Flip Flop Foundation
Health and Hygiene Considerations
Rev. February 2008
Footwear in Africa is extremely important in order to reduce trauma, hookworm and parasitic diseases that enter the bare foot. It is also important to minimize foot infections in the diabetic population, as well as to lower the risk for podoconiosis and Kaposi’s sarcoma.
Schistosomiasis (bilharziasis) is a disease caused by parasitic worms. It is not found in the United States, but affects 200 million people worldwide including people in Africa. Its highest prevalence and severity is in school-aged children. Infection occurs when your skin comes in contact with contaminated fresh water in which certain types of snails that carry schistosomes are living. The parasite leaves the snail and enters the water where it can penetrate the skin of persons who are wading, swimming, or washing in contaminated water. Within several weeks, worms grow inside the blood vessels of the body and produce eggs. The body reacts to the eggs with fever, chills, cough and muscle aches. Excretion of the eggs through urine and feces complete the life cycle of the worm. Repeated infections can damage the liver, intestines, lung and bladder. Use of proper footwear and avoidance of contaminated water can minimize the occurrence of this disease.
Source: Centers for Disease Control and Prevention. Division of Parasitic Diseases Factsheet. Schistosomiasis. August 2004
Tungiasis (tunga penetrans) is a disease caused by a parasitic flea. Although rare in the United States, it is found in tropical Africa and is highly prevalent where people live in poverty. About 42% of Nigerian children are infected with tungiasis. This disease affects the feet because this sand flea is a poor jumper and therefore burrows into the skin of the host on the bare foot or toes. Painful swelling and the development of a fibrous cyst follows. It may progress to bacteremia, gangrene, tetanus and death. The major risk factor for developing tungiasis is failure to wear shoes when walking in sand infested with fleas. The primary method of prevention is simply to wear some type of footwear.
Source: Paul McKinney, MD and L. Clifford McDonald, MD
University of Lousville School of Medicine
EMedicine, April 2006
Diabetes is a disease that affects how the body uses food for energy. It affects 13.6 million people in Africa and this is expected to double in the next 25 years. Diabetic foot infections occur because diabetes causes poor circulation in the foot combined with a lack of pain sensation, leading to non-healing foot injuries, usually ulcers. Untreated, these injuries can lead to amputation and sometimes death. Foot clinics are rare in developing countries. For example, in Senegal, there is just one foot clinic in the entire country of 4 million people. Socio-cultural practices of going barefoot contribute to this health problem; adequate footwear can minimize the diabetic foot infections and their sequelae.
Source: Diabetes and Foot Care – Put Feet First Prevent Amputations.
International Diabetes Federation. Cameroon, April 2005
Hookworm is an intestinal parasite that is caused by direct contact with soil contaminated with larvae, or by ingestion of the larvae. It infects 1 billion people worldwide and is found in Europe, Africa, Asia, and South America. The larvae typically penetrate the skin of the legs or feet and travel in the venous system to the heart, and then to the lungs where they enter the airways. Next, they are coughed up into the throat and then swallowed. In the intestine, the larvae develop into worms that attach to the bowel wall and suck blood. Excretion of the eggs into the soil completes the life cycle. Hookworm causes anemia, abdominal pain, diarrhea, and weight loss. It can also cause growth retardation. The incidence of hookworm infection may be reduced by wearing shoes.
Source: Centers for Disease Control and Prevention. Division of Parasitic Diseases Factsheet. Hookworm. August 1999.
Hotez, PJ and Pritchard DI. Hookworm Infection. Scientific American. 272 (6) June 68-74 (1995).
Podoconiosis (“mossy foot”) is a type of endemic non-filarial elephantiasis. It is prevalent in Ethiopia, Rwanda, Burundi, Cameroon, Tanzania, and Guinea, particularly in barefoot agricultural workers. Tiny particles of silica penetrate the skin of barefoot farmers who walk in volcanic soils. These particles enter the lymphatic vessels. The body reacts as if a wound is present and makes a fibrous plug that clogs the lymphatics, causing elephantiasis. This disease is preventable by wearing shoes.
Source: Podoconiosis: non-filarial elephantiasis. EW Price. Oxford University Press. NY 1990.
Podoconiosis: endemic non-filarial elephantiasis. LC Fuller. Current Opinions Infectious Disease. April 18 (2) 119 – 122 (2005).
Kaposi’s sarcoma (KS) is a rare cancer that first gained widespread attention as the hallmark of AIDS, but in Africa, this cancer was common long before the AIDS epidemic and seemed to be limited to the foot and lower legs. Endemic (not due to HIV) KS has been identified in Uganda, Sudan, the Democratic Republic of the Congo, Zambia, Zimbabwe, Kenya, Tanzania, Malawi, Nigeria and Cameroon. The distribution of endemic KS is similar to that of podoconiosis that strikes barefoot highland farmers. KS is caused by an infection with a herpesvirus (HHV-8) that is particularly virulent in someone whose immune system is suppressed. It is believed that the lymph vessels respond to soil exposure by an inflammatory response that may enable the causative virus to proliferate in the skin of the feet and legs. With the AIDS virus, the entire immune system collapses and KS is found throughout the body. Going barefoot is a risk factor for KS. Use of appropriate footwear can lower this risk.
Source: Endemic Kaposi’s sarcoma in Africa and local volcanic soils. John Ziegler. The Lancet, 1348-1351 (Nov. 1993).
Risk Factors for Kaposi’s sarcoma: A case control study of HIV – seronegative people in Uganda. John Ziegler et al. Int. J. Cancer: 103, 233 – 240 (2003).
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