Scabies in Cox's Bazar

This was first published on The Lancet on 19 August, 2023. Written by Jacqui Thornton.

Ajmot Ullah has taken his 4-year-old son to the Médecins Sans Frontières (MSF) medical facility in the Cox's Bazar refugee camp in Bangladesh, where he lives with his family. He was ushered to a special area set up in two of MSF's eight medical facilities supporting the overcrowded, cramped living conditions. The young boy had started having rashes on his hands and then on his whole body. “We spent money on doctors and pharmacies and eventually he got better, but he was reinfected with scabies very quickly”, Ullah told an MSF clinician. “He doesn't sleep much, his whole body itches, especially at night, and he cries a lot from the pain. My other two sons also have scabies, and my wife and I have symptoms too. It has become a nightmare for my family.”

Thousands are affected by the infectious skin condition. In March, 2022, MSF started to see unusually high numbers of patients with scabies, and numbers have escalated since. Between January and May of this year, MSF teams in the camps treated almost 70 000 patients for scabies—nearly double that of the same period in 2022. WHO is understood to have undertaken a survey in May, and found an average prevalence of 40%, with this rate at around 70% in some camps within the huge refugee complex.

Karsten Noko, Head of Mission for MSF in Bangladesh, who attended the WHO meeting outlining the figures, says a minority of camps had even higher prevalence. He told The Lancet: “At least one was close to 90%…We think the outbreak is out of control. We see the impact through the number of patients who come to our facility, overwhelming our teams. Our front-line medical colleagues for the past almost 18 months have been treating scabies patients every day.”

Earlier in the year, the teams received peaks of 700 patients per day, according to Pankaj Paul, Deputy Medical Coordinator of MSF Bangladesh, and in February they had to start turning people away and redirecting them to other health facilities closer to where they lived within the camps. “At the moment, we cannot treat everyone who comes in with scabies—we just don't have the capacity”, Paul said.

Save the Children has been tracking cases and in the last 3 months its eight health facilities have treated more than 4500 people. Abdullah Al-Noman, Senior Program Manager for Health at Save the Children in Cox's Bazar, says health-care workers have been given specialist training on treating the disease.

In the MSF facilities, scabies clinics allow doctors to triage patients quickly and follow the epidemiology of the disease, as well as offer additional capacity away from other patients. Scabies is treated with topical permethrin cream, which kills the scabies mite, and an oral treatment, ivermectin. But reinfection is common and can cause anxiety and discomfort. Crusted scabies can affect many organs in the body and can cause secondary infection and sepsis.

Mass drug administration (MDA) using ivermectin is WHO policy for outbreaks with a prevalence above 10% and a rapid MDA is planned for September in ten camps—shortly after the 6-year anniversary of the expulsion from Myanmar of Rohingya people on August 25, 2017. Al-Noman said WHO has 3·2 million doses in its warehouse in Cox's Bazar and is attempting to procure a further 2 million. He added that this was a vital step to break the transmission chain.

However, it is not simply a question of drugs. The source of the outbreak—unsanitary conditions—needs to be tackled. MSF is demanding improve­ments to water, sanitation, and hygiene within the camps. A study on water and sanitation conditions in 2022 showed a lack of proper sanitation and insufficient availability of water.

MSF said that while there have been considerable improvements in water and sanitation infrastructure over the last 2 years, with the installation of water networks and chlorination, there has been degradation in the maintenance. In some areas, people have access to water for just 2 h per day. In June, refugees’ soap rations were cut from four bars per month (two for washing, two for bathing) to just two bars per person, Noko said. In addition, families of six people are living in two or three rooms typically, according to Al-Noman. Torrential monsoon rains in August have displaced many families and worsened living conditions.

Noko said, “For patients who have had multiple reinfestations there is a sense of anxiety that comes with a disease that people have been going back and forth to get treatment for, and yet it seems to resurface again after some weeks.” Taher, an 18-year-old refugee living in Jamtoli camp, is one such resident. He told MSF: “I have tried my best to maintain hygiene standards, but it is hard. We share bedding, we share clothes, we share everything. Now we share scabies too.”