19th April 2013, Volume 126 Number 1373

Sarah Gray, Diana Lennon, Philippa Anderson, Joanna Stewart, Elizabeth Farrell

In New Zealand many children in disadvantaged areas suffer from a high burden of disease that does not present to primary health care services.1 In Counties Manukau District Health Board (CMDHB) there are persistent barriers to accessing primary health care that undoubtedly contribute to this lack of medical input.2 The development of a primary school based, primary health care programme focussed in low decile schools is one approach that may increase access to primary health care services for children.

Nurse-led school clinics targeting rheumatic fever (RF) prevention have previously been run in South Auckland as part of a randomised controlled trial (RCT).3 These were found to be highly acceptable to the population, with high consent and retention rates and achieved a downwards trend in rate of RF, although this did not reach statistical significance. A subsequent meta-analysis of similar school and community programmes indicates a 60% reduction in rate of RF may be achievable through this type of approach.4

Re-infection from non-treated household members may have limited the effectiveness of the RCT. An Australian study found that 43% of families who had a primary case of a GAS sore throat had at least one secondary case,5 which would support this hypothesis. A child in most decile 1 schools in South Auckland has a 1 in 200 chance of developing rheumatic fever by the end of year 8.6

This pilot was undertaken to assess whether similar levels of acceptability could be achieved if the RCT clinic model was expanded to target other conditions in addition to RF and modified to try and increase both programme effectiveness and feasibility for a non-study setting.

The RCT identified a high burden of skin infections in enrolled students7 and recent research has found that skin infections are an increasing area of concern in New Zealand1,8 with the incidence of hospitalisation for serious skin infections in children almost doubling from 298.0/100,000 in 1990 to 547.3/100,000 in 2007.8 Over time there have been disproportionate increases in infection rates in Māori and Pacific children and children from highly deprived areas.1,8

Serious skin infection is the most common medical condition hospitalised in school-aged children from CMDHB. It is reasonable to expect that timely treatment of minor skin infections will prevent progression to more severe infections that require hospital based intervention therefore the prevention and treatment of skin infections was added in this pilot. Cellulitis, scabies, impetigo and infected eczema were specifically targeted.

Methods

A ‘full primary’(years 1-8), decile one school with a roll of approximately 400 and an ethnic composition of approximately two thirds Pacific and one third Māori, was chosen as the location for the pilot. The study ran for 15 weeks from April to July 2011.
In early 2011 a public health nurse (PHN) and whānau support worker (WSW), a lay worker trained in the recognition of skin infections and swabbing of sore throats, were recruited and students consented. A local General Practitioner was also identified to support the nurse with clinical queries beyond the scope of her practice.
Once the pilot commenced the WSW, working under the supervision and delegation of the PHN, visited each classroom daily to identify students that were symptomatic with a sore throat. Throat swabbing and diagnosis of GAS infection was undertaken as per the methodology used in the RCT.3 Students with skin infections were referred to the PHN for a full health assessment.
One modification to the RCT clinic model was that the choice of appropriate antibiotics for students diagnosed with GAS throat infections in the pilot was based on recommendations set out in the NZ Rheumatic Fever Guidelines.10-11 Oral amoxycillin once daily was therefore supplied by the PHN through standing orders in place of penicillin twice daily.
For skin infections medication choices were guided by specially developed evidence-based peer reviewed skin infection management guidelines. Sodium fusidate ointment was chosen as the topical treatment of choice as it is fully funded (permethrin for scabies).
Cephalexin was supplied as the first line oral antibiotic, rather than flucloxacillin, due to relative palatability of the suspension and the fact it can be taken twice daily instead of three times daily.
Standing Orders for antibiotic use by PHNs in the school were ratified by the Middlemore Hospital Medicines Advisory Committee.
Other modifications included encouraging students and families to achieve good adherence to treatment rather than directly observing antibiotic therapy. Families were educated on the importance of completing the full course of antibiotics, students incentivised with sticker charts and families supported by regular phone calls from the PHN.
Assessment and treatment of household members of cases not attending the school (including pre-schoolers) was also offered, with view to reducing rates of re-infection and improving the health of the wider whānau. Home visits were offered both for families’ convenience and with view to enabling other risks to health (such as inadequate heating, overcrowding) to be identified and addressed.
Documentation was kept such that regular audits of clinical practice could be performed, any deficits remedied and pilot evaluation be carried out. Evaluation was a combination of formative, process and impact evaluation methodology, comprising of documentation review, key informant interviews and parent questionnaires. Outcome evaluation was not attempted due to the small size of the pilot and short time for which it was in operation.
Ethical approval was obtained from the Northern Regional Ethics Committee, Ref. NTX/10/09/097.

Results

A total of 434 students were documented as enrolled at the school for all or part of the pilot duration. Of these, 400 (92.2%) were consented into the programme. Eleven students did not return consent forms and 23 (5.3%) declined to take part.

GAS sore throats—A total of 722 throat swabs were taken from students of the school. Of these 94 were positive for GAS. Two swabs were re-swabs required due to a delay in treatment onset. Therefore there were 92/720 isolated occurrences of GAS (12.8 % positive). Two symptomatic pre-schoolers were swabbed of whom one had a positive and one a negative GAS result.

Figure 1 shows the number of sore throats swabbed each week. Excluding holidays, the mean number of throat swabs taken per week was 55.4 swabs. The average number of GAS positive swabs per week was 7.1 swabs.

Medication was provided by the PHN in 85/92 cases. The remaining seven students choose to seek medical treatment from their family GP. Sixty-nine of the 81 cases for whom self-reported antibiotic adherence was documented had ‘good’ adherence (full course completed), ten ‘intermediate’ (one dose missed or delayed) and two ‘poor’ (two or more doses missed).

A total of 337 students (84% of those consented) had at least one swab. The number of times each student was swabbed ranged from zero to eight with most students swabbed just once. Eleven students had two GAS positive swabs during the 15 week pilot.

Figure 1. Number of *Group A streptococcal positive, **”positive other” and negative swabs each week

Gray-1

* re-swabs excluded.
**’positive other’ comprises Group G and Group C streptococcal infections (not treated).
***weeks 3 and 4 were the school holidays.

Skin infections—In total, 98 episodes of skin conditions in students were referred to the PHN. In 76 of these a skin infection was diagnosed. The most common infection seen was impetigo (n=46). The most common ‘other’ skin infection diagnosed was infected insect bites (n=6).

Of the 22 students who did not have a skin infection, 10 had non-infected eczema and 10 had other non-infective skin conditions. Two students were considered to be completely well.

Table 1 shows the complete list of skin condition diagnoses made by the PHN.

Table 1: Skin conditions seen and assessed in the Pilot
Skin infections assessed and diagnosed
Diagnosis
Number of students
Impetigo
46
Infected Eczema
4
Scabies
10
Cellulitis
3
Infected insect bites
6
Infected scratch or graze
3
Infected foreign body / suture line
2
Boil
1
Cold sore
1
Other skin infection not specified
3
Total skin infections
79*
Other non-infected skin conditions assessed and diagnosed
Diagnosis
Number of Students
Eczema – non-infected
10
Insect bites – non infected
3
Grazes – non infected
3
Rash
2
Blister
1
Warts
1
None
2
Total non-infected skin conditions
22
*Three students had more than one skin infection diagnosed at a single assessment
Two pre-schoolers were diagnosed and treated by the PHN for impetigo.

The number of weekly skin assessments ranged from a high of 40 in week 1 to a low of two in week 11 (Figure 2) (holidays excluded).

Figure 2: Number of skin infections and non-infected skin conditions diagnosed each week

Gray-2

*Weeks 3 and 4 were the school holidays

The PHN supplied medication for skin infections to 56 students. Forty-five topical treatments were supplied (sodium fusidate 2% ointment or permethrin) and 16 courses of oral antibiotics (cephalexin). Five students required more than one medication. Twenty-four students were treated by their GP, either prior to self-reporting their skin infection to the WSW (n=6) or after (n=18). Three students with impetigo failed to respond to initial topical treatment and required transition to oral antibiotics.

A total of 83 students had a skin condition assessment (21% of those consented). Fourteen students were assessed twice or more of which 10/14 were diagnosed with two separate skin infections, 1/14 had three separate infections and 3/14 were diagnosed with one infection and one non-infective skin condition. Three students had multiple skin infections diagnosed at one assessment.

Other conditions—A total of 59/81 students with GAS throat infection and all 83 students assessed for a skin infection had their notes reviewed at the end of the pilot. Of these 142 students the pilot staff identified ten students with vision concerns and six with hearing concerns requiring referral to the school’s usual PHN or an optometrist.

Costs—Extrapolating pilot costs results in an estimated annual cost of $510 per student comprising $10 for consumables, $80 for diagnostic services and $420 for staffing costs.

Workload—The total number of phone calls and home visits made during the pilot were 539 and 137 respectively with an additional 51 parent consultations held at school. The highest numbers of phone calls and home visits made per week were 64 and 21 respectively. The highest number of parent consultations held at school was eight in any 1 week.

Qualitative findings—The key informants were universally supportive of the concept of the programme. Increasing the health knowledge and health literacy of all members of the school community was seen to be one of the most essential aspects of the programme, particularly by the school principal who observed that “the potential value in the clinic is immeasurable”.

Provision of free antibiotics by the PHN working under standing orders was also perceived to be a key element. It was universally felt to be both time saving to staff and empowering to families to encourage students and families to maintain good antibiotic adherence compared with directly observing therapy. The nursing team felt that this modification was useful for their professional development and provided them with a valuable opportunity to see the patient journey through from beginning to end. The relationship with primary care was seen as an area that needed strengthening.

Offering assessments to household members required intensive effort to organise and provide. Siblings were generally reported as asymptomatic or were unavailable for assessment even if home visits were undertaken. Many phone calls to families were made in the evenings and at weekends as these were the only times some parents could be contacted. The WSW’s familiarity with Samoan culture and language was found to be invaluable for this particular school community and especially important for home visits.

The opportunity to identify and address underlying housing related risk factors to health was not addressed during this pilot due to workload capacity issues but several key informants felt this modification could add much value from a public health perspective and that even if difficult to undertake the inclusion of this strategy should not be compromised because of cost or other such considerations.

Programme effectiveness was not formally assessed because of the small numbers involved in the study but the school principal considered there were fewer skin infections amongst the school students in term two 2011 compared with term two 2010. During the pilot a student at the school was diagnosed with acute rheumatic fever (ARF). This student did not report any sore throat symptoms at school prior to their presentation with ARF symptoms and was therefore not throat swabbed in the programme prior to their ARF diagnosis. The working group reviewed the clinical records and found that pilot protocols had been fully adhered to in relation to this student but that this occurrence of ARF highlighted complexities of managing students who become unwell when absent from the school setting due to sickness or holidays.

A total of 37 parent questionnaires (approximately 14%) were returned to school. Of these 34 responded that they feel it is useful to have a PHN and WSW at school to treat children with sore throats and skin infections (two were ‘unsure’ and one replied ‘no’). The other overall themes in the responses were that parents liked the fact that the programme was free and convenient and that their children were seen in a timely fashion. Nearly half of the parent respondents indicated that they had learnt something new about sore throats or skin infections during the pilot.

Discussion

The pilot uncovered a high level of unmet health need amongst students, demonstrating the importance of a programme such as this for the child population in CMDHB. A total of 92 GAS sore throats in just 15 weeks and 31 skin infections in the first week of the pilot represent a significant workload and burden of disease in a school of approximately 400 students.

Notable also are the students identified with hearing and vision concerns who had not been referred to the routine PHN service. The average numbers of swabs taken and GAS positive 5 per week per student are consistent with those of the RCT.3 It is therefore likely that other decile one schools in South Auckland would have similar health need.

The evaluation findings show that this programme is highly acceptable to the majority of key stakeholders. Importantly the school principal’s feedback was very positive. The high consent rate and positive comments obtained from parent questionnaires also indicate that the programme is likely generally acceptable to parents/caregivers although non response bias limits the validity of this finding. A significant proportion of parents chose to take their children to the GP for treatment of skin infections. It may be useful to further explore the reasons underlying this tendency.

It is likely to be feasible to take this model of delivering targeted primary health care to primary school aged children and use it on a larger scale. The programme will need to be well resourced if quality is not to be compromised. Workload is a key issue for programme expansion.

Data collection was seen as time consuming. Providing a lap top computer to enable data to be entered on site at the school and during home visits could potentially resolve this if security issues can be addressed. It will be important to liaise early with diagnostic services to ensure that they have the capacity to manage the volume of throat swabs anticipated.

Although encouraging students and families to take responsibility for achieving good antibiotic adherence appeared acceptable and self-reported levels of antibiotic adherence were high, post treatment swabs were not performed so adherence to medication could not be measured objectively. It is unclear whether a proportion of the 11 recurrent GAS infections were attributable to poor adherence to treatment rather than being true re-infections and this may need to be investigated further. Swabbing all household members (rather than just symptomatic ones) may be a consideration in regions such as this where RF is endemic.

During the pilot the PHN was unable to incorporate housing related health risk identification into her list of responsibilities due to workload capacity. Greater resourcing of the programme may be required to achieve this modification. The small numbers of household members being swabbed for sore throats and assessed for skin infections was disappointing. The reasons for this should be explored so that the full potential of this strategy can be realised.

The main strength of this approach is that it provides access to primary health care for certain targeted conditions of concern to children for whom there are well documented barriers to accessing primary health care at a population level. A focus on high risk low decile schools has the potential to reduce both the socioeconomic and ethnic disparities apparent in the child hospitalisation rates for the targeted conditions.

Additionally the incidence of rare sequalae such as post streptococcal acute glomerulo-nephritis and bone and joint disease may be reduced. While this pilot programme only included RF prevention and the identification and treatment of skin infections, it is likely that other health needs could be addressed through this model. Currently the feasibility of adding in injury prevention is being explored.

This pilot showed that school based clinics can deliver health care to children in a timely fashion, (particularly essential for infectious conditions) in a way that is convenient for them, and makes good use of frontline staff. The use of WSWs provides the dual benefits of assisting workforce development as well as strengthening cultural acceptability of the programme.

The ARF case highlighted the fact that it is possible, with a school-based programme, to miss students who become unwell during the holidays or who are absent from school for a prolonged period of time for any reason. Clear processes to cover holidays and to identify and follow up absent students need to be integral components of a school-based service. Involvement with GPs and PHOs is essential as this type of programme should be done in partnership with primary care services and not as a stand-alone initiative.

A wider roll out should be instigated with evaluation in mind so that the effectiveness and clinical safety of the programme can be assessed and monitored and the programme further modified as needs require. If multiple similar programmes are set up in New Zealand these should be standardised such that the results of all programmes can be combined to increase the statistical power to demonstrate any change in rates of rheumatic fever, hospitalisation of skin infections or other designated outcomes.

Summary

Rates of rheumatic fever and of hospitalisations for serious skin infections are high amongst New Zealand children. These conditions can lead to significant long-term sequalae if left undiagnosed and untreated but are potentially preventable. This paper looks at how acceptable and feasible it is for nurses to run clinics in low decile primary schools to diagnose and treat children with skin infections and streptococcal sore throats. This approach has the potential to reduce the number of children hospitalised for skin infections and to reduce the number of children developing rheumatic fever if it is run out on a larger scale.

Abstract

Aim

To assess the acceptability and feasibility of delivering targeted primary health care in a decile one primary school setting.

Method

A pilot public health nurse (PHN)-led clinic was set up in a South Auckland primary school (roll ~ 400). The clinic was based on a previous sore throat clinic model with modifications aimed at improving programme feasibility and effectiveness. The timely identification and treatment of Group A Streptococcal (GAS) throat infections to prevent rheumatic fever (RF), and the prevention and treatment of four skin infections (cellulitis, impetigo, infected eczema and scabies) were the focus. The pilot ran for 15 weeks from April to July 2011. Evaluation included documentation review, key school and healthcare stakeholder interviews and parent questionnaires.

Results

The consent rate was 92.2%. Of a total 722 throat swabs taken from 337 students, 94 were GAS positive. Ninety-eight assessments of skin conditions were completed at which 76 had a skin infection diagnosed, the most common infection being impetigo (n=46). Thirty-one skin infections were diagnosed in the first week of the pilot. PHN workload was high with a total of 539 phone calls, 137 home visits and 51 school-based parent consultations. The approach was highly acceptable to the majority of key stakeholders. Extrapolating pilot costs results in an estimated annual cost of $510 per student for the programme.

Conclusion

It is likely to be both acceptable and feasible to take this model of delivering targeted primary health care to school aged children and use it on a larger scale. The complexity of providing this type of service should not be underestimated and it is essential that robust processes are in place to ensure smooth, safe running of such a programme. Long-term outcome evaluation will be vital to assess programme effectiveness.

Author Information

Sarah Gray, Public Health Medicine Registrar, Public Health Team, Counties Manukau District Health Board, Auckland; Diana Lennon, Professor of Population Health of Children & Youth, Principal Investigator, Faculty of Medical and Health Sciences, The University of Auckland; Philippa Anderson, Public Health Physician, Public Health Team, Counties Manukau District Health Board, Auckland; Joanna Stewart, Biostatistician, Faculty of Medical and Health Sciences, The University of Auckland; Elizabeth Farrell RGOM MHSc, Clinical Charge Nurse, Kidz First Public Health Nursing, Counties Manukau District Health Board, Auckland

Acknowledgements

The study was jointly funded by a Health Research Council of New Zealand feasibility study grant and Counties Manukau District Health Board.

Correspondence

Diana Lennon, Professor of Population Child & Youth Health/Paediatrician in Infectious Diseases, Community Paediatrics, Department of Paediatrics: Child & Youth Health, The University of Auckland, Tamaki Campus, School of Population Health, Private Bag 92019, Auckland, 1142, New Zealand. Fax: +64 (0)9 3035932

Correspondence Email

d.lennon@auckland.ac.nz

Competing Interests

Nil.

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