International Journal of Infectious Diseases 16 (2012) e117–e120 Contents lists available at SciVerse ScienceDirect International Journal of Infectious Diseases jou rnal homepage: www.elsevier.com/locate/ijid Epidemiology of scabies in the West Bank, Palestinian Territories (Occupied) a,b b,c, Ahmad Amro , Omar Hamarsheh * a Faculty of Pharmacy, Al-Quds University, Jerusalem, Palestine b Al-Quds Nutrition and Health Research Institute, Al-Quds University, Jerusalem, Palestine c Department of Biological Sciences, Faculty of Science and Technology, Al-Quds University, PO Box 51000, Jerusalem, Palestine A R T I C L E I N F O S U M M A R Y Article history: Background: Scabies is a disease that is considered a public health problem in the Palestinian Territories Received 3 July 2011 and in other countries around the world. Scabies causes skin lesions leading to substantial morbidity, Received in revised form 6 September 2011 and is also associated with social stigma. In this study we describe the epidemiology of scabies in the Accepted 12 October 2011 West Bank, Palestine during the years 2005–2010. Corresponding Editor: William Cameron, Methods: We examined the records and profiles of a total of 1734 patients who were admitted to the Ottawa, Canada dermatology clinics of the Palestinian Ministry of Health in 2005–2010. Results: The disease was found to be prevalent in all governorates. The average annual incidence of Keywords: scabies in the West Bank for 2005–2010 was 17/100 000 population. The average number of scabies Scabies patients per year in the West Bank was 26.3 per governorate, with a significant increase in the years 2009 Epidemiology and 2010 (p < 0.001). Disease occurrence was significantly higher among children aged 10 years than Palestine in the other age groups, in adult females in the age groups of 31–40 and 41–50 years compared to males West Bank in these age groups, and in males in the age group of 11–20 years compared to females in that age group. Conclusions: Scabies was found in all governorates of the Palestinian West Bank. Individuals under 20 years of age are particularly at risk. Compulsory reporting of scabies to the Palestinian Ministry of Health would be expected to increase awareness of the disease, which is crucial for the prevention and control of scabies in the Palestinian Territories. ß 2011 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved. 5 glomerulonephritis are common. The disease is prevalent in all 1. Introduction 6 socioeconomic groups and communities throughout the world. Scabies is one of the diseases that carries a high social stigma, such Scabies is a highly contagious skin disease that is on the that patients hesitate to seek medical treatment. increase and afflicts all races and social classes in every nation. The The prevalence of scabies varies widely from one country to global prevalence has been conservatively estimated at around 300 7 1 another. In developing countries the prevalence of the disease is million cases. This disease is caused by the ectoparasitic mite of 8–10 about 5.8–8.3% among rural populations. The situation is mammalian skin, Sarcoptes scabiei var. hominis. These mites are worsening in underdeveloped countries in Africa, where preva- able to survive away from the host for 24–36 h at 21 8C and 40–80% 11–14 2,3 lence ranges from 2% to 31%. In the Arab countries like Egypt, relative humidity, and remain infective. At lower temperatures 15 the prevalence of the disease is about 2.6%. However, very few and higher humidity, these mites are able to remain infective away studies have been reported from other countries in the Arab World. from the host for about 1 week and are able to penetrate the skin at 4 The diagnosis of scabies is made by finding a typical scabies a temperature above 20 8C. burrow in the skin, especially in immunocompromised children Although scabies itself is not a fatal or life-threatening and the elderly. Incubation periods, the number of mites carried, condition, it can be severe and persistent, leading to debilitation and the intensity of the itch are variable. Although the presence of and discomfort, depression, and secondary skin infections. burrows is not always obvious in certain cases, infection of one Affected individuals may be asymptomatic or present varied skin 2,16 individual often spreads to all members of the family. The eruptions, including papules, nodules, blisters, and eczematous occurrence of itchy papules, papular crusts, or vesicular lesions is changes, superimposed with excoriations and bacterial infections. suggestive of scabies. An individual is diagnosed to have scabies Post-infective complications such as acute post-streptococcal when one or more typical lesions are present and last for longer than 2 weeks, when pruritus intensifies at night, or when at least 17 one other family member has similar lesions. Scabies is not a * Corresponding author. Tel.: +972 599197097; fax: +972 22796960. E-mail address: [email protected] (O. Hamarsheh). highly complicated infectious disease; patients can be treated with 1201-9712/$36.00 – see front matter ß 2011 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ijid.2011.10.005 e118 A. Amro, O. Hamarsheh / International Journal of Infectious Diseases 16 (2012) e117–e120 18,19 a scabicide such as 5% permethrin. Although, scabies has not been reported from the West Bank, Palestinian Territories, a high rate of infection has been reported among school children aged less 20 than 10 years, especially in poor and large families, in Gaza. Scabies in the Palestinian Territories is not mandated as a reportable disease by the Palestinian Ministry of Health (PMOH). This study was performed to estimate the prevalence of scabies in the Palestinian West Bank by analyzing the available epidemio- logical data from the PMOH dermatology clinic records, and to determine the possible factors associated with scabies distribution and transmission. 2. Materials and methods 2.1. Study design A descriptive epidemiological study based on PMOH dermatol- ogy clinic records and patient profiles was conducted between 2005 and 2010. One thousand seven hundred and thirty-four scabies patients were recorded by the PMOH directorates in the 11 governorates of the West Bank during the period 2005–2010. Due to changes in the reporting system of the PMOH, only 1241 patient profiles, which included information on age, gender, geographical origin, date of diagnosis, patient profession, and treatment, were available. Cases without a patient profile (total 493) were recorded by the directorates of health as numbers, but without details. Figure 1. Map of the West Bank, Palestinian Territories, showing the average Scabies was diagnosed clinically by the presence of burrows or number of patients per year, and in parenthesis the average annual incidence rate of erythematous papular, vesicular, or pustular lesions with itching. scabies, calculated for each governorate for the years 2005–March 2011. The table In most cases, the microscopic detection of mites, eggs, or feces indicates the population of each governorate in the middle of the year 2010. was not done. This was not considered a reportable disease by the PMOH, hence some patient records were not available. authorities and the objectives of the study were explained. All 2.2. Study area and population patient records and private data were handled confidentially. Visits were arranged to all PMOH directorates in all Palestinian 3. Results governorates in the West Bank, and all scabies records and patient profiles for the period 2005–2010 were inspected and patient One thousand seven hundred and thirty-four patient profiles information collected. The West Bank is located west of the Jordan were investigated in this study. According to PMOH protocols, the 2 River (32 00 N, 35 15 E). It has a land area of 5640 km (including diagnosis of scabies should be made by a dermatologist in a East Jerusalem) and a population of 2 514 845 people (June 2010), dermatology clinic. The clinical diagnosis usually relies on the as reported by the Palestinian Central Bureau of Statistics (PCBS; presence of papules and marks of pruritus on the hands, limbs, and http://www.pcbs.gov.ps/). The population is distributed across 11 genitalia. In most cases, microscopic detection of mites, eggs, or governorates as follows: Hebron, Bethlehem, Jerusalem, Ramallah, feces was not done. Patients were treated with 5% permethrin Jericho, Tubas, Salfit, Nablus, Qalqilya, Tulkarem, and Jenin. dermal cream. Resistance to treatment with permethrin has not Figure 1 shows a map of the locations of the study governorates. been reported by the PMOH. The average annual incidence rate of scabies in the West Bank 2.3. Data analysis during the period 2005–2010 based on 1734 patients was 17/ 100 000 population. The average annual incidence rate for the The average annual incidence rates were calculated per 100 000 individual governorates ranged from 1.3/100 000 population in population for the years 2005–2010 for each governorate. The Tubas governorate to 41.4/100 000 population in Jericho gover- average number of cases per year was calculated for each norate. In the West Bank the average number of patients per year governorate, age group, and gender during the study period. The over the 6-year period was 26.3 per governorate; this ranged from male to female ratio was calculated for each age group and Chi- 0.7 in Tubas governorate to 77.2 in Jenin governorate. The average square statistics were calculated to identify significant differences annual incidence rates and the average number of patients per year in disease incidence with regard to the study variables, such as for each governorate individually are shown in Figure 1.