Scabies is a parasitic infectious skin disease caused by a mite (Sarcoptes scabiei var. hominis). It was considered one of the most commonly neglected tropical diseases by the World Health Organization (WHO) in 2017, and the parasite can quickly spread from one individual to another, resulting in an outbreak [1-3].Globally, it is estimated to affect more than 200 million people at any time and it is endemic in many resource-poor tropical settings, with an estimated average prevalence of 5–10% in children [4]. Data on scabies in general and published information in particular, are scarce. Even though scabies is considered an endemic skin disease in many rural and urban poor communities of Ghana, the evidence is largely anecdotal. Occasionally, sections of the Ghanaian media report outbreaks of scabies among inmates of some prisons in the country; the most recent of which was the Ho Central Prisons in 2016 [5]. Scabies is one of the commonest dermatological conditions, accounting for a substantial proportion of skin disease in developing countries. The microscopic mite burrows into the skin and lays eggs, eventually triggering a host immune response that leads to intense itching and rash. Scabies infestation may be complicated by a bacterial infection, leading to the development of skin sores that, in turn, may lead to the development of more serious consequences such as septicaemia, heart disease and chronic kidney disease. The 2019 SARS?CoV?2 pandemic, which caused Coronavirus Disease 2019 (COVID?19), originated in Wuhan, China and spread across the world [6,7]. Numerous preventive precautions had been put into immediate practice worldwide and in Ghana which has recorded 54,771 cases with 335 deaths as at January 1, 2021 [8]. These included an international travel ban, transition to a distance education system, social distancing, gathering and public transport restrictions, and the campaign that encourages everyone to “stay?at?home” and in a few places was locked down.  As a result of the “stay?at?home” policy, there have been reports on an increase in the number of patient requests for dermatology outpatient clinic visits. In a dermatology outpatient clinic visit in turkey among the dermatological conditions reported scabies was the second highest, 12.8% [9]. The increase in social anxiety and stress along with the negative impact on quality of life caused by the COVID?19 pandemic may explain the proportional increase in diseases such as psoriasis, scabies and urticarial [9-12]. On October 5th, 2020 the Neglected Disease Programme (NTDP) was informed about an increase in skin infections suspected to be scabies in a sub-district in the Central Gonja District in the Savanna region. The skin lesions were intensely pruritic erythematous papules in between the fingers, groin, buttocks, and lower limbs that were laced with excoriations from repeated scratching. A team of three was constituted by the Programme Manager, NTDP, to support the local team to investigate the outbreak to verify the diagnosis, assess the magnitude, describe the outbreak per person, place, time and implement and recommend further control measures.

Outbreak Setting

The outbreak investigation was conducted between October 7-10th, 2020 in the Tulwei Sub-district, Central Gonja District. The District is located in the Savannah region, one of the newest regions of Ghana and yet the largest region in the country. Buipe is the administrative capital.Annual reports GHS, 2020).

Figure 1: Map of Ghana indicating the Savannah region.

Figure 2: Map of Central Gonja showing the Tulwei Subdistrict.

The District is traversed by two major rivers - the White Volta, which flows longitudinally through the district, and the Black Volta, which forms the district’s southern boundary with the Kintampo North Municipal. A lot of streams crisscross the district and flow into the two Volta Rivers. The District has an extrapolated population of 130,462. The district is divided into six administrative sub-districts namely: Buipe, Kusawgu, Mpaha, Tulwei, Yala and Yapei with 31 electoral areas. There are 28 public and two private health facilities. The focus of the outbreak was in the Tulwei sub-district with a total population of 9412 people. The most affected community was Digma with a population of 3833. There is a Community-based Health Planning and Services (CHPS) at Digma with a midwife and a community health nurse.

Design of the Outbreak Investigation

The investigation team comprised of the NTDP national team, District Health Management Team-Central Gonja, the Lab team from the Public Health Reference Lab-Tamale and the Dermatologist at the Regional Health Directorate-Tamale. We interviewed the District Health Management Team, The District Chief Executive Officer and other prominent members at the District Assembly including the Environmental Health officer to obtain information on the outbreak and preliminary data on those affected. We reviewed surveillance data and the initial line-list generated by the District Disease control officer (DCO). Based on the information gathered, we defined a scabies case- patient as an inhabitant of the Tulwei Sub-district, Central Gonja from January 1st- October 10th 2020 with rash, severe pruritus and/or mite burrows, the mites, mite eggs, or mite faeces identified in a skin scraping. We also defined a scabies case-patient as a person with signs and symptoms of scabies or epidemiologically-linked to a person with scabies living in the Tulwei Sub-district, Central Gonja from January 1st-October 10th 2020. We then interviewed health workers and reviewed medical records from health facilities in the sub-district meeting the case definition. Further records review was conducted in other nearby health facilities in nearby districts where some case-patients may have visited. Data abstracted included age, sex, occupation, place of residence, date of onset, date of presentation at a health facility, signs and symptoms, nature of skin infection, location of skin lesion and outcome. Active case search and community interviews were conducted to trace other cases and contacts. In the Tulwei village, the entire community was screened.

Laboratory Investigations

All laboratory tests were performed on the field. Specimens from five persons were taken for laboratory diagnosis. We performed skin scrapings at the end of the burrows in non-excoriated and non-inflamed areas of scabies lesions unto filter papers using sterile scalpel blades size# 15 for the isolation of scabies mite, their eggs, or faeces. We transferred scrapings from each site onto a microscopic slide, added 2 drops of 10% potassium hydroxide (KOH), mixed well, applied a coverslip and ensured that no air bubbles were trapped within. The Lab team examined the slides under a light microscope for mites, their eggs, or faeces.

Environmental Assessment

We conducted an environmental assessment. This included an assessment of the state of cleanliness of the environment in the communities, average household occupancy.

Ethical Considerations

This outbreak investigation was deemed a response to a public health emergency by the Ghana Health Service. Informed consent and permission were sought from the participants before the interviews. The privacy of respondents during screening and confidentiality of captured data was observed throughout the investigation. Data were kept under password and made available strictly on a need-to-know basis.

We performed a descriptive analysis of the outbreak data by person, place and time. Univariate analyses were expressed as frequency distributions, percentages, mean± SD, range, and rates (attack rates, case-fatality rates, etc.) as appropriate using epi-info version 3.3.

From October 7-10th, 2020 we identified a total of 154 scabies cases that were line-listed in Tulwei Sub-district. The overall attack rate (AR) in the sub-district was 16.3 per 1000 populations with no scabies related death (CFR = 0). Of the total scabies cases, 65% (100/154) were females (Table 1). The majority of the cases had onset of symptoms from September 2020 and the most affected body part was the hands (29%) (Figure 3,4).

Narration by the District Health Directorate

According to the District Disease Control officer (DDCO), on the 25th of September, the directorate received a distress audio recorded message from the Community Health Nurse about an increase in skin infections in the sub-district, especially in the Digma community. On the 28th September, the District Health Directorate visited the sub-district. Many of the affected people complained of an intense itching especially at night and skin rashes and made an initial diagnosis of scabies and yaws awaiting confirmation. A rapid diagnostic test was performed on a few blood samples taken from the clients and the results were negative for yaws. The Health team organized a durbar at Digma with a targeted message on environmental cleanliness, personal hygiene and the avoidance of overcrowding. The community members attributed the cause of the skin rashes to the polluted drinking water. The affected people were treated at the Digma CHPS and line-listed. The Regional Health Directorate was appropriately informed. 

Narration by the Midwife I/C Digma CHPS

According to the Midwife at the facility, the index case was a three-year-old boy whose parent brought to the CHPS with a skin infection and intense itching especially in the night on June 17, 2020. The family of this young boy and a many others had returned from the southern part of Ghana where locked down had been imposed and few cases of scabies have been confirmed. He was treated with Syp Amoxicillin and promethazine. After a few days, the child was brought back to the CHPS compound with some slight improvement but the entire family was affected by a similar rash. After a few days, 5-6 similar cases were reported from the overbank communities around the Digma village. According to the midwife I/C, the source of the infection could be from the source of water where animals and human beings use for drinking and domestic work. It is also a common practice in the village that many of the household members use the same towels and sponge.

Environmental assessment

The immediate surroundings of the environment were unclean with animal faeces littered in many places. The average household occupancy was between 10-14 persons per household.Refer (Table 1).

Table 1: Social demographic status of scabies cases, Tulwei Sub-district - Central Gonja, Savannah Region-2020.

Figure 3: Epidemic curve of scabies outbreak, Tulwei Subdistrict - Central Gonja, Savannah Region-2020.

Figure 4: Distribution of scabies lesions by body part, Tulwei Subdistrict - Central Gonja, Savannah Region-2020.

Laboratory Investigations

All laboratory tests were performed on the field. Specimens from five persons were taken for laboratory diagnosis. We performed skin scrapings at the end of the burrows in non-excoriated and non-inflamed areas of scabies lesions unto filter papers using sterile scalpel blades size# 15 for the isolation of scabies mite, their eggs, or faeces. In one sample a typical mite‘s egg was diagnosed.

We investigated a community outbreak of scabies in a deprived rural setting with high temperatures in a sub-district in the Central Gonja of Ghana which had affected mainly the youth and the young adult. Scabies occurs worldwide, however, it is the most vulnerable groups – young children and the elderly in resource-poor communities – who are especially susceptible to scabies and the secondary complications of infestation. The highest rates of infestation occur in countries with hot, tropical climates, especially in communities where overcrowding and poverty coexist, and where there is limited access to treatment. 4 In an outbreak of scabies in a preschool setting in the Greater Accra region of Ghana, children less than five years were mostly affected which is contrary to our findings where all age groups were affected especially the youth and the young adult.13 There was a community spread of the disease from our findings and this was most probably linked with the youth and the young adult, the hard-working class who had returned from the southern part of Ghana due to the covid-19 pandemic. The primary finding of our investigation was the fact that there was an outbreak of scabies and this coincided with the period Ghana experienced the peak of the COVID -19 pandemic. This finding can be addressed in the context of the pandemic-related “stay-at-home” policy which is very crucial to control the outbreak. Many people living in the southern part of Ghana who were natives from the Northern regions travelled to their native villages and towns in the North to avoid the strict ‘lock down’ period which was imposed in some parts of the country. There were also reports of scabies outbreaks in other parts of the other regions of Ghana. The severe clinical manifestation of scabies basically occurs after 4 to 6 weeks of the first infestation. This may be the reason why scabies is not seen in high numbers at the beginning of pandemic and then caused an explosion. Sarcoptes Scabei, which can live for 3 days outside the body at normal room temperature, can remain infectious for up to 10 days in hyperkeratotic crusts and become very infectious.14, 15 In this regard, there are several explanations that can address the increasing number of scabies-related patients during the pandemic. Firstly, the temporary workplace closure in the urban areas which were sources of the COVID-19 outbreak allowed patients to migrate from urban to rural areas where scabies could be seen as more commonly. Secondly, the increasingly close contact as a result of the stay at-home policy might facilitate the scabies contagiousness of individuals living in the same home. Lastly, the high hospital bed turnover rate during the COVID-19 pandemic may lead to the hospital to be one of the possible sources of scabies. According to a staff in one of the health facilities, it had been a common practice among the households in the communities that many of the household members use the same towel and sponge for bathing. It should be reiterated that, scabies is usually transmitted from person-to-person through close skin contact (e.g. living in the same residence) with an infested individual. The risk of transmission increases with the level of infestations, with the highest risk due to contact with individuals with crusted scabies. Transmission due to contact with infested personal items (e.g. clothes and bed linens) is common and also very important for individuals with crusted scabies. As there is an asymptomatic period of infestation, transmission may occur before the initially infested person develops symptoms.4 Targeted health education messages in the local dialect should be developed and shared among the community members through community durbars. This is one of the simple health interventions that health partners could come in and support with various activities which may include drama, video shows and community dialogue. In the environmental assessment, it was realized that, the average household occupancy was between 10-14 persons per household. Scabies is a contagious, itchy skin condition caused by mites burrowing and laying eggs under the skin. Scabies affects the infected individuals’ daily lives due to itching and also affects the lives of others living with them; hence, scabies is considered a public health hazard. In particular, susceptible patients, such as children or elderly people, can acquire scabies through contact. 16, 17 Targeted educational messages and community dialogue is crucial in addressing this issue. As one of the study limitations, the primary case could not be identified as the family of the index case could not provide credible information on the exact source of the infection. Hitherto the travel to the northern part of Ghana due to the covid-19 pandemic the entire family lived in an overcrowded market in the middle of Accra, the capital of Ghana where there was an outbreak of scabies. In Conclusion, there was a scabies outbreak that occurred in Tulwei Sub-district - Central Gonja, Savannah Region.  The overall attack rate of the outbreak is high. Both sharing of clothes with scabies patients, contact with scabies patient, persistent use of  same towel and sponge per household and infrequent changing of clothes were probable risk factors for the occurrence outbreak in the area. Understanding the increasing number and impacts of scabies during pandemics will allow for better preparation of countries to fight scabies infestation which is another type of outbreak. Health workers and all stakeholders must tailor-make health education messages to discourage people from overcrowding, sharing of clothes, towels and sponges at home and seek prompt medical attention with the slightest medical condition in these unusual times of the covid-19 pandemic. A number of public health interventions were undertaken.  People in the early stage of new infestation were asymptomatic and treatments for scabies did not kill the parasite’s eggs, hence best results were obtained by treating the whole household at the same time and repeating treatment in the time frame appropriate for the chosen medication. The health team organized a community durbar on the prevention of skin rashes. All the affected community members were treated with the benzene benzoate lotion and ivermectin. These interventions contributed to control the outbreak.

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