Mass Drug Administration for Scabies Control in a Population with Endemic Disease.

BACKGROUND: Scabies is an underrecognized cause of illness in many developing countries. It is associated with impetigo, which can lead to serious systemic complications. We conducted a trial of mass drug administration for scabies control in Fiji. METHODS: We randomly assigned three island communities to one of three different interventions for scabies control: standard care involving the administration of permethrin to affected persons and their contacts (standard-care group), mass administration of permethrin (permethrin group), or mass administration of ivermectin (ivermectin group). The primary outcome was the change in the prevalence of scabies and of impetigo from baseline to 12 months. RESULTS: A total of 2051 participants were enrolled; 803 were in the standard-care group, 532 in the permethrin group, and 716 in the ivermectin group. From baseline to 12 months, the prevalence of scabies declined significantly in all groups, with the greatest reduction seen in the ivermectin group. The prevalence declined from 36.6% to 18.8% in the standard-care group (relative reduction in prevalence, 49%; 95% confidence interval [CI], 37 to 60), from 41.7% to 15.8% in the permethrin group (relative reduction, 62%; 95% CI, 49 to 75), and from 32.1% to 1.9% in the ivermectin group (relative reduction, 94%; 95% CI, 83 to 100). The prevalence of impetigo also declined in all groups, with the greatest reduction seen in the ivermectin group. The prevalence declined from 21.4% to 14.6% in the standard-care group (relative reduction, 32%; 95% CI, 14 to 50), from 24.6% to 11.4% in the permethrin group (relative reduction, 54%; 95% CI, 35 to 73), and from 24.6% to 8.0% in the ivermectin group (relative reduction, 67%; 95% CI, 52 to 83). Adverse events were mild and were reported more frequently in the ivermectin group than in the permethrin group (15.6% vs. 6.8%). CONCLUSIONS: Mass drug administration, particularly the administration of ivermectin, was efficacious for the control of scabies and impetigo. (Funded by the Australian National Health and Medical Research Council; Australian New Zealand Clinical Trials Registry number, ACTRN12613000474752.).

Typhoid fever in Fiji: a reversible plague?

The country of Fiji, with a population of approximately 870 000 people, faces a growing burden of several communicable diseases including the bacterial infection typhoid fever. Surveillance data suggest that typhoid has become increasingly common in rural areas of Fiji and is more frequent amongst young adults. Transmission of the organisms that cause typhoid is facilitated by faecal contamination of food or water and may be influenced by local behavioural practices in Fiji. The Fijian Ministry of Health, with support from Australian Aid, hosted a meeting in August 2012 to develop comprehensive control and prevention strategies for typhoid fever in Fiji. International and local specialists were invited to share relevant data and discuss typhoid control options. The resultant recommendations focused on generating a clearer sense of the epidemiology of typhoid in Fiji and exploring the contribution of potential transmission pathways. Additionally, the panel suggested steps such as ensuring that recommended ciprofloxacin doses are appropriate to reduce the potential for relapse and reinfection in clinical cases, encouraging proper hand hygiene of food and drink handlers, working with water and sanitation agencies to review current sanitation practices and considering a vaccination policy targeting epidemiologically relevant populations.

Acceptability of a nationwide scabies mass drug administration (MDA) program in Fiji: a qualitative interview-based study.

Background: Fiji has among the highest global reported prevalence of scabies. Mass drug administration (MDA) has been identified as a potentially effective strategy to control scabies, but acceptability of MDA from the perspectives of people receiving and delivering scabies MDA programs remains underexplored in Fiji and globally. Methods: A qualitative study was conducted after completion of the national MDA campaign. Participants included 44 community members and 12 key informants across the Central and Western Divisions of Fiji. Semi-structured face-to-face and virtual interviews were conducted in August and September 2023. An interpretive research approach was adopted, and data were analysed using deductive and inductive techniques. Findings: We identified several barriers and facilitators to scabies MDA acceptability. Facilitators included prior experiences of scabies and knowledge of the potential health benefit of MDA, community attitudes to MDA and neighbours' adherence practices, endorsement of MDA by community leaders, community consultation and exposure to community sensitisation, and involvement of local key informants during planning and implementation. Barriers included a lack of trust in MDA campaigns, religious beliefs, limited reach of community sensitisation, and challenges to implementing MDA in urban locations. Interpretation: This is the first qualitative study documenting acceptability of a nationwide scabies-MDA globally. It identified diverse socio-structural factors that influenced MDA implementation and acceptability. Future MDA programs could benefit from widespread community sensitisation, tailored approaches to urban and rural MDA design and delivery, and the inclusion of communities in the co-design and implementation of MDA programs. Funding: The National Health and Medical Research Council (NHMRC) investigator grant-LR and the Macquarie Group Foundation 50th Celebration Awards-AS.

The Epidemiology of Scabies and Impetigo in Relation to Demographic and Residential Characteristics: Baseline Findings from the Skin Health Intervention Fiji Trial.

Scabies and associated impetigo are under-recognized causes of morbidity in many developing countries. To strengthen the evidence base for scabies control we undertook a trial of mass treatment for scabies. We report on the occurrence and predictors of scabies and impetigo in participants at baseline. Participants were recruited in six island communities and were examined for the presence of scabies and impetigo. In addition to descriptive analyses, logistic regression models were fit to assess the association between demographic variables and outcome of interest. The study enrolled 2051 participants. Scabies prevalence was 36.4% (95% confidence interval [CI] 34.3-38.5), highest in children 5-9 years (55.7%). Impetigo prevalence was 23.4% (95% CI 21.5-25.2) highest in children aged 10-14 (39.0%). People with scabies were 2.8× more likely to have impetigo. The population attributable risk of scabies as a cause of impetigo was 36.3% and 71.0% in children aged less than five years. Households with four or more people sharing the same room were more likely to have scabies and impetigo (odds ratios [OR] 1.6, 95% CI 1.2-2.2 and OR 2.3, 95% CI 1.6-3.2 respectively) compared to households with rooms occupied by a single individual. This study confirms the high burden of scabies and impetigo in Fiji and the association between these two conditions, particularly in young children. Overcrowding, young age, and clinical distribution of lesion are important risk factors for scabies and impetigo. Further studies are needed to investigate whether the decline of endemic scabies would translate into a definite reduction of the burden of associated complications.

Scabies and impetigo prevalence and risk factors in Fiji: a national survey.

BACKGROUND: Scabies is recognised as a major public health problem in many countries, and is responsible for significant morbidity due to secondary bacterial infection of the skin causing impetigo, abscesses and cellulitis, that can in turn lead to serious systemic complications such as septicaemia, kidney disease and, potentially, rheumatic heart disease. Despite the apparent burden of disease in many countries, there have been few large-scale surveys of scabies prevalence or risk factors. We undertook a population-based survey in Fiji of scabies and impetigo to evaluate the magnitude of the problem and inform public health strategies. METHODOLOGY/PRINCIPAL FINDINGS: A total of 75 communities, including villages and settlements in both urban and rural areas, were randomly selected from 305 communities across the four administrative divisions, and all residents in each location were invited to participate in skin examination by trained personnel. The study enrolled 10,887 participants. The prevalence of scabies was 23.6%, and when adjusted for age structure and geographic location based on census data, the estimated national prevalence was 18.5%. The prevalence was highest in children aged five to nine years (43.7%), followed by children aged less than five (36.5%), and there was also an indication of prevalence increasing again in older age. The prevalence of scabies was twice as high in iTaukei (indigenous) Fijians compared to Indo-Fijians. The prevalence of impetigo was 19.6%, with a peak in children aged five to nine years (34.2%). Scabies was very strongly associated with impetigo, with an estimated 93% population attributable risk. CONCLUSIONS: As far as we are aware, this is the first national survey of scabies and impetigo ever conducted. We found that scabies occurs at high levels across all age groups, ethnicities, and geographical locations. Improved strategies are urgently needed to achieve control of scabies and its complications in endemic communities.

Scabies community prevalence and mass drug administration in two Fijian villages.

BACKGROUND: Scabies has been estimated to affect approximately 300 million people worldwide each year. Scabies rates are high and pose a significant public health problem in Fiji. Community-based comparison treatment trials have not been undertaken. We estimated scabies prevalence and compared the efficacy and tolerability of mass drug administration (MDA) of benzyl benzoate lotion (BB) or oral ivermectin (IVM) in two villages in Fiji. METHODS: A prospective MDA trial was undertaken in two Fijian villages, comparing three daily applications of BB with single dose IVM or permethrin cream for those aged under two years. The therapies were offered to all community members regardless of the presence of scabies or its symptoms. The difference in prevalence was measured before and after the intervention and absolute risk reduction (ARR) and relative risk (RR) calculated. RESULTS: In the BB group, there were 572 eligible participants, of whom 435 (76%) enrolled and 201 (46%) returned for follow-up. In the IVM group, there were 667 eligible participants, of whom 325 (49%) enrolled and 126 (39%) returned. Scabies prevalence was lower after the intervention in both groups. It fell from 37.9 to 20.0% (ARR 18.0%; RR 0.52) in the BB group and from 23.7 to 9.5% (ARR 14.2%; RR 0.40) in the IVM group. CONCLUSIONS: Our study provides proof of principle that MDA for scabies can reduce scabies prevalence at the community level, and that there was no significant difference in this trial between BB and oral IVM.

Cancer epidemiology in the pacific islands - past, present and future.

The Pacific Ocean contains approximately 25,000 islands, stretching from Papua New Guinea to Easter Island, populated by mixtures of Melanesians, Micronesians and Polynesians, as well as migrant groups from Asia and Europe. The region encompasses a third of the surface of the earth although it is sparsely populated at a total of around 9 million. With the exception of some of the more populated islands, such as New Zealand and Hawaii, few surveys of chronic diseases have been conducted, but it is increasingly recognized that obesity, diabetes and associated conditions are emerging public health problems and clearly there is a need for cooperation to optimize control. Here we focus on cancer registry and epidemiological findings for Papua New Guinea, the Solomons, Vanuatu, Samoa, New Caledonia, Fiji, Polynesia, French Polynesia, Maori in New Zealand, Native Hawaiians, Micronesia, including Guam, and Aboriginal populations in Australia as assessed by PubMed searches and perusal of the International Agency for Cancer Research descriptive epidemiology database. Overall, the major cancers in males are oral and liver in Papua New Guinea and the Solomon Islands, and lung and prostate elsewhere (Fiji being exceptional in demonstrating a predominance of esophageal cancer), whereas in females it is breast and either cervix or lung, depending largely on whether cervical cancer screening program is active. In certain locations thyroid cancer is also very prevalent in females. The similarities and variation point to advantages for collaborative research to provide the evidence-base for effective cancer control programs in the region.