A Community-Directed Integrated Strongyloides Control Program in Queensland, Australia.

This paper describes two phases of a community-directed intervention to address strongyloidiasis in the remote Aboriginal community of Woorabinda in central Queensland, Australia. The first phase provides the narrative of a community-driven 'treat-and-test' mass drug administration (MDA) intervention that was co-designed by the Community Health Service and the community. The second phase is a description of the re-engagement of the community in order to disseminate the key factors for success in the previous MDA for Strongyloides stercoralis, as this information was not shared or captured in the first phase. During the first phase in 2004, there was a high prevalence of strongyloidiasis (12% faecal examination, 30% serology; n = 944 community members tested) that resulted in increased morbidity and at least one death in the community. Between 2004⁻2005, the community worked in partnership with the Community Health Service to implement a S. stercoralis control program, where all of the residents were treated with oral ivermectin, and repeat doses were given for those with positive S. stercoralis serology. The community also developed their own health promotion campaign using locally-made resources targeting relevant environmental health problems and concerns. Ninety-two percent of the community residents participated in the program, and the prevalence of strongyloidiasis at the time of the 'treat-and-test' intervention was 16.6% [95% confidence interval 14.2⁻19.3]. The cure rate after two doses of ivermectin was 79.8%, based on pre-serology and post-serology tests. The purpose of this paper is to highlight the importance of local Aboriginal leadership and governance and a high level of community involvement in this successful mass drug administration program to address S. stercoralis. The commitment required of these leaders was demanding, and involved intense work over a period of several months. Apart from controlling strongyloidiasis, the community also takes pride in having developed and implemented this program. This appears to be the first community-directed S. stercoralis control program in Australia, and is an important part of the national story of controlling infectious diseases in Indigenous communities.

Implications of male circumcision for women in Papua New Guinea: a transformational grounded theory study.

BACKGROUND: Male circumcision reduces the risk of female-to-male transmission of human immunodeficiency virus (HIV) and is being explored for HIV prevention in Papua New Guinea (PNG). PNG has a concentrated HIV epidemic which is largely heterosexually transmitted. There are a diverse range of male circumcision and penile modification practices across PNG. Exploring the implications of male circumcision for women in PNG is important to inform evidence-based health policy that will result in positive, intended consequences. METHODS: The transformational grounded theory study incorporated participatory action research and decolonizing methodologies. In Phase One, an existing data set from a male circumcision study of 861 male and 519 female participants was theoretically sampled and analyzed for women's understanding and experience of male circumcision. In Phase Two of the study, primary data were co-generated with 64 women in seven interpretive focus group discussions and 11 semi-structured interviews to develop a theoretical model of the processes used by women to manage the outcomes of male circumcision. In Phase Three participants assisted to refine the developing transformational grounded theory and identify actions required to improve health. RESULTS: Many women know a lot about male circumcision and penile modification and the consequences for themselves, their families and communities. Their ability to act on this knowledge is determined by numerous social, cultural and economic factors. A transformational grounded theory was developed with connecting categories of: Women Know a Lot, Increasing Knowledge; Increasing Options; and Acting on Choices. Properties and dimensions of each category are represented in the model, along with the intervening condition of Safety. The condition of Safety contextualises the overarching lived realty for women in PNG, enables the inclusion of men in the transformational grounded theory model, and helps to explain relationships between men and women. The theory presents the core category as Power of Choice. CONCLUSIONS: This transformational grounded theory provides a means to explore how women experience male circumcision and penile modification in PNG, including for HIV prevention. Women who have had opportunities for education have a greater range of choices and an increased opportunity to act upon these choices. However, women can only exercise their power of choice in the context of safety. The concept of Peace drawn from the Social Determinants of Health is applied in order to extend the explanatory power of the transformational grounded theory. This study shows that women's ambivalence about male circumcision is often related to lack of safety, a consequence of gender inequality in PNG.

Countries' response to WHO's travel recommendations during the 2013-2016 Ebola outbreak.

OBJECTIVE: To determine how, during the 2013-2016 Ebola outbreak in western Africa, States Parties to the World Health Organization's (WHO) 2005 International Health Regulations (IHR) followed the IHR's international travel recommendations. METHODS: In 2015, we used the Google search engine to investigate the 196 States Parties to the 2005 IHR. Information detailing Ebola-related travel regulations or restrictions of each State Party was sourced first from official government websites and then from travel and news websites. When limited, conflicting or no relevant information was found on a government website, an email inquiry was sent to a corresponding embassy in an Anglophone country. FINDINGS: We collected relevant and non-conflicting data for each of 187 States Parties. Of these, 43 (23.0%) prohibited the entry of foreigners who had recently visited a country with widespread Ebola transmission and another 15 (8.0%) imposed other substantial restrictions on such travellers: the requirement to produce a medical certificate documenting no infection with Ebola (n = 8), mandatory quarantine (n = 6) or other restrictions (n = 1). CONCLUSION: In responding to the 2013-2016 Ebola outbreak, countries had variable levels of adoption of the 2005 IHR's international travel recommendations. We identified 58 (31.0%) States Parties that exceeded or disregarded the recommendations. There is a need for more research to understand and minimize deviations from such recommendations.

Orientation of Head Lice on Human Hosts, and Consequences for Transmission of Pediculosis: The Head Lice Movement Studies.

We performed head lice movement studies to elucidate factors influencing orientation and movement of head lice. Studies included observation of lice movements on hand and forearm at different positions of the upper limb; movements exposed to unshaved and shaved forearm; and movements with and without antennae. In 57 of 60 (95.0%) observations while holding the hand down, lice moved proximal, and 3 (5%) distal. While holding the hand up, 37/60 (61.7%) moved proximal, and 23 (38.3%) distal (p < 0.0001). On the unshaved limb, 29/30 (96.7%) moved proximal, with clockwise movements in 26/30 (86.7%). After shaving, 9/30 (30%) walked proximal and 18 (60%) distal, with 12/30 (40%) clockwise movements. After antennectomy, while holding the hand up, 16/25 (64%) lice did not move, 1 (4%) walked proximal, and 8 (32%) distal. While handing the hand down, 17/25 (68%) did not move, 5 (20%) walked proximal, and 3 (12%) distal. Transmission of head lice may not only occur by head-to-head contact, but also via head-to-body contact, with movement to the head against gravitational pull. Surface factors of hand and forearm may be important in orientation for lice, in addition to gravity. Movement of lice against gravity is not governed by organs in the antennae.

A Case of Ancylostoma ceylanicum Infection Occurring in an Australian Soldier Returned from Solomon Islands.

A 26-year-old male member of the Australian Defense Force presented with a history of central abdominal pain of 4 weeks duration and peripheral eosinophilia consistent with eosinophilic enteritis. Acute hookworm disease was diagnosed as the cause. Adult worms recovered from feces after therapy with albendazole were morphologically consistent with Ancylostoma ceylanicum. As the patient had been deployed with the Regional Assistance Mission to Solomon Islands for 6 months prior to this presentation, it is very likely that the A. ceylanicum was acquired in Solomon Islands. Until now, it has been assumed that any Ancylostoma spp. recovered from humans in Solomon Islands is A. duodenale. However, this case demonstrates that human hookworm infection acquired in the Solomon Islands could be caused by A. ceylanicum.

Forecasted Impact of Climate Change on Infectious Disease and Health Security in Hawaii by 2050.

OBJECTIVE: Climate change is expected to cause extensive shifts in the epidemiology of infectious and vector-borne diseases. Scenarios on the effects of climate change typically attribute altered distribution of communicable diseases to a rise in average temperature and altered incidence of infectious diseases to weather extremes. METHODS: Recent evaluations of the effects of climate change on Hawaii have not explored this link. It may be expected that Hawaii's natural geography and robust water, sanitation, and health care infrastructure renders residents less vulnerable to many threats that are the focus on smaller, lesser developed, and more vulnerable Pacific islands. In addition, Hawaii's communicable disease surveillance and response system can act rapidly to counter increases in any disease above baseline and to redirect resources to deal with changes, particularly outbreaks due to exotic pathogens. RESULTS: The evidence base examined in this article consistently revealed very low climate sensitivity with respect to infectious and mosquito-borne diseases. CONCLUSIONS: A community resilience model is recommended to increase adaptive capacity for all possible climate change impacts rather an approach that focuses specifically on communicable diseases. (Disaster Med Public Health Preparedness. 2016;10:797-804).

Chronic strongyloidiasis - Don't look and you won't find.

BACKGROUND: Strongyloidiasis is one of the most neglected tropical diseases and it exists in Australia. Patients may have acquired their initial infection while in an endemic area. Because of the autoinfective cycle of Strongyloides stercoralis, the causative agent, these patients may remain infected for life unless effectively treated. Corticosteroids have precipitated death in more than 60% of disseminated strongyloidiasis cases. OBJECTIVE: The aim of this article is to raise awareness of the unique features of S. stercoralis and outline the important role that general practitioners (GPs) have in diagnosing and treating chronic strongyloidiasis, as well as in preventing cases of fatal hyperinfection. DISCUSSION: Chronic strongyloidiasis is not an overt disease - if you don't look for it, you won't find it. In particular, patients who have lived in an endemic area or have unexplained eosinophilia must be checked for the presence of the parasite before initiation of steroid or immunosuppressive therapy. These patients, if infected, may develop hyperinfective syndrome, which has a high fatality rate.

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.

Prevalence of soil-transmitted helminths in remote villages in East Kwaio, Solomon Islands.

OBJECTIVE: Although soil-transmitted helminths (STH) are endemic in Solomon Islands, there are few recent reports on their prevalence. This study aimed to determine the prevalence of STH in residents of remote communities in Solomon Islands. METHODS: A cross-sectional convenience-sampled survey of residents of four adjacent villages in Malaita, Solomon Islands was performed in Atoifi and Na'au in April 2011 and in Abitona and Sifilo in April 2012. All residents older than one year were invited to participate, which involved providing a single sample of faeces examined using a modified Kato-Katz technique and completing a questionnaire that asked demographic and STH-related behaviour questions. RESULTS: The overall participation rate was 52.8%, with 402 participants comprising 49.8% males. Hookworm was the predominant STH with only a single case of trichuriasis found in Atoifi. The total prevalence of hookworm was 22.6% (95% confidence interval: 18.6-27.1); the prevalence of hookworm in Abitona, Na'au and Sifilo was 20.0%, 29.9% and 27.4%, respectively, whereas in Atoifi it was 2.3% (P < 0.001). Intensity was low in all villages. Although health behaviours differed significantly between Atoifi and the other three villages, the type of toilet used was the only significant association with hookworm. DISCUSSION: Residents of Atoifi have a relative freedom from STH compared to the other three villages. Rather than a region-wide morbidity control approach, a "one village at a time" approach aiming to eliminate STH and dealing with each village as a separate autonomous unit empowered to manage its own challenges may be a preferred option.

Mental health issues from rising sea level in a remote coastal region of the Solomon Islands: current and future.

OBJECTIVE: There is little published research about mental health and climate change in the Pacific, including Solomon Islands. Solomon Islands has one of the highest rates of sea-level rise globally. The aim of this research was to document mental health issues related to sea-level rise for people in East Malaita, Solomon Islands. METHOD: A cross-sectional study was carried out in six low-lying villages in East Malaita, Solomon Islands. The researcher travelled to villages by dugout canoe. In addition to quantitative, closed-ended questions, open-ended questions with villagers explored individual and community responses to rising sea level. RESULTS: Of 60 people asked, 57 completed the questionnaire. Of these, 90% reported having seen a change in the weather patterns. Nearly all participants reported that sea-level rise is affecting them and their family and is causing fear and worry on a personal and community level. Four themes emerged from the qualitative analysis: experience of physical impacts of climate change; worry about the future; adaptation to climate change; government response needed. CONCLUSION: Given predictions of ongoing sea-level rise in the Pacific it is essential that more research is conducted to further understand the human impact of climate change for small island states which will inform local, provincial and national-level mental health responses.

Managing Community Resilience to Climate Extremes, Rapid Unsustainable Urbanization, Emergencies of Scarcity, and Biodiversity Crises by Use of a Disaster Risk Reduction Bank.

Earth's climate is changing and national and international decision-makers are recognizing that global health security requires urgent attention and a significant investment to protect the future. In most locations, current data are inadequate to conduct a full assessment of the direct and indirect health impacts of climate change. All states require this information to evaluate community-level resilience to climate extremes and climate change. A model that is being used successfully in the United Kingdom, Australia, and New Zealand is recommended to generate rapid information to assist decision-makers in the event of a disaster. The model overcomes barriers to success inherent in the traditional ''top-down'' approach to managing crises and recognizes the capacity of capable citizens and community organizers to facilitate response and recovery if provided the opportunity and resources. Local information is a prerequisite for strategic and tactical statewide planning. Time and resources are required to analyze risks within each community and what is required to prevent (mitigate), prepare, respond, recover (rehabilitate), anticipate, and assess any threatening events. Specific requirements at all levels from state to community must emphasize community roles by focusing on how best to maintain, respond, and recover public health protections and the infrastructure necessary for health security.

Communicable diseases in rural and remote Australia: the need for improved understanding and action.

INTRODUCTION: Rural and remote communities of Australia, particularly those including Aboriginal people, experience greater morbidity and mortality across a range of health outcomes compared to urban communities. Previous national data have demonstrated that rural and remote communities experience a disproportionate burden of communicable diseases compared to their urban counterparts. This systematic review was undertaken to describe the types of research that have explored the epidemiology of communicable diseases in rural and remote communities in Australia, with particular reference to the social determinants of health. METHODS: We conducted a keyword search of several databases (EMBASE, MEDLINE/PubMed, RURAL, Aboriginal and Torres Strait Islander Health Database, Web of Science Core Collection, and Google and Google Scholar websites) for peer-reviewed and grey literature that described or analysed the epidemiology of communicable diseases in rural and/or remote communities of Australia from 2004 to 2013. Exclusion criteria were applied to keep the review focused on rural and/or remote communities and the population-level epidemiological analysis of communicable diseases. RESULTS: From 2287 retrieved articles, a total of 50 remained after applying exclusion criteria. The majority of included articles were descriptive studies (41/50). Seven of the total 50 articles contained analytical studies; one systematic literature review and one experimental study were also identified. Due to the diversity of approaches in measuring disease burden, we performed a narrative synthesis of the articles according to the review objectives. Most of the articles investigated the disease burden in remote (n=37/50) and Aboriginal communities only (n=21/50). The studies highlighted a high prevalence or incidence of skin, eye and respiratory infections for remote Aboriginal communities, particularly children over the past decade. There was emerging evidence to suggest that housing and social conditions play an important role in determining the risk of skin, ear, respiratory and gastrointestinal infections in children. Other health service and sociocultural factors were also discussed by authors as influencing the epidemiology of communicable diseases in rural and remote communities. CONCLUSIONS: This systematic review identified several communicable diseases that continue to cause considerable morbidity in remote Aboriginal communities, including skin, eye and respiratory infections, particularly for children. Overall there is a substantial amount of descriptive epidemiology published, but few analytical or experimental studies. Despite a lack of empirical investigation into the social determinants of the burden of communicable disease, there is emerging evidence that has demonstrated a significant association between housing conditions and skin, ear, respiratory and gastrointestinal infections in children. There is also growing recognition of other social and environmental factors that can influence the burden of diseases in rural and remote communities. Further investment into higher quality community-based research that addresses the social determinants of communicable diseases in remote communities is warranted. The lack of research investigating zoonoses and tropical diseases was noted.

Surgical Treatment of Genital Manifestations of Lymphatic Filariasis: A Systematic Review.

Genital manifestations of lymphatic filariasis (genital LF) are a significant cause of disfigurement and disability in the developing world. Surgery is the standard treatment; however, definitive publications are lacking and best practice remains unclear. An exhaustive search strategy using keyword and subject headings was applied to Medline, EMBASE, Web of Science, CINAHL, and Scopus. Additionally citation lists, Google and Google Scholar, archives of relevant journals and websites were searched systematically. Studies with data on one or more human patient(s) who underwent surgery for genital LF were included. Articles were screened and data extracted by the first author with data verification by the second author. Fifty-seven studies were included: 18 series of ablative surgery, four series of non-ablative surgery and 35 case reports. Poor study quality, heterogeneous case definitions, lack of severity grading and limited follow-up precluded meta-analysis. Two series of simple hydrocelectomies performed in resource-limited settings reported early complication rates of 3.0-3.5 % using eversion and 5-7 % using excision, with recurrence of 7 % and 3-5 %, respectively. Complications were minimal for single-surgeon series and greater (12-18 %) when scrotal reconstruction was performed. There is little useful evidence for lymphatic bypass procedures in genital LF. Under-recognition of atypical manifestation of genital LF leads to potentially unnecessary surgeries. Surgery for genital LF is safe in resource-limited settings; however, more well-designed studies with better follow-up are needed. Research priorities include validation of case definitions and severity grading systems, and solutions to improve post-operative follow-up in resource-limited settings.

Strengthening capacity for local evidence to inform local responses to HIV in a remote Solomon Islands health service.

BACKGROUND: Documenting specific knowledge and attitudes about HIV in the culturally diverse nation of Solomon Islands is essential to inform locally targeted public health responses. As part of a large capacity-strengthening project at Atoifi Adventist Hospital in East Kwaio, Solomon Islands, researchers, using a 'learn-by-doing' process, worked with participants in public health research methods. METHODS: Overall, 43 people attended research capacity building workshops in 2011; eight joined the HIV study group. A cross-sectional survey including semi-structured interviews on HIV was conducted by the group. In February 2014, a hospital administrator was interviewed about how the 2011 study informed local HIV responses. RESULTS: Of the 53 survey participants, 64% self-assessed as having little or no HIV knowledge, but 90% knew HIV could be transmitted between men and women during sex. Less than 50% knew HIV could be transmitted between two men having sex, 45% thought HIV could be transmitted by mosquitoes and 55% agreed condoms help protect from HIV. Most participants reported negative attitudes towards people with HIV. Three years later the health administrator reported ad hoc responses to HIV because of low HIV prevalence, increasing noncommunicable diseases, staff turnover and resource shortages. DISCUSSION: This HIV study was used to strengthen research skills in local health professionals and community members in Solomon Islands. It showed that community members require accurate information about HIV transmission and that entrenched stigma is an issue. Although results provided local evidence for local response, ongoing health system challenges and little local HIV transmission meant HIV services remain rudimentary.

Willingness to Consult a Veterinarian on Physician's Advice for Zoonotic Diseases: A Formal Role for Veterinarians in Medicine?

Physicians appear to find zoonotic diseases a challenge and consider that this topic belongs more to the veterinary profession. However, veterinarians have no formal role in clinical medicine. Data were collected as part of the Queensland Social Survey 2014 to determine the willingness of the public, if diagnosed with a zoonotic disease, to consult a veterinarian on the advice of a physician. Self-reported willingness to consult with a veterinarian at the respondent's own expense was 79.8% (95% CI: 81.96%-77.46%) (976/1223). If the cost was funded by Medicare, the Australian public health insurance scheme, 90.7% (95% CI: 92.18%-88.92%) (1109/1223) would be willing to consult a veterinarian. Therefore, a large majority of Australian residents would be willing to consult with a veterinarian on the advice of their physician if they had a zoonotic disease. Does this indicate a possible new role for veterinarians under Clinical One Health?

Using a participatory action research framework to listen to Aboriginal and Torres Strait Islander people in Australia about pandemic influenza.

INTRODUCTION: This article describes the use and effectiveness of the participatory action research (PAR) framework to better understand community members' perceptions and risks of pandemic influenza. In 2009, the H1N1 influenza pandemic affected Indigenous populations more than non-Indigenous populations in Oceania and the Americas. Higher prevalence of comorbidities (diabetes, obesity, asthma and chronic obstructive pulmonary disease) as well as pregnancy in Indigenous communities may have contributed to the higher risks of severe disease. Social disparity, institutionalised racism within health services and differences in access to culturally safe health services have also been reported as contributors to disadvantage and delayed appropriate treatment. METHODS: Given these factors and the subsequent impact they had on Australian Aboriginal and Torres Strait Islander communities, the authors set out to ensure that the Australian national, state and territory pandemic plans adequately reflected the risk status of Aboriginal and Torres Strait Islander peoples and promoted meaningful engagement with communities to mitigate this risk. A national study explored the views of Aboriginal and Torres Strait Islander people and their experiences with H1N1 and used a qualitative PAR framework that was effective in gaining deep understandings from participants. Aboriginal and Torres Strait Islander community-controlled organisations and health services were involved in the implementation, interpretation and monitoring of this project. RESULTS: As a result, important features of the implementation of this PAR framework with Aboriginal and Torres Strait Islander communities and organisations emerged. These features included the importance of working in a multidisciplinary team with Aboriginal and Torres Strait Islander researchers; the complexities and importance of obtaining multi-site human research ethics approval processes; the importance and value of building the research capacity of both experienced and novice researchers in PAR; the need to use localised sampling protocols; and the process of undertaking a collective research process and enacting action research and feedback. CONCLUSIONS: The most effective responses of this project were embedded in pre-existing relationships with individuals within organisations that had been established over a long period of time between Aboriginal medical services and investigators; however, research relationships established specifically for the purposes of the project were less successful because of changes in personnel and organisational support. The participatory approach used in this study has the potential to be applied to vulnerable populations in other countries.

Hospital preparedness for Ebola virus disease: a training course in the Philippines.

OBJECTIVE: To develop, teach and evaluate a training workshop that could rapidly prepare large numbers of health professionals working in hospitals in the Philippines to detect and safely manage Ebola virus disease (EVD). The strategy was to train teams (each usually with five members) of key health professionals from public, private and local government hospitals across the Philippines who could then guide Ebola preparedness in their hospitals. METHODS: The workshop was developed collaboratively by the Philippine Department of Health and the country office of the World Health Organization. It was evaluated using a pre- and post-workshop test and two evaluation forms. χ(2) tests and linear regression analyses were conducted comparing pre- and post-workshop test results. RESULTS: A three-day workshop was developed and used to train 364 doctors, nurses and medical technologists from 78 hospitals across the Philippines in three initial batches. Knowledge about EVD increased significantly (P < 0.009) although knowledge on transmission remained suboptimal. Confidence in managing EVD increased significantly (P = 0.018) with 96% of participants feeling more prepared to safely manage EVD cases. DISCUSSION: The three-day workshop to prepare hospital staff for EVD was effective at increasing the level of knowledge about EVD and the level of confidence in managing EVD safely. This workshop could be adapted for use as baseline training in EVD in other developing countries to prepare large numbers of hospital staff to rapidly detect, isolate and safely manage EVD cases.

First human case of fatal Halicephalobus gingivalis meningoencephalitis in Australia.

Halicephalobus gingivalis (previously Micronema deletrix) is a free-living nematode known to cause opportunistic infections, mainly in horses. Human infections are very rare, but all cases described to date involved fatal meningoencephalitis. Here we report the first case of H. gingivalis infection in an Australian human patient, confirmed by nematode morphology and sequencing of ribosomal DNA. The implications of this case are discussed, particularly, the need to evaluate real-time PCR as a diagnostic tool.