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Epidemiological study of infectious skin diseases among Egyptian school children in urban and rural areas

Abd El Aal, Nagwa H.a; Mostafa, Laila A.b; Farag, Asmaa S.a; Hassan, Soha H.a

Journal of the Egyptian Women's Dermatologic Society: January 2013 - Volume 10 - Issue 1 - p 42–46
doi: 10.1097/01.EWX.0000422131.75701.17
Original articles
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Background The type and prevalence of disease in any community reflect the genetic and racial constitution of its members, their nutritional status, and social and hygiene standards. Epidemiological studies on infectious diseases are essential for developing and implementing prevention programs directed toward these diseases.

Objective The aim of the study was to investigate the prevalence of infectious skin diseases among Egyptian schoolchildren in urban (Cairo governorate) and rural areas (Gharbia governorate).

Subjects and methods A cross-sectional study was conducted. The sample included 2255 schoolchildren (1025 pupils from urban areas and 1230 pupils from rural areas) of both sexes; their mean age was 9.4±2.3 years. All children underwent a skin examination.

Results It was found that 366 (35.7%) children of the total number of urban pupils had infectious skin diseases. Bacterial infections were the most prevalent (10%), of which impetigo contagiosum accounted for 8%. This was followed by parasitic infestations (9.7%), of which pediculosis capitis was the most common (7.7%). The overall prevalence of both viral and fungal skin infections was equal (8%). Among viral infections, warts were the most prevalent (5.9%), whereas tinea capitis was the most common fungal infection (5.9%). A total of 302 (24.6%) rural pupils were affected by infectious skin diseases. The most prevalent infectious skin disease among rural children was parasitic infestation (17.9%), with pediculosis capitis being the major entity (17.2%). This was followed by viral skin infection (3.5%), of which warts were the most prevalent (2.6%), and fungal infection (1.3%), with tinea capitis being the most common. Bacterial infection (0.7%) was the least common infectious skin disease in rural areas.

Conclusion The most prevalent infectious skin disease among schoolchildren in urban areas was bacterial infection, whereas parasitic infestation was the most prevalent in rural areas. Programs on health education directed toward students and their parents with monthly school surveys on students are essential measures to combat skin infections in schoolchildren.

Departments of aDermatology and Venereology

bCommunity and Occupational Medicine, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt

Correspondence to Asmaa S. Farag, MD, Department of Dermatology and Venereology, Faculty of Medicine for Girls, Al-Azhar University, 11729 Cairo, Egypt Tel: +20 111 113 8832; fax: +20 222 638 357; e-mail: assmaa_saied@yahoo.com

Received November 14, 2011

Accepted July 10, 2012

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Introduction

Skin problems are considered upsetting, especially by schoolchildren 1. The type and prevalence of the disease in any community reflect the genetic and racial constitution of its members, their nutritional status, and social and hygiene standards 2. The incidence of disease is affected directly and indirectly by climatic conditions and is influenced by the quality and quantity of medical care. The epidemiological statistics of skin diseases provide us with baseline information on the prevalence, age, and sex differences in affected groups, their regional distribution, and the underlying factors essential for prevention programs directed toward averting the problem 3. Few epidemiological surveys have been conducted to compare infectious skin diseases in urban and rural areas of Egypt. Therefore, this study was designed to determine the prevalence of infectious skin diseases among schoolchildren in urban and rural areas of Cairo and Gharbia governorates.

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Subjects and methods

Study design

A cross-sectional study was conducted from the second term of the academic year 2008–2009 to the first term of the academic year 2009–2010.

The study was carried out among schoolchildren belonging to two urban areas of high and low socioeconomic status in Cairo governorate, namely, Nasr city [Al Mostakbal Experimental (government) language school; school A] and Ard El-lewaa (Alkods, general government school; school B), and one rural area in Gharbia governorate (Mohammed Bek El-shafey, general government school; school C) in Meet Al Mokhles village. About 50% of schoolchildren from the included schools (513, 512, and 1230 from schools A, B, and C, respectively) were screened for infectious skin diseases.

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Study population

The total sample consisted of 2255 pupils of both sexes (50.9% boys and 49.1% girls) with ages ranging from 6 to 14 years (9.4±2.3 years); 1025 pupils (45.5%) were from urban areas (Cairo governorate) and 1230 (54.5%) from rural areas (Gharbia governorate). Informed consent was taken from the parents of these children and from the respective authorities.

A multistage random sample was selected: the first stage at the level of governorates and the final at the level of schools. Thereafter, a systematic random sample was taken to select pupils from those enrolled in this study. Each selected pupil underwent a dermatological examination, and any signs of cutaneous infection were recorded. Laboratory examinations such as Wood’s lamp and KOH examinations, wherever indicated, were performed. Treatment was prescribed and explained to the parents.

The investigator visited the schools all days of the week. The time needed for conducting the skin examination ranged from 5 to 10 min for each pupil.

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Statistical analysis

The collected data were reviewed. Manual coding of the collected data was done. All statistical calculations were performed using the computer program SPSS (SPSS Inc., Chicago, Illinois, USA) version 17 for Microsoft Windows. Descriptive statistics were presented in the form of mean and SD for quantitative data and as number and percentage for qualitative data. Groups were compared using the χ2-test for qualitative data. P-values less than 0.05 were considered statistically significant.

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Results

This study included 2255 pupils: 1025 (45.5%) from urban areas (513 and 512 pupils from schools A and B, respectively) and 1230 (54.5%) from rural areas (1230 from school C). Their age ranged from 6 to 14 years with a mean age of 9.4±2.3 years. Of the children, 50.9% (1147) were boys and 49.1% (1108) were girls.

Results showed that 35.7% of schoolchildren in urban areas were affected by infectious skin diseases. The most prevalent infectious skin disease in urban areas was bacterial infections (10%), of which impetigo contagiosum (8%) was the most common, followed by parasitic infestations (9.7%), of which pediculosis capitis was the most prevalent (7.7%). However, the prevalence rate of both viral and fungal skin infections was equal (8%). Of viral infections, warts were the most common (5.9%), and tinea capitis was the most common type of fungal infection (5.9%; Figure 1, Table 1).

Figure 1

Figure 1

Table 1

Table 1

It was found that 24.6% of pupils in rural areas were affected by infectious skin diseases; 1% of them were affected by mixed skin infections. The most common infectious skin disease in rural schools was parasitic infestation (17.9%), followed by viral infections (3.5%) and fungal infections (1.3%), whereas bacterial infections represented 0.7%, as shown in Fig. 1 and table 1.

The prevalence of different skin infections in schools A, B, and C is shown in Fig. 2 and table 2.

Figure 2

Figure 2

Table 2

Table 2

The sex distribution of the infectious skin diseases among the studied schoolchildren demonstrated that impetigo, warts, tinea capitis, and scabies were more common among boys than among girls, with a significant difference (P <0.05), whereas pediculosis capitis, chicken pox, herpes simplex, and molluscum contagiosum were more common among girls than among boys, with a significant difference (P<0.05; Table 3).

Table 3

Table 3

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Discussion

Skin disorders are among the most frequently diagnosed conditions in schoolchildren in both developing and industrialized countries 4. Studies from different countries have shown cross-sectional prevalence rates ranging from 22.8 to 96.8% 5–9. Skin diseases are considered to be the second most common cause of medical consultation for children in rural communities.

The school environment makes children vulnerable to cross-transmission of communicable skin diseases, which can be transmitted to family members 10. Therefore, it is of vital importance from the point of view of community health to not only assess the prevalence of skin disease but also identify possible associated socioeconomic factors.

Results of the present study revealed that the prevalence rate of skin infections was ∼29.6% among the total studied Egyptian schoolchildren in urban (Cairo governorate) and rural areas (Gharbia governorate). The prevalence rate of skin infections was found to be 35.7% in urban areas and 24.6% in rural areas.

Bacterial skin diseases are observed in 10% of the total number of infected pupils in urban areas and 0.7% of the total number in rural areas. Impetigo contagiosum represented the majority of cases in urban areas (8%) and 0.7% in rural areas. This is in accordance with the results obtained by Ali et al. 11, who reported that bacterial skin infections were found among 10.3% of schoolchildren in Cairo governorate. The current results pointed out that the prevalence of impetigo in rural areas was lower than that reported by Baraka et al.12, who found that the prevalence of impetigo reached 1.5% among Qalyobia schoolchildren, and by Abdel Rahman et al.13, who found the prevalence among schoolchildren of Dakahlia governorate to be 3.4%.

Parasitic skin infestations were the second common prevalent skin infection (9.7%) among the total studied pupils in urban areas. Pediculosis capitis (7.7%) was the most prevalent parasitic skin infestation. This was to some extent comparable to the results of the study in the Bab El-Shareia region 11, where prevalence was 8.5% among studied schoolchildren. Parasitic skin infestations had the highest prevalence rate (17.9%) in the total rural area sample, of which pediculosis capitis (17.2%) constituted the main portion. This was comparable to the result of the study in Dakahlia governorate, where prevalence was 17.8% 11. However, the prevalence rate of pediculosis capitis was relatively low among Qaluobia schoolchildren (14.7%) 12. Studies in other countries showed a variable prevalence rate for pediculosis capitis; in Iran, the prevalence among schoolchildren was 3.8% in a sample of 1200 children 14; in Saudi Arabia, it was 5.2% among female schoolchildren in a sample of 1337 children 15. The highest prevalence rate for pediculosis capitis was found among children in India (22.6% in a sample of 2455 children) 16.

The prevalence of scabies was 2% in urban areas and 0.7% in rural areas. It was similar to the rates reported in other studies – 2.6% in Bab El-Shareia 11 and 1.7% in Qaluobia governorate 12. Similar rates for scabies were recorded among schoolchildren in Turkey (2.2%) in a sample of 785 children 10. In Poland, the prevalence was 10.4% in a sample of 10 000 children 17, whereas in Nigeria it was 4.7% in a sample of 1066 children 1. The difference between the current results and those of other studies may be due to the warm climate during the implementation of the present survey, which could have contributed to the low prevalence of scabies in rural areas.

Viral skin infections affected 8% of all the studied schoolchildren in urban areas and 3.5% in rural areas. Warts were the most prevalent and were seen in 5.9% of schoolchildren in urban areas and 2.6% in rural areas. These rates were comparable to those of the study conducted in Bab El-Shareia, where the prevalence of viral skin infections was 9.9% and that of warts was 7.3% 11. Previous reports in rural areas showed variable rates (0.3–2.8%) 12,13. Studies in other countries showed variable prevalence rates for warts among schoolchildren: 2.4% in Taiwan in a sample of 3273 children 18 and 3.8% in Turkey in a sample of 785 children 10. In India, the prevalence rate for warts among children was 2.6% in a sample of 2455 children 16. In China, the prevalence of warts was 6% in a sample of 331 children 19. In Kuwait, the prevalence was 13.1% in a sample of 10 000 children 20. The prevalence of cutaneous superficial fungal infections was 8% of the total number of pupils in urban areas and 1.3% in rural areas. These results were compatible to some extent with those reported in the study conducted in Bab El-Shareia (9.4%) 11 but were incompatible with a previous report from Assiut, a rural area, where the prevalence rate was 16.2% 21. The present study revealed that tinea capitis was the most common fungal infection among the current studied children with a prevalence rate of 5.9% in urban areas and 0.7% in rural areas. This variation in rates in different surveys could be due to different environmental factors, different survey methods, and different sample sizes.

The high prevalence of scabies, impetigo, warts, and tinea capitis among boys could be because boys engage in outdoor activities more often than girls. In addition, boys are more susceptible to cross-infection – for example, through infected towels at the barber’s and through other cross-infection activities.

In this survey the prevalence rates of infectious skin diseases among pupils of schools A, B, and C were 18.8, 52.7, and 24.4%, respectively, and the difference was statistically significant. This difference may be due to variation in the level of sanitation and hygiene, level of parents’ education, overcrowding of schools, and socioeconomic status of the pupil’s family, as school A is a government language school, whereas others are general government schools.

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Conclusion

The most prevalent infectious skin disease among schoolchildren in urban areas was bacterial infection, whereas parasitic infestation was the most prevalent in rural areas. Improvement in socioeconomic status, together with programs directed at educating parents, may be needed to decrease the prevalence of some of these skin infections. Routine school surveys should be carried out monthly for the early diagnosis and treatment of infectious skin diseases; in addition, health education, good personal hygiene, and health awareness will definitely help improve the health status of schoolchildren and prevent many communicable skin diseases.

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Acknowledgements

Conflicts of interest

There are no conflicts of interest.

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Keywords:

epidemiology; infectious skin disease; schoolchildren

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