Long Term Control of Scabies Fifteen Years after an Intensive Treatment Programme

No secondary impact of ivermectin mass drug administration for onchocerciasis elimination on the prevalence of scabies in northwestern Ethiopia

BACKGROUND

Mass drug administration (MDA) is among the five major strategies that are currently in use to control, eliminate or eradicate Neglected Tropical Diseases (NTDs). Optimising MDA to control multiple NTDs maximises impact. The objective of this study is to estimate the secondary impact of ivermectin MDA for onchocerciasis on the prevalence of scabies.

METHODS

This quasi-experimental study was conducted in Ayu Guagusa district, northwestern Ethiopia. Scabies prevalence was estimated in surveys before the MDA, at 6 and 12 months afterwards. The sample size was 1437 people from a panel of 381 randomly selected study households. Multistage sampling was employed in randomly selecting six kebeles (the lowest administrative unit) with respective gotes (small villages) and households. All members of the selected households were invited to participate in the study and participants who were available in all three surveys formed a cohort.

RESULTS

Scabies prevalence was similar prior to the MDA (13.4%, 95% CI 11.7 to 15.2%) and 6 months after (11.7%, 95% CI 10.1 to 13.2%) but was substantially greater at 12 months (22.1%, 95% CI 20.1 to 24.1%). The 6-month incidence and disappearance rates were 10.8% (95% CI 8.8 to 13.2%) and 82.6% (95% CI 75.0 to 88.6%), respectively.

CONCLUSIONS

Ivermectin MDA for onchocerciasis was not observed to have a secondary impact on the prevalence of scabies over the follow-up period of 12 months.

Living in a large family and low daily water consumption substantially expose for human scabies in rural Ethiopia: a matched analysis

BACKGROUND

Scabies has been added to the neglected tropical diseases portfolio for large-scale disease control action since 2017 and is part of the WHO roadmap for NTDs 2021-2030, targeted at ending the neglect to achieve the sustainable development goals. Previous studies have not fitted matched analysis to identify predictors of scabies infestation in Ethiopia. Information is also scarce about predictors of scabies infestation in this area. Therefore, this study aimed to identify predictors of scabies infestation in rural Aneded District, northwest Ethiopia.

METHODS

A community-based matched case-control study involving 183 cases and 549 controls was undertaken from March 1 to May 31, 2021, in rural Aneded District. A two-stage sampling technique with a house-to-house census for the screening of scabies cases was employed. A structured questionnaire with questions on sociodemographics, behavior, water supply, sanitation, and hygiene, and delivery of scabies-specific interventions was used. Pretesting, training of data collectors and supervisors, and supervision were applied to keep the data quality. A multivariable conditional logistic regression model was fitted to identify predictors of scabies.

RESULTS

Unmarried individuals or those in separated families (adjusted matched odds ratio (AmOR = 2.71; 95% CI 1.30-5.65); those unable to read and write or in illiterate families (AmOR = 5.10; 95% CI 1.81-14.36); those in large families (AmOR = 6.67; 95% CI 2.83-15.73); households that had longer travel times for water collection (AmOR = 2.27; 95% CI 1.08-4.76); those that had low daily water consumption (AmOR = 6.69; 95% CI 2.91-15.37); households that disposed of solid wastes in open fields (AmOR = 5.60; 95% CI 2.53-12.40); and households that did not receive scabies-specific interventions (AmOR = 2.98; 95% CI 1.39-6.39) had increased odds of scabies.

CONCLUSIONS

Being unmarried, illiteracy, large family, long travel time for water collection, low daily water consumption, open dumping of solid wastes, and inaccessibility of scabies-specific interventions are predictors of scabies. This information is instrumental for redesigning improved scabies-specific interventions that consider educational status, marital status, family size, water collection time, daily water consumption, solid waste disposal, and equity and optimization in delivering existing interventions in rural Ethiopia.

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

OBJECTIVES

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

DESIGN

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

SETTING

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

PARTICIPANTS

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

RESULTS

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

CONCLUSIONS

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

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.

Modelling mass drug administration strategies for reducing scabies burden in Monrovia, Liberia

Scabies is a parasitic infestation with high global burden. Mass drug administrations (MDAs) are recommended for communities with a scabies prevalence of >10%. Quantitative analyses are needed to demonstrate the likely effectiveness of MDA recommendations. In this study, we developed an agent-based model of scabies transmission calibrated to demographic and epidemiological data from Monrovia. We used this model to compare the effectiveness of MDA scenarios for achieving scabies elimination and reducing scabies burden, as measured by time until recrudescence following delivery of an MDA and disability-adjusted-life-years (DALYs) averted. Our model showed that three rounds of MDA delivered at six-month intervals and reaching 80% of the population could reduce prevalence below 2% for three years following the final round, before recrudescence. When MDAs were followed by increased treatment uptake, prevalence was maintained below 2% indefinitely. Increasing the number of and coverage of MDA rounds increased the probability of achieving elimination and the number of DALYs averted. Our results suggest that acute reduction of scabies prevalence by MDA can support a transition to improved treatment access. This study demonstrates how modelling can be used to estimate the expected impact of MDAs by projecting future epidemiological dynamics and health gains under alternative scenarios.

Mass drug administration for the control of scabies: a systematic review and meta-analysis

BACKGROUND

Scabies is a neglected tropical disease of the skin that can lead to impetigo, serious secondary bacterial infections and immune-mediated diseases. Mass drug administration (MDA) has been reported in several studies to reduce the prevalence of scabies and impetigo. We aimed to assess the efficacy of MDA for scabies on scabies and impetigo.

METHODS

We conducted a systematic review and meta-analysis of reports on the impact of MDA on scabies and impetigo. We included randomised control trials and observational evaluations reported from January 1970 to April 2021 and involving human participants. We searched PubMed, Ovid Medline, Embase and Cochrane. We considered MDA as treatment intended for the whole population, regardless of individual infection status or symptoms. The main outcome assessed was the change in scabies and impetigo prevalence following MDA. This review is registered with PROSPERO (CRD42020169839).

RESULTS

We identified 1110 records, of which 11 met inclusion criteria for the review and 9 were deemed suitable for meta-analysis for scabies and four for impetigo. Most studies were in small populations. There was a high degree of heterogeneity between studies (I 2 value 96·19%). The overall relative reduction of the impact of MDA on scabies prevalence was 79%. The effect size was comparable for MDA based on ivermectin and permethrin. MDA for scabies also led to a reduction in impetigo prevalence with a relative reduction of 66%.

CONCLUSIONS

MDA for scabies is highly effective in reducing the prevalence of scabies and impetigo. Further research is needed to determine the durability of impact, and the effectiveness of MDA regimens in larger populations.

Mass drug administration for endemic scabies: a systematic review

Background

Scabies is an extremely fastidious infestation caused by the Sarcoptes scabiei mite. It causes a persistent itch that can disrupt a person’s mental health, sleep, and overall quality of life. In endemic areas, treatment by targeting symptomatic individuals and their contacts is often unsuccessful due to an asymptomatic period and high rates of re-infection. To overcome this, Mass Drug Administration (MDA) is often used to treat the whole community, irrespective of whether individuals presently have scabies. This review summarises the evidence for the effectiveness of MDA in treating scabies.

Methods

An exhaustive literature review was conducted on MEDLINE, EMBASE, Web of Science and Scopus. All peer-reviewed articles published in English January 1990 to March 2020 were eligible and only if the studies were primary and interventional. Furthermore, the intervention had to be a pharmacological MDA method involving human subjects.

Results

TWELVE articles that qualified for inclusion were identified. MDA for scabies significantly reduced its prevalence in communities at follow up. Some of the drivers of success were communities with low levels of migration, an uptake of MDA of > 85%, the use of oral Ivermectin therapy, the treatment of children and pregnant women within the treated population, and repeated treatment for participants diagnosed with scabies at baseline.

Conclusions

The average absolute reduction in prevalence of scabies was 22.0% and the relative reduction average was 73.4%. These results suggest MDA is effective in treating scabies in the endemic community. Further evidence is needed surrounding MDA use in urban areas with increased levels of migration. Importantly, MDA should not substitute the tackling of socioeconomic factors which contribute to endemic disease such as good sanitation and hygiene.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40794-021-00143-5.

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.

A systematic review and an individual patient data meta-analysis of ivermectin use in children weighing less than fifteen kilograms: Is it time to reconsider the current contraindication?

BACKGROUND

Oral ivermectin is a safe broad spectrum anthelminthic used for treating several neglected tropical diseases (NTDs). Currently, ivermectin use is contraindicated in children weighing less than 15 kg, restricting access to this drug for the treatment of NTDs. Here we provide an updated systematic review of the literature and we conducted an individual-level patient data (IPD) meta-analysis describing the safety of ivermectin in children weighing less than 15 kg.

METHODOLOGY/PRINCIPAL FINDINGS

A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) for IPD guidelines by searching MEDLINE via PubMed, Web of Science, Ovid Embase, LILACS, Cochrane Database of Systematic Reviews, TOXLINE for all clinical trials, case series, case reports, and database entries for reports on the use of ivermectin in children weighing less than 15 kg that were published between 1 January 1980 to 25 October 2019. The protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO): CRD42017056515. A total of 3,730 publications were identified, 97 were selected for potential inclusion, but only 17 sources describing 15 studies met the minimum criteria which consisted of known weights of children less than 15 kg linked to possible adverse events, and provided comprehensive IPD. A total of 1,088 children weighing less than 15 kg were administered oral ivermectin for one of the following indications: scabies, mass drug administration for scabies control, crusted scabies, cutaneous larva migrans, myiasis, pthiriasis, strongyloidiasis, trichuriasis, and parasitic disease of unknown origin. Overall a total of 1.4% (15/1,088) of children experienced 18 adverse events all of which were mild and self-limiting. No serious adverse events were reported.

CONCLUSIONS/SIGNIFICANCE

Existing limited data suggest that oral ivermectin in children weighing less than 15 kilograms is safe. Data from well-designed clinical trials are needed to provide further assurance.

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).

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.

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.

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).

[CME Dermatology 21: Scabies - Clinical Manifestation, Diagnosis and Therapy]

CME Dermatology 21: Scabies - Clinical Manifestation, Diagnosis and Therapy Abstract. Scabies is a common contagious skin infestation found in all parts of the world affecting individuals of all ages. Its worldwide prevalence is estimated at about 200 million people at any one time. Typical manifestations consist of severe itch that is aggravated at night, and disseminated, excoriated, erythematous papules on the trunk and limbs. Diagnosis can be confirmed by microscopic examination of skin scrapings taken from skin lesions. Recommended treatments consist of Permethrin 5 % cream applied once with repetition after 7-14 days or oral ivermectin 200 µg/kg as two doses 1 week apart. Additionally, written instructions on how to behave, decontaminate textiles and apply medications should be provided to suspected cases, and all the patient's close personal contacts should be treated simultaneously. As the disease can be sexually transmitted, screening for sexually transmitted diseases is recommended in sexually active patients.

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.

Emergency Department Visits due to Scabies in the United States: A Retrospective Analysis of a Nationally Representative Emergency Department Sample

Background

Limited information exists regarding the burden of emergency department (ED) visits due to scabies in the United States. The goal of this study was to provide population-level estimates regarding scabies visits to American EDs.

Methods

This study was a retrospective analysis of the nationally representative National Emergency Department Sample from 2013 to 2015. Outcomes included adjusted odds for scabies ED visits, adjusted odds for inpatient admission due to scabies in the ED scabies population, predictors for cost of care, and seasonal/regional variation in cost and prevalence of scabies ED visits.

Results

Our patient population included 416 017 218 ED visits from 2013 to 2015, of which 356 267 were due to scabies (prevalence = 85.7 per 100 000 ED visits). The average annual expenditure for scabies ED visits was $67 125 780.36. The average cost of care for a scabies ED visit was $750.91 (±17.41). Patients visiting the ED for scabies were most likely to be male children from lower income quartiles and were most likely to present to the ED on weekdays in the fall, controlling for all other factors. Scabies ED patients that were male, older, insured by Medicare, from the highest income quartile, and from the Midwest/West were most likely to be admitted as inpatients. Older, higher income, Medicare patients in large Northeastern metropolitan cities had the greatest cost of care.

Conclusion

This study provides comprehensive nationally representative estimates of the burden of scabies ED visits on the American healthcare system. These findings are important for developing targeted interventions to decrease the incidence and burden of scabies in American EDs.

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

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

A Review of Scabies: An Infestation More than Skin Deep

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

Impact of ivermectin administered for scabies treatment on the prevalence of head lice in Atoifi, Solomon Islands

Background

Scabies and head lice are ubiquitous ectoparasitic infestations that are common across the Pacific Islands. Ivermectin is an effective treatment for both conditions, although the doses used vary. At a community level, mass drug administration (MDA) with ivermectin is an effective strategy to decrease prevalence of scabies. To what extent MDA with ivermectin will also reduce prevalence of head lice is unknown.

Methodology

Head lice prevalence was assessed before and after MDA with oral ivermectin (at a dose of 200 micrograms per kilogram of body weight) administered on day 1 and day 8. The primary outcome was the change in prevalence of head louse infestation at two weeks compared to baseline. Longer term efficacy was assessed three months after MDA.

Results

118 participants were enrolled. Baseline prevalence of active head louse infestation was 25.4% (95% CI 18.4–34.0). At two-week follow-up, prevalence was 2.5% (95% CI 0.9–7.2), a relative reduction of 89.1% (95% CI 72.7–91.4%, p<0.001). At three-month follow-up, prevalence was 7.5% (95% CI 2.7–12.3), a relative reduction of 70.6% (95% CI 72.7%-91.4%, p <0.001). Head louse infestation was associated with younger age (age ≤10 years: prevalence 46.7%; adjusted odds ratio compared to adults of 7.2, 95%CI 2.0–25.9) and with having at least one other member of the household with active head louse infestation (adjusted odds ratio 4.3, 95%CI 1.7–11.1).

Conclusions

Head louse infestation is common in the Solomon Islands. This proof of principle study shows that oral ivermectin at a dose of 200 micrograms per kilogram can reduce the burden of active head louse infestation, offering an additional collateral benefit of MDA with ivermectin for scabies control.

Trial registration

ClinicalTrials.gov NCT03236168.

Head lice and scabies are both caused by ectoparasites and lead to itchy skin conditions that are associated with secondary bacterial infections and social stigma. Both are common in developing countries. In the Solomon Islands, mass treatment of communities using ivermectin (at dose of 200 micrograms per kilogram) has been shown to be an effective strategy in reducing scabies prevalence. This study shows that the same dose of ivermectin and the same regime of mass drug administration is also effective at reducing the burden of head louse infestation, offering an additional benefit to community wide treatment.

Control Strategies for Scabies

Scabies is a neglected tropical disease of the skin, causing severe itching and stigmatizing skin lesions. Further, scabies leads to impetigo, severe bacterial infections, and post-infectious complications. Around 200 million people are affected, particularly among disadvantaged populations living in crowded conditions in tropical areas. After almost 50 years, research into scabies control has shown great promise, particularly in highly-endemic island settings, but these findings have not been widely adopted. Newer approaches, utilizing ivermectin-based mass drug administration, appear feasible and highly effective. Inclusion of scabies in the WHO portfolio of neglected tropical diseases in 2017 may facilitate renewed opportunities and momentum toward global control. However, further operational research is needed to develop evidence-based strategies for control in a range of settings, and monitor their impact. Several enabling factors are required for successful implementation, including availability of affordable drug supply. Integration with existing health programs may provide a cost-effective approach to control.

Efficacy of ivermectin mass-drug administration to control scabies in asylum seekers in the Netherlands: A retrospective cohort study between January 2014 - March 2016

Scabies is a skin infestation with the mite Sarcoptes scabiei causing itch and rash and is a major risk factor for bacterial skin infections and severe complications. Here, we evaluated the treatment outcome of 2866 asylum seekers who received (preventive) scabies treatment before and during a scabies intervention programme (SIP) in the main reception centre in the Netherlands between January 2014 and March 2016. A SIP was introduced in the main national reception centre based on frequent observations of scabies and its complications amongst Eritrean and Ethiopian asylum seekers in the Netherlands. On arrival, all asylum seekers from Eritrea or Ethiopia were checked for clinical scabies signs and received ivermectin/permethrin either as prevention or treatment. A retrospective cohort study was conducted to compare the reinfestations and complications of scabies in asylum seekers who entered the Netherlands before and during the intervention and who received ivermectin/permethrin. In total, 2866 asylum seekers received treatment during the study period (January 2014 –March 2016) of which 1359 (47.4%) had clinical signs of scabies. During the programme, most of the asylum seekers with scabies were already diagnosed on arrival as part of the SIP screening (580 (64.7%) of the 897). Asylum seekers with more than one scabies episode reduced from 42.0% (194/462) before the programme to 27.2% (243/897) during the programme (RR = 0.64, 95% CI = 0.55–0.75). Development of scabies complications later in the asylum procedure reduced from 12.3% (57/462) to 4.6% (41/897). A scabies prevention and treatment programme at start of the asylum procedure was feasible and effective in the Netherlands; patients were diagnosed early and risk of reinfestations and complications reduced. To achieve a further decrease of scabies, implementation of the programme in multiple asylum centres may be needed.

The high number of asylum seekers arriving in Europe between 2014 and 2016 emphasized the importance to expand knowledge on best practice regarding health care provision and control of infectious diseases that may come with migration. Adequate control of scabies is important to prevent severe forms of scabies and prevent spread of the disease. Studies on interventions preventing or treating scabies in asylum seekers are very limited. To the best of our knowledge, this is the first study that provides data on an intervention targeting scabies in asylum seekers. This study shows that a scabies prevention and treatment programme at start of the asylum procedure is feasible and effective in the Netherlands. Patients were diagnosed early and risk of reinfestations and complications reduced. The programme may be used both to improve clinical practice and could serve as model for future policies on similar programmes.

Ignoring the "Itch": The Global Health Problem of Scabies

Infestation with Sarcoptes scabiei var. hominis is a common human parasitic affliction endemic in tropical developing countries. Scabies is transmitted by close person-person contact, and outbreaks have been reported in reception centers for asylum seekers. Scabies presents clinically as extremely pruritic excoriated papules and linear burrows in the skin. This infestation predisposes to bacterial skin infections that can result in serious complications affecting the kidneys and possibly the heart. Treatment of individuals with scabies and their close contacts involves the use of antiparasitic agents. First-line treatment is topical 5% permethrin cream. Community mass drug administration, followed by active case finding with targeted treatment, is a promising approach that can reduce the prevalence of both scabies and bacterial skin infections. Organizations such as the International Alliance for the Control of Scabies are advocating for the development of integrated disease control strategies in an effort to decrease scabies infestation worldwide.

European guideline for the management of scabies

Scabies is caused by Sarcoptes scabiei var. hominis. The disease can be sexually transmitted. Patients' main complaint is nocturnal itch. Disseminated, excoriated, erythematous papules are usually seen on the anterior trunk and limbs. Crusted scabies occurs in immunocompromised hosts and may be associated with reduced or absent pruritus. Recommended treatments are permethrin 5% cream, oral ivermectin and benzyl benzoate 25% lotion. Alternative treatments are malathion 0.5% aqueous lotion, ivermectin 1% lotion and sulphur 6-33% cream, ointment or lotion. Crusted scabies therapy requires a topical scabicide and oral ivermectin. Mass treatment of large populations with endemic disease can be performed with a single dose of ivermectin (200 micrograms/kg of bodyweight). Partner management needs a look-back period of 2 months. Screening for other STI is recommended. Patients and close contacts should avoid sexual contact until completion of treatment and should strictly observe personal hygiene rules when living in crowded spaces. Written information should be provided to suspected cases.