Crohn’s disease in low and lower-middle income countries: A scoping review

Table 1 Mean and range number of cases of Crohn’s reported by each study included in the review, overall, by region, and by low and lower-middle income countries

Region/Country	n1	Total cases	Mean	Median	Range
Overall	2201	12725	57.84	22.00	1-980
South Asia	131	8485	64.77	17.00	1-980
India	107	8054	75.27	22.00	1-980
Sri Lanka	10	332	33.20	6.00	1-153
Pakistan	9	82	9.11	3.00	1-52
Nepal	4	16	4.00	2.00	1-11
Bangladesh	1	1	1.00	1.00	1
Middle East and North Africa	67	4165	62.16	39.00	1-226
Tunisia	41	2984	72.78	45.00	1-226
Egypt	18	361	20.06	12.50	1-100
Morocco	7	714	102.00	101.00	68-136
Syria	1	106	106.00	106.00	106
sub-Saharan Africa	16	52	3.25	1.00	1-17
Nigeria	5	15	3.00	1.00	1-8
Sudan	3	23	7.67	8.00	3-12
Ethiopia	2	8	4.00	4.00	1-7
Kenya	2	2	1.00	1.00	1-1
Cameroon	1	1	1.00	1.00	1
Ghana	1	1	1.00	1.00	1
Malawi	1	1	1.00	1.00	1
Uganda	1	1	1.00	1.00	1
East Asia and Pacific	5	15	3.00	8.00	1-6
Indonesia	2	6	3.00	3.00	1-5
Philippines	2	3	1.50	1.50	1-2
Vietnam	1	6	6.00	6.00	6
Latin America and the Caribbean	1	8	8.00	8.00	8
Bolivia	1	8	8.00	8.00	8

¹Higher than actual number of studies due to two multi-country papers reporting cases of Crohn's.

Table 2 Prevalence and incidence of Crohn's disease reported by each study included in the review, by low and lower-middle income countries

Country	Prevalence	Incidence
India	-	3.91 per 100000 (Ng et al[14], 2019)
Sri Lanka	1.2 per 100000 (Niriella et al[19], 2010)	0.52 per 100000 (Ng et al[14], 2019)
	2.33 per 100000 (Kalubowila et al[25], 2018)	0.09 per 100000 (Niriella et al[19], 2010)
Indonesia	-	0.27 per 100000 (Ng et al[14], 2019)
Philippines	-	0.14 per 100000 (Ng et al[14], 2019)

Table 3 Utilization of Crohn’s disease diagnostic and treatment services reported in studies included in the review by region and country¹

Country/ Region	Diagnostics									Medical					Surgical
	Endo-scopy	Path-ology	Radio-logy	Blood Test-ing	Stool Test-ing	Trial of ATT	Surgical/ autopsy diagnosis	Clinical diagnosis only	TB Test-ing	Cortico-steroids	Amino-salicyclates	Immuno-modulators	Biologic agents	Nutritional therapy	Colect-omy	Ost-omy	Small bowel resection	Ileoanal pouch	Stricture-plasty
Overall (n = 216)	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X
South Asia (n = 129)	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X
India (n = 107)	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X		X
Sri Lanka (n = 11)	X	X	X	X	X	X			X	X	X	X	X		X	X	X		X
Pakistan (n = 9)	X	X	X	X	X			X	X	X	X	X	X		X	X
Nepal (n = 3)	X	X	X	X			X	X		X		X	X		X		X
Bangladesh (n = 2)		X	X		X			X	X
Middle East and North Africa (n = 67)	X	X	X	X	X		X		X	X	X	X	X	X	X		X	X	X
Tunisia (n = 41)	X	X	X	X	X		X		X	X	X	X	X		X		X	X	X
Egypt (n = 18)	X	X	X	X	X		X		X	X	X	X	X	X	X		X
Morocco (n = 7)	X	X	X	X	X
sub-Saharan Africa (n = 16)	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X	X
Nigeria (n = 5)	X	X	X	X	X			X		X	X						X
Sudan (n = 3)	X	X	X	X	X		X		X	X	X
Ethiopia (n = 2)	X	X	X	X	X	X	X			X	X				X		X
Kenya (n = 2)	X	X
Uganda (n = 1)		X		X	X		X										X
Ghana (n = 1)	X	X	X	X	X
Cameroon (n = 1)	X		X	X					X		X	X				X
Malawi (n = 1)	X	X	X	X	X	X				X		X		X
East Asia and Pacific (n = 5)	X	X	X							X	X				X		X
Indonesia (n = 3)	X	X	X								X						X
Philippines (n = 2)	X									X	X
Vietnam (n = 1)	X	X													X

“X” indicates countries with at least one study describing the use of each service – see Supplementary Table 4 for number of studies reporting each service. ¹Studies from Bolivia and Syria did not report on diagnostic or treatment services availability.

Table 4 Most frequently reported diagnostic, management, access, and financial challenges and barriers to Crohn’s patients and providers in low and lower-middle income countries

Provider diagnostic challenges	Number of countries	Number of studies
Difficulty differentiating between Crohn’s and ITB	10	36
Low disease index of suspicion/clinical awareness due to perceived rarity of Crohn’s leads to underdiagnosis	8	17
Lack of quality diagnostic facilities and investigational modalities	8	14
Difficulty differentiating between Crohn’s and other infectious diseases	7	16
Difficulty differentiating between Crohn’s and UC	5	7
Diagnosis of Crohn’s made on histological exam of resected colon	2	3
Lack of reliable TB testing modalities	2	2
Provider Management Challenges
Use of biologics is limited due to cost	1	3
High risk of TB infection reactivation in patients treated with biologics	1	1
Patient Access Barriers
Lack of access to high quality health care services	4	9
Lack of education/knowledge about disease	3	3
Lack of access to Crohn’s medications	1	1
Patient Financial Barriers
Patients unable to afford treatment in general (medications and surgeries)	6	9
High cost of diagnostic testing	3	4
Lack of insurance coverage	2	4
Patients unable to afford biologics	1	3

ITB: Intestinal tuberculosis; TB: Tuberculosis; UC: Ulcerative colitis.