Most scabies cases were mild The prevalence of scabies diagnosed by doctor and nurse examiners was similar Itch was reported in A positive contact history was reported in Of those with scabies, Of those without scabies, Only four individuals 2.
Scabies was more common in males than females Prevalence of impetigo was higher in males Participants with scabies had a higher prevalence of impetigo than those without scabies 66 of , Overall, Of the 18 individuals with greater than very mild impetigo, 14 High scabies prevalence has been described in other disadvantaged populations including in children in Fiji In our study, males were more likely than females to have scabies, which has been reported previously [ 18 , 19 ], although this finding is not represented in the Global Burden of Disease Study estimates [ 20 ].
This was consistent for males and females. We found that the IACS Criteria for the diagnosis of scabies were easily integrated and implemented into our study design. Implementation of these criteria in other settings would allow comparison across studies and regions. Impetigo was positively associated with the presence of scabies, although the association was less strong than previously reported [ 13 ].
The association between scabies and impetigo in a range of settings warrants further investigation. However, in our study, more children identified contact with a friend or class member than a household member. Contact between children at school and between friends is likely to be important for disease transmission between children.
Contact history questions should be asked in an appropriate way for specific survey settings and participants. There were several limitations to our study. First, this study only focused on school children and is therefore not generalizable to other age groups. However, as scabies is highly transmissible among household contacts [ 27 ] it is likely that there would be a high prevalence amongst the household members of children with scabies. Second, we enrolled The remaining students did not participate because they were away from school or did not provide consent to participate.
Those not attending school may have been more disadvantaged with an even greater disease burden, possibly leading to an underestimate of the true prevalence. Conversely, it is possible that some families and teachers may have encouraged children with symptoms of scabies or impetigo to participate, which may have led to an overestimate of prevalence. Third, the diagnosis of scabies and impetigo in the study was based on clinical assessment of exposed areas utilizing the IACS Criteria, rather than whole body examination using dermoscopy, microscopy, or skin scrapings.
Children in low-resource settings are disproportionately affected by scabies and impetigo, predisposing them to significant morbidity and mortality. The high prevalence of scabies in this study supports the ongoing need for prevalence studies and identifying communities where the disease is endemic.
The significant burden of disease highlights the need for ongoing health promotion activities for scabies and impetigo. The very high prevalence of scabies also supports the urgent implementation of a population-scale control program in the Solomon Islands. Greater appreciation of scabies as a major global contributor to poor health in children may help to improve awareness and access to treatment in settings where scabies is endemic.
The datasets used and analyzed during the study are available from the corresponding author on reasonable request. Control of scabies, skin sores and haematuria in children in the Solomon Islands: another role for ivermectin. Bull World Health Organ. Scabies is strongly associated with acute rheumatic fever in a cohort study of Auckland children. J Paediatr Child Health. Article Google Scholar. Prevalence of scabies and impetigo worldwide: a systematic review. Lancet Infect Dis. Global, regional, and national incidence, prevalence, and years lived with disability for diseases and injuries, — a systematic analysis for the Global Burden of Disease Study Geneva: WHO; Engelman D, Steer AC.
Control strategies for scabies. Trop Med Infect Dis. International Alliance for the control of scabies Delphi p. Consensus criteria for the diagnosis of scabies: a Delphi study of international experts. Helminth control in school-age children: a guide for managers of control programmes. Infants were also more likely to have more than one body region involved The total unweighted prevalence of impetigo was very high at The adjusted prevalence of active impetigo, weighted for gender and age was The prevalence of active impetigo was higher in males than females prevalence There was no statistically significant association between active impetigo prevalence and the number of people per household.
The prevalence of active impetigo was higher in those with scabies of , In this cross-sectional survey we report a substantial prevalence of scabies and impetigo in ten villages of the Western Province of the Solomon Islands.
Our results are also similar to other studies in the Pacific region, including Fiji [ 3 , 18 — 21 ], Vanuatu [ 22 ], Timor-Leste [ 23 ] and indigenous communities of northern Australia [ 9 , 24 ]. Clinical findings and epidemiological associations supported findings from neighboring Pacific island countries. The prevalence of scabies was highest in infants and pre-school aged children, suggesting that these age groups are important in continued community transmission [ 20 ].
There was a strong association between the presence of scabies infestation and active impetigo, suggesting that scabies infestation is an important risk factor for bacterial infection of the skin.
This association is well supported by previous data from the Pacific region, including multiple studies from Fiji [ 3 , 20 ]. We did not observe a consistent association between scabies or impetigo prevalence and measures of household crowding.
The clinical distribution of scabies, in all groups but infants, followed the classic acral distribution previously described [ 1 ].
However, our finding that the lower extremities were affected more frequently than the upper limbs is in contrast to some other studies [ 3 ]. One possible explanation is a lack of footwear and clothing covering the ankles and feet in the communities we examined. Similar to previous studies, we observed that scabies in infants has a more varied presentation, with rash more commonly affecting the head and multiple body regions [ 25 ]. Our study has several limitations.
Non participation among the eligible target population was due primarily to community members not being present in the village at the time of study. A small number consented but did not wait to be examined.
We were able to adjust our analysis for age and gender, but cannot be certain of the influence of only collecting data from half of the population. Second, due to available facilities and infrastructure, clinical examination was often undertaken with limited privacy for participants. In this context, examination of all body regions was frequently not appropriate, and therefore data on severity and distribution of disease in some body areas is likely underestimated. Third, the diagnosis of scabies and impetigo was made on the basis of directed clinical history and skin examination alone.
Skin scrapings for direct microscopy and magnification with dermoscopy were not used, and may have enhanced accuracy. Diagnostic accuracy is dependent upon the clinical acumen and experience of the examiner. The examining doctor, whilst having relevant clinical experience, did not have formal training in tropical dermatology, which may have led to some diagnostic misclassification. However, our prevalence estimates are consistent with comparable studies, suggesting that this was unlikely to be a significant factor.
Further development of standardized clinical criteria and algorithms for the diagnosis of scabies and impetigo in field settings [ 26 ] would facilitate more accurate data collection and comparisons of global epidemiological data. Finally, all communities selected for the study had participated in a trachoma control program, which included community administration of a single dose of azithromycin in June As azithromycin has activity against S.
Limited previous data has supported this hypothesis [ 27 ], however further investigation into the effect of single dose azithromycin against staphylococcal and streptococcal skin disease is warranted. Despite these limitations, there are important clinical and public health implications arising from our study. These conditions place a great burden on these communities, with clinical management of individual cases consuming a significant proportion of limited health resources.
Scabies appears to be a significant risk factor for the development of active impetigo. Therefore, if public health programs are to reduce the burden of impetigo, its downstream complications and associated morbidity, there is a need to explore methods for community control of scabies.
Studies of mass drug administration using both topical scabicides and oral ivermectin in the Solomon Islands [ 18 ], Fiji [ 21 ] and other countries appear highly promising in reducing scabies and impetigo prevalence, and require serious consideration for ongoing management of these neglected tropical diseases of the skin. We thank the Solomon Islands nursing and support staff involved in the data collection process, and the warm hospitality and involvement of participating families and communities of the Western Province.
The views expressed in this article are the views of the authors alone and do not necessarily reflect the views or policy of WHO. Abstract Background Scabies and impetigo are common, important and treatable skin conditions. Methodology Ten rural villages in the Western Province of the Solomon Islands were included in the study, chosen so that data collection could be integrated with an existing project investigating clinical and serological markers of yaws.
Principal Findings The total unweighted prevalence of scabies was Conclusions and Significance Scabies and impetigo are very common in the rural Western Province of the Solomon Islands. Author Summary Scabies, a parasitic infection, and impetigo, a superficial bacterial infection, are treatable skin conditions found most commonly in resource-limited settings. Introduction Scabies is a parasitic infestation of the skin by the mite Sarcoptes scabiei var hominis.
Impetigo is different from rashes that are caused by an allergic reaction. Take poison ivy, for example. A person must come in contact with a poison ivy plant to develop a skin reaction. This rash occurs only on parts of the skin exposed to the plant. Impetigo, on the other hand, can develop anywhere on the body and spread. Spreading happens when you scratch a lesion and then touch another part of your body. In the case of impetigo, a rash may appear 4 to 10 days after exposure to the bacteria or contact with lesions.
Other rashes can have a longer incubation period. For example, a scabies rash can develop within days of skin-to-skin contact with a scabies mite. But sometimes, it can take up to six weeks for the first symptoms to appear. A chickenpox rash will usually develop 10 to 21 days after exposure to the virus. If you have a dry or itchy rash from eczema , chickenpox, or another similar ailment, scratching the rash can break your skin.
This can provide a point of entry for the staph or strep bacteria. Take steps to soothe itchy skin if you have any type of rash. This includes applying topical anti-itch cream or other soothing lotion. Keeping a rash covered with gauze can help prevent scratching and complications.
This can lead to permanent skin scarring, but these deep infections are more likely to occur in those with a weakened immune system. Other complications of impetigo can include cellulitis , which is when the infection affects the tissue underlying the skin.
The strep bacteria can also lead to poststreptococcal glomerulonephritis. This is when an immune reaction results in kidney inflammation and renal damage. Even so, you must take steps to prevent recurrent impetigo infections. Avoid sharing personal items, and wash your bath towels, linens, and any clothes worn during the infection in hot water.
You can also help avoid recurrent infections by avoiding close contact with anyone who has a skin rash or lesions. As evidenced in the industrialisation of tropical countries such as Singapore, improvements in housing along with better access to quality healthcare can significantly impact on the burden of skin infection complications such as post-streptococcal glomerulonephritis[ 38 ]. It is reasonable to conceive that skin infection is also under-recognised outside of the hospital setting. This is compounded by the poor communication of diagnosis and treatment of skin infections documented by hospital staff on discharge back to primary care providers.
Despite the high prevalence of skin infection in our population, few children had received specific treatment for impetigo in the preceding twelve months. Strategies to improve recognition of and awareness of the complications of skin infection and the importance of treatment should consider primary health care workers, community workers, teachers, environmental health providers as well as children and their families.
This study has several limitations. Firstly, we were not able to recruit all of the eligible patients during the study period due to the availability of study staff and clinical commitments at other sites. Although recruitment was opportunistic, all children admitted to the ward were approached to participate when the study site doctor was present in order to achieve a representative sample.
Secondly, in the prospective assessment, the diagnosis of skin infection was made clinically. In order to limit possible bias due to the reliance on clinical judgement, a diagnostic guide with clear clinical definitions was used as a reference tool in all cases[ 30 ]. The heightened awareness of the importance of skin health at a regional level during late , as evident in the public health response, could potentially have increased the recognition of skin infection during the retrospective data collection period and the coordinated public health response led to a documented decrease in the community prevalence of scabies between December and May [ 41 ].
Despite these potential influences our study still found that skin infection was less likely to be diagnosed and treated in the retrospective period November compared with the prospective data collection period. Finally, by virtue of the study design the assessment of clinician recognition of skin infection was performed retrospectively.
Although it is plausible that clinicians did in fact recognise skin infection but did not document this, specific treatment for skin infection was prescribed far less frequently in the retrospective analysis supporting the finding of clinician under-recognition. Notwithstanding the limitations of this study the findings have significant implications for policy and future research.
As the diagnosis of skin infections in endemic settings remains predominantly clinical, the training of health care providers is vital in improving recognition. Strategies which potentially overcome the difficulties associated with the diagnosis and treatment of individual patients such as community dermatology[ 42 — 44 ] and mass drug administration[ 45 ] should be considered.
Specific training of health workers has been shown to improve recognition and treatment of skin infection in resource-poor settings[ 46 ]. The use of integrated algorithms for the management of skin infection in health clinics has also demonstrated promise as a strategy to improve diagnosis of skin infection[ 47 , 48 ].
Improvements in the accessibility to and availability of appropriate existing diagnostic tools such as dermatoscopy in resource limited settings should occur in parallel with further research exploring novel, practical diagnostic techniques[ 49 , 50 ].
Community dermatology has demonstrated promise as an effective and affordable strategy in addressing common skin conditions including infections in low resource settings by addressing skin disease at a community level[ 42 — 44 ].
This approach encompasses several strategies including the training of community health care workers to recognize and treat skin disease, public health measures to address the determinants of skin disease, the education of community members and the prioritization of conditions to tackle based on accurate epidemiological data and simplifying their treatment[ 51 ]. Furthermore, the use of mass drug administration to target scabies has shown promise in populations with endemic disease; this strategy may allow circumvention of some of the challenges around clinical under-recognition and normalization of skin infection in selected settings[ 45 ].
Other factors outside of lack of skills and training likely contribute to the under-recognition of skin infection and warrant further investigation and intervention. Measuring potential under-recognition of skin infection at a patient and community level and exploring factors that contribute should be a focus of future studies. Certainly the phenomenon of normalisation has been described at the community level[ 21 , 24 ] and may present a major barrier to health seeking and access to appropriate treatment in resource limited settings with endemic disease[ 25 , 52 ].
It follows that any strategies to improve recognition and treatment of skin infection must consider and partner with the members of the communities which are affected[ 21 ].
Moreover, ongoing efforts to address the social determinants which lead to the disproportionate load borne by people of Aboriginal ethnicity, particularly those living in remote communities, remain of great importance[ 8 , 21 ].
On a broader scale, skin infections are neglected at a global level with regard to prioritizing funding and policy development despite causing significant morbidity and mortality in resource-limited settings[ 53 ]. Our findings of under-recognition and under-treatment of skin infection in the clinical setting highlight some of the difficulties with addressing these conditions in disadvantaged populations and affirms the ongoing need for advocacy and a coordinated global approach to tackle common skin infections such as scabies and impetigo[ 1 , 9 ].
Skin infections are under-recognised by clinicians and this leads to suboptimal treatment and likely contributes to the significant ongoing burden of sequelae. There are many factors which contribute to the challenge of addressing the problem of skin infections and improving clinician recognition and treatment of skin infections is a priority. Kind support for this project was received from the Princess Margaret Hospital Foundation in the form of the corresponding author's clinical salary.
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. National Center for Biotechnology Information , U. Published online Jul 3. Daniel K. Asha C. Kosta Y. Mumcuoglu, Editor. Author information Article notes Copyright and License information Disclaimer. Received Mar 9; Accepted Jun This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
This article has been cited by other articles in PMC. Abstract Background Complications of scabies and impetigo such as glomerulonephritis and invasive bacterial infection in Australian Aboriginal children remain significant problems and the overall global burden of disease attributable to these skin infections remains high despite the availability of effective treatment. Methods We conducted a prospective, cross-sectional study to assess the burden of scabies, impetigo, tinea and pediculosis in children admitted to two regional Australian hospitals from October to January Results patients with median age 3.
Conclusions Scabies and impetigo infections are under-recognised and hence under-treated by clinicians. Author summary Scabies and impetigo are common skin infections in children across the developing world as well as in disadvantaged populations living in developed countries. Introduction Skin infections including scabies, impetigo, tinea and pediculosis are common in children, with high prevalence in developing countries and marginalised populations within developed countries[ 1 — 4 ].
Study design We performed a prospective, cross-sectional study to ascertain prevalence of skin infection and compared this with a retrospective, cross-sectional study to assess recognition of skin infection by health professionals.
Statistical analysis The primary objective was to compare the prevalence of skin infection in the prospective study with the documented prevalence in the retrospective review. Results Study population One hundred and fifty-eight patients were included in the prospective assessment; from Broome and 56 from Port Hedland.
Open in a separate window. Fig 1. Table 1 Baseline characteristics—prospective vs retrospective. Prevalence, recognition and treatment of skin infection Prevalence of skin infection was high in the prospectively assessed group with Table 3 Treatment of skin infection prospective vs retrospective. Table 4 Risk factors for skin infection prospective only—univariate logistic analysis.
Table 5 Prevalence by age group prospective. Table 6 Prevalence by admission reason prospective. Fig 2. Impetigo microbiology. Discussion Our findings demonstrate that under-recognition of skin infections is clearly an important problem; consequentially specific treatment for skin infections is not offered by clinicians.
Conclusion Skin infections are under-recognised by clinicians and this leads to suboptimal treatment and likely contributes to the significant ongoing burden of sequelae. Funding Statement Kind support for this project was received from the Princess Margaret Hospital Foundation in the form of the corresponding author's clinical salary.
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