SummaryBackgroundScabies 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.MethodsWe 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.Findings230 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.InterpretationClinical 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.FundingPublic Health England and British Skin Foundation.
The topic of SDG interactions is a relatively new research area with many knowledge gaps. Some of these gaps are addressed in this summary of a Special Feature of Sustainability Science, including new findings and emerging issues on (1) the characteristics of SDG interactions; (2) methods/methodology to analyse these interactions; and (3) the elaboration of drivers that influence SDG synergies. The importance of scale is clear in two emerging issues. First, there is evidence of a disconnect between national planning for SDGs and their implementation at the local scale which is leading to SDG trade-offs between these scales. Second, the concept of a “critical transition zone” is introduced where SDG trade-offs pose a particular challenge to SDG implementation. These are areas (e.g., peri-urban and forest margin areas in the Global South) undergoing rapid biophysical and/or socio-economic changes and inhabited by populations especially vulnerable to these changes. While trade-offs occur among the SDGs, there are also many examples of synergies which provide opportunities for advancing multiple goals. To distinguish between synergies and the actions that exploit them, the term “synergy driver” is introduced to refer to policies and measures that positively advance two or more goals. Several examples of synergy drivers are presented, including sustainable global supply chains, people-centred early warning systems, and joint conservation-public health programmes. To make synergy drivers relevant to the broader policy community, the research community (working with stakeholders) should first consolidate knowledge about these drivers and then evaluate their effectiveness/applicability to different policy settings.
(2016) The management of scabies outbreaks in residential care facilities for the elderly in England: a review of current health protection guidelines. Epidemiology and Infection, 144 (15).
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