Impact of COVID-19 lockdown measures on mother and child health - the case of Ghana.

BACKGROUND: The lockdown measures in response to the coronavirus disease (COVID-19) have led to a wide range of unintended consequences for women and children. Until the outbreak of COVID-19, attention was on reducing maternal and infant mortality due to pregnancy and delivery complications. The aim of this study was to interrogate the impact of lockdown measures on women and children in two contrasting districts in Ghana - Krobo Odumase and Ayawaso West Wuogon. METHODS: This study adopted the mixed-method approach using both qualitative and quantitative data. The qualitative study relied on two data collection methods to explore the impacts of COVID-19 control measures on women and children in Ghana. These were: Focus Group Discussions (FGDs; n = 12) and Key Informant Interviews (KIIs; n = 18). The study complemented the qualitative data with survey data - household surveys (n = 78) which were used to support the nutrition and school closure data; and policy data gathered from government websites consisting of government responses to COVID-19. The qualitative data was analysed using the thematic approach with codes generated apriori with the NVIVO software. The quantitative data used percentages and frequencies. RESULTS: Engagements with participants in the study revealed that the lockdown measures implemented in Ghana had consequences on child and maternal health, and the health care system as a whole. Our study revealed, for example, that there was a decrease in antenatal and postnatal attendance in hospitals. Childhood vaccinations also came to a halt. Obesity and malnutrition were found to be common among children depending on the location of our study participants (urban and rural areas respectively). Our study also revealed that TB, Malaria and HIV treatment seeking reduced due to the fear of going to health facilities since those ailments manifest similar symptoms as COVID 19. CONCLUSION: Government responded to COVID-19 using different strategies however the policy response resulted in both intended and unintended consequences especially for women and children in Ghana. It is recommended that national policy directions should ensure the continuous provision of child and maternal healthcare services which are essential health services during lockdowns.

Understanding the gap between access and use: a qualitative study on barriers and facilitators to insecticide-treated net use in Ghana.

BACKGROUND: Mass and continuous distribution channels have significantly increased access to insecticide-treated nets (ITNs) in Ghana since 2000. Despite these gains, a large gap remains between ITN access and use. METHODS: A qualitative research study was carried out to explore the individual and contextual factors influencing ITN use among those with access in three sites in Ghana. Eighteen focus group discussions, and free listing and ranking activities were carried out with 174 participants; seven of those participants were selected for in-depth case study. Focus group discussions and case study interviews were audio-recorded, transcribed verbatim, and analysed thematically. RESULTS: ITN use, as described by study participants, was not binary; it varied throughout the night, across seasons, and over time. Heat was the most commonly cited barrier to consistent ITN use and contributed to low reported ITN use during the dry season. Barriers to ITN use throughout the year included skin irritation; lack of airflow in the sleeping space; and, in some cases, a lack of information on the connection between the use of ITNs and malaria prevention. Falling ill or losing a loved one to malaria was the most powerful motivator for consistent ITN use. Participants also discussed developing a habit of ITN use and the economic benefit of prevention over treatment as facilitating factors. Participants reported gender differences in ITN use, noting that men were more likely than women and children to stay outdoors late at night and more likely to sleep outdoors without an ITN. CONCLUSION: The study results suggest the greatest gains in ITN use among those with access could be made by promoting consistent use throughout the year among occasional and seasonal users. Opportunities for improving communication messages, such as increasing the time ITNs are aired before first use, as well as structural approaches to enhance the usability of ITNs in challenging contexts, such as promoting solutions for outdoor ITN use, were identified from this work. The information from this study can be used to inform social and behaviour change messaging and innovative approaches to closing the ITN use gap in Ghana.

Community perspectives on persistent transmission of lymphatic filariasis in three hotspot districts in Ghana after 15 rounds of mass drug administration: a qualitative assessment.

BACKGROUND: The Global Program for the Elimination of Lymphatic Filariasis (GPELF) started operation in 2000 and aimed at eliminating the disease by the year 2020, following 5-6 rounds of effective annual Mass Drug Administration (MDA). The MDA programme took off in Ghana in 2001 and has interrupted transmission in many areas while it has persisted in some areas after 10 or more rounds of MDA. This study was to appreciate community members' perspectives on MDA after over 15 years of implementation. Findings will inform strategies to mobilise community members to participate fully in MDA to enhance the disease elimination process. METHODS: This was a qualitative study, employing key-informant in-depth-interviews. Respondents were selected based on their recognition by community members as opinion leaders and persons who were knowledgeable about the topic of interest in the community. A snowball sampling technique was used to select respondents. RESULTS: Respondents were well informed about the MDA with most of them saying, it has been implemented for over 12 years. They were aware that the MDA was for the treatment/control of LF (elephantiasis). It came to light that MDA compliance was affected by five related barriers. These are; Medication, Personal, Health system, Disease and Social structure related barriers. Adverse effects of the drugs and the fact that many people perceived that they were not susceptibility to the infection have grossly affected the ingestion of the drugs. CONCLUSION: There is a need for community mobilization and promotional activities to explain the expected adverse reactions associated with the drugs to the people. Also the importance of why every qualified person in the community must comply with MDA must be emphasized.

Understanding the factors influencing biosecurity adoption on smallholder poultry farms in Ghana: a qualitative analysis using the COM-B model and Theoretical Domains Framework.

Introduction: Antimicrobial resistance (AMR) poses a significant global threat to public, animal, and environmental health, consequently producing downstream economic impacts. While top-down approaches to addressing AMR (e.g., laws regulating antimicrobial use) are common in high-income countries, limited enforcement capacities in low- and middle-income countries highlight the need for more bottom-up approaches. Within agriculture, efforts to apply bottom-up approaches to AMR have often focused on the promotion of biosecurity, which should reduce the need for antimicrobials by mitigating disease risk and limiting AMR transmission. Traditionally, efforts to encourage biosecurity adoption have emphasized training and awareness-raising initiatives. However, a growing body of research suggests a disconnect between knowledge and behavior, highlighting the existence of a knowledge-action gap. Method: To understand the barriers and enablers patterning the knowledge-action gap in on-farm biosecurity uptake, we draw upon models from behavioral science. We analyzed in-depth interviews and two focus group discussions with smallholder poultry producers in Ghana to understand factors underlying the intention-action gap in adopting biosecurity. As an analytical framework, we draw upon the Theoretical Domains Framework in combination with the Capability-Opportunity-Motivation Behavioral Model. Results and discussion: While smallholder poultry farmers in Ghana were aware of the importance of biosecurity practices, they struggled with consistent implementation. Financial constraints, challenges in adapting practices to the local context, and limited resources hindered adoption. Additionally, cognitive biases like prioritizing short-term gains and underestimating disease risks played a role. However, some farmers found motivation in professional identity and social influences. These findings highlight the need for designing biosecurity interventions that consider human behavioral factors and the context in which behavior occurs. This underscores the importance of collaboration across disciplines, including veterinary science and the social and behavioral sciences. Implications and recommendations for researchers and practitioners are discussed.

Reaching adolescents with health services: Systematic development of an adolescent health check-ups and wellbeing programme in Ghana (Y-Check, Ghana).

BACKGROUND: Routine health check-ups may improve adolescent health, but global guidelines are lacking. Phase 1 of the WHO-coordinated Y-Check Research Programme involved three African cities to co-produce a programme of adolescent health check-ups. We describe a systematic approach to developing a routine adolescent health check-ups and wellbeing programme (Y-Check) to contribute evidence on whether adolescent health check-ups should be part of routine health services in Ghana. METHODS: Y-Check Phase 1 was conducted in four communities in Cape Coast Ghana, over two stages using a variety of methods: (a) needs assessment and landscape analysis on the health of adolescents (existing policies/programmes, school system, adolescent health conditions) was conducted through desk-review and interviews with key informants to identify the potential content, delivery strategy and settings for adolescent health check-ups in this context; (b) co-designing the Y-Check intervention framework through person-centred participatory workshops and a consensus-building workshop with multiple stakeholders, including adolescents (10-19 years) and their parents. The study was conducted between January 2020 and October 2020. RESULTS: The Y-Check intervention consists of two check-ups with content that is tailored to the needs of younger adolescents and older adolescents; delivered at both school and community settings by a team of trained staff in multiple steps involving up to four stations. Y-Check includes a referral system for adolescents with any problems that cannot be investigated or treated on-the-spot. CONCLUSIONS: Our systematic approach to co-producing Y-Check has resulted in an intervention whose content and structure is determined by the local context, and which was adjudged by multiple stakeholders to be likely to be both useful and acceptable, and which builds on best practice. As a logical next step, the Y-Check will be subjected to pilot testing and implementation research to rigorously evaluate the feasibility, acceptability, coverage, yield of previously undiagnosed conditions and cost of these health check-ups.

The role of economic factors in shaping and constituting the household burden of neglected tropical diseases of the skin: Qualitative findings from Ghana and Ethiopia.

Tracers of health system equity, neglected tropical diseases (NTDs) disproportionately affect marginalized populations. NTDs that manifest on the skin - "skin NTDs" - are associated with scarring, disfigurement, physical disability, social exclusion, psychological distress, and economic hardship. To support development and evaluation of appropriate intervention strategies, we aimed to improve understanding of the role of economic factors in shaping and constituting the burden that skin NTDs place on households. We collected data in 2021 in two predominantly rural districts: Atwima Mponua in Ghana (where Buruli ulcer, yaws, and leprosy are endemic) and Kalu in Ethiopia (where cutaneous leishmaniasis and leprosy are endemic). We conducted interviews (n = 50) and focus group discussions (n = 14) that explored economic themes with affected individuals, caregivers, and community members and analysed the data thematically using a pre-defined framework. We found remarkable commonalities across countries and diseases. We developed a conceptual framework which illustrates skin NTDs' negative economic impact, including financial costs of care-seeking and reductions in work and schooling; categorises coping strategies by their degree of risk-pooling; and clarifies the mechanisms through which skin NTDs disproportionately affect the poorest. Despite health insurance schemes in both countries, wide-ranging, often harmful coping strategies were reported. Traditional healers were often described as more accessible, affordable and offering more flexible payment terms than formal health services, except for Ethiopia's well-established leprosy programme. Our findings are important in informing strategies to mitigate the skin NTD burden and identifying key drivers of household costs to measure in future evaluations. To reduce skin NTDs' impact on households' physical, mental, and economic wellbeing, intervention strategies should address economic constraints to prompt and effective care-seeking. While financial support and incentives for referrals and promotion of insurance enrolment may mitigate some constraints, structural interventions that decentralise care may offer more equitable and sustainable access to skin NTD care.

Improving experiences of neglected tropical diseases of the skin: Mixed methods formative research for development of a complex intervention in Atwima Mponua District, Ghana.

Integrated approaches to managing co-endemic neglected tropical diseases (NTDs) of the skin within primary healthcare services are complex and require tailoring to local contexts. We describe formative research in Atwima Mponua District in Ghana's Ashanti Region designed to inform the development of a sustainable intervention to improve access to skin NTD care. We employed a convergent, parallel, mixed-methods design, collecting data from February 2021 to February 2022. We quantitatively assessed service readiness using a standardised checklist and reviewed outpatient department registers and condition-specific case records in all government health facilities in the district. Alongside a review of policy documents, we conducted 49 interviews and 7 focus group discussions with purposively selected affected persons, caregivers, community members, health workers, and policy-makers to understand skin NTD care-seeking practices and the policy landscape. Outside the district hospital, skin NTD reporting rates in the surveyed facilities were low; supply chains for skin NTD diagnostics, consumables, and medicines had gaps; and health worker knowledge of skin NTDs was limited. Affected people described fragmented care, provided mostly by hospitals (often outside the district) or traditional healers, resulting in challenges obtaining timely diagnosis and treatment and high care-seeking costs. Affected people experienced stigma, although the extent to which stigma influenced care-seeking behaviour was unclear. National actors were more optimistic than district-level actors about local resource availability for skin NTD care and were sceptical of including traditional healers in interventions. Our findings indicate that improvement of the care cascade for affected individuals to reduce the clinical, economic, and psychosocial impact of skin NTDs is likely to require a complementary set of interventions. These findings have informed the design of a strategy to support high-quality, integrated, decentralised care for skin NTDs in Atwima Mponua, which will be assessed through a multidisciplinary evaluation.

Development of an integrated and decentralised skin health strategy to improve experiences of skin neglected tropical diseases and other skin conditions in Atwima Mponua District, Ghana.

Integrated strategies are recommended to tackle neglected tropical diseases of the skin (skin NTDs), which pose a substantial health and economic burden in many countries, including Ghana. We describe the development of an integrated and decentralised skin health strategy designed to improve experiences of skin NTDs in Atwima Mponua district in Ashanti Region. A multidisciplinary research team led an iterative process to develop an overall strategy and specific interventions, based on a theory of change informed by formative research conducted in Atwima Mponua district. The process involved preparatory work, four co-development workshops (August 2021 to November 2022), collaborative working groups to operationalise intervention components, and obtaining ethical approval. Stakeholders including affected individuals, caregivers, other community members and actors from different levels of the health system participated in co-development activities. We consulted these stakeholders at each stage of the research process, including discussion of study findings, development of our theory of change, identifying implementable solutions to identified challenges, and protocol development. Participants determined that the intervention should broadly address wounds and other skin conditions, rather than only skin NTDs, and should avoid reliance on non-governmental organisations and research teams to ensure sustainable implementation by district health teams and transferability elsewhere. The overall strategy was designed to focus on a decentralised model of care for skin conditions, while including other interventions to support a self-care delivery pathway, community engagement, and referral. Our theory of change describes the pathways through which these interventions are expected to achieve the strategy's aim, the assumptions, and problems addressed. This complex intervention strategy has been designed to respond to the local context, while maximising transferability to ensure wider relevance. Implementation is expected to begin in 2023.

Enhancing Buruli ulcer control in Ghana through social interventions: a case study from the Obom sub-district.

BACKGROUND: Buruli ulcer is considered a re-emerging disease in West Africa where it has suffered neglect over the years, though children below the age of 16 years are the worst affected in most endemic regions. Due to delayed health seeking, the disease leads to disabilities resulting from amputation and loss of vital organs like the eye leading to school dropout and other social and economic consequences for the affected family. Early treatment with antibiotics is effective; however, this involves daily oral and intramuscular injection at distant health facilities for 56 days making it a challenge among poor rural folks living on daily subsistence work. The mode of transmission of Buruli ulcer is not known and there is no effective preventive vaccine for Buruli ulcer. Thus the only effective control tool is early case detection and treatment to reduce morbidity and associated disabilities that occurs as a result of late treatment. It is therefore essential to implement interventions that remove impediments that limit early case detection; access to early effective treatment and this paper reports one such effort where the feasibility of social interventions to enhance Buruli ulcer control was assessed. METHODS: This was a qualitative study using in-depth interviews to generate information to ascertain the benefit or otherwise of the intervention implemented. Clinical records of patients to generate data to determine the feasibility and effectiveness of social interventions in the fight against Buruli ulcer was examined. In all, 56 in-depth interviews (28 at baseline and 28 at evaluation) were conducted for this report. RESULTS: At full implementation, treatment default and dropout reduced significantly from 58.8% and 52.9% at baseline to 1.5% and 1.5% respectively. The number of early case detection went up significantly. Affected families were happy with social interventions such as provision of transportation and breakfast to patients on daily basis. Families were happy with the outpatient services provided under the intervention where no patient was admitted into the hospital. CONCLUSION: The study showed that with a little more investment in early case detection, diagnosis and treatment, coupled with free transportation and breakfast for patients, most of the cases could be treated effectively with the available antibiotics to avoid disability and complications from the disease.

Social-technical interventions to reduce antimicrobial resistance in agriculture: evidence from poultry Farmer Field Schools in Ghana and Kenya.

OBJECTIVES: To assess the feasibility of the Farmer Field School approach to address the complex problem of antimicrobial resistance in agriculture, specifically within small-to-medium-scale layer poultry systems in Ghana and Kenya. Impact was assessed across three domains relevant to the emergence and selection of antimicrobial resistance, including infection, prevention, and control practices, engagement with animal health professionals, and knowledge, attitudes, and practices on antimicrobial use and antimicrobial resistance. METHODS: Farmer Field Schools were held in Ghana (N = 2) and Kenya (N = 3) across an eight-month period with an average of 18 participants in each school. After completion, a quantitative evaluation survey was administered to participants and a sample of non-participants (Ghana; N = 97) (Kenya; N = 103). Logistic and ordinary least squares regression were used to assess differences between participants and non-participants on the three domains. RESULTS: Participation in a layer poultry Farmer Field School in Ghana and Kenya is associated with self-reported reductions in antibiotic use, particularly for prevention, an increased investment in farm infection, prevention, and control practices, including the use of footbaths and personal protective equipment, and enhanced engagement with animal health professionals. CONCLUSIONS: Antimicrobial resistance is a complex problem driven by a wide range of practices and multiple stakeholders. To holistically address these factors requires the use of complex intervention approaches. The Farmer Field School approach offers a complex intervention methodology that can reduce the emergence and spread of antimicrobial resistance in agricultural systems through targeting the variety of on-farm and off-farm factors that drive resistance.

The Impacts of Animal Health Service Providers on Antimicrobial Use Attitudes and Practices: An Examination of Poultry Layer Farmers in Ghana and Kenya.

International organizations and governments have argued that animal health service providers can play a vital role in limiting antimicrobial resistance by promoting the prudent use of antimicrobials. However, there is little research on the impact of these service providers on prudent use at the farm level, especially in low- and middle-income countries where enforcement of prudent-use regulations is limited. Here, we use a mixed-methods approach to assess how animal health-seeking practices on layer farms in Ghana (n = 110) and Kenya (n = 76) impact self-reported antimicrobial usage, engagement in prudent administration and withdrawal practices and perceptions of antimicrobial resistance. In general, our results show that the frequency of health-seeking across a range of service providers (veterinarians, agrovets, and feed distributors) does not significantly correlate with prudent or non-prudent use practices or the levels of antimicrobials used. Instead, we find that patterns of antimicrobial use are linked to how much farmers invest in biosecurity (e.g., footbaths) and the following vaccination protocols. Our results emphasize that more research is required to understand the interactions between animal health service providers and farmers regarding antimicrobial use and antimicrobial resistance. Addressing these gaps will be crucial to inform antimicrobial stewardship training, curriculums and, guidelines whose ultimate purpose is to limit the selection and transmission of antimicrobial resistance.

Towards a bottom-up understanding of antimicrobial use and resistance on the farm: A knowledge, attitudes, and practices survey across livestock systems in five African countries.

The nutritional and economic potentials of livestock systems are compromised by the emergence and spread of antimicrobial resistance. A major driver of resistance is the misuse and abuse of antimicrobial drugs. The likelihood of misuse may be elevated in low- and middle-income countries where limited professional veterinary services and inadequately controlled access to drugs are assumed to promote non-prudent practices (e.g., self-administration of drugs). The extent of these practices, as well as the knowledge and attitudes motivating them, are largely unknown within most agricultural communities in low- and middle-income countries. The main objective of this study was to document dimensions of knowledge, attitudes and practices related to antimicrobial use and antimicrobial resistance in livestock systems and identify the livelihood factors associated with these dimensions. A mixed-methods ethnographic approach was used to survey households keeping layers in Ghana (N = 110) and Kenya (N = 76), pastoralists keeping cattle, sheep, and goats in Tanzania (N = 195), and broiler farmers in Zambia (N = 198), and Zimbabwe (N = 298). Across countries, we find that it is individuals who live or work at the farm who draw upon their knowledge and experiences to make decisions regarding antimicrobial use and related practices. Input from animal health professionals is rare and antimicrobials are sourced at local, privately owned agrovet drug shops. We also find that knowledge, attitudes, and particularly practices significantly varied across countries, with poultry farmers holding more knowledge, desirable attitudes, and prudent practices compared to pastoralist households. Multivariate models showed that variation in knowledge, attitudes and practices is related to several factors, including gender, disease dynamics on the farm, and source of animal health information. Study results emphasize that interventions to limit antimicrobial resistance should be founded upon a bottom-up understanding of antimicrobial use at the farm-level given limited input from animal health professionals and under-resourced regulatory capacities within most low- and middle-income countries. Establishing this bottom-up understanding across cultures and production systems will inform the development and implementation of the behavioral change interventions to combat antimicrobial resistance globally.

Environmental and Behavioral Drivers of Buruli Ulcer Disease in Selected Communities Along the Densu River Basin of Ghana: A Case-Control Study.

AbstractThe exact route of transmission of Mycobacterium ulcerans (MU) (causative agent of Buruli ulcer [BU]), risk factors, and reservoir hosts are not clearly known, although it has been identified as an environmental pathogen. This study assessed potential environmental and behavioral risk factors that influence BU infections. We conducted a case-control study where cases were matched by their demographic characteristics and place of residence. A structured questionnaire was administered to solicit information on the environmental and behavioral factors of participants that may expose them to infection. A total of 176 cases and 176 controls were enrolled into the study. Multivariate conditional logistic regression analysis identified farming in swampy areas (odds ratio [OR] = 4.10, 95% confidence interval [CI] = 3.82-7.18), farming while wearing short clothing (OR = 1,734.1, 95% CI = 68.1-44,120.9), insect bite (OR = 988.3, 95% CI = 31.4-31,115.6), and application of leaves on wounds (OR = 6.23, 95% CI = 4.74-18.11) as potential risk factors. Farming in long clothing (OR = 0.000, 95% CI = 0.00-0.14), washing wound with water and soap (OR = 0.37, 95% CI = 0.29-0.98), and application of adhesive bandage on wounds (OR = 0.31, 95% CI = 0.15-0.82) were found to be protective against BU infection. In the absence of the exact MU transmission mechanisms, education of public in BU-endemic zones on the use of protective clothing during farming activities to limit exposure of the skin and proper wound care management would be essential in the fight against BU.

Assessing and managing wounds of Buruli ulcer patients at the primary and secondary health care levels in Ghana.

BACKGROUND: Beyond Mycobacterium ulcerans-specific therapy, sound general wound management is required for successful management of Buruli ulcer (BU) patients which places them among the large and diverse group of patients in poor countries with a broken skin barrier. METHODS: Clinically BU suspicious patients were enrolled between October 2013 and August 2015 at a primary health care (PHC) center and a municipal hospital, secondary health care (SHC) center in Ghana. All patients were IS2404 PCR tested and divided into IS2404 PCR positive and negative groups. The course of wound healing was prospectively investigated including predictors of wound closure and assessment of infrastructure, supply and health staff performance. RESULTS: 53 IS2404 PCR positive patients-31 at the PHC center and 22 at the SHC center were enrolled-and additionally, 80 clinically BU suspicious, IS2404 PCR negative patients at the PHC center. The majority of the skin ulcers at the PHC center closed, without the need for surgical intervention (86.7%) compared to 40% at the SHC center, where the majority required split-skin grafting (75%) or excision (12.5%). Only 9% of wounds at the PHC center, but 50% at the SHC center were complicated by bacterial infection. The majority of patients, 54.8% at the PHC center and 68.4% at the SHC center, experienced wound pain, mostly severe and associated with wound dressing. Failure of ulcers to heal was reliably predicted by wound area reduction between week 2 and 4 after initiation of treatment in 75% at the PHC center, and 90% at the SHC center. Obvious reasons for arrested wound healing or deterioration of wound were missed additional severe pathology; at the PHC center (chronic osteomyelitis, chronic lymphedema, squamous cell carcinoma) and at the SHC center (malignant ulceration, chronic lymphedema) in addition to hygiene and wound care deficiencies. When clinically suspicious, but IS2404 PCR negative patients were recaptured in the community, 76/77 (98.7%) of analyzed wounds were either completely closed (85.7%) or almost closed (13%). Five percent were found to have important missed severe pathology (chronic osteomyelitis, ossified fibroma and suspected malignancy). CONCLUSION: The wounds of most BU patients attending the primary health care level can be adequately managed. Additionally, the patients are closer to their families and means of livelihood. Non-healing wounds can be predicted by wound area reduction between 2 to 4 weeks after initiation of treatment. Patients with clinically BU suspicious, but PCR negative ulcers need to be followed up to capture missed diagnoses.

Cultural Understanding of Wounds, Buruli Ulcers and Their Management at the Obom Sub-district of the Ga South Municipality of the Greater Accra Region of Ghana.

BACKGROUND: This study was conducted with the aim to understand some of the cultural belief systems in the management of wounds and patients practices that could contaminate wounds at the Obom sub-district of the Ga South Municipality of Ghana. METHODS: This was an ethnographic study using in-depth interviews, Focus Group Discussions and participant observation techniques for data collection. Observations were done on Buruli ulcer patients to document how they integrate local and modern wound management practices in the day-to-day handling of their wounds. Content analysis was done after the data were subjected to thematic coding and representative narratives selected for presentation. RESULTS: It was usually believed that wounds were caused by charms or spirits and, therefore, required the attention of a native healer. In instances where some patients' wounds were dressed in the hospital by clinicians whose condition/age/sex contradict the belief of the patient, the affected often redress the wounds later at home. Some of the materials often used for such wound dressing include urine and concoctions made of charcoal and gunpowder with the belief of driving out evil spirits from the wounds. CONCLUSION: Clinicians must therefore be aware of these cultural beliefs and take them into consideration when managing Buruli ulcer wounds to prevent redressing at home after clinical treatment. This may go a long way to reduce secondary infections that have been observed in Buruli ulcer wounds.

Late onset of the serological response against the 18 kDa small heat shock protein of Mycobacterium ulcerans in children.

A previous survey for clinical cases of Buruli ulcer (BU) in the Mapé Basin of Cameroon suggested that, compared to older age groups, very young children may be less exposed to Mycobacterium ulcerans. Here we determined serum IgG titres against the 18 kDa small heat shock protein (shsp) of M. ulcerans in 875 individuals living in the BU endemic river basins of the Mapé in Cameroon and the Densu in Ghana. While none of the sera collected from children below the age of four contained significant amounts of 18 kDa shsp specific antibodies, the majority of sera had high IgG titres against the Plasmodium falciparum merozoite surface protein 1 (MSP-1). These data suggest that exposure to M. ulcerans increases at an age which coincides with the children moving further away from their homes and having more intense environmental contact, including exposure to water bodies at the periphery of their villages.