Active Rheumatoid Arthritis in Central Africa: A Comparative Study Between Sudan and Sweden

The burden of rheumatoid arthritis in the Middle East and North Africa region, 1990-2019

Rheumatoid arthritis (RA) is a chronic systemic autoimmune disease. The present study reported the burden of RA in the Middle East and North Africa (MENA) region from 1990 to 2019 by age, sex, and socio-demographic index (SDI). Publicly available data from the Global Burden of Disease (GBD) 2019 study was used to report the modelled point prevalence, annual incidence, and disability-adjusted life-years (DALYs) of RA, as counts and age-standardised rates with their corresponding 95% uncertainty intervals (UIs). In 2019, RA had an age-standardised point prevalence of 120.6 per 100,000 population (107.0-135.7) and an annual incidence rate of 5.9 (5.2-6.6) in MENA, which have increased 28.3% and 25.2%, respectively, since 1990. In 2019, the number of DALYs due to RA in the region was 103.6 thousand (74.2-136.7), with an age-standardised rate of 19.0 (13.9-24.9) DALYs per 100,000 population, which has increased by 18.6% since 1990 (6.7-28.2). The highest point prevalence was found in females aged 50-54, and in males aged 45-49. The highest number of DALYs was observed in the 50-54 age group. The MENA DALY rate was lower than the global rate (19.0 vs. 39.6 per 100,000), but the rate was higher in all age groups in 2019, when compared with 1990. In addition, from 1990 to 2019 an increased burden from RA was associated with an increase in SDI. In line with global trends, the burden of RA in the MENA region showed a steady increase from 1990 to 2019. This highlights the increasing need for updating the available health data to design more accurate guidelines to enable the early detection and treatment of RA in the MENA countries.

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.

Analysis of Serum Immune Markers in Seropositive and Seronegative Rheumatoid Arthritis Among Sudanese Patients and the Relation Between the Serotype and Joint Involvement: A Cohort Study

Introduction

Rheumatoid arthritis (RA) is a chronic autoimmune disease characterized by inflammation of the synovial membrane. RA is classified as seropositive or seronegative, according to the absence or presence of primarily IgM RF, RF, and/or ACPA. The aim of this study is to identify the relationship between the serotype of rheumatoid arthritis and the level of ESR.

Methods and Materials

This is a descriptive, cross-sectional study done in Omdurman military hospital, Khartoum, Sudan. Conducted with 60 patients with RA, data were collected through a designated questionnaire which included demographic, age, gender, duration of the disease, laboratory finding. All the patients in the study were treated with conventional DMARDs and diagnosed according to the 2010 ACR/EULAR criteria; their disease activity status was assessed by DAS28/ESR. Data were analyzed using SPSS version 23.

Results

The study found that 91.7% of the patients were females, patients of age group between 36 and 50 years had the highest percentage at 38.3% followed by those between 51 and 70 years and the least age group between 20 and 35 years, 36.7% and 15%, respectively. Of all the patients 61.7% were found to be SPRA, while the remaining 38.3% were seronegative (SNRA). Altogether 55% of the patients had moderate disease activity, followed by 16.7% who had a remission, 15% had high disease activity and the remaining 13.3% had low disease activity. The metacarpophalangeal (MCP) joint was found to be the only joint that was significantly associated with DAS28 and its involvement was greater among seropositive patients. The most affected joints were found to be shoulders, knees, wrist, MCP, PIP and elbow, in that order.

Conclusion

Females, middle-age group and shoulder joint were the most affected. Most RA was found to be SPRA, and the seropositive group was found to be more associated with high disease activity, while the seronegative group was associated with remission and low disease activity.

Perceptions and Challenges Experienced by African Physicians When Prescribing Methotrexate for Rheumatic Disease: An Exploratory Study

OBJECTIVE

Guidelines for methotrexate (MTX) use in rheumatic disease may not be feasible for physicians practicing in the least developed countries. We aimed to understand the experiences of MTX prescribers relating to MTX use for rheumatic disease in African countries to inform the development of culturally and geographically appropriate recommendations.

METHODS

African physicians who self-identified as MTX prescribers from countries classified as having a low versus a medium or high Human Development Index (L-HDI versus MH-HDI) participated in semistructured interviews between August 2016 and September 2017. Interviews were transcribed verbatim, coded thematically, and stratified by HDI.

RESULTS

Physicians (23 rheumatologists; six internists) from 29 African countries were interviewed (15 L-HDI; 14 MH-HDI). Identified barriers to MTX use included inconsistent MTX supply (reported by 87% L-HDI versus 43% MH-HDI), compounded by financial restrictions (reported by 93% L-HDI versus 64% MH-HDI), patient hesitancy based partly on cultural beliefs and societal roles (reported by 71%), few prescribers (reported by 33%), prevalent infections (especially viral hepatitis, tuberculosis, and human immunodeficiency virus), and both availability and cost of monitoring tests. MTX pretreatment evaluation and starting and maximal doses were similar between L-HDI countries and MH-HDI countries.

CONCLUSION

The challenges of treating rheumatic disease in African countries include unreliable drug availability and cost, limited subspecialists, and patient beliefs. Adapting recommendations for MTX use in the context of prevalent endemic infections; ensuring safe but feasible MTX monitoring strategies, enhanced access to stable drug supply, and specialized rheumatology care; and improving patient education are key to reducing the burden of rheumatic diseases in L-HDI countries.

Association of interleukin-17A rs2275913 polymorphism with rheumatoid arthritis susceptibility in Sudanese population

Objectives:

Rheumatoid arthritis is a chronic inflammatory autoimmune disease. This study aimed to determine the association of interleukin-17A-197G/A polymorphism with rheumatoid arthritis in Sudanese patients.

Methods:

A case–control study was conducted between March and December 2018. Clinical and demographic data of the study participants were collected and analyzed. Polymerase chain reaction restriction fragment length polymorphism molecular technique was done to investigate interleukin-17A-197G/A polymorphisms. All statistical tests were considered statistically significant when p < 0.05.

Results:

The study population included 266 participants aged between 1 and 85 years, with an average of 40 years, classified into 85 (31.2%) cases (mean age 48.5 ± 11.3 years), and 181 (68.8%) controls (mean age 35.3 ± 15.9 years). The interleukin-17A homozygote AA genotype was more frequent among the control group compared to the case group; 95 (52.5%) and 7 (8.2%), respectively. The homozygote GG and the heterozygote AG genotypes were proportionally not different among the cases and control groups; 13 (54.2%) and 11 (45.8%), and 65 (46.4%) and 75 (53.6%), respectively. According to the distribution of interleukin-17A genotypes, a statistically significant difference was observed among cases with the interleukin-17A AA and AG genotypes, p values 0.001 and 0.004, respectively. For the association interleukin-17A genotypes and family history a negatively significant association was reported (95% confidence interval, –0.219, p value = 0.001). There was also a negatively significant association of interleukin-17A genotypes and anti-cyclic citrullinated peptide (95% confidence interval, −0.141, p value = 0.002).

Conclusion:

This study is the first study in Sudan established the association between interleukin-17A-197G/A (rs2275913) polymorphisms and susceptibly to rheumatoid arthritis. These findings appeal for further research in Sudan to investigate the exact role of IL-17A in immunopathology and disease severity among Sudanese rheumatoid arthritis

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.

Sudanese and Swedish patients with systemic lupus erythematosus: immunological and clinical comparisons

Objective

SLE is known to have an aggressive phenotype in black populations, but data from African cohorts are largely lacking. We therefore compared immunological and clinical profiles between Sudanese and Swedish patients using similar tools.

Methods

Consecutive SLE patients from Sudan (n = 115) and Sweden (n = 340) and from 106 Sudanese and 318 Swedish age- and sex-matched controls were included. All patients fulfilled the 1982 ACR classification criteria for SLE. Ten ANA-associated specificities and C1q-binding immune complexes (CICs) were measured. Cut-offs were established based on Sudanese and Swedish controls, respectively. Disease activity was measured with a modified SLEDAI and organ damage with the SLICC Damage Index. In a nested case–control design, Swedish and Sudanese patients were matched for age and disease duration.

Results

Females constituted 95.6% and 88.1% of Sudanese and Swedish patients, respectively (P = 0.02), with younger age at inclusion (33 vs 47.7 years; P < 0.0001) and shorter disease duration (5 vs 14 years; P < 0.0001) among Sudanese patients. Anti-Sm antibodies were more frequent in Sudanese patients, whereas anti-dsDNA, anti-histone and CICs were higher in Swedish patients. In the matched analyses, there was a trend for higher SLEDAI among Swedes. However, Sudanese patients had more damage, solely attributed to high frequencies of cranial/peripheral neuropathy and diabetes.

Conclusion

While anti-Sm is more common in Sudan than in Sweden, the opposite is found for anti-dsDNA. Sudanese patients had higher damage scores, mainly because of neuropathy and diabetes. Sudanese patients were younger, with a shorter SLE duration, possibly indicating a more severe disease course with impact on survival rates.

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.

Occurrence of anti-CCP2 and RF isotypes and their relation to age and disease severity among Sudanese patients with rheumatoid arthritis

OBJECTIVE

Anti-cyclic citrullinated peptide 2 antibodies (anti-CCP2) and rheumatoid factor (RF) in rheumatoid arthritis (RA) has been extensively assessed in industrialized countries. We investigated the diagnostic and prognostic impact of anti-CCP2 and RF isotypes in a Sudanese cross-sectional RA cohort.

METHODS

Consecutive RA patients (n = 281) diagnosed according to the 1987 ACR criteria were included 2008-2010. Anti-CCP2 and RF isotypes (IgA, IgM, and IgG) were measured by enzyme immunoassay in 262 patients, with reference intervals aligned to the same diagnostic specificity as for anti-CCP2 (97.6%) using national controls.

RESULTS

IgA RF was the predominant RA-associated autoantibody (56%), followed by IgM RF and anti-CCP2 (both 52%) and IgG RF (49%). In receiver operator characteristic analysis, IgA RF also showed the largest area under the curve. Patients with IgG RF were younger and had 8 years lower median age of disease onset compared to antibody negative patients (p < 0.0001). IgG RF was the only marker associated with a high number of involved joints (p = 0.028), and together with anti-CCP2 were the strongest markers for finger deformities (p = 0.016 and p = 0.012), respectively. No statistical differences were found for disease duration, ESR and Hb levels, and occurrence of erosions/osteopenia for any of the investigated autoantibodies.

CONCLUSION

Whereas IgA RF showed the best diagnostic performance, IgG RF associated with low age of RA onset, high number of involved joints, and finger deformities. These findings indicate that RA-associated antibodies other than conventional IgM RF and anti-CCP2 might be informative in non-Caucasian RA populations.