The Original ‘7-Year Itch’ – Coming to an Infestation Near You!

The WHO estimates that around 200 million people are infected globally at any point in time, with up to 71% prevalence in crowded or institutional settings. Annually 0.2% of global disability-adjusted life years (DALYs) are attributed to scabies, a greater burden than leprosy, schistosomiasis, or dengue. These figures may be an underestimate since there is a global lack of high-quality prevalence data and significant amounts of misdiagnosis and under-reporting. In 2017, the WHO deplored the global paucity of evidence, designated scabies as a category-A NTD, and recommended prevalence studies

By  Michael Head *

Senior Research Fellow

Clinical Informatics Research Unit and Global Health Research Institute

Faculty of Medicine, University of Southampton, UK

The Original ‘7-Year Itch’ – Coming to an Infestation Near You!

As cross-posting this article also appears on the blog site of the Royal Society for Tropical Medicine and Hygiene - RSTMH

 

It’s currently burrowed under the skin of about 200 million people around the world right now, and is spreading abuse, stigma and shame wherever it goes. Your friendly local doctor often cannot recognise it, which is perhaps fair enough given it’s less than 0.5mm long. It’s brewing up a cocktail of ongoing misery including a fair few wounds as a result of people frantically scratching themselves, fair amount of renal disease, and the occasional bout of sepsis.

Public health burden

So, let’s have a chat about the massive public health burden of scabies then. What’s that? You’d rather not? Afraid that’s all I’ve got. No, I don’t mind, do carry on eating your lunch. Oh, yes there are pictures actually. Right here, in fact.

Scabies presentations from our UK care home study (Cassell et al, Lancet Infectious Diseases, 2018)

Scabies is (if you hadn’t guessed by now) an intensely itchy skin condition, transmitted by mites. It causes rashes, and can lead to significant secondary complications including bacterial infections and renal complications. A disease of poverty, it is highly stigmatised as being “dirty” and attracts significant social stigma – the Ethiopian word for scabies “ekek” is used as a term of abuse.

The WHO estimates that around 200 million people are infected globally at any point in time (anecdotally, recent conversations with the WHO suggest that may be a significant underestimate), with up to 71% prevalence in crowded or institutional settings.

Greater burden 

Annually 0.2% of global disability-adjusted life years (DALYs) are attributed to scabies, a greater burden than leprosy, schistosomiasis, or dengue. In Ethiopia, there is an ongoing outbreak with over 400 000 scabies cases. There, 1.2 million doses of ivermectin (anti-parasitic drug) have been administered, there is a median prevalence of 33%, duration of symptoms is five months (that’s over 20 weeks of itching), and over half of cases were in children who typically did not go to school during this time.

There is a global lack of high-quality prevalence data and significant amounts of misdiagnosis and under-reporting. In 2017, the WHO deplored the global paucity of evidence, designated scabies as a category-A NTD, and recommended prevalence studies.

For our contributions – colleagues at Brighton & Sussex Medical School are leading on scabies research studies in Ethiopia and Papua New Guinea.

Pilot study on scabies diagnosis in Ghana

I have a pilot study starting in 2019 covering improved diagnosis of scabies in Ghana. This is working with public health directors in the Volta and Greater Accra regions, and includes training from Ghanaian dermatologists (from the University of Ghana, Ghana Dermatology Society, and the Rabito Clinic).

Previously, between us, we prospectively reported on scabies outbreaks in care homes in the UK (yes, there’s plenty of it in high-income countries too). This was a complex study where we were urged to exclude patients with dementia since that would make the research ethically tricky. We continued to include dementia patients. It certainly did make the ethics very tricky indeed, but we did discover that the most vulnerable patients in care homes are the ones who are most at risk of (among virtually every co-morbidity going) scabies infestation.

Lack of bathing not a cause of scabies

Oh and one further point – a lack of bathing is not a cause of scabies. It’s a common myth (being ‘unclean’), that is spread even by healthcare workers (I myself recently reviewed a paper that stated precisely that). Overcrowding and poverty are key factors (and these populations are likely to wash less). But bathing in itself is not a factor, and the WHO have in fact written to ourselves to thank us for our response (linked above).

There are effective drugs (such as ivermectin), but little in the way of diagnostics and no vaccine and plenty of misinformation and stigma. There is little in the way of policy and guidance, due to the lack of data upon which to base any guidance. Which leads us to conclude…

Scabies, perhaps the biggest global public health problem you know very little about. Now it’s an NTD, we can hopefully start to make progress on this truly neglected disease.

——————————-

 

*Dr Michael Head is a Senior Research Fellow, based in the Clinical Informatics Research Unit at the University of Southampton. He has research interests in analyses of the financing of research, evidence-informed policymaking, pneumonia and this probably-unhealthy obsession with scabies (for which he has Professor Jackie Cassell, Brighton & Sussex Medical School to thank).

m.head@soton.ac.uk
@michaelghead

 

BY THE SAME AUTHOR ON PEAH

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‘Action Alliance “Training 2020” – An Alliance for Independent Continuing Medical Education’ by Christiane Fischer 

Action Alliance “Training 2020” for Independent Continuous Medical Education

MEZIS (Mein Essen zahl ich selbst – I pay for my own lunch) has long been calling for Continuous Medical Education (CME) programs to be free of conflict of interest. On this long journey MEZIS has been able to reach an important milestone: The Alliance for Action 2020 - Alliance for Independent Continuing Medical Education

Christiane Fischer

By Christiane Fischer MD, MPH, PhD*

 Founder and Medical Managing Director at MEZIS

Action Alliance “Training 2020”

An Alliance for Independent Continuing Medical Education

 

In 2018, MEZIS (Mein Essen zahl ich selbst – I pay for my own lunch) successfully launched another tool to achieve the goal of continuing medical education without any sponsoring by the pharmaceutical industry: The Alliance for Action 2020 – Alliance for Independent Continuing Medical Education. It complements MEZIS strategy to achieve change through committees and media.

What is the background?

Organizers of Continuous Medical Education (CME) Programs such as hospital departments and professional associations often welcome support of human and financial resources from the pharmaceutical industry. An implementation of CME-Programs without sponsorship seems unthinkable for many. However, is that really true?

At the same time, more and more CME-Programs are being organized  independently and without any sponsoring by the pharmaceutical industry. Even conferences of large associations such as  the German Society of General and Family Medicine are successfully carried out without pharmaceutical support- and teach the eternal skeptics of the better. This shows there are already some good alternatives. However, they are not well-known and overarching concepts and structures for independent training are still missing.
Independent organizers also have to compete in a market place highly distorted by exorbitant sponsorship sums from the pharmaceutical industry with organizers such as Omniamed, which used to receive up to 250,000 Euros from the pharmaceutical industry for one day. In August, the Medical Chamber Stuttgart denied Omniamed any CME certification for the first time. Omniamed consequently withdrew from Germany in December 2018, hopefully paving the way for independent organizers of CME events to overtake their sponsored counterparts.

Goal

The goal of the Action Alliance is to provide independent continuing medical training. Continuing medical training must take place independently of the interests of the industry and solely in the responsibility of hospitals, professional societies, professional associations and other organs of the medical self-government. This requires a rethinking by physicians and a change in the medical training culture.

Commitment

The partners joining the Alliance commit to providing sufficiently high quality training without industry participation or financial support. In addition, in agreement with the founding members, there are criteria for content quality that are based on existing ones.

Who is already there?

We are already pleased to have the Drug Commission of the German Medical Association (AkdÄ), the German Society for General Medicine (DEGAM), the neurologist initiative “NeurologyFirst” as well as the two independent training organizations HD Med and Libermed as founding members.

Our aims until 2020

  • Bundling of existing independent concepts and structures for CME-Programs (AkdÄ, DEGAM, NF, medical chambers, HD Med, Libermed).
  • Development of a guideline for  CME-Programs as well as financing concepts (meaningful and necessary amount of annual training, quality features, requirements, practical organization, calculations).
  • The Allies provide guidance to their members in the organization and delivery of independent medical trainings.
  • Creating structures and sharing structures for organizing independent events.
  • Creating a common internet platform: https://cme-sponsorfrei.de/
  • Establishment of a quality label “Partner in the Action Alliance for Further Education 2020”.

———————————————–

Dr. Christiane Fischer was born in 1967 in Emden and grew up in the black forrest in Germany. She studied medicine in Homburg/Saar and Heidelberg and is from her postgraduation Master of Public Health (MPH). From 1999 untill 2013 she worked as the executive director of the BUKO Pharma-Kampagne focussing the impact of patents on access to drugs in poor countries. In 2007 she founded MEZIS and was part of the board until  2013. Since then she works as the Medical Director.  Since 2012 she is member of German Ethics Council.

*On the same topic on PEAH:

Interview to Christiane Fischer: MEZIS (Mein Essen zahl ich selbst – I pay for my own lunch) 

 

To Protect and Promote the Rights of Mentally-Disabled in Uganda

...Obsolete mental health legislation in Uganda has a number of deficiencies such as failure to differentiate voluntary and involuntary care, inadequate protection and promotion of the human rights of people with mental illness and the presence of slurring and stigmatizing language; and henceforth not in line with the draft mental health policy as well as current trends in mental health care...

 

By Denis Bukenya

and Michael Ssemakula

Health Rights Researchers & Advocates

Human Rights Research Documentation Center (HURIC), and PHM-Network, Uganda

Galvanizing the Action to Protect and Promote the Rights of Mentally-Disabled Individuals in the Key Populations: a Pathway to Achieve Health for All

 

Although there are efforts to improve mental health in Uganda, there remains a heavyweight number of deficiencies especially in terms of stigma and misconceptions about the predicament. There is limited appreciation of the mental health illnesses predominantly in low resource settings. Many societies in Uganda tend to demonize mental health illnesses which has resulted into human rights violations such as incarceration of persons with the mental disequilibrium. This is at the expense of the much needed psyche-socio support. Instead people with mental illnesses are subjected to unfair discrimination, detestable beatings, and poor treatment out of ignorance. This eventually results into denial of access to institutional mental health services (such as psychiatric services and  psychotherapy treatment like psychotic drugs) hence the prevalence of the traditional and spiritual divine healers, a mechanism that has been renowned for lack of a regulation thus exploitation of the victims. This increases the urgency for an inclusive prevention and rehabilitation multi-stakeholder levels of assistance through community inclusiveness in addressing the current burden of mental health disorders and the functioning of mental health programs and services in Uganda.

According to research by (Lumbuye-Guba, 2003), over 45 per cent of the youths have used drugs or alcohol. Sadly the indigenous demand for hard drugs has also unrelentingly continued to increase, with an approximation of 5-10 per cent of the populace being reliant on and consistent users; 18 per cent of men and 2 per cent of women both smoke and drink. Other drugs of abuse include cannabis, which grows extensively in the green equatorial climate of Uganda and abuse is common especially among young urban elites and juveniles. The national mental hospital shows that 30 per cent of hospital admissions are associated with drug abuse. Inhalants such as paint thinner, and glue are also common among street and slum youth. Eating of marungi (Khat) is also spreading hastily. Heroin use cases have also been reported in the country.  Services are dispersed and staff ability to address this is largely deficient.

A report by (Basangwa, 2004) assessed that 35 per cent of Ugandans suffer from some form of mental disequilibrium, of which 15 per cent need treatment. Although data proximities on mental illnesses in Uganda are very scanty, anecdotal research study evidence shows an upsurge in the occurrence of mental disorders. According to (UBOS, 2006), an envisaged 7 per cent of the households in the country had disabled members, of which 58 per cent had at the very least one individual with a mental disorder. This indicates that about 4 per cent of the households had at least a member with a mental disorder. Juveniles on the streets think drugs improve their socio-psyche lives and a major risk for street youths in Uganda today is a combination of drugs, HIV/AIDS and reckless sexual behavior.

Alliance forming in efforts to assist people affected is lacking. Worsened by gaps in the policy on the mental health such as offensive derogatory terms, which call victims, “persons suffering from mental derangement”, and existence of forced medical intervention without consent, the mental health legislation is therefore outmoded. The mental health system operates on an outdated mental health Law that was last revamped in the 1964. The legislation focuses on detention care of mentally-ill persons and is not in accordance with contemporary international human rights standards regarding mental health care. This obsolete legislation has a number of deficiencies such as failure to differentiate voluntary and involuntary care, inadequate protection and promotion of the human rights of people with mental illness and the presence of slurring and stigmatizing language; and henceforth not in line with the draft mental health policy as well as current trends in mental health care.

Services are still significantly underfunded (with only 1 per cent of the health expenditure going to mental health), and skewed towards urban areas, and mental disorders are not covered in any social insurance schemes we have in Uganda at the moment. Although mental health is one of the key components in the Health Sector Development Plan 2015/2016-2019/2020, we have no comprehensive mental health plan, and there is no information to draw a clear strategy for mental health treatment and prevention. Therefore, there is need for increased stakeholder engagement, through community involvement and participation, if national and global targets for mental health are to be attained. The mental health collaborative interventions are not moving as fast as would be expected. There is low utilization of mental health services. Health workers infrequently discuss the relationship between drug abuse and mental illnesses with populations and patients there in. Health care providers largely display negative attitudes towards mental health patients. At this prevalence rate, the gains made in prevention and control of mental illnesses could easily be reversed; yet the conditions are preventable through provision of appropriate information and ensuring the effective interventions are in place. Communication interventions through Participatory Reflection and Action methods are important means to engage policy enabling powers, government officials, public and private health professionals, traditional and religious leaders, community leaders, patients and their families in bringing about political, behavioral and societal change in reverence to mental health.

Mental-disability implications in Uganda mainly affect the youths, women, and sex workers. The majority of the young people and juveniles get affected through excessive drug use as a result of a gap in parental control and lack of guidance. Many of them end up in juveniles’ remand centres and prisons where they learn adverse behaviors and turn into intransigent criminals; therefore, we need to offer communities and parents with guidance to prevent and reduce drug use by their children and also emphasize the importance of use of clear, positive communication between parents and children. All young people deserve the best start in life. But too often, young people with mental health disorders are unable to fulfil their potential. Mental-illness unsympathetically costs individuals and society especially on the human development index.  People with mental health problems have too often in the past experienced unfair discrimination and poor treatment. In recent years however, we have seen a mild shift in attitudes towards mental health, but the stigma and misconceptions surrounding mental-illnesses still hold strong in many vulnerable settings which is an entombment towards achieving Universal Health Coverage in Uganda.

In order to address challenges facing vulnerable populations with mental disorders, emphasis should be on modifying the approaches towards appreciating the prevalence of mental disability, creating awareness, and treatment through regionalization of mental health service provision system at district level. This is an imperative mechanism that will ease access to psychosomatic health to enhance the attainment of the global goal of health for all and Sustainable Development Goal #3.5 of strengthening the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of the alcohol. Such methodologies should be purely community based through decentralization of the mental health services as a significant approach to address mental health challenges. This enables victims to continue receiving social support from their families and communities which reduces the stigma.

Owing from the above is the necessity of the egalitarian system of health service provision which needs to incorporate ways to ease accessibility of mental health services. In the Ugandan perspective is the proposition of the National Health Insurance Scheme (NHIS) to minimize the adverse implications of the catastrophic health expenditures on household welfare. However, mental health is not explicitly included in the NHIS. The challenge lies in the fact there is not known NHIS policy in Uganda today. There is light at the end of the tunnel with the NHIS Bill at the floor of parliament awaiting approval, and it is hoped that this will provide the legal framework though, as usual, the process has stagnated for a long period close to a decade.

As activists working with the People’s Health Movement in the Ugandan chapter it is incumbent upon us to acknowledge the Astana Declaration in regard to Mental Health owing to the fact that there needs to be the inclusion of Primary Health Care in Mental Health concerns in Uganda in a bid to ease access to proper mental health care. The declaration is the current guide to the attainment of strengthened UHC by mean of preventive, palliative, rehabilitative and curative care. Delivery of care to mental health in this perspective targets individuals, family, community and finally the national health system. This form of care is easily accessible since it is near people.

 

References

Lumbuye-Guba, C. (2003). Challenges of Intervening in Drug Abuse in Uganda. Kampala: National Institute on drug abuse.

Basangwa, D. (2004). Understanding Mental Health Relapse. Kampala: digitalcollections.sit.edu.

UBOS. (2006). Uganda Demographic Health Survey Preliminary report. Kampala: www.ubos.org.