Prevalence of scabies and impetigo worldwide: a systematic review

Protocol for a cluster-randomised non-inferiority trial of one versus two doses of ivermectin for the control of scabies using a mass drug administration strategy (the RISE study)

INTRODUCTION

Scabies is a significant contributor to global morbidity, affecting approximately 200 million people at any time. Scabies is endemic in many resource-limited tropical settings. Bacterial skin infection (impetigo) frequently complicates scabies infestation in these settings. Community-wide ivermectin-based mass drug administration (MDA) is an effective control strategy for scabies in island settings, with a single round of MDA reducing population prevalence by around 90%. However, current two-dose regimens present a number of barriers to programmatic MDA implementation. We designed the Regimens of Ivermectin for Scabies Elimination (RISE) trial to investigate whether one-dose MDA may be as effective as two-dose MDA in controlling scabies in high-prevalence settings.

METHODS AND ANALYSIS

RISE is a cluster-randomised non-inferiority trial. The study will be conducted in 20 isolated villages in Western Province of Solomon Islands where population prevalence of scabies is approximately 20%. Villages will be randomly allocated to receive either one dose or two doses of ivermectin-based MDA in a 1:1 ratio. The primary objective of the study is to determine if ivermectin-based MDA with one dose is as effective as MDA with two doses in reducing the prevalence of scabies after 12 months. Secondary objectives include the effect of ivermectin-based MDA on impetigo prevalence after 12 and 24 months, the prevalence of scabies at 24 months after the intervention, the impact on presentation to health facilities with scabies and impetigo, and the safety of one-dose and two-dose MDA.

ETHICS AND DISSEMINATION

This trial has been approved by the ethics review committees of the Solomon Islands and the Royal Children's Hospital, Australia. Results will be disseminated in peer-reviewed publications and in meetings with the Solomon Islands Ministry of Health and Medical Services and participating communities.

TRIAL REGISTRATION DETAILS

Australian New Zealand Clinical Trials Registry: ACTRN12618001086257. Date registered: 28 June 2018.

Scabies and Pediculosis in Penitentiary Institutions in Poland-A Study of Ectoparasitoses in Confinement Conditions

BACKGROUND

Scabies (caused by Sarcoptes scabiei var. hominis) and pediculosis (caused by Pediculus humanus) are infectious diseases common in educational institutions and long-term care centres. The aim of the study was to assess the scale of the phenomenon in confinement conditions favouring the spread of these parasitoses.

METHODS

Data on the prevalence of scabies (2001-2015) and pediculosis (2008-2015) in Polish prisoners were provided by the Central Board of Prison Service. The information for the period between 2010 and 2015 in the Lublin Province was obtained from the District Inspectorate of the Prison Service in Lublin. Correlations between the prevalence of scabies and pediculosis and the number of prisoners were analysed, as well as correlations between the number of passes granted to prisoners and the prevalence of scabies and pediculosis in incarcerated individuals.

RESULTS

The prevalence of scabies and pediculosis in Polish prisoners has been estimated at 2.3% and 1.9%, respectively.

CONCLUSIONS

Pediculosis and scabies are still current issues in Polish prisons. Convicts returning from passes and new prisoners should be carefully examined and monitored for the presence of S. scabiei var. hominis and P. humanus invasion. Education of prisoners could be a promising tool in prevention of scabies and pediculosis in correctional settings.

Estimating the global burden of scabies: what else do we need?

Scabies is one of the most common disorders identified in any estimate of global skin disease prevalence. Furthermore, quantifying its impact on individuals and societies has been problematic. There has been a lack of clear case definitions and laboratory tests. There have been few epidemiological studies, particularly those focusing on low-income countries, variation in prevalence within high-income countries, or estimates of the effect of scabies on health beyond the skin, such as renal disease or mental wellbeing. Economic studies are also lacking. However, the new strategy of integrating surveillance for skin Neglected Tropical Diseases may well produce advancements on these issues, in addition to providing an overarching structure for health improvement and disease control.

Increase of scabies infestations, Norway, 2006 to 2018

Between October and December 2018, several clinicians in Norway reported an increase in scabies diagnoses. We compared data from the Norwegian Syndromic Surveillance System on medical consultations for mite infestations with scabies treatment sales data to investigate this reported increase. From 2013 to 2018, consultations and sales of scabies treatments had almost increased by threefold, particularly affecting young adults 15–29 years. We recommend to increase awareness among clinicians to ensure timely diagnosis and treatment.

Scabies: A comprehensive review and current perspectives

Human scabies is a contagious skin infestation caused by the parasitic mite Sarcoptes scabiei var. hominis. It is a common skin disease worldwide that occurs not only in the underprivileged sections of society but also in developed countries. In 2009, World Health Organization (WHO) recognized scabies as "neglected tropical disease (NTD)" or NTD thus emphasizing the need for community awareness and proper treatment strategies. This review attempts to summarize the varied clinical presentation of the disease and describes the advances in diagnosis and management including the ongoing search for novel agents to overcome the problems associated with conventional treatments. The literature research includes peer-reviewed articles (clinical trials or scientific reviews). Studies were identified by searching electronic databases (MEDLINE and PubMed) till February 2020 and reference lists of respective articles. Only articles published in English language were included.

A randomized controlled trial comparing the effectiveness of individual versus household treatment for Scabies in Lambaréné, Gabon

Background

It is unclear whether individual treatment of scabies is similarly effective compared to household treatment. This study compared these two treatment strategies with topical benzyl benzoate for treating scabies in Lambaréné, Gabon.

Methods

Participants presenting with uncomplicated scabies were randomized into either the Individual Treatment group, where only the affected participants received treatment, or the Household Treatment group, where all family members were treated in parallel to the affected participants regardless of signs and symptoms. The primary endpoint was clinical cure after 28 days; the secondary endpoint was the proportion of affected household members per household after 28 days.

Results

After 28 days, from a total of 79 participants assessed, 67% (n = 53) were clinically cured; 59% (20/34) in the Individual Treatment group and 73% (33/45) in the Household Treatment group. Participants in the Household Treatment group had about twice the odds of being cured (odds ratio 1.9, 95% confidence interval: 0.8–4.9; p = 0.17). For the secondary outcome, an effect of similar size was observed.

Conclusions

Our findings show that treating close contacts of persons affected by scabies may be beneficial to patients and contacts, however, the benefit was less pronounced than anticipated and further research is needed to definitively answer this question.

Scabies is a skin disease caused by parasitic mites that burrow into the skin and cause itchiness and rash. Since these mites can be easily transmitted from person to person the disease is highly contagious. Many guidelines on the treatment of scabies recommend that all family members and close contacts of persons suffering from scabies should be treated alongside the affected person, in order to prevent the disease from spreading. However, there is only little evidence to be found in the medical literature on how well this practice works. We conducted a study in Lambaréné, Gabon and surrounding villages, where many cases of scabies occurred at the time, to answer this question. We found that, on average, those patients whose entire family was treated were more likely to be cured after 4 weeks, and that fewer of their family members were affected. However, the difference to patients whose families weren’t treated was smaller than expected, suggesting that larger studies are needed to definitively answer the question.

Overdiagnosis of scabies and overprescribing of scabies treatment in a scabies-endemic region

OBJECTIVE

To assess the objective evidence upon which diagnosis of scabies and subsequent prescription of permethrin cream or oral ivermectin is based at a tertiary referral hospital in the Northern Territory.

DESIGN, SETTING AND PARTICIPANTS

A retrospective cohort study of inpatients who were prescribed permethrin or ivermectin between July and September 2017 at a single tertiary referral hospital. Eighty-eight inpatient admissions, belonging to 77 unique patients, were included. This list was generated with the hospital's electronic prescribing software.

MAIN OUTCOME MEASURES

Age, ethnicity, skin diagnosis on admission, which anti-scabies medications were prescribed, which concurrent medications were prescribed to treat a rash or pruritus, which differential or concurrent skin diagnoses were made, whether the dermatology department had seen the patient during their admission, and what evidence was documented as reason for diagnosis of scabies.

RESULTS

In the cases in which scabies treatment was prescribed, less than one quarter had positive skin scrapings for scabies, and few had documentation of burrows, and documentation of a contact history combined with clinical lesions. Most cases met none of these diagnostic criteria. Very few were reviewed by the dermatology department as an inpatient.

CONCLUSIONS

There were likely high rates of diagnostic uncertainty among the cases in which scabies treatment was prescribed. It is possible that anti-scabies medications are being prescribed empirically in this hospital.

A cross-sectional study of dermatological conditions in rural and urban Timor-Leste

BACKGROUND

There is limited information about the type of skin disease in Timor-Leste. In order to determine the type and magnitude of skin disease in Timor-Leste, we conducted a cross-sectional point prevalence study of 271 patients from rural and urban Timor-Leste. The aim of the study was to estimate the magnitude and burden of dermatological disease.

METHODS

Two Australian-trained dermatologists conducted clinics in the city of Dili (urban) and village of Manusae (rural) in Timor-Leste between the period of June and July 2016. They independently recorded all patient presentations and diagnoses.

RESULTS

A total of 271 patients were reviewed over two months, of whom 37% were seen in an urban setting and 63% in a rural setting. Scabies accounted for 96% of all presentations in the rural setting, which was significantly higher than its presentation in the urban setting (8%), P < 0.001. Scabies also accounted for the majority of presentations in the paediatric population aged 10 years or younger. Fungal and bacterial skin and soft tissue infections were both more common in urban areas (P < 0.001).

CONCLUSIONS

Scabies infection remains the most prevalent dermatological condition encountered in the Timor-Leste rural population and has hopefully been addressed by a recent mass drug administration. It is important to raise awareness of the systemic problems that can arise from untreated skin infections.

Human microbiome: an academic update on human body site specific surveillance and its possible role

Human body is inhabited by vast number of microorganisms which form a complex ecological community and influence the human physiology, in the aspect of both health and diseases. These microbes show a relationship with the human immune system based on coevolution and, therefore, have a tremendous potential to contribute to the metabolic function, protection against the pathogen and in providing nutrients and energy. However, of these microbes, many carry out some functions that play a crucial role in the host physiology and may even cause diseases. The introduction of new molecular technologies such as transcriptomics, metagenomics and metabolomics has contributed to the upliftment on the findings of the microbiome linked to the humans in the recent past. These rapidly developing technologies are boosting our capacity to understand about the human body-associated microbiome and its association with the human health. The highlights of this review are inclusion of how to derive microbiome data and the interaction between human and associated microbiome to provide an insight on the role played by the microbiome in biological processes of the human body as well as the development of major human diseases.

Prevalence and associated factors of scabies in Ethiopia: systematic review and Meta-analysis

BACKGROUND

Scabies is an infectious disease that affects the skin caused by the mite Sarcoptes scabiei and it transmitted through close personal contact. Even though it is easily treatable disease, its prevalence is high and continuous as neglected tropical disease of resource-poor settings, and particularly affects young age groups. Despite of these facts, studies conducted in Ethiopia regarding to the prevalence and associated factors for scabies infestation have been highly variable and didn't well compiled. Due to that, the aim of this systematic review and meta-analysis was to estimates the overall prevalence of scabies and associated factors in all age groups in Ethiopia.

METHODS

International databases (PubMed/PMC/Midline, EMBASE, CINAHL, Web of Science, Google Scholar, Google and Science Direct) were systematically searched from December 1, 2019, to January 18, 2020. All observational studies noted the prevalence of human scabies and associated factors in Ethiopia were included. Two authors (AG and G.T) independently extracted all necessary data using a standardized data extraction format. The data which is extracted each study were analyzed using STATA Version 14.1. Heterogeneity among the included studies was assessed through the Cochrane Q test statistics and I2 test. Lastly, a random effects meta-analysis model was computed to fix overall prevalence and associated factors of scabies.

RESULTS

Twelve studies were included in this meta-analysis after 410 articles retrieved. Of these, eight studies were analyzed for prevalence estimation. The overall prevalence of scabies infestation was 14.5% (95%CI: 1.5, 27.6%) in Ethiopia. Furthermore, the subgroup analysis revealed the highest prevalence was 19.6% in Amhara region. A person from a large family size (OR: 3.1, 95% CI: 1.76, 5.67), and sharing a bed (OR: 3.59, 95%CI: 2.88, 4.47) were significantly associated with scabies.

CONCLUSION

This study revealed the prevalence of scabies infestation was 14.5% in Ethiopia which was high. Persons from high family size and any contact with scabies case were factors associated with scabies.

Randomized Trial of Community Treatment With Azithromycin and Ivermectin Mass Drug Administration for Control of Scabies and Impetigo

Background

Scabies is a public health problem in many countries, with impetigo and its complications important consequences. Ivermectin based mass drug administration (MDA) reduces the prevalence of scabies and, to a lesser extent, impetigo. We studied the impact of co-administering azithromycin on the prevalence of impetigo and antimicrobial resistance.

Methods

Six communities were randomized to receive either ivermectin-based MDA or ivermectin-based MDA co-administered with azithromycin. We measured scabies and impetigo prevalence at baseline and 12 months. We collected impetigo lesions swabs at baseline, 3 and 12 months to detect antimicrobial resistance.

Results

At baseline, scabies and impetigo prevalences were 11.8% and 10.1% in the ivermectin-only arm and 9.2% and 12.1% in the combined treatment arm. At 12 months, the prevalences had fallen to 1.0% and 2.5% in the ivermectin-only arm and 0.7% and 3.3% in the combined treatment arm. The proportion of impetigo lesions containing Staphylococcus aureus detected did not change (80% at baseline vs 86% at 12 months; no significant difference between arms) but the proportion containing pyogenic streptococci fell significantly (63% vs 23%, P < .01). At 3 months, 53% (8/15) of S. aureus isolates were macrolide-resistant in the combined treatment arm, but no resistant strains (0/13) were detected at 12 months.

Conclusions

Co-administration of azithromycin with ivermectin led to similar decreases in scabies and impetigo prevalence compared to ivermectin alone. The proportion of impetigo lesions containing pyogenic streptococci declined following MDA. There was a transient increase in the proportion of macrolide-resistant S. aureus strains following azithromycin MDA.

Clinical Trials Registration

clinicaltrials.gov (NCT02775617).

Trends in prevalence and incidence of scabies from 1990 to 2017: findings from the global Burden of disease study 2017

Scabies remains a significant public health concern globally, affecting people of all ages, races, and socioeconomic groups. The epidemic characteristics of scabies are yet unravelled, especially in high-income countries and elderly population. In this study, we sought to investigate incidence and prevalence and their trends of scabies worldwide from 1990 to 2017 via the Global Burden of Disease (GBD) Study 2017. The prevalence and incidence of scabies tend to a moderate increase after age 70. The annual percentage change in ASR of scabies prevalence and incidence increased in high SDI countries and High-income North America. Current prevention strategies should be reoriented, and much more targeted strategies should be established in some populations to forestall the increase in scabies.

Prevalence and Associations of General Practice Registrars' Management of Impetigo: A Cross-Sectional Analysis From the Registrar Clinical Encounters in Training (ReCEnT) Study

Background

Impetigo is a mild bacterial skin infection of childhood that is usually managed empirically in primary care.

Objective

To establish the prevalence and associations of impetigo in general practice (GP) registrars' consultations.

Methods

Cross-sectional analysis of the Registrar Clinical Encounters in Training (ReCEnT) study data.

Results

Impetigo was managed in 0.24% of problems and 0.43% of consultations. Patient variables associated with impetigo presentations were younger age and impetigo as a new problem, while patients with non-English-speaking backgrounds were less likely to present with impetigo. Associated registrar variables were being new to the registrar and practicing in outer regional/remote locations. Compared with all other problems/diagnoses, impetigo more often involved information seeking, ordering pathology, and prescription of medication, but less often involved follow-up or referral.

Conclusions

Impetigo accounts for 0.43 per 100 GP registrar consultations in Australia. Association with outer regional/remote areas may reflect climate and socioeconomic factors that predispose to impetigo. Associated pathology requests may reflect a lack of confidence in GP registrars' management of impetigo. Cultural differences may exist regarding health-seeking behavior relating to impetigo.

How strong is the relationship between scabies and acute rheumatic fever? An analysis of neighbourhood factors

AIM

Recent studies have linked scabies with acute rheumatic fever (ARF). We explored the relationship, by neighbourhood, between permethrin dispensing as an indicator of scabies prevalence and ARF cases over the same period.

METHODS

Incident cases of ARF notified to public health between September 2015 and June 2018 and the annual incidence of prescribing by neighbourhood over the same period were analysed. Evidence of an association between permethrin and ARF was obtained by carrying out Poisson regression of the rate of ARF in terms of permethrin rate at the census area unit level, with adjustment for ethnicity and socio-economic deprivation.

RESULTS

A total of 413 neighbourhoods were included. The incidence of ARF varied between 0 and 102 per 100 000 people per year (mean 4.3). In contrast, the annual incidence of dispensing of permethrin varied between 0 and 3201 per 100 000 people per year (mean 771). A strong association was observed between the two variables. In an adjusted quasi-Poisson model, permethrin-dispensing rates were strongly associated with ARF incidence, with a change from the 16th to the 84th centile associated with a 16.5-fold increase in incidence (95% confidence interval: 3.82-71.6).

CONCLUSIONS

Permethrin prescribing as an indicator of scabies is strongly associated with the incidence of ARF. Considered together with other studies, this evidence suggests that improving scabies control may reduce the burden of ARF in New Zealand.

An Antibody Persistent and Protective Two rSsCLP-Based Subunit Cocktail Vaccine against Sarcoptes scabiei in a Rabbit Model

Scabies is a highly contagious disease caused by Sarcoptes scabiei which burrows into stratum corneum of host's skin. In this study, after optimizing vaccination schedule, a vaccination trial is comprised of three test groups of rabbits (n = 10/group) by immunization with (1) rSsCLP5; (2) rSsCLP12; or (3) a mixture of rSsCLP5 and rSsCLP12, three biological replicates groups (n = 10/group) and three control groups (n = 10/group). Levels of specific IgG, total IgE and cytokines in sera were detected and histopathologically analyzed as indicators of vaccine effects. The results showed that 85% (17/20) of rabbits exhibited no detectable skin lesions of S. scabiei infestation in mixed protein groups compared to single protein groups with 75% (15/20) and 70% (14/20), respectively. Moreover, the deworming rates of mixed groups are increased by 10%-20% compared with that of single groups. Each of six groups immunized with rSsCLP displayed significant increases of specific IgG, total IgE, IL-10, and TNF-α. The degree of skin damage in test groups also significantly lower than that of control groups. Thus, purified rSsCLP5 and rSsCLP12 subunit cocktail vaccine induced robust immune protection and could significantly decrease mite populations to reduce the direct transmission between rabbits.

Scabies: Application of the Novel Identify-Isolate-Inform Tool for Detection and Management

Scabies is a highly contagious, globally prevalent, parasitic skin infestation caused by Sarcoptes scabiei var. hominis, also known as the itch mite. There have been outbreaks not only in the developing world, but also in the developed world among refugees and asylum seekers. Once infested with scabies mites, symptomatic patients, as well as asymptomatic carriers, quickly spread the disease through direct skin-to-skin contact. Typically, symptoms of scabies are characterized by an erythematous, papular, pruritic rash associated with burrows. Treatment of scabies involves using topical or systemic scabicides and treating secondary bacterial infections, if present. Given the prevalence and contagiousness of scabies, measures to prevent its spread are essential. Through application of the novel Identify-Isolate-Inform (3I) Tool, emergency medical providers can readily identify risk factors for exposure and important symptoms of the disease, thus limiting its spread through prompt scabicide therapy; isolate the patient until after treatment; and inform local public health authorities and hospital infection prevention, when appropriate. Ultimately, these three actions can aid public health in controlling the transmission of scabies cases, thus ensuring the protection of the general public from this highly contagious skin infestation.

Assessing knowledge of scabies among physicians working in primary health care setting

Background:

Outbreaks of scabies have been documented in 2018 among school children in Western and Central regions of Saudi Arabia. There have been concerns about the awareness of healthcare providers.

Objective:

The objective of the current study was to evaluate the knowledge of primary health care physicians about scabies diagnosis and management, as well as the factors influencing such knowledge.

Methods:

An observational cross-sectional study was conducted between September and October 2019. The target population was physicians working in primary care centers in Riyadh. Filling either hard or soft copies of the study questionnaire was used for data collection. The knowledge score was calculated from the answers for 16 knowledge questions.

Results:

A total of 216 physicians were included in the final analysis, mainly general practitioners (56.5%) and registrars (31.5%). The overall knowledge score was 67.5%± 13.9%. The highest level of knowledge was associated with age susceptibility (80.6%), followed by clinical presentation and diagnosis (78.1%), mode of transmission (75.8%), pathogen cause & incubation period (66.9%), and finally management (61.7%). In multivariate logistic regression models, a shorter time since last time information about scabies was reviewed was significantly associated with better knowledge (defined as score > median), with odds ratio = 5.84 (95% confidence interval = 2.43–14.01). Similarly, older age and higher qualification were significantly associated with better knowledge.

Discussion:

As expected, the knowledge about scabies among primary care physicians was generally inadequate. The current findings highlight the need for educational and training programs lead by health care authorities, targeting these physicians.

Scabies: A Neglected Global Disease

BACKGROUND

Scabies is a skin disease caused by an obligate human parasite mite Sarcoptes scabiei var. hominis. Children under the age of two and elderly individuals are at the greatest risk. Knowledge of this condition is important for an early diagnosis to be made and treatment to be initiated.

OBJECTIVE

The review aimed to familiarize physicians with the clinical manifestations, diagnosis, evaluation, and management of scabies.

METHODS

A search was conducted using Pubmed with the built-in "Clinical Queries" tool. The search term "Scabies" was used. The categories of "epidemiology", "diagnosis", "therapy", "prevention" and "prognosis" had a limited scope for primary clinical studies. Meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews were included. Only papers published in the English language were included. A descriptive, narrative synthesis was provided of the retrieved articles.

RESULTS

Worldwide, scabies affects 200 to 300 million individuals annually. The average prevalence is estimated to be 5 to 10% in children of developing countries. Transmission usually occurs after close prolonged skin-to-skin contact. Classic scabies is characterized by an erythematous papular eruption, serpiginous burrows, and intense pruritus. Sites of predilection include the webs of the fingers, volar wrists, lateral aspects of fingers, extensor surfaces of elbows and knees, waist, navel, abdomen, buttocks, groins, and, genitals. A clinical diagnosis of classic scabies can be made on the basis of the history and clinical findings. Other clinical variants include crusted scabies, nodular scabies, and bullous scabies. Finding the mite, ova, or fecal pellets on microscopic examination of scrapings taken from skin lesions confirms the diagnosis of scabies infestation. For eradication of scabies mites, the drugs of choice are topical permethrin and oral ivermectin.

CONCLUSION

Scabies is a highly contagious parasitic cutaneous disease that is stigmatising and debilitating. Increased awareness, accurate diagnosis, and prompt treatment are essential for the effective control of scabies and for the prevention of the spread of the disease.

Recurrence rate of scabies in patients 14 years or older in Saudi Arabia

Objectives:

To estimate the rate of scabies diagnostic recurrence and identify factors associated with the high likelihood of frequent scabies recurrences among adults in Saudi Arabia.

Methods:

This multi-center retrospective study was conducted in adult patients who were diagnosed with one or multiple recurrent infestations of scabies between January 2016 and September 2018 at the Ministry of National Guard-Health Affairs hospitals and clinics, Saudi Arabia. The number of scabies recurrences during the study period was recorded and modeled using a Poisson model.

Results:

A total of 468 adult patients (39.8±17.8, range: 14.2-105.7 years) were included in the study, resulting in 645 scabies diagnoses in which 302 (46.8%) were recurrences. The multivariate Poisson model revealed that male gender (adjusted rate ratios [aRR]: 1.465; 95%CI: 1.064 - 2.017; p=0.019), first tertile (January to April) (aRR: 3.021; 95%CI: 1.484 - 6.149; p=0.002), and high humidity (aRR: 1.066; 95%CI: 1.002 - 1.133; p=0.043) had a higher likelihood of frequent scabies recurrences.

Conclusion:

The rate of scabies recurrence among adult patients in Saudi Arabia was high, and is comparable with previous report in Japan. The study suggests that male gender, first tertile, and high humidity were independently associated with the high rate of scabies recurrences among adults. An interventional program to lower the rate of scabies recurrences and prevent outbreak should be undertaken.

Risk Factors for Acute Rheumatic Fever: Literature Review and Protocol for a Case-Control Study in New Zealand

Acute rheumatic fever (ARF) and its sequela, rheumatic heart disease (RHD), have largely disappeared from high-income countries. However, in New Zealand (NZ), rates remain unacceptably high in indigenous Māori and Pacific populations. The goal of this study is to identify potentially modifiable risk factors for ARF to support effective disease prevention policies and programmes. A case-control design is used. Cases are those meeting the standard NZ case-definition for ARF, recruited within four weeks of hospitalisation for a first episode of ARF, aged less than 20 years, and residing in the North Island of NZ. This study aims to recruit at least 120 cases and 360 controls matched by age, ethnicity, gender, deprivation, district, and time period. For data collection, a comprehensive pre-tested questionnaire focussed on exposures during the four weeks prior to illness or interview will be used. Linked data include previous hospitalisations, dental records, and school characteristics. Specimen collection includes a throat swab (Group A Streptococcus), a nasal swab (Staphylococcus aureus), blood (vitamin D, ferritin, DNA for genetic testing, immune-profiling), and head hair (nicotine). A major strength of this study is its comprehensive focus covering organism, host and environmental factors. Having closely matched controls enables the examination of a wide range of specific environmental risk factors.

The prevalence of scabies, pyoderma and other communicable dermatoses in the Bijagos Archipelago, Guinea-Bissau

INTRODUCTION

Skin diseases represent a significant public health problem in most low and middle income settings. Nevertheless, there is a relative paucity of high-quality epidemiological data on the prevalence of these conditions.

MATERIALS/METHODS

We conducted two cross-sectional population-based skin-surveys of children (6 months to 9 years old) in the Bijagós Archipelago of Guinea-Bissau during the dry season (February-March 2018) and the wet season (June-July 2018). Following a period of training, a nurse performed a standardised examination for communicable dermatoses for each participant. We calculated the prevalence of each skin condition and investigated demographic associations.

RESULTS

1062 children were enrolled in the dry season survey of whom 318 (29.9%) had at least one skin diseases. The most common diagnosis was tinea capitis (154/1062, 14.5% - 95% CI 12.5-16.8%) followed by tinea corporis (84/1062, 7.9% - 95% CI 6.4-9.7%), pyoderma (82/1062, 7.7% - 95% CI 6.2-9.5%) and scabies (56/1062. 5.2% - 95%CI 4.0-6.8%). 320 children were enrolled in the wet season survey of whom 121 (37.8%) had at least one skin problem. Tinea capitis remained the most common diagnosis (79/320, 24.7% - 95% CI 20.1-29.9%), followed by pyoderma (38/320, 11.9% - 95% CI 8.6-16.1%), tinea corporis (23/320, 7.2% - 95% 4.7-10.7%) and scabies (6/320, 1.9% - 95% CI 0.8-4.2%).

CONCLUSIONS

Our study, which utilised robust population-based cluster random sampling methodology, demonstrates the substantial disease burden caused by common communicable dermatoses in this setting. Given these findings, there is a need to consider common dermatoses as part of Universal Health Coverage to deliver 'skin-health for all'.

Skin infections in Australian Aboriginal children: a narrative review

Impetigo, scabies, cellulitis and abscesses are common in Australian Aboriginal children. These conditions adversely affect wellbeing and are associated with serious long term sequelae, including invasive infection and post‐infectious complications, such as acute post‐streptococcal glomerulonephritis and acute rheumatic fever, which occurs at the highest documented rates in the world in remote Aboriginal communities.

Observational research in remote communities in northern Australia has demonstrated a high concurrent burden of scabies and impetigo and their post‐infectious complications.

Few data are available for other Australian states, especially for urban Aboriginal children; however, nationwide hospital data indicate that the disparity between Aboriginal and non‐Aboriginal children in skin infection prevalence also exists in urban settings.

The Australian National Healthy Skin Guideline summarises evidence‐based treatment of impetigo, scabies and fungal infections in high burden settings such as remote Aboriginal communities. It recommends systemic antibiotics for children with impetigo, and either topical permethrin or oral ivermectin (second line) for the individual and their contacts as equally efficacious treatments for scabies. β‐Lactams are the treatment of choice and trimethoprim–sulfamethoxazole and clindamycin are effective alternatives for treatment of paediatric cellulitis. Abscesses require incision and drainage and a 5‐day course of trimethoprim–sulfamethoxazole or clindamycin.

Addressing normalisation of skin infections and the social determinants of skin health are key challenges for the clinician. Research is underway on community‐wide skin health programs and the role for mass drug administration which will guide future management of these common, treatable diseases.

High burden and seasonal variation of paediatric scabies and pyoderma prevalence in The Gambia: A cross-sectional study

BACKGROUND

Scabies is a WHO neglected tropical disease common in children in low- and middle-income countries. Excoriation of scabies lesions can lead to secondary pyoderma infection, most commonly by Staphyloccocus aureus and Streptococcus pyogenes (group A streptococcus, GAS), with the latter linked to acute post-streptococcal glomerulonephritis (APSGN) and potentially rheumatic heart disease (RHD). There is a paucity of data on the prevalence of these skin infections and their bacterial aetiology from Africa.

METHODOLOGY/PRINCIPAL FINDINGS

A cross-sectional study, conducted over a four-month period that included the dry and rainy season, was conducted to determine the prevalence of common skin infections in Sukuta, a peri-urban settlement in western Gambia, in children <5 years. Swabs from pyoderma lesions were cultured for S. aureus and GAS. Of 1441 children examined, 15.9% had scabies (95% CI 12.2-20.4), 17.4% had pyoderma (95% CI 10.4-27.7) and 9.7% had fungal infections (95% CI 6.6-14.0). Scabies was significantly associated with pyoderma (aOR 2.74, 95% CI 1.61-4.67). Of 250 pyoderma swabs, 80.8% were culture-positive for S. aureus, and 50.8% for GAS. Participants examined after the first rains were significantly more likely to have pyoderma than those examined before (aRR 2.42, 95% CI 1.38-4.23), whereas no difference in scabies prevalence was seen (aRR 1.08, 95% CI 0.70-1.67). Swab positivity was not affected by the season.

CONCLUSIONS/SIGNIFICANCE

High prevalence of scabies and pyoderma were observed. Pyoderma increased significantly during the rainy season. Given the high prevalence of GAS pyoderma among children, further research on the association with RHD in West Africa is warranted.

SToP (See, Treat, Prevent) skin sores and scabies trial: study protocol for a cluster randomised, stepped-wedge trial for skin disease control in remote Western Australia

INTRODUCTION

Skin is important in Australian Aboriginal culture informing kinship and identity. In many remote Aboriginal communities, scabies and impetigo are very common. Untreated skin infections are painful, itchy and frequently go untreated due to under-recognition and lack of awareness of their potential serious complications. We hypothesise that the skin infection burden in remote Aboriginal communities can be reduced by implementing streamlined training and treatment pathways integrated with environmental health and health promotion activities, tested in the See, Treat, Prevent (SToP skin sores and scabies) trial.

METHODS AND ANALYSIS

SToP will evaluate a skin control programme using a stepped-wedge, cluster randomised trial design with three intervention components (the 'SToP activities'): (1) seeing skin infections (development of training resources implemented within a community dermatology model); (2) treating skin infections (employing the latest evidence for impetigo, and scabies treatment); and (3) preventing skin infections (embedded, culturally informed health promotion and environmental health activities). Four community clusters in the remote Kimberley region of Western Australia will participate. Following baseline data collection, two clusters will be randomly allocated to the SToP activities. At 12 months, the remaining two clusters will transition to the SToP activities. The primary outcome is the diagnosis of impetigo in children (5-9 years) at school-based surveillance. Secondary outcome measures include scabies diagnosis, other child health indicators, resistance to cotrimoxazole in circulating pathogenic bacteria, determining the economic burden of skin disease and evaluating the cost effectiveness of SToP activities.

ETHICS AND DISSEMINATION

This study protocol was approved by the health ethics review committees at the Child and Adolescent Health Service (Approval number RGS0000000584), the Western Australian Aboriginal Health Ethics Committee (Reference number: 819) and the University of Western Australia (Reference RA/4/20/4123). Study findings will be shared with community members, academic and medical communities via publications and presentations, and in reports to funders. Authorship for all publications based on this study will be determined in line with the Uniform Requirements for Manuscripts Submitted to Biomedical Journals published by the International Committee of Medical Journal Editors. Sharing results with organisations and communities who contributed to the study is paramount. The results of the SToP trial will be shared with participants in a suitable format, such as a single summary page provided to participants or presentations to communities, the Kimberly Aboriginal Health Planning Forum Research Subcommittee and other stakeholders as appropriate and as requested. Communication and dissemination will require ongoing consultation with Aboriginal communities to determine appropriate formats.

TRIAL REGISTRATION NUMBER

ACTRN12618000520235.

The Relationship between Scabies and Stroke: A Population-Based Nationwide Study

BACKGROUND

Scabies is a commonly occurring infectious skin infestation that substantially impacts the quality of life, while stroke, which consists of a neurological deficit resulting from a lack of blood flow to the brain, carries sizable economic costs. The pathophysiologic mechanisms underlying both diseases involve inflammatory processes that are mediated by the immune system; however, no prior research has been conducted to explore the relationship between the two conditions.

METHODS

This population-based nationwide study utilized data from the National Health Insurance Research Database (NHIRD) of Taiwan for a total of 6628 scabies patients, who comprised a scabies group, and a randomly selected cohort of 26,509 matching patients, who served as a control group. More specifically, the medical records for the patients in both groups were checked for seven years to identify any new cases of stroke within that seven-year follow-up period. The hazard ratio (HR) of stroke for the follow-up period was then calculated using Cox proportional hazards regressions, while comorbidities and demographic characteristics were likewise analyzed.

RESULTS

During the follow-up period, 2892 patients, or 8.7%, of the overall total of 33,137 patients included in the study were newly diagnosed with a stroke. Of those newly diagnosed stroke patients, 833 were from the scabies group, and 2059 were from the control group, accounting for 12.6% and 7.8%, respectively, of the individuals in each group. With a crude hazard ratio of 1.67, the patients in the scabies group had a significantly higher risk of subsequent stroke than those in the control group, although the adjusted hazard ratio (aHR) for the scabies patients, which was determined by adjusting for covariates, was only 1.32 (95% confidence interval (CI): 1.21-1.43).

CONCLUSIONS

The results of the study indicated an elevated risk of stroke among scabies patients, an association that might be contributed to by immunopathological factors. This information could serve as a reminder to clinicians to remain alert to any indications of neurological impairment in patients previously infected with scabies.

Prevalence of scabies and impetigo in the Solomon Islands: a school survey

BACKGROUND

Scabies, a parasitic disease of the skin, is a major public health problem, largely affecting children. Scabies is often complicated by impetigo which can result in serious complications including invasive infections and immune mediated diseases. Scabies and impetigo are reported to have high prevalence in tropical settings including the Solomon Islands.

METHODS

We conducted a cross-sectional prevalence survey at Gizo Primary School in the Western Province of the Solomon Islands in August 2018. The diagnosis of scabies was based on criteria developed by the International Alliance for the Control of Scabies in 2018. Population attributable risk was calculated to determine the effect of scabies on the prevalence of impetigo, and both adjusted and unadjusted risk ratios were calculated to identify differences between sexes and age groups.

RESULTS

A total of 324 students were assessed (47.5% of those enrolled at the school). The prevalence of scabies was 54.3% (95% confidence interval [CI] 48.7-59.8) and most disease was mild (68.8%). The prevalence was higher in males (63.5%; adjusted risk ratio [ARR] 1.4, 95% CI 1.1-1.7), and in those aged 10-12 years (61.4%; ARR 1.8, 95% CI 1.1-2.9 when compared to those aged 4-6 years). The prevalence of impetigo was 32.1%, with males more likely to be affected (41.7%, ARR 1.7, 95% CI 1.2-2.4) but with no significant differences between age groups. 63.5% of those with impetigo had scabies, corresponding to a population attributable risk of 11.8%.

CONCLUSIONS

There is a very high burden of scabies and impetigo among primary school students in Gizo. There is a critical need for the development and implementation of control programs in areas where scabies is endemic.

The global prevalence of latent tuberculosis: a systematic review and meta-analysis

In 1999, the World Health Organization (WHO) estimated that one-third of the world's population had latent tuberculosis infection (LTBI), which was recently updated to one-fourth. However, this is still based on controversial assumptions in combination with tuberculin skin test (TST) surveys. Interferon-γ release assays (IGRAs) with a higher specificity than TST have since been widely implemented, but never used to estimate the global LTBI prevalence.We conducted a systematic review and meta-analysis of LTBI estimates based on both IGRA and TST results published between 2005 and 2018. Regional and global estimates of LTBI prevalence were calculated. Stratification was performed for low, intermediate and high TB incidence countries and a pooled estimate for each area was calculated using a random effects model.Among 3280 studies screened, we included 88 studies from 36 countries with 41 IGRA (n=67 167) and 67 TST estimates (n=284 644). The global prevalence of LTBI was 24.8% (95% CI 19.7-30.0%) and 21.2% (95% CI 17.9-24.4%), based on IGRA and a 10-mm TST cut-off, respectively. The prevalence estimates correlated well to WHO incidence rates (Rs=0.70, p<0.001).In the first study of the global prevalence of LTBI derived from both IGRA and TST surveys, we found that one-fourth of the world's population is infected. This is of relevance, as both tests, although imperfect, are used to identify individuals eligible for preventive therapy. Enhanced efforts are needed targeting the large pool of latently infected individuals, as this constitutes an enormous source of potential active tuberculosis.

Pruritus in ordinary scabies: IL-31 from macrophages induced by overexpression of thymic stromal lymphopoietin and periostin

BACKGROUND

Scabies is a common contagious skin disease caused by an infestation of the skin by Sarcoptes scabiei var. hominis. A hallmark symptom of scabies is severe itch.

METHODS

We sought to determine the generation of a pruritogenic cytokine, interleukin (IL)-31, together with immune profiles in skin lesions of ordinary scabies through immunohistochemical and immunofluorescent studies. To elucidate the pathological mechanisms of IL-31 generation, murine peritoneal macrophages were stimulated with various T helper 2 (Th2) cytokines and proteins ex vivo.

RESULTS

A large number of CCR4(+) Th2 cells, eosinophils, and basophils infiltrated in scabies lesions. Increased generation of IL-31, thymic stromal lymphopoietin (TSLP), and periostin was also observed. A major population of IL-31(+) cells were Arginase-1(+)/CD163(+) M2 macrophages. Murine peritoneal macrophages showed an M2 phenotype and generated IL-31 when stimulated with TSLP and periostin.

CONCLUSION

IL-31 appeared to be largely generated by M2 macrophages in ordinary scabies lesions. This IL-31 induction was mediated by TSLP and periostin.

Perinatal risk factors associated with skin infection hospitalisation in Western Australian Aboriginal and Non-Aboriginal children

BACKGROUND

Hospitalisation with skin infection in Western Australian (WA) Aboriginal children is common, with the highest rates in infants and children from remote WA.

OBJECTIVE

We aimed to quantify infant, maternal, and sociodemographic risk factors for skin infection hospitalisation in WA children, focussing on Aboriginal children aged <17 years.

METHODS

We conducted a retrospective population-based cohort study with linked perinatal and hospitalisation data on WA-born children (1996-2012), of whom 31 348 (6.7%) were Aboriginal. We used Cox regression to calculate adjusted hazard ratios and associated population attributable fractions (PAFs) for perinatal factors attributed to first hospitalisation with skin infection. To identify specific risk factors for early-onset infection, we further restricted the cohort to infants aged <1 year.

RESULTS

Overall, 5439 (17.4%) Aboriginal and 6750 (1.5%) non-Aboriginal children were hospitalised at least once with a skin infection. Aboriginal infants aged <1 year had the highest skin infection hospitalisation rate (63.2 per 1000 child-years). The strongest risk factors in Aboriginal children aged <17 years were socio-economic disadvantage, very remote location at birth, and multi-parity (≥3 previous pregnancies) accounting for 24%, 23%, and 15% of skin infection hospitalisations, respectively. Other risk factors included maternal age <20 years, maternal smoking during pregnancy, and low birthweight.

CONCLUSIONS

We have quantified the relative influence of perinatal risk factors associated with skin infection hospitalisations in WA children, providing measures indicating which factors have the potential to reduce the most hospitalisations. Our evidence not only supports existing calls for substantial government investment in addressing underlying social and environmental barriers to healthy skin in WA Aboriginal children but also identifies potential areas to target health promotion messaging at individuals/families on maternal smoking during pregnancy and skin hygiene for families.

Epidemiologic Trends and Seasonality of Scabies in South Korea, 2010-2017

Scabies is a parasitic skin infection with intense itching. Scabies infection seriously impairs quality of life, while outbreaks in medical institutions cause financial losses. This study aimed to present the annual and seasonal trend of prevalence of scabies in the national population. Scabies cases were extracted from National Health Insurance Service database and its epidemiologic characteristics were assessed. To analyze the seasonality of scabies occurrence, temperature and humidity were included in the model as weather factors, and the per capita gross national income index was adjusted. The annual prevalence by age group was 0.56-0.69 per 1,000 persons until the age of 40 years and peaked at 3.0-4.1 per 1,000 persons in the age group over 80 years. The number of women diagnosed with scabies has been consistently higher compared to that of men since 2010. Mean number of cases diagnosed as scabies was lowest in spring, approximately 4,000 cases, when the average temperature was less than 5°C at 2 months prior, whereas more than 6,000 scabies cases occurred in autumn when temperatures exceeded 25°C at 2 months prior. This study presents the epidemiological characteristics and seasonality of all cases nationwide over 8 years and will help to establish control policies.

The Challenge of Developing a Single-Dose Treatment for Scabies

Scabies is a common skin disease with an estimated worldwide incidence of 200 million people infected per year. Its morbidity and mortality is principally due to secondary bacterial infections, a link now well recognized and prompting the recent inclusion of this disease-complex in the WHO list of neglected tropical diseases. The few treatments available are poorly effective against Sarcoptes scabiei eggs and appear to induce resistance in the parasite. An ideal alternative would be a single-dose regimen that kills all developmental stages, including eggs. Drugs used in the veterinary field and applied to other arthropods could be tested experimentally in an established pig-scabies model. Moreover, functional genomics combined with target validation through biochemical research should assist in identifying new drugs.

Factors associated with scabies outbreaks in primary schools in Ethiopia: a case-control study

Background

Scabies is a neglected tropical disease affecting more than 200 million people worldwide every year. Scabies in school adolescents and young adults could affect their school performance. The current study investigates the factors associated with an outbreak of scabies at primary schools in southern Ethiopia.

Method

A team of health professionals investigated an outbreak of scabies that occurred in primary schools from May 1 to 30, 2018. An unmatched case–control study was employed to assess factors which predisposed for the scabies outbreak. Cases of scabies were individuals having a skin lesion compatible with the WHO case definitions of scabies. Controls were from the same locality with no skin lesions. Data on sociodemographic and behavioral variables were collected using questionnaires. Data on clinical presentations of scabies among cases were recorded by two trained and experienced health professionals. Factors associated with scabies were assessed using bivariate and multivariate logistic regression, and strength of association was described using odds ratio (OR) and 95% confidence intervals (CIs).

Results

A total of 711 (237 cases and 474 controls) study subjects participated in the study. The mean age of study participants was 17.56±2.66 years. Poor knowledge about scabies, adjusted odds ratio (AOR)=4.32 (95% CI: 2.93, 6.36); male sex, AOR=2.69 (95% CI: 1.82, 3.96); and parental illiteracy, AOR =3.49 (95% CI: 2.06, 5.94) predicted scabies infestation. Additionally, socioeconomic variables like sharing clothes/beds or contact with others, AOR=3.12 (95% CI: 2.12, 4.59); low household annual income, AOR=2.13 (95% CI: 1.32, 3.44); and family size greater than five, AOR=1.77 (95% CI: 1.04, 3.01) were significantly associated with scabies infestation. Inaccessibility and poor utilization of water, AOR=1.64 (95% CI: 1.12, 2.40) and poor personal hygiene, AOR=1.69 (95% CI: 1.14, 2.51) were also factors independently associated with scabies.

Conclusion

Modifiable risk factors such as personal hygiene and literacy level were found to be independent predictors of scabies infestation. Access to and utilization of water were also important predictors. Strategies for poverty alleviation and awareness creation on personal hygiene and efficient use of water are recommended for effective prevention of scabies infestation in closed institutions.

The diagnosis of scabies by non-expert examiners: A study of diagnostic accuracy

Background

Although scabies is estimated to be one of the most common skin conditions globally, prevalence data is not available in most settings. Disease mapping is required to develop and monitor successful control programs. Non-expert health workers are likely to play an important role in scabies mapping activities in endemic settings.

Methodology

Four non-expert health workers were trained in the diagnosis of scabies and impetigo. The health worker diagnosis was compared to a reference consensus diagnosis of two doctors experienced in diagnosis. The study was conducted in a primary school in Gizo, Solomon Islands, in August 2018. The six examiners consecutively assessed school students, blinded to each other’s findings. Training and diagnostic procedures followed criteria for scabies diagnosis established by the International Alliance for the Control of Scabies in 2018.

Principal findings

Amongst the 171 students who underwent clinical assessment the prevalence of scabies and impetigo according to the reference standard was 55% and 45% respectively. Sensitivity of the non-expert health workers’ diagnosis compared to the reference standard was 55.3% for scabies (95% confidence interval [CI], 50.1–60.4) with a specificity of 89.9% (95% CI 86–93.1) and 52.6% for impetigo (95% CI 46.9–58.3) with a specificity 97.8% (95% CI 95.7–99). Sensitivity for moderate to severe scabies was 93.5% (95% CI 86.3–97.6) with a specificity of 74% (95% CI 70.2–77.5).

Conclusions

Following brief training, the diagnostic accuracy of non-expert health workers for scabies and impetigo was promising, especially for moderate to severe disease. Modifications to training and processes are recommended to further improve accuracy. The diagnosis by non-expert health workers may be acceptable for scabies and impetigo mapping in endemic areas.

Scabies is a parasitic infection that leads to significant morbidity worldwide. Mapping of scabies prevalence would improve the understanding of the true burden of disease and the need for control programs in specific countries and regions. The diagnosis of scabies in low resource settings, where the disease is most prevalent, is reliant on clinical examination. A task shifting approach, utilizing local health staff, could substantially increase the feasibility to undertake mapping surveys in low-resource settings. In this study, we aimed to evaluate the diagnostic accuracy of clinical assessment of local health workers following brief training. Our study found that these non-expert health workers could diagnose scabies with moderate accuracy and diagnose more severe disease with high accuracy. Further work is needed to develop standardized training packages to ensure a high level of diagnostic accuracy by non-expert health workers.

Effects of temperature on the survival of Sarcoptes scabiei of black bear (Ursus americanus) origin

For two decades, the incidence and range of sarcoptic mange in black bears (Ursus americanus) in Pennsylvania has increased. The causative agent, Sarcoptes scabiei, can be directly or indirectly transmitted; therefore, data on environmental persistence is important for guiding management and public communications. The objective of this study was to determine the survival of S. scabiei at different temperatures. Full section skin samples and superficial skin scrapes were collected from bears immediately after euthanasia due to severe mange. After ~ 24 h on ice packs (shipment to lab), samples were placed in dishes at 0, 4, 18, or 30 °C and 60, 20, 12, and 25% relative humidity, respectively, and the percentage of mites alive, by life stage, was periodically determined. Humidity was recorded but not controlled. Temperature significantly affected mite survival, which was shortest at 0 °C (mostly ≤ 4 h) and longest at 4 °C (up to 13 days). No mites survived beyond 8 days at 18 °C or 6 days at 30 °C. Mites from full-thickness skin sections survived significantly longer than those from superficial skin scrapes. Adults typically survived longer than nymphs and larvae except at 30 °C where adults survived the shortest time. These data indicate that at cooler temperatures, S. scabiei can survive for days to over a week in the environment, especially if on host skin. However, these data also indicate that the environment is unlikely to be a long-term source of S. scabiei infection to bears, other wildlife, or domestic animals.

Impetigo incidence and treatment: a retrospective study of Dutch routine primary care data

BACKGROUND

There is a lack of recently published data on impetigo presentation incidence and treatment practices in the routine Western European primary care setting.

OBJECTIVES

To investigate impetigo incidence, treatments and recurrence in primary care in the Netherlands.

METHODS

A retrospective, observational study. Electronic records of patients treated for impetigo in 2015 at 29 general practices in Utrecht and surrounds were reviewed. An episode of impetigo was defined as one or more patient-doctor contacts within 8 weeks of the index consultation. Within an episode, patient demographics and prescribing patterns were analysed including number of treatments, and the category and sequence of individual medicines.

RESULTS

A total of 1761 impetigo episodes were managed, with an incidence rate of 13.6 per 1000 person years. Impetigo peaked in summer. Most patients, the majority children, experienced a single episode (93%), and 25% had eczema as comorbidity. Topical antibiotics (primarily fusidic acid) were the most prescribed initial treatments (85%), followed by oral antibiotics (14%). Topical antibiotics were progressively used less over subsequent treatments, while there was an inverse increase in oral antibiotic use. Topical fusidic acid as the most common first line treatment seemed satisfactory as only 12% of initial treatments with this drug received further therapy. Repeat treatments generally occurred within 7 days.

CONCLUSION

This study of impetigo prescribing patterns in primary care highlighted that Dutch general practitioners were generally adherent to national treatment guidelines. Topical treatment, and if needed systemic small-spectrum antibiotic treatment, appeared satisfactory; these findings aid in antimicrobial stewardship.

Dermatologic Problems Commonly Seen by the Allergist/Immunologist

Allergists/immunologists see a variety of skin disorders, some of which have a known immunologic basis whereas others do not. We review the prevalence, etiology, clinical presentation, and effective and low-cost care of common dermatologic conditions seen in outpatient practices. Conditions discussed include pityriasis alba, seborrheic dermatitis, rosacea, acne, tinea infections, intertrigo, lichen planus, tinea versicolor, lichen simplex chronicus, scabies, pityriasis rosea, keratosis pilaris, and seborrheic keratosis. An understanding of frequently encountered cutaneous diseases and their therapies will help provide immediate access to treatment and improve the experience for both the affected patient and the clinician.

Ectoparasites: Scabies

Scabies is an ectoparasitic dermatosis caused by Sarcoptes scabiei var. hominis and is a public health issue in all countries regardless of socioeconomic status. In high-income countries, delays in diagnosis can lead to institutional outbreaks; in low- and middle-income countries, poor access to health care contributes to disease undertreatment and long-term systemic sequelae. With scabies now recognized as a neglected tropical disease by the World Health Organization, increased awareness and systematic efforts are addressing gaps in diagnosis and treatment that impede scabies control. This review summarizes the available data and provides an update on scabies epidemiology, clinical features, diagnosis, management, and public health considerations.

The public health control of scabies: priorities for research and action

Scabies is a parasitic disease of the skin that disproportionately affects disadvantaged populations. The disease causes considerable morbidity and leads to severe bacterial infection and immune-mediated disease. Scientific advances from the past 5 years suggest that scabies is amenable to population-level control, particularly through mass drug administration. In recognition of these issues, WHO added scabies to the list of neglected tropical diseases in 2017. To develop a global control programme, key operational research questions must now be addressed. Standardised approaches to diagnosis and methods for mapping are required to further understand the burden of disease. The safety of treatments for young children, including with ivermectin and moxidectin, should be investigated. Studies are needed to inform optimum implementation of mass treatment, including the threshold for intervention, target, dosing, and frequency. Frameworks for surveillance, monitoring, and evaluation of control strategies are also necessary.

Ivermectin Dosing Strategy to Achieve Equivalent Exposure Coverage in Children and Adults

Ivermectin is a commonly used broad-spectrum antiparasitic drug, yet doses that produce consistent exposure coverage across age have not been characterized, and no data are available in children weighing < 15 kg. First, a population pharmacokinetic model is developed based on data from 200 children and 11 adults, treated with 100-600 μg/kg ivermectin. Second, model-based simulations are performed to identify a dosing strategy that achieves equivalent exposure coverage in children and adults. Median (90% confidence interval) clearance of 0.346 (0.12-0.73) L/hour/kg in pre-school-aged (2-5 years) children is similar to 0.352 (0.17-0.69) L/hour/kg in school-aged (6-12 years) children but higher than in adults (0.199 (0.10-0.31) L/hour/kg), resulting in significantly lower exposure in children following a 200 μg/kg dose. Simulations indicate that a dose increase to 300 and 250 μg/kg in children aged 2-5 and 6-12 years, respectively, will achieve equivalent ivermectin exposure coverage in children and adults.

Observations of Pediatric Disease Prevalence from Pacific Partnership 2015

Pacific Partnership is an ongoing yearly humanitarian assistance mission to Pacific Rim countries. Although many case reports and surgical successes have been documented, few data have been published specifically about the primary care mission. This article analyzes outpatient pediatric data collected during Pacific Partnership 2015. Eleven different providers documented care delivered to children from birth through age 18 yr, inclusive. Personally de-identified data were entered into spreadsheets, sorted according to country visited, and analyzed with IBM SPSS software looking for disease frequency. One thousand eighty-seven pediatric patients were seen across Fiji, Papua New Guinea (PNG), and the Philippines (PI). Asthma was the first, second, and third most prevalent diagnosis in PNG, Fiji, and PI, with a relative proportion of the total patients seen at 5.4%, 7.2%, and 5%, respectively. In PI, 123 cases of upper respiratory infection were seen, more than four times the next most common diagnosis of normal exam. Thirty-six patients with scabies were seen in Fiji (number 1), with abdominal pain at number 3 (26 cases, 6.5%). Surprisingly, helminths were rarely seen, comprising the sixteenth and fourteenth most common diagnoses in Fiji and PI and only two cases in PNG. Future Pacific Partnership missions can plan medication stock, personnel assignment, equipment needs, and educational literature based on these data.

A systematic review of scabies transmission models and data to evaluate the cost-effectiveness of scabies interventions

Background

Scabies is a common dermatological condition, affecting more than 130 million people at any time. To evaluate and/or predict the effectiveness and cost-effectiveness of scabies interventions, disease transmission modelling can be used.

Objective

To review published scabies models and data to inform the design of a comprehensive scabies transmission modelling framework to evaluate the cost-effectiveness of scabies interventions.

Methods

Systematic literature search in PubMed, Medline, Embase, CINAHL, and the Cochrane Library identified scabies studies published since the year 2000. Selected papers included modelling studies and studies on the life cycle of scabies mites, patient quality of life and resource use. Reference lists of reviews were used to identify any papers missed through the search strategy. Strengths and limitations of identified scabies models were evaluated and used to design a modelling framework. Potential model inputs were identified and discussed.

Findings

Four scabies models were published: a Markov decision tree, two compartmental models, and an agent-based, network-dependent Monte Carlo model. None of the models specifically addressed crusted scabies, which is associated with high morbidity, mortality, and increased transmission. There is a lack of reliable, comprehensive information about scabies biology and the impact this disease has on patients and society.

Discussion

Clinicians and health economists working in the field of scabies are encouraged to use the current review to inform disease transmission modelling and economic evaluations on interventions against scabies.

Scabies is a neglected tropical disease affecting more than 130 million people, with major costs on health care systems worldwide. While effective treatments exist, it is unknown which treatment strategies result in the best outcomes against the lowest costs, and to what extent this differs between communities. Health economic modelling can help answer these questions, but has rarely been used in this disease area. This review discusses all available scabies transmission models (n = 4), and uses them to create a new, comprehensive modelling framework. This framework can be used as aid for creating a scabies transmission model, the details of which will be determined by the context (population) and the question being addressed. The current paper also reviews the data that is needed to inform scabies modelling: on scabies biology, quality of life and resource use. Unfortunately, available data is limited and particularly data on crusted scabies (associated with high morbidity and mortality rates) is rare. With this review, we hope to assist researchers and policy makers to predict and/or evaluate the cost-effectiveness of interventions against scabies in their population(s) of interest. To tackle scabies, it is key to use effective treatment strategies in a cost-effective and sustainable way. The models and data described in this review, may help researchers, clinicians and funding bodies to facilitate this.

Risk factors for treatment failure in scabies: a cohort study

BACKGROUND

Treatment failure, which occurs in about one-third of cases, is considered as a major factor in the increasing incidence of scabies in developed countries.

OBJECTIVES

To identify predictors of treatment failure of scabies in ambulatory populations.

METHODS

This multicentre study compared the clinical characteristics and treatment modalities between a group of patients with scabies treated successfully and another group who were not cured 3 months after antiscabies treatment.

RESULTS

In total 210 patients with a diagnosis of scabies were included, comprising 98 patients in the treatment success group and 112 in the treatment failure group. The main risk factors for treatment failure were (i) the use of only one type of treatment, topical benzyl benzoate (BB) or oral ivermectin, vs. the combination of both treatments [odds ratio (OR) 2·15, 95% confidence interval (CI) 1·22-3·77]; (ii) the use of a single intake (vs. two) of oral ivermectin (OR 10·2. 95% CI 4·49-23·2); (iii) intake of ivermectin during a meal vs. on an empty stomach (OR 4·31, 95% CI 1·89-9·84); (iv) absence of decontamination of furnishings (OR 8·72, 95% CI 3·50-21·8), in particular sofa and cushions (OR 5·90, 95% CI 2·34-14·9), mattresses (OR 4·16, 95% CI 1·35-12·8) or car seats (OR 6·57, 95% CI 3·27-13·2) and (v) absence of written documents explaining treatment modalities (OR 5·18, 95% CI 2·57-10·4). In multivariate analysis, treatment failure was mainly associated with (i) use of a single intake (vs. two) of ivermectin (OR 6·62, 95% CI 2·71-16·2); (ii) use of BB alone vs. two intakes of ivermectin (OR 3·51, 95% CI 1·55-7·95) and (iii) absence of decontamination of furniture with acaricides (OR 5·81, 95% CI 1·96-16·7).

CONCLUSIONS

Use of topical BB alone and a single intake (vs. two) of ivermectin are predictors of treatment failure.

High burden of infectious disease and antibiotic use in early life in Australian Aboriginal communities

OBJECTIVE

To quantify the childhood infectious disease burden and antibiotic use in the Northern Territory's East Arnhem region through synthesis and analysis of historical data resources.

METHODS

We combined primary health clinic data originally reported in three separate publications stemming from the East Arnhem Healthy Skin Project (Jan-01 to Sep-07). Common statistical techniques were used to explore the prevalence of infectious conditions and the seasonality of infections, and to measure rates of antibiotic use.

RESULTS

There was a high monthly prevalence of respiratory (mean: 32% [95% confidence interval (CI): 20%, 34%]) and skin (mean: 20% [95%CI: 19%, 22%]) infectious syndromes, with upper respiratory tract infections (mean: 29% [95%CI: 27%, 31%]) and skin sores (mean: 15% [95%CI: 14%, 17%]) the most common conditions. Antibiotics were frequently prescribed with 95% (95%CI: 91%, 97%) of children having received at least one antibiotic prescription by their first birthday, and 47% having received six antibiotic prescriptions; skin sores being a key driver.

CONCLUSIONS

Early life infections drive high antibiotic prescribing rates in remote Aboriginal communities. Implications for public health: Eliminating skin disease could reduce antibiotic use by almost 20% in children under five years of age in this population.

Treatment, prevention and public health management of impetigo, scabies, crusted scabies and fungal skin infections in endemic populations: a systematic review

We conducted a systematic review of the treatment, prevention and public health control of skin infections including impetigo, scabies, crusted scabies and tinea in resource‐limited settings where skin infections are endemic. The aim is to inform strategies, guidelines and research to improve skin health in populations that are inequitably affected by infections of the skin and the downstream consequences of these. The systematic review is reported according to the PRISMA statement. From 1759 titles identified, 81 full text studies were reviewed and key findings outlined for impetigo, scabies, crusted scabies and tinea. Improvements in primary care and public health management of skin infections will have broad and lasting impacts on overall quality of life including reductions in morbidity and mortality from sepsis, skeletal infections, kidney and heart disease.

A Review of Scabies: An Infestation More than Skin Deep

Human scabies, a common infestation, has a worldwide distribution with a variable impact and presentation depending on the clinical situation. In developed, high-income settings, health institution and residential home outbreaks challenge health and social care services. In resource-poor settings, it is the downstream sequelae of staphylococcal and streptococcal bacteraemia, induced by scratching, which have a significant impact on the long-term health of communities. Over the past decade scabies has been recognised as a “neglected tropical disease” (NTD) by the World Health Organisation, has an accepted practical system of global diagnostic criteria and is being adopted into integrated programmes of mass drug administration for NTDs in field settings. This review seeks to summarise the recent advances in the understanding of scabies and highlight the advocacy and research headlines with their implication for diagnosis and management of outbreaks and individuals. In addition, it will indicate the priorities and questions that remain.