The world has changed since the last Chief Health Officer’s report. The COVID-19 pandemic has dominated global health discourse and challenged not just the health sector but populations overall socially, economically, politically and psychologically.
Our experience with COVID-19 has taught us many things:
- A renewed focus on the relationship between infectious and chronic disease. COVID-19, (particularly severe disease) plays a large role in exacerbating chronic disease such as cardiopulmonary disease1 as well as causing higher morbidity and mortality in those with pre-existing chronic disease.2
- The need to protect those that are most vulnerable. Our hospitals filled with COVID-19 patients who were older or more disadvantaged, had pre-existing health conditions, or were susceptible to more severe COVID-19 due to risk factors such as smoking and obesity. The need for more holistic approaches to prevention and control that address inequity and ensure populations are prepared for new health threats came sharply into focus.
- That we can reduce and defeat new and existing health problems through new ways of working and by working together. The COVID-19 response globally has demonstrated the capacity for “innovative health interventions that can be delivered fast if they are prioritised politically and financed adequately”, including the acceleration of science and research and engagement of communities and the public and private sectors.3
- That we need to be ready to respond to new challenges. Not only are diseases and lifestyle interrelated, but our health and resources are interrelated globally. Challenges may arise due to the emergence of new or old diseases, the impacts of large-scale natural disasters and national and international wars and civil unrest through to global economic instability that have the most effect on our most vulnerable and disadvantaged.
We are a global community and the health of Queenslanders is not just dependent on what occurs within our State but across the globe. This has been demonstrated by the impact of international travel on global COVID-19 transmission, the effects on supply lines of essential goods and medicines, the international efforts needed to develop and deliver vaccines and even the effects on our economy of international border closures.
This section highlights those relationships, what has been accomplished and what more there is to do. While this is evident across many risk factors and health conditions, here we use human immunodeficiency virus (HIV), human papillomavirus (HPV), acute rheumatic fever (ARF) and rheumatic heart disease (RHD) each of which are now have “EndGame” strategies to eliminate disease. Cardiovascular disease (CVD), diabetes, tobacco smoking and e-cigarettes (vaping), and obesity are examples of significant global health challenges that continue to dominate disease burden.
A renewed focus on the relationship between infectious and chronic diseases
The 20th century was marked by major declines in infectious diseases health burden driven by improvements in sanitation, hygiene, food security and the advent of antibiotics, antivirals and vaccines. While infectious diseases remain a leading cause of acute morbidity (for example, respiratory and gastrointestinal infections), improved health service access, vaccines, early intervention and management reduced long-term adverse outcomes and mortality in wealthy countries.
The 21st century is now witnessing the potential to end infectious diseases of global concern that are associated with significant chronic disease burden. International, national and local strategies are now in place to eliminate diseases such as HIV, HPV and cervical cancer, Group A Streptococcus (GAS) and RHD, and Tuberculosis (TB).3 These are not just a result of advances in medicine. Political will and social commitment to reducing inequity by addressing the socioeconomic and environmental determinants of health, in tandem with clinical care, are playing critical roles.
The role of the immune system
A major advance in medicine over recent decades is a greater understanding of the role of the immune system and inflammatory processes in a wide variety of physical and mental health problems.4 This has grown beyond the role of infectious agents to a greater understanding of non-infectious determinants of inflammation and immune system function and dysfunction. There is increasing evidence that chronic diseases contributing most to global disease burden, such as CVD, diabetes, stroke, cancer, chronic kidney disease, are associated with chronic inflammatory responses.4
Chronic inflammation is thought to originate early in development and persist across the lifespan,5,6 with infection burden in the first year of life associated with an increased risk of CVD, obesity, chronic lung disease and diabetes. The evidence for the role of stress and other mental health conditions in chronic systemic inflammation, including during foetal development, is expanding.7
Globally important chronic diseases such as those above also coexist with endemic and epidemic infectious diseases. There is substantial evidence that chronic diseases are risk factors in the susceptibility to, and severity of, infections. The interaction of COVID-19 with global chronic disease burden has been considered “a perfect storm, fuelling COVID-19 deaths”.8 The mechanisms by which chronic diseases increase risk are less well understood,9 but there is substantial focus on chronic inflammatory processes in key conditions resulting in impaired immune response to infectious agents.
Addressing chronic inflammation and/or infection presents new opportunities for the prevention and management of chronic diseases, including the role of vaccines and immunotherapies in concert with strengthening the responses to socio-economic and environmental determinants of health and wellbeing.
The HPV and cervical cancer success story
HPV is the most common sexually transmitted infection. It is estimated that up to 80% of people in Australia have HPV at some time in their lives. Most HPV infection is self-limiting (will generally resolve on its own) and asymptomatic.
Persistent or re-activated HPV infection with high-risk HPV subtypes, however, is the predominant cause of cervical cancer and has been variously attributed to other genital, head and neck, and oropharyngeal cancers.10 A weakened immune system is associated with an increased risk of HPV disease—people with systemic inflammatory auto-immune diseases such as systemic lupus erythematosus and rheumatoid arthritis have an increased risk of infection, including persistent infection, compared to the general population.11 This may be due to an immunocompromised state, the immunosuppressive medications used, or effects from both.
HPV vaccine and eliminating cervical cancer
The advent of an effective quadrivalent HPV vaccine targeting four strains of the virus has positively impacted the control of HPV and prevention of cervical cancer in countries with HPV vaccine schedules.12 Australia implemented a national HPV vaccination programme in 2007 for adolescent females and in 2013 extended vaccination to males—only the second country globally to do so.
In 2018, an HPV vaccine targeting nine strains replaced the earlier vaccine. Australia has one of the highest HPV vaccine uptake rates in the world10 and in 2020, 80.5% of 15-year olds had received three doses.13 Given the importance of cervical cancer globally and the promising data on the impact of vaccination, in 2020 the World Health Organization (WHO) set goals for the elimination of cervical cancer by 203014 with the following 90-70-90 targets:
- 90% of girls fully vaccinated with HPV vaccine by age 15 years
- 70% of women are screened with a high-performance test by age 35 and again by age 45
- 90% of women identified with cervical disease receive treatment (90% of women with precancer treated, and 90% of women with invasive cancer managed).14
The need to protect those that are the most vulnerable
Across almost all health conditions and outcomes, the greatest burden of disease is experienced by the most vulnerable in our communities, including in Australia.15 These include:
- infants and young children
- older age groups
- the socioeconomically disadvantaged
- people living in communities geographically distanced from major centres.
Infectious and chronic diseases can also be multipliers of vulnerability and disadvantage,16,17 particularly through resultant disability and socioeconomic impacts such as loss of income, discrimination, and social isolation. Reducing the burden of disease in these populations therefore requires holistic approaches that address the root causes of disadvantage while ensuring equitable and timely access to high quality health care and interventions to minimise morbidity and mortality.
Rheumatic Heart Disease
RHD is permanent heart damage, predominantly involving the aortic valves, caused by episodes of acute rheumatic fever (ARF) that occur after an auto-immune response to Group A Streptococcus (GAS) infection. The progression of ARF to RHD is largely preventable by prophylactic administration of monthly injections of benzathine benzylpenicillin G (BPG), combined with regular echocardiograms to detect disease progression early.
Diseases of poverty, by the 1980s, ARF and RHD were thought to have been eliminated in high-income countries, given a surge in research and control.18 The burden, however, prevails in low-middle-income settings and First Nations populations in high-income countries. The rates of RHD in First Nations Peoples are amongst the highest reported worldwide. RHD is the 4th leading cause of heart disease in First Nations peoples and is associated with significant burden19—the average age at death is 50 years. There is a section devoted to the current impacts of ARF/RHD in the First Nations peoples health and wellbeing section.
There are early signs that more treatment options will become available. In recent years, however, several promising vaccine candidates have been identified, including Australian candidates.20 In 2019, a global GAS Vaccine Consortium was established and, in the same year, the Australian Government committed $35 million to support vaccine progress to clinical trials. Pre-clinical work has progressed and, in addition to the work of the Consortium, early-stage clinical trials have begun using a vaccine developed by Griffith University and the University of Alberta in Canada.21
RHD Endgame Strategy
Australia has committed to a RHD Endgame Strategy by 2031, led by a NHMRC Centre of Research Excellence, involving 16 institutions from across Australia.22 The focus is predominantly on Aboriginal and Torres Strait Islander populations and has five priorities: Aboriginal and Torres Strait Islander leadership, community-based programs, healthy environments, early prevention, and care and support.
Similarly, in 2022 Queensland Health released its “Ending Rheumatic Heart Disease: Queensland First Nations Strategy 2021-2024”.23 The Queensland strategy also acknowledged the importance of RHD in non-Indigenous Queenslanders, particularly the Māori, Pacific Islander and refugee populations who comprise most of the cases in non-Indigenous people. Acknowledging these additional cohorts are also impacted by RHD, the Queensland strategy seeks to improve outcomes for all through regional action plans and partnerships across Queensland.
Diabetes–the modern preventable pandemic
Diabetes was recently framed as the “modern preventable pandemic” for which the lessons of the global response to COVID-19 should be applied.24 Diabetes disproportionately affects racial and ethnic minorities and other socioeconomically disadvantaged populations.25 Diabetes is a classic example of the interactions between infection, inflammation, chronic disease and their socioeconomic and environmental determinants.25
The higher frequency of infection and other adverse health outcomes in people with diabetes is considered related to hyperglycaemia, particularly if poorly controlled, which is common in disadvantaged populations. This leads to immune system dysfunction, neuropathies, decreases in the antibacterial activity of urine, and impairment to gastrointestinal and urinary function.26 There are strong associations between diabetes and globally important infections due to Mycobacterium tuberculosis27 and Staphylococcal aureus.28 In addition to the increased morbidity, infectious processes may be the first manifestation of diabetes mellitus or the precipitating factors for complications inherent to the disease, such as diabetic ketoacidosis and hypoglycemia.26
Global initiatives to reduce the burden of diabetes
In April 2021, the WHO launched the Global Diabetes Compact, a global initiative aiming for sustained improvements in diabetes prevention and care.29 The Compact’s vision is to reduce the diabetes risk and ensure that all people who are diagnosed with diabetes have access to equitable, comprehensive, affordable, and quality treatment and care.
In May 2022 the World Health Assembly endorsed five global diabetes coverage and treatment targets to be achieved by 2030.30 These aim to improve the monitoring of, and response to, diabetes within national non-communicable disease (NCD) programmes:
- 80% of people living with diabetes are diagnosed
- 80% have good control of glycaemia
- 80% of people with diagnosed diabetes have good control of blood pressure
- 60% of people with diabetes of 40 years and older receive statins
- 100% of people with type 1 diabetes have access to affordable insulin and blood glucose self-monitoring.30
To achieve these goals, a multi-sectorial, whole of community focus on supporting those most at risk of both developing disease and poor diabetes outcomes will be necessary. This is particularly relevant, given the advent of newer types of type 2 diabetes medications and their associated cost.31
Defeating health problems through new ways of working and by working together
In 1980, the WHO declared smallpox officially eradicated.32 Although the smallpox vaccine was shown to be effective against smallpox in 1801, and various countries progressively started vaccinating their populations, it was not until 1958, some 10 years after the WHO was established, that it called for a united effort to eradicate the disease.32 The smallpox story is testimony to what can be achieved through collaborative global efforts driven by political and community will.
There are now growing international efforts to eliminate other diseases of public health importance. These are being facilitated by new technologies, advances in the social and health and medical sciences, growing commitment to human rights and protection of the natural environment. The fight against HIV/AIDS, the One Health initiative focussing on interactions between humans, animals and the environment, and global commitment to addressing the burden of obesity, provide examples of current holistic approaches requiring political and social will to effect change.
HIV and AIDS
The fight against HIV and AIDS has been almost unprecedented in global health and is a clear example of how collaborative, integrated approaches can lead to significant gains in health.33 With the third Sustainable Development Goal (SDG-3) of ending the HIV/AIDS epidemic by 2030,34 the expansion of antiretroviral therapy (ART), harnessing of societal supports, sustained focus on innovation and impact, and the mobilisation of vast resources worldwide have made substantial inroads.33
Ending the AIDS epidemic
In 2015, UNAIDS released the “Fast Track” Strategy35 detailing the actions needed to accelerate ending the AIDS epidemic by 2030, consistent with the SDG-3. The overall principle of fast tracking is a life-cycle approach ensuring people have access to the appropriate HIV prevention and treatment options to fit their needs.36 On 1 December 2022, Brisbane became the 4th Australian city to join over 350 cities worldwide participating in the Fast-Track Cities initiative.37 Fast-Track Cities recognise the importance of whole of community approaches to reduce inequities that drive adverse health outcomes for those living with HIV.
The key targets for Fast Track are:
- 95% of people living with HIV will know their status
- of those with diagnosed HIV, 95% will receive sustained ART
- of those on ART, 95% maintain viral suppression
- new HIV infections are reduced from 2.1 million in 2010 to fewer than 500,000 in 2020 and fewer than 200,000 in 2030
- zero discrimination towards those with HIV/AIDS.35
In 2021, the estimated national and Queensland figures for the Fast Track targets were:38
- Nationally 91% of people living with HIV know their HIV status (91% in Queensland; 5,328 Queenslanders with diagnosed HIV)
- Nationally 92% of people diagnosed with HIV are on ART (91% in Queensland; 4,849 Queenslanders on ART)
- Nationally 98% of people receiving ART are virally suppressed (93% in Queensland; 4,509 Queenslanders achieving viral suppression).
While the burden of disease has declined substantially, particularly AIDS-related deaths, and there have been considerable improvements in quality of life for those living with HIV due to ART , the global rate of decline in annual new HIV infections did not meet the 2020 targets.39,40 Sustained global efforts are required to maintain and enhance the commitments above particularly in addressing inequity.
The One Health approach recognises that better health outcomes will be achieved if multiple sectors in human, animal, plant and environmental health work together in the design and implementation of programmes, policies, legislation and research.41 The interaction between humans and their environments in a world rapidly changing through growing population size and mobility, urbanisation, climate change and environmental degradation continues to challenge our ability to maintain population health and wellbeing.42
The transmission of the HIV virus from primate to human, the spread of Japanese encephalitis and other mosquito-borne diseases into new regions of Australia, the heightened risk of food and water-borne diseases during times of floods and drought, access to healthy food for healthy food choices and environments conducive to safe physical activity are examples of the need for One Health approaches. The One Health approach recognises that no one person, organisation or sector can address these challenges alone.41
The Queensland Alliance of One Health Sciences (QAOHS)43 was launched on Global One Health Day 2021 (3 November). QOAHS is a collaboration between The University of Queensland, industry and Queensland Government partners with an aim of improving public health policies for zoonotic diseases of local, national and global importance. It encompasses a suite of programs to improve capability in disease surveillance and analytics, advanced diagnostics, trade-offs and policy solutions, and future capability training.
Approximately two-thirds of Australian adults and children are overweight or obese.44 Obesity is now on par with smoking as the leading attributable risk factor for disease burden in Australia.15 There is considerable evidence supporting the role of obesity in the development of chronic diseases including type 2 diabetes, hypertension, cardiovascular disorders, chronic respiratory conditions and osteoarthritis.45
Importantly, childhood obesity has long-term detrimental effects on physical and psychological health, including the development of diseases like diabetes and cardiovascular diseases at a younger age.46 The role of obesity in the risk for infectious diseases, and adverse infectious disease outcomes, has historically received less attention.
Obesity is now known to be associated with increased risk of abscesses, skin and subcutaneous tissues infections, respiratory tract infections and cystitis, and a higher use of antimicrobials overall.47 Obesity is associated with an altered immune response and chronic inflammation. There is also a negative relationship between body mass index (BMI) and infection-related mortality.48 Obesity has been attributed to more severe COVID-19 disease.49
National Obesity Strategy
In 2022, Australia’s Health Ministers released the National Obesity Strategy 2022–2032.44 The Strategy recognises that without further action across society, politically, socially, economically and geographically, our future will be further impacted by weight-related diseases (acute and chronic) with significant costs to healthcare, our economy, and community wellbeing.44 The Strategy aims to achieve this through creating healthier environments, empowering Australians through building knowledge, skills and community connection and improved access to early intervention and care.
Queensland Health led the development of the National Strategy and Health and Wellbeing Queensland have developed the Queensland response Making Healthy Happen 2023-2032 (draft). This Strategy includes three bold actions plans: establishing strong foundations for change, delivering bold, transformation action, and amplifying and scaling success.
We need to be ready to respond to new challenges
The COVID-19 pandemic has demonstrated how a new threat to health can have profound impacts to global health and wellbeing. However, it is not the only challenge the world faces in adverse impacts on the gains made in reducing disease burden. The consequences of growing antibiotic resistance, uptake of new and readily available illicit drugs, declining birth rates, and increasing prevalence of mental health problems, especially in young people, are just some of the challenges we face. Importantly, several of these challenges threaten to halt or reverse the gains made in reducing the burden of important chronic diseases.
While the burden of CVD in Australia has fallen by 45% in the past two decades, it remains the 3rd leading cause of disease burden.50 While the decline is cause to celebrate, the ageing of the population, the epidemics of obesity and diabetes, and the large burden of mental health—all strongly associated with CVD—challenge this downward trajectory meaning CVD will remain a public health priority globally. Recent data suggest that between 2020 and 2029, there will still be 377,754 fatal and 991,375 non-fatal CVD events in Australians age 40 to 90.51 Several long-term CVD outcomes of COVID-19 have been reported in large studies in the US , such as abnormal heart rhythms, heart muscle inflammation, stroke and myocardial infarction52 which may impact further on disease burden.
The increased risk of infection and severe morbidity and mortality in people with CVD has been well documented for several major epidemic and endemic infectious diseases such as influenza,53 community-acquired pneumonias54 and COVID-19.55 Cardiac complications of infectious diseases such as community-acquired pneumonia are thought to be due to complex interactions between pre-existing conditions, systemic inflammation and direct pathogen-mediated damage to the cardiovascular system.56 Additionally, antibiotic resistance is a direct threat to the prevention of severe morbidity and death due to infection in people with CVD.
While medical advances in the management and treatment of CVD have been profound, the current and future impact of new challenges, not only to burden of disease, but to social and environmental determinants of CVD mean that CVD will likely remain a global public health priority.
Tobacco and vaping
The detrimental effects of tobacco smoking are well established facts. There are multiple communicable and non-communicable diseases for which morbidity and mortality are strongly associated with smoking.57
Australia is a world-leader in reducing smoking prevalence over the past two decades,58 and the decline in CVD in wealthy countries in particular over that time can be partially attributed to the decline in smoking.59 However, the rapidly increasing uptake of e-cigarettes which may or may not contain nicotine (commonly known as vaping), particularly amongst young people, has the potential to reverse these gains.
Vaping is the inhaling of an aerosol, that is made up of a fine spray of chemicals and small particles. Vaping juices can contain water, flavours, solvents and nicotine, depending on the product. Many of these components are found in traditional cigarettes and, while considered in lower quantities, this varies across vaping products.
Vaping products are often poorly labelled making it difficult to assess and there are important differences between regulated nicotine vaping products, which require a medical prescription, and unregulated products, the contents of which may not be known. The use of vapes has been proposed as a safe, or safer, alternative to tobacco and an aid to tobacco smoking cessation, however, there is considerable controversy around their use for this purpose.60–62
Vaping health effects
The potential acute and severe adverse effects of vaping came to attention during an outbreak of associated lung injury in the United States in 2019.63 There is currently insufficient evidence with respect to the long-term health outcomes of vaping,60 however nicotine is itself highly addictive, adversely impacts foetal development,64 affects brain development in children and adolescents,65 and increases the risk of cardiovascular events, irrespective of how it is consumed. There is now growing evidence of lung compromise/toxicity associated with vaping aerosols and flavourings even in the absence of nicotine66 and adverse immune responses to infectious respiratory diseases.67 E-cigarettes contain carcinogens and toxins that may lead to the development of neurological manifestations, lung cancer and CVD.68
Without concerted action to halt the uptake of e-cigarettes, including those that do not contain nicotine, in our youth, we run the risk of reversing the health gains made through the reduction of tobacco smoking. While current tobacco legislation applies to e-cigarettes, stronger regulatory action at the National level and legislative changes in Queensland are needed. The successful strategies in tobacco control such as smoke-free policies, health warnings, public education campaigns, school- and peer-based programs need to be applied to e-cigarette use. This action needs to target the social, economic and environmental determinants of e-cigarette use, particularly in young people.
Queensland e-cigarette regulations
Queensland regulates the use of e-cigarettes in public places. The sale and supply of e-cigarettes is also regulated in retail settings, where any sales to minors are prohibited and the sale of nicotine containing vapes, other than on prescription, is illegal. The regulation of e-cigarettes in Australia is still evolving, particularly at the Federal level, where there are gaps that need to be addressed.
The Commonwealth Minister for Health and Aged Care announced ‘Reignite the Fight Against Tobacco Addiction’ reforms in November 2022 which included an option to update existing advertising restrictions to capture e-cigarettes. In addition to this, other strategies that would complement State based controls include regulation of flavours, warning labels and plain packaging, product testing and pricing controls, and an increase in enforcement to prevent illegal nicotine containing supplies entering Australia and the black market.
In Queensland we are making this issue a priority and have a forward program of work that ranges from legislative change to community messaging to enforcement and surveillance of illicit supply.
The 21st century is witnessing rapid growth in our understanding of the bi-directional relationships between infectious and non-infectious diseases and their contribution to global disease burden. This has been facilitated by advances in medicine, immunology, microbiology and genomics that accelerated during the COVID-19 pandemic. Social, lifestyle and environmental factors are critical players in the space and cannot be considered in isolation to medical innovation.
These advances are now translating nationally and globally to “Endgame” strategies to eliminate several diseases. The lessons learned from successes in conditions such as cervical and other cancers, HIV/AIDS are readily transferrable to other diseases. However, many challenges remain, particularly the control of the global pandemics of diabetes and obesity, and the potential threats to the enormous strides made in smoking reduction posed by vaping.
Public health policy and strategies that incorporate both infectious and chronic diseases and their inter-relationships are core public health functions of assessing risk, surveillance, health promotion, and prevention to better protect population health. This includes identifying and quantifying chronic sequelae rather than just acute cases of infectious diseases and assessing and evaluating the role of chronic diseases in infectious disease pathogenesis. Enabling supportive, equitable communities, caring for our natural environments and taking a multi-sectoral, holistic approach to disease prevention and management are key to our success in understanding and preventing disease and supporting “Endgame” approaches to reduce or eliminate disease burden.
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