Community based integrated wound care: Results of a pilot formative research conducted in Benin and Côte d'Ivoire, West Africa.

Appropriate treatment of chronic wounds is priority in the management of Neglected Tropical Skin Diseases (NTSDs) and non-communicable diseases. We describe an integrated, community-based wound care pilot project carried out in Benin and Cote d'Ivoire that entailed both outreach education and evidence based wound care training for nurses staffing rural clinics. This research was carried out by a transdisciplinary research. Following the collection of baseline data on wound care at home and in clinics, an innovative pilot project was developed based on a critical assessment of baseline data in three parts: a pragmatic nurse training program; mass community cultural sensitive outreach programs and a mobile consultation. It came out from our investigation that several dangerous homecare and inappropriate wound treatment practices in clinics, gaps in knowledge about Neglected Tropical Skin Diseases (NTSDs), and little health staff communication with patients about appropriate wound care. Nurse training covered 11 modules including general principles of wound management and advice specific to endemic NTSDs. Nurse pre-post training knowledge scores increased substantially. Eight mass community outreach programs were conducted, followed by mobile clinics at which 850 people with skin conditions were screened. Three hundred and three (35.65%) of these people presented with wounds of which 64% were simple, 20% moderate, and 16% severe cases. Patients were followed for ten weeks to assess adherence with wound hygiene messages presented in outreach programs and repeated by nurses during screening. Over 90% of simple and moderate cases were managed appropriately at home and 98% of wounds were healed. Of the 47 cases referred to the health center, 87% came for and adhered to wound care advice. In 90% of cases, wounds healed. This pilot study provides a model for introducing integrated community based wound care in Africa.

WASH and NTDs: Outcomes and lessons learned from the implementation of a formative research study in NTD skin co-endemic communities in Benin.

Neglected Tropical Diseases (NTDs) are a diverse group of bacterial, viral, parasitic and fungal diseases affecting people, most of whom live below the poverty threshold. Several control strategies are defined against these diseases, including chemotherapy and Water, Hygiene and Sanitation (WASH). This study assesses the effect of promoting hygiene and sanitation on soil-transmitted helminthiasis s and NTDs of the skin. It took place in the communes of Ze, Lalo, and Zangnanado, three municipalities located in the south of Benin. This is a formative research that took place in three phases. The first phase entailed a baseline informations and situational analysis of the state of hygiene and health, using soil-transmitted helminthiasis and wound hygiene practices as cases studies. In the second phase, interventions to promote improved hygiene and sanitation were implemented. The third phase was devoted to post-intervention evaluation. The situation analysis showed that the prevalence of soil-transmitted helminthiasis was 6.43 and 7.10% in the municipalities of Ze and Lalo, respectively. In the communes of Zangnanado, the most common wound management practices identified were: putting sand or ashes in the wounds to keep flies away, the use of medicinal plants and the application of powder from antibiotic capsules for wound dressing. The post-intervention evaluation showed a decrease in the prevalence of soil-transmitted helminthiasis from 6.43 to 1.19% in the municipality of Lalo and from 7.10 to 1.75% in the municipality of Ze. In the commune of Zangnanado, a significant shift in wound management practices was noted, which led to the healing of several chronic wounds. This research supports the evidence that WASH-based interventions are very important to tackle neglected tropical diseases NTDs in addition to specific diseases based interventions.

Comparison of 8 weeks standard treatment (rifampicin plus clarithromycin) vs. 4 weeks standard plus amoxicillin/clavulanate treatment [RC8 vs. RCA4] to shorten Buruli ulcer disease therapy (the BLMs4BU trial): study protocol for a randomized controlled multi-centre trial in Benin.

BACKGROUND: Buruli ulcer (BU) is a neglected tropical disease caused by Mycobacterium ulcerans that affects skin, soft tissues, and bones, causing long-term morbidity, stigma, and disability. The recommended treatment for BU requires 8 weeks of daily rifampicin and clarithromycin together with wound care, physiotherapy, and sometimes tissue grafting and surgery. Recovery can take up to 1 year, and it may pose an unbearable financial burden to the household. Recent in vitro studies demonstrated that beta-lactams combined with rifampicin and clarithromycin are synergistic against M. ulcerans. Consequently, inclusion of amoxicillin/clavulanate in a triple oral therapy may potentially improve and shorten the healing process. The BLMs4BU trial aims to assess whether co-administration of amoxicillin/clavulanate with rifampicin and clarithromycin could reduce BU treatment from 8 to 4 weeks. METHODS: We propose a randomized, controlled, open-label, parallel-group, non-inferiority phase II, multi-centre trial in Benin with participants stratified according to BU category lesions and randomized to two oral regimens: (i) Standard: rifampicin plus clarithromycin therapy for 8 weeks; and (ii) Investigational: standard plus amoxicillin/clavulanate for 4 weeks. The primary efficacy outcome will be lesion healing without recurrence and without excision surgery 12 months after start of treatment (i.e. cure rate). Seventy clinically diagnosed BU patients will be recruited per arm. Patients will be followed up over 12 months and managed according to standard clinical care procedures. Decision for excision surgery will be delayed to 14 weeks after start of treatment. Two sub-studies will also be performed: a pharmacokinetic and a microbiology study. DISCUSSION: If successful, this study will create a new paradigm for BU treatment, which could inform World Health Organization policy and practice. A shortened, highly effective, all-oral regimen will improve care of BU patients and will lead to a decrease in hospitalization-related expenses and indirect and social costs and improve treatment adherence. This trial may also provide information on treatment shortening strategies for other mycobacterial infections (tuberculosis, leprosy, or non-tuberculous mycobacteria infections). TRIAL REGISTRATION: ClinicalTrials.gov NCT05169554 . Registered on 27 December 2021.

Integrated approach in the control and management of skin neglected tropical diseases in three health districts of Côte d'Ivoire.

BACKGROUND: Neglected tropical diseases (NTDs) comprise 20 communicable diseases that are prevalent in rural poor and remote communities with less access to the health system. For effective and efficient control, the WHO recommends that affected countries implement integrated control interventions that take into account the different co-endemic NTDs in the same community. However, implementing these integrated interventions involving several diseases with different etiologies, requiring different control approaches and driven by different vertical programs, remains a challenge. We report here the results and lessons learned from a pilot test of this integrated approach based on integrated screening of skin diseases in three co-endemic health districts of Côte d'Ivoire, a West African country endemic for Buruli ulcer, leprosy and yaw. METHOD: This cross-sectional study took place from April 2016 to March 2017 in 3 districts of Côte d'Ivoire co-endemic for BU, leprosy and yaws. The study was carried out in 6 stages: identification of potentially co-endemic communities; stakeholder training; social mobilization; mobile medical consultations; case detection and management; and a review meeting. RESULTS: We included in the study all patients with skin signs and symptoms at the screening stage who voluntarily accepted screening. In total, 2310 persons screened had skin lesions at the screening stage. Among them, 07 cases were diagnosed with Buruli ulcer. There were 30 leprosy cases and 15 yaws detected. Other types of ulcerations and skin conditions have been identified and represent the majority of cases detected. We learned from this pilot experience that integration can be successfully implemented in co-endemic communities in Côte d'Ivoire. Health workers are motivated and available to implement integrated interventions instead of interventions focused on a single disease. However, it is essential to provide capacity building, a minimum of drugs and consumables for the care of the patients identified, as well as follow-up of identified patients, including those with other skin conditions. CONCLUSIONS: The results of this study show that the integration of activities can be successfully implemented in co-endemic communities under the condition of staff capacity building and minimal care of identified patients.

Integrated approach in the control and management of skin neglected tropical diseases in Lalo, Benin.

BACKGROUND: Neglected Tropical Diseases (NTDs) are a group of several communicable diseases prevalent in the tropical and subtropical areas. The co-endemicity of these diseases, the similarity of the clinical signs, and need to maximize limited financial and human resources have necessitated implementation of integrated approach. Our study aims to share the lessons of this integrated approach in the fight against Buruli ulcer (BU), leprosy and yaws in a rural district in Benin. METHODS: It is a cross-sectional study using a single set of activities data conducted from May 2016 to December 2016. Health workers and community health volunteers involved in this study were trained on integrated approach of the Buruli ulcer, leprosy and yaws. Village chiefs were briefed about the activity. The trained team visited the villages and schools in the district of Lalo in Benin. After the education and awareness raising sessions, all persons with a skin lesion who presented voluntarily to the team were carefully examined in a well-lit area which respected their privacy. Suspected cases were tested as needed. The socio-demographic information and the characteristics of the lesions were collected using a form. A descriptive analysis of the epidemiological, clinical and laboratory variables of the cases was made using Excel 2013 and SPSS version 22.00. PRINCIPAL FINDINGS: In the study period, 1106 people were examined. The median (IQR) age of those examined was 11 (8; 27) years. Of 34 (3.1%) suspected BU cases, 15 (1.4%) were confirmed by PCR. Only three cases of leprosy were confirmed. The 185 (16.7%) suspected cases of yaws were all negative with the rapid test. The majority of cases were other skin conditions, including fungal infections, eczema and traumatic lesions. CONCLUSION: The integrated approach of skin NTD allows optimal use of resources and surveillance of these diseases. Sustaining this skin NTD integrated control will require the training of peripheral health workers not only on skin NTD but also on basic dermatology.

Assessment of water, sanitation, and hygiene practices and associated factors in a Buruli ulcer endemic district in Benin (West Africa).

BACKGROUND: Control of neglected tropical diseases (NTDs) requires multiple strategic approaches including water, sanitation and hygiene services (WASH). Buruli ulcer (BU), one of the 17 NTDs, remains a public health issue in Benin particularly in the district of Lalo. The availability of water as well as good hygiene are important for the management of Buruli ulcer particularly in the area of wound care one of the main component of the treatment of BU lesions. Given the growing importance of WASH in controlling NTDs and in order to assess the baseline for future cross-cutting interventions, we report here on the first study evaluating the level of WASH and associated factors in Lalo, one of the most BU-endemic districts in Benin. METHOD: A cross-sectional study was carried to assess WASH practices and associated factors in the district of Lalo. Data were collected from 600 heads of household using structured pretested questionnaire and observations triangulated with qualitative information obtained from in-depth interviews of patients, care-givers and community members. Univariate and multivariate analysis were carried to determine the relationships between the potential associated factors and the sanitation as well as hygiene status. RESULTS: BU is an important conditions in the district of Lalo with 917 new cases detected from 2006 to 2012. More than 49 % of the household surveyed used unimproved water sources for their daily needs. Only 8.7 % of the investigated household had improved sanitation facilities at home and 9.7 % had improved hygiene behavior. The type of housing as an indicator of the socioeconomic status, the permanent availability of soap and improved hygiene practices were identified as the main factors positively associated with improved sanitation status. CONCLUSIONS: In the district of Lalo in Benin, one of the most endemic for BU, the WASH indicators are very low. This study provides baseline informations for future cross-cutting interventions in this district.