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Australian Indigenous HealthBulletin Alcohol and other drugs knowledge centre Yarning Places
 

Communicable disease

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Communicable diseases

Communicable (infectious) diseases of particular relevance to Aboriginal and Torres Strait Islander people and discussed below include: tuberculosis, hepatitis (A, B, and C), sexually transmissible infections (STIs), human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS), Haemophilus influenzae type b (Hib), pneumococcal disease, meningococcal disease and skin infections [1]. Communicable diseases can be caused by bacteria (e.g. pertussis-whooping cough and tuberculosis), viruses (e.g. influenza and HIV), fungi (e.g. tinea), protozoan parasites (e.g. malaria) and larger parasites (e.g. head lice) [2]. Risk factors for communicable diseases vary according to the type of disease [1]. Improvements to sanitation, and the increased use of vaccination and antibiotics (for bacterial infections), have markedly reduced some infectious diseases in Australia [3][4].

Information regarding specific communicable diseases comes from a variety of sources, including individual studies and the state and territory notifiable disease collections [5]. Data from state and territory collections are collected and published by the National Notifiable Disease Surveillance System (NNDSS) [5], but Indigenous status is often not reported for large proportions of notifications [6]. Information about some communicable diseases, of particular importance to Aboriginal and Torres Strait Islander people, is analysed and published by specialised external agencies, including the Kirby Institute, for STIs, hepatitis and HIV/AIDS [7] and the National Centre for Immunisation Research & Surveillance (NCIRS) for vaccine-preventable diseases [8].

Tuberculosis

Tuberculosis (TB) is primarily a lung infection caused by the inhalation of Mycobacterium tuberculosis bacteria [9]. The bacteria can penetrate the lungs and multiply, potentially causing a variety of symptoms including: coughing; weight loss; loss of appetite; fever; chills; and the coughing up of blood or sputum. The main risk factors for TB are: physical contact with another person with TB; overcrowding; malnutrition; tobacco use and alcohol use [10][11]. People who are immune-compromised due to chronic diseases (e.g. diabetes and renal failure) are more at risk. Some of these risk factors are common in many Aboriginal and Torres Strait Islander communities. Another risk factor for TB is HIV infection.

Incidence

The most recent information available about TB among Indigenous people is for 2009-2013, when 158 (21%) of the 761 notifications of TB among Australian-born people in Australia were identified as Indigenous [12][13][14][15]. Around one-third (35%) of the new cases among Indigenous people were reported in the NT (56 cases), and around another one-third (32%) in Qld (51 cases) (Table 28).

Table 28. Numbers of new cases and crude notification rates of tuberculosis among Indigenous people, by jurisdiction, Australia, 2009-2013

Jurisdiction

Number

Rate

NSW

33

3.9

Vic

3

1.6

Qld

51

6.2

WA

9

2.3

SA

5

3.2

Tas

1

1.0

ACT

0

0.0

NT

56

16

Australia

158

5.5

Notes:  

  1. Population figures are for 30 June 2011 (the mid-point of the five-year period, 2009-2013)
  2. Rates are crude incidence rates per 100,000 population

Source: Derived from Barry, 2012 [12], Bareja, 2014 [13], Bareja, 2014 [14], Toms, 2015 [15], ABS, 2009 [16], ABS, 2011 [17]

Australia-wide, the crude notification rate in 2009-2013 was 5.5 cases per 100,000 population for Indigenous people; the crude notification rate was highest for the NT (16 cases per 100,000 population) (Derived from [12][13][14][15][16][17]). After age-adjustment, the notification rate for Indigenous people was 11.3 times higher than for Australian-born non-Indigenous people (Table 29).45 The notification rate of TB was higher for Indigenous people than for Australian-born non-Indigenous people across all age-groups, with rate ratios being highest for the 45-54 years and 55-64 years age-groups (Table 29) (Derived from [12][13][14][15][16][17]).

Table 29. Numbers of new cases and notification rates of tuberculosis, by Indigenous status and age-group, and Indigenous:non-Indigenous rate ratios, Australia, 2009-2013

Age-group (years)

Indigenous

Non-Indigenous

Rate ratio

 

Number

Rate

Number

Rate

0-4

4

1.1

70

1.0

1.2

5-14

10

1.5

31

0.2

7.0

15-24

13

2.2

87

0.6

4.0

25-34

21

5.2

69

0.4

12.3

35-44

29

8.3

56

0.4

23.7

45-54

45

17

64

0.4

40.3

55-64

22

14

57

0.4

31.1

65+

14

14

169

1.1

12.9

All ages

158

5.5

603

0.5

11.3

Notes:

  1. Rates are per 100,000 population
  2. Any discrepancy between the figures shown for ‘All ages’ and the sum of the number for the specific age-groups is due to age not being stated in the notification
  3. Rate ratio is the Indigenous rate divided by the non-Indigenous rate
  4. The rate ratio for ‘All ages’ is the standardised notification ratio, which is the number of Indigenous cases reported divided by the number expected if the Indigenous population had the same age-specific rates as the non-Indigenous population

Source: Derived from Barry, 2012 [12], Bareja, 2014 [13], Bareja, 2014 [14], Toms, 2015 [15], ABS, 2009 [16], ABS,2011 [17]

Hospitalisation

In 2014-15, Aboriginal and Torres Strait Islander people were hospitalised for TB at a rate of 0.2 per 1,000, after age-adjustment [18]. This rate was over four times the hospitalisation rate for TB for non-Indigenous Australians (0.06 per 1,000), after age-adjustment. Hospitalisation rates for TB were higher for Aboriginal and Torres Strait Islander people than for non-Indigenous people across all age-groups, with a rate ratio of 11.0 for the 45-64 years age-group being the highest (rates of 0.6 per 1,000 and 0.06 per 1,000 respectively).

Hepatitis

Hepatitis is an inflammation of the liver, most commonly caused by a viral infection [19]. The hepatitis viruses identified most frequently are referred to as types A, B, C46.

Hepatitis A

The hepatitis A virus (HAV) is an infection of the liver predominantly transmitted by the faecal-oral route, either through ingesting contaminated food or water or by direct contact with an infected person [20][21], including sexual contact, particularly between men [20]. HAV is often asymptomatic among young children, but symptoms among older people may include fever, fatigue, nausea, diarrhoea, jaundice, and vomiting [21]. The mortality rate due to HAV is low.

The impact of HAV among Aboriginal and Torres Strait Islander people has declined markedly since 2000, particularly after the introduction in 2005 of HAV vaccination into the national childhood vaccination schedule for Aboriginal and Torres Strait Islander children living in Qld, WA, SA and the NT [8][22]. Previously, HAV infections were much more common among Aboriginal and Torres Strait Islander children than among non-Indigenous children, particularly for those living in northern Qld, WA, SA and the NT [22]. Children aged 0-4 years were at greatest risk of HAV infection [22]. The vaccine has been shown to be at least 89% effective among Aboriginal and Torres Strait Islander people in the NT (compared with 72% effectiveness among non-Indigenous people) [21]. The decline in HAV among Aboriginal and Torres Strait Islander people is reflected in notification figures for the three-year period 2011-2013 when of the 498 notifications of HAV for people living in Australia, five were identified as Aboriginal and/or Torres Strait Islander (Derived from [23][24][25]).

Hepatitis B

Transmission of hepatitis B virus (HBV) is from contact with blood and other body fluids (semen, vaginal fluids and a low risk from saliva) from an infected individual, commonly through sexual contact or use of contaminated injecting equipment [26]. A mother may also transmit HBV to the fetus during pregnancy or to the infant during birth. Only 30-50% of people acutely infected with HBV will experience obvious symptoms, including jaundice, nausea, vomiting, and mild flu-like symptoms, but the virus can cause a more prolonged illness in which a person may look and feel well, but slowly develop chronic liver disease, cirrhosis, or liver cancer [20][26].

In 2015, of the 6,502 people with newly acquired HBV in Australia47, 221 (3%) were identified as Aboriginal and Torres Strait Islander48 [7]. The age-standardised notification rate for Aboriginal and Torres Strait Islander people was three times higher than for non-Indigenous people (66 per 100,000 and 22 per 100,000 respectively). Over the five year period 2011-2015, there was a 22% decline in the notification rates for Aboriginal and Torres Strait Islander people from 85 per 100,000 in 2011 to 66 per 100,000 in 2015. It is suggested that this reduction is due to immunisation programs for HBV.

In 2015, the rates of newly diagnosed HBV among Aboriginal and Torres Strait Islander people were higher for males than females across most age-groups, particularly among males 30-39 years and 40-49 years [7]. Rates among Aboriginal and Torres Strait Islander males were higher than for non-Indigenous males (72 per 100,000 and 22 per 100,000 respectively). Rates for Aboriginal and Torres Strait Islander females were also higher than for non-Indigenous females (59 per 100,000 and 21 per 100,000 respectively).  

In 2015, for Aboriginal and Torres Strait Islander people living in major cities and inner regional areas in WA, SA, Tas, ACT and the NT, rates of newly diagnosed HBV infection were similar or lower than those for non-Indigenous people [7]. In outer regional, remote and very remote areas, rates of newly diagnosed HBV infection were 5, 10 and 28 times higher than the rate for the non-Indigenous people respectively.

Hepatitis C

Transmission of hepatitis C virus (HCV) typically occurs via blood-to-blood contact [7]. Injecting drug use and sharing unsterile injecting equipment are the most common reasons for contracting the virus [27]. The likelihood of transmission of HCV via sexual contact is generally very low [20]. Many people who are infected with HCV do not have symptoms [28] [27] and in many cases the virus is detected through blood tests for other medical matters [28]. Some people with HCV can live relatively normal lives, largely unaffected by the virus [29], but others may develop cirrhosis, liver cancer, or liver failure [27] [29]. New treatment for HCV is now available, direct-acting antiviral therapies have been found to be highly effective [27]. There is no vaccine to protect people against HCV [20].

In 2015, of the 10,790 people diagnosed with HCV in Australia, 929 (9%) were identified as Aboriginal and Torres Strait Islander49 [7]. The age-standardised notification rate for HCV was almost five times higher for Aboriginal and Torres Strait Islander people than for non-Indigenous people (167 per 100,000 and 36 per 100,000 respectively). For Aboriginal and Torres Strait Islander people, there was an increase in rates between 2011-2015 (2011: 117 per 100,000; 2015: 167 per 100,000), compared with a 10% decrease for non-Indigenous people (2011: 40 per 100,000; 2015: 36 per 100,000).  

In 2015, the greatest disparities in age-specific rates of newly acquired HCV between Aboriginal and Torres Strait Islander males and non-Indigenous males were in the 15-19 and 20-29 years age-groups, 14 and 9 times higher respectively for Aboriginal and Torres Strait Islander males [7]. For females, differences in rates were greatest in the 20-29 and 30-39 years age-groups, these were both six times higher for Aboriginal and Torres Strait Islander females compared with non-Indigenous females.

The rates of newly diagnosed HCV infection for Aboriginal and Torres Strait Islander people in 2015 were highest for those living in major cities and inner regional areas, 14 and 7 times higher respectively than the rates reported for non-Indigenous people [7].

Haemophilus influenzae type b

Haemophilus influenzae type b (Hib) is a bacterium that can cause meningitis, epiglottitis, pneumonia, bacteraemia, cellulitis, osteomyelitis, pericarditis, and septic arthritis [30][8]. Infants and children are particularly susceptible to Hib, which is serious in its invasive form [31][32]. High rates of Hib carriage in the upper respiratory tract have been noted prior to cases of invasive disease [32]. Higher rates in Indigenous populations worldwide suggest socio-economic disadvantage, high rates of tobacco use and crowded living conditions, as probable causes [8].

Notifications of invasive Hib disease in Australia decreased by more than 95% following the commencement of nationally funded infant vaccination in 1993 [30]. The decline has been markedly evident in Aboriginal and Torres Strait Islander children, but they continue to be at higher risk of contracting Hib than non-Indigenous children [30][33].

In 2012-2014, nine (17%) of the 54 cases of invasive Hib disease notified in all jurisdictions were identified as Aboriginal and Torres Strait Islander (Derived from [34][35][36]). In this period, the average notification rate for the Aboriginal and Torres Strait Islander population was 5.3 times the rate in the total population (0.5 per 100,000 and 0.09 per 100,000 respectively).

In the period 2012-2014, infants (Indigenous and non-Indigenous) aged less than 12 months accounted for 16 (30%) of all cases (Derived from [34][35][36]). The highest notification rate for Hib was consistently in the 0-4 years age-group, which had an average rate of 0.5 per 100,000 in 2012-2014.

There were four deaths associated with Hib reported between 2012 and 2014. Two deaths were in adults over 60 years of age and two were in infants. Of these, one death was an Aboriginal and Torres Strait Islander infant who was unvaccinated [34][35][36].

Pneumococcal disease

Pneumococcal disease results from infection by the bacterium Streptococcus pneumoniae (also known as pneumococcus), which may cause pneumonia, otitis media or sinusitis when in the respiratory tract [37]. Invasive pneumococcal disease (IPD) occurs when the bacterium infects other normally sterile sites, such as blood and cerebrospinal fluid, causing bacteraemia and meningitis [30][37]. Rates of IPD are highest in infants and older people [30]. Recognised risk factors for pneumococcal disease include: diabetes; chronic respiratory and cardiac diseases; other immune-compromised conditions; tobacco use; and high levels of alcohol consumption [8][38][39][40]. In children, asthma, previous pneumonia, exposure to smoke and attendance at childcare increases susceptibility to IPD [39].

Nationally-funded vaccination for pneumococcal disease was made available in 1999 to Aboriginal and Torres Strait Islander adults aged 50 years and older and to Aboriginal and Torres Strait Islander people aged 15-49 years at high risk [8][30]. In 2001, vaccination was funded for Aboriginal and Torres Strait Islander infants and young children and for all Australian children medically at risk. From 2005, nationally-funded vaccination was made available to all Australian infants and to all people aged 65 years and older, in addition to those eligible since 1999.

Detailed data are available for IPD because it has been a notifiable disease in Australia since 2001 [39]. Aboriginal and Torres Strait Islander people have a significantly higher incidence of IPD than non-Indigenous people, however the rate of IPD for Aboriginal and Torres Strait Islander people has decreased between 2011 and 2014 (Table 30) [34][35][36][41].

Table 30. Age-adjusted notification rates for invasive pneumococcal disease, by Indigenous status, and Aboriginal and Torres Strait Islander:non-Indigenous rate ratios, Australia, 2011-2014

Year

Aboriginal and Torres Strait Islander rate  

Non-Indigenous rate

Rate ratio

2014

31

5.3

5.9

2013

32

5.2

6.2

2012

41

6.0

6.8

2011

53

6.7

8.0

Notes:

  1. Rates are per 100,000 population
  2. Rate ratio is the Aboriginal and Torres Strait Islander rate divided by the non-Indigenous rate

Source: Derived from National Notifiable Diseases Surveillance System (NNDSS), 2016 [34], NNDSS, 2015 [35], NNDSS, 2015 [36], NNDSS, 2013 [41]

In 2013, the notification rate for IPD in Aboriginal and Torres Strait Islander children aged under five years (36 per 100,000) reached its lowest rate since 2005 [35].

Age-specific rates for IPD among Aboriginal and Torres Strait Islander people in 2007-2010, were highest in the 50 years and older age-group (53 per 100,000), followed by the 0-4 years age-group (51 per 100,000) [8]. Importantly, age-specific rates for Aboriginal and Torres Strait Islander people aged 25-49 years (45 per 100,000) were almost 12 times higher than for their non-Indigenous counterparts. To some degree, the high rate ratio in this age-group corresponds to the difference in the prevalence of adult risk factors between Aboriginal and Torres Strait Islander and non-Indigenous people.

After age-adjustment, the IPD hospitalisation rate for Aboriginal and Torres Strait Islander people living in NSW, Vic, Qld, WA, SA the NT between 2005 and 2010 was 6.0 times higher than the rate for their non-Indigenous counterparts [8]. Among Aboriginal and Torres Strait Islander people, age-specific rates of hospitalisations for IPD were highest in the 0-4 years age-group (27 per 100,000), followed by the 25-49 years age-group (25 per 100,000) and the 50 years and older age-groups (24 per 100,000). Aboriginal and Torres Strait Islander people aged 25-49 years were hospitalised at a rate 14.2 times higher than for non-Indigenous people. Hospitalisation rates for pneumococcal pneumonia (not identified as IPD) were higher than those for IPD for Aboriginal and Torres Strait Islander adults and the elderly. 

In 2006-2010, of the 575 reported deaths from IPD for people living in NSW, Qld, WA, SA and the NT, 34 (6%) were identified as Aboriginal and Torres Strait Islander [8]. In children under five years of age, there were 30 deaths notified; five (17%) of which were of Aboriginal and Torres Strait Islander children.

The most recent national mortality numbers for IPD among Aboriginal and Torres Strait Islander people is for 2011 and 2012 when there were 14 and 9 deaths respectively, attributed to IPD [39].

Meningococcal disease

Meningococcal disease is caused by the bacterium Neisseria meningitidis (also known as meningococcus) [30]. The most common clinical presentation of meningococcal disease is acute bacterial meningitis [8], other possible presentations are septicaemia (with or without meningitis), pneumonia, arthritis and conjunctivitis [8][30]. Meningococcal infections can progress quickly, resulting in serious disease or deaths in otherwise healthy people [30].

Meningococcal disease is more common in infants, young children, adolescents and adults aged over 45 years [42]. Possible risk factors for the disease include: immuno-compromising diseases, living in crowded housing conditions, exposure to smokers, a recent respiratory illness and multiple kissing partners [30].

The most common groups of meningococcus found in Australia are serogroups50 B, C, W and Y [42] with B responsible for most disease in both Aboriginal and Torres Strait Islander and non-Indigenous people [8]. Vaccination has reduced the burden of serogroup C in Australia and has been funded nationally for all infants since 2003 [42]. Although there is a vaccine for serogroup B, it is only available by private purchase and not available under the National Immunisation Program (NIP) [42].

In 2015, there were 174 cases of invasive meningococcal disease notified in Australia (Indigenous status not specified) [42]. In 2014, there were 170 cases of invasive meningococcal disease notified in Australia with 21 cases (12%) identified as Aboriginal [34]; an increase from 2013 where 13 cases (8.7%) were identified as Aboriginal and one identified as Torres Strait Islander (0.7%) [35].

More detailed information is available for 2007-2010, where 104 (9.6%) of the 1,079 cases of meningococcal disease notified in Australia were identified as Aboriginal and Torres Strait Islander [8]. Around one-third (36%) of all cases were children (0-4 years); 60% of all cases identified as Aboriginal and Torres Strait Islander occurred among children aged 0-4 years. Rates generally decreased with age for both Aboriginal and Torres Strait Islander and non-Indigenous people. The average annual age-specific rate of 23 per 100,000 for Aboriginal and Torres Strait Islander children aged 0-4 years was 3.8 times that for non-Indigenous children aged 0-4 years; the rate for Aboriginal and Torres Strait Islander children aged 5-14 years was 4.1 times higher than for non-Indigenous children. After age-adjustment, the overall rate for Aboriginal and Torres Strait Islander people was 2.7 times that of other Australians.

In 2005-2010, of the 2,230 recorded hospitalisations for meningococcal disease for people living in NSW, Vic, Qld, WA, SA and NT, 189 (8.4%) were identified as Aboriginal and Torres Strait Islander [8]. Over one-third (37%) of cases were children (0-4 years), and 67% of all cases identified as Aboriginal and Torres Strait Islander occurred among children aged 0-4 years. After age-adjustment, the hospitalisation rate for meningococcal disease was 2.2 times higher for Aboriginal and Torres Strait Islander people than for non-Indigenous people. Average annual age-specific rates for Aboriginal and Torres Strait Islander people were highest in the 0-4 years age-group (41 per 100,000); a rate 3.5 times higher than for non-Indigenous children.

In 2006-2010, there were 42 deaths from meningococcal infection for people living in NSW, Qld, WA, SA and the NT, [8]. Among Aboriginal and Torres Strait Islander people, one to four deaths51 were for children under five years and one to four deaths were for those aged 5-49 years; no deaths were recorded for those aged 50 years and older.

Sexually transmitted infections

Sexually transmissible infections (STIs) are spread primarily by heterosexual or homosexual contact with an infected person [1]. STIs are caused by microorganisms that are transmitted from one person to another through semen, fluid from the vagina, anal or throat secretions, and blood [43]. Some STIs can also be transmitted under some circumstances via skin to skin contact, or from mother to baby during pregnancy and/or birth. Young people under the age of 30 are particularly vulnerable to STI infections [44]. The use of condoms is regarded as fundamental in preventing STI transmission. 

Many STIs are asymptomatic and at-risk individuals may not be diagnosed and treated unless they are tested frequently [45]. Early detection of STIs can ensure appropriate management to limit further transmission and prevent the development of complications. Contact tracing and partner notification enable diagnosis and treatment for people who may not realise that they have an STI and have the potential of reducing re-infection rates.

Many factors have been identified as contributing to the development of STIs. Factors that are particularly relevant to the Aboriginal and Torres Strait Islander population include: a younger more mobile population; socio-economic disadvantage; poor access to health services; and the lack of clinical staff who are experienced in sensitively managing sexual health issues [46][47].

Variations in notification rates over time may reflect real changes in incidence, but can also be due to the introduction of easier and more sensitive testing procedures, changes in screening programs and public awareness campaigns [34]. The high level of screening in some Aboriginal and Torres Strait Islander communities probably contributes to the higher STI rates reported for Aboriginal and Torres Strait Islander people than for non-Indigenous people.

Gonorrhoea

Gonorrhoea is caused by the bacterium Neisseria gonorrhoea [7]. In females, gonorrhoea can affect the urethra, cervix, and rectum, and in males it can affect the urethra and rectum [48]. Gonorrhoea can also infect the throat. It is highly contagious and, if left untreated, the infection can cause pelvic inflammatory disease in females and may cause damage to the testes in males. Untreated gonorrhoea can also lead to infertility in both females and males.

In 2015, there were 3,518 gonorrhoea notifications for Aboriginal and Torres Strait Islander people accounting for 19% of the notifications in Australia (Indigenous status was not reported for 36% of notifications) [7]. The notification rate52 was 10 times higher for Aboriginal and Torres Strait Islander people than for non-Indigenous people (626 per 100,000 and 62 per 100,000 respectively).

In 2015, the majority (72%) of gonorrhoea notifications for the Aboriginal and Torres Strait Islander population occurred in the 15-29 years age-group, compared with 53% in the same age-group in the non-Indigenous population [7]. Since 2011, notification rates for gonorrhoea among Aboriginal and Torres Strait Islander people declined by 22%, whereas the rates among non-Indigenous people increased by 94% during the same period.

Aboriginal and Torres Strait Islander females were more likely to be diagnosed with gonorrhoea than Aboriginal and Torres Strait Islander males, with a male to female ratio of 0.8:1, whereas in the non-Indigenous population, the number of diagnoses for males was four times the number reported for females [7]. This suggests the transmission of gonorrhoea occurs largely through heterosexual contact in the Aboriginal and Torres Strait Islander population, whereas sex between males is the predominate mode of transmission among non-Indigenous people.

Notification rates were substantially higher for Aboriginal and Torres Strait Islander people than for non-Indigenous people in major cities (twice as high), and especially higher in outer regional, remote and very remote areas of Australia (20 times, 72 times and 32 times higher respectively) [7].

Syphilis

Syphilis, caused by the organism Treponema pallidum, is a complex infection that has four identified stages: primary, secondary, latent, and tertiary [49]. In the initial stage of the infection, syphilis causes painless ulcers or sores around the mouth or genital area. If detected early, syphilis can be easily treated but, if left untreated, the infection can be very serious causing damage to the central nervous system, heart, blood vessels, skin and bones [7]. For pregnant women, untreated syphilis poses further serious health threats as the infection can be passed on to the child, possibly resulting in physical deformities and brain damage [50].

In 2015, there were 433 syphilis notifications for Aboriginal and Torres Strait Islander people accounting for 16% of the notifications in Australia (Indigenous status was not reported for 8% of notifications) [7]. The syphilis notification rate53 for Aboriginal and Torres Strait Islander people was over six times higher than for non-Indigenous people (61 per 100,000 and 10 per 100,000 respectively).

In 2015, the syphilis notification rate for Aboriginal and Torres Strait Islander people was highest in the 20-29 years age-group (164 per 100,000 in males and 166 per 100,000 for females); and for non-Indigenous people, it was highest for the 30-39 years age-group for males (39 per 100,000), and the 20-29 years age-group for females (1.5 per 100,000) [7].

In 2015, the percentage of infectious syphilis notifications for Aboriginal and Torres Strait Islander people was slightly higher for males (55%) than for females (45%) [7]. A different pattern was observed for the non-Indigenous people with males accounting for 96% of diagnoses. This indicates that transmission of infectious syphilis is mainly through heterosexual contact in the Aboriginal and Torres Strait Islander population and through sex between males in the non-Indigenous population.

Notification rates for Aboriginal and Torres Strait Islander people were highest among remote, outer regional and very remote areas, with notification rates ranging from twice the rate in major cities up to 132 times the rate in remote areas for non-Indigenous people in the same areas [7].

Chlamydia

Chlamydia is an infection caused by Chlamydia trachomatis bacteria and is asymptomatic in about 80% of cases [7]. If symptoms do occur, they can include inflammation of the urethra causing pain and penile discharge in males. In females, the main symptoms are intermenstrual bleeding and dysuria (discomfort when urinating).

In 2015, there were 6,532 notifications of chlamydia for Aboriginal and Torres Strait Islander people accounting for 9% of the notifications in Australia (Indigenous status was not reported for 51% of notifications) [7]. Chlamydia was the second most reported notifiable disease in Australia in 2015. The notification rate54 for chlamydia was more than three times higher for Aboriginal and Torres Strait Islander people than for non-Indigenous people (1,325 per 100,000 compared with 391 per 100,000).

Chlamydia is typically diagnosed among young people in both the Aboriginal and Torres Strait Islander and non-Indigenous populations [7]. In 2015, people aged 15-29 years accounted for 82% of chlamydia notifications in the Aboriginal and Torres Strait Islander population and 78% in the non-Indigenous population. For both the Aboriginal and Torres Strait Islander population and non-Indigenous population, females accounted for a greater proportion of chlamydia diagnoses than males. The rate of chlamydia notifications in Aboriginal and Torres Strait Islander females aged 15-19 and the 20-29 years age-groups was four and three times higher respectively than in the non-Indigenous population. Higher notification rates for Aboriginal and Torres Strait Islander females aged 15-19 years may be due to greater health care attendance and subsequent testing.

Notifications for chlamydia were twice as high in major cities for the Aboriginal and Torres Strait Islander population compared with the non-Indigenous population, also twice as high in inner regional areas, five times higher in outer regional areas, eight times higher in remote areas and six times higher in very remote areas [7].

Human papillomavirus and genital herpes

Human papillomavirus (HPV) and genital herpes (HSV-2) are common STIs in Australia, but they are not notifiable diseases so information is limited [44].

HIV/AIDS

The human immunodeficiency virus (HIV) is a retrovirus that infects cells in the body’s immune system [51]. The immune system becomes severely compromised if HIV is left untreated. This late stage of HIV is referred to as acquired immune deficiency syndrome (AIDS) and is life-threatening. Anti-retroviral therapy is a significant prevention approach to prevent the transmission of HIV.

HIV can be transmitted in three ways: unprotected sexual contact with an infected person; infected blood passing into another person’s bloodstream; and an infected mother can pass HIV on to her child either during birth or through breast-feeding [52]. Unprotected anal sex presents the greatest risk of exposure to HIV. Other behaviours that can put people at high risk of HIV include: unprotected vaginal sex; unprotected oral sex; and sharing injecting equipment (such as syringes and needles).

To date, Australia has successfully prevented an uncontrolled spread of HIV, and the overall rates of HIV are low in comparison with other countries [53]. However, Aboriginal and Torres Strait Islander people are regarded as being at particular risk of HIV infection due to their higher rates of STIs in many remote and very remote communities, sharing of injecting equipment and over-representation in prisons and juvenile detention [54].

In 2015, there were 1,025 cases of newly diagnosed HIV infection in Australia of which 38 (4%) were among Aboriginal and Torres Strait Islander people [7]. Age-standardised rates of HIV diagnosis were 2.2 times higher for Aboriginal and Torres Strait Islander people than non-Indigenous people (6.8 and 3.1 per 100,000 respectively). Recent changes in the age-adjusted notification rates of newly diagnosed HIV infection in the Aboriginal and Torres Strait Islander population show that in 2006 the rate was 4.2 per 100,000, then rates mostly remained stable until 2011 increasing afterwards to reach 6.8 per 100,000 in 2015. In the same period, the rate remained relatively stable for the non-Indigenous population at 3.8 per 100,000 in 2006 and 3.1 per 100,000 in 2015.

In 2015, the median age of diagnosis among Aboriginal and Torres Strait Islander people was 38 years, and males accounted for 89% of new HIV cases (Derived from [7]). Rates among Aboriginal and Torres Strait Islander males were 12 per 100,000, and among non-Indigenous males 5.8 per 100,000. Rates among Aboriginal and Torres Strait Islander females and among non-Indigenous females were lower than their male counterparts, 1.4 and 0.5 per 100,000 respectively.

One-third of all new HIV infections among the Aboriginal and Torres Strait Islander population in 2015 were reported in Qld (34%) followed by Vic (18%) and WA (18%) (Derived from [7]). In the non-Indigenous population, of all new HIV infections, 35% were reported in NSW, followed by 28% in Vic and 19% in Qld (Derived from [7][55]).

The highest rates of new HIV diagnoses for Aboriginal and Torres Strait Islander people were among those living in remote areas (9.5 per 100,000) (previously higher in urban areas), while for non-Indigenous people rates were highest in urban areas (2.9 per 100,000) [7]. The lowest rates among Aboriginal and Torres Strait Islander people were found in regional areas (7.4 per 100,000) and for non-Indigenous people rates were lowest in remote areas (1.0 per 100,000).

In terms of exposure to HIV, men who have sex with men accounted for 55% of new HIV cases among Aboriginal and Torres Strait Islander people in 2015 [7]. Heterosexual contact was also identified as a common form of exposure to HIV among Aboriginal and Torres Strait Islander people (18%). For the non-Indigenous population, 70% of all new HIV cases were attributed to the categories ‘men who have sex with men’ and 20% were attributed to ‘heterosexual contact’.

The proportion of new HIV cases attributed to injecting drug use (excluding ‘men who have sex with men’) among Aboriginal and Torres Strait Islander people increased from 6% in 2012 to 23% in 2013 to 27% in 2014 followed by a drop to 16% in 2015 [7]. For the total population in 2015, illicit drug use was the exposure category responsible for 3% of new cases (excluding ‘men who have sex with men’) [55].

Information about the occurrence of AIDS among Aboriginal and Torres Strait Islander people in 2015 is not available, but the number of new AIDS cases for the total population in 2009 was 90 [56]. In 2009, there were nine deaths from AIDS in Australia.

Skin diseases, infections and infestations

While resource-poor environments are associated with an increased burden of skin infections and infestations [57][58][59][60][61], preventative, focused and collaborative programs based within remote Aboriginal communities have had positive outcomes [62][63][64][65].

Risk factors for impetigo include poverty, overcrowding, lack of water, poor hygiene, tropical climate, scabies and other conditions affecting skin integrity [57][59][63][66][67]. The Remote Aboriginal Swimming Pool (RASP) program in WA [68] addresses some of the risk factors of skin infections by providing clean water and promoting good hygiene.

Scabies is a skin disease caused by the mite Sarcoptes scabiei that produces skin inflammation and itching [69]. Scratching in response to a scabies infestation can result in impetigo55, a bacterial infection of the skin [60][69] and recent research suggests that scabies mites could also spread bacterial infection and promote bacterial growth [61][70]. Impetigo in Aboriginal and Torres Strait Islander communities commonly involves GAS, which brings a risk of severe effects, including kidney disease and, probably, ARF and heart disease [59][61][63][70][71][72].

Prevalence

The most common skin infections affecting Aboriginal and Torres Strait Islander children are scabies and impetigo [61]. Scabies is endemic in some remote central and northern Aboriginal and Torres Strait Islander communities, affecting both adults and children. Most prevalence information is available about children [73][74] and research indicates that the significant public health problem posed by skin infections afflicts infants within a few months of birth [66][74][75]. Aboriginal and Torres Strait Islander people, particularly those living in the high-rainfall, humid areas of northern Australia, are also vulnerable to a variety of fungal and related organisms [63].

Aboriginal and Torres Strait Islander children under 15 years of age were screened between September 2004 and August 2007 in five remote NT communities for the East Arnhem Regional Healthy Skin Program (EARHSP) and it was found that the average monthly prevalence for pyoderma was 35% and for scabies 13% [65]. For children under three years of age, scabies prevalence was 23%, representing double that of children aged 3-14 years (11%). Nearly all children (92%) had presented with pyoderma and 35% with scabies once or more. A study of medical records for children born between 2001-2006 participating in the EARHSP found that 69% of children had presented with scabies and 82% had presented with skin sores during their first year of life [75]. Skin sores were seven times more likely to be present if scabies was also diagnosed than if scabies was not evident. In the Skin Sore Trial, conducted in seven remote NT communities between November 2009 and November 2012, Scabies was detected in almost 17% of Aboriginal and Torres Strait Islander children who had impetigo [61].

A review of non-infectious skin diseases in Aboriginal and Torres Strait Islander people found the prevalence of psoriasis, type 1 hypersensitivity reactions and skin cancer were lower than among non-Indigenous people, but the levels of lupus and kava dermopathy higher [76].

Burden of disease

Skin disorders, which includes chronic and acute conditions, skin infections and scabies, was responsible for 1.3% of the total burden of disease among Aboriginal and Torres Strait Islander people in 2011, with the fatal burden comprising 7.7% of the total burden due to skin disorders, and skin infections making up 70% of this fatal burden [77].

Hospitalisation

There were 8,750 hospital separations with a principal diagnosis of ‘diseases of the skin and subcutaneous tissue’ among Aboriginal and Torres Strait Islander people in 2014-15 [78], representing 4.0% of all separations among Aboriginal and Torres Strait people (excluding dialysis) (Derived from [78]). After age-adjustment, the hospitalisation rate was 2.2 times higher for Aboriginal and Torres Strait Islander people than that for non-Indigenous people [78].

Between May 2011 and May 2013 in the NT, the annual incidence of invasive GAS disease was nearly eight times higher for Aboriginal and Torres Strait Islander people than for non-Indigenous people (70 per 100,000 compared with 8.8 per 100,000), with 96% of cases resulting in hospital admissions [79]. The site of first infection was most commonly the skin. In 2005-2009, 67% of GAS bacteraemia admissions at Royal Darwin Hospital were for Aboriginal and Torres Strait Islander people, with recent or current scabies a risk factor in 30% of cases, and recent or current pyoderma in 66% of cases [80]. In 2006-2010, 10% of medical admissions to Mt Isa Hospital (Qld) for children aged under five years, were due to scabies or pyoderma, and all were Aboriginal and Torres Strait Islander children [81].

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Footnotes

45.  Reflecting the fact that the vast majority of new cases of TB in Australia are among people born overseas, particularly relatively recent arrivals from India, Vietnam, the Philippines and China, the analysis here compares the notification rates of Indigenous people with those of Australian-born non-Indigenous people.

46. There is little information about Hepatitis D and E for Aboriginal and Torres Strait Islander people.

47. For 2011-2015, Aboriginal and Torres Strait Islander status was reported in ≥50% of HBV notifications per year in WA, SA, Tas, ACT and the NT [7].

48. There were 4,070 (63%) notifications for which Indigenous status was not reported.

49. For 2011-2015, Aboriginal and Torres Strait Islander status was reported in ≥50% of HCV notifications per year in WA, SA, Tas and the NT [7].

50. A serogroup is a group of bacteria containing a common antigen.

51. The ABS only provides a range for numbers of deaths when actual numbers are low [8].

52. Gonorrhoea notification rates were based on data from Vic, Qld, WA, SA, Tas, the ACT and the NT where Aboriginal and Torres Strait Islander status was ≥50% complete per year for 2011-2015 [7].

53. For 2006-2015, Aboriginal and Torres Strait Islander status was ≥50% complete per year for syphilis notifications for all jurisdictions in Australia [7].

54. Chlamydia notifications were based on data from Qld, WA, SA and the NT where Aboriginal and Torres Strait Islander status was ≥50% complete per year for 2011-2015 [7].

55. Impetigo is also referred to as skin sores, or the broader term, pyoderma, and these terms are commonly used interchangeably [82].

 

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