Controlling communicable diseases in rural New South Wales: epidemiological research for directing health policy and practice

Massey, Peter D. (2011) Controlling communicable diseases in rural New South Wales: epidemiological research for directing health policy and practice. Professional Doctorate (Research) thesis, James Cook University.

PDF (Thesis)
Download (3MB) | Preview
View at Publisher Website:


The overall aim of this body of work was to expand the evidence base for controlling communicable diseases in regional and rural Australia, specifically conducting epidemiological research for directing health policy and practice. The diseases investigated are diverse but the setting and the risks are common, that is the Hunter New England area of New South Wales (NSW) and the people who live and work in this regional part of Australia.

The vision for health in rural, regional and remote Australia as articulated in the Healthy Horizons framework is:

"People in rural, regional and remote Australia will be as healthy as other Australians and have the skills and capacity to maintain healthy communities".

Within the context of this vision for equitable health experience there is only a limited understanding of the epidemiology and impact of prevention strategies on communicable diseases in rural, regional and remote Australia. Of particular focus in this thesis were those communicable diseases that affect Aboriginal and Torres Strait Islander people, and people in close contact with livestock and feral animals. An operational research approach was used to better understand the epidemiology and control of pandemic influenza; rural communicable disease outbreaks; invasive meningococcal and pneumococcal diseases in Aboriginal and Torres Strait Islander people; tuberculosis; brucellosis; Q fever; and malaria in rural New South Wales communities.

The studies into pandemic influenza mainly used qualitative methods. Focus groups and indepth interviews were used to explore Aboriginal and Torres Strait Islander people's experiences with the pandemic and to investigate more appropriate control strategies. This investigation occurred within a Participatory Action Research method that enabled communities to benefit through action and understanding. Structured interviews and focus groups were also used in the study into the prevention strategies for Brucellosis.

Other studies conducted within this thesis used quantitative methods including a cohort study, descriptive and analytical studies, and evaluation of outcomes. Structured surveys and medical record reviews were also used to explore the control of some communicable diseases.

This thesis presents a number of studies that display lateral and original approaches to communicable disease control. The use of a Participatory Action Research method, that included research capacity building with Aboriginal communities, and the qualitative work with feral pig hunters are unique methods in the development of communicable diseases control strategies in rural areas. In addition, the novel epidemiological approach in the submitted manuscript in Chapter 6, has not been reported elsewhere in the literature.

Pandemic influenza: A careful analysis of influenza pandemic epidemiology found that in New South Wales, Aboriginal and Torres Strait Islander people were four times more likely to be admitted to hospital with A(H1N1)pdm09 pandemic influenza than non-Aboriginal people.

Working within a Participatory Action Research framework, overseen by the Hunter New England Aboriginal Health Partnership, an interactive process of research engagement and negotiation with Aboriginal communities yielded pandemic influenza control strategies that were based on community understanding and recognition of the importance of families in the life of Aboriginal and Torres Strait Islander communities. Strategies included:

* the need for health services to undertake respectful engagement with communities;

* modifying home isolation and quarantine policies;

* family centred prevention; and

* communicating with and through grandmothers.

Prior to the 2009 pandemic considerable preparatory work was conducted in the Hunter New England regional area. Pandemic exercises were conducted and these included careful evaluation to inform a future response. The need to modify mass vaccination plans, particularly in rural areas, to effectively engage community partners was a major finding from a mass vaccination clinic exercise. A large-scale surveillance and response exercise clearly demonstrated the capacity of senior nursing staff to perform a surge function during a protracted public health response to pandemic influenza.

The epidemiological situation at the time that pandemic containment was discontinued suggests that during future events more thought should be given to the heterogeneity of disease occurrence across a state or nation. In addition the capacity of regional areas to respond needs to be considered before altering pandemic response phases.

Learning from outbreaks: Boarding schools, where people live in close proximity, are vulnerable to outbreaks of respiratory illness. A cluster of twenty-five community acquired pneumonia (CAP) in previously well adolescents attending a boarding school in rural New South Wales led to an epidemiological investigation of the outbreak. Strategies for improving influenza surveillance and control in this setting were identified. Clusters of pneumonia in boarding schools should alert clinicians to the possibility of Streptococcus pneumoniae complicating influenza infection and prompt appropriate laboratory investigations with notification to public health authorities. The outbreak in 2006 provided an excellent opportunity to test the newly set up Public Health Real-time Emergency Department Surveillance System (PHREDSS). This investigation found that using the current thresholds, PHREDSS would have trigged a signal for pneumonia syndrome in children aged 5-16 years four days earlier than the notification by the clinicians involved. Early notification of outbreaks can lead to reduction of the impact of an outbreak if control strategies can be applied.

Aboriginal and Torres Strait Islander status of people notified with invasive meningococcal and pneumococcal diseases: In New South Wales, Aboriginal and Torres Strait Islander children were not considered a particular high risk group for invasive bacterial disease. Careful analysis of invasive meningococcal disease notifications, between 1991 and 2005, found that Aboriginal and Torres Strait Islander children 0–4 years of age had a significantly higher risk when compared with non-Aboriginal children (relative risk 3.31, 2.35-4.68, 95%CI). Similarly, Aboriginal and Torres Strait Islander children aged 0-4 years had a two-to three-fold higher rate of invasive pneumococcal disease than non-Indigenous children (relative risk 2.68, 1.02–7.09, 95%CI). Linking notification data with routine hospital admission data proved a useful and time efficient surveillance strategy to increase the proportion of notifications with Aboriginal and Torres Strait Islander status recorded.

Tuberculosis (TB) and country of birth: TB rates in NSW take account of regional variations in age structure being usually presented as age-standardised rates. However the key determinant of TB risk in NSW is a resident's country of birth. Newly arrived migrants to Australia are increasingly being resettled into rural areas of Australia and may bring with them different levels of risk of TB.

During the period, 2006-2008, there were 1401 notified TB cases in NSW with 76.5% of cases born in a high-incidence country. The annualised TB rate for the high-incidence country-of-birth group was 61.2/100,000 population and compared to 1.8/100,000 population for the remainder of the population. The data were re-analysed to take account of population heterogeneity in country of origin.

Of the 152 local areas in NSW, nine had higher and four had lower TB rates in the highincidence country-of-birth population than the high-incidence country-of-birth population for the rest of NSW. The accessibility of services in these areas is currently being explored by NSW TB Services.

Brucellosis: Historically NSW was considered free from Brucella suis in feral and domestic pig populations. Epidemiological investigations found that feral pig hunting in NSW was been the common risk factor for all human brucellosis in northwest NSW in the past five years.

During 2011 in-depth interviews with feral pig hunters in the local area explored particular high risk activities during evisceration in the scrub. Respondents identified a number of strategies for reducing risk including: taking more time and visualising their hands when cutting; ensuring good lighting; taking particular care when cutting near a sow's uterus; and using latex gloves to cover cuts on their hands. These strategies should now be field trialled.

Q fever: In a review of NSW Q fever notifications, data were analysed using 3-year study periods from 1993 to 2007 to investigate possible trends and explore reported risk exposures. The epidemiology of Q fever disease in New South Wales has changed and amongst notified cases the relative importance of non-abattoir contact with livestock, wildlife or feral animals has increased. The surveillance field 'Occupation' no longer alone adequately describes risk exposure for many people notified with Q fever and a new field that describes risk exposures is required.

Medical records of the 89 patients with Q fever admitted to hospitals in the Hunter New England area during 2005-2009 were reviewed. The low level of documented cardiac assessment for Q fever patients found during the review is of concern and efforts are required to limit preventable endocarditis.

Malaria prevention A cohort study in 2006 found that six members of a group of 38 were diagnosed with malaria on return from Papua New Guinea. None of the 12 individuals who took chemoprophylaxis for the recommended period post-travel developed malaria compared to 4/24 travellers who terminated prophylaxis prematurely or 2/2 who took no chemoprophylaxis. These findings led to changes in formulary advice available to general practitioners who are the primary source of travel advice to rural Australian travellers.

Outcomes: The findings from the research in this thesis have led to a number of recommendations and changes in communicable diseases policy. The findings from the pandemic influenza work with Aboriginal communities are informing the development of new disease control strategies for NSW Health. Communication with boarding schools in north-west NSW about influenza has become part of the routine practice of the public health unit during each winter season. Aboriginal and Torres Strait Islander status is now routinely collected for all notifications of meningococcal disease. Analysing rates of TB by adjusting for high incidence country of birth has been accepted as part of the regular epidemiological reviews of TB in NSW. Q fever surveillance in NSW will include risk exposure in addition to occupation. The formulary advice available to general practitioners for malaria prevention is being changed to reflect current recommendations.

Item ID: 31902
Item Type: Thesis (Professional Doctorate (Research))
Keywords: health emergencies; public health; rural; operational research; communicable diseases mitigation; Aboriginal and Torres Strait Islanders; Q fever; invasive meningococcal disease; pneumococcal disease; tuberculosis; brucellosis; malaria; pandemic influenza
Related URLs:
Additional Information:

For this thesis, Peter Massey received the Dean's Award for Excellence 2012.

Publications arising from this thesis are available from the Related URLs field. The publications are:

Chapter 2: Massey, P.D., Miller, A., Durrheim, D.N., Speare, R., Saggers, S., and Eastwood, K. (2009) Pandemic influenza containment and the cultural and social context of indigenous communities. Rural and Remote Health, 9.

Massey, Peter D., Miller, Adrian, Saggers, Sherry, Durrheim, David N., Speare, Richard, Taylor, Kylie, Pearce, Glenn, Odo, Travis, Broome, Jennifer, Judd, Jenni, Kelly, Jenny, Blackley, Magdalena, and Clough, Alan (2011) Australian Aboriginal and Torres Strait Islander communities and the development of pandemic influenza containment strategies: community voices and community control. Health Policy, 103 (2-3). pp. 184-190.

Miller, Adrian, and Durrheim, David (2010) Aboriginal and Torres Strait Islander communities forgotten in new Australian National Action Plan for Human Influenza Pandemic: "Ask us, listen to us, share with us". Medical Journal of Australia, 193 (6). pp. 316-317.

Chapter 3: Carr, Christine, Durrheim, David, Eastwood, Keith, Massey, Peter, Jaggers, Debbie, Caelli, Meredith, Nicholl, Sonya, and Winn, Linda (2011) Australia's first pandemic influenza mass vaccination clinic exercise. Australian Journal of Emergency Management, 26 (1). pp. 47-53.

Eastwood, K., Durrheim, D.M., Massey, P.D., and Kewley, C. (2009) Australia's pandemic 'Protect' strategy: the tension between prevention and patient management. Rural and Remote Health. pp. 1-7.

Chapter 7: Massey, PD, Polkinghorne, BN, Durrheim, David, Lower, T, and Speare, Richard (2011) Blood, guts and knife cuts: reducing the risk of swine brucellosis in feral pig hunters in north-west New South Wales, Australia. Rural and Remote Health, 11 (4). pp. 1-9.

Chapter 8: Massey, Peter, Durrheim, David N., and Speare, Rick (2007) Inadequate chemoprophylaxis and the risk of malaria. Australian Family Physician, 36 (12). pp. 1058-1060.

Date Deposited: 30 Apr 2014 01:36
FoR Codes: 11 MEDICAL AND HEALTH SCIENCES > 1117 Public Health and Health Services > 111706 Epidemiology @ 40%
11 MEDICAL AND HEALTH SCIENCES > 1117 Public Health and Health Services > 111701 Aboriginal and Torres Strait Islander Health @ 40%
11 MEDICAL AND HEALTH SCIENCES > 1117 Public Health and Health Services > 111799 Public Health and Health Services not elsewhere classified @ 20%
SEO Codes: 92 HEALTH > 9203 Indigenous Health > 920302 Aboriginal and Torres Strait Islander Health - Health Status and Outcomes @ 34%
92 HEALTH > 9204 Public Health (excl. Specific Population Health) > 920404 Disease Distribution and Transmission (incl. Surveillance and Response) @ 33%
92 HEALTH > 9204 Public Health (excl. Specific Population Health) > 920407 Health Protection and/or Disaster Response @ 33%
Downloads: Total: 729
Last 12 Months: 24
More Statistics

Actions (Repository Staff Only)

Item Control Page Item Control Page