title: Risk factors for Buruli ulcer disease (Mycobacterium ulcerans Infection): results from a case-control study in Ghana.
abstract: BACKGROUND
  Morbidity due to Buruli ulcer disease (BUD), a cutaneous infection caused by Mycobacterium ulcerans, has been increasingly recognized in rural West Africa. The source and mode of transmission remain unknown.
  
  
  METHODS
  To identify BUD risk factors, we conducted a case-control study in 3 BUD-endemic districts in Ghana. We enrolled case patients with clinically diagnosed BUD and obtained skin biopsy specimens. M. ulcerans infection was confirmed by at least 1 of the following diagnostic methods: histopathologic analysis, culture, polymerase chain reaction, and Ziehl-Neelsen staining of a lesion smear. We compared characteristics of case patients with confirmed BUD with those of age- and community-matched control subjects using conditional logistic regression analysis.
  
  
  RESULTS
  Among 121 case patients with confirmed BUD, leg lesions (49%) or arm lesions (36%) were common. Male case patients were significantly more likely than female case patients to have lesions on the trunk (25% vs. 6%; P = .009). Multivariable modeling among 116 matched case-control pairs identified wading in a river as a risk factor for BUD (odds ratio [OR], 2.69; 95% confidence interval [CI], 1.27-5.68; P = .0096). Wearing a shirt while farming (OR, 0.27; 95% CI, 0.11-0.70; P = .0071), sharing indoor living space with livestock (OR, 0.36; 95% CI, 0.15-0.86; P = .022), and bathing with toilet soap (OR, 0.41; 95% CI, 0.19-0.90; P = .026) appeared to be protective. BUD was not significantly associated with penetrating injuries (P = .14), insect bites near water bodies (P = .84), bacille Calmette-Guerin vaccination (P = .33), or human immunodeficiency virus infection (P = .99).
  
  
  CONCLUSIONS
  BUD is an environmentally acquired infection strongly associated with exposure to river areas. Exposed skin may facilitate transmission. Until transmission is better defined, control strategies in BUD-endemic areas could include covering exposed skin.
authors.affiliation: National Center for Infectious Diseases, Division of Applied Public Health Training, Epidemiology Program Office, Centers for Disease Control and Prevention, Atlanta, GA, 30333, USA. pgr4@cdc.gov.
authors.forename: Pratima L
authors.initials: PL
authors.lastname: Raghunathan
authors.forename: Ellen A S
authors.initials: EA
authors.lastname: Whitney
authors.forename: Kwame
authors.initials: K
authors.lastname: Asamoa
authors.forename: Ymkje
authors.initials: Y
authors.lastname: Stienstra
authors.forename: Thomas H
authors.initials: TH
authors.lastname: Taylor
authors.forename: George K
authors.initials: GK
authors.lastname: Amofah
authors.forename: David
authors.initials: D
authors.lastname: Ofori-Adjei
authors.forename: Karen
authors.initials: K
authors.lastname: Dobos
authors.forename: Jeannette
authors.initials: J
authors.lastname: Guarner
authors.forename: Stacey
authors.initials: S
authors.lastname: Martin
authors.forename: Sonal
authors.initials: S
authors.lastname: Pathak
authors.forename: Erasmus
authors.initials: E
authors.lastname: Klutse
authors.forename: Samuel
authors.initials: S
authors.lastname: Etuaful
authors.forename: Winette T A
authors.initials: WT
authors.lastname: van der Graaf
authors.forename: Tjip S
authors.initials: TS
authors.lastname: van der Werf
authors.forename: C H
authors.initials: CH
authors.lastname: King
authors.forename: Jordan W
authors.initials: JW
authors.lastname: Tappero
authors.forename: David A
authors.initials: DA
authors.lastname: Ashford
mesh_terms: D000293:Adolescent; D000328:Adult; D016022:Case-Control Studies; D002648:Child; D002675:Child, Preschool; D005260:Female; D005869:Ghana / Q000453:epidemiology; D006801:Humans; D007223:Infant; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009165:Mycobacterium Infections, Nontuberculous / Q000453:epidemiology* / Q000382:microbiology*; D019911:Mycobacterium ulcerans / Q000302:isolation & purification*; D016017:Odds Ratio; D012307:Risk Factors; D012727:Sex Characteristics; D012883:Skin Ulcer / Q000453:epidemiology / Q000382:microbiology*