Managing skin infections in Aboriginal and Torres Strait Islander children

BACKGROUND

Skin infections are a cause of significant morbidity in Aboriginal and Torres Strait Islander populations.

OBJECTIVE

This article gives an overview of some of the issues to consider when managing a patient with a skin infection. These issues may impact on completion of treatment and development of complications in the long term.

DISCUSSION

Management should consist of treatment of the patient through medication and also general measures for the patient, their family and the community as a whole. There are significant health and socioeconomic burdens placed on communities as a result of the high rate of skin disease in some settings.

Management of skin infections in Pacific children prior to hospitalisation

INTRODUCTION

Hospital admissions for childhood skin infections in New Zealand (NZ) are on the increase. Pacific children make up a high number of those who are admitted. This study describes the parents of Pacific children's understanding and management of skin sores in the home prior to the sores becoming infected and requiring hospital admission.

METHODS

A descriptive qualitative approach combined with the Pacific research frameworks of Fa'afaletui and the Metaphor of Kakala were used to elicit parents' understanding and management of children's skin sores in the home. The semi-structured interviews were conducted in English or Samoan, and all transcribed into English.

FINDINGS

Mothers of 11 Pacific children admitted with skin infections between 2006 and 2008 were interviewed. The children's infections started with insect bites in some cases. Parents actively sought treatment to ensure children's optimal health was maintained. Initial management included a 'watch and see' approach for some, until deterioration was noted.

CONCLUSION

This is the first known study in New Zealand that has captured children's experiences when sustaining a skin infection/s and the activities that took place while seeking treatment in the community. Although most of the children received medical attention in primary health care (PHC), this did not prevent the need for hospital admission. The acuteness and seriousness of children's health on admission shows that preventive efforts need to increase and the early management of infections in PHC settings needs to be better understood.

Serious skin infections in children: a review of admissions to Gisborne Hospital (2006-2007)

AIM

Serious skin infections are an important and increasing problem in New Zealand children. The highest national rates are in the Tairawhiti (Gisborne) region on the East Coast of New Zealand's North Island, where evidence of significant ethnic disparities exists. This study aimed to describe the characteristics of serious skin infections in children hospitalised in the Tairawhiti region.

METHODS

The hospital charts of all children aged 0-14 years admitted to Gisborne Hospital between 1 January 2006 and 31 December 2007 for a serious skin infection were retrospectively reviewed and data on a range of variables analysed.

RESULTS

There were 163 cases of serious skin infections during the study period with 83% occurring in Maori children. The most common types of infection were cellulitis (38%) and subcutaneous abscesses (36%), and the most frequent sites of infection were the head, face and neck (32%) and lower limbs (32%). A previous episode of skin infection was recorded in 34% of children, with previous hospitalisation in 12%. A skin injury preceded infection in 37% of cases, more than reported in the Auckland and Wellington regions. Of the 77% of children who saw a GP 60% required immediate hospital admission. Compared with figures from the Auckland region, there were longer delays to medical care with a mean duration of symptoms of 2.5 days prior to visiting a GP. The most frequently isolated organisms were Staphylococcus aureus (48%) and Streptococcus pyogenes (20%) with similar proportions and resistance patterns to other New Zealand settings.

CONCLUSIONS

The characteristics of serious skin infections in the Tairawhiti region are largely similar to those reported in other New Zealand regions. However, some differences in preceding skin injuries and delays in seeking medical care exist which may contribute to the high incidence of hospitalised infections in the region. These differences require further investigation.

Skin infections in children in a New Zealand primary care setting: exploring beneath the tip of the iceberg

AIM

Over the past two decades there has been a documented steady rise in the incidence of hospitalised serious skin infections in New Zealand children. However there are few surveillance data from the primary care setting, where the majority of children with skin infections initially present. We aimed to describe the epidemiology of childhood skin infections presenting to primary care in a region of New Zealand with a particularly high burden of infection and compare this to hospitalised cases during the same period.

METHODS

A sample of general practitioners in the Tairawhiti (Gisborne) region recorded all cases of skin infections in 0-14 year old children diagnosed over a 10-week period in 2008. Observed case rates were directly standardised by age and ethnicity to the Tairawhiti population to give estimated rates for the whole region. Demographic data from primary care cases were compared to similar data from hospitalised cases during the same period.

RESULTS

There were 110 incident cases of skin infections seen by the nine participating general practitioners during the study period, equivalent to an annual incidence rate of 106.7 (95%CI: 85.2-127.2) cases per 1000 children in the region. For every one hospitalisation there were an estimated 14 primary care cases. Three quarters of skin infections in both primary care and hospital settings occurred in Maori children. There was no gender predominance in either setting, however hospitalised cases of serious skin infections were more likely to occur in the preschool age group whereas children aged 5-9 years predominated at the primary care level.

CONCLUSION

Skin infections are a common childhood complaint in primary care in the Tairawhiti region, with hospital-based surveillance using coded discharge data only capturing a small proportion of the overall community disease burden. Previously observed ethnic disparities in hospitalisation rates for serious skin infections reflect similar disparities in skin infection rates in primary care. The establishment of a sentinel surveillance system in the New Zealand primary care setting would facilitate further research and monitoring of this and other important conditions.

The epidemiology of serious skin infections in New Zealand children: comparing the Tairawhiti region with national trends

AIM

Serious skin infections are an increasing problem for New Zealand children with the highest national incidence in the Gisborne (Tairawhiti) region on the East Coast of New Zealand's North Island. This study aimed to describe the epidemiology of serious skin infections in children in this region, and make comparisons with equivalent national data to identify factors that might be contributing to elevated infection rates.

METHODS

Hospitalisation data were reviewed for 0-14 year old children in the Tairawhiti region discharged from hospital with a serious skin infection between 1990 and 2007. A range of demographic variables were compared to equivalent data for New Zealand cases over the same period. The ratio of observed to expected discharges was calculated after indirectly standardising the Tairawhiti population age, ethnicity and deprivation composition to that of the total New Zealand population.

RESULTS

In Tairawhiti the age-adjusted incidence of serious skin infections increased from 641.1/100,000 in 1990-1999 to 988.4/100,000 in 2000-2007, while the New Zealand incidence increased from 354.3/100,000 to 531.7/100,000. Preschool-aged children, Māori children, and those living in deprived neighbourhoods had the highest infection rates in all regions. The disparity between Māori and non-Māori children was significantly greater in Tairawhiti than nationally. The standardised ratio of observed to expected discharges in Tairawhiti compared with New Zealand was 1.42 (95%CI 1.32-1.52) in 1990-1999 and 1.28 (95%CI 1.19-1.36) in 2000-2007.

CONCLUSIONS

Serious skin infections are an increasing problem for all New Zealand children, but incidence rates in the Tairawhiti region are consistently greater than average national trends, with significantly larger ethnic disparities. The population composition of this region only partly accounts for the difference, suggesting the involvement of other unknown aetiological factors; these warrant further research.

Skin infection, housing and social circumstances in children living in remote Indigenous communities: testing conceptual and methodological approaches

BACKGROUND

Poor housing conditions in remote Indigenous communities in Australia are a major underlying factor in poor child health, including high rates of skin infections. The aim of this study is to test approaches to data collection, analysis and feedback for a follow-up study of the impact of housing conditions on child health.

METHODS

Participation was negotiated in three communities with community councils and individual participants. Data were collected by survey of dwelling condition, interviews, and audit health centre records of children aged under seven years. Community feedback comprised immediate report of items requiring urgent repair followed by a summary descriptive report. Multivariate models were developed to calculate adjusted incidence rate ratios (IRR) for skin infections and their association with aspects of household infrastructure.

RESULTS

There was a high level of participation in all communities. Health centre records were inadequate for audit in one community. The records of 138 children were available for development of multivariate analytic models. Rates of skin infection in dwellings that lacked functioning facilities for removing faeces or which had concrete floors may be up to twice as high as for other dwellings, and the latter association appears to be exacerbated by crowding. Younger children living in older dwellings may also be at approximately two-fold higher risk. A number of socioeconomic and socio-demographic variables also appear to be directly associated with high rates of skin infections.

CONCLUSION

The methods used in the pilot study were generally feasible, and the analytic approach provides meaningful results. The study provides some evidence that new and modern housing is contributing to a reduction in skin infections in Aboriginal children in remote communities, particularly when this housing leads to a reduction in crowding and the effective removal of human waste.

Benefits of swimming pools in two remote Aboriginal communities in Western Australia: intervention study

OBJECTIVE

To determine the health impact of swimming pools built with the aim of improving quality of life and reducing high rates of pyoderma and otitis media.

DESIGN

Intervention study assessing prevalence of ear disease and skin infections before and at six monthly intervals after opening of swimming pools.

SETTING

Two remote Aboriginal communities in Western Australia.

PARTICIPANTS

84 boys and 78 girls aged < 17 years.

MAIN OUTCOME MEASURES

Changes in prevalence and severity of pyoderma and perforation of tympanic membranes with or without otorrhoea over 18 months after opening of pools.

RESULTS

In community A, 61 children were seen before the pool was opened, and 41, 46, and 33 children were seen at the second, third, and fourth surveys. Equivalent figures for community B were 60, 35, 39, and 45. Prevalence of pyoderma declined significantly from 62% to 18% in community A and from 70% to 20% in community B during the 18 months after the pools opened. Over the same period, prevalence of severe pyoderma fell from 30% to 15% in community A and from 48% to 0% in community B. Prevalence of perforations of the tympanic membrane fell from 32% in both communities to 13% in community A and 18% in community B. School attendance improved in community A.

CONCLUSION

Swimming pools in remote communities were associated with reduction in prevalence of pyoderma and tympanic membrane perforations, which could result in long term benefits through reduction in chronic disease burden and improved educational and social outcomes.

Cutaneous manifestations of chronic renal failure in children of color

One hundred percent of adult patients with chronic renal failure (CRF) develop cutaneous findings as a result of uremia or due to therapeutic interventions. To date, pediatric incidence studies have been limited to Caucasian children. However, recent reports have indicated that more African American patients progress to end-stage renal disease (ESRD). This is the first study to assess the prevalence of renal failure-related skin disease in children of color, including African American and Hispanic patients. Thirty children were evaluated by history and physical examination, with assignment to one of three treatment categories: transplanted (n = 10), dialyzed (n = 16), or medically managed (n = 4). Skin findings were divided into uremic, drug-related, or infectious disease types. The incidence of skin disease was 100%. Xerosis was the single most common finding, often accompanied by pruritus. Cushinoid features were common despite the addition of steroid-sparing agents. Cyclosporin A-treated African American children had a high incidence of gingival hypertrophy (72%) and an even higher incidence of hypertrichosis (100%). Acral warts and nevi were common findings, the latter correlating with the length of immunosuppression. There is a high incidence of cosmetically disfiguring side effects (Cushinoid facies, hypertrichosis, and gingival hypertrophy) in children within all treatment categories, primarily related to drug treatment. Further study is required to determine the long-term sequelae, including psychological disturbances, of cutaneous disease in children of color with CRF.

Ethnic and geographic differences and similarities of HIV/AIDS-related mucocutaneous diseases. Danida Study Groups

BACKGROUND

A study on HIV/AIDS-related mucocutaneous manifestations has been carried out in three different ethnic and geographic areas, namely Brazil, Denmark, and Thailand.

METHODS

The Brazil cohort comprised 110 patients, the Danish cohort 150, and the Thai cohort 206 patients. The majority of the Brazil and Thai cohort patients belonged to groups III and IV according to the CDC clinical staging system, whereas the patients in Denmark called their doctors earlier and only 8% were classified in groups III and IV.

RESULTS

In all three areas the number of mucocutaneous diseases correlated well with the progression of the HIV disease. Ethnic differences were not identified, whereas geographic differences related to skin infections were marked. In the Asian cohort a generalized fungal infection was detected with characteristic mucocutaneous symptoms caused by Penicillium marneffei.

CONCLUSIONS

Teaching efforts about mucocutaneous signs as markers of HIV infection may be of value, particularly in developing areas, to allow earlier diagnosis. In future guidelines for classification of HIV/AIDS-related mucocutaneous diseases geographic considerations should be included.

Evaluation of serologic tests for diagnosis of anthrax after an outbreak of cutaneous anthrax in Paraguay

An outbreak of at least 21 cases of cutaneous anthrax occurred in rural Paraguay. A case-control study revealed that disease was associated with touching the raw meat of an ill cow (odds ration = 16.5, P = .02). Serum drawn from 12 cases and 16 colony and 2 noncolony controls 6 w after the outbreak were analyzed by electrophoretic-immunotransblots (EITB) to detect serum antibodies to the protective antigen (PA) and lethal factor components of anthrax toxin. Serum was also tested by enzyme-linked immunosorbent assay (ELISA) for the presence of antibodies to poly-D-glutamic acid capsule. Of 12 cases, 11 had a positive PA screen, for a sensitivity of 91.7% (76.1%-100%, 95% confidence interval [CI]) whereas none of the 18 controls was positive for a specificity of 100% (84.8%, one-sided binomial 95% CI). Only 6 (50%) of 12 cases (21.7%-78.3%, 95% CI) had positive lethal factor titers; all controls were negative. At a cutoff of greater than or equal to 1:32 for antibodies to capsule, 11 (91.7%) of 12 (76.1%-100%, 95% CI) were positive; 16 (88.9%) of 18 controls (74.5%-100%, 95% CI) were negative. These data suggest that the EITB for detection of antibody to PA, and ELISA for detection of anticapsule antibodies are both sensitive for the retrospective diagnosis of anthrax. Both tests were specific, but EITB may be more so than ELISA.

Cutaneous infections in blacks

We have described briefly a variety of cutaneous infections seen commonly but not exclusively in blacks. Some disorders are prevalent in blacks because of geography (high temperatures, humidity), environment, and low socioeconomic status causing over-crowding, malnutrition, and poor or delayed access to medical care. Only a few occur as a result of the unique way black hair or skin responds to trauma or infection. Physicians managing black patients with dermatologic problems should be aware of and must consider all the factors that initiate, aggravate, and perpetuate cutaneous responses under these conditions.