Buruli ulcer (BU) is a neglected tropical disease caused by
Ga West Municipality is one of the sixteen districts in the Greater Accra Region, carved out of the erstwhile Ga district which was created in 1988. The district is 60% rural and 40% periurban and urban. It is made up of about 150 communities with Amasaman as its district capital. The Ga West Municipality shares boundaries with the Ga East and the Accra Metropolitan Area to the East, Akwapim South to the North, Ga South to the South, and Ga Central to the North-South. It occupies a total land surface area of 299.578 square kilometres. The population of the municipality as of 2015 was 262,742 [
Map of Greater Accra showing Ga West (greater Accra districts maps of net) [
The evaluation was carried out at the national level using the Buruli Ulcer Control Programme, the regional level using the Greater Accra Region, the district, and community levels using the Ga West Municipality in January 2016–March 2016. A semistructured interview guide, checklist based on the Centers for Disease Control (CDC), updated guidelines for Evaluating Public Health Surveillance Systems, 2006 [
The stakeholders of NBUCP at the national level include the WHO, Central Government through the Ministry of Health, Ghana Health Service, Korle-Bu Teaching Hospital (KBTH), Clinicians and other medical personnel, all health and treatment centres, Research Institutions (NMIMR, KCCR), and Non-Governmental Organizations (NGOs) like the America Leprosy Mission (ALM). At the regional and district levels, the local government through the District Assemblies, Chiefs, and people of the community and some NGOs like World Vision International, Anesvad, from Spain. Most of the stakeholders provide logistical and financial support to the program for its activities. The research institutions support the national control programme with case confirmation. The BU surveillance system in Ga West Municipality has a standard case definition, and because ulcers and nodules are easily identified, it makes the case definition simple to detect cases.
A person presenting a painless skin nodule, plaque, or ulcer, living or having visited a BU-endemic area.
A suspected case confirmed by at least one laboratory test (ZN for AFB, PCR, culture, or histology).
Data on this system are collected mainly through a combination of passive reporting and active reporting. At the community level, health workers or CBSVs detect cases of BU and report to the health facility, active case searches during home or school visits. Some patients also report themselves. At the health facility level, diagnosis of Buruli ulcer depends on clinical presentation and laboratory confirmation. On Wednesdays, which happens to be “a clinic day” for Buruli ulcer, samples are taken from new patients by staff of Noguchi Memorial Institute for Medical Research for laboratory confirmation and registration of cases in the district BU register (BU-02 Form). Results of the test are ready after a week. Health facilities extract information from BU-01 case registration form or from the BU register to the monthly BU-02 form and deliver hard copies to the Municipal Health Directorate (MHD), precisely to the District BU Coordinator at the end of every month. No analysis of data is done at this level. The coordinator then compiles all the cases from the facilities on another BU-02 form which is reported quarterly to the regional surveillance unit and NBUCP through e-mail and hardcopy. Copies are stored in the computer and external drive. The District Disease control officer also compiles the Integrated Disease Surveillance and Response (IDSR) monthly reports and submits to the regional surveillance unit while soft copies of the monthly morbidity return forms are sent to the Health information unit every month. Soft copies are stored on computers and hard copies in files at the office. Data analysis is as well carried out at this level using Microsoft Excel to provide information to all the stakeholders in the district for action. At the regional level, the regional surveillance officer compiles all reports received from the districts. Data analysis is done to assess the trend and to give information to the regional Director of public health as well as the district Directors. The IDSR monthly report is then sent to the National Surveillance Unit (NSU) on a monthly basis while BU-02 quarterly forms are sent to NBUCP on quarterly basis. Feedback is sent to the districts in the form of emails, telephone calls, review meetings, and annual reports. At the national level, the surveillance unit of the NBUCP receives data from district and regions. Data analysis is conducted to generate age, sex, district, and regional distributions. Data analysis is carried out to generate the BU categories, clinical forms, suspected and confirmed BU cases, and trends of new and recurrent cases. After analysis of the data, feedback is sent to the regions and districts quarterly through e-mail and annual reports. At the end of each year, reports containing the total number of BU cases and the various indicators in Ghana are sent to WHO during the annual meeting in Geneva. The flow of information from one level to the other is shown in Figure
Flow chart of Buruli ulcer surveillance system.
At the national level, NBUCP has a staff strength of five and one employed by an NGO to assist the program. NBUCP has strong collaboration with the research centres for confirmation of cases. At the regional, district, and facility levels, the same officers are used for all public health and disease control activities. The integration with the health service surveillance system makes BU surveillance system less expensive to run. The main sources of funding for NBUCP include the Government of Ghana through Ministry of Health (MOH), WHO, America Leprosy Mission, NGOs such as Anesvad.
The Buruli ulcer surveillance system in Ga West is a vital source of information. The data are useful for understanding the severity of the disease and for planning and monitoring the impact of interventions put in place to minimize the morbidity and disability associated with the disease (Table
Sex, age group, and clinical forms of BU seen in Ga West, 2011–2015.
Year | Sex | Age group | Clinical forms of cases seen | ||||||
---|---|---|---|---|---|---|---|---|---|
Female | Male | <15 yrs | 15 yrs and above | Ulcer | Plaque | Oedema | Mixed forms | Nodule | |
2011 | 42 | 67 | 31 | 78 | 92 | 4 | 2 | 9 | 2 |
2012 | 32 | 38 | 19 | 51 | 63 | 1 | 1 | 4 | 1 |
2013 | 23 | 23 | 18 | 28 | 36 | 2 | 0 | 6 | 2 |
2014 | 16 | 11 | 8 | 19 | 23 | 1 | 1 | 0 | 2 |
2015 | 11 | 6 | 6 | 11 | 17 | 0 | 0 | 0 | 0 |
Total | 124 (46.1%) | 145 (53.9%) | 82 (30.5%) | 187 (69.5%) | 231 (85.9%) | 8 (2.9%) | 4 (1.4%) | 19 (7%) | 7 (2.6%) |
Categories of Buruli ulcer cases in Ga West, 2011–2015.
We assessed simplicity by the level of easiness for detection of cases and amount of follow-up that is necessary to update data on the case. Even though there is clarity in the case definition, the system was found not simple because confirmation of cases by the laboratory takes a week. Throughout the various levels of reporting, (8/10) of respondents complained of too much variable needed to fill the BU-02 form.
Flexibility was assessed by determining the surveillance system’s ability to adapt to new demands such as the integration with other diseases on the IDSR. The system was found to be flexible because it was well integrated with other diseases like Leprosy, Leishmaniasis, and Yaws.
Data quality was assessed by examining the percentage of “unknown” or “blank” responses to the items on the BU02 forms and review of sampled data. According to the report by WHO [
The systems were seen to be fairly stable partly because it makes use of the Ministry of Health/Ghana Health Service staff to collect data and manage cases. It was found that it depends heavily on NGO’s support and research institutions for confirmation of cases. Challenges with logistics, transport, and communication were also apparent during the evaluation.
All the public sector health facilities in the districts submit reports to the municipal health directorate. However, it was apparent that the private sector does not report and hence are not part of the surveillance network.
The surveillance system was representative in person, place, and time. The surveillance system collected data all year round from all the subdistricts. Over the five-year period, all persons were under surveillance. Cases were reported with variables: sexes, all ages, residence, clinical forms, location of lesion, and category of lesion. Cumulatively, 53.9% of cases were males, and children ≤15 years were 30.5% within the time period.
We assessed sensitivity by the ability of the system to pick cases. According to the clinical case definition, a total of 594 suspected cases were identified during the period and confirmed by Noguchi Memorial Institute for Medical Research (NMIMR) using polymerase chain reaction (PCR) detection of the insertion sequence IS
Trend of suspected and confirmed cases in Ga West, 2011–2015.
From 2011–2015, of 594 suspected cases, 269 were confirmed by PCR as positive. This gave a PVP of (269/594) × 100 = 45.3%
Timeliness was calculated based on the BU records from the District Health Information Management System. The sub-facilities are supposed to report on the 5th of the ensuing month, and the district BU coordinator/health information officer is supposed to enter the data into DHIMS on 15th of every month. After this date, the DHIMS captures it as late entry. Even though there was an improvement on the timeliness of reporting, on the average, the system was not timely (Table
Timeliness of reporting BU cases in (DHIMS).
Year | Timeliness (%) | Average (%) |
---|---|---|
2011 | 0 | 30.7 |
2012 | 0 | |
2013 | 14.3 | |
2014 | 39.3 | |
2015 | 100 |
In conclusion, the surveillance system in Ga West is meeting its set objectives and is useful. However, data quality, timeliness, and private participation are a challenge. It depends heavily on NGO’s support and research institutions for confirmation of cases which could affect its stability.
We, therefore, recommended that, the National Buruli Ulcer Control Program Director should provide regular logistical support for all treatment centres and bring private health facilities into the surveillance network. The district BU coordinator should always crosscheck for discrepancies in the data generated, reconciled with the disease control officer in charge of integrated disease surveillance and response monthly forms.
The data used to support the findings of this study have been deposited in the Harvard Dataverse repository (
The authors declare that they have no conflicts of interest.
RT, EA, EK, SOS, and EAA conceptualized the idea of this study. RT and EA were involved in data collection. RT performed data analyses. RT drafted the manuscript. EK, SOS, and EAA reviewed the manuscript. All authors read and approved the final manuscript.
The authors wish to acknowledge the National Buruli Ulcer Control Programme, the Greater Accra Regional Health Directorate, Ga West Municipal Health Directorate and Buruli ward for helping with the data. This work was funded from the authors’ own resources with nonmonetary support from our collaborators acknowledged above.