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Skin disease prevalence study in schoolchildren in rural Côte d'Ivoire: Implications for integration of neglected skin diseases (skin NTDs)
research-article
Author(s):
Rie Roselyne Yotsu
1
,
2
,
* ,
Kouamé Kouadio
3 ,
Bamba Vagamon
4 ,
Konan N’guessan
5 ,
Amari Jules Akpa
5 ,
Aubin Yao
5 ,
Julien Aké
5 ,
Rigobert Abbet Abbet
6 ,
Barbine Tchamba Agbor Agbor
7 ,
Roger Bedimo
7
,
8 ,
Norihisa Ishii
9 ,
L. Claire Fuller
10
,
11 ,
Roderick Hay
10 ,
Oriol Mitjà
12 ,
Henning Drechsler
7
,
8 ,
Kingsley Asiedu
13
Publication date (Electronic):
17 May 2018
Journal:
PLoS Neglected Tropical Diseases
Publisher:
Public Library of Science
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Abstract
Background
Early detection of several skin-related neglected tropical diseases (skin NTDs)–including leprosy, Buruli ulcer, yaws, and scabies- may be achieved through school surveys, but such an approach has seldom been tested systematically on a large scale in endemic countries. Additionally, a better understanding of the spectrum of skin diseases and the at-risk populations to be encountered during such surveys is necessary to facilitate the process.
Methods
We performed a school skin survey for selected NTDs and the spectrum of skin diseases, among primary schoolchildren aged 5 to 15 in Côte d’Ivoire, West Africa. This 2-phase survey took place in 49 schools from 16 villages in the Adzopé health district from November 2015 to January 2016. The first phase involved a rapid visual examination of the skin by local community healthcare workers (village nurses) to identify any skin abnormality. In a second phase, a specialized medical team including dermatologists performed a total skin examination of all screened students with any skin lesion and provided treatment where necessary.
Results
Of a total of 13,019 children, 3,504 screened positive for skin lesions and were listed for the next stage examination. The medical team examined 1,138 of these children. The overall prevalence of skin diseases was 25.6% (95% CI: 24.3–26.9%). The predominant diagnoses were fungal infections (n = 858, prevalence: 22.3%), followed by inflammatory skin diseases (n = 265, prevalence: 6.9%). Skin diseases were more common in boys and in children living along the main road with heavy traffic. One case of multi-bacillary type leprosy was detected early, along with 36 cases of scabies. Our survey was met with very good community acceptance.
Conclusion
We carried out the first large-scale integrated, two-phase pediatric multi-skin NTD survey in rural Côte d’Ivoire, effectively reaching a large population. We found a high prevalence of skin diseases in children, but only limited number of skin NTDs. With the lessons learned, we plan to expand the project to a wider area to further explore its potential to better integrate skin NTD screening in the public health agenda.
Author summary
Integration of neglected tropical diseases (NTDs) into the public health agenda has been a priority in global health for the last decade. A common feature shared by several NTDs is skin involvement. Conditions within this group of NTDs have now been classified as skin NTDs to promote wider NTD integration. Several skin NTDs including leprosy, Buruli ulcer, yaws, and scabies are co-endemic in Côte d’Ivoire, West Africa. As children are vulnerable to these diseases, we carried out the first large-scale integrated, multi-skin NTD school survey in a rural district of this country. Our strategy of involving community healthcare workers and dermatologists effectively reached a large population. However, the detection of skin NTDs may have been limited because of the low schooling and attendance rate. We found a high prevalence of skin diseases among schoolchildren (26%), possibly due to poor socio-economic status and air pollution, which requires more attention. This high prevalence of skin diseases posed a challenge for our project as the need for medications and those with dermatological skills exceeded our capacity to reach our initial target population. Our study provides important lessons that will aid the framing of future school skin surveys in sub-Saharan Africa.
Related collections
Most cited references42
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Role and outcomes of community health workers in HIV care in sub-Saharan Africa: a systematic review
Grace W Mwai, Gitau Mburu, Kwasi Torpey … (2013)
Introduction The provision of HIV treatment and care in sub-Saharan Africa faces multiple challenges, including weak health systems and attrition of trained health workers. One potential response to overcome these challenges has been to engage community health workers (CHWs). Methodology A systematic literature search for quantitative and qualitative studies describing the role and outcomes of CHWs in HIV care between inception and December 2012 in sub-Saharan Africa was performed in the following databases: PubMed, PsychINFO, Embase, Web of Science, JSTOR, WHOLIS, Google Scholar and SAGE journals online. Bibliographies of included articles were also searched. A narrative synthesis approach was used to analyze common emerging themes on the role and outcomes of CHWs in HIV care in sub-Saharan Africa. Results In total, 21 studies met the inclusion criteria, documenting a range of tasks performed by CHWs. These included patient support (counselling, home-based care, education, adherence support and livelihood support) and health service support (screening, referral and health service organization and surveillance). CHWs were reported to enhance the reach, uptake and quality of HIV services, as well as the dignity, quality of life and retention in care of people living with HIV. The presence of CHWs in clinics was reported to reduce waiting times, streamline patient flow and reduce the workload of health workers. Clinical outcomes appeared not to be compromised, with no differences in virologic failure and mortality comparing patients under community-based and those under facility-based care. Despite these benefits, CHWs faced challenges related to lack of recognition, remuneration and involvement in decision making. Conclusions CHWs can clearly contribute to HIV services delivery and strengthen human resource capacity in sub-Saharan Africa. For their contribution to be sustained, CHWs need to be recognized, remunerated and integrated in wider health systems. Further research focusing on comparative costs of CHW interventions and successful models for mainstreaming CHWs into wider health systems is needed.
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The global burden of scabies: a cross-sectional analysis from the Global Burden of Disease Study 2015
Chante Karimkhani, Danny V Colombara, Aaron Drucker … (2017)
Summary Background Numerous population-based studies have documented high prevalence of scabies in overcrowded settings, particularly among children and in tropical regions. We provide an estimate of the global burden of scabies using data from the Global Burden of Disease (GBD) Study 2015. Methods We identified scabies epidemiological data sources from an extensive literature search and hospital insurance data and analysed data sources with a Bayesian meta-regression modelling tool, DisMod-MR 2·1, to yield prevalence estimates. We combined prevalence estimates with a disability weight, measuring disfigurement, itch, and pain caused by scabies, to produce years lived with disability (YLDs). With an assumed zero mortality from scabies, YLDs were equivalent to disability-adjusted life-years (DALYs). We estimated DALYs for 195 countries divided into 21 world regions, in both sexes and 20 age groups, between 1990 and 2015. Findings Scabies was responsible for 0·21% of DALYs from all conditions studied by GBD 2015 worldwide. The world regions of east Asia (age-standardised DALYs 136·32), southeast Asia (134·57), Oceania (120·34), tropical Latin America (99·94), and south Asia (69·41) had the greatest burden of DALYs from scabies. Mean percent change of DALY rate from 1990 to 2015 was less than 8% in all world regions, except North America, which had a 23·9% increase. The five individual countries with greatest scabies burden were Indonesia (age-standardised DALYs 153·86), China (138·25), Timor-Leste (136·67), Vanuatu (131·59), and Fiji (130·91). The largest standard deviations of age-standardised DALYs between the 20 age groups were observed in southeast Asia (60·1), Oceania (58·3), and east Asia (56·5), with the greatest DALY burdens in children, adolescents, and the elderly. Interpretation The burden of scabies is greater in tropical regions, especially in children, adolescents, and elderly people. As a worldwide epidemiological assessment, GBD 2015 provides broad and frequently updated measures of scabies burden in terms of skin effects. These global data might help guide research protocols and prioritisation efforts and focus scabies treatment and control measures. Funding Bill & Melinda Gates Foundation.
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Integrated Control and Management of Neglected Tropical Skin Diseases
Oriol Mitjà, Michael Marks, Laia Bertran … (2017)
Introduction Neglected tropical diseases (NTDs) are communicable diseases that occur under conditions of poverty and are concentrated almost exclusively in impoverished populations in the developing world. NTDs affect more than 1000 million people in tropical and subtropical countries, costing developing economies billions of dollars every year. Effective control of NTDs can be achieved with the use of large-scale delivery of single-dose preventive chemotherapy (PC) or intensified disease management (IDM) or both, as is the case for some diseases such as lymphatic filariasis, trachoma, and yaws. Several NTDs exhibit significant cutaneous manifestations that are associated with long-term disfigurement and disability, including Buruli ulcer (BU); cutaneous leishmaniasis (CL); leprosy; mycetoma; yaws; hydrocele and lymphoedema (resulting from lymphatic filariasis); and depigmentation, subcutaneous nodules, severe itching, and hanging groin (resulting from onchocerciasis). Skin examination offers an opportunity to screen people in the communities or children in schools to identify multiple conditions in a single visit. This common approach to skin diseases justifies the integrated delivery of health care interventions to both increase cost-effectiveness and expand coverage. WHO’s Department of Control of NTDs (WHO/NTD) plans to promote an integrated strategy for the skin NTDs requiring IDM. Targeting skin NTDs also provides a platform for treatment of common skin conditions and, therefore, has wider public health benefits. An informal panel of experts (writing this manuscript) was established to help develop guidance in support of the new WHO strategic direction and to develop a proposal for a change in policy for the integrated control and management of the skin NTDs. A symposium at the 2015 ASTMH meeting[1] initiated a discussion of opportunities around integration of surveillance and control of NTDs that affect the skin, but this paper moves these ideas forward and includes some initial recommendations about how these opportunities could be realised. We aim to provide specific pragmatic information and actual recommendations about potential surveillance and management approaches. Burden of Skin NTDs Skin NTDs are frequently co-endemic in many countries, districts, and communities (Table 1). [2–9] While none of the skin NTDs are significant causes of mortality, they are responsible for a large number of disability-adjusted life years (DALYs) lost.[10] For example, contractures and resulting disability in BU, advanced lymphoedema and hydrocele in LF, the consequences of permanent nerve damage in leprosy, amputations in mycetoma, and bone involvement in yaws can lead to debilitating deformities and difficulty in securing employment.[11] 10.1371/journal.pntd.0005136.t001 Table 1 Characteristics of skin NTDs. Causative agent Mode of transmission Natural reservoir Geographic distribution by continent/region (Major affected countries) Key manifestation Complications Peak age (male: female ratio) Incidence (annual) year 6–13 WHO target by 2020 WHA resolution Buruli ulcer Mycobacterium ulcerans Unknown Contaminated water West and Central Africa, Western Pacific Skin ulcer Severe scarring with limb contractures 5–15 (2:1) 2,200 Control WHA57.1 (2004) Cutaneous leishmaniasis Leishmania spp. Sand fly vectors Rodents, Hyraxes Middle East, West and East Africa, Mediterranean basin, and South-America Skin ulcer, papules, nodules or plaques, Disseminated skin disease and significant facial destruction All ages (1:1) 700,000 Control WHA60.13 (2007) Filarial lymphoedema Filariae such as Wuchereria bancrofti Anopheles, Culex and Aedes mosquitoes Human Worldwide distribution Lower limb oedema Lymphoedema and elephantiasis Adults (ND) 970,000 Elimination as public health problem WHA50.29 (1997) Onchocerciasis complications Onchocerca volvulus Blackfly Simulium vectors Human West, Central and East Africa, foci in Latin America Itchy papules, vesicles, pustules, papulonodules or plaques Subcutaneous nodules; hanging groin Impetigo Physical appearance, nuisance, psychological impact, stigma Children and adults (ND) Adults (ND) NA Elimination in selected countries in Africa NA Leprosy Mycobacterium leprae Mycobacterium lepromatosis Probably respiratory route Human Worldwide distribution (India, Brazil, Bangladesh, Indonesia, DRC, Ethiopia and Nigeria) Skin patches/nodules, Thickened nerves, Sensory and/or motor disturbance Peripheral neuropathy and permanent damage of the limbs, eyes and nose 5–15 and 20–40 (1.5:1) 215,000 Elimination as public health problem WHA51.15 (1998) Mycetoma Fungal or bacterial species Inoculation via contaminated thorn or splinter Soil Worldwide distribution (Sudan, Mexico and India) Subcutaneous mass with sinuses and discharge Local destruction of subcutaneous tissue All ages (3:1 to 5:1) Unknown Control WHA69.21 (2016) Yaws Treponema pallidum ssp. pertenue Direct contact Human West and Central Africa and South Pacific Skin ulcer Involvement of the bones and joints 2–15 (1.5:1) 60,000 Eradication WHA31.58 (1978) In addition, skin NTDs result in stigmatization, discrimination, and psychological distress, which contribute to suffering and may affect health-seeking behaviours and adherence to treatment.[12] Finally, the economic impact of accessing care and rehabilitative measures can be substantial.[13] Policy Change In May 2013, the World Health Assembly (WHA) adopted resolution WHA66.12, which calls on Member States to intensify and integrate control measures to improve the health of NTD-affected populations.[14] Individual NTDs have WHA mandates, including the control of morbidity due to BU, CL, filarial lymphoedema, the elimination of onchocerciasis, the achievement of elimination of leprosy as a public health problem, and the eradication of yaws. In May 2016, the WHA adopted a resolution on mycetoma that called for the need to develop diagnostic tests and simpler treatment as well as enhanced surveillance.[15] For many years, vertical disease programmes were established to deal with priority diseases, but, increasingly, there has been a move to integrate programmes into general health services. WHO’s Department of Control of NTDs currently promotes intervention-based approaches rather than disease-specific approaches. Each vertical disease program is resource intensive, and resources are not maximized when they are fragmented. Integrating interventions should allow a common approach for case detection and community-based diagnosis, resulting in increased program efficiency through sharing of resources. We propose a new approach to neglected tropical skin diseases, in which seven diseases are grouped together. Integration is defined here to mean combining activities of two or more diseases at the same time and in the same communities with the aim of increasing efficiency. Each country and region may adapt the strategy to the prevailing local or regional co-endemicity of these diseases. The following are reasons why a policy change to the integrated approach for skin NTDs is feasible. Skin examination is an opportunity to identify multiple conditions in a single visit. Skin diseases can be suspected and diagnosed clinically by appropriately trained individuals, including community health workers and village volunteers. The case-management strategy of the skin diseases targeted is similar, including detection and diagnosis by skin examination, with or without confirmation of the diagnosis by laboratory test, and treatment by the use of effective medicines (oral treatment and/or injection) or morbidity and disability management. Benefits and Challenges The proposed integrated strategy may provide many benefits and opportunities: Increased effectiveness and efficiency. Increased impact of resources improving the opportunity and justification for investment. Increased access to timely diagnosis of cases from the communities thus enhancing disease surveillance. Alleviation of poverty as a result of morbidity caused by NTDs. Improved knowledge, capacity, and motivation of health workers and village volunteers who may see only a few or none of these diseases in single vertical programmes. Sustained awareness and knowledge of both declining and emerging diseases to enhance surveillance. Development of regional centres of excellence. Improvement in skin health overall. Despite the potential benefits, the following potential challenges should be acknowledged: Loss of vertical programmes may lead to loss of specialized expertise. Lack of adequately trained staff. Staff attrition after training. Referral centres may be unable to cope with the increased demand for skin NTD services. Risk of developing a new vertical programme, which remains poorly integrated with the existing health care system. Description of Integrated IDM NTD Implementation We propose three main linked activities in support of this integrated strategy (Box 1): firstly, identification of areas of geographic overlap; secondly, the use of training packages for the identification of multiple skin conditions; finally, integrated active case detection and use of pathways for diagnosis and management in the local community as far as possible, with referral to local health centres and district hospitals as required. Box 1. Integrated IDM-NTDs Implementation Approach Initial assessment of disease burden: conduct surveys to identify endemic areas for targeting intensified interventions. Training: validate a training program based on standardised clinical diagnostic schemes and organise training for trainers, health workers, and village volunteers. Development of an integrated control strategy for each district: suggest interventions to meet the specific needs of each district, depending on which diseases are identified in the initial assessment and survey. Social mobilisation: create demand for and a means of participating in interventions, and address specific aspects and concerns related to the diseases. Active case detection: implement active case finding in schools and communities. Case management: establish a referral pathway to undertake early diagnosis and treatment. Health facility mapping and strengthening: mapping health facilities in endemic areas to guide the needed improvements in infrastructure, equipment, and supplies to ensure optimum quality care of patients. Assessment of disease burden The first step of the integrated approach is to establish the presence or absence of disease in each district for the purpose of deciding the specific intervention(s) that might be required. Initial mapping could be based on a combination of routine surveillance data and specific population-based surveys. These data can be used to classify the Implementation Unit (IU) as a whole as being endemic or nonendemic. Usually the district level is identified as the IU, covering a population of 100,000–250,000, but the choice should be guided by feedback received from lower administrative levels (i.e., if the skin NTD is very focal, a lower administrative level such as sub-district may be chosen as the IU). Passive surveillance data in health care facilities normally includes the patient’s village of residence, which constitutes the basic mapping unit and allows identification of IUs with current or historical cases of the skin NTDs.[16] However, hidden or unknown cases would not be identified through this approach. Counts from sub-IU regions or point locations of cases during active case-finding can be collected by mobile teams visiting villages in affected areas. Rapid assessment procedures are also emerging as useful tools that provide estimates of the probability of local prevalence (e.g., prob[prevalence > 0.1]) for each IU rather than estimates of the local prevalence itself.[17] Training of health workers and village volunteers The success of an integrated approach will rely on well trained health workers and village volunteers being able to correctly identify multiple skin conditions. It is, therefore, necessary to develop, validate, and implement structured training programmes for those who will be conducting the field work as well as for the staff who will be training them. Simplified algorithms (Table 2) have shown reasonable sensitivity and specificity in diagnosing a limited range of skin conditions when compared to diagnoses made by dermatologists[18,19], but further work is needed to expand these algorithms to cover the full range of common skin conditions and skin NTDs. Simple integrated pictorial guides can also be developed to help health workers and village volunteers. Structured teledermatology resources could provide a system of support.[20] Data collection could be augmented through the use of electronic data collection tools and cloud-based data management, which have proven powerful in large-scale mapping projects.[21] 10.1371/journal.pntd.0005136.t002 Table 2 An example of key diagnostic signs for identification of targeted diseases. Key sign identified by HCW or village volunteer Diagnostic criteria utilised by HCW or referral centre Common differential diagnosis Skin ulcer Presence of ulcerative lesions with or without crusts Buruli ulcer, Cutaneous leishmaniasis, Yaws, Tropical ulcer, Stasis or venous ulcer Presence of chronic nodules or papillomatous lesions associated with ulceration Edges raised or indurated in CL and yaws; edges undermined in BU Subcutaneous mass Indurated painless swelling or mass involving the foot Mycetoma, Chromoblastomycosis, Buruli ulcer nodule or plaque, Skin cancer, Kaposi’s sarcoma, Onchocercal nodule History of penetrating injury at the same site or walking barefoot in mycetoma Sinus tracts, chronic discharge and grains in mycetoma Well-demarcated firm subcutaneous nodule(s) overlying a bony prominence (e.g., iliac crest, trochanters, ribs, sacrum) in onchocerciasis Swelling of limb or legs Painless non-pitting swelling Filarial lymphoedema, Podoconiosis, TB lymphadenitis, Leprosy oedema, Buruli ulcer oedema, Congestive heart failure oedema Skin patch Presence of a hypopigmented patch Leprosy, Pityriasis versicolor, Pityriasis alba, Vitiligo Reduced sensation within the patch in leprosy Enlarged nerves in leprosy Chronic duration (>3 months) HCW, health care worker. Conduct active case detection Scale-up of case detection activities is critical to effectively reduce the burden and transmission of skin NTDs. Even in NTDs where mass drug administration (MDA) is the initial stage of control interventions—such as yaws—as disease prevalence comes down, incident disease will still occur, for which individual diagnosis and treatment will be required to prevent resurgence.[22] Different approaches to active case detection may be used. House-to-house screening strategies yield the highest number of newly detected cases, though this strategy can be expensive and difficult to sustain. Alternative strategies include mobile teams visiting villages to screen all attendees at a central location or the use of an incentive-based approach, in which case detection is done by trained health workers detecting cases in their health centre catchment areas. In sub-Saharan Africa, trained village volunteers have also been instrumental in the detection and referral of diseases such as Buruli ulcer, Guinea worm, and leprosy.[23,24] A large network of village volunteers has also been pivotal in the Indian yaws elimination program and the program to eliminate visceral leishmaniasis.[25] Social mobilization activities will be needed prior to the start of active case detection programs. Communication efforts will focus on informing and enhancing knowledge among the general public to engage people and strengthen their participation in case finding activities. Other social mobilization avenues, including mass media, will provide a common platform by which to address social aspects associated with these diseases such as stigma and discrimination. Referral pathways It will be important to establish clear referral pathways for people with positive findings on screening for both suspected targeted diseases and non-targeted conditions, some of which can be managed at frontline health care level. Cases of skin NTDs will most often be detected at the community level by health workers or volunteers and then referred to the nearest health facility for management. Cases that cannot be managed at the primary health facility will be referred to the peripheral hospital. At this level, diagnosis and management of minor complications like skin grafting should be done. Complex cases should be referred to specialist referral centres. Community-based rehabilitation programs will need to be strengthened to support the increased case load. Improvements in the public health system are required to make treatment available and accessible at all levels. Clinical diagnosis and laboratory confirmation Clinical signs are of variable sensitivity in these diseases, so well-trained staff and diagnostic tests have an important role on diagnosis. The manifestations of leprosy have overlapping clinical features with many other skin diseases.[4] Chronic skin ulcers that fail to heal are a common presentation for all three: BU, CL, and yaws (Fig 1).[2,3,6] Skin ulcers may also result from polymicrobial infections, Haemophilus ducreyi,[13] and neuropathy (due to leprosy, diabetes) or vascular disease. Lower limb swelling of filarial lymphoedema may be mistaken for podoconiosis, TB lymphadenitis, or systemic diseases such as heart failure (Fig 2).[7] The main differential diagnoses of mycetoma are chromoblastomycosis and skin cancer.[5] 10.1371/journal.pntd.0005136.g001 Fig 1 Common skin ulcerative lesions related to neglected tropical diseases. (A) Buruli ulcer with undermined hanging edge, (B) Ill-defined ulcerated infiltrated granulomatous-looking lesions on dorsum of the hand in cutaneous leishmaniasis, (C) Early-stage yaws ulcer with raised edge and “raspberry” type appearance of the central granulation tissue, (D) Multiple yellow-crusted ulcers on the arms in secondary yaws. Images credit: Kingsley Asiedu (A,D), Oriol Mitjà (C), Jorge Postigo (B). 10.1371/journal.pntd.0005136.g002 Fig 2 Common skin neglected tropical diseases lesions. (A) Mycetoma with few active sinuses, grains, and discharge, (B) Bilateral lymphoedema of both legs in the late stage of lymphatic filariasis, (C) Hypopigmented anaesthetic macules with infiltrated edge of borderline tuberculoid leprosy. Images credit: Ahmed Fahal (A), CDC Public Health Image library (B), Rie Yotsu (C). Skin ulcer The diagnosis of skin ulcers in the tropics remains problematic as clinical features alone are insufficient to make a decision on treatment. PCR diagnostic platforms in reference laboratories are used for confirmation of many conditions, but these facilities are remote from the communities where the diseases occur. Sampling procedures like swabbing for detection of Mycobacterium ulcerans,[26] and Treponema pallidum subsp. pertenue[27] can be performed in the field. Routine diagnosis of CL is based on detection of Leishmania spp. DNA in the biopsy of skin lesions;[28] however, it is also possible to perform DNA analysis on impression smears from ulcerated CL lesions that can be collected in the field.[29] The main disadvantage of PCR is that sample transfer mechanisms from the field to reference laboratories for testing are generally slow, resulting in delays and dropout during the diagnostic process. Point-of-care tests (POCT) are available to aid clinicians to determine the etiology of skin ulcers before the patient leaves the clinical setting. Fluorescent thin layer chromatography (fTLC) is a simple and low-cost technique that can be used for detection of mycolactone in skin swabs from BU lesions at a peripheral hospital laboratory using a small bench analyser;[30] however, this test is still in the development stage. The Dual Path Platform (DPP) yaws rapid test kit, which is based on simultaneous detection of antibodies to treponemal and nontreponemal antigens, allows for serological diagnosis of yaws in the field.[31,32] Subcutaneous mass Multiple diagnostic tools are usually required to determine the extent of infections and to identify the causative agents of mycetoma and guide treatment. Ultrasound examination, fine-needle aspiration and deep-seated surgical biopsy need to be performed if feasible. The ultrasound and examination of aspirated material can be POCTs. Surgical biopsies can be processed for tissue histopathological examination, microbiology, and molecular studies. Individuals suspected of having mycetoma will need to be referred for further imaging to determine the extent of disease. Formal diagnosis of onchocerciasis is by skin snips to detect Onchocerca volvulus microfilariae. Ultrasound of suspected onchocercal nodules may reveal dead or live adult worms. Limb swelling Filarial lymphoedema is clinically difficult to distinguish from podoconiosis, but a diagnostic algorithm exists. Clinical diagnosis is accurate in settings where only podoconiosis is endemic; in settings where the two diseases may overlap, the combination of clinical history, physical examination, and blood tests for antifilarial antibody (Wb123 assay) have been used to reach a diagnosis.[33] Skin patch The diagnosis of leprosy is usually made clinically, which requires health workers to be trained to recognise the varied presentations of the disease including the immune-mediated leprosy reactional states. Skin biopsy is not routinely performed and needs to be interpreted in conjunction with the clinical features. In two leprosy referral centres in Brazil, slit skin smears were only positive in 59%[34] of patients and have not been a recommended part of leprosy programmes since 1998. Patients with suspected leprosy will need to be referred for further assessment and diagnostic procedures where necessary. Individuals suspected of having leprosy need to be assessed for nerve function impairment, and this needs to be repeated regularly during treatment and beyond. Treatment If skin NTDs are diagnosed and treated early, disabilities and disfigurements are preventable. In addition, simple skin-directed therapy can contribute to enhanced resolution and reduction in morbidity. Specific interventions Once a presumptive diagnosis is established, patients need to be referred for confirmatory diagnosis or testing and treatment except for yaws, which can be immediately treated at the time of detection using single-dose oral drugs (Table 3). Nonopioid analgesics are usually sufficient for managing mild pain related to skin lesions; however, more severe pain may complicate some diseases (e.g., neuropathic pain in leprosy or pain related to erythema nodosum leprosum). For yaws, treatment of all household contacts is necessary, even if they have no symptoms. The treatment of contacts of leprosy patients remains controversial and raises ethical issues around disclosure of diagnosis. 10.1371/journal.pntd.0005136.t003 Table 3 Recommended diagnosis and management of suspected skin lesions. Field assessment Initial management Laboratory tools Medical treatment Supportive measures Treatment of contacts Surgery Prevention of disabilities and rehabilitation Buruli ulcer Clinical Swabbing, registration and referral PCR of skin swab samples fTLC under development Oral rifampin + injectable streptomycin or oral clarithromycin for 8 weeks Wound dressing No Yes Yes Cutaneous leishmaniasis Clinical Swabbing, registration and referral Microscopy and PCR of skin swab Depends on species. Local or systemic therapy. Wound dressing No No No Filarial lymphoedema Clinical Registration and referral ICT antigen test (usually negative), and antifilarial antibodies Oral diethylcarbamazine for 12 days ± doxycycline for 4 to 6 weeks Skin barrier function improvement measures No Yes Yes Oncocerciasis Clinical Registration and referral Skin snips. Serological and antigen tests under development Oral ivermectin Pruritic rash -treatment for any itching and secondary infection If in endemic area Yes for nodules or hanging groin No Leprosy Clinical Registration and referral Slit skin smear or skin biopsy material Multidrug antibiotic therapy for 6 or 12 months. Home-based self-inspections and appropriate footwear Single dose rifampicin is being piloted but is not policy Yes Yes Mycetoma Clinical Registration and referral Microscopy examination and culture of grains/biopsy Depends on species. Long term antibiotic or antifungal. Skin barrier function improvement measures No Yes Yes Yaws Clinical Swabbing, and immediate treatment DPP test and PCR of skin swab Single oral dose of azithromycin (2nd line: injectable benzathine penicillin) Wound dressing Single dose azithromycin No No fTLC, fluorescent thin layer chromatography; ICT, immunochromatography, DPP, dual path platform yaws assay. Surgery is only occasionally needed for these diseases. In BU, antibiotic therapy (oral or injectable) is largely replacing surgical excision of tissue in active disease; surgery followed by physical therapy may be required for preventing contractures. In leprosy, surgery has long been used to correct functional and stigmatising cosmetic impairments. Early localised mycetoma lesions are amenable to surgical cure with a lower recurrence rate. Problematic onchocercal nodules can be excised, and hanging groin in onchoceriasis is amenable to surgery to reduce psychological distress. Clinical wound care and repair of skin barrier function Importantly, integrated but nonspecific interventions can be implemented for case morbidity management that can benefit patients with skin NTDs sharing similar basic pathologies. Wound management is a common approach for most skin NTDs; hence, the provision of appropriate dressings and training of health workers is important for a satisfactory outcome. Effective wound management requires access to water and simple, cheap non-adherent dressings, which keep wounds clean, protected from trauma, improve healing rates of damaged skin, and potentially prevent transmission. Skin barrier function improvement measures (e.g., washing, emollients, and compression shoes) minimize the risk of further damage in filarial lymphoedema.[35,36] Provision of simple exercise regimens with or without compression can also improve lymphoedema. The use of shoes is beneficial in the fight against several skin NTDs, and there are likely to be additional benefits such as protection against tetanus, tungiasis, and soil-transmitted helminths. Future Directions An integrated approach to the skin NTDs has the potential to reduce transmission, delays in diagnosis, and associated morbidity of these conditions and promote skin health for all. An integrated approach also has the potential to reduce costs for both patients and health systems. The WHO Department of Control of NTDs should take the lead in coordinating global efforts with the support of donors and partners, focusing on key areas (Box 2). Publication of this policy paper aims to trigger public debate about the approach and to encourage new funding to be targeted towards management of these important NTDs. Box 2. Next Steps Advocacy Increasing awareness of skin NTDs and their impact on affected communities. Promoting integrated management schemes and their potential benefits to society and donors. Networking technical and professional groups, donors, NGOs, endemic countries, and different disease control programmes. Policy Gaining consensus and support from all major stakeholders including the Ministries of Health on the way forward for implementation. Promoting a common management strategy of these diseases at community and health facility levels and resources required at each level. Research Validating a clinical algorithm for identification of skin NTDs using key symptoms and signs. Developing common clinical and laboratory diagnostic platforms for these diseases, which are practical in the field. Mapping to identify their overlap to allow integrated coordinated control and treatment activities as well as health system strengthening for service delivery. Piloting the integrated approach in one or several regions. Better understanding of the epidemiology of these diseases including transmission and interaction with poverty and water, sanitation, and hygiene (WASH). Understand community resilience and program factors that strengthen community participation. Integration of surveillance and interventions will not be possible without considerable political support, at a number of levels. There will be very real challenges to integration, including relationships with donors, potential changes to NTD management structures, and complexities in health care worker training among many others, and any of these challenges could derail efforts to achieving integrated management. Strong relationships will be required between governments, international agencies, implementing partners, and donors, with a clear plan of action supported by an evidence base to move forward an agenda of integration.
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Contributors
Rie Roselyne Yotsu:
ORCID: http://orcid.org/0000-0001-9102-1912
Role: ConceptualizationRole: Data curationRole: Formal analysisRole: Funding acquisitionRole:
InvestigationRole: MethodologyRole: Project administrationRole: ResourcesRole: SoftwareRole:
VisualizationRole: Writing – original draftRole: Writing – review & editing
Kouamé Kouadio: Role: InvestigationRole: MethodologyRole: Project administration
Bamba Vagamon: Role: InvestigationRole: Supervision
Konan N’guessan: Role: InvestigationRole: Project administration
Amari Jules Akpa: Role: InvestigationRole: MethodologyRole: Project administrationRole: Resources
Aubin Yao: Role: Project administrationRole: ResourcesRole: Supervision
Julien Aké: Role: ConceptualizationRole: Validation
Rigobert Abbet Abbet: Role: SupervisionRole: Validation
Barbine Tchamba Agbor Agbor:
ORCID: http://orcid.org/0000-0001-6161-6886
Role: Data curation
Roger Bedimo: Role: Funding acquisitionRole: SupervisionRole: VisualizationRole: Writing – review
& editing
Norihisa Ishii: Role: ConceptualizationRole: Funding acquisitionRole: ResourcesRole: SupervisionRole:
ValidationRole: Writing – review & editing
L. Claire Fuller: Role: ValidationRole: Writing – review & editing
Roderick Hay: Role: ValidationRole: Writing – review & editing
Oriol Mitjà: Role: MethodologyRole: ValidationRole: Writing – review & editing
Henning Drechsler:
ORCID: http://orcid.org/0000-0003-4026-9154
Role: Formal analysisRole: MethodologyRole: SoftwareRole: Writing – review & editing
Kingsley Asiedu: Role: ConceptualizationRole: ValidationRole: VisualizationRole: Writing – review &
editing
Joseph M. Vinetz: Role: Editor
Journal
Journal ID (nlm-ta): PLoS Negl Trop Dis
Journal ID (iso-abbrev): PLoS Negl Trop Dis
Journal ID (publisher-id): plos
Journal ID (pmc): plosntds
Title:
PLoS Neglected Tropical Diseases
Publisher:
Public Library of Science
(San Francisco, CA USA
)
ISSN
(Print):
1935-2727
ISSN
(Electronic):
1935-2735
Publication date
(Electronic):
17
May
2018
Publication date Collection:
May
2018
Volume: 12
Issue: 5
Electronic Location Identifier: e0006489
Affiliations
[6
]
National Program for Leprosy Control (PNEL), Ministry of Health and Public Hygiene,
Abidjan, Côte d’Ivoire
[7
]
Department of Medicine, VA North Texas Healthcare System, Dallas, Texas, United States
of America
[8
]
Division of Infectious Diseases, University of Texas Dallas Southwestern, Dallas,
Texas, United States of America
Author notes
Author information
Rie Roselyne Yotsu
http://orcid.org/0000-0001-9102-1912
Barbine Tchamba Agbor Agbor
http://orcid.org/0000-0001-6161-6886
Henning Drechsler
http://orcid.org/0000-0003-4026-9154
Article
Publisher ID: PNTD-D-17-02099DOI: 10.1371/journal.pntd.0006489
PMC ID: 5976208
PubMed ID: 29771976
SO-VID: 1830f3a1-f2e5-48fc-877f-ee7c6b08f4bd
License:
This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.
History
Date
received
: 4
January
2018
Date
accepted
: 2
May
2018
Page count
Figures: 5,
Tables: 3,
Pages: 18
Funding
Funded by: funder-id http://dx.doi.org/10.13039/100009619, Japan Agency for Medical Research and Development;
Award ID: 16fk0108203j0002
Award Recipient
:
Norihisa Ishii
Funded by: Grant-in-Aid for Scientific Research (KAKENHI) (JP)
Award ID: 16K21656
Award Recipient
:
ORCID: http://orcid.org/0000-0001-9102-1912
Rie Roselyne Yotsu
Funded by: National Center for Global Health and Medicine (JP)
Award ID: 26-120
Award Recipient
:
ORCID: http://orcid.org/0000-0001-9102-1912
Rie Roselyne Yotsu
Funded by: funder-id http://dx.doi.org/10.13039/100009468, Sasakawa Memorial Health Foundation;
Award Recipient
:
ORCID: http://orcid.org/0000-0001-9102-1912
Rie Roselyne Yotsu
Funded by: Ohyama Health Foundation (JP)
Award Recipient
:
ORCID: http://orcid.org/0000-0001-9102-1912
Rie Roselyne Yotsu
Funded by: St. Luke's Life Science (JP)
Award Recipient
:
ORCID: http://orcid.org/0000-0001-9102-1912
Rie Roselyne Yotsu
This study was supported by the following: 1) Sasakawa Memorial Health Foundation,
Japan (
http://www.smhf.or.jp/e/); 2) Grant-in-Aid for Scientific Research <KAKENHI>, Japan (
https://www.jsps.go.jp/english/e-grants/index.html), grant number: 16K21656; 3) National Center for Global Health and Medicine, Japan
(
http://www.ncgm.go.jp/100/010/index.html), grant number: 26-120; 4) Ohyama Health Foundation Inc, Japan (
http://ohfin.com); 5) St. Luke's Life Science Institute, Japan (
https://cce.luke.ac.jp/center/about/index.html); and 6) Research Program on Emerging and Re-emerging Infectious Diseases, Japan
Agency for Medical Research and Development (AMED), Japan (
http://www.amed.go.jp/en/), grant number: 16fk0108203j0002. Funds 1)-5) were received by RRY and 6) by NI.
The funders had no role in study design, data collection and analysis, decision to
publish, or preparation of the manuscript.
Categories
Subject:
Research Article
Subject:
Medicine and Health Sciences
Subject:
Dermatology
Subject:
Skin Diseases
Subject:
Medicine and Health Sciences
Subject:
Tropical Diseases
Subject:
Neglected Tropical Diseases
Subject:
People and Places
Subject:
Population Groupings
Subject:
Educational Status
Subject:
Schoolchildren
Subject:
Medicine and Health Sciences
Subject:
Infectious Diseases
Subject:
Fungal Diseases
Subject:
Tinea
Subject:
Tinea Versicolor
Subject:
Social Sciences
Subject:
Sociology
Subject:
Education
Subject:
Schools
Subject:
Medicine and Health Sciences
Subject:
Infectious Diseases
Subject:
Bacterial Diseases
Subject:
Leprosy
Subject:
Medicine and Health Sciences
Subject:
Tropical Diseases
Subject:
Neglected Tropical Diseases
Subject:
Leprosy
Subject:
People and Places
Subject:
Population Groupings
Subject:
Age Groups
Subject:
Children
Subject:
People and Places
Subject:
Population Groupings
Subject:
Families
Subject:
Children
Subject:
Medicine and Health Sciences
Subject:
Epidemiology
Custom metadata
PLOS Publication Stage vor-update-to-uncorrected-proof
Publication Update 2018-05-30
Data Availability All relevant data are within the paper and its Supporting Information files.
ScienceOpen disciplines: Infectious disease & Microbiology
Data availability:
ScienceOpen disciplines: Infectious disease & Microbiology