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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: [email protected] 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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