Buruli ulcer control in a highly endemic district in Ghana: role of community-based surveillance volunteers

Improving health behaviours and attitudes around podoconiosis in Northern Western Ethiopia: Implementation and intervention effectiveness

BACKGROUND

Assessing how interventions are implemented is essential to understanding why interventions may or may not achieve their intended outcomes. There is little evidence about how interventions against Neglected Tropical Diseases (NTDs) are being implemented. Guided by the Context and Implementation of Complex Intervention (CICI) framework, we evaluated an ongoing intervention against the NTD podoconiosis to examine the implementation process and its effectiveness in terms of improving shoe wearing practices, increasing knowledge and reducing stigmatizing attitudes towards podoconiosis in rural Ethiopia.

METHODS

We employed an exploratory mixed methods approach, qualitative followed by quantitative, between April and July 2022 to assess implementation agents, theory, strategy, process and outcomes of the intervention. We conducted document analysis, observations, focus group discussions, in-depth interviews and key informant interviews for the qualitative phase. We administered a survey to 369 rural residents, of whom 42 were affected by podoconiosis.

RESULTS

The implementers utilized government healthcare centers in a bid to mainstream podoconiosis services within local healthcare structures. The implementers provided training for health professionals and the public and distributed supplies to patients over a three-month period. The intervention reached 62% of patients, but female patients were less likely to participate than male patients. Only 18% of community members had participated in health education campaigns linked to the intervention. Involvement in the intervention resulted in improved shoe wearing practice and holding fewer stigmatizing attitudes. However, internalized stigma among patients was still rife; and the plan to utilize community assets to extend the intervention activities was not effective.

CONCLUSIONS

Implementers must monitor the fidelity and progression of programs on a constant basis to make corrections. They also need to expand health education, provide psychosocial support and design economic empowerment programs for patients to reduce stigma. They must also collaborate with policy makers and international partners to sustain program activities at intervention delivery points.

Multisensory medical illustrations of Buruli ulcer for improved disease detection, help seeking behaviour and adherence to treatment

Buruli ulcer (BU) is a skin infection caused by Mycobacterium ulcerans and a neglected tropical disease of the skin (skin NTD). Antibiotic treatments are available but, to be effective in the absence of surgery, BU must be detected at its earliest stages (an innocuous-looking lump under the skin) and adherence to prescribed drugs must be high. This study aimed to develop multisensory medical illustrations of BU to support communication with at-risk communities. We used a Think Aloud method to explore community health workers' (n = 6) experiences of BU with a focus on the role of their five senses, since these non-medical disease experts are familiar with the day-to-day challenges presented by BU. Thematic analysis of the transcripts identified three key themes relating to 'Detection,' 'Help Seeking,' and 'Adherence' with a transcending theme 'Senses as key facilitators of health care'. New medical illustrations, for which we coin the phrase "5D illustrations" (signifying the contribution of the five senses) were then developed to reflect these themes. The senses therefore facilitated an enriched narrative enabling the production of relevant and useful visuals for health communication. The medical artist community could utilise sensory experiences to create dynamic medical illustrations for use in practice.

Role and capacity needs of community based surveillance volunteers in the integrated management of skin neglected tropical diseases (skin NTDs): a qualitative study from central Ghana

BACKGROUND

Community Based Surveillance Volunteers (CBSVs) have been instrumental in the management of Neglected Tropical Diseases (NTDs) but a concern that their services in scale up programmes may be affected due to high attrition rates has been widely acknowledged. We explored the roles and capacity needs of existing CBSVs to inform for a successful integrated NTD management programme in Ghana and similar contexts.

METHODS

We conducted qualitative interviews with 50 CBSVs, 21 Community Nurses, 4 Disease control officers, 7 skin NTD researchers, 2 skin NTD patients and a Director of District Health Services in Central Ghana. Interviews were digitally recorded, transcribed and coded prior to translation and thematic analysis.

RESULTS

The roles of CBSVs in NTD management were shown to have an impact on disease identification, surveillance, health seeking behaviours and status of CBSVs. Lack of motivation, inadequate structures for engagement of CBSVs within the health system and delayed management of reported cases were identified as gaps that hinder effective delivery of CBSV roles. Provision of incentives as recognition for the unpaid services rendered by CBSVs was seen as a major factor to reduce the rate of CBSV attrition in this scale up programme. Other factors included the formulation of policies by government to guide CBSV engagement, regular training of CBSV in NTD management as well as provision of resources and logistics.

CONCLUSION

Measures including continuous training, institution of rewards and incentivization are important for ensuring the sustainability of CBSVs in the provision of skin NTD services in Ghana.

Utilising community volunteers can increase the detection and referral of Buruli ulcer cases in endemic communities in Southeast, Nigeria

BACKGROUND

Buruli ulcer (BU) is a debilitating neglected tropical disease which causes disability and mostly affects inhabitants in impoverished settings where access to medical care is challenging. This study aims to determine the effect of training community members as volunteers for or in the detection and referral of people who have Buruli ulcer to the hospital.

METHODS

The following study is a before and after study in the BU-endemic Local Government Areas (LGA) of Ebonyi State. A cluster random sampling technique was used to select 90 volunteers from three LGAs (30 from each LGA). In each LGA, the volunteers underwent a one-day training and six months field work to identify all those who have any form of ulcer on any part of their bodies. A short questionnaire was used to capture socio-demographic characteristics of the patient, site of the ulcer, duration of the ulcer, initial appearance of the ulcer, referral to hospital, result of laboratory investigation, and treatment received. The data was analysed using the Statistical Package for Social Sciences (SPSS) for Microsoft Windows version 20 software. The Z test statistic was used to compare the number of referred BU patients before and after the intervention by LGA. The Chi square test was used to examine the association between the dependent and independent variables.

RESULTS

The mean age of volunteers was 39 ± 9.5 while mean age of the patients was 42.3 ± 17.1. Most of the ulcers were on the legs (79.4%) and lasted 1-5 years (65.6%). There was a significant increase in the proportion of BU suspects identified by the community volunteers in all 3 LGAs (Afikpo north (p =  < 0.001), Abakaliki (p = 0.02), Ikwo (p = 0.001). The duration of the ulcer was associated with the detection and referral of the patients with higher levels of detection and referral among those whose ulcer had lasted 1-5 years in two of the LGAs (P < 0.001).

CONCLUSION

We recommend that program managers and stakeholders integrate and scale up the services of trained community health volunteers for the rapid detection of Buruli ulcer cases in rural endemic communities. Awareness and sensitization campaigns on BU preventive measures should be intensified.

Quantifying Population Burden and Effectiveness of Decentralized Surveillance Strategies for Skin-Presenting Neglected Tropical Diseases, Liberia

We evaluated programmatic approaches for skin neglected tropical disease (NTD) surveillance and completed a robust estimation of the burden of skin NTDs endemic to West Africa (Buruli ulcer, leprosy, lymphatic filariasis morbidity, and yaws). In Maryland, Liberia, exhaustive case finding by community health workers of 56,285 persons across 92 clusters identified 3,241 suspected cases. A total of 236 skin NTDs (34.0 [95% CI 29.1–38.9]/10,000 persons) were confirmed by midlevel healthcare workers trained using a tailored program. Cases showed a focal and spatially heterogeneous distribution. This community health worker‒led approach showed a higher skin NTD burden than prevailing surveillance mechanisms, but also showed high (95.1%) and equitable population coverage. Specialized training and task-shifting of diagnoses to midlevel health workers led to reliable identification of skin NTDs, but reliability of individual diagnoses varied. This multifaceted evaluation of skin NTD surveillance strategies quantifies benefits and limitations of key approaches promoted by the 2030 NTD roadmap of the World Health Organization.

The search for a Buruli Ulcer vaccine and the effectiveness of the Bacillus Calmette-Guérin vaccine

Buruli Ulcer is a neglected tropical disease that is caused by Mycobacterium ulcerans. It is not fatal; however, it manifests a range of devastating symptoms on the hosts' bodies. Various drugs and treatments are available for the disease; however, they are often costly and have adverse effects. There is still much uncertainty regarding the mode of transmission, vectors, and reservoir. At present, there are no official vector control methods, prevention methods, or a vaccine licensed to prevent infection. The Bacillus Calmette-Guérin vaccine developed against tuberculosis has some effectiveness against M. ulcerans. However, it is unable to induce long-lasting protection. Various types of vaccines have been developed based specifically against M. ulcerans; however, to date, none has entered clinical trials or has been released for public use. Additional awareness and funding are needed for research in this field and the development of more treatments, diagnostic tools, and vaccines.

Methods and Approaches for Buruli Ulcer Surveillance in Africa: Lessons Learnt and Future Directions

Over 95% of the global burden of Buruli ulcer disease (BU) caused by Mycobacterium ulcerans occurs in equatorial Africa. National and sub-national programs have implemented various approaches to improve detection and reporting of incident cases over recent decades. Regional incidence rates are currently in decline; however, surveillance targets outlined in 2012 by WHO have been missed and detection bias may contribute to these trends. In light of the new 2030 NTD roadmap and disease-specific targets, BU programs are required to strengthen case detection and begin a transition towards integration with other skin-NTDs. This transition comes with new opportunities to enhance existing BU surveillance systems and develop novel approaches for implementation and evaluation.In this review, we present a breakdown and assessment of the methods and approaches that have been the pillars of BU surveillance systems in Africa: (1) Passive case detection, (2) Data systems, (3) Clinical training, (4) Active case finding, (5) Burden estimation, and (6) Laboratory confirmation pathways. We discuss successes, challenges, and relevant case studies before highlighting opportunities for future development and evaluation including novel data collection tools, risk-based surveillance, and integrated skin-NTD surveillance. We draw on both experience and available literature to critically evaluate methods of BU surveillance in Africa and highlight new approaches to help achieve 2030 roadmap targets.

Understanding the transmission of Mycobacterium ulcerans: A step towards controlling Buruli ulcer

Mycobacterium ulcerans is the causative agent of Buruli ulcer, a rare but chronic debilitating skin and soft tissue disease found predominantly in West Africa and Southeast Australia. While a moderate body of research has examined the distribution of M. ulcerans, the specific route(s) of transmission of this bacterium remain unknown, hindering control efforts. M. ulcerans is considered an environmental pathogen given it is associated with lentic ecosystems and human-to-human spread is negligible. However, the pathogen is also carried by various mammals and invertebrates, which may serve as key reservoirs and mechanical vectors, respectively. Here, we examine and review recent evidence from these endemic regions on potential transmission pathways, noting differences in findings between Africa and Australia, and summarising the risk and protective factors associated with Buruli ulcer transmission. We also discuss evidence suggesting that environmental disturbance and human population changes precede outbreaks. We note five key research priorities, including adoption of One Health frameworks, to resolve transmission pathways and inform control strategies to reduce the spread of Buruli ulcer.

Buruli ulcer is a debilitating skin and soft tissue disease characterised by large ulcerative wounds that are treated with antibiotics or with adjunctive surgery for advanced cases. Found predominantly in West Africa and Southeast Australia, the causative agent is the environmental bacterial pathogen Mycobacterium ulcerans. Lack of understanding of transmission pathways, combined with the absence of a vaccine, has hindered efforts to control the spread of M. ulcerans. Here, in order to identify probable transmission pathways and inform future studies, we review literature linking M. ulcerans to environmental reservoirs, mammalian hosts, and potential invertebrate vectors. We also summarise factors and behaviours that reduce the risk of developing Buruli ulcer, to inform effective prevention strategies and further shed light on transmission pathways.

Community-based surveillance in internally displaced people's camps and urban settings during a complex emergency in Yemen in 2020

Background

The need for early identification of coronavirus disease (COVID-19) cases in communities was high in Yemen during the first wave of the COVID-19 epidemic because most cases presenting to health facilities were severe. Early detection of cases would allow early interventions to interrupt the transmission chains. This study aimed to describe the implementation of community-based surveillance (CBS) in in internally displaced people (IDP) camps and urban settings in Yemen from 15 April 2020 to 30 September 2020.

Methods

Following the Centers for Disease Control and Prevention guidance for evaluation of surveillance systems, we assessed the usefulness and acceptability of CBS. For acceptability, we calculated the proportion of trained volunteers who reported disease alerts. To assess the usefulness, we compared the alerts reported through the electronic diseases early warning system (eDEWS) with the alerts reported through CBS and described the response activities implemented.

Results

In Al-Mukalla City, 18% (14/78) of the volunteers reported at least one alert. In IDP camps, 58% (18/31) of volunteers reported at least one alert. In Al-Mukalla City, CBS detected 49 alerts of influenza-like illness, whereas health facilities detected 561 cases of COVID-19. In IDP camps, CBS detected 91 alerts of influenza-like illness, compared to 10 alerts detected through eDEWS. In IDP camps, CBS detected three other syndromes besides influenza-like illness (febrile illness outbreak suspicion, acute diarrhoea, and skin disease). In IDP camps, public health actions were implemented for each disease detected and no further cases were reported.

Conclusions

In Yemen, CBS was useful for detecting suspected outbreaks in IDP camps. CBS implementation did not yield expected results in general communities in urban areas in the early stage of the COVID-19 pandemic when little was known about the disease. In the urban setting, the system failed to detect suspected COVID-19 cases and other diseases despite the ongoing outbreaks reported through eDEWS. In Yemen, as in other countries, feasibility and acceptability studies should be conducted few months before CBS expansion in urban communities. The project should be expanded in IDP camps, by creating COVID-19 and other disease outbreak reporting sites.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13031-021-00394-1.

Immunity against Mycobacterium ulcerans: The subversive role of mycolactone

Mycobacterium ulcerans causes Buruli ulcer, a neglected tropical skin disease manifesting as chronic wounds that can leave victims with major, life-long deformity and disability. Differently from other mycobacterial pathogens, M ulcerans produces mycolactone, a diffusible lipid factor with unique cytotoxic and immunomodulatory properties. Both traits result from mycolactone targeting Sec61, the entry point of the secretory pathway in eukaryotic cells. By inhibiting Sec61, mycolactone prevents the host cell's production of secreted proteins, and most of its transmembrane proteins. This molecular blockade dramatically alters the functions of immune cells, thereby the generation of protective immunity. Moreover, sustained inhibition of Sec61 triggers proteotoxic stress responses leading to apoptotic cell death, which can stimulate vigorous immune responses. The dynamics of bacterial production of mycolactone and elimination by infected hosts thus critically determine the balance between its immunostimulatory and immunosuppressive effects. Following an introduction summarizing the essential information on Buruli ulcer disease, this review focuses on the current state of knowledge regarding mycolactone's regulation and biodistribution. We then detail the consequences of mycolactone-mediated Sec61 blockade on initiation and maintenance of innate and adaptive immune responses. Finally, we discuss the key questions to address in order to improve immunity to M ulcerans, and how increased knowledge of mycolactone biology may pave the way to innovative therapeutics.

Community-based door to door census of suspected people living with epilepsy: empowering community drug distributors to improve the provision of care to rural communities in Cameroon

Background

Epilepsy is a severe neurological disorder with huge psychological, social, and economic consequences, including premature deaths and loss of productivity. Sub-Saharan Africa carries the highest burden of epilepsy. The management of epilepsy in Cameroon remains unsatisfactory due to poor identification of cases and a limited knowledge of the distribution of the disease. The objective of this study was to determine whether community drug distributors (CDDs) - volunteers selected by their communities to distribute ivermectin against onchocerciasis and who have been proven efficient to deliver other health interventions such as insecticide-treated bed nets to prevent malaria, vitamin A tablets, and albendazole to treat soil transmitted helminthiasis - can be used to reliably identify people living with epilepsy to promote better management of cases.

Methods

This study was carried out in three health Districts in Cameroon. An exhaustive house to house census was carried out by trained CDDs under the supervision of local nurses. In each household, all suspected cases of epilepsy were identified. In each health district, five communities were randomly selected for a second census by trained health personnel (research team). The results of the two censuses were compared for verification purposes.

Results

A total of 53,005 people was registered in the 190 communities surveyed with 794 (1.4%) individuals identified as suspected cases of epilepsy (SCE) by the CDDs. In the 15 communities where the SCE census was verified, the average ratio between the number of suspected cases of epilepsy reported in a community by the research team and that reported by the CDDs was 1.1; this ratio was < 0.8 and > 1.2 in 6 communities.

Conclusions

The results of this study suggest that CDDs, who are present in about 200,000 communities in 31 Sub Saharan African countries where onchocerciasis is endemic, can be successfully used to assess epilepsy prevalence, and therefore map epilepsy in many African countries.

Barriers to Buruli ulcer treatment completion in the Ashanti and Central Regions, Ghana

BACKGROUND

Buruli ulcer is a chronic ulcerating skin condition, with the highest burden found in Central and West Africa where it disproportionately affects the most vulnerable populations. Treatment is demanding, comprising eight-weeks of daily antibiotics, regular wound care and possible surgical intervention. Treatment completion is key to optimising outcomes, however the degree of and barriers to this are not well understood. Recent change from injectable treatment (SR8) to oral treatment (CR8) has made it feasible to further decentralise care, potentially improving treatment access and completion. However, the impact of this and of other demographic and clinical influences on treatment completion must be explored first to ensure appropriate models of care are developed.

METHODOLOGY/PRINCIPAL FINDINGS

A retrospective clinical notes review and secondary data analysis of records from patients diagnosed between 1 January 2006-31 December 2018 at four district hospital clinics in the Ashanti and Central Regions, Ghana. Univariable analyses and multivariable logistic regression were performed to assess the association between explanatory variables and treatment completion. There were 931 patient episodes across the four clinics with overall treatment completion of 84.4%. CR8 was associated with higher treatment completion compared to SR8 (OR 4.1, P = 0.001). There was no statistically significant association found between distance from patient residence to clinic and treatment completion.

CONCLUSIONS/SIGNIFICANCE

Improved treatment completion with CR8 supports its use as first line therapy and may enable decentralisation to fully community-based care. We did not find an association between distance to care and treatment completion, though analyses were limited by data availability. However, we did find evidence that distance to care continues to be associated with more severe forms of disease, which may reflect the higher costs of accessing care and lower awareness of the condition the further a patient lives. Decentralised care must therefore also continue to support community engagement and active outreach to identify cases early.

Pharmacologic management of Mycobacterium ulcerans infection

INTRODUCTION

Pharmacological treatment of Buruli ulcer (Mycobacterium ulcerans infection; BU) is highly effective, as shown in two randomized trials in Africa.

AREAS COVERED

We review BU drug treatment - in vitro, in vivo and clinical trials (PubMed: '(Buruli OR (Mycobacterium AND ulcerans)) AND (treatment OR therapy).' We also highlight the pathogenesis of M. ulcerans infection that is dominated by mycolactone, a secreted exotoxin, that causes skin and soft tissue necrosis, and impaired immune response and tissue repair. Healing is slow, due to the delayed wash-out of mycolactone. An array of repurposed tuberculosis and leprosy drugs appears effective in vitro and in animal models. In clinical trials and observational studies, only rifamycins (notably, rifampicin), macrolides (notably, clarithromycin), aminoglycosides (notably, streptomycin) and fluoroquinolones (notably, moxifloxacin, and ciprofloxacin) have been tested.

EXPERT OPINION

A combination of rifampicin and clarithromycin is highly effective but lesions still take a long time to heal. Novel drugs like telacebec have the potential to reduce treatment duration but this drug may remain unaffordable in low-resourced settings. Research should address ulcer treatment in general; essays to measure mycolactone over time hold promise to use as a readout for studies to compare drug treatment schedules for larger lesions of Buruli ulcer.

Rifampicin and clarithromycin (extended release) versus rifampicin and streptomycin for limited Buruli ulcer lesions: a randomised, open-label, non-inferiority phase 3 trial

BACKGROUND

Buruli ulcer is a neglected tropical disease caused by Mycobacterium ulcerans infection that damages the skin and subcutis. It is most prevalent in western and central Africa and Australia. Standard antimicrobial treatment with oral rifampicin 10 mg/kg plus intramuscular streptomycin 15 mg/kg once daily for 8 weeks (RS8) is highly effective, but streptomycin injections are painful and potentially harmful. We aimed to compare the efficacy and tolerability of fully oral rifampicin 10 mg/kg plus clarithromycin 15 mg/kg extended release once daily for 8 weeks (RC8) with that of RS8 for treatment of early Buruli ulcer lesions.

METHODS

We did an open-label, non-inferiority, randomised (1:1 with blocks of six), multicentre, phase 3 clinical trial comparing fully oral RC8 with RS8 in patients with early, limited Buruli ulcer lesions. There were four trial sites in hospitals in Ghana (Agogo, Tepa, Nkawie, Dunkwa) and one in Benin (Pobè). Participants were included if they were aged 5 years or older and had typical Buruli ulcer with no more than one lesion (caterories I and II) no larger than 10 cm in diameter. The trial was open label, and neither the investigators who took measurements of the lesions nor the attending doctors were masked to treatment assignment. The primary clinical endpoint was lesion healing (ie, full epithelialisation or stable scar) without recurrence at 52 weeks after start of antimicrobial therapy. The primary endpoint and safety were assessed in the intention-to-treat population. A sample size of 332 participants was calculated to detect inferiority of RC8 by a margin of 12%. This study was registered with ClinicalTrials.gov, NCT01659437.

FINDINGS

Between Jan 1, 2013, and Dec 31, 2017, participants were recruited to the trial. We stopped recruitment after 310 participants. Median age of participants was 14 years (IQR 10-29) and 153 (52%) were female. 297 patients had PCR-confirmed Buruli ulcer; 151 (51%) were assigned to RS8 treatment, and 146 (49%) received oral RC8 treatment. In the RS8 group, lesions healed in 144 (95%, 95% CI 91 to 98) of 151 patients, whereas lesions healed in 140 (96%, 91 to 99) of 146 patients in the RC8 group. The difference in proportion, -0·5% (-5·2 to 4·2), was not significantly greater than zero (p=0·59), showing that RC8 treatment is non-inferior to RS8 treatment for lesion healing at 52 weeks. Treatment-related adverse events were recorded in 20 (13%) patients receiving RS8 and in nine (7%) patients receiving RC8. Most adverse events were grade 1-2, but one (1%) patient receiving RS8 developed serious ototoxicity and ended treatment after 6 weeks. No patients needed surgical resection. Four patients (two in each study group) had skin grafts.

INTERPRETATION

Fully oral RC8 regimen was non-inferior to RS8 for treatment of early, limited Buruli ulcer and was associated with fewer adverse events. Therefore, we propose that fully oral RC8 should be the preferred therapy for early, limited lesions of Buruli ulcer.

FUNDING

WHO with additional support from MAP International, American Leprosy Missions, Fondation Raoul Follereau France, Buruli ulcer Groningen Foundation, Sanofi-Pasteur, and BuruliVac.

Integrated approach in the control and management of skin neglected tropical diseases in three health districts of Côte d'Ivoire

BACKGROUND

Neglected tropical diseases (NTDs) comprise 20 communicable diseases that are prevalent in rural poor and remote communities with less access to the health system. For effective and efficient control, the WHO recommends that affected countries implement integrated control interventions that take into account the different co-endemic NTDs in the same community. However, implementing these integrated interventions involving several diseases with different etiologies, requiring different control approaches and driven by different vertical programs, remains a challenge. We report here the results and lessons learned from a pilot test of this integrated approach based on integrated screening of skin diseases in three co-endemic health districts of Côte d'Ivoire, a West African country endemic for Buruli ulcer, leprosy and yaw.

METHOD

This cross-sectional study took place from April 2016 to March 2017 in 3 districts of Côte d'Ivoire co-endemic for BU, leprosy and yaws. The study was carried out in 6 stages: identification of potentially co-endemic communities; stakeholder training; social mobilization; mobile medical consultations; case detection and management; and a review meeting.

RESULTS

We included in the study all patients with skin signs and symptoms at the screening stage who voluntarily accepted screening. In total, 2310 persons screened had skin lesions at the screening stage. Among them, 07 cases were diagnosed with Buruli ulcer. There were 30 leprosy cases and 15 yaws detected. Other types of ulcerations and skin conditions have been identified and represent the majority of cases detected. We learned from this pilot experience that integration can be successfully implemented in co-endemic communities in Côte d'Ivoire. Health workers are motivated and available to implement integrated interventions instead of interventions focused on a single disease. However, it is essential to provide capacity building, a minimum of drugs and consumables for the care of the patients identified, as well as follow-up of identified patients, including those with other skin conditions.

CONCLUSIONS

The results of this study show that the integration of activities can be successfully implemented in co-endemic communities under the condition of staff capacity building and minimal care of identified patients.

Paradoxical reactions in Buruli ulcer after initiation of antibiotic therapy: Relationship to bacterial load

Background

We investigated the relationship between bacterial load in Buruli ulcer (BU) lesions and the development of paradoxical reaction following initiation of antibiotic treatment.

Methods

This was a longitudinal study involving BU patients from June 2013 to June 2017. Fine needle aspirates (FNA) and swab samples were obtained to establish the diagnosis of BU by PCR. Additional samples were obtained at baseline, during and after treatment (if the lesion had not healed) for microscopy, culture and combined 16S rRNA reverse transcriptase/ IS2404 qPCR assay. Patients were followed up at regular intervals until complete healing.

Results

Forty-seven of 354 patients (13%) with PCR confirmed BU had a PR, occurring between 2 and 42 (median 6) weeks after treatment initiation. The bacterial load, the proportion of patients with positive M. ulcerans culture (15/34 (44%) vs 29/119 (24%), p = 0.025) and the proportion with positive microscopy results (19/31 (61%) vs 28/90 (31%), p = 0.003) before initiation of treatment were significantly higher in the PR compared to the no PR group. Plaques (OR 5.12; 95% CI 2.26–11.61; p<0.001), oedematous (OR 4.23; 95% CI 1.43–12.5; p = 0.009) and category II lesions (OR 2.26; 95% CI 1.14–4.48; p = 0.02) were strongly associated with the occurrence of PR. The median time to complete healing (28 vs 13 weeks, p <0.001) was significantly longer in the PR group.

Conclusions

Buruli ulcer patients who develop PR are characterized by high bacterial load in lesion samples taken at baseline and a higher rate of positive M. ulcerans culture. Occurrence of a PR was associated with delayed healing.

Trial registration

ClinicalTrials.gov NCT02153034.

Buruli ulcer is a neglected tropical skin disease caused by the third most common pathogenic mycobacterium: Mycobacterium ulcerans. Paradoxical reaction, a phenomenon observed in some patients is characterised by worsening of existing lesion(s) with attendant pain and occurrence of new lesions during or after antibiotic therapy following an initial period of clinical improvement. This significantly affects treatment outcomes. In this clinical study, tissue samples obtained from patients were subjected to 16S rRNA/ IS2404 qPCR to measure bacterial load. This was to identify a link between bacterial load in BU lesions and the development of paradoxical reactions following initiation of antibiotic treatment. We found that 13% of participants developed PR. Patients who developed PR had higher baseline bacterial load; a higher rate of positive M. ulcerans culture and persistently positive culture during antibiotic treatment. Occurrence of a paradoxical reaction was associated with delayed healing.

Community-based surveillance: A scoping review

Background

Involving community members in identifying and reporting health events for public health surveillance purposes, an approach commonly described as community-based surveillance (CBS), is increasingly gaining interest. We conducted a scoping review to list terms and definitions used to characterize CBS, to identify and summarize available guidance and recommendations, and to map information on past and existing in-country CBS systems.

Methods

We searched eight bibliographic databases and screened the worldwide web for any document mentioning an approach in which community members both collected and reported information on health events from their community for public health surveillance. Two independent reviewers performed double blind screening and data collection, any discrepancy was solved through discussion and consensus.

Findings

From the 134 included documents, several terms and definitions for CBS were retrieved. Guidance and recommendations for CBS were scattered through seven major guides and sixteen additional documents. Seventy-nine unique CBS systems implemented since 1958 in 42 countries were identified, mostly implemented in low and lower-middle income countries (79%). The systems appeared as fragmented (81% covering a limited geographical area and 70% solely implemented in a rural setting), vertical (67% with a single scope of interest), and of limited duration (median of 6 years for ongoing systems and 2 years for ended systems). Collection of information was mostly performed by recruited community members (80%).

Interpretation

While CBS has already been implemented in many countries, standardization is still required on the term and processes to be used. Further research is needed to ensure CBS integrates effectively into the overall public health surveillance system.

Understanding perceptions on 'Buruli' in northwestern Uganda: A biosocial investigation

Background

An understudied disease, little research thus far has explored responses to Buruli ulcer and quests for therapy from biosocial perspective, despite reports that people seek biomedical treatment too late.

Methods and findings

Taking an inductive approach and drawing on long-term ethnographic fieldwork in 2013–14, this article presents perspectives on this affliction of people living and working along the River Nile in northwest Uganda. Little is known biomedically about its presence, yet ‘Buruli’, as it is known locally, was and is a significant affliction in this region. Establishing a biosocial history of ‘Buruli’, largely obscured from biomedical perspectives, offers explanations for contemporary understandings, perceptions and practices.

Conclusions/Significance

We must move beyond over-simplifying and problematising ‘late presentation for treatment’ in public health, rather, develop biosocial approaches to understanding quests for therapy that take into account historical and contemporary contexts of health, healing and illness. Seeking to understand the context in which healthcare decisions are made, a biosocial approach enables greater depth and breadth of insight into the complexities of global and local public health priorities such as Buruli ulcer.

Buruli ulcer, a neglected tropical disease, has been described as an emerging public health problem in parts of sub-Saharan Africa. One of the challenges highlighted by the World Health Organisation (WHO) is improving access to biomedical healthcare. A research priority is thus to determine local understandings of skin disorders such as Buruli ulcer, and social-cultural factors that influence health-seeking. This article explores perspectives on Buruli among fisherfolk in northwestern Uganda along the River Nile, where the ulcer has previously been documented. The findings are based on a long-term ethnographic study of health, healing and illness in this region, and integrate insights from biomedical and social sciences. This biosocial approach demonstrates that, rather than seeking therapy late, people in this region sought treatment from local herbalists promptly when signs of skin lesions appeared. This was not because of non-biomedical understandings of disease. The reasons why people continue to trust local herbalists as experts in Buruli can be found in the historical context of how ulcers have been understood and managed, and the broader context of quests for therapy in this region. While the findings relate to where this study took place, the lessons learnt and biosocial approach used could be usefully applied in other settings where Buruli ulcer is endemic, and for understanding the local context of other neglected diseases and global health priorities.

Assessment of health care workers' knowledge, attitude and risk perception of Buruli ulcer disease in Southern Nigeria

Background

Poor knowledge of health care workers may be responsible for the under-diagnosis and low notification of Buruli ulcer (BU) in high-burden settings. This study assessed health care workers' knowledge, attitude and risk perception of BU in Southern Nigeria.

Methods

We conducted a cross-sectional survey among 186 health care workers recruited from 58 health facilities in four states of Southern Nigeria. A semi-structured interviewer-administered questionnaire was administered to all participants.

Results

The overall mean knowledge score was 8.8±2.7 (maximum 15). Only 29.0% (54/186) of the respondents had a good knowledge of BU. The mean (SD) attitude score was 4.5±1.2 (maximum 6). Also, 61.3% (114/) of the respondents had a good attitude towards BU. The overall mean (SD) risk perception score was 2.6±1.3 (maximum 5). Only 26.3% (49/) of the respondents had a good risk perception of BU disease. Previous training was an independent predictor of good knowledge (aOR 4.6), good attitude (aOR 3.8) and good risk perception (aOR 2.9) to BU.

Conclusions

Health care workers in endemic settings of Nigeria have poor knowledge of and poor risk perception of BU disease. Training of health care workers is recommended to address the identified gaps to ensure earlier diagnosis and referral to specialist centres.

Buruli Ulcer: Review of a Neglected Skin Mycobacterial Disease

Buruli ulcer is caused by Mycobacterium ulcerans This neglected disease occurs in scattered foci around the world, with a higher concentration of cases in West Africa. The mycobacteria produce mycolactones that cause tissue necrosis. The disease presents as a painless skin nodule that ulcerates as necrosis expands. Finding acid-fast bacilli in smears or histopathology, culturing the mycobacteria, and performing M. ulcerans PCR in presumptive cases confirm the diagnosis. Medical treatment with oral rifampin and intramuscular streptomycin or oral treatment with rifampin plus clarithromycin for 8 weeks is supported by the World Health Organization. This review summarizes the epidemiology, pathogenesis, clinical presentation, diagnostic tests, and advances in treatment.

The Role of Nurses and Community Health Workers in Confronting Neglected Tropical Diseases in Sub-Saharan Africa: A Systematic Review

INTRODUCTION

Neglected tropical diseases produce an enormous burden on many of the poorest and most disenfranchised populations in sub-Saharan Africa. Similar to other developing areas throughout the world, this region's dearth of skilled health providers renders Western-style primary care efforts to address such diseases unrealistic. Consequently, many countries rely on their corps of nurses and community health workers to engage with underserved and hard-to-reach populations in order provide interventions against these maladies. This article attempts to cull together recent literature on the impact that nurses and community health workers have had on neglected tropical diseases.

METHODS

A review of the literature was conducted to assess the role nurses and community health workers play in the primary, secondary, and tertiary prevention of neglected tropical diseases in sub-Saharan Africa. Articles published between January 2005 and December 2015 were reviewed in order to capture the full scope of nurses' and community health workers' responsibilities for neglected tropical disease control within their respective countries' health systems.

RESULTS

A total of 59 articles were identified that fit all inclusion criteria.

CONCLUSIONS

Successful disease control requires deep and meaningful engagement with local communities. Expanding the role of nurses and community health workers will be required if sub-Saharan African countries are to meet neglected tropical disease treatment goals and eliminate the possibility future disease transmission. Horizontal or multidisease control programs can create complimentary interactions between their different control activities as well as reduce costs through improved program efficiencies-benefits that vertical programs are not able to attain.

Burden and Historical Trend of Buruli Ulcer Prevalence in Selected Communities along the Offin River of Ghana

Buruli ulcer (BU) is a neglected tropical skin disease caused by Mycobacterium ulcerans with more than two thirds of the global cases reported in West Africa. A nationwide active BU case search conducted in 1999 identified two health districts along the Offin River as two of the three most endemic districts in Ghana. Based on recent anecdotal accounts that transmission is unstable along the Offin River, we conducted from March to June 2013 an exhaustive household survey and active case search in 13 selected communities within a five-kilometer radius along the Offin River. The overall prevalence of BU was 2.3% among the surveyed population of 20,390 inhabitants and 477 of the total 480 cases detected (99.4%) were historical (healed) cases. By estimating the year of occurrence for each case per community and taking into account available passive surveillance records of health facilities and the District Health Directorate, we observed a general trend of continuous emergence of cases in communities located midstream the Offin River whereas downstream communities showed more sporadic patterns. We monitored the incidence of cases after the survey and recorded a cumulative incidence rate of 0.04% for the 13 communities over a 17-month active surveillance period from August 2013 to December 2014. Our data reveal an overall decline in BU incidence along the Offin River similar to the general decline in BU incidence in recent years reported by the World Health Organization for West Africa.

Buruli ulcer (BU) is a tropical skin disease caused by Mycobacterium ulcerans and more than two thirds of the global cases reported in West Africa. The Offin has been considered the most endemic river valley in Ghana following a nationwide active case search conducted in 1999. Here, we present findings of an exhaustive household survey and case search of 13 selected communities along the Offin river aimed at addressing recent anecdotal accounts of unstable transmission of M. ulcerans within the river basin. We observed among the surveyed population of 20,390 inhabitants, an overall 2.3% prevalence of BU with 99.4% of the total cases detected being historical cases. We also observed a general trend of continuous and sporadic emergence of cases in mid and downstream communities, respectively. Subsequently, we detected a total of eight cases (0.04% cumulative incidence rate) in a prospective 17-month active surveillance of all 13 communities. These data confirm the recent decline in BU incidence in historically endemic communities along the Offin river basin, analogous to the observation made in recent years by the World Health Organization for West Africa.