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Communicable disease

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Communicable diseases

Communicable (infectious) diseases of particular relevance to Aboriginal and Torres Strait Islander people 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][3]. 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 [4][5].

Information regarding specific communicable diseases comes from a variety of sources, including individual studies and the state and territory notifiable disease collections. Data from state and territory collections are collected and published by the National notifiable disease surveillance system (NNDSS), but Indigenous status is often not reported for large proportions of notifications. Information about some communicable diseases is analysed and published by specialised external agencies, including the Kirby Institute - for STIs, hepatitis and HIV/AIDS and the National Centre for Immunisation Research and Surveillance - for vaccine-preventable diseases [6][7].

Tuberculosis

Tuberculosis (TB) is primarily a lung infection caused by the inhalation of the bacterium Mycobacterium tuberculosis [8]. The bacterium can penetrate the lungs and start to 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 poverty, overcrowding and malnutrition [9][10][11], other risk factors are diabetes, tobacco use, alcohol use and advanced kidney disease [9][10]; these risk factors are all common in many Aboriginal and Torres Strait Islander communities. Another risk factor for TB is HIV infection [10][12].

Extent of tuberculosis among Aboriginal and Torres Strait Islander people

The most recent information 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 [13][14][15][16]. 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 34).

Table 34. 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

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 [13], Bareja, 2014 [14], Bareja, 2014 [15], Toms, 2015 [16], ABS, 2009 [17], ABS, 2011 [18]

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 [13][14][15][16][17][18]). After age-adjustment, the notification rate for Indigenous people was 11.3 times than for Australian-born non-Indigenous people (Table 35).1 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 35) (Derived from [13][14][15][16][17][18]).

Table 35. 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

140.3

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 [13], Bareja, 2014 [14], Bareja, 2014 [15], Toms, 2015 [16], ABS, 2009 [17], ABS,2011 [18]

Hepatitis

Hepatitis is an inflammation of the liver, most commonly caused by a viral infection [19]. The viruses identified most frequently are referred to as types A, B, C2.

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. The mortality rate due to HAV is low.

Extent of HAV among Aboriginal and Torres Strait Islander people

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 [7][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 Indigenous people in the NT (compared with 72% effectiveness among non-Indigenous people) [21]. The great decline among Aboriginal and Torres Strait Islander people in Australia is reflected in notification figures for the three-year period 2011-2013 when of the 498 notifications of HAV for people living in Australia, 5 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 [3]. A mother may also transmit HBV to the foetus during pregnancy or to the infant during birth [3]. 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 [3][20].

Extent of HBV among Aboriginal and Torres Strait Islander people

Of the 884 people with newly acquired HBV in Australia in the five-year period 2010-2015, 84 (9.5%) were identified as Aboriginal and Torres Strait Islander (Derived from [25][26]). The crude notification rate of newly acquired HBV of 2.9 per 100,000 for Aboriginal and Torres Strait Islander people was 3.6 times the rate of 0.8 per 100,000 for non-Indigenous people. (Derived from [17][25][26][27]). There was a 44% decline in notification rates for Aboriginal and Torres Strait Islander people from 90 per 100,000 in 2010 to 50 per 100,000 in 2014 [26]. It is suggested that this reduction is due to immunisation programs for HBV.

The rates of newly diagnosed HBV in 2014 were substantially higher for males than females across all age-groups, particularly among males 30-39 years and 60 years and above [26]. The male to female ratio of newly acquired HBV among Aboriginal and Torres Strait Islander people was 13:1 compared with 3:1 in the non-Indigenous population.

In 2014, for Aboriginal and Torres Strait Islander people living in major cities and inner regional areas in WA, SA, Tasmania, the NT and the ACT, the rates of newly diagnosed HBV infection were similar or lower than those for non-Indigenous people [26]. In outer regional, remote and very remote areas, rates of newly diagnosed HBV infection were 3, 4 and 6 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 [28]. Injecting drug use is the most common method of contracting the virus and is responsible for the vast majority of cases [23][26][29]. 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 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, but others may develop cirrhosis, liver cancer, or liver failure [30]. Treatment for HCV is available, but its success is dependent on several factors, including the HCV genotype. There is no vaccine to protect people against HCV [20].

Extent of HCV among Aboriginal and Torres Strait Islander people

Unlike for HBV, the identification of Indigenous status in notifications of HCV is not good: for the five year period 2010 to 2014 Aboriginal and Torres Strait Islander status was not reported in 59% of newly diagnosed HCV cases across Australia (Derived from [17][27][31]).

Of the 52,763 people diagnosed with HCV in Australia in the five-year period 2010-2014, 3,775 (7.2%) were identified as Aboriginal and Torres Strait Islanders (Derived from [17][27][31]). In this period, the crude notification rate for HCV was 7.8 times higher for Aboriginal and Torres Strait Islander people than for non-Indigenous people (128 and 16 per 100,000, respectively).

In contrast to some other reported communicable diseases, the rates of newly diagnosed HCV infection for Aboriginal and Torres Strait Islander people were highest for those living in inner major cities and inner regional areas: 12 and 9 times higher respectively than the rates reported for non-Indigenous people [26]. For newly acquired HCV in the Aboriginal and Torres Strait Islander population in NSW, WA, SA, Tas, Vic, the NT and the ACT, the notification rate increased from 6 per 100,000 in 2010, to 16 per 100,000 in 2014 [26].

In 2014, the greatest disparity in age-specific rates between Aboriginal and Torres Strait Islander people and non-Indigenous people was in the 20-29 years age-group: the rate of newly acquired HCV was almost 20 times higher for Aboriginal and Torres Strait Islander males and 9 times higher for Aboriginal and Torres Strait Islander females, compared with non-Indigenous males and females [26].

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 [3][7][32][33]. Infants and children are particularly susceptible to Hib, which is serious in its invasive form. High rates of Hib carriage in the upper respiratory tract have been noted prior to cases of invasive disease [34]. Higher rates in Indigenous populations worldwide suggest socioeconomic disadvantage, particularly high rates of tobacco use and crowded living conditions, as the probable cause [7].

Extent of Hib disease among Indigenous people

Notifications of invasive Hib disease in Australia decreased by more than 95% following the commencement of nationally funded infant vaccination in 1993 [35]. 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 [33].

In 2010-2013, 14 (19%) of the 72 cases of invasive Hib disease notified in all jurisdictions were identified as Indigenous (Derived from [35][36][37][38]). Children (Indigenous and non-Indigenous) aged 0-4 years accounted for 46% of all cases.

In 2007-2010, 25 (29%) of the 85 cases of invasive Hib disease notified in all jurisdictions were identified as Indigenous [7]. Children (Indigenous and non-Indigenous) aged 0-4 years accounted for 40% of all cases; Indigenous children aged 0-4 years accounted for 18% of all cases and 60% of Indigenous cases. The age-specific rate of 5.6 per 100,000 for Indigenous children aged 0-4 years was 15.7 times that for other children, with rates higher for Indigenous people in every age-group. After age-adjustment, the overall notification rate was 12.9 times higher for Indigenous people than for non-Indigenous people.

There were two deaths reported in 2012 and one death in 2013 associated with Hib [35][38]. No infant deaths were reported in 2013 [38]. No deaths coded as Haemophilus meningitis (likely to be due to Hib) for people living in NSW, NT, Qld, SA and WA in 2006-2010 [7].

Pneumococcal disease

Pneumococcal disease results from infection by the bacterium Streptococcus pneumoniae (also known as pneumococcus), which may cause pneumonia when in the respiratory tract [7]. Invasive pneumococcal disease (IPD) occurs when the bacterium infects other normally sterile sites, such as blood and cerebrospinal fluid, causing bacteraemia and meningitis. Rates of IPD are highest in infants and older people [39]. 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 [40][7][41][42]. In children, asthma, previous pneumonia, exposure to smoke and attendance at childcare increases susceptibility to IPD [42].

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 [7][39]. 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.

Extent of invasive pneumococcal disease among Aboriginal and Torres Strait Islander people

Detailed data are available for IPD because it has been a notifiable disease in Australia since 2001 [43]. 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 2013 [38]. Based on notifications for all jurisdictions in 2011-2013, the age-adjusted rate of IPD for Aboriginal and Torres Strait Islander people was: 53 per 100,000 in 2011, 41 per 100,000 in 2012 and 32 per 100,000 in 2013 [35][37][38]. 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 [38].

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) [7]. Importantly, age-specific rates for Aboriginal and Torres Strait Islander people aged 25-49 (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, NT, Qld, SA, Vic and WA between 2005 and 2010 was 6.0 times higher than the rate for their non-Indigenous counterparts [7]. 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 more than twice those for IPD for Aboriginal and Torres Strait Islander adults aged 25-49 years and almost four times higher for Aboriginal and Torres Strait Islander people aged 50 years and older.

In 2006-2010, of the 575 reported deaths from IPD for people living in NSW, NT, Qld, SA and WA, 34 (6%) were identified as Aboriginal and Torres Strait Islanders [7]. In children under 5 years of age, there were 30 deaths notified; five (17%) of which were of Aboriginal and Torres Strait Islander children.

Meningococcal disease

Meningococcal disease is caused by the bacterium Neisseria meningitidis (also known as meningococcus) [7][44]. Manifestations of meningococcal disease include meningitis, bacteraemia without meningitis, pneumonia and septic arthritis. Meningococcus often causes serious disease that progresses swiftly, with fatality rates of 10-15%; those who survive have a 10-20% probability of lasting health issues. Meningococcal disease is more common in infants and young children [7][44][45]. Possible risk factors for the disease include living in crowded housing conditions, exposure to smokers, recent illness and multiple kissing partners [44].

The most common groups of meningococcus found in Australia are serogroups3 B and C, with B responsible for most disease in both Indigenous and other people [7][44][45]. Vaccination against serogroup C was funded nationally for all infants from 2003; a catch-up program for all people aged up to 19 years ended in 2007 [45]. Vaccination has reduced the burden of serogroup C meningococcal disease in Australia, but currently there is no vaccination program for serogroup B [7]. A newly licensed vaccination for this serogroup has the potential to reduce the gap in meningococcal disease between Indigenous and other Australians.

Extent of meningococcal disease among Aboriginal and Torres Strait people

Notification rates for both serogroups of meningococcal disease are higher for Aboriginal and Torres Strait Islander people than for other Australians [7]. In 2013, there were 149 cases of meningococcal disease notified in Australia; a 33% decrease from the number of cases reported in 2012 (223) [35][38]. Of these, 13 cases (9%) were identified as Aboriginal and 1 (0.7%) was identified as Torres Strait Islander; similar proportions were reported in 2012 where 22 (10%) of cases were identified as Aboriginal (10%) and 3 were Torres Strait Islander (1.3%) [35]. More in depth information was provided for 2007-2010, where 104 (10%) of the 1,079 cases of meningococcal disease notified in all jurisdictions were identified as Aboriginal and Torres Strait Islander. Around one-third (36%) of all cases were children (0-4 years), and 60% of all cases which were 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 their non-Indigenous counterparts; the rate for Aboriginal and Torres Strait Islander children aged 5-14 years was 4.1 times higher than for other children. After age-adjustment, the overall rate for Aboriginal and Torres Strait Islander people was 2.7 times that of other Australians.

Of the 2,230 recorded hospitalisations for meningococcal disease for people living in NSW, NT, Qld, SA, Vic and WA in 2005-10, 189 (9%) were identified as Aboriginal and Torres Strait Islander [7]. 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 other children.

There were 42 deaths from meningococcal infection for people living in NSW, NT, Qld, SA and WA in 2006-2010 [7]. Among Aboriginal and Torres Strait Islander people, up to four deaths4 occurred in the 0-4 years and 5-49 years age-groups; no deaths were recorded for those aged 50 years and older.

Sexually transmitted infections

Sexually transmissible infections (STIs) are infections that 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 [46]. Some STIs can also be transmitted under some circumstances via skin to skin contact, or from mother to baby during pregnancy and/or birth. Most STI cases are found among sexually active adolescents and young adults, and access to and use of condoms is regarded as fundamental in preventing STI transmission [47][48].

The majority of STIs are asymptomatic or produce only mild symptoms [49][50]. Many people affected find out they have an infection through screening and contact tracing. STIs can usually be effectively treated if diagnosed early, but, if left untreated, they may lead to complications [1].

Many factors have been identified as contributing to the development of STIs. Factors that are particularly relevant to the Indigenous population include: a younger more mobile population; socio-economic disadvantage; poor access to health services; and lack of clinical staff who have the competence and sensitivity to deal with sexual health issues among Indigenous people [51][52].

Human papillomavirus (HPV) and genital herpes are common STIs in Australia, but they are not notifiable diseases [5]. 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, greater targeted screening, and public awareness campaigns [37]. The high level of screening in some Indigenous communities probably contributes to the higher STI rates reported for Indigenous people than for non-Indigenous people.

Gonorrhoea

Gonorrhoea is caused by the bacterium Neisseria gonorrhoeae [53]. In women, gonorrhoea can affect the urethra, cervix, and rectum, and in men it can affect the urethra and rectum. Gonorrhoea can also infect the throat in women and men. Gonorrhoea is highly contagious and, if left untreated, the infection can cause pelvic inflammatory disease in women and may cause damage to the testes in men. Untreated gonorrhoea can lead to infertility in both women and men.

Extent of gonorrhoea among Aboriginal and Torres Strait Islander people

Aboriginal and Torres Strait Islander people accounted for 23% of gonorrhoea notifications in 2014 (Indigenous status was not reported for 33% of notifications) [26]. The notification rate was 18 times higher for Aboriginal and Torres Strait Islander people than for their non-Indigenous counterparts (859 and 49 per 100,000, respectively). Notification rates were substantially higher in the Aboriginal and Torres Strait Islander population than in the non-Indigenous population in all areas of residence especially in outer regional, remote and very remote areas of Australia, 31 times, 69 times and 44 times higher, respectively.

In 2014, the majority (70%) of gonorrhoea notifications for the Aboriginal and Torres Strait Islander population in Vic, WA, SA, Tas, NT and the ACT occurred in the 15-29 years age-group, with 30% in the 15-19 years age-group compared with 7% in the same age-group in the non-Indigenous population and 40% in the 20-29 year old age-group compared with 49% in the same age-group in the non-Indigenous population [26].

Aboriginal and Torres Strait Islander females were marginally more likely to be diagnosed with gonorrhoea than Aboriginal and Torres Strait Islander males however in the non-Indigenous population, the number of diagnoses for males was four times the number reported for females [26]. 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.

Syphilis

Syphilis, caused by the organism Treponema pallidum, is a complex infection that has four identified stages: primary, secondary, latent, and tertiary [54]. 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 brain, heart, blood vessels, skin, intestinal tract, and bones [6]. 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 [55].

Extent of syphilis among Aboriginal and Torres Strait Islander people

In 2014, 235 (12%) of the 1,999 people newly diagnosed with infectious syphilis were identified as Aboriginal and Torres Strait Islander (Indigenous status was not reported for 9% of notifications) [26]. The notification rate for Aboriginal and Torres Strait Islander people was over 3 times more than the rate for non-Indigenous people (32 per 100,000 and 8 per 100,000 respectively). Notification rates in the Aboriginal and Torres Strait Islander population were highest among remote, outer regional and very remote areas, with notification rates ranging from twice the rate in major cities up to 304 times the rate in remote areas for the non-Indigenous population in the same areas. In 2014, the notification rate in the Aboriginal and Torres Strait Islander population for infectious syphilis was highest for the 15-19 year age-group, 72 and 128 per 100,000 in males and females respectively; and in the non-Indigenous population it was highest for the 30-39 age-group, 31 per 100,000 in males.

In 2014, the percentage of infectious syphilis diagnoses in the Aboriginal and Torres Strait Islander population was slightly higher for males (52%) than for females (48%) [26]. A different pattern was observed in the non-Indigenous population with males accounting for 97% 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 non-Indigenous population.

Chlamydia

Chlamydia is caused by the bacterium Chlamydia trachomatis [49]. In women it can cause cervicitis, endometritis, and pelvic inflammatory disease, which can lead to tubal factor infertility and ectopic pregnancy. In men, it can cause urethritis, epididymo-orchitis, and prostatitis. Due to the lack of obvious symptoms for many cases of the disease, the incidence of chlamydia is underestimated in notification data.

Extent of chlamydia among Aboriginal and Torres Strait Islander people

Chlamydia was the most reported notifiable disease in Australia in 2014 [26]. Aboriginal and Torres Strait Islander people accounted for 8% of the notifications of chlamydia in 2014 (Indigenous status was not reported for 63% of notifications). The notification rate for chlamydia was more than 3 times higher for Aboriginal and Torres Strait Islander people than for non-Indigenous people (1,341 per 100,000 compared with 389 per 100,000).

Chlamydia is typically diagnosed among adolescents and young adults in both the Aboriginal and Torres Strait Islander and non-Indigenous populations [26]. In 2014, people aged 15-29 years accounted for around 80% of chlamydia notifications in both populations.

For both the Aboriginal and Torres Strait Islander and non-Indigenous populations, females accounted for a greater proportion of chlamydia diagnoses than males in 2014 [26]. Higher notification rates for Aboriginal and Torres Strait Islander females aged 15-29 years may be due to a greater disease burden and/or greater access to health services and subsequent testing for females.

Notifications for chlamydia were twice as high in major cities for the Aboriginal and Torres Strait Islander population compared with the non-Indigenous population, twice as high in inner regional areas, five times higher in outer regional areas, seven times higher in remote and very remote areas [26].

HIV/AIDS

The human immunodeficiency virus (HIV) is a retrovirus that destroys cells in the body’s immune system [56]. Untreated, the virus weakens immune system functioning to the point where minor infections may become fatal [57]. This late stage of HIV is referred to as acquired immune deficiency syndrome (AIDS). At present there is no vaccine to prevent HIV, nor is there a cure, but anti-retroviral therapy has dramatically reduced the number of HIV cases progressing to AIDS [28][56].

The transmission of HIV occurs in one of 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 [58]. 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 [59]. However, Aboriginal and Torres Strait Islander people are regarded as being at particular risk of HIV infection due to their higher rates of STIs, limited access to health care, and over-representation in prisons and juvenile detention [60].

Extent of HIV/AIDS among Aboriginal and Torres Strait Islander people

National surveillance data show that in 2014 there were 1,081 cases of newly diagnosed HIV infection of which 33 (3%) were among Aboriginal and Torres Strait Islander people (Derived from [26])5. Age-standardised rates of HIV diagnosis were 1.6 times higher for Indigenous people than non-Indigenous people (5.9 and 3.7 per 100,000 respectively). Prior to this period, the age-adjusted notification rate of newly diagnosed HIV infection in the Indigenous population was 3.6 per 100,000 in 2005, then rates mostly remained stable until 2011 and then increased in 2012-14 reaching 5.9 per 100,000 in 2014. In this period, the rate remained stable for the non-Indigenous population at 4.0 per 100,000 in 2005 and 3.7 per 100,000 in 2014.

In 2014, the median age of diagnosis among Aboriginal and Torres Strait Islander people was 34 years, and males accounted for 76% of new HIV cases [26]. Rates among Aboriginal and Torres Strait Islander males were 9.6 per 100,000, and among non-Indigenous males were 7.0 per 100,000. Rates among Aboriginal and Torres Strait Islander and non-Indigenous women were lower than men, 2.4 and 0.3 per 100,000 respectively.

Three-quarters of all new HIV infections among the Aboriginal and Torres Strait Islander population in 2014 were reported in Qld (42%) and NSW (21%) (Derived from [26]). Among the non-Indigenous population, half of all new infections occurred in NSW (32%) and Vic (28%) (Derived from [31]). The highest rates of new HIV diagnoses, among both Indigenous people and non-Indigenous people were among those living in major cities 11 per 100,000 and 6.0 per 100,000 respectively [26]. The lowest rates among Aboriginal and Torres Strait Islander people were found in remote areas compared with very remote areas for non-Indigenous people.

In terms of exposure to HIV, men who have sex with men accounted for 39% of new HIV cases among Aboriginal and Torres Strait Islander people in 2014 [26]. Heterosexual contact was also identified as a common form of exposure to HIV among Indigenous people (15%). Among non-Indigenous people, 74% of all new HIV cases in 2014 were attributed to the categories ‘men who have sex with men’ and ‘heterosexual contact’ (19%) (Derived from [31]).

The proportion of new HIV cases attributed to injecting drug use among Aboriginal and Torres Strait Islander Australians decreased substantially from 2010 (18%) to 2011 (4%), then there was a substantial increase from 6% in 2012 to 23% in 2013 and 27% in 2014 [26]. Illicit drug use was responsible for 2% of new cases among non-Indigenous people (Derived from [31]).

Information about the occurrence of AIDS in the Aboriginal and Torres Strait Islander population in 2014 is not available, but the number of new AIDS cases for the total population in 2009 was only 90 [61]. In 2009, there were nine deaths from AIDS in Australia.

Skin diseases, infections and infestations

Susceptibility to skin infections and infestations increases with poor living conditions and overcrowding [62][63]. High rates of skin infections can be a burden on communities and require management for individuals and general measures for families and communities [64]. The significant public health problem posed by skin infections in many remote Aboriginal and Torres Strait Islander communities, particularly among Aboriginal and Torres Strait Islander children, requires appropriate education, improved hygiene and reduced overcrowding [65]. Evidence shows that there are benefits associated with swimming pools for reducing the prevalence and severity of skin sores in children, as seen in studies in remote communities of the NT, WA and SA [66].

Extent of skin diseases, infections and infestations among Aboriginal and Torres Strait Islander people
Scabies

Scabies is a skin disease caused by the mite Sarcoptes scabiei and produces skin inflammation and itching [67]. It is endemic in some remote central and northern Aboriginal and Torres Strait Islander communities affecting both adults and children, however, most prevalence information is available about children [68][69]. The East Arnhem regional healthy skin program reported that more than 70% of children had presented to the clinic with scabies at least once in the period 2002-2005 and almost all before they reached 2 years of age [69]. The East Arnhem Land scabies control program, which monitored and evaluated three East Arnhem Land remote communities in the NT between August 2011 and June 2013, reported a significant reduction of crusted scabies and scabies-related presentations. This was achieved through a preventive and long-term case management approach, active surveillance was recommended to improve outcomes for communities with endemic levels of scabies [70].

A study of medical records for children born between 2001 and 2005 in a remote community in the NT found that 68% of children had presented with scabies during their first year of life, and 77% had presented in the first two years [65]. A study conducted in an urban Indigenous population in North Qld in 2005-2006 reported 19% of young people had scabies [71].

Pyoderma

Scratching in response to the inflammation and itching of scabies infestation can result in pyoderma (also referred to as impetigo or skin sores), a bacterial infection of the skin that can lead to kidney disease and possibly heart disease [67]. A study of a remote community in the NT found that 82% of children had presented with pyoderma in their first year of life and 87% in their first two years [65]. Sixty-five per cent of Indigenous youths were diagnosed with pyoderma in a study conducted in an urban community of North Qld in 2005-2006 [71]. The pyoderma in Aboriginal and Torres Strait Islander communities commonly involves GAS, which is responsible for continuing outbreaks of acute post-streptococcal glomerulonephritis and ARF [72][73].

Other skin infections

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 [72].

A review of non-infectious skin diseases in Indigenous 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 [74].

Hospitalisation

Skin conditions can be linked to serious complications, which can result in hospitalisation and, very uncommonly, death [63][65]. ICD ‘Diseases of the skin and subcutaneous tissue’ was responsible for 9,271 hospital separations among Aboriginal and Torres Strait Islander people nationally in 2013-14, accounting for 2.3% of all Indigenous hospitalisations (including care involving dialysis) [75]. In 2011-12, ‘diseases of the skin and subcutaneous tissue’ was responsible for 7,994 hospital separations among Aboriginal and Torres Strait Islander people nationally, accounting for 3.9% of all Indigenous hospitalisations (excluding dialysis) [76]. After age-adjustment, the separation rate was 2.5 times higher for Aboriginal and Torres Strait Islander people than that for other Australians.

In 2006-2010, 10% of medical admissions to Mt Isa Hospital for children aged under 5 years were due to scabies or pyoderma, and all were Indigenous children [77]. An analysis of admissions to the Alice Springs Hospital in 2003-2006 found the mean annual incidence rate of Staphylococcus aureus bacteraemia (SAB) was around 20 times higher for Indigenous people than for non-Indigenous people (161 per 100,000 compared with 8.1 per 100,000) [78]. SAB was community-acquired in over 70% of cases, with skin infections being more common among Indigenous people than among non-Indigenous people.

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Endnotes

  1. 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.
  2. There is little information about Hepatitis D and E for Aboriginal and Torres Strait Islander people.
  3. A serogroup is a group of bacteria containing a common antigen.
  4. The ABS only provides a range for numbers of deaths when actual numbers are low.
  5. Previous reports have included all diagnosis (including those who were overseas when first diagnosed) meaning the number of diagnosis in this report will be lower than reported in previous years.
 
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