Prevalence of Skin Disease among Nursing Home Staff in Southern Taiwan

Transcription

1 Industril Helth 2002, 40, Short Communiction Prevlence of Skin Disese mong Nursing Home Stff in Southern Tiwn Derek Richrd SMITH 1, 2, Yue-Ling Leon GUO 2, 3, Yung-Ling LEE 2, 3, Fu-Sen HSIEH 4, Suh-Jen CHANG 5, nd Hmm-Ming SHEU 4 * 1 Fculty of Sciences, The University of Southern Queenslnd, Toowoomb, Queenslnd, Austrli 2 Deprtment of Environmentl nd Occuptionl Helth, Ntionl Cheng Kung University Medicl College, Tinn, Tiwn 3 Centre for Occuptionl Helth, Ntionl Cheng Kung University Medicl College, Tinn, Tiwn 4 Deprtment of Dermtology, Ntionl Cheng Kung University Hospitl, 138 Sheng Li Rod, Tinn 704, Tiwn 5 Bureu of Public Helth, Tinn City, Tinn, Tiwn Received Februry 7, 2001 nd ccepted October 30, 2001 Abstrct: To estblish the prevlence of skin disese mong nursing home workers in southern Tiwn, dermtologicl exmintion ws performed on 75 nursing home stff from 11 institutions in Tinn county. Fungl infections were the most common skin diseses identified, ffecting 21.4% of ll employees. Other conditions included xerosis (13.3%), scbies (10.7%) nd dermtitis (8.0%). Fungus ws found minly on the feet nd hnds (68.7% nd 31.3% of ll fungl cses respectively). Most xerosis sites were identified on the lower leg (90.0% of ll xerosis cses), while ll workers with scbies hd the disese on their forerm. Dermtitis ws dignosed predomintely on the forerm (50.0% of ll dermtitis cses). The prevlence of fungus nd scbies ws higher thn other studies, while dermtitis occurred less frequently thn previous reports. Although not sttisticlly significnt, we believe tht wet work nd occuptionl contct with nursing home ptients my hve been importnt risk fctors for these conditions. Key words: Nursing home stff, Skin disese, Southern Tiwn, Fungus, Xerosis, Scbies Tiwn is presently undergoing drmtic shift in demogrphic structure due to rpid public helth improvements nd subsequent life expectncy gins. With 8.5% of the popultion now ged over 65 yers, t lest individuls require dily ssistnce t some level 1). New demnds on helth cre systems hve lso evolved s the clssicl notion of filil piety nd extended fmily cre declines. With their reltives unble to ssume trditionl cre-giving roles, nursing home services re emerging s both significnt helth cre industry nd employer. Around 11.5% of the ntions 9 million workers re currently involved in the helth nd community services sector 2). Occuptionl skin disese ppers to be resonbly common in southern Tiwn nd hs been previously reported in hirdressers 3) *To whom correspondence should be ddressed. nd fruit frmers 4). Occuptionl scbies hs lso been reported in hospitl environment 5). Although nursing home stff often visit our outptient deprtment with vrious skin diseses, no specific dermtologicl investigtions of their cohort hve been crried out in this region. Therefore, we undertook the current study to determine the prevlence of skin disese mong nursing home workers in southern Tiwn. This study ws reviewed nd pproved by the Tinn Helth Deprtment in Among the 21 nursing homes currently registered in Tinn, we specificlly trgeted the lrger institutions with more thn 2 full-time employees nd strtified them by geogrphicl loction. From this group, 11 fcilities were then selected t rndom; one from ech re of Tinn city. Between 1999 nd 2000, ech nursing home ws sent detiled questionnire to be completed by

2 SKIN DISEASE IN TAIWANESE NURSING HOME STAFF 55 Tble 1. Demogrphic items nd sttisticl nlysis of risk fctors n % Risk fctors b p vlue Gender Femle ( ) 0.37 Mle Work sttus Full-time ( ) 0.36 Prt-time Job description c Helth cre worker ( ) 0.82 Administrtion ( ) 0.93 Miscellneous ( ) 0.39 Food service ( ) 0.50 Men (±SD) Age (yrs) 40.9 ± ( ) e 0.27 Durtion (yrs) d 2.5 ± ( ) e 0.81 Percentge of ll stff (N=75). b Logistic regression clculted using the presence of skin disese s the dependent vrible nd workplce items s the independent vribles (odds rtio, 95% CI). c Odds rtios clculted for ech job description using the remining job descriptions s the reference ctegory (i.e. helth cre worker/not helth cre worker). d Durtion of employment in current job description. e Odds rtios clculted for incresing increments of 1 yer in ge nd 1 yer in employment durtion respectively. ll stff. Questions included job title, job description, employment history, working hours, eduction levels, ptient contct nd description of previous skin diseses. A totl of 84 employees were recruited, lthough 9 did not complete the questionnire stisfctorily, leving 75 (89.3%) for the finl nlysis. The excluded stff were similr in ge nd sex s the exmined group. After obtining their informed consent, workers were physiclly exmined by dermtologists for the presence of skin diseses. Fungl infection nd scbies were visully dignosed using stndrd dermtologicl techniques 6). Ares cliniclly positive for fungus nd scbies were lso scrped nd prepred in 10% KOH solution for microscopic lbortory nlysis. Of the other skin diseses, xerosis ws defined s skin with dryness, itching nd scles. A grde of xerosis severity from 0 to +4 (mild to severe) ws lso ssigned to this condition 7). Dermtitis ws visully dignosed s previously described 3). All dt ws entered into spredsheet progrm before being nlyzed by JMP sttisticl softwre (SAS Institute Inc, ). Multiple logistic regression ws clculted using the presence of skin disese s the dependent vrible nd vrious workplce items s the independent vribles (odds rtio, 95% CI). Vribles were chosen using the stepwise selection method. The odds rtios for ech job description were derived using the remining job descriptions s the reference ctegory (i.e. helth cre worker/not helth cre worker). Odds rtios for ge nd durtion of employment were clculted using incresing increments of 1 yer in ge nd 1 yer in employment durtion respectively. Sttisticl ssocitions between selected workplce tsks nd the presence of specific skin diseses were lso investigted using the chi-squre test. P vlues bove 0.05 were regrded s sttisticlly insignificnt. Our subjects consisted of 67 women (89.4%) nd 8 men (10.6%), with men ge of 40.9 yers (S.D.11.9) nd medin ge of 45 yers. Their ge rnged from 18 to 69 yers, with most ged below 40 yers (40.0%). Employees working 40 or more hours per week were considered full-time nd ccounted for 74.7% of the totl popultion (Tble 1). Although the men employment length ws 2.5 yers, more thn one third of employees (38.7%) hd worked in their current job for less thn yer. The men working week ws 39.4 hours, but 42.7% of ll stff reported working more thn 48 hours every week. Senior high school (36.0%) nd primry school (29.3%) were the most common eduction levels chieved by stff. No employees hd eduction beyond the bchelor degree level. Helth cre workers represented more thn three-qurters of ll employees (78.7%), followed by dministrtive officers (9.3%), miscellneous workers (6.7%), nd food service workers (5.3%). More thn hlf of ll femle stff (56.7%) were employed s ptient service workers nd one qurter (26.9%) s nurses. By contrst, only 12.5% of the mle employees were ptient service workers, while there were no mle nurses or kitchen stff in our study. Most mle stff were ctegorized miscellneous, including mngers nd owners. Mny employees undertook multiple duties involving ptient contct regrdless of their job description. Sttisticl nlysis

3 56 DR SMITH et l. Tble 2. Skin disese prevlence by ctegory Tble 3. Skin disese prevlence by body site loction n % Fungl b Xerosis Scbies Dermtitis Fungl infections (16) b, c Tine pedis Tine unguium Cndid pronychi Xerosis (10) d, e X+1 grde X+2 grde Scbies (8) f Clinicl dignosis Lbortory confirmed Dermtitis (6) g Non-defined Contct Irritnt Percentge of ll stff (N=75). b Figures in prenthesis represent the totl for ech ctegory. c No sttisticl ssocition with wshing ptients (p=0.19). d No sttisticl ssocition with incresing ge (p=0.28). e One stff member hd xerosis of both the +1 nd +2 grde. f No sttisticl ssocition with ptient contct (p=0.82). g No sttisticl ssocition with wshing ptients (p=0.94). indicted tht no demogrphic items of nursing home workers were significntly ssocited with the presence of skin disese. A totl of 62 workers (82.7%) were involved in ptient contct every dy, 61 femles (91.5% of ll femle stff) nd 1 mle (12.5% of ll mle stff). The most frequent ptient contct ws moving the ptient (61.3%), followed by chnging their bed (57.3%), chnging their clothes (56.0%) nd wshing the ptient (32.0%). Fungl infections were the most common skin diseses dignosed during this study, ffecting 21.4% of ll stff. The prevlence of fungl subctegories were s follows: tine pedis (8.0%), tine unguium (6.7%) nd cndid pronychi (6.7%). Ten workers were dignosed with xerosis (13.3% of ll stff). One stff member hd xerosis of both the +1 nd +2 grde. The verge ge of xerosis cses (42.5 yrs) ws higher thn the generl stff popultion (40.9 yrs), lthough this difference ws not sttisticlly significnt (p=0.11). Eight employees (10.7%) were cliniclly positive for scbies, with one cse confirmed by microscopic nlysis (1.3%). Dermtitis nd ppules of unknown etiology were dignosed in 8.0% nd 5.3% of stff respectively. All other dermtologicl problems ffected less thn 3.0% of stff (Tble 2). Sttisticl nlysis reveled no significnt ssocitions between the presence of fungl infections nd wshing ptients (p=0.19), xerosis Trunk Abdomen Bck Axill Arms Upper rm Forerm c 50.0 Hnd 31.3 d Legs Thigh Lower leg Feet Percentge of cses for ech ctegory (n=16, 10, 8 nd 6 respectively). b Fungl infection includes tine pedis, tine unguium nd cndid pronychi collectively. c 100% of the stff dignosed with scbies hd the disese on their forerms. d There were totl of 5 cses of cndid pronychi dignosed on the hnd, representing 31.3% of ll fungl cses identified. nd incresing ge (p=0.28), scbies nd contct with ptients (p=0.82) nd between dermtitis nd wshing ptients (p=0.94). Fungl infections predominntly ffected the feet (68.7% of ll fungl infections) nd hnds (31.3%). Most xerosis sites occurred on the lower leg (90.0% of ll xerosis cses), while ll stff with scbies hd the disese on their forerm (100%). Dermtitis ws dignosed predominntly on the forerm (50.0% of ll dermtitis) nd upper rm (33.3%). No stff hd dermtitis dignosed on the legs, nor ws fungus witnessed nywhere on the trunk during this study (Tble 3). Fungl infections re common skin disese mong humn beings nd re often ssocited with moist conditions of the extremities. Our study reveled fungl infections ffecting 21.4% of the totl stff popultion. Tine pedis ws the most common fungl ctegory ffecting 8.0% of ll stff, which is higher thn previously reported bckground level of 2.9% in Spin 8) nd 4.1% in estern Tiwn 9). Tine unguium ws dignosed t 6.7%, which is lso higher thn previously reported bckground level of 2.8% in Spin 8). As the reltive humidity verged 70% during our reserch, we suspect tht Tiwn s tropicl climte my hve been contributory fctor in these elevted results. Wet work, such s wshing ptients, cooking nd clening re common tsks undertken by nursing home employees. Pronychi is lso well-documented occuptionl skin infection in stff who regulrly undertke wet work 10). Although fungl infections were not sttisticlly ssocited with wshing ptients, the Industril Helth 2002, 40, 54 58

4 SKIN DISEASE IN TAIWANESE NURSING HOME STAFF 57 existence of cndid pronychi on the hnds of our stff (6.7%) suggests tht wet work my hve been contributory fctor in some cses. Xerosis is usully n ged relted condition resulting from the grdul depletion of strtum corneum lipids 11) nd nturl moisturizing fctors over time 12). Our study reveled thirteen percent of stff with xerosis (10 stff with 11 sites), of which 81.8% were the mild +1 grde. It is possible tht Tiwn s high irborne wter content helped reduce certin mount of more severe cses. The verge ge of xerosis cses ws higher thn the generl stff popultion, lthough this ssocition ws sttisticlly insignificnt. Xerosis ws seen most frequently on the nterior spect of the lower leg, which is common feture of ging humn skin 12). Therefore, we suspect tht the presence of xerosis during our reserch my simply reflect the beginning of nturl skin moisture depletion processes mongst the older employees. Although xerosis cerbted by workplce irritnts could not be totlly excluded, none of the workers with xerosis hd ny skin exposure to the lower extremities. Scbies is common humn skin infection cused by the mite Srcoptes scbiei nd one tht usully results from direct contct with n infected person. Nosocomil scbies is n occsionl problem for helth cre workers due to their close nd repeted contct with ptients 5). Our study reveled this disese mong 10.7% of stff working in 3 out of 11 (27.3%) institutions visited, which suggests tht occuptionl exposure vried from institute to institute. One cse ws confirmed by microscopic detection, giving confirmtion rte of 12.5%. This low confirmtion rte is supported by previous reports of dignostic difficulty mong helthy people suffering scbies 13). By loction, ll cses were seen on the forerm (100%) nd lmost two-thirds lso included the upper rm (62.5% of ll scbies cses). This body site distribution is similr to previous report of nosocomil scbies in southern Tiwn where 90% of the ffected helth cre workers hd lesions on their rms 5). Although scbies infections re often found on the hnds nd finger-webs during nosocomil outbreks 5), no stff in our study hd ny hnd involvement. We ttribute this phenomen to the consistent use of nti-scbies preprtions redily vilble within some of the nursing homes. Quite possibly some infected workers were only prtilly treting their infesttion rther thn totlly erdicting it. In these cses, scbies trnsmission my hve occurred between stff, fmily members nd bck to nursing home ptients. There were no significtion sttisticl ssocitions between the presence of scbies nd either demogrphic items or ptient contct duties. Although the community distribution of scbies is not well reserched in southern Tiwn, previous study of estern Tiwnese hs documented prevlence rte of 1.4% 9). Therefore, the 10.7% scbies prevlence during our study suggests tht nursing home stff in southern Tiwn hve higher levels of this disese thn in the generl popultion. Occuptionl dermtitis my be defined s pthologicl skin condition where the mjor cusl or contributory fctor is workplce exposure. Three fctors re importnt including contct with irritnts, individul physiologicl fctors nd environmentl influences 14). The condition most commonly ffects the hnds. Dermtitis ws dignosed in eight percent of the stff during our study, which is considerbly lower thn other investigtions of Tiwnese hirdressers (83%) 3) nd fruit frmers (30%) 4). Dermtitis occurred minly on the forerm (50.0% of ll cses) nd upper rm (33.3% of ll cses). Interestingly, the hnds were reltively unffected (16.7%), which is unusul for helth cre workers s they re often exposed to derml irritnts (such s wter) during their dily tsks. However, we did dignose one cse of irritnt hnd dermtitis tht ppered to be cused by the repeted nd unnecessry ppliction of nti-scbies mediction. Although dermtitis is known to occur in high levels mong cooks nd kitchen stff 15), only one of the ffected employees ws kitchen worker (16.7%). Furthermore, the presence of dermtitis ws not sttisticlly ssocited with wshing ptients. The occuptionl implictions of these findings re lso difficult to scertin due to the condition s low prevlence (only 6 stff in totl). Overll, our study reveled tht fungl infections were the most common skin diseses mong nursing home stff, ffecting 21.4% of them. Other conditions included xerosis (13.3%), scbies (10.7%), dermtitis (8.0%) nd ppules (5.3%). When compred to previous reserch, our results suggest tht fungus nd scbies occur more frequently mong nursing home employees in southern Tiwn. Conversely, dermtitis ws dignosed t lower levels thn in other studies. As the incresing demnd for ged cre services is reltively new socil phenomen for this country, we nticipte future elevtions of skin disese mongst Tiwnese nursing home workers. No sttisticlly significnt risk fctors could be derived during our study, therefore we suggest tht further reserch is required to investigte the complicity of workplce fctors on skin disese. Acknowledgements We would like to thnk Associte Professor Ron Atkinson from the University of Southern Queenslnd for his support

5 58 DR SMITH et l. throughout this project. Derek Richrd Smith ws lso the recipient of University of Southern Queenslnd Postgrdute Reserch Awrd. Reference 1) Lee ML (2000) Helth cre system in trnsitionl society: Tiwn experience. Presented t the IRFD Genev 2000 Conference, June 26th. 2) Council of Lbor Affirs, Tiwn, ROC (2000) Sttisticl bstrct of lbor inspection yerbook, Republic of Chin, Council of Lbor Affirs, Executive Yun, Tipei. 3) Guo YL, Wng BJ, Lee JYY, Chou SY (1994) Occuptionl hnd dermtoses of hirdressers in Tinn city. Occup Environ Med 51, ) Guo YL, Wng BJ, Lee CC, Wng JD (1996) Prevlence of dermtoses nd skin sensitistion ssocited with use of pesticides in fruit frmers of southern Tiwn. Occup Environ Med 53, ) Hsueh PR, Lin BH, Hwng CC, Hsieh, BL, Liu JC, Lin M (1992) Nosocomil outbrek of scbies. J Formos Med Assoc 91, ) Shelley WB, Shelley ED (1992) Advnced dermtologic dignosis, WB Sunders, Phildelphi. 7) Serup J (1997) Dry skin (xerosis): clinicl scoring nd instrumentl chrcteriztion. In: Bioengineering of the skin, skin surfce imging nd nlysis. eds. by Wilhelm KP, Elsner P, Berrdesc E, Mibch HI, , CRC Press, Boc Rton. 8) Pere S, Rmos MJ, Gru M, Gonzlez A, Norieg AR, del Plcio A (2000) Prevlence nd risk fctors of tine unguium nd tine pedis in the generl popultion in Spin. J Clin Microbiol 38, ) Wu YH, Su HY, Hsieh YJ (2000) Survey of infectious skin diseses nd skin infesttions mong primry school students of Titung county, estern Tiwn. J Formos Med Assoc 99, ) Hochmn LG (1995) Pronychi: more thn just n bscess. Int J Dermtol 34, ) Ghdilly R, Brown BE, Sequeir-Mrtin SM, Feingold KR, Elis PM (1995) The ged epiderml permebility brrier. Structurl, functionl nd lipid biochemicl bnormlities in humns nd senescent murine model. J Clin Invest 95, ) Shenefelt PD, Fenske NA (1990) Aging nd the skin: recognizing nd mnging common disorders. Geritrics 45, ) Wolf R, Avigd J, Brenner S (1995) Scbies: the dignosis of typicl cses. Cutis 55, ) Dougls E, Rushton L, Willims HC (1999) Is occuptionl dermtitis being tken seriously by UK industries? Occup Med 49, ) Hlkier-Sørensen L (1996) Occuptionl skin diseses. Contct Dermtitis 35, (Suppl), Industril Helth 2002, 40, 54 58