Development of Miwatj Strongyloides

Clinical Audit Tool

Wendy Page MBBS, FRACGP, FACRRM, MPH&TM

Miwatj Health Aboriginal Corporation

PhD candidate

James Cook University

Late Emeritus Prof. Rick Speare

Overview• Aim –Using IT recall systems to evaluate and monitor current

implementation of chronic strongyloidiasis control program in endemicarea.

• Background

– Locations for endemic communities

– Understanding the lifecycle and what makes strongyloidiasis different

– Primary Health care intervention – opportunistic testing (serology, treatment and follow-up)

• Clinical audit tool to monitor and evaluate primary health care intervention (MSPI)

1. What number and proportion of Indigenous current resident clients aged 15years and over have been tested for strongyloidiasis?

2. What number and proportion of clients who have been tested have tested positive on their last test?

• Results– preliminary

• Outcomes

Conway D.J., Lindo J.F., Robinson R.D., Bundy D.A.P. Towards Effective Control of Strongyloidiasis. Parasitology Today 11 (11) 1995

“Despite widespread recognition of the clinical consequences of infection, control of infection in endemic communities has rarely been

attempted”.

New advances enable effective control

- diagnosis, treatment, short life span of parasite in environment

Significance

Life Cycle Strongyloides stercoralis April 2015

Strongyloides serology declines to

negative with effective treatment.

0.5

1

1.5

2

200 400 600 800 1000 1200

Ivermectin

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1.5

20

0

40

0

60

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80

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1000 1200

Single dose Albendazole

Days

Single dose Albendazole

0.5

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1.5

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200

400 600 800

1000 1200

S ingle dose A lbendazole

Days

I verm ect in

S ingle dose

A lbendazole

S ingle dose

A lbendazole

S ingle dose

A lbendazole

3 doses of Albendazole

Page, W. A., Dempsey, K., & McCarthy, J. S. (2006). Utility of serological follow-up of chronic strongyloidiasis after anthelminthic chemotherapy. Transactions of the Royal Society of Tropical Medicine and Hygiene, 100(11), 1056-1062.

Taylor, Hugh R. Stemming the tide of River Blindness: the early years of ivermectin.

Med J Aust. 2003;179(11-12): 617-619. • “In 1978, a Japanese scientist collected a fungus species that was to

revolutionise the treatment of onchocerciasis from beside a golf course in Kawano, Japan – I have been told it was from beside the fifth fairway. This fungus made a compound that was called in the lab MK 933. Later it was called ivermectin. It was not good as an antibiotic, but it was a very potent killer of parasites.”

• “.. One of the most significant breakthroughs in tropical medicine in the past 25 years.”

• 2015 Nobel Prize for medicine (Shared) – Satoshi Omura & William C. Campbell

• Ivermectin is currently the most effective treatment for strongyloidiasis – however dosing regimen to eradicate strongyloidiasis varies for individuals and

requires further study

– a national register for strongyloidiasis is recommended

Aim of ATSI AdultHealth Check

The aim of the MBS health assessment is to help ensure that ATSI people receive primary health care matched to their needs, by encouraging early detection, diagnosis and intervention for common and treatable conditions that cause morbidity and early mortality.

Registration at Clinic

Investigation request

Serology result

Indigenous Adult Health Assessment1-2 yearly

NTAHKPINumber & % AHC completed in last2 years

Number & % tested

Sero positiveSero negativeNumber & % positiveSero positive

Recall for Rx

Record treatment & dosage & date

Recall for 2nd Rx

Record treatment & dosage & date

Sero neg

Miwatj Strongyloidiasis Register

Record sero result

Seropositivefollow-up

Overview

Q 1

Q 2

Q 4

Q 3

Recall for follow-up serology 6 months

Strongyloides serology included in Indigenous Adult Health Check

Recall for strongyloidiasis treatment

Recall for Strongyloidiasis Follow-up6months after 2nd Treatment

Clinical Audit tool to evaluate and monitor: Miwatj Strongyloidiasis Performance Indicator

(MSPI)• 1. What number and proportion of current

resident Indigenous clients aged 15 years and over have been tested for strongyloidiasis?

• 2. What number and proportion of those clients who have been tested, have tested positive on their last strongyloides serology test?

Communicare Working listMiwatj Strongyloides PI

• Names and number of positives and latest serology result and date of last test

– Who needs follow up – Needs treatment--* priority

– Needs follow up after treatment

• Names and numbers of negatives

– No action required

• Names and numbers of not tested

– Check if current patients- update address

Strongyloides report

Clinic 1 @ 30/6/15

Not tested

Positive

Negative

Strongyloides report

Clinic 1 30/9/16

Not tested

Positive

Negative

Clinic 1 30/6/15

Not tested

Positive

Negative

Proportion of Indigenous resident clients aged 15yo and over who have been tested since 1/7/2012

Proportion of those tested who were positive on last serology test.

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Pe

rce

nta

ge

31/12/2012 30/06/2013 31/12/2013 30/06/2014 31/12/2014 30/06/2015 31/12/2015 30/06/2016 30/09/2016

Tested/Total 39 68 75 75 78 78 84 84 84

Pos/Tested 73 70 51 40 30 29 28 24 19

MSPI Community 1

Strongyloides PIClinic 3 30/6/15

Not tested

Positive

Negative

Clinic 3 30/9/16

Not tested

Positive

Negative

Proportion of Indigenous resident clients aged 15yo and over who have been tested since 1/7/2012

Proportion of those tested who were positive on last serology test.

0

10

20

30

40

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60

70

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Pe

rce

nta

ge

6/30/14 12/31/14 6/30/15 12/31/15 6/30/16 9/30/16

Tested/Total 7 8 19 36 47 50

Pos/Tested 59 45 39 36 29 25

MSPI Community 3

Community Clinic 1Reflection on last serology result

• Outcomes of 80 positive cases since 1/7/2012

• 64% (51)declined to negative

• 25% (20) need treatment completion (5% (10)known to be currently away)

• 10% (8)waiting follow up after treatment (5% known to be currently away)

• 1% (1)recurrence/reinfection

Limitations of Study

• Adults 15 years and over• MSPI positives does not identify who has already

been treated and waiting 6 month follow up –need additional report for feedback to clinicians (Continuous Quality Improvement)

• Turnover of clinical staff need awareness of strongyloides protocol

• Follow up serology is opportunistic –needs to be a sustainable system that works in the real world

• More than one treatment may be required

Impact and Outcome Measures• Change in health provider behaviour

o Number and proportion of current resident adults aged 15 years and over who have been tested for strongyloidiasis (Change in proportion tested = Impact evaluation)

• Change in population being measured

o Number and proportion of current resident adults aged 15 years and over who have tested positive for strongyloidiasis on last test (Prevalence= Outcome evaluation)

Conclusions

• Early evidence from MSPI that opportunistic serology testing, treatment and follow up serology program can decrease rates of chronic strongyloidiasis in an endemic community

• Provides evidence to support NTAHKPI for strongyloidiasis for endemic communities

• Recommend incorporating into existing primary health care program in endemic communities

Acknowledgements

• Miwatj Health Aboriginal Corporation- board, staff, community members

• JCU Advisers- Late Emeritus Prof Rick Speare, David MacLaren, Prof Jeni Judd

• JCU PhD Cohort Group

• Communicare systems – Steve White

• National Strongyloides Working Group-– late Frank O’Donohoo

• AMSANT CQI collaborative –Kerry & Louise

• CRG NTAHKPI- Liz Moore

Contain the worm