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

Investigators: 

Principal Investigator:

• Professor Asha Bowen | Head, END RHD Research Program and Healthy Skin & ARF Prevention, Telethon Kids Institute (Perth)

Co-Investigators:

• Dr Janessa Pickering | Senior Research Officer, Strep A Pathogenesis and Diagnostics, Telethon Kids Institute (Perth)
• Rebecca Famlonga | Senior Research Officer, Healthy Skin & ARF Prevention, Telethon Kids Institute (Broome)
• Dr Dylan Barth | Honorary Research Associate, Healthy Skin & ARF Prevention, Telethon Kids Institute (Perth)
• Professor David Atkinson | 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, Telethon Kids Institute; 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 TKI’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)