The Ethiopian SORT IT Course “Stopping the itch”: mass drug administration for scabies outbreak control covered for over nine million people in Ethiopia

Introduction: In 2018, the Ethiopian Ministry of Health embarked on a Mass Drug Administration (MDA) campaign that involved over 9 million people in Ethiopia – the largest scabies MDA campaign ever conducted on a global level. We describe its implementation and report on a) numbers screened and identified with scabies, b) treatment category and drug type and c) human resources used, duration, and cost of the campaign. Methodology: The MDA campaign was conducted according to national guidelines and activities including: planning and organization, engagement of local leaders, community mobilisation and advocacy, awareness-raising among health workers, field implementation, and monitoring and evaluation. The campaign was conducted between July and August 2018. Results: The MDA campaign was implemented by about 15,000 people, mostly from the community, over an average of 6 days and reached 9, 057, 427 people. A total of 875,890 (9.7%) scabies cases were detected and 995,471 (11.0%) contacts received treatment. (Contact-to-case ratio = 1.3). Scabies prevalence varied, the highest prevalence was seen in Central Gondar (39.2%), South Gondar (16.7%) and North Gondar (15.0%), these neighbouring zones contributing more than two third of all scabies cases in the region. Of 1,738,304 (93%) who received treatment, 94% received ivermectin, the rest topical permethrin and sulfur. The average coverage capacity of an MDA campaign staff member was 84 people per day. The total cost was 11,696,333 United States Dollars (USD). Cost per 100,000 population = 129,135 USD. Conclusions: This experience of rapid-large scale implementation would be useful to scale up similar interventions and “stop the itch” in other regions of Ethiopia.


Introduction
Human scabies, caused by the mite Sarcoptes scabiei var hominis is transmitted through person-toperson contact. It is a Neglected Tropical Disease (NTD) of public health importance [1] and one of the "commonest dermatological conditions" in tropical climates where overcrowding and poverty exist [2]. Globally there are an estimated 175 million scabies cases, causing debilitating itch, social stigmatization, and complications including septicaemia, glomerulonephritis and chronic rheumatic heart disease [3][4][5][6][7].
In Ethiopia, national attention on the disease followed reports of scabies outbreaks in droughtaffected areas in 2015 [8]. Mass drug administration (MDA) campaigns which involve administration of scabies treatments (ivermectin and permethrin) to large communities is known to be useful for controlling scabies and reducing community prevalence by more than 90% [8][9][10].

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The Amhara region in Ethiopia is one of the scabies endemic areas in the country. In 2015, the Ethiopian Federal Ministry of Health embarked on an MDA campaign resulting in the screening of 1.2 million people and treatment for 850, 200 cases and contacts [8]. The experience guided to a much broader campaign that took place in 2018 and involved over 9 million people.
During the 2018 campaign, aggregate data were routinely collected and uniquely; the entire target population was screened for scabies prior to drug administration. This MDA campaign provided first an opportunity to get information on community scabies prevalence. This is more reliable than health facilitybased data as health-seeking behaviour, access and availability of treatments may affect attendance, and prevalence may be underestimated [11]. A systematic review of scabies prevalence studies published between 1985 to 2015 included only five African countries (Egypt, Tanzania, Ethiopia, Nigeria and Cameroon with prevalence ranging 0.2 to 9.2%) highlighting the paucity of prevalence data in Africa [5,7].
Second, the "how to deliver" of an MDA campaign involving over 9 million people, which has never been described previously. The experience and knowledge may guide the scale-up of scabies control in Ethiopia and beyond. Previous publications on scabies MDA campaigns have focused on the pacific islands and on small populations [10,11]. A PubMed search revealed no MDA studies from the African region on a scale of millions. Such information can also contribute to the Sustainable Development Goal (SDGs) target of eliminating NTDs by 2030 [12].
We aimed to describe the implementation of a mass drug administration campaign conducted for scabies outbreak control in the Amhara region of Ethiopia between June and August 2018.
The specific objectives were to report on a) numbers screened and identified with scabies (cases and contacts) stratified by geographic zones, b) scabies cases treated according to treatment category and treatment type and c) the human resources, duration of the campaign and associated costs.

Study design
Cross-sectional descriptive study using routine monitoring data from the MDA campaign.

General setting
Ethiopia is a landlocked country in the horn of Africa, with a population of 99 million. It shares borders with Eritrea in the north and northeast, Djibouti and Somalia in the east, Sudan and South Sudan to the west, and Kenya to the South [13]. The country has limited health coverage (39% of the entire population) and the current annual health expenditure per capita is 24 United States Dollars (USD) [14]. Ethiopia registers 16 of the 21 NTDs on the WHO list [15].

Specific setting -Amhara region
The Amhara Regional State in the North West of the country is the second-most populous region (21,234,988 inhabitants) after Oromia Region. It is divided into 13 administrative Zones and 142 districts (Woreda's) ( Figure 1). This region has an estimated population density of 108.2 persons per square kilometer. The average household size is 4.3 persons, with 85% of the population living in rural areas [13]. The Amhara Region covers approximately 161,828.4 Km 2 . The region's topography embraces plains, gorges, plateaus, hills and mountains [16].

The Mass Drug Administration campaign for scabies
The MDA campaign was conducted in line with regional guidelines for large-scale scabies control [17]. A preliminary survey was conducted in all zones of the Amhara Region between May 14 th to June 20 th, 2018, in order to determine scabies prevalence and guide the MDA campaign process. Figure 2 shows the mapping of scabies cases detected during this exercise. In brief, it included: planning and organization, community mobilisation and advocacy, awareness-raising among health workers, engagement of local leaders, field implementation, logistics and monitoring and evaluation. The specific activities of the MDA 30S campaign are shown in Table 1. Drug treatment based on age-group and pregnancy/lactation status are shown in Table 2.
The MDA strategy was based on community scabies prevalence. When community prevalence was less than 15%, the drug was given for cases and contacts after the active household screening. When community prevalence was equal or greater than 15%, no screening was needed and the community was subjected to mass drug administration. Treatment for scabies with ivermectin or permethrin involves two doses given one week apart. For Sulfur, the ointment is applied daily for three consecutive days. [17] A scabies case was defined as the presence of itching with a typical lesion in the inter-digital areas of the hands, inter-gluteal and/or genitalia area and/or Political commitment and coordination -Soliciting high-level political commitment at government and community level (community leaders /elders) -Establishing appropriate inter-sectoral coordination sub-committees Baseline data and action plan development -Collection of base-line data on populations from household screening -Drug forecasting, health worker availability and addressing hard to reach areas.

Definitions of cases and contacts of scabies
-Developing a plan of action, that specifies the target population, target area, timelines for the various activities.
-Developing logistics planning and monitoring tools -Adapting training materials/ guidelines Social and resource mobilization -Social Mobilization (Community awareness raising and advocacy) -Resource mobilization (logistics, human resources, drugs) Training and distribution of supplies -Organizing district-level training of MDA teams -Conducting micro-planning workshops -Distribution of drugs, supplies and other campaign materials to all sites/teams Intra-campaign (MDA Implementation) Crowd control -Ensure that order is maintained around screening sites. Drug distribution.
-Fixed treatment center screening by MDA teams -Providing treatment for cases and contacts -Logistics and supplies: Monitor logistics and drug availability and address shortages if any through reserve stocks. Community reassurance -Provide clarifications and answer questions when asked. Supervision and monitoring -Monitor daily coverage and drug utilization reports through completed tally sheets.
-Mobilize contingency resources to address exceptional situations such as delays or shortages in screening teams -On the job supervision of campaign implementation Post-campaign (Reporting and feedback) -Compiling data -Compiling MDA report -Post campaign surveillance -Report writing and feedback 31S have had close contact with an individual who had itching or lesions in a typical distribution.
A scabies contact was defined as a person who did not fulfil the clinical criteria of a scabies case but had direct contact (skin-to-skin) with a suspected or confirmed case in the two months preceding the onset of scabies in the identified case.

Study population and period
The study included all individuals screened for scabies during the MDA campaign in the Amhara Region from July to August 2018.

Data collection
Data on household scabies screening and treatment were collected on standardized reporting forms by Health Extension Workers (HEW), compiled at the district level and entered into a dedicated database. District data were transferred to the zone and finally to the regional public health emergency management directorate. All HEWs were trained on scabies identification, data collection and were supervised by a member of the district Monitoring and Evaluation unit, who was part of the MDA team. Data entry was done from tally sheets into Microsoft Excel by a dedicated person at the district level. This database (MDA database) constituted the data source for the study.

Data analysis and statistics
Scabies cases detected by zones were standardized as percentages to give estimated prevalence by zone. The "population coverage capacity per campaign staff per day" was calculated using the formula [target population ÷ total number of campaign staff used ÷ duration of the campaign in days]. Results were presented descriptively.

Ethics considerations
Permission to conduct the study was obtained from the Amhara Regional Health Bureau. Ethics approval was received from the Amhara regional Public Health Institution ethical review board, Bahir Dar, Ethiopia.

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The study was also approved by the Ethics Advisory Group of the International Union against Tuberculosis and Lung Disease, Paris, France. As this was a record review study without patient identifiers, the issue of informed patient consent did not apply. Table 3 shows the numbers of individuals screened and identified with scabies by geographic zone in the Amhara region. Thus, of 21,384,072 people in the 13 zones of the Amhara region, 9, 057, 427(42%) people were targeted (screened) for the MDA campaign. A total of 875,890 (9.7%) scabies cases were detected with 995,471 (11 %) contacts, all of whom were treated (contact-to-case ratio = 1.3).

Numbers screened and identified with scabies (cases and contacts) by geographic zones
Scabies prevalence varied by zone and ranged between 0.2% and 39.2%, the highest prevalence was seen in Central Gondar (39.2%) followed by South Gondar (16.7%) and North Gondar (15%). These three neighbouring zones contributed 70.9 % of all scabies cases detected in the region.

Numbers (and proportion) of scabies cases and contacts stratified by treatment category and treatment type
Of 1,871,361 scabies cases and contacts who should have been treated for scabies, 1,738,304 (93%) were registered as having received treatment, the vast majority (94%) having received ivermectin. Information on treatment type was specified for all, while the treatment category (age group and pregnancy status) was unrecorded in 789,581 individuals (45.4%). Of 948,723 individuals for whom both treatment category and treatment type were recorded, all individuals aged ≥18 years received ivermectin while it was avoided in all pregnant and lactating mothers. This is in line with national guidelines.
In children aged 2-6 years who were eligible (148881 cases and 131099 contacts) to receive ivermectin [17], only 73.9% of cases and 71% of contacts received the drug. The remaining were given permethrin and or sulphur (Table 4). Table 5 shows the numbers of human resources used in the MDA campaign, the duration (in days) and the population coverage capacity by a worker per day.

Human resources used, duration of the MDA and cost of the campaign
The MDA campaign mobilized 14,796 people mostly from the community and was conducted over an average of 6 days. The average population coverage capacity of one MDA staff member was 84 people per day ( Table 5).
The total cost to screen and treat 9,057,427 people was 11,696,333 United States Dollars (USD). Cost per 100,000 population = 129,135 USD or 1.29 USD/person ( Table 6).

Discussion
This is the first study from Africa describing the large-scale implementation of a mass drug administration campaign for scabies conducted in an average of 6 days, reaching 9 million people and costing about 1.29 USD per person. Regional scabies prevalence was 9.7% and reached 39.2 % in one zone. Close to 15 thousand people were mobilized for MDA implementation, mostly from the community.
This experience is unique in terms of coverage and important as it shows a possible way forward in implementing large scale scabies control, a key to achieving the SDG target of eliminating scabies by 2030 [12].
A study strength is that we integrated a robust monitoring and evaluation system, included a monitoring and evaluation officer and supervised datarelated issues at central level (region). Furthermore, there were strict definitions for scabies cases and contacts and we thus believe our data is robust. Finally, this study addresses an identified NTD operational research priority in Ethiopia and may impact policy.
The main limitation of the study is that at the community level information was documented paper based and transfer of the paper based data in to Excel sheet was done in district health offices. And in the process entering the paper based information to Excel, the data management group had to clean up some illegible and missed information. This resulted in some incomplete data (i.e. number of treated, treatment category and number of campaign staff used).
The study findings highlight several policy and practice implications. First, conducting a campaign that managed to mobilize almost 15,000 workers and reach over nine million people in about a week is a mammoth task. This campaign would not have been possible if the strategy was to rely on health workers within health facilities (15,634 available in the region) [18]. The rapid and large-scale MDA campaign was feasible, thanks to ensuring the prior engagement of community leaders and the community including HEWs. Except for a driver, a finance officer and a monitoring officer, all other members of the implementation team were from the community. In Ethiopia, community-based HEWs 34S include groups like the "Women Health Development Army" who played a vital role in the success of campaigns. Such groups constitute a stable network that can catalyse community participation geared to improving community health [19]. The global polio eradication campaign has reported a similar experience of success [20].
Second, the three neighbouring zones of Gondar had the highest scabies prevalence and constituted more than two-thirds of all cases. Importantly, the average contact-to-case ratio in those zones was just 1.1 on average, implying that intense scabies transmission had already occurred, and almost all potential contacts were already infected. In such a scenario, investing much time and resources in an individual screening before initiating scabies treatment does not make sense in public health. It is likely to be more cost-effective to embark on mass drug administration, without screening.
The beneficial spin-off of this approach would be that, with ivermectin as treatment option soil transmitted helminths, ecto-parasites (pediculosis), onchocerciasis and filariasis would all be treated at the same time as "a one shot approach".
As ivermectin is known to be safe and is already being used in the MDA strategy for onchocerciasis and filariasis control, this would be an opportunity and a logical step forward [21][22][23].
Finally, although children aged two to five years were eligible to receive Ivermectin according to the scabies guideline, about 30% of cases and contacts received drugs other than ivermectin. There were no reported ivermectin stock out and the reason for this finding is unclear. A possible explanation would be the existing incoherence with the national onchocerciasis guideline which contrary to the scabies guideline, does not recommend ivermectin for children under five years. This difference in guidelines might have confused health workers and needs to be further discussed at the national level.

Conclusion
In Ethiopia, it was feasible to conduct a rapid MDA campaign covering over nine million people. This experience of conducting a rapid large-scale scabies campaign implementation could be useful to scale up similar interventions and "stop the itch" in other regions of Ethiopia and beyond.