BURULI ULCER

Disease
Buruli ulcer, a disease caused by Mycobacterium ulcerans has since 1980 emerged as an important cause of human suffering. The causative organism is from the family of bacteria which causes tuberculosis and leprosy. It destroys skin, underlying tissues and causes deformities. Lesions occur mainly in the limbs.

Buruli ulcer is the third most common mycobacterial infection in healthy people after tuberculosis and leprosy and the most poorly understood of these three diseases. It was first detected in 1948 among farmers in Australia (where it is known as Bairnsdale ulcer). However, cases were described as early as 1897 in Uganda by Sir Albert Cook. Most patients are women and children who live in rural areas near rivers or wetlands. Not much is known about the mode of transmission to human beings.

Prevalence: Buruli ulcer, named after an area of Uganda which was the site of many cases in the 1960s, is most common in West Africa. All countries along the Gulf of Guinea are now affected. In Côte d'Ivoire, approximately 15,000 cases have been recorded since 1978 where up to 16 percent of the population in some villages are affected. In Benin, 4,000 cases have been recorded since 1989; in Ghana (6,000 recorded cases in a national survey in 1999) up to 22 per cent of villagers are affected in some areas. There is evidence of huge underreporting of the disease.

It is found in marshy parts of the tropical and subtropical regions of Africa, Asia, Latin America and the Western Pacific. Cases have been reported or suspected in Angola, Australia, Benin, Bolivia, Burkina Faso, Cameroon, China, Congo, Côte d'Ivoire, Democratic Republic of Congo, Equatorial Guinea, French Guyana, Gabon, Ghana, Guinea, India, Indonesia, Japan, Liberia, Malaysia, Mexico, Papua New Guinea, Peru, Sierra Leone, Sri Lanka, Sudan, Suriname, Togo and Uganda. A few cases have been reported in non-endemic areas in North America and Europe linked to international travel.

Symptoms: The disease often starts as a painless swelling in the skin. A nodule develops beneath the skin's surface teeming with mycobacteria. Unlike other mycobacteria, M. ulcerans produces a toxin, which destroys tissue and suppresses the immune system. Massive areas of skin and sometimes bone are destroyed causing gross deformities. When lesions heal, scarring may cause restricted movement of limbs and other permanent disabilities. One important feature of Buruli ulcer is the minimally painful nature of the disease which may partly explain why those affected do not seek prompt treatment.

Treatment: Treatment of Buruli ulcer with antibiotics has been unsuccessful to date although the organism is sensitive in-vitro to some of the antibiotics used for treatment of tuberculosis. Current research findings indicate that a combination of an aminoglycoside (amikacin or streptomycin) and rifampicin cures Buruli ulcer in mice. At the present time, the only treatment available is surgery to remove the lesion followed by a skin graft if necessary. This is both costly and dangerous, leading to the loss of large amount of tissues/or permanent disability. Early detection and surgical removal of small lesions could prevent many complications.

Prevention: BCG vaccination appears to offer some short-term protection from the disease. At the present time, BCG vaccination is the only biomedical intervention that may help control Buruli ulcer in the highly affected areas.

Social and economic implications: Access to health services is restricted in endemic areas. Patients often seek treatment late causing frequent and severe complications and prolonging costly hospitalization. Treatment cost per patient far exceeds annual per capita health spending. In Ghana, the average cost of treatment is estimated at US$ 780 per patient. At the same time, treatment for early lesions could cost about US$ 20-30 per patient with very limited hospitalization. In some areas, about 20%-25% of people with healed lesions are disabled. With an increasing number of cases, and associated complications, the long-term economic and social impact of Buruli ulcer on rural populations could be substantial.

WHO recommendations

The World Health Organization has recognized Buruli ulcer as an emerging public health threat and has established the Global Buruli Ulcer Initiative (GBUI) to coordinate control and research efforts world-wide. A Buruli Ulcer Advisory Committee was established in 1998 to guide the Organization's work, and in the same year, WHO held an international conference in Yamoussoukro, Côte d'Ivoire, to share information and further develop a global strategy for Buruli ulcer control and research. At that conference, representatives from more than 20 countries signed the Yamoussoukro Declaration on Buruli Ulcer as a pledge to control the disease. Since then, the response from the affected countries, NGOs, donors and the research communities has been most encouraging.

In the past, lack of information on Buruli ulcer may be partly responsible for the low level of attention accorded to the disease. To address this information gap, WHO has published the following materials:

source: WHO

Related Links:

International Reconstructive Surgery

Buruli Busters Action