Knowledge and practices of health practitioners on treatment of Buruli ulcer in the Mbonge, Ekondo Titi and Muyuka Health Districts, South West Region, Cameroon

Introduction After tuberculosis and leprosy, Buruli ulcer (BU) is the third most common mycobacterial infection. Buruli ulcer begins as a localized skin lesion that progresses to extensive ulceration thus leading to functional disability, loss of economic productivity and social stigma. This study is aimed at assessing the knowledge and practices among health practitioners on the treatment of BU in the Mbonge, Ekondo Titi and Muyuka Health Districts of the South West Region of Cameroon. Methods This is a cross-sectional study that investigates participants' knowledge and practices on the treatment of BU. The study uses a qualitative method of structured questionnaires in the process of data collection. Results Seventy percent (70%) of the participants acknowledged they encounter cases of BU in their respective Hospitals or Health centers. Among these, 48% agreed they managed BU in their facilities and up to 91.7% noted that their community members are aware that BU is managed in their facility while seventy percent of the medical practitioners indicated they cannot identify the various stages of BU. Eighty-one percent of the practitioners from Muyuka HD indicated they could not identify the various stages of BU. More than 63% of the practitioners regarded BU patients as normal people in their communities however, practitioners that practiced for less than 5 years were likely not to admit BU patients in the same room with other patients. Beliefs such as being cursed (47.06%) and being possessed (29.41%) were reported by practitioners that acknowledged the existence of traditional beliefs in the community. Conclusion Despite the fact that a majority of the health practitioners knew what BU is, most of them demonstrated lack of knowledge on the identification of the various stages and management of the illness. Practitioners demonstrated positive attitude towards patients although they would not admit them in the same room with other patients. Considering the poor knowledge on identification and management demonstrated by most of the practitioners, management of the disease would be inadequate and may even aggravate the patient's situation. Training and onsite mentorship on screening, identification and management of BU is therefore highly recommended amongst health personnel practicing in endemic areas.


Introduction
After tuberculosis and leprosy, Buruli ulcer (BU) is the third most common mycobacterial infection [1]. BU begins as a localized skin lesion that progresses to extensive ulceration, leading to functional disability, loss of economic productivity, and social stigma [2]. In Australia BU is called Brainsdale disease. Since the 1998 World Health Organization (WHO) Buruli ulcer initiative, there has been increased attention to research efforts for treatment and control of BU. Buruli ulcer, Bairnsdale ulcer and Daintree ulcer are all local names given to the same disease that is caused by Mycobacterium ulcerans. The responsible organism is an acid-fast Mycobacterium of the same genus as the tuberculosis bacilli. This environmental bacterium produces a destructive toxin and mycolactone which leads to tissue damage that inhibits the immune response [3]. M. ulcerans infects the skin and subcutaneous tissues that progresses to indolent nonulcerated and ulcerated lesions [4]. M. ulcerans grows optimally at a temperature of 90oF (32°C) in the tropical and sub-tropical zones on earth [5]. Considering Cameroon as one of the most affected areas in Africa, there has been intense study on various aspects of this debilitating disease in the country. Prevalence studies of BU by [6] and [7] in the Nyong River basin in Akonolinga identified 436 and 125 cases of BU respectively. Also, studies by [8] show that the age adjusted cumulative incidence in elderly people is similar to that in children because of contact with the river which is a risk factor. The current Bacille Calmette-Guérin (BCG) vaccine appears to offer some short-term protection against BU however, there is on-going research for a vaccine to treat Buruli ulcer because a safe and effective vaccine may be the most effective way to combat Buruli ulcer in the long term. Although the first report of Buruli ulcer from Africa dates back to 1897 when Sir Albert Cook described cases of chronic ulceration in Uganda, the first definitive description of Mycobacterium ulcerans was published in 1948 [4].
Cases of human disease occur in over 30 countries worldwide. For instance, disease foci have been reported from tropical areas in Asia (Malaysia, Papua New Guinea and Sri Lanka) and Latin America (Guyana, Mexico, Peru). In addition, the largest numbers of patients with Buruli ulcer disease have been detected in sub-Saharan Africa [9]. Foci have also been identified in Australia (Queensland and the Southern Territory) [10]. The earliest reports from Africa came from the South-West of Kinshasa in the Democratic Republic of the Congo where the disease is prevalent [11]. Later, there were reports of hundreds of patients in Uganda, from a refugee camp in Kinyara, near the Nile river, in a county that was called Buruli, hence the name "Buruli ulcer" [12]. The last training on BU offered to health care providers in the SWR was in 2007 thus indicating that a high proportion of health care providers (medical doctors, nurses and laboratory technicians), especially those recruited after the training could have little or no knowledge on the identification and management of BU. It is therefore evident that there is need for evaluation of knowledge and practices of health care providers in the SWR of Cameroon to make recommendations on ways to facilitate disease identification and prompt treatment to minimize the physical, economic and social impacts of the disease. The major objective of this study was to assess the knowledge of medical practitioners about BU with regards to its transmission, prevention and treatment, and also to determine their behavior towards BU disease sufferers. were noted ( Figure 6).

Discussion
Among the health practitioners, out of the 70% that acknowledged they usually encounter BU cases in their health facilities, surprisingly, less than one-third of the practitioners confirmed that they could identify the various stages of BU. 60% of the practitioners also thought BU can be prevented by citing specific possible means through which the debilitating illness can be prevented. According to information obtained from community members during FGDs in a related study and in consideration of the fact that a handful of the health practitioners were unable to identify and manage BU cases in their health facilities, they were tempted to seek treatment elsewhere.
They mentioned prayers (miracles) and herbalists/witchdoctors as alternative places for treatment [13].

Competing interests
The authors declare no competing interests.

Acknowledgments
We are grateful to all who participated in this research.