Infection of scabies and evaluation on the effect of treatment among the out-patients in the department of dermatology and venerelogy of birdem hospital, Dhaka.
Introduction
Bangladesh is one of the poorest country of the world with the highest density of population to about 124 million. About 80% of population live in the rural areas, where poverty, illiteracy, ignorance, high family members, disease and disasters are the constant companion of them. Whit per capita income only tk 1760. with increase population, socio-economic condition become poor and due to this population explosion all the reversible socio-demographic conditions and goes in favor of disease occurrence, recurrence and complications. In addition, over crowding, urbanization, industrialization, migration, excessive use of chemicals and cosmetic s, environmental pollution, green house effect, education, delayed marriage and use of multiple partner are also major factors for initiation and transmission of disease.
Skin is the largest organ of the human body, covering the entire surface of the body. The skin is subjected to a wide range of medical conditions and infections ranging from simple manifestations to complicated ones like skin cancer. Skin diseases are due to infection, exposure, use pf cosmetics, diet and stress. Other skin diseases are caused by insects and parasites such as ticks, mites, fleas and fungi. Scabies is an example of very common contagious skin disease caused by a parasitic mite, Sarcoptes scabiei.
The relation between this disease and human’s socio-demographic characteristics are very important to know because it deal with how people in different societies and social groups explain the cause of illness, the type of treatment they believe and to whom they turn if they go get ill.
Skin and Venereal disease are a public health problem in developing countries. Though it occurs in all classes of the society but people living in insanitary and poor housing conditions suffer more from the disease, poverty stricken people with poor hygienic habits and unclean clothing are the usual victim of the diseases.
Though skin diseases are a common occurrence in developing countries like Bangladesh, there are not so many statistics to prove the exact frequency of skin diseases in the country. In many studies it has been shown that about 30%-40% of our populations are suffering from skin diseases of which approximately 80% are scabies and pyogenic infections.
Scabies is an important skin disease. It is a public health problem. There are many public health problems from which people of the under developed countries suffer. They suffer because of ignorance, illiteracy, poverty and apathy towards health problem. These factors exist in Bangladesh where Scabies is a problem.
Scabies is an ancient affliction, estimated to have infected humans for more than 2500 years. Prior to the 17th Century, the condition of scabies was knownby many names and widely believed to be a humoral disease, possibly associated with a mite. Aristotle (384 to 322 BC) was the first person believed to rave identified scabies mites, describing them as “lice in the flesh,” which resulted n vesicles However, the disease was first ascribed to the mite by Giovan Cosimo 3oDomo in 1687. It was the first human disease recognized to be caused by a specificpathogen.
Scabies is a prevalent skin condition that affects people of all classes and ethnicities all over the world. Worldwide, the prevalence of scabies has been estimated at 300 million cases annually, although this figure may be an overestimate. Scabies is endemic in many tropical and subtropical areas, such as Africa, Egypt, Central and South America, northern and central Australia, the Caribbean Islands, India and Southeast Asia.
Scabies is an important disease of children although it affects people of all ages. It has a tendency of high prevalence among children. Tariq et al. (2002) conducted a study to determine the prevalence of scabies in Karachi, Pakistan, during 1996-97 and found that the prevalence of scabies was greater in adults than inchildren in both years. In Bangladesh infants are more affected along with respiratory diseases and in parts of Bangladesh, the number of children with “the itch” exceeds the number with diarrhea and respiratory diseases combined. In aboriginal communities in northern Australia, prevalence of up to 50% amongchildren has been described, despite the availability of effective chemotherapy (WHO 2008).
Scabies is a neglected parasitic disease that is a major public health in many resource-poor regions. Prevalence rates are extremely high in tribes in Australia, in Africa, in South America, and in other developing of the world. Incidence in parts of Central America and South America n Southeast Asia approach approximately 100%. Heukelbach et al (2003) reported that tungiasis and pediculosis and to a lesser extent scabies and cutaneous larva migrans (CLM) were hyper endemic in many poor communities in north-east Brazil but neglected by both population and physicians of that community.
In industrialized countries, scabies is observed primarily in sporadic Individual cases and institutional outbreaks. In the United States and in other developed regions around the world, scabies occurs in epidemics in nursing homes, hospitals, long-term care facilities, and other institutions. It is seenfrequently in the homeless populations but occurs episodically in other populations as well. Scabies is currently widespread in North America and Europe, with no evidence that this epidemic is abÏÆing. A lower prevalence of scabies infestation has been observed in African-Americans than in other ethnic groups in the United States.
Badiaga et al. (2005) conducted a study to find out the prevalence of skin infection in sheltered homeless of Marseilles, France. The study revealed that pediculosis (19.1%), scabies (3.8%), impetigo (2.4%), folliculitis (4.8%) and tinea is (3.2%) had statistically significant occurrences in homeless. While Downs et 1999) conducted a study to show the epidemiological of head lice and scabies in UK showed that scabies was significantly more prevalent in urbanized areas (P 00001), in children and women (P < 0-000001) and commoner in the winter compared to the summer.
The prevalence of scabies in many populations rises and falls cyclically, king every 15-25 years, for reasons unknown. Many accounts of the epidemiology of scabies suggest that epidemics or pandemics occur in 30-year cycles, but this may be an oversimplification of its incidence. These accounts coincided with the major wars of the 20th century. Because it is not a reportable disease, and data are based on variable notification, the incidence of scabies is cult to ascertain. Indeed, while epidemics have been reported (1919-1925, 6-1949, 1964-1979), it is clearly an endemic disease in many tropical and Topical regions. Scabies was considered to have a cyclical rise in incidence every 20 years by Downs et al. (1 999).
Epidemiological studies also indicate that the prevalence of scabies is not affected by sex, race, age or socioeconomic status. The primary contributing ors in contracting scabies seem to be poverty and overcrowded living conditions. Notwithstanding this, certain groups are more affected by the disease l others. Lone et al. (2000) carried out a study on external parasitic infestations in the Lower Silesia region of Poland and showed a direct relationship between the l incidence of scabies and low standard ecological indices, as well as social-economic setting of the communities.
While scabies appears to be more common in the younger population, it certainly occurs in all ages, all ethnic groups, all socioeconomic levels and in both sexes. It is not directly related to hygiene, but it is associated with poverty and crowding. Epidemics of scabies can arise in areas of poverty, poor sanitation, poor water-supply or overcrowding.
The WHO considers scabies to be a water-related disease because of the connection between bathing and personal hygiene to prevention or control of its spread. The tick that causes scabies, however, is not dependent on water for transmission or for any part of its life cycle.
Scabies continues to be an important parasitic disease that persists throughout the world despite the availability of various acaricides used for its control. Disease control requires treatment of the affected individual and all people they have bear in contact with, but is often hampered by inappropriate or delayed diagnosis, poor treatment compliance and improper use of topical compounds such as permethrin, lindane or benzyl benzoate. In addition to concerns over toxicity with such compounds, parasite resistance seems to be increasing.
A wide range of clinical manifestations may be seen in scabies, from classic pruritic papules and burrows to secondary features such as impetigo. Bullas lesions are a less frequent. Twenty cases of scabies presenting with bulla have been reported so far in the medical literature. Scabies must be considered in patients presenting with recent onset of unexplained pruritic bullas lesions. Biopsy and immunofluorescence studies together with skin scrapings for Sarcoptes scabiei could help to differentiate these cases from bullas pemphigoid. Antiscabietic treatment results in resolution of bullas lesions in the affected patients (Ansarin et al. 2006).
In developing parts of the world treatment of scabies is expensive, which helps to increase the endemics of the disease. Treatment of scabies in poor countries needs to integrate drug treatment programmed with efforts to improve the socioeconomic conditions and education programmed to reduce stigma. More sensitive and specific clinical and laboratory-based diagnostic methods, as well as new therapeutic strategies are also needed.
Elgart (2003) after a study declared that 5% permethrin was the best treatment for scabies in infants and young children. While Abedin et al. (2007) conducted a study to compare the efficacy of permethrin cream and oral ivermectin in treatment of scabies. They concluded that mass treatment of scabies with ivermectin in an endemic population was more efficacious as compared to topical permethrin application in reducing the baseline prevalence, decreasing the chain of transmission and chances of re-infection.
Identification of the problems:
Scabies is a common parasitic infection of the skin. It occurs throughout the world with an estimated global prevalence of 300 million cases, but is particularly problematic in areas of poor sanitation, overcrowding and social disruption and is endemic in many resource-poor countries. It causes substantial morbidity from secondary infections and post-infective complications such as acute post-streptococcal glomerulonephritis. Serious adverse effects have been reported for some drugs used to treat scabies. In Bangladesh prevalence of scabies is alarmingly high. Low socio-economic conditions, poor standard of living, poor hygienic habits, ignorance, poverty and lack of health education are the reasons behind this high incidence of scabies.
Significance of the study:
Scabies is a worldwide disease and a major public health problem in many developing countries, related primarily to poverty and overcrowding. It is a major global health problem in many indigenous and Third World communities like Bangladesh. The aim of the present study was to assess the socio-demographic conditions of the scabies infected out-patients in the Department of Dermatology & Venereology of BIRDEM Hospital, Dhaka and to evaluate the drug (permethrin) treatment result among them. The findings will help in developing awareness among the patients on proper care and on proper hygienic practices. Moreover young scientists or researchers may get certain help from the findings and the baseline information of this study will help them to take further study and will help the planners and policy makers to take appropriate measures to prevent and care the disease in the community.
Justification:
Prevention is better than cure. With this view preventive programme was launched long ago to minimize the sufferings of mankind. Preventive programmes against most diseases have become successful to a great extent. Ancient historical references to scabies go as far back as the Babylonian and later Roman ears. Scabies have always plagued soldiers because the highly contagious infestation flourishes when war conditions force to live in close, filthy surroundings.
Scabies is one of the major public health problems throughout the developing world. In Bangladesh, the problem of Scabies is also a major public health problem. Here treatment facilities are less and it has turned into a bigger medical and social problem. The consequence of these problems is serious for the patients as well as for the society.
Studies on skin diseases are very much clinical and there is a no wide spread study in this regard. And these limited studies were carried out mainly in the outpatient departments of different medical colleges. These studies revealed that there is a high prevalence of skin diseases.
Skin diseases are highly contagious and many of these can be prevented. So, this study was designed to identify the magnitude of disease in relation to socio-demographic characteristics among the outpatients of the skin and veneral disease department. This may help the policymaker, planners and future researchers to go ahead with the devastating uncontrolled burning problem of the diseases.
Hypothesis:
Adequate knowledge among the outpatients about the causes and complications of Scabies is lacking.
Objectives of the study:
The main objectives of the study were to clinical observation of scabies infection and to evaluate on the effect of treatment among the Out- patients in the Department of Dermatology & Venereology of BIRDEM Hospital, Dhaka.
Other objectives:
• To study the socio-demographic characteristics of the patients.
• To study the relationship between scabies and socio-economic condition of the
Patients.
• To find out the relationship between scabies and hygienic level of the patients.
• To identify the factors influencing the transmission of scabies.
• To recommend possible ways and means to control and prevention of scabies.
Operational Definition: Socio-economic status:
• Socio-economic status of the patients was determined by their monthly family
income.
• Lower socio-economic group had a monthly family income of Tk. < 5000.
• Middle socio-economic group had a monthly family income of Tk. 5000-10000.
• Upper socio-economic group had a monthly family income of Tk. >10000.
Educational status:
• Educational status of the patients was recorded in the following ways:
• Illiterate: The patients having no formal education and unable to read and write.
• Primary level: The patients who had attended any level from class I to V.
• Secondary level: The patients who had attended any level from class VI to X.
• SSC level: The patients who had passed Secondary School Certificate
Examination.
• HSC level: The patients who had passed Higher Secondary School Certificate
Examination.
• Degree and above: The patients who had passed the Bachelor Degree or any
Other qualification above the Bachelor Degree.
Overcrowding assessment :
When more people were residing irrespective of rooms-persons distribution as mentioned bellow then it was termed as over crowding.
Normally, 1 room for 2 persons
2 rooms for 3 persons
3 rooms for 5 persons
4 rooms for 7 persons
5 rooms for 10 persons
REVIEW OF LITERATURE
Scabies is a common parasitic infection of global proportion. Worldwide, an estimated 300 million cases occur annually. The arthropod Sarcoptes scabiei var. hominis causes an intensely pruritic and highly contagious skin infestation, which affects males and females of all socioeconomic stratas and all ethnic groups.
Scabies has been reported for more than 2500 years. Aristotle (384 to 322 BC) was the first person believed to have identified scabies mites, describing them as “lice in the flesh” and utilizing the term “akari.” Subsequently, scabies has been mentioned by many different writers, including Arabic physician Hasan and Tabari, around 970, Hildegard (1098 to 1179), and the Moorish physician Avenzoar (1091 to 1162).
In 1687, Bonomo and Cestoni accurately described the cause of scabies in a letter. Their description recounted the parasitic nature, transmission, possible cures and microscopic drawings of the mite and eggs of S. scabiei was believed to be the first mention of the parasitic theory of infectious diseases. Nevertheless, it was not until 1868, 2 centuries later, that the cause of scabies was established with the publication of a treatise by Hebra (19a, 52).
Ahmed and Aftabuddin (1977) conducted a study namely “Common skin diseases (analysis of 7,636 cases).” A total of 7,636 patients attending the Outpatient Clinic of the Skin and Venereal Disease Department, Medical College Hospital, Mymensingh, were analyzed in relation to skin affection, place of residence, seasonal variation of skin diseases, age incidence and site involved with skin diseases. In over 70% of patients, the skin condition diagnosed was either pyoderma or scabies. Majority of these patients came from rural areas. Greater umber of patients with pyoderma sought medical help during summer whereas arepatients with scabies came during winter. Pyoderma was common in young children but incidence of scabies was distributed in all age groups.
Nigam et al. (1977) reported on “A clinic-epidemiological study of cables in Jhensi city in India.” The study revealed that scabies trouble some and problematic disease is now reaching epidemic proportion in most of the world. In his study the prevalence of scabies was found 12.5% of the population examined and 26.2% of the households. Scabies was encountered more in children and younger age groups (61.4%) and it was less above years (10.9%).
Stanton et al. (1987) conducted a study to estimate the annual risk of infestation with scabies in children, to describe its involvement of other family members, and to determine some of the familial and individual risk factors for apparent infestation by scabies. They followed 766 children less than 6 years of age from October 1984 to September 1985 in Dhaka, Bangladesh. During that period 589 (77%) children appeared to have been infected with scabies, and 125 (16%) children were infested for more than 6 months. Of the factors examined, direct and indirect indicators of decreased wealth and incorrect hygiene practices correlated with higher rates of apparent infestation, although scabies rates remained high at all socioeconomic levels.
A study named “Scabies and Pyoderma in Lilongwe, Malawi, Prevalence and Seasonal Fluctuation” was conducted by Johannes et al. (1989). From January 1988 to June 1989, a total of 34,002 patients were observed in the Dermatology Clinic attached to the Kamuzu Central Hospital, Lilongwe, Malawi. Of these patients, 15,526 (45.7%) were children and 18,476 (54.3%) were adults. The prevalence of scabies was 40.4% in children and 31.6% in adults, whereas the prevalence of impetigo/bacterial skin infections was 26% in children and 10.4% in adults. Based on data accumulated for periods of 1 month, the incidence rate of scabies was highest during the cold, dry season (May-November) and the incidence rate of skin infection was highest during the hot, rainy season (December-April). Since the patients who were studied lived predominantly in rural settings, an explanation for the higher incidence rate of scabies during the cold season could be close body contact resulting from the overcrowding within the houses. The reason for the increase in the incidence rate of pyoderma during the rainy season might be linked to deficiencies in hygienic precautions. A community-based intervention strategy with children as its target population was proposed to combat these diseases.
A study of skin disease pattern at the out patients Department of Dhaka Medical College Hospital carried out by Bhuyan (1990), revealed that 27,937 Patients out of 41,062 cases or 68.44% of the cases were suffering from scabies which were more than two third of the cases, followed by tineasis 93.67%), eczema (3.46), impetigo (1.78%), folliculitis(1.35%), acne vulgaris (1.33%), bulbous and urticaria (1.1%). Other skin diseases such as contact dermatitis, pitvriasis, Herpes Zoster, verrucae, vitiligo and melanoderma were diagnosed in less than 1% of patients in each case. Children under 5 years of age suffered more from scabies(6.37%), impetigo (0.11%), contact dermatitis (0.09%), furuncles 0.06%) than the children of age 5-12 years with 4.25%, 0.07%, 0.06% and 0.03% respectively. Male attended more with scabies (36.89%), impetigo (0.98%), folliculitis (1.02%), bullas (0.72%) and furuncles (0.53%) than female with H.49%, 0.80%, 0.34%, 0.52%, 0.52% and 0.31% respectively. But female attended more with candidiasis of skin (0.30%), contact dermatitis (0.51%) than malewith 0.04%, 0.46%, 0.47% and 0.05% respectively.
Zaman (1993) carried out a study in Lahore, Pakistan and found that the prevalence of scabies was 6.7%, which prevailed thought the year.
According to 1995 statistic of Dhaka Community Hospital, in Bangladesh, predominant diseases/symptoms were acid secretion, heartburn, dyspepsia, gastritis, peptic ulcer (10. 16%), diarrhea (10.84%), cold (6.7%) fever (11.55%), cables, abscess (3.63%), rheumatism (3.28%), malaria (3.28%), asthma (2.54%), influenza (3.07%), blood pressure (1.67%) typhoid (1.56%), measles (0.96), tuberculosis (0.53%), and others.
Downs et al. (1999) conducted a study on “The epidemiology of head lice andscabies in the UK”. Using information obtained from the Office of National statistics, Royal College of General Practitioners Weekly Returns Service, department of Health, local surveys of school children from Bristol and drug sales f insecticides, they had confirmed that there had been a rise in the prevalence of both scabies and head lice. They had shown that scabies was significantly more prevalent in urbanized areas (P < 0-00001), north of the country (P < 0-000001), in children and women (P < 0-000001) and commoner in the winter compared to the summer. Scabies was also shown to have a cyclical rise in incidence roughly every 20 years. Head lice were shown to be significantly more prevalent in children and mothers (P < 0-000001) though both conditions were seen in all age groups. Head lice were also less common during the summer. Host behavior patterns, a symptomatic carriage, drug resistance and tourism from countries or districts with a higher incidence might be important factors in that high prevalence of both scabies and head lice.
Hegazy et al. (1999) from the Departments of Dermatology and community Medicine, Faculty of Medicine, Mansoura University, Mansoura,Egypt, conducted a study to determine the magnitude of scabies infestation in an Egyptian village and to evaluate the control measures after 1 year. This study was carried out on 3,147 residents of Mit-Moaned village in Dakahlia governorate, Egypt.It was a cross-sectional follow-up study where the same individuals examined in round I were re-examined in round in. The two rounds were separated by a period of 1 year, during which infested patients were followed up and new cases were discovered (round II). Patients and their household contacts received treatment with topical permethrin. Patients showing resistance to permethrin received a single oral dose of ivermectin. In round III, the overall prevalence rate of scabies was reduced from 5.4% in round I to 1.1%. The incidence of new cases among susceptible persons during round n was 1.1%. Scabies was significantly (P < 0.05) more prevalent among families of large size, high crowding index at night, low socioeconomic standards, and those receiving their water supply from a hand pump. Children younger than 10 years showed the highest prevalence.
Bockarie et al. (2000) reported that treatment with ivermectin reduces the high prevalence of scabies in a village in Papua New Guinea.
Lonc et al. (2000) carried out a comparative study on external parasitic infestations among inhabitants of Legnica, Walbrzych, and Wroclaw districts, in the Lower Silesia region of Poland. This study showed a direct relationship between the high incidence of scabies and low standard ecological indices, as well as social economic setting of the communities. In the years 1990-1997, the highest mean incidences of scabies per 100,000 people (80 and 46) were noted, respectively, in the Legnica and Walbrzych districts, compared to only 7.9 in the Wroclaw district. Infestation was correlated with percentages of the population with higher education (4.8, 4.2, 10.1, respectively) and the number of patients per physician (795, 632, 288, respectively), and the percentages of degraded land and land threatened by degradation (10/37, 5/16, 0.7/10, respectively), forest stands damaged by gases and particulates (99.4,99.4,58.8, respectively) and air pollution emission indices in the towns of Legnica and Walbrzych (30 and 21 tons/km2) and Wroclaw (16). Scabies infestation was highest in children and teenagers (0-19) and was gender-associated (in all age groups, women were more often infested than men). A decreasing rate of scabies infestation, especially from the mid-1990s, was noted for both scabies and pediculosis in Walbrzych district, in the 0-19-yr-old inhabitants, it varied from 0.75% in 1994 to 0.41% in 1996.
A survey of skin diseases and skin infestations among primary school student of Taitung of Taiwan was carried out by Wuys et al. (2000) which revealed that most common infectious skin diseases were pediculosis capitis (12.9%), verruca vulgaris (5.1%), tinea versicolor (4.4%), tinea pedis (4.0%) and scabies (1.4%). Most skin diseases including pediculosis capitis, scabies, verruca vulgaris, verruca plantaris, folliculitis, puoderma and tinea infection were more common in rural area than urban area.
Tariq et al. (2002) conducted a study to determine the prevalence of scabies in Karachi, Pakistan, during 1996-91. Data were collected from scabies patients treated at the Institute of Skin Diseases, Sindh. Results revealed a decrease in the number of scabies cases from 1996 (n=85,785 cases) to 1997 (n=74,591 cases). The prevalence of scabies was greater in adults than in children in both years. The number of adult scabies patients was very high in 1996 (n=72,559 cases), which decreased remarkably in 1997 (n=48,096 cases). Among children, the prevalence increased from 13,186 cases in 1996 to 26,495 cases in 1997. The prevalence of scabies was higher in females than in males in 1996 and this situation altered in 1997. A seasonal variation in scabies incidence was observed. Maximum incidence was observed during winter.
Heukelbach et al. (2003) conducted two studies to assess disease perception and health care seeking behavior in relation to parasitic skin diseases and to determine their public health importance. The first study comprised a representative cross-sectional survey of the population of a slum in north-east Brazil. Inhabitants were examined for the presence of scabies, tungiasis, pediculosis and cutaneous larva migrans (CLM). The second study assessed health care seeking behavior related to these ectoparasitic diseases of patients attending a Primary Health Care Centre (PHCC) adjacent to the slum. Point prevalence rates in the community were: head lice 43.3%, tungiasis 33.6%, scabies 8.8% and CLM 3.1%. Point prevalence rates of patients attending the PHCC were: head lice 38.2%, tungiasis 19.1%, scabies 18.8% and CLM 2.1%. Only 28 of 54 patients with scabies, three of 55 patients with tungiasis, four of six patients with CLM and zero of 110 patients with head lice sought medical assistance.
Hospital Episode Statistics, Department of Health, England (2003) revealed that 0.0032% (414) of hospital consultant episodes from January 2002 to June 2003 was for scabies and 85% of hospital consultant episodes for scabies required hospital admission.
Buffet and Dupin (2003) conducted a study on “Current treatments for scabies” and found that in France, a combination of benzyl benzoate 10% and sulfiram 2% was used mostly according to professional consensus. While the most studied product was the cream permethrin 5% which was available in the USA and UK.
Elgart (2003) conducted a study on the “Cost-benefit analysis of ivermectin, permethrin and benzyl benzoate in the management of infantile and childhood scabies.” At the end of the study the opinion of the author was that 5% permethrin was the best treatment for scabies in infants and young children.
WHO (2005) conducted a study to assess the effects of a 3-year programme aimed at controlling scabies on five small lagoon islands in the Solomon Islands by monitoring scabies, skin sores, streptococcal skin contamination, serology and haematuria in the island children. Control was achieved by treating almost all residents of each island once or twice within 2 weeks with ivermectin, except for children who weighed less than 15 kg and pregnant women, for whom 5% permethrin cream was used. Reintroduction of scabies was controlled by treating returning residents and visitors, whether or not they had evident scabies. Prevalence of scabies dropped from 25% to less than 1% (P < 0.001); prevalence of sores from 40% to 21% (P < 0.001); streptococcal contamination of the fingers decreased significantly (P = 0.02 and 0.047, respectively) and anti-DNase B levels decreased (P = 0.002). Both the proportion of children with haematuria and its mean level fell (P = 0.002 and P < 0.001, respectively).
Savin (2005) reviewed studies on scabies in Edinburgh from 1815 to 2000 and revealed some data on the epidemiology of scabies in Edinburgh. The author studied data of Royal Infirmary of Edinburgh (RIE) and Edinburgh Dispensary for Diseases of the Skin (EDDS) from 1896 to 1970 and found that the percentage of new patients with scabies seen at the skin clinic of the RIE from 1908 to 1969, and at the EDDS from 1896 to 1963 showed some distinct patterns. At both clinics the figures peaked during the two World Wars (1914-1918, 1939-1945) with low levels persisting thereafter.
Badiaga et al. (2005) conducted a study to find out the prevalence of skin infections in sheltered homeless of Marseilles, France. There were 498 cases and 200 control subjects. Dermatologic manifestations reported and observed in homeless compared to controls. It was found that compared to the control subjects, a significantly higher proportion of cases had skin diseases (38% vs. 0.5%, p <0.0001). Pediculosis (19.1% vs. 0%, p < 0.0001), scabies (3.8% vs. 0%, p < 0.0001), impetigo (2.4% vs. 0%, p < 0.0001), folliculitis (4.8% vs. 1.5%, p < 0.0001) and tinea pedis (3.2% vs. 0.5%, p = 0.02%) had statistically significant occurrences in the cases as compared to the control population.
Heukelbach et al. (2005) conducted a community-based study to assess the prevalence, seasonal variation and morbidity of pediculosis capitis and scabies in poor neighborhoods in north-east Brazil. The study comprised cross-sectional surveys of a representative population of an urban slum (n = 1460) and a fishing community (n = 605). Prevalence of pediculosis capitis was 43.4% in the slum and 28.1% in the fishing community. Children aged 10-14 years and females were most frequently affected. Scabies was present in 8.8% of the population in the slum and in 3.8% of the population in the fishing community. There was no consistent pattern of age distribution. Superinfection was common in patients with scabies, and cervical lymphadenopathy in patients with pediculosis capitis.
Hamm et al. (2006) conducted a study named “Treatment of scabies with 5% permethrin cream: results of a German multicenter study.” 106 patients in 13 centers were enrolled in the study. 34% of them were children or adolescents. 78.3% of patients were either severely (3 body sites) or very severely (4-5 sites) affected. The cure rate on day 28+7-3 was 95.1%. Pruritus declined markedly and continuously. In general, the cream was well tolerated and side effects were almost invariably mild.
Karim et al. (2007) studied on the socio-demographic characteristics of children infested with scabies in densely populated communities of residential madrashas (Islamic education institutes) in Dhaka. Of the 492 children, 98% had scabies and 71% of children who had scabies had been re-infected (96% during the winter). Randomly assigned anti-scabies drugs revealed an average cure rate of
85.5%. Seventy-four percent of children were living in poorly ventilated buildings with overcrowded sleeping arrangements. They had poor personal hygiene: 21% shared towels, 8% shared undergarments, 30% shared bed linen, and 81% kept their used clothes on a communal line or shelf. Sanitation was also poor: 39% bathed infrequently, although 97% carried out mandatory ablution. Most children (61%) washed their clothes (including undergarments) two or three times a fortnight, 35% did so every 2-3 days and 3.7% washed their clothes on alternative days. Disease severity and re-infection were associated with infrequent washing of clothes (P < 0.001) and bed linen (P < 0.001), overcrowded sleeping arrangements (P < 0.001) and infrequent bathing (P < 0.001) with soap (P < 0.001). This was further related to household income (P < 0.001 for both).
Abedin et al. (2007) conducted a study to compare the efficacy of mass treatment of scabies with permethrin cream and oral ivermectin in a closed population of 84 children living in an urban hostel of Delhi. After mass treatment with 2 doses of oral ivermectin, one case was recorded in following 6 months, as compared to 22 cases in preceding 6 months when children were treated with a single application of 5% permethrin. From this study they concluded that Mass treatment of scabies with ivermectin in an endemic population was more efficacious as compared to topical permethrin application in reducing the baseline prevalence, decreasing the chain of transmission and chances of reinfection.
A study named “The Epidemiology of Group A Streptococcal Infections in Fiji (Fiji GrASP) – Part 4 -The Prevalence of Group A Streptococcal Pyoderma and Scabies in Infants in Fiji” was conducted by the National Institute of Allergy and Infectious Diseases (NIAID) in 2007. The purposes of this study were to estimate the number of cases of and to describe the features of rheumatic heart disease, pyoderma, and scabies in school age children in Fiji. The primary endpoints of the study would be to determine the prevalence of echocardiogramconfirmed rheumatic heart disease and to determine the prevalence of pyoderma assessed using a standardized tool. The secondary endpoints would be to determine the prevalence of scabies assessed using a standardized tool.
MATERIALS AND METHODS
Type of study:
It was a cross-sectional follow-up study to observe scabies infection and to evaluate on the effect of treatment among the out-patients in the Department of Dermatology & Venereology of BIRDEM Hospital, Dhaka.
Study area:
The study was conducted among the out-patients in the Department of Dermatology & Venereology of BIRDEM Hospital, Dhaka. This place was selected as it is situated near Dhaka University and it provides adequate facilities for the investigation and treatment of skin patients. Moreover the Head of the skin Department of BIRDEM Hospital showed a keen interest for this research work.
Period of study:
The study was conducted from 1st July 2009 to 30th July 2010. To complete research work precisely study period was divided in a systematic way. The 1st half period was spent on literature review, topic selection, development of protocol, formation of questionnaire and data collection. The subsequent period was utilized for data collection and analysis, report writing, printing and submission.
Study population:
All patients who visited to the Department of Dermatology & Venereology of BIRDEM Hospital, Dhaka, during the period of data collection were the population of this study.
Sample size and sampling procedure:
A total of 150 patients were purposively taken as a sample size. The purposive random sampling procedure was followed for data collection. At first the Medical officer diagnosed the cases on the basis of clinical features. Then the laboratory diagnosis was done by the lab attendant. The patient was then referred to the researcher for interview.
Instruments of the study:
A structured questionnaire
Scalpel
Slide and cover slip
Compound microscope
Cotton
Gloves
Modifying factors and variables:
Age.
Sex.
Marital status
Educational status.
Educational status of mother in case of children
Occupation
Monthly family income.
Number of persons living in a room
Habit of bed sharing
Habit of taking bath regularly
Habit of cloth sharing
Habit of towel sharing
Habit of bed cloth washing
Family history of the disease
Recurrence of the disease
Compliance of the patients
Treatment history
Data collection:
A structured questionnaire was prepared for data collection at the beginning of the study. A completely randomized sampling procedure was carried out for data collection. Prior to data collection a verbal consent was taken from the respondents. Interview was conducted from July 2009 to March 2010 in between 9 A.M. to 1 P.M. Interview was carried out mostly through face to face interview by recording of all relevant information through structured questionnaire. The same individuals observed for the first time were re-examined after a period of 4 weeks, during which infested patients were followed up. In a few number of cases result of the treatment was reported over phone.
Data processing and analysis:
After collection of data, the obtained data was processed and analyzed to present as tables and graphs. The data was checked, verified, edited and analyzed quantitatively before tabulation. Some tables and graphs were prepared using MS Word and MS Excel software’s to highlight data.
DESCRIPTION OF THE DISEASE
What is scabies?
Scabies in Latin means “itch”. Scabies is a very contagious infestation of the skin caused by the mite Sarcoptes scabei. Female mites burrow into the skin, creating small, threadlike tunnels that can sometimes be seen on the skin. The mites lay eggs and leave feces in these tunnels causing an intensely itchy skin condition. The infection is highly contagious and easily passed on by close physical contact. Scabies spreads rapidly under crowded conditions where there is frequent skin-to-skin contact between people, such as in hospitals, institutions, child-care facilities, and nursing homes. The disease is common, found worldwide, and affects people of all races, ages, genders and social classes. Scabies can occur both in humans and other animals.
Causative agent of scabies:
Scabies is caused by a tiny mite, called Sarcoptes scabie var hominis, an arthropod of the order Acarina. The scabies mite is an obligate parasite and completes its entire life cycle on humans.
Classification:
S. scabiei is an obligate ectoparasitic arthropod taxonomically grouped in the class Arachnida, subclass Acari, order Astigmata and family Sarcoptidae (Schmidt and Roberts, 2000).
Over 15 different varieties or strains have been described from various hosts, although morphologically they appear to be similar. However, cross infestation experiments and molecular epidemiological studies indicate clear physiological and genetic differences between host strains.
Morphology:
The S. scabiei var hominis mite that infects humans is female and can just be seen with the naked eye. The adult female is approximately 0.3 to 0.5 mm long by 0.3 mm wide, and the male is slightly smaller, around 0.25 mm long by 0.2 mm wide. S. scabiei is creamy white with brown sclerotized legs and mouthparts. Larvae have six legs, and nymphs and adults have eight legs, with stalked pulvilli (suckers) present on legs 1 and 2 of both the male and female adult mites, enabling them to grip the substrate. Additionally, mites bear spur-like claws, and they have six or seven pairs of spine-like projections on their dorsal surfaces. The adult male is distinguishable from the female by its smaller size, darker color, and the presence of stalked pulvilli on leg 4 as leg 4 in the adult female ends in long setae.
Life Cycle:
The male fertilizes the female on human skin and then dies. Newly mated females burrow into human skin, using proteolytic enzymes to dissolve the stratum conium of the epidermis. The mite has 4 pairs of legs and tracheal breaths and thus does not penetrate deeper than the outer layer of the epidermis. The female deposits eggs in the burrows. It lays two to three eggs per day for up to 6 weeks at a time, resulting in raised papules on the skin’s surface. The eggs incubate and hatch after 3-5 days (range up to 8 d). About 90% of the hatched mites die, but those that survive go through various molting stages. Developmental instars include egg, larva, protonymph and tritonymph . Adult mites emerge on the surface of the skin after approximately 2 weeks and reach maturity after a little more than 2 weeks. However, it appears that less than 1% of the laid eggs develop into adult mites. The female adults, who never leave their burrows, die after 1 -2 months.
Photograph-1: Scabies Mite, Sarcoptes scabiei
Photograph-2: Lifecycle of Scabies Mite, Sarcoptes scabiei
Survival and Infectivity of the mite:
S. scabiei are unable to fly or jump. They crawl at a rate of 2.5 cm/min. While the mite’s life cycle occurs completely on its host, they are able to live on bedding, clothes, or other surfaces at room temperature for about 48 hours while remaining capable of infestation and burrowing. At temperatures below 20°C S. scabiei are immobile, although they can survive such temperatures for extended periods. The mites’ ability to infest the host decreases with increased time off the host. The sightless mite uses odor and thermal stimuli for active host taxis. The probability of being infected is related to the number of mites on the infected person and the length of contact.
Mode of transmission:
Scabies is a highly contagious disease. Transmission is predominantly mediated by direct, prolonged, skin-to-skin contact with an infected person. Contact must be prolonged (a quick handshake or hug will usually not spread infestation). Infestation is easily spread to sexual partners and household members. Infestation may also occur by clothing, sharing towels, and bedding.
Signs and Symptoms:
It takes several weeks from the time of initial infestation for scabies symptoms to develop (incubation period). People who become reinfested develop symptoms within a few days.
The most common symptom of scabies is severe itching which is due to delayed allergic response which occurs generally 30-40 days after infestation. The itching may be worse at night or after a hot bath.
A scabies infection begins as small, itchy bumps, blisters, or pus-filled bumps that break when it is scratched.
A burrow (a short S-shaped track that indicates the mite’s movement under the skin) may be visible. The mite may appear at the end of burrow or independently.
The mite dissolves into the skin using proteolysis enzyme and lays eggs inside the burrows which appear as thin, short, gray brown, wavy channel on the skin.
This infection may be secondarily infected by bacteria when scratched. This bacterial infection is called impetigo. Untreated scabies is often associated with pyoderma from secondary infection with group A streptococcus. Other complications of scabies include furunculous and cellulites. The streptococci in the abrasion can lead to pyelonephritis, abscesses, pyogenic pneumonia, sepsis and death.
The areas of the body most commonly affected by scabies are the webs of fingers, surface of wrists, in the folds under the arms. The other parts of the body generally affected are the breasts of females, genital areas of male and lower buttocks. In woman the nipple and areola of the breasts are affected often and in men red papules or nodules appear on the penile glands, shaft and scrotum. While scabies is spared on faces and head of adults it is seen in infants. People with less immunity for example those with HIV infection or those treated with immunosuppressive drugs like steroids the rashes may spread more widely.
Types of scabies:
Scabies are of two types:
• Classic or Ordinary scabies
• Norwegian or crusted scabies
Classic or Ordinary scabies:
Clinical presentation with a primary infestation of scabies is reported to take place 4 to 6 weeks after infection. The evidence of infection is very little during the first month (range, 2-6 weeks), but after 4 weeks and with subsequent infections, a delayed-type IV hypersensitivity reaction occurs due to mites, eggs, and scybala (packet of feces). The time required to induce immunity in primary infestations probably accounts for the latent period of 4 weeks of asymptomatic infection. In re-infestation, the sensitized individual may develop a reaction rapidly (within hours).
In a classic scabies infection, mites that live on host ranges anywhere between 5 and 15 in number. Skin eruption, and its associated intense itching, is the hallmark of classic scabies.
Norwegian or crusted scabies:
In people with less immunity for example those with HIV infection or those treated with immunosuppressive drugs like steroids, the rashes may spread more widely and such type of scabies is called Norwegian scabies. It is so called because the first description was from Norway in the mid 1800s. It is a highly contagious and distinctive form of scabies. In this variant, hundreds to millions of mites live on the host especially who is immunocompromised, elderly, or physically and/or mentally disabled and impaired. Extensive, widespread, crusted lesions appear with thick, hyperkeratotic scales over the elbows, knees, palms, and soles. Serum immunoglobulin E (IgE) and immunoglobulin G (IgG) levels are extremely high in these patients, yet the immune reaction does not seem to be protective. Cell-mediated immunity in classic scabies demonstrates a predominantly CD4 T-cell infiltrate in the skin, while one study suggests CDS predominance in crusted scabies.
People with crusted scabies have been recognized as “core-transmitters”. Patients with crusted scabies may also remain infectious for long periods of time because of the difficulty in eradicating mites from heavily crusted areas of the skin. Patients with crusted scabies are a common cause of institutional outbreaks of scabies.
Host immune response in scabies:
Studies of the symptoms and signs of scabies pointed to the development of host immunity, but until the recent Scabies Gene Discovery Project, only a small number of the antigens responsible for the immune reactions to scabies had been sequenced and characterized. Consequently, there is a dearth of literature reporting scabies-specific humoral or cellular immunity. Limited past investigations of humoral immunity in scabies patients show contradictory results and have used whole-mite scabietic extracts from other hosts, such as dogs. Immunoblotting studies demonstrate that sera from crusted scabies patients showed strong IgE binding to up to 21 S. scabiei var. canis proteins. However, the identity of these allergens was unknown. Patients with crusted scabies are noted to have extremely high serum levels of total IgE and IgG. Cell-mediated host immune responses have been identified primarily by histopathological examination of skin biopsy specimens from scabies lesions. Mite burrows are surrounded by inflammatory cell infiltrates comprising eosinophils, lymphocytes, and histiocytes. Furthermore, biopsy specimens containing both mites and inflammatory papules have been observed to contain IgE deposits in vessel walls in the upper dermis. Unknown components in an extract of S. scabiei var. canis have been shown to influence cytokine expression in cultured human keratinocytes, fibroblasts, human peripheral blood mononuclear cells, and dendritic cells. Current studies are investigating scabies patients’ antibody and cellular responses to specific recombinant S. scabiei var. hominis antigens. Results have identified patients with both crusted and ordinary scabies to have strong peripheral blood mononuclear cell proliferative responses and IgE antibody responses to multiple S. scabiei homologues to house dust mite allergens (Walton and Currie, unpublished). Scabies mite-inactivated serine protease paralogues have been identified both internally in the mite gut and externally in feces. Furthermore, human IgG has been identified in the guts of mites, which must presumably also contain the serine protease cascades of both the blood clotting and complement fixation pathways. Complement has been shown to be an important component in a host’s defense against ticks. Both of these pathways must be inhibited while simultaneous digestion of epidermal protein as food takes place.
Diagnosis of scabies:
Currently there is no efficient means of diagnosing scabies. To date, diagnosis is via clinical signs and microscopic examination of skin scrapings, but experience has shown that the sensitivity of these traditional tests is less than 50%. Detecting visible lesions can be difficult, as they are often obscured by eczema or impetigo are atypical. Detection of burrows with India ink was advocated more man 20 years ago, but the test is often impractical and is not routinely used.
Clinical Diagnosis:
Scabies is usually diagnosed on history and examination. Diagnosis is most commonly made by looking at the burrows or rash. A skin scraping may be taken to look for mites, eggs, or mite fecal matter to confirm the diagnosis. If a skin :scraping or biopsy is taken and returns negative, it is possible that you may still be infested. Typically, there are fewer than 10 mites on the entire body of an infested person and this makes it easy for an infestation to be missed. A history of itching in several family members over the same period is almost path gnomonic. However, lack of a history of itching in family members does not exclude scabies.
Microscopy:
Definitive diagnosis is based on the identification of mites, eggs, eggshell fragments, or mite fecal pellets from skin scrapings (e.g., from scabies papules or from under the fingernails) or by the detection of the mite at the end of its burrow. One or two drops of mineral oil are applied to the lesion, which is then scraped or shaved and the specimens are examined after clearing in 10% KOH with a light microscope under low power. This method provides excellent specificity but has \ low sensitivity for ordinary scabies, due to the low numbers of parasites. A skin biopsy may confirm the diagnosis of scabies if a mite or parts of it can be identified. However, in most cases, the histological appearance is that of nonspecific, delayed hypersensitivity with superficial and deep per vascular inflammatory mononuclear cell infiltrates with numerous eosinophils, papillary edema, and epidermal prognosis. In practice, identifying a mite is challenging, and a negative result, even from an expert, does not rule out scabies. Presumptive therapy can be used as a diagnosis, but its value is questionable and confounded by the variable delay until resolution of symptoms following therapy. A positive response to treatment cannot exclude the spontaneous disappearance of a dermatological disease other than scabies, and a negative response does not exclude scabies, especially with resistant mites. In the absence of confirmed mites, diagnosis is currently based entirely on clinical and epidemiological findings. Given the extensive differential diagnoses, the specificity of clinical diagnosis is poor, especially for those inexperienced regarding scabies. Furthermore, there are the difficulties in distinguishing among active infestation, residual skin reaction, and reinfestation.
Antibody Detection:
Studies document that scabies mite infestation causes the production of measurable antibodies in infested host species. Furthermore, host IgG has been demonstrated in the anterior midgut and esophagus of fresh mites. Enzyme-linked immunosorbent assays have now been developed for the detection of antibodies to S. scabiei in pigs and dogs. These assays rely on whole-mite antigen preparations derived from S. scabiei var. suis and the itch-mite of the red fox, S. scabiei var. vulpes, and therefore have limitations in availability and specificity. Importantly, a recent study looking at cross-reacting IgG antibodies to the fox mite antigen in human scabies reported a sensitivity of only 48%, in comparison with 80% in pig scabies and 84% in dog scabies. This is not surprising, as studies using molecular markers suggest that S. scabiei organisms from humans and animals are genetically distinct and that interbreeding or cross-infection appears to be extremely rare.
Treatment of scabies:
Treatment options include either topical or oral medication. Topical options include permethrin cream, lindane, benzyl benzoate, crotamiton lotion and cream, sulfur, Tea tree oil, oil of the leaves of Lippia multiflora Moldenke, a shrub found growing in West Africa Savannah. Oral options include ivermectin.
Permethrin:
The medication most commonly used treatment of choice at the moment is permethrin (5% cream), in view of its relative safety, ease of application, and as it tends not to irritate the skin. The cream will need to be applied to the skin all over the body from the neck down to the toes, not just the area with the rash, and must remain on the skin for 8 to 12 hours. Then it will be washed off and clean clothes should be put on. It is best to apply at bedtime and then wash off in the morning. This treatment is then repeated in 1 week. After treatment, itching may continue for up to 4 weeks. Permethrin (5% cream) is safe for use in children as young as 2 months. Pregnant women may receive the permethrin once or can receive another medication, sulfur in petroleum, at night for three nights.
Permethrin 5% dermal cream is well tolerated and has low toxicity; side effects from permethrin seem to be rare. But burning and stinging sensations, purities and temporary redness of the skin can occur.
Lindane:
Lindane has been used successfully for many years but is less effective than permethrin. It has been withdrawn in many other countries because of reports of aplitic anemia. It is neurotoxin to humans if ingested or if excessive percutaneous absorption occurs. Some drug can be stored in body fat and excreted in breast milk.
Benzyl benzoate:
Benzyl benzoate is not a first choice treatment for scabies. In adults it tends to be used after other treatments haven’t worked. This is washed off after twenty four hours, and repeated two or three times. It’s not recommended for children. The main problem with benzyl benzoate is that it can cause a burning feeling when you put it on your skin. It may also cause a rash where you’ve put it on. Benzyl benzoate is not used in children.
Crotamiton:
This treatment can help to get rid of scabies. One study found it helped about 9 in 10 people got rid of their scabies. Two other studies found crotamiton didn’t work as well as permethrin.
Malathion:
The patients need to cover whole body, including neck, face, scalp and ears with the lotion and to keep it on for 24 hours and then to wash it off. If they get soap anywhere on their body before they’ve had the cream on for 24 hours, they need to put more on. They need to repeat the process after seven days.The main side effect for malathion is a burning feeling on your skin.
Ivermectin tablets:
The oral anti parasitic drug ivermectin is an effective scabicide. If other treatments haven’t cleared the infection, or the patients have a more serious type of scabies called crusted or Norwegian scabies, then the doctor might prescribe ivermectin tablets. Two doses of ivermectin (200 ug/kg body weight two weeks apart) seem to be as effective as a single application of permethrin. However, the drug has not been evaluated in children weighing less than 15 kg.
Natural Treatment for Scabies
Natural scabies treatments and home remedies for treating scabies can help to avoid the spread of the scabies mites to other people. Dermisil is a scabies home remedy that kills the scabies mites from the outside and works from the inside as well.
Make a neem leaf paste with fresh or dried neem leaves and an equal quantity of turmeric powder mixed with mustard oil. This should be applied on the body and left for an hour or so. Then the person should bath. Repeat for 7-10 days till all lesions have healed.