Spanish Academy of Dermatology and Venereology (AEDV) expert recommendations for the management of sexual transmitted parasitosis. Scabies, and pediculosis pubis

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.

[Translated article] Spanish Academy of Dermatology and Venereology (AEDV) expert recommendations for the management of sexual transmitted parasitosis. Scabies, and pediculosis pubis

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.

Scabies Infection While Expressing Human Milk for Critically Ill Infants: Is It Safe?

Background: Scabies infections of the breast in lactating individuals are not well described, especially how maternal infection can impact human milk feeding of hospitalized infants in the intensive care setting. Methods: This case report presents a critically ill female infant with a complex surgical history whose mother had an active scabies infection around the breast postpartum and wished to provide expressed human milk. Results: In this case report, human milk was recommended despite maternal scabies infection. Conclusion: Given the limited information that is known about the risk of scabies transmission in human milk for critically ill infants, this case adds to the knowledge base and supports the call for further research.

First report of interspecific transmission of sarcoptic mange from Iberian ibex to wild boar

BACKGROUND

Sarcoptic mange is a globally distributed parasitic disease caused by the burrowing mite Sarcoptes scabiei. This mite has a certain degree of host specificity, although interspecific transmission can occur among phylogenetically related species or through prey-predator mediated exposure. In 2018, a wild boar (Sus scrofa) with lesions compatible with sarcoptic mange was hunted in Ports de Tortosa i Beseit Natural Park (PTB, north-eastern Spain), where an active epizootic outbreak of sarcoptic mange is affecting Iberian ibexes (Capra pyrenaica) since 2014.

METHODS

A complete necropsy, skin scrapings and skin digestions with hydroxide potassium were performed to confirm the diagnosis. Routine histopathological analysis, toluidine blue staining and immunohistochemistry were used to characterize the lesions and the inflammatory infiltrate. Finally, 10 specific S. scabiei microsatellites were molecularly genotyped through polymerase chain reactions in mites obtained from the affected wild boar. For phylogenetic comparison, mites obtained from sympatric Iberian ibexes and allopatric wild boars and Iberian ibexes from southern Spain were analysed.

RESULTS

Sarcoptes scabiei was visually and molecularly identified in the infested wild boar from PTB, causing skin lesions with dermal inflammatory infiltrate rich in T and B cells, which indicate an adaptive immune response. Three S. scabiei genetic clusters were identified: one included mites from southern Iberian ibexes, another included mites from southern wild boars, and a third one distinctively grouped the wild boar from PTB with the sympatric ibexes.

CONCLUSIONS

To the authors' knowledge, this is the first reported case of sarcoptic mange in wild boar in Spain and the first documented case of S. scabiei cross-transmission from a wild ruminant host to a wild boar. The wild boar presented an ordinary scabies type reaction, which is typical of the self-limiting infestations reported in other cases of interspecific transmission.

Kenneth Mellanby Commander of the Order of the British Empire (CBE) (1908-1993). The facts about scabies

Kenneth Mellanby was a distinguished biologist specialising in entomology. He helped to establish the first university in Nigeria and undertook pioneering work on the use of insecticides in agriculture. However, he will best be remembered for a series of experiments which he undertook on human volunteers during the Second World War. These experiments established the mechanism of transmission of scabies and allowed its effective control at a time when the condition had reached epidemic proportions, causing a significant adverse effect on public morale and military effectiveness. Mellanby's wartime monograph on scabies remains to this day the definitive work on the disease and is still studied by dermatologists. His subsequent book Human Guinea Pigs is a remarkable account of the privations to which wartime volunteers willingly submitted themselves in a way that would have never passed any current medical ethics committee.

Sarcoptic Mange of Fox Origin in Multiple Farm Animals and Scabies in Humans, Switzerland, 2018

Fox-derived Sarcoptes scabiei mites caused an outbreak of mange on a farm in Switzerland in 2018. Pruritic skin lesions suggestive of S. scabiei mite infestation developed in 4 humans who had direct contact with affected farm animals but not foxes. Sarcoptic mange is continuously spreading; such outbreaks affecting humans could start occurring more frequently.

A systematic review of scabies transmission models and data to evaluate the cost-effectiveness of scabies interventions

Background

Scabies is a common dermatological condition, affecting more than 130 million people at any time. To evaluate and/or predict the effectiveness and cost-effectiveness of scabies interventions, disease transmission modelling can be used.

Objective

To review published scabies models and data to inform the design of a comprehensive scabies transmission modelling framework to evaluate the cost-effectiveness of scabies interventions.

Methods

Systematic literature search in PubMed, Medline, Embase, CINAHL, and the Cochrane Library identified scabies studies published since the year 2000. Selected papers included modelling studies and studies on the life cycle of scabies mites, patient quality of life and resource use. Reference lists of reviews were used to identify any papers missed through the search strategy. Strengths and limitations of identified scabies models were evaluated and used to design a modelling framework. Potential model inputs were identified and discussed.

Findings

Four scabies models were published: a Markov decision tree, two compartmental models, and an agent-based, network-dependent Monte Carlo model. None of the models specifically addressed crusted scabies, which is associated with high morbidity, mortality, and increased transmission. There is a lack of reliable, comprehensive information about scabies biology and the impact this disease has on patients and society.

Discussion

Clinicians and health economists working in the field of scabies are encouraged to use the current review to inform disease transmission modelling and economic evaluations on interventions against scabies.

Scabies is a neglected tropical disease affecting more than 130 million people, with major costs on health care systems worldwide. While effective treatments exist, it is unknown which treatment strategies result in the best outcomes against the lowest costs, and to what extent this differs between communities. Health economic modelling can help answer these questions, but has rarely been used in this disease area. This review discusses all available scabies transmission models (n = 4), and uses them to create a new, comprehensive modelling framework. This framework can be used as aid for creating a scabies transmission model, the details of which will be determined by the context (population) and the question being addressed. The current paper also reviews the data that is needed to inform scabies modelling: on scabies biology, quality of life and resource use. Unfortunately, available data is limited and particularly data on crusted scabies (associated with high morbidity and mortality rates) is rare. With this review, we hope to assist researchers and policy makers to predict and/or evaluate the cost-effectiveness of interventions against scabies in their population(s) of interest. To tackle scabies, it is key to use effective treatment strategies in a cost-effective and sustainable way. The models and data described in this review, may help researchers, clinicians and funding bodies to facilitate this.

A biological model of scabies infection dynamics and treatment informs mass drug administration strategies to increase the likelihood of elimination

Infections with Sarcoptes scabiei, or scabies, remain common in many disadvantaged populations. Mass drug administration (MDA) has been used in such settings to achieve a rapid reduction in infection and transmission, with the goal of eliminating the public health burden of scabies. While prevalence has been observed to fall substantially following such an intervention, in some instances resurgence of infection to baseline levels has occurred over several years. To explore the biology underpinning this phenomenon, we have developed a theoretical model of scabies life-cycle and transmission dynamics in a homogeneously mixing population, and simulate the impact of mass drug treatment strategies acting on egg and mite life cycle stages (ovicidal) or mites alone (non-ovicidal). In order to investigate the dynamics of the system, we first define and calculate the optimal interval between treatment doses. We calculate the probability of eradication as a function of the number of optimally-timed successive treatment doses and the number of years over which a program is run. For the non-ovicidal intervention, we first show that at least two optimally-timed doses are required to achieve eradication. We then demonstrate that while more doses over a small number of years provides the highest chance of eradication, a similar outcome can be achieved with fewer doses delivered annually over a longer period of time. For the ovicidal intervention, we find that doses should be delivered as close together as possible. This work provides a platform for further research into optimal treatment strategies which may incorporate heterogeneity of transmission, and the interplay between MDA and enhancement of continuing scabies surveillance and treatment strategies.

Management of a family outbreak of scabies with high risk of spread to other community and hospital facilities

BACKGROUND

In developed countries, scabies is observed sporadically or as institutional outbreaks in hospitals and other health facilities. In the family context, outbreaks generally involve a limited number of cases.

METHODS

A local health authority in Emilia-Romagna (Northern Italy) carried out an epidemiologic investigation on a family outbreak of scabies that included an unusually high number of cases. Its possible connection with a nosocomial case in a long-term care facility (LTCF) and outbreak management are discussed.

RESULTS

Among the household members, 8 confirmed cases occurred (attack rate, 87.5%). Another case was reported in a patient of an LTCF where one of the family cases worked as a sociosanitary operator. In total, 244 contacts were placed under surveillance. The control strategy focused on a mass information campaign addressed to all contacts and the training of health care personnel. In addition, specific prophylaxis (permethrin 5%) was performed in 108 high-risk contacts and LTCF patients and staff.

CONCLUSIONS

The control measures were successful in preventing the spread of the outbreak. However, misdiagnosis and the tendency of people to hide the symptoms caused the late recognition and underestimation of the cases, contributing to delayed control measures and increasing the economic and human resources required for outbreak management.

What's eating you? scabies in the developing world

Scabies infestation is a major cause of impetigo and subsequent renal failure in the developing world, and efforts to eradicate widespread infestation are underway. Ivermectin, topical sulfur, and topical benzyl benzoate often are used to treat widespread outbreaks.

Social living mitigates the costs of a chronic illness in a cooperative carnivore

Infection risk is assumed to increase with social group size, and thus be a cost of group living. We assess infection risk and costs with respect to group size using data from an epidemic of sarcoptic mange (Sarcoptes scabiei) among grey wolves (Canis lupus). We demonstrate that group size does not predict infection risk and that individual costs of infection, in terms of reduced survival, can be entirely offset by having sufficient numbers of pack-mates. Infected individuals experience increased mortality hazards with increasing proportions of infected pack-mates, but healthy individuals remain unaffected. The social support of group hunting and territory defence are two possible mechanisms mediating infection costs. This is likely a common phenomenon among other social species and chronic infections, but difficult to detect in systems where infection status cannot be measured continuously over time.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Managing skin infections in Aboriginal and Torres Strait Islander children

BACKGROUND

Skin infections are a cause of significant morbidity in Aboriginal and Torres Strait Islander populations.

OBJECTIVE

This article gives an overview of some of the issues to consider when managing a patient with a skin infection. These issues may impact on completion of treatment and development of complications in the long term.

DISCUSSION

Management should consist of treatment of the patient through medication and also general measures for the patient, their family and the community as a whole. There are significant health and socioeconomic burdens placed on communities as a result of the high rate of skin disease in some settings.

Neonatal rash - a case study

An infant, aged 48 days, is brought in by her mother to her doctor because of a rash that started during the neonatal period.

[Scabies in 2012]

Scabies is a parasitic infection known all over the world and particularly in a low socioeconomic context and in institutions. The transmission is mainly direct from skin-to-skin. An increase of cases has been observed in Geneva since October 2011. To confirm the diagnosis, a precise clinical and microbiological examination is required and highly recommended before starting a treatment. Scabies management includes treatment of the patient and his close contacts with antiparasitic drugs as well as thorough cleaning of clothes and bed linen. When available, oral ivermectine is the treatment of choice, topical permethrine is prescribed when ivermectine cannot be used or in association with it in severe presentations. In Switzerland, ivermectine is not readily available, it is expensive and not reimbursed by insurances.

Management of scabies

Scabies is a common contagious parasitic dermatosis. Transmission of the mite Sarcoptes scabiei var hominis generally occurs by skin-to-skin contact, but with crusted scabies it may also occur through fomites, such as infected clothing or bedding. Diagnosis is usually clinical. A 2010 updated Cochrane review concluded that management of scabies is based on topical scabicides, mainly 5% permethrin. However, oral ivermectin, although not licensed in many countries, may be useful, particularly for patients who cannot tolerate or comply with topical therapy and in institutional scabies epidemics. Patients should also receive detailed information about the infestation to limit further spreading. Cases resulting from close physical or sexual contact, even without symptoms, should be systematically treated. Hygienic measures should be taken after treatment is completed. Patients should be followed to confirm cure, including resolution of itching, which may take up to 4 weeks or longer.

Control strategies for endemic childhood scabies

Human scabies is a major global public health issue, with an estimated 300 million cases per year worldwide. Prevalence rates are particularly high in many third-world regions and within various indigenous communities in developed countries. Infestation with Sarcoptes Scabiei is associated with group-A streptococcal pyoderma which in turn predisposes to rheumatic fever, acute glomerulonephritis and their respective long-term sequelae: rheumatic heart disease and chronic renal insufficiency. The documented difficulties inherent in achieving scabies control within affected communities have motivated us to develop a network-dependent Monte-Carlo model of the scabies contagion, with the dual aims of gaining insight into its dynamics, and in determining the effects of various treatment strategies. Here we show that scabies burden is adversely affected by increases in average network degree, prominent network clustering, and by a person-to-person transmissibility of greater magnitude. We demonstrate that creating a community-specific model allows for the determination of an effective treatment protocol that can satisfy any pre-defined target prevalence. We find frequent low-density treatment protocols are inherently advantageous in comparison with infrequent mass screening and treatment regimes: prevalence rates are lower when compared with protocols that administer the same number of treatments over a given time interval less frequently, and frequent low-density treatment protocols have economic, practical and public acceptance advantages that may facilitate their long-term implementation. This work demonstrates the importance of stochasticity, community structure and the heterogeneity of individuals in influencing the dynamics of the human scabies contagion, and provides a practical method for investigating the outcomes of various intervention strategies.

[Animal mites transmissible to humans and associated zoonosis]

Mites that affect animals (acariasis) can occasionally be transmitted to humans by incidental contact producing pruritus and dermatitis. Animals such as dogs, cats, mice, birds and reptiles, harbour several mite species. Hemophage mites and those that feed on lymph have the potential of transmitting important zoonotic agents (cuales??). The presence of lesions of unclear origin and a history of contact with pets or wild animals should alert towards the possibility of acariasis. Diagnosis is based on direct visualization of the mite,analysis of its morphology and obtaining information on the animal host. Awareness of these acarosis and the responsible care of pets and animals are the most relevant preventive measures.

Sarcoptic mange of gazelle (Gazella subguttarosa) and its medical importance in Iran

Sarcoptes scabiei infestation was diagnosed in four freshly dead and three net-captured gazelle while ranging freely. The captured animals presented with an alopecic pruritic skin disease with signs of crusted skin lesions, numerous small nodules which first appeared on the lips or nostrils and then it also extended towards the eyelids, around the ears, and, in some cases, over entire face, neck, trunk, and legs. Skin over the affected area gradually became bald, thick and hard, being dry and doughy to the touch, and serous fluid or sometimes blood oozes from the lesions which had a severe malodor. Skin scrapings confirmed the presence of the mite S. scabiei. Histopathology of lesions demonstrated marked acanthosis, hyperkeratosis, and parakeratosis. Microscopical examination also revealed all stages of S. scabiei, which were located mainly in the stratum corneum and also in the stratum granulosum. During the capture and sampling of the animals, four persons ranging in age from 25 to 62 years were exposed to scabies. Two relatives of one of them have been also affected by familiar contact. Clinical signs appeared within 9 days of exposure. They developed several pruretic erythematous papules with intense itching.

Brote de sarna en un hospital terciario a partir de un caso de sarna costrosa

In February 2005 we performed an epidemiological study of an outbreak of scabies in a tertiary-care hospital which started from a crusted scabies case. We detected 10 secondary cases, 8 in healthcare workers and 2 in hospitalized patients. The attack rate was 4.1%. In contrast to previously described outbreaks, the crusted scabies case was recognized at admission. The outbreak causes were: lacking adherence to contact precautions, long stay of the primary case in the hospital ward and delay of specific treatment. The main control measures were: alerting the hospital services about the outbreak, performing epidemiologic surveillance, coordinating with the Hospital Direction and the Occupational Health Department, education of healthcare workers in control measures, implementation of isolation measures and treatment of cases and contacts with 5% permethrin topical lotion.

Scabies and Pediculosis Pubis: An Update of Treatment Regimens and General Review

Ectoparasites continue to be a common cause of skin disease throughout the world. The present article dissects the epidemiological profile and treatment of both Sarcoptes scabiei variant hominis and pediculosis pubis.

Scabies: a ubiquitous neglected skin disease

Scabies has been a scourge among human beings for thousands of years. Its worldwide occurrence with epidemics during war, famine, and overcrowding is responsible for an estimated 300 million people currently infested. Scabies refers to the various skin lesions produced by female mites, and their eggs and scybala that are deposited in the epidermis, leading to delayed-type hypersensitivity reaction. Recent immunological findings such as cross-reactivity with house dust mite allergens and an altered T-helper-1/T-helper-2 pattern contribute to a better understanding of the pathomechanism. Furthermore, progress in molecular biology and cloning of relevant antigens could enable the development of a diagnostic ELISA system and candidate vaccines in the near future. Typical and atypical clinical presentations with pruritus as a hallmark of scabies occur in young, pregnant, immunocompromised, and elderly patients and include bullous and crusted (Norwegian) manifestations as well as those masked by steroid use (scabies incognito). This article reviews scabies management strategies in developed countries and resource-poor communities as well as typical complications, including the emergence of resistance and drug-related adverse events. Other problems such as post-scabies eczema and reinfestation, and newer treatments such as ivermectin are also discussed.

Nosocomial scabies

Scabies is a parasitic dermatosis with a worldwide distribution. This infestation affects millions of people annually and may cause large nosocomial outbreaks with considerable morbidity among patients and healthcare workers. Immunocompromised or elderly institutionalized patients admitted with unrecognized crusted scabies are the main source of nosocomial transmission. Factors that facilitate the development of hospital-acquired scabies and nosocomial epidemics are: poor knowledge of scabies epidemiology, unfamiliarity of healthcare workers with atypical presentations, long incubation period, diagnostic delay and incomplete monitoring. Within hospitals, containment of an outbreak relies on the strict implementation of appropriate infection control measures and treatment administration to contacts. It is associated with a considerable working and economic burden.

Outbreak: 10 tips to make scabies scamper

PROBLEM

Most nursing homes are aware of the pandemonium an outbreak of scabies can cause-the laundry alone occupies staff for days. Debilitated residents and those who have poor selfcare skills require considerable help with the activities associated with the eradication of Sarcoptes scabiei. How can a consultant pharmacist help?

SOLUTION

Consultant pharmacists should cultivate a "high index of suspicion" for scabies. Scabies mites live their entire lives on the human host as obligate parasites. They are able to survive elsewhere for only up to 48 hours, making transmission via fomite (blankets, towels, or any object that can transmit infectious agents) possible, but unlikely. Transmission follows close personal contact, and passing contact like handshaking is insufficient to pass the mites. Crowded living conditions, such as those associated with emergency shelters, and close and repeated contact, like that which occurs in classrooms, fuel cluster outbreaks.

Diseases and mortality in free-ranging brown bear (Ursus arctos), gray wolf (Canis lupus), and wolverine (Gulo gulo) in Sweden

Ninety-eight brown bears (Ursus arctos), 20 gray wolves (Canis lupus), and 27 wolverines (Gulo gulo), all free-ranging, were submitted to the National Veterinary Institute, Uppsala, Sweden, during 1987-2001 for investigation of diseases and causes of mortality. The most common cause of natural death in brown bears was infanticide. Infanticide also was observed in wolverines but not in wolves. Traumatic injuries, originating from road or railway accidents, were the most common cause of death in wolves and occurred occasionally in brown bears. Most wolverines were submitted as forensic cases in which illegal hunting/poaching was suspected. Sarcoptic mange was observed in several wolves but not in brown bears or wolverines. Sarcoptic mange most likely was acquired from infected red foxes (Vulpes vulpes) that were killed by wolves. Other parasites and infectious diseases were only found sporadically.

The incidence of molluscum contagiosum, scabies and lichen planus

We aimed to describe the incidence of new episodes of molluscum contagiosum, scabies and lichen planus presenting to general practitioners in England and Wales. We examined data collected in a sentinel practice network (the Weekly Returns Service of the Royal College of General Practitioners) in which about half a million persons were observed each year over the period 1994-2003. The incidence of molluscum contagiosum in males was 243/100,000 person-years and in females 231; of scabies, males 351, females 437; of lichen planus, males 32, females 37. Incidence varied by year and age. Ninety per cent of molluscum contagiosum episodes were reported in children aged 0-14 years, where incidence in 2000 (midpoint of a 6-year period of stable incidence) was 1265/100,000 (95% CI 1240-1290). Scabies affected all ages and annual incidence ranged between 233 (95% CI 220-246) in 2003 and 470 (95% CI 452-488) in 2000. Lichen planus occurred chiefly in persons aged over 45 years: incidence (all ages) ranged between 27 (95% CI 23-31) in 2003 and 43 (95% CI 37-49) in 1998. The relative risk of female to male incidence (all ages) of molluscum contagiosum was 0.95 (95% CI 0.91-0.99); of scabies 1.25 (95% CI 1.21-1.28); and of lichen planus 1.19 (95% CI 1.08-1.13).

[Nosocomial outbreak of scabies in a psychiatric hospital--epidemiological assessment and prophylactic treatment with oral ivermectin]

OBJECTIVES

To evaluate the effectiveness of mass treatment with ivermectin of scabies outbreak in institutional settings. To determine the factors, such as host susceptibility and scabetic exposure level associated with the onset of scabies.

METHODS

The authors investigated a nosocomial scabies outbreak in a close psychiatric ward. The index case was a man with steroid-induced localized crusted scabies. Twenty-six patients were diagnosed with scabies, 4 of them had relapse of scabies, while no staff was infested. Despite frequent surveillance and treatment of symptomatic patients with 1% gamma-benzenehexachloride (gamma-BHC: Lindane), new cases were observed. Thus, all 69 patients in the ward were treated with ivermectin (200 microg/kg) simultaneously on day 105 of the outbreak (the mass treatment). Patients who had scabies were compared with patients who had no scabies in terms of age, body weight, diabetes, physical functions, topical administration of corticosteroid, proximity to the index patient, and problematic behavior.

RESULTS

The mass treatment was implemented without a significant adverse event. Although two patients developed symptoms of scabies after the mass treatment, no patient in the ward had been diagnosed with scabies since the 98th day of the treatment. Regarding factors associated with the scabies onset, the only statistically significant factor was proximity to the index patient with crusted scabies.

CONCLUSIONS

Oral ivermectin was safe and effective for controlling scabies in institutional settings. The exposure level to scabetic mites was more important than host susceptibility in determining the risk of scabies onset.

Tuberculosis, chickenpox and scabies outbreaks in an orphanage for children with HIV/AIDS in Jamaica

OBJECTIVES

The aim of this study is to describe the investigation and management of outbreaks of acute tuberculosis, varicella zoster virus and scabies in a residential facility for children with HIV/AIDS.

METHOD

A review of the results and management for diagnosed cases of acute TB (four between 2001 and 2002) as well as varicella zoster virus (15) and scabies (14) (concurrent in March--June 2003), in a residential facility housing 24 abandoned children with HIV/AIDS was conducted. Outbreak control methods and challenges are described The modified WHO criteria were used for TB diagnosis. The diagnoses of varicella and scabies were entirely clinical.

RESULTS

Of the surviving 22 children, 12 (mean age 8 years 2 months) were female, and 10 (mean age 5 years 6 months) were male. Full immunization (primary series) was documented for 16 children, partial in one child, unknown status was documented in five children. One child had received varicella vaccine previously. Eleven (50%) children had been receiving antiretroviral triple therapy since 2002 (all in Centers for Diseases Control immunological categories 2-3). Two of the four children with tuberculosis died between 2001 and 2002; these were not on antiretroviral therapy--the 2 survivors are still on antiretroviral therapy. All staff mantoux test results were negative. Fifteen (68%) children developed chickenpox as well as three caregivers. The index case was a 13-year-old resident attending a nearby school with HIV negative children. This varicella outbreak went on to affect household members for the caregivers as well as other residential facilities nearby. Scabies affected 14 children (no caregivers); the index cases were most likely three new child residents who entered the institution in 2002 (from other homes) with histories of scabies infestation. Chickenpox and scabies dual infection occurred in seven (31%) of residents. No cases of herpes zoster, disseminated varicella infection or death because of varicella occurred Diagnosed cases of chickenpox were treated with oral acyclovir Knowledge about these disease outbreaks and their control was generally lacking.

CONCLUSIONS

Improvement in immunization coverage for children and staff as well as educating staff about infectious disease outbreaks, is necessary for effective control. Appropriate screening for infection/disease for all susceptible persons is essential along with timely reporting of outbreaks/reportable diseases. There is need for increased awareness of acute opportunistic infections in children with HIV/AIDS living in close proximity.

[Nosocomial outbreak of scabies from a Norwegian scabies case]

OBJECTIVE

To describe a nosocomial outbreak of scabies occurred in August 1999, resulting from exposure to an undiagnosed Norwegian scabies case, in Mexico City.

MATERIAL AND METHODS

After reviewing the index case, we isolated the patient and identified secondary scabies cases among employees working in the affected ward, their relatives, and inpatients. Only individuals complaining from skin lesions and pruritus were included as infested cases. Control measures as contact isolation, proper handling of contaminated clothes, and topical treatment were implemented.

RESULTS

A patient with AIDS (index case) with a severe water and electrolyte imbalance was admitted to the Hospital de Infectologia (Infectious Diseases Hospital) of the Centro Medico Nacional La Raza (La Raza National Medical Center) in Mexico City from July 19 to August 20, 1999. Twenty-eight days after the index case admission, scabies cases occurred among health workers. Norwegian scabies was suspected and confirmed by microscopic evidence of the mites on a specimen of scabs from the index case. We identified 48 secondary cases with clinical scabies: 71% health workers, mainly nurses (79%); 23% health workers' relatives; and 6% inpatients. The mean incubation period was 15 days (range 12 to 27). Skin rashes commonly involved the upper extremities (60%) but not the hands.

CONCLUSIONS

This paper highlights the difficulties in diagnosing Norwegian scabies in an immunosuppressed host, as well as the importance of ensuring that health workers follow standard precautions at all times. The English version of this paper is available at: http://www.insp.mx/salud/index.html.

[Diagnostic image (198). Four hospital employees with itch]

Four employees working on an Internal Medicine ward complained of itch after contact with an HIV-positive woman with crusted scabies.

[Nosocomial infection of scabies in national hospitals and sanatoria in Japan]

The aim of this study was to investigate cases of nosocomial infection of scabies in the national hospitals in Japan. Questionnaires sent to 183 hospitals and sanatoria were returned by 93. Fifty-three cases in 24 institutions of nosocomial infection were reported in the past 5 years. No nosocomial infection was reported from 7 sanatoria for Hansen's diseases where the patients were relatively older and had higher ADL scores. It took 7.5 weeks on the average to eliminate nosocomial infection and more than 8 weeks were required to control them in the hospitals where more than 10 cases had occurred. Benzyl benzoate, gamma benzene hexachloride, and Pyrethroids, which were not approved as drugs for the treatment of scabies in Japan, were used in the all institutions where nosocomial infection occurred except for one institution. Problems to be solved were as follows; (1) delay of diagnosis and treatment, (2) lack of nursing staff, (3) difficulties of complete isolation due to lack of spaces, inability of patients to understand the need for isolation and also the psychological instability of the isolated patients, (4) recurrence due to the use of ineffective drugs, (5) insufficient information about the prevalence of scabies in the previous institutions, (6) misdiagnosis of non-scabies patients with itchy skin rash as the scabies, (7) inconsisitent care due to poor evaluation of skin lesions.