Are scabies and impetigo “normalised”? A cross-sectional comparative study of hospitalised children in northern Australia assessing clinical recognition and treatment of skin infections

Abstract

BackgroundComplications of scabies and impetigo such as glomerulonephritis and invasive bacterial infection in Australian Aboriginal children remain significant problems and the overall global burden of disease attributable to these skin infections remains high despite the availability of effective treatment. We hypothesised that one factor contributing to this high burden is that skin infection is under-recognised and hence under-treated, in settings where prevalence is high.MethodsWe conducted a prospective, cross-sectional study to assess the burden of scabies, impetigo, tinea and pediculosis in children admitted to two regional Australian hospitals from October 2015 to January 2016. A retrospective chart review of patients admitted in November 2014 (mid-point of the prospective data collection in the preceding year) was performed. Prevalence of documented skin infection was compared in the prospective and retrospective population to assess clinician recognition and treatment of skin infections.Results158 patients with median age 3.6 years, 74% Aboriginal, were prospectively recruited. 77 patient records were retrospectively reviewed. Scabies (8.2% vs 0.0%, OR N/A, p = 0.006) and impetigo (49.4% vs 19.5%, OR 4.0 (95% confidence interval [CI 2.1–7.7) were more prevalent in the prospective analysis. Skin examination was only documented in 45.5% of cases in the retrospective review. Patients in the prospective analysis were more likely to be prescribed specific treatment for skin infection compared with those in the retrospective review (31.6% vs 5.2%, OR 8.5 (95% CI 2.9–24.4).ConclusionsScabies and impetigo infections are under-recognised and hence under-treated by clinicians. Improving the recognition and treatment of skin infections by clinicians is a priority to reduce the high burden of skin infection and subsequent sequelae in paediatric populations where scabies and impetigo are endemic.

Perinatal risk factors associated with skin infection hospitalisation in Western Australian Aboriginal and Non‐Aboriginal children

“…Whilst skin infections are generally viewed as a primary care issue, we have previously identified in WA that 14.8% of Aboriginal children and 1.5% of non‐Aboriginal children are hospitalised at least once for skin infections (1996‐2012) during childhood, with rates in Aboriginal infants 20 times that of their non‐Aboriginal counterparts . We have also confirmed that skin infections are under‐reported in hospitalised patients due to under‐recognition and normalisation, suggesting that the burden of skin infection hospitalisations might be substantially higher …”

“…If diagnosed early, most skin infections could be treated in the community, reducing the need for hospitalisation. A key social determinant to be addressed in remote communities is access to health clinics but potentially the more fundamental issues are the under‐recognition of skin infections and hence under‐treatment by health care workers . Strategies to encourage improved diagnosis and hence treatment have been outlined in the recently released National Healthy Skin Guideline with accompanying pictorial training algorithms for health care workers (https://infectiousdiseases.telethonkids.org.au/our-research/skin-guidelines, accessed 19 Feb, 2019).…”

We won't find what we don't look for: Identifying barriers and enablers of chronic wet cough in Aboriginal children

“…Also, the high prevalence of cough may contribute to its normalization, thereby resulting in under or delayed diagnosis of PBB/CSLD . Similarly, normalization of skin conditions in Aboriginal children has reportedly resulted in under‐recognition and under‐treatment of skin disease . The combination of clinicians’ high threshold for management, reduced disease‐specific knowledge and normalization of chronic wet cough by patients may result in delayed diagnosis and risk of disease progression…”

Skin infections in Australian Aboriginal children: a narrative review

“…More than 50% of all children admitted to hospital in two regional centres studied had a skin infection (49% had impetigo and 8% had scabies), and in these high prevalence settings, health care workers were underreporting skin infections. 31 Linked hospitalisation data for all children born in WA between 1996 and 2012 (n = 469 589), of whom 6.7% were Aboriginal, found that hospitalisation rates for skin infections were 15 times higher for Aboriginal children than non-Aboriginal children (95% CI, 14.5-15.5; P < 0.001), and most commonly they were for abscesses (42.2%), cellulitis (26.0%), impetigo (14.3%) and scabies (15.8%). 32 Three studies reported impetigo prevalence in Queensland, 15,17,24 ranging from 13% to 43%.…”