Anna Ralph

Anna Ralph
Menzies School of Health Research · Division of Global and Tropical Health

Doctor of Philosophy

About

127
Publications
30,040
Reads
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2,828
Citations
Citations since 2016
76 Research Items
2180 Citations
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20162017201820192020202120220100200300400
20162017201820192020202120220100200300400
20162017201820192020202120220100200300400
Additional affiliations
June 2012 - January 2018
Royal Darwin Hospital
Position
  • Staff Specialist in Infectious Diseases and General Medicine

Publications

Publications (127)
Article
Full-text available
Background Rheumatic Heart Disease (RHD), a chronic acquired heart-valve disease, is a major contributor to morbidity and mortality among Indigenous Australians. We estimate the probability and determinants of progressing from RHD diagnosis to cardiovascular complications/death in the Australian population, addressing methodological shortcomings in...
Chapter
The chief focus of secondary prevention is antibiotic prophylaxis. This comprises long-term antibiotic therapy for individuals with acute rheumatic fever (ARF) or rheumatic heart disease (RHD), to prevent ARF recurrences triggered by recurrent group A streptococcal infections, and thereby prevent development or worsening of RHD. Standard recommenda...
Article
Full-text available
Context: Indigenous children and adolescents in Australia and globally bear the burden of acute rheumatic fever (ARF). It has been virtually eliminated in well-resourced, developed settings. ARF is an autoimmune response to infection with group A Streptococcus. The mainstay of management is long-acting intramuscular penicillin injections to prevent...
Article
Objectives Using echocardiographic screening, to estimate the prevalence of rheumatic heart disease (RHD ) in a remote Northern Territory town. Design Prospective, cross‐sectional echocardiographic screening study; results compared with data from the NT rheumatic heart disease register. Setting, participants People aged 5–20 years living in Manin...
Article
Full-text available
Introduction Rheumatic heart disease (RHD) causes significant morbidity and mortality in young people from disadvantaged populations. Early detection through echocardiography screening can facilitate early access to treatment. Large-scale implementation of screening could be feasible with the combination of inexpensive standalone ultrasound transdu...
Book
Full-text available
This storybook inspired by the 2020 coronavirus pandemic aims to empower young children who have been impacted by the social or health consequences of this infection.
Article
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Background: Gastrointestinal tuberculosis (TB) is diagnostically challenging; therefore, many cases are treated presumptively. We aimed to describe features and outcomes of gastrointestinal TB, determine whether a clinical algorithm could distinguish TB from non-TB diagnoses, and calculate accuracy of diagnostic tests. Methods: We conducted a pr...
Preprint
Background Gastrointestinal tuberculosis (TB) is diagnostically challenging; therefore, many cases are treated presumptively. We aimed to describe features and outcomes of gastrointestinal TB, determine whether a clinical algorithm could distinguish TB from non-TB diagnoses, and calculate accuracy of diagnostic tests. Methods We conducted a prospec...
Article
Importance Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia is associated with mortality of more than 20%. Combining standard therapy with a β-lactam antibiotic has been associated with reduced mortality, although adequately powered randomized clinical trials of this intervention have not been conducted. Objective To determine whether...
Preprint
Gastrointestinal tuberculosis (TB) is diagnostically challenging; therefore, many cases are treated presumptively. We aimed to describe features and outcomes of gastrointestinal TB, determine whether a clinical algorithm could distinguish TB from non-TB diagnoses, and calculate accuracy of diagnostic tests. Methods We conducted a prospective cohort...
Article
Full-text available
Purpose: Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) persist as public health issues in developing countries and among disadvantaged communities in high-income countries, with rates in Aboriginal and Torres Strait Islander peoples in Australia among the highest recorded globally. A robust evidence base is critical to support poli...
Article
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We report a case of acute rheumatic fever with severe pancarditis occurring simultaneously with probable acute post-streptococcal glomerulonephritis in a previously well, Australian Aboriginal, 29-year-old male. These autoimmune streptococcal sequelae are usually considered pathogenetically distinct, and concurrence has not previously been reported...
Article
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Indonesia has the third highest tuberculosis (TB) caseload internationally. A cornerstone for strengthening health systems to respond to TB is a well-trained workforce. In a partnership between Indonesian and Australian institutions, TB training was run during 2018 to strengthen the local capacity to meet End TB strategy targets. This paper aims to...
Article
Full-text available
The prevalence of rheumatic heart disease (RHD) in the Aboriginal population of the Australian Northern Territory is high, and Streptococcus pyogenes skin infections likely contribute to this. A promising candidate S. pyogenes "30mer" vaccine is composed of 30 pharyngitis associated type-specific antigens from the S. pyogenes M protein. Cross opson...
Article
Full-text available
Objectives: We report a cluster of acute rheumatic fever (ARF) cases and the public health response in a high‐burden Australian setting. Methods: The public health unit was notified of an increase in ARF cases in a remote Australian Aboriginal community. A multi‐disciplinary group coordinated the response. Household contacts were screened for ARF o...
Article
This study aimed to identify recurrent acute rheumatic fever (ARF) episodes which occurred despite adherence to prophylactic benzathine penicillin G (BPG). Data from Australia's Northern Territory were analyzed; ARF recurrences between 2012 and 2017 diagnosed while the person was prescribed BPG were identified. Days at risk (DAR)-median and interqu...
Article
Full-text available
Background People in close contact with tuberculosis should have screening and appropriate management, as an opportunity for active case detection and prevention. However, implementation of tuberculosis contact screening and management is limited in high-burden settings. Behaviour change is needed across three levels of the healthcare system—policy...
Article
Full-text available
Background In high-burden settings, guidelines recommend antibiotic treatment for all suspected Group A Streptococcus (GAS) infections to prevent rheumatic fever and post-streptococcal glomerulonephritis. Highly-sensitive rapid GAS tests could reduce unnecessary antibiotic use in these settings. Methods Prospective study of the Xpert® Xpress Strep...
Article
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Background: Randomised controlled trials of adjunctive vitamin D in pulmonary tuberculosis (TB) treatment have yielded conflicting results. Individual participant data meta-analysis could identify factors explaining this variation. Methods: We meta-analysed individual participant data from randomised controlled trials of vitamin D in patients re...
Article
Full-text available
Strategies to date have been ineffective in reducing high rates of rheumatic heart disease (RHD) in Australian Aboriginal people; a disease caused by streptococcal infections. A remote Aboriginal community initiated a collaboration to work towards elimination of RHD. Based in ‘both-way learning’ (reciprocal knowledge co-creation), the aim of this s...
Article
Objective This study investigated the delivery of guideline-recommended services for the management of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) in Australian primary healthcare centres participating in the Audit and Best Practice for Chronic Disease (ABCD) National Research Partnership project. MethodsARF and RHD clinical audit...
Article
Full-text available
Background Acute rheumatic fever (ARF) and rheumatic heart disease cause substantial burdens worldwide. Long‐term antibiotic secondary prophylaxis is used to prevent disease progression, but evidence for benefits of different adherence levels is limited. Using data from northern Australia, we identified factors associated with adherence, and the as...
Data
Table S1. Characteristics of People Who Progressed From Acute Rheumatic Fever to Rheumatic Heart Disease
Article
Full-text available
Australian First Nations people waiting for appointments at Aboriginal Community Controlled Health Organisations around the country will now see culturally relevant and locally produced content on the waiting room TVs. Aboriginal Health TV, which launched in October, provides messages about leading health issues including smoking, eye and ear check...
Article
Two male travelers with histories of gout and hazardous alcohol consumption, presented with a triad of severe culture-positive disseminated gonococcal infection, crystal-positive polyarticular gout, and gonococcal soft tissue collections, following unprotected sexual contact in The Philippines. Both men initially attributed symptoms to gout, since...
Article
Background: Globally, there is wide variation in streptococcal titer upper limits of normal (ULN) for antistreptolysin O (ASO) and anti-deoxyribonuclease B (ADB) used as evidence of recent group A streptococcal (GAS) infection to diagnose acute rheumatic fever (ARF). Methods: We audited ASO and ADB titers among individuals with ARF in New Zealan...
Article
High rates of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) in Australia predominate in young Aboriginal people highlighting underlying racial and equity issues. This article focuses on the perceptions of the disease among young Aboriginal people living in remote Australia. Participant understanding was constrained by clinicians’ us...
Article
Full-text available
Background: Rheumatic heart disease is a high-burden condition in Australian Aboriginal communities. We evaluated a stepped-wedge, community, randomized trial at 10 Aboriginal communities from 2013 to 2015. A multifaceted intervention was implemented using quality improvement and chronic care model approaches to improve delivery of penicillin prop...
Article
Full-text available
Background Health system strengthening is needed to improve delivery of secondary prophylaxis against rheumatic heart disease. Methods and Results We undertook a stepped‐wedge, randomized trial in northern Australia. Five pairs of Indigenous community clinics entered the study at 3‐month steps. Study phases comprised a 12 month baseline phase, 3 m...
Article
Full-text available
Background: Rheumatic heart disease (RHD) poses a major disease burden among disadvantaged populations globally. It results from acute rheumatic fever (ARF), a complication of Group A Streptococcal (GAS) infection. These conditions are acknowledged as diseases of poverty, however the role of specific social and environmental factors in GAS infecti...
Data
Summary of dwelling characteristics and facilities and GAS infection, ARF and RHD. (DOCX)
Data
National Institute of health Study Quality Assessment Tool template. (PDF)
Data
Summary of education and GAS infection, ARF and RHD. (DOCX)
Data
Summary of nutrition and GAS infection, ARF and RHD. (DOCX)
Data
Summary of crowding and GAS infection, ARF and RHD. (DOCX)
Data
Summary of income and GAS infection, ARF and RHD. (DOCX)
Data
Summary of socioeconomic status and GAS infection, ARF and RHD. (DOCX)
Data
Summary of employment and GAS infection, ARF and RHD. (DOCX)
Article
Full-text available
Background Prevention of rheumatic heart disease (RHD) remains challenging in high-burden settings globally. After acute rheumatic fever (ARF), secondary antibiotic prophylaxis is required to prevent RHD. International guidelines on recommended durations of secondary prophylaxis differ, with scope for clinician discretion. Because ARF risk decrease...
Book
Full-text available
Tuberculosis is thankfully an uncommon disease in Australia, but careful expert management is needed when cases occur. “Management of tuberculosis” is written to help Australian practitioners in providing safe and effective care in a range of clinical scenarios relating to tuberculosis. This book includes approaches to diagnosis, prevention and tre...
Article
Full-text available
Background Rheumatic heart disease (RHD) is a major cause of premature death in low and middle-income countries. The greatest barrier to RHD control is neglect of the disease in national health policies and a lack of prevalence data that might inform control efforts. Myanmar is making remarkable progress against many infectious diseases, but there...
Data
RHD Finalized DATA for PLoS One.xlsx. (XLSX)
Article
Aboriginal children in northern Australia have high rates of rheumatic fever and rheumatic heart disease, which are chronic conditions because of the need for long-term treatment and monitoring. This article critically reviews the literature on transition to adult care for children with chronic conditions and considers applicability to the care of...
Article
Full-text available
Background: Indigenous Australians experience high rates of chronic conditions. It is often asserted Indigenous Australians have low adherence to medication; however there has not been a comprehensive examination of the evidence. This systematic literature review presents data from studies of Indigenous Australians on adherence rates and identifie...
Article
Full-text available
Background Rheumatic heart disease (RHD) is a chronic cardiac condition with an infectious aetiology, causing high disease burden in low-income settings. Affected individuals are young and associated morbidity is high. However, RHD is relatively neglected due to the populations involved and its lower incidence relative to other heart diseases. Met...
Article
Full-text available
Background: In Australia's Northern Territory, most Aboriginal people primarily speak an Aboriginal language. Poor communication between healthcare providers and Aboriginal people results in adverse outcomes including death. This study aimed to identify remediable barriers to utilisation of Aboriginal Interpreter services at the Northern Territory...
Article
Full-text available
Objective: To explore young Aboriginal people's and clinicians' experiences of injection pain for the 10 years of penicillin injections children are prescribed to prevent rheumatic fever recurrences. Methods: Aboriginal children on the penicillin regimen and clinicians were purposively recruited from four remote sites in Australia. Semi-structur...
Article
Tuberculosis, a bacterial infection caused by Mycobacterium tuberculosis (M. tuberculosis), remains a disease of major global importance. The World Health Organisation (WHO) has estimated that there were 8.6 million infections and 1.3 million deaths from this disease in 2012 (World Health Organisation, Global Tuberculosis Report: WHO Report 2013, 2...
Article
Full-text available
Objective In high-burden Australian states and territories, registers of patients with acute rheumatic fever and rheumatic heart disease are maintained for patient management, monitoring of system performance and research. Data validation was undertaken for the Australian Northern Territory Rheumatic Heart Disease Register to determine quality and...
Data
Rheumatic heart disease prophylaxis adherence validation dataset. (XLSX)
Data
Rheumatic heart disease prophylaxis adherence Stata code. (DOCX)
Article
Full-text available
Background Vitamin D deficiency (low plasma 25-hydroxyvitamin D [25D] concentration) is often reported in tuberculosis. Adjunctive vitamin D has been tested for its potential to improve treatment outcomes, but has proven largely ineffective. To better understand vitamin D in tuberculosis, we investigated determinants of 25D and its immunologically...
Article
Full-text available
Acute rheumatic fever and its consequence, rheumatic heart disease, remain important problems in remote indigenous Australian communities. Aboriginal and Torres Strait Islander people living in urban settings, Maori and Pacific Islanders, and immigrants from developing countries are also likely to be at elevated risk. Guidelines and resources are a...
Article
Full-text available
Opinion statement Early recognition of group A streptococcal pharyngitis and appropriate management with benzathine penicillin using local clinical prediction rules together with validated rapi-strep testing when available should be incorporated in primary health care. A directed approach to the differential diagnosis of acute rheumatic fever now i...
Article
Full-text available
Background Nocardia is an opportunistic pathogen that can cause life-threatening disease. We aimed to characterise the epidemiological, microbiological and clinical features of nocardiosis in the tropical north of Australia. Methods We conducted a retrospective cohort study of nocardiosis diagnosed between 1997 and 2014. Population-based incidence...
Article
Full-text available
Background: -We investigated adverse outcomes for people with acute rheumatic fever (ARF) and rheumatic heart disease (RHD), and the effect of comorbidities and demographic factors on these outcomes. Methods: -Utilising linked data (RHD register, hospital and mortality data) for residents of the Northern Territory of Australia, we calculated ARF...
Technical Report
Full-text available
The Patient Educator service existed at Royal Darwin Hospital (RDH) in Australia’s Northern Territory from 2001-2009. This service comprised two nurses fluent in Yolŋu Matha (North East Arnhem language group) who would assist in providing health-related information to patients, and act as an intermediary between healthcare providers and Aboriginal...