Scabies in healthcare settings

Global prevalence and predictors of scabies among prisoners: systematic review and meta-analysis

INTRODUCTION

Scabies is a widespread issue in prisons due to overcrowded living conditions and limited healthcare resources. A recent study published in the Journal of Infection and Public Health discovered that the prevalence of scabies varies greatly among prisoners in different regions and facilities. This review aimed to determine the global prevalence and predictors of scabies among prisoners by conducting a systematic review and meta-analysis.

METHODS

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis checklist to report the findings of our systematic review and meta-analysis. Relevant databases including PubMed, Cochrane Library, ScienceDirect, and other grey literature databases were used to search and retrieve articles. The study included both published and unpublished research written in English languages for studies reporting the prevalence of human scabies among prisoners. This review has been registered on PROSPERO. The heterogeneity of the data was evaluated using the I2 statistic. A meta-analysis was conducted using STATA 17 software, with a 95% confidence interval. The researchers also conducted publication bias and sensitivity analysis.

RESULTS

The review included 7 studies involving 1, 309,323 prisoners. All included studies involved cross-sectional study design. The prevalence of scabies among prisoners ranges from 0.72% in Italy to 41.01% in Cameroon. The global pooled prevalence of human scabies among prisoners was found to be 6.57% (95% CI; 2.16-19.94). According to subgroup analysis, the overall prevalence of scabies among African prisoners was 19.55% (95% CI; 9.44-40.45), while the prevalence among prisoners outside of Africa was 1.57% (95% CI; 0.77-3.19). The length of time spent in prison, sharing of clothing or beds, and hygiene practices were found to be factors that were significantly associated with the likelihood of prisoners developing human scabies.

CONCLUSION

The overall prevalence of human scabies is high among prisoners worldwide. Prisoners who spent more time in prison shared clothing or beds, and had poor hygiene practices were more likely to develop human scabies. Thus, efforts should be made by policymakers and program administrators to decrease the prevalence of scabies in prisons. The protocol for this systematic review and meta-analysis was registered in the International Prospective Register of Systematic Reviews with registration number CRD42024516064.

Infection Control among Healthcare Workers and Management of a Scabies Outbreak in a Large Italian University Hospital

This retrospective observational study describes the results of an ad-hoc designated prevention protocol aimed at containing the spread of the scabies infestation among healthcare workers (HCWs) of a large University Hospital in Italy. The outbreak started on October 2022 and a preventive protocol was set up thanks to a multidisciplinary approach. HCWs at high scabies risk were defined as subjects working in Operative Units with a scabies prevalence higher than 2%, close contacts of a confirmed case of scabies, or HCWs with signs and symptoms of the disease. All cases at high scabies risk underwent a dermatological examination, and the infested HCWs were suspended from work until definitive healing. Mass drug administration was established for all HCWs working in Operative Units with a scabies prevalence higher than 2%. Until March 2023, out of 183 screening dermatological examinations, 21 (11.5%) were diagnostic for scabies. Between 11 October 2022 (date of the first diagnosed scabies case) and 6 March 2023 (the end of incubation period related to the last case detected), the frequency of scabies was 0.35% (21 scabies cases/6000 HCWs). The duration of the outbreak in our hospital was 14.7 weeks. Statistical analysis shows a significant association between scabies and being a nurse and having an allergy to dust mites. We obtained a low frequency of scabies infection, limiting the duration of the outbreak and the related economic burden.

The current available diagnostic tools and treatments of scabies and scabies variants: An updated narrative review

Scabies is a neglected tropical disease that continues to have global impacts and long-term health consequences. It is caused by the mite Sarcoptes scabei var. hominis, which is an obligate ectoparasite that lives in the epidermis of the human skin. Scabies is common in poor communities due to overcrowding in places like old age homes, prisons, and homeless and displaced children. However, developed countries are also susceptible to scabies infestations, such as in institutional outbreaks or small epidemics under war conditions or during natural disasters. The diagnosis of scabies may be assisted by invasive and noninvasive tools; However, the history and examination findings are usually adequate to confirm the clinical suspicion. Here, we present an updated review of scabies by focusing on the diagnostic approaches, treatment, and prevention of scabies.

Benign Anorectal Disorder Management in Low-Resource Settings

There are many benign anorectal disorders, which can make patients seek care. In low-resource settings, the incidence of those pathologies is not different from the industrialized and western world. However, an interesting difference colorectal surgeons and gastroenterologists can face is the fact that many patients do not seek help or are not aware and have little opportunities to be helped. Latin America population is estimated to be around 8% of the world population, with Brazil having the largest percentage. Infectious diseases, which were previously under control or were steadily declining, have emerged. For example, we have seen resurgence of dengue, malaria, and syphilis in pregnancy, as well as other sexually transmitted diseases that can affect the anorectal region. In this article, we will address the most common benign anorectal disorders.

Sexually Transmitted Infections Treatment Guidelines, 2021

These guidelines for the treatment of persons who have or are at risk for sexually transmitted infections (STIs) were updated by CDC after consultation with professionals knowledgeable in the field of STIs who met in Atlanta, Georgia, June 11–14, 2019. The information in this report updates the 2015 guidelines. These guidelines discuss 1) updated recommendations for treatment of Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis; 2) addition of metronidazole to the recommended treatment regimen for pelvic inflammatory disease; 3) alternative treatment options for bacterial vaginosis; 4) management of Mycoplasma genitalium; 5) human papillomavirus vaccine recommendations and counseling messages; 6) expanded risk factors for syphilis testing among pregnant women; 7) one-time testing for hepatitis C infection; 8) evaluation of men who have sex with men after sexual assault; and 9) two-step testing for serologic diagnosis of genital herpes simplex virus. Physicians and other health care providers can use these guidelines to assist in prevention and treatment of STIs.

Community perspectives on scabies, impetigo and mass drug administration in Fiji: A qualitative study

Scabies is endemic in Fiji and is a significant cause of morbidity. Little is known about the sociocultural beliefs and practices that affect the occurrence of scabies and impetigo, or community attitudes towards the strategy of mass drug administration that is emerging as a public health option for scabies and impetigo control in Fiji and other countries. Data were collected during semi-structured interviews with 33 community members in four locations in Fiji’s Northern Division. Thematic analysis examined participants’ lived experiences of scabies and impetigo; community knowledge and perceptions about scabies and impetigo aetiology and transmission; community-based treatment and prevention measures; and attitudes towards mass drug administration. Many indigenous Fijian (iTaukei) participants noted extensive and ongoing experience of scabies and impetigo among children in their families and communities, but only one participant of Indian descent (Indo-Fijian) identified personal childhood experience of scabies. Scabies and impetigo were perceived as diseases affecting children, impacting on school attendance and families’ quality of sleep. Awareness of scabies and impetigo was considerable, but there were major misconceptions around disease causation and transmission. Traditional remedies were preferred for scabies treatment, followed by biomedicines provided by local health centres and hospitals. Treatment of close household contacts was not prioritised. Attitudes towards mass drug administration to control scabies were mostly positive, although some concerns were noted about adverse effects and hesitation to participate in the planned scabies elimination programme. Findings from this first study to document perspectives and experiences related to scabies and impetigo and their management in the Asia Pacific region illustrate that a community-centred approach to scabies and impetigo is needed for the success of control efforts in Fiji, and most likely in other affected countries. This includes community-based health promotion messaging on the social dynamics of scabies transmission, and a campaign of education and community engagement prior to mass drug administration.

Scabies is a skin disease causing discomfort from severe itchiness. It can lead to secondary bacterial infection of the skin (impetigo) that can in turn lead to systemic complications, including septicaemia, kidney disease and rheumatic heart disease. It can also cause sleep disorders and a reduced quality of life. Recently added to the World Health Organization list of neglected tropical diseases, scabies is estimated to affect 150 million people globally each year and is endemic in many Pacific Island countries, including Fiji. We aimed to increase understanding of community beliefs and practices that affect the occurrence of scabies and impetigo, and assess community attitudes towards the use of mass drug administration for scabies and impetigo control in Fiji. The impact of scabies and impetigo on participants’ quality of life included poor sleep quality, school absenteeism and social isolation, especially among children. Participants had awareness of scabies and impetigo, however, misconceptions around the cause and the ways in which these diseases were transmitted between individuals were common. Participants often reported choosing traditional medical remedies to treat scabies; treatment at health centres was mainly sought for secondary skin infections. Attitudes towards mass drug administration were positive, although some concerns regarding adverse effects were noted. Improved strategies, including a community-centred response, are needed for the success of control efforts in Fiji.

Prevalence of scabies in long-term care hospitals in South Korea

BACKGROUND

Scabies is a common contagious skin disease. With the economic growth in South Korea, the incidence of scabies has decreased. However, with the recent advancements in medical facilities, mainly the establishment of long-term care hospitals (LTCHs), scabies is now considered an emerging public health problem.

METHODOLOGY/PRINCIPAL FINDINGS

To examine the prevalence and management of scabies in LTCHs in South Korea, we contacted all 1,336 LTCHs registered at the Health Insurance Review and Assessment Service in South Korea in 2018. A total of 110 LTCHs completed a questionnaire, and we analyzed their responses. In the last 5 years, 71.8% (79/110) of LTCHs had a high incidence of scabies (suspected/confirmed cases). Usually, patients aged older than 80 years (45.5%) were diagnosed with the disease, with more women being affected than men. Only 30.0% of the patients were transferred to scabies-restricted rooms, and very few LTCHs (7.0%) had special departments for scabies. Fifty-five (61.1%) of 90 LTCHs reported contact between scabies patients and nurses, nurse aides, caregivers, and other employees (hereinafter, referred to as primary exposure), with 29 (32.2%) LTCHs reporting infections due to primary exposure. The most common challenges in managing scabies were patient isolation (47.8%), diagnosis (31.1%), management of individuals exposed to an individual with scabies (17.8%), lack of staff for managing the patients (16.7%), and treatment (11.1%).

CONCLUSIONS

The incidence rate of scabies in LTCHs in South Korea has increased. Regular and enhanced staff training is needed, considering that most hospitals rarely focused on the handling of equipment and furniture used by scabies patients and on educating their healthcare staff. These findings can be used to develop various strategies to reduce the prevalence of scabies.

The public health importance of scabies in community domiciliary care settings: an exploratory cross-sectional survey of Health Protection Teams in England

Scabies is a contagious skin infection commonly occurring in institutions such as care homes. However, a large proportion of vulnerable people in England receive domiciliary care in the community and their experience of scabies has not been described. We undertook a pragmatic cross-sectional survey of Health Protection Teams (HPTs) in England to determine the burden of scabies related to domiciliary care. Fifteen cases or outbreaks were notified to HPTs between January 2013 and December 2017. Although a relatively uncommon event for individual HPTs, they were complex to manage and required the co-ordination of multiple stakeholders. Diagnosis was often delayed and required several clinical consultations. A lack of guidance led to difficulties establishing stakeholder roles and responsibilities and sources of funding for treatment. The stigmatisation of scabies sometimes affected the quality of care provided to patients, such as use of excessive personal protective equipment. Our study demonstrates that scabies is an issue of public health importance for domiciliary care service providers and users, and research is required to better understand the impacts of the disease and to develop evidence-based guidance. More generally, there is a need for simpler treatment regimens and methods of diagnosing scabies.

Clinical presentation and risk factors of increased scabies cases in the Western region of Saudi Arabia in 2016-2018

OBJECTIVES

To describe the clinical characteristics of scabies in the Makkah province and analyze risk factors associated with the outbreak.  Methods: A cross-sectional study was conducted between June 2016 and June 2018 by collecting the data of patients reported to have infestations at King Abdulaziz Medical City, Makkah, Saudi Arabia. A comparative analysis was conducted of patients reported before and during the outbreak of scabies.  Results: Of the 352 patients identified, the range of cases was 0-24 cases per month before the months of the outbreak (March to April 2018). However, the actual number of cases reported increased 2.8 times the expected maximum in April 2018. Saudi nationals were 2.5 times more affected than non-Saudi nationals during the outbreak period compared to before the outbreak (95%CI: 1.02, 6.05, p=0.045). Symptoms involving upper arms, axillae (53.7% versus 68.7%, p=0.048), and torso (50% versus 66.4%, p=0.033) were significantly under-represented among outbreak patients. The presence of additional comorbidities was reported more frequently in patients diagnosed with scabies before versus during the outbreak months (25.8% versus 8.2%, p=0.014). Permethrin prescriptions increased (75.6% versus 41%), crotamiton prescriptions decreased (13.5% versus 48%), and the hospitalization was lower (3.8% versus 13.5%) during the outbreak.  Conclusion: The clinical presentation and risk factors of scabies change significantly with scabies outbreaks, and consequently so do the lines of treatment in Saudi Arabia. The present study highlights the importance of adopting strategies related to community infection control and prevention.

Do we know how scabies outbreaks in residential and nursing care homes for the elderly should be managed? A systematic review of interventions using a novel approach to assess evidence quality

Currently no national guidelines exist for the management of scabies outbreaks in residential or nursing care homes for the elderly in the United Kingdom. In this setting, diagnosis and treatment of scabies outbreaks is often delayed and optimal drug treatment, environmental control measures and even outcome measures are unclear. We undertook a systematic review to establish the efficacy of outbreak management interventions and determine evidence-based recommendations. Four electronic databases were searched for relevant studies, which were assessed using a quality assessment tool drawing on STROBE guidelines to describe the quality of observational data. Nineteen outbreak reports were identified, describing both drug treatment and environmental management measures. The quality of data was poor; none reported all outcome measures and only four described symptom relief measures. We were unable to make definitive evidence-based recommendations. We draw on the results to propose a framework for data collection in future observational studies of scabies outbreaks. While high-quality randomised controlled trials are needed to determine optimal drug treatment, evidence on environmental measures will need augmentation through other literature studies. The quality assessment tool designed is a useful resource for reporting of outcome measures including patient-reported measures in future outbreaks.

Rate and factors for scabies recurrence in children in Saudi Arabia: a retrospective study

Background

Despite the fact that several scabies outbreaks emerged in schools in Saudi Arabia in 2018, no study has investigated the risk of scabies recurrence among children in Saudi Arabia. This study aimed to estimate the rate of scabies recurrence and identify factors that were associated with an increased risk of recurrence among children.

Methods

This is a multi-center retrospective study of children (age < 14 years) who were diagnosed between May 20, 2015 and September 12, 2018 with one or multiple recurrent scabies at the Ministry of National Guard Health Affairs (MNGHA) hospitals and clinics in Saudi Arabia. Data were obtained from an electronic health system, BestCare database.

Results

A sample of 264 children analyzed (mean age of 6.7 years) resulted in a cumulative number of 316 scabies diagnoses in which 86 (27.2%) experienced scabies recurrence (at least once). Independent factors associated with a high risk of scabies recurrence: older children (adjusted hazard ratio [aHR], 1.036; 95% CI, 1.002–1.072; P = 0.039), female gender (aHR, 1.734; 95% CI, 1.329–2.262; P = 0.001), Western region of Saudi Arabia (aHR, 1.548; 95% CI, 1.115–2.151; P = 0.009), and 2nd tertile season [May to August] (aHR, 2.368; 95% CI, 1.706–3.288; P = 0.001).

Conclusions

The study demonstrated that the recurrence rate of scabies among children is high. Older children, the female gender, the Western region of Saudi Arabia, and the seasonality were independently associated with an increased risk of scabies recurrence. High temperature and low humidity should be explored as leading factors for scabies infestations in Saudi Arabia. Findings derived from this study may be useful for clinicians and governments in optimizing clinical management of scabies cases and contacts.

Identifying the time to cure for patients with classic scabies after infection control intervention in acute care hospital settings

Scabies is a re-emerging parasitic disease, particularly in hospitalized patients. This is a retrospective study analyzing adult patients with scabies admitted to a referral university hospital between 2008 and 2018. All patients were treated an average of 3times using scabicides; the median isolation period and time to cure were 14 and 15days, respectively.

Infected with Scabies Again? Focus in Management in Long-Term Care Facilities

Scabies is a significant public health condition in long-term care facilities, plaguing even developed countries. Although treatments are available, eradication and control of scabies cases still remain a challenge due to delays in diagnosis and difficulties in maintaining preventive and surveillance measures. Prompt treatment of patients and their contacts that are affected, along with concomitant education of health staff and family members, are paramount. Environmental disinfestation is also a concern.

Treatment of scabies using a tea tree oil-based gel formulation in Australian Aboriginal children: protocol for a randomised controlled trial

INTRODUCTION

In remote Aboriginal communities in Australia, scabies affects 7 out of 10 children before their first birthday. This is more than six times the rate seen in the rest of the developed world. Scabies infestation is frequently complicated by bacterial infection, leading to the development of skin sores and other more serious consequences, such as septicaemia and chronic heart and kidney diseases. Tea tree oil (TTO) has been used as an antimicrobial agent for several decades with proven clinical efficacy. Preclinical investigations have demonstrated superior scabicidal properties of TTO compared with widely used scabicidal agents, such as permethrin 5% cream and ivermectin. However, current data are insufficient to warrant a broad recommendation for its use for the management of scabies because previous studies were small or limited to in vitro observations.

METHODS AND ANALYSIS

A pragmatic first trial will examine the clinical efficacy of a simple and low-cost TTO treatment against paediatric scabies and the prevention of associated secondary bacterial infections, with 1:1 randomisation of 200 participants (Aboriginal children, aged 5-16 years and living in remote Australia) into active control (permethrin 5% cream) and treatment (5% TTO gel) groups. The primary outcome for the study is clinical cure (complete resolution). Secondary outcome measures will include relief of symptoms, recurrence rate, adverse effects, adherence to treatment regimen and patient acceptability.

ETHICS AND DISSEMINATION

The project has received approvals from the University of Canberra Human Research Ethics Committee (HREC 16-133), Wurli-Wurlinjang Health Service Indigenous subcommittee and the Aboriginal Medical Services Alliance Northern Territory reference group. The results of this study will be published in core scientific publications, with extensive knowledge exchange activities with non-academic audiences throughout the duration of the project.

TRIAL REGISTRATION

ACTRN12617000902392; Pre-results.

The Epidemiology of Scabies and Impetigo in Relation to Demographic and Residential Characteristics: Baseline Findings from the Skin Health Intervention Fiji Trial

Scabies and associated impetigo are under-recognized causes of morbidity in many developing countries. To strengthen the evidence base for scabies control we undertook a trial of mass treatment for scabies. We report on the occurrence and predictors of scabies and impetigo in participants at baseline. Participants were recruited in six island communities and were examined for the presence of scabies and impetigo. In addition to descriptive analyses, logistic regression models were fit to assess the association between demographic variables and outcome of interest. The study enrolled 2051 participants. Scabies prevalence was 36.4% (95% confidence interval [CI] 34.3-38.5), highest in children 5-9 years (55.7%). Impetigo prevalence was 23.4% (95% CI 21.5-25.2) highest in children aged 10-14 (39.0%). People with scabies were 2.8× more likely to have impetigo. The population attributable risk of scabies as a cause of impetigo was 36.3% and 71.0% in children aged less than five years. Households with four or more people sharing the same room were more likely to have scabies and impetigo (odds ratios [OR] 1.6, 95% CI 1.2-2.2 and OR 2.3, 95% CI 1.6-3.2 respectively) compared to households with rooms occupied by a single individual. This study confirms the high burden of scabies and impetigo in Fiji and the association between these two conditions, particularly in young children. Overcrowding, young age, and clinical distribution of lesion are important risk factors for scabies and impetigo. Further studies are needed to investigate whether the decline of endemic scabies would translate into a definite reduction of the burden of associated complications.

The management of scabies outbreaks in residential care facilities for the elderly in England: a review of current health protection guidelines

Commonly thought of as a disease of poverty and overcrowding in resource-poor settings globally, scabies is also an important public health issue in residential care facilities for the elderly (RCFE) in high-income countries such as the UK. We compared and contrasted current local Health Protection Team (HPT) guidelines for the management of scabies outbreaks in RCFE throughout England. We performed content analysis on 20 guidelines, and used this to create a quantitative report of their variation in key dimensions. Although the guidelines were generally consistent on issues such as the treatment protocols for individual patients, there was substantial variation in their recommendations regarding the prophylactic treatment of contacts, infection control measures and the roles and responsibilities of individual stakeholders. Most guidelines did not adequately address the logistical challenges associated with mass treatment in this setting. We conclude that the heterogeneous nature of the guidelines reviewed is an argument in favour of national guidelines being produced.

Scabies outbreak among healthcare workers in a German acute care hospital

BACKGROUND

This article reports on a scabies outbreak among healthcare workers (HCW) in an acute care hospital. The outbreak was associated with a patient suffering from a chronic skin disease that was later diagnosed as crusted scabies.

OBJECTIVE

The objective was to determine the outbreak drivers and define a prevention strategy against future outbreaks.

METHODS

All staff that had contact with the patient were treated with 5% permethrin ointment. An interdisciplinary outbreak investigation team was established. The team conducted a questionnaire-based case-control study.

FINDINGS

After the permethrin treatment, no further case was found. Twenty-seven HCWs who had contact with the index patient answered the questionnaire (response rate 73%). The outbreak questionnaire revealed 13 cases of secondary scabies among HCWs. In the multivariable analysis, a lack of glove use (odds ratio [OR], 9.8; P value = 0.036) and frequent close physical contact (OR, 8.151; P value = 0.038) were associated with increased risk of scabies acquisition.

DISCUSSION

The scabies outbreak was most likely driven by three factors: an index patient with crusted scabies; a delayed diagnosis of this patient; and close physical contact without gloves during his hospital stay. The use of disposable gloves for patients with unclear dermatological diagnosis have the potential to limit future scabies outbreaks.

A scabies outbreak in a diabetic and collagen disease ward: Management and prevention

Scabies is an infection caused by Sarcoptes scabiei. In developed countries, scabies remains an important public health problem in hospitals and care facilities among elderly or immunocompromised patients. There are a number of medical providers who have not experienced scabies and there has been confusion surrounding its management and prevention. Therefore, the aim of the present study was to identify the optimal approach for the management and prevention of scabies. A scabies outbreak occurred between June 2014 and October 2014 in the Toho University School of Medicine, Omori Hospital (Tokyo, Japan), and the current study investigates factors concerning the outbreak, such as disease recognition, diagnostic strategy, medical staff experience and correspondence after the outbreak occurred. Six patients were newly diagnosed with scabies including patients, medical staff and family of the medical staff. An infection control committee was implemented and required a follow-up survey of 181 people (144 patients and 37 medical staff). It took ~4 months to resolve the outbreak. Scabies is highly infectious, and sufficient knowledge is required to care for the patients and prevent the infection of healthy people. In this example, the spread of infection was controlled by prompt action.

A Study of Clinical Profile and Quality of Life in Patients with Scabies at a Rural Tertiary Care Centre

INTRODUCTION

Scabies is a contagious disease primarily related to poverty and overcrowding, it rapidly spreads from person to person specially in people with poor hygiene. We come across many patients from rural areas with scabies. In India the incidence ranges from 13% to 59% in rural and urban areas. Many people complain of sleep disturbances and affection of work and leisure activities due to itching. Very few studies are done in India about the affection of quality of life in such patients.

AIM

To study the demographic details, clinical profile and quality of life in patients with scabies.

MATERIALS AND METHODS

A prospective, observational and cross-sectional study conducted at Department of Dermatology and Venereology, rural based tertiary care centre, Gujarat for a period of 6 months from March to August 2015, after ethical approval from the institute. Study included all patients with clinical features suggestive of scabies. The data including age, sex, occupation, education, socioeconomic status, complaints, past history, family history and clinical features along with the questionnaire for affection of quality of life were recorded in predesigned proforma and detailed analysis was done. Total of 102 newly diagnosed scabies patients attending skin OPD were included in the study.

RESULTS

Out of 102 patients, 50.98% were males. The most common age group affected was 21-40 years, in 44.11% patients. Students were commonly affected with 41.17% followed by housewives with 20.58% cases. Most common lesion seen was papules in 84.3% followed by excoriations in 82.3% cases. Maximum 51.6% adults had small effect on quality of life while 62.5% children reported minimal effect on quality of life.

CONCLUSION

Scabies is an important and commonly encountered health problem which is highly contagious and if not attended timely and adequately can affect the quality of life in the form of work affection, sleep disturbances and psychosocial problems in patients as well as its family members. This could be easily prevented if the patients of scabies are recognised and treated early and proper awareness is must to avoid recurrences. The profile of scabies patients helps in early recognition of scabies even at the peripheral centers.

Therapeutic Potential of Tea Tree Oil for Scabies

Globally, scabies affects more than 130 million people at any time. In the developed world, outbreaks in health institutions and vulnerable communities result in a significant economic burden. A review of the literature demonstrates the emergence of resistance toward classical scabicidal treatments and the lack of effectiveness of currently available scabicides in reducing the inflammatory skin reactions and pyodermal progression that occurs in predisposed patient cohorts. Tea tree oil (TTO) has demonstrated promising acaricidal effects against scabies mites in vitro and has also been successfully used as an adjuvant topical medication for the treatment of crusted scabies, including cases that did not respond to standard treatments. Emerging acaricide resistance threatens the future usefulness of currently used gold standard treatments (oral ivermectin and topical permethrin) for scabies. The imminent development of new chemical entities is doubtful. The cumulative acaricidal, antibacterial, antipruritic, anti-inflammatory, and wound healing effects of TTO may have the potential to successfully reduce the burden of scabies infection and the associated bacterial complications. This review summarizes current knowledge on the use of TTO for the treatment of scabies. On the strength of existing data for TTO, larger scale, randomized controlled clinical trials are warranted.

Scabies

Scabies is a contagious skin infestation caused by a mite. It causes significant global morbidity, with an estimated 300 million cases annually. Although it can affect individuals at any socioeconomic level, individuals who live in poverty or in overcrowded conditions are at much higher risk for scabies. Lack of local expertise can result in failure to recognize scabies, leading to delayed diagnosis and inadequate treatment of cases and contacts. Scabies disproportionately affects many Indigenous (First Nations, Inuit, Métis) communities where risk factors are present. Scabies risk is also higher in young children, the elderly and immunocompromised individuals. Institutional outbreaks of scabies have also been reported. Apart from a very itchy rash, scabies can lead to secondary bacterial infections and related complications, as well as to stigmatization, depression, insomnia and significant financial costs. Topical antiscabies lotions are still the mainstay of treatment, but oral ivermectin has also proven effective under certain circumstances. Asymptomatic and symptomatic household members should all be treated at the same time. In Canada and globally, the presence of scabies is usually a symptom of poor living conditions and a sign that basic necessities need improvement. Clinicians who work with Indigenous communities can improve their ability to diagnose and treat scabies, and should advocate for better living conditions where scabies is prevalent.

The Potential for a Blood Test for Scabies

Background

Scabies afflicts millions of people worldwide, but it is very difficult to diagnose by the usual skin scrape test, and a presumptive diagnosis is often made based on clinical signs such as rash and intense itch. A sensitive and specific blood test to detect scabies would allow a physician to quickly make a correct diagnosis.

Objective

Our objective was to profile the mite-specific antibodies present in the sera of patients with ordinary scabies.

Methods

Sera of 91 patients were screened for Ig, IgD, IgE, IgG and IgM antibodies to S. scabiei, as well as to the house dust mites Dermatophagoides farinae, D. pteronyssinus and Euroglyphus maynei.

Results

45%, 27% and 2.2% of the patients had measurable amounts of mixed Ig, IgG and IgE that recognized scabies mite antigens. However, 73.6% of the scabies patients had serum IgM that recognized scabies proteins, and all except two of them also had IgM that recognized all of the three species of dust mites. No patient had serum antibody exclusively reactive to scabies mite antigens.

Conclusions

Co-sensitization or cross-reactivity between antigens from scabies and house dust mites confounds developing a blood test for scabies.

Scabies, caused by the mite S. scabiei that burrows in the skin of humans, is a contagious skin disease that affects millions of people worldwide. It is a significant public health burden in economically disadvantaged populations, and outbreaks are common in nursing homes, daycare facilities, schools and workplaces in developed countries. It causes significant morbidity, and in chronic cases, associated bacterial infections can lead to renal and cardiac diseases. Scabies is very difficult to diagnose by the usual skin scrape test, and a presumptive diagnosis is often made based on clinical signs such as rash and itch that can mimic other skin disease. A sensitive and specific blood test to detect scabies-specific antibodies would allow a physician to quickly make a correct diagnosis. Our manuscript reports the antibody isotype profiles of the sera of two groups of patients with ordinary scabies (17 from the US and 74 from Brazil) and concludes that such a blood test should be based on circulating IgM type antibodies that do not also recognize antigens of the related and ubiquitous house dust mites. Both are important considerations for research for developing a blood test for the diagnosis of scabies.

Scabies: an ancient global disease with a need for new therapies

BACKGROUND

Scabies is an ancient disease (documented as far back as 2500 years ago). It affects about 300 million people annually worldwide, and the prevalence is as high as about 60% in Indigenous and Torres Strait Islander children in Australia. This is more than six times the rate seen in the rest of the developed world. Scabies is frequently complicated by bacterial infection leading to the development of skin sores and other more serious consequences such as septicaemia and chronic heart and kidney diseases. This causes a substantial social and economic burden especially in resource poor communities around the world.

DISCUSSION

Very few treatment options are currently available for the management of scabies infection. In this manuscript we briefly discuss the clinical consequences of scabies and the problems found (studies conducted in Australia) with the currently used topical and oral treatments. Current scabies treatment options are fairly ineffective in preventing treatment relapse, inflammatory skin reactions and associated bacterial skin infections. None have ovicidal, antibacterial, anti-inflammatory and/or anti-pruritic properties. Treatments which are currently available for scabies can be problematic with adverse effects and perhaps of greater concern the risk of treatment failure. The development of new chemical entities is doubtful in the near future. Though there may be potential for immunological control, the development of a vaccine or other immunotherapy modalities may be decades away. The emergence of resistance among scabies mites to classical scabicides and ineffectiveness of current treatments (in reducing inflammatory skin reactions and secondary bacterial infections associated with scabies), raise serious concerns regarding current therapy. Treatment adherence difficulties, and safety and efficacy uncertainties in the young and elderly, all signal the need to identify new treatments for scabies.

Management of nosocomial scabies, an outbreak of occupational disease

BACKGROUND

The optimal approach to managing institutional scabies outbreaks has yet to be defined. We report on outbreak managements are needed.

METHODS

We report on a large outbreak of scabies in three acute care wards in a tertiary university teaching hospital in the Netherlands.

RESULTS

The outbreak potentially effected 460 patients and 185 health care workers who had been exposed to the index patient.

CONCLUSION

Containment of an outbreak relies on a quick and strict implementation of appropriate infection control measures and should include simultaneous treatment of all infested persons and exposed contacts to prevent secondary spread and prolonged post-intervention surveillance.

Implementing systems thinking for infection prevention: The cessation of repeated scabies outbreaks in a respiratory care ward

BACKGROUND

Root cause analysis (RCA) is often adopted to complement epidemiologic investigation for outbreaks and infection-related adverse events in hospitals; however, RCA has been argued to have limited effectiveness in preventing such events. We describe how an innovative systems analysis approach halted repeated scabies outbreaks, and highlight the importance of systems thinking for outbreaks analysis and sustaining effective infection prevention and control.

METHODS

Following RCA for a third successive outbreak of scabies over a 17-month period in a 60-bed respiratory care ward of a Taiwan hospital, a systems-oriented event analysis (SOEA) model was used to reanalyze the outbreak. Both approaches and the recommendations were compared.

RESULTS

No nosocomial scabies have been reported for more than 1975 days since implementation of the SOEA. Previous intervals between seeming eradication and repeat outbreaks following RCA were 270 days and 180 days. Achieving a sustainable positive resolution relied on applying systems thinking and the holistic analysis of the system, not merely looking for root causes of events.

CONCLUSION

To improve the effectiveness of outbreaks analysis and infection control, an emphasis on systems thinking is critical, along with a practical approach to ensure its effective implementation. The SOEA model provides the necessary framework and is a viable complementary approach, or alternative, to RCA.

Development of Conventional and Real-Time Quantitative PCR Assays for Diagnosis and Monitoring of Scabies

Scabies remains the most prevalent, endemic, and neglected ectoparasitic infestation globally and can cause institutional outbreaks. The sensitivity of routine microscopy for demonstration of Sarcoptes scabiei mites or eggs in skin scrapings is only about 50%. Except for three studies using conventional or two-tube nested PCR on a small number of cases, no systematic study has been performed to improve the laboratory diagnosis of this important infection. We developed a conventional and a real-time quantitative PCR (qPCR) assay based on the mitochondrial cytochrome c oxidase subunit 1 (cox1) gene of S. scabiei. The cox1 gene is relatively well conserved, with its sequence having no high levels of similarity to the sequences of other human skin mites, pathogenic zoonotic mites, or common house dust mite species. This mitochondrial gene is also present in large quantities in arthropod cells, potentially improving the sensitivity of a PCR-based assay. In our study, both assays were specific and were more sensitive than microscopy in diagnosing scabies, with positive and negative predictive values of 100%. The S. scabiei DNA copy number in the microscopy-positive specimens was significantly higher than that in the microscopy-negative specimens (median S. scabiei DNA copy number, 3.604 versus 2.457 log10 copies per reaction; P = 0.0213). In the patient with crusted scabies, the qPCR assay performed on lesional skin swabs instead of scrapings revealed that the parasite DNA load took about 2 weeks to become negative after treatment. The utility of using lesional skin swabs as an alternative sample for diagnosis of scabies by PCR should be further evaluated.

Scabies in the nursing home

Scabies infection is antediluvian and ubiquitous both in developing and developed countries, yet often neglected. Scabies has a predilection to infect vulnerable subsets of population in crowding conditions, typically applicable to residents in the nursing home. The mite incites a unique immunological response from human hosts. Scabies does not manifest as a singular skin condition and may present atypically in older adults, the majority of nursing home residents, where delay has deleterious consequences. Further, pruritus or itching, the hallmark of scabies infection, is a common complaint from a variety of causes among older adults. Hence, the diagnosis is often delayed or missed. There are several pharmacological treatment options; long-term care practitioners need to understand the characteristics of each agent before selection. Even more relevant is the importance of nonpharmacological aspects of management, crucial in the success of averting spread or outbreaks in long-term care settings.

Scabies outbreaks in residential care homes: factors associated with late recognition, burden and impact. A mixed methods study in England

Scabies is an important public health problem in residential care homes. Delayed diagnosis contributes to outbreaks, which may be prolonged and difficult to control. We investigated factors influencing outbreak recognition, diagnosis and treatment, and staff experiences of outbreak control, identifying areas for intervention. We carried out a semi-structured survey of managers, affected residents and staff of seven care homes reporting suspected scabies outbreaks in southern England over a 6-month period. Attack rates ranged from 2% to 50%, and most cases had dementia (37/39, 95%). Cases were diagnosed clinically by GPs (59%) or home staff (41%), none by dermatologists. Most outbreaks were attributable to avoidably late diagnosis of the index case. Participants reported considerable challenges in managing scabies outbreaks, including late diagnosis and recognition of outbreaks; logistically difficult mass treatment; distressing treatment processes and high costs. This study demonstrates the need for improved support for care homes in detecting and managing these outbreaks.

Control of scabies outbreaks in an Italian hospital: an information-centered management strategy

BACKGROUND

Scabies is a dermatologic infestation caused by Sarcoptes scabiei. In industrialized countries, hospitals and other health structures can sometimes be hit. The optimal management of scabies outbreaks still has to be established, mass prophylaxis being one possible option.

METHODS

To identify the optimal approach to containing this re-emerging disease, a local health authority in Lombardy, Northern Italy, carried out an epidemiologic study into 2 scabies epidemics that took place from September to December 2012 in a 600-bed hospital with 26,000 admissions a year.

RESULTS

Over a 3-month period, there were 12 cases of scabies on 4 wards; 43 contacts received prophylaxis. When the first cases were identified, an information campaign involving all hospital personnel was immediately set up. Regular staff meetings were organized, and information leaflets were distributed to patients. Family doctors of discharged patients were informed of the outbreak.

CONCLUSION

A management model based on an information-centered strategy was used in place of mass prophylaxis to deal with scabies epidemics. The success of this approach was confirmed by the managers of the hospital involved (reduced expenditure for prophylactic drugs) and by hospital staff who did not have to deal with potential drug adverse effects.

Interventions for preventing the spread of infestation in close contacts of people with scabies

BACKGROUND

Scabies, caused by Sarcoptes scabiei variety hominis or the human itch mite, is a common parasitic infection. While anyone can become infected, it causes significant morbidity in immunocompromised hosts and it spreads easily between human hosts where there is overcrowding or poor sanitation. The most common symptom reported is itch which is worse at night. As the symptoms are attributed to an allergic reaction to the mite, symptoms usually develop between four to six weeks after primary infection. Therefore, people may be infected for some time prior to developing symptoms. During this time, while asymptomatic, they may spread infection to others they are in close contact with. Consequently, it is usually recommended that when an index case is being treated, others who have been in close contact with the index case should also be provided with treatment.

OBJECTIVES

To assess the effects of prophylactic interventions for contacts of people with scabies to prevent infestation in the contacts.

SEARCH METHODS

We searched electronic databases (Cochrane Occupational Safety and Health Review Group Specialised Register, CENTRAL (The Cochrane Library), MEDLINE (Ovid), Pubmed, EMBASE, LILACS, CINAHL, OpenGrey and WHO ICTRP) up to November 2013.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or cluster RCTs which compared prophylactic interventions which were given to contacts of index cases with scabies infestation. Interventions could be compared to each other, or to placebo or to no treatment. Both drug treatments and non-drug treatments were acceptable.

DATA COLLECTION AND ANALYSIS

Two authors intended to extract dichotomous data (developed infection or did not develop infection) for the effects of interventions and report this as risk ratios with 95% confidence intervals. We intended to report any adverse outcomes similarly.

MAIN RESULTS

We did not include any trials in this review. Out of 29 potentially-relevant studies, we excluded 16 RCTs as the data for the contacts were either not reported or were reported only in combination with the outcomes for the index cases. We excluded a further 11 studies as they were not RCTs. We also excluded one study as not all subjects were examined at baseline and follow-up, and another as it was a case study.

AUTHORS' CONCLUSIONS

The effects of providing prophylactic treatments for contacts of people with scabies to prevent infestation are unknown. We need well-designed RCTs of the use of prophylactic measures to prevent the transmission of scabies conducted with people who had the opportunity for prolonged skin contact with an index case, such as family members, healthcare workers or residential care personnel, within the previous six weeks.

Advanced aging skin and itch: addressing an unmet need

Itch is the most common skin disorder in the elderly and frequently diminishes quality of life in this population. The high prevalence of pruritus in elderly patients is attributed in part to the decline in the normal physiology of the advanced aging skin, and reflects poor hydration, impaired skin barrier, and altered neural function, all ultimately contributing to inflammation and pruritus. As the elderly population continues to grow, practitioners need to be aware of how to evaluate and manage pruritus, recognizing the common conditions contributing to itch in elderly patients as well as the challenges of treatment in this group. Ultimately, management of pruritus will require an individually tailored approach that is guided by a patient's general health, severity of symptoms, and the potential adverse effects of itch therapies.

Infections in psychiatric facilities, with an emphasis on outbreaks

Outbreaks of infectious diseases in psychiatric units are very different from those in intensive care units or acute medical-surgical units. Outbreaks in psychiatric units are most often caused by agents circulating in the community. Infection control in psychiatric units also faces unique challenges due to the characteristics of the patients and facilities.

Scratching the itch: new tools to advance understanding of scabies

Scabies remains a significant public health problem worldwide. Research into aspects of Sarcoptes scabiei biology and host-parasite interactions has been impeded by an inability to maintain mites in vitro and by limited access to parasite material and infected subjects. The generation of comprehensive expressed sequence tag libraries has enabled the initial characterisation of molecules of interest to diagnostics, vaccines, and drug resistance. The recent development and utilisation of animal models, combined with next-generation technologies, is anticipated to lead to new strategies to prevent, diagnose, and treat scabies, ultimately improving skin health in both human and veterinary settings. This article will summarise recent molecular and immunologic advances on scabies, and will address priorities for the exciting 'next chapter' of scabies research.

Rapid control of a scabies outbreak at a tertiary care hospital without ward closure

BACKGROUND

Although scabies outbreaks in hospitals are frequent, the optimal approach to management of these outbreaks has not yet been defined. We describe a hospital scabies outbreak that was successfully controlled without ward closure.

METHODS

An outbreak of scabies at a teaching hospital and subsequent control measures were investigated. Outcomes included the number of cases affecting patients and staff, number of patients and staff requiring prophylaxis, duration of the outbreak, and cost of the outbreak. Outcomes were compared with those in a similar outbreak occurring at the same hospital 20 years earlier and with other published descriptions of hospital scabies outbreaks.

RESULTS

In January 2010, a patient who had undergone renal transplantation was admitted 3 times to St. Michael's Hospital, but a diagnosis of scabies was not considered until the final admission. Widespread exposure of patients and staff on 2 wards prompted the establishment of an outbreak management team. Initial interventions focused on isolation and treatment of the index case and on contact tracing to identify and treat secondary cases and to offer prophylaxis to direct contacts. Five symptomatic staff members and 2 patient cases were quickly identified, an outbreak was declared, and mass simultaneous prophylaxis was initiated on the 2 involved wards. A single case occurred 2 weeks after the mass prophylaxis program in a staff member who had not received the prophylaxis. Six weeks after the onset of symptoms, the end of the outbreak was declared. No additional cases have been reported up to the time of publication. The total cost of the outbreak was $20,000.

CONCLUSIONS

Early recognition of crusted scabies is essential to prevent outbreaks. Once an outbreak occurs, prompt control of the index patient and rapid tracing of contacts to identify secondary cases are necessary. When prolonged exposure to a case of crusted scabies results in multiple secondary cases, institution of simultaneous mass prophylaxis is the most efficient strategy for terminating the outbreak and can be implemented without ward closure.

Control of large institutional scabies outbreaks

BACKGROUND

Scabies outbreaks in community facilities may reach large dimensions and take a protracted course. Highly contagious crusted scabies is a major cause of nosocomial outbreaks.

PATIENTS AND METHODS

On the occasion of an extensive scabies outbreak in a north Bavarian sheltered workshop and its associated residential homes with over 500 exposed individuals, a multifaceted control strategy was developed and pursued. Knowledge from a comprehensive review of the literature was utilized.

RESULTS

Our successful scabies elimination concept includes: 1) Careful organization (formation of an outbreak management team, registration and information of all exposed individuals, prospective time management, financial calculation); 2) simultaneous clinical examination of all individuals at risk; 3) synchronous topical treatment of all exposed individuals with permethrin 5 % cream on day 0, repeated treatment of proven and doubtful cases on days 1 and 14; systemic treatment of selected cases with oral ivermectin; 4) decontamination and quarantine measures; 5) follow-up investigations and repeated treatment if indicated.

CONCLUSIONS

Management of large institutional scabies outbreaks requires a high degree of motivation, communication skills and perseverance.

Pruritus in elderly patients--eruptions of senescence

Geriatric patients are frequently afflicted by pruritic dermatoses. Most pruritic elderly patients present with a skin eruption. The high prevalence of pruritic inflammatory skin disorders in elderly patients is a consequence of three physiological changes that occur with aging: (1) the epidermal barrier repair is diminished; (2) the immune systems of elderly patients are activated and have defective Th1 function along with enhanced Th2 function (immunosenescense); and (3) neurodegenerative disorders may lead to pruritus by their central or peripheral effects. These consequences of aging may all afflict the same patient, explaining why elderly people often have multiple overlapping skin conditions. The following article outlines the pathogenesis of the most common forms of pruritic skin disease in elderly patients and the hallmarks that allow the dermatologist to establish an accurate diagnosis and also suggests a management strategy for each common type of pruritic skin disease in the elderly patient.