For BU, the central level responsible for the administration, coordination and scientific support of the National Program for the Control of BU comprises the program’s Coordination Department, headed by a Coordinating Director, and six technical, administrative and financial services.
The intermediate level is composed of referral structures with adequate technical platforms such as an operating theater for standardized case management. There are 7 of these centers: 2 are public and 5 are private religious centers.
It is apparent from this presentation that the management of leprosy, BU, yaws and other common dermatological conditions is structured differently, which makes it difficult to develop an integrated strategy for their control.
Study site and Method
The study was conducted in the 3 health districts of Divo, Zouan-Hounien and Oumé in Côte d’Ivoire between April 2016 and March 2017. These districts are co-endemic for BU, leprosy and yaws. Localities in these 3 districts were targeted based on co-endemicity criteria.
The 3 health districts have different geographical and demographic characteristics. The District of Zouan-Hounien, with its 210,453 inhabitants, is located in a mountainous region. The Districts of Divo and Oumé, which respectively have 404,821 and 296,670 inhabitants, are located in the middle of Côte d’Ivoire forest belt.
From a health standpoint, the District of Zouan-Hounien, Divo and Oumé have 24, 42 and 25 peripheral health centers respectively. The District of Divo has a regional hospital with surgical unit dedicated to the management of complicated BU and leprosy cases.
This is a cross-sectional study using routine data which targeted populations in communities co-endemic for BU, leprosy and yaws in 3 Districts of Côte d’Ivoire implemented between April 2016 and March 2017 in 6 stages: identification of potentially co-endemic communities; stakeholder training; social mobilization; mobile medical consultations; case detection and management; and a review meeting.
- Identification of co-endemic communities: During this phase, the co-endemic localities were identified through analysis of available data.
For leprosy and BU, the statistical data for the last five years available at the two programs were used. As for yaws, the national statistical yearbook of 2015 [16] was used. It should be noted that these cases of yaws were reported essentially on a clinical basis without biological confirmation. As a result, 64 communities were selected in the 3 Districts: 10 localities in Divo; 34 in Zouan-Hounien and 20 in Oumé.
- Training of stakeholders: For the successful implementation of this approach, a training was provided on the 3 diseases, to 44 nurses on diagnosis and care and 50 community health workers on the suspicion of lesions and referral routes
- Social mobilization and sensitization: After the identification of the 64 communities, letters were sent to community leaders and to community radio stations for social mobilization. “Town criers” were also involved in announcing the event. Sensitization kits comprised of a generator, a sound system, a video projector and a projection screen were acquired for the implementation of sensitization activities. Some Information, Education and Communication (IEC) materials for BU, Leprosy and yaws were distributed. These activities consisted of screenings of selected films and pictures on the diseases. These screenings were commented by the nurses.
- Mobile medical consultations: During this phase, five teams were formed. Each team was composed of qualified and specialized human resources in the fields of BU, leprosy and yaws (doctors, nurse specialists in dermatology, nurses, communication officers, etc.). The consultations took place in well-day light lit rooms and ensuring the respect of the patient’s privacy. These patients were pre-registered, thus allowing those with skin lesions to be sorted out. They were then consulted by nurses under the supervision of their trainers.
Only patients with skin lesions were included in this study. Patients that had general diseases without skin lesion were excluded and referred to the nearest health facility
- Case detection and management: The leprosy and BU screening was done according to the WHO clinical criteria. Case confirmation was made by PCR at the Pasteur Institute of Côte d’Ivoire. BU lesions were classified according to the WHO categories: Category I (a single lesion with a diameter 5 cm); Category II (a single lesion with a diameter between 5 and 15 cm); Category III (a single lesion with a diameter >15 cm; multiple lesions; osteomyelitis; a lesion located in a critical area such as the eyes, breasts or genitals) [17]. The yaws screening was done on the basis of clinical suspicion and confirmed by two rapid tests. The first test was SD Bioline Syphilis 3.0; then patients who tested positive were confirmed by DPP ® Syphilis Screen & confirm Assay. Cases of leprosy were diagnosed on the basis of the clinical lesions by specialist nurses with proven experience in leprosy control.
All patients identified benefited from free treatment on-site within the community. After receiving the initial treatment onsite, complicated cases were referred to the peripheral health center or to the specialized referral facility. The new leprosy cases received the multidrug therapy.
BU cases were referred to the nurse at the peripheral health center for treatment. Old BU and leprosy cases attended counseling sessions for the prevention of infirmity or disability. Some were given vaseline (petroleum jelly) or shea butter for the maintenance of their scars and to prevent skin dryness.
All cases of yaws were treated with azithromycin free of charge. Adequate treatment was given for the other dermatological conditions. It was most often antifungal medicines, soap, scabicides, vaseline (petroleum jelly) or shea butter as indicated. The necessary inputs for bandages and dressings were also made available to patients.
- The review meeting: This meeting brought together all the stakeholders at the health district level thus allowing them to: review the process; give feedback to the health authorities; organize the follow-up of the identified cases; analyze the strengths and weaknesses as well as lessons learned.
Statistical analysis of the data
All study data were recorded and processed with the software Microsoft Excel 2007. The graphs were also developed with the same software. The frequencies of the different pathologies detected were calculated. The SWOT (Strength, Weakness, Opportunity and Threat) was conducted by 4 doctors of the Buruli ulcer programme and two nurses specialists in leprosy. This staff that has experience with community-based disease control interventions. The SWOT matrix was used to analyze the strengths and weaknesses of the activity.