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Vaccine preventable diseases in indigenous populations—International perspectives
Vaccine 25 (2007) 7281–7284
Conference report
Vaccine preventable diseases in indigenous populations—International perspectives Satellite Symposium of the 5th International Symposium on Pneumococci and Pneumococcal Diseases, April 2006, Alice Springs, Australia Keywords: American native continental ancestry group; Immunization; Oceanic ancestry group; Vaccine preventable diseases
1. Background Pneumococcal disease has disproportionately affected indigenous people in several developed countries, and vaccines have had a significant impact on reducing the disparity in disease burden between indigenous and non-indigenous people in recent years. Accordingly, the 5th International Symposium on Pneumococci and Pneumococcal Diseases (ISPPD5), held in Alice Springs in April 2006, provided an opportunity for researchers and other health professionals working in the area of indigenous health and vaccination in various countries, to meet, exchange information and increase collaboration. A 1-day satellite symposium was organised for this purpose by the National Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases in Australia and the Centre for American Indian Health (CAIH) at Johns Hopkins University in the United States. This was the first meeting of its kind and included presentations from Australia, Canada, New Zealand and the United States. These four countries were selected for their common characteristics of having indigenous populations which experienced colonisation by a European country, dispossession, and currently poorer socioeconomic and health status compared to their respective non-indigenous populations. This paper summarises information presented at the meeting.
2. Patterns of ill health, vaccine-preventable disease and health programs In the past, indigenous people in each of these countries experienced devastation by introduced diseases, many of which were or are now vaccine preventable. While there have been considerable improvements in health status, indigenous people in all four countries still experience lower life expectancy and generally poorer health compared to 0264-410X/$ – see front matter doi:10.1016/j.vaccine.2007.08.006
non-indigenous people [1–4]. In the recent past vaccination has eliminated or vastly reduced vaccine preventable diseases, and the large disparities between indigenous and non-indigenous people in the burdens of diseases such as hepatitis A [5] and B [6], Haemophilus influenzae type b (Hib) [7], and invasive pneumococcal disease (IPD) [8]. While some challenges in vaccine preventable diseases continue, the major sources of health inequity are now chronic disease, injury and excessive drug and alcohol use [1–4]. There was broad agreement on the important role of social determinants, such as remote residence, the quality of housing, access to clean water, education, employment, and access to health care in this continuing health inequity. Health expenditure on indigenous people, although in general slightly higher per capita than for non-indigenous people, was not commensurate with their much greater need. Each country has some form of health service dedicated to indigenous people—Aboriginal Community Controlled Health Services in Australia [9], M¯aori Health Providers in New Zealand [10], the Indian Health Service in the United States [11] and First Nations and Inuit Health Branch in Canada [12]. Health services in all countries emphasise culturally appropriate services, community control or involvement, and holistic care. These services have contributed to improvements in health status and the social determinants of health in recent decades. Data were presented from the Indian Health Service showing the impact of their housing and sanitation programs on improved living conditions and rates of related diseases. This underlined the importance of health services being able to provide good quality data to demonstrate their effectiveness. Tribal Epidemiology Centers have been established to facilitate this. More recently, integrated information technology systems are being used to enhance patient follow-up and clinical management. In Canada there is no indigenous identifier in most data collections, and the highly devolved health care delivery sys-
7282
Conference report / Vaccine 25 (2007) 7281–7284
tem complicates the collection of data on Aboriginal peoples. However, the value of accurately collecting these data was demonstrated by a study in Alberta. Data on ethnicity were collected by the Alberta component of the national Immunization Monitoring Program Active (IMPACT) program. The demonstrated higher rates of IPD in Aboriginal children resulted in a catch-up program being funded for Aboriginal children up to 60 months of age when the conjugate vaccine was first introduced. Invasive disease due to Hib is one current example of common issues in different indigenous populations. Before the introduction of a conjugate vaccine in the early 1990s the highest recorded rates in the world were in indigenous children in North America and Australia. The disease was found at a younger age and meningitis was the predominant manifestation in indigenous children, in contrast to an older average age of infection and more common epiglottitis in nonindigenous children. Vaccination has been very successful in decreasing disease rates in all four countries, but they have remained higher in indigenous children in parts of Australia and arctic North America [7,8]. This provides a potential area of collaboration to study the reasons and possible solutions.
3. Research and community participation Community suspicion or mistrust of research due to bad experiences in the past was a theme common to indigenous people in all four countries. Sometimes termed “Helicopter Research”, it involved researchers coming to communities for brief periods to carry out research of value to the researchers, without really informing the communities on whom the research was being conducted. Sacred objects were sometimes removed, photos or biological samples taken contrary to the desires of the community, then the researchers left, never to return. There was no benefit to the communities and the information gathered was often used to portray them negatively. All four countries now pursue models that involve community participation in setting research priorities and involvement in conducting the research, building the capacity of indigenous researchers to conduct research and non-indigenous researchers to work collaboratively, and building partnerships between indigenous communities and research organisations. The desired outcome is research that is of relevance to indigenous communities and provides some benefits to them. 3.1. Australia The Cooperative Research Centre (CRC) model was established by the Australian Government to foster research between organisations working in related areas. The CRC for Aboriginal Health [13] follows a “Facilitated Development” approach rather than competitive research funding. This involves (predominantly indigenous) stakeholder organ-
isations identifying key research areas, which are then prioritised by the majority indigenous CRC board. Partner organisations then develop the research methodology. 3.2. New Zealand “M¯aori Responsiveness” must be addressed in all applications for research to institutional ethics committees, for District Health Board approval of research in health services and for research grant funding. The principle of “equal explanatory power”, where research is designed to provide rigorous, detailed information for M¯aori in addition to the non-M¯aori and/or “total” populations, is also beginning to be applied. 3.3. Canada The “Ownership, Control, Access, Possession” principles of Aboriginal research are increasingly applied. The Canadian Institutes for Health Research fund research into Aboriginal health, but so far not for studies on vaccine preventable diseases or vaccination in Aboriginal people. Several factors may contribute to this, including the predominance of small remote communities making coordinated research difficult, low prevalence of vaccine preventable diseases requiring large numbers of participants in studies, and other health issues being regarded as in more urgent need of research. 3.4. United States The Federal Department of Health and Human Services funds the Native American Research Centers for Health program. This provides funding for partnerships between tribes or related organisations and research organisations, to train American Indian and Alaskan Native (AI/AN) researchers, increase capacity for collaboration and create competition in research relevant to AI/AN peoples. This program requires community control of data collected through these research projects. A Tribal Leaders Advisory Council has also been established to advise on research funded by the Federal Government. There was some discussion around the logistical difficulties of increased requirements for community consultation and community control of research and data. In general, however, it was felt that while these require more time and resources to establish, this is outweighed by the benefits of improved relationships with communities, community participation and value of the research. Community ownership of data may be seen as a possible obstacle to obtaining research funding, but if clarified at the early stages of preparation for a project, is not necessarily a barrier.
4. Success stories in research related to vaccination Several vaccination-related research projects were described that were carried out using these principles
Conference report / Vaccine 25 (2007) 7281–7284
and which provided information that was very beneficial to the indigenous communities that participated in the research. 4.1. Australia The “PneuMum” project [14] carried out by the Menzies School of Health Research and the Centre for International Child Health at the University of Melbourne is a maternal vaccine trial aimed at preventing otitis media in Indigenous infants in the Northern Territory. Other interventions such as pneumococcal conjugate vaccination (PCV) have had little impact on the very high rates of otitis media, in part due to colonization and infection occurring within days of birth, well before the first dose of PCV is due at 2 months of age, and the wide range of pneumococcal serotypes causing ear disease. This trial will compare maternal vaccination with the 23vPPV, given antepartum or immediately postpartum, with control participants given adult diphtheria, tetanus and acellular pertussis vaccine at delivery. Primary outcomes include nasopharyngeal carriage and the prevalence of middle ear disease among indigenous infants at 7 months of age. Additional outcomes include antibody transmission (cord blood and breast milk) and infant response to PCV. The trial is being conducted in urban Darwin and the Tiwi Islands, and commenced following an extensive community consultation period, and a community forum, which resulted in the establishment of an Indigenous Reference Group (IRG). The IRG is considered central to the success of this trial, with the fundamental task of protecting cultural values of communities and participants, and providing an Indigenous managed forum for community and participant concerns to be raised. A partnering agreement has been established between the Queensland Institute for Medical Research (QIMR) in Brisbane and the WuChopperen Aboriginal Health Service in Cairns. This has resulted in the research expertise of QIMR being applied to the health priorities identified by the Aboriginal Medical Service. Skin disease and rheumatic fever were identified as priorities for research. A prevalence study of skin pathogens in WuChopperen clients has described the predominant skin pathogens for the first time. Samples from this study may be used to inform the development of a Group A Streptococcal vaccine for the prevention of rheumatic fever. 4.2. New Zealand The 15-year epidemic of meningococcal B disease in New Zealand has predominantly affected M¯aori and Pacific Islander children. An outer membrane vesicle vaccine specific for this epidemic clone was developed through a collaboration between Chiron Vaccines and the National Institute of Public Health in Norway [15]. Given the disproportionately large number of cases in M¯aori and Pacific Islander (M/PI) children and examples of lower effective-
7283
ness of some other vaccines in some high-risk groups, it was important that any efficacy estimate reflect that of M/PI children as well as those of European origin. The efficacy trial aimed for population-based equitable access enrolment. This included establishing a Community Advisory Board to represent all sectors of the community. The most effective tools for recruiting participants were local radio advertisements, promotion by staff at maternity services and targeted mailings. As a result, the study sample was representative of the ethnic and socioeconomic mix of New Zealand society. The trial found the vaccine produced adequate immune responses in the total population but was not able to estimate immune response in the subpopulations. Population vaccination commenced in 2004 and notified cases have decreased each subsequent year. 4.3. United States Higher rates of rotavirus disease and different serotype distributions are experienced by AI/AN compared to nonindigenous children in the US. Previous rotavirus vaccines, and some other vaccines, have been less effective in AI/AN children. It was, therefore, important to include AI/AN children in a recent international trial of a new rotavirus vaccine. The CAIH has built a relationship with Navajo and White Mountain Apache communities over decades and carried out many successful studies [16]. An important component of this relationship is the use of field workers on the research team who discuss in native language the reasons for doing the study, the need for new effective vaccines in their community, the long term commitment of the CAIH and their previous record in research in these communities. As a result this trial was conducted in Navajo and White Mountain Apache children and the vaccine found to be safe and effective in this population [17].
5. Options for continuing collaboration Two options were discussed for promoting the potential for collaboration and learning from each other’s experiences initiated by this meeting. • An indigenous reference group. The possibility of an international indigenous reference group to review and provide comment about the need and most appropriate mechanisms for research in vaccine preventable diseases was raised. There are several issues still to be clarified, such as the nature of indigenous representation, and how it would connect with other work on indigenous health, considering the holistic attitude to health in many indigenous cultures. • An international working group or interest group. Such a group could meet periodically by e-mail, telephone or in person to discuss issues of common interest and possible multi-centre projects. International Circumpolar Surveillance is one possible model for this—a collabo-
7284
Conference report / Vaccine 25 (2007) 7281–7284
ration of several countries with indigenous populations living in polar regions. They carry out enhanced surveillance of diseases of interest, including IPD and Hib disease. An e-mail interest group may be an initial step towards improving communication, with a view to another satellite meeting at ISPPD6 in 2008 in Iceland. References [1] Australian Bureau of Statistics, Australian Institute of Health and Welfare. The Health and Welfare of Australia’s Aboriginal and Torres Strait Islander peoples, 2005. Report number 4704.0. Canberra: Australian Capital Territory; 2005. [2] First Nations and Inuit Health Branch. A statistical profile on the health of first nations in Canada. Ottawa, Ontario: Health Canada; 2003, http://www.hc-sc.gc.ca/fnih-spni/pubs/gen/stats profil e.html. [3] New Zealand Ministry of Health. Our Health, Our Future – Hauora Pakari, Koiora Roa – The Health of New Zealanders 1999. Wellington, NZ: New Zealand Ministry of Health; 1999 http://www.moh.govt.nz/ moh.nsf/49ba80c00757b8804c256673001d47d0/ 6910156be95e706e4c2568800002e403?OpenDocument. [4] Palagiano C, Shalala DE, Trujillo MH, Hartz GJ, Paisano EL. Trends in Indian health, 1998–99. Indian Health Service, US Department of Health and Human Services; 1999. [5] Bialek SR, Thoroughman DA, Hu D, Simard EP, Chattin J, Cheek J, et al. Hepatitis A incidence and hepatitis A vaccination among American Indians and Alaska Natives, 1990–2001. Am J Public Health 2004;94:996–1001. [6] Patrick DM, Bigham M, Ng H, White R, Tweed A, Skowronski DM. Elimination of acute hepatitis B among adolescents after one decade of an immunization program targeting Grade 6 students. Pediatr Infect Dis J 2003;22:874–7. [7] Singleton R, Hammit L, Hennessey T, Bulkow L, DeByle C, Parkinson A, et al. The Alaska Haemophilus influenzae type b experience: lessons in controlling a vaccine-preventable disease. Pediatrics 2006;118:e421–9. [8] Menzies R, McIntyre P, Beard F. Vaccine preventable diseases and vaccination coverage in Aboriginal and Torres Strait Islander people, Australia, 1999 to 2002. Commun Dis Int 2004;28(S1). [9] The National Aboriginal Community Controlled Health Organisation. http://www.naccho.org.au/ [accessed 8 February 2007]. [10] New Zealand Ministry of Health. Maori Health Directorate web site. http://www.maorihealth.govt.nz/2004/index.php [accessed 6 January 2006]. [11] US Department of Health and Human Services. Indian Health Service. http://www.ihs.gov/ [accessed 8 February 2007]. [12] Health Canada. First Nations and Inuit Health Branch. http://www.hcsc.gc.ca/ahc-asc/branch-dirgen/fnihb-dgspni/index e.html [accessed 8 February 2007]. [13] Cooperative Research Centre for Aboriginal Health. http://www.crcah. org.au/ [accessed 8 February 2007]. [14] Dunbar M, Moberley S, Nelson S, Leach A, Andrews R. Clear not simple: an approach to community consultation for a maternal pneumococcal vaccine trial among Indigenous women in the Northern Territory of Australia. Vaccine 2007;25:2385–8. [15] O’Hallahan J, Lennon D, Oster P. The strategy to control New Zealand’s epidemic of group B meningococcal disease. Pediatr Infect Dis J 2004;23:S293–8. [16] O’Brien KL, Shaw J, Weatherholtz R, Reid R, Watt J, Croll J, et al. Epidemiology of invasive Streptococcus pneumoniae among Navajo children in the era before use of conjugate pneumococcal vaccines, 1989–1996. Am J Epidemiol 2004;160:270–8. [17] Vesikari T, Matson DO, Dennehy P, Van Damme P, Santosham M, Rodiguez Z, et al. Safety and efficacy of a pentavalent human-bovine (WC3) reassortant rotavirus vaccine. N Engl J Med 2006;354:23–33.
Rob Menzies ∗ Peter McIntyre National Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases, The Children’s Hospital at Westmead, Locked Bag 4001, Westmead, New South Wales 2145, Australia Ray Reid Katherine O’Brien Mathu Santosham James Watt Johns Hopkins Centre for American Indian Health, School of Hygiene and Public Health, Johns Hopkins University, 624 North Broadway, Baltimore 21205, MD, USA Geoffrey Angeles Alex Brown Melissa Dunbar Amanda Leach Menzies School of Health Research, P.O. Box 41096, Casuarina, Northern Territory 0811, Australia Sue Crengle Diana Lennon Henare Mason University of Auckland, Private Bag 92019, Auckland Mail Centre, Auckland 1142, New Zealand Charles Grim Leo Nolan Phil Smith Indian Health Service, 801 Thompson Avenue Suite 440, Rockville, MD 20852, USA Gina Dumaresq Ruth Richardson First Nations and Inuit Health Branch, Public Health Agency of Canada, 130 Colonnade Road, A.L. 6501H, Ottawa, Ontario K1A 0K9, Canada Sarah Moberley Department of Paedatrics, The University of Melbourne, Victoria 3010, Australia Janelle Stirling Queensland Institute of Medical Research, PO Royal Brisbane Hospital, Queensland 4029, Australia Mick Gooda Cooperative Research Centre for Aboriginal Health, P.O. Box 41096, Casuarina, Northern Territory 0811, Australia Michael Green Queen’s University, 99 University Avenue, Kingston, Ontario K7L 3N6, Canada ∗ Corresponding
author. Tel.: +61 2 9845 1423; fax: +61 2 9845 1418. E-mail address: [email protected] (R. Menzies) 18 April 2007 Available online 27 August 2007
Conference report
Vaccine preventable diseases in indigenous populations—International perspectives Satellite Symposium of the 5th International Symposium on Pneumococci and Pneumococcal Diseases, April 2006, Alice Springs, Australia Keywords: American native continental ancestry group; Immunization; Oceanic ancestry group; Vaccine preventable diseases
1. Background Pneumococcal disease has disproportionately affected indigenous people in several developed countries, and vaccines have had a significant impact on reducing the disparity in disease burden between indigenous and non-indigenous people in recent years. Accordingly, the 5th International Symposium on Pneumococci and Pneumococcal Diseases (ISPPD5), held in Alice Springs in April 2006, provided an opportunity for researchers and other health professionals working in the area of indigenous health and vaccination in various countries, to meet, exchange information and increase collaboration. A 1-day satellite symposium was organised for this purpose by the National Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases in Australia and the Centre for American Indian Health (CAIH) at Johns Hopkins University in the United States. This was the first meeting of its kind and included presentations from Australia, Canada, New Zealand and the United States. These four countries were selected for their common characteristics of having indigenous populations which experienced colonisation by a European country, dispossession, and currently poorer socioeconomic and health status compared to their respective non-indigenous populations. This paper summarises information presented at the meeting.
2. Patterns of ill health, vaccine-preventable disease and health programs In the past, indigenous people in each of these countries experienced devastation by introduced diseases, many of which were or are now vaccine preventable. While there have been considerable improvements in health status, indigenous people in all four countries still experience lower life expectancy and generally poorer health compared to 0264-410X/$ – see front matter doi:10.1016/j.vaccine.2007.08.006
non-indigenous people [1–4]. In the recent past vaccination has eliminated or vastly reduced vaccine preventable diseases, and the large disparities between indigenous and non-indigenous people in the burdens of diseases such as hepatitis A [5] and B [6], Haemophilus influenzae type b (Hib) [7], and invasive pneumococcal disease (IPD) [8]. While some challenges in vaccine preventable diseases continue, the major sources of health inequity are now chronic disease, injury and excessive drug and alcohol use [1–4]. There was broad agreement on the important role of social determinants, such as remote residence, the quality of housing, access to clean water, education, employment, and access to health care in this continuing health inequity. Health expenditure on indigenous people, although in general slightly higher per capita than for non-indigenous people, was not commensurate with their much greater need. Each country has some form of health service dedicated to indigenous people—Aboriginal Community Controlled Health Services in Australia [9], M¯aori Health Providers in New Zealand [10], the Indian Health Service in the United States [11] and First Nations and Inuit Health Branch in Canada [12]. Health services in all countries emphasise culturally appropriate services, community control or involvement, and holistic care. These services have contributed to improvements in health status and the social determinants of health in recent decades. Data were presented from the Indian Health Service showing the impact of their housing and sanitation programs on improved living conditions and rates of related diseases. This underlined the importance of health services being able to provide good quality data to demonstrate their effectiveness. Tribal Epidemiology Centers have been established to facilitate this. More recently, integrated information technology systems are being used to enhance patient follow-up and clinical management. In Canada there is no indigenous identifier in most data collections, and the highly devolved health care delivery sys-
7282
Conference report / Vaccine 25 (2007) 7281–7284
tem complicates the collection of data on Aboriginal peoples. However, the value of accurately collecting these data was demonstrated by a study in Alberta. Data on ethnicity were collected by the Alberta component of the national Immunization Monitoring Program Active (IMPACT) program. The demonstrated higher rates of IPD in Aboriginal children resulted in a catch-up program being funded for Aboriginal children up to 60 months of age when the conjugate vaccine was first introduced. Invasive disease due to Hib is one current example of common issues in different indigenous populations. Before the introduction of a conjugate vaccine in the early 1990s the highest recorded rates in the world were in indigenous children in North America and Australia. The disease was found at a younger age and meningitis was the predominant manifestation in indigenous children, in contrast to an older average age of infection and more common epiglottitis in nonindigenous children. Vaccination has been very successful in decreasing disease rates in all four countries, but they have remained higher in indigenous children in parts of Australia and arctic North America [7,8]. This provides a potential area of collaboration to study the reasons and possible solutions.
3. Research and community participation Community suspicion or mistrust of research due to bad experiences in the past was a theme common to indigenous people in all four countries. Sometimes termed “Helicopter Research”, it involved researchers coming to communities for brief periods to carry out research of value to the researchers, without really informing the communities on whom the research was being conducted. Sacred objects were sometimes removed, photos or biological samples taken contrary to the desires of the community, then the researchers left, never to return. There was no benefit to the communities and the information gathered was often used to portray them negatively. All four countries now pursue models that involve community participation in setting research priorities and involvement in conducting the research, building the capacity of indigenous researchers to conduct research and non-indigenous researchers to work collaboratively, and building partnerships between indigenous communities and research organisations. The desired outcome is research that is of relevance to indigenous communities and provides some benefits to them. 3.1. Australia The Cooperative Research Centre (CRC) model was established by the Australian Government to foster research between organisations working in related areas. The CRC for Aboriginal Health [13] follows a “Facilitated Development” approach rather than competitive research funding. This involves (predominantly indigenous) stakeholder organ-
isations identifying key research areas, which are then prioritised by the majority indigenous CRC board. Partner organisations then develop the research methodology. 3.2. New Zealand “M¯aori Responsiveness” must be addressed in all applications for research to institutional ethics committees, for District Health Board approval of research in health services and for research grant funding. The principle of “equal explanatory power”, where research is designed to provide rigorous, detailed information for M¯aori in addition to the non-M¯aori and/or “total” populations, is also beginning to be applied. 3.3. Canada The “Ownership, Control, Access, Possession” principles of Aboriginal research are increasingly applied. The Canadian Institutes for Health Research fund research into Aboriginal health, but so far not for studies on vaccine preventable diseases or vaccination in Aboriginal people. Several factors may contribute to this, including the predominance of small remote communities making coordinated research difficult, low prevalence of vaccine preventable diseases requiring large numbers of participants in studies, and other health issues being regarded as in more urgent need of research. 3.4. United States The Federal Department of Health and Human Services funds the Native American Research Centers for Health program. This provides funding for partnerships between tribes or related organisations and research organisations, to train American Indian and Alaskan Native (AI/AN) researchers, increase capacity for collaboration and create competition in research relevant to AI/AN peoples. This program requires community control of data collected through these research projects. A Tribal Leaders Advisory Council has also been established to advise on research funded by the Federal Government. There was some discussion around the logistical difficulties of increased requirements for community consultation and community control of research and data. In general, however, it was felt that while these require more time and resources to establish, this is outweighed by the benefits of improved relationships with communities, community participation and value of the research. Community ownership of data may be seen as a possible obstacle to obtaining research funding, but if clarified at the early stages of preparation for a project, is not necessarily a barrier.
4. Success stories in research related to vaccination Several vaccination-related research projects were described that were carried out using these principles
Conference report / Vaccine 25 (2007) 7281–7284
and which provided information that was very beneficial to the indigenous communities that participated in the research. 4.1. Australia The “PneuMum” project [14] carried out by the Menzies School of Health Research and the Centre for International Child Health at the University of Melbourne is a maternal vaccine trial aimed at preventing otitis media in Indigenous infants in the Northern Territory. Other interventions such as pneumococcal conjugate vaccination (PCV) have had little impact on the very high rates of otitis media, in part due to colonization and infection occurring within days of birth, well before the first dose of PCV is due at 2 months of age, and the wide range of pneumococcal serotypes causing ear disease. This trial will compare maternal vaccination with the 23vPPV, given antepartum or immediately postpartum, with control participants given adult diphtheria, tetanus and acellular pertussis vaccine at delivery. Primary outcomes include nasopharyngeal carriage and the prevalence of middle ear disease among indigenous infants at 7 months of age. Additional outcomes include antibody transmission (cord blood and breast milk) and infant response to PCV. The trial is being conducted in urban Darwin and the Tiwi Islands, and commenced following an extensive community consultation period, and a community forum, which resulted in the establishment of an Indigenous Reference Group (IRG). The IRG is considered central to the success of this trial, with the fundamental task of protecting cultural values of communities and participants, and providing an Indigenous managed forum for community and participant concerns to be raised. A partnering agreement has been established between the Queensland Institute for Medical Research (QIMR) in Brisbane and the WuChopperen Aboriginal Health Service in Cairns. This has resulted in the research expertise of QIMR being applied to the health priorities identified by the Aboriginal Medical Service. Skin disease and rheumatic fever were identified as priorities for research. A prevalence study of skin pathogens in WuChopperen clients has described the predominant skin pathogens for the first time. Samples from this study may be used to inform the development of a Group A Streptococcal vaccine for the prevention of rheumatic fever. 4.2. New Zealand The 15-year epidemic of meningococcal B disease in New Zealand has predominantly affected M¯aori and Pacific Islander children. An outer membrane vesicle vaccine specific for this epidemic clone was developed through a collaboration between Chiron Vaccines and the National Institute of Public Health in Norway [15]. Given the disproportionately large number of cases in M¯aori and Pacific Islander (M/PI) children and examples of lower effective-
7283
ness of some other vaccines in some high-risk groups, it was important that any efficacy estimate reflect that of M/PI children as well as those of European origin. The efficacy trial aimed for population-based equitable access enrolment. This included establishing a Community Advisory Board to represent all sectors of the community. The most effective tools for recruiting participants were local radio advertisements, promotion by staff at maternity services and targeted mailings. As a result, the study sample was representative of the ethnic and socioeconomic mix of New Zealand society. The trial found the vaccine produced adequate immune responses in the total population but was not able to estimate immune response in the subpopulations. Population vaccination commenced in 2004 and notified cases have decreased each subsequent year. 4.3. United States Higher rates of rotavirus disease and different serotype distributions are experienced by AI/AN compared to nonindigenous children in the US. Previous rotavirus vaccines, and some other vaccines, have been less effective in AI/AN children. It was, therefore, important to include AI/AN children in a recent international trial of a new rotavirus vaccine. The CAIH has built a relationship with Navajo and White Mountain Apache communities over decades and carried out many successful studies [16]. An important component of this relationship is the use of field workers on the research team who discuss in native language the reasons for doing the study, the need for new effective vaccines in their community, the long term commitment of the CAIH and their previous record in research in these communities. As a result this trial was conducted in Navajo and White Mountain Apache children and the vaccine found to be safe and effective in this population [17].
5. Options for continuing collaboration Two options were discussed for promoting the potential for collaboration and learning from each other’s experiences initiated by this meeting. • An indigenous reference group. The possibility of an international indigenous reference group to review and provide comment about the need and most appropriate mechanisms for research in vaccine preventable diseases was raised. There are several issues still to be clarified, such as the nature of indigenous representation, and how it would connect with other work on indigenous health, considering the holistic attitude to health in many indigenous cultures. • An international working group or interest group. Such a group could meet periodically by e-mail, telephone or in person to discuss issues of common interest and possible multi-centre projects. International Circumpolar Surveillance is one possible model for this—a collabo-
7284
Conference report / Vaccine 25 (2007) 7281–7284
ration of several countries with indigenous populations living in polar regions. They carry out enhanced surveillance of diseases of interest, including IPD and Hib disease. An e-mail interest group may be an initial step towards improving communication, with a view to another satellite meeting at ISPPD6 in 2008 in Iceland. References [1] Australian Bureau of Statistics, Australian Institute of Health and Welfare. The Health and Welfare of Australia’s Aboriginal and Torres Strait Islander peoples, 2005. Report number 4704.0. Canberra: Australian Capital Territory; 2005. [2] First Nations and Inuit Health Branch. A statistical profile on the health of first nations in Canada. Ottawa, Ontario: Health Canada; 2003, http://www.hc-sc.gc.ca/fnih-spni/pubs/gen/stats profil e.html. [3] New Zealand Ministry of Health. Our Health, Our Future – Hauora Pakari, Koiora Roa – The Health of New Zealanders 1999. Wellington, NZ: New Zealand Ministry of Health; 1999 http://www.moh.govt.nz/ moh.nsf/49ba80c00757b8804c256673001d47d0/ 6910156be95e706e4c2568800002e403?OpenDocument. [4] Palagiano C, Shalala DE, Trujillo MH, Hartz GJ, Paisano EL. Trends in Indian health, 1998–99. Indian Health Service, US Department of Health and Human Services; 1999. [5] Bialek SR, Thoroughman DA, Hu D, Simard EP, Chattin J, Cheek J, et al. Hepatitis A incidence and hepatitis A vaccination among American Indians and Alaska Natives, 1990–2001. Am J Public Health 2004;94:996–1001. [6] Patrick DM, Bigham M, Ng H, White R, Tweed A, Skowronski DM. Elimination of acute hepatitis B among adolescents after one decade of an immunization program targeting Grade 6 students. Pediatr Infect Dis J 2003;22:874–7. [7] Singleton R, Hammit L, Hennessey T, Bulkow L, DeByle C, Parkinson A, et al. The Alaska Haemophilus influenzae type b experience: lessons in controlling a vaccine-preventable disease. Pediatrics 2006;118:e421–9. [8] Menzies R, McIntyre P, Beard F. Vaccine preventable diseases and vaccination coverage in Aboriginal and Torres Strait Islander people, Australia, 1999 to 2002. Commun Dis Int 2004;28(S1). [9] The National Aboriginal Community Controlled Health Organisation. http://www.naccho.org.au/ [accessed 8 February 2007]. [10] New Zealand Ministry of Health. Maori Health Directorate web site. http://www.maorihealth.govt.nz/2004/index.php [accessed 6 January 2006]. [11] US Department of Health and Human Services. Indian Health Service. http://www.ihs.gov/ [accessed 8 February 2007]. [12] Health Canada. First Nations and Inuit Health Branch. http://www.hcsc.gc.ca/ahc-asc/branch-dirgen/fnihb-dgspni/index e.html [accessed 8 February 2007]. [13] Cooperative Research Centre for Aboriginal Health. http://www.crcah. org.au/ [accessed 8 February 2007]. [14] Dunbar M, Moberley S, Nelson S, Leach A, Andrews R. Clear not simple: an approach to community consultation for a maternal pneumococcal vaccine trial among Indigenous women in the Northern Territory of Australia. Vaccine 2007;25:2385–8. [15] O’Hallahan J, Lennon D, Oster P. The strategy to control New Zealand’s epidemic of group B meningococcal disease. Pediatr Infect Dis J 2004;23:S293–8. [16] O’Brien KL, Shaw J, Weatherholtz R, Reid R, Watt J, Croll J, et al. Epidemiology of invasive Streptococcus pneumoniae among Navajo children in the era before use of conjugate pneumococcal vaccines, 1989–1996. Am J Epidemiol 2004;160:270–8. [17] Vesikari T, Matson DO, Dennehy P, Van Damme P, Santosham M, Rodiguez Z, et al. Safety and efficacy of a pentavalent human-bovine (WC3) reassortant rotavirus vaccine. N Engl J Med 2006;354:23–33.
Rob Menzies ∗ Peter McIntyre National Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases, The Children’s Hospital at Westmead, Locked Bag 4001, Westmead, New South Wales 2145, Australia Ray Reid Katherine O’Brien Mathu Santosham James Watt Johns Hopkins Centre for American Indian Health, School of Hygiene and Public Health, Johns Hopkins University, 624 North Broadway, Baltimore 21205, MD, USA Geoffrey Angeles Alex Brown Melissa Dunbar Amanda Leach Menzies School of Health Research, P.O. Box 41096, Casuarina, Northern Territory 0811, Australia Sue Crengle Diana Lennon Henare Mason University of Auckland, Private Bag 92019, Auckland Mail Centre, Auckland 1142, New Zealand Charles Grim Leo Nolan Phil Smith Indian Health Service, 801 Thompson Avenue Suite 440, Rockville, MD 20852, USA Gina Dumaresq Ruth Richardson First Nations and Inuit Health Branch, Public Health Agency of Canada, 130 Colonnade Road, A.L. 6501H, Ottawa, Ontario K1A 0K9, Canada Sarah Moberley Department of Paedatrics, The University of Melbourne, Victoria 3010, Australia Janelle Stirling Queensland Institute of Medical Research, PO Royal Brisbane Hospital, Queensland 4029, Australia Mick Gooda Cooperative Research Centre for Aboriginal Health, P.O. Box 41096, Casuarina, Northern Territory 0811, Australia Michael Green Queen’s University, 99 University Avenue, Kingston, Ontario K7L 3N6, Canada ∗ Corresponding
author. Tel.: +61 2 9845 1423; fax: +61 2 9845 1418. E-mail address: [email protected] (R. Menzies) 18 April 2007 Available online 27 August 2007