Community based Scabies Detection by Trained Non-medical

Personnel

Eliza Miranda, Sri Linuwih Menaldi, Rahadi Rihatmadja, Melani Marissa, Mufqi H. Priyanto,

Sandra

Widaty

Dermatology and Venereology Department, Medical Faculty Universitas Indonesia,Jakarta-Indonesia

Keywords: scabies, detection, community based, non-medical personnel, sensitivity

Abstract: Scabies infection is one of the common infectious disease occurred in developing countries, including

Indonesia. Late diagnosis of scabies leads to prolonged infection, decrease the quality of life, and learning

disability in children. Scabies diagnosis is challenging since people awareness to the disease is low, and

trained medical personnel and the supporting equipment for diagnosing scabies are not distributed equally.

To encounter this problem, community empowerment in scabies active case detection was done at a boarding

school located in Bogor, West Java where scabies prevalence is high. This is a pilot study to evaluate the

performance of the active case detection by community empowerment in a small-scale population. Six

supervisors (non-medical personnel) from the boarding school were trained by dermatovenereologist to

identify scabies and asked to examine 128 participated students. Later, the students also clinically examined

by dermatovenereologist as comparison and confirmation test. Hypothesis comparison was tested using chi

square test. The result for diagnostic study showed a wide range of sensitivity and specificity, respectively

from 56 % to 97 % and 0 % to 74 %. Positive predictive and negative predictive values from 67 % to 95 %

and 0 % to 56 %. Five out of six non-medical personnel have sensitivity above 60 %, more than the basis

estimation of a screening study. We conclude that trained non-medical personal has ability to perform

community based scabies detection among high prevalence scabies population.

1 INTRODUCTION

Based from the latest World Health Organization

(WHO) data, incidence rate of scabies reach 130

million population worldwide, with varying

prevalence from 0,3 % to 46 % in low-to-middle

income countries. In 2010, it is estimated that the

direct effect of scabies infection on the skin cause 1.5

million people living with disabilities (WHO, 2018).

Scabies, which also called “the itch”, “pamaan itch”,

and “seven years itch”, causing enormous itchy

symptom that can last for years without proper

medication. Sarcoptes scabiei, the parasite that

causes scabies infection, can infected anyone at any

time. Moreover, scabies is much more easily

transmitted and endemic in densely populated

community setting where low hygiene, close skin

contact, and sharing personal equipment are

commonly found, such as boarding school, daycare,

orphanage, geriatric housing care, prisons, and

refugee camp (Sungkar, 2015).

Clinical diagnosis of scabies could be made by

finding two of four scabies cardinal signs. The first

cardinal sign is nocturnal pruritus, or itching that

occur especially at night caused by increasing activity

of the parasite at high humidity and hot temperatures.

The second cardinal sign is that scabies infection

occurring on a group of people. The third cardinal

sign is by finding tunnels-like lesions that is a

pathognomonic sign of scabies parasite on

predilection sites. And the last one is the present of

parasite, either by direct examination with

dermoscopy or microscopic examination, which is a

major support of the diagnosis of scabies (Boediardjo

and Handoko, 2015). But the problem with the last

cardinal sign is much more difficult to prove and

perform, since the parasite is not always present in the

symptomatic patients. It is also become a problems

when diagnosing scabies especially in rural area since

medical professional personnel and diagnostic tools

resources are limited.

An early detection of scabies become important

since untreated scabies infection could lead to several

Miranda, E., Menaldi, S., Rihatmadja, R., Marissa, M., Priyanto, M. and Widaty, S.

Community based Scabies Detection by Trained Non-medical Personnel.

DOI: 10.5220/0008153901990203

In Proceedings of the 23rd Regional Conference of Dermatology (RCD 2018), pages 199-203

ISBN: 978-989-758-494-7

199

complications and decreasing of patient’s life quality.

A new method to increase scabies detection rate in

community is urgently needed to increase scabies

early detection in community setting, thus could

promote to scabies early treatment, terminate scabies

transmission, and reduce morbidity caused by scabies

infection. Previous study showed that community

empowerment is able to make a sustainable and

equitable change for surrounding environment

associated with health improvement (Laverack,

2006). We conducted a study on community based

empowerment of scabies detection by trained non-

medical personnel (NMP) in small-scale society with

a high prevalence of scabies infection. The main

purpose of this study is to evaluate the performance

of the scabies active case detection by trained NMP

in community compared to detection made by

dermatovenereologist in a small-scale population.

2 METHODS

This is a diagnostic study to evaluate the hypothesis

of trained NMP’s ability in scabies active case

detection and early detection of scabies infection by

recognizing the clinical sign and symptoms of

scabies. The study was performed in a boarding

school located in Tajur, Citeureup, Bogor, West Java,

where high-risk population of scabies infection

resides in December 2017. Ethical approval was

granted by Ethical Clearance Committee of Medical

Faculty Universitas Indonesia. Counseling and

training on scabies detection based on clinical sign

and symptoms were provided by

dermatovenereologist to the 16 supervisors in the

boarding school using the guidance of scabies

detection form called “DeSkab” (deteksi skabies) that

has been established before by medical experts in

dermatovenereology. After that we performed

theoretically and practically test to define trained

NMP included further in this study. Later, 3 female

and 3 male supervisors who obtained the highest

score then called NMP A, B, C for female, and NMP

D, E, F, for male supervisors, asked to examine 69

female students and 59 male students according to the

same gender.

The students are selected by consecutive sampling

by their attendance list. Each of the NMP have

different examination place and student’s scabies

detection form to each other, so they don’t have the

possibilities to look on another examination result.

One student must have going through all the NMP’s

short history taking and few physical examinations

that listed on the scabies detection form. The

diagnosis of scabies infection by NMP based on

“DeSkab” occur when 3 criteria were full filled,

which are history of itchy present especially at night,

history of the same itchy problem from the closest

friend in dormitory or their family back then at home,

and by finding lesion on predilection areas.

Confirmation of the scabies infection made by a

dermatovenereologist as the comparison. Diagnosis

made by dermatovenereologist were blinded.

The results both from trained NMPs and

dermatovenereologist collected and processed for

further statistical calculation. Calculation of

sensitivity, specificity, positive predictive (PPV),

negative predictive values (NPV) were tested with

bivariate analysis for diagnostic testing by chi square

2 x 2 table using STATA 15

version.

3 RESULTS

There were 6 trained NMP included in this study and

128 students were examined blindly both by trained

NMP and dermatovenereologist. Trained NMP

sociodemography characteristic described on Table 1.

Trained NMP consisted from the same ratio of 50

% female-male gender. The trained NMP came in

variety of age group and educational background. The

trained NMP mostly come from the 21-30 years old

(66,7 %) and the most common educational

background is bachelor degree (50 %).

Table 1: Sociodemography characteristic of trained non-medical personnel (n=6).

Variables Cate

ories n %

Sex Female 3 50

Male 350

e 21-30

ears ol

4 66.7

31-40

ears ol

2 33.3

Education Senior hi

h233.3

Diploma 1 16.7

Bachelo

350

RCD 2018 - The 23rd Regional Conference of Dermatology 2018

200

As we explained on the previous method section,

3 female trained NMP A to C were asked to examine

69 female students and 3 male trained NMP D to F

were asked to examine 59 male students that include

in this study. NMP A to C performed complete

examination to 55, 57, and 52 students, and NMP D

to F examined 51, 44, and 42 students respectively.

Table 2. Comparison between the result from 6 trained NMP and dermatovenereologist.

Dermatovenereolo

n Resul

+ - Sn Sp PPV

MP A 55 + 32 16 86 11 67 29

0.802

- 52

MP B 57 + 22 6 56 67 79 41 0.105

- 17 12

MP C 52 + 22 5 67 74 81 56 0.005

- 11 14

MP D 51 + 40 2 83 33 95 11 0.000

- 81

MP E 44 + 39 3 95 0 93 0 0.695

- 20

MP F 42 + 38 2 97 33 95 50 0.016

- 11

The result showed that the highest sensitivity is 97

% and specificity is 74 %. Most of NMP have

sensitivity rates higher than specificity rate which is

more desirable in screening purpose, except on NMP

B (56 % vs 67 %) and C (67 % vs 74 %). P value from

NMP C statistically significant but not significantly

meaningful in clinical judgment for screening

purpose (67 % vs 74%, p value 0.005) because the

sensitivity is lower than specificity but has p value <

0.05. In the other hand, NMP D and F showed

meaningful clinical judgement for screening purpose

and statistically significant (83 % vs 33 %, p value

0.000; 97 % vs 33 %, p value 0.016). All PPV have

higher value then NPV (67 % to 95 % vs 0 % to 56

%) because this study performed in a high prevalence

of scabies infection.

4 DISCUSSIONS

This is a pilot study to test the ability of non-medical

personnel to identify scabies infection, in the setting

of screening test in limited resource area. There were

no study about empowering NMP as an active scabies

detection before. In 2005 there was a study by

primary health care workers to identify several

common skin diseases in Africa including scabies.

They used the different methods to establish scabies

diagnosis by finding 3 predilection sites involvement

which showed sensitivity, specificity, PPV, and NPV

of 79.7 %, 99.5 %, 96.4 %, and 97 % respectively

(Mahe et al., 2005). Those rates were achieved by

primary health care workers with medical educational

background.

The result from female trained NMP showed

sufficient sensitivity rates while on male trained NMP

showed much better rates. For specificity, the results

varied with a wide range within female-male trained

NMP. It looks like the trained male NMP had better

ability in scabies detection rather than female NMP.

If we took closer on their educational background, all

trained NMP actually came from equal educational

background. Moreover, they already passed the test

and obtained the highest score before they choose to

examine the students. Here we conclude that

educational background might have no correlation to

their different result. So we tried to look on some risk

factors that came from the students that were gender

and hygiene personality. Both female and male have

the same possibilities to scabies infection, but Hilmy

and Ratnasari in different studies reported that the

incidence of scabies infection in male students were

higher (51.6% and 57.4%, respectively) at two

different boarding school in East Jakarta (Hilmy,

2011; Ratnasari and Sungkar, 2014). This might be

due to hygiene personality that female students tends

to be much better than male students. Severity of

scabies infection is closely related to personal

hygiene. The risk for scabies infection in people with

lack of personal hygiene is 6 times higher than people

with good personal hygiene

(Sungkar, 2015).

During the examination, female trained NMP could

be more difficult to identify scabies because the

Community based Scabies Detection by Trained Non-medical Personnel

201

lesion in female students were not as severe as in male

students.

Diagnostic study commonly evaluated by their

sensitivity and specificity. Estimation of the basic

value of a screening study is that it’s sensitivity must

be at least 50 % if there is no hypothesis before to

show that the probability or chance for an instrument

to detect a true-positive is in balance with at least 50

On the other hand, minimum value of sensitivity

if there is any hypothesis before will be expected to

be higher at least 70 % (Choplin andLundy, 2001;

Arroll, Khin, and Kerse, 2003; Bujang and Adnan,

2016). In this study, five out of six trained NMP have

sensitivity above 60 %, more than the basis estimation

of a screening study.

PPV is the probability that a subject with

abnormal or positive test actually has the disease,

meanwhile NPV is the probability that the subject has

no disease given a negative test result. PPV or NPV

are the key characteristics of a screening program. It

is important to remember that the PPV or NPV are

dependent on both the population under study and the

technical characteristics of the screening test

(Goetzinger and Odibo, 2016). A screening test with

relatively high sensitivity and specificity may still

have a low PPV if the population prevalence is

sufficiently low. Thus, to assess a proposed screening

test it is necessary to evaluate both the technical and

population characteristics (Maxim, Niebo, and Utell,

2014). All the result of this study showed higher PPV

than NPV. With this high PPV, we could apply this

screening method to other communities with a high

probability of scabies prevalence, so it might be able

to identify the possibility of true-positive scabies

well.

There is difficulty in establish scabies diagnosis

due to the lack of gold standard examination. Using

the current reference standard (scraping or biopsy),

there are problems associated with excluding case

with negative skin scrapping results because this

technique is far from being 100 % accurate. It also

happened with dermoscopy, showed the limitation

that is excluding false negative because there is no

reference standard for ruling out or verifying the

absence of scabies infection. A systematic review on

scabies diagnostic methods showed that the diagnosis

of scabies infection is often imprecise or speculative.

None of the reviewed studies met the criteria for high

quality evidence based on established methodology

filters (Leung and Miller, 2011).

Comparison for the examination result from NMP

using dermatovenereologist clinical and knowledge

judgement as gold standard in line with a statement

from Leung that clinical experience and judgement

come into priority in diagnosis of scabies and may

even include a treatment trial in some cases (Leung

and Miller, 2011). We conclude that sensitivity rate

achieved by trained NMP in this study were higher

than the basic estimation for diagnostic screening

tools.

5 CONCLUSIONS

Active case scabies detection by trained NMP in this

study showed a good sensitivity rate. It might be

applied to high scabies prevalence population. The

cases could be referred to the primary health care

earlier for proper treatment, stop the transmission,

and reduce the morbidity rates. We also recommend

that NMP training on scabies detection must be

implemented periodically to achieve a higher result.

ACKNOWLEDGEMENTS

The author wishes to thank Dr. dr. Aria Kekalih, MTI

for the statistical analysis, and dr. Rinadewi

Astriningrum, Sp.KK, dr. Adhimukti T. Sampurna,

Sp.KK, dr. Yudo Irawan, Sp.KK for the contribution

during the study performed. There is no conflict of

interest in this study.

REFERENCES

Arroll, B., Khin, N., Kerse, N., 2003. Screening for

depression in primary care with two verbally asked

questions: cross sectional study. BMJ, 327(7424), pp.

1144-1146.

Boediardja, S.A., Handoko, R.P., 2015. Skabies. In:

Menaldi, S.L., Bramono K, Indriatmi W, editors. Ilmu

Penyakit Kulit dan Kelamin. Jakarta: Badan Penerbit

FKUI, pp. 137-40.

Bujang, M.A., Adnan, T.H., 2016. Requirements for

Minimum Sample Size for Sensitivity and Specificity

Analysis. J Clin Diagn Res, 10(10), YE01-YE6.

Choplin, N.T., Lundy, D.C., 2001. The sensitivity and

specificity of scanning laser polarimetry in the

detection of glaucoma in a clinical setting.

Ophthalmology, 108(5), pp. 899-904.

Goetzinger, K.R., Odibo, A.O., 2011. Statistical analysis

and interpretation of prenatal diagnostic imaging

studies, Part 1: evaluating the efficiency of screening

and diagnostic tests. J Ultrasound Med, 30(8), pp.

1121-1127.

Hilmy, F., 2011. Prevalensi Penyakit Skabies dan

Hubungannya Dengan Karakteristik Santri Pesantren

RCD 2018 - The 23rd Regional Conference of Dermatology 2018

202

X Jakarta Timur (Skripsi). Jakarta: Universitas

Indonesia;.

Laverack, G., 2006. Improving health outcomes through

community empowerment: a review of the literature. J

Health Popul Nutr, 24(1), pp. 113-120.

Leung, V., Miller, M., 2011. Detection of scabies: A

systematic review of diagnostic methods. Can J Infect

Dis Med Microbiol, 22(4), pp. 43-46.

Mahe, A., Faye, O., N'Diaye, H.T., Ly, F., Konare, H.,

Keita, S., et al., 2005. Definition of an algorithm for the

management of common skin diseases at primary health

care level in sub-Saharan Africa. Trans R Soc Trop Med

Hyg, 99(1), pp. 39-47.

Maxim, L.D., Niebo, R., Utell, M.J., 2014. Screening tests:

a review with examples. Inhal Toxicol, 26(13), pp. 811-

828.

Ratnasari, A.F., Sungkar, S., 2014. Prevalensi Skabies dan

Faktor-Faktor yang Berhubungan di Pesantren X

Jakarta Timur. EJKI, 1:2.

Sungkar, S., 2015. Epidemiologi Skabies. In: Sungkar S,

editor. Skabies: Etilogi, Patogenesis, Pengobatan,

Pemberantasan, dan Pencegahan. Jakarta: Badan

Penerbit FKUI.

WHO, 2018. Scabies 2018 [cited 2018 January 15].

Available from:

http://www.who.int/lymphatic_filariasis/epidemiology

/scabies/en/.

Community based Scabies Detection by Trained Non-medical Personnel

203