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Strong, enduring partnerships exist between the Northern Territory and Timor-Leste, and in recent years collaborations have led to significant developments in health system capacity in Timor-Leste. Laboratory strengthening has been a key focus; improved diagnostic microbiology capability, especially in the National Health Laboratory, is having an impact on individual patient management and outcomes, epidemiological surveillance, and public health responses to communicable disease challenges including antimicrobial resistance.

Background Lack of access to diagnostic testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can limit disease surveillance in remote areas. Serological surveillance can indicate the true extent and distribution of infections in such settings. Methods This study monitored SARS-CoV-2 seroprevalence in residual serum samples salvaged from laboratories at five healthcare facilities across Timor-Leste from March to October 2021. Results Seroprevalence increased from 8.3% to 87.0% during the study period. Potential immunity gaps were identified among children aged 0–15 y (who had not been eligible for vaccination) and individuals aged >60 y. Conclusions Efforts to vaccinate vulnerable individuals including older people should be maintained. Residual serum samples can be analysed to give local, contemporary information about the extent and distribution of antibodies to infections, especially SARS-CoV-2, in areas where epidemiological information is limited.

BackgroundEnteric pathogens contribute to child malnutrition in low-to-middle-income countries. In Timor-Leste, there has been limited study of this relationship.Methodology/Principal findingsWe investigated enteric disease, stunting, and malnutrition in children in Dili, Timor-Leste (July 2019 – October 2020). Sixty infants received up to four home visits. We collected faecal samples, demographics, anthropometrics, food and water sources, feeding practices, and animal husbandry details. For 160 children admitted to Hospital Nacional Guido Valadares with clinical diagnosis of severe diarrhoea or severe acute malnutrition (SAM), we collected faecal samples, diagnostics, and anthropometrics. Faeces were tested by polymerase chain reaction (PCR) using the BioFire®FilmArray®Gastrointestinal Panel. Descriptive analyses and regression analyses were conducted using R.We detected enteric pathogens in 68.8% (95% confidence interval [CI] 60.4–76.2%) of infants, 88.6% of children with SAM (95% CI 81.7–93.3%), and 93.8% of children with severe diarrhoea (95% CI 67.7– 99.7%). DiarrhoeagenicEscherichia coliandCampylobacterspp. were most frequently detected. A median weight-for-height Z-score (WHZ) of -1.1 (interquartile range [IQR] -2.0 to -0.1) for infants across all home visits, -3.9 (IQR -4.7 to -3.0) for children with SAM and -2.6 (IQR -4.2 to -1.1) for children with severe diarrhoea was observed.The most common admission diagnosis was SAM (88.1%, 95% CI 81.7–92.5%). Hospitalised children had increased odds ofShigella/enteroinvasiveE. coli(OR 11.4, 95% CI 2.8–47.3) andGiardia lambliadetection (OR 31.7, 95% CI 3.6–280) compared with infants. For home visits, bottle feeding was associated with increased odds of pathogen detection (OR 8.2, 95% CI 1.1–59.7).Conclusions/SignificanceWe detected high prevalence of enteric pathogens and signs of malnutrition in children in Dili. Our pilot is proof of concept for a study to fully explore the risk factors and associations between enteric pathogens and malnutrition in Timor-Leste.Author summaryEnteric pathogens are a contributing factor to child malnutrition in low-to-middle-income countries. This study investigated the relationship between enteric disease, malnutrition, and stunting in children in Dili, Timor-Leste. Sixty infants received up to four home visits and 160 children were admitted to the hospital with a clinical diagnosis of severe diarrhoea or severe acute malnutrition. Faecal samples were collected and tested for enteric pathogens and risk factors were explored. The study found that enteric pathogens were detected in most infants and children with malnutrition and diarrhea. The most commonly detected pathogens were diarrheagenicEscherichia coliandCampylobacterspp. Most children exhibited signs of malnutrition from infancy, and hospitalised children had a higher likelihood of having certain enteric pathogens. Feeding practices, water use, and animal cohabitation may pose risks for enteric pathogen infection. The results suggest that enteric pathogens are a significant problem in Dili, Timor-Leste, and further research is needed to explore the complexity of risk factors.

IntroductionHistoric disruption in health infrastructure combined with data from a recent vaccine coverage survey suggests there are likely significant immunity gaps to vaccine preventable diseases and high risk of outbreaks in Timor-Leste. Community-based serological surveillance is an important tool to augment understanding of population-level immunity achieved through vaccine coverage and/or derived from prior infection.Methods and analysisThis national population-representative serosurvey will take a three-stage cluster sample and aims to include 5600 individuals above one year of age. Serum samples will be collected by phlebotomy and analysed for measles immunoglobulin G (IgG), rubella IgG, severe acute respiratory syndrome coronavirus-2 anti-spike protein IgG, hepatitis B surface antibody and hepatitis B core antigen using commercially available chemiluminescent immunoassays or enzyme-linked immunosorbent assays. In addition to crude prevalence estimates and to account for differences in Timor-Leste’s age structure, we will calculate stratified age-standardised prevalence estimates, using Asia in 2013 as the standard population. Additionally, this survey will derive a national asset of serum and dried blood spot samples which can be used for further investigation of infectious disease sero-epidemiology and/or validation of existing and novel serological assays for infectious diseases.Ethics and disseminationEthical approval has been obtained from the Research Ethics and Technical Committee of the Instituto Nacional da Saúde,Timor-Leste and the Human Research Ethics Committee of the Northern Territory Department of Health and Menzies School of Health Research, Australia. Co-designing this study with Timor-Leste Ministry-of-Health and other relevant partner organisations will allow immediate translation of findings into public health policy (which may include changes to routine immunisation service delivery and/or plans for supplementary immunisation activities).STRENGTHS AND LIMITATIONS OF THIS STUDYThis project is one of very few large-scale, community-based, population-representative serosurveys to be conducted in low-middle income countries.It will provide accurate seroprevalence estimates for multiple vaccine-preventable diseases, which will immediately inform public health policy and support an ongoing programme of vaccine research in Timor-Leste and the surrounding region.A national asset of bio-banked serum samples will be derived, which can be used in cross-sectional and prospective studies of infectious disease epidemiology, including those which evaluate disease control interventions.Diverse, remote communities across Timor-Leste will be visited, with primary sample analysis occurring at the National Health Laboratory in Timor-Leste. Therefore, fieldwork and laboratory-related logistical challenges will need to be overcome.

Background: Echocardiographic screening can detect asymptomatic cases of rheumatic heart disease (RHD), facilitating access to treatment. Barriers to implementation of echocardiographic screening include the requirement for expensive equipment and expert practitioners. We aimed to evaluate the diagnostic accuracy of an abbreviated echocardiographic screening protocol (single parasternal-long-axis view with a sweep of the heart) performed by briefly trained, nonexpert practitioners using handheld ultrasound devices. Methods: Participants aged 5 to 20 years in Timor-Leste and the Northern Territory of Australia had 2 echocardiograms: one performed by an expert echocardiographer using a GE Vivid I or Vivid Q portable ultrasound device (reference test), and one performed by a nonexpert practitioner using a GE Vscan handheld ultrasound device (index test). The accuracy of the index test, compared with the reference test, for identifying cases with definite or borderline RHD was determined. Results: There were 3111 enrolled participants; 2573 had both an index test and reference test. Median age was 12 years (interquartile range, 10–15); 58.2% were female. Proportion with definite or borderline RHD was 5.52% (95% CI, 4.70–6.47); proportion with definite RHD was 3.23% (95% CI, 2.61–3.98). Compared with the reference test, sensitivity of the index test for definite or borderline RHD was 70.4% (95% CI, 62.2–77.8), specificity was 78.1% (95% CI, 76.4–79.8). Conclusions: Nonexpert practitioners can be trained to perform single parasternal-long-axis view with a sweep of the heart echocardiography. However, the specificity and sensitivity are inadequate for echocardiographic screening. Improved training for nonexpert practitioners should be investigated.

An outbreak of Salmonella Muenchen gastroenteritis occurred in a remote coastal Aboriginal community in the Northern Territory (NT) of Australia. There were 22 people sick (attack rate 55%); 7 had laboratory confirmed S. Muenchen infection; 2 required medical evacuation and admission to the intensive care unit (ICU). We conducted a descriptive case series to investigate the outbreak. All cases ate meat from a single green turtle (Chelonia mydas). The animal's pre-death stress, improper butchering, insufficient cooking and the unsatisfactory storage of meat all likely contributed to the outbreak. Turtle meat should be prepared safely, cooked thoroughly and stored appropriately to avoid Salmonella infection.

Introduction Scabies and impetigo are common and important skin conditions which are often neglected in developing countries. Limited data have been published on the prevalence of scabies and impetigo in Timor-Leste. Sequelae including cellulitis, bacteraemia, nephritis, acute rheumatic fever and rheumatic heart disease contribute significantly to the burden of disease. Methods School students were recruited from schools in Dili (urban) and Ermera (rural) in Timor-Leste for an epidemiological study in October 2016. A standard questionnaire was used to record demographics, anthropometry and skin examination results. Impetigo and scabies were diagnosed based on clinical examination of exposed surfaces, and clinical photographs were reviewed for correlation by an infectious diseases paediatrician. Prevalence of scabies and impetigo were calculated and binary risk factor associations were described using relative risks and 95% confidence intervals. Adjusted odds ratios were calculated using logistic regression multivariate analysis. Continuous variables were analysed for associations using the Mann-Whitney Rank Sum test. Results The study enrolled 1396 students; median age 11 years (interquartile range (IQR) 9–15). The prevalence of scabies was 22.4% (95% CI 20.2–24.7%) and active impetigo 9.7% (95% CI 8.3–11.4%); 68.2% of students had evidence of either active or healed impetigo. Students in Ermera were more likely than those in Dili to have scabies (prevalence 32.0% vs 5.2%, aOR 8.1 (95% CI 5.2–12.4), p

Between October 2012 and October 2013, unprecedented high numbers of Barmah Forest virus (BFV) disease cases were reported in the Northern Territory (NT). An investigation was launched by the NT Department of Health in cooperation with the Department of Primary Industry and Fisheries and the Department of Land Resource Management to investigate possible causes for this phenomenon. The investigation included virus isolations from mosquitoes collected in Darwin urban areas, BFV antibody testing in peri-urban small mammals and a human BFV disease case series investigation of recent cases. No BFV was isolated from the 4641 mosquitoes tested, none of the mammals tested positive for BFV antibodies, and the high BFV disease case numbers did not correlate with the relatively low mosquito vector numbers trapped in 2012-2013. It was estimated that up to 89% of the 79 human cases investigated did not have an acute arboviral illness and therefore had tested falsely positive. An Alere PanBio BFV immunoglobulin M enzyme-linked immunosorbent assay test kit is generally used to test for BFV, with the BFV disease case definition based on immunoglobulin M positives only. Other jurisdictions in Australia also reported high numbers of BFV disease cases, with the majority of the cases suspected to be false positives. Therefore, current testing methods need to be revised to reflect the true numbers of BFV disease cases occurring in Australia and to provide correct diagnoses for patients.