Skin disorders and disease profile of poverty: analysis of medical records in Tigray, northern Ethiopia, 2005–2007

The NLR SkinApp: Testing a Supporting mHealth Tool for Frontline Health Workers Performing Skin Screening in Ethiopia and Tanzania

Background: The prevalence of skin diseases such as leprosy, and limited dermatological knowledge among frontline health workers (FHWs) in rural areas of Sub-Saharan Africa, led to the development of the NLR SkinApp: a mobile application (app) that supports FHWs to promptly diagnose and treat, or suspect and refer patients with skin diseases. The app includes common skin diseases, neglected tropical skin diseases (skin NTDs) such as leprosy, and HIV/AIDS-related skin conditions. This study aimed to test the supporting role of the NLR SkinApp by examining the diagnostic accuracy of its third edition. Methods: A cross-sectional study was conducted in East Hararghe, Ethiopia, as well as the Mwanza and Morogoro region, Tanzania, in 2018-2019. Diagnostic accuracy was measured against a diagnosis confirmed by two dermatologists/dermatological medical experts (reference standard) in terms of sensitivity, specificity, positive predictive value, and negative predictive value. The potential negative effect of an incorrect management recommendation was expressed on a scale of one to four. Results: A total of 443 patients with suspected skin conditions were included. The FHWs using the NLR SkinApp diagnosed 45% of the patients accurately. The values of the sensitivity of the FHWs using the NLR SkinApp in determining the correct diagnosis ranged from 23% for HIV/AIDS-related skin conditions to 76.9% for eczema, and the specificity from 69.6% for eczema to 99.3% for tinea capitis/corporis. The inter-rater reliability among the FHWs for the diagnoses made, expressed as the percent agreement, was 58% compared to 96% among the dermatologists. Of the management recommendations given on the basis of incorrect diagnoses, around one-third could have a potential negative effect. Conclusions: The results for diagnosing eczema are encouraging, demonstrating the potential contribution of the NLR SkinApp to dermatological and leprosy care by FHWs. Further studies with a bigger sample size and comparing FHWs with and without using the NLR SkinApp are needed to obtain a better understanding of the added value of the NLR SkinApp as a mobile health (mHealth) tool in supporting FHWs to diagnose and treat skin diseases.

Scabies in the Amhara region of northern Ethiopia: a cross-sectional study of prevalence, determinants, clinical presentation and community knowledge

BACKGROUND

The WHO aims to prevent, eliminate or control neglected tropical diseases, including scabies, by 2030. However, limited epidemiological data presented a challenge to control efforts, especially in high burden countries. There was a major scabies outbreak in northern Ethiopia starting in 2015 and prevalence has since increased across much of the country.

OBJECTIVE

To estimate scabies prevalence, identify its predictors, and assess community perception of, and knowledge about, the infestation.

DESIGN

Population-based cross-sectional study.

STUDY SETTING

Ayu Guagusa district, Amhara region, northern Ethiopia.

PARTICIPANTS

1437 people who were members of 381 randomly selected households participated in the study. Five trained mid-level health workers clinically diagnosed people with scabies.

OUTCOME MEASURES

Clinically diagnosed scabies infestation.

DATA ANALYSIS

Multi-level logistic regression models were fitted to adjust for individual and household-level confounding variables, and identify predictors of scabies infestation.

RESULTS

Scabies prevalence was 13.4% (95% CI 11.8 to 15.5). Households of more than five people (adjusted OR (aOR)=3.5, 95% CI 1.2 to 10.2) were associated with increased odds of developing scabies, however, females had lower odds (aOR=0.5 95% CI 0.3 to 0.8). Scabietic lesions most frequently involved the trunk (62.0%), and vesicles were the most common types of lesions (67.7%). Two-thirds of adult study participants had heard about scabies and most obtained scabies related information from informal sources. Only 32% of cases sought care for scabies from any source.

CONCLUSION

Scabies prevalence was high, signifying the need for community-based control interventions. Host density and sex were important predictors of scabies. Despite the favourable attitude toward the effectiveness of scabies treatment, healthcare seeking was low.

Patterns of Skin Disease in the Context of a High Prevalence HIV Population in Botswana

The authors reviewed outpatients in a tertiary dermatology clinic in Botswana to expand knowledge on patterns of skin disease in this population with a high prevalence of human immunodeficiency virus (HIV). Approximately one-third of new and follow-up patients were HIV positive. Common dermatologic conditions included eczematous eruptions, viral and fungal infections, malignant neoplasms, vascular disorders, disorders of pigmentation, and mechanical/physical injury-related disorders. HIV has impacted patterns of dermatologic disease in Botswana, with Kaposi sarcoma being the most frequently biopsied condition. Given the shortage of dermatology specialists, resources should be allocated toward education and management of these most prevalent skin conditions.

Factors associated with scabies outbreaks in primary schools in Ethiopia: a case-control study

Background

Scabies is a neglected tropical disease affecting more than 200 million people worldwide every year. Scabies in school adolescents and young adults could affect their school performance. The current study investigates the factors associated with an outbreak of scabies at primary schools in southern Ethiopia.

Method

A team of health professionals investigated an outbreak of scabies that occurred in primary schools from May 1 to 30, 2018. An unmatched case–control study was employed to assess factors which predisposed for the scabies outbreak. Cases of scabies were individuals having a skin lesion compatible with the WHO case definitions of scabies. Controls were from the same locality with no skin lesions. Data on sociodemographic and behavioral variables were collected using questionnaires. Data on clinical presentations of scabies among cases were recorded by two trained and experienced health professionals. Factors associated with scabies were assessed using bivariate and multivariate logistic regression, and strength of association was described using odds ratio (OR) and 95% confidence intervals (CIs).

Results

A total of 711 (237 cases and 474 controls) study subjects participated in the study. The mean age of study participants was 17.56±2.66 years. Poor knowledge about scabies, adjusted odds ratio (AOR)=4.32 (95% CI: 2.93, 6.36); male sex, AOR=2.69 (95% CI: 1.82, 3.96); and parental illiteracy, AOR =3.49 (95% CI: 2.06, 5.94) predicted scabies infestation. Additionally, socioeconomic variables like sharing clothes/beds or contact with others, AOR=3.12 (95% CI: 2.12, 4.59); low household annual income, AOR=2.13 (95% CI: 1.32, 3.44); and family size greater than five, AOR=1.77 (95% CI: 1.04, 3.01) were significantly associated with scabies infestation. Inaccessibility and poor utilization of water, AOR=1.64 (95% CI: 1.12, 2.40) and poor personal hygiene, AOR=1.69 (95% CI: 1.14, 2.51) were also factors independently associated with scabies.

Conclusion

Modifiable risk factors such as personal hygiene and literacy level were found to be independent predictors of scabies infestation. Access to and utilization of water were also important predictors. Strategies for poverty alleviation and awareness creation on personal hygiene and efficient use of water are recommended for effective prevention of scabies infestation in closed institutions.

Investigation of a Scabies Outbreak in Drought-Affected Areas in Ethiopia

The impact of the severe drought in Ethiopia, attributed to El Niño weather conditions, has led to high levels of malnutrition that have, in turn, increased the potential for disease outbreaks. In 2015, Ethiopia faced a scabies outbreak in drought-affected areas where there was a shortage of safe water for drinking and personal hygiene. Following a house-to-house census to assess the prevalence of scabies, a detailed study was conducted looking at the disease burden. Following the outbreak report, training was provided on scabies identification and management for zonal and district health officials from administrative districts affected by the drought (nutritional hot-spot woredas). The training was cascaded down to the health extension workers in the affected areas. Screening and management guidelines and protocols were also distributed. House-to-house data collection was undertaken by 450 health extension workers (HEWs) to assess the prevalence of scabies. The HEWs used a simplified reporting tool. Subsequently, data were collected and validated in two zones and six woredas from 474 participants who had been diagnosed with scabies using a standardized questionnaire. This was designed to look at the specificity of the diagnosis of scabies, age distribution, severity, duration of illness, secondary infection and other sociodemographic variables as preparation for mass drug administration (MDA). The HEWs screened 1,125,770 people in the 68 districts in Amhara Region and a total of 379,000 confirmed cases of scabies was identified. The prevalence in the different districts ranged from 2% to 67% and the median was 33.5% [interquartile range (IQR) 19⁻48%]. 49% of cases were school-aged children. The detailed study of 474 individuals who were recorded as scabies cases revealed that the specificity of the diagnosis of scabies by the HEWs was 98.3%. The mean duration of illness was 5 months (SD of ± 2.8). One third of patients were recorded as having severe illness, 75.1% of cases had affected family members, and 30% of affected children were noted to have secondary bacterial infection. Eleven percent of the students had discontinued school due to scabies or/and drought and 85% of these had secondary bacterial infection. These community-based data serve as reliable proxy indicators for community-based burden assessment of the scabies epidemic. This study will also provide a good basis for advocating the use of a community-level clinical diagnostic scheme for scabies using an algorithm with a simple combination of signs and symptoms in resource-poor settings.

Dermatophytosis: Prevalence of Dermatophytes and Non-Dermatophyte Fungi from Patients Attending Arsho Advanced Medical Laboratory, Addis Ababa, Ethiopia

BACKGROUND

Dermatophytosis is a disease of major public health problem around the globe causing a considerable morbidity.

OBJECTIVE

To study the prevalence of dermatophytosis and the spectrum of fungi implicated in causing the infection.

METHODS

Nail, skin, and scalp scrapings were collected from 318 patients and were used for microscopy and culture study. Fungal pathogens were identified by studying the macroscopic and microscopic characteristics of their colonies.

RESULT

Tinea capitis was the predominant clinical manifestation consisting of 48.1% of the cases. Among 153 patients with tinea capitis, 73.2% were in the age group of 1-14 years. Of 318 study participants, 213 (67.98%) were found to be positive for dermatophytosis microbiologically. Out of 164 fungal isolates, 86 were dermatophytes and 78 were non-dermatophyte fungi. Among 86 dermatophytes, T. violaceum represented 38.4% of dermatophyte isolates and 89.7% of the isolates were recovered from tinea capitis. Of 76 non-dermatophyte molds, Aspergillus spp., Scytalidium dimidiatum, and Cladosporium spp. were the most common isolates, respectively.

CONCLUSIONS

Failure to detect or isolate fungal pathogens in a large number of clinical samples revealed the limitation of clinical diagnosis in differentiating dermatophytosis from other skin infections demonstrating that clinical diagnosis should be coupled with laboratory methods. Recovery of large number of non-dermatophyte fungi along with dermatophytes in our study showed that non-dermatophyte fungi are emerging as important causes of dermatophytosis, warranting the implementation of intensive epidemiological studies of dermatophytosis across the country.

Dermatophytes and dermatophytosis in the eastern and southern parts of Africa

Dermatophytosis is currently a disease of global importance and a public health burden. It is caused by dermatophytes, which attack and grow on dead animal keratin. Dermatophytes belong to three genera, namely, Epidermophyton, Microsporum, and Trichophyton. The predominant clinical forms and causative agents vary from one region of the world to another. Poor socioeconomic status, high population densities, and poor sanitary conditions are some of the factors responsible for the high prevalence of dermatophytosis in many developing countries, which include countries in southern and eastern Africa, the focus of this review. To the best of our knowledge, there is currently no review article on published findings on dermatophytosis in the eastern and southern parts of Africa. This information will be of interest to the medical and research community since the world has become a global village. This review covers published research findings in eastern and southern regions of Africa until this date. The countries covered in the current review include Kenya, Ethiopia, Tanzania, South Africa, Mozambique, Madagascar, Malawi, Rwanda, Burundi, Uganda, Zambia, Zimbabwe, and Botswana. T. violaceum is the most common human etiological agent in all the countries under review with prevalence ranging from 56.7% to 95%, except for Madagascar (M. langeronii, reclassified as M. audouinii), Uganda (M. gypseum) and Malawi (M. audouinii). Tinea capitis was the most clinical type, followed by tinea corporis. Etiological agents of animal dermatophytoses were variable in the countries where they were reported. Major risk factors for dermatophytoses are age, climatic, and socioeconomic factors.

Prevalence of and Factors Associated with Negative Microscopic Diagnosis of Cutaneous Leishmaniasis in Rural Peru

Cutaneous leishmaniasis is endemic to South America where diagnosis is most commonly conducted via microscopy. Patients with suspected leishmaniasis were referred for enrollment by the Ministry of Health (MoH) in Lima, Iquitos, Puerto Maldonado, and several rural areas of Peru. A 43-question survey requesting age, gender, occupation, characterization of the lesion(s), history of leishmaniasis, and insect-deterrent behaviors was administered. Polymerase chain reaction (PCR) was conducted on lesion materials at the Naval Medical Research Unit No. 6 in Lima, and the results were compared with those obtained by the MoH using microscopy. Factors associated with negative microscopy and positive PCR results were identified using χ² test, t-test, and multivariate logistic regression analyses. Negative microscopy with positive PCR occurred in 31% (123/403) of the 403 cases. After adjusting for confounders, binary multivariate logistic regression analyses revealed that negative microscopy with positive PCR was associated with patients who were male (adjusted odds ration [OR] = 1.93 [1.06-3.53], P = 0.032), had previous leishmaniasis (adjusted OR = 2.93 [1.65-5.22], P < 0.0001), had larger lesions (adjusted OR = 1.02 [1.003-1.03], P = 0.016), and/or had a longer duration between lesion appearance and PCR testing (adjusted OR = 1.12 [1.02-1.22], P = 0.017). Future research should focus on further exploration of these underlying variables, discovery of other factors that may be associated with negative microscopy diagnosis, and the development and implementation of improved testing in endemic regions.

Operational research on the correlation between skin diseases and HIV infection in Tigray region, Ethiopia

BACKGROUND

In Ethiopia, skin diseases are among the leading causes of outpatient attendance to primary health service. Correlation of skin diseases and HIV has long been recognized and used to guide medical management in resource-limited settings. Therefore, this study aims to assess the correlation of skin diseases and HIV infection, to estimate epidemiological distribution in the study area, and to provide health workers of skin indicators for HIV early detection.

METHODS

The operational research was designed as a case-control study and carried out in three intervention districts of Tigray region; baseline and final data on skin diseases and HIV were compared with those of three control districts matched for population size, density, and environmental characteristics. Health workers of intervention districts were trained on skin diseases/STIs diagnosis and treatment. Data were collected from study and control districts and then analyzed at the Italian Dermatological Centre (IDC) in Mekele.

RESULTS

In the research period, a total of 1044 HIV positive patients were detected. Disorders of skin and mucous membranes statistically related with HIV (P < 0.05) were tongue papillary atrophy (80%), oral hairy leukoplakia (69%), herpes zoster (66%), oral candidiasis (50%), pruritic papular eruption (43%), condylomata acuminata (38%), and telogen effluvium (27%).

CONCLUSIONS

The high frequency of oral disorders and telogen effluvium is not described in literature and may be indicative for case detection. Operational research offers significant gains on health service delivery and outcomes at relatively low cost and in a short timeframe.

Correlation between Socioeconomic Status and Clinical Course in Patients with Cutaneous Leishmaniasis

OBJECTIVE

Leishmaniasis has long been known as a poverty-associated disease, which is particularly prevalent in developing and less developed countries. The role of socioeconomic status in the clinical course of the disease is less clearly defined. In this study, we investigated the potential relationship between the clinical course of cutaneous leishmaniasis in terms of its evolution into chronic forms and the socioeconomic status of the patients.

METHODS

A total of 140 patients attending the dermatology clinic in Imam Reza Hospital, Mashhad, Iran, were enrolled. The patients were grouped into high, medium, and low socioeconomic classes according to a comprehensive questionnaire. They received routine treatment protocols for leishmaniasis and were followed up for 1 year.

RESULTS

We found a statistically significant relationship between the clinical course of the disease and socioeconomic status.

CONCLUSION

Poverty might prolong the course of cutaneous leishmaniasis for many different reasons.

Tinea capitis in schoolchildren in a rural area in southern Ethiopia

OBJECTIVES

Skin diseases, especially tinea capitis, represent some of the most frequent causes of morbidity in developing countries. The aim of this study was to examine the prevalences of fungal infections in schoolchildren in a primary school located in a rural area in southern Ethiopia and to perform an analysis of the risk factors associated with tinea capitis.

METHODS

This school-based, prospective cross-sectional study was conducted in October 2012 in Gambo School, Kore, West Arsi, Oromya Region, Ethiopia. Detailed interviews and dermatological examinations were performed. No laboratory examinations were conducted.

RESULTS

A total of 647 students were interviewed and examined. The mean age of these children was 10 years (range: 4-14 years). Of the children examined, 236 had some type of dermatophytosis (prevalence: 36.5%, 95% confidence interval [CI] 32.8-40.3), which represented the most frequent type of skin problem. The prevalence of dermatophytoses was more common in males than in females (42.2% and 30.5%, respectively; P = 0.002), and among pupils aged 5-7 years (46.9%; P < 0.001). A total of 159 (prevalence: 24.6%, 95% CI 21.3-28.1) children had tinea capitis, 56 (8.7%) had tinea pedis, 50 (7.7%) had tinea corporis, and six (0.9%) had tinea unguium. In multivariate analysis, the risk factors for tinea capitis were: age (odds ratio [OR] 0.75, 95% CI 0.69-0.84; P < 0.001), and male gender (OR 2.56, 95% CI 1.69-13.39; P = 0.002).

CONCLUSIONS

Fungal dermatoses, especially tinea capitis, are common in primary schoolchildren in rural areas of southern Ethiopia, especially in young boys.

Dermatopathology practice in ethiopia

CONTEXT

Dermatologic diseases are extremely common among the Ethiopian population and are a significant cause of morbidity. However, few studies exist in the literature that describe the incidence and clinical and histologic features of biopsied cutaneous lesions.

OBJECTIVES

To categorize the cutaneous diseases observed in skin biopsies at the All African Leprosy Rehabilitation and Training Center (ALERT) in Addis Ababa, Ethiopia, and to describe the clinical and histologic features of dermatopathologic diagnoses most frequently encountered in this practice setting.

DATA SOURCES

Pathology reports of 2342 cutaneous specimens received at ALERT in Addis Ababa, Ethiopia, were reviewed to determine the range and frequency of cutaneous diseases and dermatoses diagnosed from January 2007 through December 2010.

CONCLUSIONS

The range of cutaneous diseases observed in skin biopsies at ALERT was varied and included inflammatory dermatoses (27%), infectious diseases (24%), and malignant and benign cutaneous neoplasms (22% and 20%, respectively). The most common conditions observed in this study were squamous cell carcinoma (8% of total cases), eczema (6% of total cases), leishmaniasis (6% of total cases), tuberculosis (6% of total cases), and benign nevi (4% of total cases).

Epidemiology of skin disorders in Ethiopian children and adolescents: an analysis of records from the Italian Dermatological Centre, Mekelle, Tigray, Ethiopia, 2005 to 2009

Skin disorders are an important problem in children living in developing countries, but only a few epidemiologic investigations on pediatric dermatoses are available in the literature. Our study is an analysis of the range and frequency of skin diseases presenting to the Italian Dermatological Center in a pediatric Ethiopian population. A retrospective analysis was performed on 17,967 medical records of children aged 0 to 18 years attending the Italian Dermatological Centre in Mekele (Ethiopia) from January 2005 to December 2009. Infections and infestations accounted for 47% of the disorders seen; fungal infections were the most common (44.1%), followed by bacterial and parasitic diseases. Dermatitis constituted the second most common diagnostic category (24.7%) of the disorders seen, and contact dermatitis was the most common diagnosis (48.8%). Pigmentary disorders and disorders of skin appendages were more common in girls, whereas fungal and parasitic infections were more common in boys. Bacterial and parasitic infections were more common in children younger than 1 year old, fungal infections in those aged 1 to 5.9, and disorders of skin appendages and pigmentary disorders in those aged 15 to 18. These findings demonstrate that most of the disorders seen could be easily managed in clinical practice with appropriate skill development. It is crucial to ensure that training of medical students and pediatricians focuses on accurate recognition, diagnosis, and management of these common skin diseases and that families, teachers, health workers, and nurses be educated about the most common signs of prevalent skin diseases to help facilitate appropriate care.

Managing skin disease in resource-poor environments - the role of community-oriented training and control programs

Programs that have been devised to improve the lot of patients with skin disease, or disease presenting with skin signs and symptoms, in resource-poor regions have focused mainly on education and training or community-oriented control measures. However, both have in common an objective of managing disease at population level. Training has been delivered in different ways both by direct teaching for varying periods of time or by web-based and electronic communication; control measures have been less in evidence and there is a great need for more support from funding agencies. Despite this, there is now a growing number of successful initiatives in health improvement for skin conditions that cover many parts of the world. This report describes many of these schemes as an example of what can be done to help patients.

Epidemiological and geographical aspects of leishmaniasis in Tigray, northern Ethiopia: a retrospective analysis of medical records, 2005-2008

Leishmaniasis is one of the most neglected tropical diseases and epidemic outbreaks often occur worldwide. This paper reports some epidemiological features of the disease in Tigray, northern Ethiopia, with the aim of studying the disease distribution and the environmental factors that may have influenced it. Medical records from patients with Leishmania attending the Italian Dermatological Centre of Mekele in the period 2005-2008 were retrospectively reviewed. Age and gender distribution, clinical types, occupation, co-morbidity, urban/rural origin, altitude and rainfall were investigated. The result was 471 patients affected and the prevalent clinical form was cutaneous leishmaniasis (86%). Five main risk areas were identified in the Tigray highlands and only isolated cases were reported at altitudes below 1700m. The variables related to a higher risk of catching leishmaniasis were male gender, age over-14, poor education, outdoor activities and living at high altitudes. Climatic and environmental changes occurring in this region and land degradation are discussed as factors influencing leishmaniasis distribution. Further research including field missions and geomapping is needed to quantify the actual disease burden in the region.