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Tier 1 - Health status and outcomes

1.04 Respiratory disease

Key facts

Why is it important?

Respiratory diseases, such as asthma, chronic obstructive pulmonary disease (COPD) (including bronchitis and emphysema), pneumonia and invasive pneumococcal disease, are a major cause of poor health and death for Aboriginal and Torres Strait Islander people. Around two-fifths (42%) of the respiratory disease burden among Indigenous Australians in 2011 was attributed to smoking (AIHW 2016).

High rates of pneumonia are associated with factors such as other respiratory diseases, poor living conditions, malnutrition, smoking and harmful use of alcohol (Grau et al. 2014; Janu et al. 2014; Lim et al. 2014). Pneumococcal immunisation programs targeting Indigenous Australians demonstrate substantially lower coverage than recommended (National Aboriginal Community Controlled Health Organisation and The Royal Australian College of General Practitioners 2018). Young children and those in older age groups are most at risk. Indigenous children in the Northern Territory have a rate of radiologically confirmed pneumonia (that is, determined by a chest x-ray) that is among the highest in the world (O’Grady et al. 2010).

Asthma can affect physical functioning and attendance at school and work. It commonly coexists with other chronic conditions and low socioeconomic status. Deaths due to asthma occur in all age groups, but the risk of dying from asthma increases with age.

COPD is a serious lung disease that mainly affects older people and is associated with and caused by smoking, environmental pollutants and childhood infectious diseases such as pneumonia and bronchitis (Australian Institute of Health and Welfare 2019). Currently, 41% of Indigenous Australians aged 15 and over smoke, 2.9 times the non-Indigenous rate (see measure 2.15 Tobacco use). COPD is characterised by chronic obstruction of lung airflow that interferes with breathing. An analysis has found that among Indigenous Australians aged 55 and over that were hospitalised for COPD, cancer is a common comorbidity (Australian Institute of Health and Welfare 2011). The impaired lung function of people with COPD increases their lung cancer risk, and the risk of lung cancer is much higher in COPD patients with severe disease (Australian Institute of Health and Welfare 2014).

Burden of disease

Respiratory diseases (excluding acute infections) accounted for 8% of the total disease burden for Indigenous Australians in 2011. Asthma (41%) and COPD (38%) were the main contributors to the respiratory disease burden for Indigenous Australians. The burden from respiratory diseases in Indigenous Australians was 2.5 times the rate of non-Indigenous Australians and contributed 10% to the gap in total burden between Indigenous and non-Indigenous Australians. The burden for respiratory diseases was predominantly non-fatal (69%). Indigenous females experienced a higher burden (55%) compared with males (45%) (AIHW 2016).

Findings

What does the data tell us?

Deaths from respiratory diseases

In the period 2014–2018, there were 1,383 deaths of Indigenous Australians (9% of the total deaths of Indigenous Australians) due to respiratory diseases in the five jurisdictions combined with Indigenous identification data of adequate quality (New South Wales, Queensland, Western Australia, South Australia and the Northern Territory) (Table D1.04.1). This was twice the rate for non‑Indigenous Australians (104 and 52 per 100,000, respectively) (Table D1.23.1).

From 1998 to 2018, there was a 33% decline in deaths caused by respiratory diseases for Indigenous Australians (from 160 to 109 per 100,000). However, there was no significant change from 2006 onwards (Table D1.23.21, Figure 1.04.1).

Figure 1.04.1: Age-standardised mortality rates, respiratory diseases, by Indigenous status, NSW, Qld, WA, SA and NT, 1998–2018

This line chart shows that the rate of mortality caused by respiratory diseases for Indigenous Australians decreased from 160 per 100,000 to 101 per 100,000 in 2018 and that for non-Indigenous Australians the rate varied between 47 and 58 per 100,000 over the same period.

Source: Table D1.23.21. AIHW and ABS analysis of the ABS Causes of Death Collection.

For deaths of Indigenous Australians due to respiratory diseases in the period 2014–2018, 62% (856) were attributed to COPD, 17% (232) were due to pneumonia and influenza and 5% (63) were due to asthma. The rate of COPD was higher for Indigenous males compared with Indigenous females (79 and 61 per 100,000, respectively). The rate of COPD for Indigenous Australians (69 per 100,000) was 2.7 times the rate of non-Indigenous Australians (25 per 100,000) (Table D1.23.14, Figure 1.04.2).

Figure 1.04.2: Deaths from respiratory diseases for Indigenous Australians, by sex, NSW, Qld, WA, SA and NT, 2014–2018

This bar chart shows, for Indigenous Australians, the rate of mortality caused by respiratory diseases was higher for males than for females (117 per 100,000 compared with 96 per 100,000. In particular, rates of chronic obstructive pulmonary disorder were 79 per 100,000 for males and 61 per 100,000 for females.

Source: Table D1.23.14. AIHW and ABS analysis of the ABS Causes of Death Collection.

Self-reported data

Self-reported data on respiratory diseases is available from the 2018–19 National Aboriginal and Torres Strait Islander Health Survey.

In 2018–19, 29% (238,020) of Indigenous Australians self-reported having a respiratory disease lasting or likely to last six months or more (Table D1.04.2).

The most commonly self-reported respiratory conditions for Indigenous Australians were asthma (16%), chronic sinusitis (7.4%) and COPD (3.4%). After adjusting for differences in the age structure between the two populations, Indigenous Australians were 2.2 times as likely to report COPD (5% and 2%, respectively) and 1.6 times as likely to report asthma as non‑Indigenous Australians (18% and 11%, respectively) (Table 6.3) (ABS 2019) (Figure 1.04.3).

Figure 1.04.3: Age-standardised proportion reporting respiratory disease, by Indigenous status, 2018–19

This bar chart shows that 33% of Indigenous Australians and 30% of non-Indigenous Australians reported having respiratory diseases. In particular, 18% of Indigenous Australians and 11% of non-Indigenous reported having Asthma.

Source:  National Aboriginal and Torres Strait Islander Health Survey 2018–19 (ABS Table 6.3).

The proportion of self-reported asthma for Indigenous Australians was 16% in 2018-19, about the same as in 2012-13 (18%) (10).

Indigenous females (32%) reported a higher rate of respiratory diseases compared with Indigenous males (26%) (9).

Indigenous Australians living in Non‑remote areas (32%) reported a higher rate of respiratory disease than those in Remote areas (15%). By jurisdiction, Indigenous Australians living in Tasmania reported the highest rate (43%), while those in the Northern Territory reported the lowest (12%).

There was also an increase in the rate of respiratory diseases as age increased, ranging from 19% for Indigenous Australians aged 0–14, to 37% in the 45–54 age group (Table D1.04.2).

Hospitalisations

Although hospitalisation statistics reflect separations from hospital rather than the prevalence or incidence of diseases in the community, they are a measure of the occurrence of conditions requiring acute care.

Between July 2015 and June 2017, there were 51,766 hospitalisations with a principal diagnosis of a respiratory disease among Indigenous Australians (9.5% of total Indigenous hospitalisations, excluding dialysis) (Table D1.02.5).

After adjusting for differences in the age structure between the two populations, the hospitalisation rate of Indigenous Australians for respiratory diseases was 2.2 times the rate for non‑Indigenous Australians (41 and 18 per 1,000 respectively) (Table D1.04.7, Figure 1.04.4).

The hospitalisation rate for respiratory diseases for Indigenous Australians was highest for those aged 65 and over (101 per 1,000), followed by those aged 0–4 (79 per 1,000) (Table D1.04.8, Figure 1.04.4).

Figure 1.04.4: Age-specific hospitalisation rates for a principal diagnosis of diseases of the respiratory system, by Indigenous status and age, Australia, July 2015 to June 2017

This bar chart shows that, the hospitalisation rate for a principal diagnosis of diseases of the respiratory system was 41 per1,000 for Indigenous Australians and 18 per 1,000 for non-Indigenous Australians. For Indigenous Australians, the rate increased with age from 12 per 1,000 for the 15-24 age groups to 101 per 1,000 for those aged 65 and over. The rate for children aged 0 to 4 was 79 per 1,000 for Indigenous Australians and 49 per 1,000 for non-Indigenous Australians.

Note: Totals are age-standardised.

Source: Table D1.04.8. AIHW analysis of National Hospital Morbidity Database.

In the period from July 2015 to June 2017, pneumonia (21%) was the most common type of respiratory disease for which Indigenous Australians were hospitalised, followed by bronchitis and emphysema (19%). The greatest differences in rates between Indigenous and non-Indigenous Australians were for bronchitis and emphysema (a difference of 9.3 per 1,000) and pneumonia (a difference of 6.7 per 1,000) (Table D1.04.10).

Indigenous Australians aged 35–44 (5.2 per 1,000) were 16 times as likely as non-Indigenous Australians (0.3 per 1,000) to be hospitalised for bronchitis and emphysema (Table D1.04.16).

The hospitalisation rate of Indigenous Australians for respiratory diseases was highest in the Northern Territory (68 per 1,000) followed by Western Australia (52 per 1,000) (Table D1.04.7, Figure 1.04.5).

Figure 1.04.5: Age-standardised hospitalisation rates for a principal diagnosis of diseases of the respiratory system, by Indigenous status and jurisdiction, Australia, July 2015 to June 2017

This bar chart shows that for Indigenous Australians the hospitalisation rate for a principal diagnosis of diseases of the respiratory system was highest in the Northern Territory (68 per 1,000), followed by Western Australia (52 per 1,000), and was lowest in Tasmania (16 per 1,000).

Source: Table D1.04.7. AIHW analysis of National Hospital Morbidity Database.

Indigenous Australians living in Remote areas were 2.5 times as likely to be hospitalised for respiratory diseases compared with those living in Major cities (71 and 29 per 1,000, respectively), however the rate was similar across remoteness areas for non-Indigenous Australians (Table D1.04.9, Figure 1.04.6).

Figure 1.04.6: Age-standardised hospitalisations for a principal diagnosis of diseases of the respiratory system, by Indigenous status and remoteness, Australia, July 2015 to June 2017

This bar chart shows that, for Indigenous Australians the hospitalisation rate for a principal diagnosis of diseases of the respiratory system was 41 per 1,000 and 18 per 1,000 for non-Indigenous Australians. The rate for Indigenous Australians increased with remoteness  from 29 per 1,000 in Major cities to 71 per 1,000 in Remote areas; In very remote areas the rate was 67 per 1,000. For non-Indigenous Australians, the rate was similar among remoteness categories ranging from 18 to 21 per 1,000.

 Source: Table D1.04.9. AIHW analysis of National Hospital Morbidity Database.

Considering hospitalisations for respiratory diseases by jurisdiction and remoteness, the greatest relative difference between Indigenous and non-Indigenous Australians was in Remote areas of Western Australia, followed by Remote areas of South Australia (where the rate for Indigenous Australians were 4.6 times and 3.7 times the rate of non-Indigenous Australians, respectively) (Table D1.04.217).

Between 2004–05 and 2016–17, there was a 22% increase in the hospitalisation rate for Indigenous Australians due to respiratory diseases in the six jurisdictions combined with Indigenous identification data of adequate quality (New South Wales, Victoria, Queensland, Western Australia, South Australia and the Northern Territory). The rate for Indigenous children aged 0–4 increased by 33% in the same six jurisdictions combined over the same period (Table D1.04.11, Table D1.04.12, Figure 1.04.7).

Figure 1.04.7: Age-standardised hospitalisation rates for principal diagnosis of diseases of the respiratory system, by Indigenous status, NSW, Vic, Qld, WA, SA and NT, 2004–05 to 2016–17

This line chart shows that, for Indigenous Australians the hospitalisation rate for a principal diagnosis of diseases of the respiratory system increased from 35 per 1,000 in 2004-05 to 44 per 1,000 in 2016-17, and increased from 16 to 19 per 1,000 for non-Indigenous Australians.

Source: Table D1.04.11. AIHW analysis of National Hospital Morbidity Database.

Notifiable diseases

Notifiable diseases data are collected by States and Territories under their public health legislation. This legislation has required medical practitioners, and some other classes of people, to notify health authorities of certain communicable and other diseases (DoHA 2003).

Infection with invasive Streptococcus pneumoniae is responsible for significant morbidity and mortality worldwide, especially in the very young, the elderly and those with predisposing risk factors (DoH 2016). In the three-year period of 2016–2018 there were 626 notifications of invasive pneumococcal disease for Indigenous Australians, representing 14% of all cases notified (Table D1.04.15).

What do research and evaluations tell us?

A recent study in the Northern Territory found that Indigenous patients referred to respiratory specialist outreach teams in remote and rural communities of the Top End have a significantly higher rate of smoking and COPD compared with non-Indigenous patients referred to this service. Bronchiectasis is also more common among Indigenous patients (Kruavit et al. 2017). The study suggested there is a need to focus resources on reducing the rate of smoking in these areas, and further improve the quality of health care with a focus on primary health care. In addition to education provided by the respiratory outreach team, Indigenous health workers could provide information on tobacco and quit support to the community. Another recent study conducted in the Top End found that Indigenous patients with COPD had a higher prevalence of smoking, moderate to severe airflow obstruction on spirometry and were frequently co-diagnosed with bronchiectasis with increased severity of ventilatory impairment, compared with Indigenous patients who did not have a diagnosis of COPD (Heraganahally et al. 2019).

Research conducted in the United States suggested that public health approaches, such as tobacco control, addressing air pollution and occupational exposures, have the best chance of substantially reducing the burden of lung disease around the world. These could have enormous effects on reducing morbidity and mortality caused by lung disease (Schluger & Koppaka 2014). The World Health Organization Framework Convention on Tobacco Control acknowledges the need to take measures to promote the participation of indigenous peoples and communities in the development, implementation and evaluation of tobacco control programs (WHO 2003). It recognises the effectiveness and importance of non-price measures in reducing the demand for tobacco, including protection from exposure to tobacco smoke; and education, communication, training and public awareness.

A recent overview of respiratory diseases in Indigenous children found a lack of research among Indigenous children living in urban and regional areas, as most research has been conducted in remote areas (Australian Indigenous HealthInfoNet 2020). The overview identified a 2013–2015 study of Indigenous children who visited the Caboolture Community Medical clinic in northern Brisbane, which found that 33% had symptoms of an acute respiratory infection, and 22% went to the clinic specifically because of an acute respiratory infection (Hall et al. 2017). A subsequent study of mostly Indigenous children who visited the Caboolture Community Medical clinic over a similar period in 2013–2015 found that, in an average month, about one-quarter of the children were attending the clinic with an acute respiratory infection with a cough. The study results indicated that one in five children will develop a chronic cough following acute respiratory infections with a cough. The overview also identified several community-based studies in remote areas. A 2010–2013 study of Indigenous children from 25 remote Northern Territory communities found that 59% of children had a runny nose and 39% had a cough (Leach et al. 2016). Another study of Indigenous children born between 2001 and 2006 in five remote Northern Territory communities found that by the time they turned one year old, 96% of babies had gone to their health service with at least one infection, many infections were recurrent, and infections of the upper respiratory tract were the most common (Kearns et al. 2013).

Universal pneumococcal conjugate vaccine (PCV) programs began for Indigenous Australian children in 2001 and all Australian children in 2005, and 13-valent PCV was introduced in 2011 (Meder et al. 2020). To help prevent pneumococcal disease it is recommended that Indigenous children are vaccinated with 13-valent PCV at two, four and six months of age, with an additional dose given at 12–18 months of age if living in Queensland, the Northern Territory, Western Australia or South Australia (NACCHO and The Royal Australian College of General Practitioners 2018). An assessment of the effect of PCV examined acute lower respiratory infection (ALRI) hospital admissions of Indigenous infants in the Northern Territory from 2006 to 2015, across three periods of different PCV use (Binks et al. 2020). The study found that there was a 30% reduction in bacterial-coded pneumonia hospitalisations during the 2011–2015 period in which 13-valent PCV was used. The authors concluded that while the findings supported the use of this vaccine, one in five Indigenous infants continued to be hospitalised with an ALRI within their first year of life, and a combination of environmental and biomedical approaches are needed.

Researchers have conducted a range of studies of respiratory disease services. These include a study in Western Australia that found that the implementation of an integrated COPD multidisciplinary community service reduced respiratory hospitalisations in the long term (Chung et al. 2016). A large pilot study in Queensland showed the importance of working with communities and Indigenous staff in the development and delivery of a culturally appropriate and accessible specialist respiratory service (Medlin et al. 2014). The Indigenous Respiratory Outreach Care (IROC) program aims to develop and deliver culturally appropriate specialist respiratory outreach services and resources to Indigenous Australians in rural and remote Queensland communities, improve access to specialist respiratory services; and increase awareness of lung health in Indigenous communities. A study of children attending IROC clinics found that the model of care led to significant lung function improvement for Indigenous children with asthma and bronchiectasis (Collaro et al. 2020). Researchers in New Zealand also found that Māori participants felt strongly discouraged to attend pulmonary rehabilitation when culturally appropriate communication and relationship-building was absent (Levack et al. 2016).

Implications

While the mortality rate of Indigenous Australians due to respiratory diseases has fallen since 1998, most of this decline occurred prior to 2006. Since 2006, there has been no significant change in the mortality rate. Further, self-reported respiratory diseases, hospitalisation and mortality rates are still around twice as high for Indigenous Australians compared with non-Indigenous Australians. While rates of self-reported asthma and COPD for Indigenous Australians were similar in 2012–13 and 2018–19 (ABS 2019), overall, there was a 22% increase in the hospitalisation rate for Indigenous Australians due to respiratory diseases between 2004–05 and 2016–17. Chronic respiratory diseases, especially COPD and asthma, are major contributors to the burden of disease for Indigenous Australians.

While it is important to manage patients with chronic respiratory diseases effectively, much of this burden is preventable and public health approaches are critical to prevent their occurrence. Initiatives addressing smoking (including second-hand smoke), immunisation, living conditions, overcrowding, chronic disease and access to health care are likely to contribute to improvements in respiratory disease (Johnston et al. 2010; Torzillo & Chang 2014). Culturally appropriate communication and health services are essential to ensure Indigenous Australians feel comfortable to participate in disease prevention and medical therapies.

Further research into individual respiratory conditions for Indigenous Australians is needed particularly in Non-remote settings. The aggregated statistics provide an unclear picture, with higher self-reported prevalence in Non-remote areas, but higher hospitalisations in Remote areas. The degree to which this reflects issues around access to health care and the severity of particular acute illnesses requiring hospitalisation in Remote areas, or the validity of the self-report survey data in Remote areas, is not clear. In Australia, a number of health policies have been implemented to reduce the burden of chronic respiratory disease among Indigenous Australians, including the Indigenous Australians’ Health Programme, National Strategic Action Plan for Lung Conditions and the National Asthma Strategy.

The data in this measure predate the arrival of COVID-19. An analysis of the impact of COVID-19 on Indigenous Australians will be a topic for future research.

The policy context is at Policies and strategies.

References

  • ABS (Australian Bureau of Statistics) 2019. National Aboriginal and Torres Strait Islander Health Survey, 2018–19. 4715.0. Canberra: ABS.
  • AIHW (Australian Institute of Health and Welfare) 2011. Asthma in Australia 2011: with a focus chapter on chronic obstructive pulmonary disease. Canberra: AIHW.

  • AIHW 2014. Coronary heart disease and chronic obstructive pulmonary disease in Indigenous Australians. Canberra: AIHW.

  • AIHW 2016. Australian Burden of Disease Study: impact and causes of illness and death in Aboriginal and Torres Strait Islander people 2011. Australian Burden of Disease Study series 6. Cat. no. BOD 7. Canberra: AIHW.
  • AIHW 2019. Chronic obstructive pulmonary disease (COPD). Canberra: AIHW. 
  • Australian Indigenous HealthInfoNet 2020. Summary of respiratory diseases among Aboriginal and Torres Strait Islander children. Perth, WA.
  • Binks MJ, Beissbarth J, Oguoma VM, Pizzutto SJ, Leach AJ, Smith-Vaughan HC et al. 2020. Acute lower respiratory infections in Indigenous infants in Australia's Northern Territory across three eras of pneumococcal conjugate vaccine use (2006–15): a population-based cohort study. The Lancet Child & Adolescent Health 4:425-34.
  • Chung LP, Lake F, Hyde E, McCamley C, Phuangmalai N, Lim M et al. 2016. Integrated multidisciplinary community service for chronic obstructive pulmonary disease reduces hospitalisations. Internal Medicine Journal 46:427-34.
  • Collaro AJ, Chang AB, Marchant JM, Masters IB, Rodwell LT, Takken AJ et al. 2020. Culturally Appropriate Outreach Specialist Respiratory Medical Care Improves the Lung Function of Children in Regional and Remote Queensland. Lung:1-9.
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  • Heraganahally SS, Wasgewatta SL, McNamara K, Eisemberg CC, Budd RC, Mehra S et al. 2019. Chronic Obstructive Pulmonary Disease In Aboriginal Patients Of The Northern Territory Of Australia: A Landscape Perspective. International Journal of Chronic Obstructive Pulmonary Disease 14:2205.
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  • Johnston V, Walker N, Thomas DP, Glover M, Chang AB, Bullen C et al. 2010. The study protocol for a randomized controlled trial of a family-centred tobacco control program about environmental tobacco smoke (ETS) to reduce respiratory illness in Indigenous infants. BMC Public Health 10:114.
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  • Leach AJ, Wigger C, Beissbarth J, Woltring D, Andrews R, Chatfield MD et al. 2016. General health, otitis media, nasopharyngeal carriage and middle ear microbiology in Northern Territory Aboriginal children vaccinated during consecutive periods of 10-valent or 13-valent pneumococcal conjugate vaccines. International journal of pediatric otorhinolaryngology 86:224-32.
  • Levack WM, Jones B, Grainger R, Boland P, Brown M & Ingham TR 2016. Whakawhanaungatanga: the importance of culturally meaningful connections to improve uptake of pulmonary rehabilitation by Māori with COPD–a qualitative study. International Journal of Chronic Obstructive Pulmonary Disease 11:489.
  • Lim FJ, Lehmann D, McLoughlin A, Harrison C, Willis J, Giele C et al. 2014. Risk factors and comorbidities for invasive pneumococcal disease in Western Australian Aboriginal and non-Aboriginal people. Pneumonia 4:24-34.
  • Meder KN, Jayasinghe S, Beard F, Dey A, Kirk M, Cook H et al. 2020. Long-term Impact of Pneumococcal Conjugate Vaccines on Invasive Disease and Pneumonia Hospitalizations in Indigenous and Non-Indigenous Australians. Clinical Infectious Diseases 70:2607-15.
  • Medlin LG, Chang AB, Fong K, Jackson R, Bishop P, Dent A et al. 2014. Indigenous Respiratory Outreach Care: the first 18 months of a specialist respiratory outreach service to rural and remote Indigenous communities in Queensland, Australia. Australian Health Review 38:447-53.
  • NACCHO (National Aboriginal Community Controlled Health Organisation) and The Royal Australian College of General Practitioners 2018. National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people. Third edition. East Melbourne, Vic.
  • O’Grady K, Taylor-Thomson DM, Chang AB, Torzillo PJ, Morris PS, Mackenzie GA et al. 2010. Rates of radiologically confirmed pneumonia as defined by the World Health Organization in Northern Territory Indigenous children. The Medical Journal of Australia 192:592-5.
  • Schluger NW & Koppaka R 2014. Lung disease in a global context. A call for public health action. Annals of the American Thoracic Society 11:407-16.
  • Torzillo PJ & Chang AB 2014. Acute respiratory infections among Indigenous children. The Medical Journal of Australia 200:559-60.
  • WHO (World Health Organization) 2003. WHO Framework Convention on Tobacco Control. Geneva, Switzerland.

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