Ulcerative Colitis in Low and Lower-Middle Income Countries: A Scoping Review

Introduction: Ulcerative Colitis (UC) is a chronic inflammatory bowel disease that is emerging as a global burden. Due to the lack of disease registries and diagnostic capacity in low and lower-middle-income countries (LLMICs), the epidemiology and care of UC have not been well established in LLMICs. The aim of this study was to determine the burden, diagnostic and treatment capacity, and challenges or barriers to individuals with UC and their providers in LLMICs. Methods: We utilized a full search strategy in PubMed, Embase, and World Health Organization (WHO) Global IndexMedicus for data collection. The titles and abstracts of all the publications were screened and reviewed by two independent reviewers. A descriptive review of the relevant data extracted from the selected publications was analyzed in Excel. Results: A total of 4,601 publications were extracted from the database search and 483 relevant studies were included in this review. Only 24 of all the 82 LLMICs (29.26 %) have published data on individuals with UC. Overall, the highest number of studies came from Iran, followed by India, and Tunisia. The mean number of UC patients reported per study is 139.72 and the median is 60, with a wide range from 1-3232. The reported UC prevalence, incidence, and mortality in the included studies are rare and vary greatly, ranging from 0.1 to 46.7 per 100,000, 0.5 to 23.7 per 100,000, and 0.16% to 1.3% respectively. Of the 483 publications describing cases of UC, 133 proposed at least one diagnostic, management, access, or financial barrier to individuals with UC and providers. Low disease index suspicion leading to under-diagnosis, difficulty differentiating between UC and Crohn’s disease and other infectious causes, and lack of trained personnel, as well as reliable tests, were reported as diagnostic challenges in the studies. The most notable patient barriers were lack of education or knowledge about the disease, lack of access to quality service and UC medications, psychological factors, and religious beliefs. Financial barriers were reported frequently which included the high cost of diagnostic testing and biologics. (Figure) Conclusion: The prevalence of UC is increasing worldwide and this scoping review has highlighted the challenges faced by the patients and providers in LLMICs. In the future, it is imperative for further population-based studies and literature to establish the burden of UC in the world’s most resource-poor- countries where there is a substantial lack of knowledge and underdiagnosis of UC. (Table) Table 1. - Mean and range number of cases of ulcerative colitis reported by each study included in the review, overall, by region, and by low and lower-middle income countries Region/Country Number of studies Total number of cases Mean Median Range Overall 483 68320 139.72 60 1-3232 South Asia Bangladesh 5 241 48.2 12 1-164 India 160 37679 2597.19 64.5 1-3232 Indonesia 2 87 43.5 43.5 1-86 Nepal 9 468 52 2 1-416 Pakistan 17 1560 91.76 54 1-550 Sri Lanka 10 1544 154.4 146.5 16-348 Middle East and North Africa Algeria 3 78 39 39 1-46 Egypt 28 2174 77.64 28 1-896 Iran 170 21676 125 75 1-1914 Morocco 10 418 41.8 32 1-110 Syria 3 3 1 1 0 Tunisia 36 1944 247.8 59 1-202 Sub-Saharan Africa Burkina Faso 1 6 6 6 0 Ethiopia 1 5 5 5 0 Ghana 4 55 13.75 12.5 6-24 Kenya 1 4 4 4 0 Nigeria 14 63 4.5 3 1-20 Sudan 3 101 33.66 16 12-73 Tanzania 1 1 1 1 0 Togo 1 4 4 4 0 Uganda 1 4 4 4 0 Zimbabwe 5 28 5.6 8 1-10 Central Asia Uzbekistan 1 167 167 167 0 Latin America and the Caribbean Bolivia 1 10 10 10 0 Figure 1.: A: Flow diagram depicting number of studies identified and excluded at each stage of the review process B: Map of LLMICs with published and no published cases of ulcerative colitis C: Number of studies by country D: Number of studies by region