AN INCREASING SCABIES INCIDENCE IN CROATIA: A CALL FOR COORDINATED 
ACTION AMONG DERMATOLOGISTS, PHYSICIANS AND EPIDEMIOLOGISTS
Liborija LUGOVIĆ-MIHIĆ1,2, Marija DELAŠ AŽDAJIĆ1*, Sanja KUREČIĆ FILIPOVIĆ3, Iva BUKVIĆ1, 
Ivana PRKAČIN1, Danijela ŠTIMAC GRBIĆ3,4, Mirjana Lana KOSANOVIĆ LIČINA5
1Sestre milosrdnice University Hospital Center, Department of dermatology and Venereology, Zagreb, Croatia
2School of Dental Medicine, University of Zagreb, Zagreb, Croatia 
3Croatian Institute of Public Health, Zagreb, Croatia
4School of Medicine, University of Zagreb, Zagreb, Croatia
5Andrija Stampar Teaching Institute of Public Health, Divison for Epidemiology, Zagreb, Croatia
*Corresponding author: Tel. + 385 91 739 68 48; E-mail: marijadela@yahoo.com; marija.delas.azdajic@kbcsm.hr
10.2478/sjph-2020-0033 Zdr Varst. 2020;59(4):264-272
264
VEČANJE POJAVNOSTI SKABIESA NA HRVAŠKEM: POZIV K USKLAJENEMU 
UKREPANJU DERMATOLOGOV, SPLOŠNIH ZDRAVNIKOV IN EPIDEMIOLOGOV
Lugović-Mihić L, Delaš Aždajić M, Kurečić Filipović S, Bukvić I, Prkačin I, Štimac Grbić D, Kosanović Ličina ML. An increasing scabies incidence in Croatia: a call 
for coordinated action among dermatologists, physicians and epidemiologists. Zdr Varst. 2020;59(4):264-272. doi: 10.2478/sjph-2020-0033.
Received: May 12, 2020
Accepted: Sep 18, 2020 
Original scientific article
ABSTRACT
Keywords: 
scabies, epidemiology, 
outbreaks, Croatia, 
neglected tropical 
diseases
IZVLEČEK
Ključne besede: 
skabies, 
epidemiologija, izbruhi, 
Hrvaška, zanemarjene 
tropske bolezni   
Introduction: The aim of our study was to examine the scabies incidence in the Croatian population and to analyse 
potential related factors.
Methods: This mixed ecological study is based on a retrospective medical record review. National data from 
communicable disease reports was sourced and analysed for an 11-year period (2007-2017), with more focus on 
the period 2014-2017. Descriptive statistics were used to calculate trends. Differences between the groups were 
studied using Chi-square test and Kendall’s tau (τ) correlation coefficient. Levels of significance were set at p<0.05 
or p<0.01.
Results: From 2007 to 2017, scabies infestation in Croatia increased by 6-fold, particularly affecting children and 
young adults (19 years or younger). In the period 2014-2017, border counties which are part of migration flows were 
the counties with the highest average scabies incidences. A linear trend of increase in the number of tourists, 
immigrants and scabies infestations was noted on the national level for the analysed period, although a significant 
association was not observed. Regarding outbreaks of scabies within institutions, more than 80% of outbreaks 
occurred in institutions for adults. In the capital, Zagreb, the crude incidence rate increased 3-fold between 2014 
and 2017. 
Conclusions: The increased incidence of scabies, large disparities between counties, and prolonged outbreaks 
within families due to under-recognition and misdiagnoses points to a need for increased awareness among health 
practitioners. To the best of our knowledge, this is the first recent epidemiologic analysis on this topic, not only in 
Croatia but within the wider geographic region as well.
Uvod: Cilj naše študije je bil preučiti pojavnost skabiesa pri hrvaški populaciji in analizirati morebitne povezane 
dejavnike.
Metode: Ta mešana ekološka študija je temeljila na retrospektivnem pregledu zdravstvenih kartotek. Pridobili 
in analizirali smo nacionalne podatke iz poročil o nalezljivih boleznih za 11-letno obdobje (2007–2017), pri 
čemer smo se bolj osredotočili na obdobje 2014–2017. Za izračun trendov smo uporabili opisno statistiko. Razlike 
med skupinami smo preučili s testom hi-kvadrat in Kendallovim korelacijskim koeficientom tau (τ). Stopnja 
pomembnosti je bila nastavljena na p < 0,05 ali p < 0,01.
Rezultati: Od leta 2007 do 2017 se je pojavnost okužb s skabiesom na Hrvaškem povečala za šestkrat, pri čemer 
je bolezen prizadela zlasti otroke in mlajše odrasle (stare 19 let ali manj). V obdobju 2014–2017 so bila obmejna 
okrožja, ki so del migracijskih tokov, tista z najvišjo povprečno pojavnostjo skabiesa. V analiziranem obdobju 
je bil na nacionalni ravni opažen linearen trend povečevanja števila turistov, imigrantov in okužb s skabiesom, 
čeprav ni bilo opaziti pomembne povezanosti. Kar zadeva izbruhe skabiesa v zavodih, se jih je več kot 80 % zgodilo 
v zavodih za odrasle. V prestolnici Zagrebu se je groba incidenčna stopnja med letoma 2014 in 2017 povečala za 
trikrat. 
Sklepi: Povečana incidenca skabiesa, velika neskladja med okrožji in dolgotrajni izbruhi v družinah zaradi 
premajhnega prepoznavanja in napačnih diagnoz kažejo na potrebo po večji ozaveščenosti zdravstvenih delavcev. 
Po naših podatkih je to prva epidemiološka analiza, ki je bila pred kratkim opravljena na to temo, ne samo na 
Hrvaškem, temveč tudi na širšem geografskem območju.
© Nacionalni inštitut za javno zdravje, Slovenija. 
1 INTRODUCTION
Scabies is a skin infestation caused by the mite Sarcoptes 
scabiei var. hominis. This disease most commonly presents 
as classic scabies with the intense, pruritic eruption at 
certain characteristic localizations such as the sides and 
webs of the fingers, wrists, axillae, areolae, and genitalia 
(1). The transmission of scabies usually happens through 
direct and prolonged skin-to-skin contact of at least ten 
minutes, thus scabies commonly occurs within the family 
and among people who live together or who are sexual 
partners. On the other hand, transmission via casual 
skin contact and fomites (clothing, bedclothes, or other 
objects) is rare (2-4). It is very difficult to contract scabies 
from brief, casual touching, like handshakes or hugs. A 
diagnosis is based on a patient’s clinical picture and is 
confirmed by microscopic detection of the scabies mites, 
eggs, or faeces (5). 
Epidemiological data shows that, as of 2015, scabies 
affects about 204 million people worldwide (2.8% of 
the population) (6). According to results from the Global 
Burden of Disease Study 2015, there was a 6.6% increase in 
the global incidence of scabies over the preceding 11-year 
period (2005 - 2015) (6). Recently published data confirm 
that scabies has a seasonal pattern, and most patients are 
infested in the winter and autumn (7).
Scabies infestation is more common in tropical regions (East 
Asia, Southeast Asia, Oceania, tropical Latin America, and 
South Asia), with prevalence estimates ranging from 0.2 to 
71%, with the highest rates in the Pacific region and Latin 
America (8). Moreover, since European epidemiological 
studies are rare (8) and scabies is not a notifiable disease 
in many countries (2), it still represents a global and 
significant problem. Scabies is equally common in both 
sexes and among people of different ages, and is one of 
the three most common skin disorders in children (9, 10). 
However, lately there is growing data in the literature on 
the correlation between scabies incidence and population 
movements, particularly for refugees and asylum seekers 
coming to Western Europe, since they generally come 
from countries with a high prevalence of scabies (11, 12).
The direct effect of scabies on infected persons and its 
secondary effects on children, families, and communities 
worldwide is a strong impetus for advancing the agenda 
for global scabies control (13). Due to the important 
effects of this disease on global health, the World Health 
Organization’s Department of Control of Skin Neglected 
Tropical Diseases (NTDs) has begun promoting the idea of 
a strategy for integrated scabies control and management 
(14).
In recent years there has been greater public discussion 
concerning the increased frequency of scabies in Croatia 
(15). Physicians and dermatovenerologists have seen this 
10.2478/sjph-2020-0033 Zdr Varst. 2020;59(4):264-272
265
increase reflected in their practices, although to date 
there have been no wider epidemiologic analyses on this 
topic.  
The objective of this study was thus to examine the 
time trends in incidence rates of scabies in Croatia and 
its capital, as well as its geographical patterns, in order 
to provide researchers and policymakers in Croatia and 
the broader region with relevant epidemiological data in 
order to develop effective disease control strategies and 
reduce current socioeconomic inequalities in treatment of 
scabies. 
2 METHODS
2.1 Study Design 
This is mixed ecological study that makes us of exploratory 
studies of both spatial and temporal patterns. 
2.2 Units of Observation
There are two types of units of observation included in 
this study. In an exploratory study of temporal patterns 
in Croatia a single year is the unit of observation, while 
in the exploratory study of temporal patterns of scabies 
occurrence in Zagreb in the present study the unit of 
observation is a month. In our exploratory study of spatial 
patterns, the unit of observation is a county and there are 
21 units included in the research.
2.3 Sources of Data 
We analysed data from communicable disease notifications 
for scabies cases in Croatia for the period between 2007 
and 2017, with more detailed analysis by the counties, 
age, facility and month in the period from 2014 to 2017. 
No identifiable personal were used for this study, and the 
dataset used is not openly available.
Reporting communicable diseases is mandatory in Croatia 
and regulated by the Health Care Act, the Act on the 
Protection of the Population against Communicable 
Diseases, the list of communicable diseases the control 
and prevention of which is of interest to Croatia and the 
ordinance on the method of reporting communicable 
diseases (16-18). Licensed health care professionals and 
health care institutions are required to report selected 
communicable diseases through the standardized 
questionnaire to the epidemiology service (part of the 
Croatian network of public health institutes), which is 
finally received and stored at the Croatian Institute of 
Public Health. The routinely collected health data used 
in this study were sourced from the state-owned Croatian 
Institute of Public Health database. This nationally 
representative database is available only on request. 
Therefore, in order to address our research objectives, 
our multidisciplinary team (consisting of epidemiologists, 
10.2478/sjph-2020-0033 Zdr Varst. 2020;59(4):264-272
266
public health specialists and dermatovenereologists) 
utilized different mechanisms for sourcing and analysis of 
the data.
2.4 Methods of Data Analysis 
A scabies case is defined as an individual whose skin 
scrapings reveal mites, mite eggs or mite faeces, or as 
an individual with typical clinical signs epidemiologically 
linked to laboratory-confirmed cases. The average 
annual incidence rate per 100,000 inhabitants in 
Croatia was calculated by county using data from The 
Census of Population, Households and Dwellings 2011 
from the Croatian Bureau of Statistics (19). Age specific 
annual incidences, along with seasonal trends, were 
both calculated on the national level. We also analysed 
outbreak reports by number of recognized and reported 
outbreaks, duration and facilities involved. In addition, 
we analysed percentile changes in relative (per capita) 
number of tourists, immigrants and patients with scabies 
by counties. The change over time is represented by 
standardized regression coefficient (beta) – ranging 
from -1 (complete negative linear association) over 0 (no 
association) to 1 (complete positive linear association).
For the analyses, we used SPSS FOR WINDOWS ver. 20.0 
(SPSS, Chicago, IL, USA). Descriptive statistics were used 
to process data, calculate trends and create tables and 
graphs. Differences between the counties in the number of 
patients with scabies, relative to county size (The Census 
of Population, Households and Dwellings 2011 from the 
Croatian Bureau of Statistics) (19) were studied using Chi-
square test, while Kendall’s tau (τ) correlation coefficient 
was used to calculate the correlations between the time 
changes in relative number of tourists, immigrants and 
patients with scabies by Croatian counties. Kendall’s 
tau was used due to small sample size (n=21) and non-
normality of the parameter distributions.
Levels of significance were set to p<0.05 or p<0.01.
Figure 1. The scabies incidence rates in Croatia in the period 
2007-2017.
3 RESULTS
3.1 Temporal Pattern of Scabies Incidence in Croatia, 
2007-2017
Our results show an increasing trend in scabies incidence 
across Croatia between 2007 and 2017. The incidence 
rate increased 6-fold during that 11-year period, with the 
steepest increase in the last four years (2014-2017) (Figure 
1).
Table 1. The scabies incidence rates by age group in Croatia in the period 2014-2017.
2014
2015
2016
2017
Average
79.92
81.33
94.97
110.01
91.56
31.96
32.68
49.75
60.47
43.72
64.57
50.98
79.01
87.93
70.62
26.24
20.02
36.50
29.27
28.01
75.37
81.74
95.44
98.87
87.85
18.99
21.40
38.14
33.83
28.09
61.43
57.74
97.88
124.50
85.39
23.72
20.40
37.32
34.32
28.94
31.41
24.82
38.78
34.61
32.41
Year Age
0-4 20-2910-14 40-495-9 30-3915-19 50-59 >60
Within the 2014-2017 period, the highest average 
incidences in Croatia were recorded among children 
younger than 4 years old, preschool and elementary 
school children aged 5-9 years and adolescents of ages 15-
19 (Table 1). From 2014 to 2017, we observed a total of 106 
outbreaks of scabies within families and within adult foster 
care homes, nursing homes and other facilities throughout 
Croatia. Health care professionals and assistants were 
among those infected.
3.2 Temporal Pattern of Scabies Incidence in Zagreb, 
2014-2017
In the City of Zagreb, the crude incidence rate increased 
3-fold between 2014 and 2017 (Figure 2, Table 2), 
compared with the same period in Croatia. The majority 
of cases were recorded during winter and autumn.
267
10.2478/sjph-2020-0033 Zdr Varst. 2020;59(4):264-272
than the national rate during the same period. In 2017, 
2,224 cases were reported in Croatia, corresponding to 
a crude incidence rate of 51.90/100,000. Notably, four 
counties (Sisak-Moslavina, Vukovar-Srijem, Osijek-Baranja 
and Međimurje County) had almost twice the national 
incidence rate for 2017 (Table 2, Figure 3). 
3.3 Spatial Pattern of Scabies Incidence by County and 
its Relationship to Migration and Tourism 
Between 2014-2017, large discrepancies were observed 
at the county level, with some counties continuously 
having notably higher incidence rates (Sisak-Moslavina, 
Vukovar-Srijem, Osijek-Baranja and Međimurje County) 
or lower rates (Varaždin and Bjelovar-Bilogora County) 
Figure 3. Scabies incidence by county and migration flows, 
Croatia, 2017. Migration flows data available from 
Arsenijević et al. 2017 (20) and Arsenijević et al. 
2018 (21).
Figure 2. The scabies incidence rates by month in the City of Zagreb, Croatia in the period 2014-2017.
Table 2. The scabies incidence rates by county in Croatia in 
the period 2014-2017.
Sisak-Moslavina County
Vukovar-Srijem County 
Osijek-Baranja County 
Brod-Posavina County 
Međimurje County 
Virovitica-Podravina County 
City of Zagreb  
Lika-Senj County 
Zadar County 
Koprivnica-Križevci County 
Karlovac County
Požega-Slavonia County 
Dubrovnik-Neretva County
Zagreb County 
Istria County 
Krapina-Zagorje County 
Šibenik-Knin County 
Split-Dalmatia County 
Primorje-Gorski Kotar County 
Varaždin County 
Bjelovar-Bilogora County
Croatia
43.49
81.88
46.55
45.40
60.63
30.65
17.34
41.24
18.23
44.12
83.79
39.73
48.14
18.61
20.67
21.07
28.34
45.29
48.95
22.73
17.53
36.00
29.58
93.03
55.08
75.04
97.54
60.12
22.53
39.27
26.47
41.53
20.17
7.69
39.16
20.82
13.46
27.84
12.80
32.98
19.24
6.82
5.84
32.90
118.88
118.09
96.71
94.59
62.39
128.48
48.23
35.34
17.06
18.17
29.48
38.44
51.40
30.28
22.59
71.49
22.86
39.14
22.96
7.39
21.71
50.60
109.60
98.59
95.73
20.81
80.84
56.58
53.54
49.09
52.94
46.72
42.67
35.88
39.16
38.48
36.53
34.61
32.00
33.42
21.95
15.35
27.55
51.90
Year
2014 2014 2014 2014
10.2478/sjph-2020-0033 Zdr Varst. 2020;59(4):264-272
268
On average, around 40% of outbreaks in the observed 
period (2014-2017) lasted for several months due to late 
recognition and diagnosis, particularly among families. 
Regarding outbreaks of scabies within institutions, more 
than 80% were in institutions for adults and nearly half of 
them were recognized and resolved within one month. In 
Zagreb during the same period we detected 13 outbreaks, 
two-quarters within families. During autumn 2016, the 
first outbreak of scabies in an asylum centre (as part of 
the migrant crisis) was epidemiologically investigated and 
resolved within three months.
In each of the observed years (2014-2017) there was a large 
difference in scabies incidence among counties. According 
this statistical analysis of available data, the scabies 
incidence was not evenly distributed among counties, 
and this irregular distribution was statistically significant. 
Thus, some counties significantly deviated from the 
expected epidemiological data. In the 2014 χ2=416.95, 
df=20, p<0.01; in 2015 χ2=679.44, df=20, p<0.01, in 2016 
χ2=919.71, df=20, p<0.01, and in 2017 χ2=556.14, df=20, 
p<0.01. The largest discrepancy between the observed 
and theoretically expected cases of scabies in 2014 were 
found in Karlovac County (fo=104, ft=46.4), in 2015 in 
Vukovar-Srijem County (fo=167, ft=59), in 2016 in Varaždin 
County (fo=13, ft=89.1) and in 2017 in Vukovar-Srijem 
County (fo=177, ft=93.2). 
Figure 4. Relative percental dynamics of number of 
tourists, immigrants, and scabies over the four-
year period in Croatia.
Table 3. Linear approximation of change over time (2014 – 
2017) in relative number (per capita) of tourists, 
immigrants and patients with scabies by counties.
Zagreb County
Krapina-Zagorje County
Sisak-Moslavina County
Karlovac County
Varaždin County
Koprivnica-Križevci County
Bjelovar-Bilogora County
Primorje-Gorski Kotar County
Lika-Senj County
Virovitica-Podravina County
Požega-Slavonia County
Brod-Posavina County
Zadar County
Osijek-Baranja County
Šibenik-Knin County
Vukovar-Srijem County
Split-Dalmatia County
Istria County
Dubrovnik-Neretva County 
Međimurje County
City of Zagreb
Croatia
1.00
0.99
0.89
0.99
0.96
0.88
0.93
1.00
0.97
0.59
0.97
0.93
0.98
0.98
0.96
0.99
0.99
1.00
0.98
0.65
0.99
0.99
0.99
0.91
0.99
0.96
0.92
0.98
0.96
0.95
0.72
0.99
0.95
0.94
0.93
0.99
-0.03
0.78
0.96
0.97
0.18
1.00
0.95
0.99
0.92
0.74
0.92
-0.57
-0.49
-0.46
0.64
-0.70
0.15
0.70
0.26
0.96
0.48
0.99
0.25
0.85
-0.51
0.64
-0.01
0.00
0.98
0.92
TouristsCounty Immigrants Scabies
Figure 4 represents the percentile change in relative (per 
capita) number of tourists, immigrants and patients with 
scabies in Croatia. An almost linear trend of increase can 
be observed for the number of tourists and immigrants. On 
the other hand, for the number of patients with scabies, 
there is a small decrease from 2014 to 2015, then sharp 
increase from 2015 to 2016, followed by relative stability 
from 2016 to 2017.
The results in Table 3 show that the change in the relative 
number of tourists over observed time period is positive 
in all counties. In most of the counties the trend is almost 
linear (close to 1). The time trend of the relative number 
of immigrants by counties is also positive in most of the 
Croatian counties. The exceptions are Šibenik-Knin County, 
with no change (β=-.033), and Dubrovnik-Neretva County 
with a small and insubstantial change (β=-.181). However, 
the trend of change in the relative number of patients 
with scabies is not uniform, and varies greatly across the 
counties – from an evident increase (i.e. Osijek-Baranja 
County - β=.990) to relative stability (i.e. Međimurje 
County - β=-.003) to a substantial decrease (i.e. Primorje-
Gorski Kotar County - β=-.704). 
The correlations between trends of the relative number 
tourists and relative number of patients with scabies 
was τ=-.052 (p=.878), and between those of the relative 
number of immigrants and relative number of patients 
with scabies was τ=.153 (p=.345). These insignificant 
(p>.05) correlations indicate that time trends of relative 
change in number of tourists or immigrants by counties are 
unrelated to the time trends of relative change in number 
of patients with scabies in the respective counties.
10.2478/sjph-2020-0033 Zdr Varst. 2020;59(4):264-272
269
4 DISCUSSION 
4.1 Summary of the Most Important Findings
According to our research and the obtained data, our 
initial suspicion on the increasing trend in scabies 
incidence in Croatia was confirmed on the national level 
in this study. Thus, in the period between 2007 and 2017, 
a 6-fold increase of the scabies incidence rate was found, 
and the steepest increase was in the last four 4 years 
of the analysed period. Most of the scabies cases were 
among children and adolescents. These results indicate 
the need to raise awareness among health care providers, 
especially those working with children and adolescents 
with itches, with the aim not to misdiagnose scabies. 
Concerning the possible associations among scabies 
incidence, tourists and immigrants, we confirmed an 
increasing number of tourists and immigrants in the period 
2014-2017. However, time trends of the relative change 
in number of tourists and immigrants by counties were 
not related to the relative change of scabies infestations. 
Although statistical significance was not present, 
the highest scabies incidence rates were recorded in 
Međimurje and Vukovar-Srijem counties, which indicates 
moderate influence of the proximity of the border and 
influence of movements of people on scabies outbreaks.
Concerning seasonal variations of scabies, our data for 
the City of Zagreb (monitored over a period of four years, 
2014-2017) showed that infestation counts multiplied in 
winter and autumn months, thus confirming an influence 
of seasonal trends on scabies outbreaks. Therefore, 
our results may be a basis for the planning of further 
preventive measures.
4.2 Comparison of Study Findings with Reports in the 
Literature
According to the data in the literature, worldwide, 
scabies affects an estimated 100 million people across 
all continents and countries. Regardless, scabies is not a 
priority on the global health agenda, even though interest 
in the disease is increasing (11). However, outbreaks and 
management vary from country to country, and thus 
priority and management do as well (22). 
Several trends and related factors have been found 
to be important for scabies outbreaks. Thus, a strong 
connection among scabies, migration and travel has 
been reported (11, 12, 15, 23). Since scabies moves with 
people, mass migration due to political and socioeconomic 
factors can promote its spread, as seen recently with 
the influx of asylum seekers arriving in Western Europe 
from high-prevalence countries (11, 12). Since scabies 
is transmitted by close person-to-person contact, it is 
logical that outbreaks have been reported in reception 
centres for asylum seekers across Europe (11). Previous 
studies claim that immigrants are at a higher risk of 
acquiring common communicable diseases compared to 
the native Western European population (23). Although 
most refugees in Croatia are only in transit, refugee and 
migration flows can still have an impact on the occurrence 
of scabies in the country. A recent study suggested 
that scabies cases rose at the time when refugees and 
migrants were intensively coming from the Middle East 
to Western Europe via the Southeastern European route 
(Turkey-Greece-Serbia-Croatia-Slovenia-Austria) (15). Data 
presented in this study supports this observation, since 
an approximately 6-fold increase in scabies incidence was 
confirmed in Croatia between 2007-2017. According to 
our results, local geography could have a great influence 
on this, as indicated by the increased scabies incidence 
in areas close to the borders with Serbia and Bosnia and 
Herzegovina, and those along refugee migration routes. 
Late recognition and the delay of proper treatment, 
along with an increase in regular and irregular migration 
from neighbouring countries with high incidence rates of 
scabies (Bosnia and Hercegovina, Kosovo, Serbia), likely 
caused this upward trend in scabies cases in Croatia 
during this time.
According to data from Germany, the prevalence of scabies 
is higher among refugees than in the general population; 
however, the risk of outbreaks themselves is not high 
(24). Recent analysis of the health status and disease 
burden of unaccompanied asylum-seeking adolescents in 
Germany (cross-sectional pilot study) showed the highest 
prevalence of infestation in sub-Saharan Africans (86.7%), 
including the highest prevalence of parasites in general 
(46.7%), with a higher disease burden among females (25). 
Similar results were obtained by Kortas et al., who found 
a total of 47.7% of the subjects with scabies infestations 
originated from Afghanistan and 25.0% from Eritrea (26). 
Consequently, there is a need for thorough medical 
and psychological screenings after the arrival of such 
individuals in order to reduce the individual disease burden 
and risk of infestation for others. It is also necessary to 
lower barriers to health care access for unaccompanied 
asylum-seeking minors and allow for need-specific health 
care and prevention (27).
Significantly, another possible cause for the increase 
could be Croatia’s 2013 admission into the European Union 
and the consequent increase in travel to the country 
(23). An important, related factor could be the increase 
in Croatia’s tourism rate over the last few years, which 
might indicate the influence of travel and tourism on the 
scabies rate. Our results indicate linear increases in the 
number of tourists, immigrants and scabies infestations 
on the national level for the analysed period, although 
with no statistically significant association. According 
to a previous study of skin disorders among travellers 
returning from tropical and non-tropical countries, more 
than 20% of all such disorders were caused by arthropods 
10.2478/sjph-2020-0033 Zdr Varst. 2020;59(4):264-272
270
and about 50% by infectious pathogens (27). As such, pre-
travel consultations should include specific prophylaxis 
and consider the most common risk factors for each 
destination (28).
Moreover, close contact among young people during 
travel, concerts and festivals can influence scabies rates. 
Large summer concerts and festivals have become popular 
in Croatia in recent years, and it is possible that casual sex 
and poor hygiene in these crowded conditions contribute 
to incidence rates (29). This corresponds to our results, 
as they have confirmed that young people predominated 
among scabies patients. More public attention should thus 
be directed to the prevention of scabies among youth, 
especially due to their lifestyles. Appropriate hygiene 
in overcrowded places, such as mass gathering events, 
is also important. According to a previous retrospective 
analysis (data from 145 countries) of the infection burden 
from inadequate water, sanitation and hygiene in low- and 
middle-income settings, there is a need for better risk 
reduction, including the provision of reliable piped water, 
treatment of community sewage and awareness of hand 
hygiene (30). 
Seasonal variations should be also mentioned, since a 
connection between scabies occurrence and weather 
conditions and the seasons was observed (31). According 
to previously published data, scabies infestations are 
especially common in winter (31). Thus, Liu et al. 
monitored the influence of temperature on scabies 
incidence and observed that, overall, the incidence of 
scabies was negatively correlated with temperature but 
positively correlated with humidity (30). Our results 
support the seasonal character of scabies, as the majority 
of cases were recorded during winter, but also in autumn 
(Zagreb). It is possible that increased scabies infestation 
in winter is a result of closer contact between people in 
indoor environments. It should also be considered that 
scabies cases are often reported weeks or even months 
after the patient has contracted it. For example, a case 
is only reported in winter months when the patient first 
sees their physician, when the symptoms are troublesome 
enough, but the infestation could actually have started 
in the summer or autumn, coinciding with the patient’s 
travel during vacation. 
Considering the data in the literature, it is also 
important to mention an increased risk for outbreaks 
at nursing homes and extended-care facilities since 
elderly persons tend to develop crusted scabies due to 
disease- or medication-related immunosuppression (24, 
32). According to a previous smaller study conducted in 
the City of Zagreb, 10% of scabies cases were found in 
medical health personnel, predominantly in those working 
in nursing homes and psychiatric wards (33). In our study, 
we found a prominent number of scabies outbreaks within 
families, adult foster care homes, nursing homes and other 
facilities throughout Croatia. Our results indicate a need 
for increased caution and preventive measures for these 
populations and settings. Since health care professionals 
and assistants were among those infected, focus should 
be also on appropriate hygienic measures while working 
with patients.
Unfortunately, although scabies is a major public 
health problem and causes a significant disease burden 
worldwide, there are no agreed-upon international 
diagnostic guidelines (34). Thus, we can mention that due 
to the frequent setting of the diagnosis based only on the 
clinical picture, it is difficult to know the real number of 
scabies cases. Thompson et al. found that only 56% of 
clinical trials in medical databases specified which clinical 
findings were used for diagnosis (predominantly rash, rash 
distribution, pruritus and mite burrows) (35). According 
to their findings, parasitological testing was used in 63% 
of trials, more frequently in clinic-based than in field 
studies, and nearly one-quarter of trials (24%) did not 
perform diagnostic methods at all, which can lead to the 
further spread of scabies. However, in field conditions, 
the psychological and physical profiles of scabies patients 
may help in the early recognition of scabies, which is very 
useful, especially at peripheral care centres (36). 
4.3 Limitations and Strengths of the Study 
This retrospective, observational study, based on the 
official data presents the first national research regarding 
scabies incidence in Croatia, with findings based on the 
obligatory report data collected from all health care 
institutions in Croatia (for the years between 2007 and 
2017). To the best of our knowledge, this is the first recent 
epidemiologic analysis on this topic, not only in Croatia 
but within the wider geographic region as well.
However, the limitation of this study is the lack of detailed 
data regarding the trend of scabies incidence throughout 
the years, since health care providers who send the report 
about communicable disease do not always answer all the 
questions in the report form. Therefore, we provided a 
more detailed analysis for the City of Zagreb (the capital 
of Croatia), since it accounts for one-quarter of whole 
Croatian population and has the highest number of 
hospitals and medical professionals at the national level. 
This study also found a possible impact of changes in the 
Croatian population, for example due to migration. In 
addition, we could only assume that health care providers 
reported all the scabies cases for the analysed period, 
although this might not have happened. 
4.4 The Importance of the Study for Public Health and 
Other Professions in Croatia
The importance of this study is to emphasize the need for 
the implementation of existing standardized guidelines 
10.2478/sjph-2020-0033 Zdr Varst. 2020;59(4):264-272
271
with the aim early recognition and timely reporting of 
scabies. Furthermore, despite a universal health care 
system that provides mandatory health insurance for all 
residents, there is some inequality in health status in 
Croatia, similar to as in neighbouring countries such as 
Slovenia (37).
Late recognition of scabies by physicians also presents a 
problem, and is likely linked to the country’s previously 
low rate – some medical doctors had not even seen scabies 
cases before, so did not think to suspect this infestation. 
It should also be remembered that some infected persons 
can have false negative results, leading to problems in 
practice when patients are treated ineffectively (38). 
When initial cases of scabies go undetected, these 
infected persons are then not able to prevent the 
spread of the disease in their immediate environments. 
Furthermore, there are many examples of non-compliance 
with treatment in practice. It is thus necessary to train 
general practitioners and medical staff on the early 
recognition, proper and timely diagnostics and notification 
of first cases. Special attention should be directed to the 
age groups with increased occurrence of scabies, such as 
children and adolescents. In addition, knowledge of basic 
hygienic measures is necessary from early childhood, 
and should be provided by kindergarten teachers (39), 
parents and other members of society. The epidemiology 
service has an important role in identifying contacts and 
applying preventive measures, stressing the necessity of 
conducting therapy and scabies management. Likewise, 
epidemiologists can do this only if they receive timely 
notification of the first sporadic case or early notification 
of an outbreak. Therefore, coordinated efforts between 
different sectors and collaboration among a range of 
health care providers (dermatologists, physicians and 
epidemiologists) is crucial (40).
4.5 Possibilities for Future Research in the Field
This study opens a new perspective on the transmission 
dynamic for this important but neglected communicable 
disease. Further research should be focused on the 
relationship between scabies incidence and other factors, 
such as tourism, both in Croatia and elsewhere. More 
attention should be directed to the research of scabies 
incidence in those countries with an increased number 
of movements, especially those with a rapidly growing 
annual number of tourists and migrants. In addition, 
wider epidemiological studies should be conducted 
internationally in order to compare trends among countries 
and regions. More research on scabies in clinical practice 
is recommended, with the focus on other possible related 
factors on scabies outbreaks and misdiagnosing of this 
disease.
5 CONCLUSION
The increased incidence of scabies, large disparities 
between counties, and prolonged outbreaks within 
families due late recognition and misdiagnoses points to a 
need for increased awareness among health practitioners 
on the occurrence of scabies in Croatia. For this, timely 
collaboration among general practitioners, health care 
professionals in resident and nursing homes, dermatologists 
and epidemiologists is crucial. The provision of timely 
diagnostics and treatment is a necessity, along with 
strict adherence to infestation control measures. Patient 
follow-ups and the prophylactic treatment of household 
members, patients, and staff who have had prolonged 
skin-to-skin contact with scabies cases is crucial in order 
to avoid outbreaks. 
DISCLOSURE STATEMENT
The authors have no conflicts of interest to declare.
FUNDING 
None.
ETHICAL APPROVAL
No identifiable human data were used for this study, and 
the dataset used is not openly available.
REFERENCES 
1. Anderson K, Anderson LE, Glanze WD. Mosby’s medical, nursing, & 
allied health dictionary. 4th ed. New York: Mosby-Year Book, 1994. 
2. Fuller LC. Epidemiology of scabies. Curr Opin Infect Dis. 2013;26:123. 
doi: 10.1097/QCO.0b013e32835eb851.
3. Heukelbach J, Feldmeier H. Scabies. Lancet. 2006;367:1767. doi: 
10.1016/S0140-6736(06)68772-2.
4. Chosidow O. Clinical practices. Scabies. N Engl J Med. 2006;354:1718. 
doi: 10.1056/NEJMcp052784.
5. Hengge UR, Currie BJ, Jager G, Lupi O, Schwartz RA. Scabies: a 
ubiquitous neglected skin disease. Lancet Infect Dis. 2006;6:769-79.
6. GBD 2015 Disease and Injury Incidence and Prevalence, Collaborators. 
Global, regional, and national incidence, prevalence, and years lived 
with disability for 310 diseases and injuries, 1990–2015: a systematic 
analysis for the Global Burden of Disease Study 2015. Lancet. 
2016;388:1545-602. doi: 10.1016/S0140-6736(16)31678-6.
7. Amato E, Dansie LS, Grøneng GM, Blix HS, Bentele H, Veneti L, et al. 
Increase of scabies infestations, Norway, 2006 to 2018. Euro Surveill. 
2019;24(23):190020. doi: 10.2807/1560-7917.ES.2019.24.23.190020
8. Romani L, Steers AC, Whitfeld MJ, Kaldor JM. Prevalence of scabies 
and impetigo worldwide: a systematic review. Lancet Infect Dis. 2015; 
15:960-7. doi: 10.1016/S1473-3099(15)00132-2.
9. World Health Organization. Scabies. Geneva: WHO, 2015. Accessed 
April 1st, 2020 at: https://www.who.int/neglected_diseases/diseases/
scabies/en/.
10.2478/sjph-2020-0033 Zdr Varst. 2020;59(4):264-272
272
10. Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzati M, et al. 
Years lived with disability (YLDs) for 1160 sequelae of 289 diseases 
and injuries 1990-2010: a systematic analysis for the Global Burden 
of Disease Study 2010. Lancet. 2012;380:2163-96. doi: 10.1016/S0140-
6736(12)61729-2.
11. Stamm LV, Strowd LC. Ignoring the “Itch”: the global health problem 
of scabies. Am J Trop Med Hyg. 2017;97:1647-9. doi: 10.4269/
ajtmh.17-0242.
12. Beeres D, Omansen TF, Heidema  A, Cornish D, Vonk M, Stienstra 
Y. Scabies amongst  asylium seekers: prevalence and effect of 
the scabies hygiene programme. European congress of clinical 
microbiology and infectious diseases, Amsterdram, 2016. Accessed 
April 1st, 2020 at: http://www.escmid.org/escmid_publications/
escmid_elibraty/?q=scabies&L=0&x=0&y=0.
13. Engelman D, Kiang K, Chosidow O, McCarthy J, Fuller C, Lammie 
P, et al. Members of the International Alliance for the control of 
scabies. Toward the global control of human scabies: introducing the 
international alliance for the control of scabies. PLoS Negl Trop Dis. 
2013;7:e2167. doi: 10.1371/journal.pntd.0002167.
14. Mitja O, Marks M, Bertran L, Kollie K, Argaw D, Fahal AH, et al. 
Integrated control and management of neglected tropical skin 
diseases. PLoS Negl Trop Dis. 2017;11:e0005136. doi: 10.1371/journal.
pntd.0005136.
15. Lugović-Mihić L. The increase in Croatia’s scabies incidence: how 
did refugees and traveling contribute? Travel Med Infect Dis. 
2019;pii:S1477-8939(19)30033-X. doi: 10.1016/j.tmaid.2019.02.002.
16. Zakon o zdravstvenoj zaštiti. Narodne novine. 100/2018.
17. Croatian Parliament. Zakon o izmjenama i dopunama Zakona o zaštiti 
pučanstva od zaraznih bolesti  Narodne novine. 130/2017.
18. Ministry of Health. Pravilnik o načinu prijavljivanja zaraznih bolesti. 
Narodne novine. 23/1994.
19. Croatian Bureau of Statistics. The census of population, households 
and dwellings 2011. Accessed April 8th, 2020 at: https://www.dzs.hr/
hrv/censuses/census2011/censuslogo.htm.
20. Arsenijević J, Schillberg E, Ponthieu A, Malvisi L, Waeil AEA, 
Argenziano S, et al. A crisis of protection and safe passage: violence 
experienced by migrants/refugees travelling along the Western Balkan 
corridor to Northern Europe. Confl Health. 2017;11:6.
21. Arsenijević J, Burtscher D, Ponthieu A, Severy N, Contenta A, Moissain 
S, et al. “I feel like I am less than other people”: Health-related 
vulnerabilities of male migrants travelling alone on their journey to 
Europe. Soc Sci Med. 2018;209:86-94.
22. Goldstein BG, Goldstein AO. Scabies: epidemiology, clinical features, 
and diagnosis. In: Ofori AO, editor. UpToDate. Waltham (MA): 
UpToDate, 2019. Accessed April 8th, 2020 at: https://www.uptodate.
com/contents/scabies-epidemiology-clinical-features-and-diagnosis.  
23. Limina RM, Baitelli G, Marcantoni C, Covolo L, Festa A, Speziani F, 
et al. Frequency of infectious diseases in immigrants in a western 
European country: a population-based study. J Immigr Minor Health. 
2015;17:66-75. doi: 10.1007/s10903-013-9888-3.
24. Sunderkötter C, Feldmeier H, Fölster-Holst R, Geisel B, Klinke-Rehbein 
S, Nast A, et al. S1 guidelines on the diagnosis and treatment of 
scabies - short version. J Dtsch Dermatol Ges. 2016;14:1155-67. doi: 
10.1111/ddg.13130.
25. Marquardt L, Krämer A, Fischer F, Prüfer-Krämer L. Health status 
and disease burden of unaccompanied asylum-seeking adolescents in 
Bielefeld, Germany: cross-sectional pilot study. Trop Med Int Health. 
2016;21:210-8. doi: 10.1111/tmi.12649.
26. Kortas AZ, Polenz J, von Hayek J, Rüdiger S, Rottbauer W, Storr U, 
et al. Screening for infectious diseases among asylum seekers newly 
arrived in Germany in 2015: a systematic single-centre analysis. Public 
Health. 2017;153:1-8. doi: 10.1016/j.puhe.2017.07.011.
27. Karimkhani C, Colombara DV, Drucker AM, Norton SA, Hay R, 
Engleman D, et al. The global burden of scabies: a cross-sectional 
analysis from the global burden of disease study 2015. Lancet Infect 
Dis. 2017;17:1247-54. doi: 10.1016/S1473-3099(17)30483-8.
28. Herbinger KH, Siess C, Nothdurft H, Von Sonnenburg F, Löscher T. Skin 
disorders among travellers returning from tropical and non-tropical 
countries consulting a travel medicine clinic. Trop Med Int Health. 
2011;16:1457-64. doi: 10.1111/j.1365-3156.2011.02840.x.
29. Jeličić P, Capak K, Poljak V, Novosel IP, Vučina VV. Scabies in Croatia 
- epidemic or media sensation. In: 26th Scientific and eduactional 
seminar with international participation DDD and ZUPP 2014: 
disinfection, disinsection, deratization and protection of stored 
agricultural products. Split, 2014:151-8. 
30. Liu JM, Wang HW, Chang FW, Liu YP, Chiu FH, Lin YC, et al. The effects 
of climate factors on scabies: a 14-year population-based study in 
Taiwan. Parasite. 2016;23:54. doi: 10.1051/parasite/2016065.
31. Prüss-Ustün A, Bartram J, Clasen T, Colford JM, Cumming O, Curtis 
V, et al. Burden of disease from inadequate water, sanitation and 
hygiene in low- and middle-income settings: a retrospective analysis 
of data from 145 countries. Trop Med Int Health. 2014;19:894-905. doi: 
10.1111/tmi.12329.
32. Buczek A, Pabis B, Bartosik K, Stanislawek IM, Salata M, Pabis A. 
Epidemiological study of scabies in different environmental conditions 
in central Poland. Ann Epidemiol. 2006;16:423-8. doi: 10.1016/j.
annepidem.2005.06.058.
33. Kosanović Ličina ML, Quiaios A, Tešić V, Domingues J, Sá N. The profile 
of scabies patients in Zagreb. Psychiatr Danub. 2014;26:533-6. 
34. Bhat SA, Mounsey KE, Liu X, Walton SF. Host immune responses to the 
itch mite, Sarcoptes scabiei, in humans. Parasit Vectors. 2017;10:385. 
doi: 10.1186/s13071-017-2320-4.
35. Thompson MJ, Engelman D, Gholam K, Fuller LC, Steer AC. Systematic 
review of the diagnosis of scabies in therapeutic trials. Clin Exp 
Dermatol. 2017;42:481-7. doi: 10.1111/ced.13152.
36. Nair PA, Vora RV, Jivani NB, Gandhi SS. A study of clinical profile and 
quality of life in patients with scabies at a rural tertiary care centre. J 
Clin Diagn Res. 2016;10:WC01-5. doi: 1 0.7860/JCDR/2016/20938.8703.
37. Zadnik V, Guillaume E, Lokar K, Žagar T, Primic Žakelj M, Launoy G, et 
al. Slovenian version of the European deprivation index at municipality 
level. Zdr Varst. 2018;57:47-54. doi: 10.2478/sjph-2018-0007.
38. Walton SF, Currie BJ. Problems in diagnosing scabies, a global disease 
in human and animal populations. Clin Microbiol Rev. 2007;20:268-79. 
doi: 10.1128/CMR.00042-06.
39. Slabe D, Fink R, Dolenc E, Kvas A. Knowledge of health principles among 
professionals in Slovenian kindergartens. Zdr Varst. 2016;55:185-94. 
doi: 10.1515/sjph-2016-0024
40. Chandler DJ, Fuller LC. A Review of scabies: an infestation more than 
skin deep. Dermatology. 2019;235:79-90. doi: 10.1159/000495290.