Integrated approach in the management of skin NTDs: Situational analysis of the integrated screening campaigns of skin diseases (leprosy, Buruli ulcer and yaws) in three health districts of Côte d’Ivoire

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 an effective and efficient control, the WHO recommends to affected countries the implementation of 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 three skin NTDs. 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. It 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. were diagnosed on the basis of the clinical lesions by specialist nurses with proven experience in leprosy control.


Results
In total, 2310 persons were screened with skin diseases. Among them, 07 cases were diagnosed as 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 detected, as well as follow up of detected 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 a staff capacity building and a minimal care of the detected patients.

Background
As defined by the WHO, Neglected Tropical Diseases (NTDs) currently include 20 prevalent communicable diseases in tropical and subtropical areas. These diseases affect more than a billion people in poor rural communities with limited access to health care [1]. The National Programme for the Elimination of Leprosy; The National Programme for Buruli Ulcer Control; There is no specific programme for yaws eradication. Yaws management, as per of other skin diseases, falls into the general health system. 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 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.  Table   1. It resulted from the SWOT analysis that the integration of activities is possible and benefit from the current national interest in the management of NTDs and the commitment of the partners. The human resources are available and will be able to take care of some of the common skin diseases in their health zone, provided that they benefit from capacity building and availability of necessary consumables for the care and follow-up of the detected patients. However, the increased workload resulting from the implementation of this approach, requiring front line health workers to examine and test all skin lesions could be a major threat (Table 2).   [19,20] as in Malawi [21].
Apart from the skin NTD, many others of skin diseases (97.75%) were detected and treated. This confirms one of the results of Msyamboza et al, who also noticed that the actors involved in the management of leprosy had acquired the ability to detect many other skin diseases [21]. In addition,to kick off the series of campaigns, the nurses in the targeted health areas, who were already experienced in the management BU and leprosy and were available, benefited from capacity building. This theoretically made them better equipped to diagnose and take care of other skin conditions. The effect of this activity could be measured through their active and operational involvement during the mobile consultation sessions. These health professionals were able to accurately identify and adequately manage various skin diseases as indicated in the results of our study. For example, only 7 cases were referred to a higher level for better care. Those were mainly chronic wounds of various etiologies as well as some cases of yaws or dermatomycosis.
Eight cases of yaws detected by the nurses and confirmed positive by the rapid test during the last campaign give evidence to the quality of the diagnosis.
What is the degree of ownership of this integrated approach by the different actors in where it does not always have easy access to the health system [15].
In addition to health professionals, community health workers were trained in the recognition of suspicious cases and in social mobilization. It is certainly difficult to assess the impact of these sessions on the behavioral changes of the population; we however know that the presence of children (50%) and women (45%) is linked to sensitization sessions (these two categories are the most vulnerable to and the most affected by NTDs).
According to the WHO, "many neglected tropical diseases affect women and children disproportionately. Those living in remote areas are the most vulnerable to infections and to their biological and socio-cultural consequences." It should be noted however that implementation requires the mobilization of human resources but also the analysis and definition of the package of activities to be carried out, as recommended by Mitjà et al [14]. As a matter of fact, the campaigns we conducted in Côte d'Ivoire took into account that recommendation by including sensitization, screening and patient care in our package. The logistical assets and the necessary drugs and inputs were mobilized. Moreover the majority of screened cases were taken care of within the community. Subsequently, the follow-up of these cases was carried out by the nurses in the peripheral health centers. The other constraint that must be resolved to ensure the sustainability of this integrated approach is the free accessibility or at least the affordability of drugs for other diseases similar to BU and leprosy. Most dermatological drugs are on the list of essential drugs in Côte d'Ivoire but are not available in first-contact facilities. Patients will only come when they have easy access to medications. Financial accessibility makes it easy to access health care and allows better management of the disease, through the use of health facilities from the earliest symptoms of illness and the availability of medications [26].
Some cases of diagnostic difficulties by nurses were noted; such cases were few. For example, the two cases of neurofibromatosis were diagnosed by supervising physicians and were referred for treatment. To deal with such cases, it is necessary to provide the support of a dermatologist or of a nurse specialized in dermatology and leprosy during these interventions. Teledermatology consultations with determatologist is also an alternative. Whatsapp is a possible solution.

Conclusions
Our study based on the implementation of the integrated approach in the management of NTDs took place in 3 districts in Côte d'Ivoire. The results of this study show that the integration of activities is possible given the national interest in the control of NTDs and the commitment of the partners. The human resources are available and will be able to take care of some of the common skin diseases in their health area. It is essential that these human resources benefit from capacity building and that they have the necessary equipment for the care and follow-up of the patients detected, including those with other dermatoses.

Declarations
Ethics approval and consent to participate Technical notes about the activities were sent to the higher-ranking ministerial authorities in charge of health and public hygiene in Côte d'Ivoire. The regional and departmental health authorities were involved in the campaigns. The rural populations concerned were sensitized and freely agreed to participate in the study and present their health problem.
During the consultations, the privacy of the patients was respected.
Informed consent was obtained orally from all adult participants and from parents, caretakers, or legal representatives of participants aged ≤18 years after obtaining their assessment. Verbal informed consent was necessitated given for the need to provide more details about the study in local languages. The use of verbal informed consent was approved by the institutional review board of the Ministry of Health and Public Hygiene.
Verbal informed consent was documented in a register as "verbal informed consent given: yes or no".
Data were processed with strict respect for confidentiality and anonymity.