KNOWLEDGE OF BURULI ULCER AMONG MEDICAL PERSONNEL IN SOUTH-WEST, NIGERIA

Running Title: Knowledge of Buruli Ulcer among Medical Personnel

1. AJOGBASILE Fehintola (B.Sc) Redeemer’s University, Ede, Osun State, Nigeria

2. OKE Adewale Adegboyega* (MSc.) Redeemer’s University, Ede, Osun State, Nigeria.

3. KOMOLAFE Isaac Omotosho Olumuyiwa (PhD.) Redeemer’s University, Ede, Osun

State, Nigeria

*Corresponding Author:

OKE Adewale Adegboyega

Department of Biological Sciences, Redeemer’s University, Off Gbogban – Oshogbo Road, P. M. B. 230, Ede, Osun State.

E-mail Address: okead@run.edu.ng Phone No.: +234-808393985596, 08106363873

1. All the authors listed contributed equally to the research and the preparation of the

manuscript.

2. The authors declare there is no competing or conflicts of interest.

3. No funding received from any organization for the research and the preparation of the

manuscript

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ABSTRACT

Background: Buruli ulcer (BU) is a devastating and debilitating infection of the skin and

subcutaneous tissue caused by Mycobacterium ulcerans and it is one of the world’s neglected

tropical/sub-tropical diseases. Except in endemic areas, BU awareness is very poor or non-

existent even among medical personnel.

Objectives: The primary aim of this study was to assess the knowledge of BU among medical

personnel whose responsibility it is to diagnose, treat and report cases of BU as they present to

their health facilities in order to generate basic epidemiological data of the disease.

Methods: A total of 120 questionnaires were distributed to healthcare personnel in sixteen

hospitals/clinics in three states of south-west Nigeria.

Results: The results showed that 85%, 43% and 57% of doctors, nurses and medical laboratory

scientists respectively claimed to have heard of BU prior to this study but further answers

revealed their poor knowledge of the disease. While 59%, 85% and 71% of doctors, nurses and

laboratory technologists did not know the causative agent of Buruli ulcer, 95% of doctors did not

know how the agent is transmitted. None of the respondents knew the clinical forms of Buruli

ulcer nor the unique features of the disease. 92% of nurses did not know that BU is a skin

disease while 88% of doctors and 97% of nurses could not differentiate BU from other ulcers.

Some doctors (9%) and nurses (7%) said antiviral drugs could be used to treat BU whereas the

disease is caused by a mycobacterium. All the 120 (100%) respondents said BU exists only in

northern Nigeria whereas all the cases described till date, except one from Benue State, are from

southern Nigeria.

Conclusion: This poor knowledge of BU among health practitioners could hamper the detection,

prevention, control, treatment and surveillance of the disease.

Key words:

Buruli ulcer, knowledge evaluation, medical personnel, South-West Nigeria.

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Introduction

Buruli ulcer (BU) is majorly an infectious tropical or sub-tropical disease of the skin and

subcutaneous tissue caused by the bacterium, Mycobacterium ulcerans.[1-3] As one of the

seventeen neglected tropical diseases, BU has been reported in at least 30 countries worldwide

(Fig 1).[4]

The endemicity of BU is primarily associated with aquatic environment in remote and rural areas

especially among communities situated near lakes, other stagnant pools of water, wetlands or

slow-flowing streams particularly in tropical and subtropical countries in Central America,

Australia, south-east Asia and Africa. However, the major burden of disease falls on West and

Central African countries especially Benin Republic, Cameroon, Cote d’Ivoire, Congo-

Brazzaville, Democratic Republic of Congo (DRC), Ghana and Togo.[4-7] Buruli ulcer is

regarded as an emerging disease that has attracted the attention of WHO with the establishment

of the Global Buruli Ulcer Initiative in 1998.[8]

Buruli ulcer usually presents as painless, or at best, a minimally painful, slowly progressive,

slowly healing but brutally disfiguring and crippling skin disease of humans. The process of

infection typically starts with a small painless nodule which progresses to an extensive skin peel-

off and subsequent destruction of the subcutaneous tissue, resulting into a large nectrotizing ulcer

with characteristic undermined edges over the course of several weeks. Occasionally bones are

involved and may be destroyed too resulting in osteomyelitis especially in bones adjacent to

cutaneous lesions and causing non-functional life-long disability/deformity of the affected parts.

[6,9,10] Though BU patients, particularly in sub-saharan Africa, are mostly children under 15 years

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of age, it also affects healthy people of all ages, races, and socio-economic classes and the major

known risk factor is proximity to water bodies.

Gray et al (1967) documented the first cases of BU in Nigeria in the Benue River valley around

Bambus area in the then Adamawa Province. [11] About a decade later, Oluwasanmi et al (1976)

described another case of Buruli ulcer in a Caucasian family residing close to a newly

constructed dam on the campus of the University of Ibadan in south-west Nigeria. This led to

the discovery of 23 more cases within and around Ibadan metropolis. The next two decades

witnessed no follow-up search or research on Buruli ulcer in Nigeria but unofficial reports show

that Buruli ulcer was still an emerging health hazard. Between 1998 and 2000, the Institute of

Tropical Medicine in Belgium confirmed Buruli ulcer cases from samples sent to it from the

Leprosy and Tuberculosis Hospital in Moniaya-Ogoja, Cross River State .[12-15]

In 2006, a WHO team in collaboration with the health authorities in Nigeria conducted a 5-day

case search for the disease in five states in the south-south and south-east regions of Nigeria. 37

specimens obtained from as many patients were examined at the Institute of Tropical Medicine,

Antwerp, Belgium, using the IS2404 PCR method.[16] 14 (38%) of the suspected cases were

positive for BU.

A recent publication of retrospective data of PCR-confirmed Nigerian patients with Buruli ulcer

treated in a treatment centre in the neighbouring Benin Republic gives credence to the fact that

Buruli ulcer is still present in Nigeria and may be more prevalent that had been previously

thought.[15] The fact that Buruli ulcer is not a reportable disease even in most endemic areas and

the variability in the clinical presentation of the disease leading to Buruli ulcer being mistaken

for other forms of skin ulcer do not make the determination of the burden of disease any easier.

However, the perceived lack of familiarity with the disease by health care givers, even when

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presented with WHO-confirmed images of the disease (Fig. 2) was the major focus of this study

and it was designed to assess the knowledge of BU and at the same time create awareness of the

disease among medical personnel which in turn, is expected to bring about a change in the

management and documentation of BU at the study sites and other hospitals in south-west

Nigeria. This study has not been carried out in Nigeria before.

Method

Study design

The evaluation of knowledge of medical personnel on Buruli ulcer entailed the design of a

questionnaire which was in two sections. The first section included the name/address of the

hospital or clinic, the type of hospital or clinic (public or private), the location of the hospital or

clinic (urban, semi urban or rural environment), the professional calling of the medical personnel

(doctor, nurse or medical laboratory scientist), sex, marital status, age and the working

experience in the health sector.

The second section contained the tools to assess the knowledge of medical personnel on Buruli

ulcer.

Study sites

This study was conducted in three states of south-west, Nigeria (Oyo, Ogun and Lagos States).

In Oyo State, the hospitals/clinics in which the study was conducted were the University College

Hospital (UCH), Oke-Ado Hospital, Ibadan Central Hospital, St. Mary Catholic Hospital,

Adeoyo Maternity Hospital and Zartech Health centre, all in Ibadan. The Redeemed Christian

Church Maternity Centre, Redeemer Health Centre, Redeemer’s University Health Centre,

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Olabisi Onabanjo University Teaching Hospital (OOUTH) and the State hospital, Ijebu-ode were

the study centres in Ogun State.

In Lagos State, the Lagos State University Teaching Hospital (LASUTH), General Hospital

Lagos Island, McDonald’s Hospital, Isalu Hospital and Adeniran Ogunsanya College of

Education Health Centre were the study centres used.

Study population

Over a period of 3 months, 120 questionnaires were distributed to relevant medical professionals

in various hospitals at different locations. The medical personnel involved in this exercise were

the doctors, nurses and medical laboratory scientists. All questionnaires were served and

retrieved same day while the researcher waited.

Data entry and statistical analysis

The data generated from the questionnaires were appropriately inputted into the computer and

analyzed using the Statistical Package for Social Science (SPSS), Evaluation Version 15.0. The

descriptive analysis was conducted using frequency tables for all the hospitals in the three states.

Results and Discussion

All the questionnaires distributed (100%) were returned for analysis. 8(53) of the

hospitals/clinics were government-owned while the remaining 7(47) were private facilities. The

number and percentage distribution of questionnaires were Oyo state (42/35%), Ogun state

(43/35.83%) and 35 (29.17%) in Lagos state. The study focused on three important medical

professionals - doctors (34/28.3%), nurses (72/60.0%) and medical laboratory scientists

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(14/11.67%). In terms of professional experience, the medical personnel that participated in this

study had a working experience ranging from 1 – 24 years (Fig. 3).

The results showed that 85.3% of the doctors claimed to have heard of Buruli ulcer, but only

58.8% claimed to have seen it on the skin. 60% did not know the causative agent of the disease

and only 10% of those who claimed to know got it right to be Mycobacterium ulcerans. 21%

claimed to know the mode of transmission of this disease but only 5% of them incriminated

aquatic insects while 24% said that BU could be transmitted from person to person which is not

correct. [5]

44% agreed that there was a link between Buruli ulcer, tuberculosis and leprosy but only 10%

knew that the causative agents all belong to the same (Mycobacterium) genus. None of the

doctors knew either the unique features of Buruli ulcer or the major clinical forms of it; yet, 12%

claimed they could differentiate Buruli ulcers from other ulcers or wounds. In addition, 41% of

the doctors admitted that Buruli ulcer was in Nigeria but only in the northern part. This is not

true as all the cases identified till date, were discovered in the south except the index case

discovered in Benue State in the Middle Belt. [16, 11,13-15]

While 43% of the nurses claimed to have heard about Buruli ulcer prior to this study through

various means, only 17% also claimed to have seen it, yet 92% could not associate BU, with the

skin. None of the nurses knew the causative agent of Buruli ulcer, yet, 10% of them claimed to

know the mode of transmission of Buruli ulcer, and 24% of them said that BU could be

transmitted from one person to another which is not true. 6% agreed that there was a link

between Buruli ulcer, tuberculosis and leprosy but none of them could explain the link.

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However, only 3% of the nurses said they could differentiate Buruli ulcer from other ulcers and

wounds but none of them knew the unique features and clinical forms of the ulcer. While only

15% of the nurses said BU was in Nigeria, all of them (100%) believed that the disease could

only be found in the northern part of the country. Among the laboratory scientists, 57% affirmed

they had heard about Buruli ulcer before, 36% claimed to have seen it, 29% claimed to know the

causative agent but only 5% got it right. 86% of them did not know the mode of transmission of

Buruli ulcer but 14% said transmission from one person to another was possible which is not

true. While 21% of them claimed to know the link between Buruli ulcer, tuberculosis and

leprosy, which they could not explain, 64% claimed they could differentiate Buruli ulcer from

other ulcers/wounds but none of them knew the unique features of the disease. Furthermore,

21% also believed Buruli ulcer was in Nigeria, but only in the northern part, which is not true.

Generally, a larger percentage of the respondents (70%) believed Buruli ulcer to be a neglected

disease because they did not know much about the disease. This study exposed the poor

knowledge of Buruli ulcer among the medical personnel particularly the nurses who represent

the first line of contact with suspected BU patients at the outpatient department (OPD).

Furthermore, the fact that all respondents (100%) believed that BU was not in southern Nigeria

would have negative impact on the diagnosis, treatment, reporting and surveillance of BU in

those healthcare institutions.

However, the level of awareness among medical personnel in south-west Nigeria when

compared to other BU endemic countries such as Ghana and Benin Republic in Africa is

unacceptably poor and unsatisfactory as it bothers on sheer ignorance. This can make it difficult

to generate basic epidemiological data, manage, prevent or eradicate Buruli ulcer in Nigeria.

The ultimate goal therefore, is to create awareness among the medical personnel and the general

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populace as a whole by organizing seminars, training workshops like the one that was carried out

in Ghana by the Buruli Ulcer Management Team. [17] Moreover, health education and awareness

can be conducted through posters, drama, jingles, television, radio station, newspapers and others

especially in the rural areas of Nigeria. This would help to scale up the control strategy of early

detection and treatment of Buruli ulcer in the affected areas just like it did in Cameroun. [33]

Furthermore, the full support of Government at all tiers of governance and the participation of

NGOs in providing the necessary funding and materials for the programme and research is

important.

A recent publication which emanated from Benin Republic identifies the south-western part of

Nigeria as an important endemic area for BU and enjoins the WHO, Nigerian Health Authorities

and NGO’s to concentrate their research efforts into this area for an in-depth epidemiological

study of BU in south-west Nigeria. [15]

Acknowledgements

We want to acknowledge all the doctors, nurses and medical laboratory technologists who

participated in this study and many thanks also to Dr. Ezra Gayawan, for his technical assistance.

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Figure Legends

Fig 1 - Geographical distribution of BU worldwide

Fig 2 - WHO-confirmed Buruli ulcer images

Fig 3 - Bar chart Showing Professional experience of medical personnel enrolled in the study

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