
==== Front
J Migr Health
J Migr Health
Journal of Migration and Health
2666-6235
Elsevier

S2666-6235(24)00010-2
10.1016/j.jmh.2024.100220
100220
Article
Prevalence of scabies and its associated environmental risk factors among the Forcibly Displaced Myanmar Nationals living in the Cox's Bazar district of Bangladesh
Rahman Md. Shakkor a
Hasan A.B.M. Nahid a
Jahan Ishrat a
Sharif Azaz Bin azaz.sharif@northsouth.edu
ab⁎
a Department of Public Health, North South University, Bashundhra, Dhaka 1229, Bangladesh
b Global Health Institute, North South University, Bashundhra, Dhaka 1229, Bangladesh
⁎ Corresponding author. azaz.sharif@northsouth.edu
27 2 2024
2024
27 2 2024
9 10022019 9 2023
24 1 2024
26 2 2024
© 2024 The Authors. Published by Elsevier Ltd.
2024

https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction

The Forcibly Displaced Myanmar Nationals (FDMNs) residing in refugee camps face various health challenges, including a rising prevalence of scabies, exacerbated by overcrowded conditions and limited healthcare access. This study aims to assess scabies prevalence, clinical features, and environmental factors among FDMNs, aiding interventions and recommendations for better health outcomes.

Methodology

A cross-sectional study was conducted from April to May 2023 in six camps of Teknaf/Ukhia Cox's Bazar. Using a multistage sampling technique, 12 blocks were identified, and FDMNs seeking healthcare services from Primary Health Care posts were invited to participate in the study. Participants were adults, and children who volunteered to participate in this study. Scabies diagnosis was based on clinical examinations of exposed body areas by trained health professionals. Data on sociodemographic factors, environmental risk factors, and scabies symptoms were obtained through a semi-structured questionnaire administered by trained interviewers. Statistical analysis included descriptive statistics, Chi-square tests, and binary logistic regression models to explore associations between scabies infection and other explanatory factors.

Result

A total of 679 FDMNs participated in the study, with a mean age of 29.13 years. Overall, 66.42 % of participants were diagnosed with scabies. Age, marital status, history of scabies infection, previous skin infection, family history of scabies and skin infection, floor type, pet animal, dust exposure, and seasonal exposure were significantly associated with the scabies infection. Binary logistic regression suggested that having history of scabies infection (OR 3.98, 95 % CI: 1.86 to 8.49, p < 0.001), skin infection (OR 2.46, 95 % CI: 1.32 to 4.58, p = 0.004), having family history of scabies infection (OR 3.06, 95 % CI: 1.29 to 7.23, p = 0.011), family history of skin infection (OR 27.41, 95% CI: 14.46 to 51.97, P < 0.001), having contact with street animal (OR 2.16, 95% CI: 1.27 to 3.66, P = 0.004), and winter season (OR 3.33, 95 % CI: 1.89 to 5.87, p < 0.001) were significantly associated with scabies infection.

Conclusion

Tailored public health measures targeting hygiene, living conditions, and animal contact can mitigate the spread of scabies, particularly among vulnerable groups like Rohingya refugees, necessitating collaboration between stakeholders.

Keywords

Scabies
Skin disease
FDMN
Rohingya community
Environmental factors
==== Body
pmcIntroduction

Forcibly Displaced Myanmar Nationals (FDMNs) are used to describe the Rohingya population, consistent with the terminology used by the Government of Bangladesh. This term is also acknowledged to be used interchangeably with "Rohingya refugees" in alignment with the international framework recognized by the UN. Both terms refer to the same population affected by displacement from Myanmar. The usage is intended to reflect the terminology employed by the relevant authorities and international organizations involved in addressing the humanitarian situation (Khan et al., 2023). The FDMN people have been forced to migrate to Bangladesh since 1978 (Khan et al., 2023). In Myanmar's Rakhine state, Rohingya people have endured decades of systematic discrimination, statelessness, and targeted violence. People of all ages and genders have been forced into Bangladesh by persecution for many years, with significant increases following violent attacks in 1978, 1991–1992, and 2016–2017. According to UN Fact-Finding, a sizeable population fled across the border to save their lives after a genocide occurred in August 2017 (Independent International Fact-Finding Mission on Myanmar | OHCHR [Internet] 2019). Over 700,000 Rohingya refugees escaped to Cox's Bazar, a coastal city in southern Bangladesh (Dussich, 2018 May 31), where they have settled in camps for FDMNs ((Inter-Sector Coordination Group (ISCG) 2022; Rashid et al., 2021)). The FDMNs face numerous challenges, including inadequate sanitation, overcrowded living conditions, and limited access to healthcare (Hotez et al., 2008). Crowded unhygienic living conditions increase their susceptibility and vulnerability to various communicable diseases. The most reported infectious diseases are cough and cold with or without pneumonia, acute watery diarrhea, fever, skin diseases, and acute respiratory infections (Islam et al., 2019). Recently, scabies, caused by Sarcoptes scabiei var. hominis, a parasitic mite, have emerged as one of the most common afflictions within the FDMN community (Ming, 2018).

Scabies affect more than 300 million individuals every year, which equals 2.8% of the world's population (Scabies, 2006). According to epidemiological data from various regions of the world, the prevalence of scabies is estimated to vary from 0.2% to 71% (Aždajić et al., 2022). The Pacific region and Latin America have shown the highest prevalence (Hay et al., 2012). Geographically, scabies infections are more common in locations with tropical climates, impoverished nations, and inadequate access to water (Romani et al., 2015). Scabies was listed as a neglected tropical disease by the World Health Organization (WHO) (El-Moamly, 2021). The infestation affects hundreds of millions of individuals in impoverished urban and rural communities worldwide (Scabies, 2006; Murray et al., Dec; Jackson et al., 2007). Scabies outbreaks in closed groups have been documented mainly in high-income countries, but the disease is more prevalent in resource-poor communities in low- and middle-income countries with a tropical climate (Andersen et al., 1; Heukelbach et al., Apr; Heukelbach et al., 1). East Asia, Southeast Asia, Oceania, tropical Latin America, and South Asia had the highest scabies prevalence rates (Romani et al., 1). In Bangladesh, the situation is particularly alarming. About 40% of the FDMNs residing in refugee camps are estimated to suffer from scabies, and in some camps, this number rises to as high as 70% (Noko, 2023; Medecins Sans Frontiers 2017).

These figures are significantly influenced by the environmental conditions in the camps (Jackson et al., 2007). According to a report by Medicine Sans Frontieres (MSF), the combination of overcrowded shelters, inadequate access to water, and close physical contact among the inhabitants create an environment conducive to rapid mite transmission (Noko, 2023). Furthermore, close proximity and frequent physical contact facilitate the rapid spread of the mite (Scabies, 2006). A study in Brazil reported high prevalence and re-infestations in endemic settings are correlated with armed conflicts, homelessness, crowding, and shared use of clothes, beds, and pillows (Feldmeier et al., 2009). Another study conducted among prisoners of Cameroon found that a lower level of education and sharing a bed or clothes were risk factors for having scabies (Kouotou et al., 2018). According to research in Poland, people who lived in poor sanitary and hygienic conditions were more prone to scabies (Buczek et al., 2006).

Scabies not only present a substantial burden to the healthcare system but also cause considerable suffering for those affected. Clinical manifestations include intense pruritus and lesions primarily on the abdomen, interdigital spaces, and inguinal region, often leading to secondary bacterial infections and serious complications such as cellulitis, abscesses, impetigo, septicemia, glomerulonephritis, and potentially renal failure and rheumatic heart diseases (Scabies, 2006; Ugbomoiko et al., 2018; Dagne et al., 2019). Moreover, chronic itching can lead to significant psychological and behavioral disturbances (Ugbomoiko et al., 2018).

Assessing the prevalence of scabies in the Rohingya population is essential for identifying environmental risk factors, developing effective interventions, and determining where resource allocation is required.Therefore, the current study's objectives are as follows,

General objective

To determine the prevalence of scabies infection and the associated environmental risk factors of scabies among Forcibly Displaced Myanmar Nationals (FDMN) in the Rohingya Camp of Cox-Bazar

Specific objectives

1. To estimate the percentage of scabies infections in the Forcibly Displaced Myanmar Nationals (FDMN/Rohingya) living in Rohingya Camp, Cox-Bazar

2. To find out the pattern of clinical features of scabies among Rohingya refugees in Rohingya Camp, Cox-Bazar

3. To assess the association between sociodemographic factors and scabies among Rohingya refugees in Rohingya Camp, Cox-Bazar

4. To determine the association between environmental risk factors and scabies among Rohingya refugees in Rohingya Camp, Cox-Bazar.

Understanding distinct clinical manifestations in the FDMN population can aid healthcare providers with improved scabies management. In addition, identifying these environmental factors within the Rohingya community will help formulate appropriate recommendations for improving living conditions and implementing effective preventive measures.

Methods

Study areas

This study was conducted in 6 camps located in Teknaf/Ukhia in Cox's Bazar district (Camp 2 w, 2e, 6, 8, 22, 25). Cox's Bazar is a coastal city located 150 kms south of Chittagong district and 298 km southeast of Dhaka district. This district, one of the largest in Bangladesh, covers an area of 2491.85 sq. km, situated between 91°59′ and 92°08′ east longitudes and 21°24′ and 21°36′ north latitudes (Britannica 2015). There are approximately 2,289,990 residents living in Cox's Bazar, with the FDMN community accounting for over 900,000 of this population (ICT Unit L 2020; UNHCR 2023). The district is divided into 8 Upazilas, 71 unions, and 4 City Corporations and hosts various health facilities, including a medical college hospital and several different tiers of Healthcare Centers (ICT Unit L 2020).

Study design and sampling technique

This descriptive cross-sectional study was conducted from April to May 2023 within the Rohingya camps of Cox's Bazar. Multistage sampling technique was used to select samples from the Rohingya refugee camps in Cox's Bazar. Initially, six camps were selected via simple random sampling. Each camp is subdivided into 4–8 blocks. Within each block, there are households, and primary health care posts. Two blocks were identified randomly within these camps, resulting in 12 blocks. The FDMNs residing in these blocks who came to receive healthcare services from these Primary Health Care posts were approached to participate in the study. All the participants who consented to participate in this study were recruited as our study sample.

Using a confidence level of 95% and a 5% margin of error, the sample size was calculated based on a scabies prevalence rate of 10.2% identified in the 2022 WHO rapid community mapping on scabies (WHO 2022). The sample size was determined using the formula n = z^2pq/d^2, yielding a minimum of 141 subjects. The study team reached a larger sample size (n = 679) than the required sample size. While we understand the conventional use of a 50% prevalence assumption in unknown populations, our decision to rely on the WHO-provided prevalence rate of 10.2% was driven by the availability of specific and recent data. Even if we considered a 50% prevalence, our sample size estimate would have been 384 (which is lower than the considered sample size).

Diagnostic approach

Scabies were diagnosed based on a physical examination conducted by trained health professionals. In the present study, scabies were clinically diagnosed without the use of any equipment. The examination of scabies was restricted to readily exposed areas of the body, such as the foot, leg to the thigh, hand to the upper arm, scalp, and neck. A comprehensive body examination was not performed because it was impractical to do so in the field. Therefore, a limited examination was conducted on areas (hands, feet, and lower legs) where approximately 90 percent of scabies cases are detected (Marks et al., 2020). The breasts, groin, and genitalia were not inspected by the data collectors. These sensitive locations were not examined unless specifically requested by participants. Children were instructed to take off their footwear prior to the examination. All children were examined in the presence of their parents or guardians and informed consent was obtained from their parents or guardians. Macules, papules, crusted papules (if a small hemorrhage crusts), vesicles, and nodules were distinguished as primary lesions (Scabies, 2006; Jackson et al., 2007). Study participants who had such clinical manifestations were diagnosed as scabies, and those without clinical manifestations were considered as free from scabies.

Data collection tool and procedure

The data collection tool was developed by reviewing different literature on similar studies and the social context of the refugee population (Ugbomoiko et al., 2018; Dagne et al., 2019; Zeba et al., 2012). Data collection employed a semi-structured questionnaire developed in English and further translated into Bengali by a language expert. During the interviewing of the study participants, a local interpreter was present to convey the meaning of the questions to the study participants if necessary. The questionnaire was used to collect data on sociodemographic factors, environmental risk factors, and symptoms of scabies. A pretest was conducted on 5% of the total sample size two weeks before data collection. Trained interviewers conducted face-to-face interviews under the supervision of the principal investigator to mitigate potential bias.

Ethical committee approval

The study protocol for this study was approved by the Ethical Review Committee of the North South University, Dhaka, Bangladesh, and the Refugee Relief and Repatriation Commissioner (RRRC). After a thorough explanation of the study protocol, adult participants and the parents or legal guardians of minors provided informed consent prior to the study. According to the requirements of the ethical review committee, patient information was made confidential. All items in the manuscript have been included according to the STROBE guideline.

Study variables

Sociodemographic variables included are age, sex, education level, marital status, history of prior scabies infection, history of other skin infections, and family history of skin and scabies infections. Age groups were defined as follows: below 18 years, 19–36 years, 37–55 years, 56–70 years. The inclusion of specific environmental variables in our study was based on a thorough review of existing literature on scabies and the social context of the study population. Environmental risk-related factors encompass family size, crowding index, floor type, pet ownership, contact with street animals, dust exposure, and seasonal variation to scabies (Ugbomoiko et al., 2018; Dagne et al., 2019; Zeba et al., 2012; Salah Hegab et al., 2015). The crowding index was calculated by dividing the number of usual residents by the number of bedrooms. The continuous variable was reclassified into two categories: (1) < 1.5 and (2) > 1.5 (Salah Hegab et al., 2015). Clinical symptoms of scabies include itching, watery discharge from the site(s) of infection, sleep disturbances, time of increasing itching, and time of severity of scabies symptoms.

Statistical analysis

After collecting the data, the authors carefully reviewed each response to ensure its accuracy, comprehensiveness, and internal consistency. Missing or inconsistent data was discarded. Subsequently, the relevant information was entered into the computer, and the statistical analysis was conducted using STATA version 17. Descriptive statistics were employed to obtain frequencies and percentages. The chi-square test was used to explore the association between each independent variable and the dependent variable. A binary logistic regression model was used to identify the variables associated with the prevalence of scabies. We opt to include all the explanatory variables in the regression model irrespective of their significance in the bivariate relationship. The results were considered significant at 5 % level (p value <0.05).

Results

Scabies affected a significant proportion of the participants (66.42%). Table 1 describes the study population and their sociodemographic and environmental characteristics. Nearly half of the participants were between 19 and 36, bringing the average age to 29.13 (SD = 0.56). The study group had almost the same number of men and women. A significant percentage of the participants were documented as lacking literacy skills. A substantial influence was also played by the respondent's family history, with 41.53% having a positive family history of scabies and 71.58% having a positive family history of other skin illnesses, respectively. Most participants resided in densely populated living conditions and lived in homes with cement flooring. Regarding animal contact, more than half of the study sample reported no contact with street animals, and approximately ninety percent did not own pets. Many individuals reported exposure to dust. Notably, scabies infection occurred in both summer and winter, with a considerably higher incidence during the winter than in summer.Table 1 Description of the study population and their sociodemographic and environmental characteristics (n = 679).

Table 1:Independent Variable	Categories	Total (%)	
Age in year	Mean ± SD 29.13 ± 0.56	
Below 18	156 (22.97)	
19–36	339 (49.93)	
37–55	141 (20.77)	
56–70	43 (6.33)	
Sex	Female	328 (48.31)	
Male	351 (51.69)	
Education	Illiterate	516 (75.99)	
literate	163 (24.01)	
Marital Status	Married	532 (78.35)	
Unmarried	147 (21.65)	
Previous Scabies infection	No	360 (53.02)	
Yes	319 (46.98)	
Previous Skin Infection	No	389 (57.29)	
Yes	290 (42.71)	
Family History of scabies infection	No	397 (58.47)	
Yes	282 (41.53)	
Family History skin infection	No	193 (28.42)	
Yes	486 (71.58)	
Family Size	1–5 member	338 (49.78)	
6–10 member	276 (40.65)	
More than 11 members	65 (9.57)	
Crowding Index	Not Crowded	47 (6.92)	
Crowded	632 (93.08)	
Floor Type	Soil	179 (26.36)	
Cemented	500 (73.64)	
Pet Animal	No	606 (89.25)	
Yes	73 (10.75)	
Contact with street Animal	No	370 (54.49)	
Yes	309 (45.51)	
Dust Exposure	No	109 (16.05)	
Yes	570 (83.95)	
Season	Summer	188 (27.69)	
Winter	491 (72.31)	

First, we thoroughly examined the data, focusing on identifying outliers and anomalous observations, especially in the context of self-reported information. Upon careful examination, we report that no outliers or anomalous observations were detected in our dataset.

Fig. 1 illustrates the distribution of the clinical manifestations of scabies. Predominantly, scabies symptoms were experienced during the night (98.45%), while only a minimal percentage (1.55%) reported symptoms becoming severe during the day. The majority of affected individuals (68.74%) experienced persistent symptoms throughout the day. Disturbances in sleep were notable, with 77.61% attributing disruptions to itching and pain. Almost half of the participants reported experiencing moderate itching, followed by light itching (28.82%) and severe itching (25.72%). Additionally, 90.92% of participants reported water discharge from the affected areas.Fig. 1 Distribution of the clinical manifestation of scabies (n = 679).

Fig. 1:

Table 2 describes the bivariate analysis between sociodemographic and environmental characteristics and the presence of scabies. The highest prevalence of scabies was seen in those aged 19–36 and then again in those aged 56 and higher. Scabies infection was significantly associated with marital status, with married people having a higher rate of infection than single people. Scabies infection was also much more common in people with a history of scabies or other skin illnesses. Floor type was significantly linked to scabies infection. Scabies infection infections were higher in households with pets than in those without. Many individuals reported exposure to dust, which was significantly associated with scabies. Notably, scabies infection occurred in both summer and winter, with a significantly higher incidence during the winter than in summer.Table 2 Description of bivariate analysis between sociodemographic and environmental characteristics and the presence of scabies (n = 679).

Table 2:Independent Variable	Categories	Scabies infection	P-value	
Absent%	Present%	
Age in year	Mean ± SD 29.13 ± 0.56			0.001	
Below 18	42.31	57.69	
19–36	26.25	73.75	
37–55	44.19	55.81	
56–70	33.58	66.70	
Sex	Female	32.93	67.07	0.728	
Male	34.19	65.81	
Education	Illiterate	34.11	65.89	0.603	
literate	31.90	68.10	
Marital Status	Married	31.02	68.98	0.007	
Unmarried	42.86	57.14	
Previous Scabies infection	No	57.78	42.22	p<0.001	
Yes	6.27	93.73	
Previous Skin Infection	No	46.79	53.21	p<0.001	
Yes	15.86	84.14	
Family History of scabies infection	No	53.40	46.6	p<0.001	
Yes	5.67	94.33	
Family History skin infection	No	83.42	16.58	p<0.001	
Yes	13.79	86.21	
Family Size	1–5 member	35.21	64.79	0.65	
6–10 member	32.25	67.75	
More than 11 members	30.77	69.23	
Crowding Index	Not Crowded	40.43	59.57	0.30	
Crowded	33.07	66.93	
Floor Type	Soil	25.70	74.30	0.009	
Cemented	36.40	63.60	
Pet Animal	No	34.98	65.02	0.026	
Yes	21.92	78.08	
Contact with street Animal	No	36.76	63.24	0.05	
Yes	29.77	70.23	
Dust Exposure	No	46.79	53.21	p<0.001	
Yes	31.05	68.95	
Season	Summer	44.68	55.32	p<0.001	
Winter	29.33	70.67	

As shown in Table 3, a binary logistic regression model was constructed to assess the impact of explanatory variables on the infestations of scabies. Participants with a history of scabies or skin infections displayed 3.98- and 2.46-times higher odds of developing scabies, respectively. A striking familial influence was evident, with individuals possessing a family history of skin infection exhibiting a substantial increase in scabies odds. Additionally, contact with street animals correlated with a 2.16-fold rise in likelihood. Notably, the odds of scabies infection were 3.33 times higher during winter compared to summer, highlighting a seasonal dimension to the affliction. These findings collectively elucidate key determinants of scabies, emphasizing the complex interplay of individual, familial, and environmental factors in its occurrence.Table 3 Binary logistic regression analysis to explore the relationship between the independent variables and scabies (n = 679).

Table 3:Variable	Categories	OR	95 % CI	P- value	
LL	UL	
Age in year	<18 Years (Ref)					
19–36 Years	1.42	0.60	3.34	0.426	
37–55 Years	1.21	0.46	3.20	0.705	
56–70 years	1.16	0.32	4.26	0.818	
Sex	Female (Ref)					
Male	0.82	0.50	1.37	0.454	
Education	Illiterate (Ref)					
Literate	0.71	0.40	1.28	0.250	
Marital Status	Unmarried (Ref)					
Married	1.59	0.65	3.87	0.308	
Previous Scabies infection	No (Ref)					
Yes	3.98	1.86	8.49	p<0.001	
Previous Skin Infection	No (Ref)					
Yes	2.46	1.32	4.58	0.004	
Family History of scabies infection	No (Ref)					
Yes	3.06	1.29	7.23	0.011	
Family History of skin infection	No (Ref)					
Yes	27.41	14.46	51.97	p<0.001	
Family Size	Small (Ref)					
Medium	0.90	0.51	1.59	0.719	
Large (>11)	1.27	0.52	3.12	0.598	
Crowding Index	Not Crowded (Ref)					
Crowded	0.42	0.14	1.29	0.129	
Floor Type	Soil (Ref)					
Cemented	0.81	0.44	1.50	0.509	
Pet Animal	No (Ref)					
Yes	1.66	0.70	3.96	0.253	
Contact with street Animal	No (Ref)					
Yes	2.16	1.27	3.66	0.004	
Dust Exposure	No (Ref)					
Yes	0.99	0.53	1.85	0.983	
Season	Summer (Ref)					
Winter	3.33	1.89	5.87	p<0.001	

We ran a few goodness-of-fit measures to check the appropriateness of the logistic regression analysis that we used to model scabies infection. First, the hypothesis of model correctness was tested using the Hosmer-Lemeshow test, which provided a p-value of 0.53. This indicates that we do not have enough evidence to reject the hypothesis of the correct model, i.e., our model fits the data well. In addition, the Akaike's information criterion (AIC) and Bayesian information criterion (BIC) values were 462.14 and 548.03, respectively. Considering the cutoff value at 75%, the sensitivity and specificity of our model were 81.15% and 88.16%, respectively. And our model correctly specifies the presence and absence of scabies 83.51% of the time. The area under the Receiver Operator Characteristic (ROC) curve was 92.74%, demonstrating better predictive accuracy of our model.

Discussion

Scabies constitute a neglected public health issue in developing countries, including Bangladesh. Within the Rohingya (FDMN) refugee camps, a deteriorating scabies outbreak (10.2% as reported by WHO) has emerged due to extreme poverty, inadequate nutrition, homelessness, and poor hygiene conditions (WHO 2022). The congested and overcrowded environment of the refugee camp facilitates the swift transmission of contagious ailments such as skin and respiratory conditions (Islam and Nuzhath, 2018). To the best of the authors’ knowledge, this study stands as the first endeavor to investigate the prevalence of scabies infection and examine clinical and environmental factors among the FDMN population in the Cox's Bazar refugee camps. Additionally, this research aims to identify potential associated factors for scabies infections.

This cross-sectional study revealed that 66.42% of the refugee camp's population was afflicted with scabies. This rate exceeded the prevalence reported by MSF in their study on the FDMN (40.00%) (Noko, 2023). This variance could arise from their inclusion of a larger sample size, methodological dissimilarities between the studies, and variations in study duration and setting. However, a recent WHO report hints at prevalence rates as high as 70% in certain FDMN camps, closely to our findings (Rashid et al., 2021).

The initial suspicion of the increasing trend of scabies infection among different age groups in Rohingya refugee camps has been revealed in this study. Individuals aged 19–36 and those over 55 exhibited the highest prevalence rates. This observation aligns with earlier research that identified elevated scabies rates within this age group (Reichert et al., Jun). Several factors, such as increased social interactions among young adults and compromised immune system function in the elderly, could contribute to this association (Wick and Zanni, 2004). The gender-specific patterns in scabies prevalence did not achieve statistical significance despite the study population having almost equal proportions of males and females.

In the current study, we found an interaction between marital status and scabies infection, highlighting that married individuals exhibit a higher prevalence of scabies compared to their unmarried counterparts. This finding indicates that married people's living conditions and social behaviors may increase the risk of spreading scabies. FDMN individuals commonly marry at a young age and bear children within one to two years of marriage, promoting the rapid expansion of their families (Hossain and Hossain, 2023). Our research uncovered that a majority of these individuals originate from large families. However, the escalating pace at which their families are growing surpasses their housing's capacity to expand concurrently (Abul Kalam Azad et al., 2022). Consequently, they find themselves compelled to dwell in the same tents or slums as before marriage, leading to cramped living conditions (Ugbomoiko et al., 2018). Scabies are more common among illiterate people, highlighting the connection between literacy and health. This agrees with the results of an Egyptian study that revealed that the level of education of both the participants and their parents affected the severity of scabies symptoms (Salah Hegab et al., 2015). These results highlight the need to focus health education initiatives on individuals with low levels of education. Therefore, an overcrowded environment exaggerates the spread of the infestation (Wick and Zanni, 2004). People living in overcrowded environments among larger families compared to smaller ones increase sharing of clothes, beds, and other daily amenities (Wick and Zanni, 2004). Scabies are known for their spreading quickly in crowded areas where close body and skin contact occurs (Wick and Zanni, 2004).

Based on the findings, individuals who had previously experienced a scabies infection exhibited a significantly higher likelihood of facing scabies again compared to those without a prior infection. They were more than four times as likely to develop scabies once more than those who had not been previously infected. This finding suggests that prior exposure to scabies might confer susceptibility or vulnerability to subsequent infestations. Individuals with a history of scabies infection may exhibit modified immune responses or diminished immunity on subsequent infestations, causing them to be more vulnerable to reinfection (Ong and Vasanwala, 2018).

As indicated by the research findings, the significant association of the family history of scabies and other skin infections with it raises intriguing questions about the potential underlying mechanisms responsible for this association. One possible explanation for the observed correlation is a genetic predisposition within family members (Andriantsoanirina et al., Dec). Certain genetic factors may render individuals more susceptible, making them more prone to contracting the mites and experiencing prolonged or recurrent infections (Walton, 2010). Alongside genetic considerations, shared environments within families may also exert an influence on the transmission and persistence of scabies.

According to our findings, several environmental factors have been linked to scabies infection. Living in crowded areas and being exposed to dust were associated with scabies. These findings are consistent with previously identified risk factors for scabies infection, which include close physical contact and poor hygiene conditions (Zeba et al., 2012; Wick and Zanni, 2004). Intriguingly, the type of floor material was significantly associated with the prevalence of scabies infection in the current study, with a higher prevalence observed in homes with soil floors than cemented floors. Previous evidence from an African nation also suggested that house type and structure played a role in scabies transmission (Walton, 2010).

The result reveals a significant association between seasonal variation and scabies prevalence. Throughout the winter, people tend to stay indoors more frequently, fostering closer interactions among family members and household residents. This closeness makes it easier for scabies mites to spread from one person to another. Additionally, the reduced frequency of bathing and infrequent clothing changes during colder months may lead to the accumulation of scabies mites on the skin. Conversely, warmer seasons often prompt people to engage in outdoor activities, resulting in reduced contact and fewer opportunities for scabies mites to spread. Several studies conducted across different countries have illuminated how seasonal changes impact scabies (Liu et al., 2016; Downs et al., Mar).

To mitigate the spread of scabies, public health interventions should emphasize education about personal hygiene practices, particularly among those with previous scabies experiences and family histories. Additionally, efforts to reduce contact with street animals and improve living conditions, particularly during the winter months, could contribute to the prevention of scabies outbreaks. Public health campaigns should focus on these risk factors to raise awareness, promote early detection, and ultimately reduce the burden of scabies in affected communities. Collaborative efforts between healthcare providers, humanitarian organizations, and local communities are crucial to effectively address the scabies burden within Rohingya refugee camps and similar settings.

Policy implications

Addressing scabies in Rohingya refugee camps demands urgent, collaborative action from policymakers, governments, clinicians, NGOs, and international health organizations. Prioritizing enhanced screening and treatment programs for all camps is imperative. Family-centered interventions focusing on influential families should educate them on prevention, personal hygiene, and the importance of avoiding sharing bedding and clothing. Simultaneously, efforts to decongest camps and enhance sanitation facilities are crucial for reducing transmission. International support and funding are pivotal for implementing comprehensive scabies control programs, integrating with existing healthcare services, empowering community health workers, and promoting research and innovation. Education and awareness campaigns should emphasize the significance of personal hygiene and individual responsibility in reducing transmission risks. Recognizing the Primary Health Care level as a critical entry point for scabies prevention and management is paramount. Advocacy efforts should be intensified to secure increased funding for Primary Health Care, addressing the often disproportionate allocation compared to other healthcare levels.

Strengths and limitations

The strengths of this research lie in its comprehensive study design and sampling technique, both of which ensured a representative and generalizable sample from the FDMN community in Cox's Bazar. The study utilized information from trained health professionals for clinical diagnosis, thereby enhancing the accuracy of scabies identification. However, several limitations need to be acknowledged when interpreting the findings of this study. Firstly, the cross-sectional design limits the ability to establish causality or temporal relationships between variables. Longitudinal studies would provide more robust evidence regarding the risk factors and dynamics of scabies infection. Secondly, the reliance on self-reported data may introduce recall bias and potentially lead to misclassification of variables. Finally, due to the design of this study or due to possible seasonality, our study may not be free from selection biases.

Conclusion

This study provides valuable insights into the socio-demographic, clinical, and environmental factors associated with scabies infection. The findings highlighted that scabies infection is associated with various factors, including age, marital status, education level, previous scabies and skin infections, family history, living conditions, contact with animals, dust exposure, and seasonal variations. Further research is affirmed to explore the underlying mechanisms and develop targeted interventions to effectively control scabies transmission and improve patient outcomes among the refugees.

Source of funding

This research was conducted without any external funding.

Data sharing statements

We are committed to sharing our research data upon request.

CRediT authorship contribution statement

Md. Shakkor Rahman: Writing – original draft, Project administration, Investigation, Data curation, Conceptualization. A.B.M. Nahid Hasan: . Ishrat Jahan: Writing – review & editing, Writing – original draft, Resources, Methodology, Formal analysis, Data curation. Azaz Bin Sharif: Writing – review & editing, Writing – original draft, Supervision, Project administration, Methodology, Investigation, Formal analysis, Conceptualization.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix Supplementary materials

Image, application 1

Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.jmh.2024.100220.
==== Refs
References

Abul Kalam Azad M. Zakaria M. Nachrin T. Chandra Das M. Cheng F. Xu J Family planning knowledge, attitude and practice among Rohingya women living in refugee camps in Bangladesh: a cross-sectional study Reprod. Health 19 1 2022 1 12 34980183
Andersen B.M. Haugen H. Rasch M. Haugen A.H. Tageson A. Outbreak of scabies in Norwegian nursing homes and home care patients: control and prevention J. Hosp. Infect. 45 2 2000 160 164 [cited 2023 Jun 19]Available from: http://www.journalofhospitalinfection.com/article/S0195670199907168/fulltext 10860693
Andriantsoanirina V. Ariey F. Izri A. Bernigaud C. Fang F. Charrel R. Sarcoptes Scabiei mites in humans are distributed into three genetically distinct clades Clin. Microbiol. Infect. 21 12 2015 1107 1114 26278670
Aždajić M.D. Bešlić I. Gašić A. Ferara N. Pedić L. Lugović-Mihić L. Increased scabies incidence at the beginning of the 21st century: what do reports from Europe and the world show? Life 12 10 2022
Bangladesh: MSF calls for an urgent and comprehensive response to the scabies outbreak in Cox's Bazar refugee camps - Médecins Sans Frontières(MSF)/Doctors Without Borders.
Britannica. Cox's Bazar, Bangladesh [Internet]. Encyclopædia Britannica. 2015 [cited 2023 Jun 20]. Available from: https://www.britannica.com/place/Coxs-Bazar.
Buczek A. Pabis B. Bartosik K. Stanislawek I.M. Salata M. Pabis A. Epidemiological study of scabies in different environmental conditions in central Poland Ann. Epidemiol. 16 6 2006 423 428 16198600
Dagne H. Dessie A. Destaw B. Yallew W.W. Gizaw Z. Prevalence and associated factors of scabies among school children in Dabat district, northwest Ethiopia, 2018 Environ. Health Prev. Med. 24 1 2019 1 8 30611201
Downs A.M.R. Mimouni D. Grotto I. Gdalevich M. Seasonal variation in scabies Br. J. Dermatol. 150 3 2004 602 603 15030355
Dussich J.P.J. The Ongoing Genocidal Crisis of the Rohingya Minority in Myanmar. J. Vict. Vict. Justice. 2018 [cited 2023 Jun 19];1(1):4–24. Available from: https://journals.sagepub.com/doi/10.1177/2516606918764998.
El-Moamly A.A. Scabies as a part of the World Health Organization roadmap for neglected tropical diseases 2021–2030: what we know and what we need to do for global control Trop. Med. Health 49 1 2021
Feldmeier H. Jackson A. Ariza L. Lins Calheiros C.M. de Lima Soares V. Oliveira F.A. The epidemiology of scabies in an impoverished community in rural Brazil: presence and severity of disease are associated with poor living conditions and illiteracy J. Am. Acad. Dermatol. 60 3 2009 436 443 19064303
Hay R.J. Steer A.C. Engelman D. Walton S. Scabies in the developing world-its prevalence, complications, and management Clin. Microbiol. Infect. 18 4 2012 313 323 10.1111/j.1469-0691.2012.03798.x Available from: 22429456
Heukelbach J., Mazigo H.D., Ugbomoiko U.S. Impact of scabies in resource-poor communities. Curr. Opin. Infect. Dis.. 2013 [cited 2023 Jun 19];26(2):127–32. Available from: https://journals.lww.com/co-infectiousdiseases/Fulltext/2013/04000/Impact_of_scabies_in_resource_poor_communities.6.aspx.
Heukelbach J. Wilcke T. Winter B. Feldmeier H. Epidemiology and morbidity of scabies and pediculosis capitis in resource-poor communities in Brazil Br. J. Dermatol. 153 1 2005 150 156 10.1111/j.1365-2133.2005.06591.x [cited 2023 Jun 19]Available from: 16029341
Hossain M.A. Hossain M.B. Understanding fertility behavior of the forcibly displaced Myanmar Nationals in Bangladesh: a qualitative study PLoS ONE 18 5 May 2023 1 19
Hotez P.J. Bottazzi M.E. Franco-Paredes C. Ault S.K. Periago M.R. The neglected tropical diseases of Latin America and the Caribbean: a review of disease burden and distribution and a roadmap for control and elimination PLoS Negl. Trop. Dis. 2 9 2008
ICT Unit L. Local Government Engineering Department (LGED) [Internet]. LGED. 2020 [cited 2023 Jun 20]. Available from: https://oldweb.lged.gov.bd/DistrictArea2.aspx?Area=UnionParishad&DistrictID=13.
Independent International Fact-Finding Mission on Myanmar | OHCHR [Internet]. United Nations Human Rights Council. 2019 [cited 2023 Jun 19]. Available from: https://www.ohchr.org/en/hr-bodies/hrc/myanmar-ffm/index.
Inter-Sector Coordination Group (ISCG). 2022 Joint Response Plan : Rohingya Humanitarian Crisis (January - December 2022). 2022;(December):1–96. Available from: www.humanitarianresponse.info/en/operations/bangladesh.
Islam M. Rushmi Z. Nayeem M. Reza H. Prevalence of diseases among Rohingya refugees in Bangladesh: a comprehensive study IOSR J. Nurs. Heal. Sci. 8 2 2019 14 21
Islam M.M. Nuzhath T. Health risks of Rohingya refugee population in Bangladesh: a call for global attention J. Glob. Health 8 2 2018 8 11
Jackson A. Heukelbach J. Filho A.F.D.S. Campelo E.D.B. Feldmeier H. Clinical features and associated morbidity of scabies in a rural community in Alagoas, Brazil Trop. Med. Int. Heal. 12 4 2007 493 502
Khan A.I. Islam M.T. Khan Z.H. Tanvir N.A. Amin M.A. Khan I.I. Implementation and delivery of oral cholera vaccination campaigns in humanitarian crisis settings among Rohingya Myanmar nationals in cox's bazar, Bangladesh Vaccines 11 4 2023 1991 1992
Kouotou E.A. Nansseu J.R.N. Sangare A. Moguieu Bogne L.L. Sieleunou I. Adegbidi H. Burden of human scabies in sub-Saharan African prisons: evidence from the west region of Cameroon Australas. J. Dermatol. 59 1 2018 e6 10 28251621
Liu J.M. Wang H.W. Chang F.W. Liu Y.P. Chiu F.H. Lin Y.C. The effects of climate factors on scabies. A 14-year population-based study in Taiwan Parasite 23 2016
Marks M. Romani L. Sokana O. Neko L. Harrington R. Nasi T. Prevalence of scabies and impetigo 3 years after mass drug administration with ivermectin and azithromycin Clin. Infect. Dis. 70 8 2020 1591 1595 31131410
Medecins Sans Frontiers. Health Survey in Kutupalong and Balukhali Refugee Settlements, Cox ’s Bazar, Bangladesh. 2017;(December):37–40. Available from: https://www.msf.org/sites/default/files/coxsbazar_healthsurveyreport_dec2017_final1.pdf.
Ming S. Bangladesh Rohingya crisis update – August 2018 | MSF [Internet]. MSF. 2018 [cited 2023 Jun 19]. Available from: https://www.msf.org/bangladesh-rohingya-crisis-update-–-august-2018.
Murray C.J.L. Vos T. Lozano R. Naghavi M. Flaxman A.D. Michaud C. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010 Lancet 380 9859 2012 2197 2223 23245608
Noko K. Bangladesh: scabies in Rohingya refugee camps [Internet]. MSF. 2023 [cited 2023 Jun 19]. Available from: https://msfsouthasia.org/bangladesh-scabies-in-rohingya-refugee-camps/.
Ong C. Vasanwala F. Infected with scabies again? Focus in management in long-term care facilities Diseases 7 1 2018 3 30597979
Rashid R. Uddin A.M.S. Nu P.C. Salam A. Barua S. Mannan A. A descriptive study of Forcefully Displaced Myanmar Nationals (FDMN) presenting for care at public health sector hospitals in Bangladesh Glob. Health Action 14 1 2021 10.1080/16549716.2021.1968124 Available from
Reichert F. Schulz M. Mertens E. Lachmann R. Aebischer A. Reemergence of scabies driven by adolescents and young adults, Germany, 2009–2018 - volume 27, number 6—June 2021 - emerging infectious diseases journal - CDC Emerg. Infect. Dis. 27 6 2021 1693 1696 34013873
Romani L., Steer A.C., Whitfeld M.J., Kaldor J.M. Prevalence of scabies and impetigo worldwide: a systematic review. Lancet Infect. Dis. 2015 [cited 2023 Jun 19];15(8):960–7. Available from: http://www.thelancet.com/article/S1473309915001322/fulltext.
Salah Hegab D. Mahfouz Kato A. Ali Kabbash I. Maged Dabish G. Scabies among primary schoolchildren in Egypt: sociomedical environmental study in Kafr El-Sheikh administrative area Clin. Cosmet. Investig. Dermatol. 8 2015 105 111
Chosidow O. Scabies. N. Engl. J. Med.. 2006 Apr 20 [cited 2023 Jun 19];354(16):1718–27. Available from: https://www.nejm.org/doi/10.1056/NEJMcp052784.
Ugbomoiko U.S. Oyedeji S.A. Babamale O.A. Heukelbach J. Scabies in resource-poor communities in Nasarawa State, Nigeria: epidemiology, clinical features and factors associated with infestation Trop. Med. Infect. Dis. 3 2 2018 13 15 30274411
UNHCR. Rohingya Refugee Crisis Explained [Internet]. UNHCR. 2023 [cited 2023 Jun 20]. Available from: https://www.unrefugees.org/news/rohingya-refugee-crisis-explained/.
Walton S.F. The immunology of susceptibility and resistance to scabies Parasite Immunol. 32 8 2010 532 540 20626808
WHO. WHO Action on Scabies: outbreak in the Rohingya displacement camps - Bangladesh | ReliefWeb [Internet]. 2022 [cited 2023 Jun 20]. Available from: https://reliefweb.int/report/bangladesh/who-action-scabies-outbreak-rohingya-displacement-camps.
Wick J.Y. Zanni G.R. In the Elderly Consult. Pharm. 19 3 2004 195 213
Zeba N., Shaikh D.M., Memon K.N., Khoharo H.K. Scabies in Relation to Hygiene and Other Factors in Patients Visiting Liaquat University Hospital, Sindh, Pakistan. Int J Sci Res [Internet]. 2012;3(8):241–4. Available from: https://www.researchgate.net/publication/343389941_Scabies_in_Relation_to_Hygiene_and_Other_Factors_in_Patients_Visiting_Liaquat_University_Hospital_Sindh_Pakistan.
