alicespringstomind

I wrote this essay in 2001 as part of Master of Public Health & Tropical Medicine; subsequently published in online book: Rural and Remote Environmental Health.  Keeping it here for posterity.

Important factors in achieving and maintaining good health include adequate housing, access to clean water and the removal of refuse and human waste (ABS, 1999). These factors have a direct relationship with the prevalence of skin infections and infestations, including scabies. Conditions of poverty, poor hygiene, overcrowding and malnutrition
all contribute to scabies infestations (Braunstein, 1995). These conditions are identified as common experiences of people in Aboriginal communities throughout Australia (Reid and Trompf, 1991; GWA, 1994). It is not surprising then that scabies infestations are a
common public health concern in Aboriginal communities (Freeman and Rotem, 1999; Carapetis and Currie, 1999; Reid and Trompf, 1991; GWA, 1994).

Scabies is a disease of the skin caused by the Sarcoptes scabiei mite whose natural reservoir is human skin (Schaechter et al., 1993). Scabies infestation not only causes intense inflammation and itching, but by breaching the protective barrier of the skin it can predispose the host to bacterial skin infection and subsequent complications (Schaechter et al., 1993).

Group A streptococcal skin infection is of serious concern in the Aboriginal population. Transmission is closely related to overcrowded living conditions, poor hygiene and scabies infestations (Carapetis and Currie, 1999). The high rate of skin infections allows
Streptococcus to circulate in communities for prolonged periods, leading to the high rates of post streptococcal disease (Territory Health Services, 1997). Post streptococcal glomerulonephritis plays a significant role in the pathogenesis of serious renal disease (Reid and Trompf, 1991), which occurs at a disproportionately high rate in the indigenous population (ABS, 1999). The post streptococcal diseases of acute rheumatic fever and rheumatic heart disease also occur at disproportionately high rates. Aboriginal Australians living in the Top End of the Northern Territory experience the highest published incidence rates in the world of acute rheumatic fever and among the highest
prevalence rates of rheumatic heart disease (Carapetis and Currie, 1999).  It is argued that severe scabies contributes to malnutrition in children due to the increased energy requirements for sores to heal (Territory Health Services, 1997).  There is therefore, a strong need for effective measures to be taken as a matter of urgency in preventing the prevalence of scabies in Aboriginal communities.

Scabies programs have proven effective in improving the prevalence of scabies and related skin infections when appropriate treatment and follow up is implemented (Carapetis et al., 1997). It is also acknowledged that health programs and policies must enlist the active participation and involvement of community members in order to achieve improved health outcomes (Golds et al., 1997).

The community studied consists of 21 houses situated outside Katherine in the Northern Territory. Including the transient population, between 150 and over 200 people live in this community.  It was noticed in May 1999 at both the nearby community based Health Center and the local hospital that frequent presentations of people with scabies from this community were occurring. The Health Center assumed responsibility for addressing this problem as the primary health care provider.

After the scabies epidemic had been identified, the Health Center decided to conduct a scabies program to provide treatment and preventive measures. A small team of health professionals including medical officers, Aboriginal health workers and environmental health officers were coordinated to attend the community and speak with members of the community council about the problem. Council members voiced their concerns and the health team offered options for solutions. The council gave consent for a scabies program to be conducted in the community and a series of dates were agreed upon.

Three requirements for a successful community scabies program are identified by Territory Health Services (1997), being:
· Community support and education in the application of a single community scabies treatment of all residents at the same time.
· A maintenance program involving a simple screen of all children less than 15 years old, three times per year, to check skin for scabies and skin sores.
· An ongoing community education and evaluation of the program.

Community support was obtained by discussing the problem with community leaders who were able to appropriately inform the rest of the community and provide consent for the program to be conducted. The health team then attended the community on a prearranged date to conduct an environmental check, which involved assessment of:
· how many rooms per house
· how many people inhabiting each house
· numbers of pets
· availability of clean water
· availability of adequate waste disposal.

Findings from this assessment found that:
· the average house has two bedrooms, a living area and outdoor undercover area with open fire for cooking;
· between 10 and 15 people may live in each house at any one time;
· between three and five dogs or more per household;
· houses share ablution blocks where clean cold water is available with showers, tubs and pay-to-use washing machines, but hot water was unavailable anywhere in the
community;
· the local Community Development and Employment Program provides a weekly waste disposal service, including collection of waste from large rubbish drums situated around
the community and picking up litter from the grounds;
· a septic sewage system operates in the community, with sewage being pumped to a nearby field where it is treated.

Overcrowding was a clear concern in the community. The District Council was lobbied about this and two more houses were built in an attempt to address the issue. Given the degree of overcrowding, however, two extra houses have not relieved the experience of overcrowding in this community.

The lack of hot water available anywhere in the community was identified as an issue that needed to be addressed fairly urgently. The scabies program was conducted in late July, being the middle of the Dry Season when nights can become quite cool in this region. As such, it was found that community members were reluctant to shower due to the availability of only cold water. It has been impossible to find out exactly what was done to introduce hot water to this community, but apparently the Environmental Health Officers contacted the District Council who provided facilities for hot water to be installed as a matter of urgency.

Once the community survey had been conducted and issues highlighted, the health team prepared to conduct a week-long scabies treatment program in the community.  Aboriginal Health Workers attended in-house education sessions to ensure appropriate understanding of the issues and confidence in diagnosing scabies. The team gathered resources for community education, including posters depicting basic hygiene practices and pet care. As the community does not have a community center, these were displayed
in the back of the vehicles from which workers were based throughout the program.

Because of the genetic distinction between human and dog scabies, control programs for human scabies do not require resources directed against zoonotic infection from dogs (Walton et al., 1999). Human scabies is mainly transmitted by body contact and washing
of linen and clothes has been found to be of minimal benefit in a scabies control program (Lloyd, 1998). However, in order to improve dog health and promote personal hygiene practices, these two issues were both included in the control program. Health Workers reinforced to households that a restriction of two to three animals per house was required for optimum health standards. Dogs were desexed and dewormed, and where it was identified that there were too many dogs or dogs were too unwell, consent was obtained as possible to have them put down. Aboriginal Health Workers taught families about the importance of washing clothes and linen regularly and showering daily to reduce the risk of infection. This was at most minimally successful owing to the difficulty of ‘preaching’ to people in their own homes, particularly when some of the Aboriginal Health Workers were related to community members, and when facilities for hygiene are so basic.

During the screening week at least 15 Aboriginal Health Workers and two Medical Officers attended the community on a daily basis for four days. Reducing the rate of scabies requires treatment of all possible human hosts at the same time (Territory Health Services, 1997, Carapetis et al., 1997). It was intended to screen every person in the community and treat those diagnosed with scabies within the space of these four days. Any person diagnosed with scabies was given permethrin 5% cream (Lyclear) and taught (including demonstration where possible, eg on a young baby) how to apply and when to remove the cream.  Family members living with an infected person were also treated prophylactically.  Anyone diagnosed as having infected scabies sores was administered a single dose of intramuscular benzathine penicillin to treat potential streptococcus.  Other skin problems were documented and treated as appropriate (e.g. ringworm).

By way of addressing other health issues concurrently, the health team implemented other screening during the scabies control program. Children were measured and had their weight, height and head circumference plotted on a Road to Health Chart to assess their growth and development. Hemoglobin levels, blood sugar levels and blood pressures were assessed and deworming antibiotics were administered to everyone. This allowed the health team to assess the general health of the community and refer those requiring follow up to the medical officers who were present.

Problems experienced during this screening and treatment program included the health team’s inability to ensure all community members used the cream. One Health Worker reported that 10 tubes of Lyclear were found sitting in one household, unused, days after the program had finished.

Since the scabies control program conducted at this community, the Health Center have been restricted by resources to provide any follow up to the program, so the maintenance program recommended by Territory Health Services has not occurred. Data was not collated into a report, and the community did not receive any information about the success of the program. A medical officer involved in the control program stated that it was only minimally successful in the short term, and that it has not reduced the number of people from this community presenting with scabies infestations.

The scabies control program outlined in this report provides a short term strategy for treating scabies and preventing its serious consequences. Despite the effort and resources that were allocated to this program, a number of recommendations were omitted, leading to the relative failure of the program. These omissions were exacerbated by the inherent problems of conducting such a program in a small local community where the shame of having your lifestyle criticized can lead to resentment and refusal to actively participate in efforts to address the problem. The ongoing issue of
overcrowding has not been addressed adequately to ensure that once scabies is controlled in the community, it will remain so.

Whether or not this program had been successful in meeting it’s objectives, the fact remains that long term success will only be achieved when the underlying social, environmental and political factors which lead to these and other preventable
diseases in Aboriginal communities are alleviated (Carapetis and Currie, 1999).  Long-term achievement in proper environmental health conditions for Aboriginal communities is the subject of a number of obstacles and complications.  These include cultural issues; the number and range of agencies responsible for providing services that affect environmental health without an effective coordination between agencies; issues of funding between local, state and federal levels; and issues of social disadvantage which are too complex to discuss under the limits of this report (GWA, 1994).  Until a coordinated focus is provided for addressing these multi-faceted problems, ‘band aid’ measures such as this scabies control program will continue to be applied with limited success.

References

ABS – Australian Bureau of Statistics and Australian Institute of Health and Welfare
(1999) The Health and Welfare of Australia’s Aboriginal and Torres Strait Islander
Peoples, Commonwealth of Australia, Canberra

Braunstein WB (1995) Scabies. In: Principles and Practice of Infectious Diseases, Fourth
Edition, (eds.) GL Mandell, JE Bennett, R Dolin. Churchill Livingstone, Melbourne.

Carapetis JR and Currie BJ (1999) Mortality due to acute rheumatic fever and rheumatic
heart disease in the Northern Territory: a preventable cause of death in Aboriginal
people. Australian and New Zealand Journal of Public Health 23:134-136.

Carapetis JR, Connors C, Yarmirr D, Krause V, Currie B (1997) Success of a scabies control program in an Australian Aboriginal community. Paediatric Infectious Diseases Journal 16:123-126

Freeman P and Rotem A (1999) Essential Primary Health Care Services for Health
Development in Remote Aboriginal Communities in the Northern Territory.  University of New South Wales, Sydney.

Golds M, King R, Meiklejohn B, Campion S, Wise M (1997) Healthy Aboriginal communities. Australian and New Zealand Journal of Public Health. 21:56-58.

GWA – Government of Western Australia (1994) Task Force on Aboriginal Social
Justice, Report of the Task Force. Government of Western Australia, Perth.

Hoy W, Matthews W, McCredie DA, Pugsley DJ, Hayhurst BG, Rees M, Kile E, Walker K, Wang Z (1998) The multidimensional nature of renal disease: rates and associations of
albuminuria in an Australian Aboriginal community. Kidney International 54:25-28.

Lloyd CR (1998) Washing machine usage in remote Aboriginal communities. Australian
and New Zealand Journal of Public Health 22:60-61.

Reid J and Trompf P (1991) The Health of Aboriginal Australia. Harcourt Brace Jovanovich, Sydney

Schaechter M, Medoff G, Eisenstein BI (1993) Mechanisms of Microbial Disease, Second Edition. Williams and Wilkins, Maryland.

Territory Health Services (1997) Guidelines for the control of acute post-streptococcal
glomerulonephritis. Center for Disease Control, Northern Territory Government, Darwin. http://www.nt.gov.au/nths.

Walton S, Choy J, Bonson A, Valle A, McBroom J, Taplin D, Arlian L, Mathews J, Currie B, Kemp D (1999) Genetically distinct dog-derived and human-derived Sarcoptes scabiei in scabies-endemic communities in northern Australia. American Journal of Tropical Medicine and Hygiene 61:145-148.