- Email: [email protected]
Scabies among the French armed forces in 2015
Accepted Manuscript Scabies among the French Armed Forces in 2015 Constance Brossier, Jean-Jacques Morand, Anne Breton, Cyrille Gallineau, Xavier Thauvin, Franck Berger, Jean-Baptiste Meynard, Remy Michel, Sandrine Duron, MD, MPH PII:
S0163-4453(16)30154-2
DOI:
10.1016/j.jinf.2016.06.009
Reference:
YJINF 3769
To appear in:
Journal of Infection
Received Date: 22 June 2016 Revised Date:
27 June 2016
Accepted Date: 28 June 2016
Please cite this article as: Brossier C, Morand J-J, Breton A, Gallineau C, Thauvin X, Berger F, Meynard J-B, Michel R, Duron S, Scabies among the French Armed Forces in 2015, Journal of Infection (2016), doi: 10.1016/j.jinf.2016.06.009. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Title: Scabies among the French Armed Forces in 2015
Authors: Constance Brossier1, Jean-Jacques Morand2,3, Anne Breton4, Cyrille Gallineau5, Xavier Thauvin1, 6, Franck Berger1, Jean-Baptiste Meynard1, 3, Remy Michel1, 3, Sandrine Duron1
1) French Armed Forces Center for Epidemiology and Public Health (CESPA), Marseille, France
RI PT
Affiliations:
2) Sainte-Anne Military Teaching Hospital, Dermatology department, Toulon, France
SC
3) Ecole du Val de Grâce, Paris, France
4) Military Medical Treatment Facility, Vannes-Coëtquidan, France
M AN U
5) Military Medical Treatment Facility, Pamiers, France
6) French National Geographic Institute (IGN), Saint-Mandé, France
Corresponding author: Sandrine Duron, MD, MPH
Centre d’épidémiologie et de santé publique des armées
TE D
Camp militaire de Sainte-Marthe - BP 40 026 - 13 568 Marseille Cedex 02, France Tel: + 33 (0) 4 91 63 79 43
Fax: + 33 (0) 4 91 63 78 25
AC C
EP
E-mail address: [email protected]
ACCEPTED MANUSCRIPT Abstract:
Keywords: scabies; epidemiological surveillance ; public health
M AN U
TE D EP
• •
Incidence of scabies among French armed forces was estimated at 11 cases per 10 000 person-years in 2015. Scabies is complex to handle notably in community settings. Physicians should be well trained and informed on scabies management to control its spread and limit re-infestation.
AC C
•
SC
Highlights:
RI PT
Amid a resurgence of the disease in France, scabies has recently been added to the French armed forces mandatory epidemiological surveillance system. Incidence of scabies was thus estimated at 11 cases per 10 000 person-years among military personnel, which is lower than in the general population. Diagnosing and handling cases of scabies is complex, which stresses the need for healthcare personnel to be well trained and informed on this disease in order to control its spread and limit re-infestation.
ACCEPTED MANUSCRIPT We read with interest the article by Yeoh et al. [1] previously published in this journal and we would like to continue this debate by presenting the experience of French armed forces regarding scabies and notably the management of this disease within community settings. Scabies is a highly contagious parasitic skin disease caused by colonization of the stratum corneum by scabiei var hominis. According to the World Health Organization, the global annual incidence of scabies is around 300 million cases [2].
RI PT
In France, only cases of scabies occurring in healthcare settings are notifiable diseases. Therefore, estimating the incidence of the disease among the general population is complex [3].
SC
Over the past few years, reports of several clusters as well as increasing resistance to scabicides have suggested a resurgence of scabies and alerted the French Institute for Public Health Surveillance [4].
M AN U
During the same period, among the French armed forces, numerous cases of scabies have been reported to the French Armed Forces Center for Epidemiology and Public Health. Consequently, due to its potential epidemic impact and negative consequences on the military community, scabies was added to the mandatory French armed forces epidemiological surveillance system in 2015. The aim of this letter is to describe scabies among the French armed forces in 2015.
TE D
Within the armed forces, epidemiological surveillance refers to all active duty servicemen and women. All 305 French military medical treatment facilities take part in this weekly surveillance of 59 health events [5]. Since January 2015, any suspected case of scabies must be reported according to the following criteria. The criterion for case reporting is solely clinical, and declarations must be based on a diagnosis established by a healthcare professional, with or without additional tests (dermoscopie or parasitological examination).
EP
The recommendations and guidelines produced by French national health authorities and public health institutes are used to manage such cases in French armed forces settings [6].
AC C
Incidence of scabies, expressed in person-years (PY), was calculated using military workforce data provided by the social observatory of the Ministry of Defense. In 2015, 340 cases of scabies were reported among the French armed forces, with an estimated incidence of 11 cases per 10 000 PY in continental France. Due to the low incidence among troops deployed abroad (3 cases per 10 000 PY), the following results will focus only on continental France. Among these 340 cases, 31 clusters were reported, with a median number of 2 cases per cluster (range = 2-102). The 4 main clusters concerned 102, 40, 25 and 15 patients (Figure 1), and 3 out of 4 occurred in training settings or just after a training period. The fourth cluster occurred a few weeks after an operational mission on national territory. The 2 peaks observed in April and November (Figure 1) were linked to these clusters. In May, no cluster was reported, but there were 4 isolated independent cases.
ACCEPTED MANUSCRIPT According to the geographic distribution of the notified cases, scabies was spread all over continental France. However, the incidence seemed to be higher in Northeastern and South Western France, due to large clusters (Figure 2).
SC
RI PT
In the French general population, the incidence of scabies was estimated at between 33 and 35 cases per 10 000 person-years (PY), using proxy data gathered from 2005 to 2009 [4]. Therefore, according to the data shown here, the incidence observed among the French armed forces was likely to be lower than in the general population. However, comparison with French national data is not easy for several reasons. First of all, the standardized morbidity ratio could not be calculated, as scabies is not a notifiable disease in France except in healthcare settings [7, 8]. Secondly, service members constitute a specific population, mostly young, selected according to health criteria and consequently in overall good health, leading to a probable healthy worker effect. This is outweighed by specific military living conditions, community settings with frequent promiscuity. Few data are published on incidence in foreign armed forces. Despite great variability, our data are compatible with those reported previously [9, 10, 11].
M AN U
Regarding biases, our data partially underestimate the actual situation, as French servicemen and women could consult any physician, including civilians, so their military general practitioner was not always aware of their disease. Furthermore, scabies is frequently misdiagnosed and mistaken for eczema or bedbugs for instance, hence the need for diagnostic confirmation by a dermatologist using dermoscopy. But scabies is also frequently over-diagnosed, especially in the context of a cluster or outbreak. Finally, we think that our estimate is a reliable reflection of the real incidence.
EP
TE D
Direct transmission through close extended contacts is known to be the main way of transmission for scabies. However, in some situations, transmission can also be indirect via the environment, and more precisely through clothes, bed linen or fabric covering furniture. While indirect transmission of scabies is generally infrequent, it is a likely means of transmission in community settings, and was often suspected in the clusters observed in the French armed forces in 2015. This stresses the need for strict compliance with general hygiene recommendations, especially for the treatment and washing of clothing, bed linen and towels.
AC C
Effective treatment of scabies depends on simultaneous treatment of all cases and contacts, civilians and household included. This recommendation is difficult to implement due to logistical reason, especially the complexity and cost of treatment. In France, oral treatment is partially reimbursed (65%), while topical treatment is not covered by health insurance. Yet, the two kinds of treatment are often combined for greater efficiency. These difficulties could lead to re-infestation of patients or persistent outbreaks. In community settings, the other issue to address is the lack of visibility and control over the service providers in charge of washing clothing, bed linen and towels. Finally, simultaneous treatment of cases and contacts is challenging due to high mobility within the armed forces. Scabies is still seen as a shameful illness, linked, in the collective consciousness, to poverty and precariousness. This poor image makes the management of cases and clusters even more challenging. We saw, in some of the clusters reported above, several people not involved in management efforts who made irrelevant decisions or took inadequate personal
ACCEPTED MANUSCRIPT initiatives. Communication actions to increase information and awareness among the concerned community—extended to relatives—are decisive in this context [12].
SC
RI PT
In conclusion, in the developed world, scabies is known to affect vulnerable communities and healthcare settings. Data collected among the French armed forces show that scabies remains a topical issue and also affects healthy young people. The complexity of handling cases of scabies stresses the need for healthcare workers to be well trained and informed on this disease in order to control its spread and limit re-infestation.
Acknowledgments
M AN U
The authors would like to thank all the military generalist practioners and their teams who, by the quality of their work, played an active part in the French armed forces epidemiological surveillance network.
Funding or grants
AC C
EP
TE D
We have no funding source or grants to declare.
ACCEPTED MANUSCRIPT References [1] Yeoh D.K., Bowen A.C., Carapetis J.R. Impetigo and scabies - Disease burden and modern treatment strategies. J Infect. 2016 ; 72 : 61-67. [2] World Health Organization. Scabies. Available on WHO website: www.who.int/lymphatic_filariasis/epidemiology/scabies/en/. Accessed on 13th April 2016.
RI PT
[3] De Sainte Marie B, et al. [Therapeutic failure in scabies: An observational study]. Ann Dermatol Venereol. 2016; 143(1):9-15.
SC
[4] Bitar D, Castor C, Che D, Fischer A, Haeghebaert S, Thiolet JM. La gale est-elle en augmentation en France ? Etat des lieux à partir de diverses enquêtes régionales et nationales – 2008-2010. Institut de veille Sanitaire. 2011. Available on Santé Publique France website : www.invs.sante.fr. Accessed on 22nd June 2016.
M AN U
[5] French Ministry of Defense. French Armed Forces Health service. Epidemiological surveillance within French armed forces. IM n°1000/ DEF/DCSSA/AST/TEC/2 . November 2001. [6] French High Council for Public Health. Management of one or several cases of scabies. 2012. Available on HCPH website : http://www.hcsp.fr/Explore.cgi/avisrapportsdomaine?clefr=313. Accessed on 22nd June 2016. [7] Downs AMR, Harvey I, Kennedy CTC. The epidemiology of head lice and scabies in the UK. Epidemiol Infect. 1999;122:471-477.
TE D
[8] Ancelle T, Ancelle-Park R, Antoine D et al. La gale dans les établissements pour personnes âgées en France en 1996. Bulletin épidémiologique hebdomadaire. 1997 ; 7: 279. [9] Kimchi N, Green MS, Stone D. Epidemiologic characteristics of scabies in the Israel defense force. Int J Dermatol. 1989; 28: 180-82.
EP
[10] Mimouni D, Ankol OE, Davidovitch M, et al. Seasonality trends of scabies in a young adult population : a 20-year follow-up. Br J Dermatol. 2003; 149: 157-59.
AC C
[11] Melton LJ, Brazin SA, Damm SR. Scabies in the United States navy. AJPH. 1978; 68:776-78. [12] Castor C, Bernadou I. Epidémie de gale communautaire – Guide d’investigation et d’aide à la gestion. Institut de veille sanitaire. 2008. Available on Santé Publique France website : www.invs.sante.fr. Accessed on 22nd June 2016.
ACCEPTED MANUSCRIPT 140
100 80 60
Cases among clusters
40
Isolated cases
RI PT
Number of cases
120
20
SC
0
AC C
EP
TE D
M AN U
Figure 1: Monthly number of cases and clusters of scabies reported to the French armed forces epidemiological surveillance system - 2015
RI PT
ACCEPTED MANUSCRIPT
TE D
M AN U
SC
Incidence rates of scabies\10 000 PY
* Red lines do not correspond to the official national administrative division but to the limits of coverage by each military medical treatment centers.
AC C
EP
Figure 2: Geographic distribution of cases of scabies among French armed forces, continental France - 2015.
S0163-4453(16)30154-2
DOI:
10.1016/j.jinf.2016.06.009
Reference:
YJINF 3769
To appear in:
Journal of Infection
Received Date: 22 June 2016 Revised Date:
27 June 2016
Accepted Date: 28 June 2016
Please cite this article as: Brossier C, Morand J-J, Breton A, Gallineau C, Thauvin X, Berger F, Meynard J-B, Michel R, Duron S, Scabies among the French Armed Forces in 2015, Journal of Infection (2016), doi: 10.1016/j.jinf.2016.06.009. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Title: Scabies among the French Armed Forces in 2015
Authors: Constance Brossier1, Jean-Jacques Morand2,3, Anne Breton4, Cyrille Gallineau5, Xavier Thauvin1, 6, Franck Berger1, Jean-Baptiste Meynard1, 3, Remy Michel1, 3, Sandrine Duron1
1) French Armed Forces Center for Epidemiology and Public Health (CESPA), Marseille, France
RI PT
Affiliations:
2) Sainte-Anne Military Teaching Hospital, Dermatology department, Toulon, France
SC
3) Ecole du Val de Grâce, Paris, France
4) Military Medical Treatment Facility, Vannes-Coëtquidan, France
M AN U
5) Military Medical Treatment Facility, Pamiers, France
6) French National Geographic Institute (IGN), Saint-Mandé, France
Corresponding author: Sandrine Duron, MD, MPH
Centre d’épidémiologie et de santé publique des armées
TE D
Camp militaire de Sainte-Marthe - BP 40 026 - 13 568 Marseille Cedex 02, France Tel: + 33 (0) 4 91 63 79 43
Fax: + 33 (0) 4 91 63 78 25
AC C
EP
E-mail address: [email protected]
ACCEPTED MANUSCRIPT Abstract:
Keywords: scabies; epidemiological surveillance ; public health
M AN U
TE D EP
• •
Incidence of scabies among French armed forces was estimated at 11 cases per 10 000 person-years in 2015. Scabies is complex to handle notably in community settings. Physicians should be well trained and informed on scabies management to control its spread and limit re-infestation.
AC C
•
SC
Highlights:
RI PT
Amid a resurgence of the disease in France, scabies has recently been added to the French armed forces mandatory epidemiological surveillance system. Incidence of scabies was thus estimated at 11 cases per 10 000 person-years among military personnel, which is lower than in the general population. Diagnosing and handling cases of scabies is complex, which stresses the need for healthcare personnel to be well trained and informed on this disease in order to control its spread and limit re-infestation.
ACCEPTED MANUSCRIPT We read with interest the article by Yeoh et al. [1] previously published in this journal and we would like to continue this debate by presenting the experience of French armed forces regarding scabies and notably the management of this disease within community settings. Scabies is a highly contagious parasitic skin disease caused by colonization of the stratum corneum by scabiei var hominis. According to the World Health Organization, the global annual incidence of scabies is around 300 million cases [2].
RI PT
In France, only cases of scabies occurring in healthcare settings are notifiable diseases. Therefore, estimating the incidence of the disease among the general population is complex [3].
SC
Over the past few years, reports of several clusters as well as increasing resistance to scabicides have suggested a resurgence of scabies and alerted the French Institute for Public Health Surveillance [4].
M AN U
During the same period, among the French armed forces, numerous cases of scabies have been reported to the French Armed Forces Center for Epidemiology and Public Health. Consequently, due to its potential epidemic impact and negative consequences on the military community, scabies was added to the mandatory French armed forces epidemiological surveillance system in 2015. The aim of this letter is to describe scabies among the French armed forces in 2015.
TE D
Within the armed forces, epidemiological surveillance refers to all active duty servicemen and women. All 305 French military medical treatment facilities take part in this weekly surveillance of 59 health events [5]. Since January 2015, any suspected case of scabies must be reported according to the following criteria. The criterion for case reporting is solely clinical, and declarations must be based on a diagnosis established by a healthcare professional, with or without additional tests (dermoscopie or parasitological examination).
EP
The recommendations and guidelines produced by French national health authorities and public health institutes are used to manage such cases in French armed forces settings [6].
AC C
Incidence of scabies, expressed in person-years (PY), was calculated using military workforce data provided by the social observatory of the Ministry of Defense. In 2015, 340 cases of scabies were reported among the French armed forces, with an estimated incidence of 11 cases per 10 000 PY in continental France. Due to the low incidence among troops deployed abroad (3 cases per 10 000 PY), the following results will focus only on continental France. Among these 340 cases, 31 clusters were reported, with a median number of 2 cases per cluster (range = 2-102). The 4 main clusters concerned 102, 40, 25 and 15 patients (Figure 1), and 3 out of 4 occurred in training settings or just after a training period. The fourth cluster occurred a few weeks after an operational mission on national territory. The 2 peaks observed in April and November (Figure 1) were linked to these clusters. In May, no cluster was reported, but there were 4 isolated independent cases.
ACCEPTED MANUSCRIPT According to the geographic distribution of the notified cases, scabies was spread all over continental France. However, the incidence seemed to be higher in Northeastern and South Western France, due to large clusters (Figure 2).
SC
RI PT
In the French general population, the incidence of scabies was estimated at between 33 and 35 cases per 10 000 person-years (PY), using proxy data gathered from 2005 to 2009 [4]. Therefore, according to the data shown here, the incidence observed among the French armed forces was likely to be lower than in the general population. However, comparison with French national data is not easy for several reasons. First of all, the standardized morbidity ratio could not be calculated, as scabies is not a notifiable disease in France except in healthcare settings [7, 8]. Secondly, service members constitute a specific population, mostly young, selected according to health criteria and consequently in overall good health, leading to a probable healthy worker effect. This is outweighed by specific military living conditions, community settings with frequent promiscuity. Few data are published on incidence in foreign armed forces. Despite great variability, our data are compatible with those reported previously [9, 10, 11].
M AN U
Regarding biases, our data partially underestimate the actual situation, as French servicemen and women could consult any physician, including civilians, so their military general practitioner was not always aware of their disease. Furthermore, scabies is frequently misdiagnosed and mistaken for eczema or bedbugs for instance, hence the need for diagnostic confirmation by a dermatologist using dermoscopy. But scabies is also frequently over-diagnosed, especially in the context of a cluster or outbreak. Finally, we think that our estimate is a reliable reflection of the real incidence.
EP
TE D
Direct transmission through close extended contacts is known to be the main way of transmission for scabies. However, in some situations, transmission can also be indirect via the environment, and more precisely through clothes, bed linen or fabric covering furniture. While indirect transmission of scabies is generally infrequent, it is a likely means of transmission in community settings, and was often suspected in the clusters observed in the French armed forces in 2015. This stresses the need for strict compliance with general hygiene recommendations, especially for the treatment and washing of clothing, bed linen and towels.
AC C
Effective treatment of scabies depends on simultaneous treatment of all cases and contacts, civilians and household included. This recommendation is difficult to implement due to logistical reason, especially the complexity and cost of treatment. In France, oral treatment is partially reimbursed (65%), while topical treatment is not covered by health insurance. Yet, the two kinds of treatment are often combined for greater efficiency. These difficulties could lead to re-infestation of patients or persistent outbreaks. In community settings, the other issue to address is the lack of visibility and control over the service providers in charge of washing clothing, bed linen and towels. Finally, simultaneous treatment of cases and contacts is challenging due to high mobility within the armed forces. Scabies is still seen as a shameful illness, linked, in the collective consciousness, to poverty and precariousness. This poor image makes the management of cases and clusters even more challenging. We saw, in some of the clusters reported above, several people not involved in management efforts who made irrelevant decisions or took inadequate personal
ACCEPTED MANUSCRIPT initiatives. Communication actions to increase information and awareness among the concerned community—extended to relatives—are decisive in this context [12].
SC
RI PT
In conclusion, in the developed world, scabies is known to affect vulnerable communities and healthcare settings. Data collected among the French armed forces show that scabies remains a topical issue and also affects healthy young people. The complexity of handling cases of scabies stresses the need for healthcare workers to be well trained and informed on this disease in order to control its spread and limit re-infestation.
Acknowledgments
M AN U
The authors would like to thank all the military generalist practioners and their teams who, by the quality of their work, played an active part in the French armed forces epidemiological surveillance network.
Funding or grants
AC C
EP
TE D
We have no funding source or grants to declare.
ACCEPTED MANUSCRIPT References [1] Yeoh D.K., Bowen A.C., Carapetis J.R. Impetigo and scabies - Disease burden and modern treatment strategies. J Infect. 2016 ; 72 : 61-67. [2] World Health Organization. Scabies. Available on WHO website: www.who.int/lymphatic_filariasis/epidemiology/scabies/en/. Accessed on 13th April 2016.
RI PT
[3] De Sainte Marie B, et al. [Therapeutic failure in scabies: An observational study]. Ann Dermatol Venereol. 2016; 143(1):9-15.
SC
[4] Bitar D, Castor C, Che D, Fischer A, Haeghebaert S, Thiolet JM. La gale est-elle en augmentation en France ? Etat des lieux à partir de diverses enquêtes régionales et nationales – 2008-2010. Institut de veille Sanitaire. 2011. Available on Santé Publique France website : www.invs.sante.fr. Accessed on 22nd June 2016.
M AN U
[5] French Ministry of Defense. French Armed Forces Health service. Epidemiological surveillance within French armed forces. IM n°1000/ DEF/DCSSA/AST/TEC/2 . November 2001. [6] French High Council for Public Health. Management of one or several cases of scabies. 2012. Available on HCPH website : http://www.hcsp.fr/Explore.cgi/avisrapportsdomaine?clefr=313. Accessed on 22nd June 2016. [7] Downs AMR, Harvey I, Kennedy CTC. The epidemiology of head lice and scabies in the UK. Epidemiol Infect. 1999;122:471-477.
TE D
[8] Ancelle T, Ancelle-Park R, Antoine D et al. La gale dans les établissements pour personnes âgées en France en 1996. Bulletin épidémiologique hebdomadaire. 1997 ; 7: 279. [9] Kimchi N, Green MS, Stone D. Epidemiologic characteristics of scabies in the Israel defense force. Int J Dermatol. 1989; 28: 180-82.
EP
[10] Mimouni D, Ankol OE, Davidovitch M, et al. Seasonality trends of scabies in a young adult population : a 20-year follow-up. Br J Dermatol. 2003; 149: 157-59.
AC C
[11] Melton LJ, Brazin SA, Damm SR. Scabies in the United States navy. AJPH. 1978; 68:776-78. [12] Castor C, Bernadou I. Epidémie de gale communautaire – Guide d’investigation et d’aide à la gestion. Institut de veille sanitaire. 2008. Available on Santé Publique France website : www.invs.sante.fr. Accessed on 22nd June 2016.
ACCEPTED MANUSCRIPT 140
100 80 60
Cases among clusters
40
Isolated cases
RI PT
Number of cases
120
20
SC
0
AC C
EP
TE D
M AN U
Figure 1: Monthly number of cases and clusters of scabies reported to the French armed forces epidemiological surveillance system - 2015
RI PT
ACCEPTED MANUSCRIPT
TE D
M AN U
SC
Incidence rates of scabies\10 000 PY
* Red lines do not correspond to the official national administrative division but to the limits of coverage by each military medical treatment centers.
AC C
EP
Figure 2: Geographic distribution of cases of scabies among French armed forces, continental France - 2015.