International spotlight on Indigenous public health equity

Prominent Maori health advocate Adrian Te Patu led a yarning circle at the 15^th World Congress of Public Health, which unanimously supported the establishment of an Indigenous Working Group within the World Federation of Public Health Associations.

Mr Te Patu is the first Indigenous representative on the WFPHA Governing Council and is well-known throughout is homeland New Zealand and internationally for his campaigning on health issues.

He will now formalise the Indigenous Working Group, following its acceptance at the World Congress, which was held in Melbourne in April.

The Indigenous Working Group will provide an opportunity to bring to the global public health and civil society arena a visible and prominent Indigenous voice that privileges an Indigenous world view and narrative.

“We intend to create a platform for change with the aim to address the health inequities experience by Indigenous peoples worldwide,” Mr Te Patu said.

The group was formed on the 50^th anniversary of the WFPHA, at the 15th World Congress conference, when 40 Indigenous and non-Indigenous conference delegates of the yarning circle unanimously supported in principle its establishment.

The Public Health Association of Australia hosted the yarning circle that was led by Mr Te Patu.

A yarning circle, also known as a dialogue circle, comes from the traditional Aboriginal process of discussing issues in an inclusive and collaborative manner.

All participants are invited to have their say in a non-judgemental environment.

The WFPHA’s function and mandate includes its link into the global health governance mechanisms such as the World Health Organisation.

Chris Johnson

Cholera vaccination campaign focussing on Somalia

A second stage of a major vaccination campaign to halt the spread of cholera got underway in March and April in three drought-ravaged regions of Somalia.

Gavi, the Vaccine Alliance, delivered 953,000 doses of Oral Cholera Vaccine to the country to protect more than 450,000 people from the disease.

The campaign took place in three of the worst-hit regions, Banadir, Kismayo and Beledweyne, with the vaccine being given in two doses to everyone over the age of one. The first round ran from 15-19 March and the second from 18-22 April.

The vaccines were procured, transported and stored at the appropriate temperature by UNICEF. They are being administered by the Government of Somalia with the support of World Health Organisation (WHO) and UNICEF; while UNICEF and others continue to improve water and sanitation infrastructure and promote behaviour change. As well as providing the vaccines, Gavi has provided US$550,000 to support the campaign.

Seth Berkley, CEO of Gavi, said the people of Somalia are going through unimaginable suffering.

“After years of conflict, a severe drought has brought the country to the brink of famine and now a suspected cholera outbreak threatens to become a nationwide epidemic,” he said.

“These lifesaving vaccines will play a vital role in slowing the spread of the disease, buying valuable time to put the right water, sanitation and hygiene infrastructure in place to stop the root causes of this outbreak.”

Dr Ghulam Popal, WHO Representative in Somalia, said cholera was a major health issue in Somalia.

“The current drought has worsened the situation for many. Therefore we’re very glad to have the support of Gavi to implement the first OCV campaign in Somalia,” Dr Popal said.

“We are very hopeful that the vaccination campaign will control outbreaks, and eventually save lives.”

The current severe drought in Somalia has forced communities to use contaminated water, helping cholera to spread. A total of 25,000 cases of Acute Watery Diarrhoea/cholera have been reported since the beginning of 2017, causing at least 524 deaths. Surveillance reports indicate that the epidemic is now spreading to areas inaccessible to aid workers.

UNICEF Somalia Representative, Steven Lauwerier said the vaccination campaign was an emergency measure.

“We need to continue to tackle the main cause of such outbreaks,” he said.

“UNICEF, donors, government and other stakeholders are making some progress in improving access to safe water and promoting good sanitation and hygiene practices and this needs to be scaled up urgently.”

Gavi, the Vaccine Alliance is a public-private partnership committed to saving children’s lives and protecting people’s health by increasing equitable use of vaccines in lower-income countries.

The Vaccine Alliance brings together developing country and donor governments, the World Health Organization, UNICEF, the World Bank, the vaccine industry, technical agencies, civil society, the Bill & Melinda Gates Foundation and other private sector partners.

Gavi uses innovative finance mechanisms, including co-financing by recipient countries, to secure sustainable funding and adequate supply of quality vaccines. Since 2000, Gavi has contributed to the immunisation of nearly 580 million children and the prevention of approximately 8 million future deaths.

Chris Johnson

The Australasian Society for Infectious Diseases and Refugee Health Network of Australia recommendations for health assessment for people from refugee-like backgrounds: an abridged outline

There are currently more than 65 million people who have been forcibly displaced worldwide, including 21.3 million people with formal refugee status, over half of whom are aged under 18 years.1 More than 15 000 refugees have resettled in Australia in the 2015–16 financial year, which includes a proportion of the 12 000 refugees from Syria and Iraq recently added to Australia’s humanitarian intake.2 In addition, around 30 000 asylum seekers who arrived by plane or boat are currently in Australia awaiting visa outcomes.3

People from refugee-like backgrounds are likely to have experienced disruption of basic services, poverty, food insecurity, poor living conditions and prolonged uncertainty; they may have experienced significant human rights violations, trauma or torture. These circumstances place them at increased risk of complex physical and mental health conditions. They face numerous barriers to accessing health care after arrival in Australia, such as language, financial stress, competing priorities in the settlement period, and difficulties understanding and navigating the health care system.4–6 Most people require the assistance of an interpreter for clinical consultations.7 Offering a full health assessment to newly arrived refugees and asylum seekers is a positive step towards healthy settlement, and helps manage health inequity through the provision of catch-up immunisation and the identification and management of infectious and other health conditions.

These guidelines update the Australasian Society of Infectious Diseases (ASID) guidelines for the diagnosis, management and prevention of infectious diseases in recently arrived refugees8 published in 2009 and previously summarised in the MJA.9 When these recommendations were first published, more than 60% of humanitarian entrants arriving in Australia were from sub-Saharan Africa10 and had a high prevalence of malaria, schistosomiasis and hepatitis B virus (HBV) infection.11–15 The initial guidelines were primarily intended to help specialists and general practitioners to diagnose, manage and prevent infectious diseases. Since then, there have been changes in refugee-source countries — with more arrivals from the Middle East and Asia and fewer from sub-Saharan Africa16,17 — and an increased number of asylum seekers arriving by boat,18 alongside complex and changing asylum seeker policies and changes in health service provision for these populations. In this context, we reviewed the 2009 recommendations to ensure relevance for a broad range of health professionals and to include advice on equitable access to health care, regardless of Medicare or visa status. The revised guidelines are intended for health care providers caring for people from refugee-like backgrounds, including GPs, refugee health nurses, refugee health specialists, infectious diseases physicians and other medical specialists.

This article summarises the full guidelines, which contain detailed literature reviews, recommendations on diagnosis and management along with explanations, supporting evidence and links to other resources. The full version is available at http://www.asid.net.au/documents/item/1225.

Methods

The guideline development process is summarised in Box 1. The two key organisations developing these guidelines are ASID and the Refugee Health Network of Australia. ASID is Australia’s peak body representing infectious diseases physicians, medical microbiologists and other experts in the fields of the prevention, diagnosis and treatment of human and animal infections. The Refugee Health Network is a multidisciplinary network of health professionals across Australia with expertise in refugee health.20

We defined clinical questions using the PIPOH framework (population, intervention, professionals, outcomes and health care setting).21 The chapter authors and the Expert Advisory Group developed recommendations based on reviews of available evidence, using systematic reviews where possible. Australian prevalence data also informed screening recommendations; for example, the low reported prevalence of chlamydia (0.8–2.0%) infections and absence of gonorrhoea infections in refugee cohorts in Australia13,22–24 (and in other developed countries25–27) informed the new recommendation for risk-based sexually transmitted infection (STI) screening.

Despite the intention to assign levels of evidence to each recommendation, there was limited published high level evidence in most areas, and virtually all recommendations are based on expert consensus. Consensus was not reached regarding the recommendations relating to human immunodeficiency virus (HIV) and STIs.

The term “refugee-like” is used to describe people who are refugees under the United Nations Refugee Convention,28 those who hold a humanitarian visa, people from refugee-like backgrounds who have entered under other migration streams, and people seeking asylum in Australia. “Refugee-like” acknowledges that people may have had refugee experience in their countries of origin or transit, but do not have formal refugee status.

Current pre-departure screening

All permanent migrants to Australia have a pre-migration immigration medical examination 3–12 months before departure,29 which includes a full medical history and examination. Investigations depend on age, risk factors and visa type,30 and include:

a chest x-ray for current or previous tuberculosis ([TB]; age ≥ 11 years);
screening for latent TB infection with an interferon-γ release assay or tuberculin skin test (for children aged 2–10 years, if they hold humanitarian visas, come from high prevalence countries or have had prior household contact);
HIV serology (age ≥ 15 years, unaccompanied minors);
hepatitis B surface antigen (HBsAg) testing (pregnant women, unaccompanied minors, onshore protection visas, health care workers);
hepatitis C virus (HCV) antibody testing (onshore protection visas, health care workers); and
syphilis serology (age ≥ 15 years, humanitarian visas, onshore protection visas).

Humanitarian entrants are also offered a voluntary pre-departure health check depending on departure location and visa subtype.31 The pre-departure health check includes a rapid diagnostic test and treatment for malaria in endemic areas; empirical treatment for helminth infections with a single dose of albendazole; measles, mumps and rubella vaccination; and yellow fever and polio vaccination where relevant. The current cohort of refugees arriving from Syria will have extended screening incorporating the immigration medical examination and pre-departure health check, with additional mental health review and immunisations.

People seeking asylum who arrived by boat have generally had a health assessment on arrival in immigration detention — although clinical experience suggests that investigations and detention health care varies, especially for children. However, asylum seekers who arrived by plane will not have had a pre-departure immigration medical examination.

General recommendations

Our overarching recommendation is to offer all people from refugee-like backgrounds, including children, a comprehensive health assessment and management plan, ideally within 1 month of arrival in Australia. This assessment can be offered at any time after arrival if the initial contact with a GP or clinic is delayed, and should also be offered to asylum seekers after release from detention. Humanitarian entrants who have been in Australia for less than 12 months are eligible for a GP Medicare-rebatable health assessment. Such assessments may take place in a primary care setting or in a multidisciplinary refugee health clinic. Documented overseas screening and immunisations, and clinical assessment should also guide diagnostic testing.

Health care providers should adhere to the principles of person-centred care when completing post-arrival assessments.32,33 These include: respect for the patient’s values, preferences and needs; coordination and integration of care with the patient’s family and other health care providers; optimising communication and education, provision of interpreters where required (the Doctors Priority Line for the federal government-funded Translating and Interpreting Service is 1300 131 450) and use of visual and written aids and teach-back techniques to support health literacy.34 It is important to explain that a health assessment is voluntary and results will not affect visa status or asylum claims.

Specific recommendations

Recommendations are divided into two sections: infectious and non-infectious conditions. Box 2 provides a checklist of all recommended tests, and Box 3 sets out details of country-specific recommendations. A brief overview is provided below. For more detailed recommendations regarding management, follow-up and considerations for children and in pregnancy, see the full guidelines.

Infectious conditions

TB:

Offer latent TB infection testing with the intention to offer preventive treatment and follow-up.
Offer screening for latent TB infection to all people aged ≤ 35 years.
Children aged 2–10 years may have been screened for latent TB infection as part of their pre-departure screening.
Screening and preventive treatment for latent TB infection in people > 35 years will depend on individual risk factors and jurisdictional requirements in the particular state or territory.
Use either a tuberculin skin test or interferon-γ release assay (blood) to screen for latent TB infection.
A tuberculin skin test is preferred over interferon-γ release assay for children < 5 years of age.
Refer patients with positive tuberculin skin test or interferon-γ release assay results to specialist tuberculosis services for assessment and exclusion of active TB and consideration of treatment for latent TB infection.
Refer any individuals with suspected active TB to specialist services, regardless of screening test results.

Malaria:

Investigations for malaria should be performed for anyone who has travelled from or through an endemic malaria area (Box 3), within 3 months of arrival if asymptomatic, or any time in the first 12 months if there is fever (regardless of pre-departure malaria testing or treatment).
Test with both thick and thin blood films and an antigen-based rapid diagnostic test.
All people with malaria should be treated by, or in consultation with, a specialist infectious diseases service.

HIV:

Offer HIV testing to all people aged ≥ 15 years and all unaccompanied or separated minors, as prior negative tests do not exclude the possibility of subsequent acquisition of HIV (note that consensus was not reached regarding this recommendation).

HBV:

Offer testing for HBV infection to all, unless it has been completed as part of the immigration medical examination.
A complete HBV assessment includes HBsAg, HB surface antibody and HB core antibody testing.
If the HBsAg test result is positive, further assessment and follow-up with clinical assessment, abdominal ultrasound and blood tests are required.

HCV:

Offer testing for HCV to people if they have:
- risk factors for HCV;
- lived in a country with a high prevalence (> 3%) of HCV (Box 3); or
- an uncertain history of travel or risk factors.
Initial testing is with an HCV antibody test. If the result is positive, request an HCV RNA test.
If the HCV RNA test result is positive, refer to a doctor accredited to treat HCV for further assessment.

Schistosomiasis:

Offer blood testing for Schistosoma serology if people have lived in or travelled through endemic countries (Box 3).
If serology is negative, no follow-up is required.
If serology is positive or equivocal:
- treat with praziquantel in two doses of 20 mg/kg, 4 hours apart, orally; and
- perform stool microscopy for ova, urine dipstick for haematuria, and end-urine microscopy for ova if there is haematuria.
If ova are seen in urine or stool, evaluate further for end-organ disease.

Strongyloidiasis:

Offer blood testing for Strongyloides stercoralis serology to all.
If serology is positive or equivocal:
- check for eosinophilia and perform stool microscopy for ova, cysts and parasites; and
- treat with ivermectin 200 μg/kg (weight ≥ 15 kg), on days 1 and 14 and repeat eosinophil count and stool sample if abnormal.
Refer pregnant women or children < 15 kg for specialist management.

Intestinal parasites:

Check full blood examination for eosinophilia.
If pre-departure albendazole therapy is documented:
- if there are no eosinophilia and no symptoms, no investigation or treatment is required; and
- if there is eosinophilia, perform stool microscopy for ova, cysts and parasites, followed by directed treatment.
If no documented pre-departure albendazole therapy, depending on local resources and practices, there are two acceptable options:
- empirical single dose albendazole therapy (age > 6 months, weight < 10 kg, dose 200 mg; weight ≥ 10 kg, dose 400 mg; avoid in pregnancy, class D drug); or
- perform stool microscopy for ova, cysts and parasites, followed by directed treatment.

Helicobacter pylori:

Routine screening for H. pylori infection is not recommended.
Screen with either stool antigen or breath test in adults from high risk groups (family history of gastric cancer, symptoms and signs of peptic ulcer disease, or dyspepsia).
Children with chronic abdominal pain or anorexia should have other common causes of their symptoms considered in addition to H. pylori infection.
Treat all those with a positive test (see the full guidelines for details, tables 1.5 and 9.1).

STIs:

Offer an STI screen to people with a risk factor for acquiring an STI or on request. Universal post-arrival screening for STIs for people from refugee-like backgrounds is not supported by current evidence.
A complete STI screen includes a self-collected vaginal swab or first pass urine nucleic acid amplification test and consideration of throat and rectal swabs for chlamydia and gonorrhoea, and serology for syphilis, HIV and HBV.
Syphilis serology should be offered to unaccompanied and separated children < 15 years.

Skin conditions:

The skin should be examined as part of the initial physical examination.
Differential diagnoses will depend on the area of origin (see table 11.1 in full guidelines for details).

Immunisation:

Provide catch-up immunisation so that people of refugee background are immunised equivalent to an Australian-born person of the same age.
In the absence of written immunisation documentation, full catch-up immunisation is recommended.
Varicella serology is recommended for people aged ≥ 14 years if there is no history of natural infection.
Rubella serology should be completed in women of childbearing age.

Non-infectious conditions

Anaemia and other nutritional problems:

Offer full blood examination screening for anaemia and other blood conditions to all.
Offer screening for iron deficiency with serum ferritin to children, women of childbearing age, and men who have risk factors.
Check vitamin D status as part of initial health screening in people with one or more risk factors for low vitamin D.
People with low vitamin D should be treated to restore their levels to the normal range with either daily dosing or high dose therapy, paired with advice about sun exposure.
Consider screening for vitamin B₁₂ deficiency in people with history of restricted food access, especially those from Bhutan, Afghanistan, Iran and the Horn of Africa.

Chronic non-communicable diseases in adults:

Offer screening for non-communicable diseases in line with the Royal Australian College of General Practitioners Red Book35 recommendations, including assessment for:
- smoking, nutrition, alcohol and physical activity;
- obesity, diabetes, hypertension, cardiovascular disease, chronic obstructive pulmonary disease and lipid disorders; and
- breast, bowel and cervical cancer.
Assess diabetes and cardiovascular disease risk earlier for those from regions with a higher prevalence of non-communicable diseases, or those with an increased body mass index or waist circumference.

Mental health:

A trauma informed assessment of emotional wellbeing and mental health is part of post-arrival screening. Being aware of the potential for past trauma and impact on wellbeing is essential, although it is generally not advisable to ask specifically about details in the first visits.
Consider functional impairment, behavioural difficulties and developmental progress as well as mental health symptoms when assessing children.

Hearing, vision and oral health:

A clinical assessment of hearing, visual acuity and dental health should be part of primary care health screening.

Women’s health:

Offer women standard preventive screening, taking into account individual risk factors for chronic diseases and bowel, breast and cervical cancer.
Consider pregnancy and breastfeeding and offer appropriate life stage advice and education, such as contraceptive advice where needed, to all women, including adolescents.
Practitioners should be aware of clinical problems, terminology and legislation related to female genital mutilation or cutting and forced marriage.

Box 1 –
Guideline development process

An EAG, consisting of refugee health professionals, was formed and it included two ID physicians, an ID and general physician, two GPs, a public health physician, a general paediatrician and a refugee health nurse. An editorial subgroup was also formed.
The EAG determined the list of priority conditions in consultation with refugee health specialists and RACGP Refugee Health Special Interest Group clinicians, incorporating information from consultations with refugee background communities19 and previous ASID refugee health guidelines.
Each condition was assigned to a primary specialist author with paediatrician and primary care or specialist co-authors. Twenty-eight authors from six states and territories were involved in writing the first draft.
The EAG reviewed the first draft to ensure consistency with the framework and the rest of the guidelines. They were then revised by the primary authors.
External expert review authors reviewed the second draft and they were then revised by the primary authors.
The EAG and the refugee health nurse subcommittee reviewed the third draft.
The stakeholders reviewed the fourth draft: ASID, NTAC, RHeaNA, RACGP Refugee Health Special Interest Group, RACP, RACP AChSHM, the Victorian Foundation for the Survivors of Torture, the Multicultural Centre for Women’s Health, the Asylum Seeker Resource Centre, the Ethnic Communities Council of Victoria and community members.
The comments from the stakeholders were returned to the authors for review and the EAG compiled the final version.
ASID, RACP, NTAC and AChSHM endorsed the final version.

AChSHM = Australasian Chapter of Sexual Health Medicine. ASID = Australasian Society for Infectious Diseases. EAG = Expert Advisory Group. GP = general practitioner. ID = infectious diseases. NTAC = National Tuberculosis Advisory Council. RACGP = Royal Australian College of General Practitioners. RACP = Royal Australasian College of Physicians. RHeaNA = Refugee Health Network of Australia. Adapted from the ASID and RHeaNA Recommendations for comprehensive post-arrival health assessment for people from refugee-like backgrounds (2016; https://www.asid.net.au/documents/item/1225) with permission from ASID.

Box 2 –
Short checklist of recommendations for post-arrival health assessment of people from refugee-like backgrounds

Offer test to

Test

Comments and target condition

All

Full blood examination

Anaemia, iron deficiency, eosinophilia

Hepatitis B serology (HBsAg, HBsAb, HBcAb)

HBsAg testing introduced overseas in 2016 for Syrian and Iraqi refugee cohort and may have been completed in other groups

Strongyloides stercoralis serology

Strongyloidiasis

HIV serology*

≥ 15 years or unaccompanied or separated minor
Also part of IME for age ≥ 15 years

TST or IGRA

Offer test if intention to treat. All ≤ 35years; if≥ 35 years, depends on risk factors and local jurisdiction. TST preferred for children < 5 yearsTST or IGRA testing introduced in 2016 as part of IME for children 2–10 years (humanitarian entrants, high prevalence countries, prior household contact)
LTBI

Varicella serology

≥ 14 years if no known history of disease
Determine immunisation status

Visual acuity

Vision status, other eye disease

Glaucoma assessment

Africans > 40 years and others > 50 years

Dental review

Caries, periodontal disease, other oral health issues

Hearing review

Hearing impairment

Social and emotional wellbeing and mental health

Mental illness, trauma exposure, protective factors

Developmental delay or learning concerns

Children and adolescents
Developmental issues, disability, trauma exposure

Preventive health as per RACGP35

Non-communicable diseases, consider screening earlier than usual age

Catch-up vaccinations

Vaccine preventable diseases, including hepatitis B

Risk-based

Rubella IgG

Women of childbearing age
Determines immunisation status

Ferritin

Men who have risk factors, women and childrenIron deficiency anaemia

Vitamin D, also check calcium, phosphate, and alkaline phosphatase in children

Risk factors if dark skin or lack of sun exposure
Low vitamin D, rickets

Vitamin B₁₂

Arrival < 6 months, food insecurity, vegan diet or from Bhutan, Afghanistan, Iran or Horn of Africa
Nutritional deficiency, risk for developmental disability in infants

First pass urine or self-obtained vaginal swabs for gonorrhoea and chlamydia PCR

Risk factors for STI or on request*

Syphilis serology

Risk factors for STIs, unaccompanied or separated minors. Part of IME in humanitarian entrants aged ≥ 15 years

Helicobacter pylori stool antigen or breath test

Gastritis, peptic ulcer disease, family history of gastric cancer, dyspepsia

Stool microscopy (ova, cysts and parasites)

If no documented pre-departure albendazole or persisting eosinophilia despite albendazoleIntestinal parasites

Country-based (Box 3)

Schistosoma serology

Schistosomiasis

Malaria thick and thin films and rapid diagnostic test

Malaria

HCV Ab, and HCV RNA if HCV Ab positive

HCV, also test if risk factors, regardless of country of origin

HBcAb = hepatitis B core antibody. HBsAb = hepatitis B surface antibody. HBsAg = hepatitis B surface antigen. HCV = hepatitis C virus. HCV Ab = hepatitis C antibody. HIV = human immunodeficiency virus. IGRA = interferon-γ release assay. IME = immigration medical examination. LBTI = latent tuberculosis infection. PCR = polymerase chain reaction. TST = tuberculin skin test. * The panel did not reach consensus on these recommendations. See full guideline at http://www.asid.net.au/documents/item/1225 for details.

Box 3 –
Top 20 countries of origin for refugees and asylum seekers2,3,16 and country-specific recommendations for malaria, schistosomiasis and hepatitis C screening*

Country of birth

Malaria36

Schistosomiasis37

Hepatitis C^†38

Afghanistan

Bangladesh

Yes

Bhutan

Yes

Burma

Yes

China

Congo

Yes

Egypt

Yes

Eritrea

Yes

India

Yes

Iran

Iraq

Yes

Lebanon

Pakistan

Yes

Somalia

Yes

Sri Lanka

Yes

Stateless^‡

Yes

Sudan

Yes

Syria

Yes

Consider

Vietnam

* There are regional variations in the prevalence of these conditions within some countries. We have taken the conservative approach of recommending screening for all people from an endemic country rather than basing the recommendation on exact place of residence. Note that some refugees and asylum seekers may have been exposed during transit through countries not listed here. See full guideline for further details. † People with risk factors for hepatitis C should be tested regardless of country of origin. ‡ “Stateless” in this table refers to people of Rohingyan origin. Adapted from the ASID and RHeaNA Recommendations for comprehensive post-arrival health assessment for people from refugee-like backgrounds (2016; https://www.asid.net.au/documents/item/1225) with permission from ASID.

WHO targets depression

Data released by the World Health Organisation show more than 300 million people around the globe are now living with depression.

It is now the leading cause of ill-health and disability worldwide.

The latest calculations were revealed to mark World Health Day, April 7.

“These new figures are a wake-up call for all countries to re-think their approaches to mental health and to treat it with the urgency that it deserves,” WHO Director-General Margaret Chan said.

The number of people with depression has grown more than 18 per cent from 2005 to 2015.

WHO is now conducting a year-long campaign called Depression: let’s talk, with the aim of encouraging more people with depression to seek help. This is also the theme of the 2017 World Health Day.

“The continuing stigma associated with mental illness was the reason why we decided to name our campaign Depression: let’s talk,” said Shekhar Saxena, Director of the Department of Mental Health and Substance Abuse at WHO.

“For someone living with depression, talking to a person they trust is often the first step towards treatment and recovery.”

Chris Johnson

[Comment] Offline: The case against (and for) public health

When you walk into the atrium of WHO in Geneva, and if you look carefully, you will discover the head of Andrija Stampar. His face is strong, dignified, and wise. He commands your respect. His presence is rightly prominent. Stampar was the first President of the World Health Assembly in 1948. He dedicated the final decade of his life to WHO, and to what we now call global health. His contribution was inestimable. Through his work as a young district medical officer in Croatia, and then as director of public health for the new Kingdom of Yugoslavia, he showed how nations could build effective public health systems around a common vision for health and wellbeing.

[Comment] The global shortage of health workers—an opportunity to transform care

There is a worldwide shortage of health-care workers and the situation is worsening. WHO has forecast an 18 million shortfall by 2030, over twice the 7 million shortfall estimated in 2013.1 The alarm about insufficient staffing levels was raised a decade ago in the World Health Report 2006: Working Together for Health, which described the then global shortage as a “crisis”.2 The situation is even more critical today. What can be done?

Global women’s health issues: sex and gender matter

Empowering women improves both productivity and health outcomes

Although the terms “sex” and “gender” are commonly used as synonyms, they refer to two distinct concepts. Sex refers to the biological differences between men and women, whereas gender refers to socially defined roles, behaviours and expectations. Being clear about the distinction between the two terms is important, as the contribution to women’s health of sex and gender are likely to be different, and therefore also our solutions for reducing disparities. Sex differences are increasingly recognised as being important for conditions such as cardiovascular disease,1 for example, and while physiological differences in coronary vasculature can contribute to different presentations and manifestations of disease, gender influences health behaviours, risks, and access to health services.2 We argue that taking gender into account, as well as sex, is critical to improving health outcomes.

Gender inequality keeps women poor, makes them more vulnerable to violence as well as to illness, and limits their access to education, health care, and social justice.2 Globally, women and girls are more susceptible to poverty, violence and disability.3 Regardless of their country of residence, Indigenous women across the world experience greater health disparities, and Aboriginal and Torres Islander women are at greater risk of accidents, murder, and intimate partner violence than other Australian women.4 Women are disproportionally affected by conflict, and those who are refugees also experience substantial difficulties and challenges in gaining access to health services, and they consequently have poorer health outcomes.5,6 In recent decades, several health indicators for women have improved, including maternal and child mortality,7 but much remains to be done to reduce health disparities. Women and girls are increasingly susceptible to HIV and AIDS in many countries, and there is a clear association between exposure to violence and infection. In sub-Saharan Africa, women aged 15–24 years are more likely to be HIV-positive than any other age–sex group, and they carry the greatest burden of the disease.8

Disparities are also evident across a range of other health problems, including preventable conditions such as cervical and breast cancer. As the world makes the epidemiological shift in the burden of disease from communicable to non-communicable diseases, the burden of disease in women will also increase.9

The Sustainable Development Goals (SDGs) of the United Nations provide us with stretch targets for improved health and wellbeing, and also require that fundamental social, political and economic factors which contribute to inequity and health disparities be targeted.10 These 17 SDGs and 169 specific targets focus our attention on the critical issues affecting global health and the wellbeing of our planet. Increasing the participation of women in decision-making positions, particularly of women from minority groups, is an important strategy for achieving gender equality (SDG 5). Striving to achieve the aims of the other SDGs without recognising the importance of gender and sex differences will limit the likelihood of success.3

Meeting the targets of the SDGs will require approaching women’s health from a socio-cultural perspective in which gender is assessed as a factor, shifting the focus from discussing only sex-based differences in women’s health. Viewing women’s health from a life course approach, identifying the importance of cultural, contextual and structural perspectives, as well as recognising transitions such as birth, girlhood, adolescence and ageing as periods of vulnerability is important.2 The higher life expectancy of women is frequently associated with poverty, disability and isolation, which necessitate additional health and social services.11,12 Achieving the SDGs will require structural transformations in local communities across the globe, and also in national and international governance. Ensuring that women have access to education is integral to maximising their participation in society and, as a consequence, their health.

Gender inequalities are often regarded as being restricted to low and middle income countries, but disparities are pervasive in all economies, including that of Australia.13 Gender-related violence is widespread globally, and there are more similarities than differences between countries in this regard, motivating global collaborations in potential solutions, such as e-health initiatives, allowing access to confidential resources.14,15 Developing integrated and coordinated strategies is needed to improve women’s health. The Australian Longitudinal Study on Women’s Health, a nationally representative sample of more than 40 000 women in three age cohorts, is generating valuable information that can help guide interventions in women’s health across their lifespan, and not just in Australia, but across the globe.16 This study highlights not only sex-based problems in women’s health, but also important gender-related factors that affect women’s health, such as social circumstances and health-seeking behaviours. It will be a valuable resource for health planning in the future, and will identify important gender-related factors that should be considered by health care policy, practice, education and research.

In July 2010, the General Assembly of the United Nations established UN Women, the United Nations Entity for Gender Equality and the Empowerment of Women. UN Women has successfully focused on problems specific to individual countries and cross-jurisdictional activities, as well as on global activities. Eliminating violence against women, and promoting economic empowerment, leadership and participation across the globe are crucial to improving health and achieving the SDGs of the UN. These structural problems are difficult to overcome, and gender inequities are evident even in Australia.

Developing and evaluating interventions that take both sex and gender into consideration will be important for achieving both the SDGs and the mission of UN Women. Strong, healthy women contribute to a just, cohesive and civil society. As health professionals, it is important that we consider the need for tailored and targeted strategies that meet the needs of women and girls. Just as importantly, we need social, political and economic systems that value women and ensure their maximal participation at all levels of governance and government.

Maternal mortality trends in Australia

Maternal death is low and decreasing in Australia, but continuing surveillance is important

The death of a mother or a baby has significant short and long term impacts for the surviving family members and for the community and health workers who cared for them. The World Health Organization estimates that 303 000 women died in pregnancy and childbirth in 2015, with 99% of these deaths occurring in low income countries.1

In Australia, a series of reports regarding maternal deaths has been published over the past five decades; the first in the series covered the 1964–1966 triennium.2 These reports examine the deaths that occurred during pregnancy or within 42 days of the end of pregnancy. They are compilations of data sourced from multidisciplinary state maternal mortality review committees that undertake detailed reviews of each case.

The incidence of maternal death is expressed as a maternal mortality ratio (MMR). The MMR is the number of deaths due to complications of the pregnancy (direct deaths) or aggravation of existing disease processes by the pregnancy (indirect deaths) per 100 000 women giving birth. The calculation does not include deaths from unrelated causes that occur in pregnancy or the puerperium (incidental deaths) and deaths that occur more than 42 days after the end of a pregnancy.

The MMR in Australia is low; it has decreased from 41.2 in the 1964–1966 period to 7.1 in the years 2008–2012.3 The comparable figures are 14.7 for the period 2010–2012 in New Zealand4 and 9.0 for the period 2011–2013 in the United Kingdom.5

Until now, publications in the Maternal deaths in Australia series have been irregular. The Australian Institute of Health and Welfare (AIHW) established the National Maternity Data Development Project (NMDDP) in response to the recommendations in the 2008 Maternity Services Review from the Commonwealth and the subsequent 2010–2015 National Maternity Services Plan.6 A recent report regarding the progress of the NMDDP notes that sustainable data collection on national maternal mortality will be established to facilitate “consistent and regular national reporting” of maternal mortality in the future.6

The genesis of the almost sixfold reduction in maternal death rates in Australia is multifactorial, including the improved general health of the population and the availability of better health care options, such as the availability of antibiotics, blood transfusion, safer anaesthesia and effective diagnostic ultrasound. Advanced maternal age, maternal obesity and caesarean deliveries3,5 are all associated with an increase in the risk of maternal death, and any future growth in their incidence will threaten the efforts to further reduce the maternal mortality rate.

In the list of most common causes of death, infection, abortion and pre-eclampsia have been replaced by maternal cardiovascular disease and psychosocial health problems, while obstetric haemorrhage and thromboembolism remain prominent. The current method of classifying maternal deaths into direct, indirect and incidental deaths was first used in the report on the 1973–1975 triennium.7 Between that first 1973–1975 report and the most recent one for 2008–2012, 944 direct and indirect maternal deaths have been reported in Australia. Over that 48-year period, cardiovascular disease (MMR, 1.5), sepsis (MMR, 1.3) and obstetric haemorrhage (MMR, 1.1) have been the most prominent causes of death.

Aboriginal and Torres Strait Islander women are twice as likely to die in association with pregnancy and childbirth as other Australian women. In 2008–2012, the Aboriginal and Torres Strait Islander MMR was 13.8 compared with 6.6 for non-Indigenous Australian women who gave birth.3 The differential between the MMRs is decreasing and caution should be exercised in drawing conclusions due to the small numbers analysed. The leading causes of maternal deaths among Aboriginal and Torres Strait Islander women were cardiovascular conditions, sepsis and psychosocial conditions.

Women aged 35 years or over were more than twice as likely as their younger counterparts to die in association with pregnancy and childbirth, and those aged 40 years or more were over three times more likely to die in association with pregnancy and childbirth.3

Of the six most prominent causes of maternal death between 1973 and 2012, psychosocial death is the only group where the MMR is rising; the incidence of maternal death due to cardiovascular disease, obstetric haemorrhage, thromboembolism, hypertensive disorders and sepsis are all decreasing. Most of the deaths classified as psychosocial deaths are due to suicide, although some are related to fatal complications of substance misuse and homicide in domestic situations. While some of that apparent rise may be due to changes in the ascertainment of maternal deaths in general and to problems reporting both maternal suicide and deaths due to substance misuse in particular, it is clear that more needs to be done in this sphere. There is a growing belief that a significant portion of late maternal deaths are related to suicide; however, without a clear review of the cases by multidisciplinary committees, the relationship between pregnancy and suicide more than 42 days after the end of pregnancy remains speculative.

It is not clear whether the incidence of suicide in association with pregnancy is more or less common than in comparable non-pregnant women. This comparison is fraught, as the true denominator for pregnancy is not known due to lack of information regarding pregnancies lost as a result of miscarriage and termination. Given that caveat, the overall suicide rate in the 15- to 45-year-old Australian female population in 2006–2010 was 6.0 per 100 000 women,8 while the maternal mortality rate due to psychosocial issues in the same period was 0.9 per 100 000 women giving birth. A similar finding has recently been noted in the United States.9 Nevertheless, the apparently increasing incidence of psychosocial maternal death is a matter of concern, given that pregnant women are among the most medically supervised members of the population.

Screening during pregnancy for mental health, substance misuse and domestic violence problems is recommended,10 but it is not universally undertaken. All maternity care providers should commit to making these items a standard part of their care delivery. The follow-up of identified concerns by the relevant specialist services must be a priority and should continue for a significant period after the end of pregnancy. Similar screening attention is needed for women who had miscarriages and pregnancy terminations.

In many cases, an autopsy is necessary to understand the true cause of a maternal death. A number of causes of maternal death, such as amniotic fluid embolism and pulmonary thromboembolism, may be easily confused clinically. In the case of amniotic fluid embolism, for example, the diagnosis can only be confirmed by autopsy. The question of an autopsy should be pursued with the family by a senior clinician, and the presumption of a diagnosis that has been made in an intensive care unit or similar setting should not be an excuse to not request this critical form of investigation.

Maternal death is one of the few defined core sentinel events in health care; however, it is disturbing to find that a significant portion of these deaths have not been subjected to a root cause analysis or similar review. The application of a systematic review to identify gaps in hospital systems and health care processes, which are not immediately apparent and may have contributed to the occurrence of an event, should be applied to all maternal deaths, whether occurring in the public or private health systems.

The question of the presence or absence of contributory factors is now being actively pursued by some state and territory maternal mortality review committees, and similar questions are also being raised internationally. A consolidation of such information is yet to be published in an Australia-wide context. Experience with such review in New Zealand11 has shown that more than 50% of maternal deaths were associated with contributory factors, and 35% of the deaths were potentially avoidable.

The Victorian Consultative Council on Obstetric and Paediatric Mortality and Morbidity model12 appears to be of value, and examines two questions:

Were suboptimal care factors identified?
What was the relevance of any suboptimal care factors identified?

Suboptimal care factors may be classified as factors related to the woman, her family and social situation, factors related to access to care and factors related to professional care. Moreover, these factors may be classified as identified but unlikely to have contributed to the outcome (insignificant), identified and might have contributed to the outcome (possible), or identified and likely to have contributed to the outcome (significant).

It is critical to maintain a continuing intensive surveillance of maternal death — with particular reference to recognised risk factors — and to examine the contributory factors. Health departments must require that all direct and indirect maternal deaths are subjected to a systematic review. At present, data on late maternal deaths — occurring more than 42 days after the end of pregnancy — are not collected in all states and territories and are not reported nationally. Reviews of late maternal deaths and of severe maternal morbidity are future necessities, but the resources and methodologies are not yet available at a national level.

Science delivers another jab at anti-vaxxers

Image: AMA President Dr Michael Gannon (right) launches the Australian Academy of Science’s Science of Immunisation booklet with Health Minister Sussan Ley and Nobel Laureate Professor Peter Doherty at Parliament House on Monday.

The Federal Government’s No Jab No Pay vaccination policy is working to boost vaccination rates, but there is no room for complacency, AMA President Dr Michael Gannon has warned.

Speaking at the launch of the Australian Academy of Science’s The Science of Immunisation: Questions and Answers booklet alongside Health Minister Susan Ley and Nobel Laureate Professor Peter Doherty, Dr Gannon said vaccination had been one of the great success stories of modern medicine and public health, savings millions of lives every year.

Data from the Australian Childhood Immunisation Register showed that 93 per cent of children nationwide were fully immunised at 12 months, 90.7 per cent were fully vaccinated at two years, and 92.9 per cent were fully covered at five years.

But although child immunisations rates in most of the country were above 90 per cent, the AMA President said there was a need to lift them even higher, particularly in areas such as the Gold Coast, the north coast of New South Wales and parts of western Sydney, where they were as low as 86 per cent.

“One of the reasons for vaccine hesitancy or vaccine refusal is the proliferation of material that seeks to link vaccination with ill health,” Dr Gannon told the launch at Parliament House. “While thoroughly disproven, we still see people linking the MMR [measles, mumps, rubella] vaccine with autism. This is genuinely troubling. This claim has been thoroughly and comprehensively disproven.”

Ms Ley said often parents had not kept their child’s vaccination up-to-date simply because of competing demands on their time.

The Minister said the Government was not trying to force people to have their children vaccinated, but the No Jab No Pay policy meant there would be consequences in terms of reduced welfare payments and access to childcare, and was a prod to many to make their child’s immunisation a priority.

According to the Government, the new rules, which came into effect at the start of the year, have resulted in almost 6000 children previously denied vaccination on the grounds that their parents were conscientious objectors being fully immunised, while a further 148,000 whose vaccinations were not up-to-date have been immunised again.

Dr Gannon said the figures showed that the policy was working “extremely well. There are thousands of children whose parents had conscientiously objected [to vaccination] who no longer conscientiously object”.

But he warned the measure will do little to budge “rusted on” objectors, and might have “minimal impact on families in wealthier parts of Australia,” some of which had low immunisation rates.

Objections to vaccination are typically based on claims about safety, including widely and repeatedly discredited allegations that immunisation is associated with autism.

The latest outbreak of anti-vaccination sentiment accompanied plans by the Castlemaine Local and International Film Festival to screen a show claiming that US health authorities have covered up evidence linking a vaccine to autism.

The festival eventually withdrew the film following widespread community outcry, including from Dr Gannon, who said the director of the show was a “charlatan” and “entirely discredited”.

Dr Gannon said vaccines are subject to rigorous safety assessments and surveillance, and are carefully scrutinised before being added to the immunisation schedule.

Though a small number of children suffer mild and temporary side effects from vaccination, serious problems are very rare.

By comparison, the World Health Organisation estimates that vaccinations saves between two and three billion lives each year.

More than 70,000 copies of the original AAS booklet have been distributed since its launch in 2012, and Dr Gannon said the latest version would be an important aid for doctors and parents in helping counter the dangerous misinformation being circulated by opponents of immunisation.

No Jab, No Pay — no planning for migrant children

Migration should be considered by immunisation policy

The Social Services Legislation Amendment (No Jab, No Pay) Act 2015 (Cwlth) was passed in November 2015, closing the conscientious objection exemption to immunisation requirements for family assistance payments. The intention was to reinforce the importance of immunisation and protect public health, especially for children.1,2 While these aims are sound, there are far-reaching, presumably unintended, consequences for migrant and refugee children.

The legislative changes (which took effect in January 2016) require children and young people under 20 years of age to be up to date for their early childhood immunisations in order to qualify for the Child Care Benefit, Child Care Rebate and Family Tax Benefit Part A supplement (Box).3 These Centrelink payments are available for Australian citizens and people holding a permanent visa (including offshore humanitarian entrants), special category visa or certain temporary visas (including temporary protection visas). Immunisation status is assessed through the Australian Childhood Immunisation Register (ACIR), which is linked to Medicare.

Medical contraindications (including immunosuppression and anaphylaxis) and natural immunity are still grounds for vaccination exemption. However, the legislation now specifies that only general practitioners can certify exemptions, with the expectation that specialists will refer back to GPs.2 The legislation is paired with a number of supporting measures, including funded catch-up immunisations (time-limited for people aged 10–19 years), expansion of the ACIR to include all people under 20 years of age,4 and provider incentive payments for catch-up vaccination in children aged less than 7 years.5

There are multiple issues arising for refugee and migrant children. First, any child arriving and receiving catch-up vaccination in Australia after the age of 7 years who is eligible for these Centrelink payments will lose them until their ACIR record is updated, even if he or she is fully immunised. Before 1 January 2016, the upper age limit for data entry into the ACIR was 7 years — overseas and catch-up vaccinations could not be recorded on the register for older children. Australia’s Humanitarian Programme intake has been 13 750 people annually, with around 50% aged less than 18 years on arrival.6 Therefore, up to 35 000 refugee children and young people (those who have arrived at the age of 7 years or older and are currently under 20 years of age) will need their vaccination status assessed and ACIR records entered. This number will increase when other migrant children meeting the residency requirements for Centrelink payments are included.

The workforce challenges regarding the No Jab, No Pay measures are substantial. Immunisation providers across Victoria report that refugee families have received (multiple) letters from Centrelink. This has resulted in large numbers of people presenting to services, and an increased demand for providers to clarify previous vaccination history, notify the ACIR of these details, and provide catch-up vaccines where needed. Providers report being inundated, under-prepared and inadequately resourced to meet demand.

Establishing prior vaccination is difficult, time consuming, and may not be possible. Refugee-background families tend to be mobile in the early years of settlement, and often see multiple providers for health care, which may (or may not) include immunisation. Children may receive vaccinations in different parts of the health system — from GPs, from specialists, at school, and, particularly in Victoria, through local government areas (LGAs).7 However, comprehensive records are rare, and information about past vaccinations is often unavailable.

Reporting to the ACIR is time consuming, and there is variation in how information is handled. Providers estimate it takes 20 minutes to enter a full vaccine history into the ACIR online, and longer if overseas vaccinations are recorded. They report delays between submission and registration of data on the ACIR. While on-site vaccines are usually registered within 24 hours, prior vaccines (administered in Australia or overseas) take 1–3 weeks, and individual errors can result in batches of ACIR entries being rejected, affecting ACIR registration for multiple individuals. Many services are now faxing records to the ACIR due to inadequate capacity to enter information directly; these are taking up to 8 weeks to register and delays appear to be increasing. Providers report discrepancies between Centrelink and the ACIR, and cases where families have been sent Centrelink letters, despite children being registered as fully immunised on the ACIR. Paediatricians are the key workforce in childhood immunisation; however, unlike, GPs, they are not automatically registered with the ACIR and the process to obtain or activate specialist ACIR registration is complicated. While specialists may have prescribed catch-up vaccines, they are usually not able to enter this information onto the ACIR, which reduces the opportunity to disseminate the workload and enhance ACIR recording.

Catch-up immunisation generally requires three visits over at least 4 months (four visits over 10 months for children aged 4–9 years), with several vaccines on each visit. Calculating catch-up schedules for migrant children is complex and far more difficult than providing a missed schedule point for an Australian-born child. Primary Health Networks and LGAs report that many GPs feel poorly equipped to deal with this complexity and the time requirements and, in Victoria, are deferring this work to LGAs.

The increase in workload is not reflected in funding arrangements, and the new provider catch-up incentive payments are not structured to support best practice immunisation. Catch-up incentive payments ($6 additional to ACIR notification payments) are only available for children aged less than 7 years, and for vaccines given after 1 January 2016 that are more than 2 months overdue. Thus, if an immunisation provider gives the first doses of a catch-up schedule and recalls the child 1 month later (the minimum interval and best practice), the second vaccinations will not trigger a catch-up incentive payment, as they are not considered to be overdue in relation to the first. Further, the national due and overdue rules in relation to hepatitis B8 are not consistent with the minimum catch-up dosing intervals recommended by the Australian immunisation handbook.9 Hepatitis B vaccination at 0, 1 and 4 months (minimum intervals) will register the child as overdue at the time of the final dose (3 months from previous dose), risking loss of Centrelink payments.

Finally, there is complexity concerning medical contraindications and natural immunity, in that the new legislation specifies that only GPs can provide this information. Many refugee children do not require hepatitis B (or other) vaccines, on the basis of natural immunity from infection or immunity from (undocumented) overseas vaccination. Hepatitis B serology is part of the routine post-arrival refugee health assessment, detecting both infection and immunity. Available Australian data suggest that around 30% of East African and 50% of Karen refugee children have immunity to hepatitis B,10,11 and 2–5% of African children are infected with hepatitis B.12 Many children have thus completed catch-up vaccination without needing hepatitis B (or other) vaccines, but will not be regarded as up to date on the ACIR. They will need a medical exemption form completed by a GP; however, many families have changed GPs in the years after settlement and/or were initially managed and immunised at specialist or nurse-led clinics. GPs will likely be asked to enter historical information on behalf of other providers (which will be almost impossible to verify) and there may be considerable reluctance to do so.

These issues are likely to create duplications within the health system in:

appointments — where children had specialist refugee health screening, it is feasible that an LGA may refer children to GPs who may refer them to specialists to clarify immunisation history and serology, who will then refer children back to the GPs for the medical exemption form, who in turn refer them back to the LGA for vaccine delivery;
serology — where there is no documentation, GPs and specialists (and families) may choose repeat hepatitis B serology instead of undertaking three immunisation visits; or
vaccines — where vaccination history or natural immunity cannot be established.

All these options incur additional costs and represent inefficiencies in the health system.

While the No Jab, No Pay policy offers an opportunity to improve immunisation coverage rates, the legislation will exclude thousands of Australia’s most disadvantaged families from Centrelink payments as a result of system issues rather than any form of conscientious objection. Clinical experience suggests that refugee background families are extremely pro-immunisation, which is consistent with the large numbers presenting to clarify their children’s immunisation status and access catch-up vaccinations. Unfortunately, the legislative and policy changes presume continuity of care, administration of early childhood vaccines during early childhood, prior use of the ACIR, and centralised immunisation delivery, which is not the reality for migrant families.

There are several strategies that could reduce the impact of the No Jab, No Pay measures on migrant children. There is a strong argument to apply the legislation prospectively (to children born 2009 onwards) or to extend the period before Centrelink payments are affected, allowing adequate lead time for entering data into the ACIR and obtain catch-up vaccination if needed. Due and overdue rules and catch-up incentive payments should be structured to support best practice, including removal of the payment age limit. Funding for catch-up vaccinations in those aged 10 years and older should be ongoing, and better resources to support providers, including a whole-of-life calculator and information on refugee immunisation, would increase efficiency and remove barriers to service delivery. Extending the ACIR across the lifespan offers an opportunity to address usability issues and capture relevant demography to monitor immunisation in this group. Finally, authority to document medical exemptions, specialist ACIR registration and workforce pressures require urgent attention. Fundamentally, good policy development should recognise that migration is part of the fabric of Australia, and it is not clear this has been adequately considered in the implementation of No Jab, No Pay.

Box –
Family assistance payments affected by the No Jab, No Pay measures

Family Tax Benefit Part A (FTB-A) is a two-part payment supporting disadvantaged families with dependent children or secondary students younger than 20 years of age, consisting of an adjusted base rate and a supplement of up to $726.35 per child at the end of the financial year. The maximum adjusted taxable income limits for FTB-A are over $100 000, and it is likely most refugee background families will be eligible for this payment.
The Child Care Benefit supports costs of registered/approved childcare and outside-school-hour care, with current rates of $4.17 per hour or $208.50 per week (85% for school-aged children), which is income-tested and adjusted for family size, service type and hours attended.
The Child Care Rebate (non-income-tested) covers 50% of out-of-pocket expenses for childcare to an annual limit for each child, in addition to other childcare assistance.
Together, these benefits are a substantial support for families with children. For further information, go to https://www.humanservices.gov.au/customer/subjects/payments-families.