more_vertFor many decades WHO has provided invaluable guidelines for the health care of children in low-income and middle-income countries where resources are limited. The principles behind these guidelines are that they use a minimum number of clinical signs to identify the condition in question and classify its severity, are simple to understand and implement, use essential medicines and appropriate technology, and are fit for the context for which they are designed. Historically, the most successful clinical guidelines have been on the use of simple interventions for common diseases, including oral rehydration salts for dehydration from gastroenteritis and antibiotics for pneumonia.
Preference: Infectious Diseases and Parasitology
434
[Editorial] UK guidance on human–animal hybrid research
Last week, the Academy of Medical Sciences in the UK welcomed the publication of new guidelines by the Home Office on the use of animals containing human material (ACHM) based on the Academy’s recommendations in their report published in 2011. This research involves the introduction of human DNA sequences, cells, or tissues into animals to create animal models of human diseases to enable their study more accurately, where alternative approaches are not morally or ethically possible, or are insufficient.
Birth defect fears deepen as Zika spreads
Evidence linking the rapidly spreading Zika virus to birth defects is mounting, adding to the urgency of efforts to develop a vaccine and underlining calls for co-ordinated international efforts to control its spread.
A recent spate of microcephaly cases involving women who were infected with Zika while pregnant – including one where the virus was found in a newborn’s brain tissue – has strengthened suspicions the disease is responsible for severe abnormalities.
Thirty-four countries have been hit so far in the current outbreak, most of them in Latin America, according to the World Health Organisation. In Brazil alone, around 1.5 million cases have been reported, and a further 25,000 are suspected in Colombia.
But the disease has also spread to the Pacific. Ongoing transmission has been reported in Tonga, where 542 suspected cases have been identified, and Samoa.
Though there is no evidence of Zika virus transmission in Australia, Chief Medical Officer Professor Chris Baggoley has warned there is a “continuing risk” of the disease being imported into the country from infected areas – so far this year, seven cases have been confirmed, all involving returning travellers.
Disturbingly, two pregnant women who recently travelled to Zika-prone regions have tested positive to the virus – one if Victoria, the other in Queensland.
Health authorities have convened a Communicable Disease Network Australian working group to monitor the international outbreak and advise on public health measures.
Though the effects of the disease are considered relatively mild in adults, the WHO has declared the outbreak a public health emergency of international concern because of mounting fears it is causing serious birth defects.
WHO Director-General Dr Margaret Chan said last week that although a causal relationship between Zika virus infection in pregnancy and microcephaly (babies born with abnormally small heads) was not yet scientifically proven, it was “strongly suspected”.
Evidence of a causative link between the virus and severe congenital abnormalities is strengthening.
Last month, a mother in Hawaii who was infected with the Zika virus during her pregnancy gave birth to a baby with microcephaly, and the US Centers for Disease Control reported on 10 February the Zika infection was evident in the case of two babies born with microcephaly who subsequently died, and two instances of miscarriage. In addition, the New England Journal of Medicine reported the case of a Slovenian woman who suffered a Zika-like illness while pregnant in Brazil. Her baby developed microcephaly, and the Zika virus was found in its brain tissue.
“The level of alarm is extremely high,” Dr Chan said. “Arrival of the virus in some places has been associated with a steep increase in the birth of babies with abnormally small heads and in cases of Guillain-Barre syndrome.”
In declaring a health emergency, the WHO has urged a coordinated international response to the virus threat, including improved surveillance of infections and the detection of congenital malformations, intensified mosquito control measures, and the expedited development of diagnostic tests and vaccines.
There is currently no treatment or immunisation for Zika, and although 15 companies or groups are working on a vaccine, the WHO has warned it is likely to be 18 months before one is ready for trial.
Their task is complicated by uncertainty about how the virus is spread. Though mosquitos are considered the prime culprit, there are suspicions it may also be spread though bodily fluids, particularly blood and semen.
As a precaution, the Australian Red Cross Blood Service has deferred collecting blood from donors who have travelled to countries with mosquito-borne viruses such as dengue and malaria.
The virus, which is closely related to the dengue virus, was first detected in 1947, and since 2012 there have only been 30 confirmed cases in Australia, all of them involving infection acquired overseas.
Members of the European Society of Clinical Microbiology and Infectious Diseases have warned that the next stage of the epidemic may involve the re-emergence of Zika in sub-Saharan Africa and, from there, southern Europe.
The Department of Foreign Affairs and Trade has advised pregnant women considering travelling to countries where the Zika virus is present to defer their plans.
All other travellers are advised to take precautions to avoid being bitten by mosquitos, including wearing repellent, wearing long sleeves, and using buildings equipped with insect screens and air conditioning.
Adrian Rollins
[Comment] Not all probiotic strains prevent necrotising enterocolitis in premature infants
In The Lancet, Kate Costeloe and colleagues1 report the outcome of the highly awaited PiPS trial, assessing the potential preventive effect of the probiotic bacterium Bifidobacterium breve BBG-001 on necrotising enterocolitis, late-onset sepsis, and mortality in premature infants.1 Necrotising enterocolitis remains among the most devastating diseases encountered in premature infants. The cause of necrotising enterocolitis is an excessive inflammatory process in the intestinal mucosa that presents clinically with feeding intolerance, abdominal distension, and bloody stools.
Socio-demographic and structural barriers to being tested for chlamydia in general practice
General practice is at the forefront of health care in Australia, with more than 85% of the Australian population consulting a general practitioner each year.1 Preventive health care is an important activity in general practice, and includes the prevention of illness, the early detection of infection or disease, and the promotion and maintenance of health.2 While prevention is key to Australia’s future health, it is also critical in redressing the health disparities experienced by disadvantaged and vulnerable populations.
Chlamydia screening is a key preventive care activity for young Australian adults. Guidelines recommend that sexually active men and women aged 15–29 years have an annual chlamydia test,2 but less than 10% of this age group are screened each year in general practice.3 There are well documented barriers to the uptake of chlamydia screening, from the perspective of both the GP and the patient. For GPs, these barriers include time, lack of awareness or knowledge about chlamydia, lack of support for partner notification, and concern about embarrassing their patient.4,5 For patients, barriers include the cost of the GP consultation and the chlamydia test, availability of transport to the clinic, lack of knowledge about the need for testing, the location of the pathology collection site, embarrassment or unease about providing a specimen, and, for those living in rural and remote areas of Australia, fears about confidentiality, the lack of female GPs, and health care availability.6–12
The Australian Government funded a chlamydia screening trial in 2009 to determine whether annual chlamydia testing in general practice for 16–29-year-old men and women would reduce the population burden of chlamydia.13 As part of this ongoing trial, clinics in the intervention group have provided a multifaceted intervention designed to facilitate increased chlamydia testing.
We found in an earlier study that not all patients will follow through and have a chlamydia test when a GP requests one.14 Our trial provided the opportunity to investigate factors associated with not having a test after it has been requested by a GP. Further, our findings can be extrapolated to other preventive health activities in general practice where tests are requested.
Methods
Setting
The Australian Chlamydia Control Effectiveness Pilot (ACCEPt) is a cluster randomised controlled trial of a chlamydia testing intervention in general practice that commenced in mid-2010 and will be completed in late 2015. All 134 GP clinics in 54 rural and regional towns in Victoria (18 towns), New South Wales (21), South Australia (four) and Queensland (11) were recruited for the trial. A further eight clinics in metropolitan Melbourne were also recruited, for a total of 142 clinics. To be eligible for inclusion in the trial, towns had to have a minimum population of 500 people aged 16–29 years (2006 census) and fewer than seven clinics. Towns were excluded if a military base, university or mine was nearby, or if it was a tourist town. A list for each state was drawn up, and towns randomly selected until the required sample size was obtained. More than 90% of invited clinics agreed to participate. Towns were randomised to either a chlamydia testing intervention group or to a control group. Clinics in the intervention group were asked to target 16–29-year-old men and women for annual testing; they received a multifactorial intervention that included audit and feedback on their chlamydia testing rates, and incentive payments for each chlamydia test requested. Control clinics were requested to continue usual chlamydia control practices.
Data collection
A data extraction tool (GRHANITE) was installed on computers in 122 of the 142 participating clinics. Reasons for not being able to install the tool included the clinic not having a computer (two clinics), non-compatible medical records software (12 clinics) and refusal by the clinic (six clinics). This tool extracts de-identified patient consultation and chlamydia testing data on a weekly basis from the patient medical records database.15 Compatible medical records software includes Medical Director, Best Practice, GENIE, Zedmed, Medtech 32, Communicare, SHIP and practiX. Data included in the analysis were patient age and sex, clinic postcode, chlamydia test request (yes v no) and chlamydia test result (positive v negative v test not done). Additional clinic-specific data were obtained, such as whether the clinic bulk-billed consultations (a payment option in Australia: the doctor does not charge the patient for the consultation but is instead reimbursed directly by Medicare) and whether pathology or specimen collection was available on site. The socio-economic profile of the geographical location of each clinic was obtained by linking their postcodes with the Australian Bureau of Statistics’ 2011 Socio-Economic Indexes for Area–Index of Relative Socio-economic Disadvantage (SEIFA-IRSD).16 The IRSD scores areas according to relative disadvantage, ranging from 600 (most disadvantaged) to 1200 (least disadvantaged). The geographical location of the clinic was also classified according to rurality according to the 2007 Australian Standard Geographical Classification System–Remoteness Area (ASGC-RA).17 The ASCG-RA categorises areas according to their physical distance from urban centres (ie, access to goods and services). Its categories, in order of increasing remoteness, are major cities, inner regional, outer regional, remote, and very remote. No participating clinic was in the very remote category. For each clinic postcode, the proportion of the population with Aboriginal and/or Torres Strait Islander background was obtained. Chlamydia prevalence is higher among Aboriginal people, and it is important to determine whether there are any barriers to their having a test when requested by a GP.18
Data analysis
All chlamydia test requests were extracted for the period 1 January 2013 – 31 December 2013. The primary outcome for analysis was defined as “no test conducted” following a GP request. Factors associated with this outcome were explored using logistic regression; univariate and multivariate odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. All variables were included in the multivariate analysis. Effect modification was explored by fitting interaction terms to the model. Our main analysis was restricted to clinics participating in the intervention arm of the trial because of the availability of data. A total of 63 of 70 intervention clinics provided data for this analysis. We were able to investigate any potential selection bias by comparing the proportions of no test outcomes for intervention and control clinics. All analyses were performed in Stata 13 (StataCorp) and were adjusted for intracluster correlation at the clinic level. IRSD scores were categorised as quintiles for ease of interpretation and analysed as a linear variable, using the least disadvantaged category as reference. Age was categorised in bands (16–19 years, 20–24 years, 25–29 years).
Ethics approval
ACCEPt received ethics approval from the Royal Australian College of General Practitioners Ethics Committee (NREEC reference number 09/019).
Results
During the study period, the overall annual testing rate of 16–29-year-old men and women in the 63 intervention clinics was 19.2% (95% CI, 16.8–21.8%). A total of 13 225 chlamydia tests were requested; 9712 (73%) were for women. Overall, 29% of chlamydia test requests were for patients aged 16–19 years; 21% were requested by clinics in metropolitan Melbourne, 55% by inner regional clinics, 22% by outer regional clinics, and 2% by clinics in remote locations. About one-third of clinics (31%) provided bulk-billing services for students and young adults; 92% provided on-site specimen collection for pathology (Box).
No test was conducted for 2545 of the requests (19.2%; 95% CI, 16.5–22.3%). Univariate analysis indicated that the odds that no test was conducted were higher for men, those aged 16–19 years, and those living in areas of higher socio-economic disadvantage. Multivariate analysis indicated that the odds of no test being conducted were higher for men (adjusted OR [aOR], 1.4; 95% CI, 1.3–1.6), those aged 16–19 years (aOR, 1.3; 95% CI, 1.1–1.4), those living in areas of greater socio-economic disadvantage (aOR, 1.2; 95% CI, 1.1–1.4 for each additional quintile of Index of Relative Socio-economic Disadvantage), and those attending clinics without on-site pathology collection (aOR, 1.4; 95% CI, 1.0–1.9). The geographical location of the clinic, the availability of bulk-billing services, and the proportion of the population who identified as Aboriginal and/or Torres Strait Islander were not associated with the likelihood of a test not being done. No significant interactions between variables were detected.
Assessment of selection bias
During the study period, the overall annual testing rate in 59 control clinics was 10.9% (95% CI, 9.4–12.8%). A total of 7148 chlamydia tests were requested; no test was conducted in 1219 instances (17.1%; 95% CI, 12.9–22.2%). There was no difference between intervention and control clinics in the proportion of instances where no test was conducted (OR [intervention v control clinics], 1.2; 95% CI, 0.8–1.7; P = 0.42). As for the intervention clinics, univariate analysis indicated that the odds of a test not being conducted were greater for men (OR, 1.2; 95% CI, 1.1–1.4) and those aged 16–19 years (OR, 1.3; 95% CI, 1.1–1.5).
Discussion
We found that about one in five young people for whom chlamydia tests were requested by a GP did not submit a specimen. Men, people aged 16–19 years, those living in areas of greater socio-economic disadvantage, and those attending clinics without on-site pathology collection were less likely to follow through and be tested for chlamydia after a GP request. It is important to note that lower age and socio-economic disadvantage are key risk factors for chlamydia,20 highlighting how vital it is that clinics establish systems which ensure that tests ordered by GPs are actually undertaken.
We found that men were more likely to not undertake a requested test. Qualitative research has provided some insight into possible reasons for this. An evaluation of a peer-led intervention in the United Kingdom that aimed to increase chlamydia screening found that embarrassment was a key issue deterring young men from screening tests, whereas women were more open and accepting.21 Another UK study found that men’s attitudes to chlamydia screening were affected by a lack of knowledge and social embarrassment about chlamydia, a reluctance to seek medical help, a perception that chlamydia was a “women’s disease”, and indifference to health promotion campaigns.22
We found that those aged 16–19 years were less likely to undergo a test requested by a GP. It is possible that concern about confidentiality and privacy in general practice may have deterred some from chlamydia screening.10 Young people are also less likely to undergo annual health checks or to seek health information,23 and they express uncertainty or misconceptions about what the test entails.24 It has been argued that simply raising awareness about the risk of chlamydia may not increase testing rates, and that providing reassurance of non-infection may be more productive.25
We found that the odds of not undertaking a requested test rose with increasing levels of socio-economic disadvantage. This is consistent with an earlier study that found that those living in disadvantaged areas in Australia had lower chlamydia testing rates.26 This is a concern because socio-economic disadvantage is a risk factor for chlamydia infection,18 so it is vital that barriers to chlamydia testing are minimised in these areas. We found that the availability of bulk-billing for the consultation was not an important deterrent. However, we do not have information about whether the cost of the test was also bulk-billed, and it is possible that lack of knowledge about its cost may have deterred some patients from having the test. Qualitative research is needed to examine this possibility.
We found that the odds of not undertaking a test were 40% higher in clinics without on-site pathology collection. Chlamydia testing can be stressful for some patients, and any inconvenience, such as having to leave the clinic to attend an off-site pathology collection centre, will deter patients from following through with a test, especially if the testing centre is not nearby. Most pathology providers in Australia offer a courier service; if patients were able to leave self-collected specimens, such as urine or vaginal swabs, at a clinic, these could be collected by the provider, potentially increasing the uptake of testing.
A number of limitations must be considered when interpreting our results. Firstly, clinics were not randomly sampled for participation in the screening trial; as a result, our results may be subject to selection bias. However, this is unlikely to be important, as more than 90% of clinics agreed to participate, our analysis accounted for intracluster correlation within clinics, and we found no differences in results between intervention and control clinics. Secondly, more than 80% of our clinics were in rural areas, so that it may not be possible to generalise our results to all Australian clinics. Thirdly, data were unavailable for seven of the intervention clinics (10%) because we were unable to install our data extraction tool on a clinic computer. Fourthly, we were unable to assess other barriers to testing, such as the physical layout of the clinic, the location of a toilet, and the availability of local transport. Our analysis was also restricted to summary measures of bulk-billing and pathology collection at the clinic. It is possible that bulk-billing at some clinics may be at the discretion of the doctor, and some doctors may be willing to allow a patient to leave a specimen for collection if on-site pathology services are not available. We were also unable to assess the reason for test requests and whether there was any difference in the failure to test between those who were symptomatic or asymptomatic at the time of the request. Finally, it is possible that there were errors in our data extraction, and that not all chlamydia test requests and results were extracted. However, this problem is unlikely to be significant, because we also collected chlamydia testing data from pathology providers to validate the data extracted for each clinic.
The strengths of our study included its large sample size. Further, more than 90% of clinics agreed to participate, we adjusted our analysis for intracluster correlation within clinics, and we investigated area-level, clinic-level and patient-level factors. We believe our results can be extrapolated to other preventive health activities targeting this age group in general practice.
Conclusions
We found that men, those aged 16–19 years, those living in areas of increasing socio-economic disadvantage and those attending clinics without on-site pathology collection services were less likely to be tested for chlamydia following a GP request. Qualitative research is needed to understand why these individuals are not tested. This is important information for health service delivery in general practice, and highlights the need for clinics to develop systems which ensure that men, younger people and those living in socio-economic disadvantaged areas have a test when requested by their GP.
Box –
Factors associated with a patient not having a test for chlamydia following a request by a general practitioner
|
Characteristic |
No tests done (total test requests) |
No tests done as proportion of test requests |
Univariate OR (95% CI) |
P |
Multivariate OR (95% CI)* |
P |
|||||||||
|
|
|||||||||||||||
|
Total |
2545 (13 255) |
19.3% |
|
|
|
|
|||||||||
|
Sex |
|
|
|
|
|
|
|||||||||
|
Women |
1738 (9712) |
17.9% |
1 |
|
1 |
|
|||||||||
|
Men |
816 (3513) |
23.2% |
1.4 (1.2–1.6) |
< 0.01 |
1.4 (1.3–1.6) |
< 0.01 |
|||||||||
|
Age |
|
|
|
|
|
|
|||||||||
|
16–19 years |
805 (3807) |
21.1% |
1.2 (1.1–1.4) |
< 0.01 |
1.3 (1.1–1.4) |
< 0.01 |
|||||||||
|
20–24 years |
1072 (5677) |
18.9% |
1.1 (0.9–1.2) |
0.30 |
1.1 (0.9–1.2) |
0.37 |
|||||||||
|
25–29 years |
668 (3741) |
17.9% |
1 |
|
1 |
|
|||||||||
|
Clinic location† |
|
|
|
|
|
|
|||||||||
|
Major cities |
559 (2757) |
20.3% |
1 |
|
1 |
|
|||||||||
|
Inner regional |
1349 (7322) |
18.4% |
0.9 (0.4–1.8) |
0.74 |
0.6 (0.3–1.3) |
0.23 |
|||||||||
|
Outer regional |
572 (2871) |
19.9% |
1.0 (0.5–2.0) |
0.95 |
0.7 (0.3–1.7) |
0.47 |
|||||||||
|
Remote |
65 (275) |
23.6% |
1.2 (0.5–3.0) |
0.67 |
0.8 (0.4–1.9) |
0.65 |
|||||||||
|
Index of Relative Socio-economic Disadvantage‡ |
NA |
NA |
1.2 (1.1–1.3) |
< 0.01 |
1.2 (1.1–1.4) |
0.01 |
|||||||||
|
Bulk-billing |
|
|
|
|
|
|
|||||||||
|
Yes |
1726 (9141) |
18.9% |
1 |
|
1 |
|
|||||||||
|
No |
819 (4084) |
20.1% |
0.9 (0.6–1.5) |
0.76 |
1.2 (0.8–1.8) |
0.36 |
|||||||||
|
On-site pathology collection |
|
|
|
|
|
|
|||||||||
|
Yes |
2292 (1219)2 |
18.8% |
1 |
|
1 |
|
|||||||||
|
No |
253 (1033) |
24.5% |
1.4 (1.0–2.0) |
0.08 |
1.4 (1.0–1.9) |
0.05 |
|||||||||
|
Aboriginal and/or Torres Strait Islander§ |
|
|
|
|
|
|
|||||||||
|
< 0.6% |
573 (3415) |
16.8% |
1 |
|
1 |
|
|||||||||
|
0.6%–1.1% |
940 (4178) |
22.5% |
1.4 (0.9–2.2) |
0.10 |
1.4 (0.8–2.4) |
0.24 |
|||||||||
|
1.2%–2.5% |
383 (2326) |
16.5% |
0.9 (0.7–1.4) |
0.91 |
1.1 (0.6–1.8) |
0.99 |
|||||||||
|
≥ 2.6% |
649 (3306) |
19.6% |
1.2 (0.9–1.6) |
0.19 |
1.1 (0.6–1.8) |
0.81 |
|||||||||
|
|
|||||||||||||||
|
NA = not applicable; OR = odds ratio. * Adjusted for all variables in the table. † Australian Standard Geographical Classification System – Remoteness Area.17 ‡ IRSD score was categorised into quintiles and analysed as a linear variable using the least disadvantaged area as reference. Odds ratio is for the change in the odds of no test being performed for each additional increase in IRSD quintile. § Proportion of population identifying as Aboriginal and/or Torres Strait Islander; based on reference 19. |
|||||||||||||||
[Comment] Rheumatology—a call for papers
Rheumatoid and autoimmune diseases are a heterogeneous group of disorders, many of which are of unknown aetiology and have heterogeneous clinical presentation. Often difficult to diagnose and to treat, these conditions are an under-appreciated group of non-communicable diseases that, according to latest Global Burden of Disease estimates,1 contribute as much as 20% of years lived with disability, worldwide. Research into the treatment, epidemiology, and public health and education interventions that might help to combat this diverse group of diseases is an urgent, unmet need.
[Comment] Offline: The reflection of ourselves we choose to ignore
Can medicine for the body and mind ever be united? The slogan “No health without mental health” was supposed to signify some kind of marriage (or truce might be a better word). But the physical and the mental still seem to occupy separate worlds, light years apart. In strategies to defeat non-communicable diseases (NCDs), the emphasis has been on four priorities—cardiovascular disease, cancer, diabetes, and chronic respiratory disease. These pathologies are important killers. They certainly deserve our attention.
[Comment] Brain health: widening the scope of NCDs
In 2011, WHO included only four groups of diseases in the non-communicable disease (NCD) category: cardiovascular diseases, cancer, respiratory diseases, and diabetes.1 Since then, there have been several WHO and UN initiatives that relate to NCDs. Yet the scope of NCDs in WHO’s NCD agenda still excludes many fatal and chronic disabling diseases. It is welcome that when the International Classification of Diseases 11th Revision comes to be implemented, in 2018, WHO statisticians will classify stroke—the second most common cause of death in people older than 60 years—as a brain disease.
[Correspondence] The promise of personalised medicine
Genomics are anticipated to have an important role in promoting population health by being used to target at-risk individuals. In 2015, Victor Dzau and colleagues1 proposed that identification of genomic variants in major complex diseases would lead to modulation of health-related behaviours, with a 10–50% reduction in disease incidence. Most studies in a Cochrane review,2 however, showed no evidence of incremental behavioural changes by patients after provision of genetic risk information alongside lifestyle interventions.
[Comment] Pulmonary pressure, telemedicine, and heart failure therapy
Heart failure is a leading cause of hospital admissions in patients with cardiac diseases and poses a huge burden for patients and societies. In recent years, major advances have been made with the introduction of new drugs and novel interventional approaches such as cardiac resynchronisation therapy. However, there is a need for further improvement, especially considering the projection for increases in heart failure prevalence caused by ageing of the population. Longer survival of patients with cardiac diseases, an effect of modern life-extending treatments, such as primary angioplasty for myocardial infarction and implantable defibrillators for prevention of sudden cardiac death, also contributes to the need for more effective therapies for heart failure.