How Simple Everyday Routines Make Us Vulnerable to Dangerous Infectious diseases

Simple everyday routines put us a step closer to contracting infectious diseases.

Simple everyday routines put us a step closer to contracting infectious diseases.

Infectious diseases contribute to poor health and mortality with a huge impact observed in developing countries. In most of these countries rural and poor populations are the most affected. This is mostly due to preexisting conditions e.g their surroundings (environment), weather conditions, lack of or limited health infrastructure and personnel, poor transportation systems and lack of resources within the population.

With such limited resources livelihoods that involve natural resources such as farming, fishing, artisan work and rearing of livestock are common among rural populations and these provide the needed food and income for these communities. These livelihoods also expose populations to various disease causing agents some of which cause serious and often fatal disease. The source of these disease causing agents include domestic and wild animals, birds, the environment, water, food, soil and infected human beings within the population. With the risk of disease, limited health infrastructure and poverty/hardship.

Imagine waking up with a small painless swelling on your limb or upper body. As days go by it ruptures, as you try to treat it with general wound cleaning and dressing agents, it does not seem to respond. Then one day it becomes this big gaping wound that is not healing but keeps growing. With time you are unable to use your limb or the affected area. The wound keeps growing and soon you can see your bone.

Imagine waking up with a small painless swelling on your limb or upper body. As days go by it ruptures, as you try to treat it with general wound cleaning and dressing agents, it does not seem to respond. Then one day it becomes this big gaping wound that is not healing but keeps growing. With time you are unable to use your limb or the affected area. The wound keeps growing and soon you can see your bone. It sounds like a scene from a horror movie, but this is a reality in some parts of the world.

BURULI ULCER

Buruli ulcer also known as Bairnsdale ulcer, Searls ulcer, Daintree ulcer, Kumusi ulcer, and mycoburuli ulcers, is a neglected tropical disease affecting populations in parts of Africa, Australia, South America and the Western Pacific regions. The disease has been reported in 33 countries with 15 regulary reporting to WHO.

It is the third common mycobacterium disease after TB and Leprosy. Buruli ulcer is caused by a bacteria, Mycobacterium ulcerans.

Lesions occur mostly on the limbs (55% on the lower limbs, 35% on the upper limbs) but can also on other parts of the body (10%). Early identification of the lesions helps prevent long hospital stays and is less costly compared to late presentation of disease.

DISEASE CLASSIFICATION
The disease is classified into three categories with regard to severity:

Category 1; Single small lesion (32%)
Category 2; Non-ulcerative and ulcerative plaque and oedematous forms (35%)
Category 3; Disseminated and mixed forms such as osteitis, osteomyelitis, joint involvement (33%).

In developed countries such as Australia and Japan, most lesions (>90%) are diagnosed in Category 1, while approximately 70% of cases are diagnosed at ulceration stage (Category 2) in all the reporting countries.

Until 2005 the only treatment was surgery.

Until 2005 the only treatment was surgery. In some cases people can be hospitalized up to 3 years. Physiotherapy is needed to help return movement in the affected limbs, while community involvement/volunteer and education crucial in early detection of disease

AFFECTED POPULATION

Affecting mostly children under the age of 15, 48% in Africa, 10% in Australia and 19% in Japan, the disease has caused debilitating effects on the affected individuals. Late presentation of the disease could mean excessive loss of tissue, infection of the bone which in turn requires surgical procedures and sometimes amputation of the limb. Since 2005 a combination of antibiotics has been used to treat buruli ulcer, this has helped many people in the affected regions as these antibiotics can cure the disease and in some cases prevent recurrence of the disease.

Antibiotics can cure the disease and in some cases prevent recurrence of the disease

The majority of cases are reported from West Africa, but Australia has seen an increase in cases in recent years.

Even though it is suspected that Buruli ulcer could be contracted from the environment or from an insect bite, the source of infection and mode of transmission is not yet known. It is therefore very difficult to know how to control and prevent the spread of the disease.

Most rural populations in endemic areas are vulnerable to the disease due to lack of knowledge on the source and mode of the disease. As they go about their livelihood they don’t know when the disease will strike.  The patients suffering from the disease are not sure how they got the disease, as most go to the hospital at a later stage, the majority when the ulcer appears. Patient history has allowed researchers and medical personnel to build timelines and suggest the various ways in which the disease could have been contracted. Some people take as long as 2 years from the time of appearance of a nodule (early stage of buruli ulcer) to the time they seek medical attention. During this time the bacteria responsible for the disease, M. ulcerans, is replicating and eating away tissue under the skin. Late identification of disease has resulted in  long hospitalization and is very costly.

Since the disease largely affects the limbs, with the majority on lower limbs (55%), upper limbs (35%) and the upper body (10%), livelihoods and families are disrupted. Children affected by the disease may spend months and sometimes years being treated in hospitals. This not only affects their education but it is a major psychological trauma, and the disease often causes serious disfigurement requiring long periods of rehabilitation. The parents of these children spend most of their income on treatment costs, some losing their businesses and livelihood.

Whilst reviewing some of the buruli ulcer cases in Ghana, most of the narratives associated the disease with marshy areas, water pools (in areas where there was sand and or gold mining), boreholes and insect bites. In Australia, the current cases in Victoria have been associated with the Bellarine and Mornington Peninsulla, where marshy areas also exist. Various avenues are being explored to search for animal reservoirs, as well as studying the environments where people are suspected to have contracted the disease.

While in Australia and Japan (developed countries where the disease is endemic) patients have access to advanced medical care, many in rural areas of developed countries are not able to access such kind of health care. Due to loss of livelihood and income, facing challenges with transportation and movement of the sick, or lack of support from family and the community due to stigma, many report the disease late and or chose to go to herbalists or tribal healers .

The challenges posed by buruli ulcer in rural communities require serious intervention. in Cameroon, Ghana and Benin, village community volunteers trained to identify the early stages of buruli ulcer have succeeded in identifying patients and referring them for treatment at the designated treatment centers.

village community volunteers trained to identify the early stages of buruli ulcer have succeeded in identifying patients and referring them for treatment at the designated treatment centers

This has not only assisted in early identification of disease but also averted serious infections that could have resulted in surgery or amputation of limbs. Community interventions including showing films on buruli ulcer to debunk myths on the disease, have helped bring awareness to the people.

Community interventions including showing films on buruli ulcer to debunk myths on the disease, have helped bring awareness to the people.

Campaigns are also ongoing to help with early identification of disease. It was observed that up to 78% of children infected by buruli ulcer do get cured, but adults usually report the disease at a very late stage and these ulcers are difficult to heal.

FACTS:

  • Parents are the ones who can take their children for treatment, therefore the decision they make regarding treatment is crucial. Bringing awareness to parents and the children regarding buruli and other NTDs and how treatment seeking behaviour plays a role in disease outcome gives them the needed information to understand the importance of early treatment.

 

  • Buruli ulcer affects livelihoods, children drop out of school, adults lose their jobs or are not able to work like they used to due to long treatment and debilitating effects as a result of disease.

 

  • Marshy areas seem to be a common denominator in the affected regions.

 

The plight of certain populations to buruli ulcer and NTDs is to some extent due to preexisting conditions within their surrounding and environment.

The plight of certain populations to buruli ulcer and NTDs is to some extent due to preexisting conditions within their surrounding and environment. Limited resources in poor rural populations have driven people to work in risky environments thereby exposing them to infectious disease causing agents. The lack of knowledge on the source  and mode of transmission of buruli ulcer creates enormous challenges with regard to disease control and prevention.

References 

Sopoh, G. E., Thierry Barogui, Y., Johnson, R. C., Dossou, A. D., Makoutodé, M., Vé Rin, S., … Portaels, F. (n.d.). Family Relationship, Water Contact and Occurrence of Buruli Ulcer in Benin. http://doi.org/10.1371/journal.pntd.0000746

Thierry Barogui, Y., Sopoh, G. E., Johnson, R. C., De Zeeuw, J., Dossou, A. D., Houezo, J. G., … Stienstra, Y. (2014). Contribution of the Community Health Volunteers in the Control of Buruli Ulcer in Bé nin. PLoS Negl Trop Dis, 8(10). http://doi.org/10.1371/journal.pntd.0003200

Ukwaja, K. N., Meka, A. O., Chukwuka, A., Asiedu, K. B., Huber, K. L., Eddyani, M., … Ntana, K. (n.d.). Buruli ulcer in Nigeria: results of a pilot case study in three rural districts. http://doi.org/10.1186/s40249-016-0119-8

WHO | Buruli ulcer. (2017). WHO. Retrieved from http://www.who.int/mediacentre/factsheets/fs199/en/

Yerramilli, A., Tay, E. L., Stewardson, A. J., Kelley, P. G., Bishop, E., Jenkin, G. A., … Johnson, P. D. R. (n.d.). The location of Australian Buruli ulcer lesions— Implications for unravelling disease transmission. http://doi.org/10.1371/journal.pntd.0005800
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