[Semiological features and risk factors associated with osteoarthritis of the hip in Ouagadougou (Burkina Faso)]. / Caractéristiques sémiologiques et facteurs de risque associés à la coxarthrose à Ouagadougou (Burkina Faso).

OBJECTIVE: To study the epidemiological and clinical aspects of osteoarthritis (OA) of the hip in Ouagadougou, as well as its risk factors. PATIENTS AND METHODS: This retrospective study covered cases treated over a 3-year period (February 2006 through January 2009) in the internal medicine department of the Yalgado Ouedraogo Teaching Hospital of Ouagadougou (Burkina Faso) and the surgery department of the private hospital Notre-Dame-de la Paix of Ouagadougou. All patients included had OA of the hip that met the Kellgren and Lawrence criteria. RESULTS: There were 46 patients who met the study criteria, but only 40 files could be used. The patients' mean age was 46.4 years ± 15.2 years (range 25-80 years; 10 patients were older than 56 years). Men accounted for more than half (n=23, 57.5%). The mean duration of disease was 6.2 years ± 4.5 years (range: 1-19 years). The right hip alone was concerned in 20 patients (50%), the left hip in 16 (40%), and the OA was bilateral in four (10%). Seventeen patients had sickle cell disease (42.5%), 11 SC and 6 SS. The risk factors included necrosis of the femoral head in 19 cases (59.37%), hip dysplasia in 6 (18.74%), hip trauma in 3 (9.37%), inflammatory arthropathy in 3 more (9.37%), and epiphysitis in one (3.13%). The OA of the hip was primary in 8 cases (20%). Three patients were at stage 1, 9 at stage 2, 15 at stage 3, and 13 at stage 4 according to the Arlet-Ficat classification. CONCLUSION: OA of the hip arises in a young population and is dominated by secondary OA. The dominant risk factor was aseptic necrosis of the femoral head associated with sickle cell disease. In view of the small number of patients with primary OA, no definitive conclusions can be drawn about it.

The impact of user fee removal policies on household out-of-pocket spending: evidence against the inverse equity hypothesis from a population based study in Burkina Faso.

BACKGROUND: User fee removal policies have been extensively evaluated in relation to their impact on access to care, but rarely, and mostly poorly, in relation to their impact on household out-of-pocket (OOP) spending. This paucity of evidence is surprising given that reduction in household economic burden is an explicit aim for such policies. Our study assessed the equity impact on household OOP spending for facility-based delivery of the user fee reduction policy implemented in Burkina Faso since 2007 (i.e., subsidised price set at 900 Communauté Financière Africaine francs (CFA) for all, but free for the poorest). Taking into account the challenges linked to implementing exemption policies, we aimed to test the hypothesis that the user fee reduction policy had favoured the least poor more than the poor. METHODS: We used data from six consecutive rounds (2006-2011) of a household survey conducted in the Nouna Health District. Primary outcomes are the proportion of households being fully exempted (the poorest 20% according to the policy) and the actual level of household OOP spending on facility-based delivery. The estimation of the effects relied on a Heckman selection model. This allowed us to estimate changes in OOP spending across socio-economic strata given changes in service utilisation produced by the policy. FINDINGS: A total of 2,316 women reported a delivery between 2006 and 2011. Average household OOP spending decreased from 3,827 CFA in 2006 to 1,523 in 2011, without significant differences across socio-economic strata, neither in terms of households being fully exempted from payment nor in terms of the amount paid. Payment remained regressive and substantially higher than the stipulated 900 CFA. CONCLUSIONS: The Burkinabè policy led to a significant and sustained reduction in household OOP health spending across all socio-economic groups, but failed to properly target the poorest by ensuring a progressive payment system.

[Connective tissue diseases in hospital practice in Ouagadougou (Burkina Faso)]. / Les connectivites en pratique hospitalière à Ouagadougou (Burkina Faso).

To describe the semiological and immunological features of connective tissue diseases seen at the Yalgado Ouédraogo University Hospital in Ouagadougou. A retrospective study reviewed the records of patients seen in the hospital dermatology and internal medicine departments from January 1, 2004, through December 31, 2009 and diagnosed with systemic lupus erythematosus (SLE), systemic sclerosis (ScS), dermatopolymyositis (DPM), primary Gougerot-Sjögren disease (GS), polymyositis (PM) or indeterminate connective tissue disease (ICTD) meeting the criteria of the American College of Rheumatology. The study included 42 patients, 36 women and 6 men. Their mean age was 41.2 years ±11.97 (range: 15-75). SLE was the diagnosis for 10 patients, ScS for 14, DPM for 7, primary GS for 1, PM for 1, and ICTD for 9. Hematologic (93%), cutaneous (88%), and rheumatologic (81%) abnormalities were the most frequent manifestations. The specific auto-antibodies associated with SLE patients were: anti-native DNA (3/6), anti-Sm (3/6), anti-RNP (3/6), and anti-SSA (4/6); anti-Scl 70 antibodies were present in 5 patients with ScS. Connective tissue diseases seem to be rare in Africa, south of the Sahara. However, the very fragmentary studies and the weak healthcare coverage do not allow any definitive conclusions.

[Amyloidosis in sub-Saharan Africa]. / Les amyloses en Afrique subsaharienne.

Amyloidosis is a protein folding disorder in which normally soluble proteins are deposited extracellularly as insoluble fibrils. When stained with Congo red dye, it produces apple-green birefringence under polarized light. The main amyloid proteins are AL, AA, ATTR and Aß(2)-M. The incidence of amyloidosis in sub-Saharan Africa ranges from 0.28 to 0.57% in autopsy series. Secondary AA amyloidosis is the most frequent, found in 42 to 66% of amyloidoses. Chronic infections, especially tuberculosis, are the main cause. AL amyloidosis is found in 21 to 34% of amyloidosis cases, half of them due to myeloma. Other types of amyloidosis seem rare, but are probably underdiagnosed. The clinical presentation in sub-Saharan Africa is similar to that in Western series. Further experimental and clinical studies will allow a better assessment of the characteristics of amyloidosis in sub-Saharan Africa.

Malnutrition in young children of rural Burkina Faso: comparison of survey data from 1999 with 2009.

OBJECTIVE: For measurement of progress towards the Millennium Development Goal (MDG) 1, reliable data on nutrition indicators of specific countries are essential. Malnutrition is also the main determinant for childhood mortality, which is addressed in MDG 4. METHODS: In the health and demographic surveillance area of Kossi Province in north-western Burkina Faso, nutritional parameters were compared in two cohorts of young children of the same age range from eight villages. Surveys took place in June and December of the year 1999 and 2009. A multivariate model was used to control for confounding variables. RESULTS: For the 1999 study, data were analysed for 179 and 197 children who took part in the June and December survey respectively. In 2009, corresponding data were analysed for 460 and 409 children. Prevalence of underweight was highest in December 1999 (42.6%) and lowest in December 2009 (34.1%). After adjustment for age, sex and village, there was a slight but not always significant improvement in the z-scores of weight-for-age, weight-for-length, length-for-age, and mid-arm circumference over time. CONCLUSIONS: The findings from this study confirm the still unacceptable high prevalence of malnutrition in young children of rural sub-Saharan Africa (SSA). Progress in the reduction of malnutrition remains slow on this continent making it rather unlikely that the corresponding MDGs will be achieved. Large-scale multi-sectoral community-based interventions are urgently needed for a sustainable improvement of child health in SSA.

[Disease-modifying treatment for inflammatory rheumatism in sub-Saharan Africa: outcome at 6 months of 205 Senegalese patients with rheumatoid arthritis]. / Problématique du traitement de fond des rhumatismes inflammatoires en Afrique subsaharienne: évolution à six mois de 205 patients sénégalais atteints de polyarthrite rhumatoïde.

RATIONALE: Few data are available on the treatment of rheumatoid arthritis (RA) in sub-Saharan Africa, where the diagnosis is often substantially delayed. Disease-modifying antirheumatic drugs (DMARDs) are more effective when started early. Biotherapies are not available. Given the socioeconomic constraints in sub-Saharan Africa, treatments must be selected based on locally available resources. The objective of this study was to evaluate outcomes 6 months after initiation of conventional DMARDs in Senegalese patients with RA. METHODS: We retrospectively studied consecutive RA patients seen at the rheumatology outpatient clinic of the Le Dantec Teaching Hospital, Dakar, Senegal, from January 2005 through June 2009. All patients met the ACR criteria for RA. ACR and EULAR response criteria were evaluated 6 months after treatment initiation. RESULTS: The study included 205 patients. Corticosteroids were used in 205 patients, hydroxychloroquine in 190, methotrexate in 137, and sulfasalazine in 11. Combined corticosteroid, methotrexate, and hydroxychloroquine therapy was used in 122 patients and combined corticosteroid and hydroxychloroquine therapy in 63. DMARD treatment was interrupted for at least 5 days per month for 26% of the patients, either because the drugs were out of stock at the local pharmacies and/or because the patients could not afford to purchase them. During the first 6 months of treatment, patients had a mean of 4 clinic visits, and 48% of patients missed at least one scheduled visit. After 6 months, all clinical variables had improved significantly, except the swollen joint count. The ACR20, 50, and 70 response criteria were met in 50%, 31%, and 6.9% of patients, respectively. The EULAR response was good in 53.9% of patients, moderate in 12.7%, and poor in 23.1%. DMARD therapy failed in 10.3% of patients. Half the patients had their treatment modified during the 6-month study period. DMARD therapy was discontinued in 10 patients for the following reasons: plans to become pregnant, n = 5; pregnancy during treatment, n = 2; and tuberculosis, n = 3. CONCLUSION: In Senegal, the treatment of RA relies chiefly on variable combinations of methotrexate, hydroxychloroquine, and corticosteroids. The six-month outcomes are satisfactory. Biotherapy is required in 7% to 10% of patients, a rate that could be decreased by optimizing patient follow-up. The management of chronic inflammatory joint disease couple be improved despite the limited financial resources in sub-Saharan Africa with better physician training and the incorporation of osteoarticular diseases within a vast information and education program for the general population.

[Systemic vasculitis: study of 27 cases in Senegal]. / Vascularites systémiques: 27 observations au Sénégal.

Studies on vasculitis in black Africa are rare. The purpose of this report is to describe a retrospective study of systemic vasculitis managed in the internal medicine, ORL and cardiolology departments of the Aristide le Dantec University Hospital in Dakar, Senegal from 1995 to 2007. A series of 27 cases involving 7 men and 20 women with a mean age of 49 years was compiled. Primary vasculitis included Horton disease in 3 cases, Wegener disease in 2, Takayasu disease in 1, and Buerger disease in 1. Secondary vasculitis included mixed cryoglobulinemia with Gougerot Sjögren syndrome in 7 cases, primary Goujeröt syndrome in 4, rheumatoid arthritis in 3, nodosa periarteritis with hepatitis B in 2, SHARP syndrome in 1, and polymyositis in 1. The remaining two cases involved abdominal periaortitis including one associated with retrosperitoneal fibrosis and tuberculosis and the other with spondylarthropathy. Corticotherapy in combination with anticoagulants, immunosuppressive therapy, and surgery, when necessary, allowed effective management in 24 cases. The findings of this study show that systemic vasculitis can have numerous etiologies and indicate that secondary forms are the most common. Appropriate care modalities are needed to prevent severe outcome in Senegalese hospitals.

A community-based programme to provide prompt and adequate treatment of presumptive malaria in children.

A community-based programme to ensure prompt and adequate treatment of presumptive episodes of clinical malaria in children has been established in a rural province of Burkina Faso. The implementation strategy was based on training a core group of mothers in every village and supplying community health workers with essential antimalarial drugs specially packed in age-specific bags containing a full course of treatment. Drugs were sold under a cost-recovery scheme. The programme was run in 1994 by the national malaria control centre (CNLP), and in 1995 it was developed to the provincial health team (PHT). Knowledge and awareness of malaria increased with the intervention. Drug consumption by age group was compatible with the distribution of disease, and no major problem of misuse emerged. The actual implementation costs of the intervention were US$ 0.06 per child living in the province. An evaluation of the impact of the intervention on the severity of malaria, using routine data from the health information system and taking as an indicator the proportion of malaria cases which were recorded as severe in health centres, was performed. In 1994, when the intervention was implemented on a provincial scale by CNLP, this proportion was lower than the average of the 4 preceding years (3.7% vs. 4.9%). In 1995, when the programme was implemented by the PHT, the proportion of severe cases was lower in health centres achieving a programme coverage of > or = 50% in their catchment area compared with the others (4.2% vs. 6.1%). Our experience shows that a low-cost, community-based intervention aimed at providing children with prompt and adequate treatment of presumptive episodes of clinical malaria is feasible, and suggests that it may lead to a reduction in the morbidity from severe malaria.

PIP: A low-cost, community-based pilot program established in a rural province (Sourou) in Burkina Faso in 1994 by the National Center for Malaria Control successfully provided children 0-5 years of age with prompt, adequate treatment of presumptive episodes of clinical malaria and was devolved to the provincial health team in 1995. In preparation for program implementation, a core group of mothers in every village was trained in diagnostic criteria and community health workers were supplied with essential antimalarial drugs packed in age-specific bags containing a full course of treatment. The drugs were sold under a cost-recovery scheme. During the first year of program implementation (1994), the proportion of malaria cases recorded as severe in health centers (3.7%) was lower than the average of the 4 preceding years (4.9%). In 1995, when the program was implemented locally, the proportion of severe cases was lower in health centers achieving a program coverage of 50% and above in their catchment area (4.2%) than in those with program coverage levels under 50% (6.1%). The proportion of mothers seeking help from anyone in the village (primarily a community health worker) for their child's malaria episode increased from 21% at baseline to 54% at the end of 1995, while use of chloroquine and paracetamol for treatment rose from 25% to 46%. Only brief periods of drug nonavailability occurred in 1994, generally during periods of heavy rainfall. In 1995, when the program was implemented at the provincial level, drugs were available on only 69% of total health center days. The cost of the project was US$0.06 per child living in the province. The sustainability and continued effectiveness of this program depend largely on the availability of drugs at the health center level.