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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 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.

To evaluate former Buruli ulcer disease (BUD) patients to assess the factors associated with functional limitations and subsequent employment or schooling.The previously validated Buruli ulcer functional limitation score (BUFLS) questionnaire and interviews about educational and professional consequences incurred by BUD.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.Rehabilitation programmes are urgently needed to diminish the suffering from the functional limitations and employment or schooling problems caused by BUD.

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 (or= 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 (rho = 0.66 and rho = 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.

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.