Scabies outbreaks in ten care homes for elderly people: a prospective study of clinical features, epidemiology, and treatment outcomes.

BACKGROUND: Scabies outbreaks in residential and nursing care homes for elderly people are common, subject to diagnostic delay, and hard to control. We studied clinical features, epidemiology, and outcomes of outbreaks in the UK between 2014 and 2015. METHODS: We did a prospective observational study in residential care homes for elderly people in southeast England that reported scabies outbreaks to Public Health England health protection teams. An outbreak was defined as two or more cases of scabies (in either residents or staff) at a single care home. All patients who provided informed consent were included; patients with dementia were included if a personal or nominated consultee (ie, a family member or nominated staff member) endorsed participation. Dermatology-trained physicians examined residents at initial clinical visits, which were followed by two mass treatments with topical scabicide as per local health protection team guidance. Follow-up clinical visits were held 6 weeks after initial visits. Scabies was diagnosed through pre-defined case definitions as definite, probable, or possible with dermatoscopy and microscopy as appropriate. FINDINGS: 230 residents were examined in ten outbreaks between Jan 23, 2014, and April 13, 2015. Median age was 86·9 years (IQR 81·5-92·3), 174 (76%) were female, and 157 (68%) had dementia. 61 (27%) residents were diagnosed with definite, probable, or possible scabies, of whom three had crusted scabies. Physical signs differed substantially from classic presentations. 31 (51%) of the 61 people diagnosed with scabies were asymptomatic, and only 25 (41%) had burrows. Mites were visualised with dermatoscopy in seven (11%) patients, and further confirmed by microscopy in three (5%). 35 (57%) cases had signs of scabies only on areas of the body that would normally be covered. Dementia was the only risk factor for a scabies diagnosis that we identified (odds ratio 2·37 [95% CI 1·38-4·07]). At clinical follow-up, 50 people who were initially diagnosed with scabies were examined. No new cases of scabies were detected, but infestation persisted in ten people. INTERPRETATION: Clinical presentation of scabies in elderly residents of care homes differs from classic descriptions familiar to clinicians. This difference probably contributes to delayed recognition and suboptimal management in this vulnerable group. Dermatoscopy and microscopy were of little value. Health-care workers should be aware of the different presentation of scabies in elderly people, and should do thorough examinations, particularly in people with dementia. FUNDING: Public Health England and British Skin Foundation.

Do genitourinary physicians report notifiable diseases? A survey in South East England.

Genitourinary medicine work requires public health actions. Notifiable infections may be seen in genitourinary medicine, but concerns over confidentiality could delay public health actions and outbreak management. To assess genitourinary medicine clinicians' awareness of notification of infectious disease, reporting practices and liaison with Health Protection Units, we sent postal surveys to 140 genitourinary medicine clinicians (SE HPA region) that explored prior public health training, Health Protection Unit liaison and management of possible clinical scenarios. Fifty-seven respondents reported median genitourinary medicine experience of 12 years; 29% had prior public health training, nine on the British Association for Sexual Health and HIV course. A total of 90% had heard of Health Protection Units and understood their role. Approximately one-third would not report key diseases at all, most reporting only on laboratory confirmation. In all, 83% would only notify acute hepatitis on lab confirmation; 50% would report suspected measles immediately (44% awaiting lab confirmation) and 40% would not pass on any patient details without consent. Clinicians have good knowledge of notification of infectious disease conditions but responses suggest it is not always used in clinical context. Reporting delays occur waiting for lab confirmation and liaison with local Health Protection Units may be hindered by confidentiality concerns, potentially delaying public health action. Doctors with prior public health training are more likely to report appropriately.

Managing and reporting notifiable disease in the sexual health clinic.

Notifiable infections can be and often are transmitted sexually and the process of notification often does not work well in the GUM setting. It is the statutory duty of medical practitioners to report notifiable infections, but there are a number of barriers to reporting in sexual health, in particular concerns that notification may breach confidentiality. In this article, we hope to explain the reporting process and aim to highlight why we need to report and what health protection teams do with the information provided. We hope to make the process simple so that GUM clinics can fulfil their public health obligations and enable timely and appropriate public health action to be taken.

Healthy animals, healthy people: zoonosis risk from animal contact in pet shops, a systematic review of the literature.

BACKGROUND: Around 67 million pets are owned by households in the United Kingdom, and an increasing number of these are exotic animals. Approximately a third of pets are purchased through retail outlets or direct from breeders. A wide range of infections can be associated with companion animals. OBJECTIVES: This study uses a systematic literature review to describe the transmission of zoonotic disease in humans associated with a pet shop or other location selling pets (incidents of rabies tracebacks and zoonoses from pet food were excluded). DATA SOURCES: PubMed and EMBASE. RESULTS: Fifty seven separate case reports or incidents were described in the 82 papers that were identified by the systematic review. Summary information on each incident is included in this manuscript. The infections include bacterial, viral and fungal diseases and range in severity from mild to life threatening. Infections associated with birds and rodents were the most commonly reported. Over half of the reports describe incidents in the Americas, and three of these were outbreaks involving more than 50 cases. Many of the incidents identified relate to infections in pet shop employees. LIMITATIONS: This review may have been subject to publication bias, where unusual and unexpected zoonotic infections may be over-represented in peer-reviewed publications. It was also restricted to English-language articles so that pathogens that are more common in non-Western countries, or in more exotic animals not common in Europe and the Americas, may have been under-represented. CONCLUSIONS/IMPLICATIONS: A wide spectrum of zoonotic infections are acquired from pet shops. Salmonellosis and psittacosis were the most commonly documented diseases, however more unusual infections such as tularemia also appeared in the review. Given their potential to spread zoonotic infection, it is important that pet shops act to minimise the risk as far as possible.