Skin wounds in a rural setting of Côte d'Ivoire: Population-based assessment of the burden and clinical epidemiology

Abstract

Background: Data on the burden and clinical epidemiology of skin wounds in rural sub-Saharan Africa is scant. The scale of the problem including preventable progression to chronic wounds, disability and systemic complications is largely unaddressed.

Methods: We conducted a cross-sectional study combining active (household-based survey) and passive case finding (health services-based survey) to determine the burden and clinical epidemiology of wounds within the Taabo Health and Demographic Surveillance System (HDSS) in rural Côte d'Ivoire. Patients identified with wounds received free care and were invited to participate in the wound management study simultaneously carried out in the survey area. The data were analysed for wound prevalence, stratified by wound and patient characteristics.

Results: 3842 HDSS-registered persons were surveyed. Overall wound prevalence derived from combined active and passive case finding was 13.0%. 74.1% (403/544) of patients were below the age of 15 years. Most frequent aetiologies were mechanical trauma (85.3%), furuncles (5.1%), burns (2.9%) and Buruli ulcer (2.2%). Most wounds were acute and smaller than 5 cm2 in size. 22.0% (176/799) of wounds showed evidence of secondary bacterial infection. 35.5% (22/62) of chronic wounds had persisted entirely neglected for years. Buruli ulcer prevalence was 2.3 per 1000 individuals and considerably higher than expected from an annual incidence of 0.01 per 1000 individuals as reported by WHO for Côte d'Ivoire at the time of the study.

Conclusions: Skin wounds are highly prevalent in rural West Africa, where they represent a widely neglected problem. The HDSS-based survey with combined active and passive case finding adopted in this study provides a better estimate than school- and health institution-based surveys which underestimate the frequency of skin wounds and, particularly, of neglected tropical diseases of the skin, such as Buruli ulcer and yaws. A comparison with country-specific WHO data suggests underreporting of Buruli ulcer cases.

Trial registration: Registration at ClinicalTrials.gov NCT03957447.

Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Fig 1. Study flow chart: interaction between household- and health services-based surveys and wound management study.

Patients with wounds were actively (household-based survey) and passively (health services-based survey) identified in Ahondo Health Area which is part of the Taabo Health and Demographic Surveillance System (HDSS) to determine the wound prevalence and the clinical epidemiology of wounds in a rural setting of West Africa. This was combined with an observational wound management study at three health care levels–community, health centre and district hospital–aiming at early identification and treatment of wounds [18]. This approach secured appropriate treatment for all patients identified during the wound surveys. W1 and W2: Training workshops of nurses, assistant nurses, and community health workers (CHW). IC1 and IC2: Informed consent for cross-sectional study and wound management study respectively.

Fig 2. Diagnostic cycle to review presumptive diagnosis and treatment.

Assessment steps leading to either confirmation of a presumptive clinical diagnosis or revision (light blue-coloured boxes). Clinical investigators reviewed selected cases on-site or via mobile phone consultations and performed a systematic review of each case based on clinical data and wound photographs. In case of treatment failure, the cause of treatment failure was analysed and it was decided if the current diagnosis could be maintained, but treatment had to be adapted / reinforced / intensified or the diagnosis and treatment had to be revised. If it deemed indicated additional laboratory investigations and imaging (underlying bone disease—osteomyelitis) were ordered; this was done routinely for the specific presumptive diagnoses BU, tuberculosis, yaws, and osteomyelitis conducted at local facilities, national and international laboratories as appropriate.

Fig 3. Diagnostic criteria and representative images of the main wound aetiologies affecting patients in the study population.

Diagnostic criteria are based on the WHO Manual ‘Recognizing Neglected Tropical Diseases through Changes on the Skin’ (8), and a manual assembled by the project team and provided to the local healthcare personnel at the training workshops. All representative photographs were taken from study patients.

Fig 4. Enrolment of wound events during household- (active case finding) and health services-based survey (passive case finding).

Wound event was defined as an injury (mechanical trauma, burn, etc) or a specific pathology (BU, yaws, etc) leading to one or multiple wounds. Wounds enrolled on the same date and attributed to the same aetiology were considered due to the same wound event. Specific aetiologies, such as BU or yaws, that could lead to multiple wounds over time were considered as a single wound event.

Fig 5

Age distribution by gender of the patient population (A) and of the Ahondo Health Area population (B).