tag:theconversation.com,2011:/us/topics/scabies-33148/articlesScabies – The Conversation2024-01-05T16:28:26Ztag:theconversation.com,2011:article/2204302024-01-05T16:28:26Z2024-01-05T16:28:26ZScabies: UK facing unusually large outbreaks – and treatment shortages appear mostly to blame<figure><img src="https://images.theconversation.com/files/568009/original/file-20240105-25-uz1nkq.jpg?ixlib=rb-1.1.0&rect=0%2C17%2C6000%2C3970&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Scabies causes a rash, which can be very itchy – particularly at night.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/scabies-infestation-secondary-superimposed-bacterial-infection-1499208245">Zay Nyi Nyi/ Shutterstock</a></span></figcaption></figure><p>Scabies is an unpleasant skin infection that’s common all around the world. Outbreaks happen regularly – with an estimated <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)31136-5/fulltext">450 million cases</a> occurring globally each year. But since the start of winter, outbreaks in the UK have been higher than normal. In November 2023 alone, cases were <a href="https://www.theguardian.com/society/2024/jan/01/doctors-report-nightmare-surge-in-scabies-across-uk">double the seasonal average</a>. </p>
<p>While there a probably a few factors that can explain this spike, treatment shortages appear to be at the heart of it.</p>
<p>Scabies is transmitted by mites. Mites are a type of <a href="https://www.sciencedirect.com/topics/medicine-and-dentistry/ectoparasite">ectoparasite</a> that cause disease in humans. They’re similar to head lice but smaller in size. They burrow under the skin and reproduce by laying eggs that produce more mites. </p>
<p>The infection is spread through close contact with the mites. This can happen through skin-to-skin contact with an infected person, as well as <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-019-7085-6">contact with bedding</a>, clothes or soft furniture used by someone who has scabies. </p>
<p><a href="https://www.who.int/news-room/fact-sheets/detail/scabies#:%7E:text=Overview,heart%20disease%20and%20kidney%20problems.">Symptoms of scabies</a> usually arise around a month to six weeks after infection. Initial signs can often by quite subtle – such as a rash or small sores between the fingers. This rash can also spread to <a href="https://www.nhs.uk/conditions/scabies/">other parts of the body</a>, including around the wrists and waist, groin or under the arms. The rash can be very itchy, especially at night. </p>
<p>More severe cases are often referred to as <a href="https://www.nhs.uk/conditions/scabies/">crusted scabies</a>, where there may be hundreds of mites as opposed to the 10-20 mites in typical cases of scabies. The skin rash is also more severe, with a crust over the surface of the infected area. Crusted scabies usually occurs in people who have a <a href="https://www.aad.org/public/diseases/a-z/scabies-symptoms">weaker immune system</a>. </p>
<p>Both typical and crusted scabies can lead to other skin infections, such as impetigo. It can also result in renal complications, including <a href="https://pubmed.ncbi.nlm.nih.gov/23374101/">chronic kidney disease</a>.</p>
<p>In the UK, scabies is typically treated using permethrin, a skin cream that needs to be rubbed all of the infected person’s body to kill all the mites and eggs. A second line of treatment is malathion, also a skin lotion. They are typically effective if applied properly. Two applications of the lotion, seven days apart, are <a href="https://www.nhsinform.scot/illnesses-and-conditions/skin-hair-and-nails/scabies/#treating-scabies">usually recommended</a>. Itching may take up to a month to completely subside after treatment. </p>
<h2>Outbreak causes</h2>
<p>Scabies is a disease of overcrowding. This means mites spread more easily in places where people come into close contact with each other for extended periods of time – such as schools, universities and prisons.</p>
<p><a href="https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(18)30347-5/fulltext">Residential care and nursing homes</a> are particularly high-risk settings for scabies outbreaks, with vulnerable populations and staff members alike at risk of infection.</p>
<p>While contact tracing visitors and people who came in close contact with an infected person can reduce severity of outbreaks, this is extensive and time-consuming – and can be a significant strain on public health resources.</p>
<figure class="align-center ">
<img alt="Scabies mites under a microscope." src="https://images.theconversation.com/files/568011/original/file-20240105-25-xuzsuo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/568011/original/file-20240105-25-xuzsuo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/568011/original/file-20240105-25-xuzsuo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/568011/original/file-20240105-25-xuzsuo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/568011/original/file-20240105-25-xuzsuo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/568011/original/file-20240105-25-xuzsuo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/568011/original/file-20240105-25-xuzsuo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Scabies is transmitted by mites.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/many-scabies-mites-itchmites-parasitic-microorganism-2167520453">Aliaksei Marozau/ Shutterstock</a></span>
</figcaption>
</figure>
<p>Another factor in the outbreak <a href="https://tropmedhealth.biomedcentral.com/articles/10.1186/s41182-021-00348-6">could be stigma</a> against having scabies, with many people claiming the disease is caused by being unclean or a lack of bathing. In reality, there’s <a href="https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(18)30558-9/fulltext">no good evidence</a> about a lack of washing being a risk factor. But this stigma may prevent people from seeking help. </p>
<p>While some evidence suggests that scabies incidence is <a href="https://pubmed.ncbi.nlm.nih.gov/12890210/">higher in the winter</a>, in reality outbreaks can happen at any time of the year. As such, it appears the biggest factor in the spike in scabies cases is treatment shortages. </p>
<p>Since September 2023, there’s been a shortage of <a href="https://www.bad.org.uk/uk-shortage-of-scabies-medications-is-a-snowballing-public-health-issue-dermatologists-warn/">both permethrin and malathion</a> in the UK due to supply issues. While scabies is curable, without treatment mites can continue to lay eggs and reproduce. This means any infected patients can continue to transmit the mites to other people. It remains to be seen whether these supply issues have been resolved. </p>
<p>Another option for treatment is ivermectin. Ivermectin previously made the news during the pandemic when it was wrongly thought to be a <a href="https://www.bmj.com/content/382/bmj.p1991">treatment for COVID-19</a>, although research now shows there’s <a href="https://www.cochrane.org/CD015017/INFECTN_ivermectin-preventing-and-treating-covid-19">no good evidence</a> to support these claims. </p>
<p>Ivermectin is an anti-parasitic drug and is recommended by the World Health Organization as a <a href="https://www.who.int/publications/i/item/WHO-MHP-HPS-EML-2023.02">scabies treatment</a>. However, it’s <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)32619-4/fulltext">not licensed in the UK</a> for scabies treatment, despite good data of its effectiveness and safety – though there is occasional <a href="https://www.nice.org.uk/advice/esuom29/ifp/chapter/about-ivermectin">off-license</a> use.</p>
<p>The UK Health Security Agency actually suggests ivermectin can be used to <a href="https://www.gov.uk/government/publications/scabies-management-advice-for-health-professionals/ukhsa-guidance-on-the-management-of-scabies-cases-and-outbreaks-in-long-term-care-facilities-and-other-closed-settings">manage outbreaks</a> in situations where there are problems delivering other scabies treatments. Arguably, the supply issues we’re currently seeing with other treatments could be a reason to begin using ivermectin to reduce the number of cases in the UK.</p>
<h2>Preventing infection</h2>
<p>There are many things we can all do to reduce our risk of catching and spreading scabies.</p>
<p>If anyone has symptoms that might be scabies or another skin infection, such as itching and a rash or skin wounds, these should be reported to a doctor or healthcare provider as early as possible. This is especially important if they have potentially been in close contact with a known case.</p>
<p>If you have scabies or have come into contact with someone who does, you should wash clothes and bedding at <a href="https://www.nhs.uk/conditions/scabies/">60°C or higher</a>. Anything that cannot be washed should be put into plastic bags for at least four days to contain the mites until they die.</p>
<p>Scabies outbreaks can be brought under control – but diagnosis and treatment as early as possible is required for that to happen. Treatment shortages will only prolong the symptoms experienced by the patients, and increase risks of transmission. Increasing medication supply to meet demand is important, and the use of other effective medicines – such as ivermectin – should be considered.</p><img src="https://counter.theconversation.com/content/220430/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Head has previously received funding from the Bill & Melinda Gates Foundation and the UK Department for International Development, and currently receives funding from Research England and the UK Medical Research Foundation.</span></em></p>Since September 2023, there have been shortages of usual scabies treatments.Michael Head, Senior Research Fellow in Global Health, University of SouthamptonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1483512020-11-10T10:18:28Z2020-11-10T10:18:28ZScabies: the neglected tropical disease no one wants to talk about<figure><img src="https://images.theconversation.com/files/367299/original/file-20201103-13-1jnfrxv.jpg?ixlib=rb-1.1.0&rect=7%2C7%2C5168%2C3437&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/girl-grey-shirt-scratching-her-arm-702122689">Mykola Samoilenko/Shutterstock</a></span></figcaption></figure><p>Some diseases are more likely to enter public conversation than others. COVID-19 has dominated the public discourse in 2020, while cancer and AIDS are high-profile diseases that attract significant scientific and media attention. You can safely discuss these diseases around the dinner table. Other diseases, such as scabies, not so much.</p>
<p>Scabies is classed as a neglected tropical disease. It’s out of sight and out of mind. But that doesn’t mean it isn’t there – there will be an infestation somewhere near you – take my word for it. </p>
<p>Scabies is caused by microscopic mites (<em>Sarcoptes scabiei</em>) that burrow under human skin and lay their eggs. The skin doesn’t take kindly to this infestation, which leads to an angry, itchy rash.</p>
<figure class="align-center ">
<img alt="An image of a scabies mite." src="https://images.theconversation.com/files/367301/original/file-20201103-23-1ghfn74.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/367301/original/file-20201103-23-1ghfn74.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/367301/original/file-20201103-23-1ghfn74.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/367301/original/file-20201103-23-1ghfn74.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/367301/original/file-20201103-23-1ghfn74.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/367301/original/file-20201103-23-1ghfn74.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/367301/original/file-20201103-23-1ghfn74.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The microscopic mite that causes untold misery to millions.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/scabies-sarcoptes-473745055">Blossom Tomorrow/Shutterstock</a></span>
</figcaption>
</figure>
<p>There are an estimated <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)31136-5/fulltext">455 million cases of scabies</a> globally every year. That burden is unequally distributed, with poorer countries bearing the brunt of infestations. Yet even in wealthy countries, where most neglected tropical diseases are unheard of outside of travel clinics, scabies is present, often appearing as outbreaks in institutional settings, such as <a href="https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(18)30347-5/fulltext">care homes for the elderly</a>. </p>
<p>It gets everywhere. While treatable, it is also <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1468-3083.2010.03618.x">stigmatised</a>, under-reported, often misdiagnosed, and the itch can be seriously unpleasant to bear. </p>
<h2>Stigma</h2>
<p>My team and I recently carried out research on <a href="https://academic.oup.com/trstmh/advance-article/doi/10.1093/trstmh/traa071/5898259?guestAccessKey=1652f0d0-f003-4731-942e-6b4710b2714f">scabies in Ghana</a>, describing how patients with scabies and other skin infections would travel further than necessary to report to a health centre. They bypassed their nearest centre, often heading for clinics several kilometres away, across difficult terrain. </p>
<p>The reasons for this are unclear. Colleagues in rural Ghana suggested that the day of the week that the patient reported to a clinic coincides with market day, and so the patient may combine a visit to the clinic and shopping in their nearest town during the one visit. Our statistical analysis did not bear this out, and we could not exclude the idea that patients would bypass their nearest health centre for reasons of stigma. </p>
<p>Scabies is sometimes perceived as an “unclean” condition, even in <a href="https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(18)30500-0/fulltext">the published literature</a>, and the idea that washing is a cure is widespread. <a href="https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(18)30558-9/fulltext">Bathing will not rid a patient of scabies</a> – but there are treatments that can clear it up. </p>
<p>In 2019, a <a href="https://web.archive.org/web/20190923232848/https:/www.myjoyonline.com/news/2019/September-21st/we-cant-sleep-at-night-how-scabies-outbreak-in-ne-region-is-spreading-deep-into-villages.php">huge outbreak of more than 6,000 cases of scabies</a> occurred in the north-east region of Ghana. The media reported how there was locally widespread fear at the transmission of skin rashes between villagers. A combination of misdiagnosis and misinformation resulted in some infected people being temporarily banished from their homes. </p>
<p>Local journalists met some of the patients, describing them as having “bloody open sores all over their bodies due to the excessive scratchings”. The outbreak was later correctly diagnosed and treatment was provided. But transmission to thousands of people shows the potential for large outbreaks to occur. An <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6306922/">Ethiopian outbreak</a> covered 379,000 cases of confirmed scabies. </p>
<p>In developed countries, the true prevalence is often unknown, but the institutional outbreaks can have a major <a href="https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(18)30347-5/fulltext">health</a>, <a href="http://www.sciedu.ca/journal/index.php/jnep/article/view/13693">social</a> and <a href="http://www.sciedu.ca/journal/index.php/jnep/article/view/13693">economic</a> impact. </p>
<h2>Care homes</h2>
<p>Our <a href="https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(18)30347-5/fulltext">study in The Lancet</a> showed how care home residents with dementia are more likely to end up with a scabies infection than those without dementia. Even in these settings of vulnerable populations, inequities still apply in terms of those most affected by infectious disease outbreaks. </p>
<p>Managing outbreaks in care homes is difficult and differs from how it is managed in other institutions, such as hospitals. A hospital ward is designed with infection control in mind, but care homes are quite literally that – people’s homes. </p>
<p>The COVID-19 pandemic has put these issues in a very harsh light with the thousands of excess deaths in care homes in countries such as the UK, Sweden and elsewhere. Managing scabies in the elderly is also not helped by ill-founded safety concerns about one of the main oral medicines, ivermectin. </p>
<p>A <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(05)63020-6/fulltext">1997 correspondence</a> in The Lancet reported increased mortality in care home residents being treated for scabies. It was <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(05)62377-X/fulltext">immediately criticised</a> for inadequate consideration of confounders (other factors that might have influenced the death of the resident, such as severity of dementia), and other outbreak reports have failed to confirm this association. </p>
<p>The WHO has endorsed ivermectin as safe and an essential medicine, but <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)32619-4/fulltext">it remains unlicensed</a> for scabies treatment in the UK and is rarely used despite being safe and effective. And, as an oral medicine, it is easier to use than skin creams, such as permethrin.</p>
<p>Scabies doesn’t kill many people and it doesn’t attract headlines, but don’t underestimate the power of the itch. It makes life seriously unpleasant for those with the infection and can lead to stigma and poor quality of life. Multiply that one case you are thinking of by 455 million, and there you have the global annual picture.</p><img src="https://counter.theconversation.com/content/148351/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Head has received funding for scabies research from the University of Southampton Strategic Development Fund, and was part of a scabies care home study funded by the Health Protection Agency. </span></em></p>Every year, around 455 million get scabies. Not that you’d know, because no one talks about it.Michael Head, Senior Research Fellow in Global Health, University of SouthamptonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/959792018-06-07T10:51:43Z2018-06-07T10:51:43ZMigrants’ latest health challenge: Scabies<p>Scabies, long considered a disease of the past in the developed world, is making its way back. This highly contagious parasitic skin disease, which is caused by the burrowing itch mite <em>Sarcoptes scabiei var. hominis</em>, is most commonly transmitted through personal contact in close living quarters and institutional settings, such as schools, aged care facilities, hospitals and <a href="https://ecdc.europa.eu/en/publications-data/rapid-risk-assessment-communicable-disease-risks-associated-movement-refugees">refugee camps</a>.</p>
<p>We are currently investigating the <a href="http://dx.doi.org/10.1136/bmjopen-2017-018507">treatment of scabies in human</a> and animal trials. Our <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/jcpt.12631">recent study</a> examined scabies outbreaks across the globe in close living quarters and institutional settings.</p>
<h2>On the public agenda</h2>
<p>After years of absence from the global health agenda, in 2013, scabies was added to the World Health Organization list of neglected tropical diseases. The disease has a significant and widespread health impact that extends far beyond an itchy rash.</p>
<p>Scabies is very common, with a global prevalence at any one time <a href="https://www.ncbi.nlm.nih.gov/pubmed/17123897">estimated at about 300 million cases</a>, or about 4 percent of the world’s population. The disease is endemic in a number of countries, with an average prevalence of <a href="http://apps.who.int/iris/bitstream/10665/69229/1/WHO_FCH_CAH_05.12_eng.pdf">5-10 percent in children of developing countries</a>.</p>
<p>The highest rates of scabies occur in communities in tropical regions such as Central America, the Pacific islands and Northern Australia, where more than <a href="https://www.ncbi.nlm.nih.gov/pubmed/26088526">30 percent of the residents may have scabies</a>. In a <a href="https://www.ncbi.nlm.nih.gov/pubmed/25738499">national study of Fijian residents</a> incorporating skin examination, 36.5 percent of children below 5 years of age and 43.7 percent of children aged 5 to 9 had scabies. A <a href="http://www.lowitja.org.au/disease-burden-and-health-care-clinic-attendances-young-children-remote-aboriginal-communities">study of children in two remote Northern Australian Aboriginal communities</a> found that by 1 year of age, 63 percent of children had presented with scabies.</p>
<p>Outside of occasional institutional outbreaks, scabies has long been considered a disease of the past in the developed world. However, with the influx of immigrants, mostly from North African and Middle Eastern countries due to socioeconomic and political upheaval, we have seen scabies re-emerge as a modern-day problem.</p>
<h2>Morbidity and complications</h2>
<p>Scabies infestation occurs when a mite burrows into the outermost layer of our skin, the <a href="https://www.webmd.com/skin-problems-and-treatments/picture-of-the-skin">epidermis</a>. The primary method of scabies mite transmission between humans <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2162942/">is prolonged skin-to-skin contact</a>, with about <a href="https://www.ncbi.nlm.nih.gov/pubmed/22429456">15-20 minutes of close contact</a> required for successful direct transmission.</p>
<p>In scabies infestation, hypersensitivity to the mite debris, eggs or feces causes severe, persistent itching, which can have an <a href="http://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0001563">extraordinarily unpleasant and debilitating effect</a>. Intense itching leads to <a href="https://www.ncbi.nlm.nih.gov/pubmed/17445140">disturbed sleep</a>, which consequently affects school and work attendance and performance.</p>
<p>Furthermore, scabies lesions are often secondarily infected with the bacteria <em>Streptococcus pyogenes (S. pyogenes)</em> or <em>Staphylococcus aureus (S. aureus)</em>. These bacteria can cause local skin infections that can be superficial (such as impetigo), or affect the deeper layers of the skin (such as cellulitis).</p>
<p>Infection with <em>S. pyogenes</em> can potentially lead to fatal bloodstream infections (septicaemia) and post-infection complications, including end-stage renal failure and acute rheumatic fever. Repeated episodes of this can lead to rheumatic heart disease, which is <a href="https://www.ncbi.nlm.nih.gov/pubmed/16253886">estimated</a> to affect at least 2.4 million children worldwide, with 79 percent occurring in developing countries. It is unclear how many cases of scabies lead to acute rheumatic fever and rheumatic heart disease; however, there are <a href="https://www.ncbi.nlm.nih.gov/pubmed/22327467">significantly higher rates</a> of <em>S. pyogenes</em> infections and rheumatic fever and rheumatic heart disease in communities with ongoing scabies infestations.</p>
<p>In 2010, the direct effects of scabies infestation were estimated to have resulted in more than 1.5 million disability-adjusted life years worldwide. Disability-adjusted life years is defined as years of life lost due to <a href="https://www.ncbi.nlm.nih.gov/pubmed/23245608">early death plus years lived with disability</a>.</p>
<h2>Impact of refugee migration</h2>
<p>In recent years, as conflicts and instability in the Middle East and parts of Asia and North Africa have left over <a href="http://www.unhcr.org/en-us/statistics/unhcrstats/5943e8a34/global-trends-forced-displacement-2016.html">65 million people displaced worldwide</a>, scabies outbreaks have arisen <a href="http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=21302">among refugees to the European Union</a>. There have also been health concerns over unscreened illegal immigrants bringing <a href="https://sma.org/illegal-immigration-and-the-threat-of-infectious-disease/">infectious diseases</a> into the United States. For example, in 2014, a U.S. border patrol agent reported a scabies infestation among about <a href="https://www.nationalreview.com/2014/07/scabies-spreads-among-border-detainees-ryan-lovelace/">40 immigrants</a> newly arrived by plane.</p>
<p>Refugees seeking asylum are typically being accommodated in <a href="http://www.mdpi.com/1660-4601/14/12/1484/htm">overcrowded</a> <a href="https://www.sciencedirect.com/science/article/pii/S2214109X18301256">shelters</a> for extended time periods after having traveled upon overloaded and unsafe boats or trucks. There are reports of <a href="https://www.iom.int/news/mediterranean-migrant-arrivals-reach-131772-2017-deaths-reach-2556">significant scabies infestations among migrants traveling by boat</a>, such as seen among the 1,074 migrants rescued at sea off Az Zawiyah, Libya, on Sept. 16, 2017.</p>
<p>Scabies was also the <a href="http://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0000444">most commonly reported illness in Malaysian immigration detention centers</a>, predominantly those accommodating stateless Muslim Rohingya refugees from Myanmar.</p>
<h2>Why is scabies spreading?</h2>
<p>Scabies has been recognized as a disease in humans and animals for at least 3,000 years, and was reported in ancient India, China and the Middle East. Aristotle (384-323 B.C.) described it as ‘lice of the flesh,’ and <a href="https://www.ncbi.nlm.nih.gov/pubmed/28633664">references to disease symptoms are included in the Old Testament</a>.</p>
<p>Today, poor living conditions, lack of access to clean water and overcrowding provide an ideal environment for the spread of scabies in refugee shelters. In fact, media and public health agency reports suggest that scabies is one of the <a href="http://www.ansa.it/english/news/general_news/2015/05/05/pozzallo-migrants-isolated-with-scabies_ed01456a-c241-4354-8e8c-947f1596da90.html">most commonly observed diseases in these refugee populations</a>.</p>
<p>Authors of a <a href="https://www.ncbi.nlm.nih.gov/pubmed/27072500">recent German study</a> found that, between 2004 and 2014, the number of disease outbreaks per year in centralized homes for asylum seekers increased, rising 10-fold as a contributor to <a href="https://www.ncbi.nlm.nih.gov/pubmed/27072500">total community shelter outbreaks</a>. Scabies was the third most frequent cause of outbreaks after chickenpox and measles, accounting for 19 percent of the total 615 incidents among 119 reported outbreaks. Additionally, in 2014 there were <a href="https://www.ncbi.nlm.nih.gov/pubmed/27072500">more reported outbreaks than in the past 10 years</a>, indicating that this public health problem is rapidly growing in relevance.</p>
<p>The French Institute for Public Health Service estimated that scabies accounted for <a href="http://www.francetvinfo.fr/monde/europe/migrants/a-paris-la-propagation-de-la-gale-menace-les-migrants-et-inquiete-les-ong_2229289.html">20 percent of medical diagnoses between the end of 2015 and mid-2016</a> in the <a href="http://www.dailymail.co.uk/news/article-3105501/Migrants-living-Paris-refugee-camp-used-stop-heading-Calais-Britain-forced-police-fears-sparking-scabies-epidemic.html">now dismantled refugee camp in Calais</a>, France.</p>
<p>With the continued arrival of new refugees in France and the movement of many of the Calais refugees to the Chapelle camp in Paris, <a href="http://www.francetvinfo.fr/monde/europe/migrants/a-paris-la-propagation-de-la-gale-menace-les-migrants-et-inquiete-les-ong_2229289.html">the problem of scabies persists</a>.</p>
<h2>Current challenges in managing scabies</h2>
<p><a href="http://www.racgp.org.au/afp/2017/may/scabies-a-clinical-update/">Modern treatments</a> for scabies include topical permethrin, topical benzyl benzoate and oral ivermectin for children older than 5.</p>
<p>However, there are a number of <a href="http://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0004691">challenges associated with these treatment options</a>, including poor adherence with therapy (particularly with the use of topical treatments, which require extensive skin coverage and repeated applications to treat the disease properly), unachievable costs for resource-poor communities (such as refugee populations), and increasing treatment resistance.</p>
<p>The possibility of reinfestation remains high when close contacts are not treated or the disease is endemic in a population.</p>
<p>Also, no currently available treatments possess the combined ability to kill eggs, act as an antibacterial, and have anti-inflammatory/antipruritic (anti-itch) properties. Added to this, they are all ineffective at preventing treatment relapse arising from newly hatched mites and evidence indicates the <a href="https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-015-0983-z">mites are becoming resistant to existing scabies treatments</a>.</p>
<p>Given the current treatment challenges, and the substantial clinical and economic burden of scabies and associated complications in tropical developing countries and resource-poor societies, there have been renewed appeals for coordinated global campaigns. However, <a href="https://infectiousdiseases.telethonkids.org.au/siteassets/media-images-wesfarmers-centre/national-healthy-skin-guideline-1st-ed.-2018.pdf">it has also been highlighted that</a> any <a href="http://bmjopen.bmj.com/content/8/5/e018507.full?ijkey=PkCYWz01sOeP1vd&keytype=ref">treatment strategies need to be simple and affordable and resonate well with the local challenges and cultures</a>.</p>
<p>While treatment adherence is an important factor in controlling scabies, it must be emphasized that known environmental influences contribute to scabies outbreaks and the endemic nature of the infestation in some populations. Improved living conditions and providing adequate health care and sanitation, particularly in isolated communities and refugee camps, are essential to prevent and control outbreaks, and to reduce the burden of scabies in endemic regions.</p><img src="https://counter.theconversation.com/content/95979/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jackson Thomas has received funding from the University of Canberra and ACT Gov to investigate scabies. </span></em></p><p class="fine-print"><em><span>Mark Naunton has received funding from the University of Canberra to investigate scabies in Aboriginal children in Australia.</span></em></p><p class="fine-print"><em><span>Professor Tom Calma AO received funding from the University of Canberra to investigate scabies in Aboriginal people in the Katherine region of the NT. </span></em></p><p class="fine-print"><em><span>Gregory Peterson, Julia K. Christenson, and Professor Gabrielle Cooper OAM do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Migrants face many health problems, from mental health issues to diseases. The latest threat is scabies.Jackson Thomas, Assistant Professor/Senior Lecturer in Pharmacy, University of CanberraGregory Peterson, Deputy Dean (Research) Faculty of Health, University of TasmaniaJulia K. Christenson, Research Assistant in Pharmacy, University of Canberra, University of CanberraMark Naunton, Head of Pharmacy (2013-present), University of CanberraTom Calma, Chancellor, University of CanberraLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/855322017-10-12T14:34:39Z2017-10-12T14:34:39ZMonkeypox has resurfaced in Nigeria. What you need to know<figure><img src="https://images.theconversation.com/files/189984/original/file-20171012-31408-hl0sid.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The Monkeypox virus was isolated most recently in 2012 from a dead infant mangabey (species of monkey) in Ivory Coast.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p><em>An outbreak of the rare disease Monkeypox has raised fears of an imminent epidemic in Nigeria. Infected people break out in a rash that <a href="https://www.researchgate.net/publication/8422723_Triage_of_a_febrile_patient_with_a_rash_A_comparison_of_chickenpox_monkeypox_and_smallpox">looks a lot like chicken pox</a>. But the fever, malaise, and headache from Monkeypox are usually <a href="http://www.clinicaladvisor.com/dermatology/monkeypox/article/589595/">more severe than in chicken pox infection</a>.The disease can spread quickly and in previous outbreaks one of 10 people have died. The first cases were reported <a href="http://thenationonlineng.net/outbreak-new-viral-disease-monkey-pox-hits-bayelsa/">in Bayelsa</a> state in south Nigeria in late September. Since then suspected cases have been reported in <a href="https://www.premiumtimesng.com/news/top-news/245576-monkeypox-nigeria-records-31-suspected-cases-seven-states.html">seven</a> of the country’s 36 states, including Lagos. A total of <a href="https://www.naij.com/1129585-31-suspected-cases-monkeypox-recorded-7-states.html#1129585">31 suspected cases have been reported</a>. What is Monkeypox and should the world be worried? The Conversation Africa’s Declan Okpalaeke asked Oyewale Tomori for some insights.</em> </p>
<p><strong>What is Monkeypox and how is it contracted?</strong></p>
<p><a href="http://www.who.int/mediacentre/factsheets/fs161/en/">Monkeypox</a> is a viral zoonotic disease – it’s caused by a virus transmitted from animals to humans. The virus was <a href="http://www.who.int/mediacentre/factsheets/fs161/en/">first identified in Denmark</a> in 1958 during an investigation into a pox-like disease among monkeys. Hence its name. The natural host of the virus remains undefined. But the disease has been reported in many animals including squirrels, rats, mice and primates. </p>
<p>There appear to be two distinct groups of the Monkeypox virus – <a href="https://www.cdc.gov/poxvirus/monkeypox/index.html">the Congo Basin and the West African groups</a>. The Congo Basin virus group is more virulent. According to the United States Centre for Diseases Control, the Monkeypox virus has only been isolated twice from an animal <a href="https://www.cdc.gov/poxvirus/monkeypox/transmission.html">in nature</a>; first in 1985 from an apparently ill African rodent in the Equateur Region of the Democratic Republic of Congo and in 2012 from a dead infant mangabey found in the Tai National Park in Cote d’Ivoire.</p>
<p>The first reported case of Monkeypox infection in humans was in 1970 in the <a href="http://www.who.int/mediacentre/factsheets/fs161/en/">Democratic Republic of Congo (DRC)</a>. A 9-year old boy was diagnosed in a region in which smallpox had been eliminated two years earlier. In 1996-97 there was a major outbreak of the disease in the country. </p>
<p>Most cases of human Monkeypox have been reported in the rainforest regions of the Congo Basin - particularly in the DRC where it’s considered to be endemic - and in western Africa. Other African countries reporting the disease include Ivory Coast (2 cases in 1971 and 1981), Liberia (4 cases in 1970), Sierra Leone (2 cases in 1970 and 2014), Nigeria (3 cases in 1971 and 1978), a total of six cases in Cameroon between 1976 and 1990, Central African Republic (32 cases with 2 deaths between 1984 and 2016), Gabon (8 cases in 1987 and 1992- 8), and 19 cases in Sudan in 2005. There are also reports of <a href="https://www.cdc.gov/poxvirus/monkeypox/about.html">sporadic cases in the Republic of Congo (formerly Zaire)</a>.</p>
<p>In 2003 the first reported cases of human Monkeypox outside of Africa were confirmed in the US, with a total of <a href="https://www.cdc.gov/poxvirus/monkeypox/outbreak.html">37 in six states</a>. Most of the patients had had close contact with pet prairie dogs. The virus transmission is thought to have first occurred between animals imported from Africa which had been co-housed with prairie dogs.</p>
<p>Primary infection is through direct contact with the blood, bodily fluids, or cutaneous or mucosal lesions of an infected animal. Eating inadequately cooked meat of infected animals is also a risk factor. </p>
<p>Human-to-human transmission can result from close contact with infected respiratory tract secretions, skin lesions of an infected person or objects recently contaminated by patient fluids or lesion materials. Household members of active cases are at greater risk of infection via droplet respiratory particles during prolonged face-to-face contact. </p>
<p>Transmission can also occur by inoculation or via the placenta (congenital Monkeypox). </p>
<p>Monkeypox can easily be confused with other rash illnesses such as smallpox, chickenpox, measles, bacterial skin infections, scabies, syphilis, and medication-associated allergies. </p>
<p>In the early stage of the disease Monkeypox can be distinguished from smallpox because the lymph gland gets enlarged. A laboratory test is needed for a definitive diagnosis.</p>
<p><strong>Should the world be worried about Monkeypox? How can it be treated?</strong></p>
<p>Sure, we should be worried. The disease can cause the death of one out of 10 infected people and can spread very quickly. The symptoms (fever, malaise, and headache) of Monkeypox are <a href="http://www.clinicaladvisor.com/dermatology/monkeypox/article/589595/">more severe than those of chickenpox</a>.</p>
<p>The other reason for concern is that there is no specific treatment or vaccine available for Monkeypox infection. In the past, the anti-smallpox vaccine was shown to be <a href="http://www.who.int/mediacentre/factsheets/fs161/en/">85% effective in preventing Monkeypox</a>. But smallpox has been eradicated so the <a href="http://www.who.int/mediacentre/factsheets/fs161/en/">vaccine isn’t widely available anymore</a>. </p>
<p>Nevertheless outbreaks can be controlled. The first step is preventing infections. This can be achieved through public health awareness campaigns to reduce the risk of animal-to-human transmission. Key messages would include the fact that people should avoid contact with sick or dead animals that could harbour the virus, especially in areas known to be Monkeypox hotspots. Other precautions include ensuring that infected people are isolated and that health workers caring for ill people must wear gloves and protective equipment. </p>
<p>A key part of managing the spread of the disease is good surveillance so that cases can be detected quickly and the outbreak contained. </p>
<p><strong>What’s behind the recent outbreak in Nigeria?</strong></p>
<p>At the moment only a few of the suspected cases have been confirmed. We only have laboratory confirmation of some cases. But we must remember that there are other rash illnesses that mimic Monkeypox symptoms. This is not the first report of monkeypox cases in Nigeria. Between 1971 and 1978, ten human Monkeypox infections were reported in the country. Three were laboratory confirmed (two in 1971 and one in 1978). </p>
<p><strong>Does the claim that the outbreak was triggered by government delivering free medical treatment hold any water?</strong></p>
<p>The claim of government involvement in the outbreak is absolute nonsense, and it is an unwarranted and unnecessary diversion from the main issue of confirming and controlling the spread of the disease.</p><img src="https://counter.theconversation.com/content/85532/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Oyewale Tomori does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A disease suspected to be monkeypox is on the rampage in Nigeria. In less than one month, it has spread to seven of the country’s 36 states and infected 31 people.Oyewale Tomori, Fellow, Nigerian Academy of ScienceLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/713372017-02-06T19:15:50Z2017-02-06T19:15:50ZWhy the housing shortage exacerbates scabies in Indigenous communities<p>Scabies is a disease of antiquity, one of the scourges of those on the First Fleet but no longer known for most in Australian society. However, in the far remote Northern Territory, scabies infection remains endemic, and in some regions <a href="https://www.ncbi.nlm.nih.gov/pubmed/22070701">almost 70%</a> of Aboriginal children in remote areas had been infected within their first year of life.</p>
<p>Recent research in the <a href="https://www.mja.com.au/">Medical Journal of Australia</a> estimates that as many as one in 100 Aboriginal people in the Katherine region suffers from the highly virulent infection, crusted scabies, and links this with homelessness and remote living. A person with crusted scabies has the potential to infect hundreds if not thousands of others, and these cases drive ongoing extreme rates of infection in Aboriginal communities. </p>
<h2>What is scabies?</h2>
<p><a href="https://theconversation.com/scabies-a-neglected-parasitic-disease-we-already-know-how-to-treat-68147">Scabies</a> is a tiny mite the size of a pin head. When a person is initially infected (usually by only a dozen or so of the mites), it takes a few weeks for the immune system to recognise these unwanted arthropods burrowing through the dermis (the inner layer of skin). </p>
<p>When the immune system kicks in, the extreme itch begins and the body fights back against the bugs. If a person’s immune system is working properly, the population of bugs on an individual never expands beyond a few dozen at most, and they remain relatively noncontagious. But the scratch marks from the cursed itch often cause streptococcal infections that can result in other conditions such as <a href="https://theconversation.com/why-are-aboriginal-children-still-dying-from-rheumatic-heart-disease-63814">rheumatic heart disease</a>.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/152816/original/image-20170116-16922-1q7pxqx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/152816/original/image-20170116-16922-1q7pxqx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/152816/original/image-20170116-16922-1q7pxqx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/152816/original/image-20170116-16922-1q7pxqx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/152816/original/image-20170116-16922-1q7pxqx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/152816/original/image-20170116-16922-1q7pxqx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/152816/original/image-20170116-16922-1q7pxqx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/152816/original/image-20170116-16922-1q7pxqx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Crusted scabies infection of the hand.</span>
<span class="attribution"><span class="source">Bart Currie, Menzies School of Health Research.</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>However, if an infected individual’s immune system does not work, the bugs breed prolifically in the skin and the numbers reach the many tens of thousands. At the same time, they erode the skin, making it “crusted” – a term that only makes sense when you see the crusts that constantly shed off, landing wherever the person moves. </p>
<p>These crusts are highly contagious, and thus the person infects everyone who crosses their path - on bus seats, in the cinema, on mattresses, lounge chairs and footpaths.</p>
<h2>What has scabies got to do with housing?</h2>
<p>In the Katherine region, it’s estimated as many as one in four Aboriginal people is homeless, either literally (living as fringe-dwellers in makeshift riverside camps), or technically (the <a href="http://abs.gov.au/AUSSTATS/abs@.nsf/Lookup/4922.0Main+Features12012?OpenDocument">ABS defines homelessness</a> as a situation in which a person has no alternatives to their current inadequate dwelling, has no tenure, and cannot control space for social relations).</p>
<p>As many Aboriginal people in Katherine can’t afford the private rental market, public housing is the only alternative. Currently in Katherine there is a five year wait, and to be on the wait list <a href="https://nt.gov.au/__data/assets/pdf_file/0020/202439/sf117-application-for-public-housing-form.pdf">a person needs to have a postal address</a> for the Department of Housing to communicate with them. Rules, regulations and bureaucracy around the wait list change all of the time. It is a challenge to ensure that a name stays on the wait list for the five years until a house is available. </p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/152817/original/image-20170116-16928-5ur5qk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/152817/original/image-20170116-16928-5ur5qk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/152817/original/image-20170116-16928-5ur5qk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=451&fit=crop&dpr=1 600w, https://images.theconversation.com/files/152817/original/image-20170116-16928-5ur5qk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=451&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/152817/original/image-20170116-16928-5ur5qk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=451&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/152817/original/image-20170116-16928-5ur5qk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=567&fit=crop&dpr=1 754w, https://images.theconversation.com/files/152817/original/image-20170116-16928-5ur5qk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=567&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/152817/original/image-20170116-16928-5ur5qk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=567&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Microscopic view of a small crust showing heavy infestation with scabies mites.</span>
<span class="attribution"><span class="source">Bart Currie, Menzies School of Health Research.</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Young people are forced to stay at home, even when they have children of their own. Many houses in the Katherine region have four generations under the one roof. The dream of starting a family and living in a house of their own is a distant prospect for many Aboriginal people living in Northern Australia.</p>
<p>Remote-living people have limited options to relocate to bigger centres like Katherine or Darwin without having to embrace homelessness for at least a temporary period. Many of these people’s temporary situations become permanent in bush and riverside fringe dwelling camps where there is no sanitation, running water or secure shelter.</p>
<p>Because most houses are overcrowded, visiting family members often stay in houses already on the brink of bursting. An uncle comes to town. Ashamed of his skin condition and not knowing what is causing the crusting, he hides his deformed and ugly skin under long sleeves and jeans. But the crusts drop to the floor. Everyone in the house is infected.</p>
<p>And if he is lucky enough to endure the gruelling hospital treatment to get rid of the scabies, he is likely to move back into circles of living where scabies rates are high, and the reason his immune system does not work will probably still be there. He will be reinfected within a week or so, and his infection will become crusted again within the next six months. </p>
<h2>What can be done?</h2>
<p>Crusted scabies was added to the list of notifiable diseases in the Northern Territory in 2016. This will ensure identified cases of crusted scabies will be treated in a systematic way that includes ensuring household contacts are followed up properly. </p>
<p>The Northern Territory Department of Health Centre for Disease Control is working closely with the philanthropic organisation <a href="http://onedisease.org/">One Disease</a>. They are learning from the strong successes this organisation has already achieved over the past five years in Arnhem Land, in an effort to replicate this success with other vulnerable populations in the NT.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/152819/original/image-20170116-16931-10b9jix.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/152819/original/image-20170116-16931-10b9jix.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/152819/original/image-20170116-16931-10b9jix.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=387&fit=crop&dpr=1 600w, https://images.theconversation.com/files/152819/original/image-20170116-16931-10b9jix.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=387&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/152819/original/image-20170116-16931-10b9jix.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=387&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/152819/original/image-20170116-16931-10b9jix.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=486&fit=crop&dpr=1 754w, https://images.theconversation.com/files/152819/original/image-20170116-16931-10b9jix.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=486&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/152819/original/image-20170116-16931-10b9jix.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=486&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A scabies mite.</span>
<span class="attribution"><span class="source">Bart Currie, Menzies School of Health Research.</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Australia is at the forefront of scabies research, and there are exciting developments in understanding how to tackle the challenge of scabies in areas like remote Northern Australia where great distances, tropical weather and mobile populations <a href="http://www.menzies.edu.au/page/Research/Indigenous_Health/Skin/Scabies/">create challenges</a> in eradicating the disease.</p>
<p>And the underlying problem of homelessness is far from solved. This fundamental inequality, with homelessness rates being <a href="http://www.abc.net.au/interactives/homeless/">31 times the national average</a> in regions like Katherine, has its roots in the process of colonisation and the earliest narratives of our nation’s psyche. </p>
<p>Aboriginal fringe dwellers like <a href="http://findingbennelong.com/perspectives-bennelong">Bennelong</a> still exist in Australia. Many Aboriginal people and their ancestors have never had a safe “home” since their society was ruptured by the arrival of the colonisers. In towns like Katherine, the concept of “home” for many people is still undergoing great transformation.</p>
<p>The problem of homelessness for remote Aboriginal people is arguably one of the strongest drivers of poor social and health outcomes. While homelessness may result in poor health outcomes, the fundamental solution to homelessness cannot be driven by the health care sector. Instead, more could be done by engagement between Aboriginal communities and local councils, architects, economists, social anthropologists, builders and plumbers. </p>
<p>Scabies, rheumatic heart disease, kidney disease, diabetes, and smoking all contribute to a life expectancy more than <a href="http://www.aihw.gov.au/deaths/life-expectancy/">ten years below the national average</a>. If we want to live in a country where Aboriginal people can expect to live as long as non-Aboriginal people, medical research can go only so far.</p><img src="https://counter.theconversation.com/content/71337/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon Quilty does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Scabies was one of the scourges of those on the First Fleet, but no longer known for most in Australian society. However, in the far remote North, scabies infection is endemic.Simon Quilty, General and Acute Care Physician and Senior Lecturer, Flinders University, Katherine Hospital campus, Flinders UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/681472016-11-14T19:09:55Z2016-11-14T19:09:55ZScabies: a neglected parasitic disease we already know how to treat<figure><img src="https://images.theconversation.com/files/145497/original/image-20161110-25070-1jo9pkd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Children living in tropical countries and in poverty often have high rates of infection with the scabies mite. </span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/unicefethiopia/27422673482/in/photolist-fF6fH7-fNi2S3-bpfAWr-5cxNdy-EjhEP3-HMfhX3-H1FrRd-HjT2KB-HjT8wB-HjT1oD-H19RFJ-HMfnrd-HVZ9kT-Ho2xW9-HqYEsn-H1FqN1-Gvq5N9-HqYF6M-HjT9tr-HhvVqN-H1FsFu">UNICEF Ethiopia/flickr </a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span></figcaption></figure><p>Mites living in your skin are just the start of the problems that come with having scabies. </p>
<p>The highly infectious parasitic condition is linked with extreme itchiness, bacterial infections and kidney damage, plus debilitating social and economic consequences. </p>
<p>But we’re not addressing the problem. Although a drug of known safety and efficacy is available, scabies still affects more than 100 million people across the world who can’t break free of illness and reinfection cycles. </p>
<p>This week the <a href="http://www.ntdsupport.org/cor-ntd">Coalition for Operational Research on Neglected Tropical Diseases</a> and the <a href="http://www.controlscabies.org/news/5th-global-scabies-meeting/">International Alliance for the Control of Scabies</a> met to refocus efforts to reduce the impact of scabies across the world. </p>
<h2>Scabies: mites living in your skin</h2>
<p>Scabies is a skin disease caused by infestation with a highly infectious microscopic mite, <em>Sarcoptes scabiei</em>. Less than 1mm in size, the mite burrows into the skin, and leads to intense itching and visible sores. Sleep interruption and social stigmatisation result. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/145367/original/image-20161110-26299-2ttfka.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/145367/original/image-20161110-26299-2ttfka.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=445&fit=crop&dpr=1 600w, https://images.theconversation.com/files/145367/original/image-20161110-26299-2ttfka.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=445&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/145367/original/image-20161110-26299-2ttfka.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=445&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/145367/original/image-20161110-26299-2ttfka.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=560&fit=crop&dpr=1 754w, https://images.theconversation.com/files/145367/original/image-20161110-26299-2ttfka.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=560&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/145367/original/image-20161110-26299-2ttfka.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=560&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Less than 1mm long, the scabies mite burrows into the skin and creates intense itching.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/136941790@N03/22635992060/in/photolist-ffoG6C-fF6fH7-nEcjSk-oCDASr-nWoJAB-fNi2S3-bpfAWr-9Mm8AY-9MiicF-b9xbdZ-7fwayX-9MihZt-sruAYQ-6ikkq6-6hnMCL-6h4Ndc-cog1R7-cofudy-cofunj-bVvVoz-coigm7-cogyos-cQg3Ub-cU7Zad-cQSvJu-AugnPb-71RABC-dbMybJ-vmPTY9">laboratorio diagnostica ancona IZSUM/flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Intense scratching triggered by scabies infection also allows bacteria (<em>Streptococcus pyogenes</em> and <em>Staphylococcus aureus</em>) to become established in the skin. </p>
<p>Scabies is usually treated with a topical cream: in Australia, permethrin is the common choice. </p>
<p>In addition to the infected person, household contacts are often infested with scabies, and so the whole household should be treated at once. However, uptake of treatment in household members is often very low and so re-infestation is common. In settings where the prevalence is high, it is very difficult to avoid re-infestation from other community members, especially among children. </p>
<h2>Scabies is a huge global problem</h2>
<p>Scabies affects more than 100 million people worldwide. It is especially common in the Pacific region: in Fiji, half of all primary school aged children have scabies, as well as one in five adults. Up to one third of people living in remote Australian Indigenous communities are infected. </p>
<p>While scabies itself is a distressing health issue, the greatest impacts occur as a result of associated bacterial infections. <a href="http://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0002167">Scabies commonly leads</a> to impetigo (skin sores), and severe skin and soft tissue infections and sometimes even invasive bacterial infection and <a href="http://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0002167">life-threatening toxic shock syndrome</a> can follow. </p>
<p>The body’s immune response to <em>Streptococcus pyogenes</em> bacteria can cause <a href="http://www.kidshealth.org.nz/post-streptococcal-glomerulonephritis-psgn">kidney damage</a> and possibly <a href="https://www.ncbi.nlm.nih.gov/pubmed/22327467">rheumatic heart disease</a>. </p>
<p>Scabies is therefore a cause of considerable illness and is also linked to some deaths.</p>
<h2>Scabies qualifies as a Neglected Tropical Disease</h2>
<p><a href="http://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0002167">Efforts are increasing</a> for scabies to be added to a list of conditions classified as Neglected Tropical Diseases. </p>
<p>The <a href="https://www.ncbi.nlm.nih.gov/books/NBK62521/">Neglected Tropical Disease global movement</a> began in the early 2000s in response to the <a href="http://www.un.org/millenniumgoals/">Millennium Development Goals</a>. A Department of Neglected Tropical Diseases was soon <a href="http://www.who.int/neglected_diseases/en/">established at the World Health Organisation</a> (WHO) to coordinate and support policies and strategies specifically for the control of neglected tropical diseases.</p>
<p><a href="http://www.who.int/neglected_diseases/diseases/summary/en/">Seventeen conditions</a> currently make up the Neglected Tropical Diseases list, including <a href="http://www.who.int/onchocerciasis/en/">onchocerciasis</a> (river blindness), <a href="http://www.who.int/lymphatic_filariasis/en/">lymphatic filariasis</a> (parasitic worms in the lymph system), bacterial eye infections known as <a href="http://www.who.int/trachoma/en/">blinding trachoma</a>, <a href="http://www.who.int/schistosomiasis/en/">schistosomiasis</a> (blood parasites acquired through water) and <a href="http://www.who.int/intestinal_worms/en/">soil transmitted intestinal worms</a>. </p>
<p>Although not currently on the list, scabies has many features that warrant its inclusion. These include its high prevalence in low to middle income countries and in disadvantaged communities, the social stigma it causes, the chronic morbidity associated with the disease and known success of mass drug administration as a control strategy.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/145368/original/image-20161110-26340-or08x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/145368/original/image-20161110-26340-or08x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/145368/original/image-20161110-26340-or08x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/145368/original/image-20161110-26340-or08x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/145368/original/image-20161110-26340-or08x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/145368/original/image-20161110-26340-or08x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/145368/original/image-20161110-26340-or08x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/145368/original/image-20161110-26340-or08x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The skin infection impetigo develops when bacteria colonise skin damaged through intense scratching in scabies.</span>
<span class="attribution"><span class="source">Andrew Steer</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<h2>Mass drug administration for disease control</h2>
<p><a href="http://www.who.int/neglected_diseases/preventive_chemotherapy/en/">Mass drug administration</a> is the centrepiece of ambitious global plans to eliminate several major Neglected Tropical Diseases. More than 700 million people receive mass drug administration every year through large regional and global programs supported by the World Health Organization and partners. At the community level, drugs are delivered by specially trained distribution teams. </p>
<p>The oral drug <a href="http://www.merck.com/product/usa/pi_circulars/s/stromectol/stromectol_pi.pdf">ivermectin</a> is the most frequently delivered agent, used in highly successful programs for control of <a href="http://www.who.int/lymphatic_filariasis/elimination-programme/en/">lymphatic filariasis</a> and <a href="http://www.who.int/onchocerciasis/control/en/">onchocerciasis</a>. </p>
<p>The <a href="https://www.nobelprize.org/nobel_prizes/medicine/laureates/2015/press.html">2015 Nobel Prize for Medicine</a> was awarded to William Campbell and Satoshi Omura for their discovery of ivermectin and in recognition of the contribution of the drug in improving global public health. </p>
<h2>A new approach for scabies eradication</h2>
<p>Could mass drug administration for scabies work? Mass permethrin treatment for scabies was successful in <a href="https://www.ncbi.nlm.nih.gov/pubmed/1673175">Panama</a> and <a href="https://www.ncbi.nlm.nih.gov/pubmed/11700814">Australia</a>. However, this cream is not ideal for use in public health initiatives because it is messy to apply and adherence can be low, and because the tubes are bulky and difficult to transport. </p>
<p>But scabies can also be killed effectively with ivermectin, an oral medication that comes in tablet form. </p>
<p>A <a href="https://www.ncbi.nlm.nih.gov/pubmed/26650152">clinical trial conducted in a Fijian community</a> found a single round of ivermectin mass drug administration was able to virtually eliminate scabies: prevalence was reduced from 32% to less than 2%. This reduction in scabies was associated with a 67% drop in the prevalence of scabies-linked bacterial impetigo. </p>
<p>These results provide robust initial evidence to encourage investigation of ivermectin based mass drug administration as a means to control scabies in highly endemic populations on a larger scale. The trial further strengthens the claim for scabies to be considered as a WHO-listed neglected tropical disease. </p>
<h2>Let’s get rid of scabies</h2>
<p>There are several crucial elements that will lead to successful control of scabies and the alleviation of suffering for those afflicted by the disease. Integration with programs already in place for other neglected tropical diseases (especially those that use ivermectin mass drug administration), recognition and support by WHO, and strong advocacy are essential. </p>
<p>The <a href="http://www.controlscabies.org/">International Alliance for the Control of Scabies</a> was formed in 2012 and is the key global advocacy body for scabies. The Alliance is a network of professionals, including clinicians from high-prevalence areas, public health physicians, policy makers, and researchers, all of whom are committed to the control of human scabies infestation, and to promoting the health and well-being of all those living in affected communities. </p>
<p>Further research into the effect of ivermectin based mass drug administration on the severe bacterial complications of scabies is warranted. </p>
<p>Also, operational research into acceptability and cost effectiveness of mass drug administration will have an impact through strengthening the case for placing scabies alongside other neglected tropical diseases that are targeted for global elimination.</p><img src="https://counter.theconversation.com/content/68147/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew Steer receives funding from the National Health and Medical Research Council of Australia and the National Heart Foundation of Australia. </span></em></p>Although a drug of known safety and efficacy is available, scabies still affects more than 100 million people across the world.Andrew Steer, Group Leader, Murdoch Childrens Research Institute. Associate Professor, Department of Paediatrics, University of Melbourne. Paediatric Infectious Diseases Physician, Royal Children's Hospital, Murdoch Children's Research InstituteLicensed as Creative Commons – attribution, no derivatives.