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The incidence of certain skin diseases in Western Samoa: A preliminary survey
319 RANSACTIONS OF THE ROYAL SOCIETY OF TROPICAL MEDICINE AND HYGIENE.
Vol. 44.
No. 3. December, 1950.
THE INCIDENCE OF CERTAIN SKIN DISEASES IN WESTERN SAMOA: A PRELIMINARY SURVEY.* BY
M. J. MARPLES,
Department of Bacteriology, University of Otago, New Zealand.
D u r i n g t h e s u m m e r of 1948-49, the M e d i c a l R e s e a r c h C o u n c i l of N e w Z e a l a n d s e n t a research t e a m to W e s t e r n S a m o a to m a k e a p r e l i m i n a r y s u r v e y of c e r t a i n h e a l t h p r o b l e m s . T h e o b s e r v a t i o n s d e s c r i b e d i n this p a p e r were carried o u t b y t h e a u t h o r d u r i n g the 2 m o n t h s ' r e s i d e n c e of this t e a m i n Samoa. Western Samoa is a New Zealand mandated territory and consists of two large islands, Savaii and Upotu, and a few small islands. BUXTON (1928) gives a full account of the geography and climatic conditions of Smnoa. T h e islands lie 130 miles north of Tonga and 500 miles north-east of Fiji, 13° to 14° south of the equator, and 171 ° to 173° west of Greenwich. All the islands are volcanic and surrounded by an incomplete fringing coral reef. T h e central areas of the two large islands are mountainous. The temperature is extremely equable, ranging from 26"28 ° C. in December to 25"01 ° C. in July. T h e mean annual rainfall is 2,738 ram. Droughts are unknown and there is no definite dry season. The relative humidity is high, the monthly mean for the daytime ranging between 70 and 80 per cent. The prevailing wind at all seasons has an easterly component. The vegetation is luxuriant. T h e islands support a population of approximately 70,000 Samoans (68,197 in 1945 census) about 350 Europeans and a few Chinese. The Samoan population is increasing. Nearly all the Samoans live in villages on the coast, there are very few inland settlements. They live in attractive native houses, oval in shape and consisting of a thatched roof supported on posts, and a raised floor usually made of broken-up volcanic rock. There are no walls, but mats can be let down from the roof in bad weather. The Samoans wear native dress which consists of a single piece of cloth wrapped round the waist, and called a lava-lava. This is usually the only outer garment of the children and most of the men, but the older girls and women wear an overgarment or a frock as well, and some of the men, especially those in daily contact with the European population, wear a shirt. D u r i n g this i n v e s t i g a t i o n , c h i l d r e n were e x a m i n e d f r o m several villages o n b o t h large islands, a n d also f r o m the villages s i t u a t e d o n t h e s m a l l i s l a n d s of M a n o n o a n d A p o l i m a . T h e s e lie b e t w e e n U p o l u a n d Savaii a n d each s u p p o r t s a s m a l l p o p u l a t i o n . I n all, 2,070 c h i l d r e n were e x a m i n e d , b u t n o t all received e My thanks are due to the New Zealand Medical Research Council for the privilege of being a member of the Research Team, and to the other members of the team for their help. I am especially indebted to Dr. J. C. LOPDELL, the Chief Medical Officer of Western Samoa, to Miss McHuGH, the Matron of the Apia Hospital, and to Nurse MOMOI and the many Samoans who drove me round the islands, interpreted for me and helped me in many other ways. I am also indebted to Dr. H. SILVERSTONE,who made the statistical analysis of the figures, to Sir CHARLESHERCUS for constant advice and encouragement and to my husband and sons who gave me great help in sorting out the results of this survey.
320
SKIN DISEASES IN SAMOA
as complete an examination as others. The main object of this investigation was to determine the incidence of skin diseases, but in 1,329 children, the age, sex, height and weight were also recorded. MATERIAL AND METHODS. Visits were made to different villages on the islands and all the available children were assembled. In the full examination, each child's age and sex was recorded. It was weighed and measured, and was examined for different types of skin disease, the site of the lesion or lesions being recorded. Specimens of skin from possible fungus infections were collected and subsequently examined microscopically, after digestion with caustic potash. Abnormalities and obvious infections other than skin conditions were recorded and a clinical estimation of the nutrition was made. The information collected was transferred to a punch-card system for analysis. An endeavour was made to restrict the examination to children of 12 years or less, but a few 13-year olds were present and insisted on taking part, and therefore a small sample of children of this age is included. The following skin conditions were recorded : yaws, impetigo and infected sores, boils, scabies, prickly heat, tinea versicolor and other ringworms. Only the obvious yaws lesions were noted and it is probable that a number of incipient lesions were missed. The occurrence of yaws scars was not recorded. In addition, as part of the work of the team, the boys attending the Government Secondary Boarding School outside Apia were examined, and the adults of a village in Upolu, as part of a village survey. The examination of the village adults was carried out by Dr. H. D. PURVES, the leader of the research team. The results of these examinations are included in this report. The sample of adults is rather small, and the adolescent boys in the school are not a true sample of this age-group. These boys were selected for the school partly on the grounds of physical fitness and they had received continuous care during the school year. They demonstrate rather the results of care and supervision than the incidence of skin infections in adolescent boys. RESULTS OF THE INVESTIGATIONS.
T a b l e I shows the incidence of the different skin diseases in the whole group of individuals examined. It will be noted that tile total number of lesions is greater than the number of individuals. This is due to the fact that many suffered from two or more conditions. Yaws was the most serious condition involved, as 30 per cent. of the unselected children and 24.2 per cent. of the adults were found to be carrying active lesions. Only 3.5 per cent. of the schoolboys had active yaws, although many of them showed scars. Scabies was much more prominent in the children under !2 (22 per cent.) and was slightly less common in the schoolboys (10.5 per cent.) than the adults (12 per cent.). The figures for impetigo are very
M. J. MARPLES
321
similar. On the other hand, tinea versicolor was considerably more common in the older groups. Just over 10 per cent. of the children had this infection, whereas 39 per cent. of the schoolboys and 49 per cent. of the adults showed the characteristic lesions. The above figures show the occurrence of these skin conditions in the total number of persons examined. When the results of the examination of children of known age and sex are analysed, further information concerning the age distribution of the various diseases becomes known. TABLE I.
Group.
Village children Government secondary school Village adults
Nuwtber Yaws. Scabies. exam ined.
Tinea Impetigo. Infected Boils. Prickly versi- Ringcuts. heat. color. w o r m .
£,042
630
460
473
92
38
105
4
11
17
4
12
124
30
15
12
25
2t3
121
41
4
61
24
Table II shows the incidence of skin diseases in the different age groups. Boils and infected cuts have been omitted. The first year of life is divided into two 6-month periods, after that, yearly grouping is shown. The total children of each age-group is shown in the first column, but the incidence of each disease is expressed as a percentage, so that the different ages can be compared. The percentage of children free from obvious lesions is also shown in Table II under the heading " Skin Clear." This does not mean that the skin had no scars, only 11 babies had skin in this state, the oldest being 15 months. About 50 per cent. of the children under a year old were free from skin lesions at the time of examination and the number rapidly declined in the older age-group to less than 20 per cent. After this it rose again to about 30 per cent. The incidence of each disease will be discussed separately.
Prickly Heat. This condition was seen in only the youngest children. Many of the babies appeared to be too warmly wrapped up for the climate in which they were living. The rash was noticed in the axilla, groin and around the waist. In a few cases it appeared to be infected. Two females just over a year were the oldest found suffering from prickly heat, after that it disappeared completely. This is not surprising since most of the children wore nothing except the lava-
322
SKIN D I S E A S E S IN SAMOA
TABLE I I .
T h e a g e d i s M b u t i o n of t h e p r i n c i p a l s k i n d i s e a s e s f o u n d i n S a m o a n c h i l d r e n .
Age.
O- 6 m o n t h s 7-12 ,, 1 year ... 2 years ...
5
10 11 12 13
~
..... ,, ,. ,i
.
... . .,,
0 - 1 3 y e a r s- .-.
Num ber.
Skin clear, Per cent.
Prickly heat. Per cent.
98 53 79 123 119 139 125 107 77 99 84 104 48 61 30
52.0 41 "5 16.4 26.0 16.9 17.3 18.4 21.5 18.1 30.3 21.4 28.8 29-2 34.1 23.3
18.O 8-0 2.5
25.4
1--~346
Scabies. Per cent.
Impetigo. Per cent.
Yaws. Per cent.
8.0 32.6 45.4 35.8 32.9 32.3 31.2 32.8 22.0 24.2 26.8 13.4 19.0 5.0 3.3
2.0 ,3.9 25.3 23.6 29.4 38.1 48.0 30-0 40.0 34-0 50.0 44.5 42.0
....
25.0 34-0 36'4 26.0 16.0 30.9 24.8 28.9 27'2 14.I 22.6 13.4 20.9 25.0 6-6
1-7
24.0
26.0
......
- -
Tinea versicolor. Per cent. _ _ _
i Ring! worm. Per cent. I !___
1,0 4.0 2.0 2.0 6.3 2.5 3.3 3-3 11-0 4-2 12.9 . 6.5 15.2 2.3 12.1 8.4 18-1 1 10.4
I
i7:o
E
7.0
17.9 14.4 10.1
i F
7.1 5.8 10'1
i
37-7 I 17.0
/ 130
53.3
/
16.6
10.0
lava. A number of the older girls wore a cotton frock and under-pants, and a few had European dress, some even removing two or three layers of underclothing before they could be examined. It is probable, however, that these garments were put on for the purpose of examination, and that normally the majority of younger children of both sexes wear only the lava-lava.
Scabies. This condition was the most common found in the babies, 25 per cent. of those under 6 months and 34 per cent. in the 7- to 12-month group showing lesions due to Sarcoptes. The infection reached a maximum of 36 per cent. in the children of 1 to 2 years and then showed a very gradual decline in the older age-groups. The actual mite was removed from its burrow and demonstrated in a few cases, but in the majority the condition was diagnosed on clinical grounds alone. It was observed that many of the mothers of the babies suffering from scabies themselves showed lesions, and when the fathers were available for examination they too showed evidence of scabies. Further, 10 per cent. of the schoolboys and 12 per cent. of the village adults had scabies. In order to control this condition it would be necessary to treat the adults of the community as well as the children.
M. j. MARPLES
323
As would be expected, the lesions of scabies were most commonly found on both the hands and feet. Of the children fully examined, 78 per cent. had lesions on the hands, and 48 per cent. on the feet. Legs also were commonly infected, 31 per cent. having lesions in this area, and a number of children had areas on the trunk infected. It is of interest to note that in the youngest age groups the feet showed a much higher incidence of infection than in the group of children as a whole. Seventy-three children under 2 years had scabies, and of these 68 per cent. had scabies on their hands, 70 per cent. on their feet, while 37 per cent. had lesions on the legs. This fact will be referred to in the discussion, with reference to the possible relationship between scabies, impetigo, and the onset of yaws. There is some suggestion from the figures that in the younger age-groups the females were more prone to scabies than the males.
Impetigo. This condition was also found to be very common among the children. The condition was not so prevalent in the earliest age-group as scabies, but in children of 1 to 2 years it was found in 45 per cent. examined. After this it showed a gradual decline, until among the 10-year olds only 13 per cent. showed lesions of impetigo. The condition was widespread all over the body, and a number of children had lesions of the scalp. The most common site, however, was the legs, 68 per cent. of the whole group having lesions in this area. Hands were the next areas most commonly affected, 21 per cent. having lesions in this region; 18 per cent. had lesions of the head and neck, but only 10.5 per cent. had impetiginous lesions of the feet. The difference between the sexes was not striking but in the younger agegroups the girls tended to be more commonly infected, while in the children over 8 years the boys showed the higher incidence. Impetigo was less common in the older individuals examined, only 3 per cent. of the village adults suffering from this infection, while 16 per cent. of the secondary schoolboys carried impetiginous lesions.
Infected Cuts and Boils. These conditions were much less common than the more superficial impetiginous infection. They were present in about 5 per cent. of the children of each age-group, and appeared to be equally common in the two sexes. Since tile children were running barefoot over coral, or volcanic stones, they naturally sustained constant injury, and these traumata were frequently infected, presumably by the enormous number of organisms present in the reservoir due to the widespread impetigo. As would be expected, infected cuts occurred most commonly on the arms and legs. Boils were much less common, and occurred
324
SKIN DISEASES IN SAhIOA
most frequently on legs and buttocks. Spreading infections with lymphangitis were not encountered among the children included in this survey. Yaw& This condition was found to be extremely prevalent among this group of children, and proved to be by far the most serious skin condition. Unfortunately, scars were not recorded, so that the figures quoted indicate only the incidence of active yaws and not the total child population infected. It was not found possible to distinguish between primary, secondary and tertiary stages but the number and sites of the lesions suggest that most of the children were at least in the secondary stage. Yaws was not found to be common in children of less than 1 year, the youngest cases seen were two females of 6 months. One had a single large lesion on the hand, presumably a primary yaw, but the other had lesions on both hands and feet and must already have reached the secondary stage. Two females of 9 months had yaws, one had a single lesion on the leg, the other had yaws on both arms and legs, and also had scabies in both these areas. A female aged 1 year had a single yaw on the face, while another of 17 months had generalized yaws widespread over the bo,dy. In the children whose age ranged from 1 to 2 years yaws was much more common, over 25 per cent. having active lesions. In this group the females (33 per cent.) were more commonly infected than the males (15 per cent.). The 2- to 3-year group showed a slightly lower incidence, again with fewer males than females involved, but after this the condition showed a gradual steady increase, with males showing a slightly higher incidence than females. Fifty per cent. of the children aged 9 years had yaws, and this level was more or less maintained in the older groups. It is of interest to note that only 3.8 per cent. of the secondary schoolboys had active yaws, although 24 per cent. of the village adults suffered from this infection. The small number of cases among the schoolboys is probably due to the constant supervision and treatment they received. In the yaws census taken in 1933, 50.9 per cent. of the total population was found to be suffering from the disease. The results of this investigation suggest that in spite of extensive schemes of treatment at present available in Western Samoa, the control of yaws remains a serious problem. When the sites of the lesions were analysed it was found that the soles of the feet were the areas far the most commonly affected. The lesions in this site were of the two classical types--ulcerated areas, or granulomatous lesions ; 86.7 per cent. of the children with yaws had lesions of the feet, 66.4 per cent. having lesions in this region only, while 20.3 per cent. had yaws on the feet and on some other part of the body as well. Table III shows the number of sites of yaws lesions found in the different age groups, together with the percentage of each group which had yaws only on the soles of the feet.
325
M. J. MAEPLE5 TABLE I I I .
J~ge~
N u m b e r of sites of lesions of yaws.
4
1
5 or more.
years. 0-1 1-2 2-3 3-4 4-5 5-6 6-7 7-8 8-9 9-10 10-11 11-12 Over 12
2 12 21 23 43 45 29 28 25 32 39 20 26
1 4 2 9 9 11 1 9 1 9 7
8
1
Feet only. Per cent. 26 30 43 55 74 76 66 64 92 43 71 85 67
Fungus Infections. Tinea versicolor, locglly known as " Tane," was found to be a prevalent skin condition in Samoa. It did not appear to be regarded by the Samoans as worthy of attention and in most cases was untreated. This makes it an interesting condition, worthy of further study in relation to the epidemiology of an untreated fungus infection. Such a study might yield valuable information about the natural spread of the dermatophytes. Among the children examined, tinea versicolor showed a gradual increase with age, but no age-group was exempt, since two infants, one male and one female, both under 6 months, showed the characteristic lesions. The infection became more common in the older groups and was present in about 17 per cent. of the children over 7 years. It appears to become increasingly prevalent in older groups, since 39 per cent. of the schoolboys and 49 per cent. of the village adults carried this fungus. This condition showed an entirely different distribution on the body from the ones previously discussed. The chest was the most common site, 63 per cent. of the children having lesions on the front and 35 per cent. on the back of the chest ; 22 per cent. had lesions on the face and neck but only 13 per cent. on the arms and 10 per cent. on the legs.
Other Ringworms. These also were fairly common, but less so than tinea versicolor. They took the form of sealing cireinate lesions and some were very large indeed. Many of the children had multiple lesions, o n e interesting type showed very little scaling. This type had a raised edge, and scattered over the central area
326
S K I N D I S E A S E S IN SAMOA
were raised non-vesicular patches. Scrapings from these patches as well as from the edge of the lesion showed fungal elements when examined microscopically .after digestion with caustic potash. Although tinea imbricata occurs in Samoa none of the children examined showed the classical picture with concentric rings, although many had extensive scaling lesions which were suggestive of this form of ringworm. Unfortunately, the conditions available for the culture of pathogenic fungi were wholly unsatisfactory, and contamination was overwhelming. Those cultures that were obtained belonged to the genus Trichophyton. The site of these fungus infections was interesting. No cases of ringworm of the scalp were found among the village children included in this survey, and only two cases were seen during tile whole time spent in Samoa. Both these showed fungal elements in the hair on direct examination, and both yielded cultures of Trichophyton sp. A number of children living in or near Apia were examined under Wood light, and no fluorescence was observed ; the large population of cats which inhabited the Apia hospital was also negative on examination under Wood light. It is interesting to speculate on why the Samoan children were free from tinea capitis although tinea corporis was prevalent. It is possible that the genus Microsporum, the most common cause of scalp ringworms, is rare or absent in Western Samoa. Further investigations of the species of pathogenic fungi would demonstrate whether this is so. Many of the children had impetigo of the scalp, and possibly this infection might prevent the growth of the fungus. Many of the Samoans use oil extensively on their hair and possibly this is inhibitory to a fungus infection. The back was the most common site for a ringworm, 42 per cent. of the children having their lesions in that area; 33 per cent. were infected on the chest and 17 per cent. on the face and neck. Ringworms on the legs were found in 13.5 per cent., and on the arms in only 5 per cent. No age-group was free from ringworm, and the percentage of all children infected varied from 5 to 10 per cent. Ringworms appeared to be common among adults, 19 per cent. of the village group carrying lesions. Less than 4 per cent. of the schoolboys were infected, but this again is probably due to their greater facilities for treatment.
Other Clinical Abnormalities. Umbilical Hernia. This condition appeared to be rather common among the smaller children since it was found in 43 persons. It disappeared in the older groups and appeared to become corrected without any treatment. It was present in 11 per cent. of the children under 1 year, 15 per cent. of the 1-year and 10 per cent. of the 2-year, but only in 2.5 per cent. of the 3-year olds. After this it soon disappeared, the oldest child having this type of hernia being a boy aged 6 years.
~.
J, MARPLES
O n l y one of the children examined had an inguinal hernia. boy aged 5 years.
327
This was a
Sabre Tibia and Other Bone Deformities. Sabre tibia was a fairly common finding. It was presumably a manifestation of tertiary yaws, but has not been included in the yaws figures, as IIACKETT (1946) says that it could not be regarded as solely due to yaws among the natives of Uganda. It was found in 18 of the children examined, and o f these 12 also had yaws on the feet. The youngest children with sabre tibias were a male and female, both aged 4 years. Five of the ll-year and three of the 12-year olds had this deformity. Other bone deformities were not uncommon. Abnormalities were seen in two fingers, two wrists, one elbow, one ankle, one knee, and two hips. These conditions were probably all late yaws manifestations. Two boys had bilateral talipes. One was 2 years old, the other 10. He walked on the sides of his feet, but his yaws lesions were situated on the true soles of his feet.
Other Conditions. Seven children showed evidence of rickets, the most obvious being a boy of 2 years, who showed gross evidence of undernourishment, and was found to weigh only 15½ lb. Seven children had discharging ears. One girl of 10 months had two thumbs on the left hand. They were of equal length and both had nails. Syndactyle of two toes was seen in a child of 2 years. One child was dumb, and two appeared to be feeble-minded. One of these was a b~y of 10 who had a spastic paraplegia, the other a boy of 6 who appeared from his mother's account to be a congenital epileptic.
Heights and Weights. The graph shows the mean yearly heights and weights of the children from 1 to 12 years compared with curves obtained from figures relating to New Zealand children. The period from 1 to 5 years is compared with a curve issued by the Royal New Zealand Society for the Health of Women and Children. The period from 6 to 12 years with the heights and weights of Maori boys published by LONIE (1945). Table IV shows the mean monthly weights of Samoan infants. Fifty-six males and 92 females under 1 year were weighed. The mean weights were calculated by months and fluctuations smoothed out, following the same technique as that used for the construction of growth curves for New Zealand infants by the above Society (DEEM and SILVERSTONE, 1944). A comparison with the mean weights of New Zealand infants is shown in Table IV. These observations are given with some diffidence in the knowledge that the samples were too small and that the methods used were open to error. They are, however, suggestive and indicate the need for careful investigation of the
3.~8
SKIN DISEASES IN SAI~IOA G R A P H . - - S a m o a n h e i g h t s a n d w e i g h t s c o m p a r e d w i t h N e w Z e a l a n d figures.
70 65 s5
N.Z 8
0 •
60
Id^O~l
A 0 • ~ ~ S A M OAN
,,,,
,.A
50
j SAMoA.,,"
oL
0 • v .j.
~.,,,Q,,~ • N.Z~MAOPd
O0 o • -~""~
45 gO 40
/0
~55
~0
• 0
,.z? " ~ ¢ " ~
.
^
0
~ 5 A M O A N 9.
30 50 - 25 4O
,,_e**o.~
x
I.~ 2¢ I0
I0
-
e - " * ~ /°./~ ~Jt¢~'"
2 0 3f
~
5
-
: S A M O A N 0~I
.~---XSAMOAN 9.. 0 0 0 N.Z. MAOR!SCHOOLBOY-~
:
N.Y-. PLUNKET SOC:
e--e
,
I
2
3
4
p
5
G 7
8
9
10 II 12
YL'AI~5
TABLE IV.
Comparison of the weights of New Zealand and Samoan infants.
New Age.
2 weeks ......... 3 months ......... 6
~
. . . . . . . . .
9
~
. . . . . . . . .
12 New Zealand infants aged 1"2 m o n t h s regarded as clinically satisfactory . . . . . .
Zealand males. Lb. 7 12 17 22 22
Oz. 12 13 1 4 12
23
4
Samoan males.
Lb. 7 13 17 19 21
Oz. 14 10 6 4 3
New
SalTloan
Zealand females. Lb. 7 12 16 19 21
Oz.
7 0 1
2 9
females.
Lb. 7 12 15 17 18
Oz. 11 0 8 8 5
22
growth of Samoan children. It will be seen from Table IV that while the Samoan infants up to 6 months were above the average New Zealand weights, those in the second 6 months of life were considerably below the New Zealand figures. The weight at 12 months was definitely within the lowest 20 per cent. of the New Zealand figures. Comparison of the curves in the graph suggests that the older children are shorter and lighter than the New Zealand children,
~. j. ~ARPI,ES
329
and in the older group are smaller than the Polynesian children living in New Zealand. These results bear out the clinical impression which was received during the examinations. The babies before weaning appeared well-nourished, but the children appeared to be thin and small and in each village one or two children showed signs of gross undernourishment. For example, in one village a child of 3 was examined. He was emaciated and unable to walk and weighed only 15 lb. One girl and two boys in the 1- to 2-year group each weighed only 10 lb., and six girls and six boys aged more than 2 years had weights ranging from 16 to 18 lb. The South Pacific Commission at its meeting in New Caledonia in 1949, stated that one of its projects for immediate research was the investigation of the diet of children and of their morbidity, particularly at the weaning period. It is hoped that work on Samoan children, along these lines, will be carried out in the next few years. DISCUSSION. Yaws. This preliminary survey can only serve as an indication, but the results suggest that child health in Samoa is far from satisfactory, and that the children are labouring under a fair amount of disability from skin conditions alone. Since yaws, which is the most widespread of these, has far-reaching effects in less superficial parts of the body, these conditions must influence adversely their physical development and perhaps indirectly affect their mental development. In Western Samoa, yaws appears to infect the children at a very early age, and to spread through the youngest age-groups very rapidly. HA~2KETT (1946), working in Uganda, states that yaws under the a g e o f 1 year is most unusual. His youngest patient was 18 months old, and his youngest with tertiary yaws was 6 years. TURNER and SAUNDERS(1936) and SAUNDERSand MUENCH (1937) in their survey of the incidence of yaws in Jamaica included in their criteria of diagnosis : (1) a history of yaws, including a history of infections ; (2) positive serological tests; and (3) yaws lesions seen at a medical examination. They examined 332 children under 5 years, and found that 26.5 per cent. had yaws while 36.5 per cent. of children from 5 to 9 years were infected. PARoO-CASTELLO(1939) found only a low incidence of yaws in Cuba, 8.9 per cent. of the population, but again the majority of his cases were children under 15 years. He stresses the difficulty of treatment of the disease. This survey shows an incidence in Samoa very similar to that found in Jamaica, but since only active lesions were recorded and evidence of previous infection with yaws was ignored, it seems likely that the Samoan situation is actually worse than that of Jamaica. Although the records include only active
330
SKIN DISEASES
IN SAMOA
yaws, 23.1 per cent. of children under 5 years and 39-8 per cent. of those from 5 to 9 years had yaws. Moreover, the fact that even in the earliest age-groups 30 per cent. had lesions only on the soles of their feet, and most of the rest had more than one lesion, suggests that these children had already reached at least the secondary stage of yaws. The occurrence of a sabre tibia in a child of 4 years further supports the view that yaws is acquired very early by the Samoan child. BUXTONstates that at the time he was in Samoa the treatment of yaws instituted in Samoa in 1923 by Dr. RUSSELL RITCHIE had greatly reduced the number of cases of primary and secondary yaws among the children. A further campaign directed by LAMBERT in the years 1933-34 included a survey of the whole population, and it was found at that time that 59.16 per cent. were suffering from yaws. Great ~efforts have been made to provide adequate treatment for this condition, and many thousand injections are given every year. The treatment is carried out mainly by Fiji-trained Samoan medical practitioners, working under the supervision of the European medical staff. In spite of the treatment available, yaws remains widespread, as can be seen from the present survey. One factor accounting for this has been suggested by the European medical staff. The Samoans often fail to receive t h e full course of injections, since they cease to visit the clinics as soon as the lesions begin to heal. The establishment of mobile clinics, at present in progress in the territorY , should help to ensure that the yaws patient receives his full course of treatment. Possibly the use of penicillin rather than arsenicals in the treatment at least of the infectious cases might prove more satisfactory. DWlNDELLE(1946) and his co-workers and other authorities have demonstrated the value of penicillin in the treatment of yaws. SAUNDERS, KUMM and R~RRIE (1936) published a report of a study of the relationship of certain environmental factors to the distribution of yaws. They state that " yaws has a widespread patchy distribution in Jamaica, and is prevalent wherever there is a heavy rainfall, a fertile moisture-holding soil, supporting an abundant vegetation, a peasant population living under insanitary conditions and many flies of the species Hippelates pallipes." The eight villages included in the present survey are all coastal and the rainfall and geological formation shows little variation. It was found that the two small islands of ApoIima and Manono showed by far the greatest incidence of yaws. It seems likely that one reason for the great number of cases seen in these villages lies in their isolation and difficulty of access. To reach these islands in order to attend the inhabitants the Samoan practitioner must make a long and arduous journey, and Apolima, which lies outside the coral reef, can only be visited in good weather. The entry to the harbour of this island is through a very narrow channel, and is not without excitement even on the calmest day. These factors interfere with the carrying out of a regular course of treatment, which may account for tile very widespread infection. It was noted that scabies and impetigo also showed a high incidence in Apolima and Manono. It is not possible in this report to make any statements regarding the
M. J. MARPLES
331
sanitary conditions, standard of living, or insect populations of the villages investigated. Flies were exceedingly numerous everywhere. BOXTON (1929) does not record the presence of the insect Hippelates pallipes, but he states that Musca sorbens, another member of the Diptera, was exceedingly common and was frequently seen feeding on yaws eruptions in children. The impression was also gained that the supply of water varied in quantity from village to village, and that in Apolima and Manono it was scarce. Another interesting aspect of the yaws problem lies in its relationship to certain other prevalent skin diseases. Most authorities agree that the primary lesion develops at the site of some breach in the skin, the infection being spread by direct contact, or possibly indirectly by insects. It seems possible that in Western Samoa the lesions of impetigo, particularly, and perhaps scabies also, may provide the portal of entry f o r Treponema pertenue. Both scabies and impetigo were found to be very common in the youngest age-groups and to precede the appearance of yaws. It has already been noted that in the youngest children impetigo was common on the legs and scabies on the feet, the two sites stated by TURNER and SAUNDERS (1935) as the mos t frequent for the development of the primary yaws. Analysis of the figures of this investigation does not show any correlation between the incidence of yaws at the same time as impetigo in the whole group of children, but this is not surprising, since so many children were in the later stages, and there was no evidence available as to the site and time of eruption of the primary yaw. In the children under 2 years of age, however, the situation is somewhat different. There appeared to be a greater incidence of yaws among those who were suffering from impetigo than those who were not. The probability that this finding was due to chance was 1 in 30. There was a still closer correlation in the incidence of scabies with impetigo. These findings support the above suggestion, but it would be necessary to examine a very large group of the youngest Samoan children, and include a careful study of the stage of the yaws infection in order to confirm the theory. If it were substantiated, it would suggest that control of these other skin conditions might make some contribution to the prevention and control of yaws. Both scabies and impetigo respond more readily to treatment than yaws, and public health programmes for their eradication might be a valuable contribution to the solution of the yaws problem.
Fungus Infections. The almost complete absence of tinea capitis in Samoa has already been discussed. The distribution of tinea versicolor on the body is of some interest. BUMGARNER and BURKE (1949), working in Los Angeles, record the sites of the lesions in 47 cases which they examined. They found that 96 per cent. showed the classic distribution on the trunk, but stress the importance of examining
332
SKIN DISEASES IN SAMOA
the neck where they found lesions in 25 per cent. of their cases. Only 2 per cent. of their patients had lesions on the arms, and 6 per cent. on the legs. The results of the present investigation are in agreement with their findings. The most common site for the lesions of tinea versicolor was the trunk and 22.6 per cent. had lesions of the face and neck. In Samoa, however, lesions of the arms (12.9 per cent.) and legs (10!3 per cent.) appear to be more common than in Los Angeles. The possibility that the presence of tinea versicolor might inhibit the development of other types of skin ringworms was considered. Analysis of the present findings shows no correlation between this superficial infection and other ringworms. Tinea versicolor does not appear to inhibit the development of other ringworms, and the two can occur together as is shown by the fact that six of the children examined were suffering from both tinea versicolor and another form of ringworm. SUMMARY.
(1) The results of a survey of skin conditions among children in Western Samoa are described. Among 1,346 children examined, 25.4 per cent. had no active lesions, 1"7 per cent. had prickly heat, 24 per cent. had scabies, 26 per cent. had impetigo, 32.9 per cent. had yaws, 12.3 per cent. had tinea versicolor and 6 per cent. had other types of ringworm. (2) Each condition is analysed with reference to age, distribution, and site of lesion. (3) The incidence of yaws is compared with the findings of other investigators and is discussed in relation to certain environmental factors. (4) The suggestion is made that impetigo and possibly scabies provide the portal of entry for yaws. REFERENCES. BUMGARNEII,F. E. 5: BURKE,R.C. (1949). Arch. Derm. Syph., 59, 192. BUXTON, P. A. (1928). Researches in Polynesia and Melanesia. Memoir Series London Sch. Hyg. Trop. Med., Part VI, 83. --~ 5: HOPKINS, G. H. E. (1929). Ibid., Parts I and II, 1. DEEM, H. 5: SILVEaSTONE,H. (1944). N.Z. reed. J., 43, 9. DWlNDELLE, J. H., e t al. (1946). Amer. ft. trop. Med., 26, 311. HACKETT, C.J. (1946). Trans. R. Soc. trop. Med. Hyg., 40, 206. LONIE, T. C. (1945). N.Z. reed. ft., 44, 169. PARDO-CASTELLO, V. (1939). Arch. Derm. Syph., 40, 762. SAUNDERS,GEORGEM., KUMM, ttENR¥ W. 5: REI~IE, JAMES I. (1936). Amer. ft. Hyg., 23, 558. .... 8: MUENCH,H. (1937). Amer. y. Hyg., 26, 423. TURNER, THOMASB. & SAUNDERS,GEORGEM. (1935). Ibid., 2i, 483.
Vol. 44.
No. 3. December, 1950.
THE INCIDENCE OF CERTAIN SKIN DISEASES IN WESTERN SAMOA: A PRELIMINARY SURVEY.* BY
M. J. MARPLES,
Department of Bacteriology, University of Otago, New Zealand.
D u r i n g t h e s u m m e r of 1948-49, the M e d i c a l R e s e a r c h C o u n c i l of N e w Z e a l a n d s e n t a research t e a m to W e s t e r n S a m o a to m a k e a p r e l i m i n a r y s u r v e y of c e r t a i n h e a l t h p r o b l e m s . T h e o b s e r v a t i o n s d e s c r i b e d i n this p a p e r were carried o u t b y t h e a u t h o r d u r i n g the 2 m o n t h s ' r e s i d e n c e of this t e a m i n Samoa. Western Samoa is a New Zealand mandated territory and consists of two large islands, Savaii and Upotu, and a few small islands. BUXTON (1928) gives a full account of the geography and climatic conditions of Smnoa. T h e islands lie 130 miles north of Tonga and 500 miles north-east of Fiji, 13° to 14° south of the equator, and 171 ° to 173° west of Greenwich. All the islands are volcanic and surrounded by an incomplete fringing coral reef. T h e central areas of the two large islands are mountainous. The temperature is extremely equable, ranging from 26"28 ° C. in December to 25"01 ° C. in July. T h e mean annual rainfall is 2,738 ram. Droughts are unknown and there is no definite dry season. The relative humidity is high, the monthly mean for the daytime ranging between 70 and 80 per cent. The prevailing wind at all seasons has an easterly component. The vegetation is luxuriant. T h e islands support a population of approximately 70,000 Samoans (68,197 in 1945 census) about 350 Europeans and a few Chinese. The Samoan population is increasing. Nearly all the Samoans live in villages on the coast, there are very few inland settlements. They live in attractive native houses, oval in shape and consisting of a thatched roof supported on posts, and a raised floor usually made of broken-up volcanic rock. There are no walls, but mats can be let down from the roof in bad weather. The Samoans wear native dress which consists of a single piece of cloth wrapped round the waist, and called a lava-lava. This is usually the only outer garment of the children and most of the men, but the older girls and women wear an overgarment or a frock as well, and some of the men, especially those in daily contact with the European population, wear a shirt. D u r i n g this i n v e s t i g a t i o n , c h i l d r e n were e x a m i n e d f r o m several villages o n b o t h large islands, a n d also f r o m the villages s i t u a t e d o n t h e s m a l l i s l a n d s of M a n o n o a n d A p o l i m a . T h e s e lie b e t w e e n U p o l u a n d Savaii a n d each s u p p o r t s a s m a l l p o p u l a t i o n . I n all, 2,070 c h i l d r e n were e x a m i n e d , b u t n o t all received e My thanks are due to the New Zealand Medical Research Council for the privilege of being a member of the Research Team, and to the other members of the team for their help. I am especially indebted to Dr. J. C. LOPDELL, the Chief Medical Officer of Western Samoa, to Miss McHuGH, the Matron of the Apia Hospital, and to Nurse MOMOI and the many Samoans who drove me round the islands, interpreted for me and helped me in many other ways. I am also indebted to Dr. H. SILVERSTONE,who made the statistical analysis of the figures, to Sir CHARLESHERCUS for constant advice and encouragement and to my husband and sons who gave me great help in sorting out the results of this survey.
320
SKIN DISEASES IN SAMOA
as complete an examination as others. The main object of this investigation was to determine the incidence of skin diseases, but in 1,329 children, the age, sex, height and weight were also recorded. MATERIAL AND METHODS. Visits were made to different villages on the islands and all the available children were assembled. In the full examination, each child's age and sex was recorded. It was weighed and measured, and was examined for different types of skin disease, the site of the lesion or lesions being recorded. Specimens of skin from possible fungus infections were collected and subsequently examined microscopically, after digestion with caustic potash. Abnormalities and obvious infections other than skin conditions were recorded and a clinical estimation of the nutrition was made. The information collected was transferred to a punch-card system for analysis. An endeavour was made to restrict the examination to children of 12 years or less, but a few 13-year olds were present and insisted on taking part, and therefore a small sample of children of this age is included. The following skin conditions were recorded : yaws, impetigo and infected sores, boils, scabies, prickly heat, tinea versicolor and other ringworms. Only the obvious yaws lesions were noted and it is probable that a number of incipient lesions were missed. The occurrence of yaws scars was not recorded. In addition, as part of the work of the team, the boys attending the Government Secondary Boarding School outside Apia were examined, and the adults of a village in Upolu, as part of a village survey. The examination of the village adults was carried out by Dr. H. D. PURVES, the leader of the research team. The results of these examinations are included in this report. The sample of adults is rather small, and the adolescent boys in the school are not a true sample of this age-group. These boys were selected for the school partly on the grounds of physical fitness and they had received continuous care during the school year. They demonstrate rather the results of care and supervision than the incidence of skin infections in adolescent boys. RESULTS OF THE INVESTIGATIONS.
T a b l e I shows the incidence of the different skin diseases in the whole group of individuals examined. It will be noted that tile total number of lesions is greater than the number of individuals. This is due to the fact that many suffered from two or more conditions. Yaws was the most serious condition involved, as 30 per cent. of the unselected children and 24.2 per cent. of the adults were found to be carrying active lesions. Only 3.5 per cent. of the schoolboys had active yaws, although many of them showed scars. Scabies was much more prominent in the children under !2 (22 per cent.) and was slightly less common in the schoolboys (10.5 per cent.) than the adults (12 per cent.). The figures for impetigo are very
M. J. MARPLES
321
similar. On the other hand, tinea versicolor was considerably more common in the older groups. Just over 10 per cent. of the children had this infection, whereas 39 per cent. of the schoolboys and 49 per cent. of the adults showed the characteristic lesions. The above figures show the occurrence of these skin conditions in the total number of persons examined. When the results of the examination of children of known age and sex are analysed, further information concerning the age distribution of the various diseases becomes known. TABLE I.
Group.
Village children Government secondary school Village adults
Nuwtber Yaws. Scabies. exam ined.
Tinea Impetigo. Infected Boils. Prickly versi- Ringcuts. heat. color. w o r m .
£,042
630
460
473
92
38
105
4
11
17
4
12
124
30
15
12
25
2t3
121
41
4
61
24
Table II shows the incidence of skin diseases in the different age groups. Boils and infected cuts have been omitted. The first year of life is divided into two 6-month periods, after that, yearly grouping is shown. The total children of each age-group is shown in the first column, but the incidence of each disease is expressed as a percentage, so that the different ages can be compared. The percentage of children free from obvious lesions is also shown in Table II under the heading " Skin Clear." This does not mean that the skin had no scars, only 11 babies had skin in this state, the oldest being 15 months. About 50 per cent. of the children under a year old were free from skin lesions at the time of examination and the number rapidly declined in the older age-group to less than 20 per cent. After this it rose again to about 30 per cent. The incidence of each disease will be discussed separately.
Prickly Heat. This condition was seen in only the youngest children. Many of the babies appeared to be too warmly wrapped up for the climate in which they were living. The rash was noticed in the axilla, groin and around the waist. In a few cases it appeared to be infected. Two females just over a year were the oldest found suffering from prickly heat, after that it disappeared completely. This is not surprising since most of the children wore nothing except the lava-
322
SKIN D I S E A S E S IN SAMOA
TABLE I I .
T h e a g e d i s M b u t i o n of t h e p r i n c i p a l s k i n d i s e a s e s f o u n d i n S a m o a n c h i l d r e n .
Age.
O- 6 m o n t h s 7-12 ,, 1 year ... 2 years ...
5
10 11 12 13
~
..... ,, ,. ,i
.
... . .,,
0 - 1 3 y e a r s- .-.
Num ber.
Skin clear, Per cent.
Prickly heat. Per cent.
98 53 79 123 119 139 125 107 77 99 84 104 48 61 30
52.0 41 "5 16.4 26.0 16.9 17.3 18.4 21.5 18.1 30.3 21.4 28.8 29-2 34.1 23.3
18.O 8-0 2.5
25.4
1--~346
Scabies. Per cent.
Impetigo. Per cent.
Yaws. Per cent.
8.0 32.6 45.4 35.8 32.9 32.3 31.2 32.8 22.0 24.2 26.8 13.4 19.0 5.0 3.3
2.0 ,3.9 25.3 23.6 29.4 38.1 48.0 30-0 40.0 34-0 50.0 44.5 42.0
....
25.0 34-0 36'4 26.0 16.0 30.9 24.8 28.9 27'2 14.I 22.6 13.4 20.9 25.0 6-6
1-7
24.0
26.0
......
- -
Tinea versicolor. Per cent. _ _ _
i Ring! worm. Per cent. I !___
1,0 4.0 2.0 2.0 6.3 2.5 3.3 3-3 11-0 4-2 12.9 . 6.5 15.2 2.3 12.1 8.4 18-1 1 10.4
I
i7:o
E
7.0
17.9 14.4 10.1
i F
7.1 5.8 10'1
i
37-7 I 17.0
/ 130
53.3
/
16.6
10.0
lava. A number of the older girls wore a cotton frock and under-pants, and a few had European dress, some even removing two or three layers of underclothing before they could be examined. It is probable, however, that these garments were put on for the purpose of examination, and that normally the majority of younger children of both sexes wear only the lava-lava.
Scabies. This condition was the most common found in the babies, 25 per cent. of those under 6 months and 34 per cent. in the 7- to 12-month group showing lesions due to Sarcoptes. The infection reached a maximum of 36 per cent. in the children of 1 to 2 years and then showed a very gradual decline in the older age-groups. The actual mite was removed from its burrow and demonstrated in a few cases, but in the majority the condition was diagnosed on clinical grounds alone. It was observed that many of the mothers of the babies suffering from scabies themselves showed lesions, and when the fathers were available for examination they too showed evidence of scabies. Further, 10 per cent. of the schoolboys and 12 per cent. of the village adults had scabies. In order to control this condition it would be necessary to treat the adults of the community as well as the children.
M. j. MARPLES
323
As would be expected, the lesions of scabies were most commonly found on both the hands and feet. Of the children fully examined, 78 per cent. had lesions on the hands, and 48 per cent. on the feet. Legs also were commonly infected, 31 per cent. having lesions in this area, and a number of children had areas on the trunk infected. It is of interest to note that in the youngest age groups the feet showed a much higher incidence of infection than in the group of children as a whole. Seventy-three children under 2 years had scabies, and of these 68 per cent. had scabies on their hands, 70 per cent. on their feet, while 37 per cent. had lesions on the legs. This fact will be referred to in the discussion, with reference to the possible relationship between scabies, impetigo, and the onset of yaws. There is some suggestion from the figures that in the younger age-groups the females were more prone to scabies than the males.
Impetigo. This condition was also found to be very common among the children. The condition was not so prevalent in the earliest age-group as scabies, but in children of 1 to 2 years it was found in 45 per cent. examined. After this it showed a gradual decline, until among the 10-year olds only 13 per cent. showed lesions of impetigo. The condition was widespread all over the body, and a number of children had lesions of the scalp. The most common site, however, was the legs, 68 per cent. of the whole group having lesions in this area. Hands were the next areas most commonly affected, 21 per cent. having lesions in this region; 18 per cent. had lesions of the head and neck, but only 10.5 per cent. had impetiginous lesions of the feet. The difference between the sexes was not striking but in the younger agegroups the girls tended to be more commonly infected, while in the children over 8 years the boys showed the higher incidence. Impetigo was less common in the older individuals examined, only 3 per cent. of the village adults suffering from this infection, while 16 per cent. of the secondary schoolboys carried impetiginous lesions.
Infected Cuts and Boils. These conditions were much less common than the more superficial impetiginous infection. They were present in about 5 per cent. of the children of each age-group, and appeared to be equally common in the two sexes. Since tile children were running barefoot over coral, or volcanic stones, they naturally sustained constant injury, and these traumata were frequently infected, presumably by the enormous number of organisms present in the reservoir due to the widespread impetigo. As would be expected, infected cuts occurred most commonly on the arms and legs. Boils were much less common, and occurred
324
SKIN DISEASES IN SAhIOA
most frequently on legs and buttocks. Spreading infections with lymphangitis were not encountered among the children included in this survey. Yaw& This condition was found to be extremely prevalent among this group of children, and proved to be by far the most serious skin condition. Unfortunately, scars were not recorded, so that the figures quoted indicate only the incidence of active yaws and not the total child population infected. It was not found possible to distinguish between primary, secondary and tertiary stages but the number and sites of the lesions suggest that most of the children were at least in the secondary stage. Yaws was not found to be common in children of less than 1 year, the youngest cases seen were two females of 6 months. One had a single large lesion on the hand, presumably a primary yaw, but the other had lesions on both hands and feet and must already have reached the secondary stage. Two females of 9 months had yaws, one had a single lesion on the leg, the other had yaws on both arms and legs, and also had scabies in both these areas. A female aged 1 year had a single yaw on the face, while another of 17 months had generalized yaws widespread over the bo,dy. In the children whose age ranged from 1 to 2 years yaws was much more common, over 25 per cent. having active lesions. In this group the females (33 per cent.) were more commonly infected than the males (15 per cent.). The 2- to 3-year group showed a slightly lower incidence, again with fewer males than females involved, but after this the condition showed a gradual steady increase, with males showing a slightly higher incidence than females. Fifty per cent. of the children aged 9 years had yaws, and this level was more or less maintained in the older groups. It is of interest to note that only 3.8 per cent. of the secondary schoolboys had active yaws, although 24 per cent. of the village adults suffered from this infection. The small number of cases among the schoolboys is probably due to the constant supervision and treatment they received. In the yaws census taken in 1933, 50.9 per cent. of the total population was found to be suffering from the disease. The results of this investigation suggest that in spite of extensive schemes of treatment at present available in Western Samoa, the control of yaws remains a serious problem. When the sites of the lesions were analysed it was found that the soles of the feet were the areas far the most commonly affected. The lesions in this site were of the two classical types--ulcerated areas, or granulomatous lesions ; 86.7 per cent. of the children with yaws had lesions of the feet, 66.4 per cent. having lesions in this region only, while 20.3 per cent. had yaws on the feet and on some other part of the body as well. Table III shows the number of sites of yaws lesions found in the different age groups, together with the percentage of each group which had yaws only on the soles of the feet.
325
M. J. MAEPLE5 TABLE I I I .
J~ge~
N u m b e r of sites of lesions of yaws.
4
1
5 or more.
years. 0-1 1-2 2-3 3-4 4-5 5-6 6-7 7-8 8-9 9-10 10-11 11-12 Over 12
2 12 21 23 43 45 29 28 25 32 39 20 26
1 4 2 9 9 11 1 9 1 9 7
8
1
Feet only. Per cent. 26 30 43 55 74 76 66 64 92 43 71 85 67
Fungus Infections. Tinea versicolor, locglly known as " Tane," was found to be a prevalent skin condition in Samoa. It did not appear to be regarded by the Samoans as worthy of attention and in most cases was untreated. This makes it an interesting condition, worthy of further study in relation to the epidemiology of an untreated fungus infection. Such a study might yield valuable information about the natural spread of the dermatophytes. Among the children examined, tinea versicolor showed a gradual increase with age, but no age-group was exempt, since two infants, one male and one female, both under 6 months, showed the characteristic lesions. The infection became more common in the older groups and was present in about 17 per cent. of the children over 7 years. It appears to become increasingly prevalent in older groups, since 39 per cent. of the schoolboys and 49 per cent. of the village adults carried this fungus. This condition showed an entirely different distribution on the body from the ones previously discussed. The chest was the most common site, 63 per cent. of the children having lesions on the front and 35 per cent. on the back of the chest ; 22 per cent. had lesions on the face and neck but only 13 per cent. on the arms and 10 per cent. on the legs.
Other Ringworms. These also were fairly common, but less so than tinea versicolor. They took the form of sealing cireinate lesions and some were very large indeed. Many of the children had multiple lesions, o n e interesting type showed very little scaling. This type had a raised edge, and scattered over the central area
326
S K I N D I S E A S E S IN SAMOA
were raised non-vesicular patches. Scrapings from these patches as well as from the edge of the lesion showed fungal elements when examined microscopically .after digestion with caustic potash. Although tinea imbricata occurs in Samoa none of the children examined showed the classical picture with concentric rings, although many had extensive scaling lesions which were suggestive of this form of ringworm. Unfortunately, the conditions available for the culture of pathogenic fungi were wholly unsatisfactory, and contamination was overwhelming. Those cultures that were obtained belonged to the genus Trichophyton. The site of these fungus infections was interesting. No cases of ringworm of the scalp were found among the village children included in this survey, and only two cases were seen during tile whole time spent in Samoa. Both these showed fungal elements in the hair on direct examination, and both yielded cultures of Trichophyton sp. A number of children living in or near Apia were examined under Wood light, and no fluorescence was observed ; the large population of cats which inhabited the Apia hospital was also negative on examination under Wood light. It is interesting to speculate on why the Samoan children were free from tinea capitis although tinea corporis was prevalent. It is possible that the genus Microsporum, the most common cause of scalp ringworms, is rare or absent in Western Samoa. Further investigations of the species of pathogenic fungi would demonstrate whether this is so. Many of the children had impetigo of the scalp, and possibly this infection might prevent the growth of the fungus. Many of the Samoans use oil extensively on their hair and possibly this is inhibitory to a fungus infection. The back was the most common site for a ringworm, 42 per cent. of the children having their lesions in that area; 33 per cent. were infected on the chest and 17 per cent. on the face and neck. Ringworms on the legs were found in 13.5 per cent., and on the arms in only 5 per cent. No age-group was free from ringworm, and the percentage of all children infected varied from 5 to 10 per cent. Ringworms appeared to be common among adults, 19 per cent. of the village group carrying lesions. Less than 4 per cent. of the schoolboys were infected, but this again is probably due to their greater facilities for treatment.
Other Clinical Abnormalities. Umbilical Hernia. This condition appeared to be rather common among the smaller children since it was found in 43 persons. It disappeared in the older groups and appeared to become corrected without any treatment. It was present in 11 per cent. of the children under 1 year, 15 per cent. of the 1-year and 10 per cent. of the 2-year, but only in 2.5 per cent. of the 3-year olds. After this it soon disappeared, the oldest child having this type of hernia being a boy aged 6 years.
~.
J, MARPLES
O n l y one of the children examined had an inguinal hernia. boy aged 5 years.
327
This was a
Sabre Tibia and Other Bone Deformities. Sabre tibia was a fairly common finding. It was presumably a manifestation of tertiary yaws, but has not been included in the yaws figures, as IIACKETT (1946) says that it could not be regarded as solely due to yaws among the natives of Uganda. It was found in 18 of the children examined, and o f these 12 also had yaws on the feet. The youngest children with sabre tibias were a male and female, both aged 4 years. Five of the ll-year and three of the 12-year olds had this deformity. Other bone deformities were not uncommon. Abnormalities were seen in two fingers, two wrists, one elbow, one ankle, one knee, and two hips. These conditions were probably all late yaws manifestations. Two boys had bilateral talipes. One was 2 years old, the other 10. He walked on the sides of his feet, but his yaws lesions were situated on the true soles of his feet.
Other Conditions. Seven children showed evidence of rickets, the most obvious being a boy of 2 years, who showed gross evidence of undernourishment, and was found to weigh only 15½ lb. Seven children had discharging ears. One girl of 10 months had two thumbs on the left hand. They were of equal length and both had nails. Syndactyle of two toes was seen in a child of 2 years. One child was dumb, and two appeared to be feeble-minded. One of these was a b~y of 10 who had a spastic paraplegia, the other a boy of 6 who appeared from his mother's account to be a congenital epileptic.
Heights and Weights. The graph shows the mean yearly heights and weights of the children from 1 to 12 years compared with curves obtained from figures relating to New Zealand children. The period from 1 to 5 years is compared with a curve issued by the Royal New Zealand Society for the Health of Women and Children. The period from 6 to 12 years with the heights and weights of Maori boys published by LONIE (1945). Table IV shows the mean monthly weights of Samoan infants. Fifty-six males and 92 females under 1 year were weighed. The mean weights were calculated by months and fluctuations smoothed out, following the same technique as that used for the construction of growth curves for New Zealand infants by the above Society (DEEM and SILVERSTONE, 1944). A comparison with the mean weights of New Zealand infants is shown in Table IV. These observations are given with some diffidence in the knowledge that the samples were too small and that the methods used were open to error. They are, however, suggestive and indicate the need for careful investigation of the
3.~8
SKIN DISEASES IN SAI~IOA G R A P H . - - S a m o a n h e i g h t s a n d w e i g h t s c o m p a r e d w i t h N e w Z e a l a n d figures.
70 65 s5
N.Z 8
0 •
60
Id^O~l
A 0 • ~ ~ S A M OAN
,,,,
,.A
50
j SAMoA.,,"
oL
0 • v .j.
~.,,,Q,,~ • N.Z~MAOPd
O0 o • -~""~
45 gO 40
/0
~55
~0
• 0
,.z? " ~ ¢ " ~
.
^
0
~ 5 A M O A N 9.
30 50 - 25 4O
,,_e**o.~
x
I.~ 2¢ I0
I0
-
e - " * ~ /°./~ ~Jt¢~'"
2 0 3f
~
5
-
: S A M O A N 0~I
.~---XSAMOAN 9.. 0 0 0 N.Z. MAOR!SCHOOLBOY-~
:
N.Y-. PLUNKET SOC:
e--e
,
I
2
3
4
p
5
G 7
8
9
10 II 12
YL'AI~5
TABLE IV.
Comparison of the weights of New Zealand and Samoan infants.
New Age.
2 weeks ......... 3 months ......... 6
~
. . . . . . . . .
9
~
. . . . . . . . .
12 New Zealand infants aged 1"2 m o n t h s regarded as clinically satisfactory . . . . . .
Zealand males. Lb. 7 12 17 22 22
Oz. 12 13 1 4 12
23
4
Samoan males.
Lb. 7 13 17 19 21
Oz. 14 10 6 4 3
New
SalTloan
Zealand females. Lb. 7 12 16 19 21
Oz.
7 0 1
2 9
females.
Lb. 7 12 15 17 18
Oz. 11 0 8 8 5
22
growth of Samoan children. It will be seen from Table IV that while the Samoan infants up to 6 months were above the average New Zealand weights, those in the second 6 months of life were considerably below the New Zealand figures. The weight at 12 months was definitely within the lowest 20 per cent. of the New Zealand figures. Comparison of the curves in the graph suggests that the older children are shorter and lighter than the New Zealand children,
~. j. ~ARPI,ES
329
and in the older group are smaller than the Polynesian children living in New Zealand. These results bear out the clinical impression which was received during the examinations. The babies before weaning appeared well-nourished, but the children appeared to be thin and small and in each village one or two children showed signs of gross undernourishment. For example, in one village a child of 3 was examined. He was emaciated and unable to walk and weighed only 15 lb. One girl and two boys in the 1- to 2-year group each weighed only 10 lb., and six girls and six boys aged more than 2 years had weights ranging from 16 to 18 lb. The South Pacific Commission at its meeting in New Caledonia in 1949, stated that one of its projects for immediate research was the investigation of the diet of children and of their morbidity, particularly at the weaning period. It is hoped that work on Samoan children, along these lines, will be carried out in the next few years. DISCUSSION. Yaws. This preliminary survey can only serve as an indication, but the results suggest that child health in Samoa is far from satisfactory, and that the children are labouring under a fair amount of disability from skin conditions alone. Since yaws, which is the most widespread of these, has far-reaching effects in less superficial parts of the body, these conditions must influence adversely their physical development and perhaps indirectly affect their mental development. In Western Samoa, yaws appears to infect the children at a very early age, and to spread through the youngest age-groups very rapidly. HA~2KETT (1946), working in Uganda, states that yaws under the a g e o f 1 year is most unusual. His youngest patient was 18 months old, and his youngest with tertiary yaws was 6 years. TURNER and SAUNDERS(1936) and SAUNDERSand MUENCH (1937) in their survey of the incidence of yaws in Jamaica included in their criteria of diagnosis : (1) a history of yaws, including a history of infections ; (2) positive serological tests; and (3) yaws lesions seen at a medical examination. They examined 332 children under 5 years, and found that 26.5 per cent. had yaws while 36.5 per cent. of children from 5 to 9 years were infected. PARoO-CASTELLO(1939) found only a low incidence of yaws in Cuba, 8.9 per cent. of the population, but again the majority of his cases were children under 15 years. He stresses the difficulty of treatment of the disease. This survey shows an incidence in Samoa very similar to that found in Jamaica, but since only active lesions were recorded and evidence of previous infection with yaws was ignored, it seems likely that the Samoan situation is actually worse than that of Jamaica. Although the records include only active
330
SKIN DISEASES
IN SAMOA
yaws, 23.1 per cent. of children under 5 years and 39-8 per cent. of those from 5 to 9 years had yaws. Moreover, the fact that even in the earliest age-groups 30 per cent. had lesions only on the soles of their feet, and most of the rest had more than one lesion, suggests that these children had already reached at least the secondary stage of yaws. The occurrence of a sabre tibia in a child of 4 years further supports the view that yaws is acquired very early by the Samoan child. BUXTONstates that at the time he was in Samoa the treatment of yaws instituted in Samoa in 1923 by Dr. RUSSELL RITCHIE had greatly reduced the number of cases of primary and secondary yaws among the children. A further campaign directed by LAMBERT in the years 1933-34 included a survey of the whole population, and it was found at that time that 59.16 per cent. were suffering from yaws. Great ~efforts have been made to provide adequate treatment for this condition, and many thousand injections are given every year. The treatment is carried out mainly by Fiji-trained Samoan medical practitioners, working under the supervision of the European medical staff. In spite of the treatment available, yaws remains widespread, as can be seen from the present survey. One factor accounting for this has been suggested by the European medical staff. The Samoans often fail to receive t h e full course of injections, since they cease to visit the clinics as soon as the lesions begin to heal. The establishment of mobile clinics, at present in progress in the territorY , should help to ensure that the yaws patient receives his full course of treatment. Possibly the use of penicillin rather than arsenicals in the treatment at least of the infectious cases might prove more satisfactory. DWlNDELLE(1946) and his co-workers and other authorities have demonstrated the value of penicillin in the treatment of yaws. SAUNDERS, KUMM and R~RRIE (1936) published a report of a study of the relationship of certain environmental factors to the distribution of yaws. They state that " yaws has a widespread patchy distribution in Jamaica, and is prevalent wherever there is a heavy rainfall, a fertile moisture-holding soil, supporting an abundant vegetation, a peasant population living under insanitary conditions and many flies of the species Hippelates pallipes." The eight villages included in the present survey are all coastal and the rainfall and geological formation shows little variation. It was found that the two small islands of ApoIima and Manono showed by far the greatest incidence of yaws. It seems likely that one reason for the great number of cases seen in these villages lies in their isolation and difficulty of access. To reach these islands in order to attend the inhabitants the Samoan practitioner must make a long and arduous journey, and Apolima, which lies outside the coral reef, can only be visited in good weather. The entry to the harbour of this island is through a very narrow channel, and is not without excitement even on the calmest day. These factors interfere with the carrying out of a regular course of treatment, which may account for tile very widespread infection. It was noted that scabies and impetigo also showed a high incidence in Apolima and Manono. It is not possible in this report to make any statements regarding the
M. J. MARPLES
331
sanitary conditions, standard of living, or insect populations of the villages investigated. Flies were exceedingly numerous everywhere. BOXTON (1929) does not record the presence of the insect Hippelates pallipes, but he states that Musca sorbens, another member of the Diptera, was exceedingly common and was frequently seen feeding on yaws eruptions in children. The impression was also gained that the supply of water varied in quantity from village to village, and that in Apolima and Manono it was scarce. Another interesting aspect of the yaws problem lies in its relationship to certain other prevalent skin diseases. Most authorities agree that the primary lesion develops at the site of some breach in the skin, the infection being spread by direct contact, or possibly indirectly by insects. It seems possible that in Western Samoa the lesions of impetigo, particularly, and perhaps scabies also, may provide the portal of entry f o r Treponema pertenue. Both scabies and impetigo were found to be very common in the youngest age-groups and to precede the appearance of yaws. It has already been noted that in the youngest children impetigo was common on the legs and scabies on the feet, the two sites stated by TURNER and SAUNDERS (1935) as the mos t frequent for the development of the primary yaws. Analysis of the figures of this investigation does not show any correlation between the incidence of yaws at the same time as impetigo in the whole group of children, but this is not surprising, since so many children were in the later stages, and there was no evidence available as to the site and time of eruption of the primary yaw. In the children under 2 years of age, however, the situation is somewhat different. There appeared to be a greater incidence of yaws among those who were suffering from impetigo than those who were not. The probability that this finding was due to chance was 1 in 30. There was a still closer correlation in the incidence of scabies with impetigo. These findings support the above suggestion, but it would be necessary to examine a very large group of the youngest Samoan children, and include a careful study of the stage of the yaws infection in order to confirm the theory. If it were substantiated, it would suggest that control of these other skin conditions might make some contribution to the prevention and control of yaws. Both scabies and impetigo respond more readily to treatment than yaws, and public health programmes for their eradication might be a valuable contribution to the solution of the yaws problem.
Fungus Infections. The almost complete absence of tinea capitis in Samoa has already been discussed. The distribution of tinea versicolor on the body is of some interest. BUMGARNER and BURKE (1949), working in Los Angeles, record the sites of the lesions in 47 cases which they examined. They found that 96 per cent. showed the classic distribution on the trunk, but stress the importance of examining
332
SKIN DISEASES IN SAMOA
the neck where they found lesions in 25 per cent. of their cases. Only 2 per cent. of their patients had lesions on the arms, and 6 per cent. on the legs. The results of the present investigation are in agreement with their findings. The most common site for the lesions of tinea versicolor was the trunk and 22.6 per cent. had lesions of the face and neck. In Samoa, however, lesions of the arms (12.9 per cent.) and legs (10!3 per cent.) appear to be more common than in Los Angeles. The possibility that the presence of tinea versicolor might inhibit the development of other types of skin ringworms was considered. Analysis of the present findings shows no correlation between this superficial infection and other ringworms. Tinea versicolor does not appear to inhibit the development of other ringworms, and the two can occur together as is shown by the fact that six of the children examined were suffering from both tinea versicolor and another form of ringworm. SUMMARY.
(1) The results of a survey of skin conditions among children in Western Samoa are described. Among 1,346 children examined, 25.4 per cent. had no active lesions, 1"7 per cent. had prickly heat, 24 per cent. had scabies, 26 per cent. had impetigo, 32.9 per cent. had yaws, 12.3 per cent. had tinea versicolor and 6 per cent. had other types of ringworm. (2) Each condition is analysed with reference to age, distribution, and site of lesion. (3) The incidence of yaws is compared with the findings of other investigators and is discussed in relation to certain environmental factors. (4) The suggestion is made that impetigo and possibly scabies provide the portal of entry for yaws. REFERENCES. BUMGARNEII,F. E. 5: BURKE,R.C. (1949). Arch. Derm. Syph., 59, 192. BUXTON, P. A. (1928). Researches in Polynesia and Melanesia. Memoir Series London Sch. Hyg. Trop. Med., Part VI, 83. --~ 5: HOPKINS, G. H. E. (1929). Ibid., Parts I and II, 1. DEEM, H. 5: SILVEaSTONE,H. (1944). N.Z. reed. J., 43, 9. DWlNDELLE, J. H., e t al. (1946). Amer. ft. trop. Med., 26, 311. HACKETT, C.J. (1946). Trans. R. Soc. trop. Med. Hyg., 40, 206. LONIE, T. C. (1945). N.Z. reed. ft., 44, 169. PARDO-CASTELLO, V. (1939). Arch. Derm. Syph., 40, 762. SAUNDERS,GEORGEM., KUMM, ttENR¥ W. 5: REI~IE, JAMES I. (1936). Amer. ft. Hyg., 23, 558. .... 8: MUENCH,H. (1937). Amer. y. Hyg., 26, 423. TURNER, THOMASB. & SAUNDERS,GEORGEM. (1935). Ibid., 2i, 483.