By Mikaela Seymour and Stefanie Vaccher
Pacific Australia Labour Mobility (PALM) Scheme workers and employers consistently rate healthcare, including access to sexual and reproductive health services, as a primary concern. However, little is known about their specific needs and workers’ knowledge. In 2023, we were alerted to a potential Sexually Transmitted Infection (STI) outbreak in a PALM cohort within the Townsville Hospital and Health Service jurisdiction. In this blog we describe the findings of that outbreak investigation, detailed in our recently published study, “STI and treponemal serology prevalence in a group of predominantly Solomon Islands PALM workers”.
The PALM Scheme is a collaboration between Australia and eligible Pacific nations, as well as Timor-Leste, supporting groups to work temporarily in Australia in fields such as horticulture, meatworks, hospitality and care industries. There are around 30,000 PALM workers in Australia, primarily residing in New South Wales and Queensland. Work completed by Lindy Kanan, previously published on this blog, highlights significant health challenges faced by PALM workers, including limited access to sexual and reproductive health (SRH) services.
Whilst Australian public health units are adept at managing outbreaks and have experience in community STI screening events, addressing an outbreak in a PALM cohort presented unique challenges.
First, literature searches showed a significant lack of information on the prevalence of STIs in the workers’ countries of origin. The available studies were based in antenatal clinics, which do not accurately reflect the predominantly male population in this cohort. To declare an outbreak, it is customary to demonstrate an increase in infection rates beyond what is usually expected at a given time and location; however, without a baseline, it is challenging to establish how concerned health authorities should be.
Second, PALM workers are not eligible for Medicare. Therefore, any public health response needed to be feasible within the financial constraints of the workers. In this case, extensive collaboration occurred with nib, the preferred insurance provider, the approved employer, local general practitioners, pathology providers, True Relationships and Reproductive Health (a nonprofit provider of reproductive and sexual health services in Queensland), country liaison officers and the Department of Employment and Workplace Relations. This extensive process is detailed in the project report, which we have published as a supplement to the study.
Third, the high participation rate and demand for treatment services on the part of workers was unprecedented for community sexual health screening events. In our outbreak response event, 97% of workers volunteered for screening after receiving culturally appropriate education in their language from an independent doctor from their country of origin. This suggests high demand for sexual and reproductive health services by PALM workers, and likely unmet need.
Figure 1: Detection of infection by gender during the screening event
Source: “STI and treponemal serology prevalence in a group of predominantly Solomon Islands PALM workers”.
Both the high rates of participation and high rates of test positivity were unexpected and challenging to respond to for several reasons. Firstly, it was difficult to interpret the syphilis blood test, as both Treponema pallidum pallidum (genital, sexually transmitted syphilis) and Treponema pallidum pertenue (skin syphilis, usually transmitted by children, known as yaws) are present in Solomon Islands. Due to the high levels of genetic similarity in the bacteria, it is not possible to distinguish between the two using a blood test. In discussion with Solomon Islands clinicians involved in this project, it was believed these results most likely represented STI syphilis, as previous yaws eradication mass drug administration efforts in the early 2000s make it less likely that this generation of workers would have experienced childhood yaws. Therefore, it is hypothesised, but not proven, that 42% of the cohort have latent (non-infectious) syphilis infections, and 6% possible infectious syphilis (able to transmit to others) at the time of testing, rather than skin yaws. No HIV infections were identified and gonorrhoea was rare in this cohort. Chlamydia rates were elevated compared to the general Australian population, and were more likely in women, but similar to rates reported in previous Pacific studies.
In interviews, participants denied sexual coercion or transactional sex, despite these issues previously being raised as concerns in the PALM program. However, it is acknowledged that workers are less likely to report these occurrences to a government agency. Most participants reported having a regular sexual partner. However, with respect to those reporting exclusively casual intercourse in the community, our results did not demarcate if this was with their colleagues, other PALM workers under different employers, or other community members. Further research into these behaviours would be of interest to understand potential networks of blood-borne virus (BBV) and STI transmission.
These findings have generated several recommendations which the Queensland PALM Workers Health Working Group is considering. The key consideration raised is whether offering preventive health screens to PALM workers upon arrival in Australia is appropriate and cost-effective. The high participation experienced and overwhelmingly positive feedback received during this outbreak response suggest that this activity is well accepted by workers. The authors believe that this approach would reduce future STI presentations and health complications during workers’ stay in Australia, thereby achieving cost-effectiveness, though this latter point would require consideration by a health economist.
Additional considerations include how STI results should be managed and followed up when workers return to their home countries. This screening event specifically excluded Hepatitis B and C due to concerns regarding appropriate follow-up. These conditions usually require extended courses of treatment, especially for Hepatitis B, which might be longer than the workers’ stay in Australia. Representatives of the Australian Society for HIV, Viral Hepatitis and Sexual Health Medicine, who are experts in BBVs and STIs, have been working with various Pacific nations to strengthen testing and treatment programs, which will likely make inclusion of these diseases possible in the future.
Concerns have been raised by stakeholders that workers are likely to become reinfected upon return to their home countries, which could minimise the effectiveness of an arrival screening approach. While this is possible due to future intercourse with untreated partners in home countries, we argue that preventive sexual health screening on entry to Australia could still offer benefits by reducing BBV/STI transmission within PALM worker cohorts during their stay. This includes minimising the impacts of chronic infection, such as infertility and congenital syphilis (infecting unborn babies), and social issues that may arise from returning to their home country with a BBV/STI. Furthermore, it would decrease the risk of STI transmission from the PALM workers’ community to the Australian community, where BBV and STI rates are lower. Such a proactive response also provides an opportunity to include other health promotion activities, for example relating to family planning and immunisation, as well as broader reproductive health education, which can provide ongoing benefits to workers.
Health insurers, employers, NGOs and health providers around Australia are undertaking health promotion and education activities on sexual and reproductive health with PALM workers. While many of these are of high quality, unless they are accompanied by a clinical service that allows for easily accessible and acceptable STI testing and treatment, they are unlikely to be effective. PALM workers face many barriers to sexual and reproductive health care, justifying a tailored approach. While STIs and BBVs continue to spread worldwide, the Pacific carries a disproportionate burden of these infections, and responding to these issues among PALM workers in our communities should be given priority.
This article appeared first on Devpolicy Blog, from the Development Policy Centre at The Australian National University and has been republished here with the kind permission of the editor(s). The Blog is run out of the Development Policy Centre housed in the Crawford School of Public Policy in the ANU College of Asia and the Pacific at The Australian National University.
Contributing Author(s): Dr Mikaela Seymour is a public health medical officer working in Queensland, Australia. She has experience working in rural and remote medicine in PNG, assisting in the founding of the Aerial Health Program Western Province, and has worked as a research fellow at the PNG Institute of Medical Research. Dr Stefanie Vaccher is an epidemiologist with experience working in the Solomon Islands, Papua New Guinea and Fiji. Her PhD research focused on HIV and STI prevention in Australia.
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