Daniel Engelman

Introduction: Rheumatic heart disease (RHD) is underdiagnosed globally resulting in missed treatment opportunities and adverse clinical outcomes. We describe the protocol for a study which aims to co-design, implement and conduct an evaluation of a task-sharing approach to echocardiographic active case finding for early detection and management of RHD in high-risk settings in Australia and Timor-Leste. Methods and analysis: Echocardiograms will be obtained by trained local staff using hand-held echocardiographic devices employing the 'Single Parasternal Long Axis view with a Sweep of the Heart' (SPLASH) technique and interpreted by experts remote from the site of acquisition. Approximately 1500 children and pregnant women will be screened across high-risk communities in Australia and Timor-Leste over an 18-month period. The study will use a type II effectiveness-implementation hybrid design. A tailored package of implementation strategies will be co-designed with communities and health services and mapped onto a Theory of Change framework. The clinical effectiveness will be assessed as the change in the proportion of the target population that are prescribed secondary prophylaxis for RHD by the end of the study compared with baseline. The implementation will be assessed as the adoption, penetration, sustainability, fidelity and cost of the programme with a mixed-methods theory-based and economic evaluation. Data will include numbers of normal, abnormal and uninterpretable SPLASH echocardiograms obtained, numbers of participants progressing through the cascade of care, interviews with staff and programme costs. Ethics and dissemination: Ethical approval has been obtained from the Human Research Ethics Committee of the NT Department of Health and Menzies School of Health Research, Darwin (HREC-2022-4479), the Western Australian Aboriginal Health Ethics Committee (HREC-1237) and the Instituto Nasional Saude Publika Timor-Leste Ethics and Technical Committee (03-UEPD/INSP-TL/V/2023). Informed consent is required to be enrolled. Study findings will be disseminated in the communities involved and submitted for publication. Trial registration number: NCT06002243.

Scabies and impetigo cause direct health effects and contribute to severe infectious and immune-mediated complications. Ivermectin-based mass drug administration can reduce scabies and impetigo prevalence in island settings with high prevalence, but the effectiveness in moderate-prevalence settings is not known. We conducted a single-arm, before-after community intervention trial. Mass drug administration was offered to the entire population of 4 villages in Uttarakhand, India. The treatment consisted of 2 doses, given 7 days apart, of oral ivermectin (∼200 μg/kg), or topical 5% permethrin if ivermectin was contraindicated. The primary outcome was the prevalence of scabies at 12 months compared with baseline, as diagnosed using clinical assessment and the 2020 International Alliance for the Control of Scabies criteria. Secondary outcomes included the prevalence of impetigo at each time point. The trial was registered with the Australian and New Zealand Trials Registry (ACTRN12619001712190). In January 2020, 1211 participants were enrolled (100% of the estimated village population). Treatment coverage was high-1204 (99.4%) and 1177 (97.2%) received 1 and 2 doses, respectively. Scabies was diagnosed in 91 participants (7.5%) and impetigo in 15 (1.2%). In February 2021, 1190 (98.3% of baseline) participants re-enrolled, and of these 11 had scabies (0.9%; relative risk reduction, 87.7%; 95% CI, 77.1%-93.4%) and 5 had impetigo (0.4%; relative risk reduction, 66.1%; 95% CI, 7.0%-87.6%). A single round of ivermectin-based mass drug administration substantially reduced the prevalence of scabies and impetigo in this setting with moderate scabies prevalence in northern India.

Scabies and related bacterial skin and soft tissue infections (SSTIs) are highly prevalent in many tropical, low- and middle-income settings. These skin conditions contribute to higher healthcare costs and burdens on healthcare systems. The Big Skin Health Intervention Fiji Trial ("Big SHIFT") carried out surveillance for scabies and SSTIs from July 2018 to June 2019 in the Northern Division of Fiji, an area with high prevalence of scabies, prior to a division-wide ivermectin-based mass drug administration (MDA) campaign. Using data from Big SHIFT, we sought to estimate the annual direct healthcare costs of scabies and related SSTIs for the Northern Division and extrapolate these costs to the national level. We categorized SSTIs as being potentially scabies-related or unlikely scabies-related, based on a previous study. The analysis used a health system perspective, with the main resource use categories of outpatient visits, bed days during admissions, medicines, and diagnostic tests. We extrapolated the total annual number of cases and direct healthcare costs for all divisions in Fiji based upon previous scabies and impetigo prevalence data across all divisions. The average cost per PHC presentation for scabies was US$17.7, and for potentially scabies-related SSTI was $18.3. The average cost per hospital admission for a potentially scabies-related SSTI case was $439. The estimated annual healthcare costs of scabies and related SSTIs in Fiji was US$3.0 million, with cost per capita of $3.3. Scabies and related SSTIs lead to a heavy economic burden in Fiji and prevention would reduce these healthcare costs.

Scabies is endemic in many resource-poor tropical areas, causing significant morbidity. However, our understanding of the true burden of scabies in Africa is limited, partly owing to limited capacity and challenges accessing the currently recommended diagnostic tools. The primary objective of this study was to assess the diagnostic accuracy of scabies assessments made by minimally trained field-workers. We trained field-workers with a minimum of secondary school education in the diagnosis of scabies. After the training, we assessed the diagnostic accuracy of assessments made by nine field-workers compared with the reference standard. In all, 193 individuals were assessed for scabies. The sensitivity, specificity, positive predictive value, and negative predictive value were calculated, as well as agreement (κ coefficients) between medical doctors and between field-workers. Of the 193 participants, 26% had scabies according to the reference standard. The sensitivity of field-worker diagnosis compared with the reference standard was 94% (95% CI: 90-99%), and the specificity was 96% (95% CI: 90-97%). The determination of severity by field-workers was less accurate; the sensitivity for severe scabies was 61% (95% CI: 48-74%), and the mean specificity was 97% (95% CI: 93-100%). This study demonstrated that field-workers without medical qualifications were capable of diagnosing scabies to a similar level of accuracy as experienced medical doctors after a short period of focal training. This may facilitate rapid assessments of scabies prevalence for public health purposes and decisions about mass drug administration implementation in similar settings.

Background: In Victoria, Australia, children with Pacific Islander ('Pacific') ethnicities are overrepresented in acute rheumatic fever (ARF) and rheumatic heart disease (RHD). In June 2023, ARF and RHD became notifiable in Victoria. To inform public health and clinical practice, we described young Pacific patients' and their caregivers' understandings and experiences of ARF/RHD, and identified possible ways to improve the delivery of clinical care. Methods: We established a project reference group including local Pacific people to guide this research. Pacific patients who attended an ARF/RHD clinic at The Royal Children's Hospital, Melbourne, were invited to participate, as were their caregivers. A Samoan researcher conducted qualitative 'talanoa' (conversational) interviews with patients and caregivers. A second researcher conducted semi-structured interviews with treating clinicians and other stakeholders. Interview transcripts underwent thematic analysis guided by the Tuilaepa Youth Mentoring Services Pacific Youth Wellbeing Framework. Results: We interviewed 27 participants. This included nine patients and nine caregivers, all of whom were Samoan. These 18 participants expressed a desire to learn more about ARF/RHD and connect with other affected people. While some shared their experiences of having well-liked and trusted healthcare providers, patients often struggled to have two-way clinical conversations. The need to support clinicians working with high-risk populations to improve their awareness of ARF was identified. Receiving treatment on time was a top priority for affected families, despite injection pain, inconvenience and financial costs. The need to support continuity of care for young adult patients was raised by participants. Conclusions: Pacific people living with ARF/RHD and their families require additional support to receive high quality management in Victoria. Introducing a patient register and a specialist RHD nurse would enhance access to treatment, as would removing cost barriers, improving clinical awareness of ARF/RHD and creating Victoria-specific patient resources.