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The Missing Piece Surveillance Study: A surveillance study for strep A pharyngitis and impetigo in the Kimberley, Australia

The Missing Piece Surveillance Study is a prospective surveillance study to determine the concurrent burden of skin and throat infections in children, from two remote communities in Northern Australia.

Investigators

Principal Investigator

  • Professor Asha Bowen | Head, Healthy Skin and ARF Prevention, The Kids Research Institute Australia (Perth)

Co-Investigators

  • Dr Janessa Pickering | Senior Research Officer, Strep A Pathogenesis and Diagnostics, The Kids Research Institute Australia (Perth)
  • Rebecca Famlonga | Senior Research Officer, Healthy Skin & ARF Prevention, The Kids Research Institute Australia (Broome)
  • Dr Dylan Barth | Honorary Research Associate, Healthy Skin & ARF Prevention, The Kids Research Institute Australia (Perth)
  • Professor David AThe Kidsnson | Emeritus Professor, UWA Medical School, Rural Clinical School (Broome)
  • Professor Julianne Coffin | Professor, Ngangk Yira Institute for Change, Murdoch University (Broome)
  • Professor Jonathan Carapetis | Executive Director, The Kids Research Institute Australia; Head, Strep A & Rheumatic Heart Disease and Strep A Translation (Perth)

Project description

WHAT?

The Missing Piece Surveillance Study is a prospective surveillance study to determine the concurrent burden of skin and throat infections in children, from two remote communities in Northern Australia. We want to better determine the burden of Strep A (Group A Streptococcus (GAS)) sore throats and skin sores of school children living in the Kimberley. Findings will inform better health prevention strategies needed to reduce the burden of Strep A infections and contribute to the elimination of Rheumatic Heart Disease (RHD) in Australia.

WHY?

Acute rheumatic fever (ARF) is the most common cause of acquired RHD (42-60%) in children worldwide. ARF and RHD are severe chronic diseases that cause premature deaths. Despite this being preventable in wealthy nations, Aboriginal and Torres Strait Islander (hereafter referred to as Aboriginal) children aged 5 to 15 years old, particularly from northern Australia, are most at-risk for ARF and report one of the highest ARF rates globally. Aboriginal children are also 55 times more likely to die of RHD than Australian children of other ethnicities.

ARF is an autoimmune response that begins with a throat infection (sore throat) caused by the Strep A bacterium. If the sore throat is severe and left untreated, ARF can develop 2 to 3 weeks after, causing high fever, tiredness and painful and swollen joints in the knees, ankles, elbows, and wrists.

It is well-researched and known that Strep A sore throat causes ARF. However, previous epidemiological findings from remote Aboriginal communities in northern Australia reported that Strep A sore throats were uncommon - in contrast to the high rates of Strep A skin infections (skin sores or school sores) found, yet these communities were still hyperendemic for ARF and RHD. Furthermore, molecular serotyping of Strep A in the remote communities also supports claims that ARF development may not be so clear-cut within a tropical climate and an endemic setting for skin sores. Therefore, we hypothesise that a link exists between Strep A skin sores and ARF in Australian Aboriginal populations predominantly residing in remote communities.

To investigate this link, we first need to better understand the concurrent burden of Strep A sore throat and skin sores in endemic, tropical and resource-limited settings within northern Australia. Conventionally, primary prevention strategies for ARF and Strep A vaccine development have long been based on the concept that ARF is caused solely by Strep A sore throat. With the Missing Piece Surveillance Study generating newfound evidence on the burden of Strep A sore throat and skin sores in high-risk communities for ARF and RHD, we can better inform an effective employment of primary prevention strategies for ARF, which works towards eliminating RHD.

HOW?

The Kimberley in WA was the chosen site for this project due to the high rates of ARF and RHD. This research is urgently needed to develop evidence-based guidelines and enhance primary prevention strategies for ARF. Without this study, we remain at an impasse in our ability to inform the prioritisation of treatment for sore throat, skin sores or both in Australian Aboriginal children in WA. Measurement of the concurrent burden of Strep A impetigo and pharyngitis relies upon feasible clinical assessment methods and tools. We implemented a school-based prospective surveillance programme to collect information on Strep A impetigo and pharyngitis since 2019. These school visits have ceased in late September 2022, as the analysis of research findings are underway.

SO?

Guided by The Kids’s ‘Standards for the Conduct of Aboriginal Health Research’, the Missing Piece Surveillance study team continues staying connected and working with our partners and the communities to analyse, interpret and report study results, whilst ensuring proper acknowledgement and recognition of partners and communities’ contributions.  Together, we are working towards ways of sharing our findings that are relevant to communities and explore other translation opportunities.

External collaborators

Broome Regional Aboriginal Medical Service, Catholic Education Western Australia, Derby Aboriginal Health Service Council Aboriginal Corporation

Partners

Broome Regional Aboriginal Medical Services (BRAMS), Derby Aboriginal Health Services (DAHS), Catholic Education Office of Western Australia (CEWA)

Funders

  • END RHD Centre of Research Excellence (END RHD CRE); Grant Identification Number for the Research Activity: 1080401 (CI Bowen, Barth, Carapetis)
  • WA Child Research Fund (WACRF); Grant Identification Number for the Research Activity: 2019/20R82 (CI Bowen, Pickering, Barth)
  • WA Child Research Fund (WACRF); Harnessing natural protection to improve vaccine design and primary prevention of Strep A infection 2023-2026. $600,000. (CI Pickering, Barnett, Bowen, Fulurija, Davies, Lundin)

Acknowledgement of Research Study Team Members

We thank the following people for their contributions to the Missing Piece Surveillance Study:

The Kids Research Institute Australia

  • Professor Asha Bowen | Principal Investigator & Head, END RHD Research Program and Healthy Skin & ARF Prevention (Perth)
  • Dr Janessa Pickering | Senior Research Officer, Strep A Pathogenesis and Diagnostics (Perth)
  • Rebecca Famlonga | Senior Research Officer, Healthy Skin & ARF Prevention (Broome)
  • Dr Dylan Barth | Honorary Research Associate, Healthy Skin & ARF Prevention (Perth)
  • Slade Sibosado |Operations Manager, Kimberley Aboriginal Unit (Broome)
  • Liam Bedford |Community Engagement Officer, Kimberley Aboriginal Unit (Broome)
  • Janine McNamara | Community Researcher, Aboriginal Health & Wellbeing (Broome)
  • John Jacky | Community Researcher, Aboriginal Health & Wellbeing (Broome)
  • Bernadette Wong | Research Assistant, END RHD Research Program (Perth)
  • Alexandra Whelan | Program Management Support Officer and Former Program Manager, Healthy Skin & ARF Prevention (Northern Territory)
  • Abbey Ford | SToP Trial Project Officer, Healthy Skin & ARF Prevention (Broome/Perth)
  • Marianne Mullane | SToP Trial Program Advisor and Former Program Manager, Healthy Skin & ARF Prevention (Perth)
  • Scott Winslow | Former Research Assistant, Strep A Pathogenesis and Diagnostics (Perth)
  • Megan O’Connor | Former Research Assistant, Healthy Skin & ARF Prevention (Broome)
  • Megan O'Brien | Honours Student, Healthy Skin & ARF Prevention (Perth)
  • Gelsa Cinnani | Honours Student, Healthy Skin & ARF Prevention (Perth)
  • Natasha Maginnis | Capacity Building Coordinator, Kulunga Aboriginal Unit (Perth)
  • Kristen White | Aboriginal Health Grand Challenge Program Manager, Aboriginal Health & Wellbeing (Perth)
  • Rachel Donovan | Former SToP Trial Project Officer, Healthy Skin & ARF Prevention (Broome)
  • Frieda Mc Loughlin | Former SToP Trial Project Officer, Healthy Skin & ARF Prevention (Broome)

Broome Regional Aboriginal Medical Services (BRAMS)

  • Delia Lawford | General Manager Clinical Services (Broome)
  • Neomie Dickerson | Child Health Nurse (Broome)
  • Clare Kennedy | Child Health Nurse (Broome)
  • Jayden Howard | Aboriginal Health Worker (Broome)

Derby Aboriginal Health Services (DAHS)

  • Shelley Kneebone | Chief Executive Officer (Derby)
  • Robyn Macarthur | Registered Nurse (Derby)
  • Narelle Ozies | Former Senior Manager Business Operations (Derby)
  • Jess Koenig | Former Child Health Nurse (Derby)
  • Karen Twine | Former Child Health Nurse (Derby)
  • Tatjana Menon | Former Child Health Nurse (Derby)

Catholic Education Office of WA

  • Wayne Bull | Deputy Executive Director (Perth)
  • John Nelson | Senior Research & Policy Consultant (Perth)

Publications to date

  1. Barth DD, Mullane MJ, Sampson C, Chou C, Pickering J, Nicol MP, Davies MR, Carapetis J, Bowen AC. Missing Piece Study protocol: prospective surveillance to determine the epidemiology of group A streptococcal pharyngitis and impetigo in remote Western Australia. BMJ Open. 2022 Apr 6;12(4):e057296. doi: 10.1136/bmjopen-2021-057296. Erratum in: BMJ Open. 2023 Apr 11;13(4):e057296corr1. PMID: 35387825; PMCID: PMC8987764. https://pubmed.ncbi.nlm.nih.gov/35387825/
  2. Barth DD, Cinanni G, Carapetis JR, Wyber R, Causer L, Watts C, Hengel B, Matthews S, Ralph AP, Pickering J, Cannon JW, Anderson L, Wade V, Guy RJ, Bowen AC. Roadmap to incorporating group A Streptococcus molecular point-of-care testing for remote Australia: a key activity to eliminate rheumatic heart disease. Med J Aust. 2022 Aug 28;217(6):279–82. doi: 10.5694/mja2.51692. Epub ahead of print. PMID: 36030483; PMCID: PMC9804393. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9804393/
  3. Pearce S, Bowen AC, Engel ME, de la Lande M, Barth DD. The incidence of sore throat and group A streptococcal pharyngitis in children at high risk of developing acute rheumatic fever: A systematic review and meta-analysis. PLoS One. 2020 Nov 18;15(11):e0242107. doi: 10.1371/journal.pone.0242107. PMID: 33206687; PMCID: PMC7673496. https://pubmed.ncbi.nlm.nih.gov/33206687/
  4. Pickering JL, Barth DD, Bowen AC. Performance and Practicality of a Rapid Molecular Test for the Diagnosis of Strep A Pharyngitis in a Remote Australian Setting. Am J Trop Med Hyg. 2020 Dec;103(6):2530-2532. doi: 10.4269/ajtmh.20-0341. Epub 2020 Sep 3. PMID: 32901604; PMCID: PMC7695100. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7695100/#:~:text=Molecular%20point%2Dof%2Dcare%20testing,highly%20practical%20for%20remote%20settings.
  5. Barth DD, Daw J, Xu R, Enkel S, Pickering J, McRae T, Engel ME, Carapetis J, Wyber R, Bowen AC. Modes of transmission and attack rates of group A Streptococcal infection: a protocol for a systematic review and meta-analysis. Syst Rev. 2021 Mar 31;10(1):90. doi: 10.1186/s13643-021-01641-5. PMID: 33789732; PMCID: PMC8011413. https://pubmed.ncbi.nlm.nih.gov/33789732/