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Public Health

journal homepage: www.elsevier.com/puhe

Original Research

Controlling scabies in madrasahs (Islamic religious schools)

in Bangladesh

K. Talukder a,*, M.Q.K. Talukder a, M.G. Farooque a, M. Khairul b, F. Sharmin a, I. Jerin a,

M.A. Rahman a
a
Centre for Woman and Child Health, Ashulia, Savar, Dhaka 1349, Bangladesh
b
Arsenic and Health Research Project in Bangladesh, Columbia University, New York, USA

article info summary

Article history: Objectives: To assess the effectiveness of a scabies control programme in reducing the preva-
Received 18 February 2011 lence of scabies in urban Bangladesh madrasahs, where the condition is extremely common.
Received in revised form Study design: A controlled trial involving four intervention madrasahs (total students 2359)
21 May 2012 and four control madrasahs (total students 2465) in Dhaka Metropolitan Area.
Accepted 6 September 2012 Methods: A baseline scabies sample survey was carried out on 40 and 44 students of four
Available online 9 October 2012 intervention and four control madrasahs, respectively. Another 40 students of the inter-
vention madrasahs were administered a pre-intervention test on scabies knowledge. This
Keywords: was followed by mass treatment of all students, teachers and staff of the eight madrasahs
Scabies with topical 5% permethrin cream. The subsequent intervention involved daily monitoring
Madrasah of students for five key personal hygiene practices, weekly 10-min scabies health education
Residential institutions classes, supply of simple and inexpensive products to students to prevent cross-infestation
Children to/from peers (e.g. plastic bags, clothes hangers), and chemotherapy of new students
Bangladesh detected with scabies. After 4 months of the intervention, the prevalence of scabies,
personal hygiene practices and scabies knowledge were assessed in students of the
intervention madrasahs.
Results: Before the intervention, the prevalence of scabies was 61% and 62% in intervention
and control madrasahs, respectively (P 1.00). After mass scabies treatment in all eight
madrasahs and 4 months of intervention, the prevalence of scabies was reduced to 5% and
50% in intervention and control madrasahs, respectively (P < 0.001). There were significant
improvements in all five personal hygiene practices at the intervention madrasahs. Mean
test scores for scabies knowledge were 40% before the intervention and 99% after the
intervention in the four intervention madrasahs. The cost of this programme was US$1.60
per student, and primarily included products such as plastic bags and clothes hangers, and
health education material.
Conclusions: This programme demonstrates a pragmatic and cost-effective way to control
scabies in a residential institutional setting. It is recommended that this programme
should be scaled up to all residential madrasahs in Bangladesh.
2012 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.

* Corresponding author. Tel.: 88 01713 047131.

E-mail address: khurshidtalukder@yahoo.co.uk (K. Talukder).
0033-3506/$ e see front matter 2012 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.puhe.2012.09.004
84 p u b l i c h e a l t h 1 2 7 ( 2 0 1 3 ) 8 3 e9 1
Introduction
Scabies is hyperendemic in Bangladeshi madrasahs.c In 2003,
Karim et al. showed, in a study in and around Dhaka city,1 that
98% of 492 children [mean age 11.2 (standard deviation 2.4)
years] in six residential madrasahs had scabies. This is of
significance in a country where a 2008 World Bank survey2
showed that madrasahs (aliyah,d qawmie and others) account
for 14% of all rural primary enrolment and 22% of all rural
secondary enrolment, with 87% of qawmi and 19% of aliyah
madrasahs offering at least some residential facilities.
The study by Karim et al.,1 the only detailed work of its
kind, confirmed findings from other studies3,4 that scabies is
a disease of deprivation. Karim et al. showed that more than
half of fathers and almost all mothers of madrasah students
were either illiterate or had only received primary education,
and more than half of fathers were in low-paid labouring jobs
and almost all mothers were housewives.1 They also showed
that unhygienic living conditions and poor personal hygiene
were closely associated with scabies; almost three-quarters of
madrasah children were living in poorly ventilated over-
crowded rooms, more than 80% kept their clothes on
a communal line, almost one-third shared bed linen, more
than one-fifth shared towels, almost two-fifths bathed infre-
quently, and almost two-thirds washed their clothes two or
three times a fortnight. Severe disease and relapse were
associated with household income, overcrowded sleeping
conditions, infrequent bathing with soap and infrequent
washing of clothes.
Scabies is not merely a troublesome skin condition, as
secondary skin infection with group A streptococcus can be
a precursor to both post-streptococcal glomerulonephritis5e8
and acute rheumatic fever9e11 e chronic, debilitating and
often fatal childhood conditions. Such is the concern about
renal involvement following scabies that the success of some
mass scabies treatment programmes12 has been monitored by
routine urine microscopy for haematuria.
The finding that children of school age (5e14 years) are at
increased risk of renal disease because of scabies associated
with pyoderma is borne out by hospital admission data13 from
both Dhaka Medical College Hospital (DMCH) and the Institute
of Child and Mother Health (ICMH), Matuail, Dhaka in 2000.
These show that the primary reason for hospital admission
among this age group is post-streptococcal glomerulone-
phritis e 15% at DMCH and 29% at ICMH. There were six
deaths among the 226 school-aged children admitted to ICMH
in 2000. Of these deaths, three (50%) were due to complica-
tions of post-streptococcal glomerulonephritis.
The very large population of residential madrasah
students in the country at high risk of scabies, and subse-
quently of chronic debilitating conditions such as post-
streptococcal glomerulonephritis, warrants a public health
intervention to control scabies in madrasahs. Madrasahs are
c
A residential Islamic religious educational institution
commonly found in the Indian sub-continent.
d
Aliyah madrasahs follow a secular curriculum alongside reli-
gious education and are funded by the Government.
e
Qawmi madrasahs follow a purely traditional religious
curriculum and are privately funded.
very controlled environments with a culture of obedience,
and hence provide a suitable environment for an interven-
tion where behavioural change is essential for success.
Therefore, the authors undertook a study in eight madrasahs
in Dhaka Metropolitan Area to: (1) assess the prevalence of
scabies, (2) design and implement an intervention package in
collaboration with students and teachers, and (3) assess
whether this intervention package reduced the prevalence of
scabies.
Methods
Study setting
There were 710 madrasahs in Dhaka Metropolitan Area in
2010 (600 were all-male and 110 were all-female madra-
sahs).14 Ninety percent of these madrasahs were residential.
Eight qawmi male residential madrasahs with populations of
more than 500 were selected for this prospective controlled
intervention trial, which was undertaken from September
2008 to August 2009. These eight madrasahs were selected
from four zones of Dhaka Metropolitan Area: north west,
south west, north east and south east (two madrasahs from
each zone). In each zone, one madrasah was randomly
selected to be the intervention madrasah and the other was
selected to be the control madrasah. An activity flow chart is
shown in Fig. 1.
Data collection
Students aged 6e15 years from the moktobf and hefzg sections
were recruited by systematic random sampling for data
collection. Pre- and post-intervention assessments of scabies
were performed using a structured pre-tested questionnaire.
In total, 84 students in the intervention madrasahs were
studied (44 before intervention and 40 after intervention) and
80 students in the control madrasahs were studied (40 before
intervention and 40 after intervention). The students studied
before the intervention were not the same students as those
studied after the intervention. Information was collected on
students socio-economic status, personal hygiene, scabies/
itching, nutrition and doctors observation. Furthermore,
a group of 40 older students (8e30 years of age) from the
kitabh sections of the four intervention madrasahs were
assessed before and after the intervention using 10 multiple
choice questions on scabies to assess changes in knowledge
following implementation of the scabies control programme.
These small numbers were derived from sample size calcu-
lations based on the hypothesis that a re-infection rate of
71% pre-intervention would be reduced to 30% post-
intervention.
f
moktob e nursery to kindergarten section in the madrasah
education system.
g
hefz e Quran memorisation section.
h
Kitab e the 12 regular classes in the madrasah education
system: ebtedayee, taisir, mizan, nahbemir, hedayatannahu,
kafia, shorhe jami, shorhe bekaya, hedaya, jalalain, meshkat and
daorae hadis.
 p u b l i c h e a l t h 1 2 7 ( 2 0 1 3 ) 8 3 e9 1
Fig. 1 e Activity flow chart.
Nutritional status was assessed by weighing (using elec-
tronic bathroom scales accurate to 100 g) and measuring the
height (using a locally made height meter accurate to within
1 mm) of students. Scabies was diagnosed and confirmed by
a consultant dermatologist, who was blinded regarding
whether the madrasahs were intervention or control sites. A
simplified algorithm developed for diagnosing skin condi-
tions in developing countries15 was used to diagnose
scabies. This provided the following diagnostic criteria:
presence of itching involving at least two sites of the body,
and visible lesions involving typical sites for scabies (i.e.
interdigital spaces of hands, wrists, axillae, elbows, knees,
buttocks and genitalia). Students diagnosed with scabies
were treated with 5% permethrin cream, and antibiotics if
secondarily infected. Other skin conditions such as impe-
tigo, atopic dermatitis or fungal skin infections were treated
appropriately.
Mass treatment of scabies
After baseline assessment, all residents (students, teachers
and staff) of the eight study madrasahs were treated with
permethrin 5% cream, applied to the whole body from the
neck down and washed off after 8e14 h.16 Scabies treatment
took place on the same day at each institution.
Intervention
The scabies control programme was developed by a partici-
patory method involving madrasah students, teachers and
ancillary staff, and incorporated features from scabies control
85
programmes from across the world.17e20 Key features of the 4
month intervention were as follows:
 Separate scabies orientation sessions for the principals and
teachers of each madrasah. The teachers at the interven-
tion madrasahs were given in-depth information regarding
the preventive aspects of scabies, whereas the teachers at
control madrasahs were informed primarily about the
disease and its treatment (i.e. mass treatment with
permethrin cream).
 Health education about scabies was given to all students,
teachers and staff. Class teachers were trained to take
four lessons (10 min each, repeated every 4 weeks) on
scabies over a 16-week period to increase and maintain
awareness about scabies in all students throughout the
madrasah. The lessons were: (1) what is scabies and what
are its symptoms?, (2) risk factors and risk groups,
(3) treatment and (4) prevention. A 60-page flip chart,
entitled Scabies-free madrasah, was developed for use
when training teachers, who subsequently used the flip
chart in health education sessions with students (Fig. 2).
In addition, a poster was developed to display in madra-
sahs carrying 10 key messages related to scabies control
(Fig. 3).
 A designated class scabies monitor gently reminded his
class mates and advised them if they were found to be
lacking in the key five personal hygiene practices to prevent
scabies (daily bath with soap, change of clothes within 3
days, bedding stored in polythene bags, clean clothes hung
on hangers, bedding put out in the sun once a month).
Monitors also collected data on a fixed date of the month
from 10 randomly selected students in his class for
86 p u b l i c h e a l t h 1 2 7 ( 2 0 1 3 ) 8 3 e9 1

Fig. 2 e Key messages from scabies-free madrasah flip chart.

a monthly report on the level of student compliance with
these five personal hygiene practices. These reports were
subsequently submitted to the scabies control officer in
a monthly meeting.
 During the 4-month intervention, a madrasah teacher,
designated the scabies control officer, held monthly
meetings with all the class scabies monitors to compile
a full madrasah monthly report on the five key personal
hygiene practices. The scabies control officer also moni-
tored the overall hygiene of the madrasah.
 Students with documented scabies were separated
from other students to optimise infection control.
 p u b l i c h e a l t h 1 2 7 ( 2 0 1 3 ) 8 3 e9 1
Fig. 3 e Scabies-free madrasah poster (with English translation).
Cases were treated with permethrin cream two or three times.
Treatment was proactive even in equivocal cases.
 All new staff, students and teachers were asked to take
a course of permethrin cream before starting at the madrasah.
 Each student in this programme was provided with tubes of
5% permethrin cream, large polythene bags to
store bedding, small polythene bags to store dirty clothes,
and clothes hangers to hang clothes separately. Flip charts
and posters were also distributed to madrasahs.
Project monitoring
The intervention was monitored by a research assistant who
visited each intervention madrasah weekly. He spoke with
class monitors, teachers and students regarding their ability
to carry out the planned interventions, and gave them advice
regarding how to solve problems. In addition, he collected and
compiled the monthly monitoring reports prepared by class
monitors and scabies control officers.
Analysis
Data were entered and validated using EpiInfo Version 6.04,
and analysed using Statistical Package for the Social Sciences
(SPSS Inc., Chicago, IL, USA). A wealth index was constructed
from a composite score of assets and services present in the
students home using principal components analysis.21 Soci-
odemographic parameters, personal hygiene practices and
anthropometry data of the students from the intervention and
control madrasahs were compared using Chi-squared test and
Fishers exact test. The ManneWhitney U-test was used for
non-normally distributed variables to determine if there were
any significant differences between the two groups of
madrasahs. In addition, Chi-squared test was used to assess if
87
there was a significant difference in the prevalence of scabies
between the intervention and control madrasahs before and
after 4 months of intervention.
Results
There were no significant differences (Chi-squared test)
between the control and intervention madrasahs with regard
to fathers educational qualifications and occupation, food
security status of the family, type of toilet, wealth index and
nutritional status (stunting, thinness). The students of the
control madrasahs slept in more crowded rooms than the
students of the intervention madrasahs. The characteristics of
the intervention and control groups are summarized in Table 1.
Before the intervention, there was no significant difference
(P 1.00) in the prevalence of scabies between the control and
intervention madrasahs (62% vs 61%). After the intervention,
there was a significant difference (P < 0.001) in the prevalence
of scabies between the control and intervention madrasahs
(50% vs 5%) (Fig. 4). The prevalence of scabies decreased in the
control group from 62% to 50%; this difference was not statis-
tically significant (P 0.367), and may have been due to the
mass treatment with permethrin cream that took place in both
control and intervention madrasahs at the beginning of the
study. Furthermore, the mass treatment itself may have
inadvertently taught students and teachers at the control
madrasahs that scabies can be treated with permethrin cream.
The five personal hygiene practices promoted throughout the
4-month intervention scabies control programme are shown in
Table 2. There were significant increases in all five practices in the
intervention madrasahs at the post-intervention assessment
compared with the control madrasahs. Mean test scores for
scabies knowledge among students of the intervention madra-
sahs were 40% before the intervention and 99% after the
88 p u b l i c h e a l t h 1 2 7 ( 2 0 1 3 ) 8 3 e9 1

Table 1 e Background characteristics of intervention and control groups.

Background Type of Intervention Control P
characteristics intervention group group
group (Pre n 44 (n 40) (%)
Post n 40) (%)

School educated fathera Pre 25 (58) 23 (72) 0.220

Post 28 (74) 23 (66) 0.458
Manual labourer father Pre 9 (21) 11 (28) 0.449
Post 8 (20) 6 (15) 0.556
School educated mother Pre 30 (68) 31 (78) 0.339
Post 38 (95) 29 (74) 0.011
Housewife mother Pre 39 (89) 40 (100) 0.056b
Post 39 (98) 37 (93) 0.615b
Food deficit in family Pre 14 (32) 16 (40) 0.434
Post 20 (50) 15 (38) 0.260
Sanitary toilet Pre 41 (93) 37 (93) 1.000b
Post 38 (95) 37 (93) 1.000b
Poorest wealth index Pre 5 (11) 9 (23) 0.171
Post 11 (28) 7 (18) 0.284
Stunted (height-for-age Z-score < -2.01) Pre 11 (25) 6 (15) 0.255
Post 14 (35) 9 (23) 0.217
Thin (BMI-for-age Z-score <2.01) Pre 1 (2) 2 (5) 0.603b
Post 5 (13) 10 (25) 0.152
Overweight (BMI-for-age Z-score >2.00) Pre 1 (2) 0 (0) 1.000b
Post 0 (0) 1 (3) 1.000b
Sleeping area well lit/ventilated Pre 42 (96) 39 (98) 1.000b
Post 36 (90) 32 (80) 0.210

Background Type of Intervention Control group Pc

characteristics intervention group (Pre n 44 (n 40)
group Post n 40) (mean rank)
(mean rank)

Number of earning Pre 43 42 0.804

family members Post 37 44 0.119
Mean age (years) Pre 38 47 0.078
Post 38 43 0.275
Floor space per person in dormitory (ft2) Pre 53 31 0.000
Post 52 29 0.000

a Total (n) varied in this variable as 16 out of 164 students were unaware of their fathers education level or their father was deceased.
b Fishers exact test.
c Mann-Whitney U-test.

Fig. 4 e Prevalence of scabies (%) in students of control and intervention madrasahs before and after implementation of
a scabies control programme.
 p u b l i c h e a l t h 1 2 7 ( 2 0 1 3 ) 8 3 e9 1 89

Table 2 e Personal hygiene practices before and after the scabies control programme.
Pre-intervention* Post-intervention**

Intervention % (n) Control % (n) Intervention % (n) Control % (n)

Daily use of soap during baths 2.3 (1) 2.5 (1) 85 (34) 2.5 (1)
Clothes washed more than once a week 9.1 (4) 2.5 (1) 57.5 (23) 0 (0)
Clothes hung on separate clothes line/hanger 0 (0) 0 (0) 100 (40) 0 (0)
Bedding stored separately/wrapped in polythene 0 (0) 0 (0) 100 (40) 0 (0)
Bedding put in sunlight once a month or more 2.3 (1) 0 (0) 100 (40) 0 (0)

*P > 0.05.
**P < 0.001.

intervention, implying a significant improvement in knowledge
among students as a result of the intervention. Over the 4-month
intervention period, monthly reports from scabies control officers
showed good student compliance with the five key personal
hygiene practices (all in excess of 80%). Fig. 5 shows that the only
practice that increased significantly over the 4-month interven-
tion period was putting bedding in the sun on a monthly basis,
which increased from 82% to 92%.
Costs of the programme
The main cost of this scabies control programme was the
materials (e.g. plastic bags, clothes hangers), which amounted
to US$ 3809 for the four intervention madrasahs (2359
students, i.e. US$ 1.61 per student). The personnel involved as
health educators and scabies control officers were teachers
already employed by the madrasahs. The class scabies
monitors were students without any salaries. The research
assistant, who followed up on the four madrasahs once
a week, was a full-time employee of the programme.
Discussion
This study shows that implementing a scabies control pro-
gramme using existing personnel and limited materials can
reduce the prevalence of scabies to 5% in large urban madra-
sahs, compared with a prevalence of 50% where there is no
such programme. In addition, personal hygiene practices and
student knowledge of scabies increased significantly in the
intervention madrasahs.
Students recruited in the control madrasahs were similar to
those in the intervention madrasahs in all respects except that
they slept in more crowded conditions than their intervention
counterparts. However, in the pre-intervention assessment,
both the intervention and control groups had a similarly high
prevalence of scabies. Therefore, it appears that the interven-
tion programme was the main driver for reducing the preva-
lence of scabies in the intervention madrasahs, rather than
living in less crowded living conditions.
Information about either the detection/treatment of new
cases of scabies diagnosed during the period of the interven-
tion, or the treatment of new students and teachers was not
collected in this study. The main objective was to assess the
effect of a whole package of interventions which included
both preventive measures (e.g. health education and treat-
ment of new students and teachers) and treatment of new
visible cases of scabies. As data were not collected for the
individual components of the intervention package (e.g. how
many students were treated), it is not possible to comment on
the separate contribution of individual components to the
reduced prevalence of scabies.

Fig. 5 e Summary of monthly monitoring reports about personal hygiene practices in the 4-month scabies control
programme in intervention madrasahs.
90 p u b l i c h e a l t h 1 2 7 ( 2 0 1 3 ) 8 3 e9 1
A 2007 Cochrane review22 stated Approaches to the
control of outbreaks in institutions and public health pro-
grammes to control scabies in populations with high preva-
lence require evaluation. This madrasah study provides new
direction in this difficult and neglected area of public health.
A 2009 scabies intervention23 in a highly endemic Aboriginal
community in Northern Australia described the frustration of
compliance in a population that was not convinced about the
need to apply permethrin cream in the absence of symptoms.
The treatment uptake for household contacts was only 44%,
and follow-up at 4 weeks showed that more than 9% of
susceptible contacts had developed scabies. Another inter-
vention24 targeting children from the same Australian
Aboriginal community managed to reduce rates of infected
scabies from 3.7% [95% confidence interval (CI) 2.4e4.9] to
1.5% (95% CI 0.7e2.2), a relative reduction of 59%, but there
was no significant improvement in the scabies rate (16% at
baseline and 13% over the subsequent 3-year intervention
period).
In terms of compliance, the current study population
differed significantly from the Australian Aboriginal
communities in that it consisted of institutionalized chil-
dren who have a very strong ethos of obedience.25 As
a result, any instructions given by teachers in a health
education programme such as this are likely to be followed.
An indication of this high compliance is the high return rate
of used permethrin cream tubes from the eight madrasahs
after the mass treatment nights (mean 91%, range
84e100%). In addition, the significant reduction in the
prevalence of scabies and the high uptake of the five key
personal hygiene practices is in keeping with Islamic norms
on cleanliness.26
Although oral ivermectin has been used successfully in
a number of community-based scabies interventions else-
where,27,28 there is no clinical experience with the use of this
drug in the treatment of scabies in Bangladesh.
Conclusions and recommendations
An effective intervention such as this holds promise for the
significant public health problem of scabies in Bangladeshi
residential madrasahs which are primarily in the private
sector. This intervention can be scaled up through the
Bangladesh Qawmi Madrasah Education Board, which has
some 15,000 madrasahs registered under it with approxi-
mately 4 million students and 200,000 teachers.29 Proper
monitoring is needed to ensure success in this effort. The cost
of this programme can be borne by the individual student or
by the madrasah when the students family is too poor to bear
even this small amount.
Acknowledgements
The authors would like to thank all the teachers, students and
ancillary staff of all the madrasahs that took part in this study.
The authors are also very grateful to Mr. Ryhan for data
collection.
Ethical approval
Ethical approval was obtained from the Ethical Review
Board of the Centre for Woman and Child Health. Informed
verbal consent was taken from the madrasah authorities
before information was taken from the students or before
physical examinations.
Funding
Bangladesh Medical Research Council.
Competing interests
None declared.
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