Scabies in Slovenia 1971-1995 Epidemiological study SCABIES IN SLOVENIA DURING THE 1971-95 PERIOD B. Kralj, A. Kansky, B. Žgavec and A. Kraigher ABSTRACT Scabies started to appear in Slovenia in larger number by the end of sixties. For this reason a reporting system was enforced by the Ministry of Health. Reliable data are available since 1971. The peak incidence ( 4,3%0) with 8646 cases was reached in 1972 while a second peak with 4412 cases (2,2%o) appeared in 1982. The yearly incidence of over 1000 cases stili persists. From the clinical experience it was concluded that the majority of cases were imported by guest workers from the underdeveloped regions of former Yugoslavia. KEY WORDS scabies, epidemiology, Slovenia, 1971-1995 period INTRODUCTION In the past the spread of scabies in various populations accompanied periods of wars and other major distresses, especially, when economic and hygienic conditions were rather poor. Available data confirm that the incidence of scabies in Europe has had a cyclical course, the causes of which are stili not fully understood. As already mentioned war conditions favor the outbreak of scabies. However, other factors seem to be important too. In Great Britain the incidence of scabies was rising before the outbreak of World War II. While during the years 1944-46 between 10% and 15% of ali patients attending detmatological departments were affected with scabies, by the 1950-53 period this figure dropped to 1 % (1). acta dennatovenerologica A.P.A. Vol 6, 97, No 1 Since 1963 the incidence in Europe was on increase again. In various parts of Britain during the years 1964-66 7% to 11 % of dermatologic patients were affected. In France the surge of scabies was also noted in 1963 (2) and was explained by immigration of workers from North Africa. In Germany numerous patients with scabies started to appear by the year 1965 (3,4). In Slovenia the reappearance of scabies was most probably connected with the epidemiological situation concerning scabies in the republics of former Yugo- slavia, where it started to spread from the eastern to western parts in 1963. In Macedonia the epidemy of scabies started in 1963 following the terrible earthquake in Skopje in 1962 (5). At the same tirne or a bit later the spread was noted in Bosnia (6) 35 Scabies in Slovenia 1971-1995 and a few years later in Serbia (7,8). The first alarming report from Slovenia was in 1968 by Adamčič (9). METHODS In the late sixties when an increased number of scabies cases started to appear the laboratory iden- tification of scabies mites was carried out at the mycological laboratories of the University Department of Dermatology in Ljubljana and at the Dermatology department of the General Hospital in Maribor and soon also in the dermatology departments in Celje and Novo mesto. Later on practicing dermatologists were encouraged to do the microscopic investigations by themselves. In view of the large number of affected persons the Ministry of Health of Slovenia enforced in 1968 the reporting of ali new cases of scabies. The reports were submitted to the Central Institute of Hygiene in Ljubljana. Due to the well organized dermatological care and to the mentioned reporting system reliable data on the incidence of scabies in Slovenia are available since 1971. RESULTS The available data show that since 1971 infections with scabies persist in the population of Slovenia in spite the fact that the great majority is living reasonable well including appropriate housing condi- tions. From the Fig. 1 it is evident that two peaks were observed: the first one with 8646 cases in 1972 (4,3%o of population) and the second one with 4412 in 1982 (2,2%o). In between these two peaks the lowest incidence amounting to 2422 cases (1,2%o) was observed in the 1978. During the last 10 years a definite declining incidence is evident but it did never drop under 1000 cases per year. The population of Slovenia in 1971-95 period was approximately 2 millions. Three rather characteristic lesions observed in our patients are presented in figures 2 to 4. DISCUSSION In the literature there are many publications dealing with the incidence of scabies in various populations, Fig. l. Numbers of registered cases of scabies in Slovenia in the period from 1971 to 1995. Number of cases 9000 8000 I \ ' 7000 6000 \ \ \ 1--REOISTERED CASES 5000 4000 3000 2000 \ \ o../ "' / ~ ........... ' / ..... r--- \ l'-- I""'-, \ ,_,,/ \~ ', ~~ -~ 1000 o 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1B81 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 Year 36 acta demiatovenerologica A.P.A. Vol 6, 97, No 1 Scabies in Slovenia 1971-1995 Fig. 2. Typical furrow on the penis shaft. only a few of them are however epidemically and statistically appropriate. The publication by Konstan- tinov et al. (5) is highly instructive explaining the origins of the epidemic of scabies in Macedonia during the 1963-74 period. After the disastrous earthquake in Skopje in 1962 the inhabitants were evacuated to rural areas or constraint to live under primitive housing conditions in Skopje. The authors are indicating that in the years preceding the earthquake, endemic foci of scabies existed in remote villages where the evacuated inhabitants got infected. Konstatinov et al concluded that the number of evacuees got infected and started to spread the infection upon their return to Skopje. The fact that a too long period of tirne elapsed before dermatologists and general practitioners be came aware of scabies was also important. The incidence of scabies in Slovenia is characterized by a major peak in 1972 and a minor one in 1981 and 82. As it can be detected from fig. 1 scabies is acta dennatovenerologica A .P.A. Vol 6, 97, No 1 Fig. 3. Papular probably already granulomatous lesions on the buttocks. continuously present in the Slovenian population since the outbreak of the epidemic but is definitely on decline. The persistence of scabies lasting for almost 20 years is stili not completely explained. It is assumed that the primary cause were the guest- workers from the under-developed parts of former Yugoslavia who used to come to Slovenia in elevated numbers during the late sixties and early seventies. Many of them were successfully treated far scabies Fig. 4. Papular lesions on the elbow. 37 Scabies in Slovenia 1971-1995 bere, but experienced a recurrence after visits to their families living in native villages. Such observations were rather frequently made by our dermatologists and also by general practitioners. Since the indepen- dence of Slovenia in 1991 less guest workers are coming to Slovenia, however the basic problem stili persists. Additional contributing factor to the spread of scabies are promiscuity, poor housing and alcoholism, while drug addiction seems to have been of minor importance. The observation that in persons paying attention to their personal hygiene the clinical symptoms may be scarce and therefore difficult to diagnose. Awareness of Slovenian dermatologists of the problem, good possibilities for laboratory confirmation of the diagnosis as well as the efficient reporting system may be credited for curbing the spread of scabies. CONCLUSIONS The main factors contributing to the spread of scabies in Slovenia during the period under observation may be listed as follows. l. it may be safely assumed that guest-workers from the undeveloped parts of former Yugoslavia imported scabies from endemic foci 2. many of them were successfully treated in Slovenia but were reinfected during the visits of their families 3. poor housing and low hygienic habits in a minor section of Slovenian population has also to be taken into account. 4. promiscuity and alcoholism are already well known promoting factors of scabies 5. drug addiction seems to have been of minor importance According to the experience obtained in Slovenia certain suggestions can be made in order to keep scabies under control. Weil organized medica! services and efficient reporting system are to be credited for curbing epidemic in Slovenia. Dermatologists should be aware that scabies may appear even during periods of general well being. General practitioners should be encouraged to recog- nize even atypic cases of scabies. The laboratory confirmation of mites should be available for patients with itching and unclear symptoms. REFERENCES l. Rook A. Skin diseases caused by arthropods and other venomous or noxious animals. In: Rook A, Wilkinson DS, Ebling FJG et al. Textbook of Dermatology 4th ed, Blackwell, Oxford 1986, p. 1060. 2. Shrank AB, Alexander SL. Scabies: another epidemic? Br Med J 1967; 1: 669-71 . 3. Barthelmes R, Sonnichsen N, Barthelmes H . Untersuchungen zur Zunahme der Scabieserkrank- ungen. Dermatol Monatschr 1970; 156: 881-83. 4. Wozniak KD, Weinrich l. Zur gegenwiirtigen Hiiufigkeit, Klinik und Therapie der Skabies. Dtsch Ges Wes 1972; 27: 1188-91. 5. Konstantinov D, Stanoeva Lj, Zaharijeva L, Bitoljanu V. Epidemiologic factors causing the present outbreak of scabies epidemic in the Socialist Republic Mace- donia. Acta Derm lug 1977; 4: 225-33. 6. Salčič Č. Metodologija i rezultati sistematske antiskabiozne akcije na području Sarajevskog regiona. Zbornik radova VIL kongresa dermatovenerologa Jugoslavije. Opatija-Rijeka 1972; 345- 48. 7. Matic B, Milakov J, Maric M, Stanojevic Ž. Skabies u kliničkom materialu Dermatološke klinike u Novom Sadu. ibidem 321-7. 8. Faninger A, Mihajlovska N, Odem M. Skabies na području Niša. Nar Zdravlje 1972: 28: 245-49. 9. Adamčič M. Pozor. Skabies. Zdrav vestn 1968: 37; 113-15. AUTHORS' ADDRESSES 38 Boris Kralj MD, dermatologist, Department of Dermatology, University Medica! Centre Zaloška 2, 1525 Ljubljana, Slovenia Aleksej Kansky MD, PhD, dermatologist, same address Borut Žgavec MD, same address Alenka Kraigher MD, MS, Institute of Public Health of Republic of Slovenia Trubarjeva 2, 1000 Ljubljana acta dennatovenerologica A.P.A. Vol 6, 97, No 1