Study context
Buruli ulcer and leprosy programs in Côte d’Ivoire
Control activities for Buruli ulcer (BU) and leprosy are implemented by two different programs in Cote d’Ivoire:
- The National Program for the Elimination of Leprosy;
- The National Program for Buruli Ulcer Control.
There is no specific program for yaws eradication. Yaws management, as with other skin diseases, falls under the general health system.
The structures involved in the control of leprosy are organized nationally at three levels:
- the central level: with a coordinating office headed by an executive director of the National Programme for the Elimination of Leprosy and a leprosy referral center, namely, the Institut Raoul Follereau in Adzopé.
- the intermediate level: comprises 82 health districts with 82 chief medical officers. The screening, care and follow-up of patients are under the direct responsibility of leprosy-specialist nurses or of leprosy controllers based on the health departments or districts. Some leprosy-specialist nurses are responsible for several health districts, which explains the almost universal coverage of the country.
- the peripheral level: includes 1910 first-contact health facilities. In these institutions, 500 nurses and health workers trained to look out for signs of leprosy are responsible for detecting and referring all suspicious cases to the intermediate level for confirmation of diagnosis and then for caring for and following up with patients living in their jurisdiction.
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 seven of these centers: two are public and five are faith-based centers.
It is thus apparent 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 and leprosy. 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 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 the Côte d’Ivoire forest belt.
From a health standpoint, the Districts of Zouan-Hounien, Divo and Oumé have 24, 42 and 25 peripheral health centers, respectively. The District of Divo has a regional hospital with a surgical unit dedicated to the management of complicated BU and leprosy cases.
This is a cross-sectional study using routine data that 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 the analysis of available data.
For leprosy and BU, this study used statistical data for the last five years available at the two programs. For yaws, the national statistical yearbook of 2015 [17] 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 that are co-endemic for BU and leprosy 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, training on the three diseases was provided to 44 nurses and 50 community health workers. We trained nurses and community health workers in the integrated control and management of leprosy, BU and yaws. The training of the nurses covered basic epidemiology, clinical diagnosis, differential diagnosis, complications, social consequences, performing rapid diagnostic tests for yaws and treatment of these three diseases. The training for community health workers was mainly focused on clinical diagnosis to increase their capacity to identify possible cases.
- Social mobilization and sensitization: After the identification of the 64 communities, letters were sent to community leaders and to community radio for social mobilization. “Town criers” were also involved in announcing the event. These communities were visited one by the team. Sensitization kits including 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. Movies on the diseases were presented to the population. Some comments were provided by the nurses.
- Mobile medical consultations: During this phase, five teams were formed according to the available experimented human resources for this activity. 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.). These teams are experienced in the diagnosis and management of BU leprosy and yaws: they had been involved in the control of these diseases for several years. The consultations took place in schools in rooms well-lit by day light and ensured respect for the patient’s privacy. We included in the study all patients with skin signs and symptoms at the screening stage who voluntarily accepted screening by the team. These patients were then seen by nurses under the supervision of their trainers. They were carefully examined in a well-lit area that respected their privacy. The sociodemographic information and data on lesion characteristics were collected, as well as adequate samples to confirm BU and yaws cases. Only patients with skin lesions were included in this study. Patients who had general diseases without skin lesions were excluded and referred to the nearest health facility.
- Case detection and management: The leprosy and BU screening were performed according to the WHO clinical criteria. For BU cases, swabs or fine needle aspiration were collected accordingly by experienced nurses. BU cases were confirmed by polymerase chain reaction (PCR) for IS2404 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 of 5 cm); Category II (a single lesion with a diameter between 5 and 15 cm); and 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) [18].
The yaws screening was performed 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 clinically according to the WHO clinical definition [19,20] by specialist nurses with many years of experience in leprosy control. Cases were classified as paucibacillary (≤ 5 lesions) and multibacillary (> 5 lesions or with nerve involvement (pure neuritis, or any number of skin lesions and neuritis)) according to the WHO Global Leprosy Strategy 2016–2020 [19,20].
All patients identified benefited from free treatment on-site within the community. After receiving the initial treatment onsite, patients with complicated cases were referred to the peripheral health center or to the specialized referral facility. New leprosy cases received multidrug therapy.
BU cases were referred to the health center for treatment. Former BU and leprosy patients attended counseling sessions for the prevention of impairment or disability. Some were given Vaseline (petroleum jelly) or shea butter (a locally available alternative to Vaseline) for the maintenance of their scars and prevention of skin dryness.
All cases of yaws were treated with azithromycin free of charge. Adequate treatment was given for the other skin conditions; this 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 follow-up of the identified cases, and 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 frequencies of the different pathologies detected were calculated. The SWOT (strength, weakness, opportunity and threat) analysis was conducted by 4 doctors of the Buruli ulcer program and two nurse specialists in leprosy. This staff has experience with community-based disease control interventions. The SWOT matrix was used to analyze the strengths and weaknesses of the activity.