Presentation at 3rd GRF One Health Summit 2015 Session Plenary II

1. //
Peter Schmid-Grendelmeier
Allergy Unit
Dept. Of Dermatology
University Hospital
Zuerich
Switzerland
Allergies in Africa

2. //
Dept. Of Dermatology
University Hospital
Zuerich
Switzerland

3. //
RDTC

4. //
RDTC
Henning Grossmann
E.John Masenga

5. //
KCMC
Moshi
Dar es Salaam
TANZANIA
KENYA
MALAWI
ZAMBIA
DCR
UGANDA
BURUNDI
RWANDA
Pemba
Moshi

6. //
Regional Dermatology Training Centre
Training programm for „Dermatology officers“
from 14 Nations from East/Southern Africa
(Commonwealth)
2-years long Curriculum: Dermatology
STI / HIV
Leprosy
Public Health
Teaching methods

7. //
Prevalence of atopic dermatitis in schoolchildren: in
North America & Euope 12 – 15 %
AD is a severe burden

8. //
Prevalence of atopic dermatitis in schoolchildren:
11- 14 %%

9. //
Prevalence of atopic dermatitis in schoolchildren:
14 %

10. //
Prevalence of current fl exural eczema in schoolchildren:
11.3%,
(ranging from 3.2% (Mexico) to 25.0% (Colombia).
Investig Allergol Clin Immunol 2010; Vol. 20(4): 311-323

11. //
Overall prevalence in school children
16.3%
being higher in girls (17.7&) than boys (14.8%).
The prevalence of common skin conditions in
Australian school students: 2. Atopic dermatitis.
Marks R et al. Br J Dermatol. 1999 Mar;140(3):468-73.

12. //

13. //
AD in Africa ?

14. //
Atopic Dermatitis and PubMed

15. //
In Europe
> 10‘000 citations
Atopic Dermatitis and PubMed

16. //
In Europe
> 10‘000 citations
Atopic Dermatitis and PubMed
In SubSaharan Africa
21 citations

17. //
Health system in SubSaharan Africa
About 60 EU/ Year/capita
1 MD for about 70‘000 persons
Health system in Switzerland
About 1500 EU/ Year /capita
1 MD for about 700 persons

18. //
Deckers IAG et al. PLoS ONE 2012;7(7):

19. //
Global aspects of prevalence o atopic eczema
Deckers IAG et al. PLoS ONE 2012;7(7):

20. //
Many diseases, few doctors

21. //
Fatal threats

22. //
HIV
Tbc
Malaria
Fatal threats

23. //
Long distances….

24. //
Long distances….

25. //
Long distances….

26. //
Long distances….

27. //
Long distances….

28. //

29. //
o Lack of corticosteroid use
and
o upper respiratory tract infections
associated with
exacerbations in asthma patients
at the emergency unit of
Mulago Hospital.

30. //
Atopic dermatitis in
Kilombero Region,
Tanzania
Atopic dermatitis in
Zuerich,
SWitzerland

31. //
Atopic dermatitis in
SubSaharan Africa

32. //
What is atopic eczema?What is atopic eczema?
?

33. //
Part I
Prevalence and features of
Atopic Eczema
In SubSaharan Africa

34. //
Worldwide Variation of Asthma, allergic rhinitis and
atopic dermatitis
ISAAC Study, Lancet 1998

35. //
Worldwide Variation of Asthma, allergic rhinitis and
atopic dermatitis
ISAAC Study, Lancet 1998

36. //
Worldwide Variation of Asthma, allergic rhinitis and
atopic dermatitis
ISAAC Study, Lancet 1998

37. //
Prevalence of childhood AE in Africa
Study Country Number Prevalence Year
Fekete Nigeria 8013 5.8% 1973-5
Yahya Nigeria 5982 13.8% 2000-5
Mavale-Manuel Mozambique 2630/2383 10%/8.5% 2004
Yemaneberhan Ethiopia 12876 3.1 % 2004
Nnoruka Nigeria 2871 4.8% 1999-2001
Ogunbiy Nigeria 1048 none 2005
Ogunbiyi Nigeria 1091 5.8% 1994-8
Sibanda Zimbabwe 12042 6.9% 2004
Mercer South Africa 4947 11.9 % 1999
Hartshorne South Africa 5355 16.8% 1999
Komba Tanzania 420 2.6% 2010
Amouri Tunisia 1617 0.65% 2007
RDTC Tanzania 3427 4.9 %
RDTC Zambia 185 8.6%
RDTC Swaziland 350 9.1 %

38. //

39. //
Flex Ext
Knee 29% 31%
Wrist 16% 22%
Elbow 49% 33%
Cross-sectional survey in one village (Miembeni) in the
Kilimanjaro region, Tanzania. The general population was
6953. There were 3427 children aged 0-15 years

40. //
Flex Ext Flex Ext
Knee 18% 37% 47% 16%
Wrist 17% 27% 11% 8%
Elbow 40% 39% 57% 17%
Cohort of 1019 tertiary atopic eczema patients in Nigeria
Overall 70% had extensor involvement

41. //
Papular lichenoid lesions

42. //
Palmar hyperlinearity

43. //

44. //
Validity of the full question-based version of the U.K. diagnostic criteria
Sensitivity 43.7% (95% CI 26.3-62.3)
Specificity 97.9% (97.3-98.4)
PPV 18.4% (95% CI 10.4-28.9)
NPV 99.4% (95% CI 99.0-99.6)
Visible flexural eczema alone
Sensitivity 81.2% (95% CI 63.5-92.7)
Specificity 99.0% (95% CI 98.6-99.3),
PPV 48.1% (95% CI 34.3-62.1)
NPV 99.8% (95% CI 99.5-99.9)
Validation of the U.K. diagnostic criteria for atopic eczema in a
Xhosa speaking South-African population
Charmers DA et al Brit J Dermatol 2007
Validation of ISAAC and the U.K. diagnostic criteria for atopic
dermatitis in Ethiopian children
Haileamlak A et al. Brit J Dermatol 2005
Brit J Dermatol 2007

45. //
Validity of the full question-based version of the U.K. diagnostic criteria
Sensitivity 43.7% (95% CI 26.3-62.3)
Specificity 97.9% (97.3-98.4)
PPV 18.4% (95% CI 10.4-28.9)
NPV 99.4% (95% CI 99.0-99.6)
Visible flexural eczema alone
Sensitivity 81.2% (95% CI 63.5-92.7)
Specificity 99.0% (95% CI 98.6-99.3),
PPV 48.1% (95% CI 34.3-62.1)
NPV 99.8% (95% CI 99.5-99.9)
Validation of the U.K. diagnostic criteria for atopic eczema in a
Xhosa speaking South-African population
Charmers DA et al Brit J Dermatol 2007 Brit J Dermatol 2007

46. //
Validation of the U.K. diagnostic criteria for atopic eczema in a
Xhosa speaking South-African population
Charmers DA et al Brit J Dermatol 2007 Brit J Dermatol 2007
Flexural eczema
as the
key diagnostic
Feature
Of
Atopic
Eczema

47. /
Brit J Dermatol 2005; 152: 202

48. /
Brit J Dermatol 2005; 152: 202
Hygiene hypothesis dos not fit for atopic eczema
Infections may worsen AE
Early antibiotic intervention may worsen AE

49. //
Prevalence of AD has increased between ISAAC I and II

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Prevalence of AD has increased between ISAAC I and II

51. /
Brit J Dermatol 2005; 152: 202

52. //
J Allergy Clin Immunol 2005;115:370
306 children with AD; prevalnece 4.4 %
426 controls
aged
in Jimma, Southwest Ethiopa

53. //
J Allergy Clin Immunol 2005;115:370

54. //
J Allergy Clin Immunol 2005;115:370

55. //
J Allergy Clin Immunol 2005;115:370
Askaris

56. //

57. //
Less
allergies
more
allergies
Hygienehypothesis

58. //
Less
allergies
more
allergies
Hygienehypothesis

59. /
Helminths and allergies - Ecological
ASCARIS
ASTHMA
HAY FEVER
ECZEMA
TB
Mao et al. 2000

60. //
pooled OR=0.69 (0.60-0.79)
Ascaris pooled OR=0.69 (0.59-0.80)
Hookworm pooled OR=0.68 (0.46-1.01)
Trichuris pooled OR=0.75 (0.65-0.86)
Schistosomiasis only 2 studies ~results
Feary J et al. 2011

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62. //

63. //
Haileamlak A J Allergy Clin Immunol 2005
South african childhood atopic eczema working group South African Med J 2005
Dinkela A et al Int J Dermatol 2007
Associated with
asthma and wheezing
positive SPT
parasite infestation (Trichuris)
urbanization
De Souza East Arican Med J 1992
Associated factors with AD in SubSaharan Africa

64. //
Atopic dermatitis can be life-threatening

65. //
Triggerfaktoren in AD according to age
Akdis CA et al Allergy 2006: 61: 969–987

66. //
AD
Genetics
Immune
system
Skin
structure
Environmental
factors
Nervous
system
Atopic dermatitis

67. //

68. /
Massive bacterial superinfection - One of the complications of AD

69. //
Mod from Bieber Th. New Engl J Med 2008
Staphylococci in AD
Increased skin permeability
Increased expression of CLA
Induction of IgE
against SA
Stimulation of
T cells and DC
Upregulation of IL-31

70. //
Increased skin permeability
Increased expression of CLA
Upregulation of IL-31
Staphylococci in AD

71. //
Increased skin permeability
Upregulation of IL-31
Staphylococci in AD
Prolongation and
worsening of AD

72. //
Increased skin permeability
Upregulation of IL-31
Staphylococci in AD
Prolongation and
worsening of AD
Sepsis and
Death

73. //
Atopic dermatitis in
Kilombero Region,
Tanzania
Atopic dermatitis in
Zuerich,
SWitzerland
Infectious agents
play an important role
In AD
- direct effects
- Senstizitation
- for therapeutic approach

74. //
Nov 2011
What about filaggrin mutations in the Xhosa
cohort?

75. //
What about
Atopic dermatitis in
Cape Region
South Africa
?

76. //
Xhosa speaking population in South Africa
With atopic eczema
72 patients with atopic eczema
(found in 3069 participants)
Mean age 17.8 years (12-51 years
Female: Male 52.4 : 47.6
Fatema Esmail
Gail Todd
Dept of Dermatology
Groote Schur Hospital

77. /
Pollen measurement in Tanzania / South Africa
Goal of the study:
Unknown data
Climate changes in Africa
ISAAC Questionaire Hard data

78. /
Xhosa speaking population in South Africa
Goal of the study:
What are the
sensitization patterns
In AD patients
?

79. //
Gray C et al Pediatric Allergy Immunol 2015
40 Xhosa children
40 mixed race
All with atopic dermatitis
Age 8 mts – 10 years

80. //
Gray C et al Pediatric Allergy Immunol 2015

81. //
Gray C et al Pediatric Allergy Immunol 2015
The prevalence of peanut
allergy is high in South African
children with AD, but
significantly lower in blacks
compared to mixed race
patients.
The component Ara h 2 is useful
for differentiating allergy from
tolerance in both ethnic groups.
Ninety-five% PPV for peanut
allergy tests may need to be
revised by ethnic group

82. /

83. //
Subjects (n=102) with AD of Xhosa ethnic background attending a tertiary hospital were recruited.
These patients were then matched for age, sex and ethnicity and compared with 155 healthy controls.
The subjects had bloods taken
-IgE levels (both total and specific).
-ImmunoCAP® ISAC to determine specific IgE against 103 allergens.
-ImmunoCAP for HDM, peanut and egg white.

84. //
Results

85. //

86. //

87. //
Xhosa speaking population in South Africa
With atopic eczema
3.45 4.55 0.78 4.58 3.6
3.25 2.22 0.92 3.55 2.72
3.12 3.07 2.07 3.54 3.29
3.09 0 0 0 0
1.7 1.44 0.82 2.01 2.12
1.39 1.04 0.7 1.82 2.36
1.27 0.99 0 0.7 0.98
0.91 0.66 0.74 1.14 1.57
0.82 0.89 0.99 0.79 1.35
0.56 0 0.36 0 0
0.53 0.46 0.57 0.55 0.81
0.32 0.25 0 0 0.4
0.32 0 0 0 0.5
0.3 0.65 0 0.96 1.14
0.28 0 0.25 0 0.34
31.4
29.5
26.4
21.3
17
14.8
12.3
5.8
8.3
11.7
0
5
10
15
20
25
30
35
Der p
1
Der f 1 Bla g 2 Bla g 5 Phl p 1 Ph l 5 Fel d 1 Bosb
1,2, 4
Gal d
1-3
Pen a
1
Xhosa speaking population in South Africa
With atopic eczema
Specific IgE by ISAC

88. //
Xhosa speaking population in South Africa
With atopic eczema
3.45 4.55 0.78 4.58 3.6
3.25 2.22 0.92 3.55 2.72
3.12 3.07 2.07 3.54 3.29
3.09 0 0 0 0
1.7 1.44 0.82 2.01 2.12
1.39 1.04 0.7 1.82 2.36
1.27 0.99 0 0.7 0.98
0.91 0.66 0.74 1.14 1.57
0.82 0.89 0.99 0.79 1.35
0.56 0 0.36 0 0
0.53 0.46 0.57 0.55 0.81
0.32 0.25 0 0 0.4
0.32 0 0 0 0.5
0.3 0.65 0 0.96 1.14
0.28 0 0.25 0 0.34
31.4
29.5
26.4
21.3
17
14.8
12.3
5.8
8.3
11.7
0
5
10
15
20
25
30
35
Der p
1
Der f 1 Bla g 2 Bla g 5 Phl p 1 Ph l 5 Fel d 1 Bosb
1,2, 4
Gal d
1-3
Pen a
1
Xhosa speaking population in South Africa
With atopic eczema
Specific IgE by ISAC
CockroachesHouse dust mites Grass pollen Cat

89. //
Xhosa speaking population in South Africa
With atopic eczema
3.45 4.55 0.78 4.58 3.6
3.25 2.22 0.92 3.55 2.72
3.12 3.07 2.07 3.54 3.29
3.09 0 0 0 0
1.7 1.44 0.82 2.01 2.12
1.39 1.04 0.7 1.82 2.36
1.27 0.99 0 0.7 0.98
0.91 0.66 0.74 1.14 1.57
0.82 0.89 0.99 0.79 1.35
0.56 0 0.36 0 0
0.53 0.46 0.57 0.55 0.81
0.32 0.25 0 0 0.4
0.32 0 0 0 0.5
0.3 0.65 0 0.96 1.14
0.28 0 0.25 0 0.34
31.4
29.5
26.4
21.3
17
14.8
12.3
5.8
8.3
11.7
0
5
10
15
20
25
30
35
Der p
1
Der f 1 Bla g 2 Bla g 5 Phl p 1 Ph l 5 Fel d 1 Bosb
1,2, 4
Gal d
1-3
Pen a
1
Xhosa speaking population in South Africa
With atopic eczema
Specific IgE by ISAC
CockroachesHouse dust mites Grass pollen Cat Milk Egg Tropo
myosin

90. //
Tropomyosin
Crossallergy
Anisakis
Cockroachs
Mites
Seafood

91. //
 As a new finding in AD, sensitization to Mouse (Mus m 1) is
observed as a highly relevant allergen.
Seen most commonly in AD patients from lower income
areas –
as found in inner city asthma in low income patient groups
in industrialized areas.
Is mouse the allergen indicating underprivileged patient groups?
Mouse allergen is the major allergen of public health relevance in Baltimore City
Ahluwalia SK et al. J Allery Clin Immunol 2013; 132: 830-5
Role of mouse allergens in allergic disease.
Matsui EC. Curr Allergy Asthma Rep. 2009 Sep;9(5):370-5
 Total IgE values are elevated in AD patients and controls (due
to parasite infestation, often Toxocara),
 but specific IgE is almost exclusively present in AD.
 Sensitization to house dust mites, cockroaches and
tropomyosin commonly found in AD

92. //
What is eczema?What is eczema?

93. //
Reasons of foot dermatitis

94. //
Reasons of foot dermatitis

95. //
Reasons of foot dermatitis

96. //
Reasons of foot dermatitis

97. //
Contact allergy to Thiuram Mix

98. /
„Patch test series in 158 patients
at the RDTC inTanzania
1. Nickel Sulfate
2. Thiuram Mix
3. Mercapto Mix
4. Wood mix
5. p-Phenylendiamin PPDA
6. PPD-Mix
7. Potassium dichromat
8. Fragrance -Mix
9. Balsam of Peru
10. Cobalt chloride
11. Colophony
12. Thiomersal
13. Neomycine sulfate
Entemesi et al J int Dermatol (in press)

99. //
27-years female

100. //
27-years female
Contact allergy
to
Colonphony senitization

101. //
Contact allergy
to
PPDA senitization

102. //

103. //
Annual RDTC CME
Allergy Crash Course

104. //
7th Georg Rajka Meeting
2012 in Moshi, Tanzania

105. //
7th Georg Rajka Meeting
2012 in Moshi, Tanzania

106. //
19. International CME for
Dermatology and STI in the tropics
10.-13. January 2016
RDTC Moshi, Tanzania

107. /
Asante sana
Thank you