'The medicine is not for sale': Practices of traditional healers in snakebite envenoming in Ghana.

BACKGROUND: Snakebite envenoming is a medical emergency which is common in many tropical lower- and middle-income countries. Traditional healers are frequently consulted as primary care-givers for snakebite victims in distress. Traditional healers therefore present a valuable source of information about how snakebite is perceived and handled at the community level, an understanding of which is critical to improve and extend snakebite-related healthcare. METHOD: The study was approached from the interpretive paradigm with phenomenology as a methodology. Semi-structured interviews were conducted with 19 traditional healers who treat snakebite patients in two rural settings in Ghana. From the Ashanti and Upper West regions respectively, 11 and 8 healers were purposively sampled. Interview data was coded, collated and analysed thematically using ATLAS.ti 8 software. Demographic statistics were analysed using IBM SPSS Statistics version 26. FINDINGS: Snakebite was reportedly a frequent occurrence, perceived as dangerous and often deadly by healers. Healers felt optimistic in establishing a diagnosis of snakebite using a multitude of methods, ranging from herbal applications to spiritual consultations. They were equally confident about their therapies; encompassing the administration of plant and animal-based concoctions and manipulations of bite wounds. Traditional healers were consulted for both physical and spiritual manifestations of snakebite or after insufficient pain control and lack of antivenom at hospitals; referrals by healers to hospitals were primarily done to receive antivenom and care for wound complications. Most healers welcomed opportunities to engage more productively with hospitals and clinical staff. CONCLUSIONS: The fact that traditional healers did sometimes refer victims to hospitals indicates that improvement of antivenom stocks, pain management and wound care can potentially improve health seeking at hospitals. Our results emphasize the need to explore future avenues for communication and collaboration with traditional healers to improve health seeking behaviour and the delivery of much-needed healthcare to snakebite victims.

National approaches to the vaccination of recently arrived migrants in Europe: A comparative policy analysis across 32 European countries.

BACKGROUND: Migrants may be underimmunised and at higher risk of vaccine-preventable diseases, yet there has been no comprehensive examination of what policies are currently implemented across Europe targeting child and adult migrants. We analysed vaccination policies for migrants in 32 EU/EEA countries and Switzerland. METHODS: Using framework analysis, we did a comparative analysis of national policies and guidelines pertaining to vaccination in recently arrived migrants through a systematic guideline and literature review and by approaching national experts. RESULTS: Six (18.8%) of 32 countries had comprehensive policies specific to the vaccination of migrants (two focused only on child migrants, four on both adults and children). Nineteen (59.4%) countries applied their national vaccination schedule for migrant vaccinations, predominantly focusing on children; and five (15.6%) countries had circulated additional migrant-specific resources to relevant health-care providers. In six (18.8%) countries, policies on migrant vaccination focused on outbreak-specific vaccines only. In ten (31.3%) countries, policies focused on priority vaccinations, with polio being the vaccine most commonly administered and heterogeneity noted in vaccines recommended to adults, adolescents, and children. Eighteen (56.3%) countries recommended that an individual should be considered as unvaccinated where vaccination records were missing, and vaccines re-administered. Nine (28.1%) countries reported that specific vaccinations were mandatory. CONCLUSION: There is considerable variation in policies across Europe regarding approaches to vaccination in adult and child migrants, and a lack of clarity on optimum ways forward, what vaccines to offer, with a need for robust research in this area. More emphasis must be placed on ensuring migrant-specific guidance is disseminated to front-line healthcare professionals to improve vaccine delivery and uptake in diverse migration populations across the region.

Delayed versus standard assessment for excision surgery in patients with Buruli ulcer in Benin: a randomised controlled trial.

BACKGROUND: Surgical intervention was once the mainstay of treatment for Buruli ulcer disease, a neglected tropical disease caused by Mycobacterium ulcerans. Since the introduction of streptomycin and rifampicin for 8 weeks as standard care, surgery has persisted as an adjunct therapy, but its role is uncertain. We investigated the effect of delaying the decision to operate to 14 weeks on rates of healing without surgery. METHODS: In this randomised controlled trial, we enrolled patients aged 3 years or older with confirmed disease at one hospital in Lalo, Benin. Patients were randomly assigned (1:1) to groups assessing the need for excision surgery 8 weeks (standard care) or 14 weeks after initiation of antimicrobial treatment. The primary endpoint was the number of patients healed without the need for surgery (not including skin grafting), assessed in all patients in follow-up at 50 weeks (or last observation for those healed for >10 weeks). A doctor masked to treatment assignment checked the indications for surgery according to predefined criteria. This study is registered with ClinicalTrials.gov, number NCT01432925. FINDINGS: Between July 1, 2011, and Jan 15, 2015, 119 patients were enrolled, with two patients per group lost to follow-up. 55 (96%) of 57 participants in the delayed-decision group and 52 (90%) of 58 participants in the standard-care group had healed lesions 1 year after start of antimicrobial treatment (relative risk [RR] 1·08, 95% CI 0·97-1·19). 37 (67%) of 55 patients in the delayed-decision group had their lesions healed without surgical intervention, as did 25 (48%) of 52 in the standard-care group (RR 1·40, 95% CI 1·00-1·96). The time to heal and residual functional limitations did not differ between the two groups (median time to heal 21 weeks [IQR 10-27] in the delayed-decision group and 21 weeks [10-39] in the standard-care group; functional limitations in six [11%] of 57 and three [5%] of 58 patients; p=0·32). Postponing the decision to operate resulted in reduced median duration of hospitalisation (5 days [IQR 0-187] vs 131 days [0-224]; p=0·024) and wound care (153 days [IQR 56-224] vs 182 days [94-307]; p=0·036). INTERPRETATION: In our study, patients treated for Buruli ulcer benefited from delaying the decision to operate. Even large ulcers can heal with antibiotics alone, without delaying healing rate and without an increase in residual functional limitations. FUNDING: NWO-VENI grant 241500, BUG Foundation, and UBS OPTIMUS.

Assessment and Treatment of Pain during Treatment of Buruli Ulcer.

BACKGROUND: Buruli ulcer (BU) is described as a relatively painless condition; however clinical observations reveal that patients do experience pain during their treatment. Knowledge on current pain assessment and treatment in BU is necessary to develop and implement a future guideline on pain management in BU. METHODOLOGY: A mixed methods approach was used, consisting of information retrieved from medical records on prescribed pain medication from Ghana and Benin, and semi-structured interviews with health care personnel (HCP) from Ghana on pain perceptions, assessment and treatment. Medical records (n = 149) of patients treated between 2008 and 2012 were collected between November 2012 and August 2013. Interviews (n = 11) were audio-taped, transcribed verbatim and qualitatively analyzed. PRINCIPAL FINDINGS: In 113 (84%) of the 135 included records, pain medication, mostly simple analgesics, was prescribed. In 48% of the prescriptions, an indication was not documented. HCP reported that advanced BU could be painful, especially after wound care and after a skin graft. They reported not be trained in the assessment of mild pain. Pain recognition was perceived as difficult, as patients were said to suppress or to exaggerate pain, and to have different expectations regarding acceptable pain levels. HCP reported a fear of side effects of pain medication, shortage and irregularities in the supply of pain medication, and time constraints among medical doctors for pain management. CONCLUSIONS: Professionals perceived BU disease as potentially painful, and predominantly focused on severe pain. Our study suggests that pain in BU deserves attention and should be integrated in current treatment.

Healthcare seeking behaviour for Buruli ulcer in Benin: a model to capture therapy choice of patients and healthy community members.

Buruli ulcer is a devastating condition emerging in West Africa. We investigated why patients often report late to the hospital. Health seeking behaviour determinants and stigma were studied by in-depth interviews in patients treated in hospital (n=107), patients treated traditionally (n=46) of whom 22 had active disease, and healthy community control subjects (n=107). We developed a model capturing internal and external factors affecting decision making. With increasing severity, extent and duration of Buruli ulcer, a shift of influencing factors on health seeking behaviour appears to occur. Factors causing delay in presenting to hospital were the use of traditional medicine before presenting at the treatment centre; costs and duration of admission; disease considered not serious enough; witchcraft perceived as the cause of disease; and fear of treatment, which patients expected to be amputation. This study confirms the importance of self-treatment and traditional healing in this area. Our study was performed before antimicrobial treatment was introduced in Benin; we suggest that this model and the results from this analysis should be used as a baseline from which to measure the influence of the introduction of antimicrobial treatment on health seeking behaviour for Buruli ulcer in Benin.

Assessment of functional limitations caused by Mycobacterium ulcerans infection: towards a Buruli ulcer functional limitation score.

The purpose of this study of treated Buruli ulcer patients in Ghana was to identify and assess late sequelae of treated Buruli ulcer using a goniometer, and to develop a scoring system for functional limitations. Of 78 patients, 58% (n = 45) had a reduction in the range of motion of one or more joints: 30% (n = 23) had one or more functional limitations of the leg and 21% (n = 16) of the arm; 49% (n = 38) had a functional limitation. Of all patients with affected knees, the predicted average extent of limitation was 63%. In patients with affected ankles, limitation was 78% on average; in those with elbow involvement, this was 76% on average, and in wrists involved, 65%. All of the hands involved were markedly restricted. We propose a simplified and functional scoring system that should be tested for validation in a second patient sample, and, if properly validated and adjusted, can be used in future intervention trials.