Scabies and impetigo prevalence and risk factors in Fiji: a national survey

Costs of primary healthcare presentations and hospital admissions for scabies and related skin infections in Fiji, 2018-2019

Scabies and related bacterial skin and soft tissue infections (SSTIs) are highly prevalent in many tropical, low- and middle-income settings. These skin conditions contribute to higher healthcare costs and burdens on healthcare systems. The Big Skin Health Intervention Fiji Trial ("Big SHIFT") carried out surveillance for scabies and SSTIs from July 2018 to June 2019 in the Northern Division of Fiji, an area with high prevalence of scabies, prior to a division-wide ivermectin-based mass drug administration (MDA) campaign. Using data from Big SHIFT, we sought to estimate the annual direct healthcare costs of scabies and related SSTIs for the Northern Division and extrapolate these costs to the national level. We categorized SSTIs as being potentially scabies-related or unlikely scabies-related, based on a previous study. The analysis used a health system perspective, with the main resource use categories of outpatient visits, bed days during admissions, medicines, and diagnostic tests. We extrapolated the total annual number of cases and direct healthcare costs for all divisions in Fiji based upon previous scabies and impetigo prevalence data across all divisions. The average cost per PHC presentation for scabies was US$17.7, and for potentially scabies-related SSTI was $18.3. The average cost per hospital admission for a potentially scabies-related SSTI case was $439. The estimated annual healthcare costs of scabies and related SSTIs in Fiji was US$3.0 million, with cost per capita of $3.3. Scabies and related SSTIs lead to a heavy economic burden in Fiji and prevention would reduce these healthcare costs.

Acceptability of a nationwide scabies mass drug administration (MDA) program in Fiji: a qualitative interview-based study

Background

Fiji has among the highest global reported prevalence of scabies. Mass drug administration (MDA) has been identified as a potentially effective strategy to control scabies, but acceptability of MDA from the perspectives of people receiving and delivering scabies MDA programs remains underexplored in Fiji and globally.

Methods

A qualitative study was conducted after completion of the national MDA campaign. Participants included 44 community members and 12 key informants across the Central and Western Divisions of Fiji. Semi-structured face-to-face and virtual interviews were conducted in August and September 2023. An interpretive research approach was adopted, and data were analysed using deductive and inductive techniques.

Findings

We identified several barriers and facilitators to scabies MDA acceptability. Facilitators included prior experiences of scabies and knowledge of the potential health benefit of MDA, community attitudes to MDA and neighbours' adherence practices, endorsement of MDA by community leaders, community consultation and exposure to community sensitisation, and involvement of local key informants during planning and implementation. Barriers included a lack of trust in MDA campaigns, religious beliefs, limited reach of community sensitisation, and challenges to implementing MDA in urban locations.

Interpretation

This is the first qualitative study documenting acceptability of a nationwide scabies-MDA globally. It identified diverse socio-structural factors that influenced MDA implementation and acceptability. Future MDA programs could benefit from widespread community sensitisation, tailored approaches to urban and rural MDA design and delivery, and the inclusion of communities in the co-design and implementation of MDA programs.

Funding

The National Health and Medical Research Council (NHMRC) investigator grant-LR and the Macquarie Group Foundation 50th Celebration Awards-AS.

Human scabies and sarcoptic mange in northeast Brazil: Results from a rapid assessment method covering an entire state

Scabies is a neglected tropical disease and has been highlighted as a target for control. Sarcoptic mange affects animals, but mange is also considered a zoonosis. We present rapid assessment data on scabies and sarcoptic mange collected from key informants via a web-based questionnaire in Ceará State (1265 data entries). A total of 181/184 (98.3%) municipalities reported the occurrence of human scabies; 149 (80.9%) current occurrence; 168 (91.3%) severe cases; and 113 (61.4%) severe cases currently. Sarcoptic mange was reported from 149/184 (80.9%) municipalities, and severe mange from 128 (69.9%), most commonly in dogs (117 municipalities), cats (79), pigs (17), cattle (15), horses (15), and goats (2). Respondents from 171 (92.9%) municipalities observed seasonality of occurrence. Scabies and sarcoptic mange are important public health issues in a northeast Brazilian state. The wide distribution of severe cases requires an integrated One Health approach effectively and sustainably to reduce the disease burden.

Traditional healers' perception on scabies causation and management in Ghana

INTRODUCTION

Scabies is an underdiagnosed skin infestation caused by the Sarcoptes scabiei mite. The infection causes severe itching and a skin rash but can be effectively treated using topical or systemic drugs. Scabies outbreaks are commonly reported in resource-poor countries, including Ghana. Traditional healers play an important role in primary care in rural areas. The role of these traditional healers in the management of scabies has so far not been explored. The aim of this study was therefore to investigate the perceptions of traditional healers regarding the causation and management of scabies.

METHODS

A phenomenological qualitative approach was employed. Traditional healers in the Asante Akim North and Central districts in Ghana were approached with an interview request. Using a semi-structured interview protocol, 15 traditional healers were interviewed. The results were coded and analysed, after which seven themes were extrapolated.

RESULTS

Scabies infections were frequently reported by traditional healers. Itching and skin rash were unanimously regarded as the major symptoms of scabies. The majority acknowledged the infectious nature of scabies, but no participant reported the causative organism. A dichotomous disease classification was noted, consisting of 'natural' and 'spiritual' variants each with a unique disease profile and management requirements, as reported by the traditional healers. All but two traditional healers reported to treat scabies using almost exclusively herbs and spiritual rituals.

CONCLUSION

The majority of traditional healers were open to collaboration with allopathic healthcare providers. Collaboration could broaden the primary care network in rural areas, but mistrust and lack of transparency form potential barriers to collaboration. We, therefore, emphasise the need for additional efforts to investigate strategies for future collaboration.

Prevalence and associated risk factors of scabies and impetigo: A cross-sectional study in Tutume district, Botswana

BACKGROUND

The epidemiology of scabies is poorly understood, particularly in regions with high disease burden. This lack of epidemiological data, especially in sub-Saharan Africa, hampers the control and preventative measures. This study is aimed at estimating the prevalence and associated risk factors of scabies and impetigo in the Nata and Sowa catchment areas of Tutume district.

METHODOLOGY

A cross-sectional study was conducted in the Tutume District, targeting the settlements of Manxhotae, Malelejwe, Ndutshaa, and Tshwaane. Participants were randomly selected from households in the settlements. Data were collected using questionnaires, and participants were classified as having scabies typical lesions if they met criteria B and or C of International Alliance for the Control of Scabies (IACS) consensus criteria. Statistical significance was set at p<0.05, with a 95% confidence interval for precision.

RESULTS

A total of 429 participants were enrolled across the four settlements. The overall prevalence of scabies was found to be 18.18% (95%CI 14.8-22.1). The highest prevalence of scabies was in Manxhotae at 27.1% (95%CI 21.2-34.0) and Ndutshaa at 23.4% (95%CI 13.4-37.3). Malelejwe and Tshwaane had lower prevalence of 10.4% (95%CI 6.2-16.8) and 3.4% (95%CI 0.8-12.7), respectively. Only five (5) cases of impetigo were identified. Multivariable logistic regression analysis revealed that younger age of 0-4 years, 5-18 years and a household member with an itch were strongly associated with scabies, with adjusted odds ratios (aOR) of 7.9 (95%CI 2.4-25.6) p-value 0.001, 5.7(95%CI 2.7-11.7), p-value 0.001 and 14.3(95%CI 5.3-38.5) p-value 0.001 respectively.

CONCLUSION

The prevalence of scabies in the Nata catchment area was noted to be high. The risk factors included younger age, a household member with an itch, and less frequent bathing. Prospective studies are needed to explore household disease transmission dynamics and risk factors specific to the youth.

Prevalence and determinants of impetigo in Ghana: a cross-sectional study

INTRODUCTION

Skin diseases such as impetigo pose a significant public health challenge in low resource settings. Despite this, there is a dearth of epidemiological data on the prevalence of this condition in Ghana.

METHODS

We conducted a cross sectional study in three settings in Ghana: community members in East Mamprusi district in the North East region, a secondary school in Sekyere East district, and inmates of the Kumasi central prisons both in the Ashanti region. Following a period of training, we performed a standardised skin examination on each participant to assess for scabies and impetigo. We calculated the prevalence of each skin condition and investigated determinants of impetigo.

RESULTS/ FINDINGS

Of the 1327 participants [males 64.1% and median age 22 (16-29) years], 746 (56.2%) had scabies and 186 (14%) had impetigo which was usually very mild or mild in severity. Most participants with impetigo also had scabies (161/186, 86.6%). Having an itch [RR 6.05 (95% CI 2.53-14.47)], presence of scabies burrows [RR 1.99 (95% CI 1.54-2.59)], clinical scabies [RR 3.15 (2.11-4.72)] or being in preschool [RR 4.56 (1.78-11.67)] increased the risk for impetigo. A combination of the presence of clinical scabies, age, sex and itch most accurately predicted the odds of having impetigo.

CONCLUSIONS

There is substantial burden of impetigo and scabies in Ghana. There is a need to institute measures to improve detection and control of these common dermatoses as part of Universal Health Coverage package to reduce the scourge of the diseases in this setting.

Scabies: Immunopathogenesis and pathological changes

Scabies is an itchy skin disease caused by the burrowing mite Sarcoptes scabiei. During their lifespan, the female mites invade the stratum corneum and create tunnels, in which they reside, move, feed, deposit fecal pellets, and lay eggs. Recently, scabies was included in the World Health Organization roadmap for neglected tropical diseases 2021-2030. This review attempts to summarize our knowledge about the mite's biology and the disease pathogenesis, pathological changes, and complications. Generally, the host-parasite interaction in scabies is highly complex and involves different mechanisms, some of which are yet largely unknown. Elucidation of the nature of such interaction as well as the underlying mechanisms could allow a better understanding of the mite's biology and the development of novel diagnostic and therapeutic options for scabies control programs. Moreover, identification of the molecular basis of such interaction could unveil novel targets for acaricidal agents and vaccines.

Low prevalence of scabies and impetigo in Dakar/Senegal: A cluster-randomised, cross-sectional survey

BACKGROUND

Scabies, a parasitic infection caused by Sarcoptes scabiei var. hominis, is a public health problem with significant morbidity worldwide, particularly in low-resource countries. Impetigo, a complication of scabies infection, is a risk factor for sepsis, glomerulonephritis and possibly acute rheumatic fever. Currently, the majority of epidemiological data has been collected in rural populations in the Pacific with limited applicability to urban populations in sub-Saharan Africa, where scabies is also believed to be a problem. To inform future public health programs, more reliable information about the burden of disease is required.

METHODOLOGY/PRINCIPAL FINDINGS

In July/August 2022, we conducted a cross sectional, cluster-randomised, household survey in Pikine/Dakar using the 'International Association for the Control of Scabies (IACS)' criteria to diagnose scabies and impetigo. All participants underwent a standardised clinical examination by post-graduate dermatology students. For those diagnosed with scabies, an age-adapted 'Dermatology Life Quality Index (DLQI)' questionnaire was filled. We recruited and examined 1697 participants to detect 27 cases of scabies (prevalence: 1.6%, 95% CI 0.8-3.2), mostly in school aged children. Ten participants suffered from impetigo (prevalence: 0.6%, 95% CI 0.3-1.3), 5 of which were dually infected with scabies. Risk factors for scabies infection were young age, male gender and Koranic school attendance. Of those found to have scabies, in 7 out of 22 cases (31.8%) it had a large effect on their lives according to the DLQI questionnaires filled.

CONCLUSIONS/SIGNIFICANCE

This study adds to the mapping of the burden of scabies across Africa to support public health action. With a low prevalence of scabies that is concentrated amongst poor households and children attending Koranic schools, a focused public health approach targeting Koranic schools and poor households seems to be most appropriate in this community.

Children's scabies survey indicates high prevalence and misdiagnosis in Auckland educational institutions

AIM

Here, we present results of a survey of scabies prevalence in childcare centres and primary schools in Auckland.

METHODS

Children whose parents agreed to take part in participating centres in the Auckland region were examined for scabies by general practitioners and given questionnaires of relevant symptoms. Diagnoses of clinical or suspected scabies were made according to the International Alliance for the Control of Scabies (IACS) criteria. The survey was a stratified random sample of schools and early childcare centres. A quantitative polymerase chain reaction (PCR) test was also used to complement the IACS criteria.

RESULTS

A total of 181 children were examined, with 145 children with history information, 16 of whom (11.0%) met the criteria for 'clinical' or 'suspected' scabies. Weighted analysis, accounting for the survey design, indicated that the prevalence of scabies in early childcare centres was 13.2% (95% CI: 4.3 to 22.1), with no school-aged children fulfilling these criteria. A higher proportion had clinical signs of scabies with 23 (12.7%) having typical scabies lesions and a further 43 (23.8%) had atypical lesions. A total of 64 PCR tests were taken and 15 (23%) were positive. None of these cases were receiving treatment for scabies. Five were undergoing topical skin treatment: three with topical steroid and two with calamine lotion.

CONCLUSIONS

The prevalence of children with scabies is high in early childcare centres in Auckland. Misdiagnosis is suggested by several PCR positive cases being treated by topical agents used to treat other skin conditions.

Cloth sharing with a scabies case considerably explains human scabies among children in a low socioeconomic rural community of Ethiopia

BACKGROUND

In 2020, scabies were integrated into the WHO roadmap for neglected tropical diseases, aimed at ending the negligence to realize the SDGs. Ethiopia has also introduced scabies as a notifiable disease in drought-prone localities since 2015. Many of the previous studies employed study designs that might be subject to bias. Moreover, there is no scientific evidence about scabies in this area. Hence, this study aimed to determine the prevalence and associated factors of scabies among children aged below 15 years in rural Ethiopia.

METHODS

A community-based cross-sectional study was carried out among 942 children in rural kebeles of Lay Gayent District from March through May 15, 2021. A two-stage sampling technique was applied. Data on sociodemographics, housing, water supply and sanitation, children's personal hygiene, and caregivers' knowledge about scabies were collected by a structured questionnaire. Data quality was maintained through pretesting, training of data collectors and supervisors, and supervision. An adjusted binary logistic regression was modelled to identify factors associated with scabies. The Hosmer-Lemeshow goodness-of-fit test was run to check the model fitness.

RESULTS

The prevalence of scabies was 21.5% (95% CI 19.0-24.3). Maternal illiteracy (adjusted odds ratio (AOR) = 1.61; 95% CI 1.07-2.43); low household wealth (AOR = 2.04; 95% CI 1.25-3.33); unimproved water source (AOR = 1.58; 95% CI 1.05-2.40); not cleaning a house daily (AOR = 2.43; 95% CI 1.63-3.62); not trimming nails (AOR = 2.21; 95% CI 1.50-3.25); cloth sharing with a scabies case (AOR = 11.77; 95% CI 6.94-19.97); and low caregiver knowledge about scabies (AOR = 2.44; 95% CI 1.64-3.63) were factors associated with scabies.

CONCLUSIONS

Scabies remains a significant public health issue among children aged below 15 years in the district. Maternal illiteracy, low household wealth, unimproved water source, not cleaning a house daily, not trimming nails, cloth sharing with a scabies case, and low caregiver knowledge about scabies were factors associated with scabies. Community-wide interventions with prime emphasis on improving maternal education and caregivers' knowledge about scabies, upgrading household wealth, ensuring a safe water supply, providing healthy housing, and ensuring adequate personal hygiene are warranted.

Prevalence of scabies worldwide-An updated systematic literature review in 2022

Scabies is a World Health Organization-defined neglected tropical disease, with continuously rising incidence worldwide in recent years. The aim of this study was to provide an update of the worldwide prevalence and new treatment approaches of scabies in population-based settings. MEDLINE (PubMed), Embase and LILACS databases were reviewed for English and German language population-based studies from October 2014 to March 2022. Two authors independently screened the records for eligibility, extracted all data and one critically appraised the quality of the studies and risk of bias. Systematic review registration: PROSPERO CRD42021247140. Overall, 1273 records were identified through database searching, of which 43 studies were included for the systematic review. Most of the studies (n = 31) examined the scabies prevalence in medium or low human development index countries. The highest prevalence of scabies reported in the general population (children and adults) was recorded in five randomly selected communities in Ghana (71.0%), whereas the highest scabies prevalence in studies, which only examined children (76.9%), was recorded in an Indonesian boarding school. The lowest prevalence was recorded in Uganda (0.18%). The systematic review highlights the prevalence of scabies worldwide, showing that scabies is still a serious, increasing disease that occurs globally and is clustered in developing countries. More transparent data on scabies prevalence are needed to identify risk factors to find new prevention measures.

Scabies prevalence after ivermectin-based mass drug administration for lymphatic filariasis, Samoa 2018-2019

BACKGROUND

Scabies is a common skin infestation caused by the Sarcoptes scabei mite. Ivermectin, one of three drugs used in mass drug administration (MDA) for lymphatic filariasis, is also effective for treating scabies. Ivermectin-based MDA was first conducted in Samoa in August 2018, with ivermectin being offered to those aged ≥5 years. Here, we report scabies prevalence in Samoa after MDA.

METHODS

We conducted household surveys 1.5-3.5 months (Survey 1) and 6-8 months (Survey 2) after the 2018 MDA in 35 primary sampling units. We conducted clinical examination for scabies-like rash and used International Alliance for the Control of Scabies classification criteria. We estimated scabies prevalence by age, gender and region. Multivariable logistic regression was used to assess factors associated with prevalence.

RESULTS

We surveyed 2868 people (499 households) and 2796 people (544 households) aged 0-75 years in Surveys 1 and 2, respectively. Scabies prevalence increased from 2.4% (95% CI 2.1-2.7%) to 4.4% (95% CI 4.0-4.9%) between surveys. Scabies was associated with younger age (0-4 years: aOR 3.5 [2.9-4.2]; 5-15 years: aOR 1.6 [1.4-1.8] compared to ≥16 years), female gender (aOR 1.2 [95% CI 1.1-1.4]; region (aOR range from 1.4 [1.1-1.7] to 2.5 [2.1-3.1] between regions), large households (aOR 2.6 [2.0-3.4] households ≥13), and not taking MDA in 2018 (aOR 1.3 [95% CI 1.1-1.6]).

CONCLUSIONS

We found moderate prevalence of scabies in two population-representative surveys conducted within 8 months of the 2018 MDA for lymphatic filariasis. Prevalence appeared to increase between the surveys, and ongoing surveillance is recommended, particularly in young children.

Culturally supported health promotion to See, Treat, Prevent (SToP) skin infections in Aboriginal children living in the Kimberley region of Western Australia: a qualitative analysis

Background

While there are many skin infections, reducing the burden of scabies and impetigo for remote living Aboriginal people, particularly children remains challenging. Aboriginal children living in remote communities have experienced the highest reported rate of impetigo in the world and are 15 times more likely to be admitted to hospital with a skin infection compared to non-Aboriginal children. Untreated impetigo can develop into serious disease and may contribute to the development of acute rheumatic fever (ARF) and rheumatic heart disease (RHD). As the largest organ protecting the body and visible to everyone, skin infections are often unsightly and very painful, therefore maintaining healthy skin and reducing the burden of skin infections is important for overall physical and cultural health and well-being. Biomedical treatments alone will not address these factors; therefore, a holistic, strengths-based approach that aligns with the Aboriginal world view of wellness is required to help reduce the prevalence of skin infections and their downstream consequences.

Methods

Culturally appropriate yarning sessions with community members were conducted between May 2019 and November 2020. Yarning sessions have been identified as a valid method for story sharing and collecting information. Semi-structured, face-to-face interviews and focus groups with school and clinic staff were conducted. When consent was provided, interviews were audio-recorded and saved as a digital recording in a de-identified format; for those yarning sessions not recorded, handwritten notes were scribed. Audio recordings and handwritten notes were uploaded into NVivo software prior to a thematic analysis being conducted.

Findings

Overall, there was a strong knowledge of recognition, treatment, and prevention of skin infections. However, this did not extend to the role skin infections play in causing ARF, RHD or kidney failure. Our study has confirmed three main findings: 1. The biomedical model of treatment of skin infections remained strong in interviews with staff living in the communities; 2. Community members have a reliance and belief in traditional remedies for skin infections; and 3. Ongoing education for skin infections using culturally appropriate health promotion resources.

Interpretation

While this study revealed ongoing challenges with service practices and protocols associated with treating and preventing skin infections in a remote setting, it also provides unique insights requiring further investigation. Bush medicines are not currently practiced in a clinic setting, however, using traditional medicines alongside biomedical treatment procedures facilitates cultural security for Aboriginal people. Further investigation, and advocacy to establish these into practice, procedures and protocols is warranted. Establishing protocols and practice procedures focused on improving collaborations between service providers and community members in remote communities is also recommended.

Funding

Funding was received from the National Health and Medical Research Council [NHMRC] (GNT1128950), Health Outcomes in the Tropical NORTH [HOT NORTH 113932] (Indigenous Capacity Building Grant), and WA Health Department and Healthway grants contributed to this research. A.C.B. receives a NHMRC investigator Award (GNT1175509). T.M. receives a PhD scholarship from the Australian Centre for Elimination of Neglected Tropical Diseases (ACE-NTD), an NHMRC centre of excellence (APP1153727).

One versus two doses of ivermectin-based mass drug administration for the control of scabies: A cluster randomised non-inferiority trial

BACKGROUND

Mass drug administration (MDA) based on two doses of ivermectin, one week apart, substantially reduces prevalence of both scabies and impetigo. The Regimens of Ivermectin for Scabies Elimination (RISE) trial assessed whether one-dose ivermectin-based MDA would be as effective.

METHODS

RISE was a cluster-randomised trial in Solomon Islands. We assigned 20 villages in a 1:1 ratio to one- or two-dose ivermectin-based MDA. We planned to test whether the impact of one dose on scabies prevalence at 12 and 24 months was non-inferior to two, at a 5% non-inferiority margin.

RESULTS

We deferred endpoint assessment to 21 months due to COVID-19. We enrolled 5239 participants in 20 villages at baseline and 3369 at 21 months from an estimated population of 5500. At baseline scabies prevalence was similar in the two arms (one-dose 17·2%; two-dose 13·2%). At 21 months, there was no reduction in scabies prevalence (one-dose 18·7%; two-dose 13·4%), and the confidence interval around the difference included values substantially greater than 5%. There was however a reduction in prevalence among those who had been present at the baseline assessment (one-dose 15·9%; two-dose 10·8%). Additionally, we found a reduction in both scabies severity and impetigo prevalence in both arms, to a similar degree.

CONCLUSIONS

There was no indication of an overall decline in scabies prevalence in either arm. The reduction in scabies prevalence in those present at baseline suggests that the unexpectedly high influx of people into the trial villages, likely related to the COVID-19 pandemic, may have compromised the effectiveness of the MDA. Despite the lack of effect there are important lessons to be learnt from this trial about conducting MDA for scabies in high prevalence settings.

TRIAL REGISTRATION

Registered with Australian New Zealand Clinical Trials Registry ACTRN12618001086257.

Proteomic analysis of Sarcoptes scabiei reveals that proteins differentially expressed between eggs and female adult stages are involved predominantly in genetic information processing, metabolism and/or host-parasite interactions

Presently, there is a dearth of proteomic data for parasitic mites and their relationship with the host animals. Here, using a high throughput LC-MS/MS-based approach, we undertook the first comprehensive, large-scale proteomic investigation of egg and adult female stages of the scabies mite, Sarcoptes scabiei-one of the most important parasitic mites of humans and other animals worldwide. In total, 1,761 S. scabiei proteins were identified and quantified with high confidence. Bioinformatic analyses revealed differentially expressed proteins to be involved predominantly in biological pathways or processes including genetic information processing, energy (oxidative phosphorylation), nucleotide, amino acid, carbohydrate and/or lipid metabolism, and some adaptive processes. Selected, constitutively and highly expressed proteins, such as peptidases, scabies mite inactivated protease paralogues (SMIPPs) and muscle proteins (myosin and troponin), are proposed to be involved in key biological processes within S. scabiei, host-parasite interactions and/or the pathogenesis of scabies. These proteomic data will enable future molecular, biochemical and physiological investigations of early developmental stages of S. scabiei and the discovery of novel interventions, targeting the egg stage, given its non-susceptibility to acaricides currently approved for the treatment of scabies in humans.

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.

The efficacy of sampling strategies for estimating scabies prevalence

Background

Estimating community level scabies prevalence is crucial for targeting interventions to areas of greatest need. The World Health Organisation recommends sampling at the unit of households or schools, but there is presently no standardised approach to scabies prevalence assessment. Consequently, a wide range of sampling sizes and methods have been used. As both prevalence and drivers of transmission vary across populations, there is a need to understand how sampling strategies for estimating scabies prevalence interact with local epidemiology to affect the accuracy of prevalence estimates.

Methods

We used a simulation-based approach to compare the efficacy of different scabies sampling strategies. First, we generated synthetic populations broadly representative of remote Australian Indigenous communities and assigned a scabies status to individuals to achieve a specified prevalence using different assumptions about scabies epidemiology. Second, we calculated an observed prevalence for different sampling methods and sizes.

Results

The distribution of prevalence in subpopulation groups can vary substantially when the underlying scabies assignment method changes. Across all of the scabies assignment methods combined, the simple random sampling method produces the narrowest 95% confidence interval for all sample sizes. The household sampling method introduces higher variance compared to simple random sampling when the assignment of scabies includes a household-specific component. The school sampling method overestimates community prevalence when the assignment of scabies includes an age-specific component.

Discussion

Our results indicate that there are interactions between transmission assumptions and surveillance strategies, emphasizing the need for understanding scabies transmission dynamics. We suggest using the simple random sampling method for estimating scabies prevalence. Our approach can be adapted to various populations and diseases.

Scabies is a parasitic infestation that is commonly observed in disadvantaged populations. A wide range of sampling sizes and methods have been used to estimate scabies prevalence. With differing key drivers of transmission and varying prevalence across populations, it can be challenging to determine an effective sampling strategy. In this study, we propose a simulation approach to compare the efficacy of different sampling methods and sizes. First, we generate synthetic populations and then assign a scabies status to individuals to achieve a specified prevalence using different assumptions about scabies epidemiology. Second, we calculate an observed prevalence for different sampling methods and sizes. Our results indicate that there are interactions between transmission assumptions and surveillance strategies. We suggest using the simple random sampling method for estimating prevalence as it produces the narrowest 95% confidence interval for all sampling sizes. We propose guidelines for determining a sample size to achieve a desired level of precision in 95 out 100 samples, given estimates of the population size and a priori estimates of true prevalence. Our approach can be adapted to various populations, informing an appropriate sampling strategy for estimating scabies prevalence with confidence.

Prevention of bacterial complications of scabies using mass drug administration: A population-based, before-after trial in Fiji, 2018-2020

BACKGROUND

Scabies is an important predisposing factor of impetigo which can lead to serious bacterial complications. Ivermectin-based mass drug administration can substantially reduce scabies and impetigo prevalence in endemic settings, but the impact on serious bacterial complications is not known.

METHODS

We conducted a before-after trial in the Northern Division of Fiji (population: 131,914) of mass drug administration for scabies control. Prospective surveillance was conducted from 2018 to 2020. Mass drug administration took place in 2019, involving two doses of oral ivermectin or topical permethrin, delivered alongside diethylcarbamazine and albendazole for lymphatic filariasis. The primary outcomes were incidence of hospitalisations with skin and soft tissue infections, and childhood invasive infections and post-streptococcal sequelae. Secondary outcomes included presentations to primary healthcare with skin infections and community prevalence of scabies and impetigo.

FINDINGS

The incidence of hospitalisations with skin and soft tissue infections was 17% lower after the intervention compared to baseline (388 vs 467 per 100,000 person-years; incidence rate ratio 0.83, 95% CI, 0.74 to 0.94; P = 0.002). There was no difference in incidence of childhood invasive infections and post-streptococcal sequelae. Incidence of primary healthcare presentations with scabies and skin infections was 21% lower (89.2 vs 108 per 1000 person-years, incidence rate ratio, IRR 0.79, 95% CI, 0.78 to 0.82). Crude community prevalence of scabies declined from 14.2% to 7.7% (cluster-adjusted prevalence 12.5% to 8.9%; prevalence ratio 0.71, 95% CI, 0.28 to 1.17). Cluster-adjusted prevalence of impetigo declined from 15.3% to 6.1% (prevalence ratio 0.4, 95% CI, 0.18 to 0.86).

INTERPRETATION

Mass drug administration for scabies control was associated with a substantial reduction in hospitalisations for skin and soft tissue infections.

FUNDING

National Health and Medical Research Council of Australia and Scobie and Claire Mackinnon Trust.

Community perceptions and acceptability of mass drug administration for the control of neglected tropical diseases in Asia-Pacific countries: A systematic scoping review of qualitative research

Background

Preventative chemotherapy and mass drug administration have been identified as effective strategies for the prevention, treatment, control and elimination of several NTDs in the Asia-Pacific region. Qualitative research can provide in-depth insight into the social dynamics and processes underlying effective implementation of and adherence to mass drug administration programs. This scoping review examines published qualitative literature to examine factors influencing community perceptions and acceptability of mass drug administration approaches to control NTDs in the Asia-Pacific region.

Methodology

Twenty-four peer reviewed published papers reporting qualitative data from community members and stakeholders engaged in the implementation of mass drug administration programs were identified as eligible for inclusion.

Findings

This systematic scoping review presents available data from studies focussing on lymphatic filariasis, soil-transmitted helminths and scabies in eight national settings (India, Indonesia, Philippines, Bangladesh, Laos, American Samoa, Papua New Guinea, Fiji). The review highlights the profoundly social nature of individual, interpersonal and institutional influences on community perceptions of willingness to participate in mass drug administration programs for control of neglected tropical diseases (NTD). Future NTD research and control efforts would benefit from a stronger qualitative social science lens to mass drug administration implementation, a commitment to understanding and addressing the social and structural determinants of NTDs and NTD control in complex settings, and efforts to engage local communities as equal partners and experts in the co-design of mass drug administration and other efforts to prevent, treat, control and eliminate NTDs.

Conclusion

For many countries in the Asia-Pacific region, the “low hanging fruit has been picked” in terms of where mass drug administration has worked and transmission has been stopped. The settings that remain–such as remote areas of Fiji and Papua New Guinea, or large, highly populated, multi-cultural urban settings in India and Indonesia–present huge challenges going forward.

Qualitative research can provide in-depth insight into the social dynamics and processes underlying effective implementation of and adherence to mass drug administration programs. This scoping review examines published qualitative literature to examine factors influencing community perceptions and acceptability of mass drug administration approaches to control neglected tropical diseases (NTDs) in the Asia-Pacific region. Our analyses highlight the profoundly social nature of individual, interpersonal and institutional influences on community perceptions of willingness to participate in mass drug administration programs for control of NTDs. For many countries in the Asia-Pacific region, the “low hanging fruit has been picked” in terms of where mass drug administration has worked and transmission has been stopped. The settings that remain–e.g. remote areas of Fiji and Papua New Guinea, or large, highly populated, multi-cultural urban settings in India and Indonesia–present huge challenges going forward. Future NTD research and control efforts would benefit from a stronger qualitative social science lens to mass drug administration implementation, a commitment to understanding the socio-structural determinants of NTDs and NTD control in complex settings, and engaging local communities as equal partners and experts in the co-design of mass drug administration and other efforts to prevent, treat, control and eliminate NTDs.

Costs of mass drug administration for scabies in Fiji

In 2019, the Murdoch Children’s Research Institute in partnership with the Fiji Ministry of Health and Medical Services carried out an integrated mass drug administration (MDA) for the treatment of scabies and lymphatic filariasis in the Northern Division of Fiji (population estimate 131,914). We conducted a retrospective micro-costing exercise focused on the cost of scabies control in order to inform budgeting and policy decision making in an endemic setting. We collected detailed information on financial and economic costs incurred by both parties during the course of the MDA campaign (April 2018 to July 2019). We also conducted interviews with personnel involved in the financial administration of the MDA campaign. The economic cost of delivering two doses of ivermectin was US$4.88 per person. The cost of donated drugs accounted for 36.3% of total MDA costs. In this first large-scale MDA for the public health control of scabies, the estimated cost of delivering MDA per person for scabies was considerably more expensive than the costs reported for other neglected tropical diseases. The important cost drivers included the remuneration of health care workers who were extensively involved in the campaign, coverage of hard-to-reach, mainly rural populations and the two-dose regimen of ivermectin. These results highlight the importance of these cost determinants and can be used to plan current and future MDA programs.

Scabies poses a significant burden on both health and economic systems. The Global Burden of Disease estimated that this skin disease affects more than 200 million people globally. However, the economic burden of scabies has not been studied widely and there are limited data on the cost of treating scabies in highly endemic areas. We conducted a costing study of a mass drug administration (MDA) program in the Northern Division of Fiji (population of 131,914). We collected financial and economic costs of administering ivermectin and permethrin to the whole of the Northern Division population in order to estimate the per capita cost of delivering MDA. The costs of MDA for scabies in Fiji were higher than those estimated in previous studies of MDA for other neglected tropical diseases. The study highlights significant cost components of implementing a large-scale MDA and provides key insights for the design and implementation of future MDA programs for scabies. It also adds to the general knowledge in understanding cost inputs and estimating the overall cost-effectiveness of this public health intervention.

An RNA Interference Tool to Silence Genes in Sarcoptes scabiei Eggs

In a quest for new interventions against scabies-a highly significant skin disease of mammals, caused by a parasitic mite Sarcoptes scabiei-we are focusing on finding new intervention targets. RNA interference (RNAi) could be an efficient functional genomics approach to identify such targets. The RNAi pathway is present in S. scabiei and operational in the female adult mite, but other developmental stages have not been assessed. Identifying potential intervention targets in the egg stage is particularly important because current treatments do not kill this latter stage. Here, we established an RNAi tool to silence single-copy genes in S. scabiei eggs. Using sodium hypochlorite pre-treatment, we succeeded in rendering the eggshell permeable to dsRNA without affecting larval hatching. We optimised the treatment of eggs with gene-specific dsRNAs to three single-copy target genes (designated Ss-Cof, Ss-Ddp, and Ss-Nan) which significantly and repeatedly suppressed transcription by ~66.6%, 74.3%, and 84.1%, respectively. Although no phenotypic alterations were detected in dsRNA-treated eggs for Ss-Cof and Ss-Nan, the silencing of Ss-Ddp resulted in a 38% reduction of larval hatching. This RNAi method is expected to provide a useful tool for larger-scale functional genomic investigations for the identification of essential genes as potential drug targets.

Estimation of scabies prevalence using simplified criteria and mapping procedures in three Pacific and southeast Asian countries

Background

Scabies causes considerable morbidity in disadvantaged populations. The International Alliance for the Control of Scabies (IACS) published consensus criteria in 2020 to standardize scabies diagnosis. However, these criteria are complex, and a WHO informal consultation proposed simplified criteria for mapping, to identify regions of high prevalence as targets for mass drug administration. We aimed to investigate the accuracy of simplified criteria in determining scabies prevalence, compared to the 2020 IACS criteria.

Methods

We obtained data relating to demographics, relevant history and skin lesions from all-age prevalence surveys from Fiji (n = 3365) and Solomon Islands (n = 5239), as well as school-aged children in Timor-Leste (n = 1043). We calculated prevalence using the 2020 IACS criteria and simplified criteria and compared these disease estimates.

Results

There was no significant difference in the pooled prevalence using the two methods (2020 IACS criteria: 16.6%; simplified criteria: 15.6%; difference = 0.9, [95% CI -0.1, 2.0]). In Timor-Leste, the prevalence using simplified criteria was lower (26.5% vs 33.8%). Simplified criteria had a sensitivity of 82.3% (95% CI 80.2, 84.2) and specificity of 97.6% (95% CI 97.2, 97.9) compared to the 2020 IACS criteria.

Conclusions

The scabies prevalence estimation using simplified criteria was similar to using the 2020 IACS criteria in high prevalence, tropical countries. The prevalence estimation was lower in the school-based survey in Timor-Leste. Mapping using simplified criteria may be a feasible and effective public health tool to identify priority regions for scabies control. Further work assessing use of simplified criteria for mapping in a field setting should be conducted.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12039-2.

Community control strategies for scabies: A cluster randomised noninferiority trial

BACKGROUND

Scabies is a neglected tropical disease hyperendemic to many low- and middle-income countries. Scabies can be successfully controlled using mass drug administration (MDA) using 2 doses of ivermectin-based treatment. If effective, a strategy of 1-dose ivermectin-based MDA would have substantial advantages for implementing MDA for scabies at large scale.

METHODS AND FINDINGS

We did a cluster randomised, noninferiority, open-label, 3-group unblinded study comparing the effectiveness of control strategies on community prevalence of scabies at 12 months. All residents from 35 villages on 2 Fijian islands were eligible to participate. Villages were randomised 1:1:1 to 2-dose ivermectin-based MDA (IVM-2), 1-dose ivermectin-based MDA (IVM-1), or screen and treat with topical permethrin 5% for individuals with scabies and their household contacts (SAT). All groups also received diethylcarbamazine and albendazole for lymphatic filariasis control. For IVM-2 and IVM-1, oral ivermectin was dosed at 200 μg/kg and when contraindicated substituted with permethrin. We designated a noninferiority margin of 5%. We enrolled 3,812 participants at baseline (July to November 2017) from the 35 villages with median village size of 108 (range 18 to 298). Age and sex of participants were representative of the population with 51.6% male and median age of 25 years (interquartile range 10 to 47). We enrolled 3,898 at 12 months (July to November 2018). At baseline, scabies prevalence was similar in all groups: IVM-2: 11.7% (95% confidence interval (CI) 8.5 to 16.0); IVM-1: 15.2% (95% CI 9.4 to 23.8); SAT: 13.6% (95% CI 7.9 to 22.4). At 12 months, scabies decreased substantially in all groups: IVM-2: 1.3% (95% CI 0.6 to 2.5); IVM-1: 2.7% (95% CI 1.1 to 6.5); SAT: 1.1% (95% CI 0.6 to 2.0). The risk difference in scabies prevalence at 12 months between the IVM-1 and IVM-2 groups was 1.2% (95% CI -0.2 to 2.7, p = 0.10). Limitations of the study included the method of scabies diagnosis by nonexperts, a lower baseline prevalence than anticipated, and the addition of diethylcarbamazine and albendazole to scabies treatment.

CONCLUSIONS

All 3 strategies substantially reduced prevalence. One-dose was noninferior to 2-dose ivermectin-based MDA, as was a screen and treat approach, for community control of scabies. Further trials comparing these approaches in varied settings are warranted to inform global scabies control strategies.

TRIAL REGISTRATION

Clinitrials.gov NCT03177993 and ANZCTR N12617000738325.

Scabies as a part of the World Health Organization roadmap for neglected tropical diseases 2021-2030: what we know and what we need to do for global control

Background

Scabies is an under-recognized global health problem with an unacceptably high prevalence in many settings worldwide. Fortunately, the World Health Organization (WHO) has formally designated scabies as a neglected tropical disease in 2017, in the hope of increasing awareness and encouraging efforts to eradicate it. Also, scabies has recently been included as part of the WHO roadmap for neglected tropical diseases 2021–2030, aimed at ending the neglect to attain the Sustainable Development Goals.

Main abstract body

This review article places scabies in focus. The literature was reviewed to explore discussions on controversial issues in scabies control, with the aim of clarifying whether global control of scabies is a feasible and worthwhile objective. The existing status of scabies and its burden are discussed along with future prospects for its global control. The article investigates the feasibility of scabies control and provides updates on the various impediments to this goal, such as challenges related to transmission, diagnosis, treatment, and vaccine development. Also examined are relevant research needs, success factors, and reasons for failure. This article aims to increase the global awareness of scabies and promote discussion, enhance coordinated international efforts, and ultimately, enact change at the national and worldwide levels toward the control of this preventable disease of the poor.

Conclusion

Despite the current challenges, scabies control is now within reach. With sustained interventions, continuous resources, and sincere commitment and support, scabies global control appears to be a worthwhile, realistic goal that is potentially achievable in the not so distant future.

Sarcoptes Infestation. What Is Already Known, and What Is New about Scabies at the Beginning of the Third Decade of the 21st Century?

Currently, there are three known subtypes of scabies: ordinary, crusted, and bullous. The worldwide prevalence of scabies remains high in the 21st century. To decrease the social, economic, and psychological impact on the enormous population infected, a lot of important work has been completed over the last 20 years concerning the management of scabies. For example, a standardization of guidelines for the treatment of scabies has been completed and programs have been designed for the prevention and treatment in endemic populations, called mass drug administrations. Unfortunately, these only apply to the ordinary form of scabies. Moreover, resistance to the drugs currently used in treatment is growing, which imposes the need to search for new treatments. For this purpose, new acaricides are being developed to enhance the therapeutic options for the patients' benefit and effectively treat this disease. There is also the necessity for prevention before the development of scabies. An effective vaccine has the potential to protect people before this disease, especially in endemic areas. Unfortunately, there are no such vaccines against Sarcoptes yet.

Prospective Surveillance of Primary Healthcare Presentations for Scabies and Bacterial Skin Infections in Fiji, 2018-2019

Scabies, impetigo, and other skin and soft tissue infections (SSTIs) are highly prevalent in many tropical, low-middle income settings, but information regarding their burden of disease is scarce. We conducted a surveillance of presentations of scabies and SSTIs, including impetigo, abscesses, cellulitis, and severe SSTI, to primary health facilities in Fiji. We established a monthly reporting system over the course of 50 weeks (July 2018-June 2019) for scabies and SSTIs at all 42 public primary health facilities in the Northern Division of Fiji (population, ≈131,914). For each case, information was collected regarding demographics, diagnosis, and treatment. There were 13,736 individual primary healthcare presentations with scabies, SSTI, or both (108.3 presentations per 1000 person-years; 95% confidence interval [CI], 106.6-110 presentations). The incidence was higher for males than for females (incidence rate ratio [IRR], 1.15; 95% CI, 1.11-1.19). Children younger than 5 years had the highest incidence among all age groups (339.1 per 1000 person-years). The incidence was higher among the iTaukei (indigenous) population (159.9 per 1000 person-years) compared with Fijians of Indian descent (30.1 per 1000 person-years; IRR, 5.32; 95% CI, 5.03-5.61). Abscesses had the highest incidence (63.5 per 1,000 person-years), followed by scabies (28.7 per 1,000 person-years) and impetigo (21.6 per 1,000 person-years). Scabies and SSTIs impose a substantial burden in Fiji and represent a high incidence of primary health presentations in this population. The incidence in low-middle income settings is up to 10-times higher than that in high-income settings. New public health strategies and further research are needed to address these conditions.

Prospective surveillance for invasive Staphylococcus aureus and group A Streptococcus infections in a setting with high community burden of scabies and impetigo

BACKGROUND

Invasive Staphylococcus aureus (iSA) and group A Streptococcus (iGAS) impose significant health burdens globally. Both bacteria commonly cause skin and soft tissue infections (SSTIs), which can result in invasive disease. Understanding of the incidence of iSA and iGAS remains limited in settings with a high SSTI burden.

METHODS

Prospective surveillance for admissions with iSA or iGAS was conducted at the referral hospital in Fiji's Northern Division over 48 weeks between July 2018 and June 2019.

RESULTS

There were 55 admissions for iSA and 15 admissions for iGAS (incidence 45.2 and 12.3 per 100,000 person-years, respectively). The highest incidence was found in patients aged ≥65 years (59.6 per 100,000 person-years for iSA and iGAS). The incidence of iSA was higher in indigenous Fijians (iTaukei) (71.1 per 100,000 person-years) compared with other ethnicities (incidence rate ratio 9.7, 95% confidence interval 3.5-36.9). SSTIs were found in the majority of cases of iSA (75%) and iGAS (53.3%). Thirteen of the 14 iGAS strains isolated belonged to emm cluster D (n = 5) or E (n = 8). The case fatality rate was high for both iSA (10.9%) and iGAS (33.3%).

CONCLUSIONS

The incidence of iSA and iGAS in Fiji is very high. SSTIs are common clinical foci for both iSA and iGAS. Both iSA and iGAS carry a substantial risk of death. Improved control strategies are needed to reduce the burden of iSA and iGAS in Fiji.

Paediatrics: how to manage scabies

This narrative review addresses scabies, a highly contagious, pruritic infestation of the skin caused by the mite Sarcoptes scabiei var hominis. Scabies is a common disorder that has a prevalence worldwide estimated to be between 200 and 300 million cases per year. Infestation is of greatest concern in children, the elderly, immunocompromised people and resource-poor endemic populations at risk of chronic complications. A diagnosis of scabies involves a clinical suspicion, a detailed targeted history, clinical examination and contact tracing. Dermoscopy and microscopy, where available, is confirmatory. Due to its infectivity and transmissibility, the management for scabies requires a multimodal approach: topical antiscabetic agents are the first line for most cases of childhood classic scabies and their contacts, which must also be identified and treated to prevent treatment failure and reacquisition. Environmental strategies to control fomite-related reinfestation are also recommended. Oral ivermectin, where available, is reserved for use in high-risk cases in children or in mass drug administration programmes in endemic communities. The prevention of downstream complications of scabies includes surveillance, early identification and prompt treatment for secondary bacterial infections, often superficial but can be serious and invasive with associated chronic morbidity and mortality. Post-scabetic itch and psychosocial stigma are typical sequelae of the scabies mite infestation. The early identification of patients with scabies and treatment of their contacts reduces community transmission. Although time consuming and labour intensive for caregivers, the implementation of appropriate treatment strategies usually results in prompt cure for the child and their contacts. Here, we provide a summary of treatments and recommendations for the management of paediatric scabies.

Prevalence of scabies and impetigo in school-age children in Timor-Leste

Background

Scabies and impetigo are endemic in many tropical, low- and middle-income countries. Mass drug administration (MDA) with ivermectin has emerged as a control strategy for these conditions. In 2019, Timor-Leste Ministry of Health planned to implement MDA including ivermectin for the control of lymphatic filariasis, so we undertook a baseline assessment of scabies and impetigo to better understand local epidemiology and contribute to future surveys assessing the impact of MDA.

Methods

A cross-sectional school survey was conducted in April–May 2019 at six primary schools in a semi-urban (Dili) and two rural (Ermera and Manufahi) settings. Children under 19 years of age present at school on survey days were eligible to participate, of whom we enrolled 1183. Trained health workers interviewed and examined 1043 participants to clinically diagnose scabies using the 2020 International Alliance for the Control of Scabies (IACS) diagnostic criteria, as well as impetigo. Prevalence was adjusted for age and sex. Mixed-effects logistic regression models were used to analyse odds of scabies and impetigo infection. All models accounted for clustering at the school level through the use of random effect terms. Population attributable risk of scabies as a cause of impetigo was also estimated.

Results

The overall weighted prevalence of scabies was 30.6%. Children in rural Manufahi were more likely to have scabies than those in semi-urban Dili (53.6% vs 28.2%, adjusted odds ratio [AOR] 3.5). Most cases of scabies were mild (3 to 10 lesions), and lesions were usually distributed on more than one body region. Scabies prevalence was lower among 10 to 14 year olds compared to 5 to 9 year olds. Overall weighted prevalence of impetigo was 11.3%. Relative to Dili, children in rural Ermera and Manufahi were twice as likely to have impetigo. Impetigo was twice as common in children with scabies than in those without, corresponding to an attributable risk of scabies as a cause of impetigo of 22.7%.

Conclusions

Scabies and impetigo prevalence in Timor-Leste is among the highest reported globally, particularly in rural areas. Scabies infestation was strongly associated with impetigo. Comprehensive control strategies are urgently needed in Timor-Leste.

A multicenter, community-based, mixed methods assessment of the acceptability of a triple drug regimen for elimination of lymphatic filariasis

Background

Many countries will not reach elimination targets for lymphatic filariasis in 2020 using the two-drug treatment regimen (diethylcarbamazine citrate [DEC] and albendazole [DA]). A cluster-randomized, community-based safety study performed in Fiji, Haiti, India, Indonesia and Papua New Guinea tested the safety and efficacy of a new regimen of ivermectin, DEC and albendazole (IDA).

Methodology/Principal findings

To assess acceptability of IDA and DA, a mixed methods study was embedded within this community-based safety study. The study objective was to assess the acceptability of IDA versus DA. Community surveys were performed in each country with randomly selected participants (>14 years) from the safety study participant list in both DA and IDA arms. In depth interviews (IDI) and focus group discussions (FGD) assessed acceptability-related themes. In 1919 individuals, distribution of sex, microfilariae (Mf) presence and circulating filarial antigenemia (CFA), adverse events (AE) and age were similar across arms. A composite acceptability score summed the values from nine indicators (range 9–36). The median (22.5) score indicated threshold of acceptability. There was no difference in scores for IDA and DA regimens. Mean acceptability scores across both treatment arms were: Fiji 33.7 (95% CI: 33.1–34.3); Papua New Guinea 32.9 (95% CI: 31.9–33.8); Indonesia 30.6 (95% CI: 29.8–31.3); Haiti 28.6 (95% CI: 27.8–29.4); India 26.8 (95% CI: 25.6–28) (P<0.001). AE, Mf or CFA were not associated with acceptability. Qualitative research (27 FGD; 42 IDI) highlighted professionalism and appreciation for AE support. No major concerns were detected about number of tablets. Increased uptake of LF treatment by individuals who had never complied with MDA was observed.

Conclusions/Significance

IDA and DA regimens for LF elimination were highly and equally acceptable in individuals participating in the community-based safety study in Fiji, Haiti, India, Indonesia, and Papua New Guinea. Country variation in acceptability was significant. Acceptability of the professionalism of the treatment delivery was highlighted.

The acceptability of a new combination treatment regimen for lymphatic filariasis (ivermectin, plus DEC and albendazole, or IDA) was assessed as part of a larger community-based safety study in Fiji, Haiti, India, Indonesia and Papua New Guinea. To understand how trial participants and communities felt about the new treatment, a survey was carried out with people who had participated in the safety study receiving either the standard treatment [DEC plus albendazole (DA)] or the new treatment regimen (IDA). Focus group discussions and in-depth interviews were performed in the same communities. Results showed that there was no difference in acceptability between the DA and IDA. Adverse events and presence of filarial infection did not affect acceptability. The most important indicator associated with acceptability was country. All countries accepted the treatment regimens. Fiji had the highest acceptability scores, followed by Papua New Guinea, Indonesia, Haiti and India. Results from the qualitative research showed that study participants appreciated the professionalism of the drug delivery team and the support offered for the management of any adverse events.

Defining the need for public health control of scabies in Solomon Islands

Pacific Island countries have a high burden of scabies and impetigo. Understanding of the epidemiology of these diseases is needed to target public health interventions such as mass drug administration (MDA). The aim of this study is to determine the prevalence of scabies and impetigo in Solomon Islands as well as the relationship between them and their distribution. We conducted a prevalence study in 20 villages in Western Province in Solomon Islands. All residents of the village were eligible to participate. Nurses conducted clinical assessments including history features and skin examination. Diagnosis of scabies was made using the 2020 International Alliance for the Control of Scabies diagnostic criteria. Assessments were completed on 5239 participants across 20 villages. Overall scabies prevalence was 15.0% (95%CI 11.8-19.1). There was considerable variation by village with a range of 3.3% to 42.6%. There was a higher prevalence of scabies in males (16.7%) than females (13.5%, adjusted relative risk 1.2, 95%CI 1.1-1.4). Children aged under two years had the highest prevalence (27%). Overall impetigo prevalence was 5.6% (95%CI 4.2-7.3), ranging from 1.4% to 19% by village. The population attributable risk of impetigo associated with scabies was 16.1% (95% CI 9.8-22.4). The prevalence of scabies in our study is comparable to previous studies in Solomon Islands, highlighting a persistent high burden of disease in the country, and the need for public health strategies for disease control.

Prevalence of Scabies and Impetigo 3 Years After Mass Drug Administration With Ivermectin and Azithromycin

Background

Ivermectin-based mass drug administration has emerged as a promising strategy for the control of scabies and impetigo in settings where the diseases are endemic. Current follow-up data are limited to 12 months for the majority of studies. Longer-term data are vital to inform the sustainability of interventions.

Methods

We conducted a prevalence survey for scabies and impetigo in 10 villages in Choiseul Province of the Solomon Islands 36 months after a single round of ivermectin and azithromycin mass drug coadministration. In the primary analysis, we compared the prevalence of scabies and impetigo at 36 months to the prevalence at baseline.

Results

At 36 months, the prevalence of scabies was 4.7% (95% confidence interval [CI], 3.6–6.1), which was significantly lower than at baseline (18.7%; relative reduction, 74.9%; 95% CI, 61.5%–87.7%; P < .001). The prevalence of impetigo was 9.6% (95% CI, 8.1%–11.4%), significantly lower than at baseline (24.7%; relative reduction, 61.3%; 95% CI, 38.7%–100%; P < .001). The highest prevalence of scabies was among children aged <5 years (12.5%; adjusted odds ratio, 33.2; 95% CI, 6.6–603.2), and the highest prevalence of impetigo was among children aged 5–9 years (16.4%; adjusted odds ratio, 8.1; 95% CI, 3.6–21.8).

Conclusions

There was a sustained impact of a single round of ivermectin and azithromycin mass drug coadministration on the prevalence of scabies and impetigo 3 years after the intervention. Our data provide further support to adopt this intervention as a central component of global scabies control efforts.

Clinical Trials Registration

Australian and New Zealand Trials Registry (ACTRN12615001199505).

Determinants of scabies outbreak in Takusa district of Amhara Region, Northwest Ethiopia

Background

Human scabies is a highly contagious human dermatitis disease. As indicated by the national and regional reports, the epidemic of scabies became a major public health problem in Ethiopia since 2015.

Objective

To identify the determinant factors of scabies outbreak in Takusa district, Northwest Ethiopia, 2017.

Methods

A community based unmatched case-control study among 188 participants (63 cases and 125 controls) was conducted in Takusa district from September to October 2017. Data were collected using a pretested structured questionnaire. Multivariable logistic regression analysis was computed using SPSS version 22 to identify factors associated with scabies. Odds ratio at 95% CI and p-value less than 0.05 were used to describe the strength of the association and statistical significance.

Results

The median age of cases was 20 years (ranges1-61). Presence of person with itching in the family (AOR=7.7, 95% CI:1.9-30.5), sleeping with scabies patient (AOR=3.99, 95% CI:1.37-11.7), travel to scabies epidemic area in the last six weeks (AOR=3.79, 95%CI:1.28-11.1) and infrequent use of detergent for showering (AOR=4.85; 95% CI: 1.3-17.9)) were found to be determinant factors of scabies outbreak.

Conclusion

Frequent contact with people who develop scabies at home, not using detergents for washing, and mobility of people from non-epidemic to the epidemic areas were determinant factors. Giving special emphasis on regular awareness creation to the rural community is important to prevent scabies outbreak.

Scabies and impetigo in Samoa: A school-based clinical and molecular epidemiological study

Background

Common infections of the skin such as impetigo and scabies represent a large burden of disease globally, being particularly prevalent in tropical and resource-limited settings. Efforts to address these infections through mass drug administrations have recently been shown as efficacious and safe. In Samoa, a Pacific Island nation, there is a marked lack of epidemiological data for these neglected tropical diseases, or appreciation of their drivers in this setting.

Methods

An observational, cross-sectional survey of children aged between 4 and 15 years attending primary schools in rural areas of Upolu Island, Samoa was carried out to assess the prevalence of impetigo and scabies in schoolchildren residing in rural Samoa, integrated with descriptive epidemiological and microbial genomic data. A phylogenetic assessment of local Staphylococcus aureus isolated from Samoan schoolchildren was performed to estimate putative community transmission.

Findings

In this survey, the prevalence of impetigo observed in Samoan schoolchildren was one of the highest described globally (57•1%, 95% CI [53•8-60•5%], 476/833). Associations between active impetigo and age and gender were noted, with younger children and males more commonly affected (aOR2•8 [1•8-4•7]and aOR1•8 [1•3-2•5], respectively). The prevalence of scabies was similar to that seen in other South Pacific island countries (14•4%, 95% CI [12•2-17•0%], 120/833). Transmission of S. aureus was predicted, primarily between those children attending the same school. Carriage of S. pyogenes was notably low, with pharyngeal carriage observed in less than 2% of schoolchildren, consistent with earlier studies from Samoa.

Interpretation

This study describes a considerable burden of disease attributed to impetigo and scabies in Samoa. These findings will be valuable in addressing the public health challenge posed by these conditions, providing baseline prevalence data and highlighting practical strategies to reduce transmission of relevant microbes and parasites in this setting.

Tala Tomua

O a'afiaga o le pa'u i fa'ama'i o le po'u (impetigo) ma le utu o le pa'u (scabies), ua tele naua le fanau ua maua ai i le pasefika, ma le lalolagi atoa. O fuafuaga vaai mamao ma polokalame e fofoina ai nei faafitauli, e aofia ai le inumaga o fualaau e tapeina ai nei fa'ama'i, ua aliali mai ai e mafai ona faatamaia nei fa'ama'i. E le o tele ni tusitusiga ma faamaumauga i totonu o Samoa, pe ta'atele nei fa'amai o le pa'u pe leai. Ona o le le faatauaina o nei fa'ama'i, e le o iloa fo'i ni mafuaga ma nisi tulaga e faateleina ai nei fa'ama'i o le pa'u i Samoa.

Faatinoina o le suesuega

O le suesuega faasaenisi i le fanau aoga i le va o le 4 ma le 15 tausaga o loo ao'oga i le tulaga lua i nisi o nu'u i tua i Upolu, na faatinoina ai suesuega lea, ia suesueina ai le aotelega ma fainumera o le fanau ua maua i fa'ama'I o le po'u (impetigo) ma le utu o le pa'u (scabies). O lenei foi suesuega, na fia iloa ai fo'i po'o a ituaiga siama eseese o loo maua i luga o pa'u ma tino o le fanau aoga, ina ia iloa ai foi auala ua pipisi ai nei siama mai le isi tamaitiiti i le isi, ona mafua ai lea o nei fa'ama'i o le pa'u.

Tanuuga o le suesuega

Ua faailoa mai i le suesuega, le ta'atele o le fa'ama'i o le po'u (impetigo) ua maua ai le fanau aoga (57%), i aoga na faia ai le suesuega. O se fainumera ua maualuga tele i le lalolagi atoa. E toatele atu nisi o le fanau laiti (younger) ma tama (male) e maua i le po'u nai lo isi tamaiti. O le fainumera o le utu o le pa'u (scabies) (14·4%) e tai tutusa lava ma isi motu o le Pasefika. O le feaveaina o le siama faapitoa (staph aureus) ua tupu lea i le fanau ua ao'oga i le aoga e tasi. E le toatele foi nisi o le fanau (2%) na maua i le siama faapitoa o le fa'ai (strep pyogenes) e ona mafua ai le fiva rumatika. O lenei fainumera ua tai tutusa ma suesuega faasaenisi na fai muamua i Samoa.

Aotelega

O le aotelega la o lenei suesuega faasaenisi, ua faailoaina mai ai le tele naua o le fa'ama'i o le pa'u, o po'u (impetigo) ma le utu o le pa'u (scabies) i Samoa nei. O nei foi suesuega o le a aoga tele ini polokalame ma ni fuafuaga mamao e fa'afoisia ai nei faafitauli i le soifua maloloina o le fanau i Samoa. O le a avea foi nei fainumera e faamaumauina mo le silafia e le atunuu ma le soifua maloloina, le ta'atele o nei fa'amai o le pa'u, mo le tapenaina o ni fofo talafeagai ise taimi o i luma, ina ia faaitiitina ai le pipisi o nei siami i fanau ao'oga i Samoa.

A scabies outbreak in the North East Region of Ghana: The necessity for prompt intervention

Background

There is a dearth of data on scabies from Ghana. In September 2019, local health authorities in the East Mamprusi district of northern Ghana received reports of scabies from many parts of the district. Due to on-going reports of more cases, an assessment team visited the communities to assess the effect of the earlier individual treatment on the outbreak. The assessment team furthermore aimed to contribute to the data on scabies burden in Ghana and to demonstrate the use of the International Alliance for the Control of Scabies (IACS) diagnostic tool in a field survey in a resource limited setting.

Methodology/Principal findings

This was a cross sectional study. Demographic information and medical history was collected on all participants using a REDCap questionnaire. A standardised skin examination of exposed regions of the body was performed on all participants. Scabies was diagnosed based on the criteria of the International Alliance for the Control of Scabies (IACS). Participants were mostly female (61.5%) and had a median age of 18.8 years (IQR 13–25). Two hundred out of 283 (71%) of participants had scabies with most (47%) presenting with moderate disease. Impetigo was found in 22% of participants with scabies and 10.8% of those without scabies [RR 2.27 (95% CI 1.21–4.27)]. 119 participants who received scabies treatment in the past months still had clinical evidence of the disease. 97% of participants reported a recent scabies contact. Scabies was commoner in participants ≤16 years compared to those >16 years [RR 3.06 (95% CI 1.73–5.45)].

Conclusion/Significance

The prevalence of scabies was extremely high. The lack of a systematic approach to scabies treatment led to recurrence and ongoing community spread. The IACS criteria was useful in this outbreak assessment in Ghana. Alternative strategies such as Mass drug administration may be required to contain outbreaks early in such settings.

Scabies, recently categorised as a Neglected Tropical Disease by the WHO is caused by infestation with Sarcoptes scabiei and is characterised by intense pruritus and rash that typically involves the genitalia and the web spaces of the fingers and toes. It has a large global burden and is associated with significant morbidity and socio-economic burden. Secondary bacterial infections following scabies can lead to significant complications including chronic kidney disease from glomerulonephritis and possibly rheumatic heart disease. An outbreak of scabies was reported in Ghana’s East Mamprusi district in September 2019. Despite earlier treatment of individual cases, scabies prevalence was 71%. About 19% of participants had impetigo which was mostly mild in severity. Absence of a systematic approach to treat scabies led to recurrence and ongoing community spread. The recently published IACS criteria for diagnosing scabies proved useful in this outbreak assessment in Ghana. Alternative strategies such as Mass drug administration may be required to contain outbreaks in such settings.

Burden of skin disease and associated socioeconomic status in Asia: A cross-sectional analysis from the Global Burden of Disease Study 1990-2017

Introduction

Skin diseases have a significant global impact on quality of life, mental health, and loss of income. The burden of dermatologic conditions and its relationship with socioeconomic status in Asia is currently not well understood.

Methods

We selected Global Burden of Disease Study datasets to analyze disability-adjusted life years (DALYs) in 50 Asian countries, including Central Asia, northern Asia, eastern Asia, western Asia, southeastern Asia, and southern Asia, between 1990 and 2017. We compared DALYs to the socioeconomic status using the sociodemographic index and gross domestic product per capita of a country. Statistical analysis was performed using Pearson's correlation.

Results

Some countries had higher or lower than expected age-standardized DALY rates of skin diseases. Asian countries, especially high-income countries, had a high burden of inflammatory dermatoses, including acne, alopecia areata, atopic dermatitis, contact dermatitis, decubitus ulcers, psoriasis, pruritus, and seborrheic dermatitis. The burden of infectious dermatoses was greater in low-income Asian countries. The burden of skin cancer in Asia was relatively low.

Conclusion

There is a high burden of skin disease, especially inflammatory conditions, in Asian countries, but the burden of individual dermatoses in Asia varies by country and socioeconomic status. DALYs can potentially serve as a purposeful measure for directing resources to improve the burden of skin disease in Asia.

Hospital admissions for skin and soft tissue infections in a population with endemic scabies: A prospective study in Fiji, 2018-2019

Scabies is an important predisposing factor for impetigo but its role in more serious skin and soft tissue infections (SSTIs) is not well understood. Information is limited on incidence of SSTIs in the presence of endemic scabies. We conducted a prospective study of hospital admissions for SSTIs in the Northern Division of Fiji (population: 131,914). Prospective surveillance for admissions with impetigo, abscess, cellulitis, wound infection, pyomyositis, necrotizing fasciitis, infected scabies, and crusted scabies was conducted at the Division’s referral hospital between 2018 to 2019. Information was collected on demographic characteristics, clinical features, microbiology, treatment and outcomes. Over the study period, 788 SSTI admissions were recorded corresponding to a population incidence 647 per 100,000 person-years (95%CI 571–660). Incidence was highest at the extremes of age with peak incidence in children aged <5 years (908 per 100,000) and those aged ≥65 years (1127 per 100,000). Incidence was 1.7 times higher among the Indigenous Fijian population (753 per 100,000) compared to other ethnicities (442 per 100,000). Overall case fatality rate was 3.3%, and 10.8% for those aged ≥65 years. Scabies was diagnosed concurrently in 7.6% of all patients and in 24.6% of admitted children <5 years. There is a very high burden of hospital admissions for SSTIs in Fiji compared to high-income settings especially among the youngest, oldest and indigenous population which is concordant with scabies and impetigo distribution in this population. Our findings highlight the need for strategies to reduce the burden of SSTIs in Fiji and similar settings.

Scabies is causally linked to impetigo in endemic populations. In turn, impetigo can progress to more serious skin and soft tissue infections (SSTI). However, there are few data on the epidemiology of SSTIs in settings where scabies is endemic. We conducted a prospective study of the incidence of hospitalizations for SSTIs in 2018 and 2019 at the referral centre for the Northern Division of Fiji (population of 131,914) where community scabies prevalence is very high. We measured the incidence of admissions for abscesses, cellulitis, impetigo, wound infections, pyomyositis, necrotizing fasciitis and crusted scabies. We observed a high incidence of SSTI admissions (647 cases per 100,000 person-years) with high associated morbidity and case fatality in this population. We found a very high incidence in young children, the elderly and iTaukei (Indigenous Fijian) population which is concordant with the distribution of scabies and impetigo in the community. These findings highlight SSTIs as an important public health concern and provide further impetus to advance research into strategies that will alleviate this burden.

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.

Scabies and its associated factors among under 15 years children in Wadila district, Northern Ethiopia, 2019

INTRODUCTION

scabies is a contagious ectoparasite of the skin. It is caused by the mite Sarcoptes scabiei var. hominis that causes a pruritic skin eruption. It was estimated that more than 300 million cases of scabies occur worldwide every year. It remains one of the commonest skin diseases seen in developing countries including Ethiopia. Therefore, the main aim of this study is to determine scabies prevalence and its associated factors among less than 15 years children in Wadila district, Northern Ethiopia.

METHODS

community based cross-sectional study was conducted on 583 participants from January 30th to February 28th 2019. Multistage sampling technique was used and data were collected using pre-tested interviewer administered questionnaire. SPSS version 23.0 was used for analysis and bivariable logistic regression was computed and variables having p < 0.25 was modelled in multi-variable logistic regression to control confounders. The level of statistical significance was set at p < 0.05.

RESULTS

the prevalence of scabies infestation was 23.8% in Wadila district. Not using of soap when taking shower [AOR=2.93 (95% CI:1.72-5.00)], using unimproved water source [AOR=1.82 (95% CI:1.04-3.16)], sharing clothes from scabies cases [AOR=10.10 (95% CI: 3.37-30.23)], uncleaning of the house every day [AOR=2.28 (95% CI: 1.32-3.95)], presence of pet animals at home [AOR= 3.01(95% CI: 1.66-5.45)] and went to epidemic areas of scabies [AOR= 4.09 (95% CI: 2.37-7.06) were predictors of scabies infestation.

CONCLUSION

there was higher prevalence of scabies infestation in Wadila district. Therefore, special attention should be given to under 15 years children.

A community-based validation of the International Alliance for the Control of Scabies Consensus Criteria by expert and non-expert examiners in Liberia

Background

The International Alliance for the Control of Scabies (IACS) recently published expert consensus criteria for scabies diagnosis. Formal validation of these criteria is needed to guide implementation. We conducted a study to provide detailed description of the morphology and distribution of scabies lesions as assessed by dermatologists and validate the IACS criteria for diagnosis by both expert and non-expert examiners.

Methods

Participants from a community in Monrovia, Liberia, were independently assessed by two dermatologists and six non-expert examiners. Lesion morphology and distribution were documented based on the dermatologist examination. Diagnoses were classified by IACS criteria and the sensitivity and specificity of non-expert examiner assessments calculated.

Results

Papules were the most common lesions (97.8%). Burrows were found in just under half (46.7%) and dermatoscopy was positive in a minority (13.3%). Scabies lesions were found in all body regions but more than 90% of patients could have been diagnosed by an examination of only the limbs. Severity of itch was associated with lesion number (p = 0.003). The sensitivity of non-expert examiners to detect typical scabies ranged between 69–83% and specificity 70–96%. The sensitivity of non-expert examiners was higher in more extensive disease (78–94%).

Conclusions

The IACS criteria proved a valid tool for scabies diagnosis. For the purposes of implementation papules and burrows represent truly ‘typical’ scabies lesions.

Non-expert examiners are able to diagnose scabies with a high degree of accuracy, demonstrating they could form a key component in population-level control strategies.

Scabies is a very common skin condition in both high- and low-income settings with hundreds of millions of people affected each year. Recently standardised criteria have been proposed to help improve the quality of scabies diagnosis, in particular in low income settings where the access to a skin specialist is very limited.

In this study, conducted in Liberia, expert examiners conducted a thorough examination and recorded what different types of skin problems they found in participants with and without scabies. We then compared the accuracy of a diagnosis of scabies made by dermatologists to that made by non-specialist healthcare workers who had received a short training course over three days.

We found that papules were the most common type of scabies lesion and were found in almost every single patient with scabies. A second type of skin lesion called a burrow was the next most common and was found in just under half of the participants. Other types of scabies lesions which have been described were rare in this study. We found that after the short training course the non-specialists were able to detect the majority of the cases of scabies correctly.

Our study has helped provide detailed data on exactly what types of skin changes are typical of scabies and demonstrated how short training programmes can help improve the skill of non-specialist examiners in diagnosing scabies.

Estimation of the force of infection and infectious period of skin sores in remote Australian communities using interval-censored data

Prevalence of impetigo (skin sores) remains high in remote Australian Aboriginal communities, Fiji, and other areas of socio-economic disadvantage. Skin sore infections, driven primarily in these settings by Group A Streptococcus (GAS) contribute substantially to the disease burden in these areas. Despite this, estimates for the force of infection, infectious period and basic reproductive ratio-all necessary for the construction of dynamic transmission models-have not been obtained. By utilising three datasets each containing longitudinal infection information on individuals, we estimate each of these epidemiologically important parameters. With an eye to future study design, we also quantify the optimal sampling intervals for obtaining information about these parameters. We verify the estimation method through a simulation estimation study, and test each dataset to ensure suitability to the estimation method. We find that the force of infection differs by population prevalence, and the infectious period is estimated to be between 12 and 20 days. We also find that optimal sampling interval depends on setting, with an optimal sampling interval between 9 and 11 days in a high prevalence setting, and 21 and 27 days for a lower prevalence setting. These estimates unlock future model-based investigations on the transmission dynamics of skin sores.

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.

Prevalence of scabies in Sanma Province, Vanuatu

BACKGROUND

Scabies is a common, under-reported condition in the Pacific with acute and chronic complications. In this study we explored the prevalence of scabies in Sanma Province, Vanuatu.

METHODS

We randomly selected 30 villages from nine government zones across three islands and examined residents present within these villages for scabies. Bivariate analysis and multilevel models were conducted to investigate associated demographic and household factors.

RESULTS

Of 1879 participants examined, 563 had scabies (30%, 95% CI 27.9 to 32.1) with the highest prevalence in children aged 6-10 y (38.8%, 95% CI 33.9 to 44).

CONCLUSIONS

Scabies is a significant issue in Sanma with very high prevalence in children.

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).

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.

The safety of combined triple drug therapy with ivermectin, diethylcarbamazine and albendazole in the neglected tropical diseases co-endemic setting of Fiji: A cluster randomised trial

Lymphatic filariasis has remained endemic in Fiji despite repeated mass drug administration using the well-established and safe combination of diethylcarbamazine and albendazole (DA) since 2002. In certain settings the addition of ivermectin to this combination (IDA) remains a safe strategy and is more efficacious. However, the safety has yet to be described in scabies and soil-transmitted helminth endemic settings like Fiji. Villages of Rotuma and Gau islands were randomised to either DA or IDA. Residents received weight-based treatment unblinded with standard exclusions. Participants were actively found and asked by a nurse about their health daily for the first two days and then asked to seek review for the next five days if unwell. Anyone with severe symptoms were reviewed by a doctor and any serious adverse event was reported to the Medical Monitor and Data Safety Monitoring Board. Of 3612 enrolled and eligible participants, 1216 were randomised to DA and 2396 to IDA. Age and sex in both groups were representative of the population. Over 99% (3598) of participants completed 7 days follow-up. Adverse events were reported by 600 participants (16.7%), distributed equally between treatment groups, with most graded as mild (93.2%). There were three serious adverse events, all judged not attributable to treatment by an independent medical monitor. Fatigue was the most common symptom reported by 8.5%, with headache, dizziness, nausea and arthralgia being the next four most common symptoms. Adverse events were more likely in participants with microfilaremia (43.2% versus 15.7%), but adverse event frequency was not related to the presence of scabies or soil-transmitted helminth infection. IDA has comparable safety to DA with the same frequency of adverse events experienced following community mass drug administration. The presence of co-endemic infections did not increase adverse events. IDA can be used in community programs where preventative chemotherapy is needed for control of lymphatic filariasis and other neglected tropical diseases.

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.

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.