Millicent H. Osti

Description:A 48-year-old man was referred to the dermatology clinic with a 3-month history of ulceration on his right inner thigh. The lesion began as a firm, painless, indurated nodule shortly after a trip to Australia where he spent time in rural areas. Over the following weeks, the lesion evolved into a painless, necrotic ulcer that continued to increase in size over the subsequent months. He was otherwise well with no systemic symptoms. His medical history included hypertension and hypothyroidism. Regular medications included levothyroxine and perindopril. Clinical examination revealed a 3 × 2 cm violaceous, indurated ulcer with undermined edges and a necrotic base

Description:Background: Mass drug administration (MDA) based on two doses of ivermectin, one week apart, substantially reduces prevalence of both scabies and impetigo. The Regimens of Ivermectin for Scabies Elimination (RISE) trial assessed whether one-dose ivermectin-based MDA would be as effective. Methods: RISE was a cluster-randomised trial in Solomon Islands. We assigned 20 villages in a 1:1 ratio to one- or two-dose ivermectin-based MDA. We planned to test whether the impact of one dose on scabies prevalence at 12 and 24 months was non-inferior to two, at a 5% non-inferiority margin. Results: We deferred endpoint assessment to 21 months due to COVID-19. We enrolled 5239 participants in 20 villages at baseline and 3369 at 21 months from an estimated population of 5500. At baseline scabies prevalence was similar in the two arms (one-dose 17·2%; two-dose 13·2%). At 21 months, there was no reduction in scabies prevalence (one-dose 18·7%; two-dose 13·4%), and the confidence interval around the difference included values substantially greater than 5%. There was however a reduction in prevalence among those who had been present at the baseline assessment (one-dose 15·9%; two-dose 10·8%). Additionally, we found a reduction in both scabies severity and impetigo prevalence in both arms, to a similar degree. Conclusions: There was no indication of an overall decline in scabies prevalence in either arm. The reduction in scabies prevalence in those present at baseline suggests that the unexpectedly high influx of people into the trial villages, likely related to the COVID-19 pandemic, may have compromised the effectiveness of the MDA. Despite the lack of effect there are important lessons to be learnt from this trial about conducting MDA for scabies in high prevalence settings. Trial registration: Registered with Australian New Zealand Clinical Trials Registry ACTRN12618001086257.

Description:The term 'Aboriginal' in this text has been used when referring to Aboriginal peoples living on the Anangu Pitjantjatjara Yankunytjatjara (APY) Lands. The term 'Aboriginal and Torres Strait Islander' has been used when referring to the broader community. Background: This project investigated how cultural immersion in remote Aboriginal communities influenced medical students' career intentions. Methods: An academic GP registrar (AB) interviewed 15 medical students who participated in the Adelaide Medical Students' Society Anangu Pitjantjatjara Yankunytjatjara (APY) Exchange. This program was coordinated by medical student volunteers in collaboration with the Ngaanyatjarra Pitjantjatjara Yankunytjatjara Women's Council (NPYWC). The following questions were specifically addressed: 'How does being a guest in a remote Aboriginal community influence medical students' attitudes towards Aboriginal and Torres Strait Islander health care?' and 'Does exposure to Aboriginal communities increase medical students' willingness to pursue careers in Aboriginal and Torres Strait Islander health, rural and remote medicine and/or general practice?'. Results: Interest in Aboriginal and Torres Strait Islander health care increased from 73% of participants pre-trip to 100% post-trip, in rural and remote medicine from 40% to 100%, and in general practice from 33% to 67%. The experience also challenged pre-conceptions and increased understanding of the bio-psycho-socio-spiritual aspects of Aboriginal health. Conclusions: Being a guest in remote Aboriginal communities enhanced students' personal and professional motivation to work in Aboriginal and Torres Strait Islander health, remote health and general practice.

Description:Pacific Island countries have a high burden of scabies and impetigo. Understanding of the epidemiology of these diseases is needed to target public health interventions such as mass drug administration (MDA). The aim of this study is to determine the prevalence of scabies and impetigo in Solomon Islands as well as the relationship between them and their distribution. We conducted a prevalence study in 20 villages in Western Province in Solomon Islands. All residents of the village were eligible to participate. Nurses conducted clinical assessments including history features and skin examination. Diagnosis of scabies was made using the 2020 International Alliance for the Control of Scabies diagnostic criteria. Assessments were completed on 5239 participants across 20 villages. Overall scabies prevalence was 15.0% (95%CI 11.8-19.1). There was considerable variation by village with a range of 3.3% to 42.6%. There was a higher prevalence of scabies in males (16.7%) than females (13.5%, adjusted relative risk 1.2, 95%CI 1.1-1.4). Children aged under two years had the highest prevalence (27%). Overall impetigo prevalence was 5.6% (95%CI 4.2-7.3), ranging from 1.4% to 19% by village. The population attributable risk of impetigo associated with scabies was 16.1% (95% CI 9.8-22.4). The prevalence of scabies in our study is comparable to previous studies in Solomon Islands, highlighting a persistent high burden of disease in the country, and the need for public health strategies for disease control.

Description:Introduction: Scabies is a significant contributor to global morbidity, affecting approximately 200 million people at any time. Scabies is endemic in many resource-limited tropical settings. Bacterial skin infection (impetigo) frequently complicates scabies infestation in these settings. Community-wide ivermectin-based mass drug administration (MDA) is an effective control strategy for scabies in island settings, with a single round of MDA reducing population prevalence by around 90%. However, current two-dose regimens present a number of barriers to programmatic MDA implementation. We designed the Regimens of Ivermectin for Scabies Elimination (RISE) trial to investigate whether one-dose MDA may be as effective as two-dose MDA in controlling scabies in high-prevalence settings. Methods and analysis: RISE is a cluster-randomised non-inferiority trial. The study will be conducted in 20 isolated villages in Western Province of Solomon Islands where population prevalence of scabies is approximately 20%. Villages will be randomly allocated to receive either one dose or two doses of ivermectin-based MDA in a 1:1 ratio. The primary objective of the study is to determine if ivermectin-based MDA with one dose is as effective as MDA with two doses in reducing the prevalence of scabies after 12 months. Secondary objectives include the effect of ivermectin-based MDA on impetigo prevalence after 12 and 24 months, the prevalence of scabies at 24 months after the intervention, the impact on presentation to health facilities with scabies and impetigo, and the safety of one-dose and two-dose MDA. Ethics and dissemination: This trial has been approved by the ethics review committees of the Solomon Islands and the Royal Children's Hospital, Australia. Results will be disseminated in peer-reviewed publications and in meetings with the Solomon Islands Ministry of Health and Medical Services and participating communities. Trial registration details: Australian New Zealand Clinical Trials Registry: ACTRN12618001086257. Date registered: 28 June 2018.