Scabies is one of the leading health challenges in the current European migrant crisis for both public health authorities and health care institutions [9,10,11, 19,20,21,22,23]. Although the European guideline provides recommendations for the treatment of scabies mass outbreaks, it does not make any concrete proposals for organizing its practical implementation. In collaboration with the local health care authority, we developed and tested a colour-coded algorithm, which is based on clinical signs and symptoms, to manage large numbers of refugees and other individuals with suspected or confirmed scabies. By following this algorithm, we were able to triage, examine, treat and inform a large number of patients within a short time.
To our knowledge, there is currently no algorithm available that describes the management of scabies mass outbreaks. Publications on institutional (e.g. hospitals, residential care homes) [16, 24,25,26,27] or endemic scabies [17, 28] reported various strategies to combat outbreaks, but none provided a description for the management procedures in concrete terms. However, the key steps to control scabies outbreaks are basically the same, irrespective of the setting, and include (I) a meticulous planning of the entire procedure, taking into account special constellations (e.g. necessity of involving translators in case of language barriers), (II) registration of all persons at risk and their education about important behavioural measures (III) simultaneous examination and treatment of all persons at risk, (IV) decontamination measures for potential transmitters of infection, such as clothing and other textiles, cuddly toys, etc., and (V) follow-ups including retreatments if necessary [16, 25,26,27, 29].
We have implemented all five points in our algorithm. The colour-coded process allowed us to customize the scabies management: People without signs of infestation (Group I, green) were managed, treated and discharged within minutes, giving more time and human resources to Group II (blue) and especially Group III (red). The colour-coding ensured a fast and clear flow of information and thus a smooth process at the interfaces of our algorithm. Most time-consuming in our algorithm were steps involving translators (e.g. history taking, instructions regarding treatment, decontamination measures and follow-ups).
Whereas the main steps were similar in the aforementioned studies, larger variety was reported in terms of drug choice for prophylaxis (permethrin or ivermectin) and treatment (permethrin and/or ivermectin) and regarding the dosing regimens (once or twice) - partly because of inconsistent approvals of ivermectin in European countries and regional permethrin resistances [3, 16, 24,25,26,27, 29,30,31]. Prior to our standardized management of the outbreak, we had experienced that monotherapy twice with either permethrin or oral ivermectin was not effective in some patients and for whatever reason, especially in refugees. Therefore, we treated patients with scabies twice with permethrin and oral ivermectin, as recommended in the European guideline for crusted scabies [3]. Furthermore, we treated individuals with itch but without scabies lesions (group II, blue) with two doses of oral ivermectin. Unfortunately, the European guideline does not clearly address this constellation in mass population treatment [3]. It states that a single dose of oral ivermectin is effective and that a second dose is recommended (level of evidence Ib), although the importance of this additional dose needs to be evaluated in future studies [3]. When implementing these imprecise recommendations into clinical practice, there is the risk of undertreating symptomatic, and thus possibly affected patients [26], with only a single dose of oral ivermectin, whereas asymptomatic individuals may unnecessarily be treated with two doses. Our results support the notion of differentiating mass treatment in this particular point: asymptomatic individuals can be treated with a single dose of oral ivermectin, symptomatic individuals, who do not have cutaneous signs of scabies, with two doses of the drug at one week intervals. The two treatments with a combination of permethrin and oral ivermectin, as recommended by the European Directive [3], have proven successful in our setting.
In addition, the efficiency of our algorithm is demonstrated by the fact that we were able to control the outbreak within only 8 weeks, while a retrospective study that examined institutional outbreaks over a period of 30 years identified 3 months as the usual time needed [32].
In some of the patients of our cohort, scabies lesion were mainly localized in the genital region. Similar observations were described by Beeres et al., who investigated more than 1300 refugees with scabies from Eritrea and Ethiopia, who had recently arrived in the Netherlands [9]. The authors found that scabies lesions were most common in the genital region and on the hands, each with more than 30%. From these figures we conclude that inspection of these body regions is pivotal, especially in refugees from countries where scabies is endemic.
The individuals in this study were surprisingly compliant, all participants were reached by telephone at the agreed times and appeared at the scheduled follow-up examinations. One reason for this reliability might have been the detailed information about the disease and necessary therapeutic measures, which underlines the importance of professional translators for this procedure.