Universal test and treat in Cameroon: a comparative retrospective analysis of mortality and loss to follow-up before and after a strategic change in approach to HIV care.

Introduction: an increasing number of persons living with HIV (PLHIV) are accessing antiretroviral therapy (ART) since the adoption of the universal test and treat (UTT) policy by Cameroon in 2016. We sought to evaluate the effectiveness of the UTT approach to keep this growing number of PLHIV on a lifelong treatment. Methods: a retrospective cohort analysis was conducted at the Nkongsamba Regional Hospital between 2002 and 2020, using routine data to compare the cumulative incidence of loss to follow-up (LTFU) and mortality between PLHIV initiated on ART under UTT guidelines and those initiated under the standard deferred approach. Chi-squared test was used to compare the risk of attrition between the guideline periods while multiple logistic regression modelling was used to adjust for confounders. Results: of 1627 PLHIV included for analysis, 756 (46.47%) were enrolled during the era of UTT with 545 (33.54%) initiated on ART on the same day of HIV diagnosis. The transition to the UTT era was associated with an overall reduction in the risk of LTFU by 73% (aOR = 0.27, 95%CI: 0.17 - 0.45). There was modest evidence that the odds of mortality had increased under the UTT policy by about 3-fold (aOR = 2.86, 95%CI: 0.91-8.94). Same-day initiation had no overall effect on LTFU or mortality. LTFU was lower among the same-day initiators in the first 24 months but increased thereafter above the rate among late initiators. Conclusion: overall ART programme implementation under the UTT has led to a significant decline in LTFU though mortality appeared to have increased. Ongoing efforts to keep patients on long-term treatment should be sustained while other innovative schemes are sought.

Mapping suitability for Buruli ulcer at fine spatial scales across Africa: A modelling study.

Buruli ulcer (BU) is a disabling and stigmatising neglected tropical disease (NTD). Its distribution and burden are unknown because of underdiagnosis and underreporting. It is caused by Mycobacterium ulcerans, an environmental pathogen whose environmental niche and transmission routes are not fully understood. The main control strategy is active surveillance to promote early treatment and thus limit morbidity, but these activities are mostly restricted to well-known endemic areas. A better understanding of environmental suitability for the bacterium and disease could inform targeted surveillance, and advance understanding of the ecology and burden of BU. We used previously compiled point-level datasets of BU and M. ulcerans occurrence, evidence for BU occurrence within national and sub-national areas, and a suite of relevant environmental covariates in a distribution modelling framework. We fitted relationships between BU and M. ulcerans occurrence and environmental predictors by applying regression and machine learning based algorithms, combined in an ensemble model to characterise the optimal ecological niche for the disease and bacterium across Africa at a resolution of 5km x 5km. Proximity to waterbodies was the strongest predictor of suitability for BU, followed potential evapotranspiration. The strongest predictors of suitability for M. ulcerans were deforestation and potential evapotranspiration. We identified patchy foci of suitability throughout West and Central Africa, including areas with no previous evidence of the disease. Predicted suitability for M. ulcerans was wider but overlapping with that of BU. The estimated population living in areas predicted suitable for the bacterium and disease was 46.1 million. These maps could be used to inform burden estimations and case searches which would generate a more complete understanding of the spatial distribution of BU in Africa, and may guide control programmes to identify cases beyond the well-known endemic areas.

Mapping the global distribution of Buruli ulcer: a systematic review with evidence consensus.

BACKGROUND: Buruli ulcer can cause disfigurement and long-term loss of function. It is underdiagnosed and under-reported, and its current distribution is unclear. We aimed to synthesise and evaluate data on Buruli ulcer prevalence and distribution. METHODS: We did a systematic review of Buruli ulcer prevalence and used an evidence consensus framework to describe and evaluate evidence for Buruli ulcer distribution worldwide. We searched PubMed and Web of Science databases from inception to Aug 6, 2018, for records of Buruli ulcer and Mycobacterium ulcerans detection, with no limits on study type, publication date, participant population, or location. English, French, and Spanish language publications were included. We included population-based surveys presenting Buruli ulcer prevalence estimates, or data that allowed prevalence to be estimated, in the systematic review. We extracted geographical data on the occurrence of Buruli ulcer cases and M ulcerans detection from studies of any type for the evidence consensus framework; articles that did not report original data were excluded. For the main analysis, we extracted prevalence estimates from included surveys and calculated 95% CIs using Byar's method. We included occurrence records, reports to WHO and the Global Infectious Diseases and Epidemiology Network, and surveillance data from Buruli ulcer control programmes in the evidence consensus framework to grade the strength of evidence for Buruli ulcer endemicity. This study is registered with PROSPERO, number CRD42018116260. FINDINGS: 2763 titles met the search criteria. We extracted prevalence estimates from ten studies and occurrence data from 208 studies and five unpublished surveillance datasets. Prevalence estimates within study areas ranged from 3·2 (95% CI 3·1-3·3) cases per 10 000 population in Côte d'Ivoire to 26·9 (23·5-30·7) cases per 10 000 population in Benin. There was evidence of Buruli ulcer in 32 countries and consensus on presence in 12. INTERPRETATION: The global distribution of Buruli ulcer is uncertain and potentially wider than currently recognised. Our findings represent the strongest available evidence on Buruli ulcer distribution so far and have many potential applications, from directing surveillance activities to informing burden estimates. FUNDING: AIM Initiative.

Epidemiology of onchocerciasis-associated epilepsy in the Mbam and Sanaga river valleys of Cameroon: impact of more than 13 years of ivermectin.

BACKGROUND: A high epilepsy prevalence has been reported in several onchocerciasis-endemic villages along the Mbam and Sanaga river valleys in Cameroon, including Bilomo and Kelleng. We sought to determine the prevalence of epilepsy in these two villages following more than 13 years of community-directed treatment with ivermectin (CDTI). METHODS: Door-to-door surveys were performed on the entire resident population in the villages in August 2017 and January 2018. Epilepsy was diagnosed using a 2-step approach: administration of a standardized 5-item questionnaire followed by confirmation by a neurologist. Previously published diagnostic criteria for onchocerciasis-associated epilepsy (OAE) were used. Ov16 serology was done for children aged 7-10 years to assess onchocerciasis transmission. Findings were compared with previous data from these two villages. RESULTS: A total of 1525 individuals (1321 in Bilomo and 204 in Kelleng) in 233 households were surveyed in both villages. The crude prevalence of epilepsy was 4.6% in Bilomo (2017) and 7.8% in Kelleng (2018), including 12 (15.6% of cases) persons with epilepsy (PWE) with nodding seizures. The age and sex-standardized prevalence in Kelleng decreased from 13.5% in 2004 to 9.3% in 2018 (P < 0.001). The median age of PWE shifted from 17 (IQR: 12-22) years to 24 (IQR: 20-30) years in Bilomo (P < 0.001); and slightly from 24 (IQR: 14-34) years to 28 (IQR: 21.25-36.75) years in Kelleng (P = 0.112). Furthermore, 47.6% of all tested children between 7 and 10 years had Ov16 antibodies. CONCLUSIONS: There is a decrease in epilepsy prevalence after 13 years and more of CDTI in both villages. The age-shift observed in PWE suggests that ivermectin may prevent OAE in younger residents. Ov16 seropositivity in children indicates ongoing onchocerciasis transmission possibly due to suboptimal control measures. Our findings support the existence of OAE in Cameroon and highlight the need to strengthen onchocerciasis elimination programs.

Community knowledge, perceptions and attitudes regarding leprosy in rural Cameroon: The case of Ekondotiti and Mbonge health districts in the South-west Region.

BACKGROUND: Although leprosy is one of the oldest diseases known to humanity, it remains largely misunderstood. Misconceptions about leprosy lead to stigma towards people with the disease. This study aimed at exploring the knowledge, perceptions and attitudes regarding leprosy in rural Cameroon. METHODS: We carried out a cross-sectional community survey of 233 respondents aged 15-75 years, free from leprosy, and living in two rural health districts of the South-west Region of Cameroon. A questionnaire designed to evaluate knowledge, perceptions and attitudes about leprosy was used. Binary logistic regression was used to determine independent predictors of negative attitudes. RESULTS: About 82% of respondents had heard about, and 64.4% knew someone with leprosy. Information on leprosy was mainly from community volunteers (40.6%), friends (38.0%), and the media (24%). Only 19.7% of respondents knew the cause of leprosy, and a considerable proportion linked it to a spell (25.3%), unclean blood (15.5%) and heredity (14.6%). About 72% knew that leprosy is curable and 86.3% would advise medical treatment. Attitudes towards leprosy patients were generally negative. Only 42% would shake hands, 32.6% would share the same plate, and 28.3% and 27% respectively, would allow their child to play or marry a person with leprosy. Furthermore, only 33.9% approved of participation of leprosy patients, and 42.9% of their employment. Independent predictors of negative attitudes were: the belief that leprosy is a curse; is caused by a germ; and having seen a leprosy patient. The negative attitudes were dampened by: the beliefs that leprosy is a punishment, is hereditary and is due to poor personal hygiene. CONCLUSION: An awareness intervention using community volunteers and the media, with information on the cause of leprosy, its clinical manifestations and curability, and sensitization messages correcting the misconceptions and beliefs regarding leprosy, could improve the community knowledge and attitudes towards leprosy. This would ultimately contribute to the reduction of leprosy burden in the community.

Correction: The Burden of Leprosy in Cameroon: Fifteen Years into the Post-elimination Era.

[This corrects the article DOI: 10.1371/journal.pntd.0005012.].

The Burden of Leprosy in Cameroon: Fifteen Years into the Post-elimination Era.

BACKGROUND: Cameroon achieved the elimination target of leprosy in 2000, and has maintained this status ever since. However, a number of health districts in the country continue to report significant numbers of leprosy cases. The aim of this study was to assess the burden of leprosy in Cameroon from 2000 to 2014. METHODS: We obtained and analysed using the new leprosy burden concept of analysis, leprosy surveillance data collected between 2000 and 2014 from the National Leprosy Control Programme. PRINCIPAL FINDINGS: Cameroon achieved leprosy elimination in 2000, registering a prevalence rate of 0.94/10,000 population. The prevalence rate dropped further to reach 0.20/10,000 population (78% reduction) in 2014. Similarly, the new case detection rate dropped from 4.88/100,000 population in 2000 to 1.46/100,000 population (85.3% reduction) in 2014. All 10 regions of the country achieved leprosy elimination between 2000 and 2014; however, 10 health districts were still to do so by 2014. The number of high-leprosy-burden regions decreased from 8 in 2000 to 1 in 2014. Seven and two regions were respectively medium and low-burdened at the end of 2014. At the health districts level, 18 remained at the high-leprosy-burdened level in 2014. CONCLUSION: The leprosy prevalence and detection rates as well as the overall leprosy burden in Cameroon have dropped significantly between 2000 and 2014. However, a good number of health districts remain high-leprosy-burdened. The National Leprosy Control Programme should focus efforts on these health districts in the next coming years in order to further reduce the burden of leprosy in the country.

The "Buruli Score": Development of a Multivariable Prediction Model for Diagnosis of Mycobacterium ulcerans Infection in Individuals with Ulcerative Skin Lesions, Akonolinga, Cameroon.

BACKGROUND: Access to laboratory diagnosis can be a challenge for individuals suspected of Buruli Ulcer (BU). Our objective was to develop a clinical score to assist clinicians working in resource-limited settings for BU diagnosis. METHODODOLOGY/PRINCIPAL FINDINGS: Between 2011 and 2013, individuals presenting at Akonolinga District Hospital, Cameroon, were enrolled consecutively. Clinical data were collected prospectively. Based on a latent class model using laboratory test results (ZN, PCR, culture), patients were categorized into high, or low BU likelihood. Variables associated with a high BU likelihood in a multivariate logistic model were included in the Buruli score. Score cut-offs were chosen based on calculated predictive values. Of 325 patients with an ulcerative lesion, 51 (15.7%) had a high BU likelihood. The variables identified for the Buruli score were: characteristic smell (+3 points), yellow color (+2), female gender (+2), undermining (+1), green color (+1), lesion hyposensitivity (+1), pain at rest (-1), size >5cm (-1), locoregional adenopathy (-2), age above 20 up to 40 years (-3), or above 40 (-5). This score had AUC of 0.86 (95%CI 0.82-0.89), indicating good discrimination between infected and non-infected individuals. The cut-off to reasonably exclude BU was set at scores <0 (NPV 96.5%; 95%CI 93.0-98.6). The treatment threshold was set at a cut-off ≥4 (PPV 69.0%; 95%CI 49.2-84.7). Patients with intermediate BU probability needed to be tested by PCR. CONCLUSIONS/SIGNIFICANCE: We developed a decisional algorithm based on a clinical score assessing BU probability. The Buruli score still requires further validation before it can be recommended for wide use.

Buruli Ulcer in Cameroon: The Development and Impact of the National Control Programme.

BACKGROUND: Cameroon is endemic for Buruli ulcer (BU) and organised institutional BU control began in 2002. The objective was to describe the evolution, achievements and challenges of the national BU control programme (NBUCP) and to make suggestions for scaling up the programme. METHODS: We analysed collated data on BU from 2001 to 2014 and reviewed activity reports NBUCP in Cameroon. Case-detection rates and key BU control indicators were calculated and plotted on a time scale to determine trends in performance. A linear regression analysis of BU detection rate from 2005-2014 was done. The regression coefficient was tested statistically for the significance in variation of BU detection rate. PRINCIPAL FINDINGS: In 14 years of BU control, 3700 cases were notified. The BU detection rate dropped significantly from 3.89 to 1.45 per 100 000 inhabitants. The number of BU endemic health districts rose from two to 64. Five BU diagnostic and treatment centres are functional and two more are planned for 2015. The health system has been strengthened and BU research and education has gained more interest in Cameroon. CONCLUSION/SIGNIFICANCE: Although institutional BU control Cameroon only began 30 years after the first cases were reported in 1969, a number of milestones have been attained. These would serve as stepping stones for charting the way forward and improving upon control activities in the country if the major challenge of resource allocation is dealt with.

The spectrum of skin diseases in a rural setting in Cameroon (sub-Saharan Africa).

BACKGROUND: Skin disorders are generally considered to be more prevalent in the rural areas of Cameroon. This study was carried out to verify this assumption by describing the spectrum of skin disorders in a rural setting of Cameroon. METHODS: We carried out a community-based clinical skin examination of 400 consenting subjects from 4 villages of Cameroon: Nyamanga (27%), Yebekolo (24%), Mbangassina (23%) and Bilomo (26%). RESULTS: The overall prevalence of skin diseases in our sample was 62% {95% CI: 57.2%, 66.8%} (248/400). The commonest skin disorders were: fungal infections (25.4%), parasitic infestations (21.4%), atrophic skin disorders (11.7%), hypertrophic skin disorders (9.7%), disorders of skin appendages {acne} (8.9%), benign neoplasm (6.5%), bacterial skin infections (5.2%), pigmentation disorders (4.8%), and dermatitis/eczema (4.0%). Skin infections and infestations constituted 52.82% of all skin disorders. The overall prevalence of infectious and parasitic infestation was 32.75% {95%CI: 28.17%, 37.59%} (131/400) as against 29.25% {95%CI: 24.83%, 33.98%} (117/400) for non-infectious disorders.Among people with skin infections/parasitic infestations, those with fungal infections and onchocercal skin lesions were the most prevalent, accounting for 48.1% (63/131) and 35.1% (46/131); and an overall prevalence of 15.75% {95%CI: 12.3%, 19.7%} (63/400) and 11.5% {95%CI: 8.5%, 15.0%} (46/400) respectively.There was secondary bacterial infection in 12.1% {95%CI: 8.31%, 16.82%} (30/248) of subjects with skin diseases. Hypertrophic and atrophic disorders of the skin were mainly keloids (9.68%), scarification marks (6.05%) and burn scars (5.65%). Skin diseases like dermatitis and eczema (4.03%), malignant tumours and pigmentation disorders were rare in our sample.The proportion of subjects diagnosed with skin disorders after examination (62.8%) was significantly higher than the proportion of 40.8% that declared having skin diseases (p < 0.0001). CONCLUSION: The prevalence of skin diseases in the rural Mbam valley is alarming, dominated by easily treatable or preventable skin infections and their magnitude is highly neglected by the community, contrasting with findings in the urban setting. Similar studies are needed in other ecological/demographic settings of the country in order to construct a better understanding of the epidemiology of skin disorders. This would lead to the development of national policies to improve skin care.

Knowledge and practices relating to malaria in a semi-urban area of Cameroon: choices and sources of antimalarials, self-treatment and resistance.

INTRODUCTION: Malaria is a major public health problem in Sub-Saharan Africa where it kills a child under the age of five every 30 seconds. In Cameroon, malaria accounts for 40-45% of medical consultations, 57% of hospitalization days and 40% of mortality among children below 5 years. Community knowledge and practices can enhance the fight against this disease. The aim of the study was to make a local analysis of the people's knowledge and practices relating to the choice and source of antimalarials, self-medication, malaria dosage and resistance in order to establish behavioural baseline and epidemiological determinants and their implications for malaria control. METHODS: The design was a community-based cross-sectional study in a semi-urban setting. The survey consisted of 253 volunteer participants (from among 350 contacted) from different socio-demographic backgrounds to whom structured questionnaires were administered. The respondent's consent was sought and gained and subjects who could not read or write or understand English language were communicated to in the local language. The questionnaire was administered by trained interviewers according to the schedule of the respondent. The data was analysed using SPSS. RESULTS: Antimalarials commonly cited for malaria treatment were chloroquine (26.1%) and nivaquine (14.6%) and analgesics: panadol (23%) and paracetamol (12.3%) including native drugs (6.3%). 141(55.7%) (95% confidence interval (CI): 49.6-61.8%) participants practiced self-medication of malaria. 26.1% participants knew the correct adult malarial dosage for chloroquine or nivaquine. 125(40.4%) (95% CI: 34.4-46.7%) participants got their antimalarials from health centers, 27(10.6%) from shops, 24(9.5%) from hawkers, 23(9.1%) from the open market and 16 (6.3%) from herbalists. 66 (26.1%) (95% CI: 20.7-31.5%) participants knew the correct adult dosage for chloroquine or nivaquine treatment of malaria. 85(33.6%) (95% CI: 27.8-36.6%) participants had correct knowledge of malarial resistance. Of the 85 (33.6%) participants who had correct knowledge of antimalarial drug resistance, 52(20.6%) ascribed antimalarial drug resistance to continuous fever for a long time during treatment, 15 (5.9%) to serious fever during treatment and 18 (7.1%) when chloroquine does not stop fever. 23(27.1%) participants with correct knowledge of malarial resistance were in the 31-35 age group bracket compared with other age groups (P=0.1). There was a significant difference in correct knowledge of malarial resistance and participant's profession (p=0.0). CONCLUSION: Malaria self-medication is common in Ndu but knowledge of antimalarial drug resistance is poor. Improvement in the self-treatment of malaria could be attained by providing clear information on choices of drugs for malaria treatment. Proper health information on the rational use of ant-malarial drugs must be provided in an appropriate manner to all groups of people in the society including village health workers, women associations, churches, school children, "Mngwah" opinion leaders, herbalists, health workers and chemists. Self-medication should be improved upon by giving correct information on the dosage of malaria treatment on radio, television, posters and newspapers because banning it will push many people to use it in hiding.