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By Ernest Kenu University of Ghana http://ugspace.ug.edu.gh SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA RISK PROFILE FOR TRANSMISSION OFMYCOBACTERIUM ULCERANS IN GHANA BY ERNEST KENU THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF PhD IN EPIDEMIOLOGY DEGREE JUNE, 2012 University of Ghana http://ugspace.ug.edu.gh DECLARATION I hereby declare that with the exception of the references cited to other people’s work which has been duly acknowledged, this work is the result of my own research work done under supervision and has neither in part or whole been presented elsewhere for another degree. ERNEST KENU (10297442) ACADEMIC SUPERVISORS: ……………………………. PROF. RICHARD ADANU ……………………………. PROF. COL. EDWIN AFARI (Rtd) ……………………………. PROF. OLIVER RAZUM ii University of Ghana http://ugspace.ug.edu.gh DEDICATION I dedicate this work to my dear wife Angela and my little angel Selikem. iii University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENT I wish to express my sincere gratitude to my academic supervisors, Prof. Richard Adanu , Prof E Afari all of the School of Public Health, and Prof Oliver Razum of Bielefeld University, Germany for their guidance, contributions and mentorship. My sincere thanks to Prof Fred Binka the former dean of the School of Public Health, Prof Gerd Pluschke of Swiss Tropical Institute, Prof Thomas Junghanss of University of Hiedelberg- Germany, Dr. Moses Aikins, Dr. Fred Wurapa, Dr. S.O Sackey, Dr Kezia Malm and Dr. Kofi Mensah Nyarko all of the School of Public Health for their support. Dr Michael Kaeser, for your teaching, encouragement and contributions, am most grateful. I also thank all lecturers of the School of Public Health for their guidance, support and also imparting knowledge to me. My sincere appreciation to Prof Margaret Lartey of University of Ghana Medical School for her Support, guidance, Mentorship and her motherly love in my difficulties. I thank Dr Fenna Veltman, Dr. Nana Konama Kotey, Enid Owusu, Markus Schindler, Linda Seefeld, Katarina Roltengen and Edith Tetteh for their immense support and contribution during the development of the proposal and the field work. My warmest appreciation to all the District Directors of Ga South –Dr Vera Opata, Ga West - Dr Cynthia Kwakye, Akuapem South - Dr Winful and Suhum Kraboa Koaltar for their immense support. My appreciation also goes to Regional Directors of Greater Accra, Eastern regions and National Buruli Ulcer Control Programme Manager Dr Edwin Ampadu for granting us the permission to do the research. Gerald of Geography Department, University of Ghana thank you. I wish to thank all my dedicated field assistants, Community Based Volunteers from all the sites for their hard work walking with me through that difficult terrain during the study. Chief of Potrease, Nana am grateful for the permission and guidance to the Etiwa forest to see the source of the Densu river and the historical background. I thank the DAAD- ACBRIDGE project for their financial support. Finally, I sincerely thank all who in diverse ways helped me throughout the programme. iv University of Ghana http://ugspace.ug.edu.gh ABSTRACT Buruli ulcer disease (BU) is a skin disease caused by Mycobacterium ulcerans. Currently, Buruli ulcer has been reported in over 30 countries, the subtropical regions of Asia, in Latin America, in the Western Pacific region and in Eastern and Central Africa. Even though it has been reported in other continents, West Africa is the region most affected. It is one of the neglected tropical diseases and second commonest disease caused by Mycobacterium in Ghana and third globally. Suhum-Kraboa-Coltar, Akuapem South districts in the Eastern region and Ga West and Ga South districts of Greater Accra region are some of the districts affected by Buruli ulcer. Unfortunately the exact mechanism of transmission is not known. Even though some risk factors associated with contracting the disease have been identified in previous studies, what pertains in Suhum-Kraboa-Coaltar and Akuapem South districts of the Eastern region is not known. In addition, there is lack of detailed understanding of how environmental and social conditions interact to cause the disease. Finally, the spatial distribution of BU within the communities along the course of Densu river in the study area is also not known. Spatial epidemiology has proven to be useful for understanding the geographical distribution of many diseases. Combining the Geographical Information System (GIS) technology for epidemiologic mapping of Buruli ulcer cases alongside with environmental features and a fine detail case-control study to identify risk factors associated with Buruli ulcer will provide current knowledge of the disease in the study area. This information is crucial in developing clear interventional messages for community education on the disease and which communities are most at risk. The absence of these hampers the prevention and control of BU within the municipalities and consequently leads to ineffective use of scarce resources hence the need for the research. This study sought to develop a risk v University of Ghana http://ugspace.ug.edu.gh profile for the transmission of Buruli Ulcer at the individual and at the Community level in Akuapem South and Suhum Kraboa Coaltar Districts and spatial distribution of Buruli ulcer in the communities along the entire course of the Densu river. A Case-control study with Spatial mapping was carried out. The cases were identified through active community case search. A case of Buruli ulcer was defined as any person aged 2 years or more who resides in the Suhum-Kraboa-Coaltar and Akuapem South districts diagnosed of Buruli ulcer meeting the WHO clinical case definition for M. ulcerans disease. A Control was defined as any person who resides in the same community/neighbourhood as the Buruli ulcer patient comes from but does not have the disease. Standardized questionnaires were administered to the cases as well as their controls. Geographic Positioning System (GPS) receiver was used to map the cases as well as environmental characteristics that are of particular interest in contracting BU. A backward elimination logistic regression analysis of the data indicated that presence of wetland in the neighborhood (OR=3.9, 95% CI=1.9 -8.2), insect bite in water/mud (OR=5.7, 95% CI = 2.5 -13.1), use of adhesive when injured (OR=2.7, 95% CI = 1.1- 6.8), washing in the Densu river (OR= 2.3, 95% CI = 1.1- 4.96) were significantly associated with the development of BU. Rubbing an injured area with alcohol (OR=0.21, 95% CI = 0.008-0.57) and wearing long sleeves to farm (OR=0.29, 95% CI =0.14 - 0.62) protects against BU. The mapping showed that communities upstream along the Densu River where the river is not polluted had no BU cases but BU cases were identified beyond the polluted area of the Densu river. There was clustering of cases of Buruli ulcer in some communities and these occurred in areas where the river was most contaminated .Hence to avoid contamination. vi University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS DECLARATION................................................................................................................................. ii DEDICATION....................................................................................................................................iii ACKNOWLEDGEMENT ................................................................................................................. iv ABSTRACT ......................................................................................................................................... v TABLE OF CONTENTS ................................................................................................................. vii LIST OF FIGURES/MAPS ................................................................................................................ x LIST OF TABLES ............................................................................................................................. xi CHAPTER ONE - INTRODUCTION .............................................................................................. 1 1.1 Background ................................................................................................................................... 1 1.1.1 Epidemiology .......................................................................................................................... 1 1.1.2 Clinical Presentation, diagnosis and management .............................................................. 3 1.1.3 Risk factors for Buruli ulcer ................................................................................................. 6 1.1.4 Spatial distribution ................................................................................................................ 6 1.2 Problem Statement ........................................................................................................................ 8 1.3 Justification ................................................................................................................................... 9 1.4 Objectives..................................................................................................................................... 10 1.4.1 General Objective ................................................................................................................ 10 1.4.2 Specific Objectives:
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