Journal Article

Risk Factors for Buruli Ulcer Disease (<i>Mycobacterium ulcerans</i> Infection): Results from a Case-Control Study in Ghana

Pratima L. Raghunathan, Ellen A.S. Whitney, Kwame Asamoa, Ymkje Stienstra, Thomas H. Taylor, George K. Amofah, David Ofori-Adjei, Karen Dobos, Jeannette Guarner, Stacey Martin, Sonal Pathak, Erasmus Klutse, Samuel Etuaful, Winette T.A. van der Graaf, Tjip S. van der Werf, C.H. King, Jordan W. Tappero and David A. Ashford

in Clinical Infectious Diseases

Published on behalf of Infectious Diseases Society of America

Volume 40, issue 10, pages 1445-1453
Published in print May 2005 | ISSN: 1058-4838
Published online May 2005 | e-ISSN: 1537-6591 | DOI:
Risk Factors for Buruli Ulcer Disease (Mycobacterium ulcerans Infection): Results from a Case-Control Study in Ghana

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  • Infectious Diseases
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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.


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.


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-Guérin vaccination (P = .33), or human immunodeficiency virus infection (P = .99).


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.

Journal Article.  5922 words.  Illustrated.

Subjects: Infectious Diseases ; Immunology ; Public Health and Epidemiology ; Microbiology

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