A Regional Initiative to Reduce Skin Infections amongst Aboriginal Children Living in Remote Communities of the Northern Territory, Australia Ross M. Andrews 1 *, Therese Kearns 1 , Christine Connors 2 , Colin Parker 3 , Kylie Carville 4 , Bart J. Currie 1 , Jonathan R. Carapetis 1 1 Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia, 2 Northern Territory Department of Health and Families, Darwin, Northern Territory, Australia, 3 Australasian College of Dermatologists, Boronia Park, New South Wales, Australia, 4 Murdoch Childrens Research Institute, Melbourne, Victoria, Australia Abstract Background: Linked to extreme rates of chronic heart and kidney disease, pyoderma is endemic amongst Aboriginal children in Australia’s Northern Territory (NT). Many of those with pyoderma will also have scabies. We report the results of a community-based collaboration within the East Arnhem Region, which aimed to reduce the prevalence of both skin infections in Aboriginal children. Methodology/Principal Findings: Commencing September 2004, we conducted an ecological study that included active surveillance for skin infections amongst children aged ,15 years in five remote East Arnhem communities over a three year period. Screening was undertaken by trained local community workers, usually accompanied by another project team member, using a standard data collection form. Skin infections were diagnosed clinically with the aid of a pictorial flip chart developed for the purpose. Topical 5% permethrin was provided for age-eligible children and all household contacts whenever scabies was diagnosed, whilst those with pyoderma were referred to the clinic for treatment in accordance with current guidelines. In addition, annual mass scabies treatment (5% permethrin cream) was offered to all community residents in accordance with current guidelines but was not directly observed. Pyoderma and scabies prevalence per month was determined from 6038 skin assessments conducted on 2329 children. Pyoderma prevalence dropped from 46.7% at baseline to a median of 32.4% (IQR 28.9%–41.0%) during the follow-up period – an absolute reduction of 14.7% (IQR 4.7%–16.8%). Compared to the first 18 months of observation, there was an absolute reduction in pyoderma prevalence of 18 cases per 100 children (95%CI 221.0, 216.1, p#0.001) over the last 18 months. Treatment uptake increased over the same period (absolute difference 13.4%, 95%CI 3.3, 23.6). While scabies prevalence was unchanged, the prevalence of infected scabies (that is with superimposed pyoderma) decreased from 3.7% (95%CI 2.4, 4.9) to 1.5% (95%CI 0.7, 2.2), a relative reduction of 59%. Conclusion: Although pyoderma prevalence remained unacceptably high, there was a substantial reduction overall with improvements in treatment uptake a critical factor. More acceptable alternatives, such as cotrimoxazole for pyoderma and ivermectin as a community-wide scabicide, warrant further investigation in these settings. We are encouraged by progress made through this work, where local action was led by local community members and primary health care providers with external training and support. Trial Registration: ClinicalTrials.gov NCT00884728 Citation: Andrews RM, Kearns T, Connors C, Parker C, Carville K, et al. (2009) A Regional Initiative to Reduce Skin Infections amongst Aboriginal Children Living in Remote Communities of the Northern Territory, Australia. PLoS Negl Trop Dis 3(11): e554. doi:10.1371/journal.pntd.0000554 Editor: Edward T. Ryan, Massachusetts General Hospital, United States of America Received April 20, 2009; Accepted October 19, 2009; Published November 24, 2009 Copyright: ß 2009 Andrews et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: 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. The Australasian College of Dermatologists received funding support from the Commonwealth Government Department of Health and Aging. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: The authors have declared that no competing interests exist. * E-mail: ross.andrews@menzies.edu.au Introduction Pyoderma is a generic term used to describe a clinical diagnosis of superficial bacterial skin infection [1]. Also known as skin sores or impetigo, it has been estimated that there are in excess of 111 million children with pyoderma worldwide and that many of these children will also have scabies [1]. Reported pyoderma prevalence has varied, but children living in Australian Aboriginal communities and those living in the Pacific region have generally had the highest burden, often in the range of 40–90% [2]. A recent study from Fiji [3], reported pyoderma prevalence of 25% amongst primary school children and 12% amongst infants. Like previous studies in remote Australian Aboriginal communities [4,5], the Fijian study www.plosntds.org 1 November 2009 | Volume 3 | Issue 11 | e554