Scabies is a common public health problem, globally affecting about 200 million people. It is a particular problem where there is social disruption, overcrowding, and where personal hygiene is poor. Immunosuppression, poor nutritional status, and dementia are also risk factors for scabies [1
]. Natural disasters, war, and poverty lead to overcrowding and have been associated with increased rates of transmission [4
Scabies is caused by an ecto-parasitic infestation of the skin by the human itch mite, Sarcoptes scabiei
]. It usually spreads by direct, prolonged, skin-to-skin contact with an infested individual. The main effect of scabies is debilitating itching, leading to scratching, which in turn is followed by breakdown of the barrier function of the skin and complications due to bacterial infection, ranging from impetigo, abscesses, and cellulitis, to more serious conditions such as septicemia and glomerulonephritis, leading to renal failure and rheumatic heart disease [1
The data from The International Disaster Database indicate that in Africa more than 40 million people were affected by drought in 2015–2016. Following the 2015–2016 El-Niño event, which affected many countries globally, Ethiopia experienced drought and extreme water shortage across large parts of the country. This has further limited access to water for personal hygiene and basic sanitation for many individuals, especially those in rural communities, leading to a great increase in the risk of communicable diseases like scabies and diarrheal diseases [5
Most definitions of drought describe it as a prolonged period of abnormally low rainfall, leading to a shortage of water. The effects of drought are critically dependent on both context and vulnerability of the underlying population. The development and severity of the drought depends on the background level of water use, which may also influence the timing of the onset, duration, and end of the drought, as well as the social, economic, and administrative infrastructures which address the consequences of water deficit. The impact on health is particularly dependent on the socio-economic environment that, in turn, has a direct impact on the resilience of the population. Poor health, poverty, and conflict are additional contributing factors that exacerbate the impact of drought [6
1.2. Government Priorities/Political Setting
Following official acknowledgment by the Ethiopian government of a food crisis in July 2015, the Federal Ministry of Health established a command post spearheaded by the Public Health Emergency Management (PHEM) directorate. In September 2015, the Amhara Regional State PHEM announced the first report of a scabies epidemic [8
]. To validate the diagnosis, a team of field epidemiologists and a dermatologist visited three of the areas where the claim had emerged. The experts collected data from three health centers and six health posts in addition to visiting households that had been previously diagnosed with scabies at local health facilities. The experts concluded that scabies was the major active public health problem affecting the community, with the status of an outbreak [9
Prior to September 2015, the regular review of drought-related public health emergencies, in both federal and regional PHEM disease surveillance systems, focused solely on malnutrition, diarrheal diseases, measles, malaria, and meningitis; however, there was no consideration of skin-related conditions. A recent literature review by Anderson and Davies has shown that El Niño has been associated with increases in the occurrence of sun-related skin diseases and certain vector-borne and waterborne diseases [10
]. Despite outbreak reports in some parts of the country [8
], scabies was not included in either the list of reportable diseases or the weekly reports.
After the first visit to some of the affected zones and a review of information regarding the burden of the problem, the inspection team advocated the inclusion of scabies as a separate item on the weekly surveillance list for the Federal Ministry of Health and Regional Health Bureau. Since October 2015, scabies has been included as one of the reportable diseases in the drought affected areas. The weekly PHEM surveillance reports revealed that scabies was becoming significantly more extensive than its more usual occurrence as sporadic clinical cases, and was now a public health concern affecting wider geographic areas and population groups, especially in the woredas most severely affected by drought and malnutrition. Hence, it required public mobilization and public health emergency interventions. The report revealed that the Amhara, Tigray, and Oromia regions had the highest burdens of scabies in Ethiopia.
The extent of the drought and the increased number of water-scarce woredas
with limited access to water sanitation and hygiene (WASH) interventions, further worsened the spread of the disease and its severity among the vulnerable. From the November 2015 harvest season assessment, the number of nutritional hot-spot woredas
increased to 429, involving a total population of nearly 49 million. That same month, the public health emergency management task force received a report that the number of severely affected woredas
in Amhara, Tigray, and Oromia had reached 32, and despite the limited surveillance program for scabies, the estimated total number of cases reached more than 250,000 with prevalence of at least 15% in some districts [6
In October 2015, following the national government elections, prominent officials at all levels of the administration attended an official meeting. The researchers used this as an opportunity to present the preliminary data of the burden of scabies and the recommended action to be taken by the relevant officials (zonal and woreda administrators, zonal and woreda health office officers, heads of the Regional Health Bureau, and other officials) and to advocate for region wide evidence generation in preparation for the intervention.
A systematic review of scabies prevalence studies published between 1985 and 2015, included only five African countries, highlighting the paucity of prevalence data in Africa [11
]. This house-to-house census and validation study of scabies provides a unique opportunity to ascertain community prevalence. Such data is more reliable than health facility-based data which generally underestimates prevalence, as individuals within communities may not present with scabies (perhaps because it is ‘normalized’) or because there is under-diagnosis or lack of effective treatments at clinics [12