Buruli ulcer elimination (BU)

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Disease description and causality

buruli-ulcer1Buruli ulcer is a disease of the skin caused by Mycobacterium ulcerans, a bacterium related to those that cause Tuberculosis and Leprosy. The exact mode of transmission of the infection to humans is still unknown, although there is some evidence that it may be transmitted through the bites of infected aquatic insects or penetration into the skin through minor wounds or traumas.

Buruli ulcer often starts as a painless nodule or papule of the skin, usually on the arms or legs. These then develop into large ulcers, with a whitish-yellowish base. Left untreated, those lesions lead to massive skin ulcerations. Although most ulcers eventually heal, poorly managed patients may develop severe scars and local deformities, including disabling contractures and amputations of limbs. The disease occurs most frequently in children living in rural tropical environments, with hot and humid climate, near wetlands or lowlands, along slow-flowing rivers, water bodies or swampy areas.


Disease burden, distribution and impact

Africa bears 99% of the Global burden of Buruli ulcer cases. Confirmed endemic countries are located in the following 15 West and Central African countries in 2012: Benin, Cameroon, Central African Republic, Congo, Côte d’Ivoire, the Democratic
Republic of the Congo, Equatorial Guinea, Gabon, Ghana, Guinea, Liberia, Nigeria, Sierra Leone, Togo and Uganda. These endemic countries are within a belt limited by Latitudes 10° north and south, starting with Guinea in West Africa to Uganda
in East Africa. Cumulative cases of Buruli Ulcer in the Region are estimated at 70,000 at the end of 2010. The three major endemic countries are Côte d’Ivoire, Ghana and Benin.

Buruli ulcer imposes an economic burden on affected households and on health systems that are involved in diagnosis and treatment. In Ghana the average cost of treating a case was estimated to be US$ 780 per patient during 1994–1996, an amount that far exceeded per capita government spending on health. In Cameroon, hospitalization costs accounted for 25% of households’ yearly earnings; median total costs of hospital treatment were €126.70 in 2008.


Progress in the last 10 years

  • Assessment of burden and distribution of Buruli ulcer cases is on-going in 15 African countries
  • Support to develop national Buruli ulcer control programme in 10 major endemic countries (Benin, Cameroon, Congo, Côte d’Ivoire, the Democratic Republic of the Congo, Gabon, Ghana, Guinea, Nigeria and Togo)
  • Support to develop reference laboratories with PCR for confirmation of BU diagnosis in 6 countries (Benin, Cameroon, Central Africa Republic, Côte d’Ivoire, the Democratic Republic of the Congo and Ghana)
  • Case management with antibiotics (rifampicin and streptomycin combination for 8 weeks treatment)
  • Supply free-of-charge of specific antibiotics (rifampicin and streptomycin) to all endemic countries in the Region
  • Government ownership and commitment through the Cotonou Declaration on Buruli Ulcer in March 2009
  • Research: since 2011, preparations for a trial of combined oral antibiotics (rifampicin and clarithromycin) are on-going in two countries (Benin and Ghana).


Programme goals and objectives

The goal of Buruli ulcer programme is the reduction in morbidity and disability caused by Buruli ulcer in endemic countries.


Objectives:

  • To detect and manage appropriately all Buruli ulcer case in all endemic countries of the region
  • To set up an integrated surveillance system within Integrated Disease Surveillance and Response (IDSR) to facilitate the accurate quantification of burden and distribution of Buruli ulcer
  • To promote research in order to improve knowledge on biology and epidemiology of M. ulcerans and develop simpler diagnostic tests and oral antibiotic treatment.

Targets and milestones

The target of the programme is to control the Buruli ulcer in 15 countries by 2020

The milestones are:

  • Situation analysis achieved in the 15 countries by 2015
  • Oral treatment of Buruli ulcer cases introduced in 15 countries by 2016
  • Health staff capacity strengthened for Buruli ulcer endemic management in all health districts of the 15 countries by 2020

Major operational strategies

  • Sensitization campaigns,
  • Training of health staff and community volunteers,
  • Early diagnosis of Buruli ulcer cases and active case finding integrated with outreach activities for skin NTDs (leprosy, yaws, leishmaniasis, Guinea worm and human African trypanosomiasis) in co-endemic districts,
  • Integrated cases management with other NTDs: Leprosy, Yaws, Leishmaniasis and Human African Trypanosomiasis,
  • Referral of complicated cases requiring surgery to reference hospitals at district or intermediate levels.

Major partners
ANESVAD, BURULICO, TNF, ILEP Member, Research institutions and centres: Pasteur Institutes and Centres in Abidjan, Bangui, Yaoundé, Infectious Disease Departments or Biology Centres of Australia, Belgium, France, Italy, Japan, Spain, Sweden, Switzerland and USA.

buruli-ulcer2

 

WHO Global Fact sheet on Buruli ulcer