Scabies outbreak investigation in Addet town, West Gojjam Zone, Amhara region, Northwest Ethiopia, 2017 CURRENT STATUS: POSTED

Background Globally scabies was among the 50 most common infectious diseases, with a point prevalence 0.3%-46% and in terms of morbidity, at 1.5 million disability-adjusted life years. This study investigate and asses risk factors of scabies in Addet Medhanit Alem yekolo temarie in Yilmana Densa district Amhara, Ethiopia, 2017 Methods Unmatched Case-control study was employed. Fifety five cases from line lists reviewed as per the WHO case definition. Cases were epidemiological linked to previously epidemiological confirmed cases and 118 controls were interviewed with structured questionnaires. Data was entered EPI info version 7 and analyzed by SPSS version 23. Adjusted Odds Ratios and with corresponding 95% confidence intervals were calculated to measure strength of association in multi-variable logistic regression


Conclusions
There prevalence of scabies infection was high, less than 15 years age group were most affected.
Frequent changing of cloth, frequent use of soap for body wash, sharing of cloth and presence of scabies infected individuals in the family were factors affecting scabies infection. Personal, house hygiene should be strength and avail soap for students should be considered. 3 Background Human scabies is a contagious an external parasite skin infestation caused by Sarcoptes scabiei var hominis. The mite, only visible to the naked eye, burrows into the epidermis and lays eggs, induced a host immune response that leads to sever itching in response to just a few mites [1]. The scabies mite is almost always transfered by direct, prolonged, skin-to-skin contact with a person who is already infected by scabies. An infected person can transfer scabies even if he or she has no symptoms.
Scabies can be passed from an infected person to his or her household members and sexual partners.
Scabies can communicate easily under crowded conditions where close body and skin contact is common. Areas such as nursing homes, extended-care facilities, and prisons are often sites of scabies outbreaks. Humans are the only reservior [2,3].
World Health Organization's currently incorporated scabies to the list of neglected tropical diseases (NTDs) [4]. According to Global Burden of Disease (GBD) study, scabies was among the 50 most common infectious diseases worldwide, with a point prevalence of around 0.3%-46% [5,6]. In terms of morbidity, it is estimated at 1.5 million disability-adjusted life years [7].
In addition scabies outbrek reported in three consecutive years globally in 2008 in Nepal about l4.7%, in 2009 in Malaysia, Brazil Fiji, 8.1%, 9.8% cases were reported respectively and in 2010 Malaysia was reported 31% cases [8].
Scabies outbreak becomes common in Ethiopia.Since 2016, about 373,000 scabies cases were reported in 76 Woredas in Amhara region Ethiopia [9]. It may be due to its nature of transmissibility, poor water access, the occurrence of the Elino and insufficient supply of medicines to treat those who fell ill [10]. Scratching, secondary to itching can lead to introduction of the skin with bacteria, leading to the development of impetigo (skin sores), especially in the tropics. Impetigo can end up with complication of, abscesses, sepsis in infants, acute post-streptococcal glomerulonephritis and possibly rheumatic heart disease. Studies shows that renal damage can be found in up to 10% of children with infected scabies in resource-poor settings and, in many, this persists for years following infection contributing to permanent kidney damage [6,11]. Scabies can be treated by anti scabies drugs.
Treatment of individuals with scabies and their contacts is unlikely to achieve this goal, and so there 4 is increasing interest in implementing a mass drug administration (MDA) strategy. [3,6,14] This study conducted to investigate the outbreak and assess risk factors of scabies, among Yekolo temaries in Yilmana Densa District, Amhara Region, Ethiopia

Study area and population
The outbreak investigation was conducted in xxx church on "Yekolo Tamari" [religious students] of Yilmana Densa Districts, Amhara, Ethiopia.
The district has 155 Orthodox Church, five Mosques, one protestant church and many orthodox religious students.
In Ethiopia, religious students who learn Ethiopian Ge'ez language (the classical liturgical language) are called Yekolo Temari. Ethiopian community called the students by different names such as Yekes temehirt, Ye'abinet timihirt, and yebetekihinet temehirt. However their importance is their living condition, hygienic behavior, and housing condition. These groups of people, "Yekolo-temari" are

Ethical considerations
The study approved by Amhara Public Health instituite ethical committe, and letter of support was obtaind from West Gojjam zone health department and Yilmana densa District health office. Then the 6 district Orthodox Church religious leader and Yekolo temaries teacher was informed about the investigation and written consent was obtained. For those less than 18 years students, consent was taken from their teacher, because the students living in far distance (other districts) from their family and consent to obtain from the family was not feasible. Willingness of each study participant was asked after they understand the main purposes of the study. Participants were informed that they can decline to participate at the very beginning or at any stage during the interview.
The information collected from respondents is kept confidential and Privacy of respondents was kept during interview and screening.

Descriptive Epidemiology
All cases were male, 34(62%) of them were age between 15-25 years and the mean old (standard prior to and during treatment should be washed or cleaned and dried sun or putting clothes in a plastic bag for two days and above is also effective in letting the mite die. Routine cleaning of the house and health education on prevention is important to avoid reinfection.

Discussion
Hundred percent's of respondents were male, which is similar to a study conducted Scabies Outbreak Investigation among "Yekolo Temaris" in Gondar Town, North West Ethiopia, different from a casecontrol study conducted in Enarji Enawuga District, East Gojjam zone, North West Ethiopia and a case-control study conducted Doga-Temben District, Tigray, Ethiopia [17][18][19][20]. This could be due to the fact that in Orthodox religion doctrine only males are giving spiritual services. Therefore males only engaged in yekolo timhert bets to learn how the service is given.
The prevalence of scabies was 35%; it is higher than the study conducted in Northern Ethiopia among 'Yekolo temeri' reported 22.5% and a study among school children in Fiji where the overall prevalence of scabies infection was 23.6% [18,21].This may due to yekolo temaries living in overcrowded and unsanitary conditions and numbers of cloth having to change may be lower than other communities, this may concise with the fact Scabies mites can only live about 72 hours without human contact [22].
And the finding is lower than a study conducted Sindh, Pakistan 47.6% [23]. This could be the difference in study subjects.

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The age-specific attack rate was 31% between 15-18 years. This finding is in line with a study conducted in the west of Iran 30.6% [24] and lower than a study conducted in East Badewacho District, Southern Ethiopia, which is 75% [25] and higher than. This may be due to difference in a study population, meaning in our study most of the students engaged in the school were youth, however other studies were conducted in the whole community Frequent changing of cloth was associated with scabies infection. The odds of having scabies were lower by 53% among those yekolo temaries changing their cloth frequently [18]. This finding is lower than the study conducted Doga-temben, Tigray Ethiopia and Enarj Enawuga, Amhara, Ethiopia [17,19]. The possible justification could be the difference in study participants, reagents used washing of cloth, length of stay between unclothe and clothing and number of cloth having. Frequent uses of soap for wash body were associated with scabies infection. The probability of getting scabies infection was decreased by 54% among those used soap frequently to wash their body. This finding is lower than the study conducted Doga-temben, Tigray Ethiopia and was not significantly affected in a study conducted in Gondar Town, North Western Ethiopia, and Enarj Enawuga district, Amhara, Ethiopia [17][18][19]. The reason may be the difference in sample size, type of soap they used and the difference in the study area.
Share cloth were 3.313 times increase the odds of having scabies infection when compared to people don't share cloth. This result is in line with in a study conducted in Gondar Town, North Western Ethiopia with odds of 2.76 and lower than a study conducted in Enarj Enawuga, Amhara, Ethiopia odds of 8.5. The reason may be difference in study area, sample size.
Presence of scabies infected individuals in the family was (AOR = 6.029, 95 % CI: 2.071-14.275) times higher in developed scabies infection. This finding is lower than a study conducted in Doga-temben, Tigray Ethiopia adjusted odds ratio 98.78. This may be difference in sample size.

Study limitations
We employed case control study the role of recall bias could not be ruled out and some the study population comes from outside the region then it is difficult to draw spot map (other districts) from their family and consent to obtain from the family was not feasible. Particularly, special notifications on the respondents' rights to refuse to answer questions were notified to the participants. Participants were informed that they can decline to participate at the very beginning or at any stage during the interview.
The information collected from respondents is kept confidential and Privacy of respondents was kept during interview and screening.

Not applicable
Availability of data and materials 11 The data and materials are available upon request in the principal investigator.by this email address robelhabtamu@yahoo.com and cell phone +251918706762

Competing interests
The authors declare that they have no competing interest

Funding
The authors declare that there is no financial support for this study Authors' contributions Authors' contributions Principal investigator conceived and designed the study, performed analysis, interpretation of data and drafted the manuscript. Co-authors, advise from title modification and assist during design the study, analysis, and interpretation. Tables   Due to technical limitations, Table 1 is only available as a download in the supplemental files section.