Introduction

Scabies, a highly contagious skin disease mainly affecting children, is caused by a parasitic mite Sarcoptes scabiei [1]. This disease is transmitted through direct and prolonged contact with infected skin or by using contaminated personal objects [2]. The predominant clinical manifestations of scabies include debilitating itching and scratching, often lasting for months in untreated patients [3]. Complications among these patients are frequent due to secondary bacterial infection, ranging from impetigo, abscesses, and cellulitis [4]. Scabies also causes significant morbidity, resulting from sleep disruption, concentration difficulties, and impaired productivity [5].

Being one of the most common Neglected Tropical Diseases (NTDs) with skin manifestations, scabies contributes to a substantial public health burden globally, resulting from high case numbers, disease complications, and containment costs [6,7]. Over 175 million people worldwide are infected by this disease, mostly in lower- and middle-income countries of Sub-Saharan Africa and South-East Asia, contributing to almost 4.84 million disability-adjusted life-years (DALYs) annually [8,9].

Scabies disproportionately affects children in disadvantaged settings. Overcrowded living conditions, malnutrition, shared sleeping arrangements and sharing of clothes and towels with those who are already infected are common risk factors for this disease [10,11]. Children in lower socioeconomic settings, especially those living in unhygienic and crowded areas like urban slums and orphanages, are most vulnerable to this disease [11–13]. In these children, infestations often spread rapidly due to close contact and overcrowding. However, treating this group is challenging due to delayed diagnosis, inadequate treatment, malnutrition, associated allergic and bacterial infections, and insufficient follow-up [14].

Communal settings and closed residential environments, like orphanages, where a large number of children live together in the same building or compound, are highly vulnerable for scabies due to factors like crowded living conditions and close contacts with infected peers [15]. In Bangladesh, a lower-middle-income country of south-east Asian Region, there are more than four hundred thousand orphan children [16]. Among them, approximately 9500 orphans are accommodated in 73 government-run orphanages while the private orphanages accommodate far larger number [17]. Majority of these private orphanages depends on the community donation which is often collected by the children from the households. A lot of these facilities are linked to religious schools where other children are also enrolled. Moreover, the residents of orphanages often attend community social and religious customs like funerals, prayers etc. These intense social interactions of the children living in orphanages could make them a potential source of scabies for the community. Hence, prevention and treatment of scabies in orphanages might help to reduce community burden of scabies as well. Understanding the epidemiology of scabies in orphanages would allow design effective prevention strategies. Therefore, this study aimed to determine the prevalence and associated factors of scabies among children in orphanages in Dhaka city, Bangladesh.

Methods

Diagnosis of scabies

Scabies was diagnosed in this study based on criteria for scabies diagnosis developed by the IACS, 2020 consensus criteria [20].

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https://doi.org/10.1371/journal.pntd.0013671.t004

In this study, we used the subcategory of B (clinical scabies) and C (suspected scabies) for diagnosing scabies.

The severity of scabies was defined based on the number of lesions counted as mild (1–10 lesions), moderate (11–49 lesions) and severe scabies (>50 lesions) [21].

Results

Baseline characteristics

A total of 471 orphaned children from five orphanages of Dhaka city of Bangladesh were included in this study. Their mean age was 11.9 (SD 3.24) years and majority of them were female (almost 76.9%). An orphanage accommodated a median number of 94 children. The median number of children sharing a room and a toilet were 10 and 15 respectively. Almost 16% of the children reported that they shared bed for sleeping with other children while 26% reported that they shared their personal items with others (Table 1).

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Table 1. Baseline characteristics of the children living in orphanages (n = 471).

https://doi.org/10.1371/journal.pntd.0013671.t001

Prevalence of scabies

Overall prevalence of scabies among the orphaned children was 31.6%. According to the IACS criteria, 41.6% of them were suffering from clinical scabies while the rest of 58.4% were suffering from suspected scabies. Severity of scabies was mild, moderate and severe in 60.4%, 28.2% and 11.4% children, respectively (Table 2).

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Table 2. Scabies related characteristics of the children living in orphanages.

https://doi.org/10.1371/journal.pntd.0013671.t002

Genital and inguinal area was the most commonly reported site of scabies lesion found in almost 65% of the infected children followed by interdigital space, hands, legs and abdomen (Fig 1).

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Fig 1. Sites of lesion of scabies among the children living in orphanages (n = 149) (The clip-art used in this figure was sourced from Wikimedia Commons).

https://doi.org/10.1371/journal.pntd.0013671.g001

Factors associated with scabies

We found that scabies was more prevalent in male orphans compared to their female counterparts (39.5% vs 29.3%). Moreover, children living in crowded orphanages, those who slept on floor, shared bed with other children for sleeping, shared personal items and had history of pruritus in close contacts or peers had a higher prevalence of scabies (Table 3).

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Table 3. Characteristics of children with or without scabies.

https://doi.org/10.1371/journal.pntd.0013671.t003

In logistic regression model, it was found that male children had almost 2.76 times higher odds of being infected by scabies compared to female children (aOR 2.76, 95% CI 1.14, 7.45, p-value 0.032). Other significant risk factors of scabies were increased number of children per room (aOR 1.07, 95% CI 1.03, 1.12, p-value 0.001) and history of pruritus in the close contacts or peers (aOR 1.89, 95% CI 1.04, 3.46, p-value 0.038) (Table 3).

Discussion

The objective of this study was to determine the prevalence and factors associated with scabies in orphaned children who are one of the major vulnerable groups for this disease. According to our findings, 31.6% orphaned children were affected by scabies, of which 60% were mild, 28% were moderate and 12% were severe. Among these children, 41.6% were clinically diagnosed and 58.4% were suspected for scabies according to the IACS criteria.

Scabies is a disease of poverty affecting predominantly children from low socioeconomic condition [22]. The orphanages might be the vulnerable sites for scabies endemic due to overcrowding and poor living circumstances. However, there is scarcity of evidence regarding the prevalence of this disease among orphaned children in Bangladesh. A recent study conducted by the senior author of this paper and others among children from Islamic residential religious schools (madrasahs) reported that almost one-third of the children were infected by scabies in these institutions, comparable to our findings [23].

Orphanages are found to be endemic places for scabies worldwide, especially in developing countries. For instance, a study from India reported scabies as one of the most common skin infections among the children and adolescents living in the orphanages [24]. Similar findings were reported from orphanages of other developing countries like Sudan and Ethiopia where a significant number of children living in these institutions were affected by scabies [25,26].

The prevalence of scabies among children found in our study, coincides with the findings from other developing countries. In neighboring India, the prevalence of scabies among school children ranged from 20 to 39% in different studies [27,28]. In Nepal, another country from South Asian region, the prevalence was reported as 32%, similar to our finding [29]. Few countries like Pakistan reported a higher prevalence of scabies among children (almost 57%) [30]. By contrast, majority of the other lower- and middle-income countries reported a lower prevalence of scabies like Ethiopia (19%) [31], Cameroon (18%) [32], Nigeria (13%) [33] etc. However, most of these studies were conducted in community or school settings, whereas our study was conducted in an institutional orphanage setting. Children in orphanages often come from low socioeconomic backgrounds and live in crowded conditions, which facilitate close contact with infected peers and increase the risk of scabies transmission. Furthermore, as scabies was primarily diagnosed clinically in the majority of the studies, subjective variations in the diagnostic accuracy of data collectors might contribute to differences observed between the present study and previous research.

Among our participants, male children were more vulnerable to scabies infestation compared to their counterparts, a pattern that is likely a universal phenomenon [11,31,32]. These male children usually spend most of their daytime at the field playing through touching each other and handling contaminated articles with the scabies mite from their peers, which might make them vulnerable to scabies. Personal behavioral factors, such as bed-sharing, clothing-sharing, infrequent bathing, lack of soap use, etc. have been suggested as risk factors for scabies in some studies [34]. However, our logistic regression analysis did not find a significant association between these practices and scabies, which is in line with the balance of the wider evidence base. Rather than individual behaviors, the link between poverty and scabies is more likely driven by factors such as housing density and limited access to healthcare [22]. Notably, in our study, the strongest positive association with scabies was the number of children per room. As a contagious disease, the spread of scabies is exacerbated among closely resident and interacting peer groups of children, as evidenced in our study. This aspect highlights the importance of understanding not only individual-level factors but also the dynamics of social interactions in the transmission of scabies.

Given the high prevalence of scabies reported in our study (31.6%), relying solely on individual case management is unlikely to achieve effective disease elimination in these settings, particularly where close contact with infected individuals is frequent. Therefore, a more effective strategy such as mass drug administration (MDA) using oral ivermectin for all residents and caregivers might be considered in high-burden settings [35].

Conclusions

In conclusion, our study reported a substantial level of prevalence of scabies among orphanage children in Dhaka, Bangladesh. Major factors contributing to this prevalence include male gender, overcrowded living conditions, and close contact with infected peers. Addressing this public health concern necessitates a comprehensive approach that includes interventions aimed at reducing the number of children per room and strategically minimizing contact with individuals affected by scabies when they are infective. Additionally, considering the high prevalence of scabies in the orphanages, a mass treatment program might better control the transmission of the disease. Finally, the findings of our study would guide the implementation of targeted strategies to mitigate scabies transmission within these settings, thus fostering a healthier environment for the vulnerable population of children in orphanages.

Supporting information

Acknowledgments

We acknowledge contribution of Dr. Taha Choudhury, Dr. Susmita Zaman, Dr Salwa Islam, Dr Paromita Zaman for their contribution in data collection process. The authors would like to express their sincere gratitude to Pi Research & Development Center, Dhaka, Bangladesh (www.pirdc.org), for their help in manuscript revision and editing.