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Author response to e-letter "Temperature, insect bites and impetigo"
- Alex J. Elliot, Kenneth Cross, Gillian Smith, Ian Burgess, and Douglas Fleming (18 December 2006)
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Temperature, insect bites and impetigo
- Johannes C. van der Wouden, R. Ghotb Razmjou and Sten P. Willemsen (13 November 2006)
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Alex J. Elliot, Primary Care Scientist Birmingham Research Unit of the RCGP, Lordswood House, 54 Lordswood Road, Birmingham B17 9DB, Kenneth Cross, Gillian Smith, Ian Burgess, and Douglas Fleming
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Dear Editor We thank van der Wouden and colleagues for their informative comments. We agree that there are many probable factors that influence levels of impetigo in the community. We are, however, unaware of any other studies that have specifically described an association between impetigo and insect bites: we therefore feel that it is unreasonable for van der Wouden and colleagues to dismiss the importance of the association we report. If the late summer peaks reported by both ourselves [1] and Loffeld et al. [2] were mainly due to the return of children to school, we would expect the burden of impetigo in these age groups to fall in mid- September and for there to be concurrent peaks throughout the year following other holiday breaks, which we do not see. Additionally, if the suggestion made by van der Wouden et al., that the infectious agents causing impetigo may be dependant on air temperature were correct, then their argument about the considerable and variable lag between the peak of insect bite and impetigo is equally relevant for that of temperature: we found that the peaks of temperature and insect bites were almost simultaneous, which makes it less probable that increased temperature is the major factor in the pathogenesis of impetigo. We were very careful to preclude the use of the phase “causality” throughout the paper, as van der Wouden et al. correctly point out, we could not prove causality through our analyses. We do, however, remain confident that there is an important association here, and insect bites play a major role in the development of impetigo. As we highlight in the paper, we concede that in order to obtain a definitive answer to this question, a carefully designed prospective study is required. Alex Elliot, Kenneth Cross, Gillian Smith, Ian Burgess, Douglas Fleming [1] Elliot AJ, Cross KW, Smith GE, Burgess IF, Fleming DM. The association between impetigo, insect bites and air temperature: a retrospective 5-year study (1999-2003) using morbidity data collected from a sentinel general practice network database. Fam Pract 2006; 23: 490-496. [2] Loffeld A, Davies P, Lewis A, Moss C. Seasonal occurrence of impetigo: a retrospective 8-year review (1996-2003). Clin Exp Dermatol 2005; 30: 512-514. Conflict of Interest:None declared |
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Johannes C. van der Wouden, Senior Lecturer Department of General Practice, Erasmus MC, PO Box 2040, 3000 CA Rotterdam, The Netherlands, R. Ghotb Razmjou and Sten P. Willemsen
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Dear Editor, We admire the originality of the hypothesis put forward by Elliott and co-authors.[1] However, we think the observed relationship between air temperature and the incidence of impetigo and insect bites in general practice is not sufficient to assume causality between insect bites and impetigo. Firstly, there may well be a difference in seasonal spacing of the most common bites (i.e. that of mosquitoes) and that of insect bites that are a reason for people to consult a GP. In our experience, the latter are mainly wasps, hornets, bees and ticks. It is well-known that wasps can be a nuisance during hot periods in late summer. Several alternative explanations for the temporal relationship between temperature and impetigo can be put forward. The virulence of the most common infectious agents causing impetigo may be dependent on air temperature. Furthermore, late summer is the period when schools start again and the close contact between children provides an excellent opportunity for cross-infection. Likewise, explosions of head lice commonly occur in the first weeks after the summer holidays. Finally, the considerable and variable lag between the peak of insect bites and that of impetigo precludes insect bites as a major factor in the pathogenesis of impetigo. Reference Elliot AJ, Cross KW, Smith GE, Burgess IF, Fleming DM. The association between impetigo, insect bites and air temperature: a retrospective 5-year study (1999-2003) using morbidity data collected from a sentinel general practice network database. Family Practice 2006; 23: 490-6. Conflict of Interest:None declared |
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