Mistaken identity: Reporting two cases of rare forms of extrapulmonary tuberculosis in Solomon Islands.

INTRODUCTION AND IMPORTANCE: Extrapulmonary tuberculosis (EPTB) is a relatively rare and difficult-to-diagnose manifestation of Myobacterium tuberculosis (TB) infection. CASE PRESENTATION: This study reports the cases of a 47-year-old male and a 35-year old female with rare forms of EPTB who sought medical care in Solomon Islands. Both patients presented with nondescript symptoms and a chief complaint of pain. Initial diagnosis for the male and female patient was an abacterial colon polypoid mass and a urinary tract infection (UTI) respectively. Following unsuccessful treatment for UTI and further investigation, the surgical team diagnosed the female patient with a tuberculosis spondylitis and a bilateral psoas abscess. The male patient was subsequently diagnosed with isolated colonic tuberculosis. After starting medication, the patients were discharged and prescribed 9-month treatment regimens. During outpatient treatment both patients reported suboptimal adherence. The female patient resumed treatment and showed improvement while the male patient discontinued treatment, experienced worsening symptoms, and ultimately died. CLINICAL DISCUSSION: The nonspecific symptoms of extrapulmonary TB infection make it difficult to diagnose. Cases of rare forms of EPTB are particularly challenging to identify. Misdiagnosis may further increase the likelihood of mortality and morbidity in these cases. Intensive medication counseling, patient outreach, and regularly scheduled follow-up visits may reduce the incidence of poor adherence and reduce the risk of developing drug-resistant TB. CONCLUSION: Medical practitioners in tuberculosis-endemic countries like Solomon Islands should maintain a high clinical index of suspicion in diagnosing EPTB. Future research should investigate the prevalence of TB and EPTB in the Solomon Islands.

Impact of Community Treatment With Ivermectin for the Control of Scabies on the Prevalence of Antibodies to Strongyloides stercoralis in Children.

The prevalence of antibodies to Strongyloides stercoralis was measured in 0-12-year-olds using a bead-based immunoassay before and after ivermectin mass drug administration (MDA) for scabies in the Solomon Islands. Seroprevalence was 9.3% before and 5.1% after MDA (P = .019), demonstrating collateral benefits of ivermectin MDA in this setting.

Randomized Trial of Community Treatment With Azithromycin and Ivermectin Mass Drug Administration for Control of Scabies and Impetigo.

BACKGROUND: Scabies is a public health problem in many countries, with impetigo and its complications important consequences. Ivermectin based mass drug administration (MDA) reduces the prevalence of scabies and, to a lesser extent, impetigo. We studied the impact of co-administering azithromycin on the prevalence of impetigo and antimicrobial resistance. METHODS: Six communities were randomized to receive either ivermectin-based MDA or ivermectin-based MDA co-administered with azithromycin. We measured scabies and impetigo prevalence at baseline and 12 months. We collected impetigo lesions swabs at baseline, 3 and 12 months to detect antimicrobial resistance. RESULTS: At baseline, scabies and impetigo prevalences were 11.8% and 10.1% in the ivermectin-only arm and 9.2% and 12.1% in the combined treatment arm. At 12 months, the prevalences had fallen to 1.0% and 2.5% in the ivermectin-only arm and 0.7% and 3.3% in the combined treatment arm. The proportion of impetigo lesions containing Staphylococcus aureus detected did not change (80% at baseline vs 86% at 12 months; no significant difference between arms) but the proportion containing pyogenic streptococci fell significantly (63% vs 23%, P < .01). At 3 months, 53% (8/15) of S. aureus isolates were macrolide-resistant in the combined treatment arm, but no resistant strains (0/13) were detected at 12 months. CONCLUSIONS: Co-administration of azithromycin with ivermectin led to similar decreases in scabies and impetigo prevalence compared to ivermectin alone. The proportion of impetigo lesions containing pyogenic streptococci declined following MDA. There was a transient increase in the proportion of macrolide-resistant S. aureus strains following azithromycin MDA. CLINICAL TRIALS REGISTRATION: clinicaltrials.gov (NCT02775617).

Impact of ivermectin administered for scabies treatment on the prevalence of head lice in Atoifi, Solomon Islands.

BACKGROUND: Scabies and head lice are ubiquitous ectoparasitic infestations that are common across the Pacific Islands. Ivermectin is an effective treatment for both conditions, although the doses used vary. At a community level, mass drug administration (MDA) with ivermectin is an effective strategy to decrease prevalence of scabies. To what extent MDA with ivermectin will also reduce prevalence of head lice is unknown. METHODOLOGY: Head lice prevalence was assessed before and after MDA with oral ivermectin (at a dose of 200 micrograms per kilogram of body weight) administered on day 1 and day 8. The primary outcome was the change in prevalence of head louse infestation at two weeks compared to baseline. Longer term efficacy was assessed three months after MDA. RESULTS: 118 participants were enrolled. Baseline prevalence of active head louse infestation was 25.4% (95% CI 18.4-34.0). At two-week follow-up, prevalence was 2.5% (95% CI 0.9-7.2), a relative reduction of 89.1% (95% CI 72.7-91.4%, p<0.001). At three-month follow-up, prevalence was 7.5% (95% CI 2.7-12.3), a relative reduction of 70.6% (95% CI 72.7%-91.4%, p <0.001). Head louse infestation was associated with younger age (age ≤10 years: prevalence 46.7%; adjusted odds ratio compared to adults of 7.2, 95%CI 2.0-25.9) and with having at least one other member of the household with active head louse infestation (adjusted odds ratio 4.3, 95%CI 1.7-11.1). CONCLUSIONS: Head louse infestation is common in the Solomon Islands. This proof of principle study shows that oral ivermectin at a dose of 200 micrograms per kilogram can reduce the burden of active head louse infestation, offering an additional collateral benefit of MDA with ivermectin for scabies control. TRIAL REGISTRATION: ClinicalTrials.gov NCT03236168.

Point-of-care tests for syphilis and yaws in a low-income setting - A qualitative study of healthcare worker and patient experiences.

INTRODUCTION: The human treponematoses comprise venereal syphilis and the three non-venereal or endemic treponematoses yaws, bejel, and pinta. Serological assays remain the most common diagnostic method for all treponemal infections. Point-of-care tests (POCTs) for syphilis and yaws allow testing without further development of infrastructure in populations where routine laboratory facilities are not available. Alongside the test's performance characteristics assessed through diagnostic evaluation, it is important to consider broader issues when rolling out a POCT. Experience with malaria POCT roll-out in sub-Saharan Africa has demonstrated that both healthcare worker and patient beliefs may play a major role in shaping the real-world use of POCTs. We conducted a qualitative study evaluating healthcare worker and patient perceptions of using a syphilis/yaws POCT in clinics in the East Malaita region of Malaita province in the Solomon Islands. Prior to the study serology was only routinely available at the local district hospital. METHODS: The POCT was deployed in the outpatient and ante-natal departments of a district hospital and four rural health clinics served by the hospital. Each site was provided with training and an SOP on the performance, interpretation and recording of results. Treatment for those testing positive was provided, in line with Solomon Islands Ministry of Health and Medical Services' guidelines for syphilis and yaws respectively. Alongside the implementation of the POCT we facilitated semi-structured interviews with both nurses and patients to explore individuals' experiences and beliefs in relation to use of the POCT. RESULTS AND DISCUSSION: Four main themes emerged in the interviews: 1) training and ease of performing the test; 2) time taken and ability to fit the test into a clinical workflow; 3) perceived reliability and trustworthiness of the test; and 4) level of the health care system the test was most usefully deployed. Many healthcare workers related their experience with the POCT to their experience using similar tests for malaria. Although the test was considered to take a relatively long time to perform the benefits of improved access to testing were considered positive by most healthcare workers. Qualitative data is needed to help inform better training packages to support the implementation of POCT in low-resource settings.

Incidental mosquitocidal effect of an ivermectin mass drug administration on Anopheles farauti conducted for scabies control in the Solomon Islands.

Background: The Solomon Islands is targeting elimination of malaria by 2030. The dominant vector is the predominantly exophagic, exophilic Anopheles farauti sensu strictu. This biting behaviour limits the efficacy of conventional vector control tools and highlights the need for new strategies. When administered to humans ivermectin has been shown to have a mosquitocidal effect. Mass drug administration (MDA) with ivermectin is an emerging strategy in the control of scabies. In this study we explored any incidental effect of ivermectin MDA conducted for scabies control on mosquitoes. Methods: MDA for scabies was conducted in three villages. We performed human landing catches and measured 5-day mortality amongst Anopheles mosquitoes caught before and after MDA. Cox regression was used to calculate hazard ratios (HR) for mortality between mosquitoes caught before and after MDA. Results: There was a significant increase in 5-day mortality in anopheline mosquitoes caught post-MDA which was highest on the day of MDA itself (HR 4.2 95% CI 1.8 to 10.1, p=0.001) and the following day (HR 4.4 95% CI 1.8 to 10.8, p=0.002) compared to mosquitoes caught before MDA. Conclusions: This study shows a possible mosquitocidal effect of ivermectin MDA conducted for scabies control. Studies with a larger sample size with clinical as well as entomological outcomes should be conducted in this population.

Measles outbreak investigation in a remote area of Solomon Islands, 2014.

OBJECTIVE: To describe a measles outbreak and health service response in a remote location in Malaita, Solomon Islands. METHODS: Epidemiological review of cases who presented to the Atoifi Adventist Hospital (AAH) during the outbreak period from July to December 2014. Rumour surveillance was used to gather information on unreported cases. RESULTS: A total of 117 cases were reported to AAH. The incidence rate was 123 per 10 000 individuals. Fifty-six per cent (66/117) of cases were hospitalized. Children under 5 years had the highest number of cases (n = 41) with 10 cases below 6 months old. The age-specific incidence rate of children under 5 years was 278.5 per 10 000 individuals. Eighty-two per cent of reported cases were 18 years old or younger. Rumour surveillance revealed about three quarters of children in one area of the East Kwaio Mountains had suspected measles not reported to AAH. There were three unreported deaths from measles outside AAH. During the outbreak, a total of 2453 measles-rubella vaccines were given in the AAH catchment area. CONCLUSION: A high incidence rate was observed in children and young people aged 18 years or younger, reflecting low childhood vaccination coverage. More than 50% of cases required hospitalization due to disease severity and challenges of accessing health services. The rumour surveillance discovered many unreported cases in the mountain areas and a few deaths possibly linked to the outbreak. Improvement of registration methods and follow-up systems and setting up satellite clinics are planned to improve measles surveillance and vaccination coverage.

Measles outbreak investigation in a remote area of Solomon Islands, 2014

Objective：To describe a measles outbreak and health service response in a remote location in Malaita, Solomon Islands.Introduction：Measles is a highly infectious, acute airborne viral disease with an infectious period of four days before to four days after rash onset. It has an incubation period of 10–14 days. Measles can be a serious illness with complications including otitis media, pneumonia and encephalitis.