A Study to Determine the Current Prevalenceof Buruli Ulcer in the Adult Population and Determine any Gender Issues out of The Burden of Buruli Ulcer in Ga District of Greater Accra Region
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Date
2003-09
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University of Ghana
Abstract
In this study a total of 3761 indiv iduals in six v illages were interv iewed out of which 497 clinical lesions at various stages of the diseases were identified given a crude prevalence rate of 13.2 percent or 13,215 per 100,000 compared to the National case search rate of 87.7 per 100,000 for the w hole Ga district w ith the set back mentioned in the text. The definition of adult has intentionally been chosen to start from age 15 years to enable us have a meaningful discussion of any gender issues that may arise from the disease since women of reproductive age is 15-49 years by WHO convention. Consequently the adult population formed 60.2% of the total
population surveyed. From the 2,263 adult population 357 patients were identified with clinical lesions at various stages giving a crude prevalence rate of 15.8 per cent or 15,775 per 100,000.
This prevalence gives the erroneous impression that the disease is more prevalent in the adult than in children but this could be explained by the fact that those with the scar formed the majority who obviously might have reached adult age since it takes a long time before the disease reach the scaring stage. However, the active lesions (pre-ulcerative and ulcer cases) showed majority of them being 15 years and below which is widely known by the numerous publications worldwide. The currcnt prevalence rate of Buruli ulccr in the adult population
with respect to the active lesions of the disease in the six communities was found to be 4.5 percent or 4,463 per 100,000. ii. The current prevalence rate of healed lesions in the adult population without deformity was much higher 10.1 percent or 10.075 per 100,000. iii. The current prevalence rate of healed lesions in the adult population with disability or handicaps was the least 1.2 per cent or 1,237 per 100,000. iv. Very surprisingly there were not much problem with respect to gender issues as almost all the affected adults both men and women claimed they could perform their gender roles. In the opinion of the author therefore Buruli ulcer has no effect on gender issues in these hyper-endemic rural areas where stigmatisation is not a problem. The situation may be different how ever if these patients w ith serious scar were to be in the Metropolis where people are not familiar with such scars. This can be inferred from the Media Reports in 1993. In a hyper-endemic communities therefore Buruli ulcer appears to have no
effect on gender issues the author may conclude. This conclusion is based on the responses from the questionnaires. However, the author strongly suspect that gender role is a problem considering the statement in the preceding paragraph. A further research focusing on effect of Buruli ulcer on gender roles only may confirm my suspicion. These prevalence rates has confirmed the general perception that the disease is grossly under reported in this district in particular and that the disease is hyper-endemic in the rural Ga district (in fact an epidemic by epidemiologic standard) with the highest prevalence rate in Ghana if the urban areas (where
the disease is virtually nonexistent) which form two thirds of the district population were to be excluded as mentioned earlier. The study has also confirmed the impression of Amofah et al (2002) that “the more one looks for the disease in known disease endemic and nearby areas the more likely additional cases will be found1’. Absolute illiteracy had no direct relationship w ith acquiring the disease as less than 25% of those with the disease had no form of education at all. About 38.4% of the population has had primary education while 36.6% of the affected population had completed secondary level of education. This confirms the school going age as the most affected. These are the very playful and active age group predisposing them to a break in the skin - the most likely point of entry by the microorganism. The most crucial observation by the author and the community leaders is poor sanitation and personal hygiene due to lack of potable water as the predisposing cause of the disease and not mere presence of multiple water bodies. The disease is less common among villages along the Densu lake which is a permanent water body while those villages with high prevalence in the district are virtually dry and depend on man made ponds for water during the dry season. For example the Chief of Obakrowa maintained that prior to provision of hand pump wells in that village the disease was very prevalent in the village but since then the prevalence is reducing. Danchira seems to have the highest prevalence because there is no hand pump well in the village and there are many hamlets who use manmade ponds as their source of water the nature of which is unwholesome for human
use. This village and Obakrowa have similar topographical features with very little stagnant water bodies on a high level. This observation has a scientific medical backing quoting the most eminent Public Health Physician in Ghana will be self-explanatory. “Sickness may be cured or
prevented through immunization or other direct intervention. But true health does not come from the Doctor. It comes from the food we eat the water we drink, the environment in which we live and the life sty le we adopt" unquote (Sai F.T. 2002). These words are the simplified and modern form from the Father of Modern Medicine (Hippocrates) as in the text. The disease is more common among farmers and fishmongers emphasizing sanitation and persona] hygiene as a higher predisposing factor. The relative high figures among traders might he those who had the disease at a younger age as is reflected in the prevalence in those with scar without deformity.
The site of the disease conform to the generally known - the limbs forming about 80%. Very interestingly there was one case of active Buruli ulcer in the sole of the right heel of a woman at Danchira and another at the Anal region. Multiple lesions were not uncommon like those with scar and pre-ulcerative lesion, scar with ulcer indicating re-infection is a common phenomena. However, there was no situation - where the whole household was affected; the highest was four cases in one household often members refuting person to person contact as a form of spreading the disease. All these communities are very deprived by all standards; inaccessible, poor health
facility, not affordable with acceptability problem because of poor road network, scarce health facilities, low socio-economic status and their superstitious beliefs respectively. Contrary to the general belief of low mortality about the disease, it is the authors opinion that mortality is most likely to be high in these inaccessible, unaffordable, deprived areas who do not report such mortalities to the health authorities due to superimposed under-nutrition, anaemia and secondary infection as was observed during the study. During the two month period of the survey three patients with severe form of the disease died of it without notifying the health authorities. 1 got to know them when I went back to check whether they have heeded to my advice to attend to the Health Centre and if possible take a photograph of them. The last but not the least observation is the closeness of the area or part of the district indirectly being part of the Accra Metropolis and with the rural-urban migration if the mode of transmission is later discovered to be contagious then an epidemic in the capital may he the result. The cost of containing this chronic disease w ill be very disastrous to the nation, whose per capita income is about US S300. In the light of all the above the author recommend that the first line of action to curb the spread of the disease is to provide them with potable drinking water. Those who have been provided with hand pump wells should be educated to utilize these facilities, employing participatory approaches. The education is very important because in Obakrowa for example which has the facility some of the members were still using the small streams and ponds. Health education and promotion should be intensified in all the rural communities especially emphasizing on sanitation and personal hygiene. Provision of good road network at least motorable feeder roads to all the endemic villages for health providers to get access to them and the possibility of easily obtaining transport to the Amasaman Health Centre at all times will help the communities patronizing the health facility better. Provision of basic schools in the villages to reduce the w alking distance to the nearest school some about 2-3 kilometres away. This will help improve the educational level
and the teaching and practicing of personal hygiene. The need to expand the health facility at Amasaman to a District Hospital and expanding the staff position more especially skilled surgeons and nurses in the art of skin grafting technology. At least one plastic surgeon in the Centre to start using the modern theatre facility already provided w ill encourage more Buruli ulcer patients to utilize the health facility. Finally considering the work of Hippocrates in the text, the modern version of it by Fred Sai and the advice from Lucas of Nigeria it is time contemporary public health practitioners started being pro-active in preventing more diseases by concentrating on the Environment which would solve more than half of our medical problems instead of being “consulting room Public Health physicians” to quote Dr. Coleman of School
of Public Health during his lecture to us on sanitation at Accra Metropolitan Assembly Health Directorate.
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