This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. This article has been cited by other articles in PMC. Abstract Aims. This retrospective study was to identify some challenges in the treatment of Buruli ulcer BU and present a proposed treatment regime. Materials and Methods.
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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 Ever since Mycobacterium ulcerans infection was first described in Australia in 1 and later named Buruli ulcer in Uganda 2 , cases have been reported throughout the tropical and subtropical world. One characteristic of the disease is its apparent association with bodies of water worldwide 4 , 5.
The recent identification of M. Buruli ulcer commonly affects the young, even though cases are reported in all age groups 7 , 8. Oluwasanmi et al. The disease is characteristically found more often on the extremities than on the trunk 9. The infection is usually restricted to relatively small areas and patchy in its distribution 10 , The first probable case of Buruli ulcer in Ghana was reported in the Greater Accra Region in ; the presence of additional cases along the tributaries of the Densu River in the area was considered likely In , van der Werf et al.
This report was followed by the description of a major endemic focus in Amansie West District in the same region Since then, isolated cases have been found in scattered communities in many parts of the country, generating much political and media concern and interest. In , a passive surveillance system for reporting Buruli ulcer was initiated in Ghana.
By the end of , approximately 1, cases had been reported from four regions. Gross underreporting was suspected, however, as the media continued to report cases in remote rural communities. Because most cases were known to be in relatively deprived, inaccessible areas, the routine reporting system was judged inadequate to provide a true picture of the extent of disease and the geographic distribution of cases for design of a national control program.
In addition, a case search would provide baseline data against which intervention measures could be assessed. The main objective of the national case search was to establish the extent of the disease in Ghana to facilitate development of a national program for its control. The specific objectives were to determine the epidemiologic characteristics of Buruli ulcer in Ghana and determine physical accessibility of disease-endemic communities to health-care services. Methods Definition of variables Geographic distribution was defined in terms of regional, district, subdistrict, and community distribution of cases.
The burden of disease was considered in terms of number of cases affected, age and sex distribution, clinical presentation preulcerative, ulcer, or deformity , and site of lesion. Preulcerative lesions include nodular, plaque, papular, and nonulcerative edematous forms, as described by the WHO Global Buruli Ulcer Programme 3.
Deformities include scars, constriction of limbs, ankylosis of joints, or amputations. The case search covered every district and known community in Ghana from June to July A team of 20 national facilitators was trained in the use of the survey instruments and in the clinical presentation of the disease in an endemic focus. Two facilitators were then sent to each region to train regional teams three from the regional level and two from each district.
Seven teams of two persons each from the subdistrict and communities performed the case search. The permission of the local political and traditional authorities was sought in advance, and the purpose of the search was explained to them and to all participants.
At each village and community, they showed the pictures of Buruli ulcer disease at different stages of development to as many people as possible and asked whether anyone in the village had a similar condition.
All persons with lesions that met the WHO standard case definition were interviewed with a simple questionnaire. There was no laboratory confirmation of the cases. A prepackaged dressing was given to each person identified as having ulcers, and the particulars of all the cases were provided to local health authorities for follow-up. The process was repeated in each village until the whole district was covered.
A team from the national level, including a dermatologist familiar with the disease, later validated findings in two randomly selected districts from a region where the disease had not previously been endemic.
All cases reported there were found to be consistent with the clinical case definitions used. Data Entry and Analysis Data from all the regions were entered centrally and later cross-checked and edited by EpiInfo 6 software. Data analysis was done both manually and by EpiInfo 6, as appropriate.
Information on regional population distribution was taken from the national census. About forms from Atwima District of Ashanti Region had to be excluded from the data analysis because information was incomplete on almost all variables. Records with missing data for a particular variable were also excluded from analysis of that variable. Results Figure 1. Buruli ulcer on left ankle. Figure 2 Figure 2. Healed Buruli lesions with scarring, right forearm and left knee. We identified 5, patients with 6, suspected Buruli lesions at various stages of development.
Approximately Lesions at both ulcerative and preulcerative stages were seen in 2. If only active lesions preulcerative or ulcerative were used to calculate the prevalence of the disease in Ghana, 3, of the patients The ages of those with active lesions ranged from 0.
Among patients with active lesions, age is significantly associated with sex. The age-specific odds ratio for male likelihood of having an active Buruli lesion is 0. Of 5, lesions for which the information was available, The distribution of lesions on the limbs upper or lower limbs is significantly associated with the age of the patient. The distribution of lesions on the trunk and lower limbs did not differ by sex. Among females, Figure 3 Figure 3.
Prevalence of suspected active cases of Buruli ulcer, by region, Ghana, Cases of Buruli ulcer were identified in all 10 regions. Table 1 shows the prevalence rates per region, based on estimated population figures from the census. The Central Region has the highest overall prevalence rate of active cases, followed by the Ashanti Region; the Northern and Upper West Regions had the lowest prevalence rates Figure 3.
Cases of the disease were identified in 90 Table 2 shows the prevalence rates of the disease in the 10 districts with the highest caseloads. Amansie West had the highest rate prevalence With regard to access to health care, Discussion All cases were diagnosed on the basis of clinical case definitions without laboratory confirmation; as a result, atypical cases such as early and healed lesions may be confused with other diseases endemic in Ghana e.
Experience, however, shows that in disease-endemic communities Buruli ulcer is readily diagnosed empirically. The overall crude prevalence rate of Before the case search, a cumulative total of approximately 1, cases of Buruli ulcer had been reported from five regions in Ghana over a 6-year period from to The case search has confirmed that the disease is grossly underreported.
The distribution of the disease is much more widespread than earlier thought; suspected cases were identified in all 10 regions and at least 90 of districts. Although the infection was thought to be restricted to relatively small patchy isolated foci separated by large disease-free areas 11 , our impression is that the more one looks for the disease in known disease-endemic and nearby areas the more likely additional cases will be found. Our study confirms findings elsewhere that the disease affects children more than adults 7 , 8.
Marston et al. This observation has been misinterpreted to mean that the disease affects only children. Our study demonstrates that all age groups can be affected. The preponderance of lesions on the extremities is once again confirmed by our study.
Barker noted that among girls and women there was equal frequency of arm and leg lesions, while among boys leg lesions predominate 9. Our results, however, show that lesions on the leg predominate for all age groups and both sexes.
Even for females, leg lesions were 2. This distance poses problems for patients who have to travel repeatedly for care for such a chronic ailment. The study has shown that Buruli ulcer disease in Ghana is much more widespread than previously thought.
In all areas where Buruli ulcer cases have been identified, the extent of the disease is likely to be much greater than currently recognized through the routine reporting system. The data set on the disease from the study is among the largest anywhere in the world and can contribute substantially to the epidemiologic description of this relatively new disease.
The information generated should contribute greatly to the design, implementation, and evaluation of Buruli ulcer control programs in Ghana. Amofah is deputy director of public health, Ministry of Health, Ghana. For 9 years he was regional director of health services in the Ashanti Region, where he had firsthand experience in managing Buruli ulcers. Top Acknowledgments We thank Jordan Tappero for support and constructive suggestions; members of the Buruli Ulcer Advisory Committee, Ghana, especially Afua Hesse and Pius Agbenorku and all field workers who contributed to the success of the project in diverse ways; and Mr.
Addo and Dr. Ahadzie for their immense contributions during data entry and analysis. A new mycobacterial infection in man. J Pathol Bacteriol. Mycobacterial skin ulcers in Uganda: description of a new mycobacterium Mycobacterium Buruli. Buruli ulcer: Mycobacterium ulcerans infection. Geneva: The Organisation; Wounds that will not heal. Int J Dermatol.
Buruli Ulcer in Ghana: Results of a National Case Search
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 — The evaluation was carried out at the national, regional, district, and community levels using the Ga West Municipality of the Greater Accra Region as a study site. Interviews with key stakeholders at the various levels were done using an interview guide, and observations were done with a checklist.
Buruli ulcer in Ghana
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 Ever since Mycobacterium ulcerans infection was first described in Australia in 1 and later named Buruli ulcer in Uganda 2 , cases have been reported throughout the tropical and subtropical world.
Buruli Ulcer: Treatment Challenges at Three Centres in Ghana
A Swollen patch on the middle finger B about 4 weeks later, ulcers form on the middle finger C 5. A single small less than five centimeters ulcer is category I. Larger ulcers up to 15 centimeters are category II. Ulcers that are larger, disseminated across the body, or include particularly sensitive sites e. Disease is primarily caused by a toxin produced by the bacteria, mycolactone. The mode of transmission of Buruli ulcer is not entirely known.