Buruli ulcer in southern Côte D'ivoire: dynamic schemes of perception and interpretation of modes of transmission

Knowledge, attitudes and practices towards yaws in endemic areas of Ghana, Cameroon and Côte d'Ivoire

Yaws, caused by Treponema pallidum ssp. pertenue, remains a significant public health concern in tropical regions of West Africa and the South Pacific, primarily affecting children in remote areas with limited access to hygiene and sanitation. In this study, conducted in three endemic countries of West Africa where yaws remains a significant public health concern (Ghana, Cameroon, and Côte d'Ivoire), we aimed to assess the knowledge, attitudes, and practices related to yaws among community members, community health workers (CHWs), and traditional healers. The study revealed variations in the perception of causes of yaws among community members: the majority or participants in Ghana attributed yaws to germs (60.2%); in Cameroon the most reported form of transmission was contact with or drinking infected water sources (44.6%); and in Côte d'Ivoire both of these answers were also the most prevalent (60.3% germs and 93.% water sources). A substantial proportion of participants in Côte d'Ivoire also associated yaws with witchcraft and divine punishment (44.8%). Only a small proportion of individuals in Ghana and Côte d'Ivoire correctly identified contact with an infected person as a form of transmission (11.9% and 20.7%, respectively) and less than half in Cameroon (42.6%), although more than 98% of all participants reported avoidance behaviours towards yaws infected people due to fear of getting infected. Most participants expressed a preference for seeking care at hospitals (49.2%, 60.6%, 86.2%) or health care professionals including doctors and nurses (58.5%, 41,5% and 17.2%) if they were diagnosed with yaws, although a quarter of participants in Côte d'Ivoire also sought support from traditional healers. The CHWs interviewed were generally well-trained on yaws causes and treatment options, although they often reported low availability of treatment and diagnostic tests for yaws. Our findings underscore the need for community education, awareness campaigns, ongoing CHW training, and improved access to yaws treatment and diagnostic resources. The data also suggest that collaboration with traditional healers, who usually hold a highly esteemed position in the society, such as giving training on yaws causes and transmission or exchanging knowledge on treatment options, could be beneficial in certain regions, particularly in Côte d'Ivoire.

Formulation and Stability of a 1% Clarithromycin-Based Topical Skin Cream: A New Option to Treat Buruli Ulcers?

There are more than 170 known species of non-tuberculous mycobacteria, and some are responsible for serious diseases in people infected with them. One of these is Buruli ulcers, a neglected tropical disease endemic in more than 33 countries and caused by Mycobacterium ulcerans, which infects skin tissue. Treatment consists of a long-term regimen combining the use of oral rifampin with another anti-tuberculosis drug (e.g., clarithromycin). Patients in these countries face difficulties in accessing and adhering to this therapy. This study investigates the feasibility of formulating stable, optimized clarithromycin as a topical cutaneous cream. The cream was formulated, and its stability was evaluated under different storage temperature conditions and using a stability indicator method. The results showed that the clarithromycin cream was stable for at least 60 days, even at extreme temperatures (40 °C). In conclusion, the data presented here demonstrate the stability of a new form of topical cutaneous clarithromycin, which may offer a new approach to the treatment of Buruli ulcers and clarithromycin-sensitive infections.

Buruli ulcer in Africa: Geographical distribution, ecology, risk factors, diagnosis, and indigenous plant treatment options - A comprehensive review

Buruli ulcer (BU), a neglected tropical disease (NTD), is an infection of the skin and subcutaneous tissue caused by Mycobacterium ulcerans. The disease has been documented in many South American, Asian, and Western Pacific countries and is widespread throughout much of Africa, especially in West and Central Africa. In rural areas with scarce medical care, BU is a devastating disease that can leave patients permanently disabled and socially stigmatized. Mycobacterium ulcerans is thought to produce a mycolactone toxin, which results in necrosis of the afflicted tissue and may be involved in the etiology of BU. Initially, patients may notice a painless nodule or plaque on their skin; as the disease progresses, however, it may spread to other parts of the body, including the muscles and bones. Clinical signs, microbial culture, and histological analysis of afflicted tissue all contribute to a diagnosis of BU. Though antibiotic treatment and surgical removal of infected tissue are necessary for BU management, plant-derived medicine could be an alternative in areas with limited access to conventional medicine. Herein we reviewed the geographical distribution, socioeconomic, risk factors, diagnosis, biology and ecology of the pathogen. Complex environmental, socioeconomic, and genetic factors that influence BU are discussed. Further, our review highlights future research areas needed to develop strategies to manage the disease through the use of indigenous African plants.

Accelerating the healing of hard-to-heal wounds with food supplements: nutritional analysis in the Côte d'Ivoire

OBJECTIVE

Hard-to-heal wounds are an important, yet often neglected, public health issue in low- and middle-income countries (LMICs). Malnutrition has been identified as a risk factor for prolonged healing times. However, nutritional supplements are not routinely provided for patients with hard-to-heal wounds, and so this study aimed to investigate their benefits.

METHOD

This 9-month study was conducted in the Taabo Health and Demographic Surveillance System in the south-central part of Côte d'Ivoire. Patients with wounds (≥30mm2) were recruited. Treatment was standardised for inpatients (72%) and outpatients (28%). There were three intervention groups: supplemented with soy; orange flesh sweet potato (OFSP); or both. Another group was included without supplement, serving as control. General linear models were employed to assess the effects of log initial wound size, type of wound, food treatment group, haemoglobin, sex, age, place of treatment and body mass index on the rate of wound closure.

RESULTS

The cohort consisted of 56 patients, 41 of whom were placed in intervention groups, and the remainder as controls. Within the cohort, 37 (66%) patients suffered from Buruli ulcer, 15 (27%) from traumatic wounds and four (7%) from erysipelas. We found a significant effect (p=0.004) of diet supplemented with OFSP on the wound healing rate.

CONCLUSION

OFSP is a nutritional rehabilitation supplement, characterised by a high content of beta-carotene and carbohydrates. It is associated with shortened wound healing times, reduced discomfort and reduced cost of wound care. Further research should investigate the effect of a diet rich in beta-carotene, in combination with standard medical care, on hard-to-heal wound healing in LMICs.

Perceived water-related risk factors of Buruli ulcer in two villages of south-central Côte d'Ivoire

BACKGROUND

Buruli ulcer, caused by Mycobacterium ulcerans, is a neglected tropical skin disease that is primarily endemic in West and Central Africa, including Côte d'Ivoire. Studies indicate that M. ulcerans infections are caused by contact with an environmental reservoir of the bacteria, governed by specific human biological conditions. Yet, the nature of this reservoir and the exact mode of transmission remain unknown.

METHODOLOGY

To identify ecologic risk factors of Buruli ulcer in south-central Côte d'Ivoire, we pursued a qualitative study matched with geo-referencing inquiry. Embedded in a broader integrated wound management research project, we (i) mapped households and water sources of laboratory confirmed Buruli ulcer cases and (ii) interviewed 12 patients and four health care workers to assess exposure to surface water and to deepen the understanding of perceived transmission pathways.

PRINCIPAL FINDINGS

Water availability, accessibility, and affordability were reported as key determinants for choosing water resources. Furthermore, perceived risks were related to environmental, structural, and individual factors. Despite the presence of improved water sources (e.g., drilled wells), communities heavily relied on unprotected surface water for a multitude of activities. The nearby Bandama River and seasonal waterbodies were frequently used for washing, bathing, and collection of water for drinking and cooking. Many residents also reported to cross the river on a daily basis for agricultural chores, and hence, are exposed to stagnant water during farming activities.

CONCLUSIONS/SIGNIFICANCE

Our study in two Buruli ulcer endemic villages in south-central Côte d'Ivoire revealed a wide range of water-related domestic activities that might expose people to an increased risk of contracting the disease. Environmental, biological, social, and cultural risk factors are closely interlinked and should be considered in future investigations of Buruli ulcer transmission. Active participation of the communities is key to better understand their circumstances to advance research and fight against Buruli ulcer and other neglected tropical diseases.

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.

Visible and invisible risks: Exploring washing and hygiene practices with women living on low income in Kenya

Shifting environmental conditions and poor or insufficient hygiene facilitates the transmission of bacteria and viruses between and within species of animals; between humans; and between humans and animals. Taking a One Health perspective, we used interviews to explore with 20 women living on low income in Kenya: their gendered hygiene practices and daily contact with animals; how and why they access water and sanitation facilities for themselves, their families, and any livestock; and their understandings of (zoonotic) health risks and disease transmission within their local environments. The women described how they worked every day to keep bodies and homes clean by washing bodies, surfaces and clothes. Women's hygiene practices focussed on removing visible dirt partly because of concerns for health but also to support their families' social standing in their community. While they were less aware of any 'invisible' risks to health through contact with animals or other hazards present in their daily living environments, most exercised care to source and manage water for drinking. Contaminated water was recognised as a risk to health suggesting that in this case, women accepted that there were 'invisible risks' to health, even in clear water, and took steps to mitigate them.

Impact of common skin diseases on children in rural Côte d'Ivoire with leprosy and Buruli ulcer co-endemicity: A mixed methods study

BACKGROUND

Skin-related neglected tropical diseases (skin NTDs) occur against a background of a very high prevalence of common skin diseases in sub-Saharan Africa. In this study, we examined the knowledge, attitude and practices (KAP) and the impact of common skin diseases in children living in a leprosy and Buruli ulcer (BU) co-endemic district in a west African country of Côte d'Ivoire, in order to help inform disease control efforts for skin NTDs.

METHODS AND PRINCIPLE FINDINGS

Fourteen focus group discussions (FGDs) with schoolchildren, 5 FGDs with parents of a child affected with skin disease(s), and 27 in-depth semi-structured interviews with key personnel were conducted. The Children's Dermatology Quality of Life Index (CDLQI) questionnaire was applied to 184 schoolchildren with skin diseases. We found that there was ignorance or neglect towards skin diseases in general, due to their high prevalence and also the perceived minimal impact on children's daily lives. While the median score for the CDLQI questionnaire was 5 (IQR 2-9) out of 30, a range of scores was observed. Symptoms such as pruritus and experiencing bullying by classmates contributed to reduction in their quality of life. Poor hygiene was considered as a major cause of skin diseases.

CONCLUSIONS/SIGNIFICANCE

Despite their high impact on affected populations, we observed a high level of ignorance and neglect toward common skin diseases. There is a critical need to increase awareness of skin diseases, or skin health promotion, which supports changing of the health-seeking behaviour for skin conditions. This will aid in early detection and treatment of the skin NTDs, in addition to providing benefits for those affected by other skin diseases. Educational opportunities should be utilized to their utmost. One would be associated with water, sanitation, and hygiene (WASH) strategies, but careful messages need to be developed and delivered.