Agogo, GHANA – It is few minutes to mid-day. Patients stroll into the wards. At the main entrance where the grey kiosk security post is, people stand, conversing. The security men occasionally direct people to the wards that they ask for. Across the street, people hail tro-tros. Hawkers display their wares. This is Agogo Presbyterian Hospital.
Agogo is a town in the Ashanti Akim North District and is approximately 80 kilometers from Kumasi, the Ashanti regional capital. It is also 6 miles from Konongo, a major town on the Accra-Kumasi Highway. According to GeoNames, a geographical database, Agogo has a population of 31,554 inhabitants. The Agogo Presbyterian Hospital was established on 21st, March, 1931 and is the oldest mission hospital in Ghana. Throughout the West Africa sub-region, it has made a name as a quality ophthalmological care center.
Less than a meter away from where the security post stands, on the right hand side from the main entrance is the Records Department and the Out-Patient Department (OPD). On any other day, except Wednesdays, the OPD has four consulting rooms. Housed in a detached light yellow building, each consulting room is marked with a red painting. Directly facing that building are patients who sit under a canopy, waiting for their turns to see the consultants. Bells are sounded to call the patients into the consulting rooms. From one of the rooms, a disembodied voice calls the names on the folders belonging to the patients who have been seen by the consultants. Further down, descending stairs, away from the constellation of patients, a small group of patients sit in front of Consulting Room 5. Whenever this room is opened every Wednesday, children between 5 and 15 years most especially, seep through for diagnoses and prognoses for Buruli Ulcer (BU). In the quiet, in a room that is barely 14 by 14 feet, a battle rages on.
Buruli Ulcer, one of 17 tropical neglected diseases, is a chronic debilitating skin and soft tissue infection caused by Mycobacterium ulcerans, from the same family of bacteria as Tuberculosis and Leprosy. The early stage of the infection is characterized by the active form which is non-ulcerative (papules, nodules, plaques and edema) which progresses to extensive ulceration. Unlike the causative organisms of Tuberculosis and Leprosy, BU’s produces a toxin- mycolactone – which destroys tissues and is responsible for its pathogenesis. It affects individuals in humid, rural and tropical regions.
Inside the room, a team of clinicians examine patients. Ghana is among the 33 countries, mostly tropical African countries, which report cases of BU. It frequently occurs near water bodies—slow flowing rivers, ponds, swamps, and lakes. Cases have also occurred following flooding. The first probable case of Buruli ulcer in Ghana was reported in the Greater Accra Region in 1971. van der Werf et al. in 1989 described 96 cases in the Asante Akim North District of Ashanti Region. This report was followed by the description of a major endemic focus in Amansie West District in the same region. Since then, many isolated cases have been recorded.
Mr. Kabiru Mohammed Abass, the District Buruli Ulcer coordinator ushers a girl in. She looks like a six or seven year old. She clinches to the mother. On her dorsal is an ulcer. The lead clinician goes through her folder and makes some remarks. She is asked to lie on the bed. Her ulcer is measured and the length is recorded. After which there is a swap for microscopic smear analysis. She is injected with antibiotic in the ulcer. Her mother squints and moans at a slightly higher decibel than the daughter. She is asked to wait outside the room. On the sidelines, Mr. Abass introduces me to the clinical team.
Agogo sub-district recorded 52 cases in 2012. In 2013, there were 47 cases but there was an increase of 30 in 2014. Mr. Abass explains to me that the increase might be because they expanded their program to cover many communities in 2014. They have had intensive education too. In endemic communities, there is Community Based Surveillance Volunteers (CBSVs). When the cases are reported in the early stage, the non-ulcerative stage, they are easily treated without any surgery. Out of the 77 cases that were recorded in 2014, 55 were in the early stage. About 70% of the 55 early stage cases were reported by the CBSVs, making it the most efficient source for reporting Buruli Ulcer in the district.
Mr. Abass shows me a picture of one of the 22 patients who presented ulcer stage cases. Three of them were admitted. They were all from Sekyere Afram Plains, one of the endemic areas. His left lower limp looks like it has been eaten up. Here, too, I meet Afrifa, a 16-year old boy who is returning with Buruli Ulcer after 3 or 4 years of treatment. The exact mode of transmission is not known, although the disease has been linked to contaminated water and outbreaks appear to be related to environmental changes (deforestation, agriculture, road construction, hydraulic installation, new settlements). It appears immediate hosts including aquatic animals and amebae might play a role in transmission. The causative organism has been isolated from the environment on only one occasion.
Distinctive features of Buruli ulcer include undermining edges, white cotton wool-like appearance, thickening and darkening of the surrounding lesion. For many of the endemic areas, diagnosis is by the characteristic appearance of the ulcer which is the non-active stage. Other methods of diagnosis include PCR using the IS2404 target (which is not specific to M. Ulcerans), histopathology, culture and microscopic smear stained by Ziehl-Neelsen technique. Usually, two or more methods are used in confirming cases.
BU accounts for 0.6% of total admission at the hospital and patients spend on average, 90 days in the hospital. For out-patients, they attend clinic, like the one I have come to visit, every 2 weeks for 2 months after which they come once in a month for 10months. They are given antibiotics, which by the way, are not over the counter drugs. In years past, there have been clinical trials to compare the efficacy of oral medication of those antibiotics with the injected one. Various cohorts of Streptomycin and Rifampicin, Clarithromycin and Rifampicin and others have also been tried. In some cases, surgery is performed including excision of nodules and debridement and skin grafting of ulcers.
Although BU has a low mortality rate, morbidity rate is high. Its healing often results in severe contracture scaring and deformity.
As I prepare to leave Agogo, another patient, a boy, is brought in. He is Salifu Baba. He has missed a couple of his clinic days. Mr. Abass tells me they have been unable to track him. Ordinarily, they have a system that they use to track all patients. Salifu had travelled to a place in northern Ghana.
Mr. Abass himself seems likable. This is the second time that I have met him in three years. This time, I meet a new team of clinicians (excluding him). As I listen to him relate where people live in towns and villages, I stand awe-struck. He knows this place like the back of his palm. Undoubtedly, a battle is being won because of people like him.
Three weeks after my visit to Agogo, I missed a chance to sit in a seminar at KNUST that discussed the future of diagnosis of BU. The novel technique being discussed was using PCR to probe for mycolactone using an RNA-binder as a probe.