QR82. M8 Ed5 bite C.l G365787 THE BALME LIBRARY 3 0 6 92 1008 6 5 1 7 7 University of Ghana http://ugspace.ug.edu.gh SPATIAL PATTERNS OF MYCOBACTERIUM ULCERANS INFECTION (BURULI ULCER) IN THE AKWAPIM SOUTH DISTRICT BY OHENE KESSON EDMUND A THESIS SUBMITTED TO THE DEPARTMENT OF GEOGRAPHY AND RESOURCE DEPARTMENT, UNIVERSITY OF GHANA, LEGON, IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE AWARD OF THE MASTER OF PHILOSOPHY (M.PHIL) DEGREE AUGUST 2001 University of Ghana http://ugspace.ug.edu.gh Dedication I dedicate this work to my brother-in-law Mr. John Opoku, Miss Evelyn Ohene Kesson and other brothers and sisters for their immense contribution towards my education. May the Lord bless you. University of Ghana http://ugspace.ug.edu.gh Declaration I, Ohene Kesson Edmund hereby declare that except where references were duly cited and acknowledged, this document is an outcome of my own research initiative supervised by Naa Professor John. S. Nabila and Dr. S. Agyei-Mensah. It has neither been presented in whole or in part to any examining body for another degree. Signature :.......................................................................... Candidate : Ohene Kesson Edmund Date i o S . ..... ......................% .......... Signature . /V . Principal Supervisor: Naa Professor John. S.Nabila : .......Date Signature Co-Supervisor : Dr.S. Agyei-Mensah .........Date University of Ghana http://ugspace.ug.edu.gh Acknowledgement I thank the Lord Almighty for His divine care and seeing me through this stage of my academic career. I owe a special debt of gratitude to my supervisors, Naa Professor John. S. Nabila and Dr. S. Agyei-Mensah for their guidance, advice and comments throughout the various stages of writing this thesis. I am also grateful for the kindness and help offered by Dr. Frank Bonsu of the Disease Control Unit of the Korle Bu Teaching Hospital and Dr. Tinkorang, the District Director of Health Services, Akwapim South District. Others are Mr. D. K. Opare, the District Environmental Health Officer, Akwapim South, the health personnel at the Buruli Ulcer Dressing Centre at Pakro and the staff of the Disease Control Unit of the Ministry of Health, Nsawam. I am also thankful to Mr. Ebenezer Ntiri for his immense assistance during the fieldwork at Buokrom. Others who helped in this direction were the women’s leader at Tabankro, Madam Esi, and Yaw Asrabgo also of Tabankro and not forgetting all the chiefs or regents who granted permission for the exercise to take place in their communities. My sincerest thanks also go to Dr. R. Koffie of the Council for Scientific and Industrial research Institute (CSIR), Accra, for his pieces of advise. University of Ghana http://ugspace.ug.edu.gh Abstract This study is about the spatial patterns of the Mycobacterium ulcerans infections (Buruli ulcer) in the Akwapim South district. The Triangle of Human Ecology model was used to account for the observed spatial patterns of the disease. The spatial distribution of the disease was mapped through the residential addresses of the patients as shown in the district medical records. The endemic communities were stratified into three segments namely the high, low and non­ endemic areas or zones. The settlements for the study were then randomly selected from each stratum. This was proceeded by the selection of the target population according to the research objectives. Primary data were collected from three sources namely the household heads, Buruli ulcer patients and the health personnel (including the District Director of Health Services). Besides this, direct personal observation of the natural environment as well as interviews with certain individuals yielded primary information this study. The study looked out for the magnitude of the problem, the underlying factors of the spatial patterns and the socio-economic impact on the populace. Children were found to be more vulnerable to infection than adults. Thus prevalence decreased with age with an overall slight female predominance in incidence. It was further discovered that the quality of the natural environment to a very large extent influenced the spatial variations of the disease. It was more prevalent along watercourses and low-lying areas but non-existent on high grounds with better drainage. This confirms the research proposition and findings elsewhere that the disease is more prevalent along water bodies. University of Ghana http://ugspace.ug.edu.gh Low patronage of health care facilities influenced by the socio-economic status of the respondents and the skewed distribution of such facilities was observed to have contributed to the incidence of the disease in the communities. For it is believed that accessing a health facility for advice earlier could have lessened the scourge. Restricted access to health facilities thus varies from place to place and this reflects in the spatial patterns of the disease. The disease, it was discovered had adversely affected the socio-economic lives of the patients themselves and their families due to prolonged treatment. This supports the fact by some scholars that prolonged treatment or hospitalization can bring untold hardships to both patients and their families. Efforts by the health authorities in the district to check the spread of the disease were thwarted resource constraints. The study concludes that the disease is a socio-economic problem, thus recommendations have been made, which if implemented will reduce incidence in the future. University of Ghana http://ugspace.ug.edu.gh Table of contents Title Dedication....... Declaration... Acknowledgement... Abstract........... List of figures... List of tables... List of plates... Page i ii iii v xi xi xii CHAPTER ONE: 1.0 RESEARCH PROBLEM AND CONCEPTUAL FRAMEWORK 1.1 Introduction... ......................................................... 1.2 Statement of the problem... .............................................. 1.3 Literature review.......................................................................... 1.3.1 Meaning of Buruli ulcer..................................................... 1.3.2 Clinical manifestation of Buruli ulcer................................ 1.3.3 Mode of transmission........................................................ 1.3.4 Spatial variation of the disease........................................ 1.3.5 Consequences of the disease......................................... 1.3.6 Factors underlying spatial variation of diseases.............. 1.3.7 Evidence of disease and the natural environment.......... 1.4 Conceptual framework................................................................ 1.4.1 Elaboration of the Triangle of Human Ecology model...... 1 ...1 ...4 ...12 ...12 ...14 ...17 ...18 ...21 ...23 ...25 ...27 ...27 University of Ghana http://ugspace.ug.edu.gh 1.4.2 Justification of the model for the study................ 1.5 Research objectives......................................................... 1.6 Research propositions ............................................... 1.7 Justification of the study.................................................... CHAPTER TWO: 2.0 THE STUDY AREA AND RESEARCH METHODOLOGY 2.1 Introduction..................................................................... 2.2 The study area ......................................................... 2.2.1 Location and size................................................... 2.2.2 Vegetation.............................................................. 2.2.3 Climate................................................................... 2.2.4 Topography and drainage... ........................ 2.2.5 Soils and ecological zones.................................... 2.2.6 Population.............................................................. 2.2.7 Health facilities....................................................... 2.2.8 Water and sanitation.............................................. 2.2.9 Structure of the local economy.............................. 2.2.10 Economic activities... ................................... 2.2.11 Transportation network.......................................... 2.3 Research methodology..................................................... 2.3.1 Sources of data...................................................... 2.3.2 Research instruments and target population...................... vii ...30 ...33 ...33 ...34 35 ...35 ...35 ...35 ...37 ...37 ...37 ...38 ...38 ...39 ...40 ...41 ...41 ...42 ...43 ...43 ...43 University of Ghana http://ugspace.ug.edu.gh 2.3.3 Sampling design and size... ... 2.3.4 Data analysis and presentation....... 2.3.5 Data limitations................................. ...46 ...47 ...44 CHAPTER THREE: 3.0 THE MAGNITUDE AND SPATIAL PATTERNS OF BURULI ULCER 49 3.1 Introduction... ............................................... 3.2 The magnitude of the problem.......................................... 3.3 Risk factors and transmission dynamics... ............... 3.4 Geographical distribution of the disease... ............... 3.5 Observed demographic dimensions of Buruli ulcer patients.. 3.5.1 Sex................................................... 3.5.2 Age...... ... ... ... ... 3.5.3 Occupation... ........................ 3.5.4 Religious background of the patients 3.5.5 Marital status.................................... 3.5.6 Educational background.................. 3.5.7 Ethnicity............................................ 3.5.8 Travel history of patients ... Conclusion ................................... ...49 ...49 ...54 ...56 ...60 ...60 ...62 ...64 ...65 ...66 ...66 ...67 ...69 ...71 CHAPTER FOUR: 4.0 FACTORS UNDERLYING THE OBSERVED SPATIAL PATTERNS 72 4.1 Introduction... 72 University of Ghana http://ugspace.ug.edu.gh 4.2 Buruli ulcer and the natural environment.................................................72 4.3 Utilization of health services in relation to the incidence of Buruli ulcer...........................................................................................75 4.3.1 Utilization and distance............................................................... 75 4.3.2 Ability to pay for health care........................................................81 4.3.3 Educational status and the utilization of health services by Households with respect to the incidence of the disease...........83 4.4 Lifestyles or behaviour and Buruli ulcer... ..................................... 91 4.4.1 Scarcity of drinking water and poor hygiene...............................91 4.4.2 Water contact activities that predispose the population to infection.................................................................. 94 4.4.3 the role of health w o rke rs .........................................................96 4.5 Conclusion................................................................................................98 CHAPTER FIVE: 5.0 CONSEQUENCES OF BURULI ULCER INFECTION AND STRATEGIES TO CHECK ITS SPREAD 99 5.1 Introduction... ......................................................99 5.2 Effect of the disease on the human body (Physical effect)................. 99 5.3 The stigma attached to the disease......................................................100 5.4 Effect on marriage... ...................................................................102 5.5 Effect on socio-economic activities...................................................... 103 5.5.1 Effect on education........................................................... 103 5.5.2 Effect on economic activities...................................................... 105 5.5.3 Impact on health resources.........................................................108 5.6 Strategies to check the spread of the disease... ..........................109 IX University of Ghana http://ugspace.ug.edu.gh 5.7 Conclusion. .110 CHAPTER SIX: 6.0 SUMMARY, CONCLUSION AND RECOMMENDATIONS 6.1 Summary........................................................................... 6.2 Conclusion........................................................................ 6.3 Recommendations... .............................................. Bibliography... ......................................................... Appendices... ....................................................... 112 ...112 ...114 ...115 ...122 ...128 X University of Ghana http://ugspace.ug.edu.gh List of figures Figure 1.1: Spatial distribution of Buruli ulcer cases in Ghana..................... 7 Figure 1.2: The Triangle of Human Ecology... ................................... 28 Figure 2.1: Map of the study area..................................................................36 Figure 3.1: Spatial patterns of the Buruli ulcer in the Akwapim South district....................................................................59 Figure 3.2: The sex distribution of the observed patients by residence.............. 61 Figure 3.3:The age distribution of the observed patients by residence...............62 Figure 3.4: Occupational distribution of the observed patients by residence... 64 Figure 3.5: The religious background of the patients by residence................. 65 Figure 3.6: Educational profile of the observed patients by residence 67 Figure 3.7: Ethnic background of the p a tie n ts .............................................. 68 Figure 3.8: Travel history of the observed patients by residence.................... 70 Figure 5.1: Effects of treatment on education of patients................................ 104 Figure 5.2: Economic effects of Buruli ulcer infection... ............................106 List of tables Table 1.1: Reported cases of Buruli ulcer cases in Ghana by regions between 1993 and 1997... ................................... 5 Table 1.2: Number of districts reporting cases of Buruli ulcer by regions in 1999... 6 Table 1.3: Sex distribution of Buruli ulcer cases by regions in Ghana, 1999 ......................................................... 8 Table 2.1: Buruli ulcer endemic areas by sub-districts and reported cases between 1998 and 1999 in the Akwapim South district............. 45 Table 2.2: Selected settlements and sample size for the study...................46 Table 3.1: Reported Buruli ulcer cases per district in the Eastern region in 1999.............................................................................. 50 University of Ghana http://ugspace.ug.edu.gh Table 3.2: Some ten communities with high cases of the Buruli ulcer in the Table 3.3: Table 3.4 Table 4.1 Table 4.2 Table 4.3 Table 4.4 Table 4.5 Table 4.6 Table 4.7: Table 4.8: Akwapim South district..................................................... Age and sex distribution of reported Buruli ulcer cases in the Akwapim South district between August 1998 and March 2000 ................................... Respondents’ perceptions on the cause of the disease Utilization of health services by residence....................... Respondents’ choice of medical treatment by residence... Responses on the time gap between infection and first visit to a health facility... ................................... Educational status of household heads by residence... Utilization of health services by education per household Knowledge of cause of the disease according to the educational level of household heads and patients by residence..................................................................... Knowledge of the cause of the disease by zone............. Source of drinking water for communities as indicated by the patients according to residence................................. . . 51 ...52 ...53 ...77 ...80 ...82 ...84 ...86 ...88 ...90 ...92 List of plates Plate 1: Early ulcer... ...16 Plate 2: Late ulcer... ...16 XII University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE 1.0 Research Problem and Conceptual Framework 1.1 Introduction Buruli ulcer is an emerging disease caused by mycobacterium ulcerans (from the family of bacteria, which cause tuberculosis and leprosy). It brings about severely deforming ulcers, mainly in children and women who live in rural areas near rivers or wetlands. The disease in recent years, has become a significant source of human suffering in many parts of the world, especially in West Africa where there has been a large number of cases in the last ten (10) years (WHO, 1998; Asiedu, 1999). This situation finds expression in the words of the World Health Organisation's (WHO) Regional Director for Africa, that "the incidence of Buruli ulcer is rapidly growing in West Africa, and that almost all countries along the Gulf of Guinea are now affected" The disease has been reported in at least twenty-seven (27) countries around the world, mostly in the humid tropics (Asiedu, 1999). Currently, 25 percent of all infection end up with a permanent disability (WHO, 2000). It is ranked as the third most common mycobacterium disease among humans after tuberculosis and leprosy (WHO, 1998; Asiedu, 1999). The World Health Organisation (WHO) estimates that the growing incidence of the disease in Africa will one day surpass the scourge of leprosy. In some regions, it already poses more of a health care problem than tuberculosis (WHO, 1998). For instance in an endemic area in La Cote d’ Ivoire, new cases increased more than threefold between 1987 and 1991 (Marston et. al., 1995). Approximately ten thousand cases have been recorded since 1978 in Ivory Coast, and up to 16% of the population in some villages are University of Ghana http://ugspace.ug.edu.gh afflicted (WHO, 1998). Over two thousand three hundred cases have been reported since 1989 in Benin, and in Ghana up to 22% of villages are afflicted in some areas (WHO, 1998). In addition to a large increase in new cases documented in Benin between 1986 and 1996, there has been an outward spread of the disease from initially restricted foci (Aguiar et. al., 1997). This suggests that the disease is more endemic in some areas than others. Buruli ulcer most commonly affects poor people in remote areas with limited access to health care, poor transportation system and lack of potable water (Asiedu, 1999). The problem is particularly tragic because it is children who are the most vulnerable. It is difficult to assess the burden of the disease at the global and national levels. Therefore there is a huge under-reporting of it. This makes the reported cases seem like the tip of an iceberg (Johnson, 1999). Awareness of the disease is generally low in the medical community and the general public alike (WHO, 2000). Though the disease is dreadful, seeking medical care is delayed partly due to poverty, difficult geographic access to health facilities, attribution of the illness to superstition, low literacy level, stigmatisation and failure to make a diagnosis at the early stages. These factors combine to worsen affliction caused by the disease (Asiedu, 1999). The disease apart from its medical implications has social, economic and cultural dimensions. The impact on health services and scarce health resources is great. The high cost of care can affect health institution's ability to recover cost. Complications are frequent and severe, and hospitalisation is prolonged and costly. Treatment cost per patient far exceeds per capita health spending. 2 University of Ghana http://ugspace.ug.edu.gh Socially, prolonged periods of hospitalisation can disrupt a child's schooling and the working lives of adults. A patient's income generating ability could be adversely affected. This in turn can affect the health and welfare of children in the family. In the long-term, people deformed by the disease may be rendered unemployed and will have to depend on family members for sustenance. In the midst of the growing incidence of the disease and the associated complications, it could have adverse substantial effect on rural populations where it is very common. This is because their main economic activities would be severely affected. Recognising Buruli ulcer as an emerging public health threat, the WHO in 1997 established the Global Buruli Ulcer Initiative with the aim of raising awareness about the disease, mobilising support to assist endemic countries, promoting and co­ ordinating scientific research and bringing together all interested parties. In this regard, the WHO in 1998 held an International Conference on Buruli ulcer in Yamoussoukro, La Cote d’ Ivoire. Its aim among other things was to share information and further develop a global strategy for Buruli ulcer control and research. Heads of state, health ministers, scientists and representatives of international organisations attended the conference. Representatives from more than twenty (20) countries who attended the conference signed the Yamoussoukro Declaration on Buruli ulcer and pledged to control further spread of the disease. The remarks made by the then Director-General of the WHO that "we have an enormous task ahead as we begin the fight against this disease (Buruli ulcer)" underscores the gravity of the situation. Considering the gravity of the situation on hand, participants 3 University of Ghana http://ugspace.ug.edu.gh at the conference pledged to intensify action against Buruli ulcer as part of the primary health care, provide simple surgical facilities for the treatment of the disease in its early stages, and improve and sustain health education programmes at all levels. The initiative has so far focused on three West African states: Ghana, Benin and La C6te d’Ivoire (WHO, 2000). It is worth noting that, before an individual can be adequately motivated to learn and accept better health practices, that person must appreciate a definition of existence of disease, evaluate such a disease as constituting a threat to personal and public well-being and take positive steps to alleviate such a threat. Unfortunately, most illiterates as well as some literate individuals do not believe that poor hygienic conditions can lead to an outbreak of epidemics, which can impact adversely on the population in terms of diseases. Diseases caused by insanitary conditions will be reduced if and when communities have enough safe water and practice good hygiene. This really poses a big problem to countries experiencing Buruli ulcer. From the national situation of the Buruli ulcer, it can be concluded that the disease, if not checked now, will in the future pose a serious health threat to the Ghanaian society. It is against this background that this research focuses on the spatial patterns of the disease in the Akwapim South District. 1.2 Statement of the problem The first case of Buruli ulcer in Ghana was reported at the Korle-Bu Teaching Hospital in Accra in 1971 (Bayley, 1971). Since then, cases have been described in riverine rural areas in the country. Ninety-six cases were described in the Asante 4 University of Ghana http://ugspace.ug.edu.gh Akim North District (van der Werf et. al., 1989) and ninety cases in the Amansie West District (Amofa et. al., 1993 & 1998). Thus the number of reported cases has been increasing since 1993, with its attendant socio-economic and health implications. Between 1993 and 1997,nearly two thousand cases were reported. Six of the ten regions and thirty-five of the one hundred and ten districts of the country were affected but the exact magnitude of the problem is not yet known. This points to the fact that the disease is emerging as a big threat to society and something ought to be done in order to reduce its incidence. Table 1.1 shows the reported cases of Buruli ulcer by administrative regions of Ghana between 1993 and 1997 Table 1.1:Reported cases of Buruli ulcer by regions between 1993-1997 Region 1993 1994 1995 1996 1997 Total Ashanti 300 153 95 83 139 770 Central 25 58 82 112 89 366 Greater Accra 29 47 66 14 567 723 Eastern 11 - - 11 Volta 5 - - - 5 Brong Ahafo - 4 1 4 9 Western - - - - - - Northern - - - - - Upper West - - - - - Upper East - - - - - - Total 370 262 244 213 795 1884 Source: Ministry of Hea th, 199f The situation as it was between 1993 and 1997 has changed significantly. Results of the National Buruli Ulcer Case Search, conducted by the Ministry of Health in 1999 showed an appreciable increase in the incidence and prevalence of the disease. Reported cases according to the survey results now stand at over six thousand. It showed an increasing geographical spread of the disease. Cases have so far been recorded in all the ten administrative regions. All but eighteen of the one 5 University of Ghana http://ugspace.ug.edu.gh hundred and ten districts in the country reported incidence of the disease (Ministry of Health, 1999). This is shown in Figure 1.1. Table 1.2 shows the districts in Ghana reporting incidence of the disease according to the results of the National Case Search for Buruli ulcer, Ghana, 1999. This distribution as shown on the map (Figure 1.1) indicates a uniform regional distribution but not so at the district level. Table 1. 2: Number of districts reporting cases of the Buruli ulcer per region in 1999 Region Number of districts Number reporting cases Number reporting zero cases Number reporting less than 5 cases Number reporting 5 or more cases Ashanti 18 15 3 0 15 Brong Ahafo 13 9 4 4 5 Central 12 12 0 0 5 Eastern 15 14 1 0 14 Greater Accra 5 4 1 1 3 Northern 13 10 3 2 8 Upper East 6 6 5 1 0 Upper West 5 3 2 1 2 Volta 12 9 3 4 5 Western 11 9 2 1 8 Total 110 90 20 13 77 Source: Ministry of Health, Accra, 1999 6 University of Ghana http://ugspace.ug.edu.gh FIG.1.1 NATIONAL BURULI ULCER CASE SEARCH, 1999. DISTRIBUTION OF CASES BY DISTRICT University of Ghana http://ugspace.ug.edu.gh The statistics shown in Tables 1.1 and 1.2 show the geographical distribution of the disease. They exhibit significant regional differences. Interestingly, it is prevalent in rural areas where it is believed, conducive environmental conditions prevail for the microbe to thrive. This uneven spatial trend suggests an association between the disease and the environment (natural and social). Differences in the environment partly explain much of the spatial variations in the geographical distribution. Besides the spatial trend, the disease further exhibits demographic patterns. Children and women are the most vulnerable group. However, the sex ratio is not static. It varies from region to region. Results of the National Case Search Survey undertaken in 1999 revealed a slight male dominance in the cases analysed. This information is shown in Table 1.3. It is interesting to note that the prevalence rate in Ghana decreases with age. "able 1.3: Sex distribution of cases by regions in 1999 Region Male Female Total Ashanti 705 698 1403 Brong Ahafo 159 181 340 Central 658 556 1214 Eastern 238 172 410 Greater Accra 567 597 1164 Northern 81 74 155 Upper East 36 61 97 Upper West 42 52 94 Volta 97 106 203 Western 207 153 360 Total 2790 2650 5440 Source: Ministry of Health, Accra, 1999 The incidence of the Buruli ulcer as it is in the other parts of the world, is very high in rural areas in Ghana. Some of these areas lack basic social amenities such as 8 University of Ghana http://ugspace.ug.edu.gh health facilities, potable water and good transportation system to mention a few. Lack of these facilities to some extent deters people from seeking medical care when the need arises. That apart, poor transportation system hinders spatial accessibility patterns to health facilities. Buruli ulcer has caught the attention of medical personnel in the Akwapim South District in recent times. It is becoming a serious public health problem in the district. It exhibits a patchy spatial pattern with high incidence in the remote parts of the district. It was first detected in August 1998 with over seventy cases in one of the five administrative sub-districts. A total of seventy-six cases were recorded in the district at the end of that year. This has branded the area as the Buruli ulcer endemic zone. These initial disease foci have spread to other communities in the remaining sub-districts by the beginning of 1999. However, the incidence of the disease in these new areas is not as high as it is in the initial foci. In other words, the magnitude in those areas is not as much as it is in the Pakro-Dego sub-districts. Thus some communities are described as more prone to the disease than others. Despite the number of cases reported so far, there are others who have the disease but are yet to report at any of the various health facilities for medical attention. This makes the reported cases seem like the tip of an iceberg in the district. By the end of April 2000, over one hundred cases had been registered in the whole district. These include clinical observations, pathological data and socio­ demographic information as a means of establishing the geographical distribution of endemic communities. 9 University of Ghana http://ugspace.ug.edu.gh The spread of the foci into other areas suggests a correlation between the disease and the environment. It is interesting to note that all the foci of the disease are located mainly in the remote rural areas of the district characterised by lack of health facilities, poor transportation system and lack of good drinking water. The disease, apart from its spatial variations also exhibits demographic patterns. It has affected people aged between three (3) and seventy (70). Most of the cases involve children or teenagers aged between three (3) and eighteen (18) years. The prevalence rate decreased with age; for over half of the reported cases involved people aged less than twenty years. Interestingly, there is a slight male dominance. In addition to these demographic facts, no seasonal variations in incidence were observed perhaps due to the accumulated cases over time. The incidence of the disease has been associated with lack of safe water in the areas designated as endemic. This is because some of the communities that have the disease do experience water shortage due to drying up of major water bodies as a result of deforestation. In addition to the drying up of water bodies during the dry season, some of the areas with the disease do not have adequate pipebome water as an alternative source of safe water supply. This compels the people to depend on unprotected ponds as the main source of water supply. Considering the serious health, social and economic impact associated with the disease, it is seen as a big threat to the economic and social lives of the people in these areas. Socially, children are the most vulnerable group afflicted. They may lose their education since treatment is prolonged or they may be compelled to work to support their ailing parents or guardians. This will result in loss of manpower in the 10 University of Ghana http://ugspace.ug.edu.gh future. The economic activities of affected adults will be crippled and this will impact negatively on the family in diverse ways. Ever since the disease was first detected in the district, serious efforts have been made to alleviate the plight of the afflicted and to halt its further spread. The Disease Control Unit of the Ministry of Health in the district, in collaboration with the Village Health Committees are prevailing upon those with the disease to show up for treatment yet response to the call according to the health workers is not encouraging. The question to address is why people with the disease are not showing up for treatment. It can be concluded from the discussion that although the disease is on the increase, its spatial distribution continues to be uneven. In addition, the Akwapim South District has a majority of its population engaged in agriculture. Unfortunately, this dreadful disease is threatening the well being of the people, which if not checked, will in the future grind all economic activities to a halt. Hence, the disease is worth studying so as to understand the spatial patterns of the disease in order to come out with recommendations that will help alleviate the socio-economic problems that it brings about. From the discussion so far the research questions are as follows: 1. What is the socio-economic impact of the disease on the communities? 2. Oral evidence gathered in the endemic communities indicates that the disease has been in existence for decades. The question then is, how come the disease did not receive attention from both health personnel and the public until recently. 11 University of Ghana http://ugspace.ug.edu.gh 3. What mechanism has been put in place by the District Health Management Team to identify unreported cases for treatment? The lack of any study on the spatial patterns of the Buruli ulcer in the Akwapim South District makes this study relevant. Existing work on the disease has focused attention on the mode of transmission of the causative microbe and who is affected. This interests medical scientists, epidemiologists and demographers who are currently researching Buruli ulcer. Not much interest has been shown in the identification of Buruli ulcer origins to highlight variations in socio-demographic and ecological factors that seem to promote differentials in Buruli ulcer incidence. The geographer's interest in the region, disease ecology, location and allocation of health resources, the use of appropriate health interventions and the use of maps for illustration are therefore needed to make a more meaningful contribution to health planning and development. The research assumes that the principal underlying factor in the spatial patterns of the disease in the Akwapim South District is the natural environment, which may show variation among the different sub-districts within the district. The identification of high-and low-risk Buruli ulcer areas in the district is the subject of study. The results of this investigation, it is envisaged will help health authorities in the district and elsewhere to adopt strategies to curb the disease. 1.3 Literature review 1.3.1 Meaning of Buruli ulcer Buruli ulcer is a skin ulcer caused by infection of the skin by Mycobacterium ulcerans (van der werf et.al., 1989; Asiedu, 1999). It has various geographic names 12 University of Ghana http://ugspace.ug.edu.gh such as Baimsdale ulcer, Kasong ulcer, Kakerifu ulcer, Tora ulcer, Mexican ulcer, and Kumusi ulcer just to mention but a few (Asiedu et. al., 1998). The causative organism was first described by MacCallum, who discovered acid-fast bacilli in a biopsy from a leg ulcer in a young child from Baimsdale, Australia in 1940 (Asiedu et. al., 2000). Before 1948, the disease was already known in Africa. Large ulcers, caused by mycobacterium ulcerans, were described by Sir Albert Cook in 1897 (van der Werf et. al., 1989; Asiedu, 1999; Asiedu et. al., 2000). In the period 1923 to 1935, Kleinschmidt, a missionary physician in north-east Congo, observed undermined skin lesions in acid-fast bacilli (Meyers et. al., 1974). In Africa, the history of Buruli ulcer can be divided into two main periods namely before 1980 and after 1980 (Asiedu et. al., 2000). There were many important publications before 1980 on the disease in several African countries namely Cameroon, the Democratic Republic of the Congo, Gabon, Ghana, Nigeria and Uganda. There were suspected cases in the Central African Republic, Kenya, Sudan and Tanzania, but these were never confirmed (Asiedu et. al., 2000). The most significant contributions came from the Democratic Republic of Congo and Uganda. A new focus of Buruli ulcer emerged in West Africa, after 1980 (Asiedu et. al., 2000). There has been a growing incidence of Buruli ulcer in several West African countries, especially in Benin, La C&te d’Ivoire and Ghana. The geographic area in Uganda having the first large number of identified patients gave these lesions their popular appellations, Buruli ulcer (Dodge and Lunn, 1962; Asiedu, 1999; Asiedu et. al., 2000). Geographic names for the disease are useful only in local foci. This is because the word "Buruli" for instance, cannot be 13 University of Ghana http://ugspace.ug.edu.gh applied to all parts of the world that are not situated in the Buruli district in Uganda. To this end, a non -geographic name is preferred to the large numbers of the synonyms. Thus, Pradinaud et. al.,(1998) proposed non- geographic names such as Cutaneous ulcer caused by Mycobacterium Ulcerans or Skin Ulcers caused by Mycobacterium ulcerans or perhaps better, Mycobacterium ulcerans skin ulcers. These non­ geographic names will be acceptable to all irrespective of geographic location. It (Buruli ulcer) affects people in remote rural areas with restricted access to health facilities. About 70% of cases are children up to fifteen (15) years (Asiedu, 1999). Any part of the body can be affected, however, the disease is most common in the limbs or the exposed parts of the body. It can also affect any racial group. 1.3.2 Clinical manifestation of the disease The disease starts as a painless swelling in the skin as shown in the plate. A firm and painless nodule one to three centimetres in diameter (Asiedu 1999; WHO, 1998) develops under the skin teeming with mycobacteria. Unlike other mycobacteria, Mycobacterium ulcerans produces a toxin, which destroys tissue and suppresses the immune system (WHO, 1998; Travis, 1999). The nodule, when raptures initiates the development of the ulcer. Sometimes bones, breasts, genitalia just to mention but a few are destroyed causing grossly deforming ulcers, peculiar to Buruli ulcer and easy to recognise. When lesions heal, scarring may cause restricted movement of limbs and other permanent disability. Three different clinical stages of development of the disease can be described. These are the pre-ulcerative stage marked by painless and sometimes 14 University of Ghana http://ugspace.ug.edu.gh itchy nodule. Second, the ulcerative stage involves the development of lesions and the post- ulcerative stage which is a complication resulting directly from the disease such as contracture deformities, loss of sight and amputation. Plates 1 and 2 show development of Buruli ulcer at early and advanced stages respectively. Treatment with antibiotics has been disappointing (Sciencenews, 1999) especially where there is an extensive ulceration. The futility of some past antibiotic use may reflect the fact that Africans or people with the disease generally do not visit physicians until far into the disease's progression. To this effect, early diagnosis of Mycobacterium ulcerans infection is crucial especially when scientists suspect that the microbe may sometimes reside in the body for months or years before it starts to eat away tissues. Now, the only available treatment for Buruli ulcer is surgery to cut out the lesion, with a skin graft if necessary. In severe cases (for instance when bones 15 University of Ghana http://ugspace.ug.edu.gh Stages of development of Mycobacterium ulcerans infection Plate 1: Early stage in the development of ulcer. Source: Asiedu, 1999 Plate 2: Late uicer, characterized by extensive laceration Source: Asiedu, 1999 University of Ghana http://ugspace.ug.edu.gh are destroyed) amputation may be necessary. Thus early detection and surgical removal of small nodules could prevent complications (Asiedu, 1999). Not many people die from the disease. 1.3.3 Mode of transmission The route of transmission of the causative organism (Mycobacterium ulcerans) is poorly understood. However, considerable evidence suggests that direct or indirect trauma on the skin provides a passage for the organism into the skin. In support of this hypothesis, most cases occur on exposed surfaces, particularly over bony parts of the body and in children who have higher (conscious or unconscious) trauma rate and less tough skin than adults. It has been found out that it does not occur on the trunks of Caucasians who usually keep that part of their body covered. It rather occurs mainly on the lower leg Radford (1974). This suggests that incidence rate is high in the exposed parts of the body. Further evidence by Meyers et. a!., (1974) supports the direct entry by the causative organism into the skin. It was reported in that study that 8% of the patients surveyed in the Bas region in Zaire remembered an event of specific trauma at the ultimate site of the lesion. Lastly, the disease is rarely transmitted from one patient to another. However, the possibility of case-to-case transmission person cannot be ruled out (Bruce, 1998). 17 University of Ghana http://ugspace.ug.edu.gh 1.3.4 Spatial variation of the disease Buruli ulcer shows an interesting patchy distribution around the tropical as well as in the temperate areas of Australia (van der Werf et. al., 1989). It occurs in isolated foci where it may be common, separated by large areas in which it is rare or absent. This suggests lack of even spatial spread of the disease. The disease is commonly found in remote rural villages near slow-flowing or marshy parts of the tropical and sub-tropical regions of Africa, Asia, Latin America and the Western Pacific (WHO, 1998; Asiedu, 1999). Because all major endemic foci are in wetlands of tropical or sub-tropical countries, environmental factors must be seen to be playing a crucial role in the survival of the aetiology agent. It can therefore be concluded that the disease is associated with riverine rural areas. However, the association is not very clear (Bruce, 1998; Asiedu et. al., 2000). Muelder (1988) noted that the more families depend on surface water for their daily needs, and the closer they live to it, the more probable infection becomes. In a review of all identified cases of Buruli ulcer in Uganda in 1970, Barker noted that all the five hundred and seventy-two (572) cases lived within thirty miles of the river Nile, especially around water-courses, or swamps where the river flowed through flat and swampy lands. In the same study but reported elsewhere, there was evidence of a progressive fall in incidence with increasing distance from the river Nile in two districts. It was then postulated that there was an initial focus of infection beside the river Nile, which gradually spread away from the river after major floods, which occurred in Uganda between 1962 and 1964 (Bruce, 1998). 18 University of Ghana http://ugspace.ug.edu.gh The spatial spread of the disease has also been associated with environmental changes. There have been focal outbreaks followed from flooding and man-made topographical modifications such as dams (Asiedu et. a i, 2000; WHO, 1998). This goes further to buttress the fact that the disease is associated with slow- flowing and stagnant water-bodies. According to Hayman and Asiedu (2000), infection occurs only after significant environmental changes or disturbance. In the Baimsdale district in Australia where first cases were diagnosed, there had been the worst floods in the district, when all roads and rail links were cut. Furthermore in Uganda, Barker examined cases of Mycobacterium ulcerans infection in the Busonga district on the east of the Victoria Nile, north of Lake Victoria (Barker, 1972). Although cases were known in other parts of the country, there were no known cases in that district before 1965. It was then postulated that the outbreak was related to unprecedented flooding of the lakes in Uganda between 1962 and 1965 as a result of heavy rainfall (Hayman and Asiedu, 2000; Lunn 1962). Evidence from Nigeria also indicates that infections have occurred among Caucasians living on the campus of the University of Ibadan after 1965 (Oluwasanmi et. at., 1976), when a small stream flowing through the campus was dammed to make an artificial lake. The first case reported in La C6te d'Ivoire was a seven-year- old French boy who lived beside Lake Koussou, an artificial lake in the centre of the country. Evidence from Liberia has it that there have been cases in the north of the country following the introduction of a swamp rice field to replace an upland one Ziefer et. ai., (1981). The agricultural change was accompanied by the construction of I9 University of Ghana http://ugspace.ug.edu.gh dams on the Mayor River to extend the wetlands. In Papua roe\M'