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The reliability and validity of the earlier developed Buruli ulcer functional limitation score (BUFLS) questionnaire was assessed. Of 638 former Buruli ulcer patients (of 678 individuals examined), sufficient items on daily activities ( 13 of the 19) were applicable to calculate a score. To determine the validity, the functional limitation scores of the 638 individuals were compared with the global impression of the limitations, range of motion (ROM), and the social impact (change of occupation or education) of Buruli ulcer. To determine inter-observer reliability, the functional limitation score was reassessed in 107 participants within one and three weeks after the first interview by another interviewer and interpreter. Both global impression and ROM correlated well with the functional limitation scores ( 0.66 and 0.61). The inter-observer reliability of 107 participants as measured by an intra-class correlation coefficient of 0.86 was very good. The functional limitation scores measured in the second assessment were significantly higher than in the first assessment. This should be taken into account when the functional limitation score is used for the individual patient. The BUFLS can be used as for between group comparisons of endpoints in clinical trials and in the planning of resources. tations. 5 A reduction in the range of motion (ROM) was found in 58% of the former Buruli ulcer patients in Ghana when using a goniometer. Instead of measuring the physical limitations in ROM of joints, a simple and functional scoring system to assess nature and severity of the impairment on carrying out daily activities as a result of Buruli ulcer has been proposed. 6 Based on frequency endorsement and applicability, a ques- tionnaire with 19 items of daily activities was developed. The questionnaire has a good internal consistency ( 0.89). 7,8 In this study, the validity and reliability of this questionnaire was analyzed.

Helminth infections elicit an immune response potentially enhancing susceptibility to mycobacterial diseases. Schistosomiasis and infection with Mycobacterium ulcerans show a remarkable similarity in epidemiologic characteristics in Ghana. In 2000, a case-control study was conducted in three districts in Ghana endemic for M. ulcerans. One hundred six patients with confirmed M. ulcerans disease and 106 matched community controls were included. Schistosome infection of these patients and controls was measured by an enzyme-linked immunosorbent assay that detected circulating anodic antigen in serum. Fifty percent of the participants tested positive for schistosomiasis. There was no difference in detection rates among patients and matched controls. Similarly, there were no differences in worm burden between patients and controls. These results do not support the hypothesis that susceptibility to M. ulcerans disease is driven by a co-infection with schistosomes.

Buruli ulcer, a disease with long-term consequences, is emerging in west Africa. Thus, a functional limitation scoring system is needed to assess its nature and severity. A list of daily activities was developed for this disease. Following treatment of Buruli ulcer, persons in Benin (n = 47) and Ghana (n = 41) were investigated. Nineteen items were identified with good internal consistency. Participants (median age = 14 years) could not perform 23% of their daily activities. Twenty-nine participants did not have any functional limitation. The average limitation score was 31% in Benin and 15% in Ghana (P = 0.006). The mean limitation score in participants without visible contractures (n = 65) was 13%, whereas patients with visible contractures (n = 20) or an amputation (n = 3) had a score of more than 50%. Validity and reliability should be further analyzed to optimize the scale for use in individual evaluation, as an end point in intervention trials, and in planning of resources needed for the care of patients with functional limitations.

Standardized antimycobacterial therapy is considered the treatment of choice for Buruli ulcer disease. To assess the prevalence of drug resistance among clinical Mycobacterium ulcerans isolates in Ghana, we conducted a sequence-based approach to detect mutations associated with drug resistance. We subjected clinical samples to direct DNA sequencing of rpoB and rpsL genes and compared culture and whole-genome extracts regarding the efficiency of sequence analysis; 99.1% (rpoB) and 100% (rpsL) of the patients harbored M. ulcerans wild type. In one isolate (0.9%), a point mutation of the rpoB gene at codon Ser522 leading to an amino acid change was detected. Culture extracts yielded a significantly higher sequencing efficiency than whole-genome extracts. Our data suggest a low level of drug resistance in Ghana. However, mutations associated with drug resistance do occur and require monitoring. Improved techniques are necessary to enhance the efficiency of sequence analysis of whole-genome extracts.

This study assesses the frequency of recurrences and treatment outcome after surgery of buruli ulcer dis- ease (BUD) with or without concomitant antimycobacterial treatment. Of 129 laboratory-confirmed BUD patients who underwent surgery in two treatment centers in Ghana, 79 (61%) were retrieved for follow-up 4-29 months after the initial treatment. Among 7 (9%) recurrent cases no significant association was found between recurrences and clinical or treat- ment specific factors including antimycobacterial treatment. In 21 (27%) patients, a reduced range of motion (ROM) of one or more joints was detected. Lesions other than nodules, joint involvement, and skin grafting were identified as inde- pendent risk factors. Functional limitations hampering daily activities were perceived by 22% of the patients. Compared with other studies the recurrence rate was relatively low, functional limitations were, however, frequent. This emphasizes the need for improvement of pre- and post-treatment wound care as well as rehabilitation programs.