aOverall skin biopsy availability defined as having all other equipment listed in this Figure.
Customize your JAMA Network experience by selecting one or more topics from the list below.
Identify all potential conflicts of interest that might be relevant to your comment.
Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.
Err on the side of full disclosure.
If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.
Not all submitted comments are published. Please see our commenting policy for details.
McMahon DE, Laker-Oketta M, Peters GA, McMahon PW, Oyesiku L, Freeman EE. Skin Biopsy Equipment Availability Across 7 Low-Income Countries: A Cross-Sectional Study of 6053 Health Facilities. JAMA Dermatol. 2021;157(4):462–464. doi:10.1001/jamadermatol.2020.5851
In low-income countries (LICs, World Bank Gross National Income per capita of ≤$1035) skin biopsy is essential for many dermatologic diagnoses, including cutaneous malignant abnormalities and infections.1 However, across LICs patients often have limited access to skin biopsy.1,2 In many resource-limited facilities, punch and shave biopsy equipment is not routinely available.2,3 Our prior work in sub-Saharan Africa showed that patients often forgo biopsy or require larger wedge or excisional biopsy, usually performed by a surgeon.2,3 These surgical skin biopsies can be done with low-cost equipment such as a scalpel and sutures, which have been designated by the World Health Organization as essential.4 Given the importance of skin biopsy for diagnosis of diseases requiring clinicopathologic correlation,1,2,5 we aimed to characterize availability of skin biopsy equipment using nationally representative facility data across 7 LICs.
We used public data from the service provision assessment (SPA), a cross-sectional health facility survey conducted by the Demographic and Health Survey (DHS) program. The SPA used nationally representative cluster randomized samples of health facilities and in some cases near census sampling (eMethods in the Supplement). Inclusion criteria were (1) most recent SPA survey conducted after 2012 and (2) facilities queried about minor surgical services.
Facility assessment was based on standardized DHS questionnaires implemented by trained interviewers. Skin biopsy equipment was considered available if the interviewer marked it as both present and functional. We defined minimum necessary equipment for safe skin biopsy as hand-wash (soap plus running water or hand sanitizer), skin disinfectant, lidocaine, disposable needle/syringe, scalpel blade, surgical scissors, needle holder, nonabsorbable sutures, and sharps container. Analysis including multivariable logistic regression for determinants of biopsy availability was performed in Stata statistical software (version 16, STATA Corp). All study sites had institutional review board approvals that permitted collection of site-level data for the study. The Harvard Medical School institutional review board determined this site-level data exempt from review.
Our analysis included 6053 health facilities from 7 LICs, including 977 in Malawi (16.0%), 1188 in Tanzania (20.0%), 963 in Nepal (16.0%), 396 in Senegal (6.5%), 1380 in the Democratic Republic of the Congo (23.0%), 1007 in Haiti (17.0%), and 142 in Afghanistan (2.3%) (Table). Surgical skin biopsy equipment was available at 1437 sites (24.0%), including at 640 of 1367 hospitals (47.0%), 400 of 1957 health centers (20.0%), and 395 of 2677 clinics/dispensaries (15.0%) (Figure). Minor surgical procedures were available free of charge at 227 of 3554 (6.4%) public/governmental sites, 31 of 1732 (1.8%) of private sites, and 16 of 767 nongovernmental sites (2.1%) of nongovernmental sites; however, the cost of specific equipment was not queried.
When adjusted for country and facility sector, hospitals (AOR, 4.6; 95% CI, 4.0-5.4; P < .001) and health centers (adjusted odds ratio [AOR], 1.8; 95% CI, 1.5-2.1; P < .001) had higher odds of biopsy availability compared with clinics/dispensaries. In addition, irrespective of country or facility level, nongovernmental facilities (AOR, 2.4; 95% CI, 2.0-3.0; P < .001) and private facilities (AOR, 1.7; 95% CI, 1.4-1.9; P < .001) had higher odds of skin biopsy availability compared with public facilities.
Skin biopsy equipment had low availability at health facilities sampled across 7 LICs, with decreased availability at lower-level health facilities and in the public sector. Fewer facilities offered minor surgical procedures free of cost, further limiting biopsy access. It is important to contextualize the low availability of skin biopsy equipment in the full care cascade needed to perform a biopsy and make a diagnosis. This cascade includes steps beyond the availability of biopsy equipment such as access to trained clinicians to perform the biopsy and evaluate histopathology. Our inability to measure staffing and histopathologic services more generally likely caused us to greatly overestimate skin biopsy availability; prior work has shown limited dermatology and pathology resources in LICs.5 Future work is needed to measure staff availability, histopathology services, consistency of equipment, and cost of biopsy/histopathologic analysis.2,3 Another limitation is that the availability of other biopsy equipment (eg, punch biopsies or razor blades) was not assessed. However, punch biopsies are a minority of skin biopsies performed in many LICs.1-3 However, punch biopsies are a minority of skin biopsies performed in LICs, despite efforts to improve access. Investments in skin biopsy and histopathologic capacity as well as innovations in point-of-care diagnostics to supplement traditional biopsy/histopathologic anlysis are warranted in LICs.6
Accepted for Publication: December 29, 2020.
Published Online: February 17, 2021. doi:10.1001/jamadermatol.2020.5851
Corresponding Author: Esther E. Freeman, MD, PhD, Department of Dermatology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114 (email@example.com).
Author Contributions: Ms D. McMahon and Dr Freeman had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: D. McMahon, Laker-Oketta, Freeman.
Acquisition, analysis, or interpretation of data: D. McMahon, Peters, P. McMahon, Oyesiku.
Drafting of the manuscript: D. McMahon, Freeman.
Critical revision of the manuscript for important intellectual content: Laker-Oketta, Peters, P. McMahon, Oyesiku, Freeman.
Statistical analysis: D. McMahon, Peters, P. McMahon, Freeman.
Administrative, technical, or material support: Freeman.
Conflict of Interest Disclosures: None reported.
Funding/Support: Dr Freeman’s time was supported by the National Institutes of Health (K23 AI136579).
Role of the Funder/Sponsor: The National Institutes of Health had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.