Authors : Aboa Paul Koffi, Théodore Ange Kouakou Yao, Yves Thierry Barogui, Gabriel Diez, Simplice Djakeaux, Marie Hélène Zahiri , Ghislain Emmanuel Sopoh , Silvia Santos , Kingsley Bampoe Asiedu , Roch Christian Johnson and Henri Assé
Type of publication : Research article
Date of publication : 2020
*Wathinotes are excerpts from publications chosen by WATHI and conform to the original documents. The reports used for the development of the Wathinotes are selected by WATHI based on their relevance to the country context. All Wathinotes refer to original and integral publications that are not hosted by the WATHI website, and are intended to promote the reading of these documents, which are the result of the research work of academics and experts.
This activity took place in 64 targeted locations across all 3 health districts co-endemic for BU and leprosy. The outreach activities were attended by 16,140 people.
Within the sensitized population, 2310 (15%) had skin lesions (467 with ulceration and 1843 without ulceration): 1302 cases in the district of Divo, 566 cases in the district of Oumé and 442 cases in the district of Zouan-Hounien. The median age (IQR) of the participants with skin lesions was 13 years (9.5; 31); a majority of them (61.65%) were female.
Seven cases were diagnosed as Buruli ulcer; 5 out 7 cases were category II. There were 30 leprosy cases, and 17 cases (56.7%) were female. The median age (IQR) was 53 years (39.5; 69); 21 were paucibacillary and 09 were multibacillary. There were 15 cases of yaws. In total, 467 (20.22) patients had ulcerative lesions. Most of the ulcerative lesions were posttraumatic (11.90%), when nearly half of the patients had nonulcerative lesions (42.77%) and had fungal infection
In this study, we share our experience in implementing integrated management of skin NTDs in Côte d’Ivoire. Through this experiment, we think that the integrated screening and care of patients with skin NTDs is feasible in Côte d’Ivoire. Indeed, in recent years, the number of cases of leprosy and BU has considerably decreased in Côte d’Ivoire, as in most African countries, and the WHO has provided a training guide for front-line health workers. These diseases are often co-endemic and show similar clinical signs, and financial and human resources to control them are limited. The implementation of this integrated approach in Côte d’Ivoire was organized using the tools and the human and material resources acquired as part of the efforts to control BU and leprosy.
This implementation allowed us to detect and provide care for 7 cases of BU (0.3%) and 30 cases of leprosy (1.3%), of which 21 were paucibacillary and 9 were multibacillary. Fifteen cases of yaws were detected, and 8 were confirmed by serological testing; the other 7 were diagnosed on a clinical basis because we did not have rapid screening tests during the first campaign. It is possible that one or more of those cases were syphilis instead of yaws since previous studies showed that experienced clinicians did not have their diagnosis confirmed by laboratory tests. In addition, there is a study showing syphilis in children acquired from nonsexual contact, and DPP is not useful to differentiate syphilis of yaws, which is also caused by Treponema pallidum, but in this case, T. pallidum spp. Pertenue. Both diseases can be treated efficaciously by a single dose of azithromycin.
Through this experiment, we think that the integrated screening and care of patients with skin NTDs is feasible in Côte d’Ivoire. Indeed, in recent years, the number of cases of leprosy and BU has considerably decreased in Côte d’Ivoire, as in most African countries, and the WHO has provided a training guide for front-line health workers
Apart from skin NTDs, many other skin diseases (97.75%) were detected and treated. In addition, to launch the series of campaigns, the nurses in the targeted health areas, who were already experienced in the management of BU and leprosy and were available, benefited from capacity building. This theoretically made them better equipped to diagnose and care for people with other skin conditions. The effect of this activity could be measured through their active and operational involvement during the mobile consultation sessions. These health professionals were able to accurately identify and adequately manage various skin diseases, as indicated in the results of our study.
The model of the integrated approach in the management of NTDs that we tested had ethical limits. Several people with different health problems gathered in the same place to attend mobile clinics. This had the theoretical advantage of breaking down barriers of stigma; however, in practice, it can also create a recruitment bias since people with very advanced lesions or elderly people may not present themselves in public. However, during our study, there were instances where teams did homebased consultations on the indication of community health workers. Another limitation of this study is the selection of patients with skin lesions. Patients with primary neural leprosy (PNL) or very tiny or scanty lesions may be missed. To our knowledge, there are no data on the prevalence of primary neural leprosy in Côte d’Ivoire.
This implementation allowed us to detect and provide care for 7 cases of BU (0.3%) and 30 cases of leprosy (1.3%), of which 21 were paucibacillary and 9 were multibacillary
The other constraint that must be overcome to ensure the sustainability of this integrated approach is the free accessibility or at least the affordability of drugs for other diseases similar to BU, yaws and leprosy. Most dermatological drugs are on the list of essential drugs in Côte d’Ivoire but are not available in first-contact facilities. Patients will come only when they have easy access to medications. Financial accessibility makes it easy to access health care and allows better management of the disease through the use of health facilities from the earliest symptoms of illness and the availability of medications.
Some cases of diagnostic difficulties by nurses were noted; such cases were few. For example, the two cases of neurofibromatosis were diagnosed by supervising physicians and were referred for treatment. To address such cases, it is necessary to provide the support of a dermatologist or a nurse specializing in dermatology and leprosy during these interventions. Tele dermatology consultations with dermatologists are also an alternative, and WhatsApp is a possible solution.