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Finding cases of Buruli ulcer among chronic ulcers in rural Ghana – A case for active case-searching
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Finding cases of Buruli ulcer among chronic ulcers in rural Ghana – A case for active case-searching

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Michael R. Adjei1 & Frank Baiden2
1 District Director of Health Services, Tain District, Brong Ahafo Region, Ghana
2 Clinical Research Fellow, Kintampo Health Research Centre, Kintampo, Ghana
 
Buruli ulcer is a chronic necrotising skin infection caused by Mycobacterium ulcerans. It is the third most common mycobacterial infection worldwide, after tuberculosis and leprosy. The disease is endemic in low-resource countries in sub-Saharan Africa and is classified among the neglected tropical diseases.  Between 5000–6000 cases are reported annually 1.The possible eradication of Buruli ulcer is undermined by the continued lack of an appropriate screening test, clarity about the natural reservoir of infection and the mode of transmission. One apparent characteristic of the disease however is its association with riverine areas of the tropics and sub-tropics1, 2.
 
Africa bears 99% of the Global burden of Buruli ulcer cases and Ghana is among the three most endemic countries in the world3. The Ghana national program has elimination as its target and towards this end, active case-finding is being undertaken. However, due largely to resource constraints, the active search for cases is limited to districts where the disease has been reported and transmission is considered to be active. The last time a nationwide survey on Buruli ulcer was conducted in Ghana was in 1999 4 . We report on the finding of cases among patients with chronic ulcers in a district where no cases of Buruli Ulcer have been previously reported.
 
Following the chance finding of suspicious noodle in a six year old child which was subsequently confirmed to be a Buruli ulcer, a 12-month preliminary active case search was carried out at the wound care units of the District Hospital of the Tain district in the Brong Ahafo Region from January to December 2012. Wound swabs were taken and sent to the Noguchi Memorial Institute for Medical Research for laboratory tests.
 
Ten wound swabs were performed and sent for analysis. Three (30%) patients (2 female and 1 male) were positive for M. ulcerans. The ages of patients were 15, 32 and 29 respectively. All the lesions were on the lower limbs.   Patients were farmers residing in the rural communities of the district and did not have any recent history of travel to Buruli ulcer-endemic districts in the country. All three patients had had the ulcers for at least three months and had observed only minimal improvement. Subsequent to the laboratory confirmation, a treatment course of streptomycin and rifampicin was started, with wound dressings. In all three cases, full recovery was achieved within 3 months of confirmation.
 
While, in the face of limited resources, a strategy of active search for cases of Buruli ulcer in districts traditionally recognised to be endemic is a prudent measure, the findings made in this district suggest that such as approach is unlikely to lead to elimination of the disease in the country. A better-resourced, much more aggressive approach is needed, and an active case search for Buruli Ulcer cases among chronic ulcers reporting to rural health facilities could be a cost-effective approach to identifying cases for treatment and determining the true extent of endemicity of the disease in the country.
 
References
1.            Portaels F, Silva MT, Meyers WM. Buruli ulcer. Clin Dermatol. 2009; 27(3): 291-305.
2.            Merritt RW, Walker ED, Small PL, Wallace JR, Johnson PD, Benbow ME, et al. Ecology and transmission of Buruli ulcer disease: a systematic review. PLoS Negl Trop Dis. 2010; 4(12): e911.
3.            WHO-AFRO. Buruli Ulcer Control at a glance. World Health Organisation Regional Office for Africa; 2012.
4.            Amofah G, Bonsu F, Tetteh C, Okrah J, Asamoa K, Asiedu K, et al. Buruli ulcer in Ghana: results of a national case search. Emerg Infect Dis. 2002; 8(2): 167-70.
 
Credits : Posted with the permission of Dr Michael Adjei Rockson District Director of Health Services, Tain District, Brong Ahafo Region, Ghana
 

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