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Akpan E, Thean LJ, Baskota R, Mani J, Mow M, Kama M, Tuicakau M, Kado J, Romani L, Kaldor J, Engelman D, Steer AC, Carvalho N. Costs of primary healthcare presentations and hospital admissions for scabies and related skin infections in Fiji, 2018-2019. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003706. [PMID: 39388494 DOI: 10.1371/journal.pgph.0003706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Accepted: 09/19/2024] [Indexed: 10/12/2024]
Abstract
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.
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Affiliation(s)
- Edifofon Akpan
- School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Li Jun Thean
- Murdoch Children's Research Institute, Tropical Diseases Group, Melbourne, Australia
- Department of Pediatrics, University of Melbourne, Melbourne, Australia
| | - Rabindra Baskota
- School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Jyotishna Mani
- Murdoch Children's Research Institute, Tropical Diseases Group, Melbourne, Australia
- Ministry of Health and Medical Services, Suva, Fiji
| | - Maria Mow
- Murdoch Children's Research Institute, Tropical Diseases Group, Melbourne, Australia
- Ministry of Health and Medical Services, Suva, Fiji
| | - Mike Kama
- Ministry of Health and Medical Services, Suva, Fiji
| | | | - Joseph Kado
- Ministry of Health and Medical Services, Suva, Fiji
- Telethon Kids Institute, Wesfarmers Centre for Vaccines and Infectious Diseases, Nedlands, Australia
- Medical School, University of Western Australia, Nedlands, Australia
| | - Lucia Romani
- Kirby Institute, University of New South Wales, Sydney, Australia
| | - John Kaldor
- Kirby Institute, University of New South Wales, Sydney, Australia
| | - Daniel Engelman
- Murdoch Children's Research Institute, Tropical Diseases Group, Melbourne, Australia
- Department of Pediatrics, University of Melbourne, Melbourne, Australia
- Melbourne Children's Global Health, The Royal Children's Hospital, Melbourne, Australia
| | - Andrew C Steer
- Murdoch Children's Research Institute, Tropical Diseases Group, Melbourne, Australia
- Department of Pediatrics, University of Melbourne, Melbourne, Australia
- Melbourne Children's Global Health, The Royal Children's Hospital, Melbourne, Australia
| | - Natalie Carvalho
- School of Population and Global Health, University of Melbourne, Melbourne, Australia
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Mitchell E, Tavui A, Andersson S, Lake S, Koroivueti A, Koroivueta J, Kaurasi R, Bechu V, Kaldor J, Steer A, Romani L. Acceptability of a nationwide scabies mass drug administration (MDA) program in Fiji: a qualitative interview-based study. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2024; 51:101194. [PMID: 39295851 PMCID: PMC11408017 DOI: 10.1016/j.lanwpc.2024.101194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 06/23/2024] [Accepted: 08/22/2024] [Indexed: 09/21/2024]
Abstract
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.
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Affiliation(s)
- Elke Mitchell
- Kirby Institute, UNSW Sydney, Sydney, Australia
- Melbourne School of Population and Global Heath, Melbourne University, Australia
| | - Aminiasi Tavui
- Murdoch Children's Research Institute, Melbourne, Australia
| | | | - Susanna Lake
- Murdoch Children's Research Institute, Melbourne, Australia
| | - Aminiasi Koroivueti
- Murdoch Children's Research Institute, Melbourne, Australia
- Ministry of Health and Medical Services, Fiji
| | | | | | | | - John Kaldor
- Kirby Institute, UNSW Sydney, Sydney, Australia
| | - Andrew Steer
- Murdoch Children's Research Institute, Melbourne, Australia
| | - Lucia Romani
- Kirby Institute, UNSW Sydney, Sydney, Australia
- Murdoch Children's Research Institute, Melbourne, Australia
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Yirgu R, Middleton J, Cassell JA, Bremner S, Davey G, Fekadu A. Quality of life among adults with scabies: A community-based cross-sectional study in north-western Ethiopia. PLoS Negl Trop Dis 2024; 18:e0012429. [PMID: 39163473 PMCID: PMC11364464 DOI: 10.1371/journal.pntd.0012429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 08/30/2024] [Accepted: 08/04/2024] [Indexed: 08/22/2024] Open
Abstract
INTRODUCTION Scabies undermines quality of life through its highly disturbing disease symptoms, by distorting self-perception, and secondary to social stigma. Knowledge of its effect on quality of life in general and on specific aspects of day-to-day life is key to addressing the health needs of individual patients and to evaluating gains from community-based disease control interventions. OBJECTIVES To measure the effect of scabies on the quality of life of people with the infestation. METHODS A community-based cross-sectional study was conducted in a scabies outbreak-affected district in north-western Ethiopia. The study involved 381 households and 86 adults with scabies. We used the ten-item Cardiff Dermatology Life Quality Index (DLQI) tool to collect data. Cronbach's alpha value was used to determine the internal consistency of the Amharic version of the scale. Overall and Dermatology Life Quality (DLQ) domain specific mean scores were calculated. The association between sociodemographic characteristics and scabies-related life quality impairment was tested using Kruskal-Wallis test. RESULTS Scabies moderately affected the quality of life of adults with scabies. The overall mean DLQI (mDLQI) score was 9.2 (SD = 7.6). 'Symptoms and feelings' and 'daily activity' DLQ domains had the highest mDLQI scores (3.5, SD = 1.9 and 2.2, SD = 2.5, respectively). 'Leisure activities' was the least affected domain 0.8 (SD = 1.1). In terms of severity, scabies had moderate or severe effect on DLQ of 54.7% of the participants and extremely severe effect was reported among 27% of the participants. However, no association was observed between sociodemographic characteristics and quality of life impairment. CONCLUSION Quality of life was moderately impaired among people affected by scabies. Refocusing attention on management of disease symptoms, using standard scabies treatment, and providing psychosocial support to improve self-perception of people affected with scabies may help reduce quality of life impairment.
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Affiliation(s)
- Robel Yirgu
- NIHR Global Health Research Unit on Neglected Tropical Diseases, Brighton and Sussex Medical School, Falmer, United Kingdom
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
- Center for Innovative Drug Development and Therapeutic Trials for Africa, Addis Ababa University, Addis Ababa, Ethiopia
| | - Jo Middleton
- NIHR Global Health Research Unit on Neglected Tropical Diseases, Brighton and Sussex Medical School, Falmer, United Kingdom
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, Falmer, United Kingdom
| | - Jackie A. Cassell
- NIHR Global Health Research Unit on Neglected Tropical Diseases, Brighton and Sussex Medical School, Falmer, United Kingdom
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, Falmer, United Kingdom
| | - Stephen Bremner
- NIHR Global Health Research Unit on Neglected Tropical Diseases, Brighton and Sussex Medical School, Falmer, United Kingdom
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, Falmer, United Kingdom
| | - Gail Davey
- NIHR Global Health Research Unit on Neglected Tropical Diseases, Brighton and Sussex Medical School, Falmer, United Kingdom
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Abebaw Fekadu
- NIHR Global Health Research Unit on Neglected Tropical Diseases, Brighton and Sussex Medical School, Falmer, United Kingdom
- Center for Innovative Drug Development and Therapeutic Trials for Africa, Addis Ababa University, Addis Ababa, Ethiopia
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Galván-Casas C, Ortiz-Álvarez J, Martínez-García E, Corbacho-Monné M. Spanish Academy of Dermatology and Venereology (AEDV) expert recommendations for the management of sexual transmitted parasitosis. Scabies, and pediculosis pubis. ACTAS DERMO-SIFILIOGRAFICAS 2024; 115:475-492. [PMID: 38061452 DOI: 10.1016/j.ad.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 11/16/2023] [Accepted: 11/21/2023] [Indexed: 01/28/2024] Open
Abstract
Sexually transmitted infections are communicable diseases where the pathogen is transmitted through sexual contact. The Sexually Transmitted Infections Working Group of the Spanish Academy of Dermatology and Venereology (AEDV) is engaged in the drafting of documents to guide dermatologists and health care personnel who treat Spanish patients with these infections. This document analyzes the epidemiological, clinical, therapeutic, and control characteristics of 2 sexually transmitted parasitosis: scabies due to Sarcoptes scabiei var. hominis, and pubic pediculosis due to Phthirus pubis. Both parasitoses share a sort of mixed spread through sexual and community transmission regardless of the route through which the infection was initially acquired. This specific feature creates particularities in the management and control of the infestation.
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Affiliation(s)
- C Galván-Casas
- Unidad Skin Neglected Tropical Diseases and Sexually Transmitted Infections; Fundación Lucha contra las Infecciones, Badalona, Barcelona, España; Servicio de Dermatología, Hospital Universitario de Móstoles, Móstoles, Madrid, España.
| | - J Ortiz-Álvarez
- Servicio de Dermatología, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - E Martínez-García
- Servicio de Dermatología, Hospital Virgen de la Victoria, Málaga, España
| | - M Corbacho-Monné
- Servicio de Dermatología, Hospital Universitari Parc Taulí, Sabadell, Barcelona, España
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Galván-Casas C, Ortiz-Álvarez J, Martínez-García E, Corbacho-Monné M. [Translated article] Spanish Academy of Dermatology and Venereology (AEDV) expert recommendations for the management of sexual transmitted parasitosis. Scabies, and pediculosis pubis. ACTAS DERMO-SIFILIOGRAFICAS 2024; 115:T475-T492. [PMID: 38479688 DOI: 10.1016/j.ad.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 11/21/2023] [Indexed: 05/05/2024] Open
Abstract
Sexually transmitted infections are communicable diseases where the pathogen is transmitted through sexual contact. The Sexually Transmitted Infections Working Group of the Spanish Academy of Dermatology and Venereology (AEDV) is engaged in the drafting of documents to guide dermatologists and health care personnel who treat Spanish patients with these infections. This document analyzes the epidemiological, clinical, therapeutic, and control characteristics of 2 sexually transmitted parasitosis: scabies due to Sarcoptes scabiei var. hominis, and pubic pediculosis due to Phthirus pubis. Both parasitoses share a sort of mixed spread through sexual and community transmission regardless of the route through which the infection was initially acquired. This specific feature creates particularities in the management and control of the infestation.
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Affiliation(s)
- C Galván-Casas
- Unidad Skin Neglected Tropical Diseases and Sexually Transmitted Infections; Fundació Lluita contra les Infeccions, Badalona, Barcelona, Spain; Servicio de Dermatología, Hospital Universitario de Móstoles, Móstoles, Madrid, Spain.
| | - J Ortiz-Álvarez
- Servicio de Dermatología, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - E Martínez-García
- Servicio de Dermatología, Hospital Virgen de la Victoria, Málaga, Spain
| | - M Corbacho-Monné
- Servicio de Dermatología, Hospital Universitari Parc Taulí, Sabadell, Barcelona, Spain
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Blaizot R, Armanville F, Michaud C, Boceno C, Dupart O, Pansart C, Niemetzky F, Couppie P, Nacher M, Adenis A, Chosidow O, Duvignaud A. Scabies in French Guiana: Quantitative and qualitative factors associated with therapeutic failure. J Eur Acad Dermatol Venereol 2024; 38:602-612. [PMID: 38041562 DOI: 10.1111/jdv.19688] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 11/08/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND Strategies for the control of scabies should be adapted to local settings. Traditional communities in French Guiana have non-Western conceptions of disease and health. OBJECTIVES The objectives for this study were to explore knowledge, attitudes and practices to identify potential factors associated with the failure of scabies treatment in these communities. METHODS Patients with a clinical diagnosis of scabies, seen at either the Cayenne Hospital or one of 13 health centres between 01 April 2021 and 31 August 2021, were included as participants, and were seen again after 6 weeks to check for persistence of lesions. Factors associated with treatment failure were looked for both at inclusion and at 6 weeks. Semi-structured interviews were conducted with a diversified subsample of participants. RESULTS In total, 164 participants were included in the quantitative component, and 21 were interviewed for the qualitative component. Declaring that the second treatment dose had been taken was associated with therapeutic success. Western treatments were not always affordable. Better adherence was observed with topical treatments than with oral ivermectin, whereas permethrin monotherapy was associated with failure. Scabies-associated stigma was high among Amerindians and Haitians but absent in Ndjuka Maroons. Participants reported environmental disinfection as being very complex. CONCLUSIONS The treatment of scabies in traditional Guianan communities may vary depending on local perceptions of galenic formulations, disease-associated stigma and differences in access to health care. These factors should be taken into account when devising strategies for the control of scabies aimed at traditional communities living in remote areas, and migrant populations.
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Affiliation(s)
- R Blaizot
- Centre Hospitalier de Cayenne, Service de Dermatologie, Cayenne, French Guiana
- Centre Hospitalier de Cayenne Inserm CIC 1424, Centre d'Investigations Cliniques, Cayenne, French Guiana
- UMR 1019 Tropical Biomes and Immunophysiopathology (TBIP), Université de Guyane, Cayenne, French Guiana
- Groupe Infectiologie Dermatologique- Infections Sexuellement Transmissibles, Société Française de Dermatologie, Paris, France
- Centre Hospitalier de Cayenne, Centres Délocalisés de Prévention et de Soins, Cayenne, French Guiana
| | - F Armanville
- Centre Hospitalier de Cayenne, Centres Délocalisés de Prévention et de Soins, Cayenne, French Guiana
| | - C Michaud
- Centre Hospitalier de Cayenne, Centres Délocalisés de Prévention et de Soins, Cayenne, French Guiana
| | - C Boceno
- Centre Hospitalier de Cayenne, Permanence d'Accès aux Soins de Santé, Cayenne, French Guiana
| | - O Dupart
- Centre Hospitalier de Cayenne, Permanence d'Accès aux Soins de Santé, Cayenne, French Guiana
| | - C Pansart
- Centre Hospitalier de Cayenne, Permanence d'Accès aux Soins de Santé, Cayenne, French Guiana
| | - F Niemetzky
- Centre Hospitalier de Cayenne, Centres Délocalisés de Prévention et de Soins, Cayenne, French Guiana
| | - P Couppie
- Centre Hospitalier de Cayenne, Service de Dermatologie, Cayenne, French Guiana
- UMR 1019 Tropical Biomes and Immunophysiopathology (TBIP), Université de Guyane, Cayenne, French Guiana
| | - M Nacher
- Centre Hospitalier de Cayenne Inserm CIC 1424, Centre d'Investigations Cliniques, Cayenne, French Guiana
| | - A Adenis
- Centre Hospitalier de Cayenne Inserm CIC 1424, Centre d'Investigations Cliniques, Cayenne, French Guiana
| | - O Chosidow
- Groupe Infectiologie Dermatologique- Infections Sexuellement Transmissibles, Société Française de Dermatologie, Paris, France
- Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire La Pitié-Salpêtrière, Paris, France
| | - A Duvignaud
- Department of Infectious Diseases and Tropical Medicine, CHU Bordeaux, Bordeaux, France
- Bordeaux Population Health Centre, University of Bordeaux, INSERM UMR 1219, IRD EMR 271, Bordeaux, France
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Jira SC, Matlhaba KL, Mphuthi DD. Healthcare users' knowledge and experiences regarding the management of scabies in the Deder district, Ethiopia. J Public Health Afr 2023; 14:2305. [PMID: 38162325 PMCID: PMC10755506 DOI: 10.4081/jphia.2023.2305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 02/26/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND Scabies is an ectoparasitic, highly contagious skin disease caused by a human itch mite infestation of the skin, and it is the leading cause of morbidity and disease burden in developing countries. The purpose of this study was to investigate healthcare users' current knowledge and experiences with scabies management provided at primary healthcare facilities. MATERIALS AND METHODS A qualitative research design was used to address the research objectives. Focus group interviews with 58 health care users were used to collect data. Thematic analysis was performed on the verbatim transcriptions using Tesch's approach. RESULTS The findings showed that the knowledge of healthcare users who participated in the study on scabies, its management, prevention, and control was limited. Health care users experience different challenges regarding scabies and the management thereof. Five themes emerged after data analysis. These were knowledge regarding scabies, knowledge regarding the management of scabies, knowledge regarding the prevention of scabies, perceptions regarding receiving treatment for scabies, and recommendations regarding the availability of materials and medication. CONCLUSIONS Healthcare users in the area had limited knowledge and experienced different challenges regarding scabies and their management. These challenges contribute to low-quality health services with undesirable health outcomes. To narrow this gap, consistent and programed health education was provided to the community through different modalities by using the existing health system to increase awareness regarding scabies. Following the implementation of community awareness, each community member was positioned to prevent and control scabies.
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Affiliation(s)
- Sagni Challi Jira
- Department of Malaria and Neglected Tropical Disease, Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | | | - David Ditaba Mphuthi
- Department of Health Studies, University of South Africa, Pretoria, South Africa
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Lacey JA, Marcato AJ, Chisholm RH, Campbell PT, Zachreson C, Price DJ, James TB, Morris JM, Gorrie CL, McDonald MI, Bowen AC, Giffard PM, Holt DC, Currie BJ, Carapetis JR, Andrews RM, Davies MR, Geard N, McVernon J, Tong SYC. Evaluating the role of asymptomatic throat carriage of Streptococcus pyogenes in impetigo transmission in remote Aboriginal communities in Northern Territory, Australia: a retrospective genomic analysis. THE LANCET. MICROBE 2023; 4:e524-e533. [PMID: 37211022 DOI: 10.1016/s2666-5247(23)00068-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 02/10/2023] [Accepted: 02/15/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND Streptococcus pyogenes, or group A Streptococcus (GAS), infections contribute to a high burden of disease in Aboriginal Australians, causing skin infections and immune sequelae such as rheumatic heart disease. Controlling skin infections in these populations has proven difficult, with transmission dynamics being poorly understood. We aimed to identify the relative contributions of impetigo and asymptomatic throat carriage to GAS transmission. METHODS In this genomic analysis, we retrospectively applied whole genome sequencing to GAS isolates that were collected as part of an impetigo surveillance longitudinal household survey conducted in three remote Aboriginal communities in the Northern Territory of Australia between Aug 6, 2003, and June 22, 2005. We included GAS isolates from all throats and impetigo lesions of people living in two of the previously studied communities. We classified isolates into genomic lineages based on pairwise shared core genomes of more than 99% with five or fewer single nucleotide polymorphisms. We used a household network analysis of epidemiologically and genomically linked lineages to quantify the transmission of GAS within and between households. FINDINGS We included 320 GAS isolates in our analysis: 203 (63%) from asymptomatic throat swabs and 117 (37%) from impetigo lesions. Among 64 genomic lineages (encompassing 39 emm types) we identified 264 transmission links (involving 93% of isolates), for which the probable source was asymptomatic throat carriage in 166 (63%) and impetigo lesions in 98 (37%). Links originating from impetigo cases were more frequent between households than within households. Households were infected with GAS for a mean of 57 days (SD 39 days), and once cleared, reinfected 62 days (SD 40 days) later. Increased household size and community presence of GAS and scabies were associated with slower clearance of GAS. INTERPRETATION In communities with high prevalence of endemic GAS-associated skin infection, asymptomatic throat carriage is a GAS reservoir. Public health interventions such as vaccination or community infection control programmes aimed at interrupting transmission of GAS might need to include consideration of asymptomatic throat carriage. FUNDING Australian National Health and Medical Research Council.
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Affiliation(s)
- Jake A Lacey
- Department of Infectious Diseases, University of Melbourne, Melbourne, VIC Australia; Department of Microbiology and Immunology at the Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC Australia
| | - Adrian J Marcato
- Department of Infectious Diseases, University of Melbourne, Melbourne, VIC Australia; Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC Australia
| | - Rebecca H Chisholm
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC Australia; Department of Mathematical and Physical Sciences, La Trobe University, Bundoora, VIC, Australia
| | - Patricia T Campbell
- Department of Infectious Diseases, University of Melbourne, Melbourne, VIC Australia; Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC Australia
| | - Cameron Zachreson
- School of Computing and Information systems, Faculty of Engineering and Information Technology, University of Melbourne, Melbourne, VIC Australia
| | - David J Price
- Department of Infectious Diseases, University of Melbourne, Melbourne, VIC Australia; Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC Australia
| | - Taylah B James
- Department of Infectious Diseases, University of Melbourne, Melbourne, VIC Australia; Department of Microbiology and Immunology at the Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC Australia
| | - Jacqueline M Morris
- Department of Microbiology and Immunology at the Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC Australia
| | - Claire L Gorrie
- Department of Microbiology and Immunology at the Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC Australia
| | - Malcolm I McDonald
- Division of Tropical Health and Medicine, James Cook University, Nguma-bada Campus, Cairns, QLD, Australia
| | - Asha C Bowen
- Telethon Kids Institute, University of Western Australia and Perth Children's Hospital, Perth, WA, Australia
| | - Philip M Giffard
- Global and Tropical Healthy Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia; School of Medicine, Faculty of Health, Charles Darwin University, Darwin, NT, Australia
| | - Deborah C Holt
- Global and Tropical Healthy Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia; School of Medicine, Faculty of Health, Charles Darwin University, Darwin, NT, Australia
| | - Bart J Currie
- Global and Tropical Healthy Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Jonathan R Carapetis
- Telethon Kids Institute, University of Western Australia and Perth Children's Hospital, Perth, WA, Australia
| | - Ross M Andrews
- Global and Tropical Healthy Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia; Research School of Population Health, Australian National University, Canberra, ACT, Australia
| | - Mark R Davies
- Department of Microbiology and Immunology at the Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC Australia
| | - Nicholas Geard
- School of Computing and Information systems, Faculty of Engineering and Information Technology, University of Melbourne, Melbourne, VIC Australia
| | - Jodie McVernon
- Department of Infectious Diseases, University of Melbourne, Melbourne, VIC Australia; Victorian Infectious Diseases Reference Laboratory Epidemiology Unit, University of Melbourne, Melbourne, VIC Australia
| | - Steven Y C Tong
- Department of Infectious Diseases, University of Melbourne, Melbourne, VIC Australia; Victorian Infectious Diseases Service, The Royal Melbourne Hospital, Melbourne, at the Peter Doherty Institute for Infection and Immunity VIC, Australia; Global and Tropical Healthy Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia.
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Thean LJ, Romani L, Engelman D, Wand H, Jenney A, Mani J, Paka J, Cua T, Taole S, Silai M, Ashwini K, Sahukhan A, Kama M, Tuicakau M, Kado J, Parnaby M, Carvalho N, Whitfeld M, Kaldor J, Steer AC. Prevention of bacterial complications of scabies using mass drug administration: A population-based, before-after trial in Fiji, 2018-2020. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2022; 22:100433. [PMID: 35345391 PMCID: PMC8956868 DOI: 10.1016/j.lanwpc.2022.100433] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
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.
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Affiliation(s)
- Li Jun Thean
- Tropical Diseases Group, Murdoch Children's Research Institute, Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria 3052, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria 3052, Australia
| | - Lucia Romani
- Kirby Institute, University of New South Wales, Kensington, New South Wales 2052, Australia
| | - Daniel Engelman
- Tropical Diseases Group, Murdoch Children's Research Institute, Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria 3052, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria 3052, Australia
- Melbourne Children's Global Health, Melbourne Children's Campus, The Royal Children's Hospital, Parkville, 3052 Australia
| | - Handan Wand
- Kirby Institute, University of New South Wales, Kensington, New South Wales 2052, Australia
| | - Adam Jenney
- College of Medicine, Nursing and Health Sciences, Fiji National University, Suva, Fiji
| | - Jyotishna Mani
- Tropical Diseases Group, Murdoch Children's Research Institute, Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria 3052, Australia
| | - Jessica Paka
- Tropical Diseases Group, Murdoch Children's Research Institute, Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria 3052, Australia
| | - Tuliana Cua
- Tropical Diseases Group, Murdoch Children's Research Institute, Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria 3052, Australia
| | - Sera Taole
- Tropical Diseases Group, Murdoch Children's Research Institute, Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria 3052, Australia
| | - Maciu Silai
- Tropical Diseases Group, Murdoch Children's Research Institute, Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria 3052, Australia
| | - Komal Ashwini
- Tropical Diseases Group, Murdoch Children's Research Institute, Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria 3052, Australia
| | | | - Mike Kama
- Ministry of Health and Medical Services, Suva, Fiji
| | | | - Joseph Kado
- Ministry of Health and Medical Services, Suva, Fiji
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Nedlands, Western Australia 6009, Australia
| | - Matthew Parnaby
- Tropical Diseases Group, Murdoch Children's Research Institute, Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria 3052, Australia
| | - Natalie Carvalho
- School of Population and Global Health, University of Melbourne, Carlton, Victoria 3053, Australia
| | - Margot Whitfeld
- Department of Dermatology, St. Vincent's Hospital, Darlinghurst, New South Wales 2010, Australia
- School of Medicine, University of New South Wales, Kensington, New South Wales 2052, Australia
| | - John Kaldor
- College of Medicine, Nursing and Health Sciences, Fiji National University, Suva, Fiji
| | - Andrew C. Steer
- Tropical Diseases Group, Murdoch Children's Research Institute, Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria 3052, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria 3052, Australia
- Melbourne Children's Global Health, Melbourne Children's Campus, The Royal Children's Hospital, Parkville, 3052 Australia
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10
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Mitchell E, Kelly-Hanku A, Krentel A, Romani L, Robinson LJ, Vaz Nery S, Kaldor J, Steer AC, Bell S. 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. PLoS Negl Trop Dis 2022; 16:e0010215. [PMID: 35275932 PMCID: PMC8916618 DOI: 10.1371/journal.pntd.0010215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 01/29/2022] [Indexed: 11/29/2022] Open
Abstract
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.
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Affiliation(s)
- Elke Mitchell
- Kirby Institute, UNSW Sydney, Sydney, Australia
- * E-mail:
| | - Angela Kelly-Hanku
- Kirby Institute, UNSW Sydney, Sydney, Australia
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Alison Krentel
- Bruyère Research Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Lucia Romani
- Kirby Institute, UNSW Sydney, Sydney, Australia
- Tropical Diseases Group, Murdoch Children’s Research Institute, Melbourne, Australia
| | - Leanne J. Robinson
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
- Burnet Institute, Melbourne, Australia
- School of Public Health and Preventative Medicine, Monash University, Melbourne, Australia
| | | | - John Kaldor
- Kirby Institute, UNSW Sydney, Sydney, Australia
| | - Andrew C. Steer
- Tropical Diseases Group, Murdoch Children’s Research Institute, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
- Melbourne Children’s Global Health, Melbourne Children’s Campus, The Royal Children’s Hospital, Melbourne, Australia
| | - Stephen Bell
- UQ Poche Centre for Indigenous Health, The University of Queensland, St Lucia, Australia
- School of Public Health, The University of Queensland, St Lucia, Australia
- Centre for Social Research in Health, UNSW Sydney, Sydney, Australia
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11
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Lake SJ, Kaldor JM, Hardy M, Engelman D, Steer AC, Romani L. Mass drug administration for the control of scabies: a systematic review and meta-analysis. Clin Infect Dis 2022; 75:959-967. [PMID: 35088849 PMCID: PMC9522411 DOI: 10.1093/cid/ciac042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Susanna J Lake
- Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia.,Melbourne Children's Global Health, Melbourne, Australia
| | - John M Kaldor
- Kirby Institute, University of New South Wales, Sydney, Australia
| | - Myra Hardy
- Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia.,Melbourne Children's Global Health, Melbourne, Australia
| | - Daniel Engelman
- Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia.,Melbourne Children's Global Health, Melbourne, Australia
| | - Andrew C Steer
- Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia.,Melbourne Children's Global Health, Melbourne, Australia
| | - Lucia Romani
- Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, Australia.,Kirby Institute, University of New South Wales, Sydney, Australia
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12
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Lake SJ, Engelman D, Sokana O, Nasi T, Boara D, Marks M, Whitfeld MJ, Romani L, Kaldor JM, Steer AC, Carvalho N. Health-related quality of life impact of scabies in the Solomon Islands. Trans R Soc Trop Med Hyg 2021; 116:148-156. [PMID: 34182575 PMCID: PMC8804887 DOI: 10.1093/trstmh/trab096] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/03/2021] [Accepted: 06/16/2021] [Indexed: 12/28/2022] Open
Abstract
Background Scabies causes intense itching and skin lesions. A small number of studies have shown that scabies impacts health-related quality of life (HRQoL), but no studies have been conducted in the Pacific region. We assessed the impact of scabies on HRQoL in a high-prevalence setting using the Children's Dermatology Life Quality Index (CDLQI) and Dermatology Life Quality Index (DLQI). We also assessed the validity of these tools in a Pacific Island population. Methods The study was conducted in the Solomon Islands. Participants with and without skin disease were randomly selected. HRQoL indices were scored on a scale of 0–30. Results We surveyed 1051 adults (91 with scabies) and 604 children (103 with scabies). Scabies had a small impact on HRQoL, with a median DLQI score of 2 (interquartile range [IQR] 0–6) and a CDLQI score of 2 (IQR 0–4). Scores increased linearly with severity. The greatest impact on QoL was due to itch, sleep disturbance and impacts on education and employment. Conclusions Scabies has a small but measurable impact on HRQoL. The DLQI and CDLQI scores were discriminated between the skin-related QoL of patients with scabies and the control group, indicating that these tools are appropriate to measure skin-related QoL in the Solomon Islands.
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Affiliation(s)
- Susanna J Lake
- Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Melbourne Children's Global Health, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Daniel Engelman
- Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Melbourne Children's Global Health, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Oliver Sokana
- Ministry of Health and Medical Services, Solomon Islands
| | - Titus Nasi
- Ministry of Health and Medical Services, Solomon Islands
| | - Dickson Boara
- Ministry of Health and Medical Services, Solomon Islands
| | - Michael Marks
- London School of Hygiene and Tropical Medicine, London, UK.,Hospital for Tropical Diseases, London, UK
| | - Margot J Whitfeld
- St Vincent's Hospital, University of New South Wales, Sydney, NSW, Australia
| | - Lucia Romani
- Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - John M Kaldor
- Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - Andrew C Steer
- Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Melbourne Children's Global Health, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Natalie Carvalho
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
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13
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Thompson R, Westbury S, Slape D. Paediatrics: how to manage scabies. Drugs Context 2021; 10:dic-2020-12-3. [PMID: 33828606 PMCID: PMC8007207 DOI: 10.7573/dic.2020-12-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 02/07/2021] [Indexed: 11/21/2022] Open
Abstract
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.
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Affiliation(s)
- Russell Thompson
- Faculty of Medicine, UNSW, Kensington Campus, Sydney, NSW, Australia.,Prince of Wales Hospital, Randwick, Sydney, NSW, 2031, Australia
| | - Sean Westbury
- St George Hospital, Kogarah, Sydney, NSW, 2217, Australia
| | - Dana Slape
- Department of Dermatology, Liverpool and Campbelltown Hospitals, South Western Sydney Local Health District, Sydney, NSW, Australia.,School of Medicine, Western Sydney University, Sydney, NSW, Australia.,Justice Health and Forensic Mental Health Network, Sydney, NSW, Australia
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