Professor Ferdinand Ritter von Hebra (1816–1880) was a renowned Austrian physician and dermatologist who had a deep interest in scabies and demonstrated that it was due to parasitic infestation (Fig. 1). Although the scabies mite was discovered by Bonomo in Italy in 1687, Professor von Hebra proved unequivocally that the mite was the only cause of scabies. In his Atlas of Skin Diseases he documented the mite’s burrows within the epidermis and his illustrations are unsurpassed even today. His findings are thoroughly described in his treatise on scabies, published in 1844.
During the time he was in charge of the skin diseases ward at the General Hospital of Vienna, Professor von Hebra dealt with a diverse range of skin diseases, however, the majority of these where scabies cases. In 1841, almost 2200 (82%) of 2700 inpatients had scabies, although prevalence data for Austria at that time is not available.
Scabies prevalence rates in Austria are now very low. However, as in many other developed countries, scabies outbreaks are still common, particularly in institutions such as nursing homes and prisons. With the exception of Australian indigenous communities, where the scabies prevalence rates are still high, Australia like Austria has managed to largely control scabies as a public health problem.
The burden of scabies in developing countries around the world is however much higher. The World Health Organization estimates that over 300 million people worldwide are affected by scabies each year and countries of the Pacific region, including Fiji, are recognised as having a particularly high burden of scabies and its complications.
Fiji, located about 4,700 km North East of Australia’s Eastern coast, is one of Australia’s Pacific neighbours. It has a population of 830,000 people distributed across more than 300 islands where five star hotels and resorts clash with a developing country background, where the national per capita income is US $3,500 and many villages still have communal water supply, pit toilets and subsistence living.
A 2003 dermatology teaching visit from Australia had the Fijian nurses and doctors expressing their concern that they believed scabies was their biggest health problem and they estimated it was taking up 40% of their time.
Four doctors with an interest in scabies then became partners when Austrian Karin Haar met Australian Margot Whitfeld and Fijians Meciusela Tuicakau and Josefa Koroivueta to work out the best way to find out if there really was a problem to solve and how to do it.
Preliminary data were obtained from the national dermatology clinic, based in Twomey Hospital. This showed that 38% of patients seen in the clinic had scabies or infected scabies, with children particularly being affected (Fig. 2 and 3). However, no data on community based mass treatment were available. Consequently, Dr Whitfeld and Dr Haar, together with the Fiji Ministry of Health, developed a study plan to assess the size of the problem and to look at whether mass treatment for scabies is a viable option.
A study was designed to firstly find the prevalence of scabies in two rural Fijian villages, and then to compare treatment regimes containing either benzyl benzoate or ivermectin/permethrin regimes to treat all the people registered as living in the villages, as is done when treating educational communities, prisons or nursing homes.
The results showed prevalence rates of 24 % and 38 % in two communities of approximately 1000 members. The two treatment regimes were equally effective at three weeks but ivermectin was better tolerated than benzyl benzoate in those with additional skin problems.
It became apparent that national prevalence data were required to assess whether the data from two villages were replicated throughout the country.
It was therefore decided, in conjunction with the Fiji Ministry of Health and a new member of the team, Ms Lucia Romani, to carry out a cross-sectional survey of more than 13,000 people across Fiji to assess the prevalence of scabies and better document the size of the scabies health problem. A total of 96 villages, settlements and schools were surveyed across both the Indo-Fijian and indigenous Fijian populations and all age groups.
The results of the study showed that the prevalence of scabies was 23 % of the population sampled, with 55 % of the children aged 4–7 being affected, and 33% of the 0-3 year olds. Secondary infection was found in all age groups, but maximal in those with more extensive scabies.
The literature shows that in isolated communities with this level of prevalence rates of scabies, increasing water availability and treating individuals is not sufficient. It is necessary to treat both symptomatic and asymptomatic scabies infections. In Fijian communities, treating family members and contacts may extend to 10 or 20 people. We propose that the best way to do this in highly endemic communities is to treat everybody, regardless of their symptoms.
The next step is to find the best way of implementing this in a multi-community and even national level. It is up to us to find the most efficient, well tolerated and safest way to do this in a sustainable way, whether it be with ivermectin, permethrin cream, benzyl benzoate, sulphur or a combination of treatments.
Treating scabies not only alleviates extreme itch, but also reduces its more serious complications. Most likely, Professor von Hebra would have recognized scabies as a cause of death from sepsis, but he would not have known of the role of streptococcal infected scabies in the development of post-streptococcal glomerulonephritis, rheumatic fever and rheumatic heart disease.
With over 80 % of his patients being infected with scabies, Professor Ferdinand von Hebra would probably never have imagined a dermatology ward where there could be no scabies. 130 years after his death, most developed countries have managed to keep scabies prevalence rates to less than 1 % and it is now our role to achieve this in developing countries too.
Dr Margot Whitfeld, MBBS, FACD, DTM&H
Head of Department
St Vincent’s Hospital
390 Victoria Street
Darlinghurst NSW 2010