S0835 Crohn’s Disease Among the Poorest Billion: Survey Data From Low and Lower Middle-Income Countries

Abstract

INTRODUCTION: While Crohn’s Disease has been studied extensively in high-income countries, its epidemiology and care in low and lower-middle income countries (LLMICs) is not well established due to a lack of disease registries and diagnostic capacity. This study aims to understand how IBD and Crohn’s impacts the world’s poorest. METHODS: We conducted a cross-sectional survey of gastroenterology providers in countries where the poorest billion live to determine the state of diagnostic and treatment capacity for Crohn’s in LLMICs. Quantitative data was analyzed in R and Excel. RESULTS: Of the 84 providers who expressed interest and were sent the survey link, a total of 46 survey responses from 15 countries were included, giving a response rate of 54.8% (Figure 1). The mean number of patients diagnosed with Crohn’s cared for in the last year was 89.5 overall and varied widely from 0 reported at one facility in Rwanda, to 1,000 reported at two different facilities in India (Table 1). Overall, Crohn’s disease made up 20.6% of the IBD diagnoses reported by survey respondents, with Africa having a larger proportion of Crohn’s compared to ulcerative colitis (UC) than Asia. Most of the providers reported that patients with Crohn’s typically have symptoms for between 6 and 24 months prior to diagnosis and that 26–50% of their patients live in rural areas. The most commonly reported diagnostic challenge is differentiating between Crohn’s and intestinal tuberculosis where it was reported by 70.5% of providers (Figure 2A). Gastroenterologists in Africa struggle with poor Crohn’s disease awareness among providers (47.7%) and lack of trained pathologists (36.4%). First- line Crohn’s medications and IBD surgeries like colectomy and small bowel resection are widely available while the availability of more advanced surgeries and medications is much more variable. The most widely reported challenge in managing Crohn’s disease is patients’ inability to afford biologics, reported by 65% of providers (Figure 2B). CONCLUSION: There appears to be a greater burden of Crohn’s disease in LLMICs than is indicated in the literature. While it appears that most Crohn’s patients are from urban areas as is described in the literature, there does appear to be a signal of Crohn’s in rural areas. Respondents reported many challenges in diagnosing and treating Crohn’s disease, including differentiating it from intestinal TB, poor awareness among providers, and patients’ inability to afford diagnostic testing and treatments like biologics.Figure 1.: Number of survey responses from each LLMIC included in the analysis (A); Number of gastroenterologists and endoscopy centers in each country as reported by survey respondents (B).Table 1.: Mean and range number of patients diagnosed with IBD and Crohn’s cared for in the last year, and percentage of IBD that is diagnosed as Crohn’s, reported overall, by region, and by countryFigure 2.: Challenges faced by providers in diagnosing Crohn’s disease, across all LLMICs (A); Challenges faced by providers in managing Crohn’s disease, across all LLMICs (B).