Burden and associated factors of Scabies outbreak in Guna-begemidir district, south Gondar, Amhara, Ethiopia, 2018

Background Scabies is an infestation of the skin by the human itch mite ( Sarcoptes scabiei var. hominis ). The parasite is found worldwide and affects people of all races and social classes. Studies shows that the prevalence of scabies is far different as 0.2% in developed countries up to 24% in developing countries. Ethiopia also reports scabies outbreak frequently since 2017. Recent studies show that the attack rate was 25% in Gondar city in Yekolo-temaries and 11% at Badewacho District, Southern Ethiopia. A community based unmatched (1:2 study was in guna-begemidir using collected scabies line listed data and face to face to from February 2018 with sample size of 156 cases and 312 control. The data were collected using structured questionnaire, and analyzed using SPSS version 22 statistical software. Odds Ratios (OR), P value and 95% Condence interval (CI) was computed to determine associated factors.


Abstract Background
Scabies is an infestation of the skin by the human itch mite ( Sarcoptes scabiei var. hominis ). The parasite is found worldwide and affects people of all races and social classes. Studies shows that the prevalence of scabies is far different as 0.2% in developed countries up to 24% in developing countries. Ethiopia also reports scabies outbreak frequently since 2017. Recent studies show that the attack rate was 25% in Gondar city in Yekolo-temaries and 11% at Badewacho District, Southern Ethiopia.

Methods
A community based unmatched case-control (1:2 ratios) study was conducted in guna-begemidir district, using collected scabies line listed data and face to face interview to assess risk factors from January to February 2018 with sample size of 156 cases and 312 control. The data were collected using structured questionnaire, and analyzed using SPSS version 22 statistical software. Odds Ratios (OR), P value and 95% Con dence interval (CI) was computed to determine associated factors.

Result
A total of 4269 scabies case were reported from the district, attack rate of 7.9%. Of those cases 2254 (52.8%) were males. 10 (52.6%) kebeles were affected by the outbreak. The attack rate varies by kebeles which ranges from 0.88% to 25.5%. The highest attack rate was in mena-medihanealem kebele which is 25.5%. Sleeping with Scabies Patients, washing with scabies patients in the past 6 months, putting of cloths with diseased patient cloths and Household daily water consumption were signi cantly associated with scabies diseases on multivariable analysis.

Conclusion and recommendation
Scabies is public health problem in the district. Due to delayed detection and response, the disease was highly disseminated mainly because of drug shortage throughout the region. We recommend enhancing, strong ongoing active case surveillance of scabies; health education & availing drugs to all health facilities and do more on the above signi cant variables.

Background
Scabies is an infestation of the skin by the human itch mite (Sarcoptes scabiei var. hominis). Sarcoptes scabiei is an ectoparasitic mite that burrows under the skin of mammalian hosts [1]. Scabies can develop anywhere on the skin. The distribution of scabies usually involves the sides and webs of the ngers, the exor aspects of the wrists, the extensor aspects of the elbows & waist. [2,3]. Symptoms of scabies typically begin three to six weeks after primary infestation. However, in patients who have previously been infested with scabies, symptoms usually begin within one to three days after re-infestation, presumably because of prior sensitization of the patient's immune system. Infested persons can transmit scabies, even if they do not have symptoms, until they are successfully treated and the mites and eggs are destroyed [2][3][4]. in developed countries up to 24% in developing countries [7]. By the end of 20th century the global prevalence became 5%, but become increased up to 30% during war [5]. Sub-Saharan Africa has prevalence of 1.3% − 17% [7]. It accounts prevalence of 9.7% in south East Asia, 13% in India, 6.1% in Burkina Faso school children [7,8].
Ethiopia also reports scabies outbreak frequently in Amhara, Oromia, SNNP and Tigray region since 2017 [9]. WHO states that in 1992 prevalence of scabies in 5-16 years children was 17% and from 1995 up to 1997 it became 4% but it was the 4th top diseases of the country [7]. The 2008 national health and nutrition survey also shows the prevalence was 5.5% [10]. In 2015 scabies reemerge again in Oromia, SNNP and Tigray region and the prevalence became 15% in some districts of affected regions [3]. Studies done in Gondar city in Yekolo-temaries shows that the prevalence is 10% and the overall attack rate was 22.5% [11]. On other studies done in school children of southern Ethiopia shows that the prevalence was 5.5%. Recent studies in south Gondar, tachgayint district shows the prevalence was 2.5%. but the overall attack rate was 9.4%, with highest age speci c attack rate in above 45 years age group which was 24.8% [12]. Likewise Studies done in East Badewacho District, Southern Ethiopia states the prevalence & attack rate was 11% with highest age speci c attack rate between 5 and 14 years which was 26.3% [13].

Sampling and sample size determination
We calculated the sample size using Epi Info 7 for unmatched case control study with an assumption of 95% CI, 90% power, OR of 2, ratio of controls to cases 2:1 and taking 26.6% of controls shared close with ill person from studies done in Gondar town among Yekolo-temaries [11]. The total calculated sample was 156 case and 312 controls. Cases were selected using simple random sampling technique from the registered of 420 cases in the line list document where identi ed by teams from zonal health department, district health o ce and health center staffs during veri cation, identi ed by Ethiopian interim guideline for multisectoral scabies outbreak guideline using suspected case de nition. Controls were enrolled from the family of cases or villages where cases were enrolled without the history of scabies during the study period and if no control from family we select from neighboring villages.

Data collection methods
Data was collected from cases and controls by moving house to house of exposed villages from January 30-February 25/2018. Participants were interviewed using structured questionnaires and primary data was collected from respondents by the investigator. Data of children who were unable to respond was taken from their mothers (care givers). A total of 156 cases and 312 controls were interviewed to assess their sociodemographic and other variables and exposure status.

Case De nition
Suspected case: A person with signs and symptoms consistent with scabies.
Con rmed case: A person who has a skin scraping in which mites, mite eggs or mite feces have been identi ed by a trained health care professional.

Operational de nitions
Contact: A person without signs and symptoms of scabies who had direct contact (particularly prolonged, direct, skin-to-skin contact) with a suspected or con rmed case in the two months preceding the onset of scabies signs and symptoms in the case.
Infrequent changing of clothes: Those who wear same cloth for more than one week without washing and changing General Knowledge about scabies -those who answered at least one transmission, prevention mechanism and or treatment of scabies.
Mild case -patients having less than 6 skin lesions Moderate -patients having 6-10 lesions Severe -patients having greater than 11 skin lesion and or has crusted scabies.
Attack rate -percentage of total new cases identi ed divided by risk population Monthly income -classi ed based on quartile as in four classes.

Hypothesis
The null hypothesis was stated as there is no association between socio demographic variables, access to water, frequency of bathing, washing and changing clothes and other factors with counteracting scabies.

Descriptive Epidemiology
Even though the outbreak was started since July 2017, they reported late on October 11/2017. Team from zone con rmed the existence of scabies outbreak in the area. Investigation with semi intervention was started on February 2018. Because of shortage of drugs throughout the region, intervention was done primarily on education about personal hygiene rather than early detection and treatment until June 2018.
Even though treatment was not given, cases became decline after March 2018 as seen in the gure below. 4269 scabies case were reported from the district with attack rate of 7.9%.
From the total 4269 cases 2254 (52.8%) were males. 35.1% were below 15 years and 31.6% were above 45 years with age speci c attack rate of 6.49% and 26.29% respectively. The age speci c attack rate was higher for people older than 45 years.

Analytic analysis
After doing bivariable binary logistic regression analysis, the following ten variables were entered to multivariable binary logistic regression analysis. Whereas on multivariable binary logistic regression analysis sleeping with Scabies patients, washing with scabies patients in the past 6 months, putting of cloths with diseased patient cloths and household daily water consumption became signi cantly associated variables for the development of scabies diseases. The prevalence of scabies in Guna-begemidir district was 4.2%. It was parallel with prevalence in different district of SNNP, Amhara, Oromia and Tigray region in 2015 (5% ) [10]. But was higher than prevalence of Tachgayint district, Northwest Ethiopia, which was 2.67% [12], kicha-bira district of Gambela region (0.4%) [15] and dogatemben district of Tigray region (0.03%) [16]. This might be due to delay in investigation and prevention and control activity in our study area. But it was lower than Studies done in East Badewacho District, Southern Ethiopia which was 11% [13]. Sociodemographic difference might be the possible reason for the difference. The overall attack rate of scabies in Guna-begemidir district was 7.9%. it was lower than studies done among Yekolo-temaries in st.lideta church, Gondar which was 22.5% [11] and studies done in tachgayint district (9.4%) [12]. This may be due to that in Yekolo-temaries usually frequent contact and poor hygiene is observed and in tach Gayint district during the outbreak period, there were drought disaster, due to this it was di cult to take personal hygiene and treatment for disease compared from guna. But was higher than studies done in Tigray region dogatemben district which was 0.069% [16]. This may be due to the reason that our study area there were frequent contact in the nearby affected kebeles and delayed in investigation and prevention and control activity, but nothing known about dogatemben. Age speci c attack rate was higher among age > 45 years. This is inconsistent with studies done in badewacho district, southern Ethiopia [13], kachbira district of kembata zone [15] and Tigray, dogatemben district [16] which was more in 15-18, 5-14 and less than 5 years respectively. But is similar to studies done in tachgayint [12]. This may be due to socio demographic factors.
In multivariable analysis individuals who sleep with scabies patient, washing with scabies patients in the past 6 months, putting of cloths with diseased patient cloths and Household daily water consumption were signi cant predictors for scabies. The odds of developing scabies for Individuals who sleep with scabies patient were 3.7 times higher than those who did not sleep with scabies patients (AOR = 3.70; 95% CI 2.075-6.607). This was consistent with studies done in kicha-bira district of Gambela region (AOR = 19.6 ; 95% CI 9.3-41.5) [15] and studies done among Yekolo-temaries in st.lideta church [11].
Studies done in East Badewacho District, Southern Ethiopia also were in line with our study (AOR = 12.4; 95% CI 3.05-50.9) [13]. This is due to close contact with diseased patients through sleeping together.  [12]. This is also due to cloth contacts with water inaccessibility through the fact that moving of louses from patient's cloth to others. The odds of developing scabies for Individuals who had daily water consumption of > 25 litter per person per day were 0.94 times lower than those who used less than 25 litter (AOR 0.06 95% CI 0.033-0.120). This is in line with the FMOH and CDC scabies interim guideline recommendation [1,2]. This may be due to that individuals having more water has the advantage to protect their personal hygiene like washing cloths frequently, washing hands and showering regularly which are major preventive way of the diseases [1,6,7] Conclusion In this study attack rate was high, those aged peoples were highly affected. Scabies surveillance was poor in the district. No drug was available in the district for scabies treatment. Sleeping with scabies patient, washing with scabies patient, cloth contact with scabies patient and daily water consumption were signi cantly associated with scabies diseases development. Scabies is public health problem in the district still now. Due to delayed detection and response, the disease transmitted among many people especially because of drug shortage throughout the region. There fore availing all the needed drugs for early treatment, improve their hygiene practices and living conditions through communication, information and education, enhancing strong ongoing active case surveillance, health education on treatment and prevention of scabies in the community and improve water tracking and water storage at critical service points are recommended.
Intervention undertaken  Level of scabies cases interviewed by age of Guna-begemidir district, Northwest Ethiopia, 2018