Scabies is a dermatological parasitic infestation prevalent in many regions worldwide. Classified as a neglected disease by World Health Organization (WHO) since 2017, it is often associated with poor living conditions and overcrowding. Towards the end of 2021, unusual high numbers of scabies cases in outpatient consultations were observed in two Médecins Sans Frontières’ (MSF) Primary Healthcare Centers (PHCs) in Rohingya refugee camps in Cox’s Bazar, Bangladesh. Here, we aimed to describe the epidemiological and clinical characteristics of patients with scabies consulting the clinics from July 2022–November 2023. A cross-sectional study using routinely collected data from scabies’ consultations at two MSF clinics located in camp 14 and 15 (total population 91,241 in 2023) was conducted. We retrospectively analyzed programmatic data of patients of all ages attending outpatient consultations and clinically diagnosed as scabies. Data were extracted from MSF clinical routine monitoring databases and descriptive statistics were reported. During the 16-month period, a total of 178,922 scabies consultations were recorded, amongst whom 57.7% were women and 42.3% men. Children <5 years constituted 20.5% of the cases, age-groups 6-14, 36.6%, and ≥15 years, 42.9%. Camp 15 had the highest number of cases (39.4%), followed by other camps (29.7%), and then camp 14 (24.4%). Most cases were simple scabies (79.5%); one in five were scabies with secondary infection cases. Patients were mainly treated with oral ivermectin (71.2%) and topical permethrin (24.3%); 19.5% of patients also received antibiotics. Our findings indicate that scabies is a significant health concern in the Cox’s Bazar refugee camp. This study recorded over 178000 cases in the above period. The scale of this outbreak warrants further actions, including a prevalence survey, quality implementation of mass drug administration, and multidisciplinary interventions related to camps’ living conditions such as water and sanitation.
BACKGROUND
Hepatitis E virus (HEV) is a leading cause of acute viral hepatitis, particularly in Asia and Africa, where HEV genotypes 1 and 2 are prevalent. Although a recombinant vaccine, Hecolin, is available, it has not been used to control outbreaks. The licensed three-dose regimen might pose challenges for it to be an impactful outbreak control tool. Our study aimed to estimate the effectiveness of two doses of Hecolin in the context of the first-ever reactive use of the vaccine.
METHODS
We conducted a case-control study during an HEV outbreak in the Bentiu internally displaced persons camp, South Sudan. Patients with acute jaundice syndrome (suspected cases) seeking care at the Médecins Sans Frontières hospital were screened for study eligibility. Eligible participants were those that had been eligible for vaccination (ie, living in the camp and aged 16-40 years). Confirmed cases were defined as individuals who tested positive for hepatitis E by RT-PCR or anti-HEV IgM ELISA. Each case was matched to six controls by age, sex, pregnancy status, and residence. Self-reported vaccination status was verified through vaccination cards. The primary analysis was two-dose vaccine effectiveness, which we estimated with a matched case-control design using conditional logistic regression models. In secondary analyses we estimated vaccine effectiveness using a test-negative design and the screening method. We used test-negative cases and their matched controls as a bias indicator analysis to help quantify potential health seeking behaviour biases.
FINDINGS
Between May 10 and Dec 30, 2022, we identified 859 patients with suspected hepatitis E. Of these, 201 met the eligibility criteria and 21 cases had laboratory confirmed hepatitis E. Among the confirmed cases, 10 (48%) were unvaccinated compared with 33 (27%) of 121 matched controls. In the primary analysis we estimated an unadjusted two-dose vaccine effectiveness of 67·8% (95% CI -28·6 to 91·9), and a two-dose vaccine effectiveness of 84·0% (-208·5 to 99·2) after adjustment for potential confounders. The bias indicator analysis suggested that test-negative cases might have been more likely to have been vaccinated than their matched community controls due to different health-care seeking behaviours, potentially meaning underestimation of effectiveness estimates. The test-negative design, which uses facility-matched controls, led to an adjusted two-dose effectiveness of 89·4% (56·4 to 98·0).
INTERPRETATION
Despite the small sample size, our estimates provide evidence of effectiveness of a two-dose regimen against HEV genotype 1 during a protracted outbreak, supporting its use in similar contexts.
In many ways, Marburg virus disease resembles the more well-known Ebola virus disease: The clinical syndrome is similar, management of outbreaks is similar, and the fear engendered in the population experiencing the outbreak is similar. However, diagnostics, therapeutics, and vaccines to manage patients and outbreaks are not similarly available. These have been developed but not yet approved, as outbreaks have not provided the opportunity to establish an evidence base for regulators to evaluate their use in humans. The history of outbreaks of Marburg virus disease suggests that this opportunity will not come, and so alternative pathways to regulatory approval are needed.
BACKGROUND
Traditionally in the Democratic Republic of the Congo (DRC), centralised Ebola treatment centres (ETCs) have been set exclusively for Ebola virus disease (EVD) case management during outbreaks. During the 2020 EVD outbreak in DRC’s Equateur Province, existing health centres were equipped as decentralised treatment centres (DTC) to improve access for patients with suspected EVD. Between ETCs and DTCs, we compared the time from symptom onset to admission and diagnosis among patients with suspected EVD.
METHODS
This was a cohort study based on analysis of a line-list containing demographic and clinical information of patients with suspected EVD admitted to any EVD health facility during the outbreak.
RESULTS
Of 2359 patients with suspected EVD, 363 (15%) were first admitted to a DTC. Of 1996 EVD-suspected patients initially admitted to an ETC, 72 (4%) were confirmed as EVD-positive. Of 363 EVD-suspected patients initially admitted to a DTC, 6 (2%) were confirmed and managed as EVD-positive in the DTC. Among all EVD-suspected patients, the median (interquartile range) duration between symptom onset and admission was 2 (1-4) days in a DTC compared to 4 (2-7) days in an ETC (p<0.001). Similarly, time from symptom onset to admission was significantly shorter among EVD-suspected patients ultimately diagnosed as EVD-negative.
CONCLUSIONS
Since <5% of the EVD-suspected patients admitted were eventually diagnosed with EVD, there is a need for better screening to optimise resource utilization and outbreak control. Only one in seven EVD-suspected patients were admitted to a DTC first, as the DTCs were piloted in a limited and phased manner. However, there is a case to be made for considering decentralized care especially in remote and hard-to-reach areas in places like the DRC to facilitate early access to care, contain viral shedding by patients with EVD and ensure no disrupted provision of non-EVD services.
During the 2018–2020 Ebola virus disease (EVD) outbreak, residents in Goma, Democratic Republic of the Congo, were offered a two-dose prophylactic EVD vaccine. This was the first study to evaluate the safety of this vaccine in pregnant women. Adults, including pregnant women, and children aged ≥1 year old were offered the Ad26.ZEBOV (day 0; dose 1), MVA-BN-Filo (day 56; dose 2) EVD vaccine through an open-label clinical trial. In total, 20,408 participants, including 6635 (32.5%) children, received dose 1. Fewer than 1% of non-pregnant participants experienced a serious adverse event (SAE) following dose 1; one SAE was possibly related to the Ad26.ZEBOV vaccine. Of the 1221 pregnant women, 371 (30.4%) experienced an SAE, with caesarean section being the most common event. No SAEs in pregnant women were considered related to vaccination. Of 1169 pregnancies with a known outcome, 55 (4.7%) ended in a miscarriage, and 30 (2.6%) in a stillbirth. Eleven (1.0%) live births ended in early neonatal death, and five (0.4%) had a congenital abnormality. Overall, 188/891 (21.1%) were preterm births and 79/1032 (7.6%) had low birth weight. The uptake of the two-dose regimen was high: 15,328/20,408 (75.1%). The vaccine regimen was well-tolerated among the study participants, including pregnant women, although further data, ideally from controlled trials, are needed in this crucial group.