Healthy!Skin,!Healthy!Lives!workshop!

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Healthy!Skin,!Healthy!Lives!workshop!
Perth,!12*13!December!2012!
Report!
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The!Telethon!Institute!for!Child!Health!Research!would!like!to!
acknowledge!the!WA!Department!of!Health!as!the!funding!source!
for!this!workshop.
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Executive!summary!
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The! workshop,! which! brought! together! researchers,! healthcare! providers,! policy!
makers! and! other! key! stakeholders,! focused! on! two! key! questions:! (i)! What! is! the!
current! status! and! base! of! knowledge! in! relation! to! scabies! and! skin! sore! control! in!
remote! Aboriginal! populations?! (ii)! Given! what! is! known,! if! skin! infections! in! WA’s!
remote! Aboriginal! communities! are! determined! to! be! a! health! priority,! which! actions!
can! be! taken! now! to! significantly! decrease! the! burden! of! skin! infections! in! these!
communities!over!the!next!few!years?!
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The! outcome! of! the! workshop! brought! forward! the! following! set! of! key! principles,!
which!should!be!considered!as!the!basis!for!any!future!control!program:!
(i)
CommunityJbased! ivermectin! and/or! permethrin! mass! drug! administration!
campaigns! might! have! a! role! to! play! in! significantly! lowering! the! prevalence! of!
scabies!and!related!skin!infections!in!high!burden!communities!in!WA.!However,!
such!an!intervention!should!be!considered!only!secondary!to!other!communityJ
level!interventions!that!aim!to!improve!routine!healthcare!delivery!mechanisms!
and!its!capabilities!to!systematically!screen!and!treat!for!scabies!and!associated!
skin!infections,!particularly!in!infants;!
(ii)
The! screening! and! clinical! management! of! skin! infections! can! be! improved! by!
developing! and! implementing! guidelines! and! clinical! algorithms! for! healthcare!
providers,!health!workers!and!community!workers;!
(iii) Monitoring!mechanisms!specific!to!the!early!detection!and!treatment!of!‘hyperJ
transmitters’!should!be!put!in!place;!
(iv) Any! program! aiming! to! improve! the! control! of! skin! infections! in! remote!
Aboriginal!communities!must!be!multiJfacetted!and!comprehensive!in!a!way!that!
it! also! addresses! the! broader! determinants! that! underlie! this! health! issue.! ! No!
single!intervention!or!strategy!in!itself!is!sufficient!for!the!sustainable!control!of!
skin!infections;!!!
(v)
A! commitment! to! community! participation,! education! and! empowerment! are!
essential! in! terms! of! reducing! skin! infection! rates! and! supporting! the!
acceptability!and!sustainability!of!any!interventions;!
(vi) The! monitoring! and! evaluation! of! intervention! outcomes! should! go! beyond!
measuring! the! prevalence! of! skin! infections! and! should! also! consider! other!
possible!benefits!that!may!result!from!the!program.!
!
Based!on!these!six!principles,!a!process!has!now!been!initiated!with!the!support!of!the!
WA! Department! of! Health! to! formalize! a! comprehensive! ‘Healthy! skin,! Healthy! lives’!
program!proposal!for!remote!Aboriginal!communities!in!Western!Australia.!!Additional!
consultations!with!communities!and!other!stakeholders!will!be!organized!in!the!coming!
months! with! this! proposal! in! mind.! ! Data! collection! activities! will! be! set! up! to! further!
document! the! burden! of! skin! infections! in! WA’s! remote! Aboriginal! communities,! and!
draft!materials!and!resources!will!be!prepared!that!may!be!utilized!within!the!program!
or!in!the!event!of!any!future!scabies!outbreak.!The!aim!is!to!commence!the!program’s!
implementation!by!late!2013.!!!
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This! report! summarizes! the! knowledge! and! experiences! shared! during! the! workshop,!
provides! an! overview! of! the! discussions! that! took! place! and! describes! the! next! steps!
forward!that!were!agreed!upon.!
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Abbreviations!
!
AMS!
Aboriginal!medical!service!
BHP!BIO!
BHP!Billiton!Iron!Ore!!
BSI!
CICH!
CREAHW!
blood!stream!infections!
Centre!for!International!Child!Health!
FIFO!
Centre! for! Research! Excellence! in! Aboriginal! Health! and!
Wellbeing!
FlyJin!FlyJout!
IJAEDI!
Indigenous!Australian!Early!Development!Index!
GAS!
IMCI!
MDA!
MSHR!
PSGN!
RHD!
RLSSWA!
SHIFT!
TICHR!
WAACHS!
WA!
!
!
group!A!streptococcus!
Integrated!management!of!childhood!illnesses!
mass!drug!administration!
Menzies!School!of!Health!Research!
post!streptococcal!glomerulonephritis!
rheumatic!heart!disease!
Royal!Life!Saving!Society!Western!Australia!
Skin!health!intervention!Fiji!Trial!
Telethon!Institute!for!Child!Health!Research!
Western!Australian!Aboriginal!Child!Health!Survey!
Western!Australia!
!
!Appendices!
!
1. Workshop!program!
2. List!of!participants!
3. A!paper!submitted!to!the!‘Healthy!Skin,!Healthy!Lives’!workshop!J!by!John!Boulton!
4. Skin!infections,!scabies!and!their!sequelae!–!presentation!by!Jonathan!Carapetis!
5. Healthy!Skin,!Healthy!Lives:!Setting!the!scene!–!presentation!by!Roz!Walker!
6. Impact!of!swimming!pools!on!health!of!Aboriginal!children!in!remote!communities!
of!Western!Australia!–!presentation!by!Deborah!Lehmann!
7. Current!evidence!for!effectiveness!of!swimming!pools!for!skin!infections!and!ear!
disease!–!presentation!by!David!Hendrickx!
8. Remote!Aboriginal!swimming!pool!program!–!presentation!by!Amanda!Juniper!
9. Healthy!Skin:!Experiences!from!the!NT!since!2004!–!presentation!by!Ross!Andrews!
10. Is!MDA!an!effective!public!health!measure!to!reduce!prevalence!of!scabies!and!
strongyloides?!–!presentation!by!Therese!Kearns!
11. SHIFT:!a!new!trial!of!mass!drug!administration!for!scabies!control!in!a!high!
prevalence!country!–!presentation!by!Andrew!Steer!
12. Experiences!from!the!East!Arnhem!Scabies!Control!Program!–!presentation!by!Tim!
Foster!
13. Introducing!the!International!Alliance!for!the!Control!of!Scabies!–!presentation!by!
Andrew!Steer!
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Session!1!–!Introduction!&!setting!the!scene!
!
Summary!of!the!session!
There! is! currently! considerable! interest! in! the! control! of! skin! infections! in! Western!
Australia.!!The!WA!Minister!of!Health,!Kim!Hames,!is!particularly!interested!in!the!role!
swimming! pools! could! play! in! reducing! skin! infections! and! lowering! rates! of! kidney!
disease!in!WA!Aboriginal!populations.!!In!2011!the!Telethon!Institute!for!Child!Health!
Research! (TICHR)! published! a! report! constituting! a! literature! review! of! the! current!
evidence!on!the!link!between!skin!infections!and!longJterm!kidney!disease.!!In!addition,!
TICHR!Associate!Professor!Roz!Walker!identified!scabies!and!other!skin!infections!as!a!
significant! health! problem! during! her! research! funded! through! the! BHP! Billiton! Iron!
Ore!(BHP!BIO)!Community!Investment!Program!and!Telethon!Institute!for!Child!Health!
Research!partnership.!!Her!research!involves!working!in!partnership!with! schools!and!
communities!to!implement!the!Australian!Early!Development!Index!(validated!through!
the!IndigenousJAEDI!adaptation)!and!community!program!evaluations!in!the!Pilbara.!!
!
The! aim! of! this! workshop! was! to! discuss! the! possibility! of! devising! a! broader!
intervention! for! the! improved! control! of! skin! infections! in! WA’s! remote! Aboriginal!
communities,!as!well!as!discussing!what!such!an!intervention!would!look!like!and!how!
it!might!be!evaluated.!!A!practical!and!sustainable!strategy!should!be!envisioned.!!The!
aim!is!to!put!in!a!funding!application!for!the!implementation!of!such!a!program!in!the!
near!future.!
!
Presentations!
Skin%infections,%scabies%and%their%sequelae%%%
(presentation!by!Jonathan!Carapetis,!for!slides!see!Appendix!4)!
This!presentation:!
(i)
discussed!the!kinds!of!skin!infections!that!are!prevalent!in!remote!Aboriginal!
communities;!!!
(ii)
elaborated! on! the! link! between! scabies,! bacterial! skin! infections! and! three!
other! severe! conditions:! rheumatic! heart! disease! (RHD),! postJstreptococcal!
glomerulonephritis!(PSGN)!and!blood!stream!infections!(BSI);!
(iii) highlighted! other! medical,! social! and! educational! implications! of! skin!
infections;!
(iv) introduced! a! model! for! controlling! skin! infections! using! mass! drug!
administration! (MDA)! strategies! as! a! possible! approach! to! reducing! scabies!
and!skin!sore!rates!in!remote!communities.!
!
Healthy%Skin,%Healthy%Lives%–%Setting%the%scene%
(presentation!by!Roz!Walker,!for!slides!see!Appendix!5)!
This!presentation!!
(i)
introduced! the! Centre! for! Research! Excellence! in! Aboriginal! Health! and!
Wellbeing! (CREAHW),! its! activities,! aims,! and! its! participatory! and!
empowering!research!methods;!!
(ii)
discussed! the! implementation! of! the! IJAEDI! in! the! Pilbara! through! the! BHP!
Billiton! Iron! Ore! Community! Investment! Program! and! TICHR! partnership!
and!the!implications!of!the!outcomes!of!this!project;!
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(iii)
described!the!process!that!led!up!to!the!identification!of!skin!infections!as!a!
significant!health!issue!in!the!Pilbara’s!Aboriginal!communities.!
!
Session!2!K!Introductory!presentations:!The!importance!of!skin!infections!and!
scabies,!and!measures!to!control!them.!
!
Summary!of!session!
This! session! primarily! provided! an! overview! of! the! current! base! of! knowledge!
regarding! skin! infections! in! Australia’s! remote! Aboriginal! communities! and! the! Fiji!
islands.!!Research!outcomes!of!work!performed!by!TICHR,!the!Menzies!School!of!Health!
Research!(MSHR)!and!the!Centre!for!International!Child!Health!(CICH)!were!presented.!!
Two! important! stakeholders! also! presented! an! update! of! their! activities;! Royal! Life!
Saving! Society! Western! Australia! (RLSSWA)! Jgiven! their! role! in! managing! community!
swimming!poolsJ!and!OneJDiseaseJatJaJTime,!a!notJforJprofit!dedicated!to!the!control!of!
scabies! in! remote! Aboriginal! communities.! ! Key! topics! covered! in! the! presentations!
included:!
(i)
the!effectiveness!of!swimming!pools!for!the!reduction!of!skin!infections!and!ear!
disease;!
(ii)
the! potential! and! limitations! of! MDA! strategies! for! the! control! of! scabies! and!
associated!skin!infections;!!
(iii) the! importance! of! communityJbased! approaches! for! the! effectiveness! and!
sustainability!of!any!control!intervention.!
!
Presentations!
Impact%of%swimming%pools%on%health%of%Aboriginal%children%in%remote%communities%
of%Western%Australia%
%(presentation!by!Deborah!Lehmann,!for!slides!see!Appendix!6)!
This! presentation! provided! an! overview! of! the! TICHR! swimming! pool! studies,! which!
supported!the!role!of!swimming!pools!as!a!public!health!measure!for!the!improvement!
of! skin! and! ear! health!in! remote! Aboriginal! communities.! ! The! presentation! discussed!
study! outcomes,! limitations! and! implications.! ! Deborah! Lehmann! is! currently! looking!
into!the!possibility!of!performing!a!followJup!study!to!document!the!longJterm!impact!
of!the!swimming!pools.!
!
Current% evidence% for% effectiveness% of% swimming% pools% for% skin% infections% and% ear%
disease!
(presentation!by!David!Hendrickx,!for!slides!see!Appendix!7)!
This! presentation! provided! an! overview! of! the! outcomes! of! all! previously! conducted!
studies! that! have! evaluated! the! direct! health! benefits! of! swimming! pools! in! remote!
Aboriginal!communities.!!Although!study!outcomes!differed!in!regards!to!ear!infections,!
all! studies! that! investigated! skin! health! reported! significant! reductions! in! skin! sores!
shortly! after! the! opening! of! community! swimming! pools.! ! Several! methodological!
challenges!related!to!these!kinds!of!studies!were!also!discussed.!!
!
Remote%Aboriginal%swimming%pool%program!
(presentation!by!Amanda!Juniper,!for!slides!see!Appendix!8)!
This!presentation!summarized!the!activities!of!the!RLSSWA’s!Aboriginal!swimming!pool!
program! in! six! Aboriginal! communities! in! WA.! ! These! consist! of! ensuring! the! proper!
management! and! maintenance! of! swimming! pools,! the! development! of! community!
swimming! pool! programs,! and! organizing! various! training! activities.! ! The! program!
might! be! extended! to! additional! communities! in! the! future.! ! The! RLSSWA! intends! to!
!
!
perform! an! evaluation! of! the! noJschoolJnoJpool! policy! in! the! near! future.! ! This! might!
possibly! be! done! in! collaboration! with! Curtin! University! (Population! Health! Unit)! or!
TICHR.!
!
Healthy%Skin%C%Experiences%from%the%NT%since%2004%
(presentation!by!Ross!Andrews,!for!slides!see!Appendix!9)!
This!presentation!provided!an!overview!of!the!East!Arnhem!Healthy!Skin!Project,!which!
was!implemented!by!the!MSHR!and!ran!from!2004!to!2007.!!The!program!centered!on!
community! workers! who! monitored! for! skin! infections! and! referred! people! for! care!
where!necessary.!!These!workers!received!training!and!formal!accreditation.!!!Skin!sore!
prevalences!dropped!significantly,!but!scabies!prevalences!remained!unchanged.!!!
Some!key!lessons!learned!included!the!following:!!
(i)
A!major!barrier!to!reducing!scabies!prevalence!was!the!limited!treatment!uptake!
(lyclear! scabies! cream! –! permethrin! 5%)! by! household! contacts,! making!
reinfection!common.!!Alternative!treatment!options!should!be!explored.!!
(ii)
Monitoring!activities!should!focus!on!infants,!as!they!are!‘sentinels’! for!changes!
in!incidence.!!Clinical!records!are!a!good!starting!point!to!estimate!prevalence.!
(iii) Efforts! should! be! made! to! deJnormalize! scabies! through! social! marketing!
strategies.!
!
Points!raised!during!postJpresentation!discussion:!
Prevalence! surveys! of! skin! infections! are! not! strictly! necessary,! especially! if! good!
quality!clinical!records!are!available.!
Scabies!should!not!be!portrayed!to!the!communities!as!resulting!from!bad!hygiene;!
it!should!be!made!clear!that!the!target!is!the!mite.!!The!mite!is!at!fault,!not!Aboriginal!
people.!
Social! determinants! are! important! to! consider! but! should! not! stifle! the!
implementation! of! specific! interventions! aimed! at! reducing! skin! infections.! ! The!
social! determinants! argument! can! be! disempowering! if! it! argues! that! without!
dealing!with!poverty!and!housing!nothing!can!be!done!about!scabies.!
!
Is% MDA% an% effective% public% health% measure% to% reduce% prevalence% of% scabies% and%
strongyloides?%
(presentation!by!Therese!Kearns,!for!slides!see!Appendix!10)!
This!presentation!discussed!the!implementation!and!outcomes!of!a!research!project!by!
the! MSHR! (2010J2012)! that! evaluated! the! effectiveness! of! an! ivermectin! MDA! for! the!
control!of!scabies!and!strongyloides!in!remote!Aboriginal!communities!in!the!Northern!
Territory.!!The!study!was!not!able!to!demonstrate!an!unequivocal!reduction!in!scabies!
prevalence!over!an!18Jmonth!period.!!A!low!initial!prevalence!(4%)!and!the!occurrence!
of!hyperJinfective!crusted!scabies!cases!in!the!community!during!the!course!of!the!study!
explain! this! observation.! ! Nevertheless,! intermediate! screenings! did! provide! an!
indication!that!an!ivermectin!MDA!could!lower!the!prevalence!of!scabies.!
!
Some!lessons!learned!included!the!following:!
(i)
Although! the! community! considers! ivermectin! an! acceptable! treatment!
option,! administering! it! can! be! laborJintensive! given! the! need! to! screen!
weight!and!pregnancy!status.!
!
!
(ii)
(iii)
Engaging! and! training! local! community! workers! was! essential! in! the!
implementation!of!this!study!and!in!ensuring!the!education!and!participation!
of!community!members.!
Monitoring! and! treating! crusted! scabies! cases! is! essential! for! avoiding!
scabies!outbreaks.!
!
SHIFT:% a% new% trial% of% mass% drug% administration% for% scabies% control% in% a% high%
prevalence%country!
(presentation!by!Andrew!Steer,!for!slides!see!Appendix!11)!
This! presentation! introduced! the! skin! health! intervention! Fiji! trial! (SHIFT)! that! is!
currently!being!implemented!on!several!Fijian!islands.!!The!study!will!make!a!threeJway!
comparison!between!(i)!a!standard!of!care!treatment!regimen!based!on!the!Integrated!
Management! of! Childhood! Illnesses! (IMCI)! guideline;! (ii)! a! permethrinJbased! MDA!
strategy,!and!(iii)!an!ivermectinJbased!MDA!strategy.!!The!study!will!also!consider!and!
compare! the! costJeffectiveness! of! the! different! treatment! strategies.! ! The! outcomes! of!
this!study!will!provide!important!evidence!for!determining!scabies!treatment!strategies.!!
!
Experiences%from%the%East%Arnhem%Scabies%Control%Program!
(presentation!by!Tim!Steer,!for!slides!see!Appendix!12)!
This! presentation! provided! an! overview! of! the! activities! of! 1JDiseaseJatJaJTime!
(www.1disease.org),!a!notJforJprofit!aiming!to!eliminate!scabies!as!a!public!health!issue!
throughout! Australia’s! Aboriginal! communities.! ! 1Disease! is! currently! focusing! on!
communities! in! East! Arnhem! Land,! where! they! are! implementing! a! scabies! control!
program!in!collaboration!with!Miwatj!Health.!!Their!activities!have!moved!from!a!region!
wide!MDA!approach!to!a!strategy!based!on!active!screening,!treatment,!chronic!care!and!
community! engagement,! with! a! tailored! approach! for! the! specific! needs! of! each!
community.!
!
Some!lessons!learned!included!the!following:!
(i)
Social! and! cultural! gatherings! are! highJrisk! moments! for! increased! scabies!
transmission.!!Control!strategies!should!account!for!this.!
(ii)
TurnJover!of!clinical!staff!is!an!issue,!new!healthcare!providers!arriving!in!the!
area!are!often!unaware!of!scabies,!its!symptoms!and!implications.!
(iii) Sustainability! is! an! important! consideration.! ! Therefore! exit! strategies! for!
disease!control!programs!should!be!considered!from!the!start,!ensuring!there!
is!a!communityJlevel!capacity!to!continue!activities!in!the!longer!term.!
!
Points!raised!during!discussion!after!presentation:!
Community! health! education! and! social! marketing! is! important,! but! how! do! you!
identify!the!key!messages!you!want!to!convey?!!Community!focus!groups!have!a!role!
to!play!here.!
TeleJhealth!strategies!might!be!worth!considering!from!a!diagnosis!perspective.!
Healthy! skin! events! do! not! necessarily! have! to! only! be! about! reducing! scabies!
prevalence,! but! should! also! be! valued! as! a! fun! community! activity! and! an!
opportunity!for!destigmatisation!and!health!promotion.!
!
Introducing%the%International%Alliance%for%the%Control%of%Scabies!
(presentation!by!Andrew!Steer,!for!slides!see!Appendix!13)!
!
!
This! presentation! provided! an! introduction! of! the! recently! formed! International!
Alliance! for! the! Control! of! Scabies! (IACS).! ! The! alliance! consists! of! a! multidisciplinary!
group!of!worldwide!scabies!experts!with!an!interest!in!improving!the!global!control!of!
scabies.! ! The! alliance! aims! to! advocate! for! the! recognition! of! scabies! as! a! significant!
public!health!issue!across!the!world,!as!well!as!help!identify!effective!control!strategies.!!!
In!the!short!term!the!alliance!intends!to!lobby!the!World!Health!Organization!to!ensure!
scabies!is!included!on!their!formal!list!of!neglected!tropical!diseases.!!Another!shortJtoJ
middleJterm! goal! is! to! compile! the! currently! available! data! on! scabies! burden! and!
epidemiology!and!make!it!available!online.!
!
!
!
!
Session!3:!identifying!root!causes,!influencing!factors!and!determinants!of!
skin!infections!in!WA!!
!
This! session! consisted! of! a! breakJout! and! a! plenary! component! during! which! two!
questions!were!discussed:!
1) What! do! we! currently! know! about! the! burden! of! skin! infections! in! Western!
Australia?!
2) Are!there!any!particular!determinants!that!need!to!be!considered?!
!
!“What% do% we% currently% know% about% the% burden% of% skin% infections% in% Western%
Australia?”%
!
Currently!there!is!no!comprehensive!data!available!on!the!burden!or!prevalence!of!
skin!infections!in!Western!Australia.!!Only!the!Western!Australian!Aboriginal!Child!
Health! Survey! gives! an! indication! (8,5%! of! Aboriginal! children! were! reported! by!
their! carers! to! have! ‘recurring! skin! infections’).! ! Nor! is! there! any! peerJreviewed!
literature!on!the!topic!in!this!geographical!area.!!Much!of!what!we!know!is!based!on!
anecdotal!evidence.!
Up! until! recently! the!Aboriginal! Medical! Services! (AMS)! in! Western! Australia! used!
the!communicare!system!to!manage!their!clinical!records.!!Recently!there!has!been!
an! ongoing! trend! of! moving! from! that! system! to! MMEx.! ! As! the! two! systems! are!
incompatible!with!each!other,!much!of!the!existing!digital!data!is!no!longer!directly!
available.! ! ! Additionally,! the! federal! health! system! works! on! a! different! system!
altogether.!!This!situation!results!in!data!fragmentation,!making!it!a!challenge!to!get!
a!comprehensive!overview.!
The! situation! is! better! in! the! Kimberly,! where! AMS! have! been! using! MMEx! for! a!
longer!period!than!elsewhere!in!WA.!
Scabies!has!not!been!considered!an!issue!in!Punmu!since!2010.!!This!is!probably!the!
result! of! helminth! control! programs! that! have! been! implemented! in! the! past.!!
Albendazole!and!ivermectin!were!widely!used!in!those!campaigns,!thus!also!possibly!
reducing!scabies!prevalence.!!
In! the! Kimberley,! skin! infections! seem! to! be! primarily! a! problem! in! the! larger!
communities! nearer! to! towns.! ! Access! to! healthcare! seems! more! problematic! here!
(e.g.!financial!barriers;!need!to!pay!for!a!taxi!ride!to!get!to!health!centre,!tendency!to!
delay! visit! until! condition! has! worsened).! ! These! communities! also! have! many!
additional! stressors! to! deal! with.! ! Health! staff! in! smaller,! wellJorganized!
communities! are! able! to! work! more! closely! and! effectively! with! the! community,!
resulting! in! less! skin! infections! as! well! as! other! positive! health! and! wellbeing!
outcomes.!
!
In!summary:!!
Based! on! experiences! of! health! workers! working! in! WA’s! remote! Aboriginal!
communities!we!can!say!that:!
There!are!issues!with!skin!infections!in!WA!Aboriginal!communities.!
Prevalence!of!skin!infections!fluctuates!over!time!and!varies!geographically.!
Highest!incidences!of!skin!infections!are!found!in!young!children.!!
Various!smallJscale!interventions!are!ongoing!(e.g.!in!Newman:!screening!neonates!
for!various!health!outcomes,!including!skin!infections)!
!
!
Local! data! on! the! burden! of! skin! infections! is! fragmented! and! will! require!
considerable!effort!to!compile.!
!
%
“Are%there%any%particular%determinants%that%need%to%be%considered?”%(in!addition!to!
those!mentioned!during!the!introductory!presentations)!
!
There!is!a!need!to!tackle!the!nihilism!that!can!be!strong!in!some!communities!(i.e.!“I!
have!no!control!over!this.!!Why!bother?”).!!SelfJesteem!and!selfJconfidence!need!to!be!
addressed.! ! Finding! and! engaging! champions! in! the! frame! of! a! collective! approach!
(as! opposed! to! campaigns! that! focus! on! the! individual)! is! considered! a! possible!
strategy!in!this!respect.!
There! are! no! genetic! determinants! that! may! predispose! Aboriginal! people! to! skin!
infections.!!The!relatively!high!infection!rates!found!in!Aboriginal!communities!are!
purely!due!to!environmental!factors!that!increase!exposure.!
Normalization!is!considered!an!important!determinant.!!Denormalizing!scabies!and!
other!skin!infections!is!essential.!
There! are! issues! of! stigma! and! shame! around! skin! infections! in! the! communities,!
which!impact!healthcare!seeking!behavior.!
There! is! a! general! lack! of! culturally! appropriate! health! services! (e.g.! in! Newman;!
FIFO! doctors! with! no! understanding! of! appropriate! interaction! with! Aboriginal!
people,!no!Aboriginal!health!workers),!which!also!lead!to!delays!in!seeking!care.!
!
!
!
!
Session!4:!identifying!possible!interventions!
!
This! session! consisted! of! a! breakJout! and! a! plenary! component! during! which! two!
questions!were!discussed:!
1) Which!intervention!related!considerations!should!be!taken!into!account?!
2) Which!components!might!a!WA!wide!healthy!skin!intervention!consist!of?!
!
!
“Which%intervention%related%considerations%should%be%taken%into%account?”%
!
Many!different!agencies!might!need!to!be!involved!in!a!healthy!skin!program,!these!
might!also!differ!across!regions.!
The! high! staff! turnover! rate! in! health! centers! servicing! remote! Aboriginal!
communities!is!problematic.!
FIFO! clinicians! are! often! not! familiar! with! local! guidelines! for! the! management! of!
skin!infections.!
School!nurses!currently!do!not!have!the!ability!to!prescribe!and!treat,!as!a!result!of!
which! children! often! need! to! be! referred! to! a! health! center.! ! Patients! might! not!
pursue!the!referral.!
When!considering!ivermectin!MDAs!it!is!necessary!to!take!into!account!the!practical!
implications! of! treating! under! 5’s! and! pregnant! women! (ivermectin! is! contraJ
indicated! for! these! two! groups).! ! For! example,! it! might! be! too! complex! and!
inefficient!to!perform!pregnancy!screening!amongst!all!woman!of!childbearing!age.!!
In!such!a!case!it!might!be!more!efficient!to!treat!all!woman!with!permethrin!cream.!
There!is!a!need!to!document!prevalence!rates!of!skin!infections!in!the!communities,!
preferably! by! linking! into! existing! clinical! data! (and! not! necessarily! by! setting! up!
prevalence!studies).!
There!is!a!need!for!community!consultation!and!engagement.!!Communities!should!
own!their!own!healthy!skin!programs.!
More! research! is! needed! on! how! scabies! and! other! skin! infections! are! perceived!
within!communities.!
It!is!necessary!to!acknowledge!the!heterogeneous!nature!of!Aboriginal!communities!
and!be!aware!of!any!local!differences!in!context! that!might!impact!possible!control!
strategies!(e.g.!family!feuding).!!There!is!no!oneJsizeJfitsJall!solution!possible!in!WA.!
!
“Which%components%might%a%WA%wide%healthy%skin%intervention%consist%of?”%
!
1. General!
Any!approach!should!be!inherently!multifaceted.!
There! will! be! a! need! to! build! partnerships! between! health,! education! and!
community!agencies!(interagency!collaboration).!
Sustainability!should!be!a!consideration!when!identifying!possible!interventions.!
The!program!should!not!focus!too!much!on!social!determinants!as!this!might!result!
in!losing!focus!from!the!actual!goal:!reducing!skin!infection!prevalences.!
Toolbox!idea:!Offer!a!minimum!of!good!practice!materials!and!resources!that!may!be!
used!to!implement!a!skin!health!program!at!the!community!level.!!Then!build!from!
there!to!accommodate!for!communities’!particular!needs.!
!
!
!
!
!
2. Prevention!
Hygiene/health! education! programs! have! a! role! to! play! and! should! be! an! inherent!
part!of!the!program.!
Ensuring! communities! have! access! to! showers! and! clean! water! would! be! a! basic!
facility!the!program!should!help!provide.!
The! program! should! explore! the! option! of! implementing! swimming! pools! in! the!
communities,!but…!!
o …!there!is!!a!need!to!clarify!the!factors!relating!to!swimming!pool!usage!
o …!there!is!a!need!to!document!swimming!dosage!in!relation!to!the!prevention!
and!control!of!skin!infections.!
!
3. Screening,!diagnosis!and!treatment!
Take! an! ‘implementation! science’! approach;! In! other! words,! apply! what! we! know!
about!effective!treatment!delivery!models!and!build!a!program!around!that.!
An! effective! delivery! model! might! be! to! focus! on! screening! and! treating! children!
under!the!age!of!one,!including!their!families!(+!two!followJup!visits).!A!combination!
of! ivermectin! and! permethrin! treatments! may! be! used.! ! If! the! caseload! exceeds! a!
certain!cutJoff!point!and!the!problem!is!too!large!for!health!workers!to!handle,!only!
then!consider!implementing!a!traditional!MDA.!
Effective!strategies!for!monitoring!and!treatment!of!crusted!scabies!cases!should!be!
in!place,!given!their!key!role!in!outbreaks.!
There! is! a! potential! role! for! employing! bush! medicine! as! an! auxiliary! treatment!
within! a! larger! healthy! skin! program.! ! Care! should! however! be! taken! to! ensure!
safety,! and! ideally! bush! medicine! effectiveness! should! have! been! documented! in!
laboratory!tests.!!Tea!tree!oil!is!of!interest,!but!requires!many!reapplications!(5!to!6!
times!per!day),!rendering!it!rather!unpractical.!!!
The!social!marketing!of!treatments!used!in!a!healthy!skin!program!should!also!be!a!
consideration,!as!this!could!improve!uptake.!!
Making! cream! treatments! more! pleasing! to! use! and/or! combining! such! activities!
with! personal! grooming! activities! might! be! one! novel! way! of! improving! treatment!
uptake.!
Allow!health!workers!to!prescribe!and!apply!simple!treatments,!reducing!the!need!
for!referrals!and!improving!communities’!direct!access!to!care.!
Consider! providing! treatment! options! to! communities! without! the! need! to! go! to!
clinics.! ! For! example,! shops! in! East! Arnhem! Land! currently! stock! treatments! so!
people! have! a! choice! to! do! something! about! their! skin! infections! themselves.!!
However,! such! approaches! raise! concerns! that! need! to! be! addressed! before!
implementation.!
Provide! clinical! algorithms! or! guidelines! on! skin! infections! that! can! be! used! by!
clinicians,! nurses! and! health! workers! to! improve! management! and! awareness!
thereof.!
Set! up! electronic! patient! management! systems! (e.g.! communicare,! MMEx)! to! alert!
healthcare! providers! of! the! treatment! strategies! for! various! skin! infections,! for!
example!by!means!of!an!onscreen!popJup.!
Outreach!activities!might!be!considered!as!part!of!the!program,!for!example:!
!
!
o A!‘skin!bus’!going!around!communities!and!visiting!family!homes,!providing!
screening!and!treatment!services.!
o Piggyback!on!existing!community!activities!(e.g.!footy!games,!carnivals,!…)!
Have!skins!consistently!checked!during!routine!child!health!checks,!such!as!the!WA!
Child!Health!Schedule.!!Record!conditions!and!treatment!plans.!
!
4. Health!worker!training!
Organize! ‘skin! school’! training! courses! for! health! workers,! possibly! also! for! other!
community!workers.!
Consider!training!new,!program!specific,!health!workers!by!offering!them!accredited!
health!worker!courses!and!employing!them!within!the!program.!
Ensure! education/upJskilling! of! frontJline! medical! staff,! particularly! around!
diagnosing!and!treating!scabies!and!associated!skin!infections.!
!
5. Community!health!education!
Empower!firstJtime!mothers!by!providing!them!with!information!on!skin!infections!
and!ensuring!they!have!access!to!treatment.!
There! is! a! need! to! reduce! the! stigma! surrounding! skin! infections.! ! This! might! be!
attained!through!social!marketing!strategies.!!
There! is! a! need! to! demystify! scabies! and! associated! skin! infections! within! the!
community! (‘know! thy! enemy’).! ! One! way! this! can! be! done! is! by! engaging! local!
media,!engaging!in!open!conversations!about!skin!infections!and!by!using!personal!
stories!that!communities!can!relate!to.!
Include! community! workers! without! a! formal! training! in! health! to! help! ‘tell! the!
story’!of!scabies.!
Health!promotion!activities!should!be!refreshing!and!should!strive!to!be!diverse!and!
exciting!as!to!avoid!boredom.!
!
6. Other!
Community! consultation! and! engagement! is! essential.! ! Communities! should! have!
ownership!over!their!program.!
Consider! structurally! engaging! school! nurses! in! program! screening! and! treatment!
activities.!
Engaging! existing! health! workers! might! be! difficult,! especially! in! communities!
where!the!healthcare!workforce!is!small!and!overburdened.!!Consider!training!and!
engaging!new!health!workers!(through!accredited!training),!who!would!take!up!key!
roles!in!the!healthy!skin!program.!
Consider! engaging! ‘community! care! workers’! as! advocates! that! have! a! key! role! to!
play! in! health! promotion! and! operate! as! a! link! between! communities,! researchers,!
health!care!professionals!and!schools.!
Campaigns!might!be!built!around!the!use!of!champions,!ambassadors!or!role!models!
the! communities! can! identify! with.! ! Elders! are! important! possible! role! models,!
although!younger!generation!role!models!should!also!be!considered.!
Aboriginal! health! workers! engaged! in! the! program! should! be! given! flexibility! in!
their! work! arrangements! as! to! accommodate! cultural! practices! (e.g.! grieving,!
funerals,!…)!
!
!
Session!5:!identifying!information!needs,!data!collection!activities!and!
possible!confounders!
!
This! session! consisted! of! a! breakJout! and! a! plenary! component! during! which! several!
interrelated!questions!concerning!monitoring!and!evaluation!were!discussed:!
!
“How% do% we% measure% the% outcomes% of% any% intervention?% % How% do% we% differentiate%
between%direct%and%indirect%effects?%%And%how%do%we%filter%out%confounding%factors?”%
!
First!and!foremost:!There!is!a!need!to!seek!out!and!compile!existing!prevalence!and!
burden! data! that! can! be! used! as! a! (rough)! baseline.! ! Relevant! audits! may! already!
have!been!undertaken!in!some!sites.!Optimal!use!should!be!made!of!existing!health!
centre!and!hospital!data!where!available.!!
!
Direct! indicators! which! might! provide! insight! regarding! program! effectiveness!
include:!
o Data!on!skin!infections!available!through!clinical!record!audits:!
 Health!centre,!hospital!and!emergency!admission!data!
 Consider! additional! sources! (e.g.! data! collected! by! the! Royal! Flying!
Doctor!Service)!
 Consider!possible!biases!in!these!kinds!of!data!
 Focus!on!<=1!year!olds!
o Prevalence!of!skin!infections!amongst!infants!(<1!year!olds).!
o Prevalence!of!crusted!scabies!cases.!
o Severity!of!skin!sores;!measurable!by!using!a!sore!score.!
o Evaluate! knowledge,! attitudes! and! practices! of! community! members! and!
health! workers! throughout! the! program,! in! order! to! evaluate! changes! in!
knowledge!regarding!skin!infections.!
o Evaluate!the!use!of!swimming!pools!(if!providing!access!to!swimming!pools!is!
part!of!the!healthy!skin!program).!
o Data!linkage!projects!may!be!able!to!pull!various!sources!of!data!together.!
o Monitor! changes! in! public! health! actions! and! policies! regarding! skin!
infections.!
o Apply! Continuous! Quality! Improvement! methods! (CQI)! in! evaluating! the!
outcomes!of!the!healthy!skin!program.!
!
Indirect! indicators! which! might! offer! a! measure! of! the! effectiveness! of! any! skin!
health!interventions:!
o Funding! spent! on! community! workers,! the! number! trained,! and! data! about!
their!retention.!
o Community!perceptions!of!the!healthy!skin!program.!
o Hospital! admissions! for! more! serious! diseases! associated! (possibly! in! the!
longer!term)!with!skin!infections.!
o Health!worker!workload.!
o School!data:!student!attendance!and!performance.!
o Day!care!attendance!data.!
o Referral!rates!for!child!development!services.!
o Relevant!referrals!from!health!centers!to!hospitals.!
o Exit!interviews!of!hospital!patients!to!evaluate!service!satisfaction.!
!
!
!
!
!
o Improved!access!to!health!services!
o Measures! of! social! dysfunction! and! social! emotional! wellbeing! (household!
assessment!tool)!
o Number!of!prescriptions!per!child!
!
Confounding! factors! that! need! to! be! taken! into! account! when! evaluating! the!
effectiveness!of!the!healthy!skin!program.!
o Consider! other! possible! ongoing! health! interventions! that! might! have! an!
impact!on!the!prevalence!of!skin!infections!in!the!communities.!
o Housing! development! (consider! possible! ongoing! programs! that! might! be!
improving!general!living!conditions,!particularly!overcrowding)!
o Consider!possible!effect!of!population!mobility!
o Consider!possible!effect!of!certain!community!events!or!ceremonies.!
!
Session!6:!conclusion!
!
In! this! plenary! session! the! workshop! participants! discussed! how! the! Healthy! Skin,!
Healthy!Lives!initiative!should!move!ahead.!
!
!
Key!questions!and!way!forward!
!
“Where%should%we%implement%the%healthy%skin%program%in%an%initial%phase?%%What%
are% the% ideal% characteristics% of% the% communities% where% we% could% pilot% the% healthy%
skin%program?”%
!
Communities…!!
where!skin!infections!are!an!identified!issue;!
that!want!to!be!involved;!
that! are! stable,! in! terms! of! the! community! itself,! but! also! in! regards! to! health!
provision;!
where!electronic!patient!data!is!available;!
where!other!relevant!data!collection!activities!might!already!be!ongoing;!
where!health!centers!are!sufficiently!staffed;!
where! there! is! buyJin! from! community! groups! and! services! that! might! become!
involved!in!the!program!(e.g.!schools,!swimming!pools,!playgroups,!sports!teams,!
…);!
where! there! is! an! interest! from! stakeholders,! and! possibly,! industry! partners!
(e.g.!BHP);!
that!are!clustered!around!a!larger!hub!community.!
!
“How%should%the%program%be%implemented?”%
The!workshop!participants!suggested!that!it!would!be!necessary!to:!
Set!up!a!dedicated!task!force;!
Develop!operational!procedures;!
Launch!a!community!consultation;!
Do!an!audit!of!clinical!records!in!order!to!collect!baseline!data!on!skin!infections!in!
the!communities;!
Prepare!a!communication!and!consultation!strategy;!
Seek! the! required! authorization! to! go! in! to! the! communities! with! the! healthy! skin!
program;!
Make!the!program!about!children!and!families,!not!just!research;!
Seek!highJlevel!ownership!and!buyJin!for!the!program!(Western!Australian!Country!
Health! Service,! Kimberley! Aboriginal! Medical! Services! Council,! WA! Department! of!
Health!and!Department!of!Education);!
Nominate!local!champions!as!support!in!each!site;!
Watch!for!blockers!and!develop!strategies!to!address!them;!
Apply! a! toolkit! approach:! provide! a! basic! set! of! tools! and! resources! for! the!
community,! then! expand! and! adapt! according! to! communities’! particular! needs!
drawing!on!Aboriginal!services!where!possible!
Such!a!toolkit!could!consist!of:!
o Early!prevention!/!health!promotion!resources!
!
!
o Clinical!management!guidelines/protocols!(diagnosis,!treatment!&!referral!&!
followJup)!
o Guidelines!for!multisectoral!involvement!
The! toolkit! can! make! use! of! existing! resources! (e.g.! from! the! NT! Healthy! Skin!
program);!
Consider!the!program!as!a!longJterm!process,!a!journey,!and!take!this!into!account!
when!planning!program!implementation!in!communities;!
Conduct! meetings! and! consultations! to! understand! the! ‘how’! and! the! ‘by! whom’;!
consider!who!needs!to!be!involved;!
Consider!putting!a!flowchart!together!that!suggests!a!range!of!possible!interventions!
based!on!communityJspecific!factors!(i.e.!prevalence,!available!evidence,!community!
facilities,!…);!
Learn!from!experiences!from!existing!programs!and!build!on!them;!
Work! through! existing! partnerships! and! programs! where! appropriate! (in! the!
Pilbara! for! example:! work! with! the! Jigalong! Partnership! Group,! World! Vision!
Australia,! Puntukurnu! maternal! and! child! health! program! and! the! BHPBIO!
Community!Investment!Program!which!also!funds!the!Creative!Communities!);!
Use! humor! when! working! with! communities;! make! it! fun! to! be! involved! in! the!
healthy!skin!program.!
!
!
“Who% should% be% involved% in% developing% and% implementing% the% healthy% skin%
program?”%
%
Communities! should! be! actively! engaged! in! developing! and! implementing! the!
healthy!skin!program;!
Healthcare!professionals;!
Executive!buyJin!is!necessary;!
HighJlevel! buyJin! is! very! important,! learn! lessons! from! previous! successful!
programs!in!this!regard;!
(Aboriginal)! health! services,! networks! &! community! organizations,! including! all!
Aboriginal!Regional!Health!Policy!and!Research!Forums!
State! institutions:! Department! of! Health! (Public! Health! Division),! Department! of!
Education,!Department!of!Child!Protection,!Department!of!Housing.!
Community! level! stakeholders! (e.g.! community! council,! woman’s! group,! health!
centers,!schools,!swimming!pools,!sports!clubs,!stores,!…)!
Any! relevant! NGO’s! who! are! working! with! the! communities,! such! as! World! Vision!
Australia,!Royal!Life!Saving!Society!Western!Australia;!
Training!
certification!
organisations:!
such!
as!
Marrmooditj!
(www.marrmooditj.com.au),!TAFE!and!Curtin!University!of!Technology!
!
!
Where!to!from!here?!
!
Although!an!MDA!strategy!might!have!a!role!to!play!in!reducing!the!burden!of!skin!
infections!in!WA’s!remote!Aboriginal!communities,!it!is!clear!this!should!not!be!the!
key! element! of! the! envisioned! approach.! ! Creating! community! awareness,!
!
!
!
!
!
!
!
!
!
!
!
!
stimulating!community!mobilization!and!developing!a!multisectoral!approach!are!of!
primary!importance.!
In!order!to!achieve!this,!all!relevant!stakeholders!Jboth!at!the!state!and!local!levelsJ!
will!need!to!be!engaged!in!the!coming!months.!
Data! collection! activities! need! to! be! set! up! in! order! to! be! able! to! provide! the!
program!with!baseline!data!on!the!burden!and!prevalence!of!skin!infections!in!WA’s!
remote! Aboriginal! communities.! ! To! this! end! there! is! also! a! need! to! explore!
additional! data! sources! that! might! prove! useful,! such! as! any! relevant! (linked)!
databases!that!might!be!able!to!provide!WAJwide!data!on!skin!infection!prevalence!
and! burden! (for! example! the! 0J5! Aboriginal! health! check! &! maternal! health! check!
ups)!
Evidence!and!further!clarification!regarding!the!supposed!normalisation!and!stigma!
of!skin!infections!in!WA!is!required!in!the!short!term,!as!well!as!more!information!
about!treatment!adherence!in!WA.!!An!improved!understanding!of!these!factors!will!
be!beneficial!to!the!‘healthy!skin,!healthy!lives’!!program.!
Given! the! political! interest! and! support,! and! given! the! potential! it! has! shown! in!
reducing! skin! infections,! the! strategy! of! providing! remote! Aboriginal! communities!
with!access!to!their!own!wellJmanaged!swimming!pools!is!worth!pursuing.!!!
The! WA! healthy! skin,! healthy! lives! program! is! able! to! benefit! from! the! community!
and! Aboriginal! Health! Worker! resources! that! have! previously! been! developed! for!
the!Northern!Territory’s!healthy!skin!program.!!These!resources!would!need!to! be!
adapted!to!the!WA!context.!
Based!on!the!outcomes!of!this!workshop,!TICHR!will!prepare!a!healthy!skin,!healthy!
lives! program! proposal! for! submission! to! the! WA! Department! of! Health! in! an!
attempt!to!secure!funding!for!initial!pilot!studies!in!2013!in!the!Western!Desert!(and!
potentially! beyond)! in! the! Pilbara! (given! the! identified! need! in! the! existing! TICHR!
/BHP! BIO! partnership! project! led! by! Associate! Professor! Roz! Walker;! and! the!
successful! award! through! the! CREAHW! to! fund! a! PhD! student,! David! Hendrickx! to!
undertake!key!aspects!of!this!study!in!this!area)!and!the!possible!rollJout!of!a!larger!
program!over!the!next!few!years.!
In! the! meantime,! a! plan! should! be! put! together! for! the! management! of! possible!
scabies!outbreaks!in!WA’s!remote!Aboriginal!communities.!!It!will!be!useful!to!have!
relevant!resources!available!should!such!an!outbreak!occur.!!In!the!case!of!such!an!
event,! an! initial! response! to! control! the! outbreak! can! lead! to! a! durable! followJup!
process!with!the!community.!
!
Appendix!1:!workshop!program!
!
Location:!The!UWA!Boat!Shed,!Car!Park!23,!Hackett!Drive,!Crawley!
Date:!12th!and!13th!of!December!2012!
!
Aim! of! workshop:! ! To! examine! the! current! evidence! base! for! the! importance! of! skin!
infections! in! remote! Aboriginal! communities,! measures! to! control! them! and! means! of!
monitoring!interventions,!with!a!view!to!planning!a!large!scale!implementation!in!WA!
communities.!
!
!
Day!1!–!Wednesday!12!December!2012!
!
8:30!–!9:00!
Welcome!&!scene!setting!
Jonathan!Carapetis!&!Roz!Walker!
!
9:00!–!10:50!
Introductory! presentations:! ! The! importance! of! skin! infections!
and!scabies,!and!measures!to!control!them.!
!
Skin! infections! and! their! significance,! rationale! for! the! WA! Healthy!
Skin,!Healthy!Lives!program!
Jonathan!Carapetis!
!
Healthy!Skin!Healthy!Lives,!Setting!the!Scene!
Roz!Walker!
!!
Experiences!from!WA,!including!swimming!pool!studies!
Deborah!Lehmann!
!
Current! evidence! for! effectiveness! of! swimming! pools! for! skin!
infections!and!ear!disease!!!
David!Hendrickx!
!
Swimming!pools!in!WA’s!remote!Aboriginal!communities,!an!update!!
Amanda!Juniper!
!
Experiences!from!NT,!including!healthy!skin!program!and!ivermectin!
trial!
Ross!Andrews!
!
Experiences!from!Fiji!!
Andrew!Steer!!
!
Experiences!from!‘1JDisease!at!a!Time’!!
Tim!Foster!&!Samantha!Cran!
10:50!–!11:20!
!
!
Coffee!break!
!
!
11:20!–!11:50!
11:50!–!13:00!
13:00!–!14:00!
14:00!–!15:20!
15:20!–!15:50!
15:50!–!17:10!
!
19:00!
Discussion:!What!do!we!know!&!what!are!the!gaps?!
!
Break*out! session! 1:! identifying! root! causes,! influencing! factors!
and!determinants!of!skin!infections!in!WA!
!
Lunch!
Break*out!session!2:!identifying!possible!interventions!!
!
Coffee!break!
Break*out! session! 3:! identifying! information! needs,! data!
collection!activities!and!possible!confounders!
!
Introductory! presentation:! Measuring! the! impact! of! a! healthy! skin!
program,!experiences!from!NT!
Therese!Kearns!
!
!
Group!dinner!in!Perth!
!
!
!
Day!2!–!Thursday!13!December!2012!
!
8:30!–!9:00!
9:00!–!10:30!
10:30!–!11:00!
11:00!–!12:30!
12:30!–!13:30!
13:30!–!14:00!
14:00!–!14:30!
!
!
Summary!day!1!–!introduction!day!2!
Jonathan!Carapetis!&!David!Hendrickx!!
!
Discussion:!key!questions!and!way!forward!–!part!1!
!
Coffee!break!
Discussion:!key!questions!and!way!forward!–!part!2!
!
Lunch!
Introducing!the!International!Alliance!for!the!Control!of!Scabies!
Andrew!Steer!!
!
Wrap*up!&!closing!
Jonathan!Carapetis!
!
Appendix,2:,List,of,participants
Surname
Abernethy
Andrews
First Name
Margaret,
Ross
Bessarab
Dawn,
Carapetis
Cran
Eades
Fisher
Foster,
Heiden
Hellwig
Jonathan
Samantha
Francine
Angela,
Tim
Tamika
Leonie,
Hendrickx
David
Hughes
Jones
Julie
Tanya,
Juniper
Amanda
Kearns
Lehmann
Therese,
Deborah
McCartney
Nicole,
Moon
Pearson
Raby
Shepherd
Steer
Debbie
Glenn
Edward,
Carrington
Andrew
Walker
Roz
,
Organisation
WA,Country,Health,Service
Menzies,School,of,Health,Research
Curtin,Health,Innovation,Research,Institute,
(CHIRI)
Telethon,Institute,for,Child,Health,Research
One,Disease,at,a,Time
The,Children's,Hospital,at,Westmead
Kimberley,Paediatric,and,Child,Health,Team
One,Disease,at,a,Time
Child,and,Adolescent,Health,Service
Centre,for,Research,Excellence,in,Aboriginal,
Health,and,Wellbeing,,Telethon,Institute,for,
,
,
Puntukurnu,Aboriginal,Medical,Service,(PAMS)
Email Address
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
Royal,Life,Saving,Society,T,Western,Australia,Inc.
Menzies,School,of,Health,Research
[email protected]
[email protected]
Aboriginal,Health,Division,,Department,of,Health,
[email protected]
WA
Newman/Nullagine,Communities
[email protected]
[email protected]
Royal,Perth,Hospital
[email protected]
[email protected]
Centre,for,International,Child,Health
[email protected]
Centre,for,Research,Excellence,in,Aboriginal,
[email protected]
Health,and,Wellbeing,,Telethon,Institute,for,
Appendix 3: Paper submitted to the workshop by John Boulton
Submission to the 'Healthy Skin, Healthy Lives' workshop.
Centre for Research Excellence in Aboriginal Health and Wellbeing.
Telethon Institute for Child Health Research. Dec 2012.
From John Boulton. Kimberley Paediatrics and Child Health team.
Hygiene and skin sores represent one outcome of the crisis in parenting in the Kimberley, with its
well known devastating consequences of post-streptococcal infection on premature mortality from
RHD and renal failure. To understand this we need to go back to the lives of the great grandparents
of the children whom we seen today. The image is of Elkin Umbagai and Daisy Utemorra taken
around1930 at Kunmunya Mission, NW Kimberley, decades before the community moved to
Mowanjum in the 1960s. The photo was scanned from the book celebrating “Mowanjum: 50 years
of community history” (Mowanjum Aboriginal Community 2008). Both these children grew into
famous leaders of their people. If you look closely you will see that both girls have skin sores on
their knees and shins. In those days, there was probably less risk of bacterial contamination with
streptococcus and hence risk of renal disease. However Elkin's daughter, the first Kimberley
Aboriginal woman to qualify as a registered nurse, is now a woman in her 50s and is on dialysis in
Perth.
Many women of Elkin's generation lived to a grand old age: this now rarely happens as a
consequence of diseases relating to bacterial contamination in the environment, and the future
consequences of childhood malnutrition leading to metabolic syndrome in early adult life. These
act synergistically in terms of the effect on risk of renal disease. This photo therefore acts as an
emblem of how a mismatch between the environment and how people have changed in the way
they live contributes to the appallingly high mortality in both childhood and mid-adulthood in
northern WA.
!
1
The other outcomes of equal importance of the crisis in parenting are growth faltering from
malnutrition from late infancy through the third year of life, and Fetal Alcohol Spectrum Disorder.
The short term consequences of growth faltering are the child's increased risk of infection and the
blunting of exploratory behaviour with its adverse effects on cognitive development, and the long
term effects of high risk of metabolic syndrome with early-onset insulin-resistant diabetes and early
death from macro-vascular disease (AMI). This is now accepted within the concept of
developmental origins of adult disease (fetal origins hypothesis) (Scientific Advisory Committee on
Nutrition 2011).
The burden from neuro-developmental disability from FASD has been the focus of a
comprehensive cohort study amongst children in the Fitzroy Valley, with the results to be published
in due course (Elliott 2012). The Marulu Program to prevent early life trauma (ELT) and FASD has
a focus on helping these children, and also on parenting. This program recognises the importance of
early life trauma to the later emotional wellbeing (and adversely, to the high risk of child and youth
suicide). The power of epigenetic mechanisms for maternal stress to mediate differential and
adverse response to stress in the woman's offspring during adolescence and childhood is firmly
established (Tremblay 2008), with the tragic evidence being the endemic nature of child and youth
suicide in the Kimberley.
The current situation with respect to the lack of skin hygiene for children living in remote
Aboriginal communities is arguably an example of structural violence (Farmer 2004). That is, the
vast health differential which is a second-order outcome of social inequity based in legislation: in
WA, this is the 1905 Aborigines Act. The coercive shift from forager lifestyle to a sedentary one on
missions and cattle stations occurred from c.1910 in the Kimberley; 50 years later families were
forced off the stations to live as fringe dwellers until they were able to move onto independent
communities which were established in the early 1980s, or earlier to missions such as Mowanjum
outside Derby (Jebb 2002). In my talking to older women about traditional weaning foods and how
babies were looked after, they told me how they kept the babies’ skin clean and free from sores by
using the resin in the leaves of certain eucalypts.
The well-recognised effect of this shift to sedentary living on health and hygiene-related disease
was compounded by the appalling quality of housing. In 1973 at Papunya I saw at first hand the
recently-built Whitlam government funded concrete houses, all deserted or never used; and
nowadays tiny single-roomed concrete and tin-roofed 'dog boxes' remain visible on the edge of the
missions at Kalumburu and Balgo, and on pastoral stations in the northern ranges. The crisis in
housing continues to this day with overcrowding in the Kimberley towns and communities being
the worst in the nation. The crisis in housing is better documented in the NT due to the appalling
track record of the Strategic Indigenous Housing and Infrastructure Program (Scullion 2012).
2
Not only were Aboriginal families in northern WA catapulted from a healthy forager lifestyle to
one of servility under a racist regime, they were actively excluded from the Commonwealth social
welfare programs which targeted the impoverished after Federation (McCalman 2009), as well as
those that taught the socially disadvantaged how to live in a hygienic manner from the 1930s and
1940s. For example in England, the 1944 Education Act ensured that the domestic sciences were
taught to all girls in primary school and that the majority of secondary schools would include it as a
component of the school leaving exam (Vernon 2007: 232).
In northern Australia, although the white station missus or missionary wife taught domestic science
and hygiene in those days, there was no strategy to continue such learning for adolescent girls in a
culturally appropriate way. For example Betty Ewan, the wife of the Rev Gordon Ewan of the
Australian Inland Mission (now Frontier Services) who worked in Kununurra between 1968-78,
was told to stop teaching young women the domestic skills relevant to hygiene and feeding babies
(pers comm. Rev Andrew Watts 2012).
There are two other historical dimensions to the understanding of hygiene (and skin sores as
evidence of its absence) in the conflicted interface between Aboriginal and mainstream society. The
first relates to the consequence for Aboriginal people of the concept that “cleanliness is next to
Godliness” which emerged in the mid to late nineteenth century as a epiphenomenon of
Evangelicalism which was one of the main driving forces behind industrialization and capitalism
(Ferguson 2011). (The removal of the excise on soap in 1851 led to an exponential increase in its
use, and personal and public hygiene continued to improve during the 1890s). There was thus
conflation between a person’s moral worthiness and economic efficiency and hence financial
worthiness: simply put, for those on the margin of society, being ill-kempt and doing no work
signified lack of moral and economic worth. (Echoes of this nexus remain evident in the political
discourse of the US, and in the emergence in Colombia of Protestant evangelicalism linked to
credit-based consumerism). The relevance for Aboriginal Australia is that this value-laden meme
was amplified in NT and the Kimberley with the conflation of filth, disease, and racism (Mitchell
2007). Leprosy was emblematic of this, with tragic effects on families across generations in the
Kimberley (Jebb 2002).
The second dimension to this historical understanding is that amongst the working poor in the
Edwardian period (which ended at the outbreak of war in 1914), absence of hygiene signified a slip
from “respectability” and its connotations of reliability as a breadwinner toward the cusp of
destitution as a day-labourer (McCalman 1984: 20). The absence of hygiene can therefore be
understood from an historical perspective as both an olfactory signifier of class, and as a warning in
those poverty-stricken times of the ever-present danger of destitution. Aboriginal people therefore
suffered social exclusion both from legislation and from the olfactory stigma of poverty. This is
documented through family history narrative: in West Australia through the biography by her
3
grandson of a Mirrawong child taken from her family (Kinnane 2003), and in Victoria in the stories
of the people beyond society on Jackson’s Track near Framlingham and of the Pepper family’s
exclusion from the mainstream (Tonkin 1999, Awaye 2012), as well as in formal accounts which
document the extent of social exclusion of Aboriginal people from school and work (Haebich 1988,
Choo 1990, Hetherington 2002).
The popularisation of domestic science in the 1940s in the western world, coincident with the postwar boom and increasing availability of white goods, coincided with the lowest point of the
Aboriginal population. In the Kimberley, by 1950 there had been a 95% fall in the Aboriginal
population over the preceding 60 years. From then the population doubling time has been 20 years,
now heading down to 15 years, so there has been a dislocation of the intergenerational transmission
of parenting knowledge and skills, including that relevant to hygiene and babies. Now no white
nurse of teacher would dare try and teach an Aboriginal mother how to keep her child clean and
feed him sufficient food, despite the overwhelming evidence that in the distant tropical north of
WA the failure of parents to learn such skills is at the root of the increase in the relative risk of
death from infection during infancy from 4-5 times in the past 20 years, and the increase in postneonatal mortality in the Kimberley to now 10 times that in Perth. At least half of the post-neonatal
deaths relate to sepsis (Boulton 2011).
The effect of the environmental bacterial overload on the infant has been well recognised for 50
years (Mathews 1995), and well documented particularly for bacterial colonisation of the ear. What
is not adequately recognised in Perth is the level of antibiotic resistance amongst lethal pathogens,
particularly staph aureus and strep pneumoniae. We now have to use Vancomycin in some of the
many children we treat in Broome from remote communities who present with deep soft tissue
infection and/or osteomyelitis.
Where to from here? Although swimming pools are an attractive option because they represent a
well-publicised practical way (the sheep-dip method) of decontamination of skin and ears. However
few towns, let alone communities, can afford pools, and even in district towns such as Fitzroy
Crossing and Halls Creek, the pool is often shut because they do not have a qualified pool
attendant. Few Aboriginal people are qualified with the relevant life saving ticket, and it usually
depends on young white people in the helping professions who live in these extremely small
communities comprising just a few non-Aboriginal people in a population of 1200. Also the only
remote community with a pool is Balgo, and that is run by the denominational school which has a
no school – no pool policy. That works well for the bigger children, but again has no effect in the
under 5 population which is in fact equally if not more at risk.
What we now need is an ecological perspective on the patterns of bacterial colonisation of the
environment (and antibiotic resistance), and the degree of colonisation of children's skin and ears.
4
We need strategies to reduce bacterial contamination of the micro-environment. Such strategies
would require working in close partnership with Aboriginal community leaders.
We need strategies for helping young mothers with their parenting skills, with a particular focus on
both hygiene and early nutrition.
References.
Awaye. “A want of sympathy. The letters of Percy and Lucy Pepper.” ABC Radio National.
podcast. 16.06.2012.
Boulton TJC, D’Amico A. Childhood Mortality in the First Five Years of Life:
Kimberley Health Region 2005-2010. An audit of mortality incidence by age, causality, and
locality. Kimberley Health. November 2011.
Choo C. Aboriginal Child Poverty. 1990. Child Poverty Policy Review 2. Melbourne: Brotherhood
of St Laurence.
Elliott E, Latimer J, Fitzpatrick J, Oscar J, carter M. There’s Hope in the Valley. Journal of
Paediatrics and Child Health 2012; 48:190–192
Farmer P. An anthropology of structural violence. Current Anthropology 2004; 45:305-325.
Ferguson N. 2011. Civilization. The six killer apps of Western Power. Penguin.
Haebich, A. 1988. For their own good. Aborigines and government in the SW of Western Australia
19900-1940. Perth: UWA Press.
Hetherington P. 2002. Settlers Servants and Slaves. Aboriginal and European Children in
Nineteenth-century Western Australia. University of Western Australia Press. 2002.*
Jebb MA. 2002. Blood, Sweat and Welfare: a history of white bosses and Aboriginal pastoral
workers. Nedlands, W.A. University of Western Australia Press.
Kinnane S. 2003. Shadowlines. Fremantle Arts Centre Press.
Mathews J. Aboriginal Health: historical, social, and cultural influences. in Robinson G. (ed)
Aboriginal Health: Social and Cultural Transitions. Darwin: NTU Press. 1995. P29-38.
McCalman J. 1984. Struggletown. Public and private life in Richmond 1900-1965. Melbourne
University Press. p20.
McCalman J. 2009. Colonisalism and the health transition: Aboriginal Australians and poor whites
compared, Victoria, 1850-1925.
Mitchell J. 2007. History. in Carson B, Dunbar T, Chenall RD, Bailie R. 20 (eds) Social
determinants of Indigenous health. Menzies School of Health Research. Allen and Unwin. pp41-64.
Scientific Advisory Committee on Nutrition. The influence of maternal, fetal and child nutrition on
the development of chronic disease in later life. 2011. London: TSO.
Scullion N. 'Racist reality evident in homes not fit for a dog'. Inquirer. The Weekend Australian.
Nov 24-25 2012. p21.
Tremblay J, Hamet P. Impact of genetic and epigenetic factors from early life to later disease.
Metabolism Clinical and Experimental 2008; 57 (Suppl 2): S27–S31
Vernon J. 2007. Hunger: A modern history. Cambridge: Harvard University Press.
Tonkin D, Landon C. 1999. Jackson’s Track. Memoir of a Dreamtime place. Viking.
5
Appendix 4: Skin infections, scabies and their sequelae
presentation by Professor Jonathan Carapetis
09/05/13
ARF%incidence%in%NT%
Skin%infec)ons,%scabies%and%sequelae%
Jonathan%Carape)s%
Telethon%Ins)tute%for%Child%Health%Research%
J Paediatr Child Health 2010
RHD%prevalence%by%year,%NT%Aboriginal%
Source: NT RHD control program (J Paediatr Child Health 2010)
Risk%factors%for%GAS%bacteraemia%
Epidemiol Infect 1999;122:5965
•  No)fica)ons:%%415%confirmed/23%probable%%%%
•  Indigenous%Australians:%415%%(94.7%)%
%
•  Incidence%Rates%(per%100,000%person%years)%
–  Overall/All%Ages:%%%12.5%%%(95%CI%11.3X%13.8)%
%
–  Indigenous%Australians,%0%X14%years:%%
• 94.3%%%%(95%%CI%84.2%–%105.3)%
%
–  Rate%ra)o%Indigenous:%NonXIndigenous%%%
• 53 6%%%%(95%%CI%32 6X94 8)%%
Adapted from Currie 2000
%
1
09/05/13
Scabies can be controlled in Aboriginal
communities
Dog scabies !" Human Scabies?
var. hominis 5 Panama
var. hominis 320 Australia
var. hominis 1117Australia
var. wombati 7 Australia
var. canis 9
USA
var. canis 11
USA
var. canis 12
USA
var. canis 31
USA
var. canis 32
USA
var. canis 26
USA
var. canis 25
USA
var. canis 17
Australia
var. canis 4
Australia
ex Wallaby12 Australia
var. canis 2
Australia
var. canis 12
Australia
var. canis 5
Australia
Impact of a scabies control program over 25 months
Humans- Panama
Humans- Australia
Wombats- Australia
Dogs- USA
Dogs- Australia
Multi-locus clustering using
15 hypervariable microsatellite markers
Walton et al
PIDJ 1999
Controlling scabies leads to dramatic reductions
in skin sore prevalence and severity
PIDJ 1999
2
Appendix 5: Healthy Skin, Healthy Lives: Setting the scene
presentation by Associate Professor Roz Walker
09/05/13
CRE Aims
Healthy Skin Healthy Lives
Setting the Scene
F  To conduct research to understand why
important research recommendations and
findings such as the WAACHS have not
been effectively implemented.
Roz Walker
F  To develop transformative strategies to
address ineffective research and service
delivery outcomes
CRE Outcomes
F 
F 
F 
Generate new knowledge about the
underlying causes that limit the
effectiveness of services provided to
Aboriginal people;
Identify, evaluate and document robust
best practice initiatives for dissemination
and effective translation;
Engage effectively with Aboriginal
families/communities to improve access
to and uptake of programs and services;
CPAR Approaches
genuine collaborative research requires:
F time, commitment and hard work, and a longer
term approach to Indigenous health research,
including the development of strategic
alliances (Tsey 2001:23).
F restructuring the methodology to focus on
relationship building and the research process,
rather than the usual emphasis solely on
outcomes.
CRE Methodologies
Aim to develop and apply decolonising
Aboriginal research methodologies which:
-  encompass both qualitative and
quantitative research methods
- emphasise community engagement and
partnerships, and stakeholder
collaboration.
NHMRC Ethical Guidelines in Conducting
Research in Indigenous Contexts
F  Focus on engaging communities in all
phases of the research has implications
for research methods/methodologies
F  Six core values must be met in all ethics
protocols reciprocity, respect, equality,
responsibility, survival and protection, and
spirit and integrity.
Requires Trust, CollaborativePartnership
1
09/05/13
Collaborative research
Background to Project
Collaborative research methodologies are always
activated within institutional contexts with their attendant
political and ideological underpinnings, thus require a
critical awareness…that research-in-practice may default
to the desires of the most powerful. Dunbar et al.
(2003:13) .
F  In 2007 TICHR implemented the Australian
Early Development Index (AEDI) with Martu
communities in the East Pilbara as part of the
TICHR/BHPBIO Health partnership
The difficulties in establishing and maintaining crossdisciplinary research teams highlight the need for careful
preparation and a commitment to privileging Indigenous
voices in multi-disciplinary research teams
Aims of AEDI Implementation
Overall aim:
F  To empower communities and stakeholders with
information about early childhood development in their
area, and with the skill and tools to use them.
F  To use the results AEDI as a tool to help reorient
community-level services and systems for young children
and families
F  In 2008 we trialed the AEDI (Indigenous
adaptation) project in three sites in WA- one
of them the East Pilbara
What is the AEDI?
The Australian Early Development Index (AEDI)
is a population measure of young children’s
development, based on the scores from a
teacher-completed checklist (AEDI Checklist)
which consists of around 100 questions and
measures five areas of child development
2
09/05/13
The Australian Early Development
Index
A teacher completed checklist measuring five areas
of child development:
"   Physical health and wellbeing (healthy, independent, ready for
school)
"   Social competence (plays, gets along with others, shares and is self
confident)
"   Emotional maturity (able to concentrate, help others, patient and not
aggressive or angry),
"   Language and cognitive skills (interested in reading and writing, can
What do the AEDI results tell us?
The main ways to look at the results:
1. 
Proportion (and number) of children who are
developmentally vulnerable in each domain
2. 
Overall, the number of domains in which children are
vulnerable
3. 
The geographic areas where children are vulnerable
in one or more domains
count and recognise numbers and shapes),
"   Communication skills and general knowledge (tell a story,
communicate with adults and children and articulate themselves)
Findings
The AEDI results revealed high levels of
vulnerability for these communities in
early child development and school
readiness, reinforcing the findings of
the Western Australian Aboriginal Child
Health Survey.
AEDI Summary Table – the Pilbara
Proportion of children developmentally vulnerable
Social
Language/
competence
cognitive
Physical
Emotional
Communication
Adopting a CPAR approach
Number of domains
1+
2+
F  AEDI results provide a great catalyst for
community and stakeholder engagement
change
= 33 children
F  help families/stakeholders to track
how well children are doing in the
early years at school
F  Plan, act, reflect, adapt and feedback and so
on - iterative
3
09/05/13
The scale of the disparities observed
Disparities in Physical health, mental health and school performance
(Aboriginal and non-Aboriginal children)
Working with the community
helping families,
school and health
services to work
out whether they
are doing their
best for the future
of Martu children.
Linkage of AEDI to NAPLAN
Children living in remote areas
Children living in more remote areas, compared to
those in major cities, were:
F 2–3 times as likely to die as infants or due to injury
F 30% more likely to be born with low birthweight or
to be overweight or obese and more likely to be
developmentally vulnerable at school entry, and
F 40–50% less likely to meet national minimum
standards for reading and numeracy
Headline indicators for children's health, development and wellbeing, 2011.mht
Current study
F  A partnership with BHP BIO, the Department of
Education and Training (DET) and Aboriginal
independent schools over five years to collect AEDI and
other relevant information for 4, 5, and 6 year old
children in this area.
F  involves government and non government agencies
(including World Vision Australia and YMCA), local
Aboriginal Medical Services, Aboriginal mothers groups,
community councils, and Martu health and education
officers working together to identify community-led,
culturally relevant initiatives to address a suite of
maternal and child health issues in an holistic manner.
The Current Project
F  Brings together ideas and evidence
around early child development and links
to life course trajectories and health,
education, employment outcomes
F  Draws on the WAACHS, AEDI and the
COAG OID to inform the BHPBIO
Community Investment Program
2008-2012
4
09/05/13
What we have found so far
What we have found so far
F  need strong local inter-sectoral leadership
(partner meetings)
F  need increased focus and understanding
of AEDI outcomes
F  need shared focus on barriers that prevent
equitable access to high quality programs
and services
F  Need for greater interagency /intersectoral
coordination – local, state, commonwealth
Research Rationale
Current Context
Focusing stakeholders (policy and
service providers) on the key early life
determinants of Aboriginal maternal and
childhood health outcomes is informed
by the 'causal pathways' literature which
provides strong evidence that both the
causes of disadvantage and positive
effects of interventions have their
greatest impact during the early years.
Stakeholders & communities are using
the results to:
F 
F 
F 
F 
F 
F 
F 
Focus effort in the areas of greatest need
Identify where there are service gaps and where
change in service provision is needed
Monitor early childhood development over time and
create effective community-based responses
Build a shared understanding of the importance of
early childhood
Influence new policies and programs and ways of
working together to ensure children get the best
possible start before entering school
Support communities to attract new funding into the
area
Leverage local, state and Australian government
programs
F  Need for working with the state and
independent schools and early years
centres
F  Government policies/programs have failed to
produce the desired results in health
F  Unacceptable circumstances – contaminated
water and scabies, Otitis Media
F  Children can be consigned to a life course
trajectory that is trans-generational in its
implications/outcomes
Guiding principles to engage families and
communities
1. 
2. 
3. 
4. 
5. 
6. 
Martu/Aboriginal participation and consultation
Build capacity of parents
Acknowledge and respect different learning styles
Recognition and respect for Aboriginal people and
cultures
Understand the size and distribution of the Aboriginal
population, especially in remote locations
Account for the cultural diversity of the Martu/
Aboriginal population
5
09/05/13
Principles
1. Ensure participation and consultation at all stages
including leadership, direction-setting and accountability
elements
2. Many parents who have a limited capacity to support their
children’s progress … so initiatives need to that BUILD
the CAPACITY of parents
3. Need to factor in differences in culture and language,
household composition, and transitional living ! there is
wide diversity in the circumstances of Aboriginal people.
Key research challenges
F  Keeping the project focused; staying on
track;
F  managing competing expectations;
F  once people in the community raise issues
they want something done;
F  managing different role/relationship
expectations
Where to from here?
. The challenge and opportunities for all of
us is to determine how can we work
together in ways that are empowering –
that support both cultural continuity,
connection and strengthen the capacity
and capability of individuals and
communities
Key challenges/opportunities
F  Working with various stakeholders and
their different agendas (including territory)
F  Navigating the community politics
F  Keeping the community involved
F  Understand the issues and to agree to
context relevant/appropriate measures of
success
What Martu say
‘They [young mothers] must learn about bush
medicines, bush tucker and things to help baby
grow up aboriginal way’
They must learn how to grow their babies up
from the old people
Keep it in your cultural way, you mob!’
Thank
You!
6
Appendix 6: Impact of swimming pools on health of Aboriginal children in remote communities of
Western Australia
presentation by Deborah Lehmann
09/05/13'
Impact'of'swimming'pools'on'health'of'Aboriginal'
children'in'remote'communi7es'of'Western'
Australia'
Background'
'
  High'rates'of'skin'disease,'renal'disease,'
rheuma=c'heart'disease'
  Excessive'ear'disease'
  Poor'school'aCendance'rates'
  High'rates'of'drowning''
  Limited'opportunity'for'physical'exercise''
  LiCle'or'no'recrea=onal'facili=es'
  Social'problems:'crime,'lack'of'employment'
  Anecdotes're'health'benefits'of'swimming'pool'
Deborah'Lehmann'
AIM'
Funding'
Partnerships'
  Burringurrah'and'Jigalong''
'''''Communi=es'
  WA'Department'of'Housing''
'''''&'Works'
  Royal'Life'Saving'Society'WA'
  Department'of'Educa=on'WA'
  Department'of'Health'WA'
  Friends'of'the'Ins=tute'
  Sport'&'Recrea=on'
' 'Evaluate'the'health'&'
social'impact'with'the'
introduc=on'of'
swimming'pools'in'2'
remote'WA'
Aboriginal'
communi=es.'
TEAM'
M Tennant
Project Coordinator
I Nannup
Derbarl Yerrigan Health Service
L Kelly, P Garlett
Marr Mooditj Student
J Johnston, D McAullay, K Butler Kulunga Research Network
S Weeks, M Hollins
Audiologists
D Silva, H Wright, P Richmond, J Stuart
Paediatricians
C Gordon, A Arumugaswamy G Werna
Medical Students
D Lehmann, F Stanley, P Jacoby
Epidemiologists
H Coates, F Lannigan
ENT Surgeons
H Wright, J Smith
Research assistants
Yandeyarra'
Burringurrah'
'
Jigalong'
n=250;'1600km'
'n=180:'1200km'
1'
09/05/13'
Skin'infec=ons'in'Burringurrah'
83'enrolled'
Data'Collec=on'2000V2005'
•  Con=nuous'enrolment'
•  Clinical'examina=on'6V12'
monthly'(paediatrician/ENT'
surgeon)'
 
 
70
 
%'
Skin'sores'(sore'score)'
–  Also'collected'swabs'
from'sores'
Ears'
Pool closed 3/12
prepool
Feb02
Aug03
Aug- Apr-05
04
'43''''''''31'''''''''57'''''''''44'''''''''42'
Propor=on'of'children'with'wet'or'dry'
perfora=on'of'the'ear'drum'before'and'aaer'
installa=on'of'pools'in'Burringurrah'
Pool closed 10/12
35
33%
30
25
40
non-severe
30%
30
severe
20
%
15%
15
dry perf
wet perf
10
10
5
prepool
Mar- Jul-01 Feb01
02
Aug03
Sep- Apr-05
04
0
prepool
Children'
Examined=''''54'''''''''32''''''''38'''''''''44'''''''''''52'''''''''35'''''''''31''''''''
Propor=on'of'children'with'wet'or'dry'
perfora=on'of'the'ear'drum'before'and'aaer'
installa=on'of'pools'in'Jigalong'
45
40
35
30
25
20
15
10
5
0
Jul-01
'
20
%
Mar01
Children'
Examined'=''54'''''''''40'
50
0
severe
0
60
%'
non-severe
10%
10
Skin'infec=ons'in'Jigalong'
78'enrolled'
70%
22%
20
'
70
40
30
School'aCendance'
Parent'interviews'
80
50%
50
•  Health'Centre'ACendance'
•  Social'aspects ''
 
62%
60
Pool closed
Pool closed
32%
20%
dry perf
wet perf
prepool
Mar- Jul-01 Feb01
02
Aug03
Sep04
Mar- Jul-01 Feb01
02
Aug03
Aug- Apr-05
04
Examina=on'of'clinic'records'1998'V2005'in'
Jigalong'and'Mugarinya'
•  Skin'infec=ons'
•  Ear'infec=ons'
•  Respiratory'tract'
infec=ons'
•  An=bio=cs'
prescribed'
•  Injuries'
Aug05
2'
09/05/13'
Mean'rates/child'of'documented''
skin'infec=ons''
in'2'communi=es'1998V2005'
Clinic'staffing'and'records'
  Jigalong:'131'children’s'charts'examined'
 2'doctors,'2'resident'nurses''
 Well'kept'records'
 Compared'communityVbased'with'clinicV
based'methods'
Jigalong'68%'reduc=on'
Mean%events%per%child%
2.5
  Mugarinya:'128'children’s'charts'
'examined'
Jigalong
2
Mugarinya
1.5
1
0.5
M- 77% reduction *
20
01
/0
2
20
02
/0
3
20
03
/0
4
20
0/
05
19
98
/9
19
99
/0
0
20
00
/0
1
0
 No'regular'doctors,''
 1'nurseV'resident'4'days'/week'
'
Mean'rates/child'of'documented''
middle'ear'infec=ons''
in'2'communi=es'1998V2005'
0.6
0.5
0.4
0.3
jigalong
0.2
Mugarinya
0.1
3.5
Mean%events%per%child
Jigalong 61% reduction
0.7
3
Jigalong'45%'reduc=on'
2.5
2
1.5
jigalong
1
mugarinya
0.5
0
99
8/
99
19
99
/0
0
20
00
/0
1
20
01
/0
2
20
02
/0
3
20
03
/0
4
20
04
/0
5
0
Mean'rates/child'of'documented'injuries'in'2'
communi=es'1998V2005'
0.6
0.5
0.4
0.3
0.2
jigalong
0.1
Mugarinya
0
Summary'
  Skin'infec=ons'–'declined'both'communi=es''
  O==s'media'and'an=bio=c'prescrip=on'–'decline'in'
Jigalong'only'
  Why'differences'between'communi=es?'
– ?'differences'in'health'service'delivery'and'
recording'of'events'
– ?'Real'differences'in'disease'rates'
19
98
/9
19
99
/0
0
20
00
/0
1
20
01
/0
2
20
02
/0
3
20
03
/0
4
20
0/
05
0.8
Mean'rates/child'of'documented'an=bio=cs'
prescribed'in'2'communi=es'1998V2005'
3'
09/05/13'
Well-documented clinic records in
communities with high burden of
disease can be used to impact of
public health interventions
Other'Results'
 
 
 
 
 
 
 
 
 
 
Overwhelming'support'by'both'communi=es''
No'disease'outbreaks'
School'aCendance'improved'in'one'community''
Royal'Life'Saving'Associa=on:'Increased'knowledge'of'
water'safety'&'swimming'competence''
Facili=es'used'for'recrea=on,'educa=on'
Police'reports:'Reduc=on'in'crime'
Employment'opportunity'
Training'in'research'and'clinical'skills'–'e.g.'AHWs,'medical'
students,'MSc'etc.'
More'pools'built'in'WA'and'SA'''
Evalua=on'of'pools'introduced'in'SA'
'
Issues'around'study'design'
  No'control'group/community'
–  Considered'unethical'if'unable'to'offer'pool'to'control'
community'if'found'to'be'effec=ve'
–  What'would'be'appropriate'control'community/
individual?'
  Small'sample'size'and'high'mobility'of'popula=on'
  No'data'collec=on'on'dose'effect'
  Minimal'(but'some'useful)'qualita=ve'data'
collected'
  For'o==s'media,'did'not'assess'size'of'perfora=on'
in'a'standardized'manner'
Future'
Return'to'communi=es'where'pools'were'installed'
in'1999V2000'
–  Has'there'been'longVterm'impact'on'rates'of'skin'and'
ear'disease?'
  Previous'par=cipants'will'now'be'aged'16V25yrs'
  Repeat'crossVsec=onal'survey'0V16yrs'(Jigalong,'Burringurrah)'
  Review'clinical'records'(Jigalong,'?Mugarinya)'
–  Perceived'longVterm'benefits''
  Community'members,'teachers,'health'staff,'pool'managers'
–  Nega=ve'percep=ons'
–  Pool'aCendance'over'extended'period'maintained?'
–  Pool'maintenance'issues?''Salt'versus'chlorinated'
pools'
Future'
Wider'study'covering'all'communi=es'with'pools'or'where'pools'
are'planned'+/V'communi=es'with'no'pool?'
–  What'are'community’s'primary'concern?'i.e.'what'do'people'view'as'
op=mal'way'of'addressing'the'burden'of'skin'disease'(also'heart'and'
kidney'disease)'
–  Ideal'study'design?''
  Is'an'RCT'appropriate?'(individual'randomisa=on'within'community'not'
appropriate'
–  Clinical'impact'V'?clinical'records'
–  Measure'dose'response''(is'a'swipe'card'system'feasible?)''
–  Formal'qualita=ve'study'
 
 
 
 
 
 
 
Benefits'or'disadvantages'of'pool'or'other'interven=ons'
Who'uses'pool'(e.g.'very'young'kids'have'a'lot'of'skin'and'ear'disease)'
Male/female'mixing'
Op=mal'circumstances'for'pool'management'
No'school'no'pool'policy'–'how'strict'should'it'be?'
Is'pool'having'social'benefits'in'community?'
Are'there'environmental'issues'e.g.'water'shortage'
–  Mul=faceted'approach'to'reducing'burden'of'skin'and'ear'disease'
4'
Appendix 7: Current evidence for effectiveness of swimming pools for skin infections and ear
disease
presentation by David Hendrickx
09/05/13
Current'evidence'for'
effec/veness'of'swimming'
pools'for'skin'infec/ons'
and'ear'disease''
David'Hendrickx'
'
'
'
•  Chronological'overview'
1995'@'2012'
'
•  Methodological'challenges'
'
Cover photo Flinders University swimming pools report
1995'@'2012''
Carapetis,
J. R., Johnston,
F., Nadjamerrek,
J., & Kairupan,
J. (1995). Skin
Year Institute
Area Skin?
Ear?
Outcome
sores in Aboriginal children. Journal of paediatrics and child health, 31(6):563
1995
Menzies NT
Prevalence of pyoderma in <9 yo’s !
1995'@'2012''
Skin?
Ear?
1995
Menzies
NT
Prevalence of pyoderma !
Eardrum perforations !
D  survey
sept 1994WA
(n=81) " pool opened
1994 attendance
" survey dec
1994
2008
TICHR
oct
Clinical
rates
for (n=54)
skin, ear &
D  recorded lesion type, severity, distribution respiratory infections !
Antibiotic
D  once or less per week (s-neg) vs more than
once perprescriptions
week (s-pos)!
2003
TICHR
WA
2008
TICHR
WA
Clinical attendance rates for skin, ear &
respiratory infections !
Antibiotic prescriptions !
2010
TICHR
WA
D  Results:
D  Skin infections were less severe
2010 D  Overall
DoHA prevalence
SA
! (48% to 41%) Prevalence of pyoderma !
No impact on ear health
2010
TICHR
WA
2010
DoHA
SA
2003
TICHR
WA
D  study population: school children
Year
Institute
Area
Outcome
2012
FU/DoHA SA
No impact on hearing & ear health
2012
FU/DoHA SA
2013
Menzies
2013
Menzies
NT
NT
1995'@'2012''
1995'@'2012''
D  Less severe skin sores
2012
FU/DoHA SA
An evaluation
benefits
of swimming
pools for the Outcome
hearing and ear health
Year
Instituteof the
Area
Skin?
Ear?
of young Indigenous Australians. A whole of population study across multiple
1995
Menzies NT
remote Indigenous communities. (Flinders University & DoHA, 2012)
2003
TICHR
WA
D  study population: school age children (5 to 17 yo’s; n=813) in 11 APY
2008communities
TICHR (4 intervention
WA
vs 7 control) Clinical attendance rates for skin, ear &
D  Six 6-monthly visits between March 2009 Antibiotic
and September
2011 !
prescriptions
D  Screened for hearing (audiometry), perforations (otoscopy), middle ear function
2010
TICHR
WA
(tympanometry)
D  Results:
2010
DoHA
SA
D  No differences between non-pool vs pool
communities
(aggregated)
No impact
on ear health
D 
No
effect
on
school
attendance
(no-school
no-pool
policy) & ear health
2012
FU/DoHA SA
No impact
on hearing
2013
2013
Year Institute Area Skin? Ear?
Outcome
Evaluation of the sustainability and benefits of swimming pools in the APY*
1995
Menzies NT
lands in South Australia (Department of Health and Ageing, 2010)
2003
TICHR
WA
D  study population: school age children in 4 APY communities
2008
TICHR
WA
D  four 6-monthly visits between September respiratory
2007 and April
2009 !
infections
D  Screened for eardrum perforations and skin
sores. prescriptions !
Antibiotic
D  Results:
2010
TICHR
WA
D  No impact on ear health
2010 D  DoHA
SA
sores
Lower prevalence
of skin
Menzies
NT
Menzies
NT
* Anangu Pitjantjatjara Yankunytjatjara
1
09/05/13
1995'@'2012''
An evaluation
Swimming
study
of the
for
benefits
severe
otitis
of swimming
media
pools for
Institute:
the Outcome
hearing
Annaand
Stephen,
ear health
Year
Institute
Area
Skin?
Ear? (Menzies
of young
Peter
Morris,
Indigenous
AmandaAustralians.
Leach. to beApublished
whole of population
in 2013)
study across multiple
1995
Menzies NT
remote Indigenous communities. (Flinders University & DoHA, 2012)
2003
TICHR
WA
D  study population: school age children (5 toEardrum
12 yo’s;perforations
n=89) in NT !
community
D D  study
population:
school
age children
(5 to 17 yo’s; n=813) in 11 APY
randomised
control
trial during
4 weeks:
2008
TICHR
WA
communities (4 intervention vs 7 control) Clinical attendance rates for skin, ear &
D  Daily swimming class (n=41)
D  Six 6-monthly visits between March 2009 Antibiotic
and September
2011 !
prescriptions
D  Alternate activity with swimming restrictions (n=48)
D  Screened for hearing (audiometry), perforations (otoscopy), middle ear function
2010
TICHRfor discharge
WA
(otoscopy
Prevalence
of pyoderma
! ear
D  (tympanometry)
Screened
& perforations
& swabbing),
middle
function (tympanometry)
D  Results:
2010
DoHA
SA
D  Results:
D  No differences between non-pool vs pool
communities
(aggregated)
on ear
health
D  Swimming did not impact perforation No
sizeimpact
or degree
of discharge
No effect onSA
school attendance
(no-school
no-pool
policy) & ear health
2012 D D  FU/DoHA
in prevalence
No of
impact
on hearing
No significant differences
bacteria
2013
Menzies NT
Methodological'challenges'
•  Need'for'control'groups'
•  Contamina/on'effects'
•  Pool'maintenance'
•  Popula/on'mobility'
•  Generalizability'of'findings'
•  Defining'regular'pool'use'
•  Dosage?'
•  Measuring'use'
1995'@'2012''
Skin?
Ear?
1995
Year
Menzies
Institute
NT
Area
2003
TICHR
WA
2008
TICHR
WA
Antibiotic prescriptions !
2010
TICHR
WA
2010
DoHA
SA
2012
FU/DoHA SA
2013
Menzies
NT
Outcome
Nevertheless...'
“Swimming'pools'are'a'‘public'good’'that'should'be'
available'to'all'Australian'children,'especially'those'
living'in'very'hot'places'where'there'are'few'alterna=ve'
recrea=onal'opportuni=es.'Arguments'about'direct'
health'benefits'should'not'be'a'requirement'for'one'
group'of'disadvantaged'Australians'when'we'do'not'
feel'we'need'to'make'the'same'arguments'for'other'
Australian'children.”'
'
Roe,'Y.,'&'McDermoQ,'R.'A.'(2009).'Effect'of'swimming'pools'on'an/bio/c'use'and'clinic'
aQendance'for'infec/ons'in'two'Aboriginal'communi/es'in'Western'Australia.'The'Medical'
journal'of'Australia,'190(10):602.''
2
Appendix 8: Remote Aboriginal swimming pool program
presentation by Amanda Juniper
Goal and objectives
Goal
To work with remote Aboriginal communities to improve
water safety, drowning prevention, health, social and
educational outcomes
Objectives
?  Manage safe, efficient and effective swimming pool
facilities that meet the needs and expectations of the
community
?  Encourage safe community participation within the
swimming pool facility
?  Provide a safe pool environment within each
community
?  Promote community support and patronage
?  Deliver aquatic based water safety programs to
increase levels of participation
Remote Aboriginal
Swimming Pool
Program
6 Remote Communities
2000 Burringurrah
Jigalong
Yandeyarra
2007 Bidyadanga
2008 Warmun
2010  Fitzroy Crossing
?
Balgo
Warmun
Fitzroy
Bidyadanga
Yandeyarra
Jigalong
Burringurrah
Pool activities
Pool managers
The program is driven primarily by the dedication of the 6 pool
managers
The pool managers are responsible for:
?  Facilitating and encouraging safe participation
?  Ensuring the efficient maintenance and operation
?  Ensuring the centre is well presented
?  Keeping detailed records of pool operations
?  Consulting with and working towards meeting the needs
and expectations of the community
Pool Operation
?  September to May each year
?  6 days a week, including weekends
?  5 or 6 hours a day
Benefits of the pools
Health
? Improvements in ear and skin health
? Increased physical activity
? Promotion of healthy eating
Social
? Social hub – sense of community
Community!
Swim &
Survive!
Bronze
Medallion!
Carnival
participants!
Innovative
Sessions!
Visits!
Bidyadanga!
72!
-!
120!
18!
8,056!
Burringurrah!
32!
1!
185!
25!
3,849!
Fitzroy Crossing!
194!
80!
1,008!
52!
13,233!
Jigalong!
23!
1!
102!
183!
8,843!
Warmun!
40!
-!
80!
34!
3,581!
Yandeyarra!
35!
3!
-!
137!
3,574!
TOTAL!
396!
85!
1,495!
449!
41,136!
Employment
? Local community members employed to assist with
maintenance and program delivery
Education and training
? Training in swimming and lifesaving skills
? Increased school attendance
1
Research plan 2012-14
No School No Pool policy
Aim
? Evaluate the effectiveness of the policy at
increasing school attendance rates
? Document the communities’ perspectives on
the policy
Questions?
Method
?  Compare school attendance figures during pool season
to off season over 3 years
?  If possible, compare school attendance rates before and
after the pool opened
?  Interview community members: teachers, police, health
professionals, parents and children
2
Appendix 9: Healthy Skin Experiences from the NT Since 2004
presentation by Ross Andrews
Scabies and skin sores (pyoderma)
Healthy Skin
Experiences from the NT since 2004
(not much on ivermectin trial!)
Ross Andrews
Therese Kearns (TK)
[email protected]
[email protected]
Perth, 12-13 December 2012
Scabies
Skin sores
Endemic in many remote Indigenous communities
East Arnhem Healthy Skin Project
L  Aim:
–  Reduce scabies, skin sores and tinea
in East Arnhem
L  Aim:
in East Arnhem
L  Program Components:
–  Scabies day
–  Check ups of kids 0-<15 years
–  Clinic presentations
–  Who gets treated at home
–  Scabies day
Resources
"
!
"
L  Aim:
in East Arnhem
"
!
–  Scabies day
"
!
"
!
!"
1
Resources
Resources
www.menzies.edu.au/
Resources
www.menzies.edu.au/
Healthy
Skin
Road
Jan
2004
Scabies from
30% to <10%
Sep
2004
Skin sores from
50% to <25%
Sep
2005
Jan
2005
PLoS Negl Trop Dis 2009;3(11):e554
Sep
2006
PLoS Negl Trop Dis 2009;3(5):e44
Jan
2006
Bull WHO 2008;86:275-281
June
2007
Jan
2007
Andrews et al. Ped Clin N Am 2009:1421-1440
L  Aim:
in East Arnhem
–  Scabies day
Real training
Real jobs
RealRoss
commitment
Andrews
2
Healthy
Skin
Road
Jan
2004
Sep
2004
Scabies from
30% to <10%
Skin sores from
50% to <25%
Prevalence of skin sores (pyoderma) & scabies
(1st 18 mths of screening vs 2nd 18 mths of screening)
Andrews et al. PLoS NTD 2009
Sep
2005
Jan
2005
Scabies overall
Sep
2006
13% (no change)
Jan
2006
2329 children seen
Skin sores overall
Aug
2007
46% to 28%
Jan
2007
6038 skin checks
L  Aim:
in East Arnhem
Scabies
L  69% of infants infected before 1st
birthday
–  3 times per child (IQR 1,5)
–  Scabies day
Skin sores
L  63% of infants infected
before 1st birthday
–  3 times per child (IQR 2,5)
Clucas et al. Bull WHO 2008
Clinic presentations in first year of life
Scabies: age at first presentation
East Arnhem
L  21 clinic presentations (median)
21
(IQR 15,29)
in the 1st year of life (IQR 15,29)
L  67% of visits had an infection-related cause
67%
L  Main reasons
By 1st Bday
Median (IQR)
96%
6 (3,10)
–  URTI
–  Ear disease
82%
3 (1,5)
84%
3 (2,5)
–  Skin infection
–  LRTI
75%
3 (2,5)
–  Diarrhoea
77%
3 (1,5)
Kearns et al. (under review PLoS One)
3
Skin sores: age at first presentation
Take home message #1
t load
Bucke , skin
p
s
of re
&
ease
ear dis
time
time & !
a
g
a in
Clucas et al. Bull WHO 2008
Who uses scabies cream?
L  Aim:
in East Arnhem
L  Index child with scabies (Day 0)
L  Household visit (Day 1)
–  Household members screened
–  Brief questionnaire
L  Rescreen & retreat (Day 14 & 28)
–  Scabies day
LaVincente et al. PLoS NTD 2009
Participants
Treatment uptake
Individuals:
L  40 households (596 individuals)
L  Median persons per house (IQR 12,20)
L  Most index children were treated (80%)
BUT
16
L  Only 44% of contacts reported using treatment
–  Who was most likely to treat?
L  People with scabies (OR 2.4, 95%CI 1.1,5.4)
L  Median persons per bedroom 4.2 (IQR 3.5, 5.3)
L  Median 24% of household members had scabies
at Day 0 (IQR 11,45)
L  People from a LOW-scabies burden setting
(OR 4.1, 95%CI 1.3,13.1)
4
Acquisition of scabies
Remaining scabies-free
L  349 scabies free (Day 1)
–  149 lost to follow-up
L  Factors associated with being scabies free
–  Age?
! those who acquired scabies were
significantly younger
L  185 followed up
–  Individual treatment uptake?
" did not alter risk of
L  17 (9.2%) acquired scabies
scabies acquisition
–  Household treatment uptake?
! 6 times more likely to be scabies free if all
household members were treated
Prevalence of skin sores (pyoderma)
(1st 18 mths of screening vs 2nd 18 mths of screening)
s
Scabie
m
a
e
r
c
works
not
but is
used
Skin sores overall
46% to 28%
Treatment of skin sores, 3-14 years
20%
Sep 04-Feb 06
18%
Mar 06-Aug 07
17.2%
Average monthly prevalence
16%
Skin sores
14%
12%
10%
8%
7.3%
6%
4%
3.9%
3.8%
ose,
Diagn p
u
Follow
&
Treat
ks!
It wor
2%
0%
5 or more sores
crusted/purulent sores
Treatment for Skin Sores
5
300
No Scabies lesions
20%
250
11%
10%
150
100
10%
5%
5%
4%
4%
50
0
0%
10-<20
20-<30
30-<40
40-<50
50-<60
60+
fe
f lifest yr of li
t ro
1s y s in 1
in
e
f
n
n
f li
io
io
t ro
10%
150
ntat sentat
1s y
cing
e
ese
g
t tra
orin nce in first pr bies pr
it
n
t
o
ntac
le
a
a
o
a
c
M
c
v
s
e
e
f
100
Pr ian ag ber o
for tion on
1. 
ls
5%
Med ian num entine e ! ac
2. 
s
c
d
n
e
s
e
50
M
a
3. 
nts in incid
a
f
n
I
4.  hanges
0
0%
c
200
11%
10%
5%
4%
4%
0-<10
10-<20
20-<30
30-<40
40-<50
50-<60
60+
Age Groups
Kearns et al. 3.50pm, UWA Boat Shed, today!
L  Skin sore prevalence reduced (46% to 28%)
–  Improved case management
L  Regular follow-up and treatment
–  Local workers can have an impact
L  Need to provide adequate training, support &
specific role (link with baby clinic)
–  Treatment works but is not being used
L  Now have revised indications for treatment
L  Need alternative treatments (trial underway)
L  Scabies prevalence unchanged (13%)
–  Treatment works but is not being used.
L  Ivermectin study underway
www.menzies.edu.au/
% Scabies lesions
16%
Age Groups
The Bottom Line
20%
Yes Scabies lesions
------- Mean Prevalence
15%
Number of skin checks
200
% Scabies per age group
16%
0-<10
No Scabies lesions
18%
% Scabies lesions
15%
300
Yes Scabies lesions
18%
250
Scabies prevalence by age, 2011
Scabies prevalence by age, 2011
Kearns et al. 3.50pm, UWA Boat Shed, today!
Acknowledgements
L 
East Arnhem Healthy Skin Project research team:
–  Lucy Armstrong, Norma Benger, Jonathan Carapetis
–  Kylie Carville,Danielle Clucas, Christine Connors, Bart Currie
–  Annette Nyugka Dhamarrandjii, Jessica Dhalkamarrawuy
–  Leanne Bundhala Dhurrkay, Roslyn Gundjirryirr Dhurrkay
–  Charmaine Hird, Therese Kearns, Sophie La Vincente
–  Loyla Leysley, Julie Muluymuluy Marawili
–  Dipililnga Basma Marika, Wayalwanga Marika, Lisa McHugh
–  Melita McKinnon, Colin Parker, Anna Ramatha, Paige Shreeve
–  Melissa Manini Wanambi, Yaminy Yunupingu
L 
East Arnhem Healthy Skin Project funding bodies
–  CRCAH, Rio Tinto Aboriginal Foundation, OATSIH
–  Ian Potter Foundation, Australasian College of Dematologists
–  NT Department of Health and Families
Thank you
6
Appendix 10: Is MDA an effective public health measure to reduce prevalence of
scabies and strongyloides?
presentation by Therese Kearns
Hypothesis for the project
Methods
Is MDA an effective
public health measure to
prevalence of
Sarcoptes scabiei
09/05/13
Training of research staff and
delivering community education
<  January 2010 – March 2010
Population Census & MDAs
<  March – September 2010 (month 0)
<  April – November 2011 (month 12)
Strongyloides stercoralis
Cross Sectional Surveys
<  September 2010 – March 2011 (month 6)
<  November 2011 – August 2012 (month 18)
Method of Diagnosis
Scabies
Treatment guidelines
Drug
Clinical diagnosis for scabies with
laboratory confirmed for crusted scabies
Pregnancy
Dose
Urine HcG (females aged 12-45 years)
Indications
Single dose 0.2mg/kg
≥ 15 kg and not
repeated in 10-42 days pregnant
if positive or equivocal
for strongyloides and/
or positive scabies
Ivermectin
5% permethrin Single application
Children 3.5kg-<15kg
repeated in 10-42 days Pregnant females or
if positive for scabies
pregnancy status
unknown
Scabies by month
Scabies prevalence by age at MDA #1
300
40
No Scabies lesions
35
2011 - Second Population Census
% Scabies lesions
250
25
25
23
20
16
14
15
200
10%
150
7%
6%
100
9
10
7
7
3%
50
7
1
2
3
March
3
0
April
May
June
July
Month Seen
August
5%
3%
2%
2
0
6%
4%
5
5
15%
30
No. of scabies lesions detected
20%
Yes Scabies lesions
2010 - First Population Census
35
September
0
0
October
November
0%
0-<10
10-<20
20-<30
30-<40
40-<50
50-<60
60+
Age Groups
1
09/05/13
Scabies prevalence by age at MDA #2
300
No Scabies lesions
20%
% Scabies lesions
15%
200
11%
10%
150
100
10%
5%
16%
5%
4%
4%
50
0
0%
0-<10
Characteristics
MDA #1
(n=43) (%)
MDA #2
(n=116) (%)
Median age (IQR)
Yes Scabies lesions
18%
250
Scabies Characteristics
10-<20
20-<30
30-<40
40-<50
50-<60
60+
Age Groups
Notification
Clinical
of crusted
presentations
scabies
10 (5-37)
11 (6-19)
Male
9 (21)
61 (53)
Female
34 (79)
55 (47)
IV – 1 dose
8 (19)
17 (15)
IV – 2 doses
28 (65)
77 (66)
Median time in days B/W the 2
doses (IQR)
13 (12-19)
13 (12-19)
5% permethrin – 1 application
2 (5)
8 (7)
5% permethrin – 2 applications
3 (7)
8 (7)
Median time in days B/W the 2
doses (IQR)
14 (12-21)
14 (11-21)
Treatment
Scabies prevalence
MDA#1
MDA#2
Possible crusted scabies case
identified by school
nurse and confirmed clinically by local GP
5 May 2011.
Case History
<  15 yr old female
<  Presented to school nurse
Post scabetic dermatitis MDA#2
with scabies Feb, March &
April, 5% permethrin given
<  Ivermectin 5/5 & 6/5
<  Skin scrapings 6/5
<  Evacuated to RDH 7/5
Lessons Learnt
<  MDA can lower prevalence of scabies
<  Ivermectin acceptable (96% receiving at least 1 dose)
Recommendations
<  Monitoring crusted scabies cases necessary to
minimize outbreaks esp. in low prevalence areas
<  Ivermectin labour intensive (everyone must be weighed and
<  Support needed for communities to monitor and
plan MDA if prevalence increases
<  Definition of scabies ie. itching and lesions (not very
sensitive with children in our study)
<  Ivermectin acceptable but not feasible to administer
to households in large communities (PI indicates not
<  Local community workers essential for educating
and engaging community members
<  Monitor crusted scabies cases for resistance to
treatment, possible that resistant mites can be
transferred to other individuals
females pregnancy tested)
recommend for contacts)
2
09/05/13
Recommendations
<  Use new diagnostic tools available, possible to
measure scabies antibodies from capilliary blood
spot on filter paper
3
Appendix 11: SHIFT: a new trial of mass drug administration for scabies control in a high
prevalence country
presentation by Andrew Steer
09/05/13'
!
SHIFT:!a!new!trial!of!mass!drug!
administra7on!for!scabies!control!in!
a!high!prevalence!country!
!!
Steer'A,'Whi1eld'M,'Andrews'R,'Wand'H,'Thein'HH,'
!r'
Koroivueta'J,'Tikoduadua'L,'Kaldor'J,'Romani'L,'Koroi'
A,'Tuicakau'M,'Kama'M,'Nakolinivalu'A,'Furlong'T.'
'
'
Scabies:'the'burden'of'disease'
The'Pacific'appears'to'be'a'“hotspot”:'the'Fiji'data'
'
Scabies'in'Fiji:'prevalence'
Fiji'R'crossRsecSonal'data*''
n=13,294'
'
Ppercentage of partici pants with s cabies by age
60%
50%
40%
30%
20%
10%
0%
WITH SCABIES
00
0
0
-1
51
-5
31
2
6
-1
-3
17
7
3
-6
-1
13
4
0-
Overall:!23%!
'
*Whi1ield,'Romani'et'al'Aus'Coll'Derm'ASM'2008'
'
1'
09/05/13'
Scabies'in'Fiji:'Incidence'
'
n=457'children'aged'5'–'15'years'over'10'months'
Control!of!scabies!
1.  Improved'living'condiSons'
2.  Beèr'treatment'algorithms'
–  Currently'based'on'topical'permethrin'for'cases'and'
household'contacts'
Incidence!:!51%!of!children!aged!5D15!have!a!
new!episode!of!scabies!acquisi7on!per!year!
*Steer'et'al.'PLoS'Neglected'Trop'Dis'2010'
'
Mass!Drug!Administra7on!(MDA)!
Successfully'used'for'endemic'tropical'diseases':'
'R'Onchocerciasis+
+,+Lympha1c+filariasis+
Topical!permethrin!MDA!in!Panama!*!
R'ReducSon'in'scabies'from'33%'to'1%!
Ivermec7n!MDA!in!Solomon!Islands!(n=1558)**!
R'All'residents'given'1R2'doses'
R'Review'3'Smes'per'year'
R'Returning'residents'also'treated''
*Taplin'et'al.'Lancet'1991'
!
**Lawrence'et'al.'Bull'WHO'2005'
'
Other'MDA'trials'for'scabies'
Brazil:'Scabies'3.8%'baseline'to'1.5%'at'9'months'
'
PNG:'Scabies'87%'baseline'to'26%'at'5'months'
'
Australia:'Current'beforeRafer'trial'of'ivermecSn'
for'scabies'in'the'NT'(n=1025)'
'
'
3.  Mass'drug'administraSon?'
'
'
Ivermec7n!MDA!in!Solomons!
Scabies:'baseline'25%'!'<'1%'at'3'years'
Impe7go:'baseline'40%'!'22%'at'3'years'
Ivermec7n!
  Binds'to'neurotransmièr'receptors'in'the'
peripheral'motor'synapses'of'parasites'
  First'line'treatment'of'a'number'of'parasites'
  Used'extensively'in'MDA:'
–  African'LF'Program:'149'million'treatments'
2000R7'
–  Global'LF'program:'1.9'billion'doses'over'21'years'
2'
09/05/13'
IvermecSn'in'parScular'populaSons'
'
  Children:'no'safety'data'<'15kg'
  Pregnant!women:'Category'B3'
  Lacta7ng!women:'safe'(no'passage)'
  ContraDindica7ons:'specific'medicaSons;'
neurologic'disorders'
Secondary!objec7ves!of!SHIFT!
!
1.'Assess'the'safety'of'MDA'using'topical'
permethrin'or'oral'ivermecSn'
2.'Evaluate'the'impact'of'MDA'for'scabies'on'
other'parasiSc'diseases.'
3.'Evaluate'the'costReffecSveness'of'the'
three'alternaSve'treatment'regimens.'
Study'sites'in'Fiji'
Primary!objec7ves!of!SHIFT!
1.  Assess'the'efficacy'of'MDA'for'scabies'using'
a)  topical'permethrin'or'
b)  oral'ivermecSn'for'scabies,'
'
compared'to'standard'of'care'treatment'using'
topical'permethrin'
2.'Assess'whether'oral'ivermecSn'is'at'least'as'
effecSve'as'topical'permethrin'as'MDA'
SHIFT!study!design!
  ProspecSve'community'intervenSon'trial''
  RandomisaSon'to'three'geographic'sites'
–  MDA'oral'ivermecSn'
–  MDA'topical'permethrin'
–  Supported'standard'of'care'
  Study'outcomes'assessed'at:'
–  3'months'(20%'sample)'
–  12'months'(100%)'!'primary'endpoint'
–  24'months'(20%'of'sample)'
SHIFT!7meline!
Moturiki!
Ba7ki!and!Nairai!
Ono,!Dravuni!and!Buliya!
3'
09/05/13'
SHIFT'study'procedures'
INITIAL!VISIT:!
Demographic'data'
Brief'medical'history''
Pregnancy'test'if'indicated'
Clinical'examinaSon'for'scabies'and'skin'sores'
Height,'weight,'blood'pressure,'and'nutriSonal'status.'
Faecal'sampling'
POC'tesSng'
Bacterial'swabs'of'infected'sores'
*Interven7on*!
SHIFT'study'procedures'
SUBSEQUENT!VISITS!
All'iniSal'study'procedures'repeated'
Adverse'event'quesSonnaire'
External'travel'quesSonnaire'
Health'services'uSlisaSon'
'
OTHER!DATA!COLLECTION!
AcSve'adverse'event'monitoring/q'(iniSal)'
Health'clinic'logs'for'presentaSons'with'skin'disorder'and'treatment'
administered'
Health'clinic'referrals'offRisland'
Serious'illnesses'and'deaths'
'
IntervenSons'
MDA!Ivermec7n!
'RDOT'dose'1*'for'all'
'RDOT'dose'2*'at'7R14'days'for'those'with'scabies'
'*permethrin'for'pregnant,'<15kg,'contraindicaSon'
MDA!Permethrin!
'RDOT†'dose'1'for'all'
'RDOT'dose'2'at'7R14'days'for'those'with'scabies'
StandardDofDcare!
'RParScipants'with'scabies'referred'for'treatment'under'
IMCI'guideline'
'
SHIFT'outcomes'
1.'Efficacy!against!scabies!and!skin!sores:'The'change'in'the'
prevalence'of'scabies,'at'the'3'month,'12'month'(primary'
endpoint)'and'24'month'visits,'compared'to'iniSal'visit;'likewise'for'
skin'sores.'Also'treatment'failure'and'acquisiSon''rates.'
2.'Efficacy!against!other!condi7ons:'Change'in'the'prevalence'of'the'
following'at'each'visit'compared'to'the'iniSal'visit:'hypertension,'
anaemia,'renal'impairment,'haematuria,'and'specific'parasiSc'
infecSons'(filariasis,'soil'transmièd'helminiths).'
3.'Safety:'The'occurrence'of'adverse'events,'both'nonRserious'and'
serious.''
4.'Health!and!economic!outcomes:'EffecSveness'will'be'measured'by'
the'number'of'cases'successfully'treated'and'prevalence'of'scabies'
averted'will'be'calculated.''
The!significance!of!SHIFT!
First'study:'
'Rto'compare'MDA'with'the'standard'of'care'
'RWith'two'year'follow'up'
'Rto'assess'costReffecSveness'
'
Fills'an'important'evidence'gap'not'addressed'through'
the'exisSng'before'and'afer'study'of'an'ivermecSn'
MDA'in'Australia.''
'
Major'implicaSons''for'scabies'control'in'Fiji'and'
elsewhere.'
4'
09/05/13'
NHMRC'
InvesSgators'
InvesSgators'
UNSW,'
MSHR'
MCRI'
Fiji'MOH'
Field'team'
SHIFT!governance!
Adverse'
event'
reporSng'
to'DSMB'
and'MSD'
Trial'Steering'Commièe'
OperaSons'
group'
Field'team'
SHIFT!progress!
Grant+awarded+November+2011+
Project+officer+(Lucia+Romani)+appointed+
Protocol+development+
Suva+workshop+March+2012+
Ethics+approvals+from+MCRI,+UNSW,+Fiji+MOH+
Company+agrees+to+supply+ivermec1n+
Suva+training+August+2012+
Enrolment+commenced+November+2012+
'
'
5'
Appendix 12: Experiences from the East Arnhem Scabies Control Program
presentation by Tim Foster
09/05/13'
The*EASCP*is*a*joint=ini>a>ve*of*1Disease,*Miwatj*
Health*and*NT*Department*of*Health*
Partners*
Experiences*from*the*East*Arnhem*
Scabies*Control*Program*
Healthy'Skin,'Healthy'Lives'Workshop'
Principles*
2. Reduce'scabies'and'
skinsore'rates'by'50%'
3. Support'environmental'
health'and'regulatory'
iniFaFves'
'
12th*December*
*
The*program*strategy*has*shiHed*focus*from*scabies*
MDA*to*case*management*of*Crusted*Scabies*
Dec*2010*–Jul*2011*
RegionIwide'
IvermecFn'MDA'
Goals*
1. Eliminate'crusted'
scabies'as'a'public'
health'issue''
Aug*2011*=*Present*
Crusted'scabies'management'&''
high'intensity'scabies'control'
1. Community'elders'
guide'implementaFon''
2. Community'workers'
implement'program'
3. CollaboraFon'with'
health'centres'and'
regional'health'
services'
'
Program*ac>vi>es*in*10*communi>es*since*mid=2011*
Maningrida'
 'Sep'‘12:'Supported'NT'
Health'Trachoma'Program'
Gunyangara*&*Birritjimi'
 Nov'‘11:'HHHS'Week''
 Jan'’12:'Skin'screening'
 Managing'1'CS'paFent'
 Ongoing'support'for'families'
with'recurrent'scabies'
 2'community'workers'
Milingimbi'
 Sep'‘11:'HHHS'Week'
 Jul'‘12:'Clinic'inIservice;'
Dermatologist'visit'
Yirrkala'
 Apr'‘12:'School'screening'
 Jul'‘12:'Skin'screening;'
 Oct'‘12:'MiniIskin'day'
 Nov'‘12:'Clinic'inIservice'
 Managing'7'CS'paFents'
 2'community'workers'
Ramingining'
 Jul'‘12:'Clinic'inIservice;'
 'Sep'‘12:'HHHS'week'
Gapuwiyak'
 Aug'‘11:'HHHS'Week'
 Sep'‘11:'Skin'screening'
Angurugu'
 Apr'‘12:'Clinic'inIservice'
Dhaniya*
 Jul'‘12:'Scabies'treatments'
provided'during'funeral'
Numbulwar'
 Jul'‘12:'Clinic'inIservice'
 Oct'‘12:'HHHS'week'
Tailored*approach*to*specific*need*of*community*
Umbakumba'
 Apr'’12:'School'screening'
Eight*individuals*with*Crusted*Scabies*now*following*
chronic*care*management*plans*
Crusted*Scabies*before*the*EASCP*
v
ser
rol*
ont
ies*c
cab
*&*S
ies
cab
d*S
ste
Cru
Treated*as*acute*condi>on*
  Frequent'hospitalisaFon'
  Inevitable'relapse'
ls*
eve
ice*l
'
Embedded*
field*team*
Advanced*
support*
Devasta>ng*impacts*
  High'mortality'rate'
  SFgma,'disfiguring'
  Core'transmiêrs'
  Impact'on'work,'school'&'family'
Crusted*Scabies*during*EASCP*
Treated*as*chronic*condi>on*
  Fortnightly/monthly'visits'
  Skin'checks,'preventaFve'
treatments'
'
Rebuilt*lives*and*rela>onships*
  Individuals'free'from'crusFng''
  Families'free'from'scabies'
  Back'to'work'&'school'
Basic*support*
Standardised*
tool*kit*
Due*to*success*of*program,*CARPA*guidelines*now**
advise*chronic*care*approach*for*Crusted*Scabies*
Source:'Walton'et'al.'2008'
1'
09/05/13'
Healthy*Homes,*Healthy*Skin*events*in*6*communi>es*
An>cpated*impact*of*scabies*control*interven>ons*
Visitor with
Crusted Scabies
Surveillance*&*social*marke>ng*
Healthy*Skin*Week/MDA*
Crusted*Scabies*mgmt*
No*interven>ons*
All*interven>ons*
Scabies*
Prevalence*
Ceremony
Ceremony
Wet season
Communitywide treatment
Communitywide treatment
Long run ave.
Public*health/*
medical*
interven>ons*
CommunityIled'surveillance'and'social'markeFng'to'encourage'early'treatment'
Time*
Our*results*so*far*
Crusted'Scabies'case'management'has'had'lifeIchanging'impacts*
Crusted*Scabies*management*in*
Yirrkala*and*Gunyangara*
Prior*to*Aug*‘11*
  Eight'uncontrolled'cases'of'CS'
  Frequent'relapses'&'hospitalisaFons'
  High'mortality'risk'
  Recurrent'scabies'in'close'contacts'
  Absence'from'school'&'work'
  Psychosocial'impacts'
'
Now*
  No'uncontrolled'cases''
  Significant'reducFon'in'hospitalisaFons'
  Reduced'mortality'risk'
  People'back'to'work'and'school'
  Reduced'risk'of'child'removal'
Numerous*challenges*encountered*and*lessons*
learned*along*the*way*
Scabies*control*across*East*Arnhem*
Gunyangara*&*Birritjimi*
  Healthy(Skin(Week(&(6(week(follow3up(
–  Nov'‘11:'28%'scabies'and'11%'skin'sores'
–  Jan’12:'14%'(6%)'scabies'and'16%'(7%)'
skin'sores*
Gapuwiyak*
  Healthy(Skin(Week(&(6(week(follow3up(
–  Aug'‘11:'23%'scabies''
–  Sep'‘11:'13%'scabies'
Yirrkala*
  School(screening((5315(yrs)(
Challenges*
  Overcrowding'&'mobility'
  Resistance'to'permethrin'
  Turnover'of'clinical'staff'
  Accurate'CS'diagnoses'
  Obtaining'staFsFcally'robust'
screening'results'
  ScalingIup'program'
Lessons*
  Need'for'flexibility'and'rapid'
adaptaFon'I'responsive'to'
community'needs'
  Building'and'supporFng'local'
workforces'
  Fostering'relaFonships'&'trust''
  Filling'gaps'rather'than'
subsFtute'
–  Feb'‘11:'11%'scabies'and/or'skin'sores'
–  Apr'’12:'7%'scabies'and/or'skin'sores'
  Screening((<5(years)(
–  Aug'‘12:'30%'scabies'and/or'skin'sores'
Looking*ahead*
 
 
 
 
 
 
 
Monitoring'&'evaluaFon'
Social'markeFng'
Funerals'and'ceremonies'
Advocacy'
Next'generaFon'scabies'cream'
ScaleIup'program'
Exit'strategy'
Thank*you*
www.1disease.org*
2'
Appendix 13: Introducing the International Alliance for the Control of Scabies
presentation by Andrew Steer
09/05/13'
Mission'statement'
The$Interna*onal$Alliance$for$the$Control$of$
Scabies$(IACS)$is$a$global$network$commi;ed$
to$the$control$and$elimina*on$of$human$
scabies$in$order$to$improve$the$health$and$
wellbeing$of$all$those$living$in$affected$
communi*es.'
Membership'
Organising'commi8ee'
Olivier'Chosidow'(Université'ParisBest'Créteil'Val'de'Marne,'France)'
Claire'Fuller'(InternaIonal'FoundaIon'of'Dermatology,'London,'UK)'
Roderick'Hay'(InternaIonal'FoundaIon'of'Dermatology,'London,'UK)'
Patrick'Lammie'(Centres'for'Disease'Control'and'PrevenIon,USA)'
James'McCarthy'(Queensland'InsItute'of'Medical'Research,'Australia)'
Andrew'Steer'(University'of'Melbourne,'Melbourne,'Australia)'
Daniel'Engelman'(University'of'Melbourne,'Melbourne,'Australia)'
'
A$proxy$for$poverty$and$disadvantage$
Affect$popula*ons$with$low$visibility$and$li;le$
poli*cal$voice$
Do$not$travel$widely$
Scabies'is'an'“NTD”'
Cause$s*gma$and$discrimina*on,$especially$of$
girls$and$women$
Have$an$important$impact$on$morbidity$and$
mortality$
Are$rela*vely$neglected$by$research$
Can$be$controlled,$prevented$and$possibly$
eliminated$using$effec*ve$and$feasible$
solu*ons$
1'
09/05/13'
Scabies'is'an'“NTD”'
What'are'the'NTDs?'
Scabies
Buruli'Ulcer'
Key$*mepoints$along$the$way:$
1998:'WHO'meeIng'and'formaIon'of'GBUI'
1999:'Yammoussoukro'DeclaraIon'
h8p://www.who.int/buruli/yamoussoukro_declaraIon/en/index.html''
2004:'WHA'resoluIon'57.1'calling'for'increased'
surveillance'and'control,'intensified'research'to'
develop'tools'to'diagnose,'treat'and'prevent'the'
disease'
2009:'Contonou'DeclaraIon'
'
'
h8p://apps.who.int/gb/ebwha/pdf_files/WHA57/A57_R1Ben.pdf''
h8p://www.who.int/neglected_diseases/Benin_declaraIon_2009_eng_ok.pdf''
IACS'
  Take'the'big'picture'like'GBUI'
Key$steps$along$the$way$for$GBUI$
B  FormaIon'of'GBUI'
B  Burden'of'disease'studies'and'declaraIon'of'endemic'countries'
B  IdenIficaIon'and'recogniIon'of'leaders'within'endemic'countries'
with'mulIBcountry'network'
B  RecogniIon'of'the'disease'as'a'priority'by'endemic'country'MOH’s'
B  Establishment'of'key'funding'donors'and'NGOs'
B  IdenIficaIon'of'and'invesIgaIon'into'key'research'quesIons'
B  Establishment'of'leadership'group'(TAG)'and'6'working'groups:'
– 
– 
– 
– 
– 
– 
Strategy'implementaIon'and'coordinaIon''
Care'and'support''
Laboratory'support'network''
Drug'treatment''
Epidemiology'and'surveillance''
Research''
Inaugural'meeIng:'
Taskforce'for'Global'Health,'Decatur'Atlanta'
16th'November'2012'
  But'make'achievable'acIon'points'for'2013'
2'
09/05/13'
Aims'of'inaugural'meeIng'
1.'To'reach'a'consensus'on'an'overall'mission'statement'for'IACS'
2.'To'discuss'the'aims'of'IACS'
3.'To'develop'strategic'yet'achievable'acIon'points''
4.'To'form'working'groups'to'progress'these'acIon'points'in'2013''
5.'To'sign'off'the'PLOS'NTD'Viewpoint'arIcle'
6.'To'build'ongoing'relaIonships'between'people'with'the'same'goal''
7.'To'plan'for'a'higher'impact'meeIng'in'2013'
4'major'areas'
Advocacy$
&$funding$
Control$
strategies$
Epi$&$
Research$
priori*es$
surveillance$
QuesIons'considered'during'the'meeIng'
BHow'can'we'increase'the'visibility'of'scabies'as'a'global'public'
health'problem?''
'
BHow'can'we'integrate'and'prioriIse'endemic'country'
involvement?'
'
BHow'can'we'link'into'acIviIes'already'occurring'with'other'
NTD’s?'
'
BHow'can'we'strategically'catch'the'a8enIon'of'global'funders?'
'
BWhat'key'steps'are'required'to'achieve'our'aims?'In'what'order'
should'they'be'prioriIsed?'
'
'
Outline'of'meeIng'
0900Q0930:
'
0930Q1015:
'
'
'
'
'
'
'
1015Q1030:
'
1030Q1150:
'
1150Q1215:
'
1215Q1315:
'
1315Q1400:
'Introductory'presentaIons'
'Breakout'sessions'
'
'BAdvocacy'and'funding'
'
'BControl'and'research'prioriIes'
'
'BEpi'and'surveillance'
OUTCOMES'FROM'THE'MEETING'
'Morning'tea'
'PresentaIon'and'discussion'from'groups'
'Biological'research'update'
'Lunch'(and'further'discussion!)'
'Discussion'of'future'plans'for'IACS'
3'
09/05/13'
Overall'
FormaIon'of'working'groups'for'acIon'points'
'
Consensus'and'signBoff'of'report'for'meeIng,'
with'circulaIon'
'
Decision're:'meeIng'plan'for'2013'
Advocacy'
4.''MulIBcountry'network'
'BIdenIfy'and'engage'countries'
'
5.'DeclaraIon'
1.  PreparaIon'
2.  Country'and'partner'signBup'
6.'Funding'prioriIes'for'IACS'acIviIes'2012/13'
Advocacy'
1.  “ScienIfic'bomb”:''
1.  PublicaIons'–'PLOS'NTD,'Current'Opinion'
2.  List'of'meeIngs'
'
2.  Website'
1.  WHO'
2.  IACS'standBalone'
'
3.  Engaging'partners:'
1. 
2. 
3. 
4. 
WHO'
Other'NGOs:'CDC,'BMGF,'Wellcome'
Pharma'
Other'NTD’s'
Epidemiology'and'surveillance'
1.  Case'definiIon'and'epidemiology'guidelines'
1.  For'validaIon'
2.  Mapping'exercise'
1.  GBD'data'
2.  Available'prevalence'data'
3.  Country'network'data'
3.  IdenIficaIon'of'atBrisk'populaIons'
'
Control'and'Research'
1.  Establishing'NTD'links'
1.  CosIng'of'training'for'NTD'rollBout'
2.  ConsideraIon'of'treatment'opIons'
2.  IdenIfy'disease'control'research'prioriIes'
3.  CirculaIon'of'basic'science'research'prioriIes'
4'

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