This retrospective study was to identify some challenges in the treatment of Buruli ulcer BU and present a proposed treatment regime. Materials and Methods. Information from patients medical records, hospital database, and follow-up findings on BU treatment procedures from to and from to at three research sites in Ghana were reviewed to determine the treatment challenges encountered. Data needed were recorded and analyzed, and results presented using SPSS version A total of BU patients information was selected for the study.

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Buruli ulcer BU is a skin disease caused by Mycobacterium ulcerans. Its exact mode of transmission is not known. Previous studies have identified demographic, socio-economic, health and hygiene as well as environment related risk factors. We conducted a case control study. A structured questionnaire on host, demographic, environmental, and behavioural factors was administered to participants.

A total of cases and community controls were interviewed. This study identified the presence of wetland, insect bites in water, use of adhesive when injured, and washing in the river as risk factors for BU; and covering limbs during farming as well as use of alcohol after insect bites as protective factors against BU in Ghana.

Until paths of transmission are unraveled, control strategies in BU endemic areas should focus on these known risk factors. Mycobacterium ulcerans is the causative agent of Buruli ulcer BU which affects the skin, can lead to extensive ulceration, and often results in disabilities. The exact mode of transmission of the disease is still unknown. Previous studies have identified demographic, socio-economic, health and hygiene, as well as environment, related risk factors for BU.

This case-control study was done to ascertain the risk factors in a study area in Ghana which was previously non-endemic for BU. This study found presence of wetland, insect bites in water, use of adhesive when injured, and washing in the Densu river as risk factors associated with BU. These factors were similar to previous studies and hence should be used in the implementation of national BU control strategies.

Editor: Richard O. This is an open-access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests: All authors declare that they have no competing interests.

Buruli ulcer BU is a chronic debilitating skin disease caused by Mycobacterium ulcerans [1] , [2]. BU depicts the third and second most common mycobacterial disease, globally and in Ghana, respectively [3] , [4]. Currently, BU has been reported in over 30 countries in four continents [1] , [2] , [5] , [6] but West Africa is the region most affected [1] , [6]. The first case of BU in Ghana was reported in by Barley [7] , [8] , and ever since over communities have reported cases.

Amofah et al found the highest prevalence rate of Jacobsen and Padgett systematically reviewed extensive epidemiological studies done to identify risk factors associated with M. The commonly reported risk factors associated with BU were slow flowing or stagnant water [4] , [10] — [13] , wading [14] , [15] or washing clothes in swampy areas of slow flowing waters [16] , and the use of short clothes during farming [15] , [16].

Merritt et. Other risk factors reported were close proximity to human disturbed aquatic habitats [6] , the use of unprotected water from swamps [17] and rivers [4] , [7] , and agricultural land use [18].

Reduced risk for BU, however was associated with the use of protected water sources in some settings [14] , [17] as well as hygienic practices such as use of soap for bathing, use of alcohol to clean wounds, or injured sites and proper wound care [4] , [14] , [15]. Researchers in Amansie West District of Ghana demonstrated spatial relationship between BU prevalence and the immunosuppressant arsenic [13]. With regard to the role of insect bites in the transmission of M. Series of studies demonstrated mosquitoes and water bugs to carry M.

Australian studies showed association of mosquito related risk factors with BU [26] , [27] , and experimental infection of mice bitten by infected water bugs in laboratory provided evidence to support their involvement [21] , [28]. The argument for mosquitoes as vectors gained more ground when the use of bed nets was found to reduce the risk of BU [4] , [15] , [29]. Children aged less than fifteen years are overrepresented compared to adults albeit any age can be affected [6] , [7] , [30] , [31].

Even though such risk factors have been identified, the exact mechanism by which humans contract BU in or near aquatic habitats is still not known. It has been hypothesized that M. Without knowing the exact mode of transmission, the only recommendations to effectively prevent and control BU should be based on the currently known risk factors. Here, we conducted a case control study to identify the risk factors for BU in these previously non-endemic districts.

A probable case was defined as any person aged 2 years or more who resided in either the SKC or AS District presenting with active BU and clinically diagnosed between May to December by trained and specialized health professionals. A confirmed case was defined as a probable case with evidence of M.

Information was provided to all members of the various communities and subsequently individually to the participants. Enrollment into the study was voluntary.

All adult subjects provided written informed consent and a parent or guardian of any child participant provided written informed consent on their behalf. The approval was renewed yearly during the period of the study. We used the power calculation tool Epi Info software version 3. We set alpha to 0. The minimum of the odds ratio OR for the association between cases and controls was set at 2. We obtained a sample size of participants, made up of cases and controls.

The research team was introduced to the head of the community, opinion leaders and solicited their cooperation on the research being carried out. Research assistants administered standardized questionnaires that covered issues on demography age, gender, place of residence, marital status, occupation, and educational status , and behavioral activities swimming, wading, fishing, wearing of protective clothing and personal hygiene.

All questions were closed-ended and the questionnaires were verbally administered in English or the local language, Twi. Wound swabs from ulcers and fine needle aspirates from nodules were used for laboratory confirmation.

BU was the dependent variable and demographic, host related, environmental and behavioural factors as the independent variables. Significance level was set at a p-value less than 0.

The variables in the final model were retained after a step-by-step backward elimination using multiple conditional logistic regression. A total of probable BU patients were enrolled, from which Among those, 66 The median age of the confirmed cases was 28 years ranging from 2 to years.

The commonest age group affected was above 24 years with Among the case patients In addition to the various BU active lesions, contracture deformities were observed in twelve of the cases with active lesions, extensive scar due to BU in five of the cases and one patient had had amputation of the right little toe. Ethnic group distribution of the parents of the participants were Akan, Ewe and Ga Adangme.

For parental ethnic groups An association between the ethnic group of the parents of the case patients and the community controls was assessed and it was realized that, BU was less common in the Akan ethnic group compared to the Ewe and Ga Adangme. There was a significant association between level of education and risk of BU. Individuals with higher education were protected from developing BU as compared to those without education Table 2. Past history of tuberculosis and schistosomiasis were all not significantly associated with BU Table 2.

However, wading in other rivers or streams, fetching of water and fishing in Densu river were not significantly associated with BU. Rubbing the area with alcohol after an insect bite 0. Farming with long sleeve clothes and rubbing an insect bite area with alcohol were associated with decreased risk of contracting BU. Without doubt, all limitations associated with the case control study approach apply to this investigation.

Most of the case patients have been living with the disease for more than two years, hence prevalent cases rather than incident cases were recruited. For a chronic and rare disease like BU, association of disease persistence may be confounded with disease development. Also, recall bias remained a major limitation to this study, both from case patients and respondent parents on behalf of their wards.

However, the interviewers were trained to ensure that appropriate responses were elicited from the respondents so as to minimize any form of bias or confounding effects to the findings. This study comes sequent to several epidemiological studies identifying risk factors for transmission of BU [4] , [7] , [13] , [14] , [15] , [25] , [29] , [32] , [33] , [34] , and our findings validate in the Eastern Region of Ghana what has been reported in other countries. This implies that most of the case patients presented or were diagnosed late, probably due to factors such as transportation costs, feeding costs, and productivity loss [3] , [35] , [36].

This may be the underlying reason for the high median age of the participants in the study. It was found that This is in contrast to an earlier study done in the Ashanti Region of Ghana reporting more frequent affection of the left leg [24] , a finding which could also not be confirmed by other studies [37] , [40].

Concerning earlier findings of predisposition for or genetic link to BU [33] the present result show albeit not significant in the multivariate model that BU was less common in the Akan ethnic group. No significant relationship was found between anamnesis of a past tuberculosis [15] nor to a protective role of BCG vaccination to BU, as indicated by previous reports [4] , [15] , [26] , [30] , [41] , [42]. Case patients reported more frequently insect bites in water or wading in mud than the community controls did, which was evident as statistically significant in other studies [15] , [26].

This finding tends to support the hypothesis that M. Likewise, an appropriate initial treatment upon injury like rubbing the area with alcohol seems to offer protection against development of BU.

Surprisingly, the use of adhesive bandage when hurt increased the odds of contracting BU, probably owing to the fact that often adhesive bandages were already being used by other persons and thus contaminated. In fact, most such bandages looked old and dirty. Wading, swimming, and fishing in the Densu river were not identified as risk factors for BU.

Swimming was not widely practiced in the study area [7] although a study in Cote d'Ivoire found such an association [16]. The type of fishing undertaken in the Eastern Region of Ghana differs from habits in many areas that did identify correlations to fishing activities [4] , [15] , [16].

Here, commonly either lines with hooks or small nets are being placed at the bank of the river hence resulting in little or no contact to water. The present study confirms, however, findings of other studies [4] , [15] , [16] that arming with long sleeves and long pants protects against BU. Long clothes may protect from small injuries or insect bites as possible means of entry for M.

In line with previous studies, the use of soap for washing was found to be associated with a decreased risk of M. In order to approach the role of mosquitoes in the transmission of BU, we used the protection of bed nets as a proxy to assess association to contracting BU. In accordance with Raghunathan's finding [4] , this study showed no evidence for protective effects of bed net usage. Since other studies showed the contrary [14] , [15] , [26] we reason that in malaria endemic countries, the role of mosquitoes in the transmission of BU may be under investigated.

Likewise, and also in contrast to earlier reports [4] , [15] , the present study showed no evidence of association between the use of mosquito coils and BU. In this newly identified BU endemic area of the SKC and AS Districts in the Eastern Region of Ghana, our study identified as risk factors the presence of wetlands, insect bites in water, use of adhesive when injured and washing in the Densu river.


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Buruli ulcer BU is one of the most neglected tropical diseases caused by Mycobacterium ulcerans. The Ga West Municipality is an endemic area for Buruli ulcer, and we evaluated the BU surveillance system to determine whether the system is meeting its objectives and to assess its attributes. Materials and Methods. We reviewed records and dataset on Buruli ulcer for the period —


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A national search for cases of Buruli ulcer in Ghana identified 5, patients, with 6, clinical lesions at various stages. The overall crude national prevalence rate of active lesions was The case search demonstrated widespread disease and gross underreporting compared with the routine reporting system. The epidemiologic information gathered will contribute to the design of control programs for Buruli ulcer. Buruli ulcer disease is assuming public health importance in many countries, prompting the establishment of a Global Buruli Ulcer Initiative by the World Health Organization WHO in early

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