Skin Disorders in Vulnerable Populations: Causes, Impacts and Challenges 9811538786, 9789811538780

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Fingani Annie Mphande

Skin Disorders in Vulnerable Populations Causes, Impacts and Challenges

Skin Disorders in Vulnerable Populations

Fingani Annie Mphande

Skin Disorders in Vulnerable Populations Causes, Impacts and Challenges

123

Fingani Annie Mphande Faculty of Medicine King Mongkut’s Institute of Technology Ladkrabang (KMITL) Bangkok, Thailand Public Health and Infectious Disease Consultant Bangkok, Thailand

ISBN 978-981-15-3878-0 ISBN 978-981-15-3879-7 https://doi.org/10.1007/978-981-15-3879-7

(eBook)

© Springer Nature Singapore Pte Ltd. 2020 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore

For Syelwike Jenny Dorothy Mphande

Preface

Skin diseases (SDs) are a public health problem in many parts of the world. While other skin conditions are non-communicable, communicable (infectious) skin diseases pose a huge burden in low-income (LIC) as well as low-to-middle income countries (LMIC). Poor reporting from these regions has made it difficult to estimate the disease burden in the affected countries. The low mortality rate of skin diseases has resulted in less priority being attributed to these ailments compared to diseases with high mortality in resource-poor countries and communities. Some of these skin diseases are also part of what are known as neglected tropical diseases (NTDs), a set of debilitating diseases affecting certain populations in tropical countries. Skin diseases, especially those affecting poor and/or vulnerable communities, receive very little coverage. The low mortality owing to these diseases has translated to limited resources being allocated to tackle this public health problem despite the enormous burden. Although most skin diseases are treatable, limited access to treatment and poor diagnosis have allowed for persistence of these diseases in limited resource communities. Finding ways to manage skin infections and disorders is essential to improve the health and livelihoods of the affected populations. Innovative methods are required to improve management and treatment of these ailments in vulnerable communities. Skin diseases not only impact the infected individual, but also their families, communities and livelihoods. Understanding skin diseases and their causes could assist in better infection, prevention and control in endemic populations. Skin Disorders in Vulnerable Populations—Causes, Impacts and Challenges explores skin diseases, their aetiologies and impact on populations in resource-poor countries and communities. The book highlights the various skin diseases (disorders) affecting vulnerable communities in many parts of the world, including Africa, South East Asia, the South pacific and Oceania as well as South America. This book uniquely addresses the various types of skin diseases and how these ailments disrupt the lives of many physically, economically and socially. The book also compiles study reports from various settings and how each setting may present different challenges in implementation and management of infection prevention and vii

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control measures. Skin Disorders in Vulnerable Populations—Causes, Impacts and Challenges also highlights strategies that have led to successful elimination of diseases in some countries. Skin Disorders in Vulnerable Populations—Causes, Impacts and Challenges is aimed at igniting discussions on topics that are often sidelined and/or neglected and shed a light on the burden carried by vulnerable communities as they live with the impacts of skin diseases. Many of the affected may never report to any health facility for treatment due to fear of stigma, limited mobility, as well as lack of resources to meet the costs of treatment and/or long-term management. There is a need to encourage reporting of skin diseases in endemic areas to ensure better estimates of mortality and morbidity due to these disorders. Several visits to a skin clinic in a low-income country setting and seeing the morbidity due to skin diseases was an inspiration to write this book. Most of those who came to seek treatment had travelled long distances and had tried alternative treatment which at this point seemed futile. The skin clinic was their last hope. Many of the patients were from limited resource backgrounds most of whom would not make it to a follow up visit due to lack of resources. This grim picture is repeated in many resource-poor countries and communities. The compilation of this book involved interviews with a dermatologist who has worked at one of these clinics for over 20 years, treating and managing patients with various skin disorders. Literature review on various peer-reviewed publications as well as documentaries provided a greater understanding at the impact of these diseases globally. I hope this book will spark conversations and actions that will encourage not only research, but also availability of resources to assist in the management and treatment of skin diseases in vulnerable populations. Skin Disorders in Vulnerable Populations—Causes, Impacts and Challenges provides an essential resource for academic institutions, researchers, students, governments, non-governmental organisations and all stakeholders involved in public health, as well as in rural development and various projects in vulnerable populations. Bangkok, Thailand April, 2020

Fingani Annie Mphande

Acknowledgements

I would like to thank Mr. J. Malanda for all the insights and conversations on the various skin diseases. His vast experience provided an invaluable resource to the compilation of this book. My gratitude goes to all who provided permission for use of the photos in this book. Jessica Shortall, Jimmy Malanda, WHO and its partners who took the photos, thank you, your photos have helped show the indescribable impact of skin diseases. To all people and organisations that gave me support during this project, including publishers and editors, accept my sincere appreciation. My publishers, Alexandra Westcott Campbell, Ameena Jafaar, and the team at Springer in Singapore and associated offices, thank you for your support and guidance. A big thank you to my family and friends, who supported me through this project; thank you for all your prayers and encouragement.

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Permissions

All material used in this manuscript have been duly acknowledged and cited accordingly. The photographs of buruli ulcer, Guinea worm, leishmaniases, tungiasis and scabies were used with permission from WHO. The photo of podoconiosis was used with permission from Jessica Shortall. The photos from J. Malanda/MW were used with permission from Jimmy Malanda.

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Contents

1 Skin Diseases: Need for Attention . . . . . . . . . . . . . . . . . 1.1 The Extent of the Problem . . . . . . . . . . . . . . . . . . . 1.2 Economic Status, Livelihoods and Disease . . . . . . . . 1.2.1 Seeking Treatment for Skin Diseases . . . . . . 1.3 Skin Diseases and Limited Resource Populations . . . 1.3.1 Assessing the Needs . . . . . . . . . . . . . . . . . . 1.3.2 Identifying the Needs . . . . . . . . . . . . . . . . . 1.3.3 Applying the Necessary Interventions . . . . . 1.4 The Global Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.5 Benefits of Control and Prevention of Skin Diseases 1.6 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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2 The Structure and Function of the Skin . . 2.1 The Skin . . . . . . . . . . . . . . . . . . . . . . 2.1.1 Structure and Function . . . . . . 2.2 The Structures . . . . . . . . . . . . . . . . . . 2.2.1 Epidermis . . . . . . . . . . . . . . . 2.2.2 Dermis . . . . . . . . . . . . . . . . . 2.3 Host-Parasite Interactions . . . . . . . . . . 2.3.1 Immune Responses . . . . . . . . 2.3.2 Innate and Adaptive Immunity 2.4 Conclusion . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . .

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3 Types of Skin Disease and Their Causes . . . . . . . . . . . . . . . . . . . 3.1 Disease Aetiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2 Epidermal Parasitic Skin Diseases (EPSD) . . . . . . . . . . . . . . . 3.2.1 Why Are Skin Diseases Neglected When They Cause Great Morbidity in the Affected Populations? . . . . . .

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3.2.2 3.2.3

Setting and Vulnerability to Disease . . . . . . . Sanitation, Prevailing Climatic Conditions, and Poor Knowledge About Skin Diseases and Their Causes Play a Role in the Success of EPSD . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2.4 Scabies . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2.5 Tungiasis . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2.6 Leishmaniasis . . . . . . . . . . . . . . . . . . . . . . . 3.2.7 Guinea Worm . . . . . . . . . . . . . . . . . . . . . . . 3.2.8 Onchocerciasis (River Blindness) . . . . . . . . . 3.2.9 Lymphatic Filariasis . . . . . . . . . . . . . . . . . . . 3.2.10 Podoconiosis . . . . . . . . . . . . . . . . . . . . . . . . 3.2.11 Pediculosis Capitis . . . . . . . . . . . . . . . . . . . . 3.2.12 Hookworm Related Larva Migrans . . . . . . . . 3.3 Bacterial Skin Diseases . . . . . . . . . . . . . . . . . . . . . . . 3.3.1 Impetigo . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3.2 Yaws . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3.3 Buruli Ulcer . . . . . . . . . . . . . . . . . . . . . . . . 3.4 Viral Skin Infections . . . . . . . . . . . . . . . . . . . . . . . . . 3.4.1 Herpes Simplex Virus (HSV) . . . . . . . . . . . . 3.4.2 Herpes Zoster (HZ)—Shingles . . . . . . . . . . . 3.5 Superficial Fungal Infections (SFI) . . . . . . . . . . . . . . 3.5.1 Tinea Capitis . . . . . . . . . . . . . . . . . . . . . . . . 3.5.2 Tinea Cruris . . . . . . . . . . . . . . . . . . . . . . . . 3.5.3 Tinea Pedis . . . . . . . . . . . . . . . . . . . . . . . . . 3.5.4 Tinea Corporis . . . . . . . . . . . . . . . . . . . . . . . 3.6 Papulosquamous Skin Conditions . . . . . . . . . . . . . . . 3.6.1 Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.6.2 Seborrheic Dermatitis . . . . . . . . . . . . . . . . . . 3.6.3 Pityriasis Rosea . . . . . . . . . . . . . . . . . . . . . . 3.6.4 Lichen Planus . . . . . . . . . . . . . . . . . . . . . . . 3.7 Eczema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.8 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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4 Impact of Skin Diseases in Limited Resource Countries . . . . 4.1 Impact of Skin Diseases and Limited Resource Countries . 4.1.1 Impact of Skin Diseases on the Quality of Life . . 4.1.2 Social and Economic Impacts of Skin Diseases . . 4.1.3 Impact of Skin Diseases on Livelihoods . . . . . . . 4.1.4 Impact of Skin Diseases on Health . . . . . . . . . . . 4.1.5 Emerging Drug Resistance . . . . . . . . . . . . . . . . . 4.2 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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5 Prevention, Treatment and Control of Skin Diseases . . . . 5.1 Infectious Disease Prevention and Control . . . . . . . . . . 5.2 Surveillance and Skin Diseases—Using Smallpox as an Example . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2.1 Lessons from Smallpox Elimination Campaign Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.3 Skin Disease Prevention Strategies . . . . . . . . . . . . . . . 5.3.1 Surveillance and Collaboration . . . . . . . . . . . . 5.3.2 Early Detection of Disease . . . . . . . . . . . . . . . 5.4 Skin Diseases Within the Community . . . . . . . . . . . . . 5.4.1 Availability of Knowledge of Disease Within the Community . . . . . . . . . . . . . . . . . . . . . . . 5.4.2 Willingness to Seek Treatment . . . . . . . . . . . . 5.4.3 Diagnostic Tools and Treatment . . . . . . . . . . . 5.5 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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6 Potential Public Health Measures to Tackle Skin Diseases . . 6.1 Existing Tools and Public Health Measures Tackling Skin Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.1.1 Mass Drug Administration (MDA) . . . . . . . . . . . 6.1.2 Synergistic Approaches in Disease Control . . . . . 6.1.3 Challenges of MDA . . . . . . . . . . . . . . . . . . . . . . 6.1.4 The Global Program to Eliminate Lymphatic Filariasis (GPELF) . . . . . . . . . . . . . . . . . . . . . . . 6.1.5 The Global Campaign to Eradicate Dracunculiasis 6.2 Challenges Faced by the Existing Tools . . . . . . . . . . . . . . 6.2.1 Lack of Data . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.2.2 Access to Tools and Trained Personnel . . . . . . . . 6.2.3 Conflicts and Political Instability . . . . . . . . . . . . . 6.3 Global Plan to Tackle Skin Diseases . . . . . . . . . . . . . . . . 6.3.1 Understand the Burden of Disease . . . . . . . . . . . 6.3.2 Telemedicine/Tele Dermatology-Addressing Training Deficits . . . . . . . . . . . . . . . . . . . . . . . . 6.4 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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7 Studies from Literature 7.1 Buruli Ulcer . . . . . . 7.2 Scabies . . . . . . . . . 7.3 Tungiasis . . . . . . . . 7.4 Yaws . . . . . . . . . . . 7.5 Podoconiosis . . . . . 7.6 Lymphatic Filariasis

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7.7 Leishmaniasis . . . . . . 7.8 Fungal Infections and 7.9 Conclusion . . . . . . . . References . . . . . . . . . . . .

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8 Reducing Burden of Disease . . . . . . . . . . . . . . . . . . . . . . 8.1 Sustainable Livelihood, Implementation Science and Disease Burden . . . . . . . . . . . . . . . . . . . . . . . . . 8.1.1 Disease Burden and Human Capital . . . . . . . 8.1.2 Disease Burden and Physical Capital . . . . . . . 8.1.3 Disease Burden and Natural Capital . . . . . . . 8.1.4 Disease Burden and Social Capital . . . . . . . . 8.1.5 Disease Burden and Financial Capital . . . . . . 8.1.6 Livelihood Determinants and Disease Burden 8.2 Risks and Challenges . . . . . . . . . . . . . . . . . . . . . . . . 8.2.1 Unknown Risks and Challenges . . . . . . . . . . 8.3 Disease Burden and Communities . . . . . . . . . . . . . . . 8.3.1 Disease Burden and Community Setting . . . . 8.3.2 Disease Burden and Culture . . . . . . . . . . . . . 8.4 Public Health and Policy Aspects on Skin Diseases . . 8.5 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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9 Milestones; Disease Elimination Success Stories . . . . 9.1 Disease Elimination and Eradication . . . . . . . . . . 9.1.1 Diseases up for Eradication . . . . . . . . . . 9.2 Disease Eradication and Elimination Terminology 9.2.1 Lymphatic Filariasis (LF) in Sri Lanka . . 9.3 Strategies in Disease Elimination . . . . . . . . . . . . . 9.4 Custom Made Strategies (CMS) . . . . . . . . . . . . . 9.5 Problems, Constraints and Success . . . . . . . . . . . 9.6 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177

Acronyms

SD SDC DALYs YLD LIC LMIC WHO NTD LC DC dDC pDC TRM PAMPS PRR EPSD HrCLM HSV STI LP CLP OLP SEP GPELF LF PacELF VL CL

Skin Diseases/ Disorders Skin Diseases and Conditions Disability Adjusted Life Years Years Lost to Disability Low Income Countries Low -Middle Income Countries World Health Organization Neglected Tropical Diseases Langerhan Cell Dendritic Cells Dermal Dendritic Cells Peripheral Dendritic Cells Resident Memory T-Cells Parasite Associated Molecular Patterns Pattern Recognition Receptors Epidermal parasitic Skin Diseases Hookworm-related cutaneous larva migrans Herpes Simplex Virus Sexually Transmitted Infections Lichen Planus Cutaneous Lichen Planus Oral Lichen Planus Smallpox Eradication Program Global Program to Eliminate Lymphatic Filariasis Lymphatic Filariasis Pacific Program to Eliminate Lymphatic Filariasis Visceral Leishmaniasis Cutaneous Leishmaniasis

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Chapter 1

Skin Diseases: Need for Attention

Abstract Skin diseases (SDs) are a public health problem in many parts of the world, especially in resource poor countries and communities. Some of these skin diseases are part of what are known as neglected tropical diseases (NTDs), a set of debilitating diseases affecting certain populations in tropical countries. As of 2014, the total world population was 7.2 billion with 6 billion living in less developed countries and 3.384 billion living in rural areas. Skin disorders affect 21–85% of the world’s population (1.26–5.1 billion people) living in low-and middle-income countries. Despite the morbidity and mortality caused by these diseases, the attention given is not proportional to the burden. The burden of skin diseases in low income (LIC) and other low to middle income countries (LMIC) is difficult to estimate owing to poor reporting in some countries. Despite the huge burden of disease, skin diseases have a low mortality rate, and as such they are given less priority compared to other diseases with high mortality. As a result of the low mortality, limited resources are allocated to tackle this public health problem although the burden is enormous. Although most skin diseases are treatable, limited access to treatment and poor diagnosis have allowed for persistence of these diseases in limited-resource communities. Finding ways to manage skin infections and disorders is essential to improve the health and livelihoods of the affected populations. Innovative ways are required to address SDs in vulnerable communities globally. Keywords Skin diseases · Neglected tropical diseases · Disease burden · DALYs · Poverty · Rural populations · Disease prevention · Disease control · Morbidity · Mortality Synopsis Health related quality of life instruments are tools designed to assess the quality of life in various populations and interventions. HR-QOL can be generic or disease specific. There are hundreds of generic HR-QOL worldwide but the most commonly used ones in the English language include; • • • •

the Medical Outcomes Study 36-Item Short Form (SF-36) health survey; the Nottingham Health Profile (NHP); the Sickness Impact Profile (SIP); the Dartmouth Primary care Cooperative Information Project (COOP) Charts;

© Springer Nature Singapore Pte Ltd. 2020 F. A. Mphande, Skin Disorders in Vulnerable Populations, https://doi.org/10.1007/978-981-15-3879-7_1

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1 Skin Diseases: Need for Attention

• the Quality of Well-Being (QWB) Scale; • the Health Utilities Index (HUI); • the EuroQol Instrument (EQ-5D). A good HR-QOL is characterized by how simple, reliable, quick and easy to perform and score, and how well it is accepted. While the SF-36 health survey is the most commonly used HR-QOL measure, the Dartmouth COOP Charts was designed for use in everyday clinical practice and provides immediate feedback to clinicians about the health status of their patients. On the other hand, the NHP focus was to reflect perceptions of lay individuals rather than those of health. The selection of HR-QOL depends on the purpose, the targeted measure, characteristic of the population (Such as health status, language, culture and age), and the setting and or environment where the measure will be assumed (e.g. routine clinical visit, clinical trial). The choice of HR-QOL therefore should depend on the needs to be measured. In dermatology, a number of HR-QOL instruments have been developed to measure the effects of treatment and disease progression, well-being and the value that patients put to their skin health (dermatologic state of health). Currently there are generic, skin-specific and skin-disease-specific measures for use in adults. The generic tools include; • Dermatology Life Quality Index (DLQI) • Dermatology Quality of Life Scales (DQoLS) • Dermatology-Specific Quality of Life Instrument for Contact Dermatitis (DSQLCD) • Family Dermatology Life Quality Index (FDLQI) • Skindex (Skindex) Skin diseases considerably affect the quality of life in infected individuals

1.1 The Extent of the Problem In populations worldwide, pruritus, eczema, impetigo, scabies, and molluscum contagiosum are among the top 50 most prevalent infectious diseases globally. Skin diseases are responsible for 4% of the non-fatal disease burden, highlighting the need for skin diseases to be included in future global strategies (Fig. 1.1) (Hay et al., 2014). The non-fatal disease burden includes disability which cannot be ignored. SDs affect people in all parts of the world no matter their background, race, financial status, social status and economic status. But how is it that while some parts of the world have managed to find ways of combating skin diseases, others are still struggling to control and manage these diseases? A study measuring the burden of SDs worldwide focusing on 15 skin diseases from 188 countries showed that these conditions contributed to approximately 2% of the global burden of diseases by measuring disability-adjusted life years (DALYs) (Hay et al., 2014; Karimkhani, Dellavalle et al. 2017). SDs were the 18th leading

1.1 The Extent of the Problem

3

Fig. 1.1 Global Burden of Skin Diseases. The burden of skin diseases around the world. ATG— Antigua, VCT—St Vincents, BAR—Barbados, COM—Comoros, DMA—Dominica, FJI—Fiji, FSM—Federated States of Micronesia, GRD—Grenada, KIR—Christmas Island, LCA—St Lucia, MDV—Maldives, MHL—Marshall Islands, MLT—Malta, MUS—Mauritius, SGP—Singapore, SLB—Solomon Islands, SYC—Seychelles, TLS—Timor—Leste, TON—Tonga, TTO—Trinidad and Tobago, VUT—Vanuatu, WSM—Western Samoa. Global Burden of Skin Diseases © Hay et al. (2014)

cause of global DALYs in Global Burden of Disease 2013 and were the fourth leading cause of disability worldwide (Table 1.1) (Hay et al., 2014; Karimkhani, Dellavalle et al., 2017). In the United states, it is estimated that nearly 85 million Americans were seen by a doctor for at least one SDs in 2013 (Lim et al., 2017). The burden of skin diseases in low income (LIC) and other low to middle income countries (LMIC) is difficult to estimate, owing to poor reporting in some countries (Tatem, Rogers, & Hay, 2006). Despite the lack of data, skin diseases are some of the most commonly occurring conditions in tropical countries. A study conducted in 187 countries estimated that 15 categories of skin diseases contributed to the global burden of diseases between 1990 and 2010 (Hay et al., 2013; Hollestein & Nijsten, 2014). Fungal skin diseases and acne were among the top 10 most prevalent diseases worldwide in 2010, with pruritus, eczema, impetigo, scabies, and molluscum contagiosum among the top 50 (Hay et al., 2013).

1.2 Economic Status, Livelihoods and Disease SDs have been associated with economic status, with people of lower economic status carrying most of the disease burden (Fig. 1.1). Some of the skin diseases appear in

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Table 1.1 Collective Global DALYs and DALY Ranks Disease

Global DALY

DALY Rank

Ischemic heart disease

129,800,000

1

Lower respiratory infections

115,200,000

2

Cerebrovascular disease

102,200,000

3

Diarrheal disease

89,523,909

4

Malaria

82,688,806

5

HIV/AIDS

81,549,177

6

Low back pain

80,666,896

7

Pre-term birth complications

76,979,669

8

Chronic obstructive pulmonary disease

76,778, 819

9

Road injury

75,487,102

10

Major depressive disorder

63,239,334

11

Neonatal encephalopathy (birth asphyxia and birth trauma)

50,162, 510

12

Tuberculosis

49,399,351

13

Diabetes mellitus

46,857,136

14

Iron-deficiency anaemia

45,349,897

15

Sepsis and other infectious disorders of the newborn baby

44,236,488

16

Congenital anomalies

38,890,019

17

Skin conditions

36,921,995

18

Self-harm

36,654,590

19

Falls

35,405,935

20

Source Roderick et al. (2014)

the WHO list of neglected tropical diseases and various interventions are in place to try and reduce this. The morbidity from SD affects the livelihoods of the affected individuals and communities due to deformities and disabilities as a result of disease. These deformities and disabilities have also led to social exclusion and stigma and in some cases mental illness (Deribe et al., 2015; Engelman et al., 2016; Feldmeier, Sentongo, & Krantz, 2013; Feldmeier & Heukelbach, 2009; Hofstraat & Van Brakel, 2015; Mousley et al., 2014). As livelihood provides a source of income, DALYs lost due to disease have a serious effect on the quality of life of the affected individuals and communities.

1.2.1 Seeking Treatment for Skin Diseases In limited resource communities, seeking medical attention is a privilege not a priority as seeking medical attention depends on several factors. These include:

1.2 Economic Status, Livelihoods and Disease

5

a. Financial/Economic Factors With limited resources, consideration on the cost of treatment is of utmost importance. By weighing which is more costly, living with the condition or seeking treatment, the option which less costly will most likely be chosen. Unless morbidity is observed with the condition, there is a greater likelihood that people will not seek treatment. Costs also include: transportation to the nearest clinic, cost of consultation, drugs/treatment, and the impact of these costs on the household (Mphande, 2016). b. Social and Behaviour Factors Skin diseases/conditions are visible, as such they considerably affect the life of the infected individual. People suffering from skin diseases may be socially isolated and stigmatised due to their skin conditions. Since most of the general population in most countries do not have the right information regarding skin conditions, stigma is most often the first reaction. Stigma not only exists in communities but also in health care services where primary healthcare workers have little information regarding skin diseases and their treatment. Neglect of SDs and poor and or ineffective treatment of skin diseases has resulted in crippling and debilitating effects that often permanently affect the lives of the affected individuals (Fig. 1.2). If the skin condition is “hidden” (affects parts of the body which are not easily visible), people tend to keep the disease a “secret”. But if the disease is visible, social stigma plays a role and this could force people to seek treatment no matter the cost. On the other hand, social stigma can also negatively affect treatment seeking behaviour, when individuals are socially discriminated against, they may also stay away from seeking treatment.

Neglected Tropical Diseases (NTD) (Affecng vulnerable populaons globally)

Leishmaniases Yaws Scabies Leprosy Other ectoparasic diseases

Neglected Skin Diseases (Some of which are listed as NTD by WHO)

Negavely affect

Health Livelihood Poverty Sgma/Social Exclusion

Fig. 1.2 Neglected Tropical Diseases affecting the skin. Some skin diseases are among some of the neglected tropical disease listed by WHO. Neglected skin diseases not only affect the health, but also livelihoods of affected individuals. Morbidity from skin diseases could lead to poverty due to loss of livelihood, and also to social factors such as stigma/social exclusion

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1.3 Skin Diseases and Limited Resource Populations 1.3.1 Assessing the Needs Assessing the situation in different countries and regions of the world can assist in understanding the scale of the problem. Despite studies being conducted in many parts of the world and prevalence data published, there are gaps in these reports due to missing data (Hay et al., 2013; Karimkhani, Colombara et al., 2017). Not all countries report data on SDs and the accuracy of the data for those reporting may be challenging in some circumstances. This may be due to limited coverage of the data collection, challenges in accessing affected populations as well as limited resources to carry out surveillance to assess the extent of disease. With missing or limited data, it is difficult to come up with appropriate and effective strategies that can assist in building better control and prevention schemes in the affected countries (Girma, Astatkie, & Asnake, 2018; Moto, Maingi, & Nyamache, 2015; Yotsu et al., 2015). Despite dermatoses affecting all ages and both males and females, age and sex-specificity has often been reported (Kalu, Wagbatsoma, Ogbaini-Emovon, Nwadike, & Ojide, 2015). A study of hospital records in Nigeria revealed that approximately 48% of children visiting the paediatrics department had an infectious skin disease. In most cases the disease was recorded as ‘non-specific dermatitis’, suggesting limited knowledge by the attending health personnel (Emodi, Ikefuna, Uchendu, & Duru, 2010). The incidence pattern of infectious skin diseases may differ depending on the age of the children: taenia and bacterial skin infection are common in younger children while acne vulgaris and pityriasis versicolor are common amongst adolescents. Significant morbidity due to skin diseases may include, disfigurement, disability and reduction to quality of life. These are some of the crucial factors to consider when focusing on skin diseases. The economic strain brought about by treatment costs on the family by skin diseases cannot be ignored. The challenges in management of infectious skin diseases in limited resource settings can also be attributed to the scarcity of basic skills in skin disease management (Ackumey, Kwakye-Maclean, Ampadu, de Savigny, & Weiss, 2011; Barogui et al., 2018; Clinical Cases in Infections and Infestations of the Skin, 2015; Engelman et al., 2016). Dominance of treatable and/or preventable skin infections in rural communities in contrast with urban reflects the limited availability of clinical services. A study conducted in the slums in Brazil revealed that some healthcare workers only diagnosed skin diseases if they were pointed out to them by a patient. The study observed that ectoparasitic infections such as scabies, tungiasis, and pediculosis, were ignored by both the affected communities and the health personnel; showing lack of awareness, experience and knowledge in the process of dealing with ectoparasites (Heukelbach et al., 2003; Vincente et al., 2009).

1.3 Skin Diseases and Limited Resource Populations

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1.3.2 Identifying the Needs Ability for countries to set up short, medium, and long-term goals can assist in keeping track of what is achievable with the available resources and the duration it takes to attain the set goals. By identifying needs including assessing behaviours associated with disease, infrastructure, resources, hygiene, disease causing pathogens, types of diseases, knowledge and living conditions; strategies can be formulated according to the needs. Identifying needs gives countries the opportunity to set up their own specific targets and strive to achieve them. Better management of skin diseases both at household, community and national level could lead to improvement in identification, diagnosis and prevention efforts (Rosenbaum et al., 2017). By identifying the factors associated with disease, appropriate interventions can be applied. Scabies is a typical example: a significant association between scabies and overcrowding has been reported in places such as hospitals, nursing homes, schools, prisons and households. In Cameroon and Togo, sharing of beds and clothing were some of the contributing factors associated with scabies (Akakpo et al., 2013; Armand Kouotou et al., 2012). Therefore, control strategies with a component of reducing overcrowding may be used to address scabies in these communities.

1.3.3 Applying the Necessary Interventions After identifying the needs, it is possible to predict or devise the appropriate interventions. The interventions should be in collaboration with the affected communities as well as other relevant stakeholders to ensure commitment and participation.

1.4 The Global Plan Between 2008–2015, the global plan from WHO included to prevent, control, eliminate or eradicate NTDs. The current list of NTDs includes some SDs. Every region has its own disease targets for NTDs (Table 1.2). The objectives of the global plans for skin diseases should be similar: • To eliminate or eradicate those diseases targeted in resolutions of the World Health Assembly and regional committees. • To reduce significantly the burden of other tool-ready diseases through current interventions. • To ensure that interventions using novel approaches are available and promoted, and that they are accessible for tool-deficient diseases. • Global Plan: Tool-ready diseases targeted by resolutions of the World Health Assembly and regional committees for elimination or eradication include dracunculiasis, leprosy and lymphatic filariasis. Other tool-ready diseases include:

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Table 1.2 Neglected tropical diseases associated with skin diseases targeted by region. Neglected tropical diseases in the various regions of the world including skin NTDs Region Africa

Americas

Eastern mediterranean

South East Asia

Western pacific

Buruli ulcer

Chagas disease

Leishmaniases

Anthroponotic leishmaniasis (Kala-azar)

Lymphatic Filariasis

Leprosy

European anthrax

Leprosy

Drancuculiasis

Lymphatic filariasis

Lymphatric filariasis

Lesishmaniasis

Onchocerciasis

Yaws

Leprosy

Fungal and ectoparasitic skin diseases

Lymphatic

Leishmaniases

Filariasis Onchocerciasis

Parasitic zoonoses

Yaws

anthroponotic leishmaniasis, blinding trachoma, cysticercosis, echinococcosis, onchocerciasis, rabies, schistosomiasis, soil-transmitted helminthiasis and yaws. Tool-deficient diseases listed are: anthrax, brucellosis, buruli ulcer, Chagas disease, dengue, human African trypanosomiasis, Japanese encephalitis and leishmaniases.

1.5 Benefits of Control and Prevention of Skin Diseases Although most skin diseases are treatable, inadequate access to diagnosis and treatment have allowed for proliferation of these diseases in limited resource communities. Choosing the right and effective treatment for a community could assist in reducing the disease burden. While one form of treatment may be effective in one population, it may not present similar outcomes in a different population (Ly, Caumes, Ndaw, Ndiaye, & Mahé, 2009). Whatever the mode of treatment, improved control and prevention of skin diseases would be a major contribution to poverty alleviation and in reaching the health-related sustainable development goals. By tackling challenges faced by affected countries in establishing, implementing and sustaining measures of skin disease prevention and control, communities may benefit socially and economically.

1.5 Benefits of Control and Prevention of Skin Diseases

9

While the affected communities would place high priority in seeing an end to these diseases, they are unable to manage and control such diseases on their own. It is difficult for affected populations, most of whom are poor and neglected, to convince policy makers to facilitate necessary change. While interventions may be available and, in some cases, implemented, sustainability of these interventions becomes a challenge. If the intervention depends on donor funding and or donations, cessation of such donations implies the end of the project. As such strides that may have been achieved are quickly lost and the problem resurfaces. Lack of sustainability of the intervention allows for re-emergence of the diseases (Barogui et al., 2018; Bockarie, Kelly-Hope, Rebollo, & Molyneux, 2013; Hay et al., 2014). Whenever possible, strategies and interventions that are introduced should be of a kind that are locally sustainable. Skin diseases are prevalent in younger age groups thereby affecting their growth and development (Cocks et al., 2016; Msyamboza et al., 2012; Njiru, Yeboah-Manu, Stinear, & Fyfe, 2012; Ukwaja et al., 2016; Vincent et al., 2014; Vincente et al., 2009; Wiese, Elson, & Feldeier, 2018). If countries are to achieve better prevention and control of SD, they must tackle the poor diagnosis and lack of knowledge of skin diseases that so often prevail among both health workers and the affected population. One way to tackle poor diagnosis is by use of mobile phone technology (tele dermatology). By exploiting existing tools, it is possible to improve diagnosis and treatment of SD. Health workers can take pictures of the skin lesions and or disorder, the picture can then be sent to a consultant for advice on possible diagnosis and treatment as well as comments. With the subjective nature of diagnosis of SD, teledermatology could prove to be a useful tool in diagnosis and treatment of SD. See Chap. 6 for further discussion on tele dermatology.

1.6 Conclusion Management of SD at primary healthcare level continues to be a challenge for most countries that have limited resources (LMICs). The obstacles to achieving this include limited trained personnel, lack of ample knowledge of SD, poor diagnosis and limited access to required treatment. Identifying the right diagnostic tools for SD in resource poor nations, could assist in reducing the burden of these diseases. If primary healthcare workers would be able to connect with a dermatologist through telemedicine and or tele-dermatology even in the remote parts of the world, this would be a good start. Finding ways to manage SD is an important component of improving the health and livelihoods of affected populations. Innovative ways are required to address SD in vulnerable communities globally.

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References Ackumey, M. M., Kwakye-Maclean, C., Ampadu, E. O., de Savigny, D., & Weiss, M. G. (2011). Health services for Buruli ulcer control: Lessons from a field study in Ghana. PLoS Neglected Tropical Diseases. https://doi.org/10.1371/journal.pntd.0001187. Akakpo, A. S., Ekouevi, D. K., Toure, A. M., Saka, B., Sogan, A., Almeida, S., … & Pitche, P. (2013). Communication courte Pathologie cutanée et infection à VIH chez les détenus à Lomé, Togo: étude de 194 cas Skin disease and HIV infection among inmates in Lomé, Togo: a study of 194 prisoners. Médecine et Santé Tropicales, 24, 326–328. https://doi.org/10.1684/mst.2013. 0182. Armand Kouotou, E., Richie Nansseu, J. N., Sieleunou, I., Defo, D., Zoung-Kanyi Bissek, A.-C., & Claude Ndjitoyap Ndam, E. (2012). A phase I study of daily treatment with a ceramide-dominant triple lipid mixture commencing in neonates. https://doi.org/10.1186/s12895-015-0031-0. Barogui, Y. T., Diez, G., Anagonou, E., Johnson, R. C., Gomido, I. C., Amoukpo, H., … Kingsley, A. (2018). Integrated approach in the control and management of skin neglected tropical diseases in Lalo, Benin. PLoS Neglected Tropical Diseases, 12(6). https://doi.org/10.1371/journal.pntd. 0006584. Bockarie, M. J., Kelly-Hope, L. A., Rebollo, M., & Molyneux, D. H. (2013). Preventive chemotherapy as a strategy for elimination of neglected tropical parasitic diseases: Endgame challenges. Philosophical Transactions of the Royal Society B: Biological Sciences. https://doi.org/10.1098/ rstb.2012.0144. Clinical Cases in Infections and Infestations of the Skin. (2015). In Clinical Cases in Infections and Infestations of the Skin. https://doi.org/10.1007/978-3-319-14295-1. Cocks, N., Rainima-Qaniuci, M., Yalen, C., Macleod, C., Nakolinivalu, A., Migchelsen, S., … & Marks, M. (2016). Community seroprevalence survey for yaws and trachoma in the Western Division of Fiji. Transactions of the Royal Society of Tropical Medicine and Hygiene. https://doi. org/10.1093/trstmh/trw069. Deribe, K., Wanji, S., Shafi, O., M Tukahebwa, E., Umulisa, I., Molyneux, D. H., & Davey, G. (2015). The feasibility of eliminating podoconiosis. Bulletin of the World Health Organization. https://doi.org/10.2471/BLT.14.150276. Emodi, I. J., Ikefuna, A. N., Uchendu, U., & Duru, A. (2010). Skin diseases among children attending the out patient clinic of the University of Nigeria teaching hospital, Enug. African Health Sciences. Engelman, D., Fuller, L. C., Solomon, A. W., McCarthy, J. S., Hay, R. J., Lammie, P. J., & Steer, A. C. (2016). Opportunities for integrated control of neglected tropical diseases that affect the skin. Trends in Parasitology, 32. https://doi.org/10.1016/j.pt.2016.08.005. Feldmeier, H., Sentongo, E., & Krantz, I. (2013). Tungiasis (sand flea disease): A parasitic disease with particular challenges for public health. European Journal of Clinical Microbiology and Infectious Diseases, 32, 19–26. https://doi.org/10.1007/s10096-012-1725-4. Feldmeier, H., & Heukelbach, J. (2009). Epidermal parasitic skin diseases: A neglected category of poverty-associated plagues. Bulletin of the World Health Organization, 87, 152–159. https:// doi.org/10.2471/BLT.07.047308. Girma, M., Astatkie, A., & Asnake, S. (2018). Prevalence and risk factors of tungiasis among children of Wensho district, southern Ethiopia. BMC Infectious Diseases. https://doi.org/10.1186/ s12879-018-3373-5. Hay, R. J, Johns, N. E., Williams, H. C., Bolliger, I. W., Dellavalle, R. P., Margolis, D. J., … & Naghavi, M. (2013). The global burden of skin disease in 2010: An analysis of the prevalence and impact of skin conditions. The Journal of Investigative Dermatology, 134(6), 1–8. https:// doi.org/10.1038/jid.2013.446. Hay, R. J., Johns, N. E., Williams, H. C., Bolliger, I. W., Dellavalle, R. P., Margolis, D. J., … & Naghavi, M. (2014). The global burden of skin disease in 2010: An analysis of the prevalence and impact of skin conditions. Journal of Investigative Dermatology. https://doi.org/10.1038/jid. 2013.446.

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Hay, R. J., Johns, N. E., Williams, H. C., Bolliger, I. W., Dellavalle, R. P., Margolis, D. J., … & Wulf, S. K. (2014). The global burden of skin disease in 2010: An analysis of the prevalence and impact of skin conditions. Journal of Investigative Dermatology, 134(6), 1527–1534. Hay, S. I., Battle, K. E., Pigott, D. M., Smith, D. L., Moyes, C. L., Bhatt, S., … & Gething, P. W. (2013). Global mapping of infectious disease. Philosophical Transactions of the Royal Society of London. Series B, Biological Sciences, 368(1614), 20120250. https://doi.org/10.1098/rstb.2012. 0250. Heukelbach, J., Van Haeff, E., Rump, B., Wilcke, T., Sab??ia Moura, R. C., & Feldmeier, H. (2003). Parasitic skin diseases: Health care-seeking in a slum in north-east Brazil. Tropical Medicine and International Health, 8(4), 368–373. https://doi.org/10.1046/j.1365-3156.2003.01038.x. Hofstraat, K., & Van Brakel, W. H. (2015). Social stigma towards neglected tropical diseases: A systematic review. International Health. https://doi.org/10.1093/inthealth/ihv071. Hollestein, L. M., & Nijsten, T. (2014). An Insight into the global burden of skin diseases the global burden of disease (GBD) 2010 study. Journal of Investigative Dermatology, 134(10), 1499–1501. https://doi.org/10.1038/jid.2013.513. Kalu, E. I., Wagbatsoma, V., Ogbaini-Emovon, E., Nwadike, V. U., & Ojide, C. K. (2015). Age and sex prevalence of infectious dermatoses among primary school children in a rural South-Eastern Nigerian community. Pan African Medical Journal. https://doi.org/10.11604/pamj.2015.20.182. 6069. Karimkhani, C., Colombara, D. V., Drucker, A. M., Norton, S. A., Hay, R., Engelman, D., … & Dellavalle, R. P. (2017). The global burden of scabies: A cross-sectional analysis from the Global Burden of Disease Study 2015. The Lancet Infectious Diseases. https://doi.org/10.1016/S14733099(17)30483-8. Karimkhani, C., Dellavalle, R. P., Coffeng, L. E., Flohr, C., Hay, R. J., Langan, S. M., … & Naghavi, M. (2017). Global skin disease morbidity and mortality an update from the global burden of disease study 2013. JAMA Dermatology. https://doi.org/10.1001/jamadermatol.2016.5538. Lim, H. W., Collins, S. A. B., Resneck, J. S., Bolognia, J. L., Hodge, J. A., Rohrer, T. A., … & Moyano, J. V. (2017). The burden of skin disease in the United States. Journal of the American Academy of Dermatology. https://doi.org/10.1016/j.jaad.2016.12.043. Ly, F., Caumes, E., Ndaw, C. A. T., Ndiaye, B., & Mahé, A. (2009). Ivermectin versus benzyl benzoate applied once or twice to treat human scabies in Dakar, Senegal: A randomized controlled trial. Bulletin of the World Health Organization. https://doi.org/10.2471/BLT.08.052308. Moto, J. N., Maingi, J. M., & Nyamache, A. K. (2015). Prevalence of Tinea capitis in school going children from Mathare, informal settlement in Nairobi, Kenya. BMC Research Notes, 8(1). https:// doi.org/10.1186/s13104-015-1240-7. Mousley, E., Deribea, K., Tamiru, A., Tomczyk, S., Hanlon, C., & Davey, G. (2014). Mental distress and podoconiosis in Northern Ethiopia: A comparative cross-sectional study. International Health. https://doi.org/10.1093/inthealth/ihu043. Mphande, F. A. (2016). Infectious diseases and rural livelihood in developing countries. https:// doi.org/10.1007/978-981-10-0428-5. Msyamboza, K. P., Mawaya, L. R., Kubwalo, H. W., Ng’oma, D., Liabunya, M., Manjolo, S., … & Somba, W. W. (2012). Burden of leprosy in Malawi: community camp-based cross-sectional study. BMC International Health and Human Rights, 12(1), 12. https://doi.org/10.1186/1472698X-12-12. Njiru, Z. K., Yeboah-Manu, D., Stinear, T. P., & Fyfe, J. A. M. (2012). Rapid and Sensitive Detection of Mycobacterium ulcerans by Use of a Loop-Mediated Isothermal Amplification Test. https:// doi.org/10.1128/JCM.06460-11. Rosenbaum, B. E., Klein, R., Hagan, P. G., Seadey, M.-Y., Larteley Quarcoo, N., Hoffmann, R., … Rosenbaum, B. (2017). Dermatology in Ghana: a retrospective review of skin disease at the Korle Bu Teaching Hospital Dermatology Clinic. https://doi.org/10.11604/pamj.2017.26.125.10954. Tatem, A. J., Rogers, D. J., & Hay, S. I. (2006). Global Transport Networks and Infectious Disease Spread. In A. G. and D. J. R. Simon I. Hay (Ed.), Advances in Parasitology (pp. 293–343). Academic Press.

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Ukwaja, K. N., Meka, A. O., Chukwuka, A., Asiedu, K. B., Huber, K. L., Eddyani, M., … Ntana, K. (2016). Buruli ulcer in Nigeria: results of a pilot case study in three rural districts. https://doi. org/10.1186/s40249-016-0119-8. Vincent, Q. B., Ardant, M. F., Adeye, A., Goundote, A., Saint-André, J. P., Cottin, J., … & Alcaïs, A. (2014). Clinical epidemiology of laboratory-confirmed Buruli ulcer in Benin: A cohort study. The Lancet Global Health, 2(7). https://doi.org/10.1016/S2214-109X(14)70223-2. Vincente, S. La, Kearns, T., Connors, C., Cameron, S., Carapetis, J., & Andrews, R. (2009). Community management of endemic scabies in remote aboriginal communities of Northern Australia: Low treatment uptake and high ongoing acquisition. PLoS Negl Trop Dis, 3(5). https://doi.org/ 10.1371/journal.pntd.0000444. Wiese, S., Elson, L., & Feldmeier, H. (2018). Tungiasis-related life quality impairment in children living in rural Kenya. PLoS Neglected Tropical Diseases, 12(1). https://doi.org/10.1371/journal. pntd.0005939. Yotsu, R. R., Murase, C., Sugawara, M., Suzuki, K., Nakanaga, K., Ishii, N., & Asiedu, K. (2015). Revisiting Buruli ulcer. Journal of Dermatology. https://doi.org/10.1111/1346-8138.13049.

Chapter 2

The Structure and Function of the Skin

Abstract The skin is part of the integumentary system which forms a physical barrier between the body and the outside elements. The integumentary system comprises the skin and its appendages such as hair, nails, and glands. There are various levels through which the skin protects the body from infections and other harmful external forces. Divided into different layers, the skin forms a platform for the immune cells that fight invading pathogens and promote healing. The various immune responses allow the body to develop strong immunity against pathogens. Keywords The skin · Skin function · Immunity · Skin structure · Sensory organ · Epidermis · Dermis Synopsis Immunity is the ability of the body to fight off invading pathogens. These pathogens can range from bacteria, viruses, parasites to fungi and yeast. There are two types of immunity, the early and less specific innate immunity and the more specific adaptive immunity. While innate immunity fights off any invasion, the adaptive immunity is pathogen specific and relies on memory of previous encounters with the pathogen. Thus, if an individual encounter’s a pathogen for the first time, innate immune responses are triggered immediately. During this time the adaptive immunity is taking stock of the invader and preparing memory antibodies to fight against it. If this individual encounter’s the same pathogen next time, the adaptive immunity is able to fight off the infection. For example, if an individual contracted disease A and survived the infection, if after a while the same person got infected by disease A, their body will be well prepared to fight off the latest infection. On the other hand, if the same individual was infected by disease C, their body does not have any memory of the disease C as such the individual will succumb to the disease.

2.1 The Skin The skin forms an impermeable outer layer preventing the entry of water and other external elements including bacteria, parasites, viruses and other disease-causing pathogens. The skin is part of the immune system, fighting off invaders; while a © Springer Nature Singapore Pte Ltd. 2020 F. A. Mphande, Skin Disorders in Vulnerable Populations, https://doi.org/10.1007/978-981-15-3879-7_2

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Fig. 2.1 The Skin-sensory organ, immunity and protection. The skin forms the protective outer layer of the body; it is a sensory organ filled with nerve cells and is the platform for various immune mechanisms that protect against disease and provide immunity

network of nerve terminals in the skin enable it to sense the environment (Fig. 2.1). This chapter will focus on the skin and how it protects against infection and its role in the immune system.

2.1.1 Structure and Function Apart from being the external covering of the body, forming a barrier against pathogens, dust and many other elements, the skin is a platform for various activities including nutrition and interaction with the environment. The skin is full of sensory receptors which can sense external stimuli, including heat, cold and pain. The nerves embedded in the skin discriminate all these stimuli (Owens & Lumpkin, 2014). The outermost layer is the epidermis, followed by the dermis with its network of blood vessels and the subcutaneous tissue (Fig. 2.2). When the skin is broken, bacteria, fungi, parasites and other disease-causing pathogens find the opportunity to penetrate the epidermis and access the inner layers of the skin (Feldmeier & Heukelbach, 2009; Giacani & Lukehart, 2014; Lukoye et al., 2013). The skin reacts through various mechanisms to fight these pathogens and the resulting infections (Chiller, Selkin, & Murakawa, 2001; Grice & Segre, 2011; Swe, Zakrzewski, Kelly, Krause, & Fischer, 2014; Walton, 2010). The skin is also the centre of a variety of inflammatory processes; these include allergy, immunity against infections, tumour immunity, and autoimmunity (Byrd, Belkaid, & Segre, 2018). In order to mount an effective immune response, the skin uses resident cells (Fig. 2.2). These include Langerhan cells, memory T-cells, and keratinocytes in the epidermis. Dermal dendritic cells, T-cells and fibroblasts are some of the immune cells present in the dermis, while endothelial cells are located in the blood vessels. The skin uses these resident cells and recruits other cell populations to the skin to fight against invasion.

2.2 The Structures

15 FUNCTION

IMMUNE CELLS • Langerhan cells • Memory T-cells • Keranocytes

Epidermis • Dermal dendric cells • T-Cells • Fibroblasts • Endothelial cells

• Surveillance • Early detecon of infecon • Control of pathogens encountered previously • Sense pathogens and injury

Dermis Blood Vessels Adipose layer

• Present chemokines and adhesion molecules to immune cells

• Adipocytes

Fig. 2.2 The skin structure. The skin is composed of several layers each made up of many kinds of cells which perform different functions. The outer layer of the skin is the epidermis, followed by the dermis which is supplied with blood vessels. The adipose layer is the fatty layer of the skin

2.2 The Structures 2.2.1 Epidermis This is the outer most and protective layer of the skin. The epidermis is comprised of five strata (layers); starting with the outermost layer, these layers are: the stratum corneum, stratum lucidum, stratum granulosum, stratum spinosum, and the basal layer. The stratum corneum is made up of dead keratin cells which migrate from the living basal layer. Melanocytes which give the skin its colour and provide protection against UV rays, are found in the basal layer. The epidermis relies on diffusion from the dermal cells to get its nutrients as it has no blood vessels. The stratum corneum protects the skin from the outside world, including water loss from the body (Seneschal, Clark, Gehad, Baecher-Allan, & Kupper, 2012).

2.2.2 Dermis While the epidermis is made up of epithelial cells, the dermis is made up of connective tissue. There are two distinct layers in the dermis, the papillary dermis and the reticular dermis. The papillary dermis contains thin and loose connective tissue which allows for changes in shape and position of components in this layer. The papillary dermis also contains blood vessels and nerve endings. The reticular dermis comprises thicker and denser connective tissue; this is where glands, hair follicles and erector pili are found. A summary of the skin structure, its components and characteristics are described in the (Table 2.1).

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2 The Structure and Function of the Skin

Table 2.1 Structure of the Skin, Components and Characteristics Skin layer

Components

Characteristics

Epidermis—contains epithelial tissue

Stratum lucidum

Dead keratinocytes that have lost all their nuclei and organelles

Stratum granulosum

Granular layer with keratohaylin granules

Stratum spinosum

Contains desmosomes and immune cells, the Langerhans cells

Basal layer

Made up of keratinocytes, in this layer cells undergo rapid cell division and move up to the top layers

Papillary dermis

Contains thin/loose connective tissue made up of actin and collagen. The connective tissue in this layer can easily change shape and position. This layer contains blood vessels as well as nerve endings

Reticular dermis

Has thicker and denser connective tissue. Hair follicles, glands as well as arector pili muscles are found in this layer

Dermis—Contains connective tissue

Blood vessels—Comprised of endothelial cells

Adipose/Subcutaneous fat—Comprised of fat and connective tissue

Supply blood to the upper layers of the skin. The blood supply is a source of nutrients and through endothelial cells, present chemokines and adhesion molecules to immune cells Fat cells and fibrous tissue

Provides insulation from heat and cold and acts as a cushion and energy storage

2.3 Host-Parasite Interactions The skin is often the first point of contact with disease causing microorganisms. These include bacteria, fungi, viruses, and parasites. Epidermal parasitic skin diseases result from parasites taking advantage of broken skin and or burrowing through the skin to access the inner layers. As these microorganisms penetrate and interact with the skin, there is a phenomenon known as a host-parasite interaction. Upon encountering the microorganisms, the resident immune cells send signals that stimulate an appropriate host-response to tackle the invading pathogens. As the pathogen continues to live

2.3 Host-Parasite Interactions

17

within the host, these interactions become a complex network as the pathogen tries to evade the host immune system through various mechanisms at its disposal, while the host employs various mechanisms to destroy the pathogen (Combe et al., 2017; Haldar, Murphy, Milner, & Taylor, 2007; Zeeuwen, Kleerebezem, Timmerman, & Schalkwijk, 2013).

2.3.1 Immune Responses The skin acts as a barrier and first line of defence against infections. Its defence cells, the Langerhans (dendritic) cells and keratinocytes are alerted when a pathogen invades and provoke an immune response. When these cells encounter a pathogen, the cells secrete antibodies, serine proteases, complements and enzymes to attack and destroy the invader. Skin resident immune cells are an important element in providing the first line of defence against pathogens (Table 2.2). Dendritic cells (DCs) play an important role in immune response. They were first reported in the 1970’s (R. M. Steinman, 1973; Ralph M. Steinman & Cohn, Table 2.2 Skin Resident cells and their functions. Showing skin resident dendritic cells and their functions

Cell type

Function

Langerhan cells (LC)

• Activation of CD8+ T cells • Differentiation of CD4+ cells into TH2 • Cytotoxic lymphocyte (CTL) response

Dermal CD14+ cells

• Differentiation of CD1+ cells into TfH • Humoral immunity

Dermal CD1a cells

• CD8 + T cell activation

Macrophage

• Sense infection/injury and initiate innate immune response

Mast cell

• Part of the innate immune system

Keratinocyte

• Sense tissue damage and produce inflammatory cytokines

Fibroblast

• Sense tissue damage and produce inflammatory cytokines

Endothelial cell

• Sense tissue damage and produce inflammatory cytokines

Resident memory T cells (TRM)

• Rapid antigen (non-specific) response

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2 The Structure and Function of the Skin

1974). These cells act as a sentry, carrying out surveillance in the body and acting as informants to the adaptive immune system of any invasions by foreign bodies. There are several types of DCs, these include those that are found in blood and those resident in the skin. The skin resident DCs are the Langerhans cells (LC), Dermal CD14+ , and the Dermal CD1a dendritic cells (Table 2.2). Each DC population has been characterized by the production of different cytokines and may initiate distinct inflammatory responses following activation. For example, paces have been reported to initiate antifungal immunity (Ramirez-Ortiz et al., 2011), whereas dices initiate antiviral immunity. These roles are not likely to be exclusive: different DC populations may contribute to different immune responses in multiple ways. Macrophages are skin-resident immune cells with high phagocytic capacity and motility. Although they are less likely than DCs to present antigen to T cells, due to relative cell numbers, they are capable of activating immune responses. Macrophages also “clean up” debris from dead or dying cells, invading pathogens, or environmental stressors (Minutti, Knipper, Allen, & Zaiss, 2017). Autophagy Apart from dendritic cells, other skin resident cells including keratinocytes, fibroblasts, endothelial cells and resident memory T cells, provide protection by sensing tissue damage and injury, producing inflammatory cytokines to fight the infection and providing rapid antigen response. The cells damaged through injury, infection and or other processes are cleared through a process called autophagy. Autophagy is an important process which removes damaged cellular organelles through a selfdigestion process (Rabinowitz & White, 2010). Current research has shown that autophagy plays a role in inflammation, pathogen clearance and antigen presentation (Deretic, Saitoh, & Akira, 2013; Mariño, Niso-Santano, Baehrecke, & Kroemer, 2014; Ravikumar et al., 2010). Autophagy has been shown to play a regulatory role by targeting UV damaged keratinocytes as well as melanocytes (Lee et al., 2011; Murase et al., 2013). Resident Memory T Cells (Trm) Resident memory T cells (TRM) are distinctively unique from the blood T-cells. These cells react against specific pathogens encountered in the skin/epithelia and have been suggested to form a protective barrier with a role in protective immunity (Jiang et al., 2012; Liu et al., 2010). The role of TRM in skin diseases as well as healthy state is yet to be investigated (Watanabe, 2019).

2.3.2 Innate and Adaptive Immunity Innate Immune Response The skin has two major lines of defence, the first being the innate immunity, which when stimulated activates the second line of defence, the adaptive immunity.

2.3 Host-Parasite Interactions

19

Characteristics of the innate immunity include ability to recognize pathogens (including bacteria, fungi and viruses) and parasite associated molecular patterns (PAMPs) through pattern recognition receptors (PRRs) (Martinon, Mayor, & Tschopp, 2009; Medzhitov, Preston-Hurlburt, & Janeway, 1997). Pattern recognition receptors are expressed by various cells including; monocytes, neutrophils, dendritic cells, macrophages, keratinocytes and epithelial cells (Martinon et al., 2009). Innate pattern recognition does not depend on previous encounter with the invading substance. When activated, immune cells can respond in various ways (Table 2.3). Adaptive Immune Response Unlike the innate immune response, adaptive immune responses are highly specific and rely on memory of previous encounters with a pathogen. An adaptive immune response is initiated later in the infection as a second line of defence. Adaptive immunity is characterized by mediating an immunologic memory response. There Table 2.3 Innate Immune cells. Innate immune cells and their respective responses Cell type

Response

Keratinocyte

– Express toll like receptors (TLR) – Secrete cytokines IL6, IL-10, IL18, ILB and tumor necrosis factors (TNF) (Corsini & Galli, 2000)

Dendritic cells

– Present antigens to naïve T-cells – Dermal dendritic cells (dDCs), plasmacytoid dendritic cells (pDCs), Langerhan cells (LCs) are the only DCs in the epidermis (Agner, Martins, Manoel, & Dos Reis, 2011; Kissenpfennig et al., 2005; Randolph, 2001) – pDCs produce IFN-α, IFN-β, FN-I, IFN-W, and IFN-t (Type 1 IFN subtypes) – Activate production of IL-12, IL-15, IL-18, and IL-23 by mDCs

Neutrophils

– Have anti-microbial and anti-inflamatory reaction through production of ROS (Mantovani, Cassatella, Costantini, & Jaillon, 2011).

Mast cells

– Show high affinity of IgE receptor – Express TLR-1, TLR-2, TLR-3, TLR-4, TLR-6, TLR-7 and TLR-9 (Toulon et al., 2009) – Secretion of late-pro-inflamatory mediators; IL-3, IL-4, IL-5, IL-6, IL-8, IL-9, IL-11, IL-13, TFF and chemokines; CCL2, CCL3, CCL4 (Kaplan, Igyártó, & Gaspari, 2012)

Natural Killer Cells

– Induce apoptosis of keratinocytes – In abundance in inflammatory skin diseases including psoriasis, lichen planus and allergic contact dermatitis (ACD)

T cells

– Activate dDcs, through the production of TNF and IFN γ (Lebre et al., 2007) – Produce growth factors essential for wound healing – Produce cytokines associated with Th1, Th2, and Th17 cells

Innate lymphoid cells (ILC)

– Non-cytotoxic ILC can produce IFN-γ and TNF and are involved in bacterial and parasitic intracellular immunity (C.S.N. et al., 2014)

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2 The Structure and Function of the Skin

Table 2.4 B- Cell and T- Cell Response. Adaptive immune response, showing B-cell and T-cell responses Cell type

Response

B- Cells

Produce antibodies directed against specific antigens of the infective host

T- Cells

– Use Th1, Th2 and Th17 to fight infection – Th1 produces IFN g which promotes antibody mediated- response – Th-17 produces IL-17, and IL-21, IL-22, and IL-26 which promote neutrophil recruitment and abscess formation

are two types of the adaptive immune response; the antibody mediated response involving B-cells and the cell mediated response involving T-cells (Girardi, 2007) (Table 2.4).

2.4 Conclusion Apart from protecting the body from external elements, the skin is a platform of various interactions that protect, repair and restore the body. From infective pathogens to injury, the skin deploys the required protection through the immediate innate immune response and further through adaptive responses which use memory of previously encountered pathogens.

References Byrd, A. L., Belkaid, Y., & Segre, J. A. (2018). The human skin microbiome. Nature Reviews Microbiology. https://doi.org/10.1038/nrmicro.2017.157. Chiller, K., Selkin, B. A., & Murakawa, G. J. (2001). Skin microflora and bacterial infections of the skin. Journal of Investigation Dermatology Symposia Processes, 6(1087-0024 SB-IM), 170–174. https://doi.org/10.1046/j.0022-202x.2001.00043.x. Combe, M., Velvin, C. J., Morris, A., Garchitorena, A., Carolan, K., Sanhueza, D., … Gozlan, R. E. (2017). Global and local environmental changes as drivers of Buruli ulcer emergence. Emerging Microbes & Infections, 6. https://doi.org/10.1038/emi.2017.7. Deretic, V., Saitoh, T., & Akira, S. (2013). Autophagy in infection, inflammation and immunity. Nature Reviews Immunology. https://doi.org/10.1038/nri3532. Feldmeier, H., & Heukelbach, J. (2009). Epidermal parasitic skin diseases: A neglected category of poverty-associated plagues. Bulletin of the World Health Organization, 87, 152–159. https:// doi.org/10.2471/BLT.07.047308. Giacani, L., & Lukehart, S. A. (2014). The endemic treponematoses. Clinical Microbiology Reviews, 27. https://doi.org/10.1128/CMR.00070-13. Girardi, M. (2007). Cutaneous perspectives on adaptive immunity. Clinical Reviews in Allergy and Immunology. https://doi.org/10.1007/s12016-007-0040-9. Grice, E. a, & Segre, J. a. (2011). The skin microbiome. Nature Reviews. Microbiology, 9(4), 244–253. https://doi.org/10.1038/nrmicro2537.

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Haldar, K., Murphy, S. C., Milner, D. A., & Taylor, T. E. (2007). Malaria: Mechanisms of erythrocytic infection and pathological correlates of severe disease. Annual Review of Pathology, 2, 217–249. https://doi.org/10.1146/annurev.pathol.2.010506.091913. Jiang, X., Clark, R. A., Liu, L., Wagers, A. J., Fuhlbrigge, R. C., & Kupper, T. S. (2012). Skin infection generates non-migratory memory CD8 + T RM cells providing global skin immunity. Nature. https://doi.org/10.1038/nature10851. Lee, H.-M., Shin, D.-M., Yuk, J.-M., Shi, G., Choi, D.-K., Lee, S.-H., … Jo, E.-K. (2011). Autophagy negatively regulates keratinocyte inflammatory responses via scaffolding protein p62/SQSTM1. The Journal of Immunology. https://doi.org/10.4049/jimmunol.1001954. Liu, L., Zhong, Q., Tian, T., Dubin, K., Athale, S. K., & Kupper, T. S. (2010). Epidermal injury and infection during poxvirus immunization is crucial for the generation of highly protective T cell-mediated immunity. Nature Medicine. https://doi.org/10.1038/nm.2078. Lukoye, D., Adatu, F., Musisi, K., Kasule, G. W., Were, W., Odeke, R., … Joloba, M. L. (2013). Anti-tuberculosis drug resistance among new and previously treated sputum smear-positive tuberculosis patients in Uganda: results of the first national survey. PloS One, 8(8), e70763. https:// doi.org/10.1371/journal.pone.0070763. Mariño, G., Niso-Santano, M., Baehrecke, E. H., & Kroemer, G. (2014). Self-consumption: The interplay of autophagy and apoptosis. Nature Reviews Molecular Cell Biology. https://doi.org/ 10.1038/nrm3735. Martinon, F., Mayor, A., & Tschopp, J. (2009). The inflammasomes: Guardians of the body. Annual Review of Immunology. https://doi.org/10.1146/annurev.immunol.021908.132715. Medzhitov, R., Preston-Hurlburt, P., & Janeway, C. A. J. (1997). A human homologue of the Drosophila activation of adaptive immunity. Nature. Minutti, C. M., Knipper, J. A., Allen, J. E., & Zaiss, D. M. W. (2017). Tissue-specific contribution of macrophages to wound healing. Seminars in Cell and Developmental Biology. https://doi.org/ 10.1016/j.semcdb.2016.08.006. Murase, D., Hachiya, A., Takano, K., Hicks, R., Visscher, M. O., Kitahara, T., … Yoshimori, T. (2013). Autophagy has a significant role in determining skin color by regulating melanosome degradation in keratinocytes. Journal of Investigative Dermatology. https://doi.org/10.1038/jid. 2013.165. Owens, D. M., & Lumpkin, E. A. (2014). Diversification and specialization of touch receptors in skin. Cold Spring Harbor Perspectives in Medicine. https://doi.org/10.1101/cshperspect. a013656. Rabinowitz, J. D., & White, E. (2010). Autophagy and metabolism. Science. https://doi.org/10. 1126/science.1193497. Ramirez-Ortiz, Z. G., Lee, C. K., Wang, J. P., Boon, L., Specht, C. A., & Levitz, S. M. (2011). A nonredundant role for plasmacytoid dendritic cells in host defense against the human fungal pathogen Aspergillus fumigatus. Cell Host & Microbe, 9(5), 415–424. https://doi.org/10.1016/J. CHOM.2011.04.007. Ravikumar, B., Sarkar, S., Davies, J. E., Futter, M., Garcia-Arencibia, M., Green-Thompson, Z. W., … Rubinsztein, D. C. (2010). Regulation of mammalian autophagy in physiology and pathophysiology. Physiological Reviews. https://doi.org/10.1152/physrev.00030.2009. Seneschal, J., Clark, R. A., Gehad, A., Baecher-Allan, C. M., & Kupper, T. S. (2012). Human epidermal langerhans cells maintain immune homeostasis in skin by activating skin resident regulatory T cells. Immunity. https://doi.org/10.1016/j.immuni.2012.03.018. Swe, P. M., Zakrzewski, M., Kelly, A., Krause, L., & Fischer, K. (2014). Scabies mites alter the skin microbiome and promote growth of opportunistic pathogens in a porcine model. PLoS Neglected Tropical Diseases. https://doi.org/10.1371/journal.pntd.0002897. Walton, S. F. (2010). The immunology of susceptibility and resistance to scabies. Parasite Immunology. https://doi.org/10.1111/j.1365-3024.2010.01218.x.

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Watanabe, R. (2019). Protective and pathogenic roles of resident memory T cells in human skin disorders. Journal of Dermatological Science. https://doi.org/10.1016/j.jdermsci.2019.06.001. Zeeuwen, P. L. J. M., Kleerebezem, M., Timmerman, H. M., & Schalkwijk, J. (2013). Microbiome and skin diseases. Current Opinion in Allergy and Clinical Immunology, 13(5), 514–520. https:// doi.org/10.1097/ACI.0b013e328364ebeb.

Chapter 3

Types of Skin Disease and Their Causes

Abstract Aetiology of disease is the study of the causation of disease or the science associated with the cause of the disease. Disease aetiology is classified into three categories: intrinsic, extrinsic and idiopathic. Epidermal parasitic skin diseases (EPSDs) are among the commonest skin disorders in developing countries. Six of these diseases are included in the WHO neglected disease category. Prevailing conditions such as poor sanitation, lack of resources and infrastructure, existing climatic conditions and lack of knowledge about disease aetiology, prevention and control play an important role in outcomes of EPSDs. Understanding the aetiology of skin diseases including epidermal parasitic diseases, bacterial, viral, and papulosquamous infections is crucial in the fight against these diseases. EPSDs affect mainly poor populations and have been termed diseases of poverty. There are also other predisposing conditions that have allowed skin diseases to flourish in resource poor countries, including ambient temperatures, environment and quality of nutrition. The existence of poverty and predisposing conditions in resource poor countries has made these populations vulnerable to many diseases. The role of limited primary healthcare and the frequency of other infections should not be underestimated. Keywords Epidermal parasitic diseases · Papullosquamous infections · Bacterial disease · Viral diseases · Fungal diseases · Skin disorders · Disease aetiology · Superficial fungal infections · Dermatophytes · NTDs Synopsis Disease aetiology is a medical term used to describe the causes of disease. Aetiology thus can be understood as the science that helps the world understand the origin or causes of disease, and the factors that perpetuate and predispose individuals and or populations to disease. These factors include inherited or genetic conditions that can be passed on from one generation to the next, metabolic disorders affecting the hormonal and immune systems, infectious agents, as well as unknown causes. Complications in these Metabolic pathways can cause disease some of which could be fatal. Infectious agents are the most widely known causes of disorders, these include pathogens such as bacteria, viruses, fungi, yeast and parasites. The most challenging of them all are the unknown causes, without knowledge of what is causing disease, the focus shifts to treating symptoms; as prevention and control is near to impossible. © Springer Nature Singapore Pte Ltd. 2020 F. A. Mphande, Skin Disorders in Vulnerable Populations, https://doi.org/10.1007/978-981-15-3879-7_3

23

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3 Types of Skin Disease and Their Causes

Skin Diseases

Extrinsic (Common where resources are limited)

Parasi c Skin Infec ons

Viral Skin Infec ons

Bacterial Skin Infec ons

Intrinsic (Uncommon but Increasing in incidence in Low Resource Countries)

Fungal Skin Infec ons

Eczma Psoriasis Seborrheic derma s Lichen planus Pityriasis rosae Secondary Syphilis

Fig. 3.1 Types of skin diseases and their causes

3.1 Disease Aetiology What is “Aetiology”? Aetio—refers to causation or cause while—ology refers to the scientific study. Therefore, aetiology of disease is the study of the causation of disease or the science associated with the cause of the disease. Disease aetiology is divided into three categories, intrinsic, extrinsic and idiopathic. Intrinsic disease aetiologies are those that are from within the body, such as; inherited or genetic conditions, metabolic or hormonal disorders, neoplastic disorders, allergies and immune disorders. Extrinsic disease aetiologies are those from without or outside the body, such as infectious agents (bacteria, viruses, fungi and parasites), animal bites or stings, chemicals, electricity, radiation as well as causes resulting from a medical professional’s actions or within a medical setting (iatrogenic) (Fig. 3.1). Idiopathic disease aetiologies are those with unknown causes. This chapter will focus on extrinsic disease aetiologies, mainly infectious agents including bacteria, viruses, fungi and parasites.

3.2 Epidermal Parasitic Skin Diseases (EPSD) Epidermal parasitic skin diseases (EPSD) are amongst the common skin diseases in developing countries. Epidermal parasitic diseases include scabies, pediculosis capitis, pediculosis corporis, pediculosis pubis, tungiasis, cutaneous leishmaniasis, Guinea-worm disease (dracunculiasis), lymphatic filariasis (LF), river blindness (onchocerciasis), and hookworm related cutaneous larva migrans (HrCLM). Seven of these diseases are amongst the WHO neglected diseases (NTD) category (scabies, leishmaniasis, Guinea- worm disease (dracunculiasis), lymphatic filariasis,

3.2 Epidermal Parasitic Skin Diseases (EPSD)

25

river blindness (onchocerciasis), buruli ulcer, and yaws (World Health Organisation(WHO), 2016a) (Table 3.1). This chapter will focus on the seven epidermal parasitic skin diseases listed on the WHO NTD list and tungiasis which, though not listed on the NTD list, is still a problem in rural populations in sub-Saharan Africa and parts of South America (Jörg Heukelbach, Sales De Oliveira, Hesse, & Feldmeier, 2001). Table 3.1 Epidermal parasitic skin diseases; their causes, mode of transmission and endemic regions Disease

Parasite/Infective Agent

Mode of Transmission

Occurrence

Scabies Tungiasis

Sarcoptes scabiei

PP, S, F

Worldwide

Tunga penetrans

SS, (F)

Caribbean, sub Saharan Africa, South America

Leishmaniasis

Leishmania species

Infectious bite

North Africa, Middle East, but has been reported in parts of Europe, South America, and Asia

Guinea-worm disease (dracunculiasis)

Dracunculus medinensis

Drinking unfiltered water containing copepods infected with larvae of D. medinensis

Five countries in sub-Saharan Africa, as of 2018

Lymphatic filariasis

Wuchereria Bancrofti (90%), Brugia spp. (10%)

Infectious bite of a mosquito

Tropical and sub-tropical regions

River blindness (onchocerciasis)

Onchocerca volvulus

Infectious bite of a blackfly

Inter-tropical zones linked with presence of black flies, including Latin America and Arabian Peninsula

Pediculosis capitis

Pediculus humanus var. capitis

PP, F

Worldwide

Pediculosis corporis

Pediculus humanus var. corporis

PP, F

Limited to countries with cold climate

Pediculosis pubis

Phthirus pubis

S, F, (PP)

Worldwide

Hookworm-related cutaneous larva migrans

A. caninum, A. braziliense, Uncinaria stenocephala

SS, (F)

Mainly in countries with hot climate

PP, Person to Person transmission S, Sexual transmission F, Formite transmission SS, Soil to Skin transmission

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3 Types of Skin Disease and Their Causes

3.2.1 Why Are Skin Diseases Neglected When They Cause Great Morbidity in the Affected Populations? The neglect of skin diseases can be attributed to the low priority these illnesses have compared to malaria, TB, and other infectious diseases with high mortalities. This low priority results in minimal resources being allocated to tackle skin infections; including lack of specialized personnel, lack of equipment and diagnostic tools/infrastructure, and lack of commitment and implementation of disease control strategies. Secondly, skin diseases are often associated with poverty and resource poor communities. People living in such communities are often caught up in the vicious cycle of poverty which contributes to poor living conditions and culminates to ill health. These populations are often marginalized, and their plight often ignored or goes unnoticed. This gives opportunity for skin diseases to flourish. Despite the low mortalities, skin diseases impose a heavy burden on the affected communities and the extent of morbidity due to these diseases should not go unnoticed (Table 3.1). Effects of skin diseases including inability to walk, loss of digits and other affected parts, itching, and abnormal skin appearance; greatly affect the social aspects of the infected individual as well as their mental wellbeing. Children infected with skin diseases struggle to keep up with their studies, owing to stigma which may have considerable effects on their self-esteem. Chronic absenteeism considerably affects their performance and grades in school. Co-infections due to bacteria further complicate skin infections, making the outcomes far worse.

3.2.2 Setting and Vulnerability to Disease The interplay between lack of resources and existence of diseases that are perpetuated by low income and humble living must be stressed. In a low-income country struggling with its economy as well as keeping its health system functional, urban populations tend to have somewhat better health facilities than rural areas. Social and political structures have allowed for poor communities to be marginalized and supported the needs for the politically powerful, the rich and socially significant individuals. With the voices of the marginalized barely being heard, populations in rural and resource poor settings are left vulnerable to diseases. People living in urban areas may therefore have better choices of health facilities than rural populations. However, diseases of poverty may also be common in resource-poor neighbourhoods of urban areas, such as slum communities. Despite being an urban setting, the living conditions and the environment in slum communities provides a breeding ground for not only cholera, malaria and other highly contagious diseases but also skin diseases and co-infections. With more resources committed to urban areas than rural areas, diseases of poverty tend to prevail more in rural populations.

3.2 Epidermal Parasitic Skin Diseases (EPSD)

27

Extrinsic skin diseases are common in rural populations and resource poor settings. In most of these communities, social and cultural barriers have played a role on perception of skin diseases. How a disease is perceived by a community most often depends on the social and cultural lens. This perception affects how individuals with disease are treated, this includes social and cultural acceptance e.g. whether infected individuals can participate in certain cultural ceremonies and social events. Economic structures including the cost of treatment has led to some populations being more vulnerable to disease. The ability to access quality medical care and medicine determines disease outcomes. Resource poor communities are deprived of both due to their economic status and setting, making them more vulnerable to diseases. Lack of resources and inability to access proper medical care has allowed for primary care givers to miss out on opportunities to develop themselves. Most of the primary care givers tend to be women, and young girls, who may be forced to resign from their jobs and or drop out of school in order to care for their sick relations. However, boys have also dropped out of school to take care of their families struggling economically due to disease and or loss of a bread winner.

3.2.3 Sanitation, Prevailing Climatic Conditions, and Poor Knowledge About Skin Diseases and Their Causes Play a Role in the Success of EPSD The complexity of factors perpetuating the spread of skin diseases in limited resource communities should not be underestimated. While the interplay between economic status, environmental and behavioural factors exists in these communities, it is difficult to address each factor separately. Prevailing conditions such as poor sanitation, lack of resources and infrastructure, existing climatic conditions and lack of knowledge of disease aetiology, prevention and control have been shown to play an important role in outcomes of EPSD. Seasonal spread of diseases with some being more prevalent during the dry months while others are prevalent in the rainy season is an example of prevailing climatic conditions. For example, in endemic areas, high prevalence of tungiasis has been observed during the dry months while HrCLM has been observed in the wet months. Despite EPSDs being associated with poverty, individuals from high income communities can contract the disease when visiting these endemic areas. Thus, knowledge about skin diseases and their causes is essential to prevent contracting these diseases. Availability of reservoirs for parasites responsible for EPSDs such as domesticated animals and rodents do play a role in the spread of such infections in resource poor communities. Behavioural factors such as drying clothes on the ground, not only expose these garments to parasite contaminated environments but also becomes a means of spreading these parasites to humans. As people put on the contaminated

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3 Types of Skin Disease and Their Causes

clothes, they are exposed to eggs, larvae and many other infective forms of the parasites that can survive in the environment. As such although sanitation and hygiene have been attributed to play a role in the spread of diseases such as scabies, environmental factors can not be excluded. It has been shown that in some communities where individuals take frequent baths, and in some cases where they have a clean water supply source, there may still be scabies infestations. The poor diagnosis of skin diseases by health personnel can also be attributed to lack of access to reference material for skin diseases/conditions for primary health providers which may affect their assessment and willingness to treat skin conditions.

3.2.4 Scabies Scabies is a parasitic skin disease caused by infestation of the skin by a microscopic mite Sarcoptes scabiei var. hominis. Also known as the human itch mite, S. scabei burrows and lays eggs in the upper layer of the skin (epidermis) resulting into severe itching and a pimple-like rash (Hay et al., 2013) (Fig. 3.2). Scabies is a highly contagious skin diseases associated with poor hygiene; it affects vulnerable communities in limited resource countries. When the scabies mite burrows into the skin, it releases elements that induce inflammatory and immune responses by the host. The parasite also releases materials that can suppress aspects of the host responses, allowing the mite to evade the host defence mechanisms. The ability of the mite to evade the host immune mechanisms allows it to survive inside the host’s skin without being destroyed by the host defences. As the host fights the infection, lesions that are due to inflammatory immune responses appear on the host’s skin. The mites exhibit anti-inflammatory, anti-immune and anti-complement activities that aid their survival within the host. Excretions from the mite induce responses from immune

©Dr Andrew Steer Fingers infected with scabies

Fig. 3.2 Scabies. Fingers infected with scabies, with pustules (indicated by arrows) occurring between the fingers; scratching can result in opening of the pustules creating opportunity for bacteria infection. Scabies © Dr Andrew Steer, WHO https://www.who.int/neglected_diseases/diseases/ scabies/en/

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cells within the host, including: keratinocytes, fibroblasts, macrophages, mast cells, lymphocytes, Langerhans cells and other dendritic cells, and endothelial cells of the microvasculature. Scabies is listed as one of the NTDs by WHO and causes significant morbidity and mortality in the affected populations (Hermann Feldmeier & Heukelbach, 2009; Hay et al., 2013; Hotez & Kamath, 2009). Human scabies has been known to spread not only through contact with an infected individual but also linen, furniture, toys and clothes harbouring live mites (Arlian, Estes, & Vyszenski-Moher, 1988). Sarcoptes scabiei mites can survive for a few days off their host and are able to detect the human host through stimuli that allows them to find the host in close proximity (Mlombe, 2008). This behaviour may facilitate their finding a host if they are dislodged from it. Thus, direct contact with an infected host may not be required for humans and other mammals to acquire S. scabiei. Scabies is widespread in Europe and other parts of the world. The parasitic aetiology of the disease was outlined by Giovanni Cosomo Bonomo around 1687 Known by different names in Europe, itch for the English, and Krätze for the German, Bonomo established scabies as one of the earliest human diseases with a known cause (Lane, 2011). The scratching following the itchy skin results in breakage of the epidermis allowing for secondary bacterial infections to occur. The rash can appear on various parts of the body including hands, feet, torso, genitalia and buttocks. Scabies can be divided into early stage where the pimple-like rash appears, advanced stage where the rash is infected and severe stage in the form of crusted scabies.

3.2.4.1

Scabies and Livelihood

Scabies is an easily treatable and preventable parasitic skin disease worldwide. The disease is among the five diseases that have been identified as causes of non-fatal disability (YLD) in Oceania, sub-Saharan Africa and Latin America (Hay et al.,2014b). Apart from scabies, other diseases include; impetigo, acne vulgaris, fungal infections, and cellulitis. Scabies mite infections occur on different parts of the body, but the regions mostly affected are wrists and elbows and in adult patients, genitals, feet, buttocks, axillae, breasts, and waistline are also favoured sites of infection. The infection can seriously affect movement and ability to perform regular day to day activities. Secondary infections due to bacteria may develop in the lesions, further complicating the disease. The morbidity from scabies greatly affects livelihoods. With the greatest burden in children and adolescents, those affected may miss out on school and other activities required for their development. Overcrowding and close contact with infected individuals has been attributed as the most common mode of transmission for the disease. Scabies outbreaks have been observed in households, prisons, schools, care homes, hospitals and many other communities which are prone to overcrowding as well as offering favourable conditions for the spread of the mites. In Chile, where the prevalence of scabies is between 1 and 5%, poor personal hygiene, promiscuity and crowding are some of the factors that have been associated with the spread of scabies (Moreno, 2011). A population-based survey

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carried out in ten rural villages in Solomon Islands revealed a high prevalence of scabies in children between the ages of 1 to 4 years. A strong association between scabies and impetigo was also discovered; 41.1% of active impetigo patients were also found to have scabies (Mason et al., 2016). Community control strategies for scabies may also help reduce the burden of impetigo and scabies as well as other downstream conditions that may result from infections with these two conditions. in remote indigenous communities in Australia, co-infection of epidermal scabies lesions by Group A Streptococci or Staphylococcus aureus is thought to be responsible for the high rate of rheumatic heart disease and chronic kidney disease (Valery et al., 2008).

3.2.5 Tungiasis Tungiasis is a zoonotic neglected tropical disease affecting both animals and humans. In humans, tungiasis is caused by infestation of female sand fleas (Tunga penetrans). The flea is known by various names including chigger flea, sand flea, chigoe flea, jigger, nigua, pique, bicho de pe, dicho de porco, and jatemba (WHO | Tungiasis, 2016). The flea embeds itself by burrowing into the skin and remains there until it dies (Fig. 3.3). While inside the skin the flea remains in contact with the outside through its last segments which protrude out and are used to breathe, defeacate, copulate and release eggs into the environment (Feldmeier et al., 2002). The opening also acts as a portal for other infections. Tungiasis is endemic throughout Central and South America, on several Caribbean Islands including Trinidad, Tobago, and Haiti and sub-Saharan Africa. Along the coast of Kenya, the prevalence of tungiasis ranged from 11 to 50% in school-age children (Njau, Wanzala, Mutugi, Ariza, & Heukelbach, 2012; Wiese, Elson, Reichert, Mambo, & Feldmeier, 2017). Studies on

a

Tungiasis-associated pathology at the heel

b

Mul ple sand flea lesions at the finger ps

Fig. 3.3 Tungiasis affecting the heel (a) and fingers (b), The parasite Tunga penetrans burrows through the skin with segments of the body exposed to the outside; disfigurement fingers is shown. http://www9.who.int/bulletin/volumes/87/2/07-047308/en/. Tungiasis © Hermann Feldmeier and Jorg Heukelbach, 2009, WHO http://www9.who.int/bulletin/volumes/87/2/07-047308/en/

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epidemiological characteristics of tungiasis in Africa are scanty hence more work is required to establish the prevalence of the disease in various communities. The life cycle of tungiasis involves the environment and the host, be it human and or animal. After release of the eggs by the embedded Tunga penetrans, the flea develops into adult stages within the nearby surroundings, and the adult flea penetrates the human skin most often through bare feet (Nagy et al., 2007). Itching and local irritation of the affected area occur as a result of the burrowing and development of the flea. This in turn prompts scratching exposing the skin to other pathogens which may lead to bacterial superinfections, abscesses, lesions and inflammation of the lymphatic channels (lymphangitis). As the infection progresses, affected individuals have limited mobility. Domestic animals such as pigs, cattle, dogs, and cats as well as rats, are some of the known reservoirs in rural and poor urban areas respectively (Feldmeier et al., 2004; Pilger et al., 2008; Witt et al., 2007).

3.2.6 Leishmaniasis Leishmaniasis is a parasitic vectorborne disease caused by a protozoan parasite Leishmania. The parasite is transmitted by an infective bite from a female phlebotomine fly. Leishmaniases are a group of diseases caused by protozoan parasites from more than 15 Leishmania species. The most common species responsible for disease include L. major, transmitted from animal reservoirs to humans by Phlebotomus papatasi; and L. tropica transmitted from person to person by P. sergenti (WHO, 2017). Leishmaniasis is found in almost all regions of the world but the important foci of infection are in Central and South America, southern Europe, North and East Africa, the Middle East, and the Indian subcontinent. Leishmaniasis starts with appearance of a papule which may enlarge into a nodule or a plaque. The resulting sore is self-healing but leaves behind a depressed scar. In humans, there are four major forms of Leishmaniasis, cutaneous leishmaniasis (CL), mucocutaneous leishmaniasis (ML), visceral leishmaniasis (VL) also known as kala-azar, and post-kala-azar dermal leishmaniasis (PKDL) (Fig. 3.4). Visceral leishmaniasis (Kala-azar) is the most serious form of the disease and is fatal if left untreated (Alvar, Yactayo, & Bern, 2006; World Health Organisation (WHO), 2016b). Apart from VL, the rest of the manifestations are also known as tegumentary forms. People infected with leishmania may remain asymptomatic for a long time (Andrade-Narvaez, Loría-Cervera, Sosa-Bibiano, & Van Wynsberghe, 2016; Ostyn et al., 2011). Despite the decrease in cases of VL owing to better diagnosis and access to treatment and vector control in parts of Asia, fatalities are still observed in parts of East Africa (Burza, Croft, & Boelaert, 2018). Leishmaniasis affects mostly poor populations in the affected areas and is linked to malnutrition, population displacement, poor housing, and fragile immune system

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a

b

WHO/C.Black

Child with cutaneous leishmaniasis awai ng treatment in Kabul, Afghanistan.

Girl suffering from visceral leishmaniasis – a poten ally fatal condi on, if untreated - with markers showing signs of liver and spleen enlargement. Libo Kemkem district, Ethiopia

WHO

c Pa ent with postkala-azar-dermal leishmaniasis. Was earlier treated and cured for visceral leishmaniasis. Libo Kemkem district, Ethiopia.

WHO

Fig. 3.4 Leishmaniasis. Leishmaniasis, Cutaneous leishmaniasis (CL) in a young boy (a), Visceral leishmaniasis (VL) in a young girl (b) and Dermal leishmaniasis (Post kala-a-zar) in a man (c). Leishmaniasis © WHO/ C. Black, https://www.who.int/leishmaniasis/resources/photo_gallery/ gallery/en/

amongst others. Close to 1 million cases are recorded with an estimated 20,000– 30,000 deaths every year (Alvar et al., 2012; Bern, Maguire, & Alvar, 2008; Goto & Lindoso, 2010; Ready, 2014). Not all people carrying Leishmania parasites will develop the diseases, only a small proportion of those infected develop the disease.

3.2.7 Guinea Worm The parasite Dracunculus medinensis or “Guinea-worm” is known to cause guinea worm disease, dracunculiasis. The disease which is on track to eradication has been drastically reduced from 3.5 million cases in 1986 to only 1 human study reported as of March 2019 and over 180 countries being certified free of the disease. People are infected by the guinea worm larvae through drinking water contaminated by the Cyclops, a flea infected with mature guinea worm larvae (Fig. 3.6). There is no drug or vaccine available for the disease, but through appropriate prevention and control measures, it is possible to eradicate the disease. Guinea worm eradication strategies include; • Surveillance to establish trends, distribution of cases including response to control measures, • Community education on water safety, filtration and treatment,

3.2 Epidermal Parasitic Skin Diseases (EPSD)

33

Biswas G./NICD

Fig. 3.5 Worm emerging from hand and foot. When the worm emerges it has to be pulled out slowly, the process is painful and may take weeks before the whole worm is pulled out. Worm emerging from hand and foot © Biswas G./ NCID, WHO https://www.who.int/dracunculiasis/home_example/en/

• Voluntary isolation of patients, including avoiding immersing limbs, from which the worm is emerging in sources of drinking water (Awofeso, 2013; Biswas, Sankara, Agua-Agum, & Maiga, 2013). The infected individual is incapacitated for months as the worm emerges (Fig. 3.5). This results in children missing school, disruption and or complete loss of livelihoods, stigma and loss of financial security.

3.2.8 Onchocerciasis (River Blindness) River blindness is a parasitic disease caused by a filarial worm Onchocerca volvulus and is transmitted by the black fly (simulium species). The disease is endemic in parts of Africa and South America (Fig. 3.7). The life cycle of O. volvulus occurs in the vector, the blackfly and in the human body where the worm matures (Fig. 3.8). Within the human body, the adult female microfilaria worm releases microfilaria (larval worms) which migrate to the skin and eyes where they die causing itching and lesions in the eye (eye manifestations). Repeated exposure results into irreversible blindness and skin disfigurement also known as leopard skin and or lizard skin (Hotez & Kamath, 2009) https://www.who. int/blindness/partnerships/onchocerciasis_disease_information/en/. While the larvae are the infective stage of the parasites, it is only when the adult female worms release the microfilariae that the disease can be detected in stool, urine and sputum.

34

3 Types of Skin Disease and Their Causes Person drinks water contaminated with cyclops (water flea) that are carrying third-stage guinea worm larvae

The larvae develop into second and third stage larvae within the cylops

Upon contact with water the emerging worm releases first stage larvae, which are ingested by the cyclops

Worm larvae are released in the stomach where they mature and mate

The worms migrate to various parts of the body. A er one year the worm emerge, usually from the feet

Fig. 3.6 Life Cycle of the Guinea worm. The guinea worm is transmitted through drinking water contaminated with the water flea (cyclops) carrying third stage larvae of the worm; upon maturing and mating in the stomach the worms migrate to the skin where they release the first stage larvae upon contact with water

3.2.9 Lymphatic Filariasis Lymphatic filariasis (LF) is an infectious disease affecting humans in many parts of the world, particularly in low resource countries (Fig. 3.9). The disease affects both men and women causing swelling of limbs and the groin (hydrocele, in men). The infectious agent responsible for the disease are threadlike nematode worms Wuchereria bancrofti, Brugia malayi, and B. timori, 80–100 mm long (W. bancrofti), or 43–55 mm long (B. malayi) (Goel & Goel, 2016; Hotez et al., 2015; Wertheim, Horby, & Woodall, 2012; World Health Organisation (WHO), 2016a). Humans are the main reservoir of the disease however there are non-human reservoirs including, monkeys (in Southeast Asia), some wild carnivores, dogs, and cats which may also be infected with B. malayi. The reservoir for W. bancrofti is not yet known (Wertheim et al., 2012). Filariasis is a vectorborne diseases transmitted by mosquitoes. Some of the vectors include Culex quinquefasciatus for W. bancrofti: Anopheles spp., and Aedes spp. (in the Pacific Islands); for B. malayi: Mansonia, Anopheles, and Aedes; for B. timori, An. barbirostris. When a mosquito bites an infected individual, it ingests microfilariae in human blood. Inside the mosquito, the microfilariae develop into larvae within 2 weeks and

3.2 Epidermal Parasitic Skin Diseases (EPSD)

35

Fig. 3.7 Distribution of Onchocerciasis as of 2017. Distribution of the guinea worm, the disease is endemic in Africa and Latin America. Distribution of onchocerciasis 2017 © WHO Blackfly Stage

3

2

Human Stage

4

The larvae develop into L1, L2 and finally L3

L3 larvae migrate to the blackfly mouthparts (proboscis) and the blackfly infects the human as it takes a blood meal

Microfilariae penetrate the blackfly midgut and develop into larvae

Black fly takes a blood meal from infected host, consuming microfilariae

1

6

5

Adults will stay in the subcutaneous nodule where they mate and finally release microfilariae

The larvae migrate into the subcutaneous ssue

Unsheathed microfilariae move to the skin and the lymph and connec ve ssue where they can be detected during diagnos c tests

7

Fig. 3.8 The life cycle of O. volvulus involves two hosts, the human host and the blackfly. While the larval stages develop in the blackfly, the adult worms mature and develop in humans

migrate to the mosquito mouth parts. When this mosquito takes another blood meal, the larvae are deposited onto the skin and invade through the wound. The larvae then travel to the lymphatic system where they develop into adults, and mate to produce microfilariae. The microfilariae then migrate to the blood where they will be picked up by another mosquito during a blood meal. The duration for worms to mature

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3 Types of Skin Disease and Their Causes

Fig. 3.9 Lymphatic filariasis endemic countries as of 2016. Map showing distribution of lymphatic filariasis; the disease is endemic in Africa, Latin America and South East Asia. Lymphatic filariasis endemic countries as of 2016 © WHO

varies between the worms, with B. malayi having a 3–6 months incubation period and W. bancrofti and B. timori, 6–12 months (Fig. 3.10).

3.2.10 Podoconiosis Podoconiosis also known as non-filarial elephantiasis (mossy feet) is a disease that affects the lower extremities; legs and feet. The disease affects the lymphatic vessels of the lower extremities resulting in deformities (Fig. 3.11). Podoconiosis is a geochemical disease occurring in individuals exposed to red clay soil derived from alkalic volcanic rock. The disease has been reported in parts of Africa, South and Central America, and South East Asia (Davey, Tekola, & Newport, 2007). The disease is not well understood but has crippling effects on the affected individuals and population. Although mortality due to the disease is rare, the disease is highly disfiguring and a source of psychological distress on infected individuals and their families (Hofstraat & Van Brakel, 2015; Mousley et al., 2014; Tomczyk, Tamiru, & Davey, 2012). These include;

3.2 Epidermal Parasitic Skin Diseases (EPSD)

37 1

Microfilariae migrate to the mosquito 7 mouthparts (proboscis)

An infected mosquito releases larvae into the human body while taking a blood meal

2 Larvae migrate to the lympha c system and develop into adult worms

6 Microfilariae develop into infec ve larval stages L1, L2 and L3

Human Stages

Mosquito Stages

5

The mosquito ingest microfilariae while taking a blood meal from an infected individual

4

Microfilariae are released into the blood stream

3

The worms can stay for five to seven years, damaging and causing blockages to the lympha c system, swelling and fevers

Fig. 3.10 Life cycle of lymphatic filariasis. The microfilariae are the infective stage of the parasite; the parasites are introduced into the human body through a bite from a mosquito carrying the parasites; the microfilariae then mature and mate within the human body releasing microfilariae which are taken up by another mosquito taking a blood meal from an infected individual

Fig. 3.11 Podoconiosis. Podoconiosis, showing swelling and deformities on legs and feet; photo used with permission from Jessica Shortall. Podoconiosis © Jessica Shortall

• Unwillingness to marry a person suffering from podoconiosis or a family member from a podoconiosis-affected family. • Avoiding patients and family members. • Avoiding physical contact with patients. • Patients are excluded from social events like weddings and funerals.

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• • • •

Spitting on patients. Pinching nose when walking past patients at a distance. Unwillingness of classmates to sit with patients at the same desk in school. Unwillingness of unaffected family members to approach an affected household member. • Use of derogatorily terms on affected individuals. Stigma experienced by podoconiosis patients and their families has a huge impact on the quality of life. Studies in Ethiopia have revealed strong podoconiosis related stigma. People experienced social stigma at church, at school resulting in school dropout, infected individuals were excluded from weddings and or funerals, and in the market place where the community will not buy products from them, greatly affecting their livelihoods (Mousley et al., 2014). The main challenge with podoconiosis as a public health problem is that not only are the patients shunned by their communities but also health professionals making it difficult for the affected individuals to get the needed healthcare. These experiences have contributed to higher mental distress in infected individuals compared to healthy controls, suggesting an association between podoconiosis and reduced quality of life and depression. Podoconiosis Patient Coping Strategies Patients living with podoconiosis experience many types of discrimination, most of which are distressing and sometimes leading to suicidal thoughts. A study in Southern Ethiopia where the disease is endemic, found that patients have devised several coping strategies. Most of the coping strategies involved avoidant behaviours such as; • Avoiding participation in public and or social gatherings- Individuals living with the disease (this may include close relatives) avoid going to in church, school, funerals and weddings to protect themselves from stigmatizing attitudes. • Avoiding marriage- Infected individuals will avoid marriage to non-patients or avoid marriage completely. • Patients may change place of residence. • Involvement in premarital sex during mate selection. • Seeking divorce, if they were married. • In extreme cases patients have suicidal thoughts and may avoid seeking treatment Economic burden due to podoconiosis Direct costs due to podoconiosis are estimated to be approximately 143 USD per person per year with a 45% loss of all working days per year. This is a huge burden on populations that survive on less than two dollars a day (Below the poverty line). In Wolaita Zone, Southern Ethiopia, with a population of 1.5 million people, the overall cost of podoconiosis was more than 16 million US dollars per year. Most of the patients in Western and Southern Ethiopia (76–100%) were in the economically productive age groups of 15–64 years a cause for concern with regard to economic sustainability (Tekola, Mariam, & Davey, 2006).

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3.2.11 Pediculosis Capitis Pediculosis capitis is one of the most common ectoparasitic diseases worldwide. The disease is a result of infestations with head lice Pediculus humanus capitis. The disease usually affects children between the age range of 5–13 years. The lice infest hairy parts of the body (scalp, eyebrows, eyelashes), and clothing with the eggs, larvae or adults. Apart from the eggs, all stages of the lice feed on human blood. The most common symptoms of lice infestation include itching and rash, but many children are asymptomatic. Head lice infestations are frequently found in school settings or institutions. Head lice survive less than one to two days if they fall off the scalp and cannot feed (Feldmeier & Heukelbach, 2009; Hay et al., 1994; Heukelbach et al., 2003). Chronic heavy infestation among school children may lead to anaemia, but also psychological stress among children and those affected (Feldmeier & Heukelbach, 2009; Kalu, Wagbatsoma, Ogbaini-Emovon, Nwadike, & Ojide, 2015).

3.2.12 Hookworm Related Larva Migrans The human hookworm presents a major disease burden worldwide. Infections with the parasite have been associated with iron deficiency and iron deficiency anaemia in infected patients, with a high prevalence in children and the elderly (Brooker et al., 2007). Nutritional deficiencies due to hookworm infestation have also been observed. Since it does not cause important skin problems, this topic will not be addressed in this section. On the other hand, skin problems from hookworm occur when animal hookworms invade humans resulting in hookworm-related cutaneous larva migrans (HrCLM). HrCLM is a parasitic skin disease caused by the migration of animal hookworm larvae in the epidermis. Animal hookworms including Ancylostoma braziliense and A. caninum are found in soil contaminated with animal feaces and can penetrate the human skin. The worms remain in the epidermis as they are unable to penetrate the basal membrane or develop further to complete their life cycle, having entered the wrong host. They therefore wriggle along in the skin, causing a snake-like track of raised and blistering skin that is intensely itchy (Fig. 3.12). If not treated, the skin pathology can be prolonged for months. HrCLM is a self-limiting disease and is prevalent in resource poor communities in limited resource countries with sporadic occurrence in high-income countries (Feldmeier & Schuster, 2012; Feldmeier & Heukelbach, 2009). In HrCLM dogs and cats are the definitive hosts and humans do not carry the sexually active stages of the worm, even though the cycle is the same in both human and the definitive host. Adult worms are present in small intestines of the dogs and cats, they lay eggs which are passed out in stool. With favourable conditions the eggs hatch within 1 to 2 days releasing rabdiform larvae which continue to grow in the feaces and or soil. The infective filariae form larvae survive in the soil for 3 to 4 weeks with favourable conditions and can penetrate the animal host upon contact

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J.Malanda/MW

3 Types of Skin Disease and Their Causes

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J.Malanda/MW

Fig. 3.12 Hookworm related larva migrans. Cutaneous larva migrans, showing a snake—like raised track of blistering skin where the hook worm is embedded, on the face (a) and foot (b) of a child. Hookworm related larva migrans © Jimmy Malanda

with the skin. The larvae are then carried through the blood vessels to the alveoli of the lungs up the bronchioles and into the pharynx where they are swallowed and mature into adults. Human infection happens when the filariform stage of a cat or dog hookworm penetrates the skin, but the worm cannot penetrate further (Fig. 3.13). In human hookworm life cycle, in step 4, the larvae penetrate the skin, their development is arrested and remain dormant until they are re-activated and enter the small intestines where they develop into adults, mate and lay eggs. Thereafter the cycle continues just like HrCLM cycle.

3.3 Bacterial Skin Diseases Bacterial skin diseases cause debilitating effects if not treated promptly. While countries are working hard on the elimination of some of the bacterial diseases such as Leprosy, there are still other bacterial diseases that are affecting both children and adults in developing countries. Bacterial skin diseases usually take advantage of broken skin where the bacteria enter and colonise causing infection (Chiller, Selkin, & Murakawa, 2001; Laube, 2004). Some bacterial diseases are highly infectious (e.g. Impetigo), while others cause crippling effects on the infected individuals (e.g. Leprosy, buruli ulcer, necrotizing fasciitis) (Fig. 3.14). What are the factors contributing to the occurrence of bacterial skin diseases in developing countries?

3.3 Bacterial Skin Diseases

41 The larva penetrate the skin of cats and or dogs and move to the pharynx where they are swallowed

Rhabdiform larva develops into a filariform larva in the environment

3

The filariform larva infects humans and is not able to complete cycle

4

The adult worms will develop and mate within the intes nes, laying eggs which are released in feaces

Rhabdiform larva

2

6

Eggs in feaces

1 Fig. 3.13 Life cycle of Hookworm related larva migrans. Cats and dogs are the definitive hosts for the HrCLM and humans do not carry sexual stages. The larva is swallowed by the animals and migrated to the pharynx where it is swallowed; the mature worms develop mate and lay eggs in the intestines

a

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J. Malanda/MW

J. Malanda/MW

Fig. 3.14 Bacteria skin infections. Some examples of bacteria skin infections, showing necrotising fasciitis (commonly known as flesh-eating disease) a very aggressive skin infection which is caused by a mixture of bacteria types (a) and leprosy caused by Mycobacterium leprae (b). Bacteria skin infections © Jimmy Malanda

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3 Types of Skin Disease and Their Causes

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Fig. 3.15 Impetigo. Impetigo contagiosum on legs (a) and on the head (b) showing oozing sores. Impetigo © Jimmy Malanda

3.3.1 Impetigo Impetigo is a highly infectious bacterial disease most affecting children worldwide with a huge burden in low to middle income countries. Staphylococcus aureus and Streptococcus pyogenes play a role in causing impetigo. Impetigo prevalence is highest in Oceania, in both resource-poor countries and underprivileged populations within high-income countries. The disease presents in two forms; nonbullous impetigo which accounts for 70% of the cases and is due to S. aureus infection, S. pyogenes or a combination of both organisms; and bullous impetigo which is a result of S. aureus. Nonbullous impetigo has no bullae while bullous form of the disease has bullae. Bullae are fluid filled lesions. Impetigo appears as oozing sores on the face especially around the mouth and nose and on hands and feet of children. When the sores burst, they form honey coloured crusts (Fig. 3.15). The sores can spread to other parts of the body through contact by fingers, towels as well as clothing. The sores are mildly itchy. In the bullous form of the infection, large blisters may be observed on the trunk of children as well as infants. Ecthyma is a more serious form of impetigo where the blisters penetrate deeper into the skin resulting in painful pus-filled ulcers (Laube, 2004; Lopez & Lartchenko, 2006).

3.3.2 Yaws Yaws is a chronic infection that affects mainly the skin, bone and cartilage. The disease occurs often in poor communities in warm, humid, tropical areas of Africa,

3.3 Bacterial Skin Diseases

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Asia and Latin America. A bacterium called Treponema pertenue, a subspecies of Treponema pallidum that causes venereal syphilis, is the microorganism responsible for causing yaws. However, despite the close connection with T. pallidum, yaws is a non-venereal infection. Approximately 75% of people affected are children under 15 years of age (peak incidence occurs in children aged 6–10 years); males and females are affected; and no race is exempt. Yaws is transmitted mainly through direct skin contact with an infected person. A single skin lesion develops at the point of entry of the bacterium after 2–4 weeks. Without treatment, multiple lesions appear all over the body. The disease is rarely fatal; however, it can lead to chronic disfigurement and disability. Yaws can be treated with a single dose of a cheap and effective antibiotic: e.g. Benzathine Penicillin injection or a single dose of oral azithromycin. Overcrowding, poor personal hygiene and poor sanitation have been implicated to facilitate the spread of the disease. Mass treatment in Cameroon in the 1950’s reduced the disease to the extent that it was believed to have been eradicated. In 2010, new cases were detected in Bankim and is a re-emerging disease in Papua, New Guinea (Awah et al., 2018; Mitjà et al., 2015; Mitjà, Šmajs, & Bassat, 2013). Yaws is divided into two stages, the early, infectious and late non-infectious stage. The early stage is characterized by development of a papule at the site of entry of the disease-causing organism. The papule, full of the disease-causing organism, may persist for 3–6 months followed by natural healing. Without treatment, skin lesions may spread all over the body resulting bone pain and lesions. Yaws can also appear as late as five years after initial infection. Clinical diagnosis can be achieved through a dark field microscopic examination of a skin sample from the lesion although blood tests specific for syphilis can also be used in yaws diagnosis. The signs for yaws infection include; a painless ulcer with scab, papillomas and palmar/plantar hyperkeratosis (thickening). Treatment can be achieved through a single intramuscular injection of Benzathine Penicillin and for those allergic to penicillin, tetracycline, erythromycin or doxycycline could be used. Without treatment, yaws can result in disfiguring and disabling complications including gross destruction of the skin and bones as well as deformities of the legs, nose, palate, and upper jaw. At present, there is no vaccine to prevent yaws (Marks, Lebari, Solomon, & Higgins, 2015; Mitjà et al., 2015). Interruption of transmission is one way to prevent yaws.

3.3.2.1

Past Efforts to Control Yaws

Between 1950 and 1970, WHO and UNICEF led a worldwide campaign to control yaws in 46 countries. Mass campaigns using mobile teams in all 46 endemic countries led to the treatment of 50 million people and by 1970, the prevalence of the disease had decreased by 95%. After the success in the 1970s, most of the vertical programmes in many countries were dismantled and yaws activities were integrated into the primary health care system to deal with the “last cases”. This led to the reduction of resources, attention and commitment for yaws activities, leading to gradual disappearance of the efforts. The disease began to appear again in the late 1970s leading to renewed

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3 Types of Skin Disease and Their Causes

efforts to fight the disease. Lack of political will and resources led to failed attempts to revive the efforts. Renewed efforts to eliminate the disease were stepped up in 1995 although global coordination is yet to be achieved. Since the disease only occurs in humans, and only few localized foci of infection remain, and with the availability of a potent and cost-effective treatment; experts believe yaws can be eliminated.

3.3.3 Buruli Ulcer Buruli ulcer (BU) also known as Bairnsdale ulcer, Searls ulcer, Daintree ulcer, Kumusi ulcer, and mycoburuli ulcers, is a neglected tropical disease affecting populations in parts of Africa, Australia, South America and the Western Pacific regions. The disease has been reported in 33 countries with 15 regularly reporting to WHO (Fig. 3.16). BU is caused by Mycobacterium ulcerans, and is the third common mycobacterium disease after TB, caused by Mycobacterium tuberculosis; and Leprosy, caused by Mycobaterium leprae (World Health Organisation (WHO), 2017). Buruli ulcer has been reported in rural West Africa, Central Africa, New Guinea, Latin America and Tropical regions of Asia.

Fig. 3.16 Global distribution of Buruli ulcer as of 2018. Distribution of buruli ulcer as of 2018; showing endemic regions, most cases occur in some countries in Africa, with increased prevalence in Australia. Distribution of Buruli ulcer © WHO

3.3 Bacterial Skin Diseases

a

45

c

b

Dr A. Paintsil, Ghana

d

Dr R. Zilliox, France

Dr A. Tiendrebéogo, Nigeria

f

e

Papule

Dr J. Hayman, Australia

Dr J. Bun ne, Australia

Dr P. Johnson, Australia

Fig. 3.17 Three stages of Buruli ulcer. Buruli ulcer on dark (a–c) and light (d–f) skin complexion showing the different stages of the disease. Category I (a, d) characterised by a lesion also known as early stage (papule); Category II (b, e) also known as ulcerative stage; and Category III (c, f) showing advanced ulceration most often involving the bone. Three stages of Buruli ulcer © Dr A. Paintsil (Ghana), Dr R. Zilliox (France), Dr A. Tiendrebéogo (Nigeria), Dr J. Hayman (Australia), Dr J. Buntine (Australia), Dr P. Johnson, (Australia), WHO

Buruli ulcer is a chronic, devastating bacterial skin disease mainly affecting the skin and sometimes the bone. The mode of transmission of M. ulcerans to humans is still unknown; however, the bacteria is present in the environment. The disease is divided into three categories; category I which is characterized by small lesions (32%); Category II is characterized by non-ulcerative plaque and oedematous forms (35%) and category III categorized by osteitis, osteomyelitis, and joint involvement (Fig. 3.17) (World Health Organisation (WHO), 2017). The disease can be diagnosed at all three stages, while Australia and Japan are able to identify approximately 90% of the disease during category I, at least 70% of the cases in Africa are identified during category III (Fig. 3.18). According to WHO, there are some countries that are actively reporting cases of BU while, others who were previously reporting are currently not actively reporting (Table 3.2).

3.3.3.1

Affected Population

Affecting mostly children under the age of 15 (48% in Africa, 10% in Australia and 19% in Japan), the disease has caused lasting effects on the affected individuals. Late presentation of the disease could mean excessive loss of tissue, and infection of the bone which may require surgical procedures and sometimes amputation of the limb.

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3 Types of Skin Disease and Their Causes

a

b

c B

Dr D. Phanzu, DemocraƟc Republic of the Congo

Dr Y. Lugor, Sudan

d

Dr J. BunƟne, Australia

e

Professor H. Assé, Côte d'Ivoire

Dr K. Asiedu, Nigeria

Fig. 3.18 Buruli ulcer on various parts of the body. Buruli ulcer on different parts of the body, torso, arms, and legs, images from various doctors in Sudan (a), Democratic Republic of Congo (b), Australia (c), Cote d’Ivoire (d), and Nigeria (e). Buruli ulcer on various parts of the body © Dr Y. Lugor (Sudan), Dr D. Phanzu (Democratic Republic of the Congo), Dr J. Buntine (Australia), Professor H. Assé (Côte D’Ivoire), Dr K. Asiedu (Nigeria), WHO Table 3.2 Countries that have reported Buruli ulcer cases. Buruli ulcer is endemic in 33 countries with cases being regularly reported by some countries

Countries Currently Reporting to WHO Country, Region

Countries Previously Reporting to WHO Country, Region

Benin, Africa

Angola, Africa

Cameroon, Africa

Burkina Faso, Africa

Côte d’Ivoire, Africa

Equatorial Guinea, Africa

Congo, Africa

Kenya, Africa

Democratic Republic of the Congo, Africa

Malawi, Africa

Gabon, Africa

South Sudan, Africa

Ghana, Africa

Uganda, Africa

Guinea, Africa

Brazil, Americas

Liberia, Africa

Mexico, Americas

Nigeria, Africa

Peru, Americas

Sierra Leone, Africa

Suriname, Americas

Togo, Africa

Indonesia, South-East Asia

French Guiana, Americas

Sri Lanka, South-East Asia

Australia, Western Pacific

China, Western Pacific

Japan, Western Pacific

Kiribati, Western Pacific, and

Papua New Guinea, Western Pacific

Malaysia, Western Pacific

3.3 Bacterial Skin Diseases

47

Since 2005 a combination of antibiotics has been used to treat BU; this has helped many people in the affected regions as these antibiotics can cure the disease and, in some cases, prevent recurrence of the disease (Asiedu & Wansbrough-Jones, 2007; Lavender et al., 2007; Yerramilli et al., 2017; Yotsu et al., 2015, 2018). Previously the majority of cases were reported from West Africa, but in recent years, there has been an increase of reports of BU from Australia. Even though it is suspected that BU could be contracted from the environment or from an insect bite, the source of infection and mode of transmission is not yet known. It is therefore very difficult to know how to control and prevent the spread of the disease. Most rural populations in endemic areas are vulnerable to the disease due to lack of knowledge about the source and mode of transmission of the disease. The patients suffering from the disease are not sure how they got the disease, and most go to the hospital at a later stage, the majority when the ulcer appears. Patient history has allowed researchers and medical personnel to build timelines and suggest the various ways in which the disease could have been contracted. Some people take as long as 2 years from the time of appearance of a nodule (early stage of buruli ulcer) to the time they seek medical attention. During this time the bacteria responsible for the disease, M. ulcerans, is replicating and eating away tissue under the skin. Late identification of disease has resulted in long hospitalization and can be costly. Since the disease largely affects the limbs, with the majority on lower limbs (55%), upper limbs (35%) and the upper body (10%), livelihoods and families are disrupted (Yerramilli et al., 2017). Children affected by the disease may spend months and sometimes years being treated in hospitals. This not only affects their education, but it contributes to major psychological trauma, as the disease often causes serious disfigurement requiring long periods of rehabilitation. The parents of these children spend most of their income on treatment costs, some losing their businesses and livelihood.

3.3.3.2

Narratives

In the affected countries in Africa, most of the narratives have associated the disease with marshy areas, water pools (in areas where there was sand and or gold mining), boreholes and insect bites. In Australia, the current cases in Victoria have been associated with the Bellarine and Mornington Peninsula, where marshy areas also exist. Various avenues are being explored to search for animal reservoirs, as well as studying the environments where people are suspected to have contracted the disease. While in Australia and Japan (developed countries where the disease is endemic) patients have access to advanced medical care, many in rural areas of developed countries are not able to readily access such kind of health services. This could be due to various reasons including poor access to health services (in form of distance, transportation as well as availability of the health services), financial constraints within the family, or lack of support from family and the community due to stigma. As such, in limited resource settings, many report the disease late and or chose to go to herbalists or tribal healers first.

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3.3.3.3

3 Types of Skin Disease and Their Causes

Decision Making

Parents and or caregivers are the ones who can take their children for treatment, therefore the decision they make regarding treatment is crucial. Bringing awareness to parents/caregivers and the children regarding BU, and how treatment seeking behaviour plays a role in disease outcome provides the needed information to understand the importance of early treatment. Marshy areas seem to be a common denominator in the affected regions. The plight of certain populations to BU can be attributed to pre-existing conditions within their surrounding and environment. Limited resources in poor rural populations have driven people to work in risky environments thereby at high risk of encountering infectious disease—causing agents. The lack of knowledge about the source and mode of transmission of BU creates enormous challenges with regard to disease control and prevention. In countries where BU is endemic or has been reported, there is a high possibility that health workers and volunteers can actively look for and easily identify cases. Subsequently in countries where there is lack of reporting on BU, it may not mean that the disease is not there, but maybe lack of knowledge about the disease contributes to poor diagnosis hence reporting.

3.3.3.4

Community Volunteers

The challenges posed by buruli ulcer in rural communities require serious intervention. In Cameroon, Ghana and Benin, village community volunteers trained to identify the early stages of buruli ulcer have succeeded in identifying patients and referring them for treatment at the designated treatment centres. This has not only assisted in early identification of disease but also averted serious infections that could have resulted in surgery or amputation of limbs as well as huge economic costs on the family. Community interventions including films on BU to debunk myths on the disease, have helped bring awareness to masses. Campaigns are also ongoing to help with early identification of disease. It was observed that up to 78% of children infected by BU do get cured, but adults who usually report the disease at a very late stage, their ulcers are difficult to heal (Thierry Barogui et al., 2014).

3.4 Viral Skin Infections 3.4.1 Herpes Simplex Virus (HSV) For the past decades, association of HIV infection and HSV have been documented. HSV-2 is a sexually transmitted infection (STIs) which occurs in two forms; herpes simplex virus type 1 (HSV-1) and herpes simplex virus type 2 (HSV-2). Both HSV-1

3.4 Viral Skin Infections

49

and 2 are lifelong infections, which means once one contracts the disease, they will have it for life. Symptoms of HSV include painful blisters/ulcers at the site of infection, that is the mouth for oral herpes and genital area for genital herpes. The disease is highly contagious during the symptomatic phase (when the symptoms are present) but can still be transmitted in the absence of symptoms (asymptomatic phase). Severe symptoms of HSV can be observed in immunocompromised individuals such as those with advance HIV infection (Schiffer et al., 2013). HSV-1 Herpes simplex virus type 1 (HSV-1) is mainly transmitted through oral contact, including oral to oral contact and oral to genital contact resulting in oral herpes (cold sores) and genital herpes respectively. Individuals who already have contracted HSV1 oral herpes are highly unlikely to acquire subsequent infections with HSV-1 genital herpes infection. In rare instances, HSV-1 genital herpes can be transmitted from infected mother to her infant during delivery, leading to neonatal herpes. Neonatal herpes can result in lasting neurological disability and or death. Women who acquire genital herpes before they get pregnant have a very low risk of transmitting the disease to their infants unlike those that acquire the infection late in pregnancy (Schiffer et al., 2013). HSV-2 On the other hand, HSV-2 is a sexually transmitted infection which causes genital herpes. It has been shown that HSV-2 infection increases the risk of HIV acquisition (Looker et al., 2017). HSV-2 infection is characterised by painful genital ulcers which recur periodically (Gupta et al., 2007). Genital herpes is asymptomatic in approximately 80–90% of individuals, although these individuals can shed and transmit the virus during this period (Gupta, Gartner, Sethupathy, Hatzigeorgiou, & Fraser, 2006; Schiffer & Corey, 2013). Some of the risk factors associated with HSV-2 include age, sex, partner change rate, condom use, and male circumcision (Kaushic, Roth, Anipindi, & Xiu, 2011; Tobian et al., 2009). Genital ulceration and viral shedding occur most frequently in the first year of infection (Phipps et al., 2011).

3.4.2 Herpes Zoster (HZ)—Shingles Herpes Zoster (also known as shingles)is a disease affecting nerve tissues. HZ is a result of reactivation of Varicella zoster virus (VZV) responsible for chickenpox which lay dormant in the spinal and cranial ganglia. The disease is associated with short and or long- term manifestations. Complications due to disease can be classified into dermatological, neurological, ophthalmological and or visceral. Dermatological complications can be in form of secondary bacterial infections, while long-term pain and neurogenic weakness (segmental zoster paresis) are associated with neurological complications. Secondary glaucoma, keratitis, and iridocyclitis are associated with

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3 Types of Skin Disease and Their Causes

opthalmological complications. In visceral complication, pneumonia and hepatitis may occur (Bloch & Johnson, 2012; Johnson et al., 2015). Immunocompromised individuals, such as those living with HIV/AIDS and or older (50 years and above) are at high risk of disease (Laube, 2004; Mahe, Bobin, Coulibaly, & Tounkara, 1997). Individuals suffering from HZ can thus transmit VZV to seronegative individuals which may in turn develop chickenpox (VZV) but not HZ. When VZV is activated the virus travels through the sensory nerve to the corresponding area on the skin supplied by that single sensory nerve root (dermatome). The pattern of the resulting rash signifies the affected nerve (Fig. 3.19). Symptoms associated with HZ include; prodromal itching and or pain, pustulation of vesicles and a scab within 2–4 weeks. Pain due to HZ can be categorized into three phases. • Acute Pain Phase; which lasts for 1 month • Sub-acute Pain Phase; for pain occurring 90 days after the healing of the rash • Post Herpetic Neuralgia (PHN) Pain Phase; for pain occurring more than 90 days after the onset of the rash. PHN is responsible for most of the HZ disease-related burden as the debilitating pain can last for months to years. Factors including age, immunosuppression, and other comorbidities have been associated with PHN. An effective attenuated vaccine for PHN is available although there is still need to review the evidence on the likelihood of protecting individuals from developing PHN.

a

J. Malanda/MW

b

J. Malanda/MW

c

J. Malanda/MW

Fig. 3.19 Herpes zoster rash. Herpes zoster usually affects one dermatome (unilateral infection), in rare cases bilateral infections (two dermatomes) occur; here unilateral infection of HZ showing pustules on the torso (a), healing on lower face (mandibular division of the trigeminal nerve (V3)) (b), and crust on the upper face (ophthalmic region of the trigeminal nerve (V1)) (c). Herpes zoster rash © Jimmy Malanda

3.5 Superficial Fungal Infections (SFI)

51

3.5 Superficial Fungal Infections (SFI) Fungal and yeast infections are very common among populations especially in humid environments (Hay, Johns, Williams, Bolliger, Dellavalle et al., 2014). According to the global burden of skin diseases analysis, fungal skin infections were among the top 10 prevalent diseases worldwide in 2010. Some of the reservoirs of fungal skin infections include, soil, animals, and infected humans. The most common fungal infections include; Tinea capitis, Tinea cruris, and Tinea pedis. Fungi that cause superficial skin infections are known as dermatophytes. Dermatophyte infections are common worldwide and affect people of all ages and sexes (Hay, 2017; Oke, Onayemi, Olasode, Omisore, & Oninla, 2014). Superficial fungal infections are transmitted through person to person contact, contact with soil and animals carrying fungal spores. Dermatophytes affect different parts of the body (Fig. 3.20). Fungal infections affecting the scalp are commonly known as tinea capitis, while those affecting the feet are known as tinea pedis, those affecting the groin are referred to as tinea cruris and the rest are known as tinea corporis. Chronic SFI have been reported to affect 20% of the population globally (Hay, 2017). Dermatophytes can be classified according to the disease-causing genera such as Trichophyton (affecting hair, skin and nails), Epidermophyton (affecting skin and nails), and Microsporum (affecting skin and hair). Secondly, they can be classified according to mode of transmission. Anthropophilic (human to human), zoophilic (animal to humans) and geophilic (soil to humans). Finally, dermatophytes can be classified according to the sites of infection, these include tinea capitis (affecting the head), tinea corporis (affecting the body), tinea cruris (affecting the groin), and tinea pedis (affecting the feet) (Hay, 2017).

a

b

J. Malanda/MW

J. Malanda/MW

Fig. 3.20 Tinea. Tinea unguinum affecting the fingernails (a), and Tinea capitis (b). Tinea © Jimmy Malanda

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3 Types of Skin Disease and Their Causes

3.5.1 Tinea Capitis Tinea capitis primarily affects children with peak incidence between the ages of 3 and 9 years (Frieden, 1987). Tinea capitis is common in non-Caucasian populations (Prevost, 1983). Microsporum and Trycophyton spp. are implicated as the common causes of T. capitis. Tinea capitis infection is a result of invasion of the hair shaft by fungi. There are three forms of the disease; Non-inflammatory: diffuse scaly scalp where initially erythematous papules appear around the hair shaft followed by scaly alopecia with hair broken just above the scalp. Due to arthrospores covering the hair, it looks gray and lusterless (Frieden, 1987). Inflammatory diffuse: pustular kerion which is characterized by scattered painful pruritic pustular folliculitis with kerion (boggy nodules studded with broken hair and purulent sticky material) with subsequent development of alopecia and scarring. The ‘Black dot’: is associated with endothrix infections, where the hairs becomes fragile and break easily at scalp level. The remaining infected follicles appear as black dots with various levels of scaling and inflammation. Infection results when the fungal spores stay within the hair shaft causing noninflammatory infections. Endothrix infections can progress to become chronic infections through to adult life and are a result of infections with Trichophyton tonsurans, T.violaceum and T. soudanense. Endothrix reactions do not show fluorescence when examined under Woods lamp (Kolli, 2015). In ectothrix infection the fungal hyphae and spores (arthroconidia) cover the outside of the hair and can be identified using Woods lamp examination using longwave ultra-violet light. In this type of infection there is fragmentation of the mycelium into conidia around the hair shaft or just beneath the cuticle (Frieden & Howard, 1994). Examples of ectothrix infections include mild ringworm or prepubertal tinea (Graypatch ring-worm) capitis infections. Unlike endothrix infections, ectothrix infections are inflammatory and depending on the degree of inflammation, scarring may occur. Microsporum canis is responsible for Gray-patch ringworm.

3.5.2 Tinea Cruris Tinea cruris also known as jock itch is a superficial fungal infection affecting the skin around the inner thighs and the groin area. The infection is rarely seen in children but frequently observed in people who sweat a lot including athletes and obese adult men and women (Gupta, Chaudhry, & Elewski, 2003). In the United states of America, Trycophyton rubrum is the common cause of infection (Van Heerden & Vismer, 1997). Jock itch is characterized by itchy often ring shaped rash in the genitals, buttocks, inner thighs and moist areas. The rash may consist of a line of raised blisters which are often itchy or burn and the skin appears flaky and scaly. The disease can spread through sharing towels or clothing. Since the fungus responsible

3.5 Superficial Fungal Infections (SFI)

53

for jock itch is the same fungus responsible for athlete’s foot, it is common for the fungi to spread from the feet to the groin area through hands or towels.

3.5.3 Tinea Pedis Tinea pedis refers to dermatophytes affecting the feet and spaces between the toes (inter-digital spaces). Trycophyton rubrum is the common fungus responsible for the disease. The disease can spread through shared footwear, socks, shoes, towels with an infected individual. Symptoms include, itching, stinging and or burning sensation between the toes, blisters, cracking and peeling of the skin mostly between toes and soles, discoloured toe nails and nails pulling away from the nail bed.

3.5.4 Tinea Corporis Refers to dermatophyte infection on the torso, and limbs and any part of the body. Commonly known as ringworm, symptoms start within 4 to 10 days after contact with the fungus. It is characterised by circular shaped rashes with slightly raised edges. The skin inside the ring usually looks healthy but the rashes are itchy and over the course of the infection they spread resulting in rings that multiply and or merge together. The disease can be spread through, person to person contact, animal to human contact, contact with objects such as clothing, beddings and other items that were in contact with an infected individual and contact with contaminated soil. Tinea corporis is more common in children than adults. Risk factors associated with dermatophytes include living in damp and humid environments, excessive sweating, contact sports, weak immune system, overcrowding and sharing clothing, beddings and or towels.

3.6 Papulosquamous Skin Conditions Papulosquamous skin conditions include psoriasis, seborrheic dermatitis, pityriasis rosae and lichen planus. These diseases present varying aetiologies but all present scaly plaques and papules also known as papulosquamous lesions (Karimkhani et al., 2017).

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3 Types of Skin Disease and Their Causes

3.6.1 Psoriasis Psoriasis is a result of dysregulation of the cell-mediated adaptive immune response (Fig. 3.21). The disease is characterized by over stimulated TH1 pathway response in genetically predisposed individuals. The psoriac plates are a result of overproduction of TH-1 related cytokines, IL-12, 17 and 23 (Fonacier, Dreskin, & Leung, 2010). Over production of these cytokines results in formation of psoriac plates. The disease is characterized as an auto immune disease that results in rapid build-up of skin cells resulting in scaling on the skin surface. The scales appear on different parts of the body including hands, feet, neck, scalp, face and torso. Red inflamed patches cover the skin in plaque psoriasis, while small pink spots are observed in guttate psoriasis. The spots are rarely thick or raised as in plaque psoriasis (Luba & Stulberg, 2006; Raychaudhuri, Maverakis, & Raychaudhuri, 2014). In pustular psoriasis pus-filled blisters and broad areas of red inflamed skin are observed. The disease is typically localized in the hands and feet though it can be widespread (Raychaudhuri et al., 2014). Inverse psoriasis is observed under armpits or breasts and in the groin and skinfolds of the genitals. In inverse proriasis, the scales often slough off in large sections and is life threatening (Raychaudhuri et al., 2014). Erythrodermic psoriasis is a very rare but severe type of psoriasis. It covers large areas with the skin appearing sun burned. Fever and serious illness are a common occurrence in this type of the disease.

J. Malanda/MW

Fig. 3.21 Psoriasis. Psoriasis on arms and hands. Psoriasis © Jimmy Malanda

3.6 Papulosquamous Skin Conditions

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3.6.2 Seborrheic Dermatitis This is a skin condition that mainly affects the scalp, causing scaly patches, red skin and stubborn dandruff. Seborrheic dermatitis is characterized by dandruff on the scalp, hair, eyebrows, beard and or moustache, patches of greasy skin covered with flaky white or yellow scales or crusts, red skin and itching. The causes of the disease are not yet known, but the disease has been associated with Malassezia (yeast) that is present in the oil secretion on the skin. The disease has also been associated with irregular response of the immune system. Risk factors include neurologic and psychiatric conditions e.g. Parkinson’s disease and depression, a weakened immune system including organ transplant patients, people with HIV/AIDS, cancers and alcoholic pancreatitis (Duvic, 1991). With the increase in incidence of HIV/AIDS in sub Saharan Africa there has been a rise in some diseases that were rare in people of colour; these include papulosquamous skin infections that are now fast appearing with a more aggressive presentation than before (Duvic, 1991).

3.6.3 Pityriasis Rosea Pityriasis rosea (PR) is an acute, self-limiting papulosquamous infection characterized by a red rash, also known as a herald patch. The rash often starts from the neck and trunk followed by multiple secondary scaly lesions on the trunk. The disease affects healthy individuals and is common in children and the elderly. The cause of the disease is yet unknown although various theories have been explored with some evidence that the rash is triggered by viral infections. There is no evidence at present to indicate that the disease is contagious. The symptoms include sore throat, gastrointestinal disturbances, fever and arthralgia preceding the eruption (Urbina, Das, & Sudy, 2017).

3.6.4 Lichen Planus Lichen planus is another papulosquamous infection, like PR the disease is not contagious. The disease is a mucocutaneous disorder characterized by a chronic rash with scaly skin plaques (Krupaa, Sankari, Masthan, & Rajesh, 2015; Sharma, BiałynickiBirula, Schwartz, & Janniger, 2012) (Fig. 3.22). The cause of the disease is yet unknown although it has been linked to autoimmune disorders. Affecting the stratified squamous epithelium of the skin, LP affects oral and genital mucous membranes nails and scalp (Canto, Müller, Freitas, & Santos, 2010). Currently, two types

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3 Types of Skin Disease and Their Causes

J. Malanda/MW

Fig. 3.22 Lichen planus. Lichen planus © Jimmy Malanda

of LP have been described; oral LP and cutaneous LP (Lavanya, Rao, Jayanthi, & Ranganathan, 2011). Cutaneous LP (CLP) This type of LP is characterized by purple, pruritic (itchy), polygonal papules and plaques (5 ps) (Edwards & Kelsch, 2002). Cutaneous LP presents as a cutaneous and mucosal eruption, rarely manifesting with only oral and nail findings (Krupaa et al., 2015). The disease begins as a discrete, flat-topped papules which may merge into larger plaques that are initially red and gradually become reddish purple. The papules have an umblicated centre with characteristic greyish- white striations (Wickham’s striae) on the surface. The lesions often occur on the flexus surfaces of the limbs, inner aspects of the knees, the thighs and trunk. In a phenomenon called Köbner phenomenon, the lesions may also appear in the lines of trauma (Sharma et al., 2012). The primary symptom of cutaneous LP is the severe pruritis with varying degrees of severity. Scalp and nail involvement have been reported in some patients, while oesphagus, conjunctiva, larynx and face are rarely involved (Davarmanesh, Samsami Dehaghani, Deilami, Monabbati, & Dastgheib, 2012; Edwards & Kelsch, 2002; Sugerman, Satterwhite, & Bigby, 2000). Oral LP (OLP) Oral LP has been linked to gram negative anaerobic bacilli and spirochetes (Scully et al., 1998) with some studies suggesting the role of Helicobacter pylori (Moravvej, Hoseini, Barikbin, Malekzadeh, & Razavi, 2007; Vainio, Huovinen, Liutu, Uksila, & Leino, 2000). Oral LP has also been associated with Herpes simplex virus (HPV), Epstein Barr virus (EBV), human herpes virus- 6 (HHV-6) and HIV (Campisi et al., 2004; Gorsky & Epstein, 2011; Sand, Jalouli, Larsson, & Hirsch, 2002; Yildirim,

3.6 Papulosquamous Skin Conditions

57

Sengüven, & Demir, 2011). Other studies have suggested hepatitis C virus as the causative agent of OLP (Alves, Almeida, & Cabral, 2011; Konidena & Pavani, 2011). Oral LP is found in the oral cavity and is characterized by radiating white, gray, velvety threadlike papules arranged in a net-like pattern forming lacy reticular patches, streaks and rings. Wickham striae are also present with a characteristic white dot at the intersection of the striae (Arya Rajendran, 2014). The mouth lesions may appear weeks and or months before cutaneous lesions and are present on the buccal mucosa, tongue, lips, gingiva, floor of the mouth and palate. Oral LP has six clinical presentations reticular, erosive, atrophic, plaque-like papular and bullous. Erosive is the most significant form of the disease while the bullous form is the most unusual exhibiting blisters that rupture resulting in painful ulcerations (Sharma, Saimbi, & Koirala, 2008).

3.7 Eczema Eczma is a skin condition affecting children as well as adults globally. It is characterized by red, itchy skin (Fig. 3.23). The condition can range from mild, moderate to severe but in many cases, it is manageable. There are several types of eczema, these include atopic dermatitis, contact dermatitis, dishydrotic eczema, nummular eczema, seborrheic dermatitis and stasis dermatitis (Johansen et al., 2011; Kantor, Thyssen, Paller, & Silverberg, 2016). The skin condition is common in babies and children who often develop eczema especially on their cheeks and chin, although it can also appear anywhere on the body. Eczema is a non-contagious disease and is believed to be a result of predisposed genes and environmental triggers (Diepgen, 2012; Hay et al., 2013). The cause of the disease is unknown, but researchers believe an irritant or an allergen ‘switches on” the immune system, skin cells don’t behave as they should causing an eczema

J. Malanda/MW

J. Malanda/MW

Eczema hepaƟcum

Eczema/Scleroderma

Fig. 3.23 Showing different types of Eczema on the face, neck, torso and arm. Eczma © Jimmy Malanda

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3 Types of Skin Disease and Their Causes

flare-up. The symptoms of eczema include; dry, red and inflamed, sensitive skin, severe itching, dark coloured skin patches, oozing and formation of crusts. Severe itching can lead to people scratching the skin until it bleeds, thereby worsening the disease.

3.8 Conclusion Understanding the aetiology of skin diseases including epidermal parasitic diseases, bacterial, viral, and papulosquamous is crucial in the fight against these diseases. Epidermal parasitic diseases affect majority poor populations and have been termed diseases of poverty. There are also other predisposing conditions that have allowed skin diseases to flourish in resource poor countries. The existence of poverty and predisposing conditions in resource poor countries has made these populations vulnerable to the wide range of skin diseases described above. The role of limited primary healthcare and other infectious diseases should not be underestimated.

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Chapter 4

Impact of Skin Diseases in Limited Resource Countries

Abstract From itchy skin, swollen limbs, amputations and irreversible blindness, the impact of skin diseases is visible. The social and psychological impact brought about by these morbidities though invisible, could have lasting effects on the infected individuals. The huge burden of SD is carried by low income countries and resource poor communities both in wealthy and poor nations. Most resource poor countries lack adequately trained personnel to handle the various outcomes brought about by skin diseases. Skin disease have an impact on the quality of life, social and economic status of the affected individuals and their families. As of 2010, globally, skin diseases were ranked as the fourth leading cause of non-fatal disease burden in both high- and low-income countries. Most of the public health challenges in resource poor countries have been attributed to poverty. Besides poverty, there are other underlying factors that have exacerbated this problem. With skin diseases, access to relevant treatment and health personnel/services have played a role in the disease being rampant in resource poor communities. With limited resources, low income countries must prioritize which diseases to invest their resources in. Owing to the low mortality attributed to skin diseases, they are often left out in the national budgets, allowing them to cause further morbidity. This morbidity affects individuals’ livelihoods with social exclusion and stigma forcing many to hide and disassociate themselves from their communities. Keywords Disease burden · Impact of skin diseases · Poverty · Morbidity · Stigma · Human impacts · Social impacts · Economic impacts · Mental health · Livelihoods Synopsis These photos below summarize some of the impacts of skin diseases and condition on populations. With limited resource countries and communities carrying most of the burden, children are not spared. From cutaneous and visceral leishmaniasis (A,B) to Guinea worm (dracunculiasis) and buruli ulcer (C,D), the morbidity brought about by these diseases is visible. Children miss out on school and many activities necessary for their growth and development, while adults struggle to carry on their day to day activities and most often lose their livelihoods. Apart from the visible scars

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testament to the disease, stigma due to morbidity from skin NTDs leaves lasting psychological scars on the affected individuals and families. Mental health status further complicate the problems as individuals try to put their lives together after surviving the disease. Skin diseases are real and many are suffering the impacts of these diseases. Disfigurement and disability that ensues after skin NTDs cannot be ignored. Thus, there is need for commitment and collaboration to help fight these diseases and find lasting solutions to reduce morbidity and if possible, stop transmission, and eliminate these ailments.

WHO/C.Black

A

WHO

© Biswas G./NICD

C

National Buruli ulcer control programme, Benin

B

D

4.1 Impact of Skin Diseases and Limited Resource Countries To understand the impact of skin diseases on the population, it is worthwhile to comprehend the effects of skin diseases on the affected individual (Fig. 4.1). Skin diseases have a huge impact on the quality of life including the social and economic well-being of a person living with either an acute (short term) and or chronic (persisting or recurring) disease (Table 4.1) (Roderick J Hay et al., 2013).

4.1.1 Impact of Skin Diseases on the Quality of Life Quality of life in this case means the day to day living of an individual. Skin diseases often cause pain and itching which not only cause discomfort but also considerable disturbance and affect concentration. Lack of concentration can affect the quality of

4.1 Impact of Skin Diseases and Limited Resource Countries

Impact on Quality of Life • Pain • Itching • Excessive dryness of skin and scaling • Sleep disturbance • Appearance • Morbidity

• Stress and mental health related illnesses

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Socio-Economic Impacts • Sgma • Exclusion from society • Segregaon in amenies e.g. loans, jobs, educaon and training programs • Medical requirements to treat the condion e.g. ointments

Fig. 4.1 Why skin diseases thrive. Skin diseases impact the quality of life as well as social and economic well-being of affected individuals and their families, stress and mental health related illnesses are often the inevitable outcome

work and as well as poor performance both at work and or school (Schuster et al., 2011; Walker et al., 2017; Wiese, Elson, & Feldmeier, 2018). Severe pain can also paralyze an individual forcing them to stay home and resulting in loss of time and opportunities. For diseases such as eczma and other papulosquamous infections, excessive dryness of skin and scaling can also result in pain as well as appearance of plaques which may cause social discomfort (Griffiths & Barker, 2007; Luba & Stulberg, 2006; Sharma, Białynicki-Birula, Schwartz, & Janniger, 2012). Individuals may be forced to dress in a certain way to hide the affected areas and may suffer from excessive stress as they try to cope with the disease. Excessive itching for example in case of scabies, tungiasis, and other skin conditions that may present with such symptoms, as well as pain, can also result in sleep disturbance. Lack of sleep will affect all aspects of the affected individuals life through fatigue and poor concentration (Hermann Feldmeier, Eisele, Sabóia-Moura, & Heukelbach, 2003; Karimkhani, Colombara, et al., 2017; Karimkhani, Dellavalle, et al., 2017; Reithinger, Brooker, & Kolaczinski, 2007; Rosmaninho et al., 2010). Skin diseases in general have varying degrees in which they can affect the appearance of the affected individuals. From break outs, oozing sores and wounds to excessive swelling and loss of parts of the body. People living with diseases including podoconiosis, elephantiasis, tungiasis, leprosy, exhibit various changes in appearance including excessive swelling and disfigurement, which highly affect self-esteem, self-worth, confidence and psychological well-being. The change in appearance can also contribute to divorce and social exclusion in many cases and are as source of

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stress and other mental health related illnesses (Fig. 4.1) (Davey, Tekola, & Newport, 2007; Franklin, Tora, Deribe, Reda, & Davey, 2013; Mousley et al., 2014). Some skin diseases such as scabies and tungiasis are associated with poor hygiene often with low economic status, thus people suffering from these diseases are psychologically affected trying to fit in their communities. For people living with chronic infections such as elephantiasis/filariasis, hemocoele, and podoconiosis, these diseases have serious effect on their movement, and this presents major impact on livelihood as well as the family. Management of these diseases including care for the affected limbs, requires effort from family members or health workers. For people living with tungiasis and scabies, if the disease is not treated early enough, secondary infections could result in more serious complications that could result in contracture and disfigurement.

4.1.2 Social and Economic Impacts of Skin Diseases Stigma is a common reaction in a society when people encounter something they are not used to and or is different from their usual perspective. Due to morbidities from skin diseases, exclusion is one of the resulting consequences. Affected individuals and their families are often excluded from social gatherings such as wedding ceremonies, church, and other festivities within their communities due to disease. In Ethiopia, it was reported that patients suffering from podoconiosis not only were they excluded but also their family members. People could not marry and individual with the disease and or any associated family members. For those who contracted the disease while married, they often experienced divorce (Tomczyk, Tamiru, & Davey, 2012; Tora, Mengiste, Davey, & Semrau, 2018). Systematic exclusion of those affected by disease include shunning businesses of those suffering from skin diseases in fear of contracting the disease; disassociating them from any form of gathering including leadership positions and spreading rumours that are often untrue to stigmatise affected individuals. Individuals with visible symptoms may be denied loans and any financial assistance that could assist in boosting the business. Social exclusion has a huge impact on the economic wellbeing of the affected individuals and their families through loss of income and most often closure of businesses (H. Feldmeier, Sentongo, & Krantz, 2013). Children suffering from tungiasis, scabies, leishmaniasis, buruli ulcer, tinea and other visible fungal, viral and bacterial skin infections are unable to attend school due to physical illness as well as the stigma that is associated with the infection. Affected individuals, are often ridiculed and isolated from the rest of the community. Such persons may suffer silently, at times failing to get help because they are neglected. For diseases such as buruli ulcer, long hospitalization results in children missing out on education. Furthermore, disfigurement due to disease results in children being unable to reintegrate into their communities; and lacking confidence, they may prefer to stay hidden at home than attend school where they often face stigma and isolation. Long hospitalization often stagnates the mental, social and psychological development of

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Table 4.1 Impact of Skin Diseases on various age groups. The impact of skin diseases on different groups may vary, with education and child development affected in children and those of school going age; livelihoods, human development and social skills are affected in adolescents and adults Age range

Areas affected

Children 0–15 years

Education, Child development, Social skills

Adolescents 13–18 years

Education, Social skills, human development

Adults 18–25

Education, Social skills, Financial development

Adults 25–40

Social skills, human development, financial skills, livelihoods

Over 40 years

Livelihoods, human development

a child, greatly affecting their growth and development (Amoussouhoui et al., 2018; Barogui et al., 2018; Hay et al., 2014; Karunamoorthi, 2013; Seth, Cheldize, Brown, & Freeman, 2017). In an effort to combat skin diseases through self-treatment, a substantial amount of resources may be spent on the wrong medicine, fake drugs which instead of treating the disease, could make them worse with terrible outcomes. People living with chronic diseases may have to endure bills for ointments and other forms of treatment required for management of the skin condition.

4.1.3 Impact of Skin Diseases on Livelihoods In Mexico skin diseases were reported as one of the causes of wastage of family income through ineffective treatment (R J Hay et al., 1994). This is also true elsewhere where people waste money on ineffective treatments and when all fails, the affected individuals pursue health service providers as a last resort. For diseases such as buruli ulcer, delay in diagnosis would result in more complicated cases which would be more costly to affected individuals and their families.

4.1.4 Impact of Skin Diseases on Health In limited resource countries, skin diseases are barely recognised as a public health priority especially where priorities are given to diseases with high mortality despite the high morbidity due to skin diseases. Within the primary healthcare system, in these regions, skin diseases rarely have dedicated laboratories for research and or diagnosis. Seldom will a patient be sent to a laboratory for further testing and diagnosis of a skin disease. On the other hand, poorly treated skin diseases cost governments a substantial amount of money as they deal with complications resulting from the disease including, disability, and other comorbidities that may be a result of an untreated skin conditions. Management of the various morbidities due to skin diseases also

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require financial commitment including setting up infrastructure and training personnel to manage the various challenges due to disease. The financial burden from skin diseases may also include development and facilitation of national control programs to control, prevent and eradicate skin diseases. These may involve surveillance within communities, employing community volunteers and community health workers, integrated disease control programs as well as decentralized community-based treatment.

4.1.5 Emerging Drug Resistance With prolonged drug exposure there is a is a risk of emerging drug resistance. In LMIC, this is further complicated by availability of unregulated drugs, generic medicines with varying quality, as well as incorrect use of drugs either through self-medication, and or wrong dosage. With ongoing mass treatment through MDA as a measure to control, prevent and eradicate diseases, development of drug resistance to the available first line treatment drugs could jeopardise efforts. The re-emergence of yaws in individuals who had previously received mass treatment with azithromycin is one of these indicators. Furthermore, mutations were observed in 23S ribosomal RNA genes conferring resistance to azithromycin. Despite reduction of transmission of the disease, this is one area of concern regarding one-time mass treatment with antibiotics. The question is how long does the drug pressure have to be maintained to eradicate the disease while keeping chances of drug resistance at bay? Is one-time mass treatment enough? How sustainable is this method in resource poor countries?

4.2 Conclusion Morbidities due to skin diseases have substantial impacts on the affected individuals. These morbidities affect the quality of life including social and economic impacts which affect the financial and mental well-being. Social exclusion and stigma greatly impact livelihoods forcing many to lose their sources of income, as they hide and disassociate themselves from their communities. The growing burden of skin diseases has a huge impact not only in the affected communities but also the countries which must deal with the consequences of morbidities due to disease.

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improve the management of Buruli ulcer in the Ouinhi district of Benin, West Africa. PLoS Neglected Tropical Diseases, 12(3). https://doi.org/10.1371/journal.pntd.0006291. Barogui, Y. T., Diez, G., Anagonou, E., Johnson, R. C., Gomido, I. C., Amoukpo, H., … Kingsley, A. (2018). Integrated approach in the control and management of skin neglected tropical diseases in Lalo, Benin. PLoS Neglected Tropical Diseases, 12(6). https://doi.org/10.1371/journal.pntd. 0006584. Davey, G., Tekola, F., & Newport, M. J. (2007). Podoconiosis: non-infectious geochemical elephantiasis. Transactions of the Royal Society of Tropical Medicine and Hygiene. https://doi.org/ 10.1016/j.trstmh.2007.08.013. Feldmeier, H., Sentongo, E., & Krantz, I. (2013). Tungiasis (sand flea disease): A parasitic disease with particular challenges for public health. European Journal of Clinical Microbiology and Infectious Diseases, 32, 19–26. https://doi.org/10.1007/s10096-012-1725-4. Feldmeier, Hermann, Eisele, M., Sabóia-Moura, R. C., & Heukelbach, J. (2003). Severe tungiasis in underprivileged communities: Case series from Brazil. Emerging Infectious Diseases, 9(8), 949–955. https://doi.org/10.3201/eid0908.030041. Franklin, H., Tora, A., Deribe, K., Reda, A. A., & Davey, G. (2013). Development of a scale to measure stigma related to podoconiosis in Southern Ethiopia. BMC Public Health. https://doi. org/10.1186/1471-2458-13-298. Griffiths, C. E., & Barker, J. N. (2007). Pathogenesis and clinical features of psoriasis. Lancet. https://doi.org/10.1016/S0140-6736(07)61128-3. Hay, R. J., Estrada Castanon, R., Alarcon Hernandez, H., Chavez Lopez, G., Lopez Fuentes, L. F., Paredes Solis, S., et al. (1994). Wastage of family income on skin disease in Mexico. BMJ (Clinical Research Ed.), 309(6958), 848. https://doi.org/10.1136/bmj.309.6958.848. Hay, R. J., Johns, N. E., Williams, H. C., Bolliger, I. W., Dellavalle, R. P., Margolis, D. J., … Wulf, S. K. (2014). The global burden of skin disease in 2010: An analysis of the prevalence and impact of skin conditions. Journal of Investigative Dermatology, 134(6), 1527–1534. Hay, Roderick J., Johns, N. E., Williams, H. C., Bolliger, I. W., Dellavalle, R. P., Margolis, D. J., et al. (2013). The global burden of skin disease in 2010: An analysis of the prevalence and impact of skin conditions. The Journal of Investigative Dermatology, 134(6), 1–8. https://doi.org/10. 1038/jid.2013.446. Karimkhani, C., Colombara, D. V., Drucker, A. M., Norton, S. A., Hay, R., Engelman, D., … Dellavalle, R. P. (2017). The global burden of scabies: a cross-sectional analysis from the Global Burden of Disease Study 2015. The Lancet Infectious Diseases. https://doi.org/10.1016/S14733099(17)30483-8. Karimkhani, C., Dellavalle, R. P., Coffeng, L. E., Flohr, C., Hay, R. J., Langan, S. M., … Naghavi, M. (2017). Global skin disease morbidity and mortality an update from the global burden of disease study 2013. JAMA Dermatology. https://doi.org/10.1001/jamadermatol.2016.5538. Karunamoorthi, K. (2013). Tungiasis: A neglected epidermal parasitic skin disease of marginalized populations—A call for global science and policy. Parasitology Research. https://doi.org/10. 1007/s00436-013-3551-8. Klepac, P., Metcalf, C. J. E., McLean, A. R., & Hampson, K. (2013). Towards the endgame and beyond: Complexities and challenges for the elimination of infectious diseases. Philosophical Transactions of the Royal Society B: Biological Sciences. https://doi.org/10.1098/rstb.2012.0137. Luba, K. M., & Stulberg, D. L. (2006). Chronic plaque psoriasis. American Family Physician. Mousley, E., Deribea, K., Tamiru, A., Tomczyk, S., Hanlon, C., & Davey, G. (2014). Mental distress and podoconiosis in Northern Ethiopia: A comparative cross-sectional study. International Health. https://doi.org/10.1093/inthealth/ihu043. Reithinger, R., Brooker, S., & Kolaczinski, J. H. (2007). Visceral leishmaniasis in eastern Africa— current status. Transactions of the Royal Society of Tropical Medicine and Hygiene. https://doi. org/10.1016/j.trstmh.2007.06.001. Rosmaninho, A., Vilaça, S., Costa, V., Sarmento, A., Amorim, I., & Selores, M. (2010). Tunga penetrans: Painful lesions on the feet—The first imported case from Guinea-Bissau. Study reports in Medicine. https://doi.org/10.1155/2010/681302.

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Schuster, A., Lesshafft, H., Talhari, S., Guedes de Oliveira, S., Ignatius, R., & Feldmeier, H. (2011). Life quality impairment caused by hookworm-related cutaneous larva migrans in resource-poor communities in Manaus, Brazil. PLoS Neglected Tropical Diseases. https://doi.org/10.1371/ journal.pntd.0001355. Seth, D., Cheldize, K., Brown, D., & Freeman, E. E. (2017). Global burden of skin disease: Inequities and innovations. Current Dermatology Reports. https://doi.org/10.1007/s13671-017-0192-7. Sharma, A., Białynicki-Birula, R., Schwartz, R. A., & Janniger, C. K. (2012). Lichen planus: An update and review. Cutis. Tomczyk, S., Tamiru, A., & Davey, G. (2012). Addressing the neglected tropical disease podoconiosis in Northern Ethiopia: Lessons learned from a new community podoconiosis program. PLoS Neglected Tropical Diseases. https://doi.org/10.1371/journal.pntd.0001560. Tora, A., Mengiste, A., Davey, G., & Semrau, M. (2018). Community involvement in the care of persons affected by Podoconiosis—A lesson for other skin NTDs. Tropical Medicine and Infectious Disease. https://doi.org/10.3390/tropicalmed3030087. Walker, S. L., Lebas, E., De Sario, V., Deyasso, Z., Doni, S. N., Marks, M., … Lambert, S. M. (2017). The prevalence and association with health-related quality of life of tungiasis and scabies in schoolchildren in southern Ethiopia. PLoS Neglected Tropical Diseases. https://doi.org/10. 1371/journal.pntd.0005808. Wiese, S., Elson, L., & Feldmeier, H. (2018). Tungiasis-related life quality impairment in children living in rural Kenya. PLoS Neglected Tropical Diseases, 12(1). https://doi.org/10.1371/journal. pntd.0005939.

Chapter 5

Prevention, Treatment and Control of Skin Diseases

Abstract Lack of funding associated with weak political commitment and fragile health systems has contributed to resurgence of diseases that were once almost eliminated; it has also led to poor reporting of cases. Proper diagnosis of disease allows for appropriate treatment and implementation of accurate prevention and control measures. Knowing the conditions that trigger and or perpetuate disease could assist in applying the right measures for prevention and control. Research, collaborations between various stakeholders, commitment from governments and non-governmental organisations are pillars of disease prevention and control. Disease prevention efforts through surveillance, mass treatment programs, active search for disease and choice for the right disease prevention measures are steps in the right direction. Keywords Disease prevention · Disease control · Mass drug administration · Disease detection · Diagnostic tools · Western medicine · Traditional medicine Synopsis The global dedication to eradicate smallpox is one of the greatest stories of human determination to fight a disease. Some of the strategies employed during the smallpox eradication campaign included making the vaccine accessible to everyone in any part of the world. Many walked far and wide to train and educate populations on the dangers of smallpox and ways to prevent the disease. While the vaccine campaign was ongoing, the hunt for cases globally was also in force. This led to finding all cases of smallpox and successfully vaccinated millions of people culminating in the eradication of the disease. Disease prevention and control is a commitment and requires determination.

5.1 Infectious Disease Prevention and Control To achieve prevention and control of skin diseases, there is need for support from governments as well as local and international stakeholders to provide interventions at no cost, to benefit poor populations. The responsibility for governments to offer © Springer Nature Singapore Pte Ltd. 2020 F. A. Mphande, Skin Disorders in Vulnerable Populations, https://doi.org/10.1007/978-981-15-3879-7_5

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primary healthcare to all is an essential human right for underprivileged communities in order to achieve disease prevention and control. Infectious disease prevention and control can be achieved through various aspects including; surveillance, preventative therapy e.g. vaccination campaigns, mass drug administration (MDA) campaigns, mass communication and community involvement.

5.2 Surveillance and Skin Diseases—Using Smallpox as an Example Surveillance can be conducted in various forms, as active or passive surveillance (Ackumey, Kwakye-Maclean, Ampadu, de Savigny, & Weiss, 2011). It can be conducted through: • Institutions, for example healthcare providers who report to a central body that will analyse and interpret reported data; • Active search (syndromic surveillance) for disease and or symptoms of the disease in the community: this could be through community health workers and other trained personnel able to recognize and report the disease and or its symptoms; • monitoring of existing data, to identify possible and or existing cases. In all these forms of surveillance, the key factor is to collect information on a particular disease and translate this information into substance that can be understood by policy makers as well as the general public. One of the memorable campaigns on skin disease prevention and control was that of smallpox. The world was eager to eliminate a disease that had caused suffering to many globally; and the disease was eradicated.

5.2.1 Lessons from Smallpox Elimination Campaign Strategy The smallpox eradication programme (SEP) ran between 1966 and 1980 with the aim of eradicating smallpox, a contagious and often fatal viral disease affecting the skin. There was collaboration between countries, from the most developed to the least developed countries. Campaigns were conducted to vaccinate communities and the search for any suspected cases. Community awareness campaigns were conducted using various methods in order to reach all masses. Pictorial guides, and recognition cards were used in communities, villages and schools to spread the information on the dangers of smallpox and rewards were provided for anyone bringing information on cases. Surveillance teams and ‘smallpox detectives’ checked for vaccination scars and possible cases. The global collaboration and effectiveness of the surveillance teams all around the world is commendable. The campaign reached every corner of

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the world and every population, rich or poor, near and remote. Contrary with current neglected skin diseases, smallpox was a public health problem globally and managed to get global attention.

5.3 Skin Disease Prevention Strategies 5.3.1 Surveillance and Collaboration In Ghana a BU prevention and treatment programme (BUPaT) was set up to improve early case detection and management of buruli ulcer disease. The strategies employed during this programme included reviewing patient records, reviewing program reports, holding a stakeholder forum and key informant interviews, focus group discussions, clinic visits and observations (Ackumey et al., 2011). This mixed approach managed to bring together health personnel, communities and other stakeholders strengthening the implementation of the program. The collaboration at national, municipality and community level by the various stakeholders assisted in strengthening the health system. The programme also showed that health education and community-based surveillance were essential in encouraging early treatment. By creating a patient database, stakeholders were able to follow up on the progress of treatment on various patients.

5.3.2 Early Detection of Disease In the 1950s, Mass treatment campaigns were conducted in Cameroon that reduced yaws to levels so low that the disease was presumed eliminated. However epidemiological studies revealed the persisting presence of yaws (Geizer, 1986). Five approaches were set up to detect yaws at clinical and community levels in Bankim, Cameroon. These were; • Passive yaws detection at local clinics • Community-based case detection by hospital staff who relied on community health workers to identify cases • Yaws screening during BU outreach programs • School-based screening programs • House to house active surveillance Household surveys proved very successful in early detection of yaws cases. It was also observed that combining various approaches worked synergistically, a fact that proved valuable in the yaws eradication program (Um Boock, Awah, Mou, & Nichter, n.d.). The rapid cure of yaws following early detection and treatment brought confidence in early BU treatment (Barogui et al., 2018).

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5.4 Skin Diseases Within the Community 5.4.1 Availability of Knowledge of Disease Within the Community Community knowledge of disease, attitudes and beliefs towards a particular disease are key in designing tailor made strategies for disease prevention and control. Engaging the private sector, the community and health workers can assist in bringing disease awareness, early detection and prevention and control. Limited knowledge and skills among health workers is a challenge to disease prevention and control; therefore, improving knowledge and skills of health workers could improve disease detection and diagnosis. Better detection and diagnosis of disease could assist in early detection and reduce mortality and morbidity. Logistical and complex bureaucracy can affect the decision making process that is crucial for disease awareness, treatment, prevention and control. Knowledge of disease in communities can help with early detection and help prevent disability. If the community is aware of the risks of various skin diseases, there is a higher likelihood that they will be more willing to engage in prevention and control efforts.

5.4.2 Willingness to Seek Treatment Late presentation of disease has been a challenge in resource poor communities. In cultures where strong beliefs in traditional medicine and or spiritual healers exist, communities tend to explore this route at the onset of the disease and only go to the hospital when all has failed (Hatchett et al., 2004; Hotez et al., 2015; Izugbara & Afangideh, 2005). This not only affects the disease progression but also the length of time it may take to treat the disease as well as disease outcomes. In the case of buruli ulcer, late presentation of the disease makes the difference between simple antibiotic treatment (at early presentation) to long stays in hospital and often amputations (late presentation). The economic costs incurred as a result of late presentation of the disease can be substantial. People may choose to go to the hospital at a later stage because of attitudes they encounter when they visit the healthcare centres. The attitude of healthcare workers towards a patient may affect the patients’ willingness to seek treatment. When patients are treated with respect, they can be more willing to seek treatment next time they are sick compared to those that were treated disrespectfully. Age is another factor that can affect the willingness to seek treatment. Adults can easily make the decision to go and seek treatment while children depend on an adult to make that decision for them. The decision to seek treatment for children is usually made by their parents and or adults who are responsible for them. Orphaned children as well as homeless children are more vulnerable in this regard. Another vulnerable

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population are the elderly. Their age may affect their ability to seek treatment at the right time as they depend on their family or people in their communities for assistance. Stigma due to disease has affected the confidence and social status of people in communities. Suffering from certain skin diseases may put an individual in a challenging position. People may be shunned, laughed at, called names or banned from attending public functions. In such circumstances the infected individual may choose to hide the infection until they can’t hide in any further at which point the disease maybe out of hand or may be more difficult to treat.

5.4.2.1

Traditional Treatment Approach

Apart from being a cultural norm in some parts of the world, there are other reasons why many people seek treatment from a traditional healer before going to the hospital. Some of the reasons are cost, distance to the hospital, and beliefs about causes of disease. Financial constraints in resource poor households have led people to make choices on what is worth their income, the cost of treatment as well as transportation to and from the hospital (which depends on distance) is of high priority. A study in the south pacific islands of Vanuatu revealed that 54% of TB patients would initially consult a traditional healer first not only for TB but also for any other illness (Viney et al., 2014). It was observed that delays of two weeks up to six years, as a result of seeking treatment from the traditional healers, resulted in delayed diagnosis (Viney et al., 2014). In Malawi, 37% of patients visited a traditional healer before seeking medical care at the hospital. The traditional healers claimed to know about TB, with some claiming to have healed patients and some claiming to have sent patients to the hospital when their treatment is curative (Brouwer, Boeree, Kager, Varkevisser, & Harries, 1998). Rural communities, particularly in resource poor countries not only face challenges with TB but also various skin diseases. Similarly TB, the treatment seeking behaviour for skin diseases is also subject to cost of treatment, distance from the nearest hospital, as well as decisions within the household on where to seek treatment first. Cheaper treatment at traditional healers has allowed for preference to this mode of treatment compared to modern medicine (Satimia, McBride, & Leppard, 1998). Traditional medicine involves use of plants, plant parts, formulations, as well as animal parts with dosages and side effects not well documented (Hossan et al., 2009). Traditional medicine has existed for years across the world with tribes that have passed the concoctions down the generations and integrated traditional medical systems such as Ayurveda, a plant based medicinal traditional system in India (Hossan et al., 2009; Mukhtar & Kalsi, 2018). There have been debates as to whether traditional healers have contributed to or undermined health interventions. In the case of BU, efforts have been made to have traditional healers work with clinics. In Bankim, Cameroon, efforts were made to train and encourage the healers to refer BU cases as early as possible to the clinics instead of trying to treat them (Awah, 2015). Efforts have been and are being made to train traditional healers in various parts of the world to enhance collaboration between

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traditional methods of treatment and western medicine (Awah, 2015; Brouwer et al., 1998; Hossan et al., 2009; Ukwaja et al., n.d.; Viney et al., 2014).

5.4.2.2

Western Medicine Treatment Approach

Implementation of various preventive and therapeutic measures, based on research, are markers of the western approach to addressing disease problems. The organized approach of tackling various public health challenges separates western medicine from traditional medicine. While the search for causality through various tests can distinguish various disease aspects in western medical approach, traditional medicine focusses on the balance within the body and other elements associated with disease, be it environmental and or physical. These two approaches have different ways of disease treatment, prevention and control. In the past five years, there has been an increase in BU cases in Australia (Wallace et al., 2017; World Health Organisation(WHO), 2017; Rie R. Yotsu et al., 2015). Researchers are still working to find out what could be causing this recent upsurge. A standard treatment for BU is available from antibiotic treatment, with surgery and amputation as a last resort. Apart from the financial resources and the strength of the health systems, the treatment seeking behaviour plays a crucial role in the disease (Asiedu & Wansbrough-Jones, 2007) treatment procedure and the length of time it may take to cure the disease. Aside from treatment, BU awareness is crucial in early detection of disease. With the source of the disease-causing bacteria and the mode of transmission not yet known, early detection has remained one of the important factors in disease treatment. In resource poor regions disease detection has rather been a challenge. In a study in Bankim district in Cameroon, mass outreach programs and school based screenings in communities assisted in identifying new cases of yaws and BU. Culturally sensitive mass outreach educational programs together with school-based programs were shown to be particularly effective in detection of BU and yaws (Um Boock et al., n.d.). Targeted mass treatment has been used as a treatment and preventative measure for various skin diseases including yaws, BU as well as pyodermas in communities around the world (Marks, Mitjà, Solomon, Asiedu, & Mabey, 2014). In aboriginal communities in the Northern territory mass treatment for pyoderma and scabies showed a substantial reduction in the disease and improved treatment uptake (Andrews et al., 2009). Despite the success, there is need for community management when dealing with endemic diseases in order for the treatment to be effective and sustainable (Vincente et al., 2009). Lack of sustainability for Mass treatment programs may contribute to drug resistance and requires careful consideration (Barkwell et al., 1997; Bowen, Tong, Chatfield, & Carapetis, n.d.; Chiller, Selkin, & Murakawa, 2001; Mitjà et al., 2018; Šmajs, Pašteková, & Grillová, 2015; Tasani et al., 2016; Vincente et al., 2009). In the case of podoconiosis, concerns have been raised about the economic sustainability and scale up of podoconiosis treatment activities. However,

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a study by Tamiru et al. found that most patients were willing to pay for podoconiosis treatment services, suggesting that a subsidized cost-recovery system could be used to increase podoconiosis treatment utilization and sustainability of efforts (Deribe et al., 2017; Tamiru et al., 2014). Accurate diagnosis of podoconiosis is important for case management, surveillance, and research. Although there is no gold standard point-of-care diagnostic tool; the diagnosis of podoconiosis is established clinically. Although lymphoedema of the lower leg in endemic areas is highly suggestive of the disease, there are no exclusive clinical signs that are diagnostic for podoconiosis. Currently, podoconiosis is diagnosed through clinical exclusion based on history, physical examination and certain disease-specific tests to exclude common differential diagnoses. Training of health workers, advocacy and collaboration with various stakeholders are some of the strategies that have been employed in Cameroon, Uganda and Ethiopia to fight podoconiosis (Deribe et al., 2015; Hofstraat & Van Brakel, 2015; Molla, Tomczyk, Amberbir, Tamiru, & Davey, 2012; Tekola, Mariam, & Davey, 2006).

5.4.3 Diagnostic Tools and Treatment Proper diagnosis of disease allows for appropriate treatment and implementation of accurate prevention and control measures. Knowing the conditions that trigger and or perpetuate disease could assist in applying the right measures for prevention and control. Interventions such as vaccinations, over-the-counter treatment, and prescription drugs have been used to control, manage and prevent disease. Some skin conditions have been associated with HIV/AIDS and if a patient presents with these conditions, and depending on the severity of the condition, there is a high likelihood that the patient is HIV positive. Management of the HIV infection in these persons may assist with the resolution of the skin condition. When the source of disease is unknown, the challenge to manage, prevent and control the disease is complicated. This is the case with BU. BU has been associated with the African continent more than the rest of the world. Most patients in endemic African countries are children under 15 years of age, while in Australia it tends to be mixed ages. The cases of BU in Africa have been associated with widespread speculation on the part of community members regarding the source of the disease. Some have associated the disease with spiritual forces, while others are simply confused as to how they got the disease. These beliefs have also affected the decisions regarding treatment and where the affected individuals/families seek treatment. Some people seek traditional medicine from spiritual/traditional healers within their communities, while other go to hospitals in search of western medicine. The treatment approaches taken by traditional healers and medical doctors vary widely. In Australia and Japan, early detection of BU has allowed for people with BU to be treated earlier during the onset of the disease.

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5.5 Conclusion Research, collaborations between various stakeholders, commitment from governments and non-governmental organisations are pillars to disease prevention and control. Disease prevention efforts through surveillance, mass treatment programs, active search for disease and choice for the right disease prevention measures are steps in the right direction. For disease prevention and control in the long run, resources must be made available for sustainable preventive strategies.

References Ackumey, M. M., Kwakye-Maclean, C., Ampadu, E. O., de Savigny, D., & Weiss, M. G. (2011). Health services for buruli ulcer control: Lessons from a field study in Ghana. PLoS Neglected Tropical Diseases. https://doi.org/10.1371/journal.pntd.0001187. Andrews, R. M., Kearns, T., Connors, C., Parker, C., Carville, K., Currie, B. J., & Carapetis, J. R. (2009). A Regional Initiative to Reduce Skin Infections amongst Aboriginal Children Living in Remote Communities of the Northern Territory, Australia. PLoS Negl Trop Dis, 3(11). https:// doi.org/10.1371/journal.pntd.0000554. Asiedu, K., & Wansbrough-Jones, M. (2007). Mycobacterium ulcerans infection (Buruli or Bairnsdale ulcer): Challenges in developing management strategies. Medical Journal of Australia. Awah, P. K. (2015). Role of traditional healers in a community of practice (COP) for buruli ulcer (BU) care in Cameroon, Africa. Tropical Medicine and International Health. Barkwell, R., Shields, S., Walton, S. F., Carson, C. F., Naunton, M., & Baby, K. E. (1997). Deaths associated with ivermectin treatment of scabies. The Lancet, 349(9059), 1144–1145. https://doi. org/10.1016/S0140-6736(05)63020-6. Barogui, Y. T., Diez, G., Anagonou, E., Johnson, R. C., Gomido, I. C., Amoukpo, H., … Kingsley, A. (2018). Integrated approach in the control and management of skin neglected tropical diseases in Lalo, Benin. PLoS Neglected Tropical Diseases, 12(6). https://doi.org/10.1371/journal.pntd. 0006584. Bowen, A. C., Tong, S. Y., Chatfield, M. D., & Carapetis, J. R. (n.d.). The microbiology of impetigo in Indigenous children: associations between Streptococcus pyogenes, Staphylococcus aureus, scabies, and nasal carriage. https://doi.org/10.1186/s12879-014-0727-5. Brouwer, J. A., Boeree, M. J., Kager, P., Varkevisser, C. M., & Harries, A. D. (1998). Traditional healers and pulmonary tuberculosis in Malawi. International Journal of Tuberculosis and Lung Disease. Chiller, K., Selkin, B. A., & Murakawa, G. J. (2001). Skin microflora and bacterial infections of the skin. Journal of Investigative Dermatology Symposium Proceedings6(1087-0024 SB-IM), 170–174. https://doi.org/10.1046/j.0022-202x.2001.00043.x. Deribe, K., Kebede, B., Mengistu, B., Negussie, H., Sileshi, M., Tamiru, M., … Fentaye, A. (2017). Podoconiosis in Ethiopia: From neglect to priority public health problem. Ethiopian Medical Journal. Deribe, K., Wanji, S., Shafi, O., M Tukahebwa, E., Umulisa, I., Molyneux, D. H., et al. (2015). The feasibility of eliminating podoconiosis. Bulletin of the World Health Organization. https://doi. org/10.2471/BLT.14.150276. Geizer, I. (1986). Yaws in the Western Pacific region: An overview. The Southeast Asian Journal of TropicalMedicine and Public Health. Hatchett, L. A., Kaponda, C. P. N., Chihana, C. N., Chilemba, E., Nyando, M., Simwaka, A., & Levy, J. (2004). Health-seeking patterns for AIDS in Malawi. AIDS Care, 16(7), 827–833. https:// doi.org/10.1080/09540120412331290112.

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Low Treatment Uptake and High Ongoing Acquisition. PLoS Neglected Tropical Diseases, 3(5). https://doi.org/10.1371/journal.pntd.0000444. Viney, K. A., Johnson, P., Tagaro, M., Fanai, S., Linh, N. N., Kelly, P., … Sleigh, A. (2014). Tuberculosis patients’ knowledge and beliefs about tuberculosis: A mixed methods study from the Pacific Island nation of Vanuatu. BMC Public Health. https://doi.org/10.1186/1471-245814-467. Wallace, J. R., Mangas, K. M., Porter, J. L., Marcsisin, R., Pidot, S. J., Howden, B., … Stinear, T. P. (2017). Mycobacterium ulcerans low infectious dose and mechanical transmission support insect bites and puncturing injuries in the spread of buruli ulcer. PLoS Neglected Tropical Diseases, 11(4). https://doi.org/10.1371/journal.pntd.0005553. World Health Organisation (WHO). (2017). WHO, Buruli ulcer. WHO. Retrieved from http://www. who.int/mediacentre/factsheets/fs199/en/. Yotsu, Rie R., Murase, C., Sugawara, M., Suzuki, K., Nakanaga, K., Ishii, N., et al. (2015). Revisiting Buruli ulcer. Journal of Dermatology. https://doi.org/10.1111/1346-8138.13049.

Chapter 6

Potential Public Health Measures to Tackle Skin Diseases

Abstract Skin diseases are a big challenge in resource poor communities around the world; both in high-and low-income countries. In the past decades various control programmes have been set up in efforts to control, prevent and disrupt transmission leading to elimination of some of the infectious diseases. Mass drug administration/treatment (MDA) recommended by WHO, has been used for diseases including yaws, onchocerciasis, trachoma, lymphatic Filariasis and other skin NTDs in resource poor countries. Apart from MDA, telemedicine could be one of the tools that can be exploited to relieve the disease burden in limited resource countries. Improving access to primary healthcare may also assist in reducing the disease burden. Enhancing local knowledge of skin diseases and preventive and control measures through health education and community campaigns could provide the community with essential knowledge on how to manage skin diseases. Keywords Disease setting · Extreme poverty · Vulnerable populations · Telemedicine · Tele dermatology · Sanitation · Climate · Infectious diseases · Mass drug administration Synopsis From community involvement, collection and interpretation of data to novel methods of diagnosis and treatment of diseases, there are many potential public health measures that can be applied in affected populations to tackle diseases. MDA, is one method that has been used in various communities worldwide to tackle skin diseases. Among the skin NTDs that have been targeted for MDA include; scabies, yaws, lymphatic filariasis and river blindness. MDAs have been used in many parts of the world including, Australia, and the pacific islands of Fiji, Papua New Guinea and Solomon Islands, to tackle scabies and yaws. In South America, MDA campaigns have resulted in the elimination of river blindness in Colombia, Mexico, Ecuador and Guatemala, and have contributed to the reduction of river blindness in endemic countries in West and East Africa. It has also been observed that by using one drug at different dosages, it is possible to target more than one disease. For example, Ivermectin (Mectizan), can be used to treat several parasitic infections including scabies, river blindness and lymphatic filariasis. Similarly, management of chronic diseases such as lymphatic filariasis and podoconiosis, both that affect the limbs © Springer Nature Singapore Pte Ltd. 2020 F. A. Mphande, Skin Disorders in Vulnerable Populations, https://doi.org/10.1007/978-981-15-3879-7_6

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can be combined in areas where both diseases are endemic. This includes care for the affected limbs as well as mental health services that may be required to support the affected individuals from psychological trauma due to disease. Implementation of disease prevention and control measures for multiple diseases could reduce costs and could play a positive role in compliance.

6.1 Existing Tools and Public Health Measures Tackling Skin Diseases Globally, both high and low-income countries are faced with the burden of skin diseases (Arlian & Morgan, 2017; Karimkhani et al., 2017a, 2017b). Diseases such as scabies, tungiasis lymphatic filariasis, and most epidermal parasitic diseases present a huge burden to the affected communities, and various measures have been set up to tackle these diseases. These include; MDA, international collaborations to gather data and prepare repositories, community involvement and awareness, modern diagnostic tools, professional training and research to find better control and prevention measures.

6.1.1 Mass Drug Administration (MDA) In the past decades various disease control programmes have been set up in efforts to control, prevent and disrupt transmission leading to elimination of some of the infectious diseases. For skin diseases and conditions, several global programmes were set up to eliminate specific diseases.

6.1.2 Synergistic Approaches in Disease Control Use of various approaches to fight disease seemed to work well in the yaws campaign. One of these approaches was MDA. For yaws and trachoma, the drug azithromycin was found to be effective in controlling and preventing disease. Earlier on azithromycin was used at low doses (20 mg/kg) to control trachoma while higher doses (30 mg/kg) are recommended for treatment of yaws. However, it has been observed that T. pallidum pertenue, the causative agent for yaws is developing resistance to azithromycin in Ghana even though better outcomes were observed in the Solomon Islands. Could the lower doses used during trachoma MDA have contributed to the drug resistance? Conducting a single MDA using one drug to combat two different infections could be cost effective as shown in Vanuatu but considerations should be taken to ensure that there minimal chances of developing drug resistance.

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Table 6.1 Past and current disease strategies in yaws control Past strategies to control yaws

Current strategies (In response to the resurgence in the 1970’s)

Emphasis on assessing prevalence and infectious yaws cases at population-level

Control programs should be based on clinically active yaws in the sample population

Mass surveys covering large proportions of endemic populations with selective and or mass treatment using procaine penicillin G with 2% aluminum monostearate (PAM)

Mass drug administration for the whole population

Survey results were used to determine fitting control methods

Treatment of all active contacts and children under 15 years of age

Further surveys were conducted to identify and treat formerly untreated cases and their contacts

Treatment of all active cases and all household members based on the level of prevalence of clinically active yaws in the community

Establishment of national control programs with the assistance of WHO and UNICEF

Total mass treatment in remote areas with limited access to healthcare even if the prevalence is less than 10%

Another drug that has been shown to work on two different NTD is ivermectin. Ivermectin has been shown to be effective on lymphatic filariasis, onchocerciasis as well as scabies. In Fiji, a follow up after 24 months of the Skin Health Intervention Fiji Trial(SHIFT), where an ivermectin based regimen was used showed a reduction in prevalence of scabies and had an effect on impetigo. On the other hand, in the Solomon islands, co-administration of ivermectin and azithromycin was tested for the first time to observe the safety of using both drugs in combination. The study showed that co-administration of ivermectin and azithromycin was safe, and it was the first time this kind of treatment was tested on a large-scale. Thus, the possibility of running a single MDA targeting more than one disease may prove to be effective in the long run allowing for integrated disease management. Other combinations that have been evaluated in the past are those targeting LF, and positive outcomes were observed using a combination of ivermectin, diethylcarbamazine, and albendazole. The success of the treatment led to the adoption of the regimen by WHO for LF control. Examples of past and present approaches for yaws are outlined (Table 6.1).

6.1.3 Challenges of MDA MDA is a method of delivering medicine to populations and sub-populations as a treatment, preventative and control therapy. The drugs being administered in MDA are considered safe, are affordable and are essential to prevent the development and spread of the disease (Webster, Molyneux, Hotez, & Fenwick, 2014). The objectives of MDA are;

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• To reduce transmission of disease (Chandrasena, Premaratna, Gunaratna, & de Silva, 2018; Currie, 2015; Engelman et al., 2016; Hotez, 2011; Hotez et al., 2015; Kearns et al., 2015; Marks et al., 2014; Mohammed, Deb, Stanton, & Molyneux, n.d.; R. U. Rao et al., 2014), • To decrease, and if possible, prevent, morbidity and disease symptoms, • To improve global health. Extensive coverage of MDAs requires financial support and commitment not only from the affected countries but also international stakeholders and the donor community. These resources are essential for implementation, monitoring and evaluation as well as sustainability of the project. Some of the challenges facing MDA programmes globally include; • Civil unrest (e.g. in South Sudan, DRC, Syria, Afghanistan, Yemen, Burundi), • Logistics and effective deployment of mass treatment and targeted treatment programs in endemic communities, • Unexpected disease outbreaks e.g. the Ebola epidemic in Liberia, Sierra Leone and Guinea, and subsequently in DRC, • Non-compliance to treatment (WHO, 2016), • Development of drug resistance by targeted pathogens (Webster et al., 2014), • Ability of local health care systems to maintain high priority on infectious disease and elimination programs, • Monitoring by using point of care serologic surveys and maintaining high levels of community participation.

6.1.4 The Global Program to Eliminate Lymphatic Filariasis (GPELF) The global program to eliminate lymphatic filariasis (GPELF) was set up in the year 2000, with the goal to eliminate LF as a public health problem by 2020 (Mohammed et al., n.d.; Ndeffo-Mbah & Galvani, 2017; WHO, 2016). The Global Programme to Eliminate Lymphatic Filariasis (GPELF) represents the collective quest of governments, research institutions, donors, and non-governmental organizations to fulfil the global commitment by stopping the spread of infection and alleviating suffering among patients. The program was set up on two pillars, the first being to interrupt transmission through administration of a single dose of deworming drug combinations (Albendazole + diethyl carbamazine (DEC) or albendazole + Ivermectin) to the entire population in endemic areas. The second pillar was to alleviate suffering and disability for those with lymphoedema and hydrocele. The ivermectin and albendazole combination is recommended in areas coendemic with onchocerciasis due to the adverse effect of DEC in individuals coinfected with onchocerciasis (Thomsen, Sanuku, Baea, & et al., 2016). These doubledrug treatments have an effect on transmission, as they mainly clear microfilariae that

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cause transmission, but have minimal effect on adult filariasis worms (Ndeffo-Mbah & Galvani, 2017). A triple drug regimen combining ivermectin, DEC, and albendazole has proved much more effective at clearing both microfilariae and adult worms, leading to a shift from double-drug to triple-drug therapy. This shift could potentially accelerate progress towards elimination goals substantially, except in regions and communities where onchocerciasis and loasis are endemic due to adverse effects with ivermectin and DEC, respectively. Using mathematical models to translate individual level clinical trial results to population level effectiveness of the triple drug trial regimen, Irvine et al. deduce that the triple drug regimen could improve interruption of transmission (Irvine, Stolk, Smith, & et al., 2016). This would accelerate elimination of LF by 1–2 years in low prevalence areas and 4–5 years in moderate to high prevalence zones. The study also shows that expanding MDA coverage beyond 75% would be essential to meet WHO’s elimination goals (Irvine, Stolk, Smith, & et al., 2016). In the south pacific, the Pacific programme to eliminate lymphatic filariasis (PacELF) was set up earlier than the GPLEF. By 1999 the PacELF was fully operational within the region.

6.1.5 The Global Campaign to Eradicate Dracunculiasis In 1980 an initiative from the Centre for Disease Control and Prevention (CDC) saw the birth of the global campaign to eradicate dracunculiasis (Guinea worm disease). The programme was adopted in 1981 with the goal to provide safe drinking water to all those who had no access. Even though the implementation of the programme took a slow start, by 1997 dracunculiasis (Guinea worm disease, (GWD)) has been reduced by 97%. By the end of 1997, Pakistan had been certified free of dracunculiasis, India had halted transmission of the disease, and Yemen had only seven cases in the entire year. In Africa, Kenya had reported no indigenous cases since May 1994, Cameroon had only one indigenous case since September 1996, while Senegal and Chad reported only 4 and 25 cases in 1997, respectively. Several factors allowed for the possibility of elimination of GWD, these include; • The biological nature of the disease and the promising technical possibilities of eradication. Since the guinea worm depends on the human host for reproduction and dissemination, if there were no more human cases available there was a chance that the disease could be eliminated. The existence of the guinea worm in dogs has complicated the these efforts (Hopkins et al., 2018). • Community knowledge of the worm made it easy to understand and diagnose signs and symptoms of the disease. • The emergence of the worm is highly predictable. • Previous success stories meant there was a chance of eradicating the disease.

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The incidence of cases of dracunculiasis have dramatically fallen, but there are still cases occurring. As of 2016, the number of cases reported worldwide decreased by 83% despite continued transmission in Chad, Ethiopia, Mali and South Sudan (Hopkins, Ruiz-Tiben, Eberhard, Roy, & Weiss, 2017). In 2017, the cases of dracunculiasis reduced worldwide with only 30 cases reported (compared to 35 million in 1986). Although this is a worthy achievement, the emergence of the guinea worm in dogs is a matter of concern for the eradication efforts.

6.2 Challenges Faced by the Existing Tools 6.2.1 Lack of Data Despite the availability of global data on the burden of skin diseases, the lack of upto-date data from the affected countries creates a major challenge in designing public health policies and measures to tackle these diseases. Most communities affected by skin diseases have little or no data available on the existing disease burden. This could be attributed to; • • • •

Lack of routine data collection, Poor implementation of data collection programs, Lack of and or poor surveillance, monitoring and evaluation, Lack of resources to achieve quality data collection, management and dissemination.

6.2.2 Access to Tools and Trained Personnel Tackling skin diseases and conditions requires various tools. Thus far, MDA, international collaborations, qualified personnel to handle the diseases and different diagnostic tools have been employed to help reduce the burden of these diseases. While high income countries have enough resources to invest in these tools; resource poor countries struggle to access even the basic tools. Most resource poor countries depend on donations to manage their MDA programmes, making most of these programmes unsustainable at a country level. While the burden of skin diseases within the affected communities is high, the mortality due to disease is minimal making it a least priority on healthcare budgets. This also implies that there is less investment in training individuals to tackle these diseases. In turn the available health personnel in the affected countries are unable to identify and make proper diagnosis on certain skin diseases as well as provide the appropriate treatment. This translates to the lack of diagnostic tools, medicines and other forms of interventions that may assist in reducing the burden of the disease.

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Table 6.2 Skin diseases are among the targeted neglected diseases in Africa, Americas, Eastern Mediterranean, South East Asia and Western pacific regions Targeted skin NTDs by region Region

Disease rargets

Africa

Buruli ulcer, dracunculiasis, leprosy, leishmaniases, lymphatic filariasis, onchocerciasis, yaws

Americas

Chagas disease, leprosy, lymphatic filariasis, onchocerciasis, fungal and ectoparasitic skin diseases, leishmaniases

Eastern Mediterranean

Leishmaniases

South East Asia

Kala-a zar (anthroponoticleishmaniasis), leprosy, lymphatic filariasis, yaws

Western pacific

Lymphatic filariasis, schistomiasis, soil transmited helminthiasis

6.2.3 Conflicts and Political Instability Conflict can be defined as a serious difference in opinions, the resulting disagreement may lead to fighting and at times culminate in a full-blown war. Conflicts have led to civil unrests, civil wars, cross border wars and refugees. Refugees are one of the most vulnerable communities, their living conditions are appalling, have poor access to food, water, shelter and basic amenities for survival and they are often plagued by infectious diseases (Accorsi et al., 2005; WHO, 2017). Skin diseases such as scabies, and cutaneous leishmaniasis have been reported in some refugee populations. Overcrowding and poor living conditions have been implicated to the increase of skin diseases (Inci et al., 2015). The lack of access to healthcare and poor sanitation may result in secondary bacterial infections which take advantage of the broken skin. Conflict has perpetuated skin diseases in some communities (Cropley, 2008). Owing to conflict, the populations are unable to access primary healthcare. With skin infections, if the diseases go untreated, they could easily spread to other members of the community. Political instability and conflict also affect implementation of control measures such as MDA, vaccination and disease awareness campaigns (Table 6.2).

6.3 Global Plan to Tackle Skin Diseases 6.3.1 Understand the Burden of Disease Understanding the burden of the disease both locally and globally is the first element to address when planning to tackle skin diseases (Fig. 6.1). While there are challenges in obtaining accurate data due to limited reporting by affected countries, accurate global estimates are essential to design appropriate strategies. Although a global plan may exist, a local/national plan is required. National plans should go into details of the various challenges posed by skin diseases and suggest sustainable

90 Fig. 6.1 Tackling skin diseases. The disease burden is often underrepresented due to missing data, commitment to tackle disease burden requires a concerted effort from communities, national governments, and global partners

6 Potential Public Health Measures to Tackle Skin Diseases

Disease Burden

Global Plan

Naonal Plan

Community Plan

and effective measures to tackle disease. These should include financial resources, adequately trained personnel with sufficient knowledge of the disease, and implementation strategies suited to the available resources on the ground. If possible, understanding the needs in every community regarding the risks and factors contributing to the spread of the disease may assist in designing a plan suitable for that community. Thus, a combination of a functioning community, national and global plan could contribute to reducing disease burden.

6.3.2 Telemedicine/Tele Dermatology-Addressing Training Deficits For decades technology has been incorporated in communicating, transferring as well as relaying valuable medical information between patients and health practitioners (Ryu, 2010). Even though this technology has not developed at the same pace within the various fields of healthcare, in urban and rural settings, as well as the different economies globally, it is being used worldwide (Aranda-Jan, Mohutsiwa-Dibe, & Loukanova, 2014; Edwards & Patel, 2003; Littman-Quinn, Mibenge, Antwi, Chandra, & Kovarik, 2013; Warshaw, Greer, Hillman, & Hagel, 2010). Telemedicine has been used in various interventions including; online psychological interventions (Barak, Hen, Boniel-Nissim, & Shapira, 2008); remote monitoring for chronic heart failure (Clark, Inglis, McAlister, Cleland, & Stewart, 2007); tele monitoring for respiratory conditions (Jaana, Pare, & Sicotte, 2009); remote monitoring for chronic heart failure; tele monitoring for respiratory conditions; smoking cessation programmes computer and web-based (Myung, McDonnell, Kazinets, Hong, & Moskowitz, 2009); for secondary prevention of coronary heart disease (Neubeck

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Beer chances of accurate diagnosis from unskilled personnel as a result of collaboraon with skilled personnel outcomes

Greater impact on disease prevenon and control

Beer chances of accurate diagnosis

Limited and or poor diagnosc outcomes

Improved diagnosis and beer outcomes

Higher likelihood of beer diagnosis and outcomes

Unskilled Personnel

Collaboraon through tele-dermatology Fig. 6.2 Use of tele-dermatology to improve diagnosis of skin diseases with skilled personnel/experts assisting unskilled personnel to achieve better diagnosis

et al., 2009); telepsychiatry (Ryu, 2010), telehealth for diabetes (Polisena, Coyle, Coyle, & McGill, 2009), as well as tele-dermatology. Telemedicine has been effective in communicating with patients in their homes where health personnel are able to follow up, monitor vital signs, monitor intake and adherence to prescription, send appointment reminders and offer advice to their patients via telephone. With the challenges in resource poor countries and remote areas regarding access to healthcare services (Ekeland, Bowes, & Flottorp, 2010), telemedicine could be one of the tools that can be exploited to relieve this burden. Telemedicine could also be used to reduce the knowledge gap and the limited number of skilled specialists. This could be achieved by facilitating collaboration between countries and or institutions with experts in various skills those with health practitioners lacking the skill set (Fig. 6.2). Tele dermatology will assist in better chances of accurate diagnosis of SD, although further research is required to confirm this.

6.3.2.1

Importance of Teledermatology

Tele-dermatology is useful for patients in remote and areas that are difficult to access; which may lack the required facilities to ensure proper diagnosis and treatment of the disease (Bashshur et al., 2016). Tele-dermatology can be used for diagnosis, treatment as well as follow up of patients after initial consultation. This in turn reduces the travel and other related costs for the patient, including transport and working hours.

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Teledermatology most often requires ability to have high resolution images and connectivity thus the need for technological expertise (Maguiness, Searles, From, & Swiggum, 2004; Miot, Paixão, & Wen, 2005; Rao & Lombardi, 2009). There are several models of tele dermatology: 1. Synchronous (real time) model; this requires live transmission of images. 2. Asynchronous (store-and-forward) model; this is where the images can be taken and stored and later forwarded to an expert, this does not require active connectivity. 3. Hybrid model: this model combines both the synchronous and asynchronous models. This method involves high resolution images that are used in combination with video conferencing. The asynchronous model of tele dermatology is widely used due to affordability and less technological requirement. Most studies that have been conducted on tele dermatology are reported from high income countries including United states, Netherlands, Canada, Austria, Denmark, Italy, Norway, Singapore and the UK. These studies were conducted to assess clinical outcomes of tele-dermatology. The studies used either the hybrid model or exclusively the synchronous model in other cases. These studies used tele-dermatology to determine diagnosis and or treatment and in a few cases the method was used provide advice to other health practitioners (Bowns, Collins, Walters, & McDonagh, 2006). Thus, tele-dermatology can be used to not only determine diagnosis, but also provide advice and training to other health practitioners (Assis, Palhares, Alkmim, & Marcolino, 2013). If tele-dermatology is to be used in a facility, there is need for training staff in digital imaging and assessment of skin diseases as well as standardized treatment. There is also need to identify multi-disciplinary experts in the field who can provide remote support. Most of the studies have shown the diagnostic accuracy and reliability of tele diagnosis with good correlation observed between tele diagnosis and face to face diagnosis. Most of these studies have been conducted in high income countries with ample resources to handle requirements for tele-dermatology. The question to consider is how can this technology be exploited in limited resource countries? With some promising outcomes in telemedicine, tele-dermatology could be one way forward to reduce the burden of skin diseases in vulnerable communities, rural and resource poor communities. Tele dermatology can be used, among other things, for skin examination, to triage cases in primary care settings, to follow up and monitor patients progress on their skin condition (Börve et al., 2015). Although there are varying opinions regarding the effectiveness of telemedicine and primary care as well as face-to-face consultations, this is still an ongoing chapter in medicine and more evidence and research is required to link the intervention to outcomes. An example of successes in telemedicine is that of Maine, a rural and economically challenged town where telemedicine was used in primary care. The project in Maine illustrates the need to address clinical needs, the importance of support and collaboration between stakeholders. In Botswana, telemedicine was used

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in projects for women’s health in collaboration with their partner university in the US where they screened for cervical cancer, radiology, oral medicine and dermatology (Oliveira et al., 2017). While many developed countries are incorporating telemedicine in their healthcare systems, for developing countries this is still work in progress.

6.4 Conclusion Tackling skin diseases is an enormous task for resource poor countries where most of these diseases are endemic. Mass treatment campaigns have been used as a preventative measure for some of the diseases. Primary healthcare still remains a challenge, hence improving access to primary healthcare may assist in reducing the disease burden. Enhancing local knowledge of skin diseases and preventive and control measures through health education and community campaigns could provide the community with essential knowledge on how to manage skin diseases. Through telemedicine and tele-dermatology collaborations, it is possible to reduce the knowledge gap and could be used as a temporary measure while training local health personnel to tackle skin diseases.

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Chapter 7

Studies from Literature

Abstract This chapter will review studies from literature on various skin diseases, most of which are neglected, and at times barely known by unaffected populations in the endemic countries. These will include; Buruli ulcer (BU), yaws, scabies, cutaneous leishmaniasis (CL), parasitic fungal infections, lymphatic filariasis (LF), podoconiosis (non-filarial elephantiasis), and tungiasis. Morbidity owing to disease results in loss of livelihoods, stigma, absence from school and isolation. This chapter will review studies and analyse the effects of disease on populations, their contributing factors, the community response, the socio-economic consequences, and how healthcare practitioners are managing and handling skin disease in various parts of the world. One interesting aspect is that treatment and management of skin diseases in resource poor nations compared to high income nations. Keywords Podoconiosis · Tungiasis · Buruli ulcer · Scabies · Yaws · Guinea worm · Lymphatic filariasis · Tinea · Leishmaniasis · Community involvement Synopsis Neglected tropical diseases (NTDs) are a group of infectious diseases that affect billions of people most of them living in limited resource countries. Among these NTDs is a subset that affect the skin. These skin NTDs include Buruli ulcer (BU), Guinea worm (dracunculiasis), leishmaniases, leprosy, lymphatic filariasis (LF), scabies, river blindness, hookworm related cutaneous larval migrans (HrCLM), and yaws. Despite these diseases affecting people in low income countries, BU has been reported on the increase in Australia while scabies is endemic worldwide among resource poor and vulnerable communities. Reports from various countries provide information on some of the underlying causes of these diseases, their impact on affected communities, modes of transmission and control as well as the various disease characteristics and the affected communities. While some of the skin NTDs are treatable (e.g. scabies, yaws, leishmaniases, leprosy, LF), the morbidity caused by these diseases can be enormous resulting in permanent disability. On the other hand, for those diseases with unknown mode of transmission, such as BU, disease prevention and control measures are rather complicated. Control measures rely on early detection and treatment of the disease before severe outcomes set in. Thus, disease management for skin NTDs not only requires the complexities of managing © Springer Nature Singapore Pte Ltd. 2020 F. A. Mphande, Skin Disorders in Vulnerable Populations, https://doi.org/10.1007/978-981-15-3879-7_7

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the progression and dissemination of the disease, but also, the mental health effects that may occur as a result of disability from the disease. The narratives in the studies presented in this chapter, give a glimpse of skin NTDs including podoconiosis (nonfilarial elephantiasis) and tungiasis. In Chap. 3, aetiologies of various skin diseases were outlined; in this chapter, a summary of peer reviewed articles on various skin diseases will addressed. For each study, the objectives, methodology key points will be reported followed by points of interest to ponder on.

7.1 Buruli Ulcer Study reports 1–5 focus on buruli ulcer. For an account on buruli ulcer, see Sect. 3.3.3. in Chap. 3. STUDY REPORT 1: COMMUNITY PARTICIPATION TO IDENTIFY MEMBERS WITH LONG-STANDING ULCERS Key words: case identification, buruli ulcer, community participation Title: Buruli Ulcer in Nigeria: Results of a Pilot Study report in Three Rural Districts (Ukwaja et al., 2016) Objective: To assess the magnitude and epidemiology of BU in the South region of Nigeria. Method: This was a cross-sectional survey involving three communities in the Ogoja territory. Sensitisation programmes were conducted, and participants were asked to identify members of the community with long—standing ulcers, while traditional healers were asked to refer their clients with non-healing ulcers. All suspected cases had clinical evaluation and those with a positive result were referred to the hospital. Key Points: The authors observed that; • There was gross underestimation of BU cases in the territory. • There was no deliberate effort to report notifiable diseases to WHO. • A form of denial, where countries refuse to accept that the disease is endemic and or a problem in their countries. This attitude hampers efforts for case finding and elimination of the disease. • A difference in distribution of lesions between males and females was also noted where; females had equal number of lesions on upper and lower limbs, while males had lesions predominantly on their lower limbs. • Success in disease management was attributed to free treatment offered to the patients.

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The fact that the majority of positive cases in this study were women is of interest. What could be the reason behind? Could it be that women are more inclined to participate in community campaigns compared to men? A combination of different methods and strategies may yield more cases. STUDY REPORT 2: COMMUNITY HEALTH VOLUNTEERS AND BENIN Key words: community health volunteers, buruli ulcer control, community village volunteers Title: Contribution of the Community Health Volunteers in the Control of Buruli Ulcer in Bénin (Thierry Barogui et al., 2014) Objective: To look at the contribution of different actors in the current referral system in Benin, their influence on the stage of disease at presentation in the hospital and on the diagnostic confirmation rate of BU, using IS2404 PCR. Method: This was a retrospective observational study, information was collected from one of the four BU centres in Benin for a period of two years. The information was collected using WHO/BUO1 forms and the following information was collected; General characteristics of the patient, results of diagnostic tests, presence of functional limitations at the start of treatment, lesion size, patients delay, referral system. Key Points: The following were the outcomes of the study; • Patients referred to the hospital by community health volunteers appeared to be in the earlier stages of the disease compared to those referred through different methods. • A significant difference was observed in patients presenting early stage lesions (category I and II), among the different referring systems. • Patients referred by family members and self-reporting patients had less delays compared to patients referred by other actors (≥12 weeks). • 68.1% and 61% of patients referred by CHV and self-reporting had early stage lesions respectively. • Of the patients referred by CHV, 14.2% had category I lesions, 49.4% with category II or category III lesions. Points of Concern: • Quality and or training of CHV may not be uniform among communities. • Barriers in early presentation by community health workers could also be different throughout the area. • Visible functional limitation at the start of treatment lower in patients referred by CHV.

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• Visiting a traditional healer in Benin is a common practice and this may contribute to the patients delay in seeking and obtaining adequate treatment. STUDY REPORT 3: UNDERSTANDING DISEASE TRANSMISSION BY MAPPING LOCATION OF LESIONS ON THE BODY USE OF NOTIFICATION DATA Title: The Location of Australian Buruli Ulcer Lesions—Implications for Unravelling Disease Transmission (Yerramilli et al., 2017) Objective: To improve understanding of disease transmission, the study was aimed to map the location of BU lesions on the human body. Method: This was a retrospective observational study on 579 patients from 1998 to 2015, where notification data and clinical records were reviewed. Electronic density maps of lesion locations were created and compared by gender, age, presence of multiple lesions and month of infection. Key Points: • Lesions were predominantly located on lower and upper limbs, with 70% occurring on the lower limbs. Ankles, elbows and calves were the common locations. • Lower limb lesions were less common in men as compared to women. • Those with a lesion on the ankle were more likely to have multiple lesions. • Infections were likely acquired in the warmer 6 months of the year. • The mode of transmission of M. ulcerans may be the same across the globe although there is need for further research investigating disease transmission. STUDY REPORT 4: BURULI ULCER IN CONGO Title: Buruli Ulcer Disease in Republic of the Congo (Marion, Obvala, Babonneau, Asiedu, & Marsollier, 2014) Objectives: Review Previously few cases of BU were reported from Congo, despite its neighbouring countries reporting many cases. But in a WHO study in 2007–2012 by the National Leprosy, Buruli Ulcer and Yaws Control Program in Congo over 500 cases were recorded. Methods: Passive and active surveillance of Buruli ulcer was conducted in Congo during 2007–2012. Samples were obtained from BU suspected patients using a fine-needle aspirate or swab samples. The samples were sent to Angers University Hospital (Angers, France) for confirmation by quantitative PCR as described.

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Key Points: • Buruli ulcer disease affects people in several of Congo’s administrative divisions. • 84% of the reported cases were found in villages along the Kouilou River. • In contrast, the small cluster of cases diagnosed were isolated from other known endemic areas. • Identification of this zone as a high-risk area for Buruli ulcer disease will help the Ministry of Health improve early detection, biological confirmation, and treatment. Recommendations: Active and continuous surveillance is required to establish a detailed map of the villages and areas where Buruli ulcer disease is endemic; such information would enable the implementation of targeted control activities. STUDY REPORT 5: HEALTH SERVICES FOR BURULI ULCER CONTROL— LESSONS FROM A FIELD STUDY IN GHANA Title: Health Services for BU control—Lessons from Ghana (Ackumey, KwakyeMaclean, Ampadu, de Savigny, & Weiss, 2011) Objective: To assess achievements of the BUPaT programme and lessons learnt and consider the impact of the programme on broader interests of the health system. Methods: The study used a mixed-methods approach which included patients’ records review, review of programme reports, a stakeholder forum, key informant interviews, focus group discussions, clinic visits and observations. Key Points: • The health system was strengthened through extensive collaboration that existed across all levels, (national, municipality, and community). • The capacities of all stakeholders were enhanced in various aspects of health services delivery. • The programme demonstrated the importance of health education and communitybased surveillance to create awareness and encourage early treatment. • The programme was able to create a database using recommended World Health Organisation (WHO) forms. The database was a source of reference and records on the course of treatment including patient records. Recommendations: • To improve early case management of BU, there is need to strengthen existing clinics to increase access to antibiotic therapy.

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• There is need to intensify health education and surveillance: this would ultimately increase early reporting and treatment for all cases. • Further research is needed to explain the role of environmental factors for BU.

7.2 Scabies Study reports 6–11 are on scabies, Sect. 3.2.4 in Chap. 3 features a detailed discussion on scabies. STUDY REPORT 6: THE GLOBAL BURDEN OF SCABIES: A CROSSSECTIONAL ANALYSIS Title: The Global Burden of Scabies: A Cross-Sectional Analysis from The Global Burden of Disease Study 2015 (Karimkhani et al., 2017b) Objective: To estimate the global burden of scabies using data from the Global Burden of Disease (GBD) study. Methods: Scabies epidemiological data were collected from various sources, including an extensive literature search and hospital insurance data. The data were analysed using a Bayesian meta-regression modelling tool, DisMod-MR 2· 1, to estimate prevalence. The prevalence estimates were combined with disability weight, disfigurement measurements, itch, and pain caused by scabies to yield years lived with disabilities (YLDs). DALYS were estimated for 195 countries. Key Points: • Assuming that there is zero mortality from scabies, YLDs are equivalent to DALYs. • Scabies was responsible for 21% of DALYs from all conditions studied. • The greatest burden of scabies was observed in East Asia, South East Asia, Oceania, Tropical Latin America, and South Asia. • By country, the greatest burden of scabies was highest in Indonesia, China, TimorLeste, Vanuatu and Fiji. • Greatest DALY burdens were observed in children, adolescents and the elderly. STUDY REPORT 7: SCABIES—COMPARING THREE COUNTRIES IN AFRICA AND SOUTH EAST ASIA Title: Epidemiologic Aspects of Scabies in Mali, Malawi, and Cambodia (Landwehr, Keita, Pönnighaus, & Tounkara, 1998) Objective: Compare the prevalence rates of scabies in Mali, Malawi and Cambodia. Methods: In Mali, the study was conducted in Bamako where 225 primary schools in the urban district were stratified according to the prevailing socio-economic level of the parents.

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• High socio-economic level = mostly civil servants or expatriates. • Medium socio-economic level = living in high population density areas. • Low socio-economic level = living in shanty towns. Three schools were selected randomly, one from each stratum. Students were then thoroughly examined specifically for scabies and interviewed by a medical officer in 1992. Clinical inspection was supplemented by microscopy of scrapings in case of doubtful cases. In Malawi the studies were conducted in Karonga, in northern Malawi. The total population was predominantly from rural areas and was examined by paramedical workers between 1986 and 1989. The primary purpose of the examination was to identify leprosy although diagnoses of scabies were recorded and coded. In Cambodia, a total population survey was carried out in a rural area of Battambang Province by paramedical workers in 1994. The study was aimed at identifying leprosy and common skin diseases in 13 villages. Pupils from two schools in Battambang town were examined in the same year. The diagnosis of scabies was based on a review examination by a medical officer. Key Points: • The prevalence of scabies was 4% and 1.8% in children and those from higher socio-economic status respectively. • In Malawi the overall prevalence of scabies was 0.7% with the highest rate observed in children between 0–9 years (1.1%). • In Cambodia, the prevalence of scabies was 4.3% with the highest rate observed in children between 0–9 years of age (6.5%). • Poor socio-economic condition such as crowding, and public water supplies were identified as risk factors for scabies. STUDY REPORT 8: SOIL TRANSMITTED HELMINTHS, SCABIES AND MASS DRUG ADMINISTRATION-ZANZIBAR, TANZANIA Title: Soil Transmitted Helminths (STH) and Scabies In Zanzibar, Tanzania Following Mass Drug Administration for Lymphatic Filariasis—A Rapid Assessment Methodology to Assess Impact (Mohammed, Deb, Stanton, & Molyneux, 2012) Objective: To test a new methodology for assessing the impact of MDA for lymphatic filariasis on the reduction in the number of cases of STH and scabies retrospectively by checking health centre records where MDA distribution had taken place. Methods: Fifty public healthcare units (PHCU) in 10 districts were selected for the study. From each district 5 were randomly selected and data of registered cases of STH and scabies was collected for the period 2000–2005. The data was categorized according to five age groups; 0–5, 6–10, 11–15, 16–20 and 20 years and over, with 0–5 years age group representing the baseline. In order to identify cases of STH,

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records of patients indicating abdominal pains, passing worms and treated by albendazole and or mebendazole were enumerated. For scabies, patient records showing skin conditions characteristic of scabies, rashes and those who were prescribed the standard treatment scabies, were also enumerated. Key Points: • Health records show a consistent decline in cases of intestinal helminths and scabies reported by health workers in Zanzibar. • A statistically significant decline of 90–98% and 68–98% for STH and scabies was recorded respectively. • Authors suggest examining health records as a rapid way of assessing impact of MDA for both LF and Onchocerciasis. STUDY REPORT 9: SCABIES AND IMPETIGO—FIJI Title: High Burden of Impetigo and Scabies in a Tropical Country (Steer et al., 2009) Objectives: To define the burden of impetigo and scabies in children in Fiji. Methods: Three epidemiologic studies were conducted in 2006 and 2007. Study one: A cross sectional prevalence survey of school children aged 5–15 years from 21 schools in the Central Division of Fiji was conducted. Using random sampling and stratification for geographical location and ethnicity, 21 schools were selected in rural and urban Fiji. Study two: A prospective cohort study was carried out in school children aged 5–15 years in three of the 21 schools from Study One. Of the three schools, School A and school B were Indigenous Fijian schools located in a rural area, whilst school C was a larger predominantly Indo-Fijian school located in Suva, Fiji’s capital. Six visits were made to each school in a ten-month period, at two monthly intervals and microbiological specimens were collected at each visit. Study three: Cross-sectional survey of infants attending for routine checks at two maternal and child health care clinics (one rural clinic in proximity to Schools A and B, and one urban clinic in proximity to School C). Microbiological confirmation of GAS and S. aureus impetigo was undertaken in this study. A cross-sectional survey in a large number of primary school children. Key Points: • A prevalence of 25.6% and 12.2% of active impetigo was observed in primary school children and infants respectively. • For scabies, a prevalence of 18.5 and 14.0% was observed infants.

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• Impetigo was strongly associated with scabies infestation and was more common in Indigenous Fijian children than children of other ethnicities. • Group A Streptococcus was responsible for the majority of cases of active impetigo in the children in this study. STUDY REPORT 10: SCABIES AND IMPETIGO—SOLOMON ISLANDS Title: The Prevalence of Scabies and Impetigo in the Solomon Islands: A Population-Based Survey (Mason et al., 2016) Objectives: • To establish the prevalence of scabies and active impetigo in remote communities of the Western Province of the Solomon Islands. • To investigate the clinical features of disease and epidemiologic associations in this setting. Methods: This was a cross-sectional population-based study in the Western Province of the Solomon Islands during November 2014. The study was conducted in ten villages within three distinct geographical regions within the Western Province (Vona Lagoon, Roviana Lagoon and Rendova. The selected villages were also participating in a mass drug administration for trachoma using azithromycin, a drug that is also active against yaws. Key Points: • The total prevalence of scabies was 19.2, 10.4% in adults and with the highest prevalence in infants / = 30 lesions). • No specific animal species was identified as a risk factor for tungiasis. • Occurrence of tungiasis was related to living in a house with poor construction characteristics, such as mud walls, sleeping directly on the floor, the number of people per sleeping room and washing the body without soap. • Odds of having severe tungiasis were high in males, and very high when only mud puddles were available as a water source. • Lack of water permitted washing (bathing) only once a day. • In rural Kenya characteristics of poverty determine the occurrence and the severity of tungiasis. • Intra-domiciliary transmission seems to occur regularly. STUDY REPORT 14: TUNGIASIS AND LIFE QUALITY IMPAIRMENT Title: Tungiasis-Related Life Quality Impairment in Children Living in Rural Kenya (Wiese, Elson, Reichert, Mambo, & Feldmeier, 2017b) Objectives: The study aimed at assessing life quality in children living in a tungiasis endemic area in rural Kenya. Methods: Fifty children with tungiasis, living in resource-poor communities in coastal Kenya were recruited. A tool was developed based on the Dermatology Life

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Quality Index (DLQI) to determine life quality impairment associated with tungiasis in children, the tungiasis—related Dermatology of Life Quality Index (tungiasisrelated-DLQI). Pain and itching were assessed using visual scales ranging from 0 to3 points. The intensity of infection and the acute and chronic severity of tungiasis were determined using standard methods. Eligible patients were explained the procedure and a caregiver (usually the mother) was asked for informed written consent. The feet of the patient were carefully washed with soap in a bucket. Thereafter, the feet were thoroughly examined by the principal investigator in a room in which the privacy of the patient was guaranteed. Lesions were staged according to the Fortaleza classification and counted: • stage I: penetrating sand flea. • stage II: brownish/black dot with a diameter of 1–2 mm. • stage III: circular yellow-white watch glass-like patch with a diameter of 3–10 mm and with a central black dot. • stage IV: brownish-black crust with or without surrounding necrosis. Stage I to III are viable sand fleas; in stage IV the parasite is dying or already dead. Lesions manipulated with a sharp instrument, such as a needle, a safety pin, a thorn or a razor blade were documented as manipulated lesions. Patients were not asked who had tried to remove embedded sand fleas. Clinical pathology was assessed semi-quantitatively, using previously established severity scores for acute and chronic tungiasis (SSAT; SSCT). The SSAT varies from 0 to 30 points, the SSCT from 0 to 32 points. Pain and itching were assessed using visual scales ranging from 0 to 3 points. Deliberately, the figures were kept very simple to make them understandable even for small children with little school education. Key Points: • Seventy eight percent of the patients reported a moderate to very large effect of tungiasis on life quality at the time of the diagnosis. • The degree of impairment correlated with the number of viable sand fleas present in the skin. • Disturbance of sleep and concentration difficulties were the most frequent restriction categories (86% and 84%, respectively). • Life quality had improved significantly after four weeks of curative treatment. • On the individual level the amelioration of life quality correlated closely with the regression of clinical pathology. • Tungiasis considerably impairs life quality in children in rural Kenya. • Life quality improves rapidly with effective treatment.

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7.4 Yaws This section features study reports on yaws, study report 15–18. Yaws is discussed in detail in Chap. 3, Sect. 3.3.2. STUDY REPORT 15: YAWS ERADICATION EFFORTS Title: Mass Treatment with Single-Dose Azithromycin for Yaws (Mitjà, Houinei, et al., 2015) Objectives: The aim of the study was to: (1) Determine the cause of skin ulcers. (2) Identify macrolide-resistant mutations before and 6 and 12 months after mass treatment with azithromycin on a Papua New Guinean island on which yaws was endemic. Methods: Clinical surveys for active yaws, serologic surveys for latent yaws, and molecular analyses. Primary outcome indicators were the prevalence of serologically confirmed active infectious yaws in the entire population and the prevalence of latent yaws with high-titer sero-reactivity in a subgroup of children 1–15 years of age were performed. Key Points: • At baseline, 13,302 of 16,092 residents (82.7%) received one oral dose of azithromycin. • The prevalence of active infectious yaws was reduced from 2.4% before mass treatment to 0.3% at 12 months. • The prevalence of high-titer latent yaws among children was reduced from 18.3 to 6.5%. • A near-absence of high-titer sero-reactivity in children 1–5 years of age was observed. • There was no evidence of emergence of resistance to macrolides against Treponema pallidum subspecies pertenue was seen. • Mass treatment with azithromycin greatly reduced the transmission and endemicity of yaws in PNG. • 80% population coverage in mass treatment is not sufficient to extinguish local transmission. • Number and frequency of resurveys that are necessary to achieve elimination is unknown. • Monitoring will be needed until no more cases of active yaws are found and serologic tests among children 1–5 years of age are negative. • A cluster-randomized trial design would have provided stronger evidence of effect. • Elimination of the diseases is generally easier to accomplish on islands than in contiguous communities.

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STUDY REPORT 16: YAWS IN PERI-URBAN PORT MORESBY Title: Yaws in the Peri-Urban Settlements of Port Moresby, Papua New Guinea (Manning & Ogle, 2015) Objectives: The aims of the study were: (1) To conduct a clinic-based case detection of yaws within the community. (2) Study the prevalence of yaws within the community. Methods: The study was divided into two parts. The first part of the study involved clinic-based case detection at 9 Mile Clinic. Blood samples were collected from patients presenting with signs or symptoms of yaws for VDRL/TPHA testing. Confirmed cases were then noted in the clinic register including the age, sex, clinical presentation and location of confirmed cases. The VDRL titres were also recorded. Previous studies have used a titre of 16 as positive. A positive TPHA in conjunction with a positive VDRL, regardless of titre were used to determine a positive sample. Clinical presentations were divided as follows; typical yaws sores, bone/joint symptoms suggestive of yaws alone, yaws sores and bone/joint symptoms together and ‘yaws unspecified’. The patients with ‘yaws unspecified’ were those in whom clinical presentation was not recorded accurately. These were often symptomatic contacts of known yaws cases who were brought in for a check-up. The Second part of the study involved community prevalence of yaws in sites around 9 Mile Urban Clinic with a predicted high prevalence of yaws. Four survey sites were picked; Sabusa, Keto, Lareba and Laloki. The surveys were planned in advance to coincide with ‘local government’ day ensuring the presence of the majority of the population. The surveys were carried out at the local meeting area of each community. Consent was obtained from the local leaders and the survey explained in both Melanesian Pidgin and the local language. Children who were old enough to walk up to the age of 16 years were examined for raised painless papules suggestive of yaws and a history taken specifically asking about the presence of bone/joint symptoms suggestive of yaws. The study was conducted by experienced nursing and medical staff of 9 Mile Clinic with considerable experience in recognizing typical yaws sores. Key Points: • The results showed a resurgence of yaws in the peri-urban settlements of Port Moresby, Papua New Guinea. • Bone/joint symptoms may interfere with the education of affected children through prolonged absence from school. • The commonly affected joints were wrists, elbows, knees and ankles usually affected in a symmetrical pattern; an outbreak of ‘yaws’ could therefore possibly be diagnosed in error when there is an outbreak of oligoarthritis, arthralgias or ‘sore knees and ankles’. • Yaws requires resources and expertise for monitoring, assessment and control.

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STUDY REPORT 17: CULTURALLY SENSITIVE COMBINED OUTREACH PROGRAM—BURULI AND YAWS Title: Yaws Resurgence in Bankim, Cameroon: The Relative Effectiveness of Different Means of Detection in Rural Communities (Um Boock, Awah, Mou, & Nichter, 2017) Objectives: The paper examines the relative utility of five approaches to yaws detection in rural settings of Cameroon. The five approaches are: (1) Clinic-based passive case detection following awareness workshops. (2) Community-based case detection through relatively small NTD related outreach activities. (3) Community-based detection immediately following mass outreach events. (4) School-based screening programs as stand-alone activities or as follow-up to mass outreach events in communities where yaws was identified. (5) Community-based detection of yaws by labour intensive house to house active surveillance activities. Methods: This was an observational study where data was reviewed to determine the number of cases identified by each of the five approaches as stated in the objectives above. Key Points: • Only 7% of the BU cases were detected at local clinics. • Small outreach programs and household surveys detected yaws in a broad spectrum of communities. • Mass outreach programs were able to detect 70% of the cases and were the most successful of the five methods. • The five interventions for detecting yaws had a synergistic effect and proved to be valuable components of a yaws eradication program. • Well planned, culturally sensitive mass outreach educational programs accompanied by school-based programs proved to be particularly effective in Bankim. • Demonstration effect of yaws treatment (rapid cure) increased confidence in early Buruli ulcer treatment. • Mass outreach programs functioned as magnets for both diseases as well as other kinds of chronic wounds that future outreach programs need to address. STUDY REPORT 18: LOCAL KNOWLEDGE, ATTITUDES AND PRACTICES CONCERNING THE CAUSATION AND TREATMENT OF YAWS. Title: Knowledge, Attitudes and Practices Towards Yaws and Yaws-Like Skin Disease in Ghana (Marks et al., 2017) Objectives: The aim of the study was to collect both quantitative and qualitative data on local knowledge, attitudes and practices concerning the causation and treatment of yaws.

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Methods: A verbal questionnaire was used to understand perceptions of the cause and transmission of yaws, where people would go to seek for treatment and what causes them to seek treatment (what factors led them to seek treatment). Key Points: • 77% reported that “germs” were the cause of yaws lesions. • 13% believed that the disease was caused by supernatural forces. • Frequently mentioned lack of personal hygiene, irregular and inefficient bathing, and washing with dirty water as fundamental to both the cause and the prevention of yaws. • A majority of individuals reported that they would want to take an antibiotic to prevent the development of yaws if they were asymptomatic (61.2%). • Direct and indirect costs of treatment were reported as key factors affecting where participants reported they would seek care.

7.5 Podoconiosis A detailed discussion on podoconiosis is featured in Chap. 3, Sect. 3.2.10. Study reports 19–20 are on podoconiosis. STUDY REPORT 19: PODOCONIOSIS AND MENTAL DISTRESS Title: Mental Distress and Podoconiosis in Northern Ethiopia: A Comparative Cross-Sectional Study (Mousley et al., 2014) Objectives: To assess the comorbidity of podoconiosis and mental distress. Methods: A comparative cross-sectional study was conducted in 2012, including 346 people with podoconiosis and 349 healthy neighbourhood controls. Symptoms of mental distress were assessed using the validated Amharic translation of the Kessler-10 scale (K10). A linear regression analysis was conducted to identify factors associated with mental distress. Key Points: • The study documented a high burden of mental distress among people with podoconiosis compared with healthy controls. • The authors recommend integration of psychosocial care into the current morbidity management of podoconiosis.

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STUDY REPORT 20: PODOCONIOSIS AND ECONOMIC BURDEN Title: Economic Costs of Endemic Non-filarial Elephantiasis in Wolaita Zone, Ethiopia (Tekola, Mariam, & Davey, 2006) Objectives: To estimate the direct and the average productivity cost attributable to podoconiosis, and to compare the average productivity time of podoconiosis patients with non-patients. Methods: This was a matched comparative cross-sectional survey involving 702 study subjects (patients and nonpatients) supplemented by interviews with key informants in Wolaita Zone, southern Ethiopia. Key Points: • Total direct costs of podoconiosis amounted to the equivalent of US$ 143 per patient per year • The total productivity loss for a patient amounted to 45% of the total working days per year, causing a monetary loss equivalent to US$ 63. • In Wolaita zone, the overall cost of podoconiosis exceeds US$ 16 million per year. • Podoconiosis has enormous economic impact in affected areas. • Simple preventive measures (such as use of robust footwear) must be promoted by health policy makers.

7.6 Lymphatic Filariasis Section 3.2.9 in Chap. 3 is focused on lymphatic filarias and its aetiology. Study report 21–25 highlights some studied on the disease. STUDY REPORT 21: LYMPHATIC FILARIASIS AND THE URBAN SETTING Title: Urban Lymphatic Filariasis (Simonsen & Mwakitalu, 2013) Objectives: A review on currently available knowledge about urban LF and the environmental and socio-economic basis for its occurrence. Methods: Here, we review currently available knowledge about urban LF and the environmental and socio-economic basis for its occurrence. Key Points: • Wuchereria bancrofti has been documented to have a significant potential for urban transmission. • This is primarily because one of its vectors, Culex quinquefasciatus, thrives and proliferates excessively in crowded city areas with poor sanitary, sewerage and drainage facilities.

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• Urban LF also often shows a marked focality in distribution, with most cases clustered in areas inhabited by the less privileged city populations. • More knowledge about urban LF is needed, in particular on its socio-economic and human behavioural context, on the potential for transmission in regions where other LF vector species predominate, and on rapid methods for identification and mapping of risk areas, to provide a strong evidence base for its control. STUDY REPORT 22: LYMPHATIC FILARIASIS AND MENTAL HEALTH Title: The Burden of Mental Health in Lymphatic Filariasis (Ton, Mackenzie, & Molyneux, 2015) Objectives: To develop a mathematical model to calculate the burden of Disability— Adjusted Life Years (DALY) attributable to depressive illness in lymphatic filariasis and that of their caregivers using standard methods for calculating DALYs. Methods: Estimates of numbers with clinical disease was based on published estimates in 2012 and the numbers with depressive illness from the available literature were used. Key Points: • The burden of depressive illness in filariasis patients was 5.09 million disabilityadjusted life years (DALYs) and 229,537 DALYs attributable to their caregivers • These figures are around twice that of 2.78 million DALYs attributed to filariasis by the Global Burden of Disease study of 2010. • Lymphatic filariasis and other neglected tropical diseases, notably Buruli Ulcer, cutaneous leishmaniasis, leprosy, yaws, onchocerciasis and trachoma cause significant co morbidity associated with mental illness in patients. • Studies to assess the prevalence of the burden of this co-morbidity should be incorporated into any future assessment of the Global Burden of neglected tropical diseases. • The prevalence of depressive illness in caregivers who support those who suffer from these conditions is required. • Such assessments are critical for neglected tropical diseases which have such a huge global prevalence and thus will contribute a significant burden of comorbidity attributable to mental illness. STUDY REPORT 23: LYMPHATIC FILARIASIS IN AFRICA Title: Mapping and Estimating the Population at Risk from Lymphatic Filariasis in Africa (Lindsay & Thomas, 2000) Objectives: To characterize climate at sites in Africa where LF is endemic Methods: Using computerized surfaces, the climate at sites in Africa where surveys for lymphatic filariasis had taken place were characterized. Logistic regression analysis of the climate variables predicted with 76% accuracy whether sites had

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microfilaraemic patients or not. Using the logistic equation, a geographical information system to map risk of lymphatic filariasis infection across Africa was carried out and compared favourably with expert opinion. Further validation with a quasiindependent data set showed that the model predicted correctly 88% of infected sites. A similar procedure was used to map risk of microfilaraemia in Egypt, where the dominant vector species differs from those in sub-Saharan Africa. By overlaying risk maps on a 1990 population grid, and adjusting for recent population increases, we estimate that around 420 million people will be exposed to this infection in Africa in the year 2000. Key Points: This approach could be used to produce a sampling frame, based on estimated risk of microfilaraemia, for conducting filariasis surveys in countries that lack accurate distribution maps and thus save on costs. STUDY REPORT 24: LYMPHATIC FILARIASIS IN NEPAL Title: Mapping of Lymphatic Filariasis in Nepal (Sherchand, Obsomer, Thakur, & Hommel, 2003) Objectives: To map the distribution of lymphatic filariasis in Nepal Methods: Epidemiological mapping was undertaken to determine the prevalence of infection by W. bancrofti in 37 districts of Nepal between July to December 2001. The study population above 15 years of age was selected, and the immunochromatographic test (ICT Filariasis) was used to screen for circulating filarial antigen (CFA). Key Points: • The overall prevalence of lymphatic filariasis from a 4,488-sample population was 13% and 33/37 districts were found to be endemic. The highest number of cases were found at altitudes between 500–700 m; however, a substantial number of infected individuals were found in the highly populated Kathmandu valley, at altitudes between 900–1,500 m where transmission appears to take place. • Prevalence rates above 20% were found in 11 districts (with the highest rate of 40%), 6–19% were found in 15 districts, and 0.1–5% were in 7 districts. • Information on people’s knowledge, attitudes and behaviour towards filariasis was also collected by means of a structured questionnaire. • The study indicates that the prevalence of infection is far greater that was previously reported and that lymphatic filariasis should be a much higher health priority than currently given.

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STUDY REPORT 25: LYMPHATIC FILARIASIS AND CHILDHOOD INFECTION Title: Lymphatic Filariasis: An Infection of Childhood (Witt & Ottesen, 2001) Key Points: • New, highly sensitive diagnostic tests (antigen detection, ultrasound examination) now reveal, however, that LF is acquired first in childhood, often with as many as one-third of children infected before age 5. • Initial damage to the lymphatic system by the parasites generally remains subclinical for years or gives rise only to non-specific presentations of adenitis/adenopathy; however, especially after puberty the characteristic clinical features of the adult disease syndromes (lymphoedema, hydrocoele) manifest. • Recognizing that LF disease starts its development in childhood has immediate practical implications both for management and prevention of the disease in individual patients and for the broader public health efforts to overcome all childhood illnesses. • For the new World Health Organization (WHO)-supported, public-/private-sector collaboration (Global Alliance) to eliminate LF through once-yearly drug treatment, this recognition means that children will be not only the principal beneficiaries of LF elimination but also a population particularly important to target in order for the programme to achieve its twin goals of interrupting transmission and preventing disease.

7.7 Leishmaniasis Study reports 26–29 feature some studied on leishmaniasis, for more details on the disease, see Sect. 3.2.6 in Chap. 3. STUDY REPORT 26: LEISHMANIASIS AND HIV Title: Leishmaniasis as an Opportunistic Infection in HIV infected patients— Determinants of Relapse and Mortality (Pasquau et al., 2005) Objectives: To describe the clinical features and determinants for relapse and case fatality of visceral leishmaniasis in HIV-infected patients from a Spanish Mediterranean area. Methods: A total of 228 episodes of visceral leishmaniasis were diagnosed in 155 HIV-infected patients by the detection of amastigotes in bone marrow aspirates or in other tissue samples. Most patients had advanced HIV disease, with a median

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CD4+ lymphocyte cell count of 55 cells × 109 and 56% of them had a previous AIDS-indicator disease. The median duration of follow-up was 8.4 months. Key Points: • HIV-infected patients with visceral leishmaniasis presented with fever (76%), hepatomegaly (77%), splenomegaly (78%), and varying degrees of cytopenias. • Leishmania was detected in atypical sites in 22 (14%) patients. • A total of 37 (24%) patients had a relapse of visceral leishmaniasis. • Female gender was a risk factor for relapse, whereas administration of secondary prophylaxis for visceral leishmaniasis and a completed therapy for visceral leishmaniasis were protective factors against relapse. • A total of 86 (54%) patients died. • Independent determinants for survival were CD4+ lymphocyte cell count, completed therapy for leishmania, and secondary prophylaxis for visceral leishmaniasis. • The findings show that, in HIV-infected patients, visceral leishmaniasis occurs in late stages of the disease and often has a relapsing course. • Secondary prophylaxis reduces the risk of relapse. • Visceral leishmaniasis in the HIV-infected population should be included in the CDC clinical category C for the definition of AIDS in the same way that other geographically specific opportunistic infections are included. STUDY REPORT 27: LEISHMANIASIS AND THE COMMUNITY Title: Knowledge, Attitudes and Practices Related to Visceral Leishmaniasis in Rural Communities of Amhara State: A Longitudinal Study in Northwest Ethiopia (López-Perea et al., 2014) Objectives: To study knowledge and attitudes, how people perceive visceral leishmaniasis (VL). Methods: Two surveys on VL knowledge, attitudes and practices were conducted at the beginning (May 2009) and at the end (February 2011) part of a VL longitudinal study carried out in rural communities of Libo Kemkem and Fogera, two districts of the Amhara Regional State. Key Points: • VL global knowledge was very low in the area, and it improved substantially during the study period. • Specifically, from 2009 to 2011, the frequency of proper knowledge regarding VL signs and symptoms increased from 47 to 71% (p, 0.0001). • Knowledge of VL causes increased from 8 to 25% (p, 0.0001). • Knowledge about VL protection measures from 16 to 55% (p, 0.0001).

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• Improvement observed in VL knowledge was more marked among the families with no previous history of VL case. • In 2011 more than 90% of the households owned at least an impregnated bed net and had been sprayed, and attitudes towards these and other protective measures were very positive (over 94% acceptance). • VL patients and relatives should be appropriately informed and trained as they may act as successful health community agents. • VL risk behavioural patterns are subject to change as attitudes towards protective measures were very positive overall. STUDY REPORT 28: VISCERAL LEISHMANIASIS Title: Visceral Leishmaniasis: Consequences of a Neglected Disease in a Bangladeshi Community (Ahluwalia et al., 2003) Objectives: To examine the epidemiologic, social, and economic impact of Kala a zar (KA) in a village in Bangladesh. Methods: This was a population-based survey. Key Points: • Incidence of 2% per year from 2000 to 2002, with a case-fatality rate of 19% among adult women, compared with 6–8% among other demographic groups was observed. • Kala azar cases were geographically clustered in certain sections of the village. • Anti-leishmanial drug shortages and the high cost of diagnosis and treatment caused substantial emotional and economic hardship for affected families. • Communities wanted to learn more about KA and were willing to take collective action to confront the problems it causes. • To decrease the KA burden in endemic areas, community efforts should be supplemented with effective treatment programs to ensure access to appropriate and affordable diagnosis and case management. STUDY REPORT 29: CUTANEOUS LEISHMANIASIS IN GUATEMALA Title: Cutaneous Leishmaniasis in Guatemala: People’s Knowledge, Concepts and Practices (Arana, Rizzo, Navin, Klein, & Kroeger, 2000) Objectives: To determine the residents’ knowledge of the disease, their related concepts and practices, and their treatment preferences, and to identify the communication channels they use to acquire information. Methods: Ten rural communities in the northern area of Guatemala where cutaneous leishmaniasis (CL) is endemic were investigated to determine the residents’

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knowledge of the disease, their related concepts and practices, and their treatment preferences, and to identify the communication channels they use to acquire information. Key Points: • Of the 425 heads of household interviewed, 96.7% could accurately describe a typical CL lesion. • CL was found to be the fourth most frequently mentioned disease (in studies based on a free list format) and to be considered the sixth most serious (in studies based on paired comparisons). • A series of three-way comparisons, used to analyse the subjects’ concepts about the similarities of various cases, indicated that CL was considered to be most closely related to skin problems and to be different from any other group of diseases. All interviewees believed that it was necessary to receive treatment for CL, because without treatment the disease would progress, reach the bone, and take years to heal. • More than half (55%) of the respondents knew about meglumine antimonate (Glucantime), the most commonly prescribed drug for treating CL in Guatemala. • Only a few communication channels that were used by respondents to receive information were identified; the use of radio broadcasts and direct communication via the community leaders appeared to be the most effective.

7.8 Fungal Infections and Dermatophytes Study reports 30–34 review some studies on dermatophytes, a detailed discussion on superficial fungal infections is found in Chap. 3, Sect. 3.5 STUDY REPORT 30: TINEA PREVALENCE IN BARCELONA SCHOOL CHILDREN Title: Prevalence of Tinea Capitis and Tinea Pedis in Barcelona School Children (Triviño-Duran et al., 2005) Objectives: • To identify the prevalence of tinea in school children in the area with the highest immigrant population in Barcelona. • To identify the aetiologic agent. • To study the possibility of the introduction of foreign dermatophyte species and to evaluate the possibility of encountering healthy hosts.

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Methods: This was a cross-sectional study conducted between October 2002 until June 2003. The study evaluated 1305 school children, ages 3–15 years, belonging to 21 schools located in the inner city of Barcelona to determine the prevalence of tinea capitis and pedis in school children. Cultures of scalp and feet were done on each child. Key Points: • 36 (2.8%) children had tinea pedis and 3 (0.23%) had tinea capitis. • One child had tinea capitis and tinea pedis, caused by different species; T. mentagrophytes and T. rubrum respectively. • Of the 39 positive cases for dermatophytes, the etiologic agent in 18 (46.1%) was T. mentagrophytes, 17 (43.5%) T. rubrum, 2 (5.5%) Epidermophyton floccosum and 2 (5.5%) T. tonsurans. • Of these 39 cases of tinea, 15 (38.5%) were Spanish natives and 22 (56.4%) were immigrants. • There was a greater prevalence of tinea pedis among schoolchildren 13–15 years of age (64.10%), the great majority of them male. • The number of cases of tinea was significantly greater in immigrants. STUDY REPORT 31: TINEA CAPITIS IN CHILDREN FROM AN INFORMAL SETTLEMENT IN NAIROBI, KENYA Title: Prevalence of Tinea Capitis in School Going Children from Mathare, Informal Settlement in Nairobi, Kenya (Moto, Maingi, & Nyamache, 2015) Objectives: To determine the prevalence Tinea capitis in children from selected schools from an urban slum in Nairobi city of Kenya. Methods: A cross-sectional study was carried out in 150 school going children during the period between May and September 2013. A questionnaire was administered and cultures of scalps, skin scrapping/hair stubs samples were performed, to identify and confirm the etiological agents. Key Points: • The overall prevalence rates in dermatophytes infection was 81.3% (122/150). • Aetiological agents consisted of Trichophyton spp. (61.3%), Microsporum spp. (13.3%) and Epidermophyton spp. (7.3%). • Infections were single fungal (56%), duo (38%) or tipple co-infections (6%). • High prevalence of Tinea infections were observed. • T. tonsurans was the predominant etiological agent in school going children of the urban slums of Nairobi.

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STUDY REPORT 32: TINEA PEDIS, TINEA UNGUIUM OF TOENAILS AND TINEA CAPITIS AND HEALTHY CARRIERS OF DERMATOPHYTES Title: Prevalence of Tinea Pedis, Tinea Unguium of Toenails and Tinea Capitis in School Children from Barcelona (Pérez-González et al., 2009) Objectives: To evaluate the prevalence of tinea capitis, tinea pedis, and tinea unguium in children from several schools of Barcelona city. Methods: During the period of 2003–2004, a prospective cross-sectional study was carried out in 1,305 children (9% immigrant population) between the ages 3 and 15 in 17 schools in Barcelona. A systematic examination of the feet, (including nails and scalp), was performed to identify lesions compatible with tinea. Cultures of scalp and feet samples were done, and analysis of environmental samples was performed for dermatophyte isolation. Key Points: • Dermatophytes were isolated in 2.9% of the samples with a prevalence of 2.5% in feet, 0.23% in scalp, and 0.15% in nails of the feet. • The predominant etiologic agents in feet were Trichophyton mentagrophytes in 45.7% of the cases and Trichophyton rubrum in 31.4%. • In the nails, T. rubrum and Trichophyton tonsurans were isolated. • Trycophyton mentagrophytes (2 cases) and Trichophyton violaceum (1 case) were identified in scalp samples. • Forty-five per cent of dermatophytes were isolated from healthy feet, the majority of cases in children 13–15 years old (p < 0.05). • Microsporum gypsum was the only agent identified in the environmental samples and was also found in one of the cases of tinea pedis. • The results of this study demonstrate a low prevalence of tinea capitis and tinea unguium in school children of Barcelona. • A high prevalence of dermatophytes in feet was found. • It highlights the high prevalence of healthy carriers of dermatophytes in feet. STUDY REPORT 33: TINEA CAPITIS IN EUROPE—CURRENT STATUS Title: Epidemiology of Tinea Capitis in Europe: Current State and Changing Patterns (Ginter-Hanselmayer, Weger, Ilkit, & Smolle, 2007) Objectives: To obtain a general overview of the current state and changing pattern of tinea capitis in Europe. Key Points: • Microsporum canis, a zoophilic dermatophyte, is still the most common reported causative agent of tinea capitis in Europe.

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• The highest incidence of M. canis infections are mainly reported in the Mediterranean but also bordering countries like Austria, Hungary, Germany and Poland. • There is a shift towards anthrophilic tinea capitis mainly in urban areas in Europe. • The largest overall increase with anthropophilic dermatophytes has been noted with Trichophyton tonsurans mainly in the UK and with Trichophyton soudanense and Microsporum audouinii in France. • The occurrence of anthropophilic infections seems to be geographically restricted and is possibly linked to the immigration from African countries. • Children (aged 3–7 years with no predilection of gender) remain the most commonly affected, but recently an increase of tinea capitis has been observed in adults and in the elderly. • The results of the study clearly demonstrate the importance of diagnosing and proper treatment of mycotic scalp infection in the Europe. • Need for an increased level of surveillance (screening in schools), and a highly effective interdisciplinary cooperation among general practitioners, mycologists, veterinarians and dermatologists are strongly recommended. STUDY REPORT 34: PREVALENCE AND PATTERN OF SUPERFICIAL FUNGAL INFECTIONS AMONG SCHOOL CHILDREN IN SOUTH-WESTERN NIGERIA Title: The Prevalence and Pattern of Superficial Fungal Infections among School Children in Ile-Ife, South-Western Nigeria (Oke, Onayemi, Olasode, Omisore, & Oninla, 2014) Objectives: To determine the prevalence and the clinical patterns of superficial fungal infections among primary school children in Ile-Ife. Methods: A multistage sampling was conducted to select eight hundred pupils from ten primary schools in Ile-Ife. Data on epidemiological characteristics and clinical history was collected using a semi structured questionnaire and skin scrapings were also collected. Key Points: • The prevalence of superficial fungal infections among the 800 respondents was 35.0%. • Tinea capitis was the commonest infection with a prevalence of 26.9% with Tinea unguium, tinea corporis, and tinea faciei prevalence of 0.8%, 0.6%, and 0.5%, respectively. • Tinea manuum had the least prevalence of 0.1%. • Pityriasis versicolor had a prevalence of 4.4%. • Microsporum audouinii was the most isolated organism. • The study shows that the prevalence of superficial fungal infection (SFI) among primary school children in Ile-Ife is high with tinea capitis as the commonest SFI.

7.9 Conclusion

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7.9 Conclusion From the various studies outlined in this chapter the effects of the diseases on the affected populations can be recognized. From socio-economic challenges to disabilities due to disease, people living in endemic areas carry a huge burden of skin diseases. The study reports highlight the various challenges posed by skin diseases on communities. The population affected by skin diseases ranges from children to adults most of whom are associated with vulnerabilities including limited resources, struggling infrastructure, scanty knowledge and unfavourable living conditions.

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Manning, L. a, & Ogle, G. D. (2015). Yaws in the periurban settlements of Port Moresby, Papua New Guinea. Papua and New Guinea Medical Journal. Marion, E., Obvala D, Babonneau J., Kempf, M., Asiedu K. B.,& Marsollier, L. (2014). Full-text. In Emerging infectious diseases (Vol. 20). Marks, M., Kwakye-Maclean, C., Doherty, R., Adwere, P., Abdulai, A. A., Duah, F., … Ackumey, M. M. (2017). Knowledge, attitudes and practices towards yaws and yaws-like skin disease in Ghana. https://doi.org/10.1371/journal.pntd.0005820. Mason, D. S., Marks, M., Sokana, O., Solomon, A. W., Mabey, D. C., Romani, L., … Engelman, D. (2016). The prevalence of Scabies and impetigo in the Solomon Islands: A populationbased survey. Retrieved from http://journals.plos.org/plosntds/article/file?id=10.1371/journal. pntd.0004803&type=printable. Mitjà, O., Houinei, W., Moses, P., Kapa, A., Paru, R., Hays, R., … Bassat, Q. (2015). Mass treatment with single-dose azithromycin for yaws. The New England Journal of Medicine, 372(8), 703–710. https://doi.org/10.1056/NEJMoa1408586. Mohammed, K. A., Deb, R. M., Stanton, M. C., & Molyneux, D. H. (2012). Soil transmitted helminths and scabies in Zanzibar, Tanzania following mass drug administration for lymphatic filariasis—A rapid assessment methodology to assess impact. https://doi.org/10.1186/1756-33055-299. Moto, J. N., Maingi, J. M., & Nyamache, A. K. (2015). Prevalence of Tinea capitis in school going children from Mathare, informal settlement in Nairobi. Kenya: BMC Research Notes. https://doi. org/10.1186/s13104-015-1240-7. Mousley, E., Deribea, K., Tamiru, A., Tomczyk, S., Hanlon, C., & Davey, G. (2014). Mental distress and podoconiosis in Northern Ethiopia: A comparative cross-sectional study. International Health. https://doi.org/10.1093/inthealth/ihu043. Oke, O. O., Onayemi, O., Olasode, O. A., Omisore, A. G., & Oninla, O. A. (2014). The prevalence and pattern of superficial fungal infections among school children in Ile-Ife, South-Western Nigeria. Dermatology Research and Practice. https://doi.org/10.1155/2014/842917. Pasquau, F., Ena, J., Sanchez, R., Cuadrado, J. M., Amador, C., Flores, J., … Onofre, J. (2005). Leishmaniasis as an opportunistic infection in HIV-infected patients: Determinants of relapse and mortality in a collaborative study of 228 episodes in a Mediterreanean region. European Journal of Clinical Microbiology and Infectious Diseases. https://doi.org/10.1007/s10096-005-1342-6. Pérez-González, M., Torres-Rodríguez, J. M., Martínez-Roig, A., Segura, S., Griera, G., Triviño, L., et al. (2009). Prevalence of tinea pedis, tinea unguium of toenails and tinea capitis in school children from Barcelona. Revista Iberoamericana de Micologia. https://doi.org/10.1016/j.riam. 2009.03.006. Sherchand, J. B., Obsomer, V., Thakur, G. D., & Hommel, M. (2003). Mapping of lymphatic filariasis in Nepal. Filaria Journal. Simonsen, P. E., & Mwakitalu, M. E. (2013). Urban lymphatic filariasis. Parasitology Research. https://doi.org/10.1007/s00436-012-3226-x. Steer, A. C., Jenney, A. W. J., Kado, J., Batzloff, M. R., La Vincente, S., Waqatakirewa, L., … Carapetis, J. R. (2009). High burden of impetigo and scabies in a tropical country. PLoS Neglected Tropical Diseases, 3(6). https://doi.org/10.1371/journal.pntd.0000467. Tekola Ayele, F., Alemu, G., Davey, G., & Ahrens, C. (2013). Community-based survey of podoconiosis in Bedele Zuria woreda, west Ethiopia. International Health. https://doi.org/10.1093/ inthealth/iht003. Tekola, F., Mariam, D. H., & Davey, G. (2006). Economic costs of endemic non-filarial elephantiasis in Wolaita Zone, Ethiopia. Tropical Medicine and International Health. https://doi.org/10.1111/ j.1365-3156.2006.01658.x. Thierry Barogui, Y., Sopoh, G. E., Johnson, R. C., De Zeeuw, J., Dossou, A. D., Houezo, J. G., … Stienstra, Y. (2014). Contribution of the community health volunteers in the control of Buruli Ulcer in Bénin. PLoS Neglected Tropical Diseases, 8(10). https://doi.org/10.1371/journal.pntd. 0003200.

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Ton, T. G. N., Mackenzie, C., & Molyneux, D. H. (2015). The burden of mental health in lymphatic filariasis. Infectious Diseases of Poverty. https://doi.org/10.1186/s40249-015-0068-7. Triviño-Duran, L., Torres-Rodriguez, J. M., Martinez-Roig, A., Cortina, C., Belver, V., PerezGonzalez, M., et al. (2005). Prevalence of tinea capitis and tinea pedis in Barcelona Schoolchildren. Pediatric Infectious Disease Journal. https://doi.org/10.1097/01.inf.0000151044.21529.3b. Ukwaja, K. N., Meka, A. O., Chukwuka, A., Asiedu, K. B., Huber, K. L., Eddyani, M., … Ntana, K. (2016). Buruli ulcer in Nigeria: Results of a case pilot study report in three rural districts. https://doi.org/10.1186/s40249-016-0119-8. Um Boock, A., Awah, P. K., Mou, F., & Nichter, M. (2017). Yaws resurgence in Bankim, Cameroon: The relative effectiveness of different means of detection in rural communities. https://doi.org/10. 1371/journal.pntd.0005557. Wafula, S. T., Ssemugabo, C., Namuhani, N., Musoke, D., Ssempebwa, J., & Halage, A. A. (2016). Prevalence and risk factors associated with tungiasis in Mayuge district, Eastern Uganda. The Pan African Medical Journal, 24. https://doi.org/10.11604/pamj.2016.24.77.8916. WHO. (2017). Epidemiological situation. Wiese, S., Elson, L., Reichert, F., Mambo, B., & Feldmeier, H. (2017a). Prevalence, intensity and risk factors of tungiasis in Kilifi County, Kenya: I. Results from a community-based study. PLoS Neglected Tropical Diseases. https://doi.org/10.1371/journal.pntd.0005925. Wiese, S., Elson, L., Reichert, F., Mambo, B., & Feldmeier, H. (2017b). Prevalence, intensity and risk factors of tungiasis in Kilifi County, Kenya: I. Results from a community-based study. PLoS Neglected Tropical Diseases. https://doi.org/10.1371/journal.pntd.0005925. Witt, C., & Ottesen, E. A. (2001). Lymphatic filariasis: An infection of childhood. Tropical Medicine and International Health, 6, 582–606. https://doi.org/10.1046/j.1365-3156.2001.00765.x. Yerramilli, A., Tay, E. L., Stewardson, A. J., Kelley, P. G., Bishop, E., Jenkin, G. A., … Johnson, P. D. R. (2017). The location of Australian Buruli ulcer lesions—Implications for unravelling disease transmission. https://doi.org/10.1371/journal.pntd.0005800. Yotsu, R. R., Kouadio, K., Vagamon, B., N’guessan, K., Akpa, A. J., Yao, A., … Asiedu, K. (2018). Skin disease prevalence study in schoolchildren in rural Côte d’Ivoire: Implications for integration of neglected skin diseases (skin NTDs). PLoS Neglected Tropical Diseases, 12(5). https://doi. org/10.1371/journal.pntd.0006489.

Chapter 8

Reducing Burden of Disease

Abstract Disease burden can be viewed through the biomedical lens, looking at morbidity, mortality, trends and risk attribution; as well as through the economic lens looking at the direct and indirect costs brought about by the disease. In this chapter, disease burden will be reviewed by looking at the various aspects of implementation science and how this may affect resource-poor communities. An intervention that can successfully work in a financially stable community/society may not work as well in a resource poor community. Interventions that require advanced technology may prove more accessible in countries with ample resources than in limited resource countries. The challenge is to bring quality care with the resources available. Some of the possible solutions to these challenges that could ensure successful implementation of interventions include; developing capacity within the local community, understanding the local health systems, understanding local and pre-existing approaches to disease and, training health systems to engage and understand the perspective of the community towards health. Keywords Skin diseases · Implementation science/research · Disease burden · Livelihood determinants · Morbidity · Skin diseases · Sustainable livelihood Synopsis Whether a farmer, an artisan seller, a banker or a hospital personnel all have one thing in common, to earn a living. There are various ways of earning a livelihood and these livelihoods expose these individuals to all kinds of environments. While health personnel are at risk of acquiring hospital infections, due to exposure; in the same manner the banker, the artisan worker, the farmer could be exposed to infections in their work environment. By looking at the burden of disease, implementation science and sustainable livelihood, it is possible to develop tailor made strategies that could assist in reducing disease burden globally. Sustainable livelihood combines availability of skills, infrastructure, natural resources and finances to fight disease. While implementation science will ensure that interventions are managed sustainably.

© Springer Nature Singapore Pte Ltd. 2020 F. A. Mphande, Skin Disorders in Vulnerable Populations, https://doi.org/10.1007/978-981-15-3879-7_8

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8.1 Sustainable Livelihood, Implementation Science and Disease Burden Managing the disease burden in resource poor countries remains one of the biggest challenges in public health globally. While several interventions exist that can assist in reducing the disease burden, successful implementation of these interventions remain a challenge especially in communities where there are limited resources. These resources could be in form of infrastructures, capacity, finances and many more. The gaps that exist between resource poor and wealthy communities between and within countries play an important role in management of disease burden and implementation of various interventions. Implementation science is one method that encourages use of evidence- based practices, by utilizing research findings and other evidence -based practices in everyday activities to improve the quality and effectiveness of healthcare services. Through implementation science and research, it is possible to find solutions to the everincreasing disease burden in resource poor communities. By identifying the challenges in these communities it is possible to come up with successful solutions that will ensure fruitful implementation of interventions as well as developing capacity that will help improve existing health systems. In this chapter, disease burden will be reviewed by focusing on the five assets of sustainable livelihood (SL) in relation to aspects of implementation science and how together they can affect disease burden in resource poor communities. Sustainable livelihood (SL) framework is a term that covers research concerning poverty reduction, sustainability and livelihood strategies and is applicable to both rural and urban survival strategies (Chambers & Conway, 1991; Solesbury, 2003). The lack of the necessary capital to manage a disease contributes to the disease burden.

8.1.1 Disease Burden and Human Capital Human capital encompasses knowledge, skills, habits and social behaviour that contribute to the economic benefit of an individual and or community (Ellis, 1996). The attributes of human capital stated not only apply to economic development but are also important in understanding disease burden. In the field of health, human capital in form of health service practitioners and providers, health systems managers, including doctors, nurses, scientists, researchers, field workers, health surveillance assistants are a valuable asset. Lack of such results in poor health services as well as meagre management of interventions. The ability to design projects, conduct the research, interpret and dissemination of outcomes requires skills. Knowledge translation from these professionals and putting this knowledge into practice in the respective communities is a requirement for effective implementation of interventions and reducing the disease burden (Fig. 8.1).

8.1 Sustainable Livelihood, Implementation Science and Disease …

Human Capital - Limited number of health professionals, researchers and scienƟsts - Poor management of available health faciliƟes and intervenƟons

Physical Capital - Limited Reasearch and Development - Poor management of intervenƟons

Natural Capital - Displacement due to conflict and other natural disasters - PopulaƟon growth and encroachment

Social Capital - SƟgma - Displacement due to conflict and other natural disasters

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Financial Capital - Financing intervenƟon - Management of intervenƟons

DISAEASE BURDEN Fig. 8.1 Disease burden and sustainable livelihood. Sustainable livelihood is required for survival but various situations associated with livelihood can contribute to disease burden

8.1.2 Disease Burden and Physical Capital Physical capital is an asset that assists in productivity turning raw materials into finished products and or services (Ellis, 2000a). Physical capital includes infrastructure such as, buildings, roads; equipment and other finished products such as medicines, personal protective equipment as well as human capital with enough skills to run the assets (Fig. 8.1) (Abass et al., 2015; Deribe et al., 2017; Engelman et al., 2016; Feldmeier & Heukelbach, 2009; Hay et al., 1994; Lim, Chan, Alsagoff, & Ha, 2014; Tekola, Mariam, & Davey, 2006; Ton, Mackenzie, & Molyneux, 2015; Yimer, Hailu, Mulu, & Abera, 2015). Inability of resource poor countries to research, design and manufacture their own medicines and vaccines against diseases that affect them most has allowed for persistence diseases in endemic regions. With funding that is often tagged to a particular disease and or intervention, certain areas of general health are often neglected resulting in poor performance and outcomes from these areas. Investing in physical capital that would enable these countries to design and manufacture effective vaccines and medicines, and the skills (human capital) to manage the physical capital, would be beneficial in tackling disease burden within the region. With the right physical and human capital, resource poor countries will have a chance to combat skin diseases, communicable and non-communicable disease burden in the region (Fig. 8.1).

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8.1.3 Disease Burden and Natural Capital Natural capital refers to availability of land and natural resources (Barbier & Hochard, 2014; Ellis, 1996, 2000b). Population growth has allowed for people to move into areas that were inhabitable, as well as into forest and reserves which are habitats to wild animals. This encroachment has allowed for interaction between domesticated and wild animals as well as humans and wild animals. This interaction has contributed to increase in zoonotic diseases as well as emerging and re-emerging diseases. The disease burden brought about by disease outbreaks from these emerging and reemerging diseases is high in rural populations of resource poor countries (Dixon & Schafer, 2014; Tartari et al., 2015; Van Kerkhove, Bento, Mills, Ferguson, & Donnelly, 2015; Yehualashet et al., 2016). Lack of safe drinking water has allowed for people to drink water from contaminated sources resulting in diarrheal diseases, heavy metal poisoning, and other parasitic diseases associated with water (Abd El Ghany et al., 2017; Hsü & Hsü, 2017; Lawrence et al., 2005). Loss of natural capital through displacement due to conflict and other epidemics has also perpetuated disease burden in vulnerable populations. As people move away from these conflicts, many have found themselves lacking access to healthcare including medicines and vaccines resulting increased mortality from preventable diseases, emerging antibiotic resistance and increased morbidity from disease. Thus preventing conflicts and management of displaced populations ensuring that they have access to the required healthcare could assist in reducing the burden of disease (Fig. 8.1).

8.1.4 Disease Burden and Social Capital Social capital is an asset crucial in forming relationships and networks and is a valuable tool for productivity in an individual (Ellis, 2000b). Displaced communities find themselves in hostile environments and most often isolated. For those who manage to cross borders, most have limited access to healthcare as well as resources that could help them in settling in their new environment. For those displaced populations able to cross borders but without legal papers allowing them to stay in those countries, many suffer stigma and are constantly running from the law to avoid detection. This affects their ability to develop and build social relationships and most often access to loans and other available health interventions that may require showing their immigration status. For those suffering effects of disease such as deformity and disability, these outcomes have substantial impact on the affected individuals and their families (Fig. 8.1). Stigma has been experienced by individuals suffering from a disease as well as their family members. Individuals suffering from BU or those recovering or have recovered still face stigmatizing attitudes within their communities (Abass et al., 2015; de Zeeuw et al., 2014). For people suffering from diseases such as LF, podoconiosis as well as epidermal parasitic diseases, stigma has led to social exclusion, e.g. being left

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out in social gatherings, marriage and even participating in other social events (de Zeeuw et al., 2014; Feldmeier & Heukelbach, 2009; Franklin, Tora, Deribe, Reda, & Davey, 2013; Hofstraat & Van Brakel, 2015; Mousley et al., 2014). Social exclusion and stigma have often led to mental distress in the affected individuals. Thus, stigma and social exclusion has further increased the disease burden in the affected individuals and households (Fig. 8.1).

8.1.5 Disease Burden and Financial Capital Financial capital refers to wealth such as money or any mechanism that represents wealth and can be used for transaction, e.g. savings, credit and purchasable items. Management of any disease demands finances from the infected individual as well as their family/household and respective governments. As such disease does not only bring strain on family finances but also the productivity of the family as well as the nation. National disease control programmes require financial commitment from governments, politicians, as well as international organizations and non-governmental organisations (Jamison et al., 2006; Kirigia & Barry, 2008; Lim et al., 2017; Taleo et al., 2017; Wagstaff, Claeson, Hecht, & Gottret, 2003; Welburn et al., 2015). The disease burden in resource poor countries requires financial commitment at all levels, household, community, national and global level (Hotez, 2011; Orenstein et al., 2015; World Health Organisation (WHO), 2016). Lack of resources affects implementation of various interventions including access to medicines, fighting epidemics, thus contributing to disease burden (Fig. 8.1).

8.1.6 Livelihood Determinants and Disease Burden Livelihoods provide a source of income, nutrition (food) and have direct effect on health (Mphande, 2016). Poor intake of micronutrients has been associated with maternal and infant malnutrition. Most often poor nutrition is associated with lower income and or poverty. Malnutrition may lead to weakened immune function, resulting into increased severity and incidence of infectious diseases such as pneumonia, diarrhea, and malaria, TB and HIV. Malnutrition is known to increase the severity of infections such as malaria, tuberculosis, and HIV (Katona & Katona-Apte, 2008; Müller, Garenne, Kouyaté, & Becher, 2003). Other factors that could contribute to disease include; gender, inherited livelihoods, predisposed livelihoods, migration, spontaneous livelihoods, age, access, education level and family size.

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8 Reducing Burden of Disease

Gender and Disease

Gender plays an important role in disease, from caring for the sick, to cultural norms that define how different genders should behave and or carry themselves. Cultural expectations on how each gender should be, has affected the genders’ treatment seeking behaviour, disease reporting as well as social status. In Ethiopia it was observed that in patients with podoconiosis, more males were married compared to females, with more female patients being divorced compared to their male counterparts (Molla, Tomczyk, Amberbir, Tamiru, & Davey, 2012). This in turn may encourage women to hide the disease and abstain from seeking help. Outreach programs to reach vulnerable populations have helped to empower these communities and enhanced efforts of disease prevention and control through community awareness (Euser et al., 2012). Social and cultural contexts within the various countries can affect how the different genders are viewed in the context of having the disease. In communities where males are viewed as bread winners, most if not all decision within the household need to be approved by the head of the household. These decisions include how money should be spent and what takes priority. Thus, decisions such as screening for HIV, antenatal care, vaccinations and any preventative measures that may be contrary to the societal norms could be met with resistance thereby perpetuating disease (Finlayson & Downe, 2013; Khan & Qazi, 2013). On the other hand, women show greater participation in health campaigns/programs while men are reluctant to do so. Thus, men may miss out on health education as well as important information regarding disease, prevention and control.

8.1.6.2

Inherited Livelihood and Disease

In most resource poor communities, the environment plays an important role for their survival. These communities depend on the environment for food, water, shelter and livelihood. With population growth, people have encroached further and further into land which was not habitable exposing themselves to new parasites, and disease vectors. Inherited livelihoods most of which are dependent to the community and their surrounding environments, can trap people in a place where they are vulnerable to disease. People learn to accept these ailments as part of their lives and often have local/traditional remedies from the environment. The morbidity that ensues from the disease can affect productivity of the community and may result in disability further exacerbating the burden of disease.

8.1.6.3

Predisposed Livelihoods and Disease

Farmers with land in areas infested with black flies associated with onchocerciasis (river blindness) weigh the options of losing their land or staying on the land and risk contracting the disease (Mengistu, Balcha, & Britton, 1999; WHO, 2017). The same

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situation applies for individuals living in areas where diseases are endemic. Even though the risk of exposure to disease is high, this is the only place they call home and they can carry on with their livelihood; the diseases are part of their community (Cocks et al., 2016; Heukelbach et al., 2003; Leekassa, Bizuneh, Alem, Fekadu, & Shibre, 2005; Mutebi et al., 2015; Satimia, McBride, & Leppard, 1998; Yotsu et al., 2018). In Ethiopia while the lowlands farming communities are struggling with visceral leishmaniasis, the highlands are struggling with podoconiosis a disease affecting people walking bare feet and is associated with soil (Gadisa et al., 2015; Molla et al., 2012).

8.1.6.4

Migration, Spontaneous Livelihoods and Disease

Migration due to economic hardships, political instability, natural disasters and various reasons has forced people to find work for survival. People shift into unplanned livelihoods to find income for survival. Spontaneous livelihoods are most often not out of choice but out of need to survive. Migrants and those affected by natural disasters maybe exposed to all kinds of diseases as they move from place to place and most often with poor access to health. Refugees, asylum seekers as well as illegal immigrants are exposed to poor living conditions some of which put these populations at risk of communicable and non-communicable diseases. Lack of and or poor access to health facilities may result in missed vaccinations, poor or lack of diagnosis of diseases and most often death from preventable causes. In order to earn a living some of the vulnerable populations find themselves trapped in unplanned livelihoods such as prostitution, while other are trafficked, fall into drug abuse, and child labour in a promise of a better life (Fakayode, Falola, Obakeye, & Adeyemo, 2016; Kwiringira et al., 2019). While these occupations may temporarily alleviate their monetary needs, they may seriously contribute to disease burden.

8.1.6.5

Age, Access, Level of Education and Size of Family

Migration and spontaneous livelihoods have been associated with vulnerable populations around the world. These vulnerable communities include children and the elderly most of which are also affected by skin diseases and other communicable diseases. Livelihood determinants such as age, access to basic necessities, level of education and size of the family are factors for consideration in the discussion of disease burden. Skin diseases such as scabies, tungiasis, impetigo, and tinea show a significant association between age and burden of disease. Age: According to a study by the Global Burden of Disease worldwide (GBD), scabies was responsible for 0.21% of DALYs with east Asia, southeast Asia, Oceania tropical Latin America and south Asia carrying most burden (Karimkhani, Colombara, et al., 2017). By country, Indonesia, China, Timor-Leste, Vanuatu and Fiji

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carried the highest burden of the disease with the greatest DALY burden in children, adolescents and the elderly (Karimkhani, Colombara, et al., 2017). A study in Malawi revealed that 24.3% of new cases of leprosy were children. Scabies, tungiasis and dermatophytes have been observed to be common among school going children (Msyamboza et al., 2012), in Ethiopia tungiasis was highly prevalent in school children (Hay et al., 1994; Hotez & Kamath, 2009; Satimia et al., 1998; Walker et al., 2017; Yotsu et al., 2018). Children have also been affected by other neglected skin diseases such as yaws and buruli ulcer. These diseases have been shown to have a significant effect in the children’s education as well as social development (Aboagye et al., 2017; Marks, Vahi, Sokana, Chi, et al., 2015; Marks, Vahi, Sokana, Puiahi, et al., 2015; Mitjà et al., 2017; Narain, Jain, Bora, & Venkatesh, 2015; Vincent et al., 2014; Yotsu et al., 2018). Access: Morbidity due to skin conditions and infections results in crippling effects and disability. These morbidities have resulted in stigma and often denied the affected individuals’ access to needs including education, social participation and financial privileges such as loans. Lack of access could imply poor and or lack of education for children, and loss of livelihoods in adults (Effah, Ersser, & Hemingway, 2017; Feldmeier, Sentongo, & Krantz, 2013; Girma, Astatkie, & Asnake, 2018; Kofie, Attua, & Nabila, 2008; Quinn, Massey, & Speare, 2015; Satimia et al., 1998). Thus, individuals will try to hide diseases as much as possible in order to gain access to their various needs. In hiding the disease, more people may be exposed to disease and in case of migrants, the disease may spread further across borders creating a far greater disease burden. Family size: For diseases that can easily spread within the household, family size is a factor for consideration. If the family size is big and the household is crowded; diseases such as scabies can easily spread. Overcrowding has been associated with the spread of scabies as well as other ectoparasitic diseases (Oke, Onayemi, Olasode, Omisore, & Oninla, 2014; Rosumeck, Nast, & Dressler, 2018). In vulnerable communities, ectoparasitic diseases pose a huge disease burden.

8.2 Risks and Challenges To understand the burden of disease within communities there is need to understand the risks and challenges faced by these communities with regard to disease exposure, management, prevention and control (Fig. 8.2). While mortality in form of reported deaths has been often used as part of the measure for disease burden, it is just a tip of the iceberg; undeclared morbidities conceal the actual burden of the disease. Although there are commonly known risks and challenges for some disease, the unknown challenges and risks further complicate efforts of reducing the disease burden.

8.2 Risks and Challenges

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Fig. 8.2 Burden of disease—risks, challenges, morbidity. Most skin diseases and disorders are under reported and may go unnoticed within the affected communities and countries

Death

Known Morbi ty

Known Risks and Challenges

Undeclared Morbidi es

Unknown Risks and Challenges

8.2.1 Unknown Risks and Challenges Unknown risks and challenges may come in different forms; it could be in form of natural disasters or disease outbreaks, migrant populations as well as lack of information on the existing risks and challenges in a particular setting. Undeclared and or hidden morbidities may be in various forms including psychological, physical and social morbidities. It was observed that female spousal care-givers suffered more mental morbidity, physical morbidity and social morbidity compared to their male counterparts (Li & Loke, 2013). Other hidden morbidities (though not so hidden) include inequality in the quality of healthcare, this maybe on racial grounds, disparities between the rich and the poor and between rich and poor economies (Shemesh, Kleinman, Howell, & Annunziato, 2014). There are suggestions that people with underlying disease such as HIV/AIDS maybe at increased risk of contracting infectious diseases including SD (Premaor & Compston, 2018). Individuals with compromised immunity due to underlying diseases not only can catch skin diseases but also these diseases may present themselves in a much more aggressive manner presenting a huge burden. Apart from underlying disease, erratic use of topical and oral medications could lead to complications including growing resistance to antifungal agents. Since the beginning of this decade, India has been experiencing increased cases of chronic dermatophytosis. A report published in 2019 has shown through antibody and molecular studies that there is a switch in the fungus responsible for the disease; from T rubrum to T mentagrophytes. Further sequencing of the isolates revealed a specific genotype, “Indian ITS genotype” which could be associated with the widespread exploitation of topical clobetasol and other steroid molecules mixed with antifungal and antibacterial agents (Nenoff et al., 2019). Without further research in causes of morbidity, unknown risks including resistance genes can spread within communities for a while without recognition, further exacerbating the morbidity. Habits such as sharing of clothes and linen could also contribute to the growing spread of diseases in certain

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communities. Understanding the habits within families and communities could be beneficial in identifying unknown risks and causes of morbidity.

8.3 Disease Burden and Communities Various communities present different challenges regarding risk of disease. Some of the challenges include; • • • •

Community response to interventions, disease prevention and control program, setting, whether it is a rural or urban community, culture, predisposed culture and traditions that govern these communities and, livelihoods, the various ways the community is able to earn income; are some of the variables that could play a role in disease burden (Fig. 8.3).

8.3.1 Disease Burden and Community Setting Communities around the world are all unique in terms of their location, environment and surroundings, underlying culture and livelihoods. These factors not only define the community but also play an important role in designing, implementation, management, control and prevention of diseases. A Cochrane review on interventions for

Seƫng • What interven ons are applicable in a par cular se ng

Disease Burden

Culture • How predisposed cultures affect implementa on of interven ons

Livelihood • Sustainable livelihood and disease vulnerability

Fig. 8.3 Disease burden and communities. Setting, culture and livelihood are an essential part of a community and could be essential tools in designing strategies to combat disease burden in resource poor countries

8.3 Disease Burden and Communities Table 8.1 Setting plays an important role in risks of disease; people in urban and rural settings are exposed to different environments all of which could be associated with disease and disease outcome. Source Marfortt, Josviack, Lozano, Cuestas, Agüero, & Castro-Rodriguez (2018)

137

Setting Rural

Urban

Higher prevalence of vaginal deliveries

More parental history of allergies

Longer duration of exclusive breast feeding

Increased proportion of SPTa

Earlier onset of wheezing (for asthma)

Increased proportion of APIb scores

More siblings Higher rate of parental smoking Unpasteurized milk consumption Exposure to farm animals Exposure to chemicals for plant fumigation a SPT—Skin

prick test performance index

b API—Academic

improving outcomes in patients with multi morbidity and community care settings suggested the need for targeted interventions such as targeting a specific risk factor or challenge (s) individuals face with daily functioning due to disease (Trivedi, 2017). In the case of urban and rural setting, it is not only the differences in the physical environment that distinguish these settings but also the activities and lifestyle that govern these settings that play a role in the health and livelihood of communities. A study in Argentina comparing a rural farm town and urban town, 50 km away highlights the differences a setting has to risk of disease (Marfortt, Josviack, Lozano, Cuestas, & Agüero, 2018) (Table 8.1). The study showed that even though there was no difference in age, weight, height, birthweight, or gestational age between groups; there was a difference in disease outcome. The study found that maternal smoking and a positive Skin Prick Test (SPT) result increased the risk of an asthma diagnosis, whereas living in a rural area and having more siblings decreased the risk (Marfortt, Josviack, Lozano, Cuestas, & Agüero, 2018). In diseases such as podoconiosis, LF and Tungiasis, community based interventions have been shown to reduce stigma and mental health challenges due to disease. These interventions can be small scale from dressing and cleaning up wounds, to health education and management of chronic SD. In Ethiopia NGOs and faith-based organizations have created outreach programs providing treatment and care for people with podoconiosis. One organisation, Mossy feet, has been working with podoconiosis patients and turning them into community agents, able to identify patients and supporting self-care. These agents receive training which enables them to perform these tasks. These community based organisation also encourage individuals with disease to identify training, employment, and personal-development opportunities

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within the community sector. This socio-economic rehabilitation among individuals with podoconiosis has enhanced entrepreneurship through skills training, and provision of loans and educational opportunities. These opportunities may play key roles in reducing stress and other health related issues associated with stigma. Despite these interventions mental illness due to chronic SDC such as podoconiosis and LF and other debilitating SD still attract considerable stigma in affected individuals and populations. Given the similarities between the consequences of mental-health and stigma due to skin NTDs, complementing existing interventions for skin NTDs with those in the mental health field to deal with the burden of disease could be of interest. In Nigeria, community health workers have used the media to convey messages challenging misconceptions around mental health. The media campaign included jingles, radio announcements, and newspaper coverage. With appropriate training, this is a strategy that could be mimicked in combating stigma around SD to help reduce the psychological burden of the disease. Initiating conversations within communities on SD could be a great support not only for the affected communities but also the individuals living with the disease. Integrated health care services combining mental health services and debilitating SD and skin NTDs could be the way forward to reduce the burden of disease.

8.3.2 Disease Burden and Culture Culture encompasses customs, art, and social institutions of people and social groups. It defines the social behaviour, values and norms in a society. Culture is often transmitted through social learning and behaviour that supports the needs of the society according to the setting. As such within the same country, different communities in varying settings possess diverse cultural norms most of which could be unique and or overlapping. These cultures also determine how communities use healthcare services (Yapa & Bärnighausen, 2018). Culture, beliefs, experiences, skills and practices of native communities in different parts of the world has helped preserve traditional medicine. Traditional medicine is also known as alternative medicine. With lack of policies in many countries on traditional medicine, it is hard assessing the quality of traditional medicine and their products. There are cases in some communities where if western medicine fails to resolve a disease, individuals may turn to traditional medicine and vice versa. A study in Nigeria showed that some women in urban Nigeria sought rural-based healthcare services (traditional/cultural therapies) to tackle disease (“WHO | Rapid diagnosis of Buruli ulcer now possible at district-level health facilities,” 2016) (Izugbara & Afangideh, 2005). Traditional medicine is used in Asia and Africa with approximately 80% of the population depending on traditional medicine for primary healthcare. Artemisinin isolated from Artemisia annua L., used in treatment of malaria had been used for over 2000 years in China as a traditional medicine before it was discovered as an anti-malarial drug.

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Although these traditional also known as herbal medicine are widely used not all countries have regulations governing these medicines (Chaudhury & Rafei, 2001). Despite the availability of traditional medicine, poor diagnosis, and management of complications that may arise could complicate disease outcomes thus contribute to disease burden.

8.4 Public Health and Policy Aspects on Skin Diseases The direct and indirect sociocultural, economic, and health impact of skin diseases is frequently undervalued and misconstrued. Skin diseases have been neglected by the scientific community with very little research and research funding dedicated to these diseases. Policy makers often neglect SD as these diseases often affect remote and or resource poor communities. This is evidenced by limited investment in training specialists and dedicated clinics and or hospital wards to deal with SD and complications arising from these diseases. Most SD are not listed as priority diseases for control and prevention at community, national, regional and international level. Although channels exist for reporting of various infectious diseases, the burden of skin diseases is under reported. This may reflect on the priority attributed to SD both at national and global level. Sociocultural consequences such as stigma; limited data and classification where certain SD are placed under the umbrella of another disease may also contribute to the current available statistics on skin diseases. Hence if the available data is used for decision making and policy, the burden of SD could be misrepresented, and the response may not be representative of the actual burden.

8.5 Conclusion Combining resources such as human capital (skills), financial capital (resources), social capital (interactions and networks between stakeholders and communities), physical capital (mechanical resources to achieve different goals) and natural resources (what is available in the community setting) when designing community interventions is another factor for consideration. Implementation science is one tool that could be exploited in dealing with skin diseases in various settings. Identifying interventions that can successfully work in various financial settings could be essential in reducing the burden of disease. Interventions that require advanced technology may prove valuable in countries with ample resources than in limited resource countries. The challenge is to bring quality care with the resources available. Developing capacity within the local community to understand the health system and its approaches to disease as well as training health systems to engage and understand the perspective of the community towards health and disease could prove resourceful for successful implementation of interventions.

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Chapter 9

Milestones; Disease Elimination Success Stories

Abstract Since the eradication of smallpox worldwide in 1979, there have been efforts to eradicate malaria, yellow fever and yaws. Despite these efforts being unsuccessful they have contributed to better understanding of the various complexities in disease control. Currently, efforts are being made to eradicate polio and guinea worm disease. Decreasing or stopping infectious diseases in their path has been the goal for many public health practitioners for many decades. In order to interrupt transmission of disease and or achieve elimination, there is need for strategies that will be able to stop the disease in its paths. These strategies should include commitment from governments, communities, as well as collaboration with other stakeholders both locally and within the region. In this chapter elimination strategies used for Guinea worm, river blindness and lymphatic filariasis will be outlined. Whether these strategies could also be applied to other skin diseases is something for consideration. Keywords Elimination · Eradication · Interrupting transmission · River blindness · Onchocerciasis · Guinea worm · Malaria · Turkmenistan · La Reunion Synopsis In the past decade, there have been many success stories of elimination providing a glimmer of hope in the fight against infectious diseases. Some of the milestones include; elimination of onchocerciasis in Colombia, Ecuador, Mexico and Guatemala. The fight against onchocerciasis has been going on for almost half a century culminating in elimination success. Some of the strategies used include; Government commitment to fight disease, financial commitment and having the required skill set to fight the disease. A concerted effort from various stakeholders was also crucial. Disease elimination and eradication is a conversation which will continue for many years to come.

9.1 Disease Elimination and Eradication Since the successful eradication of smallpox over four decades ago, there have been success stories of elimination of diseases in various countries. What is the difference between disease eradication and elimination? © Springer Nature Singapore Pte Ltd. 2020 F. A. Mphande, Skin Disorders in Vulnerable Populations, https://doi.org/10.1007/978-981-15-3879-7_9

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According to Dowdle, disease elimination could be defined as reduction of the incidence of a disease or infection down to zero in a defined geographical area; while disease eradication is the permanent reduction of incidence of disease/infection to zero worldwide (Dowdle, 1998). While routine intervention measures may no longer needed after eradication has been achieved, there is need for continued interventions even after reaching control and elimination targets (Hotez, 2011; Karunaweera, Galappaththy, & Wirth, 2014; World Health Organisation (WHO), 2016). Disease control is defined as the reduction in incidence, prevalence, morbidity and or mortality of an infectious disease to a locally acceptable level (Dowdle, 1998; Heymann, 2006). In the past decades, re-emergence and re-establishment of diseases have occurred in places where the diseases were once controlled and or eliminated due to misunderstanding of the concept of disease control and elimination. Complete cessation of intervention activities, a reduction or complete stoppage of financial commitment to these interventions have led to re-emergence of diseases of interest (Heymann, 2006). In Sichuan province schistomiasis re-emerged 8 years after achieving control and interruption of transmission. Lack of continuation of some of the interventions that helped attain the control target were identified as contributing to the re-emergence of the disease (Liang, Yang, Zhong, & Qiu, 2006). Achieving disease control and elimination targets in one locality while surrounded by other localities that are yet to achieve this target has many challenges. These challenges include human migration, where there is fluid movement of people from areas that are yet to achieve control and elimination of the target disease to those that have achieved it (Institute of Medicine, 2003).

9.1.1 Diseases up for Eradication Achieving disease eradication and or elimination goals is no easy task but with the right strategies and resources it is possible to achieve these goals. As of 2019 the following skin diseases were sanctioned by the WHO for eradication and or elimination (Table 9.1).

9.2 Disease Eradication and Elimination Terminology In order for a disease to be declared eradicated and or eliminated, there are guidelines that have been put in place to validate the claims. Previously, different definitions for elimination were used by different countries for different diseases. This created confusion. To eliminate this confusing nomenclature, in 2016, WHO published a generic framework for NTDs to standardize the definitions of the targets and processes by which it would assess and acknowledge the claimed achievements among the NTDs.

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Table 9.1 List of skin diseases for eradication and elimination, dracunculiasis, leprosy, onchocerciasis, and lymphatic filariasis Diseases up for eradication

Diseases up for elimination

Dracunculiasis (Guinea worm disease): 1988 AFRO, 1991 WHA44.5, 2004 WHA 57.9. Target: 1995; revised to 2009

Leprosy: 1991 WHA44.9. Target: reduce cases to < 1 per 10,000 population by 2000 (quantitative) Onchocerciasis (West Africa OCP): 1973 Agreement. Target: eliminate onchocerciasis “as a public health problem” in OCP area by 2002 (qualitative) Onchocerciasis (Americas): 1991 PAHO:XIV. Target: eliminate “as a public health problem in the Americas” (morbidity) by 2007 (qualitative geo-graphic) Lymphatic filariasis: 1997 WHA50.29. Target: eliminate globally “as a public health problem” (informally: by 2020) [cites International Task Force for Disease Eradication]

Source https://www.cartercenter.org/health/itfde/who.html

Some of the definitions are outlined below. Elimination as a public health problem (EPHP) is achievement of global targets set by WHO for a specific infection and/or disease and when achieved requires continued action to maintain the target or to advance to the interruption of transmission. Countries claiming to have met the targets follow a process called validation to document EPHP. Elimination of transmission (EOT) or interruption of transmission is the reduction to zero of the incidences of infection in a defined geographical area with minimal risk of reintroduction where continued actions to prevent re-establishment of transmission may be required, but ongoing interventions (such as MDA) can be suspended. Verification, the process to document EOT. Eradication is the permanent reduction to zero of a specific pathogen globally, with no more risk of reintroduction; the process of documenting eradication is certification. Effort and evidence required to document achievements increases with EOT requiring more evidence and effort compared to EPHP and eradication requiring more evidence and effort compared to EOT and EPHP. WHO is yet to define the pathway, milestones and standardize the procedure.

9.2.1 Lymphatic Filariasis (LF) in Sri Lanka Sri Lanka was validated by WHO to have achieved EPHP level for LF. But before achieving EOT, the country faced a subtle pressure to downplay persistent LF in

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some problem areas. This led to decline in donor support for drug donations, diagnostic kits and operational activities. Lack of donor support meant that activities that led to the achievement of EOT before were not possible and or could not be carried out as effectively leading to re-emergence (recrudescence) of the disease in the communities that were once declared disease free. Premature loss of donor support was also reported for leprosy programs after the disease was declared to have achieved EPHP (Chandrasena, Premaratna, Gunaratna, & de Silva, 2018; Rao et al., 2014). Despite these challenges, Having EPHP as a target, however, has enabled substantial improved control of onchocerciasis, trachoma, leprosy and human African trypanosomiasis, as well as LF.

9.3 Strategies in Disease Elimination Achieving elimination of a disease is a process that requires commitment and strategy. By looking at the strategies employed by countries that have managed to achieve elimination of certain diseases, these could provide a way forward for countries that are yet to achieve this goal. In this section strategies that have been used in elimination and fight against guinea worm and river blindness in several countries will be reviewed. Strategy 1: Health Education and Simple, Low Cost Methods The Carter foundation has been working towards eradication and elimination of six neglected diseases. These include; river blindness, guinea worm, trachoma, schistomiasis, Lymphatic filariasis and malaria. Their strategy is to use health education, simple and low-cost methods. For the elimination of the guinea worm, water filtration using a cloth (filter) was the simple method used in the disease prevention program. While in the household a cloth would be used to filter the water, for people who are mobile, they have pipes fitted with filters, that allows them to drink water from rivers and water sources that could be infested with worms https://www.carter-center.org/health/guinea_worm/. Strategy 2: Use of Medicine through Mass Drug Administration MDA has allowed for successful elimination of river blindness in Colombia, Ecuador, Guatemala and Mexico (Colebunders et al., 2018; Nicholls et al., 2018; World Health Organisation (WHO), 2016). Mectizan has been used in the onchocerca MDA campaign. Mectizan (Ivermectin) kills the larvae in the human body (Lustigman & McCarter, 2007; Sauerbrey, 2008; Winthrop et al., 2011). By killing the larvae, morbidities such as, blindness, skin disease in infected persons and transmission of the parasite to others is stopped. Apart from MDA, health education has been used as another strategy to fight the disease. Although the disease has not be eradicated globally at present; there is a possibility of eliminating the disease in selected regions (https://www.cartercenter.org/health/guinea_worm/). While 1% of the disease occurs in South and Central America, 99% of the disease burden is in Africa. MDA with

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Bi-annual MDA of ivermec n implemented, complemented by health evalua on and community par cipa on

Onchocerciasis discovered in Colombia

1993 1965

Interrup on of parasite transmission; no infec on in flies

1998–2007 1996

Onchocerca elimina on program established (OEP)

WHO verify Colombia free of onchocerciasis

2008–2010 2004

In-depth parasitological, serological and entomological surveys conducted periodically to assess the impact of ivermec n

2013

Drug distribu on seized and observa on of 3 year post transmission surveillance

Fig. 9.1 Elimination of River blindness in Colombia. A timeline showing the steps towards elimination of onchocerciasis (river blindness) in Colombia, the first country to be declared free of the disease by WHO

Mectizan twice per year has managed to break transmission in Uganda and Sudan https://www.cartercenter.org/health/guinea_worm/. Colombia was the first country to eliminate river blindness. How did Colombia achieve this milestone? It took Colombia 12 years of 6 monthly MDA and 23 rounds of treatment using Ivermectin, serological tests, laboratory tests (PCR) and surveillance to fight the disease. Ivermectin was distributed to all eligible residents in endemic areas. From the time the disease was discovered in Colombia in 1965 to the time of elimination verification in 2013, it took almost five decades (48 years) (Nicholls et al., 2018; Sauerbrey, 2008). The commitment to eliminate the disease and the availability of resources to achieve elimination were some of the key factors to this milestone (Fig. 9.1). Other Milestones in the fight against River blindness include: • Interruption of transmission in Nigeria that saw cessation of the ivermectin MDA covering 2 million residents. • Distribution of more than 240 million treatments of Mectizan in Africa and Latin America. • Colombia became the first country to eliminate river blindness in 2013. • In 2014, 2015 and 2016; Ecuador, Mexico and Guatemala, respectively, received official verification for elimination of river blindness. Strategy 3: The door to door strategy to search for persons with skin disease This strategy has been used in the fight against malaria. The door to door strategy could incorporate health education and search for various cases of SD. Through active surveillance, the health agents could identify common SD in communities, collect samples for diagnosis and further analysis, estimate the prevalence of SD in the affected communities. This strategy requires trained personnel, financial commitment for all stakeholders, NGO’s, governments and communities.

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Strategy 4: Identify vulnerabilities This strategy requires a careful assessment of factors that make the communities vulnerable to skin diseases. These factors may include; • • • • •

Location and surrounding, such as proximity to endemic areas, Population movement and or migration, Presence and or absence of surveillance and the methods of surveillance in place, Availability and quality of treatment, Possible risk factors associated with lifestyle and pre-disposed livelihoods.

Strategy 5: Choice and implementation of interventions The choice of a strategy or a combination of strategies requires an equally effective implementation technique. There is need for a multifaceted approach including sufficient administrative support, eliminating superfluous beaurocracy, and corruption that could hamper the implementation efforts. Choice of the appropriate implementation strategy may require ability to; • • • • • • • • • • •

Identify and recognize outbreaks Eliminate the source of infection in order to interrupt transmission Identify risk groups Actively look for cases through house to house surveys Confirm cases through microscopy and molecular techniques Mandatory reporting of all SD Employ active and passive detection of cases Obtain drugs for intervention Provide prophylaxis Re-enforce surveillance for SD Provide free treatment and allocation of hospital wards for treatment and management of SD e.g. management of elephantiasis, podoconiosis, tungiasis, scabies, buruli ulcer e.t.c • Provide health information, education and communication (IEC) and behaviour change communication (BCC) through materials that are developed and distributed to families, residents in endemic and areas surrounding endemic regions. Strategy 6: Management of Cases Management of cases not only applies to endemic areas but also areas that could be possible sources of the disease outside the endemic zone. Management of cases includes; • • • • •

Early treatment of imported cases Surveillance for environmental sources and or reservoirs of disease Active case detection for people travelling from endemic areas Interregional collaboration, A systematic prophylaxis in schools

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• Destruction of mosquito breeding sites • Active case detection every 2–4 months in schools • Surveillance of households in endemic areas

9.4 Custom Made Strategies (CMS) Custom made means something made with specifications that are well suited for the intended individual. Therefore, custom made strategies are those that are suited for the intended individual, community and or specific geographic region or climate. For example, in Chad nomadic communities are known to move from place to place in search for pasture for their livestock. Since these communities are mobile, it is very difficult to administer vaccinations and other interventions for disease control and prevention. An increase in vaccination coverage was achieved by recruiting local nomads to identify nomad settlements, mobile vaccination teams, using social mobilization and vaccinating women, children and animals (Ndiaye et al., 2014). The success was attributed to; • Intersectoral collaboration between animal and human health services, • Flexibility of vaccinators who were able to vaccinate nomads no matter when and where the nomad communities were, • Government participation and, • Dedicated staff. The carter foundation, in their fight against Guinea worm employed an effective way where people can drink from any source without contracting the parasite. Using a straw-like pipe fitted with a filter, the infective stages of Guinea worm are not able to cross the filter to infect people. The filtered pipe is portable, and people can carry it with them anywhere. This custom made strategy has helped reduce infections of Guinea worm https://www.cartercenter.org/news/features/h/guinea_worm/ guinea-worm-feature-011117.html. Custom made strategies could assist in; 1. Accessing difficult to reach populations 2. Assist in breaking through cultural and communication barriers by involving people who have knowledge and understanding of the target community 3. Use delivery methods that are suitable and sustainable in the target communities Whether it is possible to design CMS to prevent and control skin diseases is a question that needs to be answered. With ample research and commitment of various stakeholders, this question will be answered in the near future.

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9.5 Problems, Constraints and Success a. Relaxed surveillance After achieving interruption of disease transmission, there is often a challenge that countries relax their fight towards elimination. This can be in form of relaxed surveillance, where resources for surveillance of disease are reduced. This may result in missing out possible resurgence and or re-emergence of the disease. Relaxed surveillance has often resulted into re-introduction and or re-emergence of a disease in areas where the disease was at the verge of elimination. Re-emergence of the disease can be attributed to several reasons. These include; • Treatment failure, • Individuals who missed mass treatment campaigns who act as possible reservoirs of the disease, • New infections. b. Shortage of qualified staff To achieve the set strategies for elimination of a particular disease, availability of skilled staff in various disciplines is required. For example, for a vectorborne disease such as river blindness, there is need for qualified skilled staff including; epidemiologists, entomologists, nurses, doctors, community health workers, laboratory technicians and many more. The skill set required for disease elimination is vast and is determined by the strategies to be implemented. Implementing scientifically sound and evidence-based approaches is required for successful management of SD. These include; • • • •

Epidemiological methods focusing on finding the source of infection, Identifying mode of transmission, Monitoring the healthy population for signs of disease, Mobile teams of professionals, epidemiologists, dermatologists, clinicians and laboratory technicians able to promptly respond and ensure coverage, performance and rapid case detection of SD in the affected areas.

9.6 Conclusion This chapter elucidates the complexity of the process and the commitment required to make disease elimination and eradication achievable. Collaboration between government, the community and other stakeholders in management and implementation of the interventions is crucial. Government commitment through financing and management of intervention programmes is necessary if elimination and or interruption of transmission is to be achieved. Vector management and employing the right strategy

9.6 Conclusion

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for prevention in a particular setting can make a difference between success and failure. Interregional cooperation is required to manage cross border migration, imported cases and well as surveillance. Custom made strategies are required because even though the populations face the same diseases, the factors that perpetuate disease in every setting are often different.

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Index

A Adaptive immunity, 18, 19 Aetiology, 24, 27, 29 Age, access, level of education and size of family, 133 Ancylostoma braziliense, 39 Anthropophilic, 51, 122 Arthrospores, 52 Asynchronous (store-and- forward) model, 92 Autophagy, 18

Colombia, 83, 147, 151 Community Volunteers, 48, 70 Congo, 46, 100 Control and Prevention of Skin Diseases, 8, 18 Cost of treatment, 5, 27, 77 Custom Made Strategies, 153 Cyclops, 32, 34, 44

B Bacteria, 13, 14, 16, 19, 23, 24, 26, 28, 29, 40, 41, 44, 47, 78 Bacterial Skin Diseases, 40 Bairnsdale ulcer, 44 Barcelona, 119, 120, 121 Benin, 48, 99, 100 Benzathine Penicillin, 43 Blackfly, 25, 33, 35 Brugia malayi, 34 B. timori, 34, 36 Burden of disease, 1, 3, 89, 102, 114, 127, 135 Buruli Ulcer, 8, 25, 40, 44, 65, 68, 69, 75, 76, 89, 97, 98, 134, 138

D Daintree ulcer, 44 DALYs, 1, 2, 4, 102, 114, 133 Dermatome, 50 Dermatophytes, 23, 51, 53, 119, 120–122, 134 Dermis, 13, 15, 16 Diagnostic Tools and Treatment, 79 Disability, 2, 3, 6, 29, 43, 49, 66, 69, 76, 86, 97, 98, 102, 114, 130, 132, 134 Disease Burden and Communities, 136 Disease Burden and Community Setting, 136 Disease Burden and Culture, 138 Disease elimination, 147, 148, 150, 154 Disease eradication, 147, 149 Disfigurement, 30, 33, 43, 47, 66–68, 102 Doxycycline, 43

C Cambodia, 102, 103 Cameroon, 7, 43, 46, 48, 75, 77, 78, 87, 105, 111 Challenges Faced by the Existing Tools, 88 Challenges of MDA, 85

E Early Detection of Disease, 75, 78 Economic burden, 38, 113 Ecthyma, 42 Ecuador, 83, 147, 150, 151 Eczema, 57, 58

© Springer Nature Singapore Pte Ltd. 2020 F. A. Mphande, Skin Disorders in Vulnerable Populations, https://doi.org/10.1007/978-981-15-3879-7

177

178 Elephantiasis, 36, 67, 97, 113, 152 Elimination, 40, 74, 83, 84, 86, 98, 109, 116, 147, 150, 151, 154 Endothrix infections, 52 Epidermal parasitic skin diseases, 16, 23, 24 Epidermophyton, 51, 120, 125 Erythrodermic psoriasis, 54 Erythromycin, 43 Ethiopia, 32, 38, 68, 79, 88, 112, 117, 132, 137 Extrinsic, 23, 27

F Fatal disease burden, 2, 65 Fiji, 3, 83, 85, 102, 104, 133 Financial capital, 129, 131, 139 Fungi, 13, 14, 16, 19, 23, 51–53

G Gender and disease, 132 Geophilic, 51 Ghana, 45, 46, 48, 84, 101, 111 Global campaign to eradicate dracunculiasis, 87 Global Plan, 7 Global Plan to Tackle Skin Diseases, 89 Global Programme to Eliminate Lymphatic Filariasis (GPELF), 86 Group A Streptococci, 30 Guatemala, 83, 118, 147, 150, 151 Guinea worm, 24, 25, 32, 34, 35, 65, 87, 97, 147, 149–151, 153 Guinea- worm disease, 24, 25

H Health related quality of life, 1 Healthcare workers, 5, 6, 9, 76 Hemocoele, 68 Herpes simplex virus, 48, 49, 56 Herpes Zoster, 49, 50 Hookworm related cutaneous larva migrans, 24, 25, 39 HrCLM, 24, 27, 39, 40, 41, 97

I Iatrogenic, 24 Idiopathic, 23, 24 Immune responses, 13, 17, 28 Immunity, 13, 17, 135 Impact of skin diseases, 65, 69, 139 Impetigo, 2, 3, 29, 40, 42, 85, 104, 133

Index Implementation Science, 127 Inherited livelihood and disease, 132 Innate immune responses, 13 Intrinsic, 24 Inverse psoriasis, 54 Ivermectin, 83, 85, 86, 87, 151 K Kumusi ulcer, 44 L Leishmaniasis, 8, 24, 25, 31, 32, 65, 68, 89, 97, 114, 116, 133 Leprosy, 5, 7, 8, 40, 41, 44, 67, 89, 97, 100, 114, 149, 150 Lichen Planus, 19, 24, 53, 55, 56 Limited Resource Populations, 6 Livelihood, 4, 5, 29, 47, 68, 127, 131, 136 Low to middle income countries, 3, 42 Lymphatic filariasis, 7, 8, 24, 25, 34, 36, 37, 83, 86, 89, 97, 103, 113, 147, 149 M Malawi, 46, 102, 134 Mass Drug Administration, 73, 83, 85, 103, 105, 150 Mectizan, 83, 150, 151 Mexico, 46, 69, 83, 147, 150 Microfilariae, 33, 35, 37, 86 Microsporum, 51, 52, 120 Migration, spontaneous livelihoods and disease, 133 Molluscum contagiosum, 2, 3 Mortality, 1, 29, 36, 65, 69, 76, 88, 116, 127, 130, 134, 148 Mycobacterium ulcerans, 44 Mycobaterium leprae, 44 N Natural capital, 136 Necrotising fasciitis, 41 Neglected tropical diseases, 1, 4, 5, 8, 97, 102, 105, 114, 119, 120, 145, 156 Nepal, 115 Nigeria, 6, 45, 46, 98, 122, 138, 151 Nodule, 31, 35, 47 O Onchocerca volvulus, 25, 33 Onchocerciasis, 8, 24, 25, 33, 35, 83, 85, 89, 104, 114, 132, 147, 149, 150

Index P Pacific programme to eliminate lymphatic filariasis (PacELF), 87 Papua New Guinea, 43, 46, 83, 110 Papule, 31, 43, 45 Papulosquamous, 23, 53, 67 Papulosquamous skin conditions, 53 Parasites, 13, 14, 16, 23, 27, 116, 132 Pediculosis, 6, 24, 25, 39 Phlebotomus papatasi, 31 Physical capital, 129 Pityriasis rosae, 24, 53 Plaque, 31, 45, 54, 57 Podoconiosis, 36–38, 67, 78, 83, 97, 112, 130, 138, 152 Predisposed livelihoods and disease, 132 Preventable skin infections, 6 Pruritus, 2, 3 Psoriasis, 19, 24, 53, 54 Public health, 1, 38, 65, 75, 83, 139, 149 Pustular psoriasis, 54

R Resident memory T cells, 17, 18 River blindness, 24, 33, 83, 97, 132, 147, 150

S Scabies, 2, 24, 28, 67, 83, 97, 102, 133, 152 Searls ulcer, 44 Seborrheic dermatitis, 53, 55 Shingles, 49 Skin Disease Prevention Strategies, 75 Skin Diseases Within the Community, 76 Skin Health Intervention Fiji Trial (SHIFT), 85 Smallpox, 73 Smallpox Eradication Programme (SEP), 74 Social and Economic Impacts of Skin Diseases, 68 Social capital, 130 Social exclusion, 4, 67, 130 Solomon islands, 3, 30, 83, 105 South East Asia, 8, 36, 46, 89, 102 Sri Lanka, 149, 46 Staphylococcus aureus, 30, 42 Stigma, 4, 5, 26, 33, 38, 47, 65, 68, 77, 97, 130 Streptococcus pyogenes, 42 Superficial Fungal Infections, 23, 51, 119, 122 Surveillance and Collaboration, 75

179 Synchronous (real time) model, 92

T Tanzania, 103 Tele dermatology, 90–92 Telemedicine, 90, 91 Tetracycline, 43 Tinea capitis, 51, 52, 119 Tinea cruris, 51, 52 Tinea pedis, 51, 53, 119, 121 Tinea unguinum, 51 T. mentagrophytes, 120 Traditional treatment approach, 77 Treponema pallidum, 43, 109 Trichophyton tonsurans, 52, 121 Trycophyton rubrum, 52 Trycophyton spp, 52 T. soudanense, 52 Tunga penetrans, 25, 30, 106 Tungiasis, 6, 24, 25, 30, 67, 84, 97, 106, 134, 137, 152 T.violaceum, 52

U Uganda, 46, 76, 106, 151

V Vectorborne disease, 31, 154 Viral Skin Infections, 48 Viruses, 13, 23, 24 Vulnerable communities, 1, 9, 28, 89, 92, 97, 133

W Western Medicine treatment approach, 78 Willingness to Seek Treatment, 76 Woods lamp, 52 Wuchereria bancrofti, 113, 25, 34

Y Yaws, 5, 8, 42, 70, 75, 78, 83, 97, 100, 109, 147 Yeast, 23, 51, 55

Z Zanzibar, 103 Zoophilic, 51, 121