Epidemiology: The challenge of practicing rheumatology in Africa

Exploring paediatric rheumatology care: a ten-year retrospective analysis of the patient population in Ghana

BACKGROUND

Rheumatic diseases can seriously impact children's general health, development, and growth. However, due to a lack of resources, paediatric rheumatology is a largely underdeveloped speciality in many African nations. Children with rheumatic disorders face obstacles in accessing specialized medical care, including lack of specialists, care centres, medication access, and limited research and education to increase understanding of paediatric rheumatic disease among healthcare practitioners. This study described the disease characteristics, prevalence, and challenges faced by paediatric rheumatic disease patients receiving care at a teaching hospital in Accra, Ghana.

METHODS

A retrospective record-based study was conducted among all paediatric cases presenting to the rheumatology clinic of the Korle Bu Teaching Hospital (KBTH) from January 2011 to December 2021. Data collected include clinical features, laboratory findings at disease presentation, andtherapeutic regimens prescribed per standard guidelines and experiences.

RESULTS

A total of 121 cases were identified as of 2021, indicating a point prevalence of 0.0011%. The majority (73%) were females with a mean age of 13.4 ± 3.2 years. The mean duration of symptoms in months experienced by patients before being successfully referred to a rheumatologist was 18 months. There were significant differences between referred and confirmed diagnoses, especially in cases involving mixed connective tissue diseases (MCTD), systemic lupus erythematosus (SLE), and juvenile dermatomyositis (JDM), suggesting that these conditions may be under-recognised. Arthralgia and arthritis were the most common presenting symptoms. More than three-quarters (86.8%) of the cases studied were treated with steroids (oral or intravenous). In cases requiring immunosuppressive therapy, methotrexate was the most commonly prescribed in 33.9% of instances. Mortality was recorded at 8.3%, with the majority involving SLE cases. Most (95.7%) of the primary caregivers expressed positive experiences regarding care received at the adult rheumatology clinic.

CONCLUSION

There were significant delays in diagnosis and diagnostic accuracy for patients with paediatric rheumatic disease (PRD). This highlights the pressing need for strengthening paediatric rheumatology services in Africa, including increasing awareness about these conditions among the public and healthcare providers to improve early diagnosis and quality of life for children with these conditions.

The outlook of rheumatological care in Africa: Current state, challenges, and recommendation

There is a gross lack of access to rheumatological access in Africa. For example, the most populous country in the continent, Nigeria, has just 30 rheumatologists serving a population of about 200 million. In Ghana, there are just 2 rheumatologists serving a population of about 28 million people. Unfortunately, the prevalence of rheumatologic and musculoskeletal diseases is on the rise in Africa. The main issues facing rheumatologic care in Africa are inadequate health professionals, inadequate research, and a weak health system. These factors have hindered the progress of rheumatologic care and treatment in the region. Prompt action must be taken in tackling these effects and to achieve better care for rheumatologic patients in Africa. This paper analyzes carefully the current state of rheumatologic care in Africa, identifying the needs for rheumatologic care, determinants of quality of rheumatologic care delivery, and the challenges currently facing rheumatology care in Africa. Also, this review gives some recommendations on ways by which the existing system of rheumatologic care in Africa can be improved.

Rheumatic diseases in Africa

Historically, rheumatic diseases have not received much attention in Africa, particularly in sub-Saharan Africa, possibly owing to a focus on the overwhelming incidence of infectious diseases and the decreased life span of the general population in this region. Global attention and support, together with better health policies and planning, have improved outcomes for many infectious diseases; thus, increasing attention is being turned to chronic non-communicable diseases. Rheumatic diseases were previously considered to be rare among Africans but there is now a growing interest in these conditions, particularly as the number of rheumatologists on the continent increases. This interest has resulted in a growing number of publications from Africa on the more commonly encountered rheumatic diseases, as well as case reports of rare diseases. Despite the limited amount of available data, some aspects of the epidemiology, genetics and clinical and laboratory features of rheumatic diseases in African populations are known, as is some detail on the use of therapeutics. Similarities and differences in these conditions can be seen across the multi-ethnic and genetically diverse African continent, and it is hoped that increased awareness of rheumatic diseases in Africa will lead to earlier diagnosis and better outcomes for patients.

The prevalence of rheumatic diseases is increasing in African countries, leading to an increased need for specialist rheumatologists and disease-modifying drugs. In this Review, the authors outline what is currently known about the state of rheumatic diseases in Africa.

In the past, there has been an emphasis on communicable diseases in Africa, but attention has now shifted towards non-communicable diseases such as rheumatic diseases.

Common rheumatic diseases are seen in Africa and are both comparable and different from presentations seen outside of Africa.

Diverse genetic and environmental factors affect the presentation of common rheumatic diseases among different African nations.

A shortage of appropriately trained staff, laboratory testing capacity and effective medications exists across the whole continent.

Advocacy and research are needed to increase awareness of the risk factors, presentations and management of rheumatic diseases in Africa.

Specialized treatment guidelines are needed for resource-poor countries in Africa.

The management of gout in Africa: challenges and opportunities

The rise in non-communicable diseases in Africa presents challenges for health systems that are burdened by infectious diseases. Gout is one of those diseases that has seen an increase in numbers worldwide, including Africa. Gout is commonly associated with comorbidities and mortality. It directly impacts the quality of life, increases health costs, decreases physical function, and significantly increases the time from work, much of which is potentially avoided if treatment is instituted early. Despite advances in understanding the pathophysiology and outcomes of gout, the quality of care delivered to patients in Africa is still suboptimal. Existing data on gout in Africa reveals a general low index of suspicion due to limited knowledge of the disease by healthcare workers resulting in late diagnosis, with severe polyarticular tophaceous gout being a common presenting feature. These late presentations are associated with avoidable disability and increase the direct and indirect costs of managing gout. The challenges are related to lack of government budgetary support for staff training, infrastructure for diagnosis, and availing medicines. The picture of gout in Africa largely mirrors the west concerning risk factors, comorbidities, and burden of disease, but with some unique presentations seen in HIV, sickle cell disease, and vertigo. We discuss the challenges of gout diagnosis and management in Africa and propose a roadmap to improve gout outcomes across Africa.

Rheumatology care of migrants from sub-Saharan Africa: a literature review and qualitative pilot study of patients' perspectives

INTRODUCTION

Rheumatologists practising in the UK National Health Service (NHS) are likely to treat migrant patients from sub-Saharan Africa. This study aimed to conduct a literature review about rheumatoid arthritis prevalence in Africa and understand the experiences of patients with rheumatological conditions, about their past healthcare in sub-Saharan Africa and their transition of care to the United Kingdom (UK).

METHODS

A systematic search and a pilot study using semi-structured interviews to gain the views of migrants from sub-Saharan Africa with rheumatological conditions was conducted.

RESULTS

Thirty-two studies reported on the prevalence of rheumatoid arthritis in Africa. Studies were small and out-of-date, and there was significant heterogeneity in prevalence rates. For the qualitative study, seven participants were recruited. Four themes were highlighted: (i) the physical and emotional impact of rheumatological conditions on participants; (ii) limited rheumatology care in sub-Saharan Africa with high costs, limited access to specialists, lack of investigations and treatments, the use of traditional medicines and poor communication by clinicians; (iii) barriers to rheumatology care in the UK such as migrants' poor understanding of rheumatological conditions and NHS entitlements; (iv) and ways to improve access to care such as patient, public and general practitioner education.

CONCLUSION

This study has highlighted the paucity of rheumatoid arthritis prevalence data in Africa and described, for the first time, the migrant's perspective of rheumatology care in sub-Saharan Africa and the transition of care to the UK. This description begins to allow healthcare providers in the UK to tailor management for this migrant population. Key Points • Rheumatological conditions are common in Africa, but there is a paucity of epidemiological data regarding the prevalence of specific conditions such as rheumatoid arthritis. • UK clinicians need to be mindful when treating migrants that access to rheumatologists and specialist investigations and treatment is limited in sub-Saharan Africa and that there is often limited public and patient understanding of rheumatological conditions. • Migrants continue to lack understanding of their NHS entitlements and fear data sharing with immigration services which can be a barrier to seeking care. • This study has exposed the lack of understanding about rheumatological conditions by the public and some general practitioners which needs to be addressed with effective education and awareness campaigns.