Tungíase: doença negligenciada causando patologia grave

JAM ACAD DERMATOL
VOLUME 60, NUMBER 3
In developing countries scabies is a common
parasitic skin disease, and it is associated with considerable
morbidity, such as excoriations, eczematization,
secondary infection leading to impetigo,
suppuration, abscess formation, lymphadenopathy,
and poststreptococcal glomerulonephritis. 1-10 In resource-poor
urban and rural communities the prevalence
of the infestation with Sarcoptes scabiei may
reach 10% in the general population and 59% in
children. 1,2,4,7,9,11-19 In an urban slum in Bangladesh,
the incidence in children younger than 5 years was
952/1000/year, indicating that nearly all children
experienced at least one infestation per year. 20 This
is in contrast to the situation in industrialized countries,
where the disease occurs sporadically in all age
groups, particularly in sexually active adults, or
causes epidemics in institutions and nursing
homes. 8,21-26
Many factors have been suggested to determine
the epidemiology of scabies in impoverished communities,
including social attitudes, population
movements, malnutrition, lack of access to health
care, inadequate treatment, deficient hygiene, and
crowding, but so far these assumptions have not
been substantiated. 3,6,7 As in most countries scabies
is not a notifiable disease, usually only large outbreaks
tend to be reported. 27 By consequence, what
is known about the epidemiology of scabies is
mainly based on data from hospital and outpatient
records or certain high-risk groups. 6,28-36 Risk factors
for occurrence of disease have rarely been studied in
Africa and Asia, 1,2,7,20 but have not been investigated
in the Americas.
We studied the epidemiology of scabies in an
impoverished rural community in Brazil during two
seasons of the year, and identified risk factors associated
with the presence of scabies and the occurrence
of severe disease. Our results show that in this
setting scabies is predominantly a disease of children
with the occurrence and severity of infestation being
related to poor living conditions and illiteracy, and
that transmission remains stable throughout the year.
METHODS
Study area
The study was performed in Feliz Deserto, a small
coastal town (3850 inhabitants) situated about 120
km south of Maceió, the capital of Alagoas State in
northeast Brazil. The study area was confined to
those districts of Feliz Deserto where, according to
the agents of the National Health Program Family
Health Program (Programa de Saúde da Família),
scabies repeatedly occurred in the past 5 years.
Climatic, social, cultural, and economic characteristics
of the study area were described previously. 10
Feldmeier et al 437
Study design
Two cross-sectional studies were performed: all
households in the study area were visited in
June/July 2003 (end of rainy season) and a second
time in October/November 2003 (peak of dry season).
All individuals who had spent at least 4 nights
per week in their household during the last 3 months
were eligible for the study. This excluded individuals
only temporarily present in the area who might have
confounded the risk factor analysis. In both door-todoor
surveys, households were revisited 3 times if an
eligible household member was absent. Each survey
was carried out within a period of 10 weeks. The
household members were examined for the presence
of scabies and other parasitic skin diseases.
Using standardized questionnaires, information on
demographic, socioeconomic, environmental, and
behavioral variables were obtained. These questionnaires
were tested before their use. To exclude
interobserver bias, all clinical examinations were
carried out by one investigator (A. J.). However,
some degree of recall bias cannot be excluded in our
setting.
Clinical examination and case definition
The household leaders were asked for a room
with good light and in which privacy was guaranteed.
In this room, the whole body including the
breasts and the genital area was thoroughly examined
for the presence of skin lesions typical for
scabies. Children younger than 10 years were only
examined in the presence of a caretaker, usually the
mother. The diagnosis of scabies was made clinically
after well-established and approved methods in the
developing world. 1,2,6,9,37 Skin scraping cannot be
considered to be of help in this setting, as its
sensitivity is low, and the method is not feasible for
surveys in resource-poor settings. 38-42
Scabies was suggested if itchy papular, papularcrusted,
or vesicular lesions were present. An individual
was defined to have scabies if at least two of
the following 3 requirements were fulfilled: presence
of one or more typical lesions for longer than 2
weeks, pruritus that intensified at night, or at least
one more family member with similar lesions. The
validity of this case definition in resource-poor
settings has been shown previously. 9
After the diagnosis of scabies was made, the
patients and their families were treated with 0.2%
deltamethrin lotion (Deltacid, Solvay Farma, São
Paulo, Brazil).
Bacterial superinfection was diagnosed when
pustules, abscesses, or suppuration were present.
Superinfected lesions were treated with oral roxithromycin
(Floxid, Solvay Farma). The draining