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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 heating 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. (C) 2008 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved.

OBJECTIVES To evaluate former Buruli ulcer disease (BUD) patients to assess the factors associated with functional limitations and subsequent employment or schooling. METHODS The previously validated Buruli ulcer functional limitation score (BUFLS) questionnaire and interviews about educational and professional consequences incurred by BUD. RESULTS Of 638 participants, 362 (57%) had a functional limitation after a median period of almost 4 years after treatment for BUD. A lesion on a joint, older age, female gender, a lesion on a distal part of an extremity and a persistent wound were found to be independent risk factors for stopping work or education. The same risk factors applied to the development of a functional limitation. Both functional limitations and financial difficulties due to BUD disease often led to job loss and school dropout. CONCLUSIONS Rehabilitation programmes are urgently needed to diminish the suffering from the functional limitations and employment or schooling problems caused by BUD.

The definitive version is available at www3.interscience.wiley.com, This study aimed to determine the distribution of Buruli ulcer (BU) in Lalo, one of the endemic districts of the Couffo department in Bénin. A total of 752 BU patients were detected in this district with 160 active and 592 inactive cases. The overall prevalence of BU in this district is 86.6 per 10,000 inhabitants, varying from 0 to 249/10,000 between sub-districts. At village level the prevalence varies between 0 and 561 cases per 10,000 inhabitants. Our findings confirm the large variation of distribution of the disease at the village level in endemic area. Children under 15 years are frequently affected. We also found a significant association between age and location of Buruli lesions. Further epidemiological and environmental studies are needed to identify the reasons for the extraordinary variation in BU distribution between villages from the same sub-district, and to confirm if it is associated with temporal variations.

To the Editor: Mycobacterium ulcerans disease, commonly called Buruli ulcer, is an emerging infectious disease in West Africa (1,2). Several forms of Buruli ulcer exist; large, chronic ulcerations or indurated plaques of the skin are the most frequent manifestations of the disease (1), and bone is sometimes involved (3). Little is known about the focal epidemiology of Buruli ulcer; incidence, prevalence, and other data are usually reported at the national or district level (4). These data convey the importance of the disease but do not show the wide variations that occur at the village level within a given district. In 2002, we investigated the disease in an arrondissement (Gnizounme) in an area in which Buruli ulcer is endemic, the commune of Lalo in Benin. Prevalence rates of Buruli ulcer varied from 0.58 to 32.62 per 1,000 inhabitants of villages in the same arrondissement. For Gnizounme Arrondissement, the overall prevalence was 10.70 per 1,000 inhabitants. These results confirmed that distribution of Buruli ulcer must be determined at geopolitical divisions lower than district or national levels, as is frequently assumed to be the case. An inverse relationship exists between the prevalence of Buruli ulcer and distance from the Couffo River, which drains the arrondissement of Gnizounme. A comparison of the relevant data for Assogbahoue and Tandji villages shows that the number of patients per 1,000 inhabitants increases gradually from 0.58 to 32.62 as the distance from the river decreases from 10 to 1 km. Recently, aquatic insects have been considered potential vectors of M. ulcerans (5,6). These aquatic insects can fly many kilometers from their source (7). This finding may partially explain how patients who live farther distances from their source of water become infected, but not as often as those who live closer. Some water bugs obtained from water collection points along the Couffo River in the village of Tandji were found to be positive for M. ulcerans by using PCR with specific insertion sequence 2404 as a target (8). If we consider domestic water sources in the arrondissement of Gnizounme, only Tandji (32.62 Buruli ulcer patients per 1,000 inhabitants) used water directly from the Couffo River. Other villages employed protected water sources for domestic purposes (boreholes, cisterns, or piped water from artesian wells). These results are similar to Barker's findings in Uganda, which showed that families who used unprotected sources of water for domestic purposes had higher prevalence rates of Buruli ulcer than those who used boreholes (9). Consequently, besides the possible influence of distance from the river on disease prevalence through potential vectors, such as insects or other factors, we hypothesize that the use of river water for domestic purposes may also play a role in the elevated prevalence of the disease in Tandji village. If this hypothesis is confirmed, preventive public health programs based on strategies that provide protected water supply systems to villages must be developed to reduce the frequency of the disease. Determining the complex relationship between distance from the Couffo River and the numbers of cases and level of protection of water supply is difficult. Our findings argue for the need to perform additional epidemiologic studies to understand more completely the key factors that determine the distribution of the disease in the entire commune of Lalo.