Tinia capitis outbreak among school students, Al Hayt, Hail, 1426 H

During the period of 4/1/1426 to 17/2/1426 an increased number of alopecia cases were reported to the Primary Health Care Center (PHCC) in Al-Hayt Muhafadha, Hail region. The situation was reported to the infectious disease department in MOH, the Directorate of Education, and the municipality. The Field Epidemiology Training Program was requested to investigate this outbreak.

Al Hayt (Fadak) is a small Muhafadha, located 200 km southwest of Hail city on the way to Al-Madina AlMonawara. It belongs administratively to Hail region, Hail directorate of health affairs. Al-Hayt health services consist of one MOH PHCC, and one school PHCC.

On the first day the investigating team discussed the problem with the Directorate General of health affairs, met the PHCC directors, public health director, and public health inspectors in Hail general health directorate. The team visited Al-Hayt PHCC, the school PHCC, and the four schools where cases had appeared.

It was found that in the international week from 3-10/1/1426, several cases of alopecia and scalp infection were reported from Fadak primary school. The school physician advised total head shaving for all the students. Within several days of shaving, the number of cases increased up to 95. This was reported to Al-Hayt PHCC and Hail General Health Directorate, which started taking appropriate actions by providing antifungal medication, Nizoral shampoo; and sick leave for infected students. The Directorate of Education inspected the four schools and fumigated all the classes. The municipality inspected the barbershops, and reported them to be unclean and shaving instruments were dirty. Most of the barbershops did not have sterilizer machines and, if available, were not used. The municipality temporary closed the barbershops after penalizing them, and ordered them to re-open only after completing the proper hygienic prerequisites.

The investigating team conducted a case control study to identify the source of the outbreak and to assess contributing factors. A case was defined as any school student in Al-Hayt city who had hair loss with or without, any of the following symptoms: itching, discharge from the scalp, scaly lesion or redness in the scalp, bad smell in the head or any other skin manifestations. Controls were selected from the colleagues of the cases, from the same class in the same school and of the same age. Two controls were selected for each case.

A total of 370 school students were interviewed, 120 of who had developed alopecia and 250 were used controls. Those students were from different educational levels (primary, intermediate, and secondary schools). The majority of the cases were primary school students. The cases appeared in 4 schools, the majority of from Fadak primary school (31%), from which the outbreak started. The ages of cases ranged from 6-21 years (mean 11 years, SD ±2.8). All were male. The majority were Saudis 117 (97.5%) and 3 were non-Saudi (2.5%). The main presenting symptoms were scalp itching 78 (65%), discharging scalp lesion 64 (53.3%), hair loss 59 (48.3%), bad smell 22 (18.4%), redness 13 (10.8), associated skin lesion in the body 4 (3.3%), and other medical problems 2 (1.7%).

Of the 120 cases, 103 (87.5%) had sought medical care and were given proper treatment; 90 (75.0%) shaved their heads; and symptoms improved spontaneously in 34 cases (28.3%).

On analysis, shaving of the head during that period was the most significant risk factor (Table 1), followed by contact with an infected person, sharing personal belongings between family members, particularly brothers' clothes. Sharing combs was not significant. Sharing towels, hats (taqqia) and Ghotra (Shemagh) were not risk factors. Switching beds with a sibling increased the risk of infection, while having a separate bed was protective. Presence of domestic animals at home was another risk factor, particularly cats.

Dermatophytes are fungi that can infect the skin, hair, and nails. These organisms, which include Trichophyton, Microsporum, and Epidermophyton species, are classified as anthropophilic, zoophilic, or geophilic, depending on whether their primary source is humans, animals, or the soil, respectively. Anthropophilic dermatophytes are the most common cause of fungal skin infections in humans. Transmission occurs from direct contact between people or from exposure to desquamated skin cells present in the environment and the spores can survive for months. Direct inoculation of the spores through breaks in the skin can lead to germination and subsequent invasion of the superficial cutaneous layers.[1] On the other hand, human infections with zoophilic species have occurred after exposure to dogs, cats, horses, cattle, pigs, rodents, poultry, hedge-hogs, and voles.[1]

The various forms of dermatophytosis, also called ringworm, are named according to the site involved. infection of the scalp is known as tinea capitis. The characteristic skin lesion is an annular scaly patch. The clinical appearance varies with the site involved, the host's immune status and the type of infecting organism.[1]

Tinea capitis is the most frequent fungal infection in children under the age of puberty. Only Microsporum and Trichophyton species cause tinea capitis. Infection begins with invasion of the stratum corneum of the scalp skin. The hairs then become infected, in one of three microscopic patterns: ectothrix, endothrix, or favus. In all three types, scaling, hair loss, and inflammation of varying degrees are present.[1]

Despite the benign curable nature of the disease, inter-human transmission of tinea capitis is nevertheless a considerable public health problem due to the increasing number of children affected and the risk of contagion in schools. In a study investigating the prevalence and etiology of tinea capitis in a primary school in Kinea, the prevalence was high 33.3%, peak age of infection was 10 years, ratio of infected males to females was 2.1, and T. tonsurans was isolated in 77.8%, T. rubrum in 4%.[2]

This study showed that sharing personal belongings between members of the same family was associated with an increased risk of infection, which agrees with recent studies that have demonstrated that transmission occurs more often in the family than the school setting, particularly indirectly by common use of grooming instruments.[1]

Oral antifungal medication with griseofulvin are the first line of drag treatment. Health education on the aetiology, treatment and prevention of tinea capitis should be given.