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Early identification of vulnerable children to protect them from harm and support them in achieving their long-term potential is a community priority. This is particularly important in the Northern Territory (NT) of Australia, where Aboriginal children are about 40% of all children, and for whom the trauma and disadvantage experienced by Aboriginal Australians has ongoing intergenerational impacts. Given that shared social determinants influence child outcomes across the domains of health, education and welfare, there is growing interest in collaborative interventions that simultaneously respond to outcomes in all domains. There is increasing recognition that many children receive services from multiple NT government agencies, however there is limited understanding of the pattern and scale of overlap of these services. In this paper, NT health, education, child protection and perinatal datasets have been linked for the first time. The records of 8,267 children born in the NT in 2006–2009 were analysed using a person-centred analytic approach. Unsupervised machine learning techniques were used to discover clusters of NT children who experience different patterns of risk. Modelling revealed four or five distinct clusters including a cluster of children who are predominantly ill and experience some neglect, a cluster who predominantly experience abuse and a cluster who predominantly experience neglect. These three, high risk clusters all have low school attendance and together comprise 10–15% of the population. There is a large group of thriving children, with low health needs, high school attendance and low CPS contact. Finally, an unexpected cluster is a modestly sized group of non-attendees, mostly Aboriginal children, who have low school attendance but are otherwise thriving. The high risk groups experience vulnerability in all three domains of health, education and child protection, supporting the need for a flexible, rather than strictly differentiated response. Interagency cooperation would be valuable to provide a suitably collective and coordinated response for the most vulnerable children. [ABSTRACT FROM AUTHOR]

Background: Streptoccocal A (Strep A, GAS) infections in Australia are responsible for significant morbidity and mortality through both invasive (iGAS) and post-streptococcal (postGAS) diseases as well as preceding superficial (sGAS) skin and throat infection. The burden of iGAS and postGAS are addressed in some jurisdictions by mandatory notification systems; in contrast, the burden of preceding sGAS has no reporting structure, and is less well defined. This review provides valuable, contemporaneous evidence on the epidemiology of sGAS presentations in Australia, informing preventative health projects such as a Streptococcal A vaccine and standardisation of primary care notification. Methods and findings: MEDLINE, Scopus, EMBASE, Web of Science, Global Health, Cochrane, CINAHL databases and the grey literature were searched for studies from an Australian setting relating to the epidemiology of sGAS infections between 1970 and 2020 inclusive. Extracted data were pooled for relevant population and subgroup analysis. From 5157 titles in the databases combined with 186 grey literature reports and following removal of duplicates, 4889 articles underwent preliminary title screening. The abstract of 519 articles were reviewed with 162 articles identified for full text review, and 38 articles identified for inclusion. The majority of data was collected for impetigo in Aboriginal and Torres Strait Islander populations, remote communities, and in the Northern Territory, Australia. A paucity of data was noted for Aboriginal and Torres Strait Islander people living in urban centres or with pharyngitis. Prevalence estimates have not significantly changed over time. Community estimates of impetigo point prevalence ranged from 5.5–66.1%, with a pooled prevalence of 27.9% [95% CI: 20.0–36.5%]. All studies excepting one included >80% Aboriginal and Torres Strait Islander people and all excepting two were in remote or very remote settings. Observed prevalence of impetigo as diagnosed in healthcare encounters was lower, with a pooled estimate of 10.6% [95% CI: 3.1–21.8%], and a range of 0.1–50.0%. Community prevalence estimates for pharyngitis ranged from 0.2–39.4%, with a pooled estimate of 12.5% [95% CI: 3.5–25.9%], higher than the prevalence of pharyngitis in healthcare encounters; ranging from 1.0–5.0%, and a pooled estimate of 2.0% [95% CI: 1.3–2.8%]. The review was limited by heterogeneity in study design and lack of comparator studies for some populations. Conclusions: Superficial Streptococcal A infections contribute to an inequitable burden of disease in Australia and persists despite public health interventions. The burden in community studies is generally higher than in health-services settings, suggesting under-recognition, possible normalisation and missed opportunities for treatment to prevent postGAS. The available, reported epidemiology is heterogeneous. Standardised nation-wide notification for sGAS disease surveillance must be considered in combination with the development of a Communicable Diseases Network of Australia (CDNA) Series of National Guideline (SoNG), to accurately define and address disease burden across populations in Australia. Trial registration: This review is registered with PROSPERO. Registration number: CRD42019140440. [ABSTRACT FROM AUTHOR]

Background: Chronic hepatitis B (CHB) is endemic in the Aboriginal population of Australia's Northern Territory (NT). However, many people's hepatitis B virus (HBV) status remains unknown. Objective: 1. To maximise the utility of existing HBV test and vaccination data in the NT by creating a linked dataset and computerised algorithmic coding. 2. To undertake rigorous quality assurance processes to establish feasibility of using the linked dataset and computerised algorithmic coding for individual care for people living with CHB. Methods: Step 1: We used deterministic data linkage to merge information from three separate patient databases. HBV testing and vaccination data from 2008–2016 was linked and extracted for 19,314 people from 21 remote Aboriginal communities in the Top End of the NT. Step 2: A computerised algorithm was developed to allocate one of ten HBV codes to each individual. Step 3: A quality assurance process was undertaken by a clinician, using standardised processes, manually reviewing all three databases, for a subset of 5,293 Aboriginal people from five communities to check the accuracy of each allocated code. Results: The process of data linking individuals was highly accurate at 99.9%. The quality assurance process detected an overall error rate of 17.7% on the HBV code generated by the computerised algorithm. Errors occurred in source documentation, primarily from the historical upload of paper-based records to electronic health records. An overall HBV prevalence of 2.6% in five communities was found, which included ten cases of CHB who were previously unaware of infection and not engaged in care. Conclusions: Data linkage of individuals was highly accurate. Data quality issues and poor sensitivity in the codes produced by the computerised algorithm were uncovered in the quality assurance process. By systematically, manually reviewing all available data we were able to allocate a HBV status to 91% of the study population. [ABSTRACT FROM AUTHOR]

Background: Chronic hepatitis B (CHB) is endemic in the Aboriginal and Torres Strait Islander population of Australia's Northern Territory. Progression to liver disease can be prevented if holistic care is provided. Low health literacy amongst health professionals is a known barrier to caring for people living with CHB. We co-designed and delivered a culturally safe "Managing hepatitis B" training course for the Aboriginal health workforce. Here, we present an evaluation of the course. Objectives: 1. To improve course participants CHB-related knowledge, attitudes, and clinical practice. 2. To evaluate the "Managing hepatitis B" training course. 3. To enable participants to have the skills and confidence to be part of the care team. Methods: We used participatory action research and culturally safe principles. We used purpose-built quantitative and qualitative evaluation tools to evaluate our "Managing hepatitis B" training course. We integrated the two forms of data, deductively analysing codes, grouped into categories, and assessed pedagogical outcomes against Kirkpatrick's training evaluation framework. Results: Eight courses were delivered between 2019 and 2023, with 130 participants from 32 communities. Pre- and post-course questionnaires demonstrated statistically significant improvements in all domains, p<0.001 on 93 matched pairs. Thematic network analysis demonstrated high levels of course acceptability and significant knowledge acquisition. Other themes identified include cultural safety, shame, previous misinformation, and misconceptions about transmission. Observations demonstrate improvements in post-course engagement, a deep understanding of CHB as well as increased participation in clinical care teams. Conclusions: The "Managing hepatitis B" training course led to a sustained improvement in the knowledge and attitudes of the Aboriginal health workforce, resulting in improved care and treatment uptake for people living with CHB. Important non-clinical outcomes included strengthening teaching and leadership skills, and empowerment. [ABSTRACT FROM AUTHOR]

Background: Positive early development is critical in shaping children's lifelong health and wellbeing. Identifying children at risk of poor development is important in targeting early interventions to children and families most in need of support. We aimed to develop a predictive model that could inform early support for vulnerable children. Methods: We analysed linked administrative records for a birth cohort of 2,380 Northern Territory children (including 1,222 Aboriginal children) who were in their first year of school in 2015 and had a completed record from the Australian Early Development Census (AEDC). The AEDC measures early child development (school readiness) across five domains of development. We fitted prediction models, for AEDC weighted summary scores, using a Partial Least Square Structural Equation Model (PLS-SEM) considering four groups of factors–pre-pregnancy, pregnancy, known at birth, and child-related factors. We first assessed the models' internal validity and then the out-of-sample predictive power (external validity) using the PLSpredict procedure. Result: We identified separate predictive models, with a good fit, for Aboriginal and non-Aboriginal children. For Aboriginal children, a significant pre-pregnancy predictor of better outcomes was higher socioeconomic status (direct, β = 0.22 and indirect, β = 0.16). Pregnancy factors (gestational diabetes and maternal smoking (indirect, β = -0.09) and child-related factors (English as a second language and not attending preschool (direct, β = -0.28) predicted poorer outcomes. Further, pregnancy and child-related factors partially mediated the effects of pre-pregnancy factors; and child-related factors fully mediated the effects of pregnancy factors on AEDC weighted scores. For non-Aboriginal children, pre-pregnancy factors (increasing maternal age, socioeconomic status, parity, and occupation of the primary carer) directly predicted better outcomes (β = 0.29). A technical observation was that variance in AEDC weighted scores was not equally captured across all five AEDC domains; for Aboriginal children results were based on only three domains (emotional maturity; social competence, and language and cognitive skills (school-based)) and for non-Aboriginal children, on a single domain (language and cognitive skills (school-based)). Conclusion: The models give insight into the interplay of multiple factors at different stages of a child's development and inform service and policy responses. Recruiting children and their families for early support programs should consider both the direct effects of the predictors and their interactions. The content and application of the AEDC measurement need to be strengthened to ensure all domains of a child's development are captured equally. [ABSTRACT FROM AUTHOR]

Introduction: Recent advances in G6PD deficiency screening and treatment are rapidly changing the landscape of radical cure of vivax malaria available for National Malaria Programs (NMPs). While NMPs await the WHO's global policy guidance on these advances, they will also need to consider different contextual factors related to the vivax burden, health system capacity, and resources available to support changes to their policies and practices. Therefore, we aim to develop an Options Assessment Toolkit (OAT) that enables NMPs to systematically determine optimal radical cure options for their given environments and potentially reduce decision-making delays. This protocol outlines the OAT development process. Methods: Utilizing participatory research methods, the OAT will be developed in four phases where the NMPs and experts will have active roles in designing the research process and the toolkit. In the first phase, an essential list of epidemiological, health system, and political & economic factors will be identified. In the second phase, 2–3 NMPs will be consulted to determine the relative priority and measurability of these factors. These factors and their threshold criteria will be validated with experts using a modified e-Delphi approach. In addition, 4–5 scenarios representing country contexts in the Asia Pacific region will be developed to obtain the expert-recommended radical cure options for each scenario. In the third phase, additional components of OAT, such as policy evaluation criteria, latest information on new radical cure options, and others, will be finalized. The OAT will be pilot-tested with other Asia Pacific NMPs in the final phase. Ethics and dissemination: Human Research Ethics Committee approval has been received from the Northern Territory, Department of Health, and Menzies School of Health Research (HREC Reference Number: 2022–4245). The OAT will be made available for the NMPs, introduced at the APMEN Vivax Working Group annual meeting, and reported in international journals. [ABSTRACT FROM AUTHOR]

Background: Cryptococcus gattii is a globally endemic pathogen causing disease in apparently immune-competent hosts. We describe a 22-year cohort study from Australia's Northern Territory to evaluate trends in epidemiology and management, and outcome predictors. Methods: A retrospective cohort study of all C. gattii infections at the northern Australian referral hospital 1996–2018 was conducted. Cases were defined as confirmed (culture-positive) or probable. Demographic, clinical and outcome data were extracted from medical records. Results: 45 individuals with C. gattii infection were included: 44 Aboriginal Australians; 35 with confirmed infection; none HIV positive out of 38 tested. Multifocal disease (pulmonary and central nervous system) occurred in 20/45 (44%). Nine people (20%) died within 12 months of diagnosis, five attributed directly to C. gattii. Significant residual disability was evident in 4/36 (11%) survivors. Predictors of mortality included: treatment before the year 2002 (4/11 versus 1/34); interruption to induction therapy (2/8 versus 3/37) and end-stage kidney disease (2/5 versus 3/40). Prolonged antifungal therapy was the standard approach in this cohort, with median treatment duration being 425 days (IQR 166–715). Ten individuals had adjunctive lung resection surgery for large pulmonary cryptococcomas (median diameter 6cm [range 2.2-10cm], versus 2.8cm [1.2-9cm] in those managed non-operatively). One died post-operatively, and 7 had thoracic surgical complications, but ultimately 9/10 (90%) treated surgically were cured compared with 10/15 (67%) who did not have lung surgery. Four patients were diagnosed with immune reconstitution inflammatory syndrome which was associated with age <40 years, brain cryptococcomas, high cerebrospinal fluid pressure, and serum cryptococcal antigen titre >1:512. Conclusion: C. gattii infection remains a challenging condition but treatment outcomes have significantly improved over 2 decades, with eradication of infection the norm. Adjunctive surgery for the management of bulky pulmonary C. gattii infection appears to increase the likelihood of durable cure and likely reduces the required duration of antifungal therapy. Author summary: Cryptococcus gattii is an environmental fungus responsible for invasive infection, predominately in the central nervous system (CNS) and lungs. There is little evidence to guide its management. We have found First Nations Australians in this region have one of the highest incidences of Cryptococcus gattii infection in the world, with rates possibly increasing. Mortality was associated with end stage kidney disease, diagnosis in earlier years of the study, and unplanned interruptions to intravenous treatment. Whilst mortality improved through the study, neurological disability such as visual or hearing impairment following cure continues to be seen and is associated with brain cryptococcomas and high cerebral spinal fluid (CSF) pressure at diagnosis or during treatment. Blocked CSF shunts are uncommon and concerns of such potential complications should not preclude necessary surgical intervention for persisting increased CSF opening pressures or hydrocephalus which has been associated with poor outcome. Infection recurrence or persistence was associated with large pulmonary cryptococcomas (over 3cm diameter) not undergoing pulmonary surgery and we recommend that surgery be considered for any pulmonary cryptococcoma with a diameter over 2 to 3cm. Eradication of infection can be expected provided there is adequate therapy but may require very prolonged antifungal treatment. [ABSTRACT FROM AUTHOR]

Background: Crusted scabies is a debilitating dermatological condition. Although still relatively rare in the urban areas of Australia, rates of crusted scabies in remote Aboriginal communities in the Northern Territory (NT) are reported to be among the highest in the world. Objective: To estimate the health system costs associated with diagnosing, treating and managing crusted scabies. Methods: A disease pathway model was developed to identify the major phases of managing crusted scabies. In recognition of the higher resource use required to treat more severe cases, the pathway differentiates between crusted scabies severity grades. The disease pathway model was populated with data from a clinical audit of 42 crusted scabies patients diagnosed in the Top-End of Australia's Northern Territory between July 1, 2016 and May 1, 2018. These data were combined with standard Australian unit costs to calculate the expected costs per patient over a 12-month period, as well as the overall population cost for treating crusted scabies. Findings: The expected health care cost per patient diagnosed with crusted scabies is $35,418 Australian dollars (AUD) (95% CI: $27,000 to $43,800), resulting in an overall cost of $1,558,392AUD (95% CI: $1,188,000 to $1,927,200) for managing all patients diagnosed in the Northern Territory in a given year (2018). By far, the biggest component of the health care costs falls on the hospital system. Discussion: This is the first cost-of-illness analysis for treating crusted scabies. Such analysis will be of value to policy makers and researchers by informing future evaluations of crusted scabies prevention programs and resource allocation decisions. Further research is needed on the wider costs of crusted scabies including non-financial impacts such as the loss in quality of life as well as the burden of care and loss of well-being for patients, families and communities. Author summary: Crusted scabies is characterised by thick skin crusting and fissuring and can lead to serious secondary infections and death from complications. Rates of crusted scabies in remote Aboriginal communities in the Northern Territory (NT) are among the highest in the world. Efforts are on the way in Australia to prevent, if not eliminate, crusted scabies. We use data from a clinical audit of 42 patients diagnosed with crusted scabies in the Top-End of the NT to estimate the health system costs associated with diagnosing, treating and managing crusted scabies for patients and their households. This cost of illness study can provide a valuable starting point for policy makers and evaluators in estimating the potential economic impact of crusted scabies prevention programs on health care service use and costs. [ABSTRACT FROM AUTHOR]

Purpose: We aimed to test the reliability and validity of two brief measures of resilience adopted for the evaluation of a preventative social-emotional curriculum implemented for Aboriginal middle school students from socially disadvantaged remote communities in Australia's Northern Territory. The questionnaires chosen were intended to measure psychological resilience and socio-cultural resilience as complementary dimensions of the capacity to cope in circumstances of significant life stress and risk of self-harm. Methods: Confirmatory factor analysis (CFA) was conducted to assess construct validity of the 10-item Connor-Davidson Resilience Scale (CD-RISC-10), a measure of psychological resilience, and the 12-item Child and Youth Resilience Measure (CYRM-12), a measure of socio-cultural resilience, with a sample of 520 students. Associations between resilience and psychological distress and emotional and behavioural difficulty were analysed in relation to life stressors to assess criterion validity of the scales. Results: CFA provided support for the validity of the respective constructs. There was good fit for both scales. However, assessment of criterion validity of the scales suggested that the adapted measure of socio-cultural resilience (CYRM-12NT) showed higher reliability and a clearer indication of predictive validity than the measure of psychological resilience (CD-RISC-10). Conclusions: The CYRM-12NT appears to be a more useful measure of resilience among Aboriginal youth exposed to significant life stress and disadvantage. However, both measures may require further development to enhance their validity and utility among potentially at-risk adolescents in socially, culturally and linguistically diverse remote Aboriginal communities. [ABSTRACT FROM AUTHOR]

Background: With the pending implementation of the Closing the Gap 2020 recommendations, there is an urgent need to better understand the contributing factors of, and pathways to positive educational outcomes for both Aboriginal and non-Aboriginal children. This deeper understanding is particularly important in the Northern Territory (NT) of Australia, in which the majority of Aboriginal children lived in remote communities and have language backgrounds other than English (i.e. 75%). Methods: This study linked the Australian Early Development Census (AEDC) to the attendance data (i.e. government preschool and primary schools) and Year 3 National Assessment Program for Literacy and Numeracy (NAPLAN). Structural equation modelling was used to investigate the pathway from self-regulation and executive function (SR-EF) at age 5 to early academic achievement (i.e. Year 3 reading/numeracy at age 8) for 3,199 NT children. Result: The study confirms the expected importance of SR-EF for all children but suggests the different pathways for Aboriginal and non-Aboriginal children. For non-Aboriginal children, there was a significant indirect effect of SR-EF (β = 0.38, p<0.001) on early academic achievement, mediated by early literacy/numeracy skills (at age 5). For Aboriginal children, there were significant indirect effects of SR-EF (β = 0.19, p<0.001) and preschool attendance (β = 0.20, p<0.001), mediated by early literacy/numeracy skills and early primary school attendance (i.e. Transition Years to Year 2 (age 5–7)). Conclusion: This study highlights the need for further investigation and development of culturally, linguistically and contextually responsive programs and policies to support SR-EF skills in the current Australian education context. There is a pressing need to better understand how current policies and programs enhance children and their families' sense of safety and support to nurture these skills. This study also confirms the critical importance of school attendance for improved educational outcomes of Aboriginal children. However, the factors contributing to non-attendance are complex, hence the solutions require multi-sectoral collaboration in place-based design for effective implementation. [ABSTRACT FROM AUTHOR]

Background: Crusted scabies is endemic in some remote Aboriginal communities in the Northern Territory (NT) of Australia and carries a high mortality risk. Improvement in active case detection (ACD) for crusted scabies is hampered by a lack of evidence about best practice. We therefore conducted a systematic review of ACD methods for leprosy, a condition with similar ACD requirements, to consider how findings could be informative to crusted scabies detection. Methods and principle findings: We conducted systematic searches in MEDLINE, CINAHL, Scopus and the Cochrane Database for Systematic Reviews for studies published since 1999 that reported at least one comparison rate (detection or prevalence rate) against which the yield of the ACD method could be assessed. The search yielded 15 eligible studies from 511. Study heterogeneity precluded meta-analysis. Contact tracing and community screening of marginalised ethnic groups yielded the highest new case detection rates. Rapid community screening campaigns, and those using less experienced screening personnel, were associated with lower suspect confirmation rates. There is insufficient data to assess whether ACD campaigns improve treatment outcomes or disease control. Conclusion: This review demonstrates the importance of ACD campaigns in communities facing the highest barriers to healthcare access and within neighbourhoods of index cases. The potential benefit of ACD for crusted scabies is not quantified, however, lessons from leprosy suggest value in follow-up with previously identified cases and their close contacts to support for scabies control and to reduce the likelihood of reinfection in the crusted scabies case. Skilled screening personnel and appropriate community engagement strategies are needed to maximise screening uptake. More research is needed to assess ACD cost effectiveness, impact on disease control, and to explore ACD methods capable of capturing the homeless and highly mobile who may be missed in household centric models. Author summary: Crusted scabies is a severely debilitating skin disease with potentially fatal consequences that is endemic in some remote Aboriginal communities in the Northern Territory (NT) of Australia. Early detection is essential to maximise the chance of recovery and help prevent transmission of scabies to others. There is little knowledge about how to actively detect crusted scabies, so we sought relevant knowledge about a disease with many similarities: leprosy. The review demonstrates the importance of ACD campaigns in communities facing the highest barriers to healthcare access and within neighbourhoods of index cases. Lessons for crusted scabies in the NT include the importance of skilled screening personnel and appropriate community engagement strategies to maximise screening uptake. More research is needed to assess ACD cost effectiveness, impact on disease control, and to explore ACD methods capable of capturing the homeless and highly mobile who may be missed in household centric models. [ABSTRACT FROM AUTHOR]

Background: Exposure to per- and polyfluoroalkyl substances (PFAS) is a public health issue globally. In Australia high concentrations of PFAS have been found in environments close to sites where Aqueous Film Forming Foams (AFFF) were historically used for firefighting activities. This has resulted in significant community concern about the potential long-term health effects of these chemicals. Objective: We describe residents' perceptions and experiences of PFAS in three regional Australian towns where exposure has occurred. Methods: We conducted focus groups to generate free-flowing open discussion on PFAS in three affected communities, including some with significant numbers of First Nations Peoples. We recruited participants using a range of media outlets and postal services. Focus group transcripts were analysed thematically to identify major shared concerns using Atlas Ti. Results: One hundred and eighty residents attended fifteen focus groups that were conducted in the three communities. They included 69 First Nations People living in three communities near the town of Katherine in the Northern Territory. Study participants were concerned about potential physical health effects of exposure to PFAS, such as cancer clusters, unexplained deaths, potential exacerbation of existing health conditions, and the future health of their children. They expressed feelings of stress and anxiety about living with uncertainty related to the possible health and the socio-economic impacts of PFAS contamination in their communities. Conclusion: While research has concentrated on the physical health effects of PFAS, more attention needs to be given to the immediate psychosocial impacts of living in an affected community. [ABSTRACT FROM AUTHOR]

Background: Scabies is listed as a neglected tropical disease by the World Health Organization. Crusted scabies affects vulnerable and immunosuppressed individuals and is highly contagious because of the enormous number of Sarcoptes scabiei mites present in the hyperkeratotic skin. Undiagnosed and untreated crusted scabies cases can result in outbreaks of scabies in residential facilities and can also undermine the success of scabies mass drug administration programs. Methods and principal findings: Crusted scabies became a formally notifiable disease in the Northern Territory of Australia in 2016. We conducted a 2-year prospective study of crusted scabies cases notified between March 2016 and February 2018, with subsequent follow up for 22 months. Demographics, clinical and laboratory data, treatment and outcomes were analysed, with cases classified by severity of disease. Over the 2-year study period, 80 patients had 92 episodes of crusted scabies; 35 (38%) were Grade 1 crusted scabies, 36 (39%) Grade 2 and 21 (23%) Grade 3. Median age was 47 years, 47 (59%) were female, 76 (95%) Indigenous Australians and 57 (71%) from remote Indigenous communities. Half the patients were diabetic and 18 (23%) were on dialysis for end-stage kidney failure. Thirteen (16%) patients had no comorbidities, and these were more likely to have Grade 3 disease. Eosinophilia was present in 60% and high immunoglobulin E in 94%. Bacteremia occurred in 11 episodes resulting in one fatality with methicillin-susceptible Staphylococcus aureus bacteremia. Two other deaths occurred during admission and 10 others died subsequent to discharge consequent to comorbidities. Treatment generally followed the recommended guidelines, with 3, 5 or 7 doses of oral ivermectin depending on the documented grade of crusted scabies, together with daily alternating topical scabicides and topical keratolytic cream. While response to this therapy was usually excellent, there were 33 episodes of recurrent crusted scabies with the majority attributed to new infection subsequent to return to a scabies-endemic community. Conclusions: Crusted scabies can be successfully treated with aggressive guideline-based therapy, but high mortality remains from underlying comorbidities. Reinfection on return to community is common while scabies remains endemic. Author summary: Undiagnosed crusted scabies patients can be index cases in outbreaks of scabies in residential facilities such as nursing homes and can undermine the success of scabies mass drug administration programs, but literature about this debilitating disease is very limited. The study describes a large cohort of patients with crusted scabies who have been treated according to established local guidelines. While the success of the initial clinical response supports the guideline-based treatment regimen for crusted scabies, with only one patient dying with scabies-related sepsis, the subsequent mortality remains high, reflecting the large burden of comorbidities in the cohort. In addition, there was a high rate of recurrent crusted scabies, attributed to new infection with scabies once the cured patients return to their scabies-endemic communities. Crusted scabies can be successfully treated using robust guidelines including multiple doses of ivermectin together with topical therapy. However, community-based initiatives such as support for 'scabies free zones' are needed to prevent re-infection and recurrent disease in those individuals who are susceptible to developing crusted scabies. Undiagnosed crusted scabies is a threat to the success of scabies mass drug administration programs and will continue to drive scabies outbreaks in residential facilities. [ABSTRACT FROM AUTHOR]

Background: Globally, trachoma is the leading cause of infectious blindness and Australia is the only developed country with endemic trachoma. It is found in remote Indigenous communities burdened with poverty, overcrowding and poor hygiene. Lack of culturally appropriate health promotion, a small trachoma workforce and lack of awareness and support for trachoma elimination in general, were early barriers. Methods: A cross-sectional pre-post study using a convenience sample, was conducted in clinics, schools and community work-settings from 63 of the 82 remote Aboriginal communities identified as being at risk of trachoma in the Northern Territory (NT). The study assessed the effect of a multi-component health promotion strategy aimed at increasing knowledge, attitude and practice amongst health, education and community support settings staff. Data were collected between 2010 and 2012. The health promotion initiatives were introduced in communities in staggered delivery over a one-year period; 272 participants were surveyed at baseline and 261 at follow-up. Results: Trachoma related knowledge, attitudes and practice increased across all settings and for all primary outcome measures. Across all settings, there was a significant increase in the proportion of participants reporting the most important thing to do if a child has a ‘dirty’ face is to ‘wash it every time its dirty’ (61.6% cf 69.7%; X2p = 0.047), a significant reduction in the proportion of respondents answering ‘no’ to the question “Is it normal for kids to have dirty faces in your community’ (40.5% cf 29.6%; X2p = 0.009) and a significant increase in reported capacity to teach others about trachoma prevention (70.8% cf 83.3%; X2p <0.001). Conclusion: Health promotion was associated with increased trachoma knowledge, attitude and practice amongst health, education and community support staff working with children and in remote NT communities. In the early stages of the trachoma health promotion program, this increased trachoma awareness and improved local workforce capacity and support for trachoma elimination in three health promotion settings in remote communities in the NT. [ABSTRACT FROM AUTHOR]

Identification and characterization of near-neighbor species are critical to the development of robust molecular diagnostic tools for biothreat agents. One such agent, Burkholderia pseudomallei, a soil bacterium and the causative agent of melioidosis, is lacking in this area because of its genomic diversity and widespread geographic distribution. The Burkholderia genus contains over 60 species and occupies a large range of environments including soil, plants, rhizospheres, water, animals and humans. The identification of novel species in new locations necessitates the need to identify the true global distribution of Burkholderia species, especially the members that are closely related to B. pseudomallei. In our current study, we used the Burkholderia-specific recA sequencing assay to analyze environmental samples from the Darwin region in the Northern Territory of Australia where melioidosis is endemic. Burkholderia recA PCR negative samples were further characterized using 16s rRNA sequencing for species identification. Phylogenetic analysis demonstrated that over 70% of the bacterial isolates were identified as B. ubonensis indicating that this species is common in the soil where B. pseudomallei is endemic. Bayesian phylogenetic analysis reveals many novel branches within the B. cepacia complex, one novel B. oklahomensis-like species, and one novel branch containing one isolate that is distinct from all other samples on the phylogenetic tree. During the analysis with recA sequencing, we discovered 2 single nucleotide polymorphisms in the reverse priming region of B. oklahomensis. A degenerate primer was developed and is proposed for future use. We conclude that the recA sequencing technique is an effective tool to classify Burkholderia and identify soil organisms in a melioidosis endemic area. Author Summary: Burkholderia is a widespread genus of bacteria that contains over 60 species. The species within Burkholderia range from environmentally important, such as isolates that breakdown pollutants, to human pathogens. Burkholderia pseudomallei, the causative agent of melioidosis, is endemic to Northern Australia and is a major public health concern in that region. We characterized 152 unknown environmental isolates using recA sequencing to identify the presence of Burkholderia bacteria in the region. The majority of bacteria identified in this study belonged to the B. ubonensis species and various species were found to inhabit the same environmental sample as the human pathogen, B. pseudomallei. The role of B. ubonensis and other Burkholderia species identified in this endemic region and how they interact with B. pseudomallei are important questions to address in order to understand the evolution of this important human pathogen. While they are occupying a similar geographic range, they must be exist in different niche in order to remain distinct species. [ABSTRACT FROM AUTHOR]

Background: International melioidosis treatment guidelines recommend a minimum 10 to 14 days' intravenous antibiotic therapy (intensive phase), followed by 3 to 6 months' oral therapy (eradication phase). This approach is associated with rates of relapse, defined as recurrence following the eradication phase, that can exceed 5%. Rates of recrudescence, defined as recurrence during the eradication phase, have not previously been reported. In response to low eradication phase completion rates in Australia, a local guideline has evolved over the last ten years recommending a longer minimum intensive phase duration for many cases of melioidosis. Methodology/ Principal Findings: This retrospective cohort study reviews antibiotic duration for the first episode of care for all patients diagnosed with melioidosis and surviving the intensive phase during a recent three year period in the tropical north of Australia's Northern Territory; we also review adherence to the current local guideline and treatment outcomes. Of 215 first episodes of melioidosis surviving the intensive phase, the median (interquartile range) intensive phase duration was 26 (14-34) days. One hundred and eight (50.2%) patients completed eradication therapy; 58 (27.0%) patients took no eradication therapy. At 28 months' follow-up, one (0.5%) relapse and eleven (5.1%) recrudescences had occurred. On exact logistic regression analysis, the only independent risk factors for recrudescence were self-discharge during the intensive phase (odds ratio 6.2 [95% confidence interval 1.2-30.0]) and septic shock (odds ratio 5.3 [95% confidence interval 1.1-25.7]). Conclusions/ Significance: Relapsed melioidosis is rare in patients who receive a minimum intensive phase duration specified by our guideline and extended according to clinical progress. Recrudescence rates may improve with reductions in rates of self-discharge. Given the low relapse rate despite a high rate of eradication therapy non-adherence, the duration and necessity of eradication therapy for different patients after guideline-concordant intensive therapy should be evaluated further. Author Summary: Melioidosis is an infection caused by the soil bacterium Burkholderia pseudomallei; patients usually present with pneumonia, blood-stream infection and/or skin or internal organ abscesses. Melioidosis occurs most commonly in northern Australia and parts of Southeast Asia. It has a high mortality rate and, with standard treatment, a relapse rate greater than 5%; patients who relapse often represent severely unwell. Treatment comprises an intensive (intravenous antibiotic) phase, followed by a prolonged eradication (oral antibiotic) phase. Previous studies have found that the intensive phase is important to prevent mortality, and the eradication phase is important to prevent relapse. However, these studies have not been designed to detect an effect of intensive therapy on relapse rate. We know that adherence to eradication therapy is poor, and many of our patients live remotely making follow-up difficult. In order to address this, we have developed a new treatment guideline which stipulates a longer intensive phase for most patients. We show that adherence to this guideline is associated with very low relapse rates despite poor adherence to eradication therapy. It is possible that for many patients the eradication phase could be shortened or avoided when this intensive phase guideline is followed; this requires further research. [ABSTRACT FROM AUTHOR]

Background: Annual biological rhythms are often depicted as predictably cyclic, but quantitative evaluations are few and rarely both cyclic and constant among years. In the monsoon tropics, the intense seasonality of rainfall frequently drives fluctuations in the populations of short-lived aquatic organisms. However, it is unclear how predictably assemblage composition will fluctuate because the intensity, onset and cessation of the wet season varies greatly among years. Methodology/Principal Findings: Adult mosquitoes were sampled using EVS suction traps baited with carbon dioxide around swamplands adjacent to the city of Darwin in northern Australia. Eleven sites were sampled weekly for five years, and one site weekly for 24 years, the sample of c. 1.4 million mosquitoes yielding 63 species. Mosquito abundance, species richness and diversity fluctuated seasonally, species richness being highly predictable. Ordination of assemblage composition demonstrated striking annual cycles that varied little from year to year. The mosquito assemblage was temporally structured by a succession of species peaks in abundance. Conclusion/Significance: Ordination provided strong visual representation of annual rhythms in assemblage composition and the means to evaluate variability among years. Because most mosquitoes breed in shallow freshwater which fluctuates with rainfall, we did not anticipate such repeatability; we conclude that mosquito assemblage composition appears adapted to predictable elements of the rainfall. [ABSTRACT FROM AUTHOR]

Background: Linked to extreme rates of chronic heart and kidney disease, pyoderma is endemic amongst Aboriginal children in Australia's Northern Territory (NT). Many of those with pyoderma will also have scabies. We report the results of a community-based collaboration within the East Arnhem Region, which aimed to reduce the prevalence of both skin infections in Aboriginal children. Methodology/Principal Findings: Commencing September 2004, we conducted an ecological study that included active surveillance for skin infections amongst children aged <15 years in five remote East Arnhem communities over a three year period. Screening was undertaken by trained local community workers, usually accompanied by another project team member, using a standard data collection form. Skin infections were diagnosed clinically with the aid of a pictorial flip chart developed for the purpose. Topical 5% permethrin was provided for age-eligible children and all household contacts whenever scabies was diagnosed, whilst those with pyoderma were referred to the clinic for treatment in accordance with current guidelines. In addition, annual mass scabies treatment (5% permethrin cream) was offered to all community residents in accordance with current guidelines but was not directly observed. Pyoderma and scabies prevalence per month was determined from 6038 skin assessments conducted on 2329 children. Pyoderma prevalence dropped from 46.7% at baseline to a median of 32.4% (IQR 28.9%–41.0%) during the follow-up period – an absolute reduction of 14.7% (IQR 4.7%–16.8%). Compared to the first 18 months of observation, there was an absolute reduction in pyoderma prevalence of 18 cases per 100 children (95%CI −21.0, −16.1, p≤0.001) over the last 18 months. Treatment uptake increased over the same period (absolute difference 13.4%, 95%CI 3.3, 23.6). While scabies prevalence was unchanged, the prevalence of infected scabies (that is with superimposed pyoderma) decreased from 3.7% (95%CI 2.4, 4.9) to 1.5% (95%CI 0.7, 2.2), a relative reduction of 59%. Conclusion: Although pyoderma prevalence remained unacceptably high, there was a substantial reduction overall with improvements in treatment uptake a critical factor. More acceptable alternatives, such as cotrimoxazole for pyoderma and ivermectin as a community-wide scabicide, warrant further investigation in these settings. We are encouraged by progress made through this work, where local action was led by local community members and primary health care providers with external training and support. Trial Registration: ClinicalTrials.gov NCT00884728 Author Summary: Skin infections are endemic in many in remote Australian Aboriginal communities and have been linked to very high rates of chronic heart and kidney disease in this population. We report the results of a regional collaboration that aimed to reduce skin infections amongst children aged less than 15 years in five remote communities. The program included annual mass scabies treatment days offered to all residents and routine screening/follow-up of children. Trained community workers helped conduct over 6000 skin assessments on 2329 children over a three year period. Of every 100 children seen at the commencement of the study, 47 were found to have skin sores and many had multiple sores. We demonstrate a reduction both in the number of children with skin sores and in the severity of those sores. On average, of every 100 children seen per month, there were 14 fewer children with skin sores and seven fewer children with multiple sores. Overall improvement in treatment uptake was a critical factor. We found no discernible impact against scabies. While the burden of skin infections remains unacceptably high, we believe the results presented here are a good news story for local action to address a serious public health problem. [ABSTRACT FROM AUTHOR]

Background: Australian healthcare quality and safety accreditation standards recommend health services partner with health care users, to ensure the highest quality of care. Aboriginal Australians with chronic and end stage kidney disease have high health care access needs. Aim: To describe the experiences of health care users of a large government kidney healthcare service provider. Methods: Within a government renal health service in the Top-End of the Northern Territory, we undertook a qualitative study involving in-depth interviews with 26 adult clients from urban, regional and remote settings who were living with kidney health conditions. Results: Client characteristics included a mean age of 55 years, 55% female and 81% identifying as Aboriginal. The kidney related conditions of client participants included CKD (11, 42.3%), haemodialysis (12, 46.2%), peritoneal dialysis (1, 3.9%), and transplant (2, 7.7%). Key themes emerging from patient interviews related to perceived gaps for clients and carers including: 1) knowledge gaps about the health condition, 2) the impact of relocation in order to access centrally-based renal care, 3) healthcare staff professionalism and qualities and 4) service environments. Overall, the experiences centred on a greater need for client-centred, respectful and culturally based healthcare support. Clients recommended the need for patient-led collective care, including sustaining an Indigenous Patient Reference Group to support ongoing healthcare service decision processes. Participants included in almost equal proportion, clients with CKD (without dialysis) and clients utilising renal replacement therapy, which adds significant weight to the client-identified recommendations for highest quality of kidney care across a wide spectrum of kidney function. Conclusion: Four major themes identified by clients related to their experience with renal care provided by this major regional health care provider: knowledge gaps of their own condition, the lived impacts of relocating to access health care, service environments, and Health Care Provider Quality. An Indigenous Patient Reference Group was one mechanism recommended to support the co-design of preferred care models. [ABSTRACT FROM AUTHOR]