MEJOR IMPOSIBLE (James L Brooks, 1997)

DALYs Disability-Adjusted Life-Years

GBD Global Disease Burden

HDI Human Development Index

MAE Master of Applied Epidemiology

MCRI Murdoch Children’s Research Institute

YLD Years Lived with Disability

RISE Regimens of Ivermectin for Scabies Elimination

2.2 Prologue

My role: Although the baseline scabies survey within the Regimens of Ivermectin for Scabies Elimination (RISE) study that I set up (see Chapter 2a, Part 2) was not feasible within my Master of Applied Epidemiology (MAE), I was able to assist the scabies team with a scabies diagnostic accuracy study as a side project to RISE for my official MAE epidemiology project. My work in setting up RISE also contributed to the set-up of the scabies diagnostic study. The scabies diagnostic study was covered by the RISE ethics approvals that I obtained, and I also assisted in identifying Gizo Primary School as the study base for the scabies diagnostic study on my scoping trip for RISE. As the scabies diagnostic study was being led by another student, Millicent Osti (MO), my new role was primarily to assist her. This included helping with study set-up and administration in the field, creating a secure database using REDCap with online and offline data entry options, and data entry. The write up and analyses of this project for my MAE chapter was conducted independently of MO, and includes the prevalence study component only.

Lessons learned and reflections: Special considerations are required when working in overseas community settings. Community engagement and investment in building relationships based on trust and respect are important when engaging and collaborating at the community level. On reflection, more time could have been spent on these considerations. For example, the concerned parents at the parent teacher night demonstrated that the community awareness component could have been more substantial. Another oversight became evident when we arrived to a week of torrential rain. Because the rain makes the unsealed roads on Ghizo Island difficult to use, most students don’t come to school because they have no way of getting there. In addition, we had assumed that the school day in Gizo ran from approximately 9-5pm, however on arrival a week before the study, we found out that it ran from 8-1pm. As the study period had been planned around the number of children that could have been screened by examiners in a 9-5 day, it meant that we had to rethink this process in the field.

Another lesson that I learnt was that it never hurts to over-communicate, especially in a cross- cultural study team. An example of this was in relation to our study recruitment method. Approximately a week before the study, we handed the information sheets and permission slips to the principal of Gizo Primary School, and asked her to pass them on to the teachers to then pass on to the students. After a few days we returned to see how things were going and were relieved that we did, as we discovered that the message had been confused, and the principal had asked the teachers to only hand the permission slips to children that they thought already had scabies.

Finally, I learnt that no matter how positive or ethically sound your intervention or study may be, it is important to consider the potential negative consequences ahead of time so that mitigation strategies can be put in place. Some of these negative consequences may be common in all settings, and some may be particular to the culture you are working in. In this study, after a few days we discovered that children who had been found to have scabies were being treated differently, and we became concerned with the potential of stigma arising. Some of the teachers had commented to the local study team that they did not want children with scabies in their classes, and some had been teased by other children. Luckily members of the local study team brought this to our attention, and they went and spoke to the teachers. Public health impact: This was the first scabies prevalence study conducted in Gizo, and the first scabies prevalence study conducted in a primary school setting in the Solomon Islands. The high prevalence of scabies and impetigo found in Gizo Primary School indicates that this setting would benefit from community-wide scabies treatment.

Acknowledgements: I would like to thank Millicent Osti, and her supervisor Daniel Engelman (both from Murdoch Children’s Research Institute [MCRI]) for allowing me to assist them with their study and to complete the prevalence assessment component. I would also like to acknowledge my field supervisor John Kaldor and Andrew Steer from MCRI for making this opportunity a possibility for me. Thank you to Ross Andrews from the Australian National University and to my academic supervisor Katie Glass for assisting with ethics applications, data analysis plans and timelines. Thank you to Matthew Parnaby from MCRI for your logistical support. I would also like to acknowledge the rest of the study team: Margot Whitfeld (St Vincents Hospital Sydney, Department of Dermatology); Michael Marks (The London School of Hygiene and Tropical Medicine); Deanne Seppy (MCRI); Tina Galona, Una Gagahe, Ender Malasa (Gizo Hospital, Western Province Solomon Islands); and of course the Western Province

2.3 Abstract

Introduction: Scabies and impetigo are associated skin conditions commonly found in resource- limited settings. Globally, the highest prevalence of these conditions is in children in the Pacific, however limited prevalence data exist. We conducted a prevalence survey of scabies and impetigo in Gizo Primary School, Western Province, Solomon Islands.

Methods: Consenting students from Gizo Primary School were clinically examined for scabies and impetigo by a paediatrician and a dermatologist over the period of 1 week during August, 2018.

Results: 171 participants were examined out of 693 eligible students. Scabies was observed in 97 participants (56.7%) of the population surveyed, a prevalence which increased to 63.7% (95% CI 55.6-71.1%) when standardised to the age and sex structure of the total school

population. Impetigo was observed in 75 participants (43.9%) of the population surveyed. When this was standardised to the age and sex distribution of the total population of Gizo Primary School, a lower impetigo prevalence of 41.9% (95% CI 44.0-50.3%) was estimated. Almost half (48%) of children with scabies also had impetigo, however the presence of scabies was not significantly associated with impetigo (relative risk 1.3, 95% CI 0.9-1.8).

Conclusions and Public Health Implications: A higher than expected prevalence of scabies and impetigo was found in Gizo Primary School. School based and community wide treatment strategies are a consideration for this setting.