University of South Florida Scholar Commons Anthropology Faculty Publications Anthropology 3-2018 Implementation of a Decentralized Community-based Treatment Program to Improve the Management of Buruli Ulcer in the Ouinhi District of Benin, West Africa Arnaud S. Amoussouhoui Buruli Ulcer Treatment Center Ghislain E. Sopoh University of Abomey Calavi Anita C. Wadagni Buruli Ulcer Treatment Center Roch C. Johnson University of Abomey Calavi Paulin Aoulou Buruli Ulcer Treatment Center See next page for additional authors Follow this and additional works at: https://scholarcommons.usf.edu/ant_facpub Scholar Commons Citation Amoussouhoui, Arnaud S.; Sopoh, Ghislain E.; Wadagni, Anita C.; Johnson, Roch C.; Aoulou, Paulin; Agbo, Inès E.; Houezo, Jean-Gabin; Boyer, Micah; and Nichter, Mark, "Implementation of a Decentralized Community-based Treatment Program to Improve the Management of Buruli Ulcer in the Ouinhi District of Benin, West Africa" (2018). Anthropology Faculty Publications. 28. https://scholarcommons.usf.edu/ant_facpub/28 This Article is brought to you for free and open access by the Anthropology at Scholar Commons. It has been accepted for inclusion in Anthropology Faculty Publications by an authorized administrator of Scholar Commons. For more information, please contact [email protected]. Authors Arnaud S. Amoussouhoui, Ghislain E. Sopoh, Anita C. Wadagni, Roch C. Johnson, Paulin Aoulou, Inès E. Agbo, Jean-Gabin Houezo, Micah Boyer, and Mark Nichter This article is available at Scholar Commons: https://scholarcommons.usf.edu/ant_facpub/28 RESEARCH ARTICLE Implementation of a decentralized community-based treatment program to improve the management of Buruli ulcer in the Ouinhi district of Benin, West Africa Arnaud Setondji Amoussouhoui1, Ghislain Emmanuel Sopoh1,2*, Anita Carolle Wadagni1, Roch Christian Johnson3, Paulin Aoulou1, Inès Elvire Agbo1, Jean-Gabin Houezo4, Micah Boyer5, Mark Nichter6 a1111111111 a1111111111 1 Buruli ulcer Treatment Center, Allada, Benin, 2 Regional Institute of Public Health of Ouidah, University of a1111111111 Abomey Calavi, Atlantique, Benin, 3 Centre Interfacultaire de Formation et de Recherche en Environnement a1111111111 et DeÂveloppement Durable, University of Abomey Calavi, Atlantique, Benin, 4 Program against Buruli ulcer, a1111111111 Health Ministry, Cotonou, Littoral, Benin, 5 Anthropology department, University of South Florida, Tampa, South Florida, United Sates of America, 6 School of Anthropology, University of Arizona, Tucson, Arizona, United States of America * [email protected] OPEN ACCESS Citation: Amoussouhoui AS, Sopoh GE, Wadagni Abstract AC, Johnson RC, Aoulou P, Agbo IE, et al. (2018) Implementation of a decentralized community- Background based treatment program to improve the management of Buruli ulcer in the Ouinhi district of Mycobacterium ulcerans infection, commonly known as Buruli ulcer (BU), is a debilitating Benin, West Africa. PLoS Negl Trop Dis 12(3): neglected tropical disease. Its management remains complex and has three main com- e0006291. https://doi.org/10.1371/journal. ponents: antibiotic treatment combining rifampicin and streptomycin for 56 days, wound pntd.0006291 dressings and skin grafts for large ulcerations, and physical therapy to prevent functional Editor: Gerd Pluschke, Swiss Tropical and Public limitations after care. In Benin, BU patient care is being integrated into the government Health Institute, SWITZERLAND health system. In this paper, we report on an innovative pilot program designed to introduce Received: August 16, 2017 BU decentralization in Ouinhi district, one of Benin's most endemic districts previously Accepted: January 31, 2018 served by centralized hospital-based care. Published: March 12, 2018 Copyright: © 2018 Amoussouhoui et al. This is an Methodology/Principal findings open access article distributed under the terms of We conducted intervention-oriented research implemented in four steps: baseline study, the Creative Commons Attribution License, which training of health district clinical staff, outreach education, outcome and impact assess- permits unrestricted use, distribution, and reproduction in any medium, provided the original ments. Study results demonstrated that early BU lesions (71% of all detected cases) could author and source are credited. be treated in the community following outreach education, and that most of the afflicted Data Availability Statement: Data are saved in a were willing to accept decentralized treatment. Ninety-three percent were successfully public repository of National Program Against treated with antibiotics alone. The impact evaluation found that community confidence in Buruli Ulcer in Benin and of University of Abomey- decentralized BU care was greatly enhanced by clinic staff who came to be seen as having Calavi from Benin. The dataset can be requested to expertise in the care of most chronic wounds. examine the verbatim and opinions of participants, for researchers who meet the criteria for access to confidential data. A data access committee, Conclusions/Significance consisting of Dr. Agossadou Didier ([email protected]), General secretary of This study documents a successful BU outreach and decentralized care program reaching the Ministry of Health and Prof Ouendo Edgar early BU cases not previously treated by a proactive centralized BU program. The pilot PLOS Neglected Tropical Diseases | https://doi.org/10.1371/journal.pntd.0006291 March 12, 2018 1 / 25 Decentralized community-based treatment program for Buruli ulcer in Benin Marius ([email protected]), Coordinator of the program further demonstrates the added value of integrated wound management for NTD Health Science Doctroal can provide this dataset control. upon request. Funding: This study resulted from a project funded by the UBS Optimus Foundation (UBS-OF) (https:// www.ubs.com/microsites/optimus-foundation/en/ home.html). The sponsors have no role and no Author summary influence on the study, including design, data The management of Buruli ulcer (BU) is complex, resulting in high costs to families and collection, analysis, decision to publish or preparation of the manuscript. health systems. Early detection and treatment heals lesions without functional limitations. Decentralization of the management of this disease into the peripheral health system Competing interests: The authors have declared remains a challenge for national control programs. We report here on an innovative pilot that no competing interests exist. intervention of decentralization of the management of BU in one of the most BU-endemic districts in Benin. The intervention was preceded by a culturally sensitive outreach cam- paign, which explained the disease's symptoms and treatment options, and increased self- referral. It also included the treatment of all chronic ulcers free of charge. While serious cases of BU were still referred to the reference hospital for treatment, study results showed that 71% of BU cases could be treated in decentralized care; of these, 93% were success- fully treated without functional limitations with antibiotics alone. The decentralized treat- ment option brought in new cases not previously treated by a proactive centralized BU program, and maintained total patient adherence to treatment protocols, in part through the support of community volunteer groups. The model developed in this pilot study may serve as the foundation and proof of concept for a larger community-based decentralized wound care agenda. Introduction Buruli ulcer (BU) is a debilitating neglected tropical disease caused by Mycobacterium ulcerans. It usually manifests through non-ulcerated lesions such as nodules, plaques, or edema, which may evolve into massive skin ulcerations, joint and bone deterioration if left untreated [1]. Most cases of BU are found in West Africa, and Benin is one of the most endemic countries [2]. Up until 13 years ago, the management of BU was surgical removal of all sites of infection. In 2004, antibiotic treatment was found effective at early stages of the disease (Category I: lesions < 5 cm in diameter; and Category II: lesions between 5 and 15 cm in diameter) [3]. At present, the management of BU has three main components: antibiotic treatment, surgical intervention, and physical therapy. Antibiotic treatment is based on daily oral rifampicin (10 mg/kg) and streptomycin (15 mg/Kg) injection for 56 days, which allows lesions whose diame- ter is less than 10 cm to heal without surgery [4, 5]. Effective antibiotic treatment at early stages thereby reduces wound dressings and avoids skin grafts, which are needed for large ulcera- tions. More advanced cases also require physical therapy to prevent disability, amputation, and functional limitations after care [6]. The National Control Program for Buruli ulcer in Benin supports four reference centers (CDTUBs) located in Allada (Atlantic department), Lalo (Couffo department), Pobè (OueÂme department) and Zangnanando (Zou department) for the detection and treatment of the dis- ease. After five years of implementing a vertical approach to BU control that relied on surgery and hospitalization, BU patient care began being integrated into the government health system in 2004 for all but Category III cases (the most serious cases), which require surgery and are referred to reference centers. PLOS Neglected Tropical Diseases | https://doi.org/10.1371/journal.pntd.0006291 March 12, 2018 2 / 25 Decentralized community-based treatment program for Buruli ulcer in Benin The