PARTICIPANTS: Seventeen remote health practitioners, five specialists undertaking outreach, five regional health administrators, and three patients from remote communities. MAIN RESULTS: The barriers faced by many remote indigenous people in accessing specialist and hospital care are substantial. Outreach delivery of specialist services has overcome some of the barriers relating to distance, communication, and cultural inappropriateness of services and has enabled an over fourfold increase in the number of consultations with people from remote communities. Key issues affecting sustainability include: an adequate specialist base; an unmet demand from primary care; integration with, accountability to and capacity building for a multidisciplinary framework centred in primary care; good communication; visits that are regular and predictable; funding and coordination that recognises responsibilities to both hospitals and the primary care sector; and regular evaluation. CONCLUSIONS: In a setting where there is a disadvantaged population with inadequate access to medical care, specialist outreach from a regional centre can provide a more equitable means of service delivery than hospital based services alone. A sustainable outreach service that is organised appropriately, responsive to local community needs, and has an adequate regional specialist base can effectively integrate with and support primary health care processes. Poorly planned and conducted outreach, however, can draw resources away and detract from primary health care.

Delay times and management of acute myocardial infarction in indigenous and non-indigenous people in the Northern Territory.

OBJECTIVES: To investigate differences in presentation and management of Indigenous and non-Indigenous patients hospitalised with acute myocardial infarction (AMI). DESIGN: Retrospective review of hospital medical records. PARTICIPANTS AND SETTING: 122 patients with definite or possible AMI admitted to hospitals in the Top End of the Northern Territory (NT) in 1996. MAIN OUTCOME MEASURES: Percentage receiving thrombolytic therapy; delays from symptom onset to primary and emergency department presentations, first and diagnostic electrocardiograms, thrombolytic therapy and aspirin; drugs prescribed during hospitalisation. RESULTS: Thrombolytic therapy was given to 12/41 Indigenous patients (29%) and 38/81 non-Indigenous patients (47%) (P = 0.06). Presentation delay over 12 hours was the reason for not giving thrombolytic therapy for 14/29 Indigenous patients (48%) and 8/43 non-Indigenous patients (19%) (P < 0.01). Median delay times were longer for Indigenous patients for all six categories of delay, although the difference was significant only for delay to emergency department presentation (10:00 versus 3:26 hours; P < 0.01) and to diagnostic electrocardiogram (8:10 versus 3:50 hours; P < 0.01). Delays were also longer for patients from rural compared with urban areas. Once diagnosed, Indigenous patients were as likely as non-Indigenous patients to receive aspirin (93% versus 96%) and beta-blockers (70% versus 69%) and more likely to receive angiotensin-converting enzyme inhibitors (60% versus 40%; P = 0.03). CONCLUSIONS: Delays in presentation affect Indigenous people living in rural and urban areas as well as non-Indigenous people living in rural areas. Concerted efforts are needed to improve health service access in rural areas and to encourage Indigenous people with persistent chest pain to present earlier.

A medical cause of death validation study of adult aboriginal deaths in the Northern Territory of Australia in 1992.

Judged on the criterion of equity, premature adult Aboriginal mortality is the most serious public health problem faced in Australia today. There have been a number of published epidemiological studies that have analysed Aboriginal cause of death data, but this is the first study to formally validate such data. The study sample included all adult Aboriginal people who lived and died in the Northern Territory in 1992, excluding residents of the Alice Springs region. The appropriateness of underlying cause of death codes was assessed by a single reviewer in light of death certificates, medical records, postmortem records and interviews with key health professional informants. Data were collected on 220 deaths. 8% (17 out of 220) of deaths were classified erroneously at the ICD-9 chapter level. Errors in death certification accounted for 64% (11 out of 17) of the chapter errors and diagnostic and coding errors for 18% (3 out of 17) each. The overall impact on mortality statistics was less severe because some cross-chapter classification errors cancelled each other out. Misclassification errors aggregated mainly in chapter VII (circulatory diseases) of the ICD-9 classification which was overcounted by 3.2%, and chapter VIII (respiratory diseases) which was overcounted by 1.3%. Before correction for misclassification error, circulatory diseases were judged to cause the highest proportion of deaths, whereas after correction, respiratory diseases accounted for the highest proportion. Despite this, the overall quality of the medical cause of death statistics was of a sufficiently good standard from a public health perspective to broadly inform health policy. Future attempts to improve the validity of medical cause of death statistics for Australian Aboriginal people should focus on the education of medical practitioners about the purpose and process of death certification.

Cardiac pathology and adult aboriginal mortality: a coronial study of sudden and external cause deaths in the top end of the Northern Territory in 1990.

A retrospective review of coronial records was performed for 179 adult decedents who came to coronial autopsy in 1990 and who had been living in the Top End of the Northern Territory at the time of death. The directly standardized rate of autopsy-examined sudden death was 7.4 times higher for Aboriginal people than for non-Aboriginal people. Coronary atherosclerosis was the cause of 37% (14/38) of the Aboriginal sudden deaths and 52% (16/31) of the non-Aboriginal sudden deaths. Evidence of coronary atherosclerosis rose with age and was seen more frequently in those dying suddenly compared to those dying of external causes. When directly standardized, the rate of autopsy-examined sudden death attributable to ischemic heart disease was 5.5 times higher for Aboriginal people than for non-Aboriginal people. Contrary to a previously published statement, there is considerable overlap between Aboriginal and non-Aboriginal heart weights, with 75% (55/73) of Aboriginal decedents and 84% (89/106) of non-Aboriginal decedents having heart weights between 250 and 500 g. We concluded that the rate of autopsy-examined sudden death from all causes, and specifically from ischemic heart disease, was much higher in Aboriginal people. However in a case of sudden death a presumptive clinical diagnosis of ischemic heart disease prior to autopsy is not justified in either Aboriginal or non-Aboriginal people, due to the high prevalence of other fatal conditions. The diagnosis of pathologically increased heart weight, which is critical in the assessment of sudden death, should be made on the same basis in both Aboriginal and non-Aboriginal people.

High mortality from renal disease and infection in Aboriginal central Australians with diabetes.

Few studies have examined the consequences of the high prevalence of diabetes in Aboriginal communities. We aimed to determine the rates and causes of mortality in all Aboriginal central Australians with diagnosed diabetes, identified by a previous study (n =374). Cohort members were followed from 1 January 1984, or the date of diagnosis (to 31 December 1986), to 31 December 1991 or death. Death certificates, medical notes and autopsy reports were examined for cause of death. There were 130 deaths in 2280.7 person-years of follow-up. Standardised mortality ratios for Aboriginal people with diabetes, compared to the Northern Territory Aboriginal population, were 209 (95 per cent confidence interval (CI) 158 to 273) for men and 169 (CI 129 to 218) for women. The difference in ratios for men and women was not statistically significant when adjusted for age (P = 0.2). The eight-year survival rates for men and women diagnosed between 1984 and 1986 were 55.8 per cent (CI 32.6 to 73.7) for men and 80.3 per cent (CI 64.8 to 89.5) for women. Renal disease was the direct cause of death in 22.3 per cent. Infection accounted for 20.8 per cent of deaths and ischaemic heart disease for 13.8 per cent. Forty-four per cent of death certificates made no mention of diabetes. Diabetes confers an additional risk of death on a population whose mortality is already markedly worse than that of other Australians. Unlike Western diabetic populations, infections and renal disease were more common causes of death than macrovascular disease. Diabetes amplifies the effect of the community prevalence of infection and renal disease.

Antineutrophil cytoplasmic antibody in uveitis and scleritis.

We report a case where the detection of antineutrophil cytoplasmic antibody (ANCA) at the time of diagnosis of a case of sclero-uveitis predicted the later development of systemic features and prompted an early and definitive diagnosis of systemic vasculitis.

An evaluation of the Widal test in the diagnosis of enteric fever.

There are no universally applicable criteria for the serological diagnosis of enteric fever. Limited statistical analysis of the Widal test could not confirm its usefulness as a diagnostic tool in The Gambia.

Clinical experience with enteric fever in The Gambia, West Africa 1981-1986.

The clinical experience with enteric fever in The Gambia over a 5-year period is presented. It remains a common cause of septicaemic illness, but the mortality rate is lower than previously reported from West Africa.