Poor Health conditions and opportunistic infections among children of Sahariya tribe of Central India: Clinical aspects and risk factors
P Sharma, P Reddy, M Barbhuiya, G Mishra, T Singh, R Prakash, S Jain, P Tiwari
sahariya tribe, scabies, skin infection, tb, tuberculosis
P Sharma, P Reddy, M Barbhuiya, G Mishra, T Singh, R Prakash, S Jain, P Tiwari. Poor Health conditions and opportunistic infections among children of Sahariya tribe of Central India: Clinical aspects and risk factors. The Internet Journal of Pediatrics and Neonatology. 2008 Volume 10 Number 2.
The present clinical case report reveals an outbreak of severe scabies infestation along with tuberculosis among young children of Sahariya tribe of Central India. More predominately young children of the tribe were found severely infested with scabies. Some of them were also registered TB patients. Appropriate clinical tests were performed to identify the actual cause of outbreak and hematological analysis of blood sample was carried out to diagnose the clinical disease. ESR, lymphocyte counts and serum LDH content was found significantly (p<.05) elevated in affected children and adult subjects, indicating the pathogenic infection (tuberculosis) and infestation (scabies) induced pathology.Weak immunity resulting from malnutrition, poor hygiene and lack of proper Medicare, in these rural and remote areas are the main predisposing factors till today. There is a need of regular follow up of local hygiene and medical facilities available in these areas followed by appropriate and timely treatment to them.
Sahariya is a primitive tribal group of central India. It is a landless community, which migrate to neighboring states in search of labor and wages during crop harvesting season. During such migration, people carry with themselves several opportunistic infections as one encountered in the present case study. The tribe lives in different villages isolated from main urban population. Population-wide surveys of Sahariya tribe for TB, carried out earlier, have reported significantly high incidence of tuberculosis in the tribe 12 . During a mass camping, organized for blood sampling of tuberculosis patients of Sahariya, heavy infection of scabies was recorded.
Although, scabies infection was spread to most of the tribal villages, the present observation was made from a representative village, Goras (District Sheopur). Most of the young children of 7-15 years of age from this village were found severely infested by the mite,
Sputum positive tuberculosis in Children:
The importance and severity of the childhood tuberculosis disease burden is recognized in many developing countries like India. There are reports on sputum positive tuberculosis in children in India. Kabra et al. (2004) 10 carried out a study in different categories of child tuberculosis and found that 11% of the child patients recruited for study could demonstrate acid fast bacilli (AFB) in their sputum specimens. This has been debated that poor yield of AFB in children patients of tuberculosis is due to paucibacillary nature of disease and inability of young children to give appropriate sputum samples, moreover, obtaining a proper sputum specimen is a difficult task, often unsuccessful, procedure for children, but it does not mean that positivity rate is very low. Wiersma et al. (2000) 11 have suggested that the yield of AFB in children with pulmonary tuberculosis can be improved by induction of sputum. In present investigation also, two out of four children could demonstrate bacilli in their sputum, while remaining two were positive for chest-X-ray only. In addition, since convincing results were obtained by TST (tuberculin skin test) and radiographic analysis, these tests become more appropriate tests for child tuberculosis detection. But, in TB endemic areas, where these tests are neither easily available nor economically feasible, sputum smear microscopy is still practicised as routine detection method for TB for all age groups. This indicate that sputum positive TB in children in India is not rare but there are difficulties in sputum specimen collection and it is the nature of disease that make reports of sputum positive TB in children rare, as we did encounter in the present study.
Materials & Methods
The open wound swabs were cultured on the Czepak dox agar culture medium at 37 o C for 48 hrs. to identify any fungal growth (primary or secondary infection) in samples collected from open wounds. The Fungal identification was made on the basis of macroconidia and culture morphology.
The skin infection was clinically diagnosed by the dermatologist as scabies, which is caused by a tiny mite
The itch and rash are the result of allergic reaction, induced by the mite. Our subjects under investigation, particularly children, showed all of the above symptoms. The hematological parameters revealed, in general, low hemoglobin level (8-12 gm %) in almost all the subjects, specifically those infected with scabies and tuberculosis both, indicating severe anemic conditions. Although, infections were also observed in adults, the intensity of the symptoms was lower. The ESR (Erythrocyte Sedimentation Rate) and serum LDH level were significantly (p<0.05) elevated in scabies infested children (see Table).
The secondary infections observed in swab cultures of open wounds revealed mainly the presence of a human skin infecting fungus,
Earlier studies have reported significantly high incidence of
Hemoglobin (Hb) concentration in blood stream is considered as a useful indicator of health and nutritional status of any individual or population group. The relatively poor hemoglobin level in the individuals examined in this study presents a direct correlation between their socio-economic conditions and clinical health. It is reported that severely malnourished individuals are likely to have their immune functions impaired 15 and show positive association with the susceptibility to infectitious diseases 16 . The increased ESR, observed in most of our tribal patients, thus, indicates existence of an infective or inflammatory destructive disease like, TB. The serum lactate dehydrogenase level usually goes high in several kinds of skin infections. The elevated serum LDH level in theses subjects further support the presence of physiological stress caused by scabies infestation or other co-infections, including
The secondary infection seen in swab cultures of open wounds revealed a human skin infecting fungus,
Weak immunity to such opportunistic pathogenic infections, resulting from malnutrition, poor hygiene and lack of proper Medicare, in these rural and remote areas are the main predisposing factors till today. Such health problems can be addressed by regular follow up of local hygiene and medical facilities available in these areas followed by appropriate and timely treatment.
Thus, present study stresses for a detailed clinical and detailed biochemical investigations of such outbreaks and their possible associations with other infections, particularly, in children whose immune responses are poor and thus, are more susceptible to pathogenic attacks. Such an outbreak was never reported earlier in this tribe. The knowledge and proper diagnosis of such outbreaks and their possible association with TB or other infections is most essential for tribal health as well as the health of healthcare personnel working with them.
We gratefully acknowledge the Department of Biotechnology (DBT), New Delhi, India, for the financial support provided through a research project to PKT. We are also thankful to the Chief Medical Officer (CMO), District Hospital, Sheopur in facilitating sampling process and Dr. P. K. Saraswat, Dermatologist (MBBS, MD), for the diagnosis of scabies.