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Targeted Call for Research - public call for research priorities in Aboriginal and Torres Strait Islander health

This submission reflects the views of
Organisation Name: 
Menzies School of Health Research
Personal Details
Specific Questions
1. What is the research priority (a significant research knowledge gap or unmet need) you are nominating? How would a TCR in this area greatly advance our understanding of this issue? (200 word maximum): 
Primordial prevention of infectious diseases and their consequences. Indigenous people, especially those living remotely, continue to suffer high rates of communicable diseases, especially those affecting the upper and lower respiratory tracts, skin and gastrointestinal tract. These commonly affect children, and result in long-term complications including hearing impairment with impacts on educational attainment, bronchiectasis, rheumatic fever, rheumatic heart disease, post-streptococcal glomerulonephritis and long-term renal damage. There may also be risks related to chronic inflammation and high antibiotic exposure. While there have been good gains in primary and secondary prevention, such as vaccine uptake and secondary prevention of rheumatic fever, interventions at the primordial level have been lacking. Primordial prevention addresses the social determinants of health, especially relating to housing hardware, functional and structural household crowding, knowledge about pathogen transmission and health-seeking behaviour. The components of poverty that are understood to be important risks for disease transmission need to be addressed in intervention studies, particularly household crowding and functionality. Current local research projects include mathematical modelling of disease transmission, evaluation of “No Germs on Me” campaign that focuses on child hand and face washing, and qualitative studies to understand the experience of living with diseases resulting from poverty.
2. What are the relevant Australian Government Priorities, and/or Ministerially-agreed State and Territory health research priorities linked to your nominated priority? (200 word maximum): 
Improving Remote Indigenous Housing is one of the six priorities for Closing the Gap in Indigenous Disadvantage. The National Partnership Agreement on Remote Indigenous Housing (NPARIH) was established to reform responsibilities between the Commonwealth, States and the Northern Territory in provision of housing and to address the housing crisis in remote communities. Importantly, the National Aboriginal and Torres Strait Islander Health Plan 2013 – 2023, identified improving housing for Aboriginal and Torres Strait Islander peoples as essential in eliminating the causes of health inequality. The Plan calls for effective strategies to address the causes of these social inequalities. The Royal Australasian College of Physicians’ Northern Territory Federal Election Statement 2016 (https://nacchocommunique.files.wordpress.com/2016/08/nt-time-for-action-on-health-policy-nt-federal-election-statement-2016.pdf) stated: ‘…an individual’s health is not only shaped by lifestyle choices but also by a range of socioeconomic factors which individuals often do not have direct control over. These … Social Determinants of Health include housing, early childhood experience, economic status, transport, built and social environments and access to resources.’ However, there is limited data from interventions such as new and renovated housing, on Indigenous health outcomes at the primordial level and particularly prevention of infectious diseases and their consequences.
3. How would a TCR in this area contribute to Aboriginal and Torres Strait Islander health and improve health outcomes for the individual and/or community? (200 word maximum): 
Successes in addressing the primordial prevention of communicable diseases would have the potential for major, far-reaching benefits. If strategies can be identified which reduce household and community-level transmission of contagious pathogens, and this translates to reductions in documented rates of common infections, then clear short and long term benefits would be evident. In the short term, there would be fewer infective episodes requiring missed days from school or work, less antibiotic treatment, hospitalisation and healthcare costs. In the long term, there would be fewer sequelae such as hearing loss (from otitis media), chronic suppurative lung conditions (from recurrent respiratory infections) or rheumatic heart disease (from recurrent streptococcal infections). There would also be less pressure from antibiotic prescribing driving escalating resistance among micro-organisms. There would be increased capacity to deal with new and emerging threats from infectious diseases. A TCR is needed to bring together the multiple agencies that impact on ability to reduce extraordinarily high rates of infection. The multiple transmission pathways of the important pathogens need to be well understood to ensure all are addressed. This requires Indigenous leadership, a multidisciplinary approach, with expertise in all infectious disease agents, embracing Indigenous Knowledge Systems and focusing on solutions.
4. How will the TCR reduce the burden of disease on the health system and Australian economy? (200 word maximum): 
Research addressing primordial prevention of infectious diseases could have wide-ranging positive impacts by simultaneously addressing respiratory, skin and gastrointestinal infections and their complications. These comprise the bulk of child morbidity. In 2002 to 2005, two remote communities of the Northern Territory, the median clinic presentation rate was 16 per child per year (23 for the first year of life). Most are for upper respiratory tract infections (32%) and skin infection (18%). This study clearly showed the high level of health service access and burden on health services. In 2013, from surveillance in 12 remote communities, the prevalence of otitis media (OM) among one year old children was 93. The prevalence of scabies was 15%, impetigo 22%, runny nose 58%, cough 40% and around 44% had recently been prescribed antibiotics. These research data describe the real and unmet burden, particularly for OM. Most of these children are eligible for hearing tests and ENT assessment for surgical interventions, but very few received these services. NPARIH was allocated $5.5 billion to deliver 4200 new houses by 2018.Evaluating such housing schemes on infectious disease burden would be highly valuable, but to date, linking housing interventions with health outcomes has not been prioritised.
5. Are there any reports or findings that support your nomination for the suggested topic? (200 word maximum): 
Evidence for the association between household crowding and rheumatic fever or otitis media: • Jaine R, Baker M, Venugopal K. Acute rheumatic fever associated with household crowding in a developed country. Pediatr Infect Dis J 2011; 30(4): 315-9. • Wannamaker LW. The epidemiology of streptococcal infections. New York, NY: Columbia University Press; 1954. • Leach AJ, Wigger C, Andrews R, Chatfield M, Smith-Vaughan H, Morris PS: Otitis media in children vaccinated during consecutive 7-valent or 10-valent pneumococcal conjugate vaccination schedules. BMC Pediatr 2014, 14(1):200. Table 7. Evidence that a household-level intervention can reduce rates of child illness: • Howden-Chapman P, Matheson A, Crane J, et al. Effect of insulating existing houses on health inequality: cluster randomised study in the community. BMJ 2007; 334(7591): 460. Evidence that hygiene can reduce rates of otitis media and antimicrobial prescription in day care centres (i.e. crowded circumstances): • Uhari M, Mottonen M: An open randomised controlled trial of infection prevention in child day-care centres. Pediatr Infect Dis J 1999, 18(8):672-677 • McDonald E, Cunningham T, Slavin N: Evaluating a handwashing with soap program in Australian remote Aboriginal communities: a pre and post intervention study design. BMC Public Health 2015, 15(1):1188.

Page reviewed: 30 August, 2018