Community-based wound management in a rural setting of Côte d'Ivoire

A versatile, bioengineered skin reconstruction device designed for use in austere environments

Austere environments in which access to medical facilities, medical personnel, or even water and electricity is limited or unavailable pose unique challenges for medical device product design. Currently existing skin substitutes are severely inadequate for the treatment of severe burns, chronic wounds, battlefield injuries, or work-related injuries in resource-limited settings. For such settings, an ideal device should be biocompatible, bioresorbable, promote tissue healing, not require trained medical personnel for deployment and use, and should enable topical drug delivery. As proof of concept for such a device, silk fibroin and an antioxidant hyaluronic acid derivative were chosen as primary constituents. The final formulation was selected to optimize tensile strength while retaining mechanical compliance and protection from reactive oxygen species (ROS). The ultimate tensile strength of the device was 438.0 KPa. Viability of dermal fibroblasts challenged with ROS-generating menadione decreased to 49.7% of control, which was rescued by pre-treatment with the hyaluronic acid derivative to 85.0% of control. The final device formulation was also tested in a standardized, validated, in vitro skin irritation test which revealed no tissue damage or statistical difference from control. Improved topical drug delivery was achieved via an integrated silk fibroin microneedle array and selective device processing to generate crosslinked/through pores. The final device including these features showed a 223% increase in small molecule epidermal permeation relative to the control. Scaffold porosity and microneedle integrity before and after application were confirmed by electron microscopy. Next, the device was designed to be self-adherent to enable deployment without the need of traditional fixation methods. Device tissue adhesive strength (12.0 MPa) was evaluated and shown to be comparable to a commercial adhesive surgical drape (12.9 MPa) and superior to an over-the-counter liquid bandage (4.1 MPa). Finally, the device's wound healing potential was assessed in an in vitro full-thickness skin wound model which showed promising device integration into the tissue and cellular migration into and above the device. Overall, these results suggest that this prototype, specifically designed for use in austere environments, is mechanically robust, is cytocompatible, protects from ROS damage, is self-adherent without traditional fixation methods, and promotes tissue repair.

Perceived water-related risk factors of Buruli ulcer in two villages of south-central Côte d'Ivoire

BACKGROUND

Buruli ulcer, caused by Mycobacterium ulcerans, is a neglected tropical skin disease that is primarily endemic in West and Central Africa, including Côte d'Ivoire. Studies indicate that M. ulcerans infections are caused by contact with an environmental reservoir of the bacteria, governed by specific human biological conditions. Yet, the nature of this reservoir and the exact mode of transmission remain unknown.

METHODOLOGY

To identify ecologic risk factors of Buruli ulcer in south-central Côte d'Ivoire, we pursued a qualitative study matched with geo-referencing inquiry. Embedded in a broader integrated wound management research project, we (i) mapped households and water sources of laboratory confirmed Buruli ulcer cases and (ii) interviewed 12 patients and four health care workers to assess exposure to surface water and to deepen the understanding of perceived transmission pathways.

PRINCIPAL FINDINGS

Water availability, accessibility, and affordability were reported as key determinants for choosing water resources. Furthermore, perceived risks were related to environmental, structural, and individual factors. Despite the presence of improved water sources (e.g., drilled wells), communities heavily relied on unprotected surface water for a multitude of activities. The nearby Bandama River and seasonal waterbodies were frequently used for washing, bathing, and collection of water for drinking and cooking. Many residents also reported to cross the river on a daily basis for agricultural chores, and hence, are exposed to stagnant water during farming activities.

CONCLUSIONS/SIGNIFICANCE

Our study in two Buruli ulcer endemic villages in south-central Côte d'Ivoire revealed a wide range of water-related domestic activities that might expose people to an increased risk of contracting the disease. Environmental, biological, social, and cultural risk factors are closely interlinked and should be considered in future investigations of Buruli ulcer transmission. Active participation of the communities is key to better understand their circumstances to advance research and fight against Buruli ulcer and other neglected tropical diseases.

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

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.

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.

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 were invited to participate in the wound management study simultaneously carried out in the survey area.

We surveyed approximately 4000 HDSS-registered persons and found a high overall wound prevalence (13.0%), predominately in children. Mechanical trauma was the leading cause, followed by furuncles, burns and Buruli ulcer. Most wounds were acute and had a size of less than 5 cm², but a substantial proportion was large, complicated, or chronic, some of the latter persisting neglected for years.

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.