Mycopathologia89, 101 106 (1985). 9 Martinus Nijhoff/Dr W. Junk Publishers, Dordrecht. Printed in the Netherlands.
The distribution of ringworm infections a m o n g primary school children in Jos, Plateau State of Nigeria C. I. C. Ogbonna, R. O. Robinson & J. M. Abubakar Department of Botany, Applied Microbiology Research Unit, University of Jos, Jos, Nigeria
Abstract A survey was carried out on the distribution of ringworm infections among school children in four primary schools in Jos, Plateau State of Nigeria. Out of a total population of 6 987,237 (3.4%) were found to he infected by this disease. There was a high incidence of both scalp and foot ringworms among the infected children. Fourteen species ofdermatophytes were isolated from the ringworm cases. The scalp ringworm had the highest number of fungal isolates. Trichophyton mentagrophyte and T. rubrum had the highest frequencies of occurrence. Some of the infected children were found to have nomadic parents who moved about with cattle.
Introduction Ringworm infections which are mild communicable skin diseases are made up of tinea capitis (ringworm of the scalp), tinea corporis (ringworm of the glabrous skin), tinea crusis (ringworm of the groin), tinea manuum (ringworm of the hand), tinea pedis (ringworm of the foot) and tinea unguim (ringworm of the nail). They form a large percentage of the cases which are met with in the practice of dermatology. Of all the ringworm cases, the most common among school children is the ringworm of the scalp (7). Bechelli (6) reported that ringworm of the scalp is observed almost exclusively in children. Kamalain and Thambiah (10) observed that out of a total of 241 children in one school, 15 (6.22%) were infected by scalp ringworm while in another school, 48 (59.80%) out of 82 children had scalp ringworm. The causal organism was found to be Trichophyton violaceum. A survey on the distribution of ringworm diseases among 602 children of both sexes in Santa Cruz (Bolivia) by Vanbreuseghem et al. (21) showed the prevalence of scalp ringworm which formed 0.5% of the cases. The causal organism was
found to be Trichophyton tonsurans. Mercantini et al. (13) evaluated the relationship between the human presence and the presence of Keratinophilic fungi from floors in Roman primary schools. They isolated 253 colonies of Keratinophilic fungi from 20 samples but could not find any correlation between the amount of gathered dust and the number of Keratinophilic fungi isolated. Reports from Nigeria on dermatophyte infections include those of Schrank (17) and Schrank and Harman (18) who showed that there was dermatophyte infections amongst referred medical cases at Ibadan and 13% dermatophyte infection amongst villagers. Okoro (14) showed that dermatophyte infections accounted for 13.7% of his dermatology cases in the Eastern Nigeria. Somorin et al. (19) found that out of a total of 3 540 school children in Lagos, 63 (1.8%) were infected by dermatophytes. Among the infected children, 38 (60.3%) were boys while 25 (39.7%) were girls, and the scalp ringworm was found to be most common. Jacyk (9) reported that during the period, May, 1974 to December 1975, the incidence of dermatophytes in Kaduna was 10.8%. Fekete (8) carried out an extensive survey on the distribution of skin dis-
102 eases in the densely populated Savannah region in West Africa. She discovered that out of 1 244 skin disease cases, 1008 (81%) were due to fungal infections. Among the fungal infections, scalp ringworm was the most prevalent. Soyinka (20) reported 55.1% incidence of dermatophyte infections among the school children he examined. He discovered that tinea capitis was the commonest fungal infection among those below the age of 12. He found that the organism responsible for the infection was M. audouinii. He also found that boys were more affected than girls and his results agreed with the findings of Pipkin (15) that children of school age especially boys are mostly susceptible to scalp ringworm. From these available reports, it appears that more attention has been given to scalp ringworm among school children. This perhaps has been so, because the head is exposed and scalp ringworm can easily be seen. The present study was conducted to find out the distribution of various types of ringworm among primary school children in Jos, Plateau State, Nigeria.
were both employed and these formed children from 'overaverage families'. Attempts were made to find out the details of the social behaviour of the ringworm affected children. Such behaviour included, the children's playing habits and playgrounds, hair-dressing habits, use of towels, bathing and clothing habits. Their association with pets and other domestic animals were also recorded. Scrapings were taken aseptically from the diseased areas of/ the ringworm infected children. Scrapings from different affected areas of the body were kept separate. The chosen schools were separately sampled. The scraping equipments were sterilized by dipping them in 100% alcohol and flaming to red heat after each scraping operation. The scrapings were plated out on sabouraud's agar medium. The plates were incubated at 27 o C for 10-20 days and re-examined a week later for the presence of dermatophytes. Drops of streptomycin sulphate solution (0.01%) were added to the culture plates to surpress the growth of bacteria. The data were subjected to the analysis of variance method of statistics.
Materials and methods
Four primary schools in Jos were visited during the period June 1982 to May 1983. These were Islamiya primary school with a population of 2 430, St. Theresa's primary school with a population of 2 039, Methodist primary school with a population of 1 296 and Fatima primary school with a population of t 222. The schools were chosen from different areas of Jos City. Examinations for the presence of ringworm diseases were carried out on different parts of the body of the school children (head, hands, body, groin and feet). Records of children with mixed infections (i.e. involving more than one part of the body) were taken. The social status of the parents of the school children was also considered. For this purpose, the children were divided into three categories. The first category of children were those whose parents had no form of employment and these were regarded as children from 'under-average families'. The second category of children were those whose fathers or mothers were employed and these constituted the children from 'average families'. While the third batch were made of children whose parents
Results
Tables 1 and 2 show that significant difference existed in the percentage incidence of ringworm infection, due to the type of ringworm and the interaction between this factor and the school. The highest number of ringworm cases were recorded in Islamiya primary school which had a total of 5.1% infection (Table 3). It was followed by St. Theresa's primary school which had 2.6% infection and the Methodist school which had 2.5% infection. The least percentage of infection was recorded in Fatima primary school which had 2.3%. Table 3 also shows the family status of the school children. There was an apparent association between the family status and the mode of infection of the children. Fourteen species of dermatophytes were isolated from the ringworm infected children in the four different schools sampled (Table 4). The scalp ringworm had the highest number of fungal isolates. This was followed by the ringworms of the body and foot which had seven and six isolates
103 Table 1. T h e a n a l y s i s o f v a r i a n c e of p e r c e n t a g e infection b y
Table 2. T h e m e a n p e r c e n t a g e i n f e c t i o n o f d i f f e r e n t f o r m s of r i n g w o r m in f o u r s c h o o l s in J o s .
v a r i o u s f o r m s o f r i n g w o r m disease in the f o u r s c h o o l s in J o s .
S.V.
D.F.
S.S.
M.S.
Replicates(3) Schools(4) Tinea infection(6) S• T Residual
2 3
7.0877 0.1405
3.5439 0.0468
5 15 46
12 246.6444 2 279.9745 3 335,3323
2 449.3298 151.9983 72.5072
Total
71
17 869.1794
Form of ringworm infection
F 0.0233 N.S. 0.0003 N.S.
Tinea capitis Tinea manuum Tinea corporis Tinea crusis Tinea pedis Mixed infection
16.1142"* 2.096*
L . S . D . (0.05) f o r T e n e a i n f e c t i o n = 7.0% L . S . D . (0.05) f o r S • = 14.0%
Abbreviations used S.V. - Source of Variation D.F. = Degrees of Freedom S.S. = Sum of Squares M.S. = Mean of Squares SXT = Schools and Tinea infection interaction N.S. = Not Significant Significant ** = Highly Significant L.S.D. = Least Significant Difference *
Islamiya
St, Theresa's
Methodist
Fatima
Mean
A 28.0b
A 30.8b
A 31.7b
A 50.4a
35.2A
B 6.4a
B
3.9a
C
D
A 14.4a
B
9.6a
B
B
3.8a
4.8a
2.8a
0.0a
3.3B
BC 8.9a
C 17.8a
12.7B
C
0.0a
D 0.0a
2.2B
A 25.6a
A 36.7a
A 37.2a
B 31.8a
32.8A
A 20.7a
B 15.3a
B 18.9a
D
13.7B
0.0b
L.S.D. 0.05 for Tinea infection = 7.0% L.S.D. 0.05 for S • T = 14.0% Capital letters (ABCD) = For comparison on vertical basis Small letters (ab) = For comparison on horizontal basis * Means followed by the same letter(s) are not significantly different at 5% level.
-
respectively. Both the hand and groin ringworm infections had apparently the least number of fungal isolates. Trichophyton mentagrophyte and T. rubrum had the highest frequencies of occurrence. These were followed by Epidermophyton floccosum. Evidently there was a high incidence of scalp ringworm among the infected children. It had 35.2 mean percentage occurrence. It was closely fol-
lowed by the ringworm of the foot (Tinea pedis) which had 32.8 mean percentage of occurrence. The other types of ringworm infection had a lower range of occurrence (2.2%- 13.7%). From the personal interview conducted among the infected children, it was noted that most of the children from Islamiya school shared their residential houses with domestic animals. Some of the
Table 3. T h e r e l a t i o n s h i p b e t w e e n the family s t a t u s o f the c h i l d r e n a n d m o d e of infection by r i n g w o r m fungi. Primary school
Islamiya
Children's family status Underaverage
Average
Overaverage
T o t a l No. of school children
Total % infection
1669
576
185
2 430
5. l
St. T h e r e s a ' s
78* 867
32* 972
15" 200
125" 2 039
2.6
Methodist
31" 616
16" 482
5* 198
52* 1 296
2.5
Fatima
18" 614
7* 420
7* 188
32* 1 222
2.3
19"
6*
3*
28*
* T h e n u m b e r o f c h i l d r e n infected in t h a t f a m i l y status.
104 Table 4. Fungal species isolated from ringworm infections examined.
Fungal species
Forms of ringworm Tinea capitis
Tinea manuum
Tinea corporis
Tinea pedis
Tinea crusis
Totals
Candida albicans
(Robin) Berkhout
-
+
1
+
4
Epiderrnophyton floccosum (Harz)
Langeron & Milochevitch Microsporum audouinii Gruby M. canis Bodin M. gypseum (Bodin)
Guiart and Grigorakis
+
+
-
+
+ +
+
+
+
+
1 3 2
Trichophyton ajelloi
(Vanbreuseghem) Ajello
+
-
1
T. gourvilii
Catanei
+
+
2
T. mentagrophyte
(Robin) Blanchard T. rubrum (Castellani) Sabouraud T. simii (Pinoy) Stockdale, Mackenzie & Austwick
+
+
+
+
+
5
+
+
+
+
+
5
+
-
+
+
+
+
+
-
-
+
-
-
Cochet and Doby Dubois
+
-
+
+
Total
13
4
7
6
3
T. soudanense
3oyeux
-
2
T. tonsurans
Malmsten
1
T. verrucosum
Bodin
-
1
T. yaoundei
3 4
34
+ = Present = Absent
c h i l d r e n r e p o r t e d t h a t t h e y had n o m a d i c p a r e n t s w h o m o v e d a b o u t w i t h cattle. It was also n o t e d t h a t some of the infected children played with flood w a t e r a n d r o a d p o t - h o l e water. It was also o b s e r v e d t h a t these p l a y - g r o u n d s w e r e c o n s t a n t l y visited by g r a z i n g cattle. S o m e of the r i n g w o r m i n f e c t e d children reported that they shared towels with their p a r e n t s . A l s o s o m e o f the a f f e c t e d c h i l d r e n said t h a t t h e y e x c h a n g e d s h o e s at t i m e s w h e n p l a y i n g . It was n o t e d t h a t the m a j o r i t y o f the scalp r i n g w o r m infected c h i l d r e n h a d t h e i r h a i r - d r e s s i n g f r o m a c o m m o n b a r b e r . O u t o f the 237 i n f e c t e d c h i l d r e n , 70
(29.54%) said t h a t t h e y h a d t h e i r b a t h 2 t o 3 t i m e s a week. T h e rest said t h a t t h e y h a d t h e i r b a t h at least 5 times a week. Discussion
T h e results o f the s u r v e y s h o w e d t h a t s c h o o l c h i l d r e n c a n be a t t a c k e d by the r i n g w o r m fungi. O u t o f a t o t a l o f 6 987 c h i l d r e n , 237 (3.4%) w e r e f o u n d to h a v e r i n g w o r m i n f e c t i o n . T h e statistical analysis o f t h o s e a f f e c t e d by this disease in the f o u r s c h o o l s i n d i c a t e t h a t t i n e a capitis a n d t i n e a pedis
105 constituted 35.2% and 32.8% of all infection cases, respectively. These two values do not show any significant difference. The other forms of ringworm had a lower range of infection (2.2%-13.7%). The interaction between the schools and the different forms of ringworm investigated was significant. The highest rate of tinea capitis infection was recorded in the Fatima primary school which had 50.4%. The other schools had a range of 28% 31,7% for the same disease. Tinea manuum had 0%-6.4% range of infection in the four schools. There was no significant difference in the rate of infection of this disease in these schools, in general. Tinea corporis had 8.9%-17.8% range of infection in the four schools. No significant difference was detected in the rate of infection of this form of disease in these schools. Tinea crusis had 0%-4.8% range of infection with no significant difference among the four schools. Tinea pedis had no significant difference in its rate of infection in the four schools. The infection range recorded for it was 25.6%-37.2%. Fatima primary school had no record of mixed infection while the other schools did not show significant difference in their records of mixed infection. These schools bad a range of 15.3%-20.7% of mixed infection. As for the rate of infection by the different forms of ringworm in a given school, the data indicate that tinea capitis, tinea corporis, tinea pedis and mixed infections were higher in occurrence than other forms of this disease. Tinea capitis and tinea pedis had greater infection than other forms of ringworm in St. Theresa's school. A similar trend was observed in the Methodist school. As for Fatima school, the highest infection was recorded for tinea capitis. It was followed by tinea pedis and tinea corporis. Some of the children infected by foot ringworm reported that they exchanged shoes while playing. This kind of practice must have contributed to the spread of this disease amongst the children. Furthermore, the spores of the fungi associated with this disease could contaminate floors, furnitures or clothing and subsequently be picked up on the feet. The humid conditions together with the normal continued maceration of the interdigital skin probably favoured the development of the fungi associated with this disease. Trichophyton mentagrophyte and other fungi associated with this disease
probably spread from infected to uninfected children by means of shed fragments of skin containing mycelium. It was noted that some of the infected children played with flood water and road pot-hole water. It is possible that the fungal isolates from the affected children originated from the soil. The presence of Keratinophilic fungi in the soil has been reported by (2, 3, 4, 5, 1). However it was observed that the children's play grounds were constantly visited by grazing cattle. It is therefore possible that the ringworm fungi were disseminated by these animals. Also the c o m m o n barber from whom some of the children obtained their hair dressing must have contributed to the spread of the head ringworm amongst the infected children. Soyinka (20) isolated M. audouinii from all the barbers instruments and from the hands of the barbers. Some of the groin-ringworm infected children said that they shared towels with their parents. It is likely that they contacted the infection from their parents because this disease is believed to be re;tricted to adults. The non-regular bathing habits of some of the infected children must have aided the development of the dermatophytes on the children's skin. Most of the ringworm infected children from Islamiya school reported that they shared their residential houses with domestic animals. The transmission of ringworm fungi can occur in both wild and domestic animals. Man and animal can act as important reservoirs of skin disease. This is particularly true of domestic pets. Dogs can harbour M. canis which can cause ringworm of the body and scalp in man, particularly in infants. The incidence of such disease in the cities is often related to the number of dogs that are kept as pets. The importance of human and animal presence in the environment, in the sense of direct interaction between human and animal 'pressure', and the presence and distribution of these fungi in the environment itself have been reported (1 I, 12). It was also stated that this interaction is, in turn, determinant of the epidemiology of diseases caused by keratinophilic fungi. From this point of view, the school environment is extremely important, being the environment of life of the population (school children) most exposed to the risk contamination. There was a close correlation between the children's family status and the mode of infection by
106 ringworm fungi. The highest number of infection was observed in children from under-average parents. The children of the Islamiya primary school had the least percentage of parents that were of average and over-average status. The highest number of ringworm infections were recorded from that school. Work is continuing on dermatophytes associated with domestic animals in Nigeria.
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