Disease burden and health-care clinic attendances for young children in remote Aboriginal communities of northern Australia
Danielle B Clucas a, Kylie S Carville b, Christine Connors c, Bart J Currie d, Jonathan R Carapetis d, Ross M Andrews d
There is a disproportionate disease burden in remote Aboriginal communities compared with the general Australian population.1–5 These discrepancies begin at birth: the perinatal mortality rate for Aboriginal infants in Darwin is three times that of the non-indigenous population.6 Health problems in these communities are similar to those seen in developing-country contexts.1,7–9 Indigenous children suffer from a wide variety of diseases including some rarely, if ever, seen in the non-indigenous population since improvements in economic and living conditions led to a reduction in the burden of infectious diseases.1
Primary health care (PHC) centres, including both Aboriginal-community controlled health services and government-run clinics, are present in most remote communities in Australia. Staff numbers vary but usually include a nurse clinic manager and Aboriginal health workers. Additional clinical nursing staff members vary depending on the size of the PHC centre and are supported by either resident or visiting medical officers. Skin infections and infestations are among the most common reasons for children in these communities to present to PHC centres.10 These conditions remain a significant public-health problem in developing countries and among indigenous populations in industrialized nations. In resource-poor communities worldwide, scabies prevalence in the general population is up to 10%.11 In remote Aboriginal communities in Australia’s Northern Territory, scabies is endemic, with up to 50% of children and 25% of adults infested at some times.12,13
Secondary infection of scabies lesions is common. Group A streptococcal pyoderma is very common in Aboriginal children in the Northern Territory,14,15 with 50–70% of cases reported to be secondary to scabies.12,13 Group A streptococcal pyoderma leads to acute poststreptococcal glomerulonephritis,16,17 and underlies most cases of invasive group A streptococcal infections, especially in tropical regions.18,19 Links between scabies and high rates of acute rheumatic fever in remote Aboriginal communities in the Northern Territory have also been postulated.20 With rates of poststreptococcal disease in these communities being among the highest in the world,21,22 prevention of scabies and skin sores in this region could have far-reaching implications.
We aimed to review clinic presentations in the first few years of life within two remote Aboriginal communities of Australia to assess the level of health-care seeking behaviour in this context and to determine the burden of scabies, skin sores and other infectious diseases.
A retrospective review of clinic records was done in two PHC centres in the remote East Arnhem region of the Northern Territory, Australia. These were two of six communities participating in the East Arnhem Regional Healthy Skin Project, a regional collaboration to reduce the prevalence of scabies, skin sores and associated chronic diseases in the participating communities, located about 500 km east of Darwin.
The two communities included in the medical-record review each had a population of about 800 people. The clinics are the only PHC centres in the communities. For the purposes of the review, the study population comprised all children born after 1 January 2001, who were resident in the two communities as of 28 September 2005, for whom we had consent to review their health records (age range 0–4.75 years).
Ethics approval was obtained from The Human Research Ethics Committee of the Northern Territory Department of Health and Community Services and Menzies School of Health Research.
The record review was undertaken during October and November 2005. Data were collected for all presentations recorded in the child’s clinic file during a period of 3 years and 9 months (1 January 2002 to 30 September 2005).
Data collected were: the date of each presentation, the child’s height and weight, any infectious reason for presentation, antibiotic prescription and any referral to hospital. Recorded reasons for presentation and classifications used were the following: scabies (either noted specifically or with reference to scabies treatment given); skin sores (any mention of skin sores or other presumed bacterial infections of the skin including boils, carbuncles, abscesses, ulcers and pustules); tinea (tinea, ringworm, fungal skin infection or treatment with tinea medication); ear disease (mention of any middle-ear infection or symptoms of such an infection, including acute and chronic suppurative otitis media or otitis media with effusion); throat infection (throat or tonsils red, pink, sore, inflamed or infected or the presence of pharyngitis or laryngitis); acute poststreptococcal glomerulonephritis; acute rheumatic fever (probable or confirmed diagnosis); lower-respiratory-tract infection (presence of pneumonia, bronchitis, bronchiolitis, chest infection or crackles or a combination of symptoms suggestive of these conditions); upper-respiratory-tract infection (any mention of an upper-respiratory-tract infection, cold or flu or symptoms of an infection including cough, runny nose or blocked nose, but not including sore throat in the absence of other symptoms); diarrhoea (diarrhoea or fluid, loose or watery bowel motions recorded); and other febrile illness (temperature of > 37.5 °C or the child noted to be febrile with no temperature recorded). Multiple reasons could be recorded for each presentation.
Multiple presentations on the same day were recorded as the one presentation. Presentations with missing or incomplete dates were excluded.
Data were analysed in Stata version 9.1.23 Data were examined per child or per presentation. Continuous skewed data were expressed as medians (interquartile range) and dichotomous data as percentages. Median presentations in the first and fourth years of life are reported for children for whom data was collected for that entire year of life. Dichotomous data were compared by use of two methods: relative risk with 95% confidence intervals (CI); and generalized estimating equations.
There were 198 children in the study population. Clinic records were reviewed for 174 children (80%). In total, there were 7273 presentation records reviewed for these 174 children. The date was incomplete or missing for a further 75 presentations, which were excluded from the study. Due to the nature of the study, and the study period used, children were followed for varying lengths of time. Data were collected from birth for 126 children, and for the entire first year of life for 114 children (the remaining 12 children were aged < 1 year at the time of the record review). The study population was 55% male.
There was a median of 16 (interquartile range, IQR: 10–22) presentations per child per year over the study period. During the first year of life, the median number of presentations per child was 23 (IQR: 13.5–30). In contrast, older children presented less frequently, with those aged 3 years having a median of 5 (IQR: 3–9) presentations per child. At least one infectious condition was reported for two-thirds (65.7%) of presentations, with a median of 2 (IQR: 1–2) infection-related problems per presentation and up to 6 at a single consultation.
Upper-respiratory-tract infection was the most common reason for presentation among those specifically monitored, noted in 32% of presentations, and seen at least once in 172 (99%) children. The number of presentations for upper-respiratory-tract infections was almost equal to that for all non-infectious reasons (34%). Skin sores, scabies or both were the next most common reason for presentation, seen at 18% of presentations. Of the 174 children, 160 (92%) had at least one presentation over the study period with skin sores or scabies. The median number of presentations in the first year of life was 3 (IQR: 1–4) for scabies and 2 (IQR: 1–5) for skin sores. Other common reasons for presentation to the PHC centre were ear disease, febrile illness, diarrhoea and lower-respiratory-tract infection (Table 1).
Scabies was recorded in a higher proportion of presentations in children aged < 1 year than in those aged 1–4 years (8.8% versus 6.8%, P = 0.007), whereas skin sores were more common in the older age group (10.5% among those aged < 1 year compared with 19.0% among those aged 1–4 years, P < 0.001). Children aged < 1 year who had scabies were 6.9 (95% CI: 5.8–8.2) times more likely to have skin sores at that presentation than those without scabies. Having scabies increased the risk of skin sores by 4.4 (95% CI: 3.9–4.9) times in children aged 1–4 years.
Of the 126 children for whom data were collected from birth, 92 (73%) and 108 (86%) presented at least once with scabies and skin sores, respectively. All of these children had presented for the first time with scabies and skin sores before they reached 2 years, with the exception of one child whose first presentation with skin sores was at age 31 months. By the age of 1 year, 63% and 69% of all children (and 87% and 81% of those ever seen with the conditions) had presented with scabies and skin sores, respectively. A large peak in first presentations for both scabies and skin sores occurred at the age of 2 months (Fig. 1 and Fig. 2).
Fig. 1. Presentations for scabies in two remote communities in East Arnhemland, January 2002 to September 2005a
Fig. 2. Presentations for skin sores in two remote communities in East Arnhemland, January 2002 to September 2005a
Table 1. Reasons for presentation of children at two remote community health clinics, East Arnhemland, January 2002 to September 2005a
Access to primary health care is a critical component of a healthy start to life. However, Aboriginal children born into the two communities reviewed in our study spend substantial time in clinics in the first year of life. Some of these visits would be for well-baby checks, but with 50% of infants presenting 23 times or more in the first year of life – about twice each month – the disease burden is clearly very high. The high frequency of presentation for medical care is also a testament to the willingness of Aboriginal people to use health services and the high workload experienced by these health services. Others have shown that Aboriginal health services in other parts of the country are similarly faced with high work loads and complex health-care needs, with more problems being dealt with per consultation than in Australian general practice.24,25
Our study represents only those cases presenting for medical care, we did not review the records for 20% of the target population and were therefore unable to determine the disease burden among this group. Absence from the clinic does not mean absence of disease, and the true burden of disease may well be even higher. Given the extraordinarily high rates of clinic presentations among the study group, illness in childhood becomes the norm, and many more instances of ill health probably remain undiagnosed.
Although our study shows that children use the health services, access to specialist care is very limited. Aboriginal health workers make up 65% of health professionals working in the community-controlled sector, but often a lower proportion in government clinics.26 Very young children are accessing medical care more, and these barriers and weaknesses will therefore have a disproportionate impact on this vulnerable group.
We describe a very high burden of disease due to respiratory-tract infections, scabies and skin sores at a very young age, clearly demonstrating that skin infections or infestations are almost universal in young Aboriginal children, and one of the most common reasons for children to present to clinics in these communities.
Respiratory-tract infections are a prominent cause of hospitalizations among young Aboriginal children,27,28 and this study indicates that they also represent most of the infectious-disease burden at the PHC level. In order to ensure that hospitalization (necessitating removal of the child from their community) is minimized, there is a need for adequate treatment of children with these infections at PHC centres and early identification of patients more likely to have severe illness. Intervention to prevent respiratory-tract infections would result in a decreased workload at PHC centres. A better understanding of the causes of these infections, including the pathogens involved, is needed. Research before the introduction of the seven-valent pneumococcal vaccine in Australia showed that Aboriginal children are infected heavily with bacterial pathogens such as Streptococcus pneumoniae and Haemophilus influenzae, and that bacterial and viral coinfections are common in children with lower-respiratory-tract infections.29–31 Vaccination against bacterial pathogens alone will not reduce the burden of infections of the upper and lower respiratory tracts, viral vaccines (from respiratory syncitial virus and influenza to adenovirus and rhinovirus) are also likely to benefit these children.
Our study identified a previously undocumented burden of scabies and skin infections starting within the first few months of life. There are few longitudinal studies of scabies and many community-based studies are episodic and focus on the overall burden. While other studies also indicate that scabies is more common in young children than in older age groups,32,33 we believe this to be the first study to demonstrate the very early age at which scabies is first acquired by almost all infants in this setting. In addition to the individual burden, monitoring of scabies and skin infections among young infants may well be a useful indicator of scabies prevalence within the broader community.
The reliance on clinic data and population figures and the semi-subjective nature of a diagnosis of scabies are limitations of this study. Furthermore, clinic data might not accurately reflect the true burden of disease in a community because not all cases will present to the clinic. As such, levels reported here are likely to be an underestimate. Furthermore the diagnosis of illnesses based solely on clinic notes is problematic. Diagnoses and sufficient detail are often not recorded and classifications of diseases may thus underestimate or overestimate the actual disease burden. Data are likely to be more accurate for obvious health problems with objective signs (e.g. skin sores), but less so where diagnosis is more subjective, such as with scabies and upper-respiratory-tract infections. Nevertheless the skin-sore data reported here, and possibly the scabies data, are, if anything, likely to underestimate true levels.
Appropriate treatment of scabies in these communities is problematic. Recommended treatment of scabies in children ages < 2 months of age in these communities is with 3 days of 10% crotamiton cream,34 this is less efficacious than 5% permethrin cream, although failure rates with both crotamiton and permethrin might be higher in children under 1 year of age than in older children.35–38
Oral ivermectin has been successful in community-based treatment programmes for scabies in Papua New Guinea,39 the Solomon Islands40 and Vanuatu,41 and has been used to treat millions of adults for nematode infections.42 Although there are limited data on the safety of ivermectin in children, it is being increasingly used in children aged > 5 years for both individual therapy and in community scabies programmes. Ivermectin will probably have an increasing role in younger children as safety data accumulate. Because of their close personal contact with adults and other children, young children with scabies and skin sores can potentially spread infections to large numbers of community members. To achieve a sustainable decrease in scabies prevalence in communities, adequate treatment of these children is important.
Treating individual cases of scabies is time consuming, expensive and ineffective.43–45 A successful community-based scabies programme has been described in Panama,46 and this has been adapted and implemented in individual remote Aboriginal communities in the Northern Territory, Australia. These community based programmes involved mass treatment with 5% permethrin cream, community clean-up days, screening and education.12,43,47 A reduction in scabies from 32.3% to less than 10% was seen in children in one community and maintained for > 2 years, with incidence and severity of pyoderma also substantially decreased.12 However, in some communities initial reductions were achieved, but levels returned towards preintervention levels within 1 year.43 There is high mobility between houses and communities in this region, which is likely to result in the reintroduction of scabies. Treating communities in isolation is unlikely to produce a sustainable decrease. The East Arnhem Regional Healthy Skin Program is a regional collaboration to reduce scabies, skin sores and associated chronic diseases. An expansion of the previously mentioned programmes, it involves six communities in the region and began in 2004.
Recommendations from this work for improved control of scabies, pyoderma and other high-burden infections include syndromic treatment protocols, community child screening and treatment of cases and contacts where appropriate and a focus on regional coordinated approaches, such as the “healthy skin days”. In addition, it is crucial to continue efforts to address the underlying causes of these extremely high rates of scabies and bacterial skin infections: overcrowding, difficulties with sanitation and continuing socioeconomic disadvantage.13
The situation in these communities in remote tropical Australia is likely to be similar in other countries in the region and elsewhere where scabies remains a problem.11 In conclusion, this study found that very young children are at high risk of skin infections and especially scabies. Further research into safe and effective treatments for scabies in this age group is needed. ■
We gratefully acknowledge Lisa McHugh and Sophie La Vincente for their advice and helpful comments, Nyree O’Connor for assistance with data collection, Charmaine Hird for her help with data entry and Obioha Ukoumunne for statistical advice. Many thanks to the staff at the community health centres for their assistance and to community members for their participation in this study. The East Arnhem Regional Healthy Skin Project received funding support from the Rio Tinto Aboriginal Foundation, the Ian Potter Foundation, the Australian Government Office of Aboriginal and Torres Strait Islander Health, and the Cooperative Research Centre for Aboriginal Health.
- Thomson N. Australian Aboriginal health and health-care. Soc Sci Med 1984; 18: 939-48 doi: 10.1016/0277-9536(84)90264-8 pmid: 6740341.
- McNeilly J, Cicchini C, Oliver D, Gracey M. Infectious disease in Aboriginal infants and children in Western Australia. Med J Aust 1983; 2: 547-51 pmid: 6633391.
- Currie BJ, Brewster DR. Childhood infections in the tropical north of Australia. J Paediatr Child Health 2001; 37: 326-30 doi: 10.1046/j.1440-1754.2001.00661.x pmid: 11532049.
- Harris L, Knight J, Henderson R. Morbidity patterns in a general paediatric unit in rural Western Australia. Med J Aust 1986; 145: 441-3 pmid: 3773828.
- Gracey M, Dennison M, Burke V. Hospital admissions of Aborigines and non-Aborigines in Western Australia, 1977-1988. Trans R Soc Trop Med Hyg 1992; 86: 694-7 doi: 10.1016/0035-9203(92)90195-I pmid: 1287948.
- Matthias GS, Morgan G. Aboriginal and non-aboriginal perinatal deaths in Darwin: a comparative view. Med J Aust 1992; 156: 533-7 pmid: 1565045.
- Moodie PM. Mortality and morbidity in Australian aboriginal children. Med J Aust 1969; 1: 180-5 pmid: 5779046.
- Bartlett B. Central Australia: medical practice in Australia’s Fourth World. Med J Aust 1991; 155: 470-2 pmid: 1921817.
- Maxwell GM, Elliott RB. Nutritional state of Australian aboriginal children. Am J Clin Nutr 1969; 22: 716-24 pmid: 5789471.
- Couzos S, Currie B. Skin Infections. In: Couzos S, Murray R, eds. Aboriginal Primary Health Care, 2nd edn. Melbourne, Oxford University Press, 2003.
- Hengge UR, Currie BJ, Jager G, Lupi O, Schwartz RA. Scabies: a ubiquitous neglected skin disease. Lancet Infect Dis 2006; 6: 769-79 doi: 10.1016/S1473-3099(06)70654-5 pmid: 17123897.
- Carapetis JR, Connors C, Yarmirr D, Krause V, Currie BJ. Success of a scabies control program in an Australian aboriginal community. Pediatr Infect Dis J 1997; 16: 494-9 doi: 10.1097/00006454-199705000-00008 pmid: 9154544.
- Currie BJ, Carapetis JR. Skin infections and infestations in Aboriginal communities in northern Australia. Australas J Dermatol 2000; 41: 139-43 doi: 10.1046/j.1440-0960.2000.00417.x pmid: 10954983.
- Bessen DE, Carapetis JR, Beall B, Katz R, Hibble M, Currie BJ, et al., et al. Contrasting molecular epidemiology of group A streptococci causing tropical and nontropical infections of the skin and throat. J Infect Dis 2000; 182: 1109-16 doi: 10.1086/315842 pmid: 10979907.
- Van Buynder PG, Gaggin JA, Martin D, Pugsley D, Mathews JD. Streptococcal infection and renal disease markers in Australian aboriginal children. Med J Aust 1992; 156: 537-40 pmid: 1565046.
- Wannamaker LW. Differences between streptococcal infections of the throat and of the skin (second of two parts). N Engl J Med 1970; 282: 78-85 pmid: 4901868.
- Streeton CL, Hanna JN, Messer RD, Merianos A. An epidemic of acute post-streptococcal glomerulonephritis among aboriginal children. J Paediatr Child Health 1995; 31: 245-8 doi: 10.1111/j.1440-1754.1995.tb00795.x pmid: 7669388.
- Hanna JN, Heazlewood RJ. The epidemiology of acute rheumatic fever in Indigenous people in north Queensland. Aust N Z J Public Health 2005; 29: 313-7 doi: 10.1111/j.1467-842X.2005.tb00199.x pmid: 16222926.
- Carapetis JR, Currie BJ, Mathews JD. Cumulative incidence of rheumatic fever in an endemic region: a guide to the susceptibility of the population? Epidemiol Infect 2000; 124: 239-44 doi: 10.1017/S0950268800003514 pmid: 10813149.
- McDonald M, Currie BJ, Carapetis JR. Acute rheumatic fever: a chink in the chain that links the heart to the throat? Lancet Infect Dis 2004; 4: 240-5 doi: 10.1016/S1473-3099(04)00975-2 pmid: 15050943.
- Carapetis JR, Wolff DR, Currie BJ. Acute rheumatic fever and rheumatic heart disease in the top end of Australia’s Northern Territory. Med J Aust 1996; 164: 146-9 pmid: 8628132.
- Carapetis JR, Currie BJ. Clinical epidemiology of rheumatic fever and rheumatic heart disease in tropical Australia. Adv Exp Med Biol 1997; 418: 233-6 pmid: 9331640.
- Stata statistical software, release 9.1. College Station, TX: Stata Corporation; 2005.
- Thomas DP, Heller RF, Hunt JM. Clinical consultations in an aboriginal community-controlled health service: a comparison with general practice. Aust N Z J Public Health 1998; 22: 86-91 pmid: 9599858.
- Larkins SL, Geia LK, Panaretto KS. Consultations in general practice and at an Aboriginal community controlled health service: do they differ? Rural Remote Health 2006; 6: 560- pmid: 16863398.
- A national training and employment strategy for Aboriginal and Torres Strait Islander health workers and professionals working in Aboriginal and Torres Strait Islander health. National Health and Medical Research Council. Canberra: AGPS; 1997.
- Carville KS, Lehmann D, Hall G, Moore H, Richmond P, de Klerk N, et al., et al. Infection is the major component of the disease burden in aboriginal and non-aboriginal Australian children: a population-based study. Pediatr Infect Dis J 2007; 26: 210-6 doi: 10.1097/01.inf.0000254148.09831.7f pmid: 17484216.
- Williams P, Gracey M, Smith P. Hospitalization of aboriginal and non-aboriginal patients for respiratory tract diseases in Western Australia, 1988-1993. Int J Epidemiol 1997; 26: 797-805 doi: 10.1093/ije/26.4.797 pmid: 9279612.
- Jacoby P, Watson K, Bowman J, Taylor A, Riley TV, Smith DW, et al., et al. Modelling the co-occurrence of Streptococcus pneumoniae with other bacterial and viral pathogens in the upper respiratory tract. Vaccine 2007; 25: 2458-64 doi: 10.1016/j.vaccine.2006.09.020 pmid: 17030494.
- Torzillo P, Dixon J, Manning K, Hutton S, Gratten M, Hueston L, et al., et al. Etiology of acute lower respiratory tract infection in Central Australian Aboriginal children. Pediatr Infect Dis J 1999; 18: 714-21 doi: 10.1097/00006454-199908000-00012 pmid: 10462342.
- Watson K, Carville K, Bowman J, Jacoby P, Riley TV, Leach AJ, et al., et al. Upper respiratory tract bacterial carriage in Aboriginal and non-Aboriginal children in a semi-arid area of Western Australia. Pediatr Infect Dis J 2006; 25: 782-90 doi: 10.1097/01.inf.0000232705.49634.68 pmid: 16940834.
- Stanton B, Khanam S, Nazrul H, Nurani S, Khair T. Scabies in urban Bangladesh. J Trop Med Hyg 1987; 90: 219-26 pmid: 3669122.
- Marples MJ, Bacon DF. Observations on yaws and certain skin diseases in Manono, Western Samoa. Trans R Soc Trop Med Hyg 1953; 47: 141-7 doi: 10.1016/0035-9203(53)90067-4 pmid: 13077709.
- Skin Conditions. In: CARPA standard treatment manual, 4th edn. Alice Springs: Central Australian Rural Practitioners Association; 2003. pp. 313-21.
- Buffet M, Dupin N. Current treatments for scabies. Fundam Clin Pharmacol 2003; 17: 217-25 doi: 10.1046/j.1472-8206.2003.00173.x pmid: 12667233.
- Taplin D, Meinking TL, Chen JA, Sanchez R. Comparison of crotamiton 10% cream (Eurax) and permethrin 5% cream (Elimite) for the treatment of scabies in children. Pediatr Dermatol 1990; 7: 67-73 pmid: 2188239.
- Cubela V, Yawalkar SJ. Clinical experience with crotamiton cream and lotion in treatment of infants with scabies. Br J Clin Pract 1978; 32: 229-31 pmid: 728333.
- Amer M, Mostafa FF, Nasr AN, el-Harras M. The role of mast cells in treatment of scabies. Int J Dermatol 1995; 34: 186-9 doi: 10.1111/j.1365-4362.1995.tb01564.x pmid: 7538495.
- Bockarie MJ, Alexander ND, Kazura JW, Bockarie F, Griffin L, Alpers MP. Treatment with ivermectin reduces the high prevalence of scabies in a village in Papua New Guinea. Acta Trop 2000; 75: 127-30 doi: 10.1016/S0001-706X(99)00087-X pmid: 10708015.
- Lawrence G, Leafasia J, Sheridan J, Hills S, Wate J, Wate C, et al., et al. Control of scabies, skin sores and haematuria in children in the Solomon Islands: another role for ivermectin. Bull World Health Organ 2005; 83: 34-42 pmid: 15682247.
- Brooks PA, Grace RF. Ivermectin is better than benzyl benzoate for childhood scabies in developing countries. J Paediatr Child Health 2002; 38: 401-4 doi: 10.1046/j.1440-1754.2002.00015.x pmid: 12174005.
- Molyneux DH. Onchocerciasis control in West Africa: current status and future of onchocerciasis control programmes. Parasitol Today 1995; 11: 399-402 doi: 10.1016/0169-4758(95)80016-6.
- Wong LC, Amega B, Barker R, Connors C, Dulla ME, Ninnal A, et al., et al. Factors supporting sustainability of a community-based scabies control program. Australas J Dermatol 2002; 43: 274-7 doi: 10.1046/j.1440-0960.2002.00626.x pmid: 12423434.
- Taplin D, Rivera A, Walker JG, Roth WI, Reno D, Meinking T. A comparative trial of three treatment schedules for the eradication of scabies. J Am Acad Dermatol 1983; 9: 550-4 pmid: 6195201.
- Taplin D, Arrue C, Walker JG, Roth WI, Rivera A. Eradication of scabies with a single treatment schedule. J Am Acad Dermatol 1983; 9: 546-50 pmid: 6195200.
- Taplin D, Porcelain SL, Meinking TL, Athey RL, Chen JA, Castillero PM, et al., et al. Community control of scabies: a model based on use of permethrin cream. Lancet 1991; 337: 1016-8 doi: 10.1016/0140-6736(91)92669-S pmid: 1673175.
- Wong LC, Amega B, Connors C, Barker R, Dulla ME, Ninnal A, et al., et al. Outcome of an interventional program for scabies in an Indigenous community. Med J Aust 2001; 175: 367-70 pmid: 11700814.
- Department of Paediatrics, University of Melbourne, Melbourne, Vic., Australia.
- Murdoch Childrens Research Institute, Melbourne, Vic., Australia.
- Northern Territory Department of Health and Community Services, Darwin, NT, Australia.
- Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia.