Aus dem Schweizerischen Tropeninstitut der Universität Basel und der Universitäts-Hautklinik der Albert-Ludwigs-Universität Freiburg i.Br.
Skin Disorders among Schoolchildren in Rural Tanzania and an Assessment of Contributing Factors and Therapeutic Needs
INAUGURAL-DISSERTATION zur Erlangung des Medizinischen Doktorgrades der Medizinischen Fakultät der Albert-Ludwigs-Universität Freiburg i.Br.
Vorgelegt 2005 von Julia Ferié geboren in Georgsmarienhütte 2 #
!!" 4 STUDIENKOORDINATOR
PD Dr. C. Hatz Leitender Arzt der tropenmedizinischen Poliklinik Schweizerisches Tropeninstitut Universität Basel Schweiz
MITGLIEDER DES DISSERTATIONSKOMMITEES:
Prof. Dr. L. Bruckner-Tuderman Geschäftsführende Direktorin Universitäts-Hautklinik Albert-Ludwigs-Universität Freiburg i.Br. Deutschland
PD Dr. P. Schmid-Grendelmeier Leitender Arzt der Allergiestation Dermatologische Klinik und Poliklinik Universitätsspital Zürich Schweiz
Prof. Dr. M. Tanner Institutsvorsteher Schweizerisches Tropeninstitut Universität Basel Schweiz
STUDIENKOORDINATOR AM IHRDC, IFAKARA/TANZANIA: Dr. B. Idindili
FACHARZT FÜR DERMATOLOGIE AM SFDDH, IFAKARA/TANZANIA: Dr. M. Mbata
UNTERSTÜTZUNG DER STATISTISCHEN AUSWERTUNG: Dr. T. A. Smith Dr. P. Vounatsou 5
for Tom and my family for our team and the children of Lihami and Michenga 6 7 Content
1 Content page
1 Content………………………………………………………………………………………. 7 2 Acknowledgements……………………………………………………………………….. 9 3 Summary…………………………………………………………………………………….. 10 4 Zusammenfassung..………………………………………………………………………. 11 5 Introduction…………………………………………………………………………………. 12 6 Methods……………………………………………………………………………………… 15 6.1 Study population, approaches and methods…………………………………… 15 6.2 Statistical analysis……………………………………………………………………19 6.3 Diagnostic criteria…………………………………………………………………… 19 6.4 Abbreviations………………………………………………………………………… 22
7 Results……………………………………………………………………………………….. 23 7.1 Study population…………………………………………………………………….. 23 7.2 Living conditions and hygiene behaviour………………………………………. 24 7.3 Prevalence of skin diseases……………………………………………………….. 24 7.4 Treatment……………………………………………………………………………… 26 7.5 Ivermectin……………………………………………………………………………... 27 7.6 Spectrum of skin diseases: details and special findings…………………….. 28 7.6.1 Infectious skin diseases………………………………………………….. 28 7.6.1.1 Dermatomycoses………………………………………………………… 28 Tinea versicolor………………………………………………………….. 28 Dermatophyte infections: tinea capitis, faciei, corporis and pedis…………………………………………………… 29 Other dermatomycoses…………………………………………………. 31 7.6.1.2 Intertrigo…………………………………………………………………... 31 7.6.1.3 Pyoderma…………………………………………………………………. 31 7.6.1.4 Wounds……………………………………………………………………. 32 7.6.1.5 Abscesses………………………………………………………………… 32 7.6.1.6 Ectoparasitic disorders………………………………………………… 33 Scabies…………………………………………………………………… 33 Scabies incidence in the area of Ifakara……………………………… 33 Pediculosis……………………………………………………………….. 34 7.6.1.7 Warts……………………………………………………………………….. 34 7.6.1.8 Other skin conditions of infectious origin…………………………...34
7.6.2 Non-infectious skin diseases……………………………………………….. 34 7.6.2.1 Pruritic dermatoses……………………………………………………... 34 7.6.2.2 Lesions due to insects………………………………………………….. 35 7.6.2.3 Eczematous lesions…………………………………………………….. 35 7.6.2.4 Keratoses…………………………………………………………………. 35 7.6.2.5 Pigmentary disorders…………………………………………………… 36 7.6.2.6 Keloids and hypertrophic scars………………………………………. 37 7.6.2.7 Acneiform lesions……………………………………………………….. 37 7.6.2.8 Other skin conditions of non-infectious origin…………………….. 38
8 Discussion………………………………………………………………………………….. 39 8.1 Study population…………………………………………………………………….. 39 8.2 Living conditions and hygiene behaviour………………………………………. 39 8.3 Prevalence of skin diseases……………………………………………………….. 40 8.4 Treatment……………………………………………………………………………… 41 8 Content
8.5 Spectrum of skin diseases: details and special findings.……………………. 42 8.5.1 Infectious skin diseases……………………………………………………… 42 8.5.1.1 Dermatomycoses………………………………………………………… 42 Tinea versicolor………………………………………………………….. 42 Dermatophyte infections: tinea capitis, faciei, corporis and pedis…………………………………………………… 44 8.5.1.2 Intertrigo…………………………………………………………………... 46 8.5.1.3 Pyoderma…………………………………………………………………. 46 8.5.1.4 Wounds……………………………………………………………………. 46 8.5.1.5 Abscesses………………………………………………………………… 47 8.5.1.6 Ectoparasitic disorders………………………………………………….47 Scabies…………………………………………………………………… 47 Scabies incidence in the area of Ifakara……………………………… 48 Pediculosis……………………………………………………………….. 49 Other ectoparasitoses…………………………………………………... 49 8.5.1.7 Warts……………………………………………………………………….. 50 8.5.1.8 Other skin conditions of infectious origin………………………….. 50
8.5.2 Non-infectious skin diseases………………………………………………... 51 8.5.2.1 Pruritic dermatoses……………………………………………………... 51 8.5.2.2 Lesions due to insects………………………………………………….. 52 8.5.2.3 Eczematous lesions…………………………………………………….. 52 8.5.2.4 Keratoses………………………………………………………………..... 53 8.5.2.5 Pigmentary disorders…………………………………………………... 53 8.5.2.6 Keloids and hypertrophic scars………………………………………. 55 8.5.2.7 Acneiform lesions……………………………………………………….. 55 8.5.2.8 Other skin conditions of non-infectious origin…………………….. 56 8.5.3 Skin diseases and HIV………………………………………………………... 56 8.6 Strengths and limitations………………………………………………………….. 57
9 Conclusion………………………………………………………………………………… 59 10 Literature…………………………………………………………………………………... 61 11 References………………………………………………………………………………… 68 12 Curriculum vitae………………………………………………………………………….. 69
13 Appendices………………………………………………………………………………... 71 Appendix A: Questionnaire and form sheet……………………………………… 73 Appendix B: Skin diseases among primary schoolchildren in Ifakara (data analysis)…………………………………………………………... 93 Appendix C: Living conditions and hygiene behaviour among the study population and their influence on the prevalence of skin diseases (data analysis)………………………………………… 175 Appendix D: Prevalence of selected skin diseases in different areas of Tanzania…………………………………... 211 Appendix E: Spectrum and prevalence of skin diseases in different areas of Tanzania and the African continent………………….. 219 9 Acknowledgements
2 Acknowledgements
It was only possible to organize, carry out, write and finish this dissertation thanks to the tremendous help and assistance of many different people. I want to express my deepest thanks and appreciation to each and everyone of them.
Dominique Bourgau Veronika Mkope Leena Bruckner-Tuderman Hassan Mshinda Almuth Dinkela Amanda Ross Hermann Feldmeier Markus Schiltknecht Armin Gemperli Peter Schmid-Grendelmeier Christoph Hatz Thomas Smith Jörg Heukelbach Adriana Tami Boniphace Idindili Marcel Tanner Peter Itin Honorathy Urassa Nada Juricevic Penelope Vounatsou Erik Krause Staff of IHRDC Ifakara/Tanzania Charles Maswi Staff of STI Basel/Switzerland Charles Mayombana Staff of the Mycology Department Marco Mbata Jürg Meyer
Thank you very much! I would especially like to thank the pupils and teachers of Lihami and Michenga Primary School.
Special thanks to Dr. Peter Schmid-Grendelmeier for being such a highly motivated expert dermatologist and a fountain of dermatologic knowledge.
Very special thanks to PD Dr. Christoph Hatz. Without him and his excellent supervision and support this project would have never come about.
Financial Support The study was supported by the German Academic Exchange Service (Deutscher Akademischer Austauschdienst, DAAD). All additional costs were covered by the Swiss Tropical Institute. 10 Summary
3 Summary
The present study was carried out to obtain data about the spectrum and prevalence of skin diseases among primary schoolchildren in Ifakara in rural Tanzania. The therapeutic needs, necessity for intervention and the influence of living conditions and hygiene behaviour on the magnitude of the prevalence were assessed. The records of healthcare facilities were checked to assess the incidence of scabies in the area of Ifakara. 820 primary school children aged 6 to 19 years old were examined. 55% of the children had one or more skin disorders. The most frequent diagnosis was tinea versicolor (prevalence: 26.2%) followed by pyoderma (8.4%) and dermatophytoses (tinea capitis: 5.4%, tinea pedis: 3.2%, tinea faciei/corporis: 2.6%). Other diagnoses included clean wounds (3.3%) and pruritic dermatoses (3.3%). Only 1.5% of the children had scabies infestations; 1.2% had eczematous lesions. Treatment was indicated in 33.2% of all diagnoses, mostly in dermatophytoses and pyoderma. The prevalence of dermatophytoses was linked with crowded living conditions, as was the prevalence of infectious skin diseases and tinea versicolor. Skin diseases did not represent a public health problem among primary school children in rural Ifakara at the time of the investigation. Treatment was considered necessary in only one third of the diagnoses and locally available drugs were sufficient for this purpose. The high prevalence of tinea versicolor was probably due to the age structure of the study population and the hot and humid climate at the time of the survey. The previous implementation of prevention measures and improving hygiene conditions probably led to the low prevalence of ectoparasitoses observed. It is unlikely that ivermectin treatment given at two and three years before this survey within the WHO Onchocercosis Control Program (OCP) continued to influence their prevalence. The prevalence rate of eczematous lesions will vary in different locations. This may explain the relatively low prevalence observed amongst the study population. High rates of attendance reported from skin clinics are probably due to an accumulation of severe cases in reference centres. Supply of health care facilities with cheap essential drugs as well as regular training of health staff is needed to guarantee adequate treatment and avoid unnecessary strains on local household budgets. Regular school visits by paramedical staff to provide treatment for the most frequent skin diseases could control conditions such as tinea capitis and tropical ulcers. Regular soap use has also shown promising results in the treatment of dermatomycoses and should be subject to investigation. 11 Zusammenfassung
4 Zusammenfassung
Die Studie wurde durchgeführt, um Daten über das Spektrum und die Prävalenz von Hautkrankheiten bei Primarschulkindern in Ifakara im ländlichen Tansania zu gewinnen. Die Notwendigkeit von Therapie und Interventionen sowie der Einfluss von Lebensbedingungen und Hygieneverhalten auf die Prävalenz wurden beurteilt. Die Auswertung von Unterlagen verschiedener Gesundheitseinrichtungen erlaubte zudem eine Einschätzung der Skabiesinzidenz im Bereich Ifakara. 820 Primarschulkinder im Alter von 6 bis 19 Jahren wurden körperlich untersucht. 55% der Kinder hatten eine oder mehrere Hautkrankheiten. Die häufigste Diagnose war Tinea versicolor (Prävalenz: 26,2%) gefolgt von Pyodermien (8,4%) und Dermatophytosen (Tinea capitis: 5,4%, Tinea pedis: 3,2%, Tinea faciei/corporis: 2,6%). Andere Diagnosen waren saubere Wunden (3,3%) und juckende Dermatosen (3,3%). Nur 1,5% der Kinder litten an Skabiesinfestationen; 1,2% hatten Ekzeme. 33,2% aller Diagnosen benötigten eine Behandlung, in erster Linie handelte es sich um Dermatophytosen und Pyodermien. Im Falle von Dermatophytosen, Tinea versicolor und infektiösen Hautkrankheiten war eine hohe Prävalenz mit einer hohen Haushaltsdichte assoziiert. Zum Zeitpunkt unserer Studie stellten Hautkrankheiten kein bedeutendes Problem für die Gesundheit von Primarschulkindern im ländlichen Tansania dar. Eine Behandlung war nur in einem Drittel der Fälle notwendig und mit vor Ort verfügbaren Medikamenten möglich. Die hohe Prävalenz von Tinea versicolor lässt sich mit der Altersstruktur der Studienpopulation sowie dem heißen, feuchten Klima zum Untersuchungszeitpunkt erklären. Die Einführung von Präventionsmaßnahmen sowie verbesserte Hygieneverhältnisse könnten die beobachtete niedrige Prävalenz von Ektoparasitosen erklären. Ein Einfluss der ein bzw. zwei Jahre zuvor erfolgten einmaligen Gabe von Ivermectin im Rahmen des Onchozerkose Kontrollprogrammes (OCP) der WHO ist dagegen unwahrscheinlich. Die Prävalenz von Ekzemen zeigt starke geographische Schwankungen, was die niedrige Prävalenz in unserer Studienpopulation erklärt. Das gehäufte Auftreten in verschiedenen Hautkliniken im subsaharischen Afrika wird am ehesten auf eine Akkumulation von Fällen in diesen Referenzzentren zurückzuführen sein. Für eine adäquate Behandlung von Hautkrankheiten auf dem Niveau der primären Gesundheitsversorgung ohne unnötige Belastungen der Haushaltsbudgets ist eine regelmäßige Versorgung von Gesundheitszentren mit erschwinglichen Medikamenten unabdingbar. Regelmäßiges Training des Personals sowie Algorithmen für das Management der häufigsten Hautkrankheiten sind weitere wichtige Maßnahmen. Gesundheitsarbeiter könnten im Rahmen regelmäßiger Schulbesuche die häufigsten Hautkrankheiten vor Ort behandeln. Der regelmäßige Gebrauch von Seife verspricht zudem eine Verbesserung der Prävention von Dermatomykosen. 12 Introduction
5 Introduction
Skin diseases are a common problem in rural Africa. Dermatological disorders are among the five most common causes of morbidity and loss of manpower in rural areas (Kopf, 1993). In some communities more than 97% of children are affected by skin diseases (Figueroa et al., 1997). The high prevalence, particularly of infectious skin diseases, appears to be accounted for by poverty, crowding, poor hygiene, difficulties in accessing clean water and plurality of sexual relations. Also inadequate management of these diseases by families, as well as by healthcare providers plays a role (Schmid-Grendelmeier et al., 2002). There are fewer than 150 dermatologists serving more than 200 million people living in Sub- Saharan Africa (Kopf, 1993). Although progress has been made in the control of some tropical diseases (e.g. dracunculiasis and onchocerciasis), others remain endemic in many areas (e.g. leishmaniasis and leprosy). On the other hand, the spectrum and prevalence of skin disorders in societies with a high standard of living, are getting closer to the pattern observed in northern countries (Gibbs, 1996) including dermatoses caused by urbanisation, modernisation and industrialisation (Stingl, 1997). Few community surveys of skin disorders in Africa have been published, with most estimates of prevalence being based on hospital, dispensary or skin clinic attendances (Gibbs, 1996). Data on the proportion of skin diseases for which a treatment would be mandatory are even more scarce. The present study was undertaken to obtain information about the spectrum and prevalence of skin diseases among primary school children in rural southern Tanzania as well as data about factors influencing the magnitude of prevalence. Furthermore the proportion of skin diseases actually requiring treatment was investigated. The findings allowed an assessment of the distribution pattern of skin diseases in Ifakara, a town with a comparatively good health infrastructure, and comparison with findings in other tropical settings during the last three decades. The data will be of worth in assessing the need for further interventions in this area and the form such interventions would preferably take.
General information about the study area The study was carried out in Ifakara, the district capital of Kilombero District, Mogoro Region, in southern Tanzania (figure 1). The district is a rural area with an estimated population of approximately 322,000 (United Republic of Tanzania, 2002). Ifakara is situated in the river plain of Kilombero River, 270 m above sea level and 320 km south-west of Tanzania's largest city Dar Es Salaam. The land lies in the fertile flood plain of the Kilombero River and most inhabitants are subsistence farmers. Other common occupations include fishing and small-scale trading (Armstrong Schellenberg et al., 2002). 13 Introduction
Figure 1: Left: Morogoro Region and Ifakara (Acosta et al., 2001). Right: Typical house near Ifakara.
Farms are often located at some distance from the family home. Major crops include rice, maize, cassava, millet, sesame, coconut and cashew nuts, which are cultivated relying on periodically flooded alluvial soils. There are two main rainy seasons, October to December and February to May, the estimated annual rainfall is 1350 mm/year (Armstrong Schellenberg et al., 2003, ©IPS Meteostar®) (table 2).
Table 2: Ifakara: climate during the time of the screening. ©IPS Meteostar® April May Average high 30°C 28°C Average low 25°C 23°C Days/rain 11 17 Kilombero District contains a broad mix of ethnic groups, but Swahili, the national language, is widely spoken. Most houses have wood-framed mud walls with thatched or corrugated roofs. Living conditions are frequently crowded. Common water sources are communal boreholes, natural spring or river water, and hand-dug wells. The roads are unpaved and transport is difficult in the rainy season.
Information on the health system The Ifakaran health system centres around St. Francis Designated District Hospital (SFDDH). A dermatology outpatient department and one dermatologist serve the entire diocese with a population of over 600,000 (Kilombero and Ulanga District combined) (Kibatala, 2002). In addition, a network of health centres and dispensaries serve the population. Maternal and child health clinics are widely available. Vaccination coverage is reasonably high, with at least 74% of children in Kilombero District receiving measles vaccination by the age of one (Armstrong Schellenberg et al., 2002). Over the counter drugs are widely available from private shops and kiosks and many people also use traditional healers. Malaria, pneumonia, and waterborne diseases such as cholera and diarrhoea are the main health problems reported by health services and in the perception of local people (Armstrong Schellenberg et al., 2003). 14 Introduction
Aspects of health economy During 1990-96, 26% of Tanzanians lived on less than $1 per day (UNICEF, 1999). However, it is difficult to interpret income data, as many families are involved in subsistence farming. In 1997, in the area of Kilombero and Ulanga, the median value of monthly household consumption and expenditure in a sample of local households was under $100, with 75% spent on food (Armstrong Schellenberg et al., 2002). The annual expenditure on health per person ranges about US$ 4 (Switzerland: US$ 2000), health insurance is almost unheard of (Schmid-Grendelmeier, 1998). 15 Methods
6 Methods
6.1 Study population, approaches and methods
Study population The study protocol was approved by the ethical committees in Basel/Switzerland (EKBB) and the ethical committee of the IHRDC/Tanzania. The study population was comprised of 820 primary school children attending two previously selected primary schools. The schools were at a distance of approximately three and eight kilometres from the centre of Ifakara. In Lihami, all 460 students were selected for examination. In Michenga 446 children (62.1% of the overall number of students, n = 718) were chosen at random for examination using a randomization table. Oral informed consent was obtained from the parents, supported by the school administration.
Examination facilities In Lihami, interviews and examinations were carried out in two small rooms (each approximately 2.5 m2 x 2 m2) with two windows serving as light source. Due to the absence of electric lighting, shutters could not be closed for greater privacy. Thus the children were undressed completely except the shorts/skirts which were lifted to check the skin still covered by clothes. Girls at the age of puberty undressed the upper part of the body with the shutters partly closed and only in the presence of female class mates. All children were asked about skin alterations or other symptoms in the genital area. If any problem was mentioned, the patient was undressed completely and examined by torch light. Later in the study a bigger examination room with a curtain allowing extra privacy was made available, allowing the children to undress completely. Due to time restrictions we were unable to question 107 children during the screening concerning their living conditions and hygiene behaviour. They were subsequently interviewed and examined for skin lesions in the genital area. In Michenga, a bright room with a curtain for privacy allowed a complete body examination of all the children. There, 220 children were chosen at random after the screening to answer questions regarding living conditions and hygiene behaviour. From this selection we were able to interview 172 children.
Examination and questionnaires To assess the spectrum and point prevalence of skin diseases as well as contributing factors, each child was asked questions regarding history, living conditions and hygiene behaviour using a standard questionnaire (see Appendix A). Then a whole body examination was performed, always by the same team of four examiners: Dr. M. Mbata, dermatologist of SFDDH, C. Maswi, clinical officer at SFDDH and A. Dinkela and J. Ferié, both medical students of the University of Freiburg. Interviews and examinations were conducted in Swahili. Pathological skin conditions were 16 Methods recorded according to the “categorization of observed skin disorders” (see Appendix A). Several diagnoses were grouped together into diagnostic groups according to their aetiology. Infectious and non-infectious diseases were differentiated. The definitions of criteria for the most important diagnoses are listed below (“Diagnostic criteria”). Scars, fresh wounds, freckles, naevi and mosquito bites were not considered as skin diseases. If several diagnoses were present in the same child, the most severe condition was described in full detail. Cases of superficial dermatomycoses enrolled in a second study (see Dinkela et al., 2005) and documented in full detail. Other findings were briefly recorded. The questionnaire was piloted in a primary school in the centre of Ifakara before commencing the study. After examination pathological lesions were documented with a digital camera. Whilst in Ifakara all diagnoses were discussed with Dr. M. Mbata. Uncertain diagnoses were discussed with an expert dermatologist in Switzerland (Dr. Schmid-Grendelmeier, Department of Dermatology, University Hospital Zürich) via email. Upon return to Switzerland, unclear diagnoses and representative cases together with the photographic documentation were again presented to Dr. Schmid-Grendelmeier as a quality control measure.
Microscopy and mycologic culture Scabies was diagnosed clinically. In addition samples were taken from lesions suspected to be due to a scabies infection using a sterile surgical blade (n° 15) and immersion oil to be placed on a slide. In the laboratory of Ifakara Health Research and Development Centre (IHRDC) samples were examined by microscope with a 10 and 40 fold magnification, for the presence of the adult mite, eggs or scybala. In the case of tinea versicolor, tinea capitis and tinea corporis, skin samples (skin scrapings and/or hair clippings) were taken and examined by microscope at IHRDC (10 and 40 fold magnification) using a 20% KOH solution. Evidence of hyphae, mycelia or large amounts of spores together with photographic documentation and clinical findings led to the final diagnosis. Quality control was performed by H. Urassa, microbiologist and research scientist at IHRDC. In the case of onychomycoses, thick, dirty toenails made a microscopic examination difficult. Since no samples could be sent to the Mycology Department of the University of Zürich/Switzerland for culture during the screening, differentiation between onychomycosis and lesions due to trauma was not reliabe. Thus, all suspected cases of onychomycoses were not included in the study. In all cases of uncertain diagnoses, samples of superficial dermatomycoses such as t. versicolor, t. capitis and t. corporis were sent to the Mycology Department of the Universitiy of Zürich/Switzerland for microscopy and culture, one, two and approximately three months after the baseline survey. For direct microscopy, slides were stained with Congo red. Culture for dermatophytes was performed using Sabouraud Glucose Agar with chloramphenicol and gentamycin as well as Mycosel agar with cycloheximid, chloramphenicol and gentamycin. Subcultures were prepared using Phenol Red Agar and Potato Dextrose Agar and microscopically examined using cotton blue. A further identification technique was the “hanging drop”. For 17 Methods
Malassezia species, Dixon agar (culture) and gram stain (microscopy) were used. No cultures could be made of the samples taken three months after the screening. For further details regarding microscopy and culture see also Dinkela et al., 2005.
Treatment indications and treatment Treatment of a skin disease was indicated 1. when required by diagnosis or clinical picture 2. to prevent aggravation of skin diseases which could severely affect the child´s health 3. to prevent further spread of skin diseases 4. in case of severe disfigurement
Table 3: Indications for treatment of different diagnoses. Infectious skin diseases Diagnostic group Diagnosis Indication no. Dermatomycoses T. versicolor 4 T. capitis 1, 2 and 3 T. faciei/corporis 1, 2 and 3 T. pedis 1 and 2 Other dermatomycoses 1 and 2 Intertrigo 1, 2 and 3 Pyoderma 1 and 2 Abscesses 1 and 2 Ectoparasitic disorders 1, 2 and 3 Warts Not mandatory Others Cheilitis 1 and 2 Non-infectious skin diseases Pruritic dermatoses Miliaria Not mandatory Generalized pruritus/xerotic Not mandatory, skin/pruritic dermatitis only desirable Lesions due to insects Rash due to mosquito bites Not mandatory Blister beetle dermatitis 1 Others (superinfected 1 and 2 mosquito bite on t. versicolor) Non-superinfected wounds/ulcers Non-superinfected wounds Not mandatory Animal bites 1 and 2 Eczematous lesions Atopic eczema 1 and 2 Contact eczema 1 and 2 Vaseline dermatitis Not mandatory Unclassifiable eczema Not mandatory Keratoses Not mandatory Pigmentary disorders Not mandatory Keloids Not mandatory Acneiform lesions Not mandatory Others Cyst 1 and 2 Tender, movable tumor 1 and 2 Itching without clinical Not mandatory, findings only desirable 18 Methods
During the screening, individuals showing the above mentioned signs or other health alterations were directly treated by the field investigators. If special wound care or drugs were required, the children were referred to the local dispensary or district hospital in Ifakara. If the child appeared to have fever the temperature was taken and the patient was sent to the health post if necessary. After the screening 244 children enrolled in a clinical trial testing the relative effectiveness of bar soap containing Triclosan against a placebo in the treatment of superficial dermatomycoses (Dinkela et al., 2005). Those children were also treated as described below after they had been followed up two months later.
Table 4: Treatment for the most frequent skin conditions. All drugs were locally available. Tinea capitis/corporis/pedis, minor cases of Clotrimazole cream, Whitfield’s Ointment tinea versicolor Tinea capitis/corporis/pedis, tinea versicolor Oral ketoconazole Tinea capitis/corporis/pedis Griseofulvine Severe tinea capitis, t. crucis Terbinafine Scabies Ivermectin, BBE Pyoderma Cloxacillin, Erythromycin Eczematous lesions Hydrocortisone cream
Ivermectin Ivermectin, the treatment of choice for onchocercosis, was included in the onchocercosis control program (OCP) of the WHO in 1987. After a Rapid Epidemiological Assessment (REA) carried out in 1995/96 according to WHO-guidelines, the area of Ifakara was considered to be hypoendemic. This means that ivermectin was not supposed to be distributed among the population. However, after the protest and pressure of local authorities it was decided to annually administer the drug to all primary school children in the area of Ifakara. Ivermectin is also active against scabies, pediculosis and cutaneous larva migrans (Datry et al., 2002). To assess any possible influence on the prevalence rates, records documenting previous ivermectin distributions at Lihami and Michenga Primary School in 2000 and/or 2001 were checked.
Assessment of the scabies incidence in the area of Ifakara To assess the incidence of scabies among the population of Ifakara, all patient records of the dispensary of Michenga and the health centre of Kibaoni from the year 2000 up to June 2003 were checked for scabies cases. The dispensary serves a population of approximately 5,600, the health centre approximately 21,600 people (Mbata, personal communication). A patient was counted as a case if the diagnoses “scabies” had been recorded or the entry “skin infection” together with bencyl benzoat emulsion (BBE) (standard treatment for scabies in health care facilities of Ifakara) (Mbata, personal communication) appeared. Furthermore, all data obtained within the inpatient surveillance on the paediatric ward of SFDDH were checked for the number of scabies infections recorded since 1999. 19 Methods
6.2 Statistical analysis FoxPro databases (version 2.6) for each module of the questionnaire were transferred to STATA (version 8.2) for analysis. Data from the two schools were pooled after a differential analysis had been made. The analysis was not restricted to children with complete data for all variables, but performed separately for each variable. As a result, the overall number of children for each question varies throughout due to missing information. Continuous variables were categorized. Chi2 and Fisher’s Exact Test in case of an expected outcome equal to or smaller than five were used to check the findings for statistical significance.
6.3 Diagnostic criteria Dermatomycoses Tinea versicolor: Shape and appearance of the lesions (Canizares et al., 1992d; Sunenshine, 1998; Piamphongsant, 1983; Gupta, 2002): - Multiform macules or patches - Lesions may coalesce and/or be perifollicular - Hypo- or hyperpigmented - Fine, adherent scales (may be absent after the use of Vaseline) Pruritus may be present. Typical localizations (Canizares et al., 1992d): - Areas with the greatest density of sebaceous glands such as the upper trunk, neck and face, sometimes on upper arms and abdomen. Rarely on other body parts. Tinea capitis: One of the three clinical criteria has to be present for diagnosis. Shape and appearance of the lesions (Canizares et al., 1992b; Shrum, 1994; Weitzman et al., 1995): 1. Scaly, dry, non-inflammatory lesions sometimes presenting grey patches or “black dots” 2. Acute, wet, and inflammatory lesions with possible suppuration or kerion formation 3. Dry, crusted, occasionally inflammatory and suppurative lesions, yellow crusts (also called “favus”). Folliculitis, bacterial superinfection, alopecia and scarring may occur. Pruritus may be present. Positive microscopy confirms diagnosis but was not regarded as necessary in this study. Tinea corporis: Shape and appearance of the lesions (Canizares et al., 1992b): - Sharply demarcated round or oval scaly patch(es) - Active vesicular border and central clearing may be present. Occasionally pustular lesions Pruritus may be present. 20 Methods
Typical localizations (Canizares et al., 1992b): - Glabrous (=hairless) skin including non-hairy parts of face, neck, trunk, limbs (not axillae, groins, interdigital spaces of hands or feet, palms or soles) Positive microscopy confirms diagnosis but was not regarded as necessary in this study. The appearance of the lesions may in some cases resemble those of tinea versicolor, especially if multiple lesions are present. In these cases, the final diagnosis was based on the culture performed in the Mycology Department of the University of Zürich/Switzerland. Tinea pedis: One of the three clinical criteria must be present for diagnosis. Shape and appearance of the lesions (Canizares et al., 1992b; Masri-Fridling, 1996; Shrum, 1994): 1. Interdigital type with maceration. It may extend to both the toes and the soles. 2. Dyshidrotic type with acute versicular, bullous or vesiculo-bullous lesions with erythema, fissuring and sometimes bacterial superinfection. Usually located on the mid-sole 3. Hyperkeratotic moccasin type; tends to be chronic and presents with scaling of the plantar surface. No vesiculation. Pruritus may be present. Microscopy or culture of mycoses was not performed in this study.
Intertrigo (Weitzmann & Summerbell, 1995; Canizares, 1975) - Includes the differential diagnoses of t. cruris, erythrasma, candidiasis or intertrigo - Localization: In the folds and the area of the groin, perianal, perineal areas or upper thighs - Reddish, reddish-white to reddish-brown or brown plaques or patches - Can be combined with erythema, erosive fissures, rings with vesicular border or lichenification - Itching or scaling may be present - Maceration may be present - Hyphae or spores found on microscopy (KOH) confirm the presence of t. cruris
Ectoparasitoses Scabies: Three features are diagnostic of scabies (Canizares et al., 1992e; Anezi, 1981; Haas, 2001; Burkhart, et al., 2000): 1. Itching (most severe at night) 2. Typical rash (small blisters and papules) and scabies burrows 3. Common localization: sides of the fingers and hands, flexor sides of the wrists, anterior parts of elbows, on the genitals and buttocks etc. 21 Methods
A history of contact with infested persons supports the diagnosis.
Pyoderma Superinfected wounds/ulcers (Mbata, 2004) - Child reports wound at the site of lesion - On examination: oozing erosions or yellow crusts Impetigo (Thappa, 2002) - Superficial vesicles or pustules - Typical thick, honey coloured crust covering superficial erosions - Thin walled flaccid bullae - Sourrounding erythema not necessarily present - Lymphadenitis and fever may be present Folliculitis (Dirschka & Hartwig, 2003) - Disseminated follicular bound papules or pustules in skin areas with hair follicles
Warts Common warts (Sahl & Mathewson, 1993) - Typical papules of 1 – 6 mm - Mainly located on finger, knees and feet Molluscum contagiosum (Thappa, 2002) - Asymptomatic papules measuring 2 to 6 mm - Skin coloured to milky white, shiny - Central umbilication sometimes containing cheesy material
Pruritic Dermatoses Generalized pruritus/xerotic skin (Mbata, 2004) - Unspecific pruritus - Dry skin may be found upon examination - No active skin lesion other than excoriation. 22 Methods
Pruritic dermatitis (Mbata, 2004) - Itching/excoriations - Little papules Miliaria (Nüchel & Zaun, 2003) - Small vesicles bursting easily leaving watery liquid (miliaria cristallina) - Red spots with secondary development of vesicles, itching (miliaria rubra/profunda)
Non-superinfected wounds/ulcers (Mbata, 2004) - Fresh wound the child got the same day OR - Wound is neither oozing nor covered by yellow crust and does not show other signs of infection or inflammation (rubor, tumor, dolor, calor, functio laesa ) - Surrounding shows postinflammatory hyperpigmentation
6.4 Abbreviations
AMO: assistant medical officer BBE: benzyl benzoat emulsion CLM: cutaneous larva migrans DMO: district medical officer EKBB: Ethisches Komitee Beider Basel HIV: human immunodeficiency virus IHRDC: Ifakara Health Research and Development Centre KOH: potassium hydroxide OCP: onchocercosis control program OPD: outpatient department RDTC: Regional Dermatology Training Centre, Moshi REA: rapid epidemiological assessment SFDDH: St. Francis Designated District Hospital T. VERSICOLOR Tinea versicolor T. CAPITIS Tinea capitis T. CORPORIS Tinea corporis T. PEDIS Tinea pedis WHO: World Health Organization 23 Results
7 Results
7.1 Study population 820 children were examined in two primary schools, in Lihami 411 students and in Michenga 409 students. The proportion of boys to girls at each school was = 1 : 0.95 (Lihami) and 1 : 0.91 (Michenga)) (table 5).
Table 5: Studied population: eligible students.
Lihami Primary Michenga Primary School School
1. Overall 718 number of 460 students
2. Number of 460 446 chosen at students random chosen for study
3. Number of 49 students not 37 examined
4. Number of 820 409 students 411 examined
Approximately 80% of the children were 6 to 14 years old. The age group 15 to 19 years was smaller in Lihami (12.9% of the children) than in Michenga (19.5% with a p-value of Pr = 0.036). Girls were significantly underrepresented in the age group 15 to 19 years (Pr = 0.027) (table 6). Due to incomplete documentation, age or sex could not be determined in eight cases.
Table 6: Studied population: distribution of age groups and sex (frequencies and percent).
Sex Age group 6-10 years 11-14 years 15-19 years Total n % n % n % n % Girls 177 52.5 162 47.1 51 38.9 390 48.0 Boys 160 47.5 182 52.9 80 61.1 422 52.0 Total 337 100.0 345 100.0 136 100.0 820* 100.0 * In eight cases, age or sex were unknown
Both schools were attended by an almost equal proportion of Christians (Lihami 49.5%, Michenga 43.6%) and Muslims (Lihami 50.5%, Michenga 56.4%). For further details regarding all results presented in this chapter, tests employed and additional information, please see Appendix B and C. 24 Results
7.2 Living conditions and hygiene behaviour 552 children were asked additional questions to assess their living conditions and hygiene behaviour (Appendix C). 68.8% (n = 380) of them attended Lihami, 31.2% (n = 172) Michenga. Most of the children’s fathers were peasants (Lihami: 55.5%, Michenga: 76.3%, Pr = 0.000). Small scale business was a less frequent source of income (Lihami: 36.5%, Michenga: 16.5%, Pr = 0.000). About 90% of the children's mothers were also peasants. 39.6% of the children lived in households with five or less members, 55.8% with six to ten members, with little variation between the two schools. The average household density was one to two persons (55%) or three to four persons (42.1%) per room. About 60% of the children shared their bed with one, about 20% with more than one person. Houses were made of loam bricks (Lihami: 87.7%, Michenga: 61.6%, Pr = 0.000) or mud (Lihami: 17.8%, Michenga: 39.5%, Pr = 0.000) and thatched with palm leaves (Lihami: 36.8%, Michenga: 62.8%, Pr = 0.000) or iron sheets (Lihami: 62.4%, Michenga: 37.8%, Pr = 0.000). The most common water source was an outside hand pump (76.0%, no difference between the schools). Only about 9% of the children had tap water at home. In Lihami, a higher proportion of families had access to tap water outside the house (Lihami: 9.2%, Michenga: 1.7%, Pr = 0.001). Most children reported that they washed twice or three times per day. It was uncommon to boil water before drinking (Lihami: 34.1%, Michenga: 15.1%, Pr = 0.000). The most frequently kept domestic animals were fowl (Lihami: 70.9% of the families, Michenga: 57.6%) followed by cats or dogs (Lihami: 17.7%, Michenga: 34.2%).
7.3 Prevalence of skin diseases
Overall prevalence Out of the 820 children examined, 448 (54.6%) were found to have one or more skin diseases (60.3% in Lihami and 48.9% in Michenga, Pr = 0.001). 346 (77.9%) children were affected by only one skin disorder. 23% of the children accounted for 40.3% of the total skin disorders. The prevalence showed a positive association with age: 47.2% of the children aged 6 to 10 years (n = 337), 58.4% of those aged 11 to 14 years (n = 344) and 66.4% of those aged 15 to 19 years (n = 131) were affected (Pr = 0.000). No difference was found between the sexes with regard to prevalence of skin disorders. 74% of the skin conditions were of infectious, 26% of non–infectious origin (ratio infectious : non-infectious diagnoses = 2.8:1).
Prevalence of infectious conditions 424 infectious skin conditions were found to affect 354 children (1.2 diagnoses per child). The overall prevalence of infectious skin diseases was 43.2% (Lihami: 49.4%, Michenga: 36.9%, Pr = 0.002). Prevalence increased with age (6 to 10 years: 34.7%, 11 to 14 years: 48.8%, 15 to 19 years: 51.9%, Pr = 0.000). No difference was found between the sexes. Infectious dermatoses were significantly associated with crowded living conditions (Pr = 0.039). They showed a prevalence of 25 Results
50.0% among children living together with more than five people and of 39.0% in smaller house- holds.
Prevalence of non-infectious conditions 140 children had 149 non-infectious skin conditions (1.06 diagnoses per child). The prevalence of non-infectious skin conditions was 17.1%. No differences regarding age, schools or sex were observed.
Table 7a: Spectrum of skin diseases among the children of Lihami and Michenga Primary School. Diagnoses were grouped according to aetiology (infectious and non-infectious origin). Infectious skin diseases % of skin Prevalence Diagnostic group Diagnosis n diseases (%) Dermatomycoses T. versicolor 215 37.5 26.2 Prevalence: 37.6% T. capitis 45 7.9 5.5 (n = 308) T. faciei/corporis 21 3.7 2.6 T. pedis 26 4.5 3.2 Other dermatomycoses 1 0.2 0.1 Intertrigo 7 1.2 0.9 Pyoderma Superinfected wounds/ulcers 59 10.3 7.2 Prevalence: 8.4% Impetigo 3 0.5 0.4 (n = 69) Folliculitis 7 1.2 0.9 Abscesses 3 0.5 0.4 Ectoparasitic Scabies 12 2.1 1.5 disorders Pruritic dermatosis (probably due to 1 0.2 0.1 Prevalence: 1.6% pediculosis corporis) (n = 13) Warts M. contagiosum 1 0.2 0.1 Prevalence: 2.7% Common warts 21 3.7 2.6 (n = 22) Others Cheilitis 2 0.3 0.2 Total infectious 424 74.0 43.2 Prevalence by diagnostic group Dermatomycoses were the most important diagnostic group with an overall prevalence of 37.6% making up 53.7% (n = 308) of the overall number of diagnoses (n = 573) (table 7a). Four of the five skin diseases most frequently found belonged to this diagnostic group. Tinea versicolor was the single most frequent diagnosis (prevalence: 26.2%) followed by dermatophytoses (t. capitis: 5.5%, t. pedis: 3.2%, t. faciei/corporis: 2.6%) (table 7a). The diagnostic group of pyoderma showed a prevalence of 8.4% accounting for 12.0% of the diagnoses. Most of the cases were due to superinfected wounds which were the second most frequent diagnosis (prevalence: 7.2%). The most frequent non-infectious diagnoses were clean wounds (3.3%) and pruritic dermatoses (3.3%). Very few ectoparasitoses were seen, most of which were scabies infestations (1.5%). 1.2% of the children had eczematous lesions (table 7b). Rain was scarcer than usual in the months the study was carried out (April to May 2003). However, the conditions were still hot and humid. Their influence on the spectrum of skin diseases has to be considered. 26 Results
Table 7b: Spectrum of skin diseases among the children of Lihami and Michenga Primary School. Diagnoses were grouped according to aetiology (infectious and non-infectious origin). Non-infectious skin diseases % of skin Prevalence Diagnostic group Diagnosis n diseases (%) Pruritic dermatoses Generalized pruritus/xerotic skin 5 0.9 0.6 Prevalence: 3.3% Pruritic dermatitis 11 1.9 1.3 (n = 27) Miliaria 11 1.9 1.3 Lesions due to insects Rash/insect bites 5 0.9 0.6 Prevalence: 1.0% Lesions due to Paederus species 2 0.3 0.2 (n = 8) (blister beetle dermatitis) Others 1 0.2 0.1 Non-superinfected 27 4.7 3.3 wounds/ulcers Eczematous lesions Contact eczema of unknown origin 4 0.7 0.5 Prevalence: 1.2% Vaseline dermatitis 1 0.2 0.1 (n = 10) Atopic eczema 1 0.2 0.1 Unclassifiable eczema 4 0.7 0.5 Keratoses Ichthyosis 1 0.2 0.1 Prevalence: 0.2% Keratosis pilaris 1 0.2 0.1 (n = 2) Pigmentary disorders Vitiligo 3 0.5 0.4 Prevalence: 1.6% Other hypopigmented skin diseases 10 1.7 1.2 (n = 13) Keloids 4 0.7 0.5 Acneiform lesions 21 3.7 2.6 Others Dandruff 14 2.4 1.7 Prevalence: 4.5% Itching without clinical finding 9 1.6 1.1 (n = 37) Dry skin 8 1.4 1.0 Alopecia arreata 1 0.2 0.1 Striae 1 0.2 0.1 Cyst 1 0.2 0.1 Soft, mobile tumor 1 0.2 0.1 Morphea 1 0.2 0.1 Unclear diagnosis 1 0.2 0.1 Total non-infectious 149 26.0 17.1 Grand total 573 100.0 54.6
7.4 Treatment Treatment was indicated in 33.2% of the diagnoses (n = 190/573) (figure 8). This corresponds to 24.8% of the children suffering from skin diseases (n = 111/448). Most of the cases (95.8%) were of infectious origin. 66.7% of the children indicated for treatment attended Lihami and 33.3% Michenga. Frequency of treatment indication was consistent between age groups and sexes. 42.9% of the infectious skin diseases (n = 182/424), most of them dermatophytoses or pyoderma (figure 8) needed therapy. Only 5.4% (n = 8/149) non-infectious diagnoses required treatment. In 25 cases (generalized pruritus/xerotic skin, pruritic dermatitis and itching without clinical finding) treatment was found to be desirable but not urgent as the children’s health was not severely 27 Results affected. 20.7% of the children (70/338) suffering from skin diseases reported previous treatment, with no difference found between the sexes.
Figure 8: Proportion of diagnoses and spectrum of skin diseases (n = 190) requiring treatment.
4% n = 573 7% 4% 33% 6%
39% 7%
Dermatophytoses 63% Pyoderma
Ectoparasitic Treatment indicated disorders 37% Tinea versicolor No treatment mandatory Intertrigo Treatment desirable Others In many cases a specification of treatment or its origin was not possible as the children were too small to give meaningful answers or had received the drug from their parents. Poorly defined treatments mentioned most frequently were cream (39.4%) or tablets (25.8%). Other common treatments were traditional medicine (10.6%) and “household remedies” (12.1%) such as local application of vaseline, oil, break fluid or kerosene. Topic and systemic antifungal agents and antibiotic treatments were used in a few cases. Access to treatment was significantly associated with the parents’ profession. Children of civil servants and small scale business people had received treatment in 40.0% and 33.3% respectively of the cases, peasants’ children in 16.4% (Pr = 0.007). This trend was even stronger with regard to the mother’s profession (Pr = 0.001). The parents’ educational level did not influence the accessibility of treatment, neither did death of mother or father.
7.5 Ivermectin Records documenting previous ivermectin distributions at Lihami and Michenga Primary School in 2000 and/or 2001 were checked. Coverage increased with age (6 to 10 years: 6.5% (11/180), 11 to 14 years: 73.9% (110/179), 15 to 19 years: 84.6% (47/52); total: n = 812). An almost equal proportion of boys and girls received the drug. 28 Results
7.6 Spectrum of skin diseases: details and special findings
7.6.1 Infectious skin diseases
7.6.1.1 Dermatomycoses
Tinea versicolor
Prevalence and clinical picture Tinea versicolor showed a prevalence of 26.2% (n = 215) equally distributed between both schools. This skin condition made up for 37.5% of the overall number of diagnoses and 50.7% of all infectious diagnoses. It represented the single most prevalent skin condition. The prevalence showed a clear association with age, older age groups being affected to a greater extent (children 6 to10 years: 12.8%, 11 to 14 years: 33.4%, 15 to 19 years: 42.8%, Pr = 0.000). No difference in prevalence was found between the sexes or between the two schools. Upon examination, t. versicolor generally presented with more than ten, grouped, confluent Figure 9: Child with tinea versicolor on the right cheek. or single macules and patches mainly on face, back, chest and neck (figure 9). In 73.5% of cases (n = 157) only one body part, usually the face (84.7%), was affected. Most commonly, the lesions were hypopigmented (176/202), typically found on the face, whilst hyperpigmented lesions (28/202) were more frequently seen on the back or chest. These lesions usually presented as confluent macules, sometimes bound to follicles and were found especially frequently in children around the age of puberty. Due to scaling, some lesions showed a greyish aspect (19/202). More than half of the patients mentioned pruritus (107/194), mainly in connection with heat.
Table 10: Parts of the body affected by t. versicolor according to age group.
6 - 10 years 11 - 14 years 15 - 19 years
Face Back Chest Nape Abdomen The distribution pattern also varied according to age. In children from 6 to 10 years, the face was the most frequent site of infection (86.0%), followed by the back (about 12%) (table 10). 29 Results
Approaching the age of puberty, lesions were found more frequently on back and chest, whilst the proportion of facial lesions decreased compared to younger age groups. In 43.6% of cases other family members were affected as well. Of the children suffering from skin diseases other than t. versicolor, only 5.6% reported other family members being affected by t. versicolor. However, this information may not be reliable.
Microscopy and mycologic culture Samples (skin scrapings) were taken in 73.5% (n = 147/200) of the cases. 82.5% (n = 118) of them were microscopically positive. Samples sent to the University of Zürich for microscopic examination one month after the screening were positive for Malassezia furfur in 96.8% (30/31) of the cases. In 38.7% (12/31) of the samples, presence of a species of Malassezia was proven by culture.
Living conditions and hygiene behaviour: influence on the prevalence of tinea versicolor Crowding at home was significantly associated with a high prevalence of t. versicolor. 33.1% of children living with more than five household members were affected, whilst 20.6% of those living in smaller households were affected (Pr = 0.006). Compared to the control group, children living in families keeping cows, sheep or goats were affected with t. versicolor more often (12.1% versus 5.6%, Pr = 0.034).
Dermatophyte infections: tinea capitis, faciei, corporis and pedis
Tinea capitis With a prevalence of 5.5% (n = 45), t. capitis was the Figure 11: Child with tinea capitis. most frequent dermatophytosis. It made up 7.9% of all diagnoses (10.6% of all infectious diagnoses). Lihami was affected to a greater extent (Lihami: 37 children, Michenga: 8 children, Pr = 0.000). The prevalence was about 10 times higher among younger children than in the oldest age group (6 to 10 years: 7.7%, 11 to 14 years: 5.3%, 15 to 19 years: 0.8%, Pr = 0.012). No difference was found between the sexes. Upon examination, t. capitis mainly presented with hypopigmented to greyish, scaly, single, grouped or disseminated patches (figure 11). Half of the lesions measured between one and three centimetres (16/ 32), whilst one fifth of the lesions (6/32) had a diameter larger than three centimetres. In 72.2% (26/36) of the children less than ten lesions were counted, whilst in the remaining cases (10/36) more than ten lesions were found. 67.5% of the children (27/40) showed diffuse or circumscribed alopecia. Papules, crusts or excoriations were rarely seen. About two thirds of the children (19/27) mentioned pruritus, mainly in connection with 30 Results exposure to heat (sun). Bacterial superinfection was present in 12.2% of the cases (5/41). No case of favus was detected. According to information provided by the children, in 46.3% (19/41) of the cases other family members were also affected by t. capitis, whilst children not affected by t. capitis mentioned infected family members in 3.5% of the cases.
Tinea faciei/corporis The prevalence of t. faciei/corporis was 2.6% (n = 21). It accounted for 3.7% of the total and for 5.0% of all infectious diagnoses. No difference regarding age, sex or school was observed. T. faciei/corporis generally presented with less than five lesions, scaling, mostly hyper- sometimes hypopigmented concentric patches (figure 12), in some cases macules, on the face, chest, arms or thighs. In 75.0% of the children lesions measured between one and three centimetres (12/16), in 18.8%
Figure 12: Child with tinea faciei on the right (3/16) they were smaller. Itching, especially cheek. in the hot sun, was reported by 87.5%, superinfection in one case. In 50.0% (9/18) of cases other family members were also affected.
Tinea pedis T. pedis showed a prevalence of 3.2% (n = 26) which is 4.5% of the total and 6.1% of all infectious diagnoses. In Lihami, prevalence was much higher than in Michenga (4.6% versus 1.7%, Pr = 0.017). Older children (15 to 19 years: 6.9%, 11 to 14 years: 2.6%, 6 to 10 years: 2.4%, Pr = 0.057, no significance) and girls (girls: 4.6%, boys: 1.9%, Pr = 0.029) also showed higher prevalence rates. T. pedis generally presented as interdigital erythema, maceration and whitish scaling. Most children had up to five lesions of the size of macules or patches. Itching, especially when hot, was reported in all cases.
Microscopy and mycologic culture of dermatophyte infections
Tinea capitis The microscopic examination of skin scrapings and hair clippings carried out in Ifakara was positive in 67.5% (27/40) of cases. In samples sent to Zürich for microscopic examination two and three months after the screening, spores were found in two cases, two others were negative. Culture revealed the presence of Phoma spp. (n = 1) and Trichophyton tonsurans (n =1).
Tinea faciei/corporis The microscopic examination of skin scrapings carried out in Ifakara was positive in 81.3% of the samples. Specimens sent to the University of Zürich for microscopic examination one and two months after the baseline survey showed fungal mycelia in one case and spores in three cases. One 31 Results sample was negative. Culture gave evidence of Trichophyton tonsurans, T. violaceum and T. mentagrophytes.
Living conditions and hygiene behaviour: influence on the prevalence of dermatophytoses Among children with dermatophytoses (tineae), prevalence and crowding at home were associated. In households with more than ten members, 40 % of the children were infected compared to 11% in smaller households (Pr = 0.000). Washing habits also seemed to influence the prevalence. It was 18.9% among children washing only once per day and successively decreased down to 10.1% among those washing three times per day (Pr = 0.036). Among those washing more than three times per day the prevalence was 31.3%. This result may be due to the small size of this subgroup.
Other dermatomycoses
One superficial mycosis probably due to candida spp. was found. No pathogen could be identified through microscopic examination.
7.6.1.2 Intertrigo The prevalence of intertrigo was 0.9% (n = 7). This corresponds to 1.2% of the overall number of diagnoses and 1.7% of all infectious skin conditions. 71.4% of all cases were found among the age group 15 to 19 years (Pr = 0.000). Six of the seven cases were found in boys. However, this result is not statistically
Figure 13: Tinea cruris in the inguinal region of a significant (Pr = 0.125). Intertrigo mainly 15 year old male. presented as hyperpigmented (5/5), single or grouped patches (figure 13). Lesions were localized in the pubic (5/7), inguinal (3/7), perianal region (1/7) and on the thighs (4/7) with an avera ge diameter of more than three centimetres. Maceration was found in two cases and bacterial superinfection in one patient. Pruritus was present in four out of five cases. Microscopic examination revealed hyphae, confirming the diagnosis of t. cruris in three cases. In one case the greyish aspect of the lesion suggested a candidiasis infection. In the remaining patients, erythrasmata or intertrigo have to be considered as differential diagnoses.
7.6.1.3 Pyoderma Pyoderma was the second most prevalent diagnostic group (8.4%, n = 69), representing 12.0% of the total diagnoses and 16.3% of all infectious diagnoses. Significant differences in the prevalenceof this diagnosis were found between Lihami (12.2%) and Michenga (4.4%, Pr = 0.000) . It showed a negative association with age (6 to 10 years: 11.0%, 11 to 14 years: 7.0%, 15 to 19 32 Results years: 5.3%, Pr = 0.066, no significance). Sex did not influence prevalence. Examination allowed for differentiation between superinfected wounds/ulcers (prevalence: 7.2%, n = 59), folliculitis (0.9%, n = 7) and impetigo (0.4%, n = 3). Superinfected wounds and ulcers generally presented as oozing, wet single ulcers and crusts mostly on the lower legs, ankles and feet. The average number of lesions was less than five. The three cases of impetigo presented as a group of yellowish crusts on face or head with a diameter of less than two centimetres. The cases of folliculitis presented with pustules and papules localized or generalized on the head. Scaling could be observed as well. In most of the cases the scalp had been shaved before.
7.6.1.4 Wounds This section presents a summary of diagnoses of superinfected wounds/ulcers, healing superinfected wounds/ulcers and non-superinfected wounds/ulcers. Wounds showed a prevalence of 10.1% (n = 86). 70% of all lesions were superinfected. Children of Lihami were affected significantly more often (Lihami: 13.4%; Michenga: 6.9%, Pr = 0.002) which was due to a higher proportion of superinfected wounds and ulcers at that school (Lihami: 9.7%: Michenga: 3.9%). Superinfections were more frequent among children between 6 to 10 years (8.9%) than among older age groups (5.4%, Pr = 0.129 - no significance). No difference was found between the sexes. Non-superinfected wounds showed approximately the same prevalence at both schools (Lihami: 3.7%, Michenga: 2.9%). Once more, younger children were more frequently affected (6 to 10 years: 5.0%, 11 to 14 years: 1.7%, 15 to 19 years: 3.1%, Pr = 0.045). The Figure 14: Child with super- sex ratio boys : girls was 2.4 (Pr = 0.048). Wounds were infected wounds on the anterior leg. most frequently localized on the lower leg, followed by feet, face and ankles.
7.6.1.5 Abscesses Abscesses showed a prevalence of 0.4% (n = 3) (0.5% of the overall number of diagnoses, 0.7% of all infectious diagnoses). The cases were described as one furunculosis, one abscess due to severe t. cruris and one healing abscess of unknown origin. It had alr eady been treated at the dispensary. 33 Results
7.6.1.6 Ectoparasitic disorders
Scabies The overall prevalence of scabies was 1.5% (n = 12). It accounted for 2.1% of all diagnoses and 2.8% of all transmittable skin diseases. Ten cases were detected in Lihami and only two cases in Michenga (Pr = 0.022). 70% of all patients at the first school were clustered among siblings of just three families. The youngest age group (6 to 10 Figure 15: Child with scabies lesions in years, n = 8/12) and boys were affected more often the interdigital spaces of the left hand. (ratio girls : boys = 0.5), but no statistical significance could be shown. Scabies generally presented with papules, excoriations and postinflammatory hyper- pigmentation. Lesions were mostly found on the sides of the fingers, wrist, cubital fossae as well as on the ulnar borders of the hands and in the gluteal area (figure 15). In about half of the children lesions affected more than one part of the body. All cases mentioned pruritus mainly at night in bed. Superinfection was present in two thirds of the children. Since burrows were not found in any of the cases, it was difficult to take samples. Only in one out of seven samples was the adult mite found through microscopy. No eggs were seen. Detection of scybala was made difficult by dirty skin. Infested children were asked questions aimed at identifying risk factors for scabies infection (Landwehr et al., 1998; Green, 1989; Craig, 1983). None of the infested children had access to running water at home. Soap was not used. All cases shared a bed with one or several persons. All these findings describe tendencies; no statistically significant results were found.
Scabies incidence in the area of Ifakara
At the dispensary in Michenga, an average of one scabies case per month was treated. 88.2% (n = 30) of all patients were five years old or younger. Boys were 3.3 times more often affected than girls (girls: n = 8, boys: n = 26). At the Kibaoni Health Centre, an average of one scabies patient per month was treated. 50% of the patients were under fives, girls presented 1.4 times more often than boys (girls: n = 26, boys: n = 18). Pooling the data of both healthcare facilities, the predominance of under fives was found to be significant (Pr = 0.045). Increased prevalence rates from January to July were not statistically significant. In some cases, instead of BBE, the official first line treatment for scabies, treatments like ASA together with procainpenicillin or cotrimoxazole had been used. Among paediatric inpatients of SFDDH, an average of 0.9 cases of scabies per month were detected 34 Results from June 1999 to June 2003. The majority of cases (86.2%, n = 30) were found among children younger than two years, only five cases were older than five. Boys were 1.6 times more often affected than girls. The prevalence showed a slight peak during the months May to September. None of the observations mentioned above was found to be statistically significant.
Pediculosis
Only one case of rash and excoriations, probably due to an infestation with body lice, was detected. No lice could be found upon examination of skin and clothing. The child had already received adequate treatment. No case of pediculosis capitis was detected.
7.6.1.7 Warts Warts showed a prevalence of 2.7% (n = 22) (3.8% of all diagnoses and 5.2% of all infectious diagnoses). Most cases were probably due to an infection with HPV, one case of Molluscum contagiosum was found. Prevalence did not show any association with school, age or sex. No case of flat warts was seen.
7.6.1.8 Other skin conditions of infectious origin For all remaining diagnoses of infectious origin, one case of angular cheilitis and one case of cheilitis predominantly affecting the lower lip, were found.
7.6.2 Non-infectious skin diseases
7.6.2.1 Pruritic dermatoses Pruritic dermatoses (generalized pruritus/xerotic skin, pruritic dermatitis and miliaria) was one of the two non-infectious diagnostic groups most frequently found. They affected 3.3% (n = 26) of the study population, representing 4.7% of the overall number of diagnoses and 18.1% of all non- infectious diagnoses. Including cases of, “itching without clinical findings”, 4.4% of the children suffered from pruritic dermatoses. For the purposes of analysis a differentiation was made between generalized pruritus/xerotic skin (n = 5) and pruritic dermatitis (n = 11). Yet, a lack of standardized terminology in the literature (see “Discussion”) and the small number of cases lead us to treat both clinical pictures as one diagnosis. The children mainly presented with pruritus and disseminated papules, excoriations and crusts on chest, abdomen or back. 15 out of these 16 children were younger than 15, yet this result was not significant. Cases of miliaria (n = 11) mostly presented with more than ten, disseminated or grouped, hypopigmented, itchy papules which were found on abdomen, chest and neck. 35 Results
7.6.2.2 Lesions due to insects Lesions due to insects showed a prevalence of 1.0% (n = 8) corresponding to 1.4% of the overall number of diagnoses and 5.4% of all non-infectious diagnoses. Rash as an allergic reaction due to mosquito bites was found in five children. The lesions were mainly found on areas not covered by clothes such as arms and hands (figure 16). Two cases of lesions caused by Paederus species, commonly known as rove (Shatin & Canizares, 1992) or “Nairobi” beetles (Schmid-Grendelmeier, personal communication), were found. These insects release pederin, an extremely toxic alkaloid if the insect is crushed on the skin (Peters et al., 2002) or feels endangered (Schmid-Grendelmeier, personal communication). For the typical presentation see figure 16.
Figure 16: Left: Rash due to mosquito bites. Right: Lesions due to Paederus species on right anterior forearm in a 15 year old girl.
7.6.2.3 Eczematous lesions Eczematous lesions showed a prevalence of 1.2% (n = 10) with no significant difference regarding school, age group or sex. They represented 1.8% of all skin diseases and 6.7% of all non-infectious diagnoses. Differentiation was made between atopic eczema (n = 1), contact eczema (n = 5) including one case of vaseline dermatitis and unclassifiable eczema (n = 4). Aetiologically, vaseline dermatitis is not an eczema. Vaseline causes an obstruction of sebaceous glands leading to typical lesions. Yet, following to the classification of van Hees and Naafs (Van Hees & Naafs, 2001a) this skin condition was counted among the diagnosis “contact eczema”.
7.6.2.4 Keratoses Keratoses were rare. A fourteen year old boy who showed dry, itchy, rough, normo- to hyperpigmented skin on the dorsal aspect of both hands and wrists was diagnosed as suffering from ichthyosis (figure 17). No signs of impaired vision which indicates a corneal dystrophy typical for 36 Results an x-chromosomal-recessive ichthyosis could be observed. No other family member was affected. At the time of the examination the boy was being treated at the hospital and by a local healer. Only one case of keratosis pilaris was found (figure 17). Figure 17: Left: Ichthyosis on dorsal aspect of both hands and wrists in a fourteen year old boy. Right: Keratosis pilaris on the waist (right side) of a twelve year old girl.
7.6.2.5 Pigmentary disorders Pigmentary disorders showed a prevalence of 1.6% (n = 13). They represented 2.3% of all skin diseases and 8.7% of all non-infectious diagnoses. We differentiated between vitiligo (n = 3) and “other hypopigmented skin diseases” of different aetiology (n =10). No difference of prevalence regarding school, age or sex was observed. No case of albinism was found. As shown in figure 18, skin lesions due to vitiligo presented differently in two of the patients seen. Due to technical problems, the third case could not be documented.
Figure 18: Left: Vitiligo lesions in a ten year old boy, right anterior thigh. Right: Vitiligo lesion on left lower leg in a fourteen year old girl.
“Other hypopigmented skin diseases” were a heterogeneous group summarizing pigmentary disorders like postinflammatory hypopigmentations, postlesional hypo – and depigmentations and leucoderma of unknown origin. As a detailed description of the different pictures would go too far 37 Results within the context of this section, some representative photos are shown below. For further details see Appendix B, section 7.6.2.5.
Figure 19: Above left: Postinflammatory hypo- pigmentation in a seven year old girl, probably after infection with t. versicolor. Above right: Postlesional depigmentation on right lower leg with eczematous alteration of surrounding skin in a fourteen year old boy. Below: Hypopigmentation of unknown origin on the left groin of a fifteen year old boy (naevus depigmentosus?)
7.6.2.6 Keloids and hypertrophic scars Keloids and hypertrophic scars showed a prevalence of 0.5% (n = 4) among the study population (0.7% of the overall number of diagnoses, 2.7% of all non-infectious diagnoses). In the cases documented, the lesions had developed after minor surgery (removal of warts on the left knee, incision and drainage of abscess in pubic region) or self induced lesions (perforation of ear lobe for earrings). All lesions were early stage keloids or hypertrophic scars and unobtrusive.
7.6.2.7 Acneiform lesions Acneiform lesions showed a prevalence of 2.6% (n = 21) (3.7% of the overall number diagnoses and 14.1% of all non-infectious diagnoses seen). As expected, a clear association with age and prevalence was observed (6 to 10 years: no cases, 11 to 14 years: 2.0%, 15 to 19 years: 10.7%, Pr = 0.000). Among the children aged 11 to 14 years, girls showed a (not significantly) higher prevalence. No case of acne conglobata was found. 38 Results
7.6.2.8 Other skin conditions of non-infectious origin Other common non-infectious dermatologic findings are shown in table 20.
Table 20: Other non-infectious skin diseases found among the children of Lihami and Michenga. Diagnos is % of skin diseases n (n = 573) Prevalence Dandruff 14 2.4 1.7 Itching without clinical finding 9 1.6 1.1 Dry skin 8 1.4 1.0 Alopecia arreata 1 0.2 0.1 Striae 1 0.2 0.1 Cyst 1 0.2 0.1 Soft, mobile tumor 1 0.2 0.1 Morphea 1 0.2 0.1 Unclear diagnosis 1 0.2 0.1 Total 37 6.6 4.5 39 Discussion
8 Discussion
8.1 Study population Various factors may have influenced the composition of the study population and represent a possible source of bias. The assessment of living conditions (Appendix C) showed that children attending Lihami Primary School generally had a slightly better socio-economic background than those attending Michenga Primary School. Specific socio-economic differences were also found with the populations of the two schools. In early 2002 the Tanzanian government abolished school fees for primary schools. A high number of children who previously could not afford to go to school entered standards one and two (Anonymous, 2002). This resulted in a higher proportion of children of a lower socio-economic background attending the lower classes. The economic and domestic necessity frequently leads adolescents to abandon school (Shengoto, personal communication). As a consequence, the higher classes are generally attended by children who are better off and thus do not have to work. Attending a higher class also means that the child was able to pay school fees through the years before the abolition. These factors explain the overrepresentation of comparatively prosperous children in the higher classes as well as the under- representation of the age group 15 to 19 years among the study population. The small proportion of females among the oldest age group may be due to pregnancy and/or domestic work which frequently lead girls to leave school earlier than boys (Shengoto, personal communication). All these points suggest that the study population may have been only partly representative for children aged 6 to 19 years in Ifakara.
8.2 Living conditions and hygiene behaviour Of the children interviewed about their living conditions and hygiene behaviour, 68.8% attended Lihami and 31.2% Michenga. This unequal distribution could represent a source of bias. The data we collected reflects the different locations of the two schools. Lihami is situated about three kilometres from the centre of Ifakara. Employment opportunities in the informal sector led to a better socio-economic status (more houses made of bricks and iron sheets). People benefited from the infrastructure of the town (e.g. taps outside the house). Michenga, about eight kilometres away from the centre of Ifakara, is a more rural area, with more people dependant upon subsistence farming. This explains slightly poorer living conditions (e.g. more houses built of mud and palm leaves, fewer taps). Health education programmes may also have focused on more “urban” areas (boiling of water was less common in Michenga). Students at Lihami nevertheless suffered from a higher prevalence of skin diseases. An attempt will be made in the following sections to explain this unexpected result. 40 Discussion
8.3 Prevalence of skin diseases All observed diagnoses and prevalence rates were compared to those of similar African or tropical settings. An overview of prevalence rates in comparable surveys from Africa is provided in Appendices D and E. In the primary schools of Lihami and Michenga, 54.6% of the children had one or more skin diseases. This prevalence is comparatively high, but still in line with other locations in rural Tanzania, where amongst children and adolescents prevalence rates ranged between 37% and 51.6% (see Appendix D). In general a high degree of variation amongst prevalence rates can be found in the tropics. 27.6% of the adolescents aged 12 to 19 years in rural Sumatra/Indonesia were affected by skin diseases (Saw et al., 2001), while prevalence was 80.4% among school children aged 5 to 16 years in Shebe/Ethiopia. These contrasting results may be partly due to real differences regarding climate, living conditions and population, but different survey methods and differing definitions of skin conditions certainly play an important role as well. Many authors emphasize the fact that skin diseases are more concentrated in younger age groups (Satimia et al., 1998; Gibbs, 1996; Porter, 1979). In the present study, prevalence rates increased with the age. This result was strongly influenced by the high prevalence of t. versicolor, the most frequent diagnosis in the present study. This skin disorder usually sets in around the age of puberty (see section 8.5.1.1, “Tinea versicolor"). Seasonal changes (Porter, 1979) may have contributed to the high overall prevalence of skin diseases observed. Dermatomycoses, representing an important proportion of the skin disorders, favour warm and moist conditions (Gupta et al., 2002), prevailing at the time of the present study (April/March 2003, end of rainy season). The prevalence of skin diseases was higher in Lihami than in Michenga. This was mainly due to higher prevalence rates of t. capitis, t. pedis, pyoderma, scabies and miliaria and explains the higher proportion of multiple skin diseases in Lihami. Possible reasons will be discussed among the respective diagnoses (section 7.5). Infectious skin diseases accounted for 74% of all dermatological disorders. This proportion agrees with the findings of Gibbs in north-western Tanzania (73.9%) (Gibbs, 1996). In rural Keneba/Gambia 83% (Porter, 1979) and in an Ethiopian school 95% (Figueroa et al., 1996) of all skin diseases were transmissible. However, in rural Keneba/Gambia, prevalence rates of infectious skin diseases ranged from 22% (dry season) to 28.2% (rainy season). A high prevalence of infectious skin diseases was significantly associated with a high household density. This finding agrees with the observations of Gibbs (Gibbs, 1996). Yet, 53.8% of all skin diseases and about 72.6% of all infectious skin diseases were dermatomycoses, especially t. versicolor. The predominance of these conditions must be borne in mind in a proper interpretation of overall prevalence and prevalence of infectious skin diseases. 41 Discussion
8.4 Treatment It is difficult to compare our data regarding the treatment requirements with findings of other community based surveys. Some authors differentiate between treatable versus non-treatable (Figueroa et al., 1996) or preventable versus non-preventable skin conditions (Simba, 1996), but we tried to assess the actual need of intervention. Lesions requiring treatment were usually dermatophytoses (t. capitis and t. corporis) and pyoderma. Other indications included intertrigo, ectoparasitic disorders, extensive t. versicolor or t. pedis. When diagnosed correctly by dispensary health staff, these skin conditions can easily be treated. Reviewing the records of a dispensary and a health centre (section 6.6.1.6, “Scabies”) it became clear that common skin conditions were often incorrectly treated (e.g. ASA plus procainpenicillin or cotrimoxazole for scabies). Although this might have been due to a shortage of appropriate drugs, these findings underline the importance of regular training for health sector employees. Algorithms for the management of common skin diseases could also help to improve treatment at primary health care level (Mahé et al., 2005). 20.7% of the children affected by skin diseases had already received some kind of treatment. If the majority of cases “cream” and “tablets” were obtained at the dispensary, about 10% to 15% of the children had sought treatment at that health care facility. However, many of the drugs were certainly obtained on the over-the-counter drug market. Among villagers in north-west Tanzania, a similar proportion (10%) of those with clinically significant skin diseases had sought treatment at a health care facility (Gibbs, 1996). Children whose parents had a regular income (civil servants and small scale business people) were more likely to receive treatment than children of peasants. High incidence of skin diseases is a considerable financial strain for household budgets in developing countries (Mahé, 2001). To avoid incurring costs patients only present at health care facilities when the disease has reached a severe state and alternative treatments have failed. Access to cheap drugs prescribed by well trained health personnel must be made available to avoid unnecessary expense for inadequate treatment. People should be encouraged to seek appropriate help in time. Maybe closer cooperation with the traditional health care system could help avoid potentially harmful treatments and to find cheap, effective and culturally accepted alternative treatments. 42 Discussion
8.5 Spectrum of skin diseases: details and special findings
8.5.1 Infectious skin diseases
8.5.1.1 Dermatomycoses
Tinea versicolor Prevalence T. versicolor was the most frequently diagnosed skin disease. In comparison with other surveys in Tanzania, the prevalence of 26.2% appears extraordinarily high. Prevalence was 1.1% in the Ngara District/north-west Tanzania (Gibbs, 1996) and 0.7% up to 4.1% in different locations across the same country (Quawoga et al., 1996, see Appendix D). In an Ethiopian primary school, 1.8% of the students had t. versicolor (Figueroa et al., 1996). However, according to the standard literature, t. versicolor is very common in the tropics and sub-tropics. In some areas half of the population was infected (Canizares, 1992d). Due to increased activity of sebaceous glands, adolescents are normally the age group with the highest prevalence (Gupta et al., 2002). Yet, the overrepresentation of this age group in the present study alone cannot satisfactorily explain the high prevalence. In the studies quoted above prevalence rates among children and adolescents were still much lower than the prevalence we observed (see Appendix D). Climatic factors have certainly favoured the development of t. versicolor at the time of the study. In the Gambia, during the rainy season, prevalence reached 18% among young adults (15 to 19 years) and dropped to approximately 8% during the dry season. Hot and humid conditions, in combination with profuse sweating at the time of the study may have enhanced the growth of Malassezia species (Shrum et al., 1994). Malnutrition and underlying diseases are further factors favouring the development of t. versicolor (Canizares, 1992d). Unfortunately, neither nutritional status nor the presence of underlying diseases could be assessed within the scope of present study. Some authors claim that t. versicolor only occurs exceptionally in children (Canizares, 1992d) and stress the onset in teenagers and young adults (Shrum et al., 1994; Porter, 1979). The reason is thought to be a lack of lipids in the skin of younger children, which Malassezia species need for their growth (Gupta et al., 2002). Yet, in the present study younger age groups also showed comparatively high prevalence rates. This supports the observations of Erchiga & Florencio (2002) who report that in tropical areas, t. versicolor is also common in infants. Maybe an early onset of puberty (Terragni et al., 1991) among the study population favoured higher prevalence rates in younger age groups. The use of Vaseline, especially on the face, which was common among the study population, could also led to higher prevalence rates among smaller children (Pontash et al., 1989). Substances containing high concentrations of complex lipids and their occlusive effect have been proven to enhance the growth of Malassezia species (Pontash et al., 1989). Alteration of the microflora and pH range also play a role (Sunenshine et al., 1998). 43 Discussion
Many authors consider infection with t. versicolor to involve a genetic susceptibility rather than contagiousness (Gupta et al., 2002) or poor hygiene (Sunenshine et al., 1998). Yet, the population of Lihami and Michenga has migrated to Ifakara from different parts of the country within the last few decades. This has caused a high genetic heterogeneity among the study population (Shengoto, personal communication) and renders a high hereditary susceptibility unlikely. No difference in prevalence could be observed between the two sexes. This agrees with the standard literature (Canizares, 1992d). On the whole t. versicolor represents a cosmetic problem (Gupta et al., 2003). In spite of the high prevalence, health interventions dealing with other skin diseases should be given priority
Clinical picture The clinical picture varied according to age. In children aged 6 to 10 years, whitish, scaly patches were found mainly on the face. In contrast to adults, this part of the body is the usual localization in children (Terragni et al., 1991). Approaching the age of puberty, the aspect changed: darker, scaly patches and sometimes follicular bound macules were found more frequently on the back and the chest and the relative frequency of facial lesions decreased. This pattern can be explained by hormonal changes in adolescents (Terragni et al., 1991). They lead to increased sebum production in the areas described, which corresponds to the lipid requirements of Malassezia species (Gupta et al., 2003).
Living conditions and hygiene behaviour: influence on the prevalence of tinea versicolor A high prevalence was significantly associated with crowded living conditions. This is surprising, since t. versicolor is neither contagious nor due to poor hygiene (Sunenshine et al., 1998). This result may be biased: crowded living conditions were significantly less common among smaller children than among older age groups. Younger children may have experienced difficulties counting, leading to an underestimation of the number of household members. As t. versicolor was more prevalent among older children and adolescents, an incorrect association between high prevalence and crowding may have resulted. Children of families keeping cows, sheep or goats showed higher prevalence rates of t. versicolor. Malassezia species found amongst animals are rarely found on humans (Guého & Meyer, 1989). Furthermore, transmission does not play a role in the epidemiology of t. versicolor (Sunenshine et al., 1998). If there is an association it may be due to as yet unknown causes. 44 Discussion
Dermatophyte infections: tinea capitis, faciei, corporis and pedis
Tinea capitis With a prevalence of 5.5%, t. capitis was the third most frequent diagnosis. This is in line with findings in other parts of rural Tanzania, where prevalence rates ranged from 2% to 4.3% (Appendix D). We found the prevalence to be significantly higher among children younger than 15 years (approximately 6%, 15 to 10 years: 0.8%). A similar pattern of infection was found in Ethiopian primary school children: 9% of the children had t. capitis, 80% younger than ten years old (Figueroa et al., 1996). Prevalence was 3% in a Gambian village, where most of the cases were younger than 15 years (Porter, 1979). T. capitis is one of the most common fungal infections in the tropics, mainly affecting younger children (Canizares, 1992c). Factors protecting the adult scalp from dermatophyte infections include sebum secretion and colonization by Malassezia species (Hayes et al., 1993). The higher prevalence observed in Lihami Primary School compared to Michenga could be due to a small epidemic. The pathogens are highly contagious and are spread, e.g. through barbershop instruments (Soyinka, 1978), combs or person to person transmission in overcrowded conditions, such as those found in the two schools (Figueroa et al., 1997). Malnutrition was discussed in the previous section as a factor favouring the development of dermatophytoses (Canizares, 1992c) (“Tinea versicolor”). Although some authors mention a higher prevalence among boys than girls (Canizares, 1992c; Porter, 1979; Soyinka, 1978), we did not observe any difference between the sexes. Samples of t. capitis processed for culture at the University Centre in Zürich showed evidence of Phoma species and Trichophyton tonsurans. T. tonsurans is one of the most common pathogens of t. capitis in tropical America, Asia and North America (Canizares, 1992c; Weitzman & Summerbell, 1995). It is only recently that dermatophytoses due to T. tonsurans have been reported in Africa (Enweani et al., 1996; Nweze, 2001; Awoderu et al., 2003; Ayaya et al., 2001; Nenoff & Haustein, 2001). Maybe a shift of pathogens, such as that observed in North America some decades ago, is now taking place on the African continent. During the 1950s, Microsporum audounii was still the prevailing dermatophyte in t. capitis in Northern America, then was replaced by T. tonsurans (Shrum et al., 1994). This phenomenon is a consequence of increased mobility due to improving infrastructure, trade and migration, which now apparently affects the society in Ifakara. Yet, the small number of samples in the present study makes general conclusions difficult to validate. Further research should investigate a possible shift of pathogens. Regarding the Phoma species found, only repeated cultures from the site of the lesions would have allowed a differentiation between contamination and an actual infection (Weitzman & Summerbell, 1995). As this was not possible, its presence has to be considered as contamination. 45 Discussion
Tinea faciei/corporis The prevalence of t. faciei/corporis was 2.6% among the study population. This is in line with other studies. They describe prevalence rates from 2.3% to 3.5% among villagers in different parts of Tanzania (Quawoga et al., 1996, see Appendix D). Prevalence was 2.7% among Ethiopian schoolchildren (Figueroa et al., 1996) and 1.1% among villagers in north-west Tanzania (Gibbs, 1996). Some authors mention higher prevalence rates among adults (Porter, 1979). However, we did not observe any difference regarding age. Culture was positive for Trichophyton violaceum (n = 1), T. mentagrophytes (n = 1) and T. tonsurans (n = 3). The first two pathogens are regularly found in African settings (Shrum et al., 1994). Yet, as discussed in the previous section, T. tonsurans is said to be uncommon in Africa (Canizares, 1992c).
Tinea pedis T. pedis showed a prevalence of 3.2%, with older children more frequently affected. With 2.1%, the prevalence was similarly high amongst villagers in northern Tanzania. Most of the cases were older than 14 years (Quawoga, 1996, see Appendix D). In Nigeria, prevalence was 2.5% among primary and 56.5% among the older secondary school children of the same town (Soyinka, 1978). This predomination in adolescents and adults is typical for t. pedis (Canizares, 1992c). This may be due to occlusive footwear which is more often used by older age groups. The moist and hyperhydrotic conditions favour the development of t. pedis (Weitzman & Summerbell, 1995). In secondary school children in Nigeria, a higher prevalence of t. pedis was directly associated with the use of footwear and uncommon among those who usually go barefoot (Soyinka, 1978). Amongst our study population, especially older children, footwear was commonly used. Yet, as the presence of shoes was not documented, no valid conclusions can be drawn. Although standard literature does not mention different prevalence rates according to sex (Canizares, 1992c), in the present study girls showed a prevalence twice as high as boys (9.4% versus 4.0%). This may be due to gender specific activities (Jang et al., 2000) such as fetching water or doing the laundry. These activities involve exposure to environments favouring the spread of pathogens. As tinea pedis infections were not confirmed by microscopic diagnosis, other, non – dermatophytic agents such as Candida spp., S. brevicaulis, H. toruloidea and Fusarium spp. (Masri-Fridling, 1996) also have to be considered as pathogens.
Living conditions and hygiene behaviour: influence on the prevalence of dermatophytoses High household density was significantly associated with a higher prevalence of dermatophytoses. This is in line with other studies (Canizares, 1992c). Reduced prevalence rates of dermatophytoses in connection with regular washing were also described by Dinkela et al. (Dinkela et al., 2005). She considers the additional use of soap to play an important role. 46 Discussion
8.5.1.2 Intertrigo In many community based surveys, tinea cruris or its differential diagnoses do not appear or it remains unclear whether the author classified it under other diagnoses. Nevertheless it is said to be the second most common dermatophytosis of the skin (Odom, 1993). The prevalence was 3.4% among villagers in rural Indonesia (Saw et al., 2001). T. cruris is usually seen in adult men (Weitzman & Summerbell, 1995). This explains the comparatively low prevalence (0.9%) as well as the predominant affliction of males older than 15 years in the present study.
8.5.1.3 Pyoderma The prevalence of pyoderma amongst the study population (8.4%) is in line with comparable study populations. Prevalence reached 8% in an Ethiopian primary school (Figueroa et al., 1996) and 8 to 10% in children in a neighbouring village of Ifakara (Degrémont et al., 1987). Populations comprising all age groups showed lower prevalence rates (Gibbs, 1996; Saw et al., 2001). This supports the conclusion that pyoderma is found especially frequently in younger children (Adriaans, 1988). Our survey was carried out at the end of the rainy season when prevalence rates of pyoderma are usually higher (Porter, 1979). A valid comparison of prevalence rates was complicated by the fact that there is no standardized definition for the term “pyoderma”. Some authors employ it for all skin infections of bacterial origin except leprosy (Porter, 1979), some only used the term “impetigo” (Satimia, 1996). In our case, this term comprised superinfected wounds or ulcers, folliculitis and impetigo. Counting tropical ulcers and wounds separately (Gibbs, 1996) may explain comparatively low prevalence rates of pyoderma in other studies. Standardized definitions are needed to allow valid comparison of different surveys.
8.5.1.4 Wounds Wounds were a common problem amongst the study population. Numerous scars on the children’s legs confirmed the frequency of superinfected abrasions and ulcers. Shortly after the present survey had started, an Italian NGO donated two new football goals and two basketball baskets to Lihami Primary School. These facilities were enthusiastically used by the children. The incidence of superinfected wounds and ulcers increased remarkably within just a few days, probably due to dust contamination (Webb, 1992). 2.7 times as many cases were seen overall in Lihami as in Michenga. As 85.5% of all cases of pyoderma were due to superinfected lesions, the prevalence of pyoderma reached 12.2% in Lihami compared to 4.4% in Michenga. Other authors also mention superinfected wounds as a common aetiology of pyoderma (Ryan, 2002; Welsh et al., 2002). Repeated contamination of wounds and the growth of bacteria can lead to osteomyelitis. Other complications are nephritis, carditis, arthritis and septicaemia (Oumeish et al., 2000). Contaminated 47 Discussion water or mud and poor living conditions favour further development into tropical ulcers (Gibbs, 1996; Webb, 1992) which predominantly affect young children (Welsh et al., 2002). Furthermore, the risk of a subsequent squamous cell carcinoma at the site of infection increases (Ryan, 2002). These factors make effective prevention measures highly desirable. Yet, considering climate and living conditions in Ifakara, the prevention of superinfections appears impossible. Other possible measurements will be discussed in chapter 9 (“Conculsions”).
8.5.1.5 Abscesses Little data were found about the prevalence of abscesses in other community based surveys. Prevalence was 1% among villagers in Musoma/Tanzania (Simba, 1996) which is similar to the low prevalence we observed (0.4%). Other authors may have included abscesses in other diagnoses, which would explain why in many studies they are not explicitly mentioned.
8.5.1.6 Ectoparasitic disorders
Scabies Prevalence The observed scabies prevalence of 1.5% appears low. Scabies is said to be highly prevalent among preschool children and adolescents in developing countries (Burkhart et al., 2000). It is abundant to endemic in tropical regions (Welsh et al., 2002). Prevalence rates were 16.1%, 9.0% and 17.0% among populations comparable to our study population (Lukume & Quawoga, 1996, see Appendix D; Figeroa, 1996). However, prevalence rates can show considerable regional variation (Landwehr et al., 1998; Craig, 1983). It was only 2.0% in a Gambian village (Porter, 1979) and 1.8% to 5% among primary school children in Bamako/ Mali (Landwehr et al., 1998). The low prevalence observed in the present study is surprising, since scabies was commonly found during the mid 80s (Hatz, personal communication). Factors favouring transmission such as crowding, limited access to water or sharing of beddings and fomites (Landwehr et al., 1998; Burkhart et al., 2000) were common among the study population (see section 7.2). The importance these factors for transmission, which occurs mostly within the household (and not at school) (Burkhart et al. 2000), was underlined by the high proportion of cases in which siblings were also affected by the condition. It is highly unlikely that the ivermectic treatment in 2000 and 2001 explains the low prevalence. Other authors report that nine months after ivermectic treatment the scabies prevalence was still significantly reduced (Heukelbach et al., 2004). Yet, after a period of more than two years, it is unlikely that it still has an effect on the study population. Re-infection by untreated household members is likely to have occurred. The conscientious use of Benzyl Benzoat Emulsion (BBE), standard treatment at health care facilities (Mbata, personal communication), may have led to a decrease of transmission of Sarcoptes scabiei. But even if adequate treatment seeking behaviour led 48 Discussion to an early treatment of index patients, treatment failures due to inefficient application can be expected (Henderson, 1992). Additionally, it is unlikely that other measures are regularly taken, such as treatment of asymptomatic household members and washing of clothing, linens etc. with hot water (Burkhart et al., 2000; Green, 1989). Cyclic fluctuations of scabies prevalence said to be due to “herd immunity” (Christophersen, 1978; Tüzün et al., 1980) are more likely to be due to wars and local epidemics (Burkhart et al., 2000). They were not relevant factors in our context. The importance of detecting ectoparasitoses in particular was repeatedly stressed within the team. Pruritus is severe in scabies infestations (Canizares, 1992e) and the study participants were promised treatment for their skin diseases. Thus it is unlikely that children concealed their symptoms or that cases were overlooked. Yet, in the absence of the typical signs and localizations of scabies infection, cases may have been mistaken for pruritic dermatoses. Scabies prevalence is higher during the cold season (Burkhart et al., 2000; Tüzün, 1980; Christophersen, 1978) and the mite prefers arid climates (Schmid-Grendelmeier, personal communication). The warm, humid climate at the time of the present survey could have contributed to the low prevalence. However, even when all of these factors are taken into consideration, the low scabies prevalence we observed cannot satisfactorily be explained.
Clinical picture and microspcopy According to the standard literature (Canizares, 1992e), the scabietic burrow is a pathognomonic sign. It is only recently that atypical scabies lacking the classical symptoms has been seen more and more frequently (Bauer et al., 2001; Wolf et al., 1995), putting the importance of these diagnostic criteria into question. Burrows were hardly ever found in the present study.
Scabies incidence in the area of Ifakara It is difficult to interpret the data we collected from peripheral health care facilities and SFDDH or compare them with similar settings as background information is lacking. Treatment-seeking behaviour, the age structure among admissions in SFDDH and other economic and socio-cultural factors certainly influenced the age and sex distribution. Remarkable discrepancies regarding the overall number of patients and the scabies incidence between the different facilities put the reliability of the data into question, as do the apparent “favourite diagnoses” of particular health staff, isolated peaks of incidence not reflected by other data and increasing incidence rates mostly opposed to the typical seasonal changes (Mimouni et al., 2003; Tüzün et al., 1980). The comparatively low incidence in the different health care facilities together with the findings of our screening only allows for the hesitant assumption of a low scabies prevalence among the population of Ifakara. 49 Discussion
Pediculosis Pediculosis corporis showed a low prevalence; no case of head lice was detected. Other authors report prevalence rates varying from 0.2% to 1.4% in rural Tanzania (Simba et al., 1996) to 57.1% (p. capitis) and 7.2% (p. corporis) in Ethiopian primary school children (Figueroa et al., 1996). Some studies found pediculosis to be uncommon (Ratnam & Jayaraju, 1979). The prevalence of ectoparasitoses is said to be low and only sometimes rises within vulnerable groups (Heukelbach & Feldmeier, 2004). Due to the stronger, thicker hair, head lice are usually less common among Africans than among other populations (Schmid-Grendelmeier, personal communication). In the present context, the nationwide policy of shaving the heads of primary school children (Shengoto, personal communication) was an additional preventative factor to the spread of head lice. Prevalence rates of body lice may have also been influenced by an adequate treatment-seeking behaviour among the population. It is unknown whether the people themselves take any further measures to control pediculosis. These factors taken together can explain the low prevalence. The ivermectic treatment in 2000/01 is unlikely to play a role (section 7.5.1.6, “Scabies”). Clothes were not systematically checked for body lice. Due to a lack of light in the examination chamber some cases may have been overseen.
Other ectoparasitoses Tungiasis No case of tunga penetrans (“jiggers”) was found, although this ectoparasitosis is said to be endemic in tropical Africa (Welsh et al., 2002). Prevalence rates ranging from 0.1% up to 10.4% among comparable study populations in rural Tanzania and Kenya were reported (Schmeller & Dzikus, 2001; Simba et al., 1996). 1 to 67% of the children interviewed in different areas of Tanzania reported an infestation within the previous month (Moestue et al., 2003). In the mid- Eighties jiggers was still a common problem in Ifakara (Hatz, personal communication). The importance of detecting tungiasis was repeatedly stressed amongst team members. The interdigital spaces of hand and feet and subungual spaces of all the children were carefully checked. The children were explicitly asked about the presence tunga penetrans (“funza”). Parents and caretakers mentioned the dry month of August as a time of generally high incidence. Arid conditions favour the incidence of jiggers, highly affected regions were virtually tunga-free during the wet season (Heukelbach, personal communication) which may explain our findings. As tungiasis also affects domestic animals (dogs, cats, pigs and peri-domestic rodents) (Heukelbach et al., 2003a), keeping pigs in stables can lead to remarkable reductions of tunga incidence (Heukelbach, personal communication). Yet this practice was already common in times of higher prevalence (Hatz, personal communication). Regular anti-ectoparasitic treatment of all dogs in the community apparently led to a significant decrease of tungiasis (Mbata, personal communication). Ivermectin can significantly reduce the prevalence of tungiasis (Heukelbach et al., 2004). However, 50 Discussion the previous distribution of this drug did not play a role in the present context (see 8.5.1.6, “Scabies”). Perhaps the study population was not representative for children of primary school age. Screenings in more remote areas or among children not attending school could have revealed different results. Cutaneous larva migrans No case of cutaneous larva migrans (CLM) was found. Information about the prevalence of CLM in Africa is scarce. Most publications refer to this ectoparasitosis mainly as a problem for tourists returning from tropical countries (Caumes, 2002, Bouchaud et al., 2000). Although in tropical countries individuals with CLM usually present to health care centres (Heukelbach et al., 2002), patients with “creeping disease” only made up 0.2% of the patients seen in a skin clinic in Mali (Mahé et al., 1998). In the past, a constant number of cases with peak incidence rates from June to December has been presenting at the dermatology OPD of SFDDH. Most of the patients were under fives (Mbata, personal communication) which is in line with other authors (Doe et al., 2001). This together with seasonal factors may explain the absence of cases among our study population. A lack of knowledge about CLM among the local population (Mbata, personal communication) as well as the absence of a local name suggests a generally low prevalence in the area of Ifakara.
According to the head teacher of Michenga Primary school and the health and vector control officer at the District Medical Office (DMO), living conditions in Ifakara have improved remarkably during the past few years. Projects assisted by the government and international NGOs have led to an improvement of sanitary facilities and to the construction of water pumps. This, together with health education at school, adult education addressing common health problems and the different factors discussed above could explain the unexpectedly low prevalence of ectoparasitoses among the study population.
8.5.1.7 Warts The overall prevalence of warts we observed (2.7%) is in line with other studies (Simba et al., 1996, Gibbs, 1996, Porter, 1979). Yet, in rural Gambia, about 40% of the cases were due to Molluscum contagiosum (Porter, 1979) compared to 0.5% in the present study.
8.5.1.8 Other skin conditions of infectious origin One case of angular cheilitis and one case of cheilitis with the lower lip being predominantly affected were described. Cheilitis angularis (Perléche) is frequently caused by candida spp. or bacterial infection, often in connection with repeated licking or atopic eczema (Dirschka & Hartwig, 2003). Malnutrition can also contribute to the development of cheilitis (Canizares, 1992g). Actinic cheilitis, often chronic, due to constant exposure to the sun, is common in rural Africa. 51 Discussion
Malignant degeneration may eventually occur (Canizares, 1992g). Superinfection is commonly found in cheilitis (Dirschka & Hartwig, 2003).
8.5.2 Non-infectious skin diseases
8.5.2.1 Pruritic dermatoses Many authors do not explicitly mention diagnoses with the symptom “pruritus”. A valid comparison of prevalence rates was also complicated by a lack of terminological standardization for the symptom “pruritus” and connected clinical findings. For the purposes of the present study “generalized pruritus/pruritic dermatitis/xerotic skin” and “itching without clinical findings” will be designated by the terms “prurigo”, “papular urticaria” and “papular pruritic dermatitis” used in the literature. 3% of the study population showed this complex of symptoms. Miliaria will be discussed separately. Among villagers in rural Tanzania, from 0.2% (Lukume, 1996) up to 7.2% (Gibbs, 1996) have previously been found to suffer from prurigo or papular urticaria. In many cases the highest prevalence rates were found among children under 15 years (Simba et al., 1996) or school children (Gibbs, 1996). Prurigo simplex, also called papular urticaria, is an allergic skin reaction to the bites of arthropods (Shatin & Canizares, 1992). It is predominantly seen in families of poor economic status and in children younger than 13 years (Shatin & Canizares, 1992). After that age, constant exposure leads to a desensibilization (Pradinaud et al., 1993). This explains the lower prevalence among older children observed by ourselves and others. Pruritus or papular pruritic dermatitis is also a frequent finding among HIV patients (Van Hees & Naafs, 2001b, Mahé et al., 1998), maybe even due to the same immunological mechanisms as in the case of insect bites (Pradinaud et al., 1993).). Yet, the prevalence of HIV was probably low among the study population (see section 8.5.3). Reactions to intestinal helminths (Schmid-Grendelmeier, personal communication) and schistosomiasis (Canizares, 1992i), parasites which are endemic in Ifakara (Hatz et al., 1990), can also cause generalized pruritus. A similar effect has malabsoption secondary to intestinal parasites (Rosenberg & Bowman, 1984, Mikhail & Mansour, 1982). In particular, vitamin A deficiency and a lack of essential fatty acids can cause a generalized xerosis (Bhattacharyya & Dutta, 1992; Oumeish & Oumeish, 2003). Onchocerciasis does not represent a possible cause as it is hypoendemic in Ifakara (see section 6.1, “Ivermectin”). Atopic eczema are an important non-infectious differential diagnoses. They can present with a papular to nodular picture in African patients (Schmid-Grendelmeier, 1998). Eczematous lesions of other origin should also be considered. Furthermore, disorders belonging to the field of internal medicine would have to be discussed in a full analysis, beyond the scope the present study. Miliaria is common and usually harmless condition in the tropics (Vasquez Botet, 1992; Porter, 1979). High temperature and humidity cause profuse sweating and favour the obstruction of the 52 Discussion eccrine duct (Vasquez Botet, 1992) leading to the typical lesions. The prevalence of 1.3% observed in Ifakara appears low considering the climate at the time of the survey. However, it is in line with other studies (Porter, 1979).
8.5.2.2 Lesions due to insects Rashes due to mosquito bites represent an allergic skin reaction (Shatin & Canizares, 1992) which is described in detail above (7.5.2.1). Blister beetle dermatitis is a skin condition rarely mentioned in community or hospital based surveys. Rove or “Nairobi” beetles show a seasonal incidence (Shatin & Canizares, 1992). Although some cases were coincidently seen in the dermatology OPD, the low prevalence (0.2%) suggests that the time of the survey did not correspond to the local “Paederus season”.
8.5.2.3 Eczematous lesions Eczematous lesions were found in 1.2% of the children. In other locations in rural Tanzania, prevalence rates ranged from 0.2% to 6.4% (Simba et al., 1996; Gibbs, 1996). These findings illustrate the considerable variation of the prevalence of eczematous eruptions in the tropics (Canizares, 1992f). Atopic eczema are said to be relatively common in East Africa (Schmid-Grendelemeier, 1998), especially among children (Canizares, 1992f). Nigeria, Kenya and Ethiopia ranged among the top- ten countries regarding the worldwide twelve-months prevalence (Anonymous, ISAAK study, 1998). Surprisingly, the prevalence was only 0.1% in Ifakara and 0.5% to 2.2% or described as “very rare” in other rural areas of the country (Quawoga et al., 1996; Masawe & Nsanzumuhire, 1975; Gibbs, 1996). Varying methodologies and definitions impair comparison of different studies (Anonymous, ISAAK study, 1998). But environmental factors in the broadest sense are also involved in the development of atopic disorders in childhood and explain variations seen within the same country (Anonymous, ISAAK study, 1998). Factors leading to higher rates, such as dietary changes, an adoption of western habits and industrial pollution (Esamai et al., 2002) were not present in Ifakara. Though considered as “high-ranking in terms of prevalence, incidence, social and economic consequences” (Oroko et al., 1992a), contact eczema also showed a surprisingly low prevalence in Ifakara. The same was result was found in other rural areas of Tanzania (Quawoga et al., 1996). As in the case of atopic eczema, exposure to eczematogeneous factors may not have played an important role within the study population. It is possible that in some cases other pruritic dermatoses were mistaken for eczema (see section 8.5.2.1) leading to an underdiagnosis. Different kinds of eczema are a common reason for consulting clinics in Tanzania (Schmid - Grendelmeier 2004, personal observation) and Nigeria (Ogunbiyi et al., 2004). Perhaps self-referral 53 Discussion has led, in these cases, to an accumulation of severe cases in reference centres, which may not reflect the actual epidemiologic situation amongst the whole population.
8.5.2.4 Keratoses, Prevalence of ichthyosis has been found to be 0.1% in Ifakara and 0.7% in northern Tanzania (Mathias, 1996). 1.1% and 0.9% of the patients in dermatology clinics in Nigeria and Ghana were ichthyosis cases (Doe et al., 2001; Ogunbiyi et al., 2004). In Ghana, it was the most frequently seen genodermatosis. This suggests that ichthyosis is as common in African as in European populations, where it is the most frequent hereditary skin disease (Bacharach – Buhles, 2003). The prevalence of keratosis pilaris among different study populations varied from 1.8% among Ethiopian to 12.5% among Turkish schoolchildren (Inanir et al., 2002). It is often associated with an atopic diathesis (Rassner et al., 2002) and can even be considered as a clinical sign of atopic dermatitis (Schmid-Grendelmeier, personal communication). The low number of cases in Ifakara would be in line with a low prevalence of atopic skin disorders (see section 8.5.2.3). Keratosis palmoplantaris punctata, an inherited skin disorder (autosomal dominant), was a common finding in a skin clinic in Northern Tanzania (Schmid-Grendelmeier, personal communication). However, no case was observed among the study population. Keratosis palmoplantaris punctata mainly presents with asymptomatic, tiny hyperkeratotic papules on the palmoplantar surface (Gruber & Ratnavel, 2003). Perhaps the, presumably high, genetic heterogeneity among the study population (see section 8.5.1.1, “Tinea versicolor”) together with an insufficient sample size could explain the absence of cases. Increased incidences at skin clinics may be due to an accumulation of cases and not necessarily reflect the real prevalence among the population.
8.5.2.5 Pigmentary disorders
Vitiligo The prevalence of vitiligo (0.4%) was in line with rates of 0.7% (Njau, 1996) and 0.3% found in other rural parts of Tanzania (Gibbs, 1996). In most countries vitiligo affects about 1% of the population. Fifty percent of cases set in before the age of twenty (Griffiths, 1992b). All cases of vitiligo we saw were localized. A differentiation between focal and segmental according to Fitzpatrick's classification (Griffiths, 1992b) could not be made from our records. Vitiligo is presumed to be an autoimmune disorder. In children and adolescents it is sometimes associated with thyroid diseases and polyglandular autoimmune syndromes such as hypoparathyreoidism, chronic mucocutaneous candidiasis and Addisons’s disease (Pinto & Bolognia, 1991). No symptoms indicating one or more of these disorders were observed in any of the cases we encountered. 54 Discussion
Other hypopigmented skin diseases The heterogeneous group of “other hypopigmented skin diseases” showed a prevalence of 1.2%. It is difficult to compare this result to findings of similar studies as many authors prefer to deal separately with the possible differential diagnoses.
Pityriasis alba Atopic eczema or resolution of atopic eczema, including pityriasis alba, are a common cause of hypopigmentation (Pinto & Bolognia, 1991). Pityriasis alba is frequently found in children. Predilection sites are face and upper extremities (Pinto & Bolognia, 1991). Prevalence reported from other study sites varies from 0.4% (Gibbs, 1996) to 5.4% (Figueroa et al., 1996) in different Eastern African locations. It is likely that a high proportion of the “leukoderma of unknown origin” found was due to pityriasis alba. In some cases of negative microscopy it may have been mistaken for t. versicolor.
Leprosy Hypopigmentation is also seen in borderline tuberculoid, tuberculoid and indeterminate varieties of leprosy (Griffiths, 1992c). In our study, no case of leprosy was found. A visit to the local leprosy clinic revealed that this disease still represents a problem in Ifakara. Yet, since this clinic is a reference centre for the whole area, self-referral led to an accumulation of cases which does not reflect the actual epidemiologic situation within the population. Due to its long “incubation” time leprosy is fairly rare in children (Schmid-Grendelmeier, personal communication). In rural southern Tanzania, the prevalence was only 0.1% (Lukume, 1996). This explains why no case of suspected leprosy was found in a sample of 820 children.
Psoriasis Healed psoriasis lesions often leave hypopigmentation (Pinto & Bolognia, 1991). Although it is less frequent in tropical than in northern climates, psoriasis is comparatively more prevalent in East Africa than in the rest of the continent (Farber & Nall, 1994). Prevalence rates vary between different ethnic groups and countries and were 1% to 3.3% in different Tanzanian locations (Gibbs, 1996; Masawe, 1973) Surprisingly, in the present study no case of psoriasis was found.
Albinism Patients with albinism were common in a skin clinic in northern Tanzania (Schmid-Grendelmeier, personal communication) and were also regularly seen in the streets of Ifakara. Yet, no case was found among the study population. Incidence of albinism is 1:1500 in Tanzania (Leppard, 2000) which may explain the absence of cases among a population of 820 children. Due to the lack of ocular pigments, albinotic children frequently show an impaired vision (Lund & Gaigher, 2002). This may hinder these children from attending school. It is not known weather other factors such as social isolation or early infanticide of albinotic children as practiced in some southern areas of 55 Discussion
Tanzania (Schmid-Grendelmeier, personal communication) could additionally explain the absence of cases.
Others Other reasons for hypo- or depigmentation include postlesional hypo- or depigmentation, congenital naevi depigmentosi and hypopigmentation secondary to drugs or application of other chemicals. A late state of onchodermatitis can also present with a spots and generalized loss of pigment (Griffiths, 1992d), but the presence of this disease was ruled out (see section 6.1, “Ivermectin”).
8.5.2.6 Keloids and hypertrophic scars Keloids are more frequent and often much more pronounced in Africans than in EurAsians (Schmid-Grendelmeier, personal communication). Among villagers in different areas of Tanzania, prevalence was 1.2% (Mathias, 1996), 0.9% (Simba, 1996) and 0.6% (Gibbs, 1996). This skin condition is rare in infancy (Laue, 1996). This may explain the comparatively low prevalence we observed (0.5%). All lesions documented had appeared following iatrogenic or self-induced trauma. No spontaneous keloid was seen. A differentiation between secondary keloids and hypertrophic scars (Harman & Canizares, 1992b) could not be made, since records of patient history did not cover the necessary details.
8.5.2.7 Acneiform lesions Prevalence of acneiform lesions was 2.7% among Ethiopian children and adolescents (Figueroa et al., 1996) and ranged from 0.6 to 4.9% in different locations in rural Tanzania (Simba et al., 1996). This is in line with the prevalence we found (2.6%). As in the present study, the highest prevalence rates were observed among adolescents and young adults (Quawoga, 1996; Satimia, 1996). This is due to the influence of androgens in children approaching the age of puberty. Children below the age of ten are rarely affected (Sahl & Mathewson, 1993). The earlier onset of puberty in females explains the higher prevalence rates among younger girls we observed in the present study. Compared to prevalence rates among European populations (12.8% in Australia; Plunkett et al., 1999), the figure found in Ifakara appears low. Yet, compared to other races, populations of European origin show higher prevalence rates of acne vulgaris (Harman & Canizares, 1992a). Drug eruptions can imitate the clinical picture of acne (Harman & Canizares, 1992c). Here, the lesions are mainly found on the trunk and no comedones are seen. Various infections such as Mollusca contagiosa or Cryptococcosis can also imitiate acne (Schmid-Grendelmeier, personal communication) and should be considered as differential diagnoses. 56 Discussion
8.5.2.8 Other skin conditions of non-infectious origin
Dandruff Dandruff is considered to be the mildest or initial form of seborrhoic dermatitis, which affects 5 to 10% of the adult population (Erchiga & Florencio, 2002). The relationship between Malassezia yeasts and seborrhoic dermatitis is still controversial, but a number of studies suggest a close association (Erchiga & Florencio, 2002; Nakabayashi et al., 2000; Midgley, 2000). Consequently, dandruff can be considered as another clinical picture of Malassezia species which showed an extraordinarily high prevalence among the study population (see section 8.5.1.1, “Tinea versicolor”). In spite of this background, the prevalence of dandruff was surprisingly low (1.7%). Trichophyton tonsurans also occasionally presents with diffuse scaling and minimal alopecia, which can easily be misdiagnosed as dandruff (Figueroa et al., 1997).
Genodermatoses Due to consanguinity, genodermatoses such as xeroderma pigmentosum are commonly found in Tanzania (Schmid-Grendelmeier, personal communication). However, apart from one case of ichthyosis, no other hereditary skin disease was found. This could be partly explained by an insufficient sample size. Furthermore, the study population showed a high genetic heterogeneity (see section 8.5.1.1, “Tinea versicolor”). Yet, it is not known whether intermarriages between the different ethnic groups are common or not. If not, consanguinity is increased.
Ethnospecific skin diseases Other typical conditions of black skin are the dactylosis spontanea (ainhum), pseudainhum and keratosis punktata of the palmar folds (see section 8.5.2.4) (Schmid-Grendelmeier, personal communication). Ainhum is a relatively common disease among black Africans with incidences ranging from 0.2-2%. The incidence of true ainhum outside Africa is low. Since 1960 only 30 cases have been reported in the USA (Selden, 2004). True ainhum is probably triggered by trauma, yet the true cause remains unknown. A fibrotic band develops from a flexural groove and constricts progressively until spontaneous autoamputation occurs. In pseudoainhum, which may be acquired or congenital, the same occurs due to a collagen band (Selden, 2004). Fully developed ainhum is uncommon in persons younger than 30 years and older than 50 years (Selden, 2004). This may explain the absence of cases among the study population.
8.5.3 Skin diseases and HIV HIV prevalence is estimated to be 13.9% among the adult population of Ifakara (IHRDC, 2004). In the present study testing of HIV serology was not possible. However, the prevalence was probably low. Newborns infected via mother-child transmission are unlikely to survive until the age of schooling. The age segment we investigated is presumed to be the least infected (Bennel, 2003). 57 Discussion
HIV prevalence rates also appear to be considerably lower among teenagers who attend school (Bennel, 2003). Among the studied population new infections due to sexual contact would only be expected in females of the oldest age group (15 to 19 years) (Bennel, 2003). Very few manifestations of the Aids would occur while the children are still attending school. Typical opportunistic infections such as herpes zoster or seborrhoic dermatitis (Van Hees & Naafs, 2001c) were not observed. As in HIV-positive patients, superficial fungal infections show special features (Marquez et al., 2001; Aly & Berger, 1996; Canizares, 1992d), some cases of extensive t. cruris (Aly & Berger, 1996) may have been triggered by HIV infection.
8.6 Strengths and limitations As far a possible the limitations of the study were discussed within the respective sections. In this section issues concerning the study as a whole will be discussed. Regarding our questionnaire, open questions could have produced more reliable information. The suggestive multiple-choice style together with shyness of the children and the attempt to please the investigator certainly influenced the answers. Yet, an unstructured interview would have exceeded the language skills of the European investigators (A. Dinkela and J. Ferié). Some questions had to be removed because they did not deliver reliable information. The documentation system employed only allowed for the description of one lesion in full detail, defined as the principal diagnosis. Further skin disorders and findings could only be briefly recorded. This may have contributed to the relatively low prevalence of some “secondary” diagnoses. Yet, the tight time schedule and a lack of manpower made a more extensive documentation difficult. A strength of the study is the fact that all examinations were performed by the same four investigators. The limited clinical experience of the two medical students (Almuth Dinkela and Julia Ferié) was compensated for by the supervision by Dr M. Mbata, a fully trained local dermatologist AMO. At the beginning of the study each finding was briefly presented to him. Later, all unclear findings were discussed together. The digital exchange with experts in Switzerland represented a further quality control. As it was not possible to store transport envelopes in clean places during the whole examination period, samples (skin scraping, hair clipping) have been contaminated in some cases. Some samples, especially in the case of t. versicolor, could not be evaluated because few samples could be obtained. In case of intertrigo, few samples could be obtained because privacy or an examiner of the same sex as the child could not always be provided. In case of t. pedis, no samples were taken. Microscopic examination and cultures of all dermatomycoses would have been desirable. Access to results of further diagnostic measures carried out in the dispensary and SFDDH in the case of pruritic dermatitis, generalized pruritus/xerotic skin and itching without clinical findings would have allowed further assessment of the origin of these symptoms. It is possible that cases of minor skin lesions such as acne, warts or dermatosis papulosa nigra were overlooked. This would explain 58 Discussion the absence of the latter. Since Lihami Primary School did not have complete and up-to-date class lists, it was difficult to check which children had already been examined. It is possible that some children were seen twice or that ill children or chronic absentees enrolled in the study. This could be an additional factor explaining the higher prevalence of skin diseases in Lihami (60.3% versus 48.9% in Michenga). 59 Conclusion
9 Conclusion
In April/May 2003 skin diseases did not represent a serious problem for the children of two primary schools in Ifakara. The majority of the skin conditions found were benign. There was no urgent need for intervention. Self-referral to the local hospital and the presence of a dermatologist appears to function in the case of more serious skin problems. The socio-cultural importance of physical appearance certainly plays a role regarding the active treatment seeking behaviour. Only in one third of the diagnoses was treatment considered as mandatory. In the majority of the cases, mainly pyoderma and dermatophytoses, drug-based therapy available within the primary health care system was possible. A closer cooperation between modern and traditional health practitioners would allow for the best use of local resources. Traditional medicine may offer cheap and equally effective alternatives to standard western treatments for some skin disorders (Satimia et al., 1998). T. versicolor was the single most frequent diagnosis representing almost 40% of all skin disorders. As it causes mainly cosmetic disturbances, health interventions regard other skin diseases as having priority. Further research should clarify the extent to which genetic and as yet unknown factors influence the prevalence of t. versicolor. Dermatophytoses represented another important group of skin diseases. Even the small number of cultures suggested a high overall proportion of Trichophyton tonsurans among the pathogens. Further investigations should assess the prevalence of this causative agent, formerly uncommon in Africa (Nenhoff & Haustein, 1997; Weitzman & Summerbell, 1995; Canizares, 1992b). The population should be sensitized to seek treatment in time. Access to cheap treatment has to be assured. Routine inspections of scalp and body at school including treatment with Whitfield’s ointment by health teachers could be a cheap and effective approach to controlling dermatophytoses (Schmeller & Dzikus, 2001). Furthermore, regular soap use has shown to reduce the prevalence of superficial dermatomycoses (Dinkela et al., 2005). Pyoderma (mainly superinfected wounds or ulcers) was the second most frequent skin problem. This skin condition could easily be treated. Yet, it still represents a significant strain on household budgets in developing countries (Mahé, 2001). The fact that the prevalence in Ifakara was high in spite of the comparatively good health infrastructure, underlines the fact that the high cost of treatment still keeps people from seeking adequate help. Easily accessible, cheap and efficient treatments are needed. Superinfected wounds and ulcers could be treated at school with gentian violet solution (Schmeller & Dzikus, 2001). To reduce the prevalence of dermatomycoses and pyoderma, the skin diseases most frequently seen in Ifakara, living conditions and hygiene still have to further be improved (Schmeller & Dzikus, 2001). Health education also plays an important role in the prevention of these skin diseases (Hoare et al., 1999) and should be given further emphasis. Algorithms for the management of common skin 60 Conclusion diseases could help with the effective identification and treatment of dermatomycoses and pyoderma at primary health care level (Mahé et al., 2005). The prevalence of ectoparasitoses was very low compared with other studies. This can partly be explained by the successful implementation of prevention measures and improving hygiene conditions. The previous distribution of Ivermectin does not explain the low prevalence rates. Further studies of the factors influencing the prevalence of ectoparasitoses are required to fully explain the findings of the present study. Eczematous lesions showed a comparatively low prevalence. Yet, these lesions are known to show varying prevalence in different locations (Canizares, 1992f). High rates of attendance reported by skin clinics (Ogunbiyi, 2004; Schmid-Grendelmeier, 1998) may be due to an accumulation of severe cases in these locations. It will be interesting to follow the influence of changing living conditions and industrialization in tropical and temperate climates on the prevalence rates of the different types of eczema. As in other surveys (Gibbs, 1996), the population studied was not affected by any of the “classical” tropical dermatoses such as onchocerciasis, yaws, leprosy, leishmaniasis or filarial lymphedema. Others have already pointed out that 'exotic' findings are overstressed in the tropical dermatology literature (Mahé et al., 1998). A higher prevalence of infectious skin diseases was significantly associated with high household density. However, the results regarding the influence of living conditions and hygiene behaviour on the prevalence of skin diseases were strongly influenced by the high prevalence of t. versicolor and partly biased. They should be considered with care. During the course of this study the need to standardize survey methods and definitions of diagnoses repeatedly became clear. This would allow a more valid comparison of studies carried out in different locations.
This report should help to reveal the actual epidemiological situation regarding skin diseases among primary school children in Ifakara/Tanzania. Since 1995, a fully trained AMO dermatologist (Dr. M. Mbata) has been working at the local hospital. The beneficial effect of his work and possibly improved hygiene conditions may already be reflected by the lower incidence of skin diseases in this area compared with earlier observations in Ifakara or recent data from other centres. The information we collected will hopefully help in the setting of priorities for future health interventions. 61 Literature
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11 References
Hatz Hatz C, Department of Medicine and Diagnostics, Swiss Tropical Institute, Basel, Switzerland
Heukelbach Heukelbach J, Department of Community Medicine, Faculty of Medicine, Federal University of Ceará, Fortaleza, Brazil
Mbata Mbtata M, Department of Dermatology, St Francis Designated District Hospital, Ifakara, Tanzania
Schmid-Grendelmeier Schmid-Grendelmeier P, Department of Dermatology, University Hospital Zürich, Switzerland
Shengoto Shengoto S, headteacher of Michenga Primary School, Ifakara, Tanzania 69 Curriculum vitae
12 Curriculum vitae
NAME - Julia Franziska Ferié DATE/PLACE OF BIRTH - March 1st, 1978 in Georgsmarienhütte, GERMANY NATIONALITY - German HOME ADRESS - HOLUNDERSTRASSE 1 49124 GEORGSMARIENHÜTTE GERMANY EMAIL: [email protected]
1984-1988 Primary education in Georgsmarienhütte, GERMANY 1988-1997 Secondary education Orientierungsstufe Oesede, G.M. Hütte, GERMANY Gymnasium Oesede, G.M. Hütte, GERMANY 1997 Abitur (A-Level) 1998 Twelve month stay in Argentina, Spanish course, two-month nursing practical at the Hospital Municipal de San Isidro, Buenos Aires, ARGENTINA 1998-2000 Medical School of the University of Leipzig, GERMANY 8/2000 Pre - Clinical Exam 2000 Medical School of the University of Freiburg, GERMANY 8/2001 First Clinical Exam 8/2001-3/2002 Six month stay in Argentina and Brazil, practicals in the Department of Obstetrics (one month) Department of Paediatrics (one month) Department of Public Health/Social Medicine (two months) of the Universidade Federal da Bahia, Salvador da Bahia, BRAZIL 2003 German Academic Exchange Service, GERMANY – “Scholarship for Scientific Training in Foreign Countries” 3-8/2003 Field study “Skin disorders among schoolchildren in rural Tanzania and an assessment of contributing factors and therapeutic needs” (MD thesis), Ifakara, TANZANIA 2003-2005 Medical School of the University of Freiburg, GERMANY 4/2005 Second Clinical Exam 4/2005-4/2006 Elective period (“Praktisches Jahr”) at the University of Freiburg/Germany (neurology), Krankenhaus Thusis/Switzerland (surgery), University of Bristol/UK (cardiology) and the University of Oxford/UK (infectious diseases) 70 71
13 APPENDICES 72 73 Appendix A
Appendix A Questionnaire
ID Number of the child: Ƒ. Ƒ. Ƒ. ƑƑƑƑ Date:______# Screening - # School - # Form – Serial number child Name of the child: Form: Sex: Age: 1 = YES 2= NO NA = Not applicable = 3 DNK = child does not know = 4
Part_A
1. Do you have any skin problems at present? yes Ƒ no Ƒ Una tatizo la ngozi yako?
2. If so, which of the following describes your problem? Tatizo lako nini?
1. itching kuwashwa yes Ƒ no Ƒ 2. depigmetation kuwa na mabaka patch yes Ƒ no Ƒ 3. change in colour: black: inabadirika rangi: nyeusi yes Ƒ no Ƒ 4. change in colour: red: inabadirika rangi: nyekuindu yes Ƒ no Ƒ 5. change in colour: white: inabadirika rangi: nyeupe yes Ƒ no Ƒ 6. rash vipele yes Ƒ no Ƒ 7. sores vidonda (NO if it does not refer to the MAIN skin problem!) yes Ƒ no Ƒ 8. does it hurt je inauma yes Ƒ no Ƒ 9. is it numb? Unasikia ganzi yes Ƒ no Ƒ
3. Do you have any other skin problem (if the child presents with several significant skin diseases, please comment in detail at the end of the questionnaire) Je una tatizo lingine la ngozi? yes Ƒ no Ƒ
4. if yes kama ndiyo: Mention eleza: CATEGORIZE! 0. NA 1. Matangatanga 2. Mapunje 3. NA 4. DNK 5. Kidonda 6. Vipele 7. Uwasho 8. Pustules which rupture leaving ulcers 9. Excema 74 Appendix A
5. When did this skin problem start? (only refers to question number one) Tatizo lako hili la ngozi lilianza lini?
1. < two weeks ago . chini ya mwiki mbili yes Ƒ no Ƒ 2. 2-4 weeks zaidi ya wiki mbili na chini ya wiki nne
If 5.1/5.2 YES – please enter 9.5/6/7 = 3 (NA)
3. 2-6 months ago zaidi ya miwezi mibili na chini ya miwezi sita 4. <1 year ago mwaka 1 5. 2 years ago miaka 2 6. 3 years ago miaka 3 7. > years ago zaidi ya miaka mitatu
6. Where did this skin problem start? (only refers to question number one) Tatizo hili limeanzia wapi? 1. scalp ngozi ya kichwa yes Ƒ no Ƒ 2. face uso yes Ƒ no Ƒ 3. neck shingo yes Ƒ no Ƒ 4. chest kifua yes Ƒ no Ƒ 5. abdomen tumba yes Ƒ no Ƒ 6. back mgongo yes Ƒ no Ƒ 7. axilla makwapa yes Ƒ no Ƒ 8. arms mkono yes Ƒ no Ƒ 9. hands viganjwa yes Ƒ no Ƒ 10. finger webs uwazi wa vidole yes Ƒ no Ƒ 11. genital region sehemu za siri yes Ƒ no Ƒ 12. thighs mapaja yes Ƒ no Ƒ 13. knees magoti yes Ƒ no Ƒ 14. lower leg miguu yes Ƒ no Ƒ 15. feet nyaao yes Ƒ no Ƒ 16. between the toes baina ya kidole cha miguu yes Ƒ no Ƒ
7. Size Ukubwa: 1. Does it remain the same? Inabakia vilevile? yes Ƒ no Ƒ 2. Is it increasing in size? Inaongezeka ukubwa? 3. Is it decreasing in size? Inapungua? 4. Is it varying in size? Inarudiarudia?
8. Does this skin disease itch (lesions described in question no. 1)? Je ugonjwa wako huu unawasha? yes Ƒ no Ƒ
9. When does it itch? Ni wakati gani unawasha zaidi? 1. in the hot sun Jua kali yes Ƒ no Ƒ 2. in bed/sleeping kintandani/ unapolala yes Ƒ no Ƒ 3. after bathing with hot water baada ya kuoga na maji joto yes Ƒ no Ƒ 4. after bathing with cold water maji baridi yes Ƒ no Ƒ
IF Question No. 5.1/ 5.2 = YES: Please fill in 3 (NA) in Question No. 9.5/ 9.6/ 9.7 75 Appendix A
5. rainy season masika yes Ƒ no Ƒ 6. hot/dry season kiangazi yes Ƒ no Ƒ 7. cold season wakati wa baridi yes Ƒ no Ƒ
13. Are there any others at home who have the same skin disease or the same signs of the skin disease as you? How many Taja wangapi: IF NO, PLEASE ENTER “0” Ƒ
15. IMMER EINGEBEN!
Apart from the skin problem(s) do you have another problem such as the following? Una tatizo lolote kati ya haya yafuatayo: 1. fever Homa yes Ƒ no Ƒ 2. fatigue Kuchoka yes Ƒ no Ƒ 3. headache unaumwa kichwa yes Ƒ no Ƒ 4. nausea kichefuchefu yes Ƒ no Ƒ 5. vomiting kutapika yes Ƒ no Ƒ 6. joint pain maumivu ya viungo yes Ƒ no Ƒ 7. edema uvimbe yes Ƒ no Ƒ 8. diarrhoea kuharisha yes Ƒ no Ƒ 9. abdominal pain maumivu ya tumbo yes Ƒ no Ƒ 10. generalized pruritus uwashwa mwili mzina yes Ƒ no Ƒ 11. Itchy scalp Kitchwa chako kina uwashwa yes Ƒ no Ƒ 12. others: vitu vingine: CATEGORIZE!
0. NA 1. Kuhoa 2. NO other complains 3. NA 4. DNK 5. Kidonda 6. Tumbo 7. Back hurts 8. pain in different body parts after having played football/ shamba work etc. 9. Eye problem 10. Ear Problem 11. Itching 12. Running nose
16. Have you received any treatment for your main skin problem? Je umetumia dawa yoyote kutibu tatizo hili? yes Ƒ no Ƒ
17. If yes, which kind of treatment? Kama ndiyo: ni dawa gani? 1. crème krimu yes Ƒ no Ƒ 2. tablets vidonge yes Ƒ no Ƒ 3. injection sindano yes Ƒ no Ƒ 4. leaves majani yes Ƒ no Ƒ 76 Appendix A
5. roots mizizi yes Ƒ no Ƒ 6. charm kombe yes Ƒ no Ƒ 7. necklace hirizi yes Ƒ no Ƒ 8. Name of the drug Jina la dawa: CATEGORIZE!
0. NA 1. Traditional medicine 2. NO name given 3. NA 4. DNK 5. Panadol 6. Aspirin 7. Breaking fluid 8. Mafuta (Vaseline/ Oil) 9. Gentiana Violet 10. Ointment
19. How long have you been taking this drug? 18. Umetumia dawa hii kwa muda gani? yes Ƒ no Ƒ 1.< 1 week kidogo zaidi wiki moja 2.< 2 weeks kidogo zaidi wiki mbili 3.< 4 weeks kidogo zaidi wiki nne 4. 2-6 moths miezi miwili hadi miezi sita 5.< 1 year kidogo zaidi mwaka mmoja 6.> 1 year zaidi ya mwaka mmoja
20. Has this drug helped? Je imekusaidia? yes Ƒ no Ƒ 19.
21. If several drugs have been used: which one has helped? Mention. CATEGORIZE! 20. Kama umetumia madawa mabali – dawa gani imesaidia? 0. NA 1. Tablets 2. Leaves from Mganga 3. NA 4. DNK
22. Have you ever been admitted to hospital? 21. Je, umewahi kulazwa hospitalini? yes Ƒ no Ƒ
23. if yes kama ndiyo: 22.
How many times? Mara ngapi? Ƒ Please enter number of admissions, if no admissions, write 0, if question 22: DNK/NA write 0
24. What were you suffering from? Ulikuwa unamwa nini? CATEGORIZE! 77 Appendix A
23. 0. NA 1. Malaria 2. Tumbo 3. NA 4. DNK 5. Tambasi 6. Kichwa 7. Homa 8. Meningitis 9. Fracture 10. Seizures 11. Asthma 12. Wounds 13. Pneumonia
25. Does any family member at home or any relative have asthma? 24. Je nyumbani kuna mtu au ndugu mwenye pumu? yes Ƒ no Ƒ
26. Does any family member at home or any relative have a skin disease different from the 25. one you have? Je nyumbani kuna mtu au ndugu mwenye ugonjwa wa ngozi mbali ya ugonjwa huu ? yes Ƒ no Ƒ
27. If yes kama ndiyo, 26. mention taja: if only 1 skin disease, please enter “0” for 27b/ 27c CATEGORIZE! 0. NA 1. Matangatanga 2. Mapunje 3. NA 4. DNK 5. Vipele 6. Vidonda
28. Apart from the drug for your (main) skin disease, do you take any other drugs? 27. Je unatumia dawa nyingine yoyote (mbali na dawa ya ugonjwa wa ngozi)?yes Ƒ no Ƒ
29. Which drugs? Dawa gani? CATEGORIZE! 28. 0. NA 1. Traditional medicine 2. NO other drug used 3. NA 4. DNK 5. Aspirin 6. Breaking fluid 7. Mafuta (Vaseline/ Oil) 8. Antiseptic solution 9. Panadol 10. Leaves 78 Appendix A
Hygiene Evaluation:
32. What is your religion?
Dini yako ni ipi? 0. NA 1. Christian Mkristo 2. Muslim Mwislamu 3. NA 4. DNK 5. No religion hamna
33. What education did your father receive? Baba yako alipata elimu gani?
PLEASE ONLY ENTER NUMBER, NOT YES/NO!
IF NUMBER OF YEARS SPENT IN PRIMARY SCHOOL MENTIONED IN DETAIL AS 33.6 (E.G. STD.4), PLEASE ENTER AS “PRIMARY SCHOOL EDUCATION” IF STD. 1-3, if less, enter NO (33.3)
1. No formal education hakusoma 2. Adult education Elimu ya watu wazima 3. Primary education shule ya msingi 4. Secondary education shule ya sekondari 5. Post-secondary baada ya sekondari
34. What is your father’s profession? Baba yako unafanya kazi gani?
0. NA 1. Peasant 2. NO profession 3. NA 4. DNK 5. Fisherman 6. Small scale businessman 7. Carpenter, matrass maker 8. Mason, brick layer, house builder 9. Service (Cook, waiter, driver, gate keeper etc.) 10. Teacher 11. Policeman 12. Fundi ya baiskeli = ya redio = ya simu 13. Imam 14. Tailor 15. dead 16. Forester 17. Nurse 18. Technical engineer 19. Manual labourer = rice mill worker 20. Transport officer, ward secretary = Gehobene Stellung im öffentlichen Dienst 79 Appendix A
35. What education did your mother receive? Mama yako alipata elimu gani?
PLEASE ONLY ENTER NUMBER, NOT YES/NO! CATEGORIZE!
IF NUMBER OF YEARS SPENT IN PRIMARY SCHOOL MENTIONED IN DETAIL AS 35.6 (E.G. STD.4), PLEASE ENTER AS “PRIMARY SCHOOL EDUCATION” IF STD: 4 – 7 COMPLETED; IF STD. 1 – 3; “NO”(35.3)
1. No formal education halisoma shuleni 2. Adult education Elimu ya watu wazima 3. Primary education shule ya msingi 4. Secondary education shule ya sekondari 5. Post-secondary baada ya sekondari
36. What is your mother’s profession? Mama yako unafanya kazi gani? 0. NA 1. Peasant 2. NO profession 3. NA 4. DNK 5. Housewife 6. Small scale businesswoman 7. Service (Cook, waitress. housemaid etc.) 8. Teacher 9. Tailor 10. dead 11. Nurse 12. Birth attendant
37. How many people live at home with you? Watu wangapi wanakaa nyumbani kwenu? NUMBER/0 = NA/DNK
38. How many rooms do you have at home alltogether? NUMBER/0 = NA/DNK Mna vyumba vingapi nyumbani?
39. What materials is your house built from? Nyumba yenu imejengwa kwa vifaa gani? 1. wooden beams miti yes Ƒ no Ƒ 2. mud udongo yes Ƒ no Ƒ 3. stones mawe yes Ƒ no Ƒ 4. bricks tofali yes Ƒ no Ƒ 5. lime chokaa yes Ƒ no Ƒ 6. palm leaves makuti / nyasi yes Ƒ no Ƒ 7. iron sheets bati yes Ƒ no Ƒ 8. others nyingine: - CATEGORIZE! 0. NA 1. Cement 2. NO other materials used 3. NA 80 Appendix A
4. DNK 5. Wooden roofing
40. Which source are you using for drinking water? Unatumia chanzo cha maji gani kwa kunywa? 1. tap water at home maji ya bomba nyumbani/ maji ya serikali yes Ƒ no Ƒ 2. tap water outside maji ya bomba nje 3. well maji ya kisima 4. hand pump maji ya bomba ya kuvuta 5. river maji ya mto 6. pond maji ya dimbwi
41. How far away is it from your house? Unatembea kwa miguu kwa muda gani mpaka chanzo hiki?
1. < 2min dakika yes Ƒ no Ƒ 2. < 10min 3. < 0.5 h 4. < 1 h
42. Do you boil drinking water? Je, unachemka maji kabala ya kunywa? yes Ƒ no Ƒ
44. Do you keep animals at home? If yes, what kind of animals? Kama ndiyo, wanyama gani?
IF NO ANIMALS ARE KEPT PLEASE FILL “2” IN EVERYWHERE
1. cows ng´ombe yes Ƒ no Ƒ 2. pigs nguruwe yes Ƒ no Ƒ 3. chickens kuku yes Ƒ no Ƒ 4. goats mbuzi yes Ƒ no Ƒ 5. cats paka yes Ƒ no Ƒ 6. dogs mbwa yes Ƒ no Ƒ 7. Others wanyama wengine: CATEGORIZE! 0. NA 1. ducks 2. NO other animals kept 3. NA 4. DNK 5. sheep 6. pigeons 7. guinea fowl 8. rabbits
48. How many people sleep in your bed? NUMBER Watu wangapi wanalala kitanda chako? 81 Appendix A
52. How often do you wash yourself? Mara ngapi unaoga? yes Ƒ no Ƒ 1. once per day mara moja kila siku yes Ƒ no Ƒ 2. twice per day mara mbili kila siku yes Ƒ no Ƒ 3. three times per day mara tatu kila siku yes Ƒ no Ƒ 4. more than 3 times per day zaidi ya mara tatu kila siku yes Ƒ no Ƒ 5. it depends inategemea yes Ƒ no Ƒ
53. How often do you use soap to wash yourself? Mara ngapi unatumia sabuni ya kuogea?
1. every time I bath wakati wowote ninapoogea yes Ƒ no Ƒ 2. whenever there is soap wakati wowote kama kuna sabuni yes Ƒ no Ƒ 3. once per day mara moja kila siku yes Ƒ no Ƒ 4. twice per day mara mbili kila siku yes Ƒ no Ƒ 5. three times per day mara tatu kila siku yes Ƒ no Ƒ 6. infrequently mara ndogo yes Ƒ no Ƒ 7. no soap available hamna sabuni yes Ƒ no Ƒ 8. never asilani yes Ƒ no Ƒ
54. What parts of your body do you wash every time you wash yourself? Sehemu gani za mwili unaosha wakati wowote unapooa? 1. Face uso yes Ƒ no Ƒ 2. Hands mikono yes Ƒ no Ƒ 3. The head kichwa yes Ƒ no Ƒ 4. The private places sehemu za siri yes Ƒ no Ƒ 5. The feet miguu yes Ƒ no Ƒ 6. The armpits kwapa yes Ƒ no Ƒ 7. The hair nywele yes Ƒ no Ƒ 8. chest kifua yes Ƒ no Ƒ 9. back mgongo yes Ƒ no Ƒ
55. Do you have a bathing area Una sehemu ya kuogea 0. NA 1. inside the house ndani ya nyumbani yes Ƒ no Ƒ 2. in the courtyard Uzioni/uwani yes Ƒ no Ƒ 3. NA 4. DNK
56. Where do you wash yourself? kwa kawaida unaoga wapi? 1. At home nyumbani yes Ƒ no Ƒ 2. At the well kisimani yes Ƒ no Ƒ 3. In the river mtoni yes Ƒ no Ƒ 4. Others sehemu zingine CATEGORIZE! 1. bombani 2. NO other place used 3. NA 4. DNK 5. 82 Appendix A
Part_B
- Serial Number - ID – Number - School - Sex - Age - SoapSerial - Soapletter
DIAGNOSIS 1: (e.g.. T. versicolor) Infectious skin disease: Yes/ No Diagnosekategorie: (e.g. „1“) Lokalisationen: 15 open spaces for Localisation
DIAGNOSIS 2: see above DIAGNOSIS 3: see above DIAGNOSIS 4: see above
Categorization of Observed Skin Disorders:
1 Infectious skin disease 2 Non-infectious skin disease 1 Dermatomykosen 8 Pruritic dermatoses
11 T. versicolor 81 Generalized Pruritus/xerotic skin 12 T. capitis 82 Miliaria 13 T. faciei/corporis 83 Pruritic dermatitis 14 Onychomykose 15 T. pedis 16 Other superficial mycoses
2 Pyoderma 9 Non-superinfected wounds/ulcers
21/24 Superinfected 91 Non-superinfected wounds wounds/ulcers/healing superinfected 92 Animal bites (not superinfected) wounds/ulcers 22/25 Impetigo/healing impetigo 23 Folliculitis
3 Intertrigo 10 Eczematous lesions
31 Intertrigo, 101 DCPA (Vaseline Dermatitis) 102 Atopic eczema 103 Unclassifyable eczema 104 Contact eczema
4 Ectoparasitic disorders 11 Keratoses:
41 Scabies 111 Ichthyosis 42 Pruritic dermatosis, probably due 112 Keratosis pilaris to pediculosis 83 Appendix A
5 Warts 12 Pigmentary disorders
51 Molluscum contagiosum 121/ 52 Common warts 122 Hypopigmentation 123 Vitiligo 124 Undefined pigmentary disorders 125 Suspicion of leprosy (tuberkoloid leprosy) 126 Other
6 Abcesses 13 Lesions due to insects
Bei Diagnosefeld bitte auch 6 eintragen! 131 Rash due to mosquito bites 132 Blister beetle dermatitis (due to Paederus species”) 133 Others
7 Others: 14 Keloids
71 Cheilitis Bei Diagnosefeld bitte 17 eintragen!
15 Acneiform lesions
Bei Diagnosefeld bitte 18 eintragen!
16 Others:
161 Alopecia areata 162 Striae 163 Dandruff 164 Cyst 165 Dry skin 166 Itching without clinical finding 167 Soft, mobile tumor 168 Unclear diagnosis 169 Morphea
Lesions indicating skin diseases found on
58.31. Scalp: Ƒ 59.32. Face: Ƒ 60.33 Gums Ƒ 61.34. Tongue Ƒ
Neck: 62.35. anterior Ƒ 63.36. posterior Ƒ
64.37. Chest: Ƒ 65.38 Abdomen: Ƒ 66.39 Back: Ƒ
Axillar region: 67.40. right Ƒ 68.41. left Ƒ
Upper arm: 69.42 Right ant. Ƒ 70.43 post. Ƒ 71.44 Left ant. Ƒ 72.45 post. Ƒ
Forearm: 73.46 Right ant. Ƒ 74.47.post. Ƒ 75.48Left ant. Ƒ 76.49post. Ƒ
Wrist: 77.50Right dorsal Ƒ 78.51 volar Ƒ 79.52 Left dorsal Ƒ 80.53 volar Ƒ 84 Appendix A
Hands: 81.54 Right dorsal Ƒ 82.55 palm Ƒ 83.56 Left dorsal Ƒ 84.57 palm Ƒ
Nails: 85.58 right hand Ƒ 86.59 left hand Ƒ 87.60 right foot Ƒ 88.61 left foot Ƒ
Gluteal region: 89.62Right Ƒ 90.63 Left Ƒ
91.64 Perianal region: Ƒ 92.65 Inguinal region: Ƒ 93.66 Pubic region: Ƒ
Thighs: 94.67 Right ant. Ƒ 95.68 post. Ƒ 96.69 Left ant. Ƒ 97.70 post. Ƒ
Knee: 98. 71 Right ant. Ƒ 99. 72 post. Ƒ 100.73 Left ant. Ƒ 101.74 post. Ƒ
Lower leg: 102.75 Right ant. Ƒ 103.76 post. Ƒ 104.77 Left ant. Ƒ 105.78 ost. Ƒ
Ankles: 106.79 Right med.Ƒ 107.80 lat. Ƒ 108.81Left med. Ƒ 109.82 lat. Ƒ
Feet: 110.83 Right dorsal Ƒ 111.84 Left dorsal Ƒ 112.85 Right sole Ƒ 113.86 Left sole Ƒ
IF SPACES ARE INSUFFICIENT, PLEASE USE FOLLOWING LOCALIZATIONS:
114: Right arm/wrist/ hand 115: Left arm/ wrist/ hand
116: Gluteal region
117: Right leg/ ankle/ foot 118: Left leg/ ankle/ foot Main Lesion:
114.87 Type of skin lesion PLEASE MARK WITH “YES” OBSERVED SKIN LESION!* Primary lesions: Macule: non-elevated, less than 1 cm Patch: non-elevated, more than 1 cm Papule: elevated lesion less than 1 cm Nodule: deeply-seated, indurated, larger than 1 cm Vesicle: with fluid less than 1 cm Bulla: with fluid, more than 1 cm Pustule: circumscribed with pus Vesiculo-pustules Wheal: edematous elevation of the skin of varying size and shape, pale pink in colour Tumour: circumscribed swelling larger than 2.5 cm in diameter Secondary lesions: scales, crust, plaque, fissure, excoriations, erosion, ulcer, atrophy, sclerosis Other: burrow, comedo, teleangiectasia, lichenification, cyst SKIN DRY/ WET/ SCALING? 85 Appendix A
*Definitions according to - Mbata M (SFDDH) - Pönninghaus J (1995) Dermatology. In: Krawinkel M, Renz-Polster H (eds.) Medical practice in developing countries. 1st edition. Jungjohann Verlag, Neckarsulm, Lübeck, Ulm, p.571
115.88 Number of lesions: if lesions can be counted, please enter numbers if multiple, please enter DISS, if numerous, enter NUM if extensive, enter EXT if non-applicable, leave blank
116.89 Distribution: 1. localized 2. generalized on one part of the body 3. generalized on more than 1 part of the body
117.90 Colour: 0. NA 1. hypopigmented 2. hyperpigmented 3. NA 4. normopigmented 5. yellowish 6. pink 7. bluish 8. greyish 9. black 10. reddish 11. whitish
118.91 Shape: 0. NA 1. circular 2. polygonal = irregular 3. NA 4. cylindrical 5. linear 6. No special shape
119.92 Demarcation: 0. NA 1. sharply 2. not sharply 3. NA
120. Diameter/length: IN CM, ONE DECIMAL! If NA: leave blank
121. Configuration: 0. NA 1. single lesion/s 2. one group 3. NA 4. in groups 5. herpetiform 6. serpinginous 7. continuous 86 Appendix A
8. rosettes 9. disseminated 10. confluent macules 11. generalized 12. irregular
EXAMINATION: - Screening: SCR - Follow Up 1: 1 - Follow Up 2: 2
INDEX CHILD: yes/ no
125.95 Tinea capitis: . 1. scalp pruritus yes Ƒ no Ƒ 2. scaling yes Ƒ no Ƒ 3. diffuse or circumscribed alopecia yes Ƒ no Ƒ 4. occipital adenopathy yes Ƒ no Ƒ 5. black dots in the remaining hair follicle after loss of hair yes Ƒ no Ƒ 6. kerion (highly inflammatory lesions) yes Ƒ no Ƒ NEW HAIR GROWTH VISIBLE: yes Ƒ no Ƒ If screening, leave blank!
126.96 Tinea corporis/ versicolor . 1. concentric lesions yes Ƒ no Ƒ 2. scaling in periphery yes Ƒ no Ƒ 3. scaling in concentric rings yes Ƒ no Ƒ 4. satellite lesions yes Ƒ no Ƒ 5. pruritus yes Ƒ no Ƒ 6. hypopigmentation yes Ƒ no Ƒ
127.97 Tinea unguium/pedis: 1. finger nails yes Ƒ no Ƒ 2. toe nails 3. chronic paronychia 4. erythematous, macerated whitish scaling, athlete’s foot (interdigital) microscopic examination: . 128.98 sample taken: 1. skin scraping yes Ƒ no Ƒ 2. nail clipping yes Ƒ no Ƒ 3. hair clipping yes Ƒ no Ƒ
129.99 evidence of: 1. hyphae yes Ƒ no Ƒ 2. mycelia yes Ƒ no Ƒ 3. spores yes Ƒ no Ƒ
Microscopy Ifakara positive? yes Ƒ no Ƒ Micoscropy Zürich: Culture Zürich 87 Appendix A
130.100 Description of pruritus:
1. no pruritus hamna kuwasha yes Ƒ no Ƒ 2. it sometimes itches a little bit wakati mwingine inawasha kidogo 3. it is a real nuisance kweri inasumbua 4. patient cannot sleep because of pruritus mgonjwa hawezi kulala kwa sababu ya kuwashwa/muwasho 5. DOES IT ITCH LESS THAN BEFORE? If screening, leave blank!
131.101 Number of lesions:
1. none yes Ƒ no Ƒ 2. one or two yes Ƒ no Ƒ 3. three to five yes Ƒ no Ƒ 4. > five yes Ƒ no Ƒ 5. dissiminated yes Ƒ no Ƒ
132.102 Size of largest lesions (diameter): 1. none yes Ƒ no Ƒ 2. <1 cm yes Ƒ no Ƒ 3. 1 to 3 yes Ƒ no Ƒ 4. > 3 cm yes Ƒ no Ƒ
133.103 Aspect of lesions: 1. none yes Ƒ no Ƒ 2. sharply deliniated with central healing yes Ƒ no Ƒ 3. grey patches yes Ƒ no Ƒ 4. yellowish-white adhearent masses (scutulae) yes Ƒ no Ƒ 5. signs of bacterial superinfection yes Ƒ no Ƒ 6. maceration (Tinea cruris) yes Ƒ no Ƒ
134.104 Hair stumps, Baldness, Skin atrophy: ONLY HEAD MYCOSES 1. none yes Ƒ no Ƒ 2. one 3. two 4. all three
135.105 Additional clinical signs ONLY HEAD MYCOSES 1. occipital adenopathy yes Ƒ no Ƒ 2. scaling yes Ƒ no Ƒ 3. kerion yes Ƒ no Ƒ 4. black dots yes Ƒ no Ƒ ______88 Appendix A
Scabies:
Clinical criteria: 136. itching yes Ƒ no Ƒ 137. itching more at night yes Ƒ no Ƒ 138. other family members also affected yes Ƒ no Ƒ
139. Characteristic lesions on common sites: 1.a sides of the fingers yes Ƒ no Ƒ 1.b wrists yes Ƒ no Ƒ 1.c ulnar border of the hands yes Ƒ no Ƒ 1.d palms yes Ƒ no Ƒ 2. anterior parts of elbows yes Ƒ no Ƒ 3. (anterior) axillary folds yes Ƒ no Ƒ 4. umbilicus yes Ƒ no Ƒ 5. external genitalia and perineum, glans penis yes Ƒ no Ƒ 6. areola of the breasts yes Ƒ no Ƒ 7. buttocks yes Ƒ no Ƒ 8. waist yes Ƒ no Ƒ 9. thighs yes Ƒ no Ƒ 10. knees yes Ƒ no Ƒ 11. ankles yes Ƒ no Ƒ 12. soles yes Ƒ no Ƒ 13. abdomen yes Ƒ no Ƒ 14. other:______yes Ƒ no Ƒ
140. raised papules yes Ƒ no Ƒ 141. rash yes Ƒ no Ƒ
Microscopic examination: 143. sample taken yes Ƒ no Ƒ 144. mites found on microscopic examination of scraping yes Ƒ no Ƒ
145. Description of pruritus: 1. no pruritus hamna kuwasha yes Ƒ no Ƒ 2. it sometimes itches a little bit wakati mwingine inawasha kidogo 3. it is a real nuisance kweri inasumbua 4. patient cannot sleep because of pruritus mgonjwa hawezi kulala kwa sababu ya kuwashwa/muwasho
147. Type of lesions (several answers possible): 1. none yes Ƒ no Ƒ 2. only papules, macules, burrow 3. crusts, generalized lichenification 4. superinfection 5. thick crusts 89 Appendix A
SUBJECTIVE IMPRESSION: 1. It got better 2. It did not get better
OCCIPITAL ADENOPATHY: yes Ƒ no Ƒ
SCORE T. VERSICOLOR SCORE T.CAPTIS SCORE T.CORPORIS SCORE T. PEDIS
Child suffers from:
If no skin disease, please leave blank. Only enter “2” if either Tinea or Scabies was found!
166.127 Scabies yes Ƒ no Ƒ 167.128 Scabies Sample taken yes Ƒ no Ƒ 168.129 Scabies Microscopic examination positive yes Ƒ no Ƒ 170.130 Scabies: Included in Triclosan-Group (AD) yes Ƒ no Ƒ 178.135 Tinea: Included in Triclosan-Group (AD) yes Ƒ no Ƒ
179.136 Patient examined by 1. MM Ƒ 2. CM Ƒ 3. AD Ƒ 4. JF Ƒ
180.137 Number of photos taken ___
Photographed lesions improved after 1 month yes Ƒ no Ƒ Photographed lesions improved after 2 months yes Ƒ no Ƒ 90 Appendix A 91 Appendix A
Screening Spectrum of Skin Diseases among Primary School Children
ID Number of the child: Ƒ. Ƒ. Ƒ. ƑƑƑƑ Date:______# Screening - # School - # Form – Serial number child Name of the child: Form: Sex: Age: 1 = YES 2= NO NA = Not applicable DNK = child does not know
1 2 9.1 15.1 8 26 4 41.1 5 3 2.1 32218.1 27 5247 4 2433228 6 3 48 5 3544329 36 4 49 6 4655430 37 42 50 7 5766531 38 43 51.1 8 6877632.1 39.1 44.1 2 54.1 7910.1 8 72223 2 8102 919.1 3334 3 9 11 3 10 2 4 4 4 5 4 3 12 4 11 3 33.1 556 5 4 13 11.1 12 42667 6 5.1 14 2 16 5377 87 215317.1 648 45.1 52.1 8 3164 220 5 40.1 22 9 4 7.1 12 3 21 6 23355.1 5213 4 22 34 3 46.1 42 6314.1 5 23 35.1 42556.1 742624 25353.1 2 6.1 8 3725 3642 3 4.______31.______15.12.______33.6______17.8.______34.______21.______35.6.______24.______36.______39.8.______27.______44.7.______29.______46.5.______92 Appendix A
4 62 85 108 62138 44159 57.1 63 86 109 126.1 3 139.1 146.1 5 160.1 2 64 87 110 2 132.1 22152.1 2 3 65 88 111 3 2 3 3 2 3 4 66 89 112 4 3443 4 5 67 90 113 545147.1 45 6 68 91 114 6 133.1 62153.1 6 7 69 92 115 127.1 2732 161 8 70 93 116 23843 162 9 71 94 117 34954 163 10 72 95 118 4510PED 5 164 11 73 96 119 128.1 611148.1 154.1 165.1 12 74 97 120 2 134.1 12 2 2 2 13 75 98 121 3 2 13 3 3 3 14 76 119 122 129.1 3 16 149 CLM 4 15 77 100 123 24140 150.1 155 16 78 101 124 3 135.1 141 2 156.1 17 79 102 TIN 130.1 2 142 32 18 80 103 125.1 23143 43 58 81 104 2 3 4 144 54 59 82 105 34SCA 145.1 151.1 157 60 83 106 4 131.1 136 22158 61 84 107 52137 33TUN 56.1.______114-121 ______DIAG 57.18.______166 ______167 123.______168 ______169 ______170 139.1.______171 ______172 ______173 ______174 ______175 ______176 ______177.1 Comments :______2 ______3 ______4 ______5 ______178 ______179 ______180 ______Diagnosis : ______93 Appendix B
Appendix B Skin diseases among primary schoolchildren in Ifakara (data analysis)
7.1 Study population Study population: age and sex distribution
AgeU group
SexU 6 - 10 11 - 14 15 - 19 Total f 177 162 51 390 45.38 41.54 13.08 100.00 52.52 47.09 38.93 48.03 m 160 182 80 422 37.91 43.13 18.96 100.00 47.48 52.91 61.07 51.97
Total 337 344 131 812 41.50 42.36 16.13 100.00 100.00 100.00 100.00 100.00
Pearson chi2(2) = 7.1903 Pr = 0.027
Study population: age distribution according to school
AgeU group
SchoolU 6 - 10 11 - 14 15 - 19 Total lihami 180 178 53 411 43.80 43.31 12.90 100.00 53.41 51.74 40.46 50.62 michenga 157 166 78 401 39.15 41.40 19.45 100.00 46.59 48.26 59.54 49.38
Total 337 344 131 812 41.50 42.36 16.13 100.00 100.00 100.00 100.00 100.00
Pearson chi2(2) = 6.6372 Pr = 0.036 94 Appendix B
7.3 Prevalence of skin diseases Prevalence of skin diseases in Lihami and Michenga
SchoolU
U Lihami Michenga TotalU
Skin 248 200 448 Diseases 55.36 44.64 100.00 60.34 48.90 54.63
No 163 209 372 Skin 43.82 56.18 100.00 Diseases 39.66 51.10 45.37
Total 411 409 820 50.12 49.88 100.00 100.00 100.00 100.00
Pearson chi2(1) = 10.8262 Pr = 0.001
Prevalence of skin diseases according to age
AgeU group
U 6 - 10 11 - 14 15 - 19 Total
No skin 178 143 44 365 Disease 48.77 39.18 12.05 100.00 52.82 41.57 33.59 44.95
Skin 159 201 87 447 Disease 35.57 44.97 19.46 100.00 47.18 58.43 66.41 55.05
Total 337 344 131 812 41.50 42.36 16.13 100.00 100.00 100.00 100.00 100.00
Pearson chi2(2) = 16.8559 Pr = 0.000 95 Appendix B
Prevalence of infectious and non-infectious skin diseases Prevalence of infectious and non–infectious skin diseases in Lihami and Michenga
0 = Children without any skin disease 1 = Children affected only by infectious skin diseases 2 = Children affected only by non – infectious skin diseases 3 = Children affected by infectious AND non-infectious skin diseases
SchoolU
U Lihami Michenga Total
0 163 209 372 43.82 56.18 100.00 39.66 51.10 45.37
1 173 135 308 56.17 43.83 100.00 42.09 33.01 37.56
2 45 49 94 47.87 52.13 100.00 10.95 11.98 11.46
3 30 16 46 65.22 34.78 100.00 7.30 3.91 5.61
Total 411 409 820 50.12 49.88 100.00 100.00 100.00 100.00
Pearson chi2(3) = 14.8028 Pr = 0.002
Prevalence of infectious skin diseases according to age
0 = Children without infectious skin diseases 1 = Children affected by infectious skin diseases
AgeU group
U 6 - 10 11 - 14 15 - 19 Total
0 220 176 63 459 47.93 38.34 13.73 100.00 65.28 51.16 48.09 56.53
1 117 168 68 353 33.14 47.59 19.26 100.00 34.72 48.84 51.91 43.47
Total 337 344 131 812 41.50 42.36 16.13 100.00 100.00 100.00 100.00 100.00
Pearson chi2(2) = 18.3326 Pr = 0.000 96 Appendix B
Prevalence of non-infectious skin diseases according to age
0 = Children without non-infectious skin diseases 1 = Children affected by non-infectious skin diseases
AgeU group
U 6 - 10 11 - 14 15 - 19 Total
0 276 294 102 672 41.07 43.75 15.18 100.00 81.90 85.47 77.86 82.76
1 61 50 29 140 43.57 35.71 20.71 100.00 18.10 14.53 22.14 17.24
Total 337 344 131 812 41.50 42.36 16.13 100.00 100.00 100.00 100.00 100.00
Pearson chi2(2) = 4.1412 Pr = 0.126
Distribution of diagnostic groups
Distribution of diagnoses Infectious skin diseases
Group 1: Dermatomycoses
SchoolU
U Lihami Michenga Total
T. versicolor 108 107 215 50.23 49.77 100.00 62.07 79.85 69.81
T. capitis 37 8 45 82.22 17.78 100.00 21.26 5.97 14.61 T. faciei/ corporis 10 11 21 47.62 52.38 100.00 5.75 8.21 6.82
T. pedis 19 7 26 73.08 26.92 100.00 10.92 5.22 8.44
Other 0 1 1 Superf. 0.00 100.00 100.00 Mycoses 0.00 0.75 0.32
Total 174 134 308 56.49 43.51 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.000 97 Appendix B
Group 2: Pyoderma
SchoolU
U Lihami Michenga Total
Superinfected 43 16 59 Wounds/ 72.88 27.12 100.00 Ulcers 86.00 84.21 85.51
Impetigo 2 1 3 66.67 33.33 100.00 4.00 5.26 4.35
Follikulitis 5 2 7 71.43 28.57 100.00 10.00 10.53 10.14
Total 50 19 69 72.46 27.54 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 1.000
Group 3: Intertrigo
SchoolU
U Lihami Michenga Total
Intertrigo 5 2 7 71.43 28.57 100.00 100.00 100.00 100.00
Group 4: Ectoparasitic disorders
SchoolU
U Lihami Michenga Total
Scabies 10 2 12 83.33 16.67 100.00 100.00 66.67 92.31
PDP* 0 1 1 0.00 100.00 100.00 0.00 33.33 7.69
Total 10 3 13 76.92 23.08 100.00 100.00 100.00 100.00
Fisher's exact test Pr= 0.231
*pruritic dermatosis, probably due to Pediculosis 98 Appendix B
Group 5: Warts
SchoolU
U Lihami Michenga Total
M. contag 0 1 1 0.00 100.00 100.00 0.00 10.00 4.55
Common 12 9 21 Warts 57.14 42.86 100.00 100.00 90.00 95.45
Total 12 10 22 54.55 45.45 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.455
Group 6: Abscesses
SchoolU
U Lihami Michenga Total
Abscesses 2 1 3 66.67 33.33 100.00 100.00 100.00 100.00
Group 7: Others
SchoolU
U Lihami Total
Cheilitis 2 2 100.00 100.00 100.00 100.00
Non-infectious skin diseases
Group 8: Pruritic dermatoses
SchoolU
U Lihami Michenga Total
Gen. pruritus/ 1 4 5 Xerotic 20.00 80.00 100.00 Skin 5.88 40.00 18.52
Miliaria 11 0 11 100.00 0.00 100.00 64.71 0.00 40.74
Pruritic 5 6 11 Dermatitis 55.45 54.55 100.00 29.41 60.00 40.74
Total 17 10 27 62.96 37.04 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.001 99 Appendix B
Group 9: Non-superinfected wounds/ulcers
SchoolU
U Lihami Michenga Total
Not 14 12 26 Superinfected 53.85 46.15 100.00 Wounds 93.33 100.00 96.30
Animal 1 0 1 Bites 100.00 0.00 100.00 (Not superinf.) 6.67 0.00 3.70
Total 15 12 27 55.56 44.44 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 1.000
Group 10: Eczematous lesions
SchoolU
U Lihami Michenga Total
Vaseline 1 0 1 Dermatitis 100.00 0.00 100.00 14.29 0.00 10.00
Atopic 1 0 1 Eczema 100.00 0.00 100.00 14.29 0.00 10.00
Unclassif. 4 0 4 Eczema 100.00 0.00 100.00 57.14 0.00 40.00
Contact 1 3 4 Eczema 25.00 75.00 100.00 14.29 100.00 40.00
Total 7 3 10 70.00 30.00 100.00 Fisher's exact test 100.00 100.00 100.00 Pr = 0.133
Group 11: Keratoses
SchoolU
U Lihami Michenga Total
Ichthyosis 0 1 1 0.00 100.00 100.00 0.00 100.00 50.00
L.spinosus 1 0 1 100.00 0.00 100.00 100.00 0.00 50.00
Total 1 1 2 50.00 50.00 100.00 Fisher's exact test 100.00 100.00 100.00 Pr = 1.000 100 Appendix B
Group 12: Pigmentary disorders
SchoolU
U Lihami Michenga Total
Hypopig. 4 6 10 40.00 60.00 100.00 66.67 85.71 76.92
Vitiligo 2 1 3 66.67 33.33 100.00 33.33 14.29 23.08
Total 6 7 13 46.15 53.85 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.559 Two other possible diagnoses were not seen: undefined pigmentary disorders; suspicion of leprosy;
Group 13: Lesions due to insects
SchoolU
U Lihami Michenga Total
Rash/ 3 2 5 Insect 60.00 40.00 100.00 bites 75.00 50.00 62.50
Paederus 1 1 2 species 50.00 50.00 100.00 25.00 25.00 25.00
Others 0 1 1 0.00 100.00 100.00 0.00 25.00 12.50
Total 4 4 8 50.00 50.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 1.000
Group 14: Keloids
SchoolU U
U Lihami Michenga Total
Keloids 1 3 4 25.00 75.00 100.00 100.00 100.00 100.00
Group 15: Acneiform lesions
SchoolU
U Lihami Michenga Total
Acneiform 11 10 21 Lesions 52.38 47.62 100.00 100.00 100.00 100.00 101 Appendix B
Group 16: Others
SchoolU
U Lihami Michenga Total
Alopecia 1 0 1 Areata 100.00 0.00 100.00 5.56 0.00 2.70
Striae 1 0 1 100.00 0.00 100.00 5.56 0.00 2.70
Dandruff 8 6 14 57.14 42.86 100.00 44.44 31.58 37.84
Cyst 1 0 1 100.00 0.00 100.00 5.56 0.00 2.70
Dry Skin 1 7 8 12.50 87.50 100.00 5.56 36.84 21.62
Itching 4 5 9 w.o. 44.44 55.56 100.00 Picture 22.22 26.32 24.32
Tender 1 0 1 movable 100.00 0.00 100.00 tumor 5.56 0.00 2.70
Unclear 1 0 1 Diagnosis 100.00 0.00 100.00 5.56 0.00 2.70
Morphea 0 1 1 0.00 100.00 100.00 0.00 5.26 2.70
Total 18 19 37 48.65 51.35 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.103 102 Appendix B
7.4 Treatment
Proportion of cases and diagnoses requiring treatment Proportion of children affected by skin diseases requiring treatment/overall number of children affected by skin diseases
1 = Treatment indicated 2 = No treatment mandatory
SchoolU
GroupU Lihami Michenga Total
1 74 37 111 66.67 33.33 100.00 29.84 18.50 24.78
2 174 163 337 51.63 48.37 100.00 70.16 81.50 75.22
Total 248 200 448 55.36 44.64 100.00 100.00 100.00 100.00
Pearson chi2(1) = 7.6372 Pr = 0.006 . Children with and without skin diseases - cases with indication for treatment/treatment not mandatory: age group
SD: Skin disease
AgeU group
U 6 - 10 11 - 14 15 - 19 TotalU
No 178 143 44 365 Skin 48.77 39.18 12.05 100.00 Diseases 52.82 41.57 33.59 44.95
SD: 46 43 21 110 Treatment 41.82 39.09 19.09 100.00 Indicated 13.65 12.50 16.03 13.55
SD: no 113 158 66 337 Treatment 33.53 46.88 19.58 100.00 Mandatory 33.53 45.93 50.38 41.50
Total 337 344 131 812 41.50 42.36 16.13 100.00 100.00 100.00 100.00 100.00
Pearson chi2(4) = 19.4296 Pr = 0.001 103 Appendix B
Children with and without skin diseases - cases with indication for treatment/treatment not mandatory: sex
SexU
U f m Total
No 173 192 365 Skin 47.40 52.60 100.00 Disease 44.36 45.50 44.95
SD: 54 56 110 Treament 49.09 50.91 100.00 Indincated 13.85 13.27 13.55
SD: no 163 174 337 Treatment 48.37 51.63 100.00 Mandatory 41.79 41.23 41.50
Total 390 422 812 48.03 51.97 100.00 100.00 100.00 100.00
Pearson chi2(2) = 0.1236 Pr = 0.940
Table: Cases requiring treatment Infectious skin diseases Diagnostic group Diagnosis No. of cases requiring treatment n (total) Dermatomycoses T. versicolor 12 (215) T. capitis 45 (45) T. faciei/corporis 21 (21) T. pedis 9 (26) Other dermatomycoses 1 (1) Intertrigo 7 (7) Pyoderma 69 (69) Abscesses 3 (3) Ectoparasitic disorders 13 (13) Warts Not mandatory Others Cheilitis 2 (2) Non-infectious skin diseases Pruritic dermatoses Miliaria Not mandatory Generalized pruritus/xerotic 16 (27) skin/pruritic dermatitis Lesions due to insects Rash due to mosquito bites Not mandatory Blister beetle dermatitis 2 (2) Others (superinf. insect bite on 1 (1) tinea versicolor) Non-superinfected wounds/ulcers Non-superinfected wounds Not mandatory Animal bites 1 (1) Eczematous lesions Atopic eczema 1 (1) Contact eczema 1 (1) Vaseline dermatitis Not mandatory Unclassifiable eczema Not mandatory 104 Appendix B
Non-infectious skin diseases Diagnostic group Diagnosis No. of cases requiring treatment n (total) Keratoses Not mandatory Pigmentary disorders Not mandatory Keloids Not mandatory Acneiform lesions Not mandatory Others Cyst 1 (1) Tender, movable tumor 1 (1) Itching without clinical findings Not mandatory
Treatment-seeking behaviour Treatment - seeking behaviour: Question: “Which kind of treatment did you use to treat your skin disease?”
TreatmentU Frequency Percent
1. Antifungal agents: Ointment 2 3.03 Antifungal lotion 1 1.52
2. Antibacterial treatment: Gentiana violet 1 1.52 Antibiotics 1 1.52
3. “Tablets” Tablets 15 22.73 Panadol 2 3.03
4. Crème 26 39.39
5. Traditional medicine 7 10.61
6. “Household remedies” Break fluid 4 6.06 Vaseline/oil 3 4.55 Kerosine 1 1.52
7. “Others”: Powder 2 3.03 Sulpha - soap 1 1.52
TotalU 66 100.00 105 Appendix B
Treatment - seeking behaviour: Factors influencing the accessibility of treatment
What is the profession of your father?
ProfessionU U SmallU
U Peasant Civil servant scale income Total
Child 22 6 22 50 Got 44.00 12.00 44.00 100.00 Treatment 16.42 40.00 33.33 23.26
No 112 9 44 165 Treatment 67.88 5.45 26.67 100.00 Obtained 83.58 60.00 66.67 76.74
Total 134 15 66 215 62.33 6.98 30.70 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.007
What is the profession of your mother?
ProfessionU U SmallU
U Peasant Civil servant scale income Total
Child 40 3 8 51 Got 78.43 5.88 15.69 100.00 Treatment 19.61 33.33 66.67 22.67
No 164 6 4 174 Treatment 94.25 3.45 2.30 100.00 Obtained 80.39 66.67 33.33 77.33
Total 204 9 12 225 90.67 4.00 5.33 100.00 Fisher's exact test 100.00 100.00 100.00 100.00 Pr = 0.001
7.5 Ivermectin Number/proportion of children in Lihami/Michenga who have received ivermectin since 2000 Children with age = unknown were dropped
School: Lihami
IvermectinU U AgeU group
Received?U 6 - 10 11 - 14 15 - 19 Total
No 169 69 5 243 69.55 28.40 2.06 100.00 93.89 38.55 9.62 59.12
Yes 11 110 47 168 6.55 65.48 27.98 100.00 6.11 61.45 90.38 40.88
Total 180 179 52 411 43.80 43.55 12.65 100.00 Pearson chi2(2) = 174.1148 100.00 100.00 100.00 100.00 Pr = 0.000 106 Appendix B
School: Michenga
IvermectinU U AgeU group
Received?U 6 - 10 11 - 14 15 - 19 Total
No 146 21 15 182 80.22 11.54 8.24 100.00 92.99 12.65 19.23 45.39
Yes 11 145 63 219 5.02 66.21 28.77 100.00 7.01 87.35 80.77 54.61
Total 157 166 78 401 39.15 41.40 19.45 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.000
Overall number of children who received ivermectin
IvermectinU U AgeU group
Received?U 6 - 10 11 - 14 15 - 19 Total
No 315 90 20 425 74.12 21.18 4.71 100.00 93.47 26.09 15.38 52.34
Yes 22 255 110 387 5.68 65.89 28.42 100.00 6.53 73.91 84.62 47.66
Total 337 345 130 812 41.50 42.49 16.01 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.000
IvermectinU U SexU
Received?U f m Total
No 201 224 425 47.29 52.71 100.00 51.54 53.08 52.34
Yes 189 198 387 48.84 51.16 100.00 48.46 46.92 47.66
Total 390 422 812 48.03 51.97 100.00 100.00 100.00 100.00
Pearson chi2(1) = 0.1932 Pr = 0.660 107 Appendix B
7.6 Spectrum of skin diseases: details and special findings
7.6.1 Infectious skin diseases
7.6.1.1 Dermatomycoses Tinea versicolor
Prevalence of t. versicolor according to school
SchoolU
U Lihami Michenga Total
Tinea 108 107 215 Versicolor 50.23 49.77 100.00 26.28 26.16 26.22
Children 303 302 605 Without 50.08 49.92 100.00 T. versicolor 73.72 73.84 73.78
Total 411 409 820 50.12 49.88 100.00 100.00 100.00 100.00
Pearson chi2(1) = 0.0014 Pr = 0.970
Seen: 215 cases of t. versicolor,
215 : 573 = 37.52 % of all diagnosis were t. versicolor 215 : 424 = 50.70 % of infectious skin diseases were t. versicolor
Prevalence of t. versicolor according to age
AgeU group
U 6 – 10 11 - 14 15 - 19 Total
Children 294 229 75 598 Without 49.16 38.29 12.54 100.00 T. versicolor 87.24 66.57 57.25 73.65
Children 43 115 56 214 With 20.09 53.74 26.17 100.00 T. versicolor 12.76 33.43 42.75 26.35
Total 337 344 131 812 41.50 42.36 16.13 100.00 100.00 100.00 100.00 100.00
Pearson chi2(2) = 59.1032 Pr = 0.000 108 Appendix B
Prevalence of t. versicolor according to sex
SexU
U f m Total
No 289 314 603 T. versicolor 47.93 52.07 100.00 73.35 74.06 73.72
T. versicolor 105 110 215 48.84 51.16 100.00 26.65 25.94 26.28
Total 394 424 818 48.17 51.83 100.00 100.00 100.00 100.00
Pearson chi2(1) = 0.0526 Pr = 0.819
Tinea versicolor: history and clinical picture
Where did this skin problem start?
T.U versicolor present T.U versicolor present
LocalizationU yes no Total U LocalizationU yes no Total U
scalp 5 180 185 finger 1 184 185 2.70 97.30 100.00 webs 0.54 99.46 100.00
face 145 40 185 78.38 21.62 100.00 genital 3 182 185 region 1.62 98.38 100.00 neck 18 167 185 9.73 90.27 100.00 thighs 3 182 185 1.62 98.38 100.00 chest 27 158 185 14.59 85.41 100.00 knees 2 183 185 1.08 98.92 100.00 abdomen 4 181 185 2.16 97.84 100.00 lower leg 5 180 185 2.70 97.30 100.00 back 30 155 185 16.22 83.78 100.00 feet 1 184 185 0.54 99.46 100.00 axilla 1 184 185 0.54 99.46 100.00 between 2 183 185 toes 1.08 98.92 100.00 arms 12 173 185 6.49 93.51 100.00
hands 1 184 185 0.54 99.46 100.00 109 Appendix B
Size
SizeU yes no Total remains 33 152 185 same 17.84 82.16 100.00 increasing 132 53 185 71.35 28.65 100.00 decreasing 16 169 185 8.65 91.35 100.00 varying 26 159 185 14.05 85.95 100.00
Does this skin disease itch? Description of pruritus
1: No pruritus 3: it is a real nuisance 2: it sometimes itches a little bit 4: patient cannot sleep because of pruritus
PruritusU
U 1 2 3 Total
Cases 88 82 25 195 T. versicolor 45.13 42.05 12.82 100.00
When does it itch?
ItchingU
U Yes No Total
Hot 93 11 104 Sun 89.42 10.58 100.00
In 14 90 104 Bed 13.46 86.54 100.00
Bathing 23 81 104 22.12 77.88 100.00
Rainy 10 62 72 Season 13.89 86.11 100.00
Hot/ 19 53 72 Dry season 26.39 73.61 100.00
Cold 11 61 72 Season 15.28 84.72 100.00
Are there any others at home who have the same signs of a skin disease as you?
FamilyU members affected
DiagnosisU No Yes TotalU
T. versicolor 114 88 202 56.44 43.56 100.00 110 Appendix B
Children without t. versicolor: is there anyone at home suffering from t. versicolor?
FamilyU members affected with t. versicolor
DiagnosisU No Yes TotalU
Children 220 13 233 Without 94.42 5.58 100.00 T. versicolor
Have you received any treatment for your main skin problem (t. versicolor)?
TreatmentU received
DiagnosisU Yes No Total U
T. versicolor 30 158 188 15.96 84.04 100.00
If yes: which kind of treatment?
1. Antifungal agents 5. Creme 2. Antibacterial treatment 6. Traditional medicine 3. Tablets 7."Household remedies" 4. Injection
KindU of treatment received
U 1 3 5 6 7 8 Total
1 4 17 1 5 2 30 3.33 13.33 56.67 3.33 16.67 6.67 100.00
Has the treatment helped?
HasU the treatment helped?
U Yes No Total
T. versicolor 17 13 30 56.67 43.33 100.00 62.96 72.22 66.67
Type of skin lesion
PresentU
LesionU Yes No Total
Macules 148 49 197 75.13 24.87 100.00
Patches 94 103 197 47.72 52.28 100.00
Papules 2 195 197 1.02 98.98 100.00
Wheal 1 196 197 0.51 99.49 100.00
Scales 16 181 197 8.12 91.88 100.00
Dry 2 195 197 1.02 98.98 100.00 111 Appendix B
Tinea versicolor: the five most frequent localizations (with respect to number of diagnoses, n = 215) Localization Frequency Percent Face 175 (214) 81.78 Back 53 (214) 24.77 Chest 42 (214) 19.63 Neck (posterior aspect) 19 (214) 8.88 Neck (anterior aspect) 15 (214) 7.01
Tinea versicolor: the most common localizations if only one part of the body was affected Localization Frequency Percent Face 133 (157) 84.71 Back 12 (157) 7.64 Chest 4 (157) 2.54 Neck (anterior aspect) 4 (157) 2.54 Neck (posterior aspect) 3 (157) 1.91
Tinea versicolor: the most common localizations according to age Age group: 6 to 10 years Localization Frequency Percent Face 37 (43) 86.05 Back 5 (43) 11.63 Chest 3 (43) 6.98 Neck (posterior aspect) 3 (43) 6.98 Upper arm (left posterior) 1 (43) 2.33 Abdomen 0 (56) 0.00 Neck (anterior aspect) 0 (56) 0.00
Age group: 11 to 14 years Localization Frequency Percent Face 95 (115) 82.61 Back 22 (115) 19.13 Chest 19 (115) 16.52 Neck (posterior aspect) 8 (115) 6.96 Neck (anterior aspect) 7 (115) 6.09 Upper arm (left posterior) 4 (115) 3.48 Abdomen 2 (115) 1.74
Age group: 15 to 19 years Localization Frequency Percent Face 42 (56) 75.00 Back 25 (56) 44.64 Chest 19 (56) 33.93 Abdomen 7 (56) 12.50 Neck (anterior aspect) 7 (56) 12.50 Neck (posterior aspect) 7 (56) 12.50 Upper arm (left posterior) 1 (56) 1.79 112 Appendix B
Number of parts of the body affected according to age
1 = Lesions localized/generalized on one part of the body 2 = Lesions found on more than one part of the body
AgeU group 1 2 Total
6 – 10 years 30 3 33 90.91 9.09 100.00 18.18 9.68 16.84
11 – 14 years 100 10 110 90.91 9.09 100.00 60.61 32.26 56.12
15 – 19 years 35 18 53 66.04 33.96 100.00 21.21 58.06 27.04
Total 165 31 196 84.18 15.82 100.00 Pearson chi2(2) = 17.9648 100.00 100.00 100.00 Pr = 0.000
Number of lesions
NumberU of_lesionsU
U Less than 10 More than 10 Total
T. versicolor 60 133 193 31.09 68.91 100.00
Colour
1. hypopigmented 3. normopigmented 1. hypopigmented 4. normopigmented 6. pink 10. reddish 4. greyish 11. whitish 8. greyish
2. hyperpigmented 5. yellowish 2. hyperpigmented 5. yellowish 7. bluish 9. black
Total number of cases observed for colour: n = 202
U a b c Total
1.Hypop. 171 4 1 176 97.16 2.27 0.57 100.00 87.13 % of all cases
2.Hyperp. 16 11 1 28 57.14 39.29 3.57 100.00 13.06 % of all cases
4.Greyish 10 8 1 19 52.63 42.11 5.26 100.00 9.41 % of all cases = scaling?
113 Appendix B
Configuration
U single 1 group in groups disseminated confl. m.* gen.** Total
T. vers. 15 6 97 10 15 2 145 10.34 4.14 66.90 6.90 10.34 1.38 100.00
* confluent macules ** generalized
Scaling (clinical picture)
ScalingU
U Yes No Total
T. versicolor 88 114 202 43.56 56.44 100.00
Microscopic examination Sample taken
U yes no Total
Skin 147 53 200 Scraping 73.5 26.5 100.00
Microscopy:
EvidenceU of yes no Total
Hyphae 114 29 143 79.72 20.28 100.00
Myceliae 63 80 143 44.06 55.94 100.00
Spores 91 46 137 66.42 33.58 100.00
Microscopy: evidence of… according to age group
AgeU group
EvidenceU of 6 - 10 11 - 19 Total
Hyphae 30 116 146 20.55 79.45 100.00 42.25 41.88 41.95
Myceliae 10 63 73 13.70 86.30 100.00 14.08 22.74 20.98
Spores 31 98 129 24.03 75.97 100.00 43.66 35.38 37.07
Total 71 277 348 20.40 79.60 100.00 100.00 100.00 100.00 Fisher's exact test Pr = 0.215 114 Appendix B
Microscopy Ifakara
PositiveU
U Yes No Total
No. 118 25 143 Samples 82.52 17.48 100.00
Culture Zürich** Fungus cultivated 1 months after screening 2 months after screening Frequency Percent Frequency Percent Malassezia Furfur 12 38.71 4 16.67 Malassezia Furfur + Trichophyton - 1 4.17 tonsurans* Culture Zürich** Fungus cultivated 1 months after screening 2 months after screening Trichophyton tonsurans* 1 3.23 - Trichophyton mentagrophytes - - Trichophyton violaceum - - Fungal mycelia - - Scopulariopsis brevicaulis* 1 3.23 1 4.17 Ulocladium spp.* - 1 4.17 Phoma spp - - Aspergillus - - Mould 15 48.39 14 58.33 Spores - - Little material - - Negative 2 6.45 3 12.20
Total 31 100.00 24 100.00 * In these cases the child also had t. capitis/corporis/faciei, the pathogen was isolated from those lesions.
Microscopy Zürich** Picture 1 month after screening 2 months after 3 months after screening screening Frequency Percent Frequency Percent Frequency Percent Malassezia furfur 30 96.77 18 75.00 9 75.00 Spores - 3 12.50 1 8.30 Only little material - 2 8.33 - Negative 1 3.23 1 4.17 2 16.60 Total 31 100.00 24 100.00 12 100.00 **In the chapter “Results” we will only deal with the samples taken one month after the screening. They served as a confirmation of our diagnosis. Later on, the influence of clima and treatment (see Dinkela et al.; 2005) was supposed to be too strong for valid statements.
Aspect of lesions
BacterialU superinfection present?
No.U cases Yes No Total
T. versicolor 1 197 198 0.51 99.49 100.00 115 Appendix B
Dermatophyte infections: tinea capitis, faciei, corporis and pedis
Prevalence of dermatophyte infections
AgeU group
U 6 - 10 11 - 14 15 - 19 TotalU
Children 297 309 120 726 Without 40.91 42.56 16.53 100.00 Derm. inf.* 88.13 89.83 91.60 89.41
Children 40 35 11 86 With 46.51 40.70 12.79 100.00 Derm. inf. 11.87 10.17 8.40 10.59
Total 337 344 131 812 41.50 42.36 16.13 100.00 100.00 100.00 100.00 100.00
Pearson chi2(2) = 1.3106 Pr = 0.519 * Dermatophyte infections
T. capitis
Prevalence of t. capitis
SchoolU
U Lihami Michenga Total
No 374 401 775 T. capitis 48.26 51.74 100.00 91.00 98.04 94.51
T. capitis 37 8 45 82.22 17.78 100.00 9.00 1.96 5.49
Total 411 409 820 50.12 49.88 100.00 100.00 100.00 100.00
Pearson chi2(1) = 19.6248 Pr = 0.000
T. capitis Seen: 45 cases of t. capitis 45 : 573 = 7.85 % of all diagnoses were t. capitis 45 : 424 = 10.61 % of all infectious skin diseases were t. capitis 116 Appendix B
Prevalence according to age group
AgeU group
T.U cap 6 - 10 11 - 14 15 - 19 TotalU
No 311 326 130 767 T. capitis 40.55 42.50 16.95 100.00 92.28 94.77 99.24 94.46
T. capitis 26 18 1 45 57.78 40.00 2.22 100.00 7.72 5.23 0.76 5.54
Total 337 344 131 812 41.50 42.36 16.13 100.00 100.00 100.00 100.00 100.00
Pearson chi2(2) = 8.8177 Pr = 0.012
Prevalence according to sex
SexU
U f m Total
No 375 398 773 T. capitis 48.51 51.49 100.00 95.18 93.87 94.50
T. capitis 19 26 45 42.22 57.78 100.00 4.82 6.13 5.50
Total 394 424 818 48.17 51.83 100.00 100.00 100.00 100.00
Pearson chi2(1) = 0.6739 Pr = 0.412
Prevalence of t. corporis/faciei
SchoolU
U Lihami Michenga Total
No 401 398 799 T. faciei/ 50.19 49.81 100.00 Corporis 97.57 97.31 97.44
T. faciei/ 10 11 21 Corporis 47.62 52.38 100.00 2.43 2.69 2.56
Total 411 409 820 50.12 49.88 100.00 Pearson chi2(1) = 0.0540 100.00 100.00 100.00 Pr = 0.816
T. faciei/corporis Seen: 21 cases of t. faciei/corporis 21 : 573 = 3.66 % of all diagnoses were t. faciei/corporis 21 : 424 = 4.95 % of all infectious skin diseases were t. faciei/corporis 117 Appendix B
Prevalence according to age group
AgeU group
T.U fac./corp. 6 - 10 11 - 14 15 - 19 Total
No 328 333 130 791 T. fac./ 41.47 42.10 16.43 100.00 Corporis 97.33 96.80 99.24 97.41
T. faciei/ 9 11 1 21 Corporis 42.86 52.38 4.76 100.00 2.67 3.20 0.76 2.59
Total 337 344 131 812 41.50 42.36 16.13 100.00 100.00 100.00 100.00 100.00
Fisher's exact Pr = 0.351
Prevalence according to sex
SexU
U f m Total
No 384 413 797 T. cap./ 48.18 51.82 100.00 Faciei 97.46 97.41 97.43
T. capitis/ 10 11 21 Faciei 47.62 52.38 100.00 2.54 2.59 2.57
Total 394 424 818 48.17 51.83 100.00 100.00 100.00 100.00
Pearson chi2(1) = 0.0026 Pr = 0.959
Prevalence of t. pedis
T. pedis
SchoolU
U Lihami Michenga Total
No 392 402 794 T. pedis 49.37 50.63 100.00 95.38 98.29 96.83
T. pedis 19 7 26 73.08 26.92 100.00 4.62 1.71 3.17
Total 411 409 820 50.12 49.88 100.00 100.00 100.00 100.00
Pearson chi2(1) = 5.6596 Pr = 0.017 118 Appendix B
T. pedis Seen: 26 cases of t. pedis 26 : 573 = 4.54 % of all diagnoses were t. pedis 26 : 424 = 6.13 % of all infectious skin diseases were t. pedis
Prevalence according to age group
AgeU group
T.U pedis 6 - 10 11 - 14 15 - 19 TotalU
No 329 335 122 786 T. pedis 41.86 42.62 15.52 100.00 97.63 97.38 93.13 96.80
T. pedis 8 9 9 26 30.77 34.62 34.62 100.00 2.37 2.62 6.87 3.20
Total 337 344 131 812 41.50 42.36 16.13 100.00 100.00 100.00 100.00 100.00
Fisher's exact Pr = 0.057
Prevalence according to sex
SexU
U f m Total
No 376 416 792 T. pedis 47.47 52.53 100.00 95.43 98.11 96.82
T. pedis 18 8 26 69.23 30.77 100.00 4.57 1.89 3.18
Total 394 424 818 48.17 51.83 100.00 100.00 100.00 100.00
Pearson chi2(1) = 4.7725 Pr = 0.029
Tinea capitis/faciei/corporis/pedis: history and clinical picture
Where did this skin problem start?
T. faciei/corporis
U Yes No Total
Face 7 10 17 41.18 58.82 100.00
Abdomen 1 16 17 5.88 94.12 100.00
Axilla 1 16 17 5.88 94.12 100.00 119 Appendix B
U Yes No Total
Arms 6 11 17 35.29 64.71 100.00
Genital 1 16 17 Area 5.88 94.12 100.00
Thighs 1 16 17 5.88 94.12 100.00
Knees 1 16 17 5.88 94.12 100.00
Size
T. capitis
SizeU Yes No Total
Remains 12 24 36 the same 33.33 66.67 100.00 increasing 20 16 36 55.56 44.44 100.00 decreasing 3 33 36 8.33 91.67 100.00 varying 4 32 36 11.11 88.89 100.00
Total 39 105 144 27.08 72.92 100.00
T. faciei/corporis
U Yes No Total remains 1 16 17 same 5.88 94.12 100.00 increasing 14 3 17 82.35 17.65 100.00 decreasing 0 17 17 0.00 100.00 100.00 varying 2 15 17 11.76 88.24 100.00
Total 17 51 68 25.00 75.00 100.00 120 Appendix B
T. pedis
U Yes No Total remains 3 4 7 same 42.86 57.14 100.00 increasing 2 5 7 28.57 71.43 100.00 decreasing 2 5 7 28.57 71.43 100.00 varying 1 6 7 14.29 85.71 100.00
When does it itch?
T. capitis T. faciei/corporis
ItchingU ItchingU
U Yes No Total U Yes No Total
Hot 19 3 22 Hot 10 4 14 Sun 86.36 13.64 100.00 Sun 71.43 28.57 100.00
In 6 16 22 In 4 10 14 Bed 27.27 72.73 100.00 Bed 28.57 71.43 100.00
Bathing 5 9 14 Bathing 1 21 22 35.71 64.29 100.00 4.55 95.45 100.00 Rainy 0 5 5 Rainy 1 15 16 Season 0.00 100.00 100.00 Season 6.25 93.75 100.00 Hot/ 1 4 5 Dry ´ 2 14 16 Dry 20.00 80.00 100.00 Season 12.50 87.50 100.00 Cold 1 4 5 Cold 3 13 16 Season 20.00 80.00 100.00 Season 18.75 81.25 100.00
Are there any others at home who have the same T. pedis signs of a skin disease as you?
U ItchingU No Yes Total
U Yes No Total T. capitis 22 19 41 Hot 4 3 7 53.66 46.34 100.00 Sun 57.14 42.86 100.00 56.41 63.33 59.42 In 5 2 7 Bed 71.43 28.57 100.00 T. faciei/ 9 9 18 corporis 50.00 50.00 100.00 Bathing 1 6 7 23.08 30.00 26.09 14.29 85.71 100.00 T. pedis 8 2 10 Rainy 3 2 5 80.00 20.00 100.00 Season 60.00 40.00 100.00 20.51 6.67 14.49
Hot/ 2 3 5 Total 39 30 69 Dry Season 40.00 60.00 100.00 56.52 43.48 100.00 Cold 2 3 5 100.00 100.00 100.00 Season 40.00 60.00 100.00 Fisher's exact test Pr = 0.295 121 Appendix B
Children without t. capitis: is there anyone at home suffering from t. capitis?
FamilyU members affected with t. capitis
DiagnosisU No Yes TotalU
Children 389 14 403 Without 96.53 3.47 100.00 T. capitis
Are there any others at home who have the same signs of a skin disease as you?
NumberU of family members affected
U 0 1 2 3 or more Total
T. capitis 22 8 9 2 41 53.66 19.51 21.95 4.88 100.00 56.41 61.54 69.23 50.00 59.42
T. faciei/ 9 4 3 2 18 Corporis 50.00 22.22 16.67 11.11 100.00 23.08 30.77 23.08 50.00 26.09
T. pedis 8 1 1 0 10 80.00 10.00 10.00 0.00 100.00 20.51 7.69 7.69 0.00 14.49
Total 39 13 3 4 69 56.52 18.84 18.84 5.80 100.00 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.800
Have you received any treatment for your main skin problem?
TreatmentU received
DiagnosisU Yes No Total U
Other 25 62 87 Skin 28.74 71.26 100.00 Diseases 35.71 23.13 25.74
T. versicolor 30 158 188 15.96 84.04 100.00 42.86 58.96 55.62
T. capitis 12 26 38 31.58 68.42 100.00 17.14 9.70 11.24
T. faciei/ 3 15 18 Corporis 16.67 83.33 100.00 4.29 5.60 5.33
T. pedis 0 7 7 0.00 100.00 100.00 0.00 2.61 2.07
Total 70 268 338 20.71 79.29 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.032 122 Appendix B
If yes: which kind of treatment?
1. Antifungal agents 2. Antibacterial treatment: 3. Tablets 4. Injection 5. Crème 6. Traditional medicine 7."Household remedies"
KindU of treatment received
U 1 3 5 6 7 Total
T. capitis 1 2 6 3 0 12 8.33 16.67 50.00 25.00 0.00 100.00
T. faciei/ 0 0 2 0 1 3 Corporis 0.00 0.00 66.67 0.00 33.33 100.00
Has the treatment helped?
HasU the treatment helped?
U Yes No Total
T. capitis 8 4 12 66.67 33.33 100.00
T. faciei/ 2 1 3 corporis 66.67 33.33 100.00
Type of skin lesion
T. capitis T. faciei/corporis
U Yes No Total U Yes No Total
Macules 10 27 37 macules 5 13 18 27.03 72.97 100.00 27.78 72.22 100.00
Patches 29 8 37 patches 13 5 18 78.38 21.62 100.00 72.22 27.78 100.00
Papules 2 35 37 papules 5 13 18 5.41 94.59 100.00 27.78 72.22 100.00
Scaling 15 22 37 scaling 3 15 18 40.54 59.46 100.00 16.67 83.33 100.00
Crusts 1 36 37 2.70 97.30 100.00
Excorr 1 36 37 2.70 97.30 100.00
T. pedis T. pedis
U Yes No Total U Yes No Total
Macules 2 7 9 erosion 1 8 9 22.22 77.78 100.00 11.11 88.89 100.00
Patches 7 2 9 wet 1 8 9 77.78 22.22 100.00 11.11 88.89 100.00 123 Appendix B
Tinea capitis/corporis: the most frequent localizations (with respect to number of diagnoses, n = 21) Localization Frequency Percent Face 8 (21) 38.10 Chest 3 (21) 14.29 Upper arm (left ant.) 3 (21) 14.29 Forearm (right ant.) 3 (21) 14.29 Forearm (left post) 3 (21) 14.29 Thighs (left ant.) 3 (21) 14.29
Number of lesions
Num./diss./ext = Numerous/dissiminated/extensive
NumberU of lesions
CountableU
U (less than 10) Uncountable Total
T. capitis 26 10 36 72.22 27.78 100.00
NumberU of lesionsU
U 1 – 5 6 – 10 More than 10 Total
T. faciei/ 12 1 4 17 T. corporis 70.59 5.88 23.53 100.00 29.27 25.00 25.00 27.87
T. pedis 5 1 2 8 62.50 12.50 37.50 25.00 100.00
NumberU of lesions
U 1 or 2 3 - 5 > 5 . TotalU
T. pedis 3 2 3 8 37.50 25.00 37.50 100.00
Colour
1. hypopigmented 1. hypopigmented T. capitis 6. pink Total number of cases observed for colour: n = 35 10. reddish 11. whitish U a b Total
2. hyperpigmented Hypopig. 14 3 17 2. hyperpigmented 82.35 17.65 100.00 = 48.57% 7. bluish 9. black
3. normopigmented Hyperpig. 9 0 9 4. normopigmented 100.00 0.00 100.00 = 25.71%
4. greyish Greyish 11 2 13 8. greyish 84.62 15.38 100.00 = 37.14%
5. yellowish Yellowish 1 0 1 5. yellowish 100.00 0.00 100.00 = 2.86% 124 Appendix B
T. faciei/corporis T. pedis Total number of cases observed for colour: n = 18 Hypopigmented in 9 out of 9 cases
U a b Total
Hypopig. 6 1 7 85.71 14.29 100.00 = 38.89%
Hyperpig. 10 0 10 100.00 0.00 100.00 = 55.56%
Greyish 2 0 2 100.00 0.00 100.00 = 11.11%
Diameter t. capitis/faciei/corporis
DiameterU
DiagnosisU 0 - 1cm 1.1 - 2cm 2.1 - 3cm >3cm - 10cm Total
T. capitis 10 8 8 6 32 31.25 25.00 25.00 18.75 100.00
T. faciei/ 3 6 6 1 16 corporis 18.75 37.50 37.50 6.25 100.00
Diameter t. pedis
DiameterU U
U < 1cm 1 – 3 cm > 3cm TotalU
T. pedis 2 5 0 7 28.57 71.43 0.00 100.00 18.18 11.11 0.00 10.77
Configuration
U single in groups disseminated irregular Total
T. capitis 10 4 3 2 19 52.63 21.05 15.79 10.53 100.00
T. faciei/ 7 0 0 0 7 Corporis 100.00 0.00 0.00 0.00 100.00
T. pedis 4 0 0 0 4 100.00 0.00 0.00 0.00 100.00
Clinical picture (t. capitis only)
1. Scalp pruritus 2. Scaling 3. Diffuse or circumscr. alopeciaU
U Yes No Total U Yes No Total Yes No Total
27 13 40 39 1 40 27 13 40 67.50 32.50 100.00 97.50 2.50 100.00 67.50 32.50 100.00 125 Appendix B
5. Black dots in the remaining hair 6. Kerion/Highly inflammatory follicle after loss of hair lesions
U Yes No Total U Yes No Total
10 30 40 3 37 40 25.00 75.00 100.00 7.50 92.50 100.00
Clinical picture (t. faciei/corporis only)
1. Concentric lesions 2. Scaling 3. Satellite lesions
U Yes No Total U Yes No Total U Yes No Total
T.fac./ 10 4 14 T. fac./ 14 4 18 T. fac./ 4 10 14 corp. 71.43 28.57 100.00 corp. 77.78 22.22 100.00 corp. 28.57 71.43 100.00 16.67 9.52 13.73 13.73 3.39 8.18 9.76 16.39 13.73
4. Pruritus Clinical picture (t. pedis only)
U Yes No Total Interdigital erythema, maceration and/or whitish scaling (Athlete´s foot) T.fac./ 11 6 17 present in all 10 described cases of t. pedis. Corp. 64.71 35.29 100.00 12.09 4.76 7.83
Microscopic examination In the case of dermatophytoses, laboratory results of samples taken during the follow ups (see Dinkela et al.; 2005) will also be considered as they contain information about the spectrum of pathogens.
Sample taken (only t. capitis/faciei/corporis, of t. pedis no samples were taken)
T. capitis T. faciei/corporis
U yes no Total U yes no Total
Skin 39 2 41 95.12 4.88 100.00 Skin 16 1 17 94.12 5.88 100.00 Hair 25 16 41 60.98 39.02 100.00 Hair 0 17 17 0.00 100.00 100.00 Total 64 18 82 78.05 21.95 100.00 Total 16 18 34 47.06 52.94 100.00 126 Appendix B
Evidence of…
T. capitis T. faciei/corporis
EvidenceU of yes no Total EvidenceU of yes no Total
Hyphae 20 20 40 Hyphae 9 7 16 50.00 50.00 100.00 56.25 43.75 100.00
Myceliae 4 36 40 Mycelia 5 11 16 10.00 90.00 100.00 31.25 68.75 100.00
Spores 22 15 37 Spores 11 5 16 59.46 40.54 100.00 68.75 31.25 100.00
Total 46 71 117 Total 25 23 48 39.32 60.68 100.00 52.08 47.92 100.00
Pearson chi2(2) = 22.6150 Pr = 0.000 Pearson chi2(2) = 4.6748 Pr = 0.097
Fisher's exact = 0.000 Fisher's exact = 0.131
Microscopy Ifakara positive? T. capitis T. faciei/corporis
U yes no Total U yes no Total
Micro 27 13 40 Micro 13 3 16 pos 67.50 32.50 100.00 pos 81.25 18.75 100.00
Micoscopy Zürich
T. capitis T. faciei/corporis
Follow up 1: No samples of t. capitis were sent to Zürich Follow up 1
U neg sp Total Follow up 2 1 1 2 3 U sp Total 33.33 66.67 100.00 No. 2 2 samples 100.00 100.00 Total 1 2 3 33.33 66.67 100.00 Total 2 2 100.00 100.00 Follow up 2
U pm sp Total
Mf: malassezia furfur 1 1 1 2 Sp: spores 50.00 50.00 100.00 Swm: sehr wenig material – only few material Neg: negative Total 1 1 2 Pm: Pilzmycelien - Mycelia 50.00 50.00 100.00 In two cases Malassezia spp were found, as a coinfection on the same body site was present. Later culture revealed the presence of T. tonsurans. 127 Appendix B
Culture Zürich
Mf: Malassezia Furfur As: Aspergillus Tm: T. mentagrophytes Sp: Spores Pho: Phoma spp Tv: T. violaceum Pm: Pilzmyzelien/fungal mycelia Mould: Mould Neg: Negative Swm: Only few material Tt: Trichophyton Sb: Scopulariopsis Ulo: Ulocladium spp. tonsurans brevicaulis
T. capitis T. faciei/corporis
Follow up 1: No samples were sent to Zürich for Follow up 1 culture
U mould tt tv Total Follow up 2 . No. 1 2 1 4 samples 25.00 50.00 25.00 100.00 U pho tt Total
No. 1 1 2 samples 50.00 50.00 100.00 Follow up 2
U mould tm tt Total
No. 1 1 1 3 samples 33.33 33.33 33.33 100.00
Description of pruritus
1: no pruritus 2: it sometimes itches a little bit 3: it is a real nuisance 4: patient cannot sleep because of pruritus
T. capitis
PruritusU
U 1 2 3 4 Total
T. capitis 12 18 9 2 41 29.27 43.90 21.95 4.88 100.00 100.00 100.00 100.00 100.00 100.00
T. faciei/corporis
PruritusU
U 1 2 3 Total
T. faciei/ 2 10 4 16 corporis 12.50 62.50 25.00 100.00 100.00 100.00 100.00 100.00
T. pedis
PruritusU
U 2 3 4 Total
T. pedis 4 2 1 7 57.14 28.57 14.29 100.00 100.00 100.00 100.00 100.00 128 Appendix B
Aspect of lesions
Sharply delinated/central healing Bacterial superinfection
U Yes No Total U Yes No Total
T. fac./ 12 5 17 T. cap. 5 36 41 Corp. 70.59 29.41 100.00 12.20 87.80 100.00 60.00 10.87 25.76 83.33 60.00 62.12
T. fac./ 1 16 17 Corp. 5.88 94.12 100.00 16.67 26.67 25.76
T. ped. 0 8 8 0.00 100.00 100.00 0.00 13.33 12.12
Total 6 60 66 9.09 90.91 100.00 100.00 100.00 100.00
Fisher's exact = 0.697
Occipital/posterior cervical adenopathy (Follow up 1 & 2, t. capitis)
Follow up 1 Follow up 2
OccipitalU adenopathy present OccipitalU adenopathy present
U Yes No Total U U Yes No TotalU
T. cap. 16 4 20 T. cap. 10 8 18 80.00 20.00 100.00 55.56 44.44 100.00 30.19 4.94 14.93 16.39 7.21 10.47
Other 37 77 114 Other 51 103 154 Tineae* 32.46 67.54 100.00 Tineae* 33.12 66.88 100.00 69.81 95.06 85.07 83.61 92.79 89.53
Total 53 81 134 Total 61 111 172 39.55 60.45 100.00 35.47 64.53 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Pearson chi2(1) = 16.0867 Pr = 0.000 Pearson chi2(1) = 3.5454 Pr = 0.060 * t. versicolor, t. faciei/corporis,t. pedis
7.6.1.2 Intertrigo
SchoolU
U Lihami Michenga Total
Intertrigo 5 2 7 71.43 28.57 100.00 100.00 100.00 100.00 129 Appendix B
Prevalence of intertrigo according to school:
SchoolU
U Lihami Michenga Total
All 406 407 813 Children 49.94 50.06 100.00 Observed 98.78 99.51 99.15
Cases 5 2 7 of 71.43 28.57 100.00 Intertrigo 1.22 0.49 0.85
Total 411 409 820 50.12 49.88 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.451
Seen: 7 cases of Intertrigo, 7 : 573 = 1.22 % of all diagnoses belonged to the diagnostic group of intertrigo 7 : 424 = 1.65 % of infectious skin diseases belonged to the diagnostic group of intertrigo
Prevalence according to age group
AgeU group
U 6 - 10 11 - 14 15 - 19 TotalU
Children 336 343 126 805 Without 41.74 42.61 15.65 100.00 Intertrigo 99.70 99.71 96.18 99.14
Intertrigo 1 1 5 7 14.29 14.29 71.43 100.00 0.30 0.29 3.82 0.86
Total 337 344 131 812 41.50 42.36 16.13 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.002
AgeU group
U 6 - 10 11 - 14 15 - 19 TotalU
Children 336 343 126 805 Without 41.74 42.61 15.65 100.00 Intertrigo 99.70 99.71 96.18 99.14
Intertrigo: 1 0 0 1 girls 100.00 0.00 0.00 100.00 0.30 0.00 0.00 0.12
Intertrigo: 0 1 5 6 boys 0.00 16.67 83.33 100.00 0.00 0.29 3.82 0.74
Total 337 344 131 812 41.50 42.36 16.13 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.000 130 Appendix B
Prevalence according to sex
SexU
U f m Total
Children 389 416 805 Without 48.32 51.68 100.00 Intertrigo 99.74 98.58 99.14
Children 1 6 7 With 14.29 85.71 100.00 Intertrigo 0.26 1.42 0.86
Total 390 422 812 48.03 51.97 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.125
Intertrigo: history and clinical picture Intertrigo: the most frequent localizations (n = 76) Localization Frequency Percent Pubic region 5 (7) 71.4 Inguinal region 3 (7) 42.9 Perianal region 1 (7) 14.3 Right ant. thigh 1 (7) 14.3 Right post. thigh 1 (7) 14.3 Left ant. thigh 1 (7) 14.3 Left post. thigh 1 (7) 14.3
Size
SizeU yes no Total
Remains 1 3 4 Same 25.00 75.00 100.00
Increasing 3 1 4 75.00 25.00 100.00
Are there any others at home who have the same signs of a skin disease as you? In the 5 cases interviewed, no other household member was affected.
Have you received any treatment for your main skin problem? None of the children (4) had received any treatment
Type of skin lesion
TypU of
LesionU Yes No Total
Patch 5 0 5 100.00 0.00 100.00
Papules 1 4 5 20.00 80.00 100.00 131 Appendix B
TypU of
LesionU Yes No Total
Pustules 1 4 5 20.00 80.00 100.00
Scaling 1 4 5 20.00 80.00 100.00
Number of lesions
NumberU of lesions
U 1 - 5 more than 5 Total
Intertrigo 3 2 5 60.00 40.00 100.00
Colour
Five cases could be described, hyperpigmentation in all five cases, greyish aspect (in this case not due to scaling) was seen once.
Diameter
DiameterU
U < 1cm > 3cm Total
Intertrigo 1 4 5 20.00 80.00 100.00
Configuration
U single in groups Total
Intertrigo 2 1 3 66.67 33.33 100.00
Description of pruritus
1: no pruritus 3: it is a real nuisance 2: it sometimes itches a little bit 4: patient cannot sleep because of pruritus
PruritusU
U 1 2 3 Total
Intertrigo 1 2 2 5 20.00 40.00 40.00 100.00
When does it itch?
U yes no Total U U yes no Total
Hot 2 1 3 Rainy 1 2 3 Sun 66.67 33.33 100.00 Season 33.33 66.67 100.00
In 1 2 3 Hot/Dry 2 1 3 Bed 33.33 66.67 100.00 Season 66.67 33.33 100.00
Bathing 2 1 3 Cold 1 2 3 6.67 33.33 100.00 Season 33.33 66.67 100.00 132 Appendix B
Aspect of lesions
AspectU Yes No Total
1 1 4 5 1 = sharply delinated/central healing 20.00 80.00 100.00 2 = grey patches . 16.67 21.05 20.00 3 = bacterial superinfection 4 = maceration 2 2 3 5 40.00 60.00 100.00 33.33 15.79 20.00
3 1 4 5 20.00 80.00 100.00 16.67 21.05 20.00
4 2 3 5 40.00 60.00 100.00 33.33 15.79 20.00
Microscopic examination Sample taken
U Yes No Total
Skin 3 1 4 Scraping 75.00 25.00 100.00
Evidence of
EvidenceU of Yes No Total
Hyphae 2 1 3 66.67 33.33 100.00
Myceliae 2 1 3 66.67 33.33 100.00
Spores 3 0 3 100.00 0.00 100.00
Microscopy Ifakara positive? Three cases, all positive.
Micoscropy Zürich No samples were sent to Zürich 133 Appendix B
7.6.1.3 Pyoderma Prevalence of pyoderma
School Lihami Michenga Total
Children 361 391 752 Without 48.01 51.99 100.00 Pyoderma 95.60 91.71
Pyoderma 50 18 68 73.53 26.47 100.00 12.17 4.40 8.29
Total 411 409 820 50.12 49.88 100.0 100.00 100.00 100.00
Pearson chi2(1) = 16.2509 Pr = 0.000
Seen: 69 cases of Pyoderma 69 : 573 = 12.04 % of all diagnoses belonged to the category pyoderma 69 : 424 = 16.27 % of all infectious skin diseases belonged to the category pyoderma
Prevalence according to age group
Age group 6 - 10 11 - 14 15 - 19 Total
No 300 320 124 744 Pyoderma 40.32 43.01 16.67 100.00 89.02 93.02 94.66 91.63
Pyoderma 37 24 7 68 54.41 35.29 10.29 100.00 10.98 6.98 5.34 8.37
Total 337 344 131 812 41.50 42.36 16.13 100.00 100.00 100.00 100.00 100.00
Pearson chi2(2) = 5.4241 Pr = 0.066
Prevalence according to sex
Sex f m Total
No 364 386 750 Pyoderma 48.53 51.47 100.00 92.39 91.04 91.69
Pyoderma 30 38 68 44.12 55.88 100.00 7.61 8.96 8.31
Total 394 424 818 48.17 51.83 100.00 Pearson chi2(1) = 0.4869 100.00 100.00 100.00 Pr = 0.485 134 Appendix B
Pyoderma: history and clinical picture The following diagnoses were pooled:
- “Superinfected Wounds/ulcers” (n = 45) and “Healing Superinfected Wounds/ulcers” (n = 14) - “Impetigo”(n = 2) and “Healing Impetigo” (n = 1).
Size
Superinfected wounds/ulcers: Impetigo: Size Yes No Total The only case described was increasing.
Remains 3 27 30 Folliculitis: The same 10.00 90.00 100.00 The two cases described were varying in size. Increases 12 18 30 40.00 60.00 100.00
Decreases 11 19 30 36.67 63.33 100.00
Varying 6 24 30 20.00 80.00 100.00
The most frequent localizations Diagnosis Localization Frequency Percent Superinfected Lower leg (right ant.) 16 (56) 28.57 wounds/ulcer Lower leg (left ant.) 15 (56) 26.79 Lower leg (right pos.) 11 (56) 19.64 Lower leg (left post.) 6 (56) 10.71 Foot (left dorsal) 5 (56) 8.93 Ankle (right lat.) 4 (56) 7.14
The most frequent localizations Diagnosis Localization Frequency Percent Impetigo Scalp 2 (3) 66.67 Folliculitis Face 2 (3) 66.67 Scalp 7 (7) 100.00
Type of skin lesion Superinfected wounds/ulcer; healing superinfected wounds/ulcers:
Type of Skin lesion Yes No Total
Nodules 2 35 37 5.41 94.59 100.00
Pustules 6 31 37 16.22 83.78 100.00
Vesicles 1 36 37 2.70 97.30 100.00
Crusts 12 25 37 32.43 67.57 100.00 135 Appendix B
Type of Skin lesion Yes No Total
Plaques 2 35 37 5.41 94.59 100.00
Excorriat. 2 35 37 5.41 94.59 100.00
Erosion 1 36 37 2.70 97.30 100.00
Ulcer 21 16 37 56.76 43.24 100.00
Oozing/ 11 26 37 Wet 29.73 70.27 100.00
Impetigo; healing impetigo: 2 cases, crusts
Folliculitis: 3 cases, pustules found in all three cases, papules and scaling in 2 cases.
Number of lesions
1 = Superinfected wounds/ulcer; healing superinfected wounds/ulcers 2 = Impetigo; healing Impetigo
Number of lesions Diagnosis 1 - 5 6 - 10 more than 10 Total
1 28 1 7 36 77.78 2.78 19.44 100.00
2 0 0 1 1 0.00 0.00 100.00 100.00
Distribution
generalizedgeneralized Diagnosis localized 1 body part more than 1 body part Total
Folliculitis 1 2 0 3 33.33 66.67 0.00 100.00 3.13 100.00 0.00 7.14
Colour
1. hypopigmented 3. normopigmented 1. hypopigmented 4. normopigmented 6. pink 10. reddish 4. greyish 11. whitish 8. greyish
2. hyperpigmented 5. yellowish 2. hyperpigmented 5. yellowish 7. bluish 9. black 136 Appendix B
Superinfected wounds/ulcer; Impetigo; healing impetigo: Healing superinfected wounds/ulcers: 2 cases; yellow
Total number of cases observed for colour: n = 36 Folliculitis: 3 cases, Colour a b c Total Hypopigmented/pink: seen once Hyperpigmented: seen once Hypopig./ 15 8 2 25 = 69.44% Normopigmented: seen twice pink 60.00 32.00 8.00 100.00
Hyperpig. 6 1 0 7 = 19.44% 85.71 14.29 0.00 100.00
Greyish 1 0 0 1 = 2.78% 100.0 0.00 0.00 100.00
Yellowish 14 2 0 16 = 44.44% 87.5 12.50 0.00 100.00
Diameter
Diameter Diagnosis 0 - 1cm 1.1 - 2cm 2.1 - 3cm >3cm - 10cm Total
(Healing) 15 17 2 1 35 Superinfected 42.86 48.57 5.71 2.86 100.00 Wounds/ulcers 78.95 94.44 100.00 100.00 87.50
(Healing) 1 1 0 0 2 Impetigo 50.00 50.00 0.00 0.00 100.00
Configuration
Diagnosis single 1 group disseminated generalized Total
(Healing) 20 2 1 1 24 Superinfected 83.33 8.33 4.17 4.17 100.00 Wounds/ulcers (Healing) 0 1 0 0 1 Impetigo 0.00 100.00 0.00 0.00 100.00 137 Appendix B
7.6.1.4 Wounds
Superinfected and non-superinfected wounds = “Wounds”
Schools School Lihami Michenga Total
Children 356 381 737 Without 48.30 51.70 100.00 Wounds 86.62 93.15 89.88
Children with 40 16 56 Superinfected 71.43 28.57 100.00 Wounds 9.73 3.91 6.83
Children with 15 12 27 Non-superinfected 55.56 44.44 100.00 Wounds 3.65 2.93 3.29
Total 411 409 820 50.12 49.88 100.00 100.00 100.00 100.00
Pearson chi2(2) = 11.4623 Pr = 0.003
Prevalence according to age group
Children with any kind of wounds
Age group 6 - 10 11 - 14 15 - 19 Total
Children 290 319 120 729 Without 39.78 43.76 16.46 100.00 Wounds 86.05 92.73 91.60 89.78
Children with 30 19 7 56 Superinfected 53.57 33.93 12.50 100.00 Wounds 8.90 5.52 5.34 6.90
Children with 17 6 4 27 Non-superinfected 62.96 22.22 14.81 100.00 Wounds 5.04 1.74 3.05 3.33
Total 337 344 131 812 41.50 42.36 16.13 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.045 138 Appendix B
Children with superinfected wounds
Age group 6 - 10 11 - 14 15 - 19 Total
Children 290 319 120 729 Without 39.78 43.76 16.46 100.00 Wounds 90.63 94.38 94.49 92.87
Children with 30 19 7 56 Superinfected 53.57 33.93 12.50 100.00 Wounds 9.38 5.62 5.51 7.13
Total 320 338 127 785 40.76 43.06 16.18 100.00 100.00 100.00 100.00 100.00
Pearson chi2(2) = 4.0977 Pr = 0.129
Children with non-superinfected wounds
Age group 6 - 10 11 - 14 15 - 19 Total
Children 290 319 120 729 Without 39.78 43.76 16.46 100.00 Wounds 94.46 98.15 96.77 96.43
Children with 17 6 4 27 Non-superinfected 62.96 22.22 14.81 100.00 Wounds 5.54 1.85 3.23 3.57
Total 307 325 124 756 40.61 42.99 16.40 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.045
Prevalence according to sex
Children with any kind of wounds
Sex f m Total
Children 357 372 729 Without 48.97 51.03 100.00 Wounds 91.54 88.15 89.78
Children with 25 31 56 Superinfected 44.64 55.36 100.00 Wounds 6.41 7.35 6.90
Children with 8 19 27 Non-superinfected 29.63 70.37 100.00 Wounds 2.05 4.50 3.33
Total 390 422 812 48.03 51.97 100.00 Pearson chi2(2) = 4.1784 100.00 100.00 100.00 Pr = 0.124 139 Appendix B
Children with superinfected wounds
Sex f m Total
Children 357 372 729 Without 48.97 51.03 100.00 Wounds 93.46 92.31 92.87
Children with 25 31 56 Superinfected 44.64 55.36 100.00 Wounds 6.54 7.69 7.13
Total 382 403 785 48.66 51.34 100.00 100.00 100.00 100.00
Pearson chi2(1) = 0.3900 Pr = 0.532
Children with non-superinfected wounds
Sex f m Total
Children 357 372 729 Without 48.97 51.03 100.00 Wounds 97.81 95.14 96.43
Children with 8 19 27 Non-superinfected 29.63 70.37 100.00 Wounds 2.19 4.86 3.57
Total 365 391 756 48.28 51.72 100.00 100.00 100.00 100.00
Pearson chi2(1) = 3.9006 Pr = 0.048
Wounds: the most frequent localizations (n = 76) Localization Frequency Percent Lower leg (right ant.) 17 (76) 22.37 Lower leg (left ant.) 15 (76) 19.74 Lower leg (right post.) 11 (76) 14.47 Foot (left dorsal) 8 (76) 10.53 Face 7 (76) 9.21 Foot (right dorsal) 6 (76) 7.89 Lower leg (left post.) 6 (76) 7.89 Ankle (right lat.) 5 (76) 6.58 Foot (left sole) 4 (76) 5.26 140 Appendix B
7.6.1.5 Abscesses
School Lihami Michenga Total
Abscesses 2 1 3 66.67 33.33 100.00
Prevalence according to school
School Liham Michenga Total
All 409 408 817 Children 50.06 49.94 100.00 Seen 99.51 99.76 99.63
Abscesses 2 1 3 66.67 33.33 100.00 0.49 0.24 0.37
Total 411 409 820 50.12 49.88 100.00 100.00 100.00 100.00 Fisher's exact test Pr = 1.000
Seen: 3 cases of abscesses, 3 : 573 = 0.52 % of all diagnoses belonged to the diagnostic group of abscesses 3 : 424 = 0.71 % of all infectious skin diseases belonged to the diagnostic group of abscesses
Prevalence according to age group Age group 6 - 10 11 - 14 15 - 19 Total
No 335 344 130 809 Abcesses 41.41 42.52 16.07 100.00 99.41 100.00 99.24 99.63
Abcesses 2 0 1 3 66.67 0.00 33.33 100.00 0.59 0.00 0.76 0.37
Total 337 344 131 812 41.50 42.36 16.13 100.00 100.00 100.00 100.00 100.00 Fisher's exact test Pr = 0.300
Prevalence according to sex
Sex f m Total
No 389 420 809 Abcesses 48.08 51.92 100.00 99.74 99.53 99.63
Abcesses 1 2 3 33.33 66.67 100.00 0.26 0.47 0.37
Total 390 422 812 48.03 51.97 100.00 100.00 100.00 100.00 Fisher's exact test Pr = 1.000 141 Appendix B
7.6.1.6 Ectoparasitic disorders
Scabies Prevalence according to school
School Lihami Michenga Total
Children 401 399 800 Without 50.13 49.88 100.00 Scabies 97.57 99.50 98.52
Children 10 2 12 With 83.33 16.67 100.00 Scabies 2.43 0.50 1.48
Total 411 401 812 50.62 49.38 100.00 100.00 100.00 100.00
Pearson chi2(1) = 5.2160 Pr = 0.022
Seen: 12 cases of scabies 12 : 573 = 2.09 % of all diagnoses were scabies 12 : 424 = 2.83 % of all infectious skin diseases were scabies
Prevalence according to age group
Age group 6 - 10 11 - 14 15 - 19 Total
No 329 341 130 800 Scabies 41.13 42.63 16.25 100.00 97.63 99.13 99.24 98.52
Scabies 8 3 1 12 66.67 25.00 8.33 100.00 2.37 0.87 0.76 1.48
Total 337 344 131 812 41.50 42.36 16.13 100.00 100.00 100.00 100.00 100.00 Fisher's exact test Pr = 0.240
Prevalence according to sex
Sex f m Total
No 386 414 800 Scabies 48.25 51.75 100.00 98.97 98.10 98.52
Scabies 4 8 12 33.33 66.67 100.00 1.03 1.90 1.48
Total 390 422 812 48.03 51.97 100.00 100.00 100.00 100.00 Pearson chi2(1) = 1.0539 Pr = 0.305 142 Appendix B
Scabies: history and clinical picture Where did this skin problem start?
Localization Yes No Total
Scalp 1 10 11 9.09 90.91 100.00
Chest 1 10 11 9.09 90.91 100.00
Abdomen 2 9 11 18.18 81.82 100.00
Back 1 10 11 9.09 90.91 100.00
Arms 7 4 11 63.64 36.36 100.00
Hands 5 6 11 45.45 54.55 100.00
Finger 1 10 11 Webs 9.09 90.91 100.00
Genital 2 9 11 Region 18.18 81.82 100.00
Thighs 1 10 11 9.09 90.91 100.00
Knees 1 10 11 9.09 90.91 100.00
Lower 1 10 11 Leg 9.09 90.91 100.00
Size
Size Yes No Total
Remains 2 9 11 The same 18.18 81.82 100.00
Increases 6 5 11 54.55 45.45 100.00
Decreases 1 10 11 9.09 90.91 100.00
Varies 4 7 11 36.36 63.64 100.00
Other family members also affected
In six out of nine cases other family members were affected 143 Appendix B
Have you received any treatment for your main skin problem?
Treatment Yes No Total
Other 66 261 327 Diseases 20.18 79.82 100.00
Scabies 4 7 11 36.36 63.64 100.00
Total 70 268 338 20.71 79.29 100.00
Fisher's exact test Pr = 0.249
If yes: which kind of treatment?
1. Antifungal agents 2. Antibacterial treatment: 3. Tablets 4. Injection 5. Creme 6. Traditional medicine 7."Household remedies" Treatment Antib. Treat. Tablets Househ. Rem. Total
Scabies 1 1 2 4 25.00 25.00 50.00 100.00
Has the treatment helped?
Yes No Total
Scabies 3 1 4 75.00 25.00 100.00
Distribution
1: localized 2: generalized on one part of the body 3: generalized on more than one part of the body
. 1 2 3 Total
Scabies 4 1 6 11 36.36 9.09 54.55 100.00
Colour
1. hypopigmented 3. normopigmented 1. hypopigmented 4. normopigmented 6. pink 10. reddish 4. greyish 11. whitish 8. greyish
2. hyperpigmented 5. yellowish 2. hyperpigmented 5. yellowish 7. bluish 9. black 144 Appendix B
Total number of cases observed for colour: n = 12
Colour a b c Total
Hypopigm./ 5 1 1 7 Pink 71.43 14.29 14.29 100.00 = 58.33% pink excorriations
Hyperpigm. 6 0 0 6 100.00 0.00 0.00 100.00 = 50.00% postinflammmatory hyperpigmentation
Normopigm. 1 1 0 2 50.00 50.00 0.00 100.00 = 16.67%
Yellowish 0 2 0 2 0.00 100.00 0.00 100.00 = 16.67% bacterial superinfection/pustules
The most frequent localizations
1. Sides of the fingers 9. Areola of the breast 2. Wrists 10. Gluteal region 3. Ulnar border of the hands 11. Waist 4. Palms 12. Thighs 5. Arm flexures 13. Knees 6. (Anterior) axillary fold 14. Ankles 7. Umbilicus 15. Soles 8. External genitalia/perineum 16. Other
Scabies lesions present Localization Yes No Total
1 8 1 9 88.89 11.11 100.00
2 8 1 9 88.89 11.11 100.00
Scabies lesions present Localization Yes No Total
3 7 2 9 77.78 22.22 100.00
4 2 7 9 22.22 77.78 100.00
5 8 1 9 88.89 11.11 100.00
6 2 7 9 22.22 77.78 100.00
7 3 6 9 33.33 66.67 100.00
8 3 6 9 33.33 66.67 100.00 145 Appendix B
Scabies lesions present Localization Yes No Total
9 0 9 9 0.00 100.00 100.00
10 7 2 9 77.78 22.22 100.00
11 1 8 9 11.11 88.89 100.00
12 1 8 9 11.11 88.89 100.00
13 1 8 9 11.11 88.89 100.00
14 0 9 9 0.00 100.00 100.00
15 0 9 9 0.00 100.00 100.00
Does this skin disease itch?
Itching in all cases where information was collected (11 children) . Description of pruritus
Pruritus Freqency Percent Cumulative
Sometimes itches A little bit 1 11.11 11.11
It is a real Nuisance 4 44.44 55.56
Patient cannot sleep Because of pruritus 4 44.44 100.00
Total 9 100.00
When does it itch?
Yes No Total
Hot 2 9 11 Sun 18.18 81.82 100.00
In 9 2 11 Bed 81.82 18.18 100.00
Bathing 2 9 11 18.18 81.82 100.00
Rainy 1 4 5 Season 20.00 80.00 100.00
Hot/ 0 5 5 Dry 0.00 100.00 100.00 Season 146 Appendix B
Yes No Total
Cold 0 5 5 Season 0.00 100.00 100.00
Itching more at night
All children asked (9 cases) felt itching more at night
Type of lesions
Type of lesion Yes No Total
Crusts, 1 8 9 Generalized 11.11 88.89 100.00 Lichenification
Superinfection 6 3 9 66.67 33.33 100.00
Sample taken
Yes No Total
Scabies 7 5 12 58.33 41.67 100.00
Microscopic examination positive
Only 1 sample out of 7 was positive
Scabies incidence in the area of Ifakara Incidence of scabies among the population attending the dispensary at Michenga and the health centre at Kibaoni/Ifakara
Figure: Number of scabies cases attended to in the dispensary at Michenga and the health centre at Kibaoni (data pooled) from January 2000 to June 2003 according to sex and age group - summary.
40 35 30 25 Male 20 Female
attended 15 10 5 Number ofscabies cases 0 0 - 5 years 6 - 10 years 10 - 20 years Older than 20 years Age group 147 Appendix B
Michenga (dispensary): the records checked covered the following periods of time: 11.03.03 – 11.07.03 21.08.00 – 19.01.01 13.02.02 – 12.07.03 18.08.00 – 12.02.02 Number of cases in 2003 Age Jan Feb Mar Apr May June July Aug Sep Oct Nov Dec 0 – 5 F 2 M 1 1 1 2 6 – 10 F M 1 10 – 20 F M > 20 F M Total 3 1 1 1 2 Number of cases in 2002 Age Jan Feb Mar Apr May June July Aug Sep Oct Nov Dec 0 – 5 F 1 M 3 1 6 – 10 F M 1 10 – 20 F M > 20 F M Total 4 1 1 Number of cases in 2001 Age Jan Feb Mar Apr May June July Aug Sep Oct Nov Dec 0 – 5 F 2 M 3 1 1 1 6 – 10 F M 10 – 20 F M > 20 F M Total 5 1 1 1 Number of cases in 2000 Age Jan Feb Mar Apr May June July Aug Sep Oct Nov Dec 0 – 5 F 1 2 M 1 1 1 1 2 1 6 – 10 F M 1 10 – 20 F M 1 > 20 F M Total 12 22 4 1 148 Appendix B
Kibaoni (health centre): the records checked covered the following periods of time: 19.05.03 – 14.05.03 15.01.02 – 31.03.02 04.04.01 – 07.09.01 01.02.01 – 12.03.01 28.11.00 – 30.07.01 01.07.02 – 06.04.03 30.11.01 – 26.03. ? 23.03.01 – 26.11.01 22.01.01 – 10.05.01 09.10.00 – 01.02.01 01.07.02 – 21.08.02 30.10.01 – 15.01.02 20.03.01 – 30.09.01 08.01.01 – 23.03.01 25.09.00 – 07.01.01 19.02.02 – 30.06.02 02.08.01 – 18.01.02 12.03.01 – 19.02.02 03.01.01 – 19.03.01 12.01.00 - ? 13.02.02 – 15.04.03 10.05.01 – 11.02.02 28.02.01 - ? 29.12.00 – 03.04.01 Number of cases in 2003 Age Jan Feb Mar Apr May June July Aug Sep Oct Nov Dec 0 – 5 f 2 m 1 6 – 10 f 1 m 10 – 20 f 1 m 1 > 20 f m 1 Total 2 23 Number of cases in 2002 Age Jan Feb Mar Apr May June July Aug Sep Oct Nov Dec 0 – 5 f m 6 – 10 f 1 m 10 – 20 f 1 m > 20 f m Total 11 Number of cases in 2001 Age Jan Feb Mar Apr May June July Aug Sep Oct Nov Dec 0 – 5 f 1 2 1 1 m 3 1 1 3 1 6 – 10 f 1 1 1 m 1 10 – 20 f 2 1 1 m 1 > 20 f 3 m 1 1 Total 3 2 7 2 5 6 1 2 Number of cases in 2000 Age Jan Feb Mar Apr May June July Aug Sep Oct Nov Dec 0 – 5 f 1 m 2 6 – 10 f m 10 – 20 f m > 20 f 3 1 m Total 15 1 149 Appendix B
Table below: Incidence of scabies among the population attending the dispensary of Michenga and the health centre of Kibaoni. Cases detected since the year 2000 according to age and sex.
Michenga (dispensary) Kibaoni (health centre) Age 2000 2001 2002 2003* Total Age 2000 2001 2002 2003* Total 0 – 5 f 3 2 1 2 80 – 5 F 1 5 2 8 m 7 6 4 5 22 M 2 9 1 12 6 – 10 f 6 – 10 F 3 1 1 5 m 1 1 1 3 M1 1 10 –20 f 10 – 20 F 4 1 1 6 m 1 1 M1 1 2 > 20 f > 20 F 4 3 7 m M2 1 3 Total 12 8 6 8 34 Total 7 28 2 7 44 * only data until July 2003 could be obtained
Overall number of cases according to time of the year Sex Jan Feb Mar Apr May June July Aug Sep Oct Nov Dec Boys 7 55 3 6 6 4 2 0 2 1 4 Girls 4 45 2 5 5 3 0 2 3 0 0 Total 11 9 10 5 11 11 7 2 2 5 1 4
Children found to be suffering from scabies at healthcare facilities of Michenga (dispensary) and Kibaoni (health centre) according to sex and time of the year
Time of the year Jan - Mar Apr – June July - Sept Oct - Dec Total
Boys 17 15 6 7 45 37.78 33.33 13.33 15.56 100.00 56.67 55.56 54.55 70.00 57.69
Girls 13 12 5 3 33 39.39 36.36 15.15 9.09 100.00 43.33 44.44 45.45 30.00 42.31
Total 30 27 11 10 78 38.46 34.62 14.10 12.82 100.00 Fisher's exact test 100.00 100.00 100.00 100.00 100.00 Pr = 0.879
Children found to be suffering from scabies at healthcare facilities of Michenga (dispensary) and Kibaoni (health centre) according to sex and time of the year
First line: boys Second line: girls Third line: total
Time of the year Jan Feb Mar April May June July Aug Sep Oct Nov Dec Total
7 5 5 3 6 6 4 2 0 2 1 4 45 15.56 11.11 11.11 6.67 13.33 13.33 8.89 4.44 0.00 4.44 2.22 8.89 100.00 63.64 55.56 50.00 60.00 54.55 54.55 57.14 100.00 0.00 40.00 100.00 100.00 57.69
4 4 5 2 5 5 3 0 2 3 0 0 33 12.12 12.12 15.15 6.06 15.15 15.15 9.09 0.00 6.06 9.09 0.00 0.00 100.00 36.36 44.44 50.00 40.00 45.45 45.45 42.86 0.00 100.00 60.00 0.00 0.00 42.31
11 9 10 5 11 11 7 2 2 5 1 4 78 14.10 11.54 12.82 6.41 14.10 14.10 8.97 2.56 2.56 6.41 1.28 5.13 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Computer failed to calculate Fisher’ exact test 150 Appendix B
Table below: Incidence of scabies among the population attended at the dispensary of Michenga and the health centre of Kibaoni (pooled). Cases detected since the year 2000 according to sex the time of the year.
12 10 8 Boys 6 Girls 4 attended 2 0
Number of scabies cases Jan Feb Mar Apr May June July Aug Sep Oct Nov Dec Month
Children found to be suffering from scabies at healthcare facilities of Michenga (dispensary) and Kibaoni (health centre) according to sex and age group
Age group (years), Michenga and Kibaoni pooled 0 - 5 6 - 10 10 – 20 >20 Total
Boys 34 4 3 3 44 77.27 9.09 6.82 6.82 100.00 68.00 44.44 33.33 30.00 56.41
Girls 16 5 6 7 34 47.06 14.71 17.65 20.59 100.00 32.00 55.56 66.67 70.00 43.59
Total 50 9 9 10 78 64.10 11.54 11.54 12.82 100.00 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.045 Incidence of Scabies among paediatric Inpatients of SFDDH Children found to be suffering from scabies in the paediatric ward of SFDDH according to sex and year Year Sex 1999 2000 2001 2002 2003 Total
Boys 14 8 1 2 2 27 51.85 29.63 3.70 7.41 7.41 100.00 66.67 57.14 100.00 50.00 50.00 61.36
Girls 7 6 0 2 2 17 41.18 35.29 0.00 11.76 11.76 100.00 33.33 42.86 0.00 50.00 50.00 38.64
Total 21 14 1 4 4 44 47.73 31.82 2.27 9.09 9.09 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Fisher's exact = 0.874 151 Appendix B
Children found to be suffering from scabies in the paediatric ward of SFDDH according to age and sex Age (years) Sex <1 1 2 3 4 5 or more Total
Boys 10 8 2 1 1 5 27 37.04 29.63 7.41 3.70 3.70 18.52 100.00 58.82 61.54 50.00 33.33 50.00 100.00 61.36
Girls 7 5 2 2 1 0 17 41.18 29.41 11.76 11.76 5.88 0.00 100.00 41.18 38.46 50.00 66.67 50.00 0.00 38.64
Total 17 13 4 3 2 5 44 38.64 29.55 9.09 6.82 4.55 11.36 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Fisher's exact test = 0.437
Age group Sex < 5 years > 5 years Total
Boys 22 5 27 81.48 18.52 100.00 56.41 100.00 61.36
Girls 17 0 17 100.00 0.00 100.00 43.59 0.00 38.64
Total 39 5 44 88.64 11.36 100.00 100.00 100.00 100.00
Fisher's exact = 0.139
Children found to be suffering from scabies in the paediatric ward of SFDDH according to sex and time of the year
First line: boys Second line: girls Third line: total
Time of the year Jan Feb Mar April May June July Aug Sep Oct Nov Dec Total
2 1 2 2 3 4 1 4 3 1 1 3 27 7.41 3.70 7.41 7.41 11.11 14.81 3.70 14.81 11.11 3.70 3.70 11.11 100.00 100.00 100.00 100.00 100.00 75.00 44.44 33.33 50.00 60.00 50.00 50.00 75.00 61.36
0 0 0 0 1 5 2 4 2 1 1 1 17 0.00 0.00 0.00 0.00 5.88 29.41 11.76 23.53 11.76 5.88 5.88 5.88 100.00 0.00 0.00 0.00 0.00 25.00 55.56 66.67 50.00 40.00 50.00 50.00 25.00 38.64
2 1 2 2 4 9 3 8 5 2 2 4 44 4.55 2.27 4.55 4.55 9.09 20.45 6.82 18.18 11.36 4.55 4.55 9.09 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Fisher's exact test = 0.870 152 Appendix B
Table below: Incidence of scabies among paediatric inpatients in SFDDH from June 1999 to June 2003 according to sex and the time of the year.
10 9 8 7 6 Girls 5 4 Boys detected 3 2 1 Number of scabies cases 0 Jan Feb Mar Apr May June July Aug Sept Okt Nov Dec Months
7.6.1.7 Warts School Lihami Michenga Total
Warts 12 10 22 54.55 45.45 100.00
Prevalence according to school
School Lihami Michenga Total
All 399 399 798 Children 50.00 50.00 100.00 Seen 97.08 97.56 97.32
Warts 12 10 22 54.55 45.45 100.00 2.92 2.44 2.68
Total 411 409 820 50.12 49.88 100.00 100.00 100.00 100.00
Pearson chi2(1) = 0.1769 Pr = 0.674
Seen: 22 cases of warts, 22 : 573 = 3.84 % of all diagnoses belonged to the diagnostic group of warts 22 : 424 = 5.19 % of all infectious skin diseases belonged to the diagnostic group of warts 153 Appendix B
Prevalence according to age group
Age group 6 - 10 11 - 14 15 - 19 Total
No 326 335 129 790 Skin 41.27 42.41 16.33 100.00 Disease 96.74 97.38 98.47 97.29
Warts 11 9 2 22 50.00 40.91 9.09 100.00 3.26 2.62 1.53 2.71
Total 337 344 131 812 41.50 42.36 16.13 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.678
Prevalence according to sex
Sex f m Total
No 377 413 790 Skin 47.72 52.28 100.00 Disease 96.67 97.87 97.29
Warts 13 9 22 59.09 40.91 100.00 3.33 2.13 2.71
Total 390 422 812 48.03 51.97 100.00 100.00 100.00 100.00
Pearson chi2(1) = 1.1084 Pr = 0.292
How many of the detected cases were due to M. contagiosum?
Lihami Michenga Total
M. contag. 0 1 1 0.00 100.00 100.00 0.00 10.00 4.55
Common 12 9 21 Warts* 57.14 42.86 100.00 100.00 90.00 95.45
Total 12 10 22 54.55 45.45 100.00 100.00 100.00 100.00 *Probably due to HPV
7.6.1.8 Other skin conditions of infectious origin
School Lihami Total
Cheilitis 2 2 100.00 100.00 100.00 100.00 154 Appendix B
7.6.2 Non-infectious skin diseases
7.6.2.1 Pruritic dermatoses
School Lihami Michenga Total
Gen. pruritus/ 1 4 5 Xerotic 20.00 80.00 100.00 Skin 5.88 40.00 18.52
Miliaria 11 0 11 100.00 0.00 100.00 64.71 0.00 40.74
Pruritic 5 6 11 Dermatitis 55.45 54.55 100.00 29.41 60.00 40.74
Total 17 10 27 62.96 37.04 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.001
Proportion “pruritic dermatoses”/overall number of diagnoses = 27/ 573 = 4.71 % Non-infectious diagnoses = 27/149 = 18.12 %
Prevalence according to school
School Lihami Michenga Total
All 394 399 793 Children 49.68 50.32 100.00 95.86 97.56 96.71
Pruritic 17 10 27 Dermatoses 62.96 37.04 100.00 4.14 2.44 3.29
Total 411 409 820 50.12 49.88 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.240 155 Appendix B
Generalized pruritus/xerotic skin – miliaria – pruritic dermatitis Prevalence according to age group
Age group
6 - 10 11 - 14 15 - 19 Total
No 322 333 130 785 Pruritic 41.02 42.42 16.56 100.00 Dermatoses 95.55 96.80 99.24 96.67
Pruritic 15 11 1 27 Dermatoses 55.56 40.74 3.70 100.00 4.45 3.20 0.76 3.33
Total 337 344 131 812 41.50 42.36 16.13 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.114
0 = Overall number of children 81 = Generalized pruritus/xerotic skin
Age group 6 - 10 11 - 14 15 - 19 Total
0 335 342 130 807 41.51 42.38 16.11 100.00 99.41 99.42 99.24 99.38
81 2 2 1 5 40.00 40.00 20.00 100.00 0.59 0.58 0.76 0.62
Total 337 344 131 812 41.50 42.36 16.13 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 1.000
0 = Overall number of children 82 = Miliaria Age group 6 - 10 11 - 14 15 - 19 Total
0 332 338 131 801 41.45 42.20 16.35 100.00 98.52 98.26 100.00 98.65
82 5 6 0 11 45.45 54.55 0.00 100.00 1.48 1.74 0.00 1.35
Total 337 344 131 812 41.50 42.36 16.13 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.362 156 Appendix B
0 = Overall number of children 83 = Pruritic dermatitis Age group 6 - 10 11 - 14 15 - 19 Total
0 329 341 131 801 41.07 42.57 16.35 100.00 97.63 99.13 100.00 98.65
83 8 3 0 11 72.73 27.27 0.00 100.00 2.37 0.87 0.00 1.35
Total 337 344 131 812 41.50 42.36 16.13 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.088
0 = Overall number of children 1 = Pruritic dermatitis and generalized pruritus/xerotic skin
Age group 6 - 14 15 - 19 Total
0 666 130 796 83.67 16.33 100.00 97.80 99.24 98.03
1 15 1 16 93.75 6.25 100.00 2.20 0.76 1.97
Total 681 131 812 83.87 16.13 100.00 100.00 100.00 100.00
Fisher's exact = 0.491
Prevalence according to sex
Sex f m Total
No 376 409 785 Pruritic 47.90 52.10 100.00 Dermatoses 96.41 96.92 96.67
Pruritic 14 13 27 Dermatoses 51.85 48.15 100.00 3.59 3.08 3.33
Total 390 422 812 48.03 51.97 100.00 100.00 100.00 100.00
Pearson chi2(1) = 0.1635 Pr = 0.686 157 Appendix B
Ivermectin since 2000
Ivermectin Yes No Total
No 149 223 372 Skin 40.05 59.95 100.00 Disease 94.90 92.15 93.23
Pruritic 8 19 27 Dermat. 29.63 70.37 100.00 5.10 7.85 6.77
Total 157 242 399 39.35 60.65 100.00 100.00 100.00 100.00
Pearson chi2(1) = 1.1462 Pr = 0.284
Generalized pruritus/xerotic skin – miliaria - pruritic dermatitis:
History and clinical Picture Where did this skin problem start?
Generalized pruritus/xerotic skin Three cases described, problem started on the chest (1), on the abdomen (1) and on the arms. Miliaria Five cases described, problem started on the Face (1) Neck (1) Back (2) Arms (1) Thighs (1) Pruritic dermatitis Nine cases described, problem started on/in the Back (2) Arms (3) Genital region (2) Lower leg (2)
Size
Generalized pruritus/xerotic skin 3 cases - 2 cases increasing - 1 case decreasing Miliaria 5 cases - 1case remaining the same - 1 case increasing - 3 cases decreasing - 1 case varying Pruritic dermatitis 8 cases - 3 remaining the same - 2 cases increasing - 1 case decreasing - 2 cases varying 158 Appendix B
Does this skin disease itch?
81 = Generalized pruritus/xerotic skin 82 = Miliaria 83 = Pruritic dermatitis
Itching Yes No Total
81 2 1 3 66.67 33.33 100.00
82 4 1 5 80.00 20.00 100.00
83 8 1 9 88.89 11.11 100.00
When does it itch? Generalized pruritus/xerotic skin 2 cases, both itching in bed
Miliaria 4 cases,
2 itching in the hot sun 2 itching in bed 2 itching after contact with water 1 itching in the hot/dry season
Pruritic dermatitis 8 cases,
4 itching in the hot sun 3 itching in bed 4 itching after contact with water 2 itching in the rainy season 1 itching in the hot/dry season 3 itching in the cold season
Are there any others at home who have the same signs of a skin disease as you?
81 = Generalized pruritus/xerotic skin 82 = Miliaria 83 = Pruritic dermatitis Affection others Diagnosis No 1 person 2 persons 3 or more people Total
81 1 1 1 0 3 33.33 33.33 33.33 0.00 100.00
82 5 2 0 0 7 71.43 28.57 0.00 0.00 100.00
83 4 4 0 1 9 44.44 44.44 0.00 11.11 100.00 159 Appendix B
Have you received any treatment for your main skin problem?
81 = Generalized pruritus/xerotic skin 82 = Miliaria 83 = Pruritic dermatitis
Diagnoses Yes No Total
81 0 3 3 0.00 100.00 100.00
82 3 2 5 60.00 40.00 100.00
83 1 8 9 11.11 88.89 100.00
If yes: which kind of treatment?
Only information about 82 = Miliaria, 3 cases observed, Antifungal agents given once Tablets given once Traditional medicine given once
Type of skin lesion
Generalized pruritus/xerotic skin Typ of Lesion Yes No Total
Patch 1 2 3 33.33 66.67 100.00
Papule 1 2 3 33.33 66.67 100.00
Crust 1 2 3 33.33 66.67 100.00
Excorr. 1 2 3 33.33 66.67 100.00 Miliaria
Typ of Lesion Yes No Total
Macules 1 4 5 20.00 80.00 100.00
Patch 1 4 5 20.00 80.00 100.00
Papules 4 1 5 80.00 20.00 100.00
Crusts 1 4 5 20.00 80.00 100.00 160 Appendix B
Pruritic dermatitis
Typ of Lesion Yes No Total
Macules 3 6 9 33.33 66.67 100.00
Papules 8 1 9 88.89 11.11 100.00
Pustules 1 8 9 11.11 88.89 100.00
Crusts 3 6 9 33.33 66.67 100.00
Pruritic dermatitis
Typ of Lesion Yes No Total
Excorriations 7 2 9 77.78 22.22 100.00
Dry skin 2 7 9 22.22 77.78 100.00
Number of lesions
Number of lesions 1 - 5 more than 10 Total
Xerotic 0 3 3 Skin 0.00 100.00 100.00
Miliaria 0 3 3 0.00 100.00 100.00
Pruritic 1 8 9 Dermatitis 11.11 88.89 100.00
Colour
1. hypopigmented 3. normopigmented 1. hypopigmented 4. normopigmented 6. pink 10. reddish 4. greyish 11. whitish 8. greyish
2. hyperpigmented 5. yellowish 2. hyperpigmented 5. yellowish 7. bluish 9. black 161 Appendix B
Generalized pruritus/xerotic skin Pruritic dermatitis Hypopigmented: once Hypopigmented: 5 times Hyperpigmented: twice Hyperpigmented: 5 times Out of n = 3 Normopigmented: once out of n = 7
Miliaria Hypopigmented: 3 times Hyperpigmented: once Out of n = 4
Diameter Diameter < 1cm 1.1 – 2cm > 3cm Total
Xerotic 1 1 0 2 Skin 50.00 50.00 0.00 100.00
Configuration single in groups disseminated confl. irregular Total
Xerotic 1 1 1 0 0 3 Skin 33.33 33.33 33.33 0.00 0.00 100.00
Miliaria 0 1 2 1 0 4 0.00 25.00 50.00 25.00 0.00 100.00
Pruritic 0 0 5 0 1 6 Dermatitis 0.00 0.00 83.33 0.00 16.67 100.00
Pruritic dermatoses: the most frequent localizations Diagnosis Localization Frequency Percent Generalized Abdomen 3 (4) 75.00 pruritus/xerotic skin Chest 2 (4) 50.00 Back 2 (4) 50.00 Miliaria Abdomen 2 (7) 28.57 Chest 2 (7) 28.57 Neck 2 (7) 28.57 Pruritic dermatitis Chest 5 (10) 50.00 Abdomen 4 (10) 40.00 Back 4 (10) 40.00 Upper arm (left post.) 4 (10) 40.00 Upper arm (left ant.) 4 (10) 40.00 162 Appendix B
7.6.2.2 Lesions due to insects
School
Lihami Michenga Total
Rash/ 3 2 5 Mosquito 60.00 40.00 100.00 Bites 75.00 50.00 62.50
Paederus 1 1 2 species 50.00 50.00 100.00 25.00 25.00 25.00
Others 0 1 1 0.00 100.00 100.00 0.00 25.00 12.50
Total 4 4 8 50.00 50.00 100.00 100.00 100.00 100.00 Fisher's exact test Pr = 1.000
Proportion diagnoses of group “Lesions due to insects” /over all number of diagnoses = 8/ 573 = 1.40 % Non-infectious diagnoses = 8/ 149 = 5.36 %
Prevalence according to school
0 = All children seen 13 = Lesions due to insects
School Lihami Michenga Total
0 407 405 812 50.12 49.88 100.00 99.03 99.02 99.02
13 4 4 8 50.00 50.00 100.00 0.97 0.98 0.98
Total 411 409 820 50.12 49.88 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 1.000 163 Appendix B
Prevalence according to age group
0 = Children without lesions due to insects 13 = Lesions due to insects
Age group 6 - 10 11 - 14 15 - 19 Total
0 335 340 129 804 41.67 42.29 16.04 100.00 99.41 98.84 98.47 99.01
13 2 4 2 8 25.00 50.00 25.00 100.00 0.59 1.16 1.53 0.99
Total 337 344 131 812 41.50 42.36 16.13 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.582
Prevalence according to sex
0 = Children without lesions due to insects 13 = Lesions due to insects
Sex Diagnosis f m Total
0 385 419 804 47.89 52.11 100.00 98.72 99.29 99.01
13 5 3 8 62.50 37.50 100.00 1.28 0.71 0.99
Total 390 422 812 48.03 51.97 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.491 Lesions due to insects: history and clinical picture Only in one out of two cases of lesions due to Paederus species could the clinical picture be documented. In this child the lesions had already almost healed already. Because of this, the clinical picture described below is not representative for the clinical presentation of a fresh lesion due to this insect. In the second case, the photo documentation (please see below) reveals the typical aspect of a beetle dermatitis. Thus the latter case was chosen for description in the results.
Size
Rash due to mosquito bites Size of lesion remains the same in 1 case Decreases in 1 case (n = 2) Lesions due to Paederus species No information “Others” (Superinfected insect bite and infection with t. versicolor) No information 164 Appendix B
Does this skin disease itch?
Rash due to mosquito bites Itching present 1 case (n = 2) Lesions due to Paederus species Itching present 1 case (n = 1) “Others” (Superinfected insect bite and infection with t. versicolor) No information
When does it itch?
Rash due to mosquito bites No information Lesions due to Paederus species Itching in bed in 1 case After bathing in 1 case In the rainy season in 1 case (n = 1) “Others” (Superinfected insect bite and infection with t. versicolor) No information
Type of skin lesion
Rash due to mosquito bites Papules observed in 2 cases, wheal observed in 1 case Lesions due to Paederus species Macule observed in 1 case “Others” (Superinfected insect bite and infection with t. versicolor) No information
Number of lesions
Rash due to mosquito bites 1 – 5 lesions in 1 case More than 10 (dissiminated) in 1 case (n = 2) Lesions due to Paederus species 1 – 5 lesions in 1 case (n = 1) “Others” (Superinfected insect bite and infection with t. versicolor) No information
Distribution
Rash due to mosquito bites localized in 1 case Generalized on more than one part of the body in 1 case (n = 2) Lesions due to Paederus species localized in 1 case (n = 1) “Others” (Superinfected insect bite and infection with t. versicolor) No information
Colour
Rash due to mosquito bites Hypopigmented in 2 cases (n = 4) Lesions due to Paederus species Hyperpigmented in 1 case (n =2) “Others” (Superinfected insect bite and infection with t. versicolor) No information 165 Appendix B
Diameter
Rash due to mosquito bites Smaller 1 cm in 1 case More than 3 cm in 1 case (n = 2) Lesions due to Paederus species More than 3 cm in 1 case (n = 1) “Others” (Superinfected insect bite and infection with t. versicolor) No information
Configuration
Rash due to mosquito bites: Single lesions in 1 case (n = 1) Lesions due to Paederus species: Single lesions in 1 case (n = 1) “Others” (Superinfected Insect bite and infection with t. versicolor): No information
Lesions due to insects: the most frequent localizations Diagnosis Localization Frequency Percent Rash due to mosquito Upper arm (right ant.) 2 (5) 40.00 bites Upper arm (right post.) 2 (5) 40.00 Upper arm (left ant.) 2 (5) 40.00 Upper arm (left post.) 2 (5) 40.00 Forearm (right post.) 2 (5) 40.00 Face 1 (5) 20.00 Abdomen 1 (5) 20.00 Forearm (right ant.) 1 (5) 20.00 Forearm (left ant.) 1 (5) 20.00 Forearm (left post.) 1 (5) 20.00 Hand (right dorsal) 1 (5) 20.00 Hand (left dorsal) 1 (5) 20.00 Thigh (right ant.) 1 (5) 20.00 Thigh (right post.) 1 (5) 20.00 Thigh (left ant.) 1 (5) 20.00 Thigh (left post.) 1 (5) 20.00 Knee (left post.) 1 (5) 20.00 Right arm/wrist/hand 1 (5) 20.00 Lesions due to Neck (ant. aspect) 1 (2) 50.00 Paederus species Forearm (right ant.) 1 (2) 50.00 166 Appendix B
7.6.2.3 Eczematous lesions
School Lihami Michenga Total
Vaseline 1 0 1 Dermatitis 100.00 0.00 100.00 14.29 0.00 10.00
Atopic 1 0 1 Eczema 100.00 0.00 100.00 14.29 0.00 10.00
Unclassif. 4 0 4 Eczema 100.00 0.00 100.00 57.14 0.00 40.00
Contact 1 3 4 Eczema 25.00 75.00 100.00 14.29 100.00 40.00
Total 7 3 10 70.00 30.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.133
Proportion “eczematous lesions” /over all number of diagnoses = 10/573 = 1.75 % Non-infectious diagnoses = 10/149 = 6.71 %
Prevalence according to school
School Lihami Michenga Total
All 404 406 810 Children 49.88 50.12 100.00 Seen 98.30 99.27 98.78
Children 7 3 10 With 70.00 30.00 100.00 Ecz. Les. 1.70 0.73 1.22
Total 411 409 820 50.12 49.88 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.341 167 Appendix B
Vaseline dermatitis/atopic eczema/unclassifiable eczema/contact eczema
= eczematous lesions Prevalence according to age group
Age group 6 - 10 11 - 14 15 - 19 Total
No 331 341 130 802 Eczematous 41.27 42.52 16.21 100.00 Lesion 98.22 99.13 99.24 98.77
Eczematous 6 3 1 10 Lesion 60.00 30.00 10.00 100.00 1.78 0.87 0.76 1.23
Total 337 344 131 812 41.50 42.36 16.13 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.574
Prevalence according to sex
Sex Diagnosis f m Total
No 384 418 802 Eczematous 47.88 52.12 100.00 Lesions 98.46 99.05 98.77
Eczematous 6 4 10 Lesions 60.00 40.00 100.00 1.54 0.95 1.23
Total 390 422 812 48.03 51.97 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.533
Vaseline dermatitis/atopic eczema/unclassifiable eczema/contact eczema
= eczematous lesions: history and clinical picture
Where did this skin problem start?
Vaseline Dermatitis No observations Atopic eczema No observations Unclassifiable eczema 1 case, started on the head Contact eczema 3 cases, 1 started on the abdomen 1 started on the back 1 started on the arms 168 Appendix B
Size
Unclassifiable eczema 1 case, increasing Contact eczema 3 cases, 2 remaining the same 1 increasing 2 varying in size
Does this skin disease itch?
Unclassifiable eczema 1 case, itching Contact eczema 3 cases, all itching
When does it itch? Unclassifiable eczema 1 case, itching in bed Contact eczema 3 cases, itching 1 in the hot sun 2 during rainy season 2 in bed 1 during hot season 2 after bathing 3 during cold season
Are there any others at home who have the same signs of a skin disease as you?
Affection others Diagnosis No 1 person 2 persons Total
Unclassifiable 1 0 0 1 Eczema 100.00 0.00 0.00 100.00
Contact 1 1 1 3 Eczema 33.33 33.33 33.33 100.00
Eczematous lesions: the most frequent localizations Diagnosis Localization Frequency Percent Vaseline Dermatitis Lower leg 1 (1) 100.00 Atopic eczema Back 1 (1) 100.00 Upper arm (ant. aspect) 1 (1) 100.00 Fore arm (ant. aspect) 1 (1) 100.00
Eczematous lesions: the most frequent localizations Diagnosis Localization Frequency Percent Unclassifiable eczema Back 2 (4) 50.00 Face 1 (4) 25.00 Chest 1 (4) 25.00 Contact eczema Back 2 (4) 50.00 Upper arm (post. asp.) 2 (4) 50.00 Fore arm (post. aspect) 2 (4) 50.00 169 Appendix B
7.6.2.4 Keratoses Prevalence according to school
School Lihami Michenga Total
Ichthyosis 0 1 1 0.00 100.00 100.00 0.00 100.00 50.00
L.spinosus 1 0 1 100.00 0.00 100.00 100.00 0.00 50.00
Total 1 1 2 50.00 50.00 100.00 100.00 100.00 100.00 Fisher's exact test Pr = 1.000
7.6.2.5 Pigmentary disorders
School Lihami Michenga Total
Vitiligo 2 1 3 66.67 33.33 100.00 33.33 14.29 23.08
Hypopig. 4 6 10 40.00 60.00 100.00 66.67 85.71 76.92
Total 6 7 13 46.15 53.85 100.00 100.00 100.00 100.00 Fisher's exact test Pr = 0.559
Three other possible diagnoses were not seen: Undefined pigmentary disorders, suspected leprosy, others
Proportion “pigmentary disorders” /over all number of diagnoses = 13/ 573 = 2.27 % Non-infectious diagnoses = 13/149 = 8.72 %
Prevalence according to school
School Lihami Michenga Total
All 405 402 807 Children 50.19 49.81 100.00 Seen 98.54 98.29 98.41
Pigmentary 6 7 13 Disorders 46.15 53.85 100.00 1.46 1.71 1.59
Total 411 409 820 50.12 49.88 100.00 Pearson chi2(1) = 0.0832 100.00 100.00 100.00 Pr = 0.773 170 Appendix B
Vitiligo/other hypopigmented skin diseases Prevalence according to age group
Age group 6 - 10 11 - 14 15 - 19 Total
No 332 339 128 799 Skin 41.55 42.43 16.02 100.00 Diseases 98.52 98.55 97.71 98.40
Vitiligo 2 1 0 3 66.67 33.33 0.00 100.00 0.59 0.29 0.00 0.37
Hypo - 3 4 3 10 Pigmentation 30.00 40.00 30.00 100.00 0.89 1.16 2.29 1.23
Total 337 344 131 812 41.50 42.36 16.13 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.678
Prevalence according to sex
Sex Diagnosis f m Total
No 384 415 799 Skin 48.06 51.94 100.00 Disease 98.46 98.34 98.40
Vitiligo 1 2 3 33.33 66.67 100.00 0.26 0.47 0.37
Hypo - 5 5 10 pigmentation 50.00 50.00 100.00 1.28 1.18 1.23
Total 390 422 812 48.03 51.97 100.00 100.00 100.00 100.00
Fisher's exact = 1.000
Most frequent localization Diagnosis Localization Frequency Percent Vitiligo Thigh (right ant.) 1 (2) 50.00 Thigh (right post.) 1 (2) 50.00 Knee (left ant.) 1 (2) 50.00 Knee (left post.) 1 (2) 50.00 Lower leg (right ant.) 1 (2) 50.00 171 Appendix B
Most frequent localization Diagnosis Localization Frequency Percent Other hypopigmented Face 4 (9) 44.44 skin diseases Chest 1 (9) 11.11 Right arm/wrist/ hand 1 (9) 11.11 Forearm (right ant.) 1 (9) 11.11 Forearm (right post.) 1 (9) 11.11 Inguinal region 1 (9) 11.11 Lower leg (left ant.) 1 (9) 11.11
7.6.2.6 Keloids and hypertrophic scars
School Liham Michenga Total
Keloids 1 3 4 25.00 75.00 100.00 100.00 100.00 100.00
Proportion of children with diagnosis “Keloids”/over all number of diagnoses = 4/573 = 0.70 %
Non-infectious diagnoses = 4/149 = 2.68 %
Prevalence according to school
School Lihami Michenga Total
All 410 406 816 children 50.25 49.75 100.00 seen 99.76 99.27 99.51
Children 1 3 4 with 25.00 75.00 100.00 keloids 0.24 0.73 0.49
Total 411 409 820 50.12 49.88 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.373 172 Appendix B
Prevalence according to age group
0 = Children without keloids 14 = Children with keloids
Age group 6 - 10 11 - 14 15 - 19 Total
0 336 343 129 808 41.58 42.45 15.97 100.00 99.70 99.71 98.47 99.51
14 1 1 2 4 25.00 25.00 50.00 100.00 0.30 0.29 1.53 0.49
Total 337 344 131 812 41.50 42.36 16.13 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.280
Prevalence according to sex
0 = Children without keloids 14 = Children with keloids
Sex f m Total
0 388 420 808 48.02 51.98 100.00 99.49 99.53 99.51
14 2 2 4 50.00 50.00 100.00 0.51 0.47 0.49
Total 390 422 812 48.03 51.97 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 1.000
Keloids: most frequent localization Diagnosis Localization Frequency Percent Keloids Pubic region 1 (4) 25.00 Right ear 1 (4) 25.00 Trunk 1 (4) 25.00 Knee (left lateral) 1 (4) 25.00 In all cases keloids were either additional Picture beside a principal lesion or were not documented in detail for other
7.6.2.7 Acneiform lesions
School Lihami Michenga Total
Acne 11 10 21 52.38 47.62 100.00 173 Appendix B
Proportion diagnosis “acneiform lesions” /over all number of diagnoses = 21/ 573 = 3.66 % Non-infectious diagnoses = 21/149 = 14.09 %
Proportion of diagnosis “acneiform lesions” /all children: 21/820 = 2.56 %
Prevalence according to age group
0 = Children without acneiform lesions 15 = Children with acneiform lesions
Age group 6 - 10 11 - 14 15 - 19 Total
0 337 337 117 791 42.60 42.60 14.79 100.00 100.00 97.97 89.31 97.41
15 0 7 14 21 0.00 33.33 66.67 100.00 0.00 2.03 10.69 2.59
Total 337 344 131 812 41.50 42.36 16.13 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.000
Age 13 14 15 16 17 18 19 Total
Acneiform 1 6 4 5 2 2 1 21 Lesions 4.76 28.57 19.05 23.81 9.52 9.52 4.76 100.00
Prevalence according to age and sex
Age group Sex 11 - 14 15 - 19 Total f 5 4 9 55.56 44.44 100.00 71.43 28.57 42.86 m 2 10 12 16.67 83.33 100.00 28.57 71.43 57.14
Total 7 14 21 33.33 66.67 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.159 Age Sex 13 14 15 16 17 18 19 Total f 1 4 1 2 0 1 0 9 m 0 2 3 3 2 1 1 12
Total 1 6 4 5 2 2 1 21 174 Appendix B
Prevalence according to sex
0 = Children without acneiform lesions 15 = Children with acneiform lesions
Sex f m Total
0 381 410 791 48.17 51.83 100.00 97.69 97.16 97.41
15 9 12 21 42.86 57.14 100.00 2.31 2.84 2.59
Total 390 422 812 48.03 51.97 100.00 100.00 100.00 100.00
Pearson chi2(1) = 0.2311 Pr = 0.631 175 Appendix C
Appendix C Living conditions and hygiene behaviour among the study population and their influence on the prevalence of skin diseases (data analysis)
1 Living conditions and hygiene behaviour among the children of Lihami and Michenga What is your religion?
Chr. Musl. Total
Lihami 186 190 376 49.47 50.53 100.00 71.26 66.20 68.61
Michenga 75 97 172 43.60 56.40 100.00 28.74 33.80 31.39
Total 261 287 548 47.63 52.37 100.00 100.00 100.00 100.00
Pearson chi2(1) = 1.6266 Pr = 0.202
What education did your father receive?
1= No formal education/Adult education 0= no information (not included in analysis) 2= Primary education 3= Secondary/post secondary education
Education 1 2 3 Total
Lihami 14 307 41 362 3.87 84.81 11.33 100.00 70.00 68.37 80.39 69.62
Michenga 6 142 10 158 3.80 89.87 6.33 100.00 30.00 31.63 19.61 30.38
Total 20 449 51 520 3.85 86.35 9.81 100.00 100.00 100.00 100.00 100.00
Pearson chi2(2) = 3.1286 Pr = 0.209 176 Appendix C
What is your father’s profession?
Profession peasant civil s. s.c.income Total
Lihami 193 28 127 348 55.46 8.05 36.49 100.00 62.46 71.79 83.55 69.60
Michenga 116 11 25 152 76.32 7.24 16.45 100.00 37.54 28.21 16.45 30.40
Total 309 39 152 500 61.80 7.80 30.40 100.00 100.00 100.00 100.00 100.00
Pearson chi2(2) = 21.5202 Pr = 0.000
“My father died”
alive dead Total
Lihami 387 24 411 94.16 5.84 100.00 49.55 61.54 50.12
Michenga 394 15 409 96.33 3.67 100.00 50.45 38.46 49.88
Total 781 39 820 95.24 4.76 100.00 100.00 100.00 100.00
Pearson chi2(1) = 2.1348 Pr = 0.144
What education did your mother receive?
1= No formal education/Adult education 0= no information (not included in analysis) 2= Primary education 3=Secondary/post secondary education
Education mother 1 2 3 Total
Lihami 28 319 20 367 7.63 86.92 5.45 100.00 53.85 71.05 71.43 69.38
Michenga 24 130 8 162 14.81 80.25 4.94 100.00 46.15 28.95 28.57 30.62
Total 52 449 28 529 9.83 84.88 5.29 100.00 100.00 100.00 100.00 100.00
Pearson chi2(2) = 6.5484 Pr = 0.038 177 Appendix C
What is your mother’s profession?
Profession peasant civil serv. Inf. sector Total
Lihami 331 7 25 363 91.18 1.93 6.89 100.00 68.96 50.00 86.21 69.41
Michenga 149 7 4 160 93.13 4.38 2.50 100.00 31.04 50.00 13.79 30.59
Total 480 14 29 523 91.78 2.68 5.54 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.040
“My mother died”
alive dead Total
Lihami 364 5 369 98.64 1.36 100.00 69.47 45.45 68.97
Michenga 160 6 166 96.39 3.61 100.00 30.53 54.55 31.03
Total 524 11 535 97.94 2.06 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.104
How many people live at home with you?
No_people 1-5 6-10 11 + Total
Lihami 151 216 14 381 39.63 56.69 3.67 100.00 69.27 70.36 56.00 69.27
Michenga 67 91 11 169 39.64 53.85 6.51 100.00 30.73 29.64 44.00 30.73
Total 218 307 25 550 39.64 55.82 4.55 100.00 100.00 100.00 100.00 100.00
Pearson chi2(2) = 2.2390 Pr = 0.326 178 Appendix C
How many people live at home with you? Density according to age group
Age group Number of People at home 6 - 10 11 - 14 15 - 19 Total
1-5 112 87 19 218 51.38 39.91 8.72 100.00 48.07 36.55 24.68 39.78
6-10 113 139 53 305 37.05 45.57 17.38 100.00 48.50 58.40 68.83 55.66
11 + 8 12 5 25 32.00 48.00 20.00 100.00 3.43 5.04 6.49 4.56
Total 233 238 77 548 42.52 43.43 14.05 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.003
How many rooms do you have at home alltogether?
No_rooms 1 o. 2 3 o. 4 5 o. 6 >6 Total
Lihami 149 66 150 17 382 39.01 17.28 39.27 4.45 100.00 66.22 68.04 71.77 77.27 69.08
Michenga 76 31 59 5 171 44.44 18.13 34.50 2.92 100.00 33.78 31.96 28.23 22.73 30.92
Total 225 97 209 22 553 40.69 17.54 37.79 3.98 100.00 100.00 100.00 100.00 100.00 100.00
Pearson chi2(3) = 2.3088 Pr = 0.511
How many people per room are living in your household?
No_rooms <=2 >2 - <=4 >4 - <=6 > 6 Total
Lihami 220 146 9 3 378 58.20 38.62 2.38 0.79 100.00 73.33 63.48 69.23 100.00 69.23
Michenga 80 84 4 0 168 47.62 50.00 2.38 0.00 100.00 26.67 36.52 30.77 0.00 30.77
Total 300 230 13 3 546 54.95 42.12 2.38 0.55 100.00 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.065 179 Appendix C
What materials is your house built from?
q39_1: wooden beams q39_2: mud Yes No Total Yes No Total
Lihami 19 364 383 Lihami 68 315 383 4.96 95.04 100.00 17.75 82.25 100.00 67.86 69.07 69.01 50.00 75.18 69.01
Mich. 9 163 172 Mich. 68 104 172 5.23 94.77 100.00 39.53 60.47 100.00 32.14 30.93 30.99 50.00 24.82 30.99
Total 28 527 555 Total 136 419 555 5.05 94.95 100.00 24.50 75.50 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Pearson chi2(1) = 0.0183 Pr = 0.892 Pearson chi2(1) = 30.4366 Pr = 0.000
q39_3: stones q39_4: bricks Yes No Total Yes No Total
Lihami 10 373 383 Lihami 336 47 383 2.61 97.39 100.00 87.73 12.27 100.00 83.33 68.69 69.01 76.02 41.59 69.01
Mich. 2 170 172 Mich. 106 66 172 1.16 98.84 100.00 61.63 38.37 100.00 16.67 31.31 30.99 23.98 58.41 30.99
Total 12 543 555 Total 442 113 555 2.16 97.84 100.00 79.64 20.36 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Fisher’s exact test Pr = 0.359 Pearson chi2(1) = 49.8676 Pr = 0.000
q39_5: lime q39_6: palm leaves Yes No Total Yes No Total
Lihami 10 373 383 Lihami 141 242 383 2.61 97.39 100.00 36.81 63.19 100.00 90.91 68.57 69.01 56.63 79.08 69.01
Mich. 1 171 172 Mich. 108 64 172 0.58 99.42 100.00 62.79 37.21 100.00 9.09 31.43 30.99 43.37 20.92 30.99
Total 11 544 555 Total 249 306 555 1.98 98.02 100.00 44.86 55.14 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.186 Pearson chi2(1) = 32.3777 Pr = 0.000 180 Appendix C
q39_7: iron sheets q39others Yes No Total Cement Wooden planks Tiles Total Lihami 25 2 1 28 Lihami 239 144 383 89.29 7.14 3.57 100.00 62.40 37.60 100.00 92.59 100.00 100.00 93.33 78.62 57.37 69.01 Mich. 2 0 0 2 Mich. 65 107 172 100.00 0.00 0.00 100.00 37.79 62.21 100.00 7.41 0.00 0.00 6.67 21.38 42.63 30.99 Total 27 2 1 30 Total 304 251 555 90.00 6.67 3.33 100.00 100.00 100.00 100.00 100.00 54.77 45.23 100.00 100.00 100.00 100.00 Fisher's exact test Pr = 1.000 Pearson chi2(1) = 29.0232 Pr = 0.000
What source are you using for drinking water?
q40_1: tap water/home q40_2: tap water outside q40_3: well Yes No Total Yes No Total Yes No Total
Lihami 34 348 382 Lihami 35 347 382 Lihami 40 342 382 8.90 91.10 100.00 9.16 90.84 100.00 10.47 89.53 100.00 68.00 69.05 68.95 92.11 67.25 68.95 65.57 69.37 68.95
Mich. 16 156 172 Mich. 3 169 172 Mich. 21 151 172 9.30 90.70 100.00 1.74 98.26 100.00 12.21 87.79 100.00 32.00 30.95 31.05 7.89 32.75 31.05 34.43 30.63 31.05
Total 50 504 554 Total 38 516 554 Total 61 493 554 9.03 90.97 100.00 6.86 93.14 100.00 11.01 88.99 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Pearson chi2(1) = 0.0233 Pearson chi2(1)= 10.2154 Pearson chi2(1) = 0.3657 Pr = 0.879 Pr = 0.001 Pr = 0.545
q40_4: hand pump q40_5: river q40_6: pond Yes No Total Yes No Total Yes No Total
Lihami 288 94 382 Lihami 4 378 382 Lihami 2 380 382 75.39 24.61 100.00 1.05 98.95 100.00 0.52 99.48 100.00 68.57 70.68 69.08 66.67 69.10 69.08 100.00 68.97 69.08
Mich. 132 39 171 Mich. 2 169 171 Mich. 0 171 171 77.19 22.81 100.00 1.17 98.83 100.00 0.00 100.00 100.00 31.43 29.32 30.92 33.33 30.90 30.92 0.00 31.03 30.92
Total 420 133 553 Total 6 547 553 Total 2 551 553 75.95 24.05 100.00 1.08 98.92 100.00 0.36 99.64 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Pearson chi2(1) = 0.2096 Pr = 0.647 Fisher's exact test Pr = 1.000 Fisher's exact test Pr = 1.000 181 Appendix C
How far away is it from your house?
Distance <=2min <=10min <=0.5h <=1h Total
Lihami 165 170 29 8 372 44.35 45.70 7.80 2.15 100.00 70.51 69.39 58.00 57.14 68.51
Michenga 69 75 21 6 171 40.35 43.86 12.28 3.51 100.00 29.49 30.61 42.00 42.86 31.49
Total 234 245 50 14 543 43.09 45.12 9.21 2.58 100.00 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.263
Do you boil drinking water?
Yes No Total
Lihami 130 251 381 34.12 65.88 100.00 83.33 63.22 68.90
Michenga 26 146 172 15.12 84.88 100.00 16.67 36.78 31.10
Total 156 397 553 28.21 71.79 100.00 100.00 100.00 100.00
Pearson chi2(1) = 21.1336 Pr = 0.000
Do you keep animals at home? If yes – what kind of animals?
Animal Fowl Rum. U.* Cats & Dogs Pigs Rabbits Total
Lihami 205 27 51 5 1 289 70.93 9.34 17.65 1.73 0.35 100.00 69.26 71.05 48.57 100.00 33.33 64.65
Michenga 91 11 54 0 2 158 57.59 6.96 34.18 0.00 1.27 100.00 30.74 28.95 51.43 0.00 66.67 35.35
Total 296 38 105 5 3 447 66.22 8.50 23.49 1.12 0.67 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.000 * Ruminating ungulates 182 Appendix C
How many people sleep in your bed?
People per bed 1 2 3 or more Total
Lihami 70 238 73 381 18.37 62.47 19.16 100.00 70.71 68.39 68.87 68.90
Michenga 29 110 33 172 16.86 63.95 19.19 100.00 29.29 31.61 31.13 31.10
Total 99 348 106 553 17.90 62.93 19.17 100.00 100.00 100.00 100.00 100.00
Pearson chi2(2) = 0.1930 Pr = 0.908
How often do you wash yourself?
Category “it depends” was excluded from analysis Washing/times per day 1x 2x 3x > 3x Total
Lihami 59 169 131 15 374 15.78 45.19 35.03 4.01 100.00 79.73 70.71 60.37 93.75 68.50
Michenga 15 70 86 1 172 8.72 40.70 50.00 0.58 100.00 20.27 29.29 39.63 6.25 31.50
Total 74 239 217 16 546 13.55 43.77 39.74 2.93 100.00 100.00 100.00 100.00 100.00 100.00
Pearson chi2(3) = 16.2429 Pr = 0.001
How often do you use soap to wash yourself?
Q53_6: infrequently q53_1: every time I bath q53_2: whenever there is soap Yes No Total Yes No Total Yes No Total
Lihami 23 354 377 Lihami 210 167 377 Lihami 64 313 377 6.10 93.90 100.00 55.70 44.30 100.00 16.98 83.02 100.00 85.19 67.82 68.67 73.94 63.02 68.67 81.01 66.60 68.67
Mich. 4 168 172 Mich. 74 98 172 Mich. 15 157 172 2.33 97.67 100.00 43.02 56.98 100.00 8.72 91.28 100.00 14.81 32.18 31.33 26.06 36.98 31.33 18.99 33.40 31.33
Total 27 522 549 Total 284 265 549 Total 79 470 549 4.92 95.08 100.00 51.73 48.27 100.00 14.39 85.61 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Pearson chi2(1) = 3.5999 Pearson chi2(1) = 7.6049 Pearson chi2(1) = 6.5339 Pr = 0.058 Pr = 0.006 Pr = 0.011 183 Appendix C
q53_8: not at all q53_3: once per day q53_4: twice per day Yes No Total Yes No Total Yes No Total
Lihami 1 376 377 Lihami 41 336 377 Lihami 83 294 377 0.27 99.73 100.00 10.88 89.12 100.00 22.02 77.98 100.00 50.00 68.86 68.80 78.85 67.61 68.67 63.85 70.17 68.67
Mich. 1 170 171 Mich. 11 161 172 Mich. 47 125 172 0.58 99.42 100.00 6.40 93.60 100.00 27.33 72.67 100.00 50.00 31.14 31.20 21.15 32.39 31.33 36.15 29.83 31.33
Total 2 546 548 Total 52 497 549 Total 130 419 549 0.36 99.64 100.00 9.47 90.53 100.00 23.68 76.32 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.527 Pearson chi2(1) = 2.7646 Pearson chi2(1) = 1.8425 Pr = 0.096 Pr = 0.175
53.b Is there any soap at q53_5: three times per day Yes No Total home ?
Lihami 66 311 377 Yes No Total 17.51 82.49 100.00 51.16 74.05 68.67 Lihami 354 23 377 93.90 6.10 100.00 Mich. 63 109 172 68.21 79.31 68.80 36.63 63.37 100.00 48.84 25.95 31.33 Mich. 165 6 171 96.49 3.51 100.00 Total 129 420 549 31.79 20.69 31.20 23.50 76.50 100.00 100.00 100.00 100.00 Total 519 29 548 94.71 5.29 100.00 Pearson chi2(1) = 24.0235 100.00 100.00 100.00 Pr = 0.000 Pearson chi2(1) = 1.5770 Pr = 0.209
Where is your bathing area?
inside courtyard Total
Lihami 15 364 379 3.96 96.04 100.00 53.57 69.60 68.78
Michenga 13 159 172 7.56 92.44 100.00 46.43 30.40 31.22
Total 28 523 551 5.08 94.92 100.00 100.00 100.00 100.00
Pearson chi2(1) = 3.1794 Pr = 0.075 184 Appendix C
Where do you wash yourself?
q56_1: at home q56_2: at the well Yes No Total Yes No Total
Lihami 361 19 380 Lihami 16 364 380 95.00 5.00 100.00 4.21 95.79 100.00 69.56 57.58 68.84 51.61 69.87 68.84
Mich. 158 14 172 Mich. 15 157 172 91.86 8.14 100.00 8.72 91.28 100.00 30.44 42.42 31.16 48.39 30.13 31.16
Total 519 33 552 Total 31 521 552 94.02 5.98 100.00 5.62 94.38 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Pearson chi2(1) = 2.0763 Pr = 0.150 Pearson chi2(1) = 4.5445 Pr = 0.033
q56_3: in the river q56_4: at the pump Yes No Total Yes No Total
Lihami 19 361 380 Lihami 5 374 379 5.00 95.00 100.00 1.32 98.68 100.00 86.36 68.11 68.84 55.56 69.00 68.78
Mich. 3 169 172 Mich. 4 168 172 1.74 98.26 100.00 2.33 97.67 100.00 13.64 31.89 31.16 44.44 31.00 31.22
Total 22 530 552 Total 9 542 551 3.99 96.01 100.00 1.63 98.37 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Pearson chi2(1) = 3.2800 Pr = 0.070 Fisher's exact test Pr = 0.471
2 Influence of living conditions and hygiene behaviour on the overall prevalence of skin diseases and infectious versus non-infectious skin diseases In the case of questions dealing with living conditions and hygiene behaviour, only significant results are presented.
Children with skin disorders versus children without skin disorders
What education did your father receive?
0 = Not known, excluded from analysis! 1= No formal education/Adult education 2= Primary education 3=Secondary/post secondary education 185 Appendix C
Education 1 2 3 Total skin 9 244 40 293 disease 3.07 83.28 13.65 100.00 45.00 54.34 78.43 56.35 no 11 205 11 227 disease 4.85 90.31 4.85 100.00 55.00 45.66 21.57 43.65
Total 20 449 51 520 3.85 86.35 9.81 100.00 100.00 100.00 100.00 100.00
Pearson chi2(2) = 11.8924 Pr = 0.003
What materials is your house built from?
1= Children with dermatoses 2= Children without dermatoses
q39_1: wooden beams q39_2: mud Yes No Total Yes No Total
1 19 295 314 1 68 246 314 6.05 93.95 100.00 21.66 78.34 100.00 67.86 55.98 56.58 50.00 58.71 56.58
2 9 ´ 232 241 2 68 173 241 3.73 96.27 100.00 28.22 71.78 100.00 32.14 44.02 43.42 50.00 41.29 43.42
Total 28 527 555 Total 136 419 555 5.05 94.95 100.00 24.50 75.50 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Pearson chi2(1) = 1.5274 Pr = 0.217 Pearson chi2(1) = 3.1714 Pr = 0.075
q39_3: stones q39_4: bricks Yes No Total Yes No Total
1 5 309 314 1 267 47 314 1.59 98.41 100.00 85.03 14.97 100.00 41.67 56.91 56.58 60.41 41.59 56.58
2 7 234 241 2 175 66 241 2.90 97.10 100.00 72.61 27.39 100.00 58.33 43.09 43.42 39.59 58.41 43.42
Total 12 543 555 Total 442 113 555 2.16 97.84 100.00 79.64 20.36 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Pearson chi2(1) = 1.1098 Pr = 0.292 Pearson chi2(1) = 12.9665 Pr = 0.000 186 Appendix C
q39_5: lime q39_6: palm leaves Yes No Total Yes No Total
1 9 305 314 1 123 191 314 2.87 97.13 100.00 39.17 60.83 100.00 81.82 56.07 56.58 49.40 62.42 56.58
2 2 239 241 2 126 115 241 0.83 99.17 100.00 52.28 47.72 100.00 18.18 43.93 43.42 50.60 37.58 43.42
Total 11 544 555 Total 249 306 555 1.98 98.02 100.00 44.86 55.14 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.125 Pearson chi2(1) = 9.4741 Pr = 0.002
q39_7: iron sheets q39others Yes No Total cement w.p.* tiles Total
1 190 124 314 1 16 0 0 16 60.51 39.49 100.00 100.00 0.00 0.00 100.00 62.50 49.40 56.58 59.26 0.00 0.00 53.33
2 114 127 241 2 11 2 1 14 47.30 52.70 100.00 78.57 14.29 7.14 100.00 37.50 50.60 43.42 40.74 100.00 100.00 46.67
Total 304 251 555 Total 27 2 1 30 54.77 45.23 100.00 90.00 6.67 3.33 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Pearson chi2(1) = 9.6001 Pr = 0.002 Fisher's exact test Pr = 0.090
* wooden planks on the roof
What source are you using for drinking water?
1 = Children with skin diseases 2 = Children without skin diseases
q40_1: tap water at home q40_2: tap water outside Yes No Total Yes No Total
1 38 275 313 0 21 292 313 12.14 87.86 100.00 6.71 93.29 100.00 76.00 54.56 56.50 55.26 56.59 56.50
2 12 229 241 1 17 224 241 4.98 95.02 100.00 7.05 92.95 100.00 24.00 45.44 43.50 44.74 43.41 43.50
Total 50 504 554 Total 38 516 554 9.03 90.97 100.00 6.86 93.14 100.00 100.00 100.00 100.00 100.00 100.00 100.00 DNK excluded from analysis Pearson chi2(1) = 8.5047 Pr = 0.004 Pearson chi2(1) = 0.0253 Pr = 0.874 187 Appendix C
q40_3: well q40_4: hand pump Yes No Total Yes No Total
0 35 278 313 0 228 84 312 11.18 88.82 100.00 73.08 26.92 100.00 57.38 56.39 56.50 54.29 63.16 56.42
1 26 215 241 1 192 49 241 10.79 89.21 100.00 79.67 20.33 100.00 42.62 43.61 43.50 45.71 36.84 43.58
Total 61 493 554 Total 420 133 553 11.01 88.99 100.00 75.95 24.05 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Pearson chi2(1) = 0.0215 Pr = 0.883 Pearson chi2(1) = 3.2338 Pr = 0.072
q40_5: river q40_6: pond Yes No Total Yes No Total
0 3 309 312 0.96 99.04 100.00 0 2 310 312 50.00 56.49 56.42 0.64 99.36 100.00 100.00 56.26 56.42 1 3 238 241 1.24 98.76 100.00 1 0 241 241 50.00 43.51 43.58 0.00 100.00 100.00 0.00 43.74 43.58 Total 6 547 553 1.08 98.92 100.00 Total 2 551 553 100.00 100.00 100.00 0.36 99.64 100.00 100.00 100.00 100.00 Fisher's exact test Pr = 1.000 Fisher's exact test Pr = 0.507
Do you boil drinking water?
Children with answer 4 = DNK were excluded from analysis
Yes No Total skin 99 214 313 disease 31.63 68.37 100.00 63.46 53.90 56.60 no 57 183 240 disease 23.75 76.25 100.00 36.54 46.10 43.40
Total 156 397 553 28.21 71.79 100.00 100.00 100.00 100.00
Pearson chi2(1) = 4.1644 Pr = 0.041 188 Appendix C
Children with infectious dermatoses or infectious & non-infectious dermatoses How many people live at home with you?
1 = Children with infectious dermatoses or infectious + non – infectious dermatoses 2 = Children without any dermatoses or only with non – infectious dermatoses
No_people 1-5 6-10 11 + Total
1 85 154 12 251 33.86 61.35 4.78 100.00 38.99 50.16 48.00 45.64
2 133 153 13 299 44.48 51.17 4.35 100.00 61.01 49.84 52.00 54.36
Total 218 307 25 550 39.64 55.82 4.55 100.00 Pearson chi2(2) = 6.4723 100.00 100.00 100.00 100.00 Pr = 0.039
Assessment of household density: “How many people live at home with you?”
1 = Children with infectious dermatoses or infectious + non – infectious dermatoses 2 = Children without any dermatoses or only with non – infectious dermatoses
Number of_people at home 1-5 6 or more Total
1 85 166 251 33.86 66.14 100.00 38.99 50.00 45.64
2 133 166 299 44.48 55.52 100.00 61.01 50.00 54.36
Total 218 332 550 39.64 60.36 100.00 100.00 100.00 100.00 Pearson chi2(1) = 6.4287 Pr = 0.011
What materials is your house built from?
1 = Children with infectious dermatoses or infectious + non – infectious dermatoses 2 = Children without any dermatoses or only with non – infectious dermatoses
Q39_1: wooden beams q39_2: mud Yes No Total Yes No Total
1 15 238 253 1 54 199 253 5.93 94.07 100.00 21.34 78.66 100.00 53.57 45.16 45.59 39.71 47.49 45.59
2 13 289 302 2 82 220 302 4.30 95.70 100.00 27.15 72.85 100.00 46.43 54.84 54.41 60.29 52.51 54.41
Total 28 527 555 Total 136 419 555 5.05 94.95 100.00 P. chi2(1) = 0.7581 24.50 75.50 100.00 P. chi2(1) = 2.5107 100.00 100.00 100.00 Pr = 0.384 100.00 100.00 100.00 Pr = 0.113 189 Appendix C q39_3: stones q39_4: bricks Yes No Total Yes No Total
1 4 249 253 1 216 37 253 1.58 98.42 100.00 85.38 14.62 100.00 33.33 45.86 45.59 48.87 32.74 45.59
2 8 294 302 2 226 76 302 2.65 97.35 100.00 74.83 25.17 100.00 66.67 54.14 54.41 51.13 67.26 54.41
Total 12 543 555 Total 442 113 555 2.16 97.84 100.00 79.64 20.36 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Pearson chi2(1) = 0.7423 Pr = 0.389 Pearson chi2(1) = 9.4338 Pr = 0.002 q39_5: lime q39_6: palm leaves Yes No Total Yes No Total
1 7 246 253 1 97 156 253 2.77 97.23 100.00 38.34 61.66 100.00 63.64 45.22 45.59 38.96 50.98 45.59
2 4 298 302 2 152 150 302 1.32 98.68 100.00 50.33 49.67 100.00 36.36 54.78 54.41 61.04 49.02 54.41
Total 11 544 555 Total 249 306 555 1.98 98.02 100.00 44.86 55.14 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Pearson chi2(1) = 1.4741 Pr = 0.225 Pearson chi2(1) = 8.0025 Pr = 0.005 q39_7: iron sheets q39others Yes No Total cement w.p.* tiles Total
1 152 101 253 1 14 0 0 14 60.08 39.92 100.00 100.00 0.00 0.00 100.00 50.00 40.24 45.59 51.85 0.00 0.00 46.67
2 152 150 302 2 13 2 1 16 50.33 49.67 100.00 81.25 12.50 6.25 100.00 50.00 59.76 54.41 48.15 100.00 100.00 53.33
Total 304 251 555 Total 27 2 1 30 54.77 45.23 100.00 90.00 6.67 3.33 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Pearson chi2(1) = 5.2808 Pr = 0.022 Fisher's exact test Pr = 0.485 * wooden planks on the roof 190 Appendix C
What source are you using for drinking water?
1 = Children with infectious dermatoses or infectious + non – infectious dermatoses 2 = Children without any dermatoses or only with non – infectious dermatoses
q40_1: tap water at home q40_2: tap water outside Yes No Total Yes No Total
1 32 221 253 1 18 235 253 12.65 87.35 100.00 7.11 92.89 100.00 64.00 43.85 45.67 47.37 45.54 45.67
2 18 283 301 2 20 281 301 5.98 94.02 100.00 6.64 93.36 100.00 36.00 56.15 54.33 52.63 54.46 54.33
Total 50 504 554 Total 38 516 554 9.03 90.97 100.00 6.86 93.14 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Pearson chi2(1) = 7.4440 Pr = 0.006 Pearson chi2(1) = 0.0476 Pr = 0.827
q40_3: well q40_4: hand pump Yes No Total Yes No Total
1 26 227 253 1 183 69 252 10.28 89.72 100.00 72.62 27.38 100.00 42.62 46.04 45.67 43.57 51.88 45.57
2 35 266 301 2 237 64 301 11.63 88.37 100.00 78.74 21.26 100.00 57.38 53.96 54.33 56.43 48.12 54.43
Total 61 493 554 Total 420 133 553 11.01 88.99 100.00 75.95 24.05 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Pearson chi2(1) = 0.2561 Pr = 0.613 Pearson chi2(1) = 2.8111 Pr = 0.094
q40_5: river q40_6: pond Yes No Total Yes No Total
1 3 249 252 1 1 251 252 1.19 98.81 100.00 0.40 99.60 100.00 50.00 45.52 45.57 50.00 45.55 45.57
2 3 298 301 2 1 300 301 1.00 99.00 100.00 0.33 99.67 100.00 50.00 54.48 54.43 50.00 54.45 54.43
Total 6 547 553 Total 2 551 553 1.08 98.92 100.00 0.36 99.64 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 1.000 Fisher's exact test Pr = 1.000 191 Appendix C
3 Tinea versicolor: assessment of living conditions and hygiene behaviour What education did your father receive?
1= No formal education/Adult education 0= no information (not included in analysis) 2= Primary education 3=Secondary/post secondary education
T. versicolor/No diagnoses:
Education 1 2 3 Total
No 11 205 11 227 skin 4.85 90.31 4.85 100.00 disease 61.11 64.06 37.93 61.85
T. vers. 7 115 18 140 5.00 82.14 12.86 100.00 38.89 35.94 62.07 38.15
Total 18 320 29 367 4.90 87.19 7.90 100.00 100.00 100.00 100.00 100.00
Pearson chi2(2) = 7.6998 Pr = 0.021
How many people live at home with you?
Number of people at home 1 - 5 6 – 10 more than 10 Total
Children 173 207 21 401 Without 43.14 51.62 5.24 100.00 T. versicolor 79.36 67.43 84.00 72.91
Children 45 100 4 149 With 30.20 67.11 2.68 100.00 T. versicolor 20.64 32.57 16.00 27.09
Total 218 307 25 550 39.64 55.82 4.55 100.00 100.00 100.00 100.00 100.00
Pearson chi2(2) = 10.8184 Pr = 0.004 Fisher's exact = 0.004
Number of people at home 1 - 5 more than 5 Total
Children 173 228 401 Without 43.14 56.86 100.00 T. versicolor 79.36 68.67 72.91
Children 45 104 149 With 30.20 69.80 100.00 T. versicolor 20.64 31.33 27.09
Total 218 332 550 39.64 60.36 100.00 Pearson chi2(1) = 7.6036 100.00 100.00 100.00 Pr = 0.006 192 Appendix C
What materials is your house built from?
T. versicolor/No diagnoses:
0 = children without any skin disease 1 = children with t. versicolor
q39_1: wooden beams q39_2: mud Yes No Total Yes No Total
0 9 232 241 0 68 173 241 3.73 96.27 100.00 28.22 71.78 100.00 42.86 62.87 61.79 66.67 60.07 61.79
1 12 137 149 1 34 115 149 8.05 91.95 100.00 22.82 77.18 100.00 57.14 37.13 38.21 33.33 39.93 38.21
Total 21 369 390 Total 102 288 390 5.38 94.62 100.00 26.15 73.85 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Pearson chi2(1) = 3.3716 Pr = 0.066 Pearson chi2(1) = 1.3886 Pr = 0.239
q39_3: stones q39_4: bricks Yes No Total Yes No Total
0 7 234 241 0 175 66 241 2.90 97.10 100.00 72.61 27.39 100.00 70.00 61.58 61.79 57.95 75.00 61.79
1 3 146 149 1 127 22 149 2.01 97.99 100.00 85.23 14.77 100.00 30.00 38.42 38.21 42.05 25.00 38.21
Total 10 380 390 Total 302 88 390 2.56 97.44 100.00 77.44 22.56 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.748 Pearson chi2(1) = 8.3937 Pr = 0.004
q39_5: lime q39_6: palm leaves Yes No Total Yes No Total
0 2 239 241 0 126 115 241 0.83 99.17 100.00 52.28 47.72 100.00 33.33 62.24 61.79 66.67 57.21 61.79
1 4 145 149 1 63 86 149 2.68 97.32 100.00 42.28 57.72 100.00 66.67 37.76 38.21 33.33 42.79 38.21
Total 6 384 390 Total 189 201 390 1.54 98.46 100.00 48.46 51.54 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.208 Pearson chi2(1) = 3.6867 Pr = 0.055 193 Appendix C
q39_7: iron sheets q39others Cement Wooden planks Tiles Yes No Total Total
0 114 127 241 0 11 2 1 14 47.30 52.70 100.00 78.57 14.29 7.14 100.00 52.38 100.00 100.00 58.33 57.00 66.84 61.79 1 10 0 0 10 1 86 63 149 100.00 0.00 0.00 100.00 57.72 42.28 100.00 47.62 0.00 0.00 41.67 43.00 33.16 38.21 Total 21 2 1 24 87.50 8.33 4.17 100.00 Total 200 190 390 100.00 100.00 100.00 100.00 51.28 48.72 100.00 Fisher's exact test Pr = 0.493 100.00 100.00 100.00
Pearson chi2(1) = 3.9978 Pr = 0.046
What source are you using for drinking water?
T. versicolor/No diagnoses:
0 = No skin disease 1 = T. versicolor
q40_1: tap water/home q40_2: tapwater outside Yes No Total Yes No Total
0 12 229 241 0 17 224 241 4.98 95.02 100.00 7.05 92.95 100.00 36.36 64.15 61.79 65.38 61.54 61.79
1 21 128 149 1 9 140 149 14.09 85.91 100.00 6.04 93.96 100.00 63.64 35.85 38.21 34.62 38.46 38.21
Total 33 357 390 Total 26 364 390 8.46 91.54 100.00 6.67 93.33 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Pearson chi2(1) = 9.8758 Pr = 0.002 Pearson chi2(1) = 0.1521 Pr = 0.697
q40_3: well q40_4: hand pump Yes No Total Yes No Total
0 26 215 241 0 192 49 241 10.79 89.21 100.00 79.67 20.33 100.00 61.90 61.78 61.79 64.86 52.69 61.95
1 16 133 149 1 104 44 148 10.74 89.26 100.00 70.27 29.73 100.00 38.10 38.22 38.21 35.14 47.31 38.05
Total 42 348 390 Total 296 93 389 10.77 89.23 100.00 76.09 23.91 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Pearson chi2(1) = 0.0002 Pr = 0.988 Pearson chi2(1) = 4.4515 Pr = 0.035 194 Appendix C
q40_5: river q40_6: pond Yes No Total No Total
0 3 238 241 1.24 98.76 100.00 0 241 241 50.00 62.14 61.95 100.00 100.00 61.95 61.95 1 3 145 148 2.03 97.97 100.00 1 148 148 50.00 37.86 38.05 100.00 100.00 38.05 38.05 Total 6 383 389 1.54 98.46 100.00 Total 389 389 100.00 100.00 100.00 100.00 100.00 100.00 100.00 Fisher's exact test Pr = 0.678
Do you keep animals at home? If yes, what kind of animals?
T. versicolor/No diagnoses: What kind of animals Fowl Rum. U.* Cats & Dogs Pigs Rabbits Total
0 131 11 52 1 1 196 66.84 5.61 26.53 0.51 0.51 100.00 60.37 42.31 72.22 33.33 50.00 61.25
1 86 15 20 2 1 124 69.35 12.10 16.13 1.61 0.81 100.00 39.63 57.69 27.78 66.67 50.00 38.75
Total 217 26 72 3 2 320 67.81 8.13 22.50 0.94 0.63 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.034 * ruminant ungulates = cows, goats, sheep
4 Dermatophyte infections (tinea capitis/faciei/corporis/pedis): assessment of living conditions and hygiene behaviour How many people live at home with you?
Number of people at home 1 - 5 6 – 10 more than 10 Total
Children 194 271 15 480 Without 40.42 56.46 3.13 100.00 Derm. inf. 88.99 88.27 60.00 87.27
Children 24 36 10 70 With 34.29 51.43 14.29 100.00 Derm. inf.* 11.01 11.73 40.00 12.73
Total 218 307 25 550 39.64 55.82 4.55 100.00 Pearson chi2(2) = 17.5973 100.00 100.00 100.00 100.00 Pr = 0.000 * dermatophyte infections 195 Appendix C
No_people 1-5 6-10 11 + Total
No 107 122 10 239 Skin 44.77 51.05 4.18 100.00 Diseases 81.68 77.22 50.00 77.35
Derm. inf.. 24 36 10 70 34.29 51.43 14.29 100.00 18.32 22.78 50.00 22.65
Total 131 158 20 309 42.39 51.13 6.47 100.00 Fisher's exact test 100.00 100.00 100.00 100.00 Pr = 0.011
No_people No_people 1-5 6+ Total 1-10 11 + Total
No 107 132 239 No 229 10 239 Skin 44.77 55.23 100.00 Skin 95.82 4.18 100.00 Disease 81.68 74.16 77.35 Disease 79.24 50.00 77.35
Derm. 24 46 70 Derm. 60 10 70 Inf. 34.29 65.71 100.00 Inf. 85.71 14.29 100.00 18.32 25.84 22.65 20.76 50.00 22.65
Total 131 178 309 Total 289 20 309 42.39 57.61 100.00 93.53 6.47 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Pearson chi2(1) = 2.4369 Pr = 0.119 Pearson chi2(1) = 9.1266 Pr = 0.003
What materials is your house built from?
Dermatophyte infections (t. capitis/faciei/corporis/pedis)/ children without dermatoses
q39_1: wooden beams q39_2: mud Yes No Total Yes No Total
No 9 232 241 No 68 173 241 Skin 3.73 96.27 100.00 Skin 28.22 71.78 100.00 Disease 69.23 77.59 77.24 Disease 77.27 77.23 77.24
Tineae 4 67 71 Tineae 20 51 71 5.63 94.37 100.00 28.17 71.83 100.00 30.77 22.41 22.76 22.73 22.77 22.76
Total 13 299 312 Total 88 224 312 4.17 95.83 100.00 28.21 71.79 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.502 Pearson chi2(1) = 0.0001 Pr = 0.994 196 Appendix C q39_3: stones q39_4: bricks Yes No Total Yes No Total
No 7 234 241 No 175 66 241 Skin 2.90 97.10 100.00 Skin 72.61 27.39 100.00 Disease 100.00 76.72 77.24 Disease 75.43 82.50 77.24
Tineae 0 71 71 Tineae 57 14 71 0.00 100.00 100.00 80.28 19.72 100.00 0.00 23.28 22.76 24.57 17.50 22.76
Total 7 305 312 Total 232 80 312 2.24 97.76 100.00 74.36 25.64 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.357 Pearson chi2(1) = 1.6911 Pr = 0.193 q39_5: lime q39_6: palm leaves Yes No Total Yes No Total
No 2 239 241 No 126 115 241 Skin 0.83 99.17 100.00 Skin 52.28 47.72 100.00 Disease 40.00 77.85 77.24 Disease 84.00 70.99 77.24
Tineae 3 68 71 Tineae 24 47 71 4.23 95.77 100.00 33.80 66.20 100.00 60.00 22.15 22.76 16.00 29.01 22.76
Total 5 307 312 Total 150 162 312 1.60 98.40 100.00 48.08 51.92 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.080 Pearson chi2(1) = 7.5023 Pr = 0.006 q39_7: iron sheets q39others Wooden Cement planks Tiles Total Yes No Total No 11 2 1 14 No 114 127 241 Skin 78.57 14.29 7.14 100.00 Skin 47.30 52.70 100.00 Disease 73.33 100.00 100.00 77.78 Disease 72.61 81.94 77.24 Derm. 4 0 0 4 Inf. 100.00 0.00 0.00 100.00 Derm. 43 28 71 26.67 0.00 0.00 22.22 Inf. 60.56 39.44 100.00 Total 15 2 1 18 27.39 18.06 22.76 83.33 11.11 5.56 100.00 100.00 100.00 100.00 100.00 Total 157 155 312 50.32 49.68 100.00 Fisher's exact test Pr = 1.000 100.00 100.00 100.00
Pearson chi2(1) = 3.8576 Pr = 0.050 197 Appendix C
How many times per day do you wash yourself?
Washing/times per day 1x 2x 3x >3x Total
Children 60 210 195 11 476 Without 12.61 44.12 40.97 2.31 100.00 Derm. inf. 81.08 87.87 89.86 68.75 87.18
Children 14 29 22 5 70 With 20.00 41.43 31.43 7.14 100.00 Derm. inf. 18.92 12.13 10.14 31.25 12.82
Total 74 239 217 16 546 13.55 43.77 39.74 2.93 100.00 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.036
5 Pyoderma: assessment of living conditions and hygiene behaviour What education did your father receive?
0= no information (not included in analysis) 2= Primary education 1= No formal education/Adult education 3=Secondary/post secondary education
Education 1 2 3 Total
No 11 205 11 227 Skin 4.85 90.31 4.85 100.00 Disease 84.62 85.42 61.11 83.76
Pyoderma 2 35 7 44 4.55 79.55 15.91 100.00 15.38 14.58 38.89 16.24
Total 13 240 18 271 4.80 88.56 6.64 100.00 Fisher's exact test 100.00 100.00 100.00 100.00 Pr = 0.035
What education did your mother receive?
0= no information (not included in analysis) 2= Primary education 1= No formal education/Adult education 3=Secondary/post secondary education
Education mother 1 2 3 Total
No 24 202 8 234 Skin 10.26 86.32 3.42 100.00 Disease 88.89 85.23 57.14 84.17
Pyoderma 3 35 6 44 6.82 79.55 13.64 100.00 11.11 14.77 42.86 15.83
Total 27 237 14 278 9.71 85.25 5.04 100.00 Fisher's exact test 100.00 100.00 100.00 100.00 Pr = 0.031 198 Appendix C
What is your mother’s profession?
Profession peasant civil serv. Inf. sector Total
No 213 3 10 226 Skin 94.25 1.33 4.42 100.00 Disease 84.19 50.00 71.43 82.78
Pyoderma 40 3 4 47 85.11 6.38 8.51 100.00 15.81 50.00 28.57 17.22
Total 253 6 14 273 92.67 2.20 5.13 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.042
Profession Profession Peas. + civil serv. Inf. sect. Total Peas. + Inf. sect. civ. serv. Total
No 215 10 225 No 223 3 226 Skin 95.56 4.44 100.00 Skin 98.67 1.33 100.00 Disease 83.98 71.43 83.33 Disease 83.52 50.00 82.78
Pyod. 41 4 45 Pyod. 44 3 47 91.11 8.89 100.00 93.62 6.38 100.00 16.02 28.57 16.67 16.48 50.00 17.22
Total 256 14 270 Total 267 6 273 94.81 5.19 100.00 97.80 2.20 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.262 Fisher's exact test Pr = 0.066
What materials is your house built from?
0 = No skin disease 2 = Pyoderma
q39_1: wooden beams q39_2: mud Yes No Total Yes No Total
0 9 232 241 0 68 173 241 3.73 96.27 100.00 28.22 71.78 100.00 81.82 82.86 82.82 90.67 80.09 82.82
2 2 48 50 2 7 43 50 4.00 96.00 100.00 14.00 86.00 100.00 18.18 17.14 17.18 9.33 19.91 17.18
Total 11 280 291 Total 75 216 291 3.78 96.22 100.00 25.77 74.23 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 1.000 Pearson chi2(1) = 4.3743 Pr = 0.036 199 Appendix C q39_3: stones q39_4: bricks Yes No Total Yes No Total
0 7 234 241 0 175 66 241 2.90 97.10 100.00 72.61 27.39 100.00 100.00 82.39 82.82 79.91 91.67 82.82
2 0 50 50 2 44 6 50 0.00 100.00 100.00 88.00 12.00 100.00 0.00 17.61 17.18 20.09 8.33 17.18
Total 7 284 291 Total 219 72 291 2.41 97.59 100.00 75.26 24.74 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.608 Pearson chi2(1) = 5.2644 Pr = 0.022 q39_5: lime q39_6: palm leaves Yes No Total Yes No Total
0 2 239 241 0 126 115 241 0.83 99.17 100.00 52.28 47.72 100.00 40.00 83.57 82.82 88.11 77.70 82.82
2 3 47 50 2 17 33 50 6.00 94.00 100.00 34.00 66.00 100.00 60.00 16.43 17.18 11.89 22.30 17.18
Total 5 286 291 Total 143 148 291 1.72 98.28 100.00 49.14 50.86 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.037 Pearson chi2(1) = 5.5378 Pr = 0.019 q39_7: iron sheets q39others Yes No Total Cement Wooden planks Tiles Total 0 11 2 1 14 0 114 127 241 78.57 14.29 7.14 100.00 47.30 52.70 100.00 78.57 100.00 100.00 82.35 78.62 86.99 82.82 2 3 0 0 3 2 31 19 50 100.00 0.00 0.00 100.00 62.00 38.00 100.00 21.43 0.00 0.00 17.65 21.38 13.01 17.18 Total 14 2 1 17 Total 145 146 291 82.35 11.76 5.88 100.00 100.00 100.00 100.00 100.00 49.83 50.17 100.00 100.00 100.00 100.00 Pearson chi2(2) = 0.7806 Pr = 0.677 Pearson chi2(1) = 3.5779 Pr = 0.059 200 Appendix C
What source are you using for drinking water?
0 = No skin disease 2 = Pyoderma
q40_1: tap water/home q40_2: tap water outside q40_3: well Yes No Total Yes No Total Yes No Total
0 12 229 241 0 17 224 241 0 26 215 241 4.98 95.02 100.00 7.05 92.95 100.00 10.79 89.21 100.00 57.14 84.81 82.82 73.91 83.58 82.82 86.67 82.38 82.82
2 9 41 50 2 6 44 50 2 4 46 50 18.00 82.00 100.00 12.00 88.00 100.00 8.00 92.00 100.00 42.86 15.19 17.18 26.09 16.42 17.18 13.33 17.62 17.18
Total 21 270 291 Total 23 268 291 Total 30 261 291 7.22 92.78 100.00 7.90 92.10 100.00 10.31 89.69 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.004 Fisher's exact test pr = 0.250 Pearson chi2(1) = 0.3482 Pr = 0.555
q40_4: hand pump q40_5: river q40_6: pond Yes No Total Yes No Total Yes No Total
0 192 49 241 0 3 238 241 0 0 241 241 79.67 20.33 100.00 1.24 98.76 100.00 0.00 100.00 100.00 84.96 75.38 82.82 100.00 82.64 82.82 0.00 83.10 82.82
2 34 16 50 2 0 50 50 2 1 49 50 68.00 32.00 100.00 0.00 100.00 100.00 2.00 98.00 100.00 15.04 24.62 17.18 0.00 17.36 17.18 100.00 16.90 17.18
Total 226 65 291 Total 3 288 291 Total 1 290 291 77.66 22.34 100.00 1.03 98.97 100.00 0.34 99.66 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Pearson chi2(1) = 3.2498 Fisher's exact test Pr = 1.000 Fisher's exact test Pr = 0.172 Pr = 0.071
6 Scabies: assessment of living conditions and hygiene behaviour How many people live at home with you?
No_people 1-5 6-10 11 + Total
Children 213 303 23 539 Without 39.52 56.22 4.27 100.00 Scabies 97.71 98.70 92.00 98.00
Children 5 4 2 11 With 45.45 36.36 18.18 100.00 Scabies 2.29 1.30 8.00 2.00
Total 218 307 25 550 39.64 55.82 4.55 100.00 Fisher's exact test 100.00 100.00 100.00 100.00 Pr = 0.082 201 Appendix C
What source are you using for drinking water?
0 = No skin disease 2 = Scabies
q40_1: tap water/home Yes No Total
No 50 493 543 Scabies 9.21 90.79 100.00 100.00 97.82 98.01
Scabies 0 11 11 0.00 100.00 100.00 0.00 2.18 1.99
Total 50 504 554 9.03 90.97 100.00 100.00 100.00 100.00 Fisher's exact test Pr = 0.611
How many people sleep in your bed?
People per bed 1 2 3 or more Total
No 99 341 102 542 Scabies 18.27 62.92 18.82 100.00 100.00 97.99 96.23 98.01
Scabies 0 7 4 11 0.00 63.64 36.36 100.00 0.00 2.01 3.77 1.99
Total 99 348 106 553 17.90 62.93 19.17 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.139
How often do you wash yourself? Category “it depends” was excluded from analysis Washing/times per day 1x 2x 3x > 3x Total
No 70 237 212 16 535 Scabies 13.08 44.30 39.63 2.99 100.00 94.59 99.16 97.70 100.00 97.99
Scabies 4 2 5 0 11 36.36 18.18 45.45 0.00 100.00 5.41 0.84 2.30 0.00 2.01
Total 74 239 217 16 546 13.55 43.77 39.74 2.93 100.00 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.104 202 Appendix C
How often do you use soap to wash yourself?
0 = No skin disease 1 = Scabies
q53_3: once per day q53_4: twice per day q53_5: three times per day Yes No Total Yes No Total Yes No Total
0 50 488 538 0 129 409 538 0 128 410 538 9.29 90.71 100.00 23.98 76.02 100.00 23.79 76.21 100.00 96.15 98.19 98.00 99.23 97.61 98.00 99.22 97.62 98.00
1 2 9 11 1 1 10 11 1 1 10 11 18.18 81.82 100.00 9.09 90.91 100.00 9.09 90.91 100.00 3.85 1.81 2.00 0.77 2.39 2.00 0.78 2.38 2.00
Total 52 497 549 Total 130 419 549 Total 129 420 549 9.47 90.53 100.00 23.68 76.32 100.00 23.50 76.50 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.280 Fisher's exact test Pr = 0.472 Fisher's exact test Pr = 0.472
Is there any soap at home ? 0 = No skin disease 1 = Scabies
Yes No Total
0 508 29 537 94.60 5.40 100.00 97.88 100.00 97.99
1 11 0 11 100.00 0.00 100.00 2.12 0.00 2.01
Total 519 29 548 94.71 5.29 100.00 100.00 100.00 100.00 Fisher's exact test Pr = 1.000
7 Generalized pruritus/xerotic skin – miliaria – pruritic dermatitis: assessment of living conditions and hygiene behaviour What education did your father receive?
0= no information (not included in analysis) 2= Primary education 1= No formal education/Adult education 3=Secondary/post secondary education Education 1 2 3 Total
No 11 205 11 227 Skin 4.85 90.31 4.85 100.00 Diseases 100.00 94.47 57.89 91.90
Pruritic 0 12 8 20 Dermatoses 0.00 60.00 40.00 100.00 0.00 5.53 42.11 8.10
Total 11 217 19 247 4.45 87.85 7.69 100.00 Fisher's exact test 100.00 100.00 100.00 100.00 Pr = 0.000 203 Appendix C
What education did your father receive?
Education 1 2 3 Total
No 20 437 43 500 Skin 4.00 87.40 8.60 100.00 Diseases 100.00 97.33 84.31 96.15
Gen. prur./ 0 3 2 5 Xerotic 0.00 60.00 40.00 100.00 Skin 0.00 0.67 3.92 0.96
Miliaria 0 5 5 10 0.00 50.00 50.00 100.00 0.00 1.11 9.80 1.92
Pruritic 0 4 1 5 Dermatitis 0.00 80.00 20.00 100.00 0.00 0.89 1.96 0.96
Total 20 449 51 520 3.85 86.35 9.81 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.004
What is your father’s profession?
Cases were excluded from analysis if the profession was unknown, (“?“&”Others”) or the father had died.
Profession peasant civil s. s.c.income Total
No 131 16 68 215 Skin 60.93 7.44 31.63 100.00 Disase 94.93 84.21 91.89 93.07
Pruritic 7 3 6 16 Dermatoses 43.75 18.75 37.50 100.00 5.07 15.79 8.11 6.93
Total 138 19 74 231 59.74 8.23 32.03 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.149
Profession peasant civil s. s.c.income Total
No 302 36 146 484 Skin 62.40 7.44 30.17 100.00 Disease 97.73 92.31 96.05 96.80
Gen. Prur./ 2 0 2 4 Xerotic 50.00 0.00 50.00 100.00 Skin 0.65 0.00 1.32 0.80
Miliaria 2 2 4 8 25.00 25.00 50.00 100.00 Fisher's exact test 0.65 5.13 2.63 1.60 Pr = 0.074 204 Appendix C
Profession peasant civil s. s.c.income Total
Pruritic 3 1 0 4 Dermatosis 75.00 25.00 0.00 100.00 0.97 2.56 0.00 0.80
Total 309 39 152 500 61.80 7.80 30.40 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.074
What education did your mother receive?
1= No formal education/Adult education 0= no information (not included in analysis) 2= Primary education 3= Secondary/post secondary education
Education mother 1 2 3 Total
No 24 202 8 234 Skin 10.26 86.32 3.42 100.00 Diseas 85.71 93.95 80.00 92.49
Pruritic 4 13 2 19 Dermatoses 21.05 68.42 10.53 100.00 14.29 6.05 20.00 7.51
Total 28 215 10 253 11.07 84.98 3.95 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.056
Education mother 1 2 3 Total
No 48 438 26 512 Skin 9.38 85.55 5.08 100.00 Disease 92.31 97.12 92.86 96.42
Gen. prur./ 1 4 0 5 Xerotic 20.00 80.00 0.00 100.00 Skin 1.92 0.89 0.00 0.94
Miliaria 1 6 2 9 11.11 66.67 22.22 100.00 1.92 1.33 7.14 1.69
Pruritic 2 3 0 5 Dermatoses 40.00 60.00 0.00 100.00 3.85 0.67 0.00 0.94
Total 52 451 28 531 9.79 84.93 5.27 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.070. 205 Appendix C
What is your mother’s profession?
Profession mother peasant civil serv. inf. sector Total
No 213 3 10 226 Skin 94.25 1.33 4.42 100.00 Disease 93.42 75.00 76.92 92.24
Pruritic 15 1 3 19 Dermatoses 78.95 5.26 15.79 100.00 6.58 25.00 23.08 7.76
Total 228 4 13 245 93.06 1.63 5.31 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr 0.056
Profession mother peasant civil serv. inf. sector Total
No 465 13 26 504 Skin 92.26 2.58 5.16 100.00 Disease 96.88 92.86 89.66 96.37
Gen. prur./ 5 0 0 5 xerotic 100.00 0.00 0.00 100.00 skin 1.04 0.00 0.00 0.96
Miliaria 6 1 2 9 66.67 11.11 22.22 100.00 1.25 7.14 6.90 1.72
Pruritic 4 0 1 5 Dermatoses 80.00 0.00 20.00 100.00 0.83 0.00 3.45 0.96
Total 480 14 29 523 91.78 2.68 5.54 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.071
Do you boil drinking water?
Yes No Total
No 57 183 240 Skin 23.75 76.25 100.00 Diseases 86.36 94.33 92.31
Pruritic 9 11 20 Dermatoses 45.00 55.00 100.00 13.64 5.67 7.69
Total 66 194 260 25.38 74.62 100.00 100.00 100.00 100.00
Pearson chi2(1) = 4.4014 Pr = 0.036 206 Appendix C
How many times do you wash per day?
Washing/times per day 1x 2x 3x >3x Total
Children 68 232 212 14 526 Without 12.93 44.11 40.30 2.66 100.00 Pruritic Derm. 91.89 97.07 97.70 87.50 96.34
Pruritic 6 7 5 2 20 Dermatoses 30.00 35.00 25.00 10.00 100.00 8.11 2.93 2.30 12.50 3.66
Total 74 239 217 16 546 13.55 43.77 39.74 2.93 100.00 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.027
8 Eczematous lesions: assessment of living conditions and hygiene behaviour (selection of indicators of the socio-economic background and washing behaviour) What education did your father receive?
1= No formal education/Adult education 0= no information (not included in analysis) 2= Primary education 3= Secondary/post secondary education
Education 1 2 3 Total
Children 20 446 48 514 Without 3.89 86.77 9.34 100.00 Eczematous L. 100.00 99.33 94.12 98.85
Eczematous 0 3 3 6 Lesions 0.00 50.00 50.00 100.00 0.00 0.67 5.88 1.15
Total 20 449 51 520 3.85 86.35 9.81 100.00 Fisher’s exact test 100.00 100.00 100.00 100.00 Pr = 0.022
What is your father’s profession?
Profession peasant civil s. s.c.income Total
Children 306 38 149 493 Without 62.07 7.71 30.22 100.00 Eczematous L. 99.03 97.44 98.03 98.60
Eczematous 3 1 3 7 Lesions 42.86 14.29 42.86 100.00 0.97 2.56 1.97 1.40
Total 309 39 152 500 61.80 7.80 30.40 100.00 Fisher’s exact test 100.00 100.00 100.00 100.00 Pr = 0.360 207 Appendix C
What education did your mother receive?
1= No formal education/Adult education 3= Secondary/post secondary education 2= Primary education 0= no information (not included in analysis)
Education mother 1 2 3 Total
Children 50 449 25 524 Without 9.54 85.69 4.77 100.00 Eczematous L. 96.15 99.56 89.29 98.68
Eczematous 2 2 3 7 Lesions 28.57 28.57 42.86 100.00 3.85 0.44 10.71 1.32
Total 52 451 28 531 9.79 84.93 5.27 100.00 Fisher’s exact test 100.00 100.00 100.00 100.00 Pr = 0.001 . What is your mother’s profession?
Profession peasant civil serv. Inf. sector Total
Children 473 14 29 516 Without 91.67 2.71 5.62 100.00 Eczematous L. 98.54 100.00 100.00 98.66
Eczematous 7 0 0 7 Lesions 100.00 0.00 0.00 100.00 1.46 0.00 0.00 1.34
Total 480 14 29 523 91.78 2.68 5.54 100.00 Fisher’s exact test 100.00 100.00 100.00 100.00 Pr = 1.000
What materials is your house built from?
No EL: Children without eczematous lesions EL: Children with eczematous lesions
q39_1: wooden beams q39_2: mud Yes No Total Yes No Total
No EL 26 521 547 No EL 133 414 547 4.75 95.25 100.00 24.31 75.69 100.00 92.86 98.86 98.56 97.79 98.81 98.56
EL 2 6 8 EL 3 5 8 25.00 75.00 100.00 37.50 62.50 100.00 7.14 1.14 1.44 2.21 1.19 1.44
Total 28 527 555 Total 136 419 555 5.05 94.95 100.00 24.50 75.50 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Fisher’s exact test Pr = 0.057 Fisher’s exact test Pr= 0.412 208 Appendix C q39_3: stones q39_4: bricks Yes No Total Yes No Total
No EL 11 536 547 No EL 436 111 547 2.01 97.99 100.00 79.71 20.29 100.00 91.67 98.71 98.56 98.64 98.23 98.56
EL 1 7 8 EL 6 2 8 12.50 87.50 100.00 75.00 25.00 100.00 8.33 1.29 1.44 1.36 1.77 1.44
Total 12 543 555 Total 442 113 555 2.16 97.84 100.00 79.64 20.36 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.161 Fisher's exact test Pr = 0.668
. q39_5: lime q39_6: palm leaves Yes No Total Yes No Total
No EL 10 537 547 No EL 247 300 547 1.83 98.17 100.00 45.16 54.84 100.00 90.91 98.71 98.56 99.20 98.04 98.56
EL 1 7 8 El 2 6 8 12.50 87.50 100.00 25.00 75.00 100.00 9.09 1.29 1.44 0.80 1.96 1.44
Total 11 544 555 Total 249 306 555 1.98 98.02 100.00 44.86 55.14 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.149 Fisher's exact test Pr = 0.306 q39_7: iron sheets q39others Yes No Total Cement Wooden planks Tiles Total
No EL 298 249 547 No EL 25 2 1 28 54.48 45.52 100.00 89.29 7.14 3.57 100.00 98.03 99.20 98.56 92.59 100.00 100.00 93.33
EL 6 2 8 EL 2 0 0 2 75.00 25.00 100.00 100.00 0.00 0.00 100.00 1.97 0.80 1.44 7.41 0.00 0.00 6.67
Total 304 251 555 Total 27 2 1 30 54.77 45.23 100.00 90.00 6.67 3.33 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.304 Fisher's exact test Pr = 1.000 209 Appendix C
What source are you using for drinking water?
No EL: Children without eczematous lesions EL: Children with eczematous lesions
q40_1: tap water/home q40_2: tap water outside q40_3: well Yes No Total Yes No Total Yes No Total
No EL 49 497 546 No EL 38 508 546 No EL 58 488 546 8.97 91.03 100.00 6.96 93.04 100.00 10.62 89.38 100.00 98.00 98.61 98.56 100.00 98.45 98.56 95.08 98.99 98.56
EL 1 7 8 EL 0 8 8 EL 3 5 8 12.50 87.50 100.00 0.00 100.00 100.00 37.50 62.50 100.00 2.00 1.39 1.44 0.00 1.55 1.44 4.92 1.01 1.44
Total 50 504 554 Total 38 516 554 Total 61 493 554 9.03 90.97 100.00 6.86 93.14 100.00 11.01 88.99 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.533 Fisher's exact test Pr = 1.000 Fisher's exact test Pr = 0.048
q40_4: hand pump q40_5: river q40_6: pond Yes No Total Yes No Total Yes No Total
No EL 416 129 545 No EL 6 539 545 No EL 1 544 545 76.33 23.67 100.00 1.10 98.90 100.00 0.18 99.82 100.00 99.05 96.99 98.55 100.00 98.54 98.55 50.00 98.73 98.55
EL 4 4 8 EL 0 8 8 EL 1 7 8 50.00 50.00 100.00 0.00 100.00 100.00 12.50 87.50 100.00 0.95 3.01 1.45 0.00 1.46 1.45 50.00 1.27 1.45
Total 420 133 553 Total 6 547 553 Total 2 551 553 75.95 24.05 100.00 1.08 98.92 100.00 0.36 99.64 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.100 Fisher's exact test Pr = 1.000 Fisher's exact test Pr = 0.029
How often do you wash yourself?
Category “it depends” was excluded from analysis Washing/times per day 1x 2x 3x > 3x Total
No EL 74 236 212 16 538 13.75 43.87 39.41 2.97 100.00 100.00 98.74 97.70 100.00 98.53
EL 0 3 5 0 8 0.00 37.50 62.50 0.00 100.00 0.00 1.26 2.30 0.00 1.47
Total 74 239 217 16 546 13.55 43.77 39.74 2.93 100.00 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 0.598 210 Appendix C
How often do you use soap to wash yourself?
No EL: Children without eczematous lesions EL: Children with eczematous lesions
q53_6: infrequently q53_1: every time I bath q53_2: whenever there is soap Yes No Total Yes No Total Yes No Total
No EL 27 514 541 No EL 278 263 541 No EL 79 462 541 4.99 95.01 100.00 51.39 48.61 100.00 14.60 85.40 100.00 100.00 98.47 98.54 97.89 99.25 98.54 100.00 98.30 98.54
EL 0 8 8 EL 6 2 8 EL 0 8 8 0.00 100.00 100.00 75.00 25.00 100.00 0.00 100.00 100.00 0.00 1.53 1.46 2.11 0.75 1.46 0.00 1.70 1.46
Total 27 522 549 Total 284 265 549 Total 79 470 549 4.92 95.08 100.00 51.73 48.27 100.00 14.39 85.61 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 1.000 Fisher's exact test Pr = 0.288 Fisher's exact test Pr = 0.610
q53_8: not at all q53_3: once per day q53_4: twice per day Yes No Total Yes No Total Yes No Total
No EL 2 538 540 No EL 52 489 541 No EL 127 414 541 0.37 99.63 100.00 9.61 90.39 100.00 23.48 76.52 100.00 100.00 98.53 98.54 100.00 98.39 98.54 97.69 98.81 98.54
EL 0 8 8 EL 0 8 8 EL 3 5 8 0.00 100.00 100.00 0.00 100.00 100.00 37.50 62.50 100.00 0.00 1.47 1.46 0.00 1.61 1.46 2.31 1.19 1.46
Total 2 546 548 Total 52 497 549 Total 130 419 549 0.36 99.64 100.00 9.47 90.53 100.00 23.68 76.32 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00
Fisher's exact test Pr = 1.000 Fisher's exact test Pr = 1.000 Fisher's exact test Pr = 0.401
Is there any soap at home ? q53_5: three times per day Yes No Total Yes No Total No EL 126 415 541 No EL 512 28 540 23.29 76.71 100.00 94.81 5.19 100.00 97.67 98.81 98.54 98.65 96.55 98.54 EL 3 5 8 EL 7 1 8 37.50 62.50 100.00 87.50 12.50 100.00 2.33 1.19 1.46 1.35 3.45 1.46 Total 129 420 549 Total 519 29 548 23.50 76.50 100.00 94.71 5.29 100.00 100.00 100.00 100.00 100.00 100.00 100.00 Fisher's exact test Pr = 0.399 Fisher's exact test Pr= 0.355 211 Appendix D
Appendix D Prevalence of selected skin diseases in different areas of Tanzania and the African continent
1 Overall prevalence of skin diseases
Altitude/ Prevalence of Region °C/annual Author Place rainfall skin diseases Present study Ifakara Southern Tanzania 270 m 54.6% 26°C in children 6–19 years 1200- 1800mm Lukume et al. 1 Wino/Songea Southern Tanzania 1200-1800m 35.6% 15-22°C 39.6% one rainy in children 6–14 years season Mathias et al.1 Malampaka/Maswa Northern Tanzania 23-25°C 50.4% 120mm 47.0% in children 6–14 years Njau et al. 1 Kimbale/Mwanga Northern Tanzania Highlands, 44.9% two rainy 47.0% seasons in children 6–14 years Quawoga et al. 1 Nambala/Arumeru Northern Tanzania 1000m 33.5% 1000- 51.3% 2000mm in children 6–14 years Satimia et al. 1 Chapwa/Mbeya South-west Tanzania Highlands 34.7% 18-25°C 37.2% long rainy in children 6–14 years season Simba et al. 1 Nyabekwabi/Musoma Northern Tanzania ? 48.3% 51.6% in children 6–14 years Gibbs 1996 Ngara district North-west Tanzania mountainous 26.9% 21°C About 37% sub-humid in children 6–10 years 1032mm Figueroa et al. Shebe/Illubabor Ethiopia 1600m 80.4% 1996 district In children 5-16 years Porter 1979 Keneba village/Kiang The Gambia October: 33.7% 21-33°C Peninsula Humidity: 60-83% 80mm April: 26.4% 21-39°C Humidity: 20-48% 0mm 1 RDTC Moshi/Tanzania, research reports 1996 212 Appendix D
2 Tinea versicolor (RDTC Moshi/Tanzania, research reports 1996)
Altitude/ Prevalence of °C/annual Author Place Region rainfall t. versicolor Present study Ifakara Southern Tanzania 270 m 26.2% 26°C in children 6–19 years 1200-1800mm Satimia et al. Chapwa/Mbeya South-west Highlands second most frequent Tanzania 18-25°C skin disease among long rainy those older than 18 season years
Mathias et al. Malampaka/Maswa Northern Tanzania 23-25°C 4.1% 120mm 4th most frequent disease in children 6- 17 years, 2nd most common in those >18years Simba et al. Nyabekwabi/Musoma Northern Tanzania ? 2.5% Lukume et al. Wino/Songea Southern Tanzania 1200-1800m <5 years: 0.0% 15-22°C 6-14 years: 0.0% one rainy season 15-24 years: 2.5% 25-34 years: 1.7% 35-44 years: 4.2% 45-54 years: 0.0% 55-64 years: 2.9% older: 0.0% Quawoga et Nambala/Arumeru Northern Tanzania 1000m <5 years: 0.6% al. 1000-2000mm 6-14 years: 0.0% 15-24 years: 1.4% 25-34 years: 1.7% older: 0.0% Njau et al. Kimbale/Mwanga Northern Tanzania Highlands, No information, all two rainy fungus were pooled seasons 213 Appendix D
3 Dermatophyte infections: tinea capitis, faciei, corporis and pedis (RDTC Moshi/Tanzania, research reports 1996)
3.1 Tinea capitis
Altitude/ Prevalence of °C/annual Author Place Region rainfall t. capitis Present study Ifakara Southern Tanzania 270 m 5.5% 26°C in children 6–19 years 1200- 1800mm Satimia et al. Chapwa/Mbeya South-west Highlands 4.3% Tanzania 18-25°C Most common skin long rainy disease 1- 13 years, season after that: few cases Mathias et al. Malampaka/Maswa Northern Tanzania 23-25°C <5 years: 0.4% 120mm 6-17 years: 2nd most common SD* adults: no info Simba et al. Nyabekwabi/Musoma Northern Tanzania ? 2.00% Lukume et al. Wino/Songea Southern Tanzania 1200-1800m <5 years: 6% 15-22°C 6-14 years: 6.5% one rainy 15-24 years: 0.8% season older: 0% Quawoga et al. Nambala/Arumeru Northern Tanzania 1000m <5 years: 16% 1000- 6-14 years: 24% 2000mm 15-24 years: 1.4% older: 0% Njau et al. Kimbale/Mwanga Northern Tanzania Highlands, No information, all two rainy fungi were pooled seasons *SD = Skin disease 214 Appendix D
3.2 Tinea faciei/corporis
Altitude/ Prevalence of °C/annual t. faciei/corporis Author Place Region rainfall Present study Ifakara Southern Tanzania 270 m 2.6% 26°C in children 6–19 years 1200-1800mm Satimia et al. Chapwa/Mbeya South-west Highlands 3.5% Tanzania 18-25°C <5years: 2.2% long rainy th season 6–17 years: 4 most common SD* >18 years: 3rd most common SD Mathias et al. Malampaka/Maswa Northern Tanzania 23-25°C <5 years: 0.7% 120mm 6-17 years: 3rd most common SD* adults: 3rd most common SD* Simba et al. Nyabekwabi/Musoma Northern Tanzania ? 2.3% Lukume et al. Wino/Songea Southern Tanzania 1200-1800m <5 years: 2.4% 15-22°C 6-14 years: 0.9% one rainy season 15-24 years: 0.8% 25-34 years: 1.7% 35-44 years: 2.1% Quawoga et Nambala/Arumeru Northern Tanzania 1000m <5 years: 1.9% al. 1000-2000mm 6-14 years: 6.2% 15-24 years: 2.9% 25-34 years: 3.9% older: 0.7% Njau et al. Kimbale/Mwanga Northern Tanzania Highlands, No information, all two rainy fungi were pooled seasons *SD = Skin disease 215 Appendix D
3.3 Tinea pedis
Altitude/ Prevalence of °C/annual t. pedis Author Place Region rainfall Present study Ifakara Southern Tanzania 270 m 3.2% 26°C in children 6–19 years 1200-1800mm Satimia et al. Chapwa/Mbeya South-west Tanzania Highlands No information 18-25°C long rainy season Mathias et al. Malampaka/Maswa Northern Tanzania 23-25°C 6th most common 120mm SD* in those older than 18 years, no information about other age groups Simba et al. Nyabekwabi/Musoma Northern Tanzania ? No information Lukume et al. Wino/Songea Southern Tanzania 1200-1800m No information 15-22°C one rainy season Quawoga et Nambala/Arumeru Northern Tanzania 1000m <5 years: 0.0% al. 1000-2000mm 6-14 years: 0.6% 15-24 years: 2.9% 25-34 years: 2.2% older: 2.8% Njau et al. Kimbale/Mwanga Northern Tanzania Highlands, No information, all two rainy fungi were pooled seasons *SD = Skin disease
4 Pyoderma (RDTC Moshi/Tanzania, research reports 1996)
Author Place Region Name of Prevalence of Diagnosis Pyoderma Present study Ifakara Southern Tanzania Pyoderma 8.3% in children 6–19 years Satimia et al. Chapwa/Mbeya South-west Tanzania Impetigo 6.0% Mathias et al. Malampaka/Maswa Northern Tanzania No information Simba et al. Nyabekwabi/Musoma Northern Tanzania Impetigo 0.6% Lukume et al. Wino/Songea Southern Tanzania Bacterial 1.0% infections Quawoga et Nambala/Arumeru Northern Tanzania Pyoderma <5 years: 1.9% al. 6-14 years: 5.4% 15-24 years: 3.6% 25-34 years: 1.7% older: 0.0% Njau et al. Kimbale/Mwanga Northern Tanzania Pyoderma <15 years: 3.0% 16-34 years: 0.6% 35-54 years: 0.6% 55 + years: 0.3% *SD = Skin disease 216 Appendix D
5 Scabies (RDTC Moshi/Tanzania, research reports 1996)
Altitude/ Prevalence of °C/annual Author Place Region rainfall Scabies Present study Ifakara Southern Tanzania 270 m 1.5% 26°C 6–10 years: 2.4% 1200- 1800mm 11–14 years: 0.9% 15 -19 years: 0.8% Satimia et al. Chapwa/Mbeya South-west Tanzania Highlands 4.0% 18-25°C <5 years: 2.2% long rainy 6-17 years: 3rd season most frequent SD >18 years: 4th most frequent SD Mathias et al. Malampaka/Maswa Northern Tanzania 23-25°C 15.2% 120mm <5 years: 26.7% 6-17 years: most frequent SD >18 years: 2nd most frequent SD Simba et al. Nyabekwabi/Musoma Northern Tanzania ? 30.4%
Lukume et al. Wino/Songea Southern Tanzania 1200-1800m 16.3% 15-22°C <5 years: 23.3% one rainy 6-14 years: 16.1% season 15-24 years: 16.3% 25-34 years: 14.4% 35-44 years: 25.0% 45-54 years: 9.6% 55-64 years: 5.7% Quawoga et Nambala/Arumeru Northern Tanzania 1000m 6.2% 1000- <5 years: 8.9% al. 2000mm 6-14 years: 9.0% 15-24 years: 8.0% 25-34 years: 2.8% older: 2.8% Njau et al. Kimbale/Mwanga Northern Tanzania Highlands, 13.6% two rainy <15 years: 23.5% seasons 16-34 years: 3.3% 35-54 years: 2.4% >55 years: 1.2%
217 Appendix D
6 Eczematous lesions (RDTC Moshi/Tanzania, research reports 1996)
Author Place Region Prevalence Type of Eczema Present study Ifakara Southern Tanzania 1.2% DCPA*: 0.1% Atopic: 0.1% Contact: 0.5% Unclassifyable: 0.5% Satimia et al. Chapwa/Mbeya South-west 3.5% Most common SD in Tanzania those older 18 years
Mathias et al. Malampaka/Maswa Northern Tanzania 1.9% < 5 years: 3rd most common SD
> 18 years: 5th most common SD
Simba et al. Nyabekwabi/Musoma Northern Tanzania 1.0% Atopic: 0.5% Seborrhoic: 0.5%
Lukume et al. Wino/Songea Southern Tanzania 2.0% Unknown
Quawoga et Nambala/Arumeru Northern Tanzania 4.0% Atopic: 1.7% al. Seborrhoic: 1.3% Contact: 1.0%
Njau et al. Kimbale/Mwanga Northern Tanzania 6.4% Most frequent non- preventable disease, highest prevalence in those < 15 years * dermatitis cruris pustulosa et atrophicans 218 Appendix D 219 Appendix E
Appendix E Spectrum and prevalence of skin diseases in different areas of Tanzania and the African continent
Author: Quawoga et al.1 Place: Nambala/Arumeru – Northern Tanzania Climate: Altitude: 1000m, annual rainfall 1000-2000mm Number of patients: n = 751 Prevalence Number Prevalence among children Diagnosis of patients (all age groups) (%) aged 6 to 14 years (%) Tinea capitis 62 8.3 24.0 Scabies 47 6.2 9.0 Tinea corporis 24 3.1 6.2 Atopic eczema 13 1.7 1.3 Tinea pedis 13 1.7 0.6 Acne 15 1.9 0 Seborrhoic dermatitis 10 1.3 0 Contact eczema 8 1.0 0 Pyoderma 15 1.9 5.4 Pityriasis versicolor 6 0.7 0 Papular urticaria 10 1.3 2.0 Chicken pox 6 0.7 1.3 Others 31 4.1 3.4 Total 260 33.5 51.3 1 RDTC Moshi/Tanzania, research reports 1996 220 Appendix E
Author: Figueroa et al.,1996 Place: Shebe/Illubabor District - Ethiopia Climate: Altitude: 1000m Number of patients: n = 112 Age (years) Diagnosis 5 - < 10 10 - 16 Number % Infestations 49 42 91 81.2 Pediculosis capitis 39 25 64 57.1 Pediculosis corporis 2 6 8 7.2 Scabies 8 11 19 17.0 Fungal infections 9 6 15 13.4 Tinea capitis Endothrix 6 2 8 7.2 Favus 2 0 2 1.8 Tinea corporis 1 2 3 2.7 Pityriasis versicolor 0 2 2 1.8 Bacterial infections 6 3 9 8.0 Pyoderma (impetigo, folliculitis) 4 2 6 5.4 Tropical ulcer 2 1 3 2.7 Viral infections 3 9 12 10.7 Viral warts 2 5 7 6.3 Molluscum contagiosum 0 3 3 2.7 Herpes zoster 1 1 2 1.8 Others 7 5 12 10.7 Pityriasis alba 5 1 6 5.4 Keratosis pilris 1 1 2 1.8 Adenoma sebaceum 0 1 1 0.9 Insect bites 1 0 1 0.9 Acne 0 1 3 2.7 Totals 74 66 140 80.4 221 Appendix E
Author: Gibbs, 1996 Place: Ngara District/North-west Tanzania Climate: Mountainous, average temperature: 21°C, sub-humid (1032mm/year) Number of patients: n = 1114 Number of patients Diagnosis (all age groups) % of skin disease % of population Ectoparasitic 161 49.4 14.2 Prurigo 82 25.2 7.2 Scabies 51 15.6 4.5 Severe scabies 5 1.5 0.4 Infected scabies 1 0.3 0.1 Papular urticaria 17 5.2 1.5 Tungiasis 5 1.5 0.4 Viral 32 9.7 2.9 Warts 21 6.4 1.8 Varicella zoster (fresh) 3 0.9 0.3 Varicella zoster (old) 7 2.1 0.6 Herpes zoster 1 0.3 0.1 Fungal 31 9.6 2.9 Tinea capitis 14 4.3 1.2 Tinea corporis 12 3.7 1.1 Tinea manuum 1 0.3 0.1 Tinea pedis 4 1.2 0.4 Bacterial Pyoderma 17 5.2 1.6 Total transmissible 241 73.9 21.6 Physical 47 14.5 4.1 environment/trauma Tropical ulcers 8 2.5 0.7 Other ulcers 8 2.5 0.7 Wounds 10 3.1 0.9 Burns (old) 6 1.8 0.5 Burns (fresh) 1 0.3 0.1 Lymphedema 5 1.5 0.4 Lymphedematous 7 2.1 0.6 keratoderma Acquired plantar 2 0.6 0.2 keratoderma Other 28 8.6 2.6 Tinea versicolor 12 3.7 1.1 Keloids 7 2.1 0.6 Vitiligo 3 0.9 0.3 Urticaria 1 0.3 0.1 Lipodermatosclerosis 1 0.3 0.1 Lichen simplex 1 0.3 0.1 Larva currens 1 0.3 0.1 Cicatrical alopecia 2 0.6 0.2 222 Appendix E
Number of patients Diagnosis (all age groups) % of skin disease % of population Inflammatory 10 3 1 Acne 1 0.3 0.1 Dermatitis 2 0.6 0.2 Psoriasis 1 0.3 0.1 Pityriasis alba 4 1.2 0.4 Seborrhoic dermatitis 1 0.3 0.1 Discoid lupus erythematosus 1 0.3 0.1 Total non-transmissible 85 26.1 7.7 Total: all skin diseases 326 100 26.9 Author: Henderson, 1996 Place: Ndebwe Village – Central Tanzania Climate: Altitude: 1200m, dry Number of patients: n = 936 Number of patients Condition (all age groups) Percent Signs of nutrit. deficiency Koilonychia 169 18.06 Angular stomatitis 14 1.49 Hypoproteinaemia 32 3.42 Phrynoderma 13 1.38 Infections and infestations Scabies 56 5.98 Pediculosis capitis 50 5.34 Dermatophyte infection 48 5.13 Bacterial infection 28 2.99 Pityriasis versicolor 14 1.49 Mollusca contagiosa 9 0.96 Leprosy 2 0.21 Pitted keratolysis 2 0.21 Herpes simplex 1 0.11 Leg ulcers and sores Sores on legs 48 5.13 Leg ulcers 28 2.99 Tumors Keloids 32 3.42 Dermatofibroma 3 3.20 Squamous cell carcimoa 2 0.21 Sebaceous nevus (scalp) 1 0.11 Solar keratosis 1 0.11 Hemangioma 1 0.11 Others Acne 54 5.77 Folliculitis (legs) 18 1.92 Ichthyosis 13 1.39 Chloasma 3 3.20 Marfan’s syndrome 1 0.11 Poliosis 1 0.11