Journal Scabies
7
Tropical medicine rounds Scabies community prevalence and mass drug administration in two Fijian villages Karin Haar 1, *, MD, MMED, MPH, Lucia Romani 2 , MSD, Raikanikoda Filimone 3 , MBBS, DipDerm, MMED, Kamal Kishore 4 , MBBS, MD, DPH, Meciusela Tuicakau 3 , MBBS, DDM, Josefa Koroivueta 3 , DSM, FACTM, John M. Kaldor 2 , PhD, Handan Wand 2 , PhD, Andrew Steer 5 , MBBS, PhD, and Margot Whitfeld 6 , FACD 1 University of Sydney, New South Wales, Australia, 2 Kirby Institute, University of New South Wales, New South Wales, Australia, 3 Ministry of Health, Suva, Fiji, 4 Fiji National University, Suva, Fiji, 5 University of Melbourne, Victoria, Australia, and 6 Department of Dermatology, St. Vincent’s Hospital Sydney, New South Wales, Australia Correspondence Dr. Margot Whitfeld, FACD Department of Dermatology St. Vincent’s Hospital Sydney Suite 4 Level 4 66 Pacific Hwy St Leonards NSW 2065 Australia E-mail: [email protected] *Present address: Robert Koch-Institute, Dept. for Infectious Disease Epidemiology, HIV/AIDS, STI and Bloodborne Infections Unit, DGZ-Ring 1, Berlin, Germany. Conflicts of interest: None. doi: 10.1111/ijd.12353 Abstract Background Scabies has been estimated to affect approximately 300 million people worldwide each year. Scabies rates are high and pose a significant public health problem in Fiji. Community-based comparison treatment trials have not been undertaken. We estimated scabies prevalence and compared the efficacy and tolerability of mass drug administration (MDA) of benzyl benzoate lotion (BB) or oral ivermectin (IVM) in two villages in Fiji. Methods A prospective MDA trial was undertaken in two Fijian villages, comparing three daily applications of BB with single dose IVM or permethrin cream for those aged under two years. The therapies were offered to all community members regardless of the presence of scabies or its symptoms. The difference in prevalence was measured before and after the intervention and absolute risk reduction (ARR) and relative risk (RR) calculated. Results In the BB group, there were 572 eligible participants, of whom 435 (76%) enrolled and 201 (46%) returned for follow-up. In the IVM group, there were 667 eligible participants, of whom 325 (49%) enrolled and 126 (39%) returned. Scabies prevalence was lower after the intervention in both groups. It fell from 37.9 to 20.0% (ARR 18.0%; RR 0.52) in the BB group and from 23.7 to 9.5% (ARR 14.2%; RR 0.40) in the IVM group. Conclusions Our study provides proof of principle that MDA for scabies can reduce scabies prevalence at the community level, and that there was no significant difference in this trial between BB and oral IVM. Introduction Scabies, due to infestation with the Sarcoptes scabiei mite, has been estimated to affect approximately 300 million people worldwide each year. Its direct impact is itching, but secondary bacterial infection with Streptococci and Staphylococci is frequent and can lead to serious and potentially fatal complications, including invasive bacte- rial infections, renal failure, and chronic rheumatic heart disease. 1–4. The highest rates of scabies in the world are found in Pacific island countries. 5 In a population-based survey in Fiji, 24% of participants had scabies, with a particularly high prevalence in young children (L. Romani, personal communication). A prospective study in Fijian schoolchil- dren documented scabies incidence at 51 cases per 100 person-years. 6 Scabies treatment is primarily with application of topi- cal agents, including benzyl benzoate and permethrin cream, which was introduced to Fiji in 2006 and is now the standard of care. 7 As S. scabiei is transmitted by close body contact or shared objects, treatment of close con- tacts is also recommended. One oral agent, ivermectin (IVM), has been used as single dose scabies treatment, repeated at two weeks if symptoms persist. 8–10 The frequency of reinfestation in endemic settings has led to consideration of mass drug administration (MDA) as a public health option for scabies control. Small, ª 2013 The Authors. International Journal of Dermatology published by John Wiley & Sons Ltd on behalf of The International Society of Dermatology. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes. 1
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Tropical medicineroundsScabiescommunityprevalenceandmassdrugadministrationintwoFijianvillagesKarinHaar1,*, MD,MMED,MPH,LuciaRomani2, MSD,RaikanikodaFilimone3, MBBS,DipDerm,MMED,KamalKishore4, MBBS,MD,DPH,MeciuselaTuicakau3, MBBS,DDM,JosefaKoroivueta3, DSM,FACTM,JohnM.Kaldor2, PhD,HandanWand2, PhD,AndrewSteer5, MBBS,PhD,andMargotWhitfeld6, FACD1UniversityofSydney,NewSouthWales,Australia,2KirbyInstitute,UniversityofNewSouthWales,NewSouthWales,Australia,3MinistryofHealth,Suva,Fiji,4Fiji NationalUniversity,Suva,Fiji,5UniversityofMelbourne,Victoria,Australia,and6DepartmentofDermatology,St.VincentsHospital Sydney,NewSouthWales,AustraliaCorrespondenceDr.MargotWhitfeld, FACDDepartmentofDermatologySt.VincentsHospital SydneySuite4Level 466PacicHwyStLeonardsNSW2065AustraliaE-mail:[email protected]*Presentaddress:RobertKoch-Institute,Dept.forInfectiousDiseaseEpidemiology,HIV/AIDS,STIandBloodborneInfectionsUnit,DGZ-Ring1,Berlin,Germany.Conictsofinterest:None.doi:10.1111/ijd.12353AbstractBackground Scabies has been estimated to affect approximately 300 million peopleworldwideeachyear.ScabiesratesarehighandposeasignicantpublichealthprobleminFiji.Community-basedcomparisontreatmenttrialshavenotbeenundertaken.Weestimatedscabiesprevalenceandcomparedtheefcacyandtolerabilityofmassdrugadministration(MDA)ofbenzylbenzoatelotion(BB)ororal ivermectin(IVM)intwovillagesinFiji.MethodsAprospectiveMDAtrial wasundertakenintwoFijianvillages, comparingthreedailyapplicationsofBBwithsingledoseIVMorpermethrincreamforthoseagedundertwoyears.Thetherapieswereofferedtoall communitymembersregardlessofthepresenceofscabiesoritssymptoms.Thedifferenceinprevalencewasmeasuredbeforeandaftertheinterventionandabsoluteriskreduction(ARR)andrelativerisk(RR)calculated.ResultsIntheBBgroup,therewere572eligibleparticipants,ofwhom435(76%)enrolledand201(46%)returnedforfollow-up.IntheIVMgroup,therewere667eligibleparticipants,ofwhom325(49%)enrolledand126(39%)returned.Scabiesprevalencewasloweraftertheinterventioninbothgroups.Itfell from37.9to20.0%(ARR18.0%;RR0.52)intheBBgroupandfrom23.7to9.5%(ARR14.2%;RR0.40)intheIVMgroup.Conclusions Our study provides proof of principle that MDA for scabies can reducescabiesprevalenceatthecommunitylevel,andthattherewasnosignicantdifferenceinthistrial betweenBBandoral IVM.IntroductionScabies, due to infestation with theSarcoptesscabiei mite,has beenestimatedtoaffect approximately 300millionpeopleworldwideeachyear. Itsdirect impact isitching,but secondary bacterial infection with Streptococci andStaphylococci is frequent and can lead to serious andpotentiallyfatal complications, includinginvasive bacte-rial infections, renal failure, andchronicrheumaticheartdisease.14.Thehighest ratesof scabiesintheworldarefoundinPacicislandcountries.5Inapopulation-basedsurveyinFiji, 24%ofparticipantshadscabies, withaparticularlyhighprevalenceinyoungchildren(L. Romani, personalcommunication).AprospectivestudyinFijianschoolchil-drendocumentedscabies incidence at 51cases per 100person-years.6Scabiestreatmentisprimarilywithapplicationoftopi-cal agents, including benzyl benzoate and permethrincream, whichwasintroducedtoFiji in2006andisnowthe standard of care.7AsS.scabiei is transmitted by closebodycontact or sharedobjects, treatment of close con-tacts is also recommended. One oral agent, ivermectin(IVM), has beenusedas single dose scabies treatment,repeated at twoweeks if symptoms persist.810Thefrequencyof reinfestationinendemicsettings hasledtoconsiderationof massdrugadministration(MDA)as a public health option for scabies control. Small,2013TheAuthors.International Journal ofDermatologypublishedbyJohnWiley&SonsLtdonbehalfofTheInternational SocietyofDermatology.ThisisanopenaccessarticleunderthetermsoftheCreativeCommonsAttribution-NonCommercial License,whichpermitsuse,distributionandreproductioninanymedium,providedtheoriginal workisproperlycitedandisnotusedforcommercial purposes.1uncontrolled studies in closed communities such as prisonsandagedcarefacilitieshavesuggestedthat treatment ofentirecommunities cansharplyreducetheprevalenceofinfestation,8,1113using either topical treatment or oralIVM, the latter perhaps offering better adherence andfewersideeffects.14Toassessthepotential roleofMDAinanopencommunitysettinginthegeneral population,we studied oral vs. topical MDA in two Fijian villages.MaterialsandmethodsWeperformedaprospectivetrial comparingtheefcacyandtolerabilityoftwoMDAtreatmentregimensforthecontrol ofscabiesbyofferingtreatmenttoall communitymembersregardlessofthepresenceofscabiesoritssymptoms.Hence,all familymembersofstudyparticipants,includingasymptomaticfamilymembersofpatientswithscabieslivingineithervillage,wereofferedtreatmentimmediatelyafterexaminationandincludedinthestudy.WeconductedthestudyintwoFijiansubdivisions(localadministrativeareas) inJuneandJuly2004. ThesiteswereselectedbytheFiji Ministryof Healthashavingapproximatelythesamenumber of inhabitantsandbeingwithina2-hour driveof thecapital, Suva, but relativelyisolatedfromeachother andfromother communities.Allocationtotreatment wasdecidedbyadministrativechancebasedontheavailabilityof medicationat start point. IntheTailevusubdivision, threecloselylinkedsettlements(Sawakasa, Dakuinuku, andLodoni, total population572)wereclassiedasonesite. IntheRewasubdivision,Raralevuvillagewasselected(total population667). All Fijiannationalslivingineither of thetwositeswereconsideredeligiblefor thestudyandwereenrolledafter signingtheconsent forms, withparentssigningfor their children. Studyparticipantswereregisteredbyname, age, andsexandwereweighedat initial visit. After enrollment, participantswereidentiedonlybytheir numericcodeandnofurther identifyingdatawereusedinthestudy.Participantswereaskedtocompletequestionnairesatenrollmentandfollow-upvisit,ineitherEnglishorFijian,andassistedbythelocal communitynurseifnecessary.Eachparticipantwasexaminedbyahealthcareprofessional withexperienceinscabiesdiagnosisandtreatmentandreviewedbyaseniordoctorifanyskinlesionswereseen.Thediagnosisofscabieswasmadeclinically,basedonthepresenceofcharacteristiclesionswithorwithoutahistoryofitch.Suspectedscabieslesions,eitherpapules,pustules,orcrustedlesionsonthetrunkandlimbs,werecountedandotherdermatologicalconditions,suchasboilsandsores,eczema,andtineaweredocumentedbeforeandaftertreatment.Ifappropriate,oralantibioticsweregivenforsecondarilyinfectedlesionsandtherapyprovidedforotherskinconditions.Theextentofscabieswasquantiedasmild(10lesionsorfewer),moderate(1149),severe(50ormore),orcrusted(conuentlesions,toomanytocount).1517Thediagnosisofinfectedlesionswasmadebasedonthepresenceoferythema,crusting,orpustules.InterventionsAll MDAstudyparticipantsintheRewasubdivisionsite(IVMgroup)aged2yearsandoverwithnomedical contraindicationsreceivedasingledoseoforal IVMat200lg/kgbodyweight(Stromectol3mgtablets;MerckSharp&Dohme,SouthGranville,NSW,Australia),roundedtowhole3mgIVMtablets.IVMwastakenorallyunderdirectobservation,immediatelyafterexamination.Childrenaged
