Can ivermectin mass drug administrations to control scabies also reduce skin and soft tissue infections? Hospitalizations and primary care presentations lower after a large-scale trial in Fiji

Scabies: a clinical update

Scabies is the most common neglected tropical disease with cutaneous manifestations, disproportionately affecting socially disadvantaged populations living in overcrowded settings. Scabies infestation is characterised by a generalised intractable pruritus, and is often complicated by secondary bacterial infection, which can lead to a range of complications. Scabies is a clinical diagnosis and requires an adequate degree of suspicion. The use of dermoscopy may improve diagnostic accuracy. In Australia, the first-line treatment recommended for scabies is topical permethrin 5% cream, applied to the whole body and repeated in one week. Oral ivermectin is subsidised by the Pharmaceutical Benefits Scheme with streamlined authority for patients who have completed and failed treatment with topical therapy, have a contraindication to topical treatment or have crusted scabies. Early identification and prompt initiation of treatment is key to minimise the disease burden of scabies.

Scabies outbreak management in refugee/migrant camps in Europe 2014-2017: a retrospective qualitative interview study of healthcare staff experiences and perspectives

OBJECTIVES

Provide insights into the experiences and perspectives of healthcare staff who treated scabies or managed outbreaks in formal and informal refugee/migrant camps in Europe 2014-2017.

DESIGN

Retrospective qualitative study using semistructured telephone interviews and framework analysis. Recruitment was done primarily through online networks of healthcare staff involved in medical care in refugee/migrant settings.

SETTING

Formal and informal refugee/migrant camps in Europe 2014-2017.

PARTICIPANTS

Twelve participants (four doctors, four nurses, three allied health workers, one medical student) who had worked in camps (six in informal camps, nine in formal ones) across 15 locations within seven European countries (Greece, Serbia, Macedonia, Turkey, France, the Netherlands, Belgium).

RESULTS

Participants reported that in camps they had worked, scabies diagnosis was primarily clinical (without dermatoscopy), and treatment and outbreak management varied highly. Seven stated scabicides were provided, while five reported that only symptomatic management was offered. They described camps as difficult places to work, with poor living standards for residents. Key perceived barriers to scabies control were (1) lack of water, sanitation and hygiene, specifically: absent/limited showers (difficult to wash off topical scabicides), and inability to wash clothes and bedding (may have increased transmission/reinfestation); (2) social factors: language, stigma, treatment non-compliance and mobility (interfering with contact tracing and follow-up treatments); (3) healthcare factors: scabicide shortages and diversity, lack of examination privacy and staff inexperience; (4) organisational factors: overcrowding, ineffective interorganisational coordination, and lack of support and maltreatment by state authorities (eg, not providing basic facilities, obstruction of self-care by camp residents and non-governmental organisation (NGO) aid).

CONCLUSIONS

We recommend development of accessible scabies guidelines for camps, use of consensus diagnostic criteria and oral ivermectin mass treatments. In addition, as much of the work described was by small, volunteer-staffed NGOs, we in the wider healthcare community should reflect how to better support such initiatives and those they serve.

Scabies in the Amhara region of northern Ethiopia: a cross-sectional study of prevalence, determinants, clinical presentation and community knowledge

BACKGROUND

The WHO aims to prevent, eliminate or control neglected tropical diseases, including scabies, by 2030. However, limited epidemiological data presented a challenge to control efforts, especially in high burden countries. There was a major scabies outbreak in northern Ethiopia starting in 2015 and prevalence has since increased across much of the country.

OBJECTIVE

To estimate scabies prevalence, identify its predictors, and assess community perception of, and knowledge about, the infestation.

DESIGN

Population-based cross-sectional study.

STUDY SETTING

Ayu Guagusa district, Amhara region, northern Ethiopia.

PARTICIPANTS

1437 people who were members of 381 randomly selected households participated in the study. Five trained mid-level health workers clinically diagnosed people with scabies.

OUTCOME MEASURES

Clinically diagnosed scabies infestation.

DATA ANALYSIS

Multi-level logistic regression models were fitted to adjust for individual and household-level confounding variables, and identify predictors of scabies infestation.

RESULTS

Scabies prevalence was 13.4% (95% CI 11.8 to 15.5). Households of more than five people (adjusted OR (aOR)=3.5, 95% CI 1.2 to 10.2) were associated with increased odds of developing scabies, however, females had lower odds (aOR=0.5 95% CI 0.3 to 0.8). Scabietic lesions most frequently involved the trunk (62.0%), and vesicles were the most common types of lesions (67.7%). Two-thirds of adult study participants had heard about scabies and most obtained scabies related information from informal sources. Only 32% of cases sought care for scabies from any source.

CONCLUSION

Scabies prevalence was high, signifying the need for community-based control interventions. Host density and sex were important predictors of scabies. Despite the favourable attitude toward the effectiveness of scabies treatment, healthcare seeking was low.

Health service needs and perspectives of a rainforest conserving community in Papua New Guinea's Ramu lowlands: a combined clinical and rapid anthropological assessment with parallel treatment of urgent cases

OBJECTIVES

Determine community needs and perspectives as part of planning health service incorporation into Wanang Conservation Area, in support of locally driven sustainable development.

DESIGN

Clinical and rapid anthropological assessment (individual primary care assessments, key informant (KI) interviews, focus groups (FGs), ethnography) with treatment of urgent cases.

SETTING

Wanang (pop. c189), a rainforest community in Madang province, Papua New Guinea.

PARTICIPANTS

129 villagers provided medical histories (54 females (f), 75 males (m); median 19 years, range 1 month to 73 years), 113 had clinical assessments (51f, 62m; median 18 years, range 1 month to 73 years). 26 ≥18 years participated in sex-stratified and age-stratified FGs (f<40 years; m<40 years; f>40 years; m>40 years). Five KIs were interviewed (1f, 4m). Daily ethnographic fieldnotes were recorded.

RESULTS

Of 113 examined, 11 were 'well' (a clinical impression based on declarations of no current illness, medical histories, conversation, no observed disease signs), 62 (30f, 32m) were treated urgently, 31 referred (15f, 16m), indicating considerable unmet need. FGs top-4 ranked health issues concorded with KI views, medical histories and clinical examinations. For example, ethnoclassifications of three ((A) 'malaria', (B) 'sotwin', (C) 'grile') translated to the five biomedical conditions diagnosed most ((A) malaria, 9 villagers; (B) upper respiratory infection, 25; lower respiratory infection, 10; tuberculosis, 9; (C) tinea imbricata, 15) and were highly represented in declared medical histories ((A) 75 participants, (B) 23, (C) 35). However, 29.2% of diagnoses (49/168) were limited to one or two people. Treatment approaches included plant medicines, stored pharmaceuticals, occasionally rituals. Travel to hospital/pharmacy was sometimes undertaken for severe/refractory disease. Service barriers included: no health patrols/accessible aid post, remote hospital, unfamiliarity with institutions and medicine costs. Service introduction priorities were: aid post, vaccinations, transport, perinatal/birth care and family planning.

CONCLUSIONS

This study enabled service planning and demonstrated a need sufficient to acquire funding to establish primary care. In doing so, it aided Wanang's community to develop sustainably, without sacrificing their forest home.

Scabies incidence and association with skin and soft tissue infection in Loyalty Islands Province, New Caledonia: A 15-year retrospective observational study using electronic health records

Background

Scabies and its complications are a public health problem in the low- and middle-income countries of the Western Pacific region. However, no data are available for the relatively wealthy French territory of New Caledonia. This study aimed to determine the incidence of scabies and its association with skin and soft tissue infection (SSTI) in Loyalty Islands Province (LIP) (20,000 inhabitants), New Caledonia.

Methodology/Principal findings

This retrospective observational study reviewed cases of scabies and SSTI extracted from the electronic health record databases of LIP clinics for the period 2004–2018. Data were validated through double sampling. The overall scabies incidence rate (IR) and scabies IRs by sex and age group were calculated. Scabies seasonality was evaluated. For children <5 years, the presence of SSTI was compared between the 3-month period preceding scabies diagnosis/treatment and the 3-month period preceding the 1-year anniversary of scabies diagnosis/treatment (self-matching).

A total of 16,843 scabies cases were extracted using a detection algorithm with a sensitivity of 96.7% and a specificity of 99.9%. From 2004 to 2018, the average overall scabies IR was 5.9% and the average scabies IR in children <1 year was 18.4%. Almost two-thirds of children aged 14 years had a history of scabies. Females were more affected, especially in the 20–39 age group (sex ratio>2). A strong seasonality was observed, with a 30% increase in winter. In children <5 years, SSTIs were 4.3 times more frequent in the 3 months preceding the scabies diagnosis than in the 3 months preceding the 1-year anniversary of scabies treatment (p<0.001).

Conclusions

Although health care is much better in New Caledonia than in neighboring countries, scabies is highly endemic in LIP. The disease is especially common in children <2 years and is associated with many SSTIs in children <5 years. Mass drug administration should be considered.

Scabies is a known public health problem in the Pacific region. This study aimed to determine the importance of scabies and associated skin infections in the Loyalty Island Province (LIP) of New Caledonia (20,000 inhabitants).

The provincial electronic medical database was searched for all cases of scabies and skin infection that occurred in the LIP population between 2004 and 2018. To evaluate the impact of scabies on skin infections, we measured the decrease in the number of skin infections in children <5 years one year after scabies treatment.

Over the study period, the average number of scabies cases occurring each year was 6 per 100 inhabitants. In children <1 year, this number was 18 per 100 inhabitants. We found that 80% of children aged 15 years had experienced at least one episode of scabies. We also observed a fourfold decrease in the number of skin infections in children <5 years 1 year after treatment. Scabies was more frequent (+30%) in winter.