High-resolution infrared thermography: a new tool to assess tungiasis-associated inflammation of the skin.

BACKGROUND: Tungiasis is highly prevalent in low- and middle-income countries but remains often under diagnosed and untreated eventually leading to chronic sequels. The objective of the study was to assess whether tungiasis-associated inflammation can be detected and quantified by high-resolution infrared thermography (HRIT) and whether after removal of the parasite inflammation resolves rapidly. METHODS: Patients with tungiasis were identified through active case finding. Clinical examination, staging, and thermal imaging as well as conventional photography were performed. In exemplary cases, the embedded sandfly was extracted and regression of inflammation was assessed by thermal imaging 4 days after extraction. RESULTS: The median perilesional temperature was significantly higher than the median temperature of the affected foot (rho = 0.480, p = 0.003). Median perilesional temperature measured by high-resolution infrared thermography was positively associated with the degree of pain (rho = 0.395, p < 0.017) and semi-quantitative scores for acute (rho = 0.380, p < 0.022) and chronic (rho = 0.337, p < 0.044) clinical pathology. Four days after surgical extraction, inflammation and hyperthermia of the affected area regressed significantly (rho = 0.457, p = 0.005). In single cases, when clinical examination was difficult, lesions were identified through HRIT. CONCLUSION: We proved that HRIT is a useful tool to assess tungiasis-associated morbidity as well as regression of clinical pathology after treatment. Additionally, HRIT might help to diagnose hidden and atypical manifestations of tungiasis. Our findings, although still preliminary, suggest that HRIT could be used for a range of infectious skin diseases prevalent in the tropics. TRIAL REGISTRATION: ISRCTN11415557, Registration date: 13 July 2011.

Treatment of tungiasis with a two-component dimeticone: a comparison between moistening the whole foot and directly targeting the embedded sand fleas.

BACKGROUND: Tungiasis (sand flea disease) is caused by the penetration of female sand fleas (Tunga penetrans, Siphonaptera) into the skin. It belongs to the neglected tropical diseases and is prevalent in South America, the Caribbean and sub-Saharan Africa. Tungiasis predominantly affects marginalized populations and resource-poor communities in both urban and rural areas. In the endemic areas, patients do not have access to an effective and safe treatment. A proof-of-principle study in rural Kenya has shown that the application of a two-component dimeticone (NYDA®) which is a mixture of two low viscosity silicone oils caused almost 80% of the embedded sand fleas to lose their viability within 7 days. METHODS: In this study we compared the efficacy of two distinct modes of application of NYDA®; one targeted application to the area where the parasite protrudes through the skin and one comprehensive application to the whole foot. RESULTS: Independent of the two modes of application, the dimeticone caused more than 95% of embedded sand fleas to lose all signs of viability within 7 days. The targeted application killed embedded sand fleas more rapidly compared to when the whole foot was covered. The proportion of viable lesions at day two were 7.0 versus 23.4% (p < 0.01) and at day five 3.9 versus 12.5% (p < 0.02). CONCLUSIONS: Our findings suggest that the dimeticone could provide a safe and effective treatment for tungiasis in areas with difficult access to health care. TRIAL REGISTRATION: ISRCTN ISRCTN74306878.

The WHO ultrasonography protocol for assessing morbidity due to Schistosoma haematobium. Acceptance and evolution over 14 years. Systematic review.

In 2000, the World Health Organization (WHO) published an ultrasound field protocol for assessing morbidity due to schistosomiasis. The present study aims to review the acceptance of the WHO protocol for Schistosoma haematobium. A PubMed literature research using the keywords "ultrasound OR ultrasonography (US) AND schistosomiasis," "US AND S. haematobium," "US AND urinary schistosomiasis" from 2001 through 2014 was performed. Thirty-eight eligible publications reporting on 17,861 patients from 13 endemic and 2 non-endemic countries were analysed. Of these, 33 referred to field studies on 17,317 patients. The Niamey protocol was applied to 15,367/17,317 (88.74%) patients in 23/33 (69.70%) of field studies (all studies: 15,649/17,861 [87.61%] patients (25/38 [68.42%] studies). The acceptance of the protocol by single country in field studies varied from 0 to 100%. It varied over time between 55.56% (5/9) in the period from 2001 to 2004, to 87.50% (7/8) from 2005 to 2008, to 62.50% (5/8) from 2009 to 2011 and 75.00% (6/8) from 2012 through 2014 (all studies: 50% [5/10], 88.89% [8/9], 62.50% [5/8], 63.64% [7/11], respectively). The Niamey protocol was applied also in 2/5 hospital studies in 282/544 (51.84%) patients.The usefulness of the WHO protocol for S. haematobium infections is confirmed by its worldwide acceptance. Some simplifications might facilitate its use also for focused ultrasound examinations performed by less skilled examiners. Organ abnormalities due to schistosomiasis detectable by ultrasonography not yet covered by the WHO protocol should be added to the additional investigations section.

From a weighing scale to a pole: a comparison of two different dosage strategies in mass treatment of Schistosomiasis haematobium.

BACKGROUND: Clinical schistosomiasis in endemic countries is treated with a single dose of praziquantel per 40 mg/kg body weight. Treating according to weight, in resource-poor settings when thousands of doses are to be administered in mass treatment campaigns, is considered problematic. A calibrated dose-pole based on height was developed and is now used in mass treatment campaigns for determining the doses for schoolchildren. The dose-pole will generate dose errors since every child population contains individuals that are either short or tall for weight. The aim of this study is to explore whether the WHO praziquantel pole is a satisfactory dose instrument for mass treatment of S. haematobium. METHODS: In 1996 and 2002, 1,694 children were surveyed in the Kilimanjaro Region, Tanzania. We compared doses given by weight to doses given by height using descriptive statistics and regression. CONCLUSIONS AND INTERPRETATION: The WHO dose-pole for praziquantel is based on height of the patient; however, children with the same height will differ in weight. Our study shows that children with the same weight could qualify for up to four different dose levels based on their height. The largest variation of doses based on the WHO dose-pole will be found in children below 20 kg of bodyweight. Using bodyweight and tablet halves as the smallest tablet division unit to determine the doses of praziquantel, one only has to identify every 6th kilogram of bodyweight; the doses will then vary a lot less than when using the WHO dose-pole.

Fear of deportation may limit legal immigrants' access to HIV/AIDS-related care: a survey of Swedish language school students in Northern Sweden.

The increasing rates of HIV infection that are currently being reported in high-income countries can be partly explained by migration from countries with generalized epidemics. Yet, early diagnosis of HIV/AIDS in immigrants remains a challenge. This study investigated factors that might be limiting immigrants' access to HIV/AIDS care. Data from 268 legal immigrant students of two Swedish language schools in Northern Sweden were analyzed using logistic regression. Thirty-seven percent reported reluctance to seek medical attention if they had HIV/AIDS. Fear of deportation emerged as the most important determinant of reluctance to seek care after adjusting for socio-demographic factors, knowledge level, stigmatizing attitudes and fear of disclosure. Targeted interventions should consider the heterogeneity of migrant communities and the complex interplay of various factors which may impede access to HIV-related services. The myth about deportation because of HIV/AIDS should be countered.

Screening migrants for tuberculosis - a missed opportunity for improving knowledge and attitudes in high-risk groups: A cross-sectional study of Swedish-language students in Umeå, Sweden.

BACKGROUND: Migrants from countries with a high-burden of tuberculosis (TB) are at a particular risk of contracting and developing the disease. In Sweden, new immigrants are routinely offered screening for the disease, yet very little is known about their beliefs about the disease which may affect healthcare-seeking behaviours. In this study we assessed recent immigrant students' knowledge of, and attitudes towards TB, and their relationship with the screening process. METHODS: Data were collected over a one-year period through a survey questionnaire completed by 268 immigrants consecutively registered at two Swedish-language schools in Umeå, Sweden. Participants originated from 133 different countries and their ages varied between 16-63 years. Descriptive and multivariate logistic regression analyses were then performed. RESULTS: Though most of them (72%) were screened, knowledge was in general poor with several misconceptions. The average knowledge score was 2.7 +/- 1.3 (SD), (maximum = 8). Only 40 (15 %) of the 268 respondents answered at least half of the 51 knowledge items correctly. The average attitude score was 5.1 +/- 3.3 (SD) (maximum = 12) which meant that most respondents held negative attitudes towards TB and diseased persons. Up to 67% lacked knowledge about sources of information while 71% requested information in their vernacular. Knowledge level was positively associated with having more than 12 years of education and being informed about TB before moving to Sweden. Attitude was positively associated with years of education and having heard about the Swedish Communicable Disease Act, but was negatively associated with being from the Middle East. Neither knowledge nor attitude were affected by health screening or exposure to TB information after immigration to Sweden. CONCLUSIONS: Though the majority had contact with Swedish health professionals through the screening process, knowledge about tuberculosis among these immigrants was low with several misconceptions and negative attitudes. Information may currently be inaccessible to most of these immigrants due to the language barrier and unfamiliarity with the Swedish healthcare system. If TB education was included as a component of screening programmes, ensuring that it was tailored to educational background, addressed misconceptions and access problems, it could well help improve TB control in these communities.

Decreasing prevalence of herpes simplex virus-2 antibodies in selected groups of women in Sweden.

High estimates of herpes simplex virus-2 (HSV-2) seroprevalence have been reported for women who were pregnant in Sweden in the 1980s, probably reflecting sexual risk-taking during the 1960s and 1970s. The aim of the present study was to evaluate the HSV-2 seroprevalence in pregnant women and in the female attendees at a clinic for sexually transmitted infections in Sweden at the beginning of the 21st century and to compare the results with those of earlier Swedish studies. Sera were collected during the period 2000 to 2002 from 299 pregnant women at an antenatal clinic and from 290 female attendees at a clinic for sexually transmitted infections in Gothenburg. To enable comparison with earlier seroprevalence data the same test method was used; Helix pomatia antigen in an enzyme-linked immunoassay. The overall HSV-2 prevalence was 10.4% for the pregnant women and 25.2% for the female attendees at the clinic for sexually transmitted infections. The seroprevalence of HSV-2 in pregnant women appears to have decreased in Sweden during the past decade, which may reflect changes in sexual behaviour.

Screening for postpartum depression with the Edinburgh Postnatal Depression Scale (EPDS): an ethical analysis.

AIMS: To assess the Edinburgh Postnatal Depression Scale (EPDS), a self-administered questionnaire created to screen for symptoms of postpartum depression in the community, from an epidemiological and ethical perspective. Screening, as the practice of investigating apparently healthy individuals to detect unrecognised disease or its precursors, has interpretation problems and is complicated by deliberations on probabilities for something to occur, on which the scientific community is unanimous. METHODS: Our ethical analysis is made using a framework with two different dimensions, the ethical principles autonomy and beneficence and the affected persons. To balance the ethical costs and the ethical benefits of EPDS an analogy with the assessment of pharmaceutics is used. RESULTS: In this article we argue that routine EPDS screening of Swedish postpartum women would lead to considerable ethical problems due to the weak scientific foundation of the screening instrument. Despite a multitude of published studies, the side-effects in terms of misclassifications have not been considered carefully. The EPDS does not function very well as a routine screening instrument. The dualism created is too reductive and fails to recognize the plurality of difference that exists in the social word. CONCLUSIONS: Public health authorities should not advocate screening of unproved value. Screening is not just a medical issue but also an ethical one.

School-based prevention of schistosomiasis: initiating a participatory action research project in northern Tanzania.

The main aim of this project was to undertake participatory action research in two primary schools in northern Tanzania in order to create enabling environments for the schoolchildren and other community members to adapt practices relevant for reducing the transmission of schistosomiasis. This paper describes the process of initiating the project. The school activities started in 2002 by screening all schoolchildren (n=1146) in the two schools for schistosomiasis and intestinal helminths and treating those infected. This was interspersed with school essay writing, video recorded dramas and household sanitation observations. The first activities made the researchers realise that they had to focus more on the teachers and change their perspective from one of "helping the research team with their project" to become full partners in the research process. Preliminary results are the actions taken by the teachers to develop a curriculum for enhanced schistosomiasis education in primary schools, making household sanitation surveys part of school activities, better links between the school and the community, and actions taken by community members to create safe swimming places. The experiences and lessons learned so far are discussed.

Female genital schistosomiasis as an evidence of a neglected cause for reproductive ill-health: a retrospective histopathological study from Tanzania.

BACKGROUND: Schistosomiasis affects the reproductive health of women. Described sequelae are ectopic pregnancy, infertility, abortion, and cervical lesions and symptoms mimicking cervical cancer and STIs. There are indications that cervical schistosomiasis lesions could become co-factors for viral infection such as HIV and HPV. METHODS: In a retrospective descriptive histopathological study clinical specimens sent between 1999 and 2005 to the pathology department of a consultant hospital in Tanzania were reviewed to analyse the occurrence and features of schistosomiasis in female genital organs. RESULTS: During the study period, schistosomiasis was histopathologically diagnosed in 423 specimens from different organs (0.7% of all specimens examined in the study period), out of those 40% were specimens from female and male organs. The specimens were sent from 24 hospitals in 13 regions of mainland Tanzania. Female genital schistosomiasis was diagnosed in 125 specimens from 111 patients. The main symptoms reported were bleeding disorders (48%), ulcer (17%), tumor (20%), lower abdominal pain (11%) and infertility (7%). The majority of cases with genital schistosomiasis were diagnosed in cervical tissue (71 cases). The confirmation of cervical cancer was specifically requested for 53 women, but the diagnosis could only be verified for 13 patients (25%), in 40 cases only severe cervical schistosomiasis was diagnosed. Vulval/labial schistosomiasis was seen in specimens from young women. Infertility was reported in four patients with schistosomiasis of the Fallopian tubes. CONCLUSION: Genital schistosomiasis adds to the disease burden of women in all age groups. Pathological consequences due to the involvement of different genital organs can be damaging for the affected women. Clinical unawareness of genital schistosomiasis can lead to misdiagnosis and therefore false and ineffective therapy. In endemic areas cervical schistosomiasis should be considered as differential diagnosis of cancer.

On the application of the von Mises distribution and angular regression methods to investigate the seasonality of disease onset.

This paper describes an approach to summarize the data arising from studies investigating the pattern of disease onset within a calendar year. Such data have been traditionally summarized into monthly counts summated over the complete years studied and patterns often examined by use of Pearson's chi(2) tests with 11 degrees of freedom. This test and others commonly used in practice are reviewed. As an alternative, we suggest that by first representing the date of onset for an individual as a point on a unit circle that the von Mises distribution with a single peak may provide a useful description of such data. Further an extension to angular regression including covariates, analogous to that used routinely in other areas of clinical research, potentially allows a more systematic and detailed investigation of possible seasonal patterns in patient subgroups. The methodology is applied to examples from the date of onset of primary angle-closure glaucoma and date of diagnosis of acute lymphoblastic leukaemia and examines in both situations how the peak onset varies with covariates. Difficulties associated with convergence to the maximum likelihood estimates of the associated parameters are described. Finally, we emphasize the need for individualized (rather than grouped) patient data to be available for study, a clear specification of the particular 'onset' time studied, and suggest that further case studies are required to evaluate the approach.

Variation in the seasonal diagnosis of acute lymphoblastic leukemia: evidence from Singapore, the United States, and Sweden.

This study investigated, by summing data over successive years, the evidence for the seasonal diagnosis of acute lymphoblastic leukemia. To do so, the authors estimated the dates of peak diagnosis over a range of geographic locations including Singapore (1968-1999), Hawaii and mainland United States (1973-1999), and western Sweden (1977-1994) at latitudes of 1.16 degrees N to 58.24 degrees N. In contrast to other studies, the authors used case-by-case information on dates, gender, and age rather than grouped data for analysis. The seasonal pattern was estimated by fitting a von Mises distribution to the data from each location. No seasonal pattern was found in Singapore, which is close to the equator and does not have marked climatic changes. Likewise, seasonality was not demonstrated in Hawaii or mainland United States despite a 26.18 degrees range of latitudes. In contrast, a significant peak (early January) was observed for western Sweden that appeared strongest for males (December 22, 95% confidence interval: November 16, January 16) and those less than age 20 years (January 14, 95% confidence interval: December 8, March 27). Thus, despite a wide geographic range of localities, there is little evidence of any seasonality in the diagnosis of acute lymphoblastic leukemia in most populations studied and no strong evidence of any influence of climate (as expressed by latitude).

Acceptance and outcome of herpes simplex virus type 2 antibody testing in patients attending an STD clinic--recognized and unrecognized infections.

The majority of herpes simplex virus type 2 (HSV-2) genital infections are asymptomatic. We wanted to evaluate the acceptance of HSV-2 antibody testing among people attending an STD clinic and to estimate, after counselling, the percentage of recognized and unrecognized HSV-2 infections. First visitors to an STD clinic were invited to participate by answering a questionnaire and taking a blood test for HSV-2 antibodies. HSV-2 seropositive individuals, who were unaware of having genital herpes, were offered an HSV-2 counselling visit and follow-up. Of 1769 patients offered testing, 57% accepted. Of 152 (15%) HSV-2 seropositive individuals, 41% had a self-reported history of genital herpes, approximately 30% had genital symptoms and 30% had no genital symptoms. The percentage of patients reporting genital symptoms was much higher in HSV-2 seropositives (45%) without a history of genital herpes than in an HSV-2 seronegative group (28%). HSV-2 antibody testing should be performed generously in all cases of uncharacteristic genital symptoms.

A six-year follow-up of schoolchildren for urinary and intestinal schistosomiasis and soil-transmitted helminthiasis in Northern Tanzania.

Two cross-sectional studies with a 6-year interval were undertaken in two primary schools in neighbouring villages in Mwanga District, Tanzania, to determine the prevalence of schistosome and soil-transmitted helminth infections before and 6 years after treatment. Within this interval, health-related interventions such as one mass treatment of the villagers, health education, improvement of sanitation and access to safe water were undertaken in the villages. In 1996, urinary schistosomiasis occurred in Kileo (n=284) and Kivulini (n=350) in 37.0 and 86.3% of the schoolchildren. Intestinal schistosomiasis was found in 22.9 and 43.5% of the children. The infection with soil-transmitted helminths ranged between 2.7 and 18.1% in both villages. After 6 years, the prevalence of urinary schistosomiasis in schoolchildren remained nearly constant in Kileo (33.5%; n=544), but dropped from 86.3% to 70.0% in Kivulini (n=514). In the latter village the proportion of children heavily infected with Schistosoma haematobium (> or = 50 eggs/10 ml urine) decreased from 53.8% to 34.4%. With the exception of hookworm infection, soil-transmitted helminthiasis and intestinal schistosomiasis were significantly less seen in 2002 compared to the baseline. The previous chemotherapy of schoolchildren and villagers in 1996 and 1998, respectively, might have led to a reduced transmission of schistosomiasis in the following years. However, the reduction of prevalence of soil-transmitted helminthiasis is more likely to be the result of health-related interventions.