WORLD HEALTH ORGANIZATION WHO/CDS/CPE/GBUI/2003.

ORGANISATION MONDIALE DE LA SANTE

DRAFT

REPORT

5TH WHO ADVISORY GROUP

MEETING ON BURULI ULCER

11–14 March 2002

WHO Headquarter, Geneva, Switzerland
© World Health Organization (2003)

This document is not a formal publication of the World Health Organization (WHO), and all rights are reserved by the Organization. The
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The views expressed in documents by named authors are solely the responsibility of those authors.
List of participants ....................................................................................................................................................3

Meeting conclusions and recommendation .............................................................................................................7

Global Buruli Ulcer Initiative ................................................................................................................................19

Mycobacterium ulcerans disease (Buruli Ulcer Disease).......................................................................................21

Update on Buruli Ulcer control activities in Benin ..............................................................................................27

Update on Buruli ulcer control activities in Côte d’Ivoire ..................................................................................29

Surgical treatment of Buruli ulcer at the peripheral health-care level ..............................................................35

Preliminary studies of débridement using clay minerals on Mycobacterium ulcerans infections and their
ramifications ............................................................................................................................................................41

Preliminary studies on débridement and scarring of Mycobacterium ulcerans infections using natural
hydrated aluminum silicates...................................................................................................................................49

Update on Buruli Ulcer activities for 2001 in Ghana ...........................................................................................51

Update on Buruli ulcer control activities in Guinea.............................................................................................53

Situation in Togo .....................................................................................................................................................59

Mycobacterium ulcerans infection in French Guyana – Situation on 31 December 2001..................................63

Update on MBU in Papua New Guinea, March 2002 ..........................................................................................67

Buruli Ulcer situation in Congo .............................................................................................................................73

Buruli ulcer situation in Malawi ............................................................................................................................75

Trends of Buruli ulcer in Uganda ..........................................................................................................................77

Application of cultured epidermis in surgical treatment of Buruli ulcer patients in Ghana (hereinafter called
the Project) – Preliminary results ..........................................................................................................................79

Diagnosis and treatment of osseous forms of the disease and its complications ................................................83

Protective effect of BCG vaccination in children against severe forms of Mycobacterium ulcerans disease
(Buruli ulcer) ...........................................................................................................................................................87

Risk factors for Buruli ulcer: age, sex and Schistosoma haematobium infection ...............................................91

Acquired anergy following Mycobacterium ulcerans infection ............................................................................95

Mycobacterium ulcerans infection – Drug treatment: 3 illustrative cases ..........................................................97

Buruli ulcer research at Noguchi Memorial Institute for Medical Research.....................................................99

The use of DNA micro-arrays to investigate the host reponse to mycolactone; how this data may lead to
novel therapies for Buruli ulcer ...........................................................................................................................101

Histopathologic characteristics of the PGL-1 immunostaining in lesions of Buruli ulcer – specificity of the
monoclonal antibody used ....................................................................................................................................103

Genome sequence analysis of Mycobacterium ulcerans......................................................................................105

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Immunological cross-reactivity between Mycobacterium ulcerans and other mycobacteria ......................... 107

Update on the activities of the Bernhard Nocht Institute for Tropical Medicine in establishing a diagnostic
unit for Mycobacterium ulcerans ......................................................................................................................... 109

Susceptibility to Mycobacterium ulcerans infection; impact of co-infection with schistosomes on the

development of Buruli ulcer ................................................................................................................................ 111

Functional limitations caused by Buruli Ulcer................................................................................................... 113

Extent of excision impacts on healing of Buruli ulcer ....................................................................................... 115

Latent Class Analysis (LCA) evaluation of four diagnostic tests for Buruli ulcer disease............................. 117

Histopathologic features of Mycobacterium ulcerans infection......................................................................... 119

A case control study to identify Modifiable Risk Factors for Buruli Ulcer Disease, Ghana, 2000 ................ 121

Experimental chemotherapy of Buruli ulcer: where do we stand? .................................................................. 123

WHO antibiotic trial ............................................................................................................................................ 127

The role of water bugs in the transmission of Mycbacterium ulcerans............................................................. 129

Advocacy, social mobilization and training for Buruli Ulcer ........................................................................... 131

Contribution of ANESVAD ................................................................................................................................. 133

The intervention of AIFO to help in the fight against Buruli ulcer in Ghana................................................. 137

Leprosy Relief Emmaüs – Switzerland (ALES) ................................................................................................. 139

Communication from the Raoul Follereau Foundation of Luxembourg (FFL).............................................. 141

Medical Assistance (MAP) International ........................................................................................................... 143

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List of participants
Dr Julien Aké Aké, Bureau régional pour l’Afrique de l’ouest, MAP International, Abidjan,
Côte d'Ivoire
Dr George Amofah, Public Health Division, Ministry of Health, Accra, Ghana
Prof. Henri Assé, Institut Raoul Follereau, Adzopé, Côte d’Ivoire
Dr David Ashford, Meningitis and Special Pathogens Branch, Centers for Disease Control and
Prevention, Atlanta, GA, United States of America
Dr Christophe Ayissi, Ministère de la Santé, Yaoundé, Cameroon
Madame Silviana Badino, Turin, Italy
Dr Adama Marie Bangoura, Programme National de lutte contre l’ulcère de Buruli, Conakry, Guinea
Dr Hilaire Bassakouaou, Ministry of Health/Ministère de la Santé, Brazzaville, Congo
Mrs Patricia Beauverd, Aide aux Lépreux Emmaüs–Suisse, Bern, Switzerland
Dr Gisela Bretzel, Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
Mr Gérard and Mrs Line Brunet de Courssou, Missillac, France
Mr Thierry Brunet de Courssou, Missillac, France
Prof. Bernard Carbonnelle, Laboratoire de Bactériologie, CHU Angers, France
Dr Lucie Avoaka Cissé, Programme National de Lutte contre les Ulcères à Mycobactéries, Abidjan,
Côte d’Ivoire
Mr Bernard Clermont, Rennes, France
Madame Bernadette Dassio, Centre Anti-Ulcère de Buruli, Zouan-Hounien, Côte d’Ivoire
Dr Sunil Deepak, Associazione Italiana Amici di Raoul Follereau, Bologna, Italy
Ms Debora Ellen, Department of Internal Medicine, University Hospital, Groningen, The Netherlands
Dr Samuel Etuaful, St Martin’s Catholic Hospital, Agroyesum, Ghana
Dr Peter Firmenich, Médecins Sans Frontières – Luxembourg
Dr Tetsuya Fujikura, International Center, Kobe International University, Kobe, Japan
Mr Kazuyuki Fukunishi, Aberystwith, United Kingdom
Mr Andrés Ginés, ANESVAD, Bilbao, Spain
Prof. Jacques Grosset, Center for Tuberculosis Research, Johns Hopkins University School of
Medicine, Baltimore, MD, United States of America
Dr Augustin Guédénon, Programme National de Lutte contre l’Ulcère de Buruli, Cotonou, Benin
A/Prof. John Hayman, Department of Anatomy and Cell Biology, Monash University, Clayton,
Melbourne, Australia
Professor Komlanvi Denis James, Faculty of Medicine and Pharmacy in Lomé, Togo
Dr Baohong Ji, Faculté de Médecine, Pitié-Salpetrière, Paris, France
A/Prof. Paul Johnson, Department of Infectious Diseases, Austin & Repatriation Medical Centre,
Heidelberg, Melbourne, Australia
Sister Joseph, Wewak General Hospital, Wewak, East Sepin Province, Wewak, Papua New Guinea
Dr Edgard Kacou, Programme National de Lutte contre les Ulcères à Mycobactéries, Abidjan,
Côte d’Ivoire

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Mr Keisuke Kanamoto, Aberystwyth, United Kingdom
Prof. Henry-Valère T. Kiniffo, Fondation luxembourgeoise Raoul Follereau, Luxembourg
Mr Robert Kohll, Fondation luxembourgeoise Raoul Follereau, Luxembourg
Dr Sébastien Kolmer, Projet Humanitaire Afrique Nord Sud, Pfastatt, France
Prof. Olumuyiawa O. Komolafe, Department of Microbiology, College of Medicine, Chichiri, Malawi
Mr Samuel Kouassi Kouakou, Groupes Bibliques des Hôpitaux de Côte d’Ivoire, Abidjan,
Côte d’Ivoire
Dr Elisabeth Le Saout, Médecins Sans Frontières, Geneva, Switzerland
Ms Verónica Malda, ANESVAD, Teófilo Guiard, Bilbao, Spain
Dr Wayne M. Meyers, Division of Microbiology, Armed Forces Institute of Pathology,
Washington D.C., United States of America
Dr Mwanatambwe Milanga, Department of Pathology, Nippon Medical School, Tokyo, Japan
Mr Fabian Mork, Reconstructive Plastic Surgery & Burns Centre, Korle-Bu Teaching Hospital, Accra,
Ghana
Prof. David Ofori-Adjei, Noguchi Memorial Institute for Medical Research, Accra, Ghana
Dr Richard Phillips, Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana
Père Marco Pirovano, Centre Anti-Ulcère de Buruli, Zouan-Hounien, Côte d’Ivoire
Mr Henri Pizani, Roussillon, France
Dr Gerd Pluschke, Department of Molecular Immunology, Swiss Tropical Institute, Bâle, Suisse
Dr Franco Poggio, Rotary International, Rotary Club Milano, Italy
Prof. Françoise Portaels, Department of Microbiology, Institute of Tropical Medicine,
Anwerp, Belgium
Dr Roger Pradinaud, Service de Dermatologie, Centre hospitalier général de Cayenne,
Cayenne, French Guiana
Dr Ghislaine Prévot-Linguet, Institut Pasteur de la Guyane, Cayenne, French Guiana
Dr G. Battista Priuli, Hôpital St Jean de Dieu, Tanguieta, Benin
Dr Jacquie Singa Nyota, Programme National de Lutte contre l’Ulcère de Buruli, Kinshasa,
Democratic Republic of Congo
Prof. Yuki Shimomura, International Center, Kobe International University, Kobe, Japan
Dr Pamela L. Small, Department of Microbiology, University of Tennessee, Knoxville, TN,
United States of America
Mrs Hiroe Soyagimi, Sasakawa Memorial Health Foundation, Tokyo, Japan
Mr René Stäheli, Aide aux Lépreux Emmaüs–Suisse, Bern, Switzerland
Ms Ymkje Stienstra, Department of Internal Medicine, University Hospital, Groningen,
The Netherlands
Dr Tim Stinear, Unité de Génétique Moléculaire Bactérienne, Institut Pasteur, Paris, France
Dr Vincent Stoffel, Projet Humanitaire Afrique Nord Sud, Pfastatt, France
Ms Margreet Teelken, Department of Internal Medicine, University Hospital, Groningen,
The Netherlands
Dr Florence Thiriéz, L’Homme et l’argile, Paris, France

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Dr Napo Tignokpa, Programme contre la Lèpre et la Tuberculose, Ministère de la Santé, Lomé, Togo
Dr Alphonse Um Boock, Aide aux Lépreux Emmaüs, Yaoundé, Cameroon
Dr Henry Wabinga, Department of Pathology, Faculty of Medicine, Makerere University
Kampala, Uganda
Dr Mark Wansbrough-Jones, Division of Infectious Disease, St. George’s Hospital Medical School,
London, United Kingdom
Dr T. S. van der Werf, Department of Internal Medicine, University Hospital, Groningen,
The Netherlands
Ms Ellen Whitney, Meningitis and Special Pathogens Branch, Centers for Disease Control
and Prevention, Atlanta, GA, United States of America
Mr Atsushi Yagi, Aberystwyth, United Kingdom
Mr Edouard Yao, Bureau Régional pour l’Afrique de l’ouest, MAP International, Abidjan,
Côte d'Ivoire
Dr Jérémie Koffi Yao, Zoukougbeu Health Center, Côte d’Ivoire

WHO SECRETARIAT

Dr Maria Neira, Director, Communicable Diseases Control, Prevention & Eradication

Dr Nevio Zagaria, Coordinator, Strategy Development & Monitoring for Eradication & Elimination
(CEE), Communicable Diseases Control, Prevention & Eradication
Dr Kingsley Asiedu, Buruli Ulcer Initiative, CEE, Communicable Diseases Control, Prevention &
Eradication
Dr Elil Renganathan, Coordinator, Social Mobilization & Training (SMT), Communicable Diseases
Control, Prevention & Eradication
Ms Asiya Odugleh, Social Mobilization & Training (SMT), Communicable Diseases Control,
Prevention & Eradication
Dr William Parks, Social Mobilization & Training (SMT), Communicable Diseases Control,
Prevention & Eradication
Dr Isabelle Nutall, HealthMap, National Capacity Strengthening, Communicable Disease Surveillance
and Response
Dr Denis Daumerie, Leprosy, Strategy Development & Monitoring for Eradication & Elimination,
Communicable Diseases Control, Prevention & Eradication
Dr John Clements, Expanded Programme on Immunization, Health Technology and Pharmaceuticals,
Vaccines & Biologicals
Dr Julian Bilous, Expanded Programme on Immunization, Health Technology and Pharmaceuticals,
Vaccines & Biologicals
Dr Takeo Morooka, Government and Private Sector Relations, External Relations & Governing Bodies

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Meeting conclusions and recommendation

Research priorities

• Identification of the mode of transmission

• Improvement of field diagnosis
• Cultural/Social/Economic impacts
• Vaccine development
• Development of a highly discriminative genotyping method(s) for M. ulcerans
• Immunological and Pathological aspects of the host
• Study of the physiological aspects of the organism
• Development of animal models

Identification of the mode of transmission

Why?
− Know the environmental risk factors
− Introduce preventative measures

Mode of Transmission - what do we know?

− Many aspects of the environment are implicated in the ecology of MU
− The concentration of MU in the environment is in constant and significant flux
− There are multiple modes of transmission

How?
− Identify environmental reservoirs, field surveys
− Insect/MU interaction studies
− Development of community level intervention strategies
− Development of more sophisticated microenvironment models
− Highly discriminative strain genotyping methods

Improvement of field diagnosis

• Accurate laboratory diagnosis is critical and this must be supported and encouraged
Why?
− Determining disease burden
− Appropriate patient care
• Develop field applicable tools for diagnosis
− specifically antigen capture ELISA type test
− serological tests
− consideration of ethical issues surrounding test application

Cultural/Social/Economic impacts
Why?
For example :
− to understand factors involved in a patients willingness to seek help and accept treatment.
− to identify factors that may be risk factors for infection
− to identify impacts on marriage, education, employment

Vaccine development
Why?
− Disease prevention
− There is good evidence that one can elicit protective immunity

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 How?
Several possibilities
− Recombinant antigens -
− Need to find MU-specific, immunodominant antibodies
− Recombinant BCG
− Toxoid

Development of a highly discriminative genotyping method for MU

Why?
− To identify the source and spread of MU in the environment (including human host)
− to distinguish recurrence from reinfection
How?
− Use the genome sequence to identify highly variable regions
− Validate the source and spread of MU with a multicentre collaboration using a well documented
reference collection of isolates

Immunological and Pathological aspects of the host

Why?
− To better understand the nature of the host response
− To identify host genetic risk factors
How?
− Immunohistochemistry
− DNA microarrays

Study the physiological aspects of the organism

Why?
− Identify potential drug targets
How?
− Studying the genome sequence
− Transcriptomics
− Proteomics

Development of animal models

Why?
− Essential for evaluating efficacy of potential vaccines
− Evaluating new treatment strategies
− Understanding disease pathogenesis

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Group work on control and surveillance

Dr George Amofah, Ghana – Chairman; Dr Julien Aké Aké, Côte d’Ivoire; Dr David A. Ashford,
United States of America; Dr Adama Marie Bangoura, Guinea; Dr Hilaire Bassakouaou, Congo;
Dr Augustin Guédénon, Benin; A/Prof. John Hayman, Australia; Dr Djatch Edgard Kacou, Côte
d’Ivoire; Dr Jackie Singa Nyota, Democratic Republic of Congo

Objective: This is a summary of a meeting of the above participants regarding issues related to
Surveillance and Control.
An initial emphasis was placed on the fact that targeting and prioritizing public health programs and
attracting international and domestic support depends on each affected country defining the burden of
Buruli ulcer disease.

How do we establish the burden of Buruli ulcer?

What is burden?

• Incidence (not just counts, expressed as rates)

− categories of severity
• Prevalence (rates – numerators and denominators are required)
− categories of illness data would be best, including recovered.
− disability estimates
• Buruli ulcer imposes considerable social and economic costs and these costs should be estimated:
− direct expenditures
− indirect expenditures

Estimating the burden is hampered by the logistical difficulties of identifying the prevalence and
incidence in affected foci. These areas may be remote and inaccessible. National public health resources
may be stretched to their limits. Trained personnel are in high demand for other activities.
• The team recommended that there be an effort to identify all foci in affected countries:
− use existing knowledge of affected areas to target surveys
− evaluate contiguous areas with population surveys
− generally, increase awareness of BU in affected countries to identify other areas

• Linkage of this effort of identifying new areas and defining incidence in known areas with
laboratory confirmation. This requires identification of referral regional laboratories that have the
capacity to confirm suspected cases (sample of suspected cases).

Establishing the burden of Buruli ulcer requires review of past data (will this be easy and how?)
and new national surveys.

It is recommended that affected countries initiate efforts in these two areas.

• Historical Data Review – Some communities in endemic countries have been mapped and but
regular updating of unmapped endemic communities may be required from time to time using
Global Positioning System (GPS) data
• National prevalence / Incidence surveys should be initiated
− it was noted that such surveys are very burdensome, and the affected countries requested
assistance from the WHO or other sources
− recommend using existing infrastructure: EPI, Guinea Worm, Leprosy or other national
programs to take advantage of existing trained personnel
• Suggested a concentration on known endemic areas first

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• Recommended that this effort be linked with establishing Surveillance Systems-Incidence can be
defined with existing program data
• Ethical Issues to consider in conducting these surveys:
− the working group recommended that the surveys should be linked with a review of capacity to
care for cases identified
− establishing burden may attract resources from national or international sources to improve that
capacity, so establishing burden is an essential first step in country planning
• Is sampling an alternative to all-inclusive population surveys?
− are there Sampling methods for diseases with focal distribution?
− recommended that WHO offer immediate assistance in identification of sampling methods that
might be used for diseases with focal distribution to attempt to estimate prevalence or incidence
without the need for house-to-house all inclusive surveys

Application of HealthMapper
Recommended that the HealthMapper software developed by WHO be adopted:
• The use of Health Mapper will provide Core Geographic Data: administrative boundaries, roads,
rivers, parks, elevation, villages, health centres, schools, demographic data
• A tool for data management: define indicators, collect, update and transfer data (village, health
facility, district /central/levels)
• A mapping interface: dynamic interface for visualisation & analysis of data in maps, charts, tables;
• This customized information and mapping system will support the national programmes to meet
strategic aims

Control and surveillance strategies in affected countries: how can they be improved?
• Surveillance and control objectives:
− define the burden
− because of the lack of data on the source and transmission of this disease, the current control
strategies are limited to early detection of disease and early treatment (surgical) to decrease the
overall severity of disease outcomes in affected countries;
• Strategies for reducing incidence are undefined, though case-control studies suggest that water
exposure may be a risk factor and clothing may be a protective factor. Further studies of the ecology
of the disease are required to guide strategies for reducing transmission
• For surveillance and control of Buruli ulcer disease (BUD), there are generally two categories of
country preparedness among the affected countries
1. Countries with established control programmes– In these countries the surveillance strategies
should be focused on the strengthening of the existing program and the adoption of the WHO
improved surveillance methods and tools for BUD;
2. Countries initiating control programmes – In these countries, there is a need for transfer of
experience and knowledge from those countries with capacity established. It was recommended
that those countries initiating programmes contact WHO, or their neighboring country
representatives from areas that have established programmes, and utilize this experience to
define their programs.

Issues for consideration in developing and improving capacity for surveillance for BUD
• Implementation of WHO Improved Surveillance Guidelines for BU is recommended for all affected
areas:
1. BU1 and BU2 forms and other documents should be included.
2. Surveillance for early detection needs to be based at the village or local level (not hospital
level). Detection of early disease and treatment to avoid severe outcomes, depends on village-
based surveillance.
3. Strategies for providing incentive to village level is needed
4. Integrate with existing village based systems
5. Recommended that BU disease be made a Nationally Notifiable Disease in affected countries;

10
 6. Recommended that NGOs and other external or internal institutions working on BU Disease
consult with the national and district health officers to integrate with the National BU
Surveillance and Control Plans:
7. It was recognized the NGOs can and do play an important role in assisting with national
surveillance and control efforts; and efforts should be made by both ministry and NGO (and in-
country private participants) should strive to strengthen communication for BUD surveillance
efforts.

Training of health workers: what needs to be done?

• Recommended that a Train the Trainers Program (TTP) be initiated by WHO for establishing and
improving surveillance and control in affected countries. This program could utilize experienced
personnel from inside affected countries and international experts. However, the emphasis should be
on surveillance and control strategies.
• This TTP could target 4 primary Groups/Areas
1. Program managers (national, regional, and local)
a) Surveillance and control program and data management
2. Community volunteers and health workers
a) Case detection and referral
b) Wound dressing, management, referral
c) GPS
3. Health care workers at referral clinics and hospitals
a) Treatment (excision, wound management, grafting, physiotherapy)
b) Quality control
4. Laboratory Staff
a) At least at national level
• There was a general recommendation that all participants make efforts to increase international
awareness
− This should be done through meetings, journals and reaching out to professional organizations
• There was a strong recommendation that the existing training modules be distributed now to
affected countries while developing the train the trainers program. Efforts should be made to
encourage affected countries to identify a BUD point person within the Ministry of Health and to
insure that such materials reach this point person.

What are the program monitoring indicators for measuring success of national surveillance and
control strategies?
• Recommended that a group revisit the AFRO office (or with Geneva) and define the final list of
indicators. This topic has been previously addressed; however, consensus is not finalized. Such a
meeting should assist in the process of finalizing a list of program monitoring indicators.

Minumum indicators could include:

• A Written National BU Disease Action Plan is Available. Each affected country is advised to
develop such a plan, if not already available. Consider using the assistance of those countries with
plans (Benin, Côte d’Ivoire, and others)
• Number of health care workers trained: proportion by district might be the best indicator
• Proportion of hospitals in affected areas that have capacity for managing all cases
• Proportion of pre-ulcerative: ulcerative disease reported

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Adjunct indicators to consider:
• Timeliness of Reporting of suspect or confirmed cases
• Delay between diagnosis and surgery of individual cases (a short time is a positive indicator) Could
this be done as part of periodic surveys in major hospitals/centers that manage Buruli ulcer cases?
• Proportion of districts that are completing their monthly reports using the BU1 and BU2 forms
• Degree of disability index (disability is an indication of more severe outcome potentially resulting
from delay in management of cases. Early detection and treatment should reduce disability.)
• Proportion of patients that are healed at 12 month follow-up (follow-up may be a great challenge for
all programs)

Additional recommendations for BUD surveillance and control

• Existing (model) national plans must be shared now with countries that are initiating activities
(Benin and Côte d'Ivoire may serve as a model for plans?)
• Further exploration of risk-factors and transmission modes should be initiated immediately at the
national and international level to define further control strategies
• Based on existing case-control and cohort studies, as well as reservoir and ecological studies,
affected countries should consider evaluations of prevention strategies now

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Group on antibiotic treatment

Professor J. Grosset (Chairman), Dr. S. Etuaful, Dr. B. Ji, Dr. N. Tignokpa, and Dr. Mark
Wansbrough-Jones

State-of-the-art

The group considered currently available information on the use of antibiotic treatment in the
management of M. ulcerans disease. The only published controlled trial of treatment was that of
clofazimine which showed no benefit. There have been numbers of case reports with variable outcomes
from which no conclusions can be drawn. More substantial data are available from in vitro studies of the
sensitivity of M. ulcerans to antibiotics and the group considered that these are likely to be an indicator
of their activity in vivo. The mouse footpad model of infection has been used extensively as a method to
assess antibiotic activity and this has shown that whereas most active drugs are bacteriostatic, rifampicin
and aminoglycosides appear to be bactericidal and, used together, have an additive effect. On the basis
of these findings, it was agreed at the 2001 meeting of the WHO advisory group that a study should be
designed to measure the efficacy of this antibiotic combination in human subjects with early lesions of
M. ulcerans disease. Twentyfive patients would be randomised into 5 groups, the first of which would
have immediate excision of the nodule according to current practice. The other 4 groups would receive
daily treatment with rifampicin and streptomycin for 2, 4, 8 or 12 weeks followed by excision of the
nodule. Clinical measurement of nodules would be performed at weekly intervals and, after excision,
nodules would be sent for histological diagnosis, AFB count, culture and CFU count, animal
inoculation, PCR and assessment of viable organisms by measurement of HSP 70 RNA.

Current situation

A protocol for this study was finalised and received ethical approval during 2001. Modifications were
made to exclude children under 15 years of age and to change the number and size of the groups so that
the total number of groups was reduced to 4, by excluding the 2 week treatment group, and each group
was enlarged to contain 10 subjects.
After an extensive training programme organised by Dr. S. Etuaful, the principal investigator,
recruitment began in October. By March 2002, 17 patients had been recruited but 2 of these had been
excluded leaving a total of 15. No side effects of treatment had been observed during regular
assessments. Of the first 6 nodules examined histologically, 4 were definitely M. ulcerans disease, 1 was
probably M. ulcerans disease and one showed non-specific inflammation. This indicated a high degree
of accuracy in clinical diagnosis which was important for a successful outcome to the study. Although
some data were available from Professor Carbonnelle’s laboratory, the group considered it too early to
make any judgements about effectiveness of the drugs because cultures are very slow growing. Clinical
assessments gave rise to cautious optimism but a full evaluation of the photographs and clinical
measurement of lesions had not been undertaken by the time of the meeting.
The group considered a suggestion that an interim analysis should be carried out by an independent team
and recommended that this should happen when results were available from 50 per cent of the patients
(ie 20). No changes should be made to the protocol unless there was reason to believe that a clear result
could not be achieved using the present protocol or unless the principal investigator had serious
concerns about continuing, for example because of adverse events.

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Action for the future

There was discussion about further studies of antibiotic treatment which could be suggested depending
on the outcome of the present investigation. It was recognised that it would be desirable to develop an
oral treatment regime which could be applied to management of children as well as adults but this
remains difficult at present. The best possible outcome of the present study would be that lesions would
be completely cured after some weeks of antibiotic treatment in which case a trial could be conducted to
assess recurrence rate after antibiotic treatment without surgery. Ulcerated lesions could be studied in
the same way. A more complex study would be needed to assess the benefit of antibiotics in complicated
ulcers for which some surgery was also needed, for example when there was spreading oedema. During
open discussion it was suggested that a study could be designed to investigate the value of antibiotics to
prevent dissemination of M. ulcerans during surgery.

Certain principles were agreed in relation to future trials:

• We should aim to ascertain the role of drug therapy in all forms of M. ulcerans disease
• As many patients as possible should be included in drug trials
• The aim of all drug trials should be to produce data of publishable quality
• Drugs should be selected on the basis of efficacy, acceptability, availability in the country and cost.

While recognising that the situation may change rapidly over the next year, the group suggested
tentatively that priority might be given to two types of trial:
1. A comparative trial of rifampicin and streptomycin against a two stage regime consisting of two oral
drugs combined with an aminoglycoside in the first stage and three oral drugs in the second stage.
This could be tested in early lesions or uncomplicated ulcers.
2. A trial of antibiotics to supplement surgery in complicated ulcers.

The design of any such trials will need to take account of progress in the development of other modes of
treatment including the use of clay and topical nitric oxide both of which were reported at the current
meeting.

Current recommendations for the use of antibiotic therapy

The group considered whether it was possible to make any recommendations about the use of antibiotics
in the current state of knowledge and concluded that, despite excellent progress in the ongoing study of
antibiotic treatment of early lesions, it would be unwise to make judgements about the outcome at this
stage.

Conclusions

1. The trial in progress is likely to yield the first evaluable scientific data about the efficacy of a
bactericidal antibiotic combination in the treatment of early M. ulcerans lesions. An interim analysis
would be valuable when results are available from the first 20 patients.
2. No recommendations can be made about the choice of antibiotics or the situations in which they
should be used in the current state of knowledge. If doctors decide that they must prescribe
antibiotics, it is recommended that they document carefully the progress and outcome in each
patient. Chaotic use of antibiotics will encourage development of resistance so their use should not
be random.
3. Controlled trials of antibiotic therapy should be planned for the future and this should be the
standard method for evaluating any new therapy.

14
Group on NGOs

1. Working with governments

• NGO's are providing substantial funding and input at country level however, some difficulties in
working with local governments.
• Governments usually ask for and would rather manage financial assistance but experience has
shown that financial contributions become channelled into government health priorities, to ease
them out of current funding shortfalls ie staff salaries rather than the particular programme funded
by the NGO.
• There are no plans of action for BU programmes except Ivory Coast and Benin which makes
planning, staff and resource management extremely difficult and a frustrating experience.
• There should be a first level of analysis i.e. is there a need for money or technical input or both?
Then a national plan of action should be developed with relevant counterparts. There should also be
a strong co-ordination and accountability.
• Some NGO's go into a country with their own agenda and begin programmes with very little
consultation with the local government, dealing mainly with private medical practices. This causes
confusion and some friction. NGO's should respect the sovereignty of the country they are working
in and work in a transparent way.
• Political commitment of national and local government is a major problem as BU is very low down
on the government's list of priorities especially as other diseases such as malaria have a higher (and
visible) disease burden. The lack of information on the burden of disease for BU makes it difficult to
persuade governments to commit to developing BU programmes.
• The lack of co-ordination within countries is a major problem as no-one knows what everyone else
is doing. The limited resources could be more effectively utilised and duplication could be avoided
by improved information sharing and co-ordination of activities.
• Sustainability is a major issue as the interventions for BU require specialised equipment and training
e.g. surgery and skin-grafting. Once outside support is no longer there how can the programme
continue to provide a service to BU sufferers? One suggestion was that BU services should be
integrated into the existing health services. New buildings that only cater for BU treatment should
not be built in isolation to treat solely BU sufferers, but either existing hospitals/clinics should be
upgraded and staff trained or new buildings should be part of an integrated package of health service
delivery.
• Staff incentives were also discussed. Some NGOs are paying the complete salaries of staff in BU
treatment centres but this is not sustainable over the long term. It creates a parallel system whereby
the same MOH health staff are receiving a higher and regular salary compared to their counterparts
in other government health centres. This creates a drain as qualified staff choose to work with NGOs
rather than the MOH. Once the funding runs out, the real danger is that the services will no longer
continue.

2. Dissemination of BU information using NGO networks

• NGOs can provide information dissemination of BU material using their existing networks eg the
leprosy elimination NGOs have strong networks built over the many years of their work with
beneficiaries, community groups and institutions.
• A note of caution on the dissemination and use of IEC materials was introduced: many IEC
materials are produced with little thought of the effect they are intended to have. The production and
dissemination of materials should be linked with a set of appropriate and specific behavioural
indicators so that their use and effect can be monitored and evaluated. IEC materials should also
have a specific behavioural focus and be part of a social mobilization/communication strategy.

15
3. Advocacy, social mobilization and fundraising

• The role of NGOs in this area is important as many of them are implementing projects and working
directly with beneficiaries as well as raising funds in their home countries.
• There needs to some mechanism to bring in the voice of NGO's as NGO's do not know who is
involved in BU activities and have very little say in how the BU programme is evolving. Some
suggestions were having a rotating presence on the BU consultative committee, WHO can also play
a central role in co-ordinating information flow e.g. a website that organisations/indiviuals can
subscribe to as an information exchange resource for NGO's and other partners would be useful.
• WHO can also co-ordinate regional and country level workshops/training with NGOs.
Communication training for health personnel was discussed because of the little knowledge of risk
factors, the lack of clear preventative measures that people can take and the current aggressive
treatments - it can be easy to scare the public.
• Advocacy: main obstacles are the lack of clear messages because of the nature of the disease e.g.
what preventative actions can people take? Who is at most risk? What treatment options are
available? The lack of a clear estimation of the burden on disease e.g. how can you persuade
governments to commit? How can you generate increased resources from donors?
• WHO has a central role to play in persuading governments and donors to commit to BU
programmes but also to raise the global profile of the disease, however, NGOs also have a
substantial role in advocacy for BU but these responsibilities need to be defined within a clear
advocacy strategy. The positive progress made in BU research needs to be put in an easily digestible
form for lay people and donors to help in the advocacy effort.
• Social mobilization is a key area and this was discussed at length. Service delivery and access to
treatment are pre-requisites for social mobilization and a delicate balance needs to be maintained
between demand and service provision. Social mobilization must be a planned process with a
behavioural goal based on appropriate "market" research and the usual KAPB studies are not
enough. The SMT team at WHO described the social mobilization strategy that they are applying
with effective results in lymphatic filariasis and dengue.
• If social mobilization aims to create behavioural demand for minor surgery, then surgical services
must be available to meet demand generated. One problem is the lack of infrastructure and skills for
these services but a “sequential roll out” approach may be feasible in locations where surgical
services are now available. NGOs should create integrated projects that upgrade services and
mobilize communities. Mobilizing communities in the absence of services is unethical and a waste
of resources.
• Capacity building for social mobilization was another issue as a many MOH IEC departments in
Africa do not have the skills and knowledge to apply strategically planned social mobilization
programmes. Consequently, there tends to be an over emphasis on material production. Training in
social mobilization for MOH IEC or Education departments should be encouraged.

4. Support of control and research activities

• It is imperative that socio-economic research takes a higher profile. The need for studies into the
social, cultural and economic impact of BU is becoming increasingly important. Patients’
perceptions about a disease, its effective treatment, and the socio-economic dislocation caused by
the illness and related symptoms, have a significant impact on when and where people go for
diagnosis and treatment. Interventions must reflect these social, cultural and economic determinants
so that the programmes are effectively and appropriately designed and therefore are sustainable.
• Current medical studies are being conducted ad hoc with very little co-ordination or involvement of
NGO's, the beneficiaries or local authorities. There is also the danger of raising expectations of
communities in the study area. Research should account for providing some kind of service to those
communities affected by the study.

16
• There was a suggestion of having a central board/committee that vets/approves research proposals
on BU, develops criteria, standards and guidelines to ensure that any further studies are balanced,
ethically sound, establish linkages with partners already working in the study area, and meet the
needs of the beneficiaries involved.

5. Priority areas for support and action – review of draft document

• WHO must strengthen it's co-ordination and facilitation role at country and regional level
• The development of national plans of action
• Socio-economic research
• Capacity building

17
Global Buruli Ulcer Initiative

1. Summary of 2001 activities (Kingsley Asiedu)

Global advocacy
1. 4th meeting of the WHO Advisory Group on Buruli ulcer, March 2001
2. Annual meeting of Programme managers and other national experts in Africa;

Development of information materials

1. Manuals on diagnosis and management
2. Comic targeting school children
3. Advocacy video (now in English, French and Spanish)
4. Video on case management (initial footage taken and will be discussed on Friday)
5. Brochure on Buruli ulcer;
6. English version of a diagnostic guide in collaboration with ITM, Antwerp, Belgium
7. Development of training modules

Country support
1. Funds were provided to support activities in Benin, Côte d'Ivoire, Ghana, Guinea, Togo
2. Preliminary evaluation of the economic burden of Buruli ulcer in Ghana

Collaboration with NGOs

1. Visit to Ghana and Côte d'Ivoire with Paul Saunderson and Wayne Meyers from American Leprosy
Mission in April 2001. ALM will support the control of Buruli ulcer activities in these 2 countries.
2. Nippon Foundation visit to Ghana in June 2001. Skin culture trial.
3. Support from ANESVAD, ALM, AFRF, MAP, MSF–Luxembourg, the Nippon Foundation, for
printing materials.
4. Meeting with ALES and MSF to discuss potential support for Cameroon.

Research
1. Drug trial in Ghana with support from AFRF, Nippon Foundation and Ministry of Health, Ghana
2. Genome sequencing project at Pasteur Institute in Paris

2. Outline for the 2002 meeting (Kingsley Asiedu)

Objectives
1. To share information on control and research activities;
2. To review current strategies for Buruli ulcer intensified control;
3. To discuss and coordinate planned future activities at the country level;
4. To review current research work on transmission, diagnosis, drug treatment and prevention and to
plan future ones;
5. To discuss possibilities for securing increased funding for Buruli ulcer activities.

Presentations
Day 1: Country presentations and discussions
Day 2: Research
Day 3: NGOs

Group work
1. Afternoon of day 3 through morning of day 4
2. Presentation at plenary in the afternoon of day 4)

19
Topics
1. Control and surveillance
2. Surgical management
3. Drug treatment
4. Prevention (BCG and others)
5. Research
6. NGOs

3. Broad areas of work for 2002–2003 (Nevio Zagaria)

Objectives
1. To intensify advocacy, partnership and resource mobilization efforts;
2. To assist affected countries in establishing effective control programmes;
3. To improve surveillance of the disease at all levels;
4. Training of health workers, village volunteers and schoolteachers;
5. To support priority research.

Advocacy and partnership

1. Annual meetings of WHO Advisory Group on Buruli ulcer;
2. Meeting of Programme Managers and other nationals experts in Africa;
3. Global advocacy and resource mobilization.
4. Development of tools
5. Close collaboration with all partners

Control activities at country level

1. National strategic plan development;
2. Inter-country training workshops on case management followed by national workshops;
3. Inter-country training workshop surveillance and health map followed by national workshops;
4. Provision of logistics and supplies to national programmes;
5. Support awareness campaigns in countries.
6. Support operational research

Surveillance
1. Better understanding of the distribution of Buruli ulcer around the world and within countries.
• Some countries that we have better information but can be improved;
• Others where no current information is available but there is the strong suspicion that the disease
exists.
2. Application of health map and you will discuss this in more detail during the group work.
3. Better data management and reporting to WHO.

Training
The focus will be on training health workers, village volunteers and schoolteachers. We have the tools
now. Dr Elil Renganathan will present the training plan on Wednesday.

Research
1. Epidemiology
2. Drug treatment trials
3. Support M. ulcerans genome sequencing project (2002)
4. Socioeconomic and behavioural
5. Other recommendations for research that come up during this meeting.

20
Mycobacterium ulcerans disease (Buruli Ulcer Disease)

Wayne M. Meyers, M.D., Ph.D., Armed Forces Institute of Pathology, Washington D.C., United
States of America
Prof. Françoise Portaels, Ph.D., Institute of Tropical Medicine, Antwerp, Belgium

Definition and etiology

Mycobacterium ulcerans is a slow-growing mycobacterium that classically infects the skin and
subcutaneous tissues, giving rise to indolent ulcers. After tuberculosis and leprosy, M. ulcerans disease
is the third most common mycobacteriosis. The etiologic agent grows optimally on routine
mycobacteriologic media at 32°C and elaborates a necrotizing immunosuppressive cytotoxin. Large
ulcers almost certainly caused by M. ulcerans were first described by Cook in Uganda in 1897; however,
the etiologic agent was not isolated and characterized until 1948 in Australia by MacCallum and
associates.
Lesions of M. ulcerans disease (MUD) have several valid synonyms (e.g. Buruli ulcer, Bairnsdale ulcer,
Searls’ ulcer). The name Buruli ulcer, which could have priority by precedence of publication, reflects
the name of the geographic site in Uganda of the first large number of reported patients; however, MUD
is more appropriate because patients often present without ulcers.

Epidemiology and transmission

The source(s) of M. ulcerans in nature is becoming clearer from epidemiological data and from
molecular biologic findings. M. ulcerans has been identified in insects and other water-dwelling animals
collected from the bottom of permanent swamps and ponds, and insects may play a role in the
transmission of MUD. The putative insect transmission of M. ulcerans does not obviate the possibility
of other modes of transmission (e.g. aerosols). While not precisely established, environmental factors
play an essential role in the survival of the etiologic agent. Koalas and possums are naturally infected in
the wild in Australia and many other species of animals have been infected experimentally. The disease
is rarely transmitted from patient to patient. Travellers to endemic areas may contract MUD.
Trauma may be the most frequent means by which M. ulcerans is introduced into the skin. The related
trauma reported has been as slight as a hypodermic needle puncture or as severe as a human bite,
gunshot or exploding land mine wounds. The highest frequencies of the disease are in children under 15
years of age. Children in rural areas of the tropics may contract MUD more often because they are
frequently scantily attired and habitually work or play in or near swamps and ponds.
Numerous countries in West and Central Africa are endemic. Some South-east Asian countries and
Australia have significant foci, and there have been a number of patients reported from South America
and Mexico. Focal outbreaks have followed flooding, human migrations, and manmade topographic
modifications such as dams, resorts, and deforestation. Population growth and increased basic
agricultural activities in wetlands put more people at risk, probably contributing to the marked increases
in incidences of MUD since about 1980, especially in West Africa where the disease is rapidly
emerging.

Clinical manifestations

Type of disease varies widely from patient to patient. Factors that may determine type of disease
include:

21
A. Etiologic agent-related
While there are genetic differences related to geographic origin of the etiologic agent, none of these
strain variations has proven to involve decisive alterations in virulence.

B. Host- and transmission-related

• Innate variables such as HLA allele type
• Specific immune response (Th1 vs Th2)
• Mycobacterial exposure history
• Size of inoculum of M. ulcerans
• Depth of inoculation of M. ulcerans into skin
• Predisposing illness (HIV, etc.)

Dr. John Hayman proposed the following classification of lesions at the March 2000 meeting of the
Global Buruli Ulcer Initiative:
1. Papule
2. Nodule
3. Papulo-nodule
4. Plaque
5. Edematous forms
6. Mixed forms

He further divided the course of the disease into Stages 0 to 4. The classification and staging are useful
frameworks for the clinician and pathologist; however, the staging of the disease must be carefully
interpreted. For example, in a clinicopathologic study of 1,324 patients in Benin over the 4-year period
1997–2000, approximately 45% had ulcerated lesions and 52% had nonulcerative disease. A high
percentage of the patients with nonulcerative disease gave no history of having had a nodular lesion, and
there was no clinicopathologic evidence of a nodule. Thus, the disease often does not progress in an
orderly fashion from one stage to another.
Based on the clinicopathologic study of material from approximately 3,500 patients with MUD
accessioned at the Armed Forces Institute of Pathology and in collaboration with numerous contributors
(especially the Institute of Tropical Medicine, Antwerp), we have attempted to develop a preliminary
draft of the natural history of the different forms of MUD. A proposed spectrum of the forms of MUD is
presented in Figure 1.

____________________________________________________________________
SPECTRUM OF Mycobacterium ulcerans DISEASE

Infection

Localized forms Disseminated forms

Nodular 1. Contiguous disseminated

Nonulcerative (plaque, edematous)

Minor ulcerative Major ulcerative Ulcerative

(Self-healing)
2. Metastatic
Cutaneous
Osteomyelitic

___________________________________________________________________
Figure 1. Spectrum of Mycobacterium ulcerans disease.

22
Comments

1. Clinical features of the forms of MUD include:

Nodular: movable, painless subcutaneous nodule approximately 2 cm in diameter.
Minor ulcerative: small, sharply limited ulcer with slight undermining, self-healing.
Major ulcerative: small to large ulcer, wide undermining, well demarcated but initially with edematous
perimeter, with late healing but occasional dissemination. Contiguous disseminated: small or large
edematous plaque that may ulcerate late.
Metastatic: spread from initial lesion to distant site, usually in skin and/or bone.

2. Clinicohistopathologic correlations of forms of MUD include:

Nodular: coagulation necrosis of the lower dermis and subcutaneous tissue, with acid-fast bacilli (AFB)
in the center of the necrotic area.
Minor ulcerative: AFB limited to central necrotic slough, with scarring of surrounding dermis.
Major ulcerative: AFB in necrotic base and adjacent areas, with pronounced undermining.
Contiguous disseminated: widespread contiguous coagulation necrosis, with AFB in panniculus and
fascia.
Metastatic: typical changes of BU at distant sites, or M. ulcerans-specific osteomyelitis.
Healing (early organization): development of infiltrations of loosely arranged lymphocytes, epithelioid
cells and giant cells. AFB scarce or absent.
Healing (late organization): development of well organized delayed-type hypersensitivity (tuberculoid)
type of granuloma, followed by scarring.

At this time, we view the projected progressions and shifts in disease forms as little more than informed
speculation. We recognize this as a primitive schema that we hope will undergo refinement as more and
more information on the disease comes to light.

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29. Lavalle Aguilar P, Iturribarria FM, Middlebrook G. Un caso de infeccion humana par
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31. Marston BJ, Diallo MO, Horsburgh CR Jr, Diomande I, Saki MZ, Kanga JM, Gbery P,
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37. Meyers WM, Tignokpa N, Priuli GB, Portaels F. Mycobacterium ulcerans infection (Buruli
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38. Mitchell PJ, Jerrett IV, Slee KJ. Skin ulcers caused by Mycobacterium ulcerans in koalas near
Bairnsdale, Australia. Pathology, 1984, 16:256–260
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40. Muelder K, Nourou A Buruli ulcer in Benin. Lancet , 1990, 336:1109–1111
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42. Palomino JC, Portaels F. Effects of decontamination methods and culture conditions on viability
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geographic origin of isolates. J Clin Microbiol,1996, 34:962–965
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Franςaise. Castellania, 1974, 2:273–274
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1974, 17:145–149
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1972, 26:23–27
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Lancet, 1969, 1:111–115
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infection in Ashanti region, Ghana. Trans R Soc Trop Med Hyg, 1989, 83:410–413
60. van der Werf TS, van der Graaf WTA, Tappero JW, Asiedu K. Mycobacterium ulcerans
infection. (Seminar) Lancet, 1999, 354:1013–1018
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nine-banded armadillo. Am J Trop Med Hyg, 1999, 61:694–697

25
Update on Buruli Ulcer control activities in Benin
Dr Augustin Guédénon, Coordinator, Programme National de utte contre l’ulcère de Buruli, Ministry
of Health, Republic of Benin

The Republic of Benin is located on the coast of West Africa It is surrounded by Nigeria to the East,
Togo to the West, Burkina Faso to the north and the Atlantic Ocean to the south. A vast land of
114 000 km2, it has a population of 6 500 000.
The country's health situation is marked by the prevalence of endemic diseases and a deteriorating
environment. The health system is of the three-level pyramid type.
Since 1998, Benin has drawn up and implemented a national programme to control an emerging disease
known as Buruli ulcer. In 2001, the Programme carried out the following activities:

1. Detection and case management

• Number of cases detected
− New cases = 478
− Recurrent cases = 34
i.e. a total of 512

• Clinical forms of new cases

− Nodule = 27 cases
− Plaque = 173 cases
− Oedematous = 4 cases
− Ulcer = 229 cases
− Osteomyelitis = 41 cases
− Scar = 4 cases

These new cases were located in the following departments: Atlantique, Littoral, Ouémé, Plateau, Mono,
Couffo, Zou and Collines.
The aggregate number of cases since 1988 is 4374.

2. Monitoring and evaluation

Case registration is fairly satisfactory. However, only one out of 3 centres fills out the WHO forms
properly. One centre uses its own form. We have attempted to evaluate a number of basic indicators,
including:
• Proportion of new cases detected in 2001:
− New cases = 478
− Total number of cases detected = 512
− Proportion of new cases = 93.35%

• Proportion of non-ulcerative cases:

− Non-ulcerative forms (nodules, oedematous, plaques) = 204
− Total number of new cases = 478
− Proportion = 42.67%

• Proportion of patients with BCG vaccination:

− Number of patients with a BCG scar = 294
− Total number of patients examined for BCG = 426
− Proportion = 69.01%

27
Training for health workers

• Number and categories of workers trained:

− Nurses: 90
− Physicians: 49

• Preparatory activities:
− Drafting a training guide
− Training for trainers

• Training method:
Hands-on training, combining guided reading, commentaries on slides, case studies, field visits and
problem-solving.

• Training monitoring
− Distribution of registration books

• Funding
− WHO: 50%
− National budget: 36%
− MSF: 14%

Advocacy and social mobilization

− Training for 30 journalists to spread knowledge about the disease.
− Broadcasting of a documentary on BU.
− Advocacy among health officials.
− Advocacy directed at the different partners: AFRF (French Raoul Follereau Association), FFL
(Raoul Follereau Foundation of Luxembourg), IMT (Antwerp Institute of Tropical Medicine) and
WHO.

Coordination activities
These consist of:
− A meeting of coordinators from WHO's AFRO Region;
− A meeting of the monitoring committee;
− Coordination of research activities

To conclude

The chief asset in the accomplishment of all these activities has been clear political will. However, we
deplore the inadequacy of the treatment facilities and of trained staff. In 2002, the Programme intends to
press ahead with training, to carry out a prevalence survey and to open an additional centre for case
management.

28
Update on Buruli ulcer control activities in Côte d’Ivoire
Prof. Jean-Marie Kanga, Director Coordinator of the National Mycobacterial ulcer Control
Programme (NMUP), Ministry of Public Health, Côte d’Ivoire
Dr Edgard Djatch Kacou, Head, Projects and epidemiology Department, NMUP
Dr Jérémie Koffi Yao, Physician, NMUP

1. Introduction

Buruli ulcer was observed for the first time in Côte d'Ivoire in 1978. However, it was not until 1989 that
the disease became widely known as a result of the detection of numerous cases in the region of Daloa,
in the Western-central part of the country.
Control activities began simultaneously, and in 1995 the National Mycobacterial Ulcer Control
Programme (NMUP) was set up; the only staff were the Executive Director and a Head of Projects and
Epidemiological Research.
After a national survey in 1997, which revealed the scale of the problem, activities mainly focused on
the prevention of severe forms, case management, community mobilization and mobilizing funds. These
activities were carried out through a series of annual plans.
From 1999 onwards, thanks to the support of a Spanish NGO, ANESVAD, it was possible to build up
the capacity of control activities by improving several case-management centres. In addition, other
NGOs began to show increasing interest.
Against this background, the Executive Director of NMUP decided that it was necessary to set a new
direction and give a fresh thrust to Buruli ulcer control, in order to enhance its effectiveness. This
involved:
– reorganization of NMUP
– the adoption of the combined (vertical and horizontal) actions strategy
– preparation of a strategic five-year plan

2. Reorganization of NMUP

Structural reorganization
Structural reorganization of the Programme and the executive directorship has been under way since
December 2001.

NMUP's organization chart now has the following appearance:

• National Health Programmes Committee, responsible for:
– defining programme orientations and strategies
– validating the plan of action for each programme
– periodically evaluating the programmes' activities
– helping to mobilize the necessary resources

• The regional committees, responsible for:

– monitoring and evaluating the overall performance of the health programmes implemented in the
region
– ensuring the programmes are properly integrated into the services' activities
– suggesting to the National Committee suitable measures for improving the performance of each
programme

29
• The Departmental Committees, responsible for:
– monitoring and evaluating the overall performance of the health programmes implemented in the
department
– ensuring the programmes are properly integrated into the services' activities
– suggesting to the Regional Committee suitable measures for improving the performance of each
programme

• The Scientific Commission

This commission liaises with Coordination Directorate, and advises the National Committee on:
– the definition and adoption of scientific, social and economic priorities for mycobacterial ulcer
control
– the definition of performance norms for Programme activities
The Commission has three sub-commissions: Research, Detection and Diagnosis, and Treatment.

• The Coordination Directorate

This has replaced the former executive directorate and reports to the Cabinet.
It is responsible for:
– drawing up the Programme's plan of action
– having the plan of action approved by the National Committee
– instituting activities
– determining the needs of the Programme and ensuring they are met
– monitoring and evaluating programme activities, in liaison with the central, regional and
departmental levels
– preparing half-yearly and annual reports

The Coordination Directorate operates with a Director-Coordinator, administrative staff and four heads
of department: Projects and Surveillance, Community Activities, Case Management and Laboratories.

Structural reorganization

• Performance of activities
A combined strategy has been introduced for the performance of activities; it combines a vertical and a
horizontal strategies. As a result, surgical case-management of patients at centres is organized vertically,
by means of missions by teams from the central level. However, community detection and surveillance
activities are organized horizontally or in decentralized fashion by the district staff. Our medium-term
objective is fully to decentralize detection and case management; this will be achieved by:

• Coverage of new zones

Six zones were previously covered. Their number was increased to eight in 2001. When the strategic
plan is complete, it is planned that 16 zones will be covered.

• Conclusion of agreements with referral centres.

Such agreements are part of efforts to improve case management, particularly that of severe forms. They
have been concluded with the Côte d'Ivoire Raoul Follereau Institute (IRFCI) and Treichville University
teaching Hospital (CHU).

30
3. Major activities in 2001

Detection and treatment campaigns in endemic areas

The intervention team comprises district staff and nurses from the rural health centres, assisted by three
physicians from the central echelon.
The main achievements have been:
− number of zones covered: 6
− number of villages visited: 38
− population examined: 31 452
− total n° of cases detected: 186
− number of nodular cases: 96 (51.6%)

Surgical missions to three cases management centres

The centres concerned were the Kongouanou clinic, the Demi Emile Centre in Zouan-Hounien and the
Saint Michel Centre in Zoukougbeu.
The surgical teams were those of Professor ASSE, from IRFCI and Professor KADIO-RICHARD from
Treichville CHU.
The main achievements are:
− number of missions performed: 14
− number of patients operated on: 256

Visit and concerts by the group TRUTH to mobilize the community

This exploratory visit was organized by NMUP, the NGO American Leprosy Missions (ALM), the
western and central Africa regional office of the NGO Medical Assistance Programme (MAP
International) and the Christian and Missionary Alliance Church (CMA).
Truth is a gospel music group that gives concerts in the United States and throughout the world in order
to gather funds for humanitarian and health activities. The group paid a visit to the Adzopé unit of the
Raoul Follereau Institute and to the dermatology centre at Treichville CHU. It also gave two free
concerts, one of them in the presence of the wife of the President of the Republic, Mrs Simone Gbagbo,
to put the message across to national public opinion. Its visit lasted from 29 March to 2 April 2001.
Preparation of a five-year strategic national plan (See, Section 5).

4. Data on medical activities at the Zoukougbeu centre

Since 1998, Zoukougbeu sub-prefecture in Daloa district has been an experimental zone for Buruli ulcer
control. It is made up of some 30 villages and camps, and has a centre providing case management for
Buruli ulcer patients, the St Michel centre, which is equipped with an operating theatre and a laboratory.
The centre is responsible for a number of activities:
− development of a network of community health workers (1 or 2 per village) to educate the
population and provide early case detection
− early case detection campaigns
− treatment of nodular forms detected
− since 2001, surgical treatment of other forms
A summary of these activities is given below to illustrate their importance in efforts to control Buruli
ulcer.

31
Case detection, 1998–2001
- total number of cases = 1651

- early forms, all types = 783

proportion: 0.9
- late forms, all types = 868

- early forms, Zoukougbeu = 539

proportion: 1.6
- late forms, Zoukougbeu = 345

Case detection in 2001

- total number of cases = 562
-
- early forms, all types = 337
proportion: 1.5
- late forms, all types = 225
-
- early forms, Zoukougbeu = 93
proportion: 2.5
- late forms, Zoukougbeu = 37
-
- AFB positive early forms = 124 (37%)

The impact of the information and case detection campaigns conducted by community health workers is
reflected in the reduction in the number of late forms and an increase in the number of early forms,
which illustrates the efficacy of this control strategy.

• Surgical treatment of ulcerative cases in 2001

- total number of patients operated on: 112
- average period of scar formation: 57 days ( from 9 to 98)
- total number of disabled patients: 8
- total number of deaths: 1

Surgical treatment was provided during missions carried out by teams from the central echelon. The
most important result of this approach has been the shortening of the time spent in hospital.
A total of 7% of patients suffered disabling sequelae. These were patients who were suffering from a
functional disability on admission. There are plans to treat these disabilities.

5. Summary of the Strategic Plan

A workshop attended by all the actors and partners involved in Buruli ulcer control and present in Côte
d'Ivoire was organized to draw up the plan. The process was broad based, participatory and consensual.
Although the plan is a national one, it will focus on 16 zones - those in which the disease is highly
endemic.
The plan covers six strategic areas of intervention: prevention at the primary level; early detection, case-
management; research promotion; training; partnership and management-coordination.

32
The case-management strategy is innovative in that it is comprehensive: it associates medical treatment
with social and educational measures, psychological, spiritual and financial support.
The plan has the following primary aims:
− to reduce the annual case-detection rate by at least 20%;
− to increase the proportion of early forms to at least 40%;
− to provide case management for at least 80% of the active cases detected;
− to provide case management for at least 10% of disabled patients.

6. Funding of activities, 2001

Source Endowment Activities Performance

amount % ratio (%)
Côte d'Ivoire, 375 660 474 48 Management 88.9
Govt. Drugs
Equipment
WHO 19 073 926 2.4 Management 51.2
ANESVAD 371 288 728 47.5 Detection 100
Surgical treatment
Research
Management
MAP 15 698 940 2 Mobilization 100
International Management
Others 907 000 0.1 Misc. donations 100
Total 782 629 068 100

7. Activities planned for 2002

The main activities planned for 2002 include:
− training for actors
− extension of the campaigns and of the case-detection network
− effective mobilization of partners
− development of an operational laboratory network
− further surgical missions

8. Prospects
The sole prospect is the implementation of the strategic plan.
This requires:
− deep political will and commitment
− effective mobilization of actors
− active support from partners

Acknowledgements
We should like to express our particular thanks to the ANESVAD foundation, and especially to her
excellency Mrs Rosa Maria BOCETA, Ambassador of the Kingdom of Spain to Côte d'Ivoire.

33
Surgical treatment of Buruli ulcer at the peripheral health-care level

Prof. Henry Assé, Institut Raoul Follereau de Côte d'Ivoire, Adzopé, Côte d’Ivoire

Buruli ulcer is associated with a very high level of morbidity. As it predominantly occurs in rural areas
in which there are no suitable treatment facilities and primarily affects children, it almost always upsets
the family unit. In order to have her child properly treated, a mother has to leave the home and, and in
most cases the region, since surgical treatment for patients is centralized in a small number of referral
hospitals.
The disease itself conceals another drama that unfolds unknown to carers: a silent drama that
undermines and gnaws away at the family unit, just as Mycobacterium ulcerans gnaws away at the
patient.
It was the image of dislocated families, of mothers and children compelled to live as refugees in the
referral centres where absolutely no social support is provided for carers, that gave me the idea of taking
care closer to patients. The idea developed further with the growing influx of highly advanced lesions
and of sequelae, most of which were caused by difficulties of access to a centre capable of providing
surgical treatment for Buruli ulcer. If it is difficult for patients to reach the surgeon, why shouldn't the
surgeon take a step towards patients? As far as I was concerned, in order to control Buruli ulcer, an all-
out effort was needed: addressing patients and endemic areas.

1. Background

Our experience of remote surgery began in earnest in 1993. It sprang from the need to run the Raoul
Follereau Institute's two centres with a single surgeon. From 1993 to 1995, I spent one week each month
treating leprosy sequelae at Manikro, 400 km from Adzopé. It turned out to be a worthwhile experience,
as it made it possible to avoid costly evacuations that were also hard for patients from the region to
accept.

In 1996
As Buruli ulcer cases began to flow into Manikro and several assistants in reconstructive surgery had
been trained, we wanted to develop the activity. However, for lack of financial backing, activity
stagnated until 1999.

In 1999 and 2000

Thanks to the funding provided for the treatment of 200 patients by the French Raoul Follereau
Association, we were able fully to develop this approach; some 229 operations were performed, 162 of
them for Buruli ulcer.

In 2001
An operating theatre was set up at Kongouanou (a first-line centre for Buruli ulcer patients) as part of a
project undertaken by the National Mycobacterial Ulcer Programme and ANESVAD.
Two other centres, one at Zoukougbeu and the other at Zouan-Hounien, have set up operating theatres.
However, all the centres are beset by staffing problems; as they are at the primary level of the health
care pyramid, they have no surgical team. The only possibility was for them to join the surgical missions
system.
As the Minister of Health was familiar with the experience of the Raoul Follereau Institute in this field,
he entrusted it with organizing and coordinating both centres' surgical activities.

35
In 2001, funding provided to the National Mycobacterial Ulcer Programme (NMUP) by ANESVAD
allowed us to provide surgical treatment in the following two centres:
• Kongouanou (350 km from Adzopé)
• Zouan-Hounien (800 km from Adzopé)

2. Activities

Several stages are required for surgical missions to become operational.

1. Visit to the peripheral centre

This visit is made by the surgical team comprising:
• 1 experienced surgeon
• 1 anaesthetist
• 1 scrub nurse
who may be assisted by a maintenance technician.

The purpose of this pre-operative visit is to examine the patients to be operated on and to assess the
centre's actual operative capacity. During the visit, the following fundamental questions must be asked:
• Which patients are to be treated in this centre?
• How far away is the nearest hospital? It is important to bear in mind that "the more isolated a centre,
the greater its need for equipment (for reasons of safety and autonomy)".
• Are there any hospital beds in the centre?
• What types of anaesthesia is the centre able to perform?
• Is the staff trained in post-operative patient monitoring?
• The next step is to make an inventory of the linen and surgical instruments and to determine the
number of operations that can be programmed with the available linen and material.
• Try out all the equipment in the operating theatre and sterilization room.
• Ensure that there is a working generating unit, or failing that, make sure that the theatre lamp has an
independent battery enabling operations to be safely completed in case of power failure.
• Finally, check the accommodation available in the centre or village.
Visits always conclude with a meeting with the centre's officials and staff to harmonize opinions, decide
on the date of the mission and discuss instructions on the preparation of patients.

Our visit to Kongouanou found that:

– no beds were available for post-operative hospitalization;
– there was no sterilization unit;
– it was impossible to administer general anaesthetics.
As a result of the visit, improvements were made in order to enhance the centre's level of autonomy and
operative capacity.

2. Preparing for the mission

An all-terrain vehicle is a vital material resource. Our experience has shown that a radio is advisable in
order to keep in touch with the referral centre.
* a mobile resuscitation kit is essential.

§ Human resources
The team is composed of the following:
− 1 experienced surgeon;
− 1 assistant surgeon;

36
− 1 anaesthetist;
− 1 scrub nurse;
− 1 driver.
The material used for the operations is normally available in the peripheral centre. However, after the
pre-operative visit it may prove necessary to bring special items from the referral centre. Where Buruli
ulcer is concerned, the following items should always be kept in reserve:
− 1 manual dermatome with sterile blades;
− 1 skin stapler for grafts.
Lastly, a small blood supply should be available if large excisions are planned.
Eventually, it may be possible to replace the scrub nurse with locally-trained staff.
Depending on field requirements, the team may be supplemented by other staff essential to the mission
(maintenance technician, physician or biologist etc.).
§ Financial resources
These include the per diem allowance for the team and the fuel allowance.

3. The mission sequence

Missions last from 5 to 6 days and generally follow the following programme.

Day 1: travel to the peripheral centre; on arrival:

• preparation of the operating theatre;
• sterilization of equipment.
Day 2, morning: medical visit; all patients are examined and decisions taken on whether to operate on
them. Patients who satisfy the criteria undergo a pre-anaesthesia examination, after which the operating
schedule is established at a staff meeting, on the basis of the number of patients who may be safely
operated on.
Day 2, afternoon:
Day 3: operations
Day 4:

Day 5: - visits to all the patients operated on;

- Training staff in post-operative care;
- Instructions for post-operative monitoring of each patient;
- Discussion of problems encountered during the mission.
Day 6: return journey

An average of 20 patients are operated on during each mission. This average figure is based on the post-
operative monitoring capacity of the local staff. At Zouan-Hounien, we were able to operate 33 patients
during a single mission.

4. Mission follow-up
This is just as important as the previous stages. Follow-up is organized in accordance with the resources
of each centre. There are two possible situations:
1) If there is no physician at the centre, we adopt one of two approaches:
• The assistant remains at the centre for an additional week to monitor patients who have been
operated;
• The assistant returns to examine the patients one week after the operation on the first patients.
2) If there is a physician at the centre, he is given training in post-operative surveillance.

37
5. Supervision

This is vital in order to improve the quality of surgical and post-operative care and to enhance the
performance of local staff.
Our supervisory team is made up of reconstructive surgery specialists.
Supervision relies on:
− direct observation of activities;
− document review (patient files, surgical report);
− interviews with staff who have taken part in the missions and with local staff;
Through these two-monthly supervisory activities we have identified qualities common to all the centres
visited:
− adequate drug supplies;
− staff motivation;
− free care;
− well organized social life at the centre.

There are nevertheless, some shortcomings:

− unqualified staff with a poor general level of education;
− lack of reliable medical files;
− over-prescription of antibiotics;
− hasty interventions that are not coordinated with rounds by outside teams.

At the end of each supervisory visit, the health workers are encouraged for their strengths and given
recommendations intended to make good their shortcomings. At the three centres, all the medical staff
has been given theoretical and practical training on:
• principles of scar management;
• principles of post-operative case management for excised and grafted patients;
• Pre-operative preparation of patients.

3. Results

Over our five years of experience, we have performed 503 operations, 378 (78%) of them for Buruli
ulcer. The operations break down as follows:
− 161 excisions
− 190 skin grafts
− 27 others (flap, etc)

Those centres that are best equipped to perform general anaesthetic have the best potential for
operations:
Manikro : 218 operations : 58%
Zouan-Hounien : 124 operations : 33%
Kongouanou : 36 operations : 9%

− At each centre, the cure rate is approximately 50% per month. Cure is thus accelerated and the
patients spend less time in the centre.

38
− Treatment is more easily accepted by families as they are no longer compelled to leave their home
environment and community. This in turn means that patients receive better support from the
community.

The overall cost of treatment is reduced through early case-management.

Finally, the early provision of treatment makes it possible to avoid functional sequelae caused by
lengthy and spontaneous scarring.
Nevertheless, there have been a number of problems.
1. Occasional difficulties of access to outlying centres during the rainy season;
2. Difficulties in coordinating some types of treatment with the local staff;
3. Reservations of some officials with regard to the administration of general anaesthetic;
4. The problem of surgical emergencies other than Buruli ulcer;
5. The difficulty of ensuring that the right type of vehicle for this kind of mission is available when
needed.

These problems are, however, far outweighed by the numerous benefits of surgery in outlying centres.

Conclusion

The search for new Buruli ulcer control strategies is never ending; we have developed the idea of remote
surgery, a form of advanced strategy that enables peripheral centres to benefit from some of the services
available at referral centres. Apart from the major constraint posed by the need for a properly equipped
operating theatre, this approach is a valuable tool for national Buruli ulcer control programmes.
For our part, we shall continue perfecting the strategy; in future, it may be possible to develop and
practice telesurgery, which is evoked more and more frequently, for the benefit of patients.

39
Preliminary studies of débridement using clay minerals on Mycobacterium
ulcerans infections and their ramifications
Line Brunet de Courssou, Infirmière Diplômée d’Etat, and her team of nurses, Missillac, France

1. Introduction

This document is not an official publication, but a collection of reflections and observations made by the
author after spending one year at proximity of patients afflicted with the dreaded Buruli ulcer or
Mycobacterium ulcerans infection. As the saying goes, things that are told in the simplest manner have
the best chance of success…

Motivation
Since ancient times, clay minerals have been used for healing purposes. Many types of animals in the
Amazonian forest appear to neutralize the toxic character of the vegetation they ingest by periodically
eating huge quantities of clay. Nowadays, in Europe, clay is frequently used to treat digestive
pathologies.
Personally, for more than 45 years, I have been using green illite clay for medical treatment on myself,
my family and friends, as well as in some dispensaries in Equatorial Guinea and Ivory Coast.
Very large lesions are predominantly seen only in developing countries, and in so-called “orphan” types
of disease. In Ivory Coast about 10 years ago, in dispensaries located in districts of precarious housing, I
had seen some strange ulcers. In popular language, these lesions were called “crocros” or “endless
ulcers”. I treated them with illite clay that achieved miraculous cures. The children talked amongst
themselves about this cure and came to us from afar for treatment.

The Anti-Buruli Ulcer Centre in Zouan-Hounien

I became aware of this “plague” only recently. In October 2000, I first met Father Marc, founder and
Director of the Buruli Ulcer Centre in Zouan-Hounien, who then asked me to try this method of
treatment with clay minerals in his Centre, in which about one hundred patients were being treated for
Buruli ulcer. This Centre is located in Zouan-Hounien, Ivory Coast, about 700 Km west of Abidjan.
This is how these preliminary studies on the effects of clay minerals on Mycobacterium ulcerans
infections were initiated. They started in January 2001 at the Centre in Zouan-Hounien.

March 2001 meeting in Geneva

I attended as an observer the March 2001 meeting in Geneva of WHO Specialist Group on Buruli Ulcer,
in order to gather information on the subject.

Purpose of the Studies

The purpose of my studies was the following:
a) To demonstrate the beneficial effects of the use of clay minerals on this disease,
b) To perfect a treatment regimen,
c) To communicate the results together with an extensive and freely available digital images library,
d) To present the results in March 2002 in Geneva to the meeting of WHO Specialist Group on Buruli
Ulcer.

41
Financing
These studies were all carried out under my direction in the Buruli Ulcer Centre at Zouan-Hounien. The
materials and apparatus required (including automatic hematology analyzer, automatic reflectance
meter, centrifuge, Zeiss microscope, etc), travel costs (road and air), computer equipment, supplies for
wound dressing as well as 6 tons of dry clay minerals crushed into powder, have been entirely financed
by my family and friends.

2. The method of treatment

Types of clay minerals

Two types of clay minerals were used in these studies:
• Green illite
• Montmorillonite

These powdered clay minerals are imported from France. Each consignment comes with an analysis
report issued by the Hygiene and Research in Public Health Laboratory of the H. Poincaré University,
NANCY 1, which certifies the total absence of microbiological contamination in the product.

Method of treatment
a) On admission, all patients are given anti-parasite treatment as well as food highly enriched in
proteins and supplemented with iron.
b) I work in clean but not sterile conditions, with great perseverance and regularity, using simple and
inexpensive equipment.
c) The previous day, the dry clay is hydrated in glass (never metal) salad bowls. It is mixed with water
coming from a lab tested well and is made up into a paste.
d) On the following morning, the clay is deposited directly to the infected parts, extending 10 to 30 cm
beyond the edges of the lesion, using wooden spoons or spatula (never metal), forming a 2 cm thick
layer. It is essential not to compact the applied clay pack.
e) The clay packs are renewed at least once a day, after cleaning the ulcer by rinsing it with running
water coming from the well. In severe “blazing” cases, the clay packs may need to be changed up to
three times a day.
f) Using a squeeze bottle filled with clay water (about 10% of clay in volume), a jet of clay water is
directed under the undermined skin at the edges of the ulcer. At the beginning of treatment, the fluid
retrieved from these washings contains decomposing adipocytes. After repeated washings, the
retrieved fluid becomes clean and serous (watery). In some cases (soft oedema), the area of the
undermined skin may involve the entire limb. We then have to ensure that the clay water reaches the
limits of the undermined areas by positioning the limb, whenever possible, in such a way that
gravity facilitates deep penetration of the clay water; gentle massages do help. This is a very time-
consuming procedure. When the infected areas have become very clean, the skin will stick again to
the underlying tissues. In one girl patient, we have achieved reattachment of the skin (dermis and
hypodermis) extending 40 cm over her arm.
g) We change over from illite to montmorillonite clay at a certain stage of the lesion débridement
episode. However, in some cases, in order to obtain a combined effect, we use both kinds of clay at
the same time, one beside the other.
h) Once the ulcer is clean, it is no longer washed with well water but with physiologic saline.
i) Over the lesion’s granulating tissues, we place gauze dressings impregnated with clay water (about
10% of clay in volume) in order to keep the lesion clean.
j) When the purple-colored scarring edge is uniformly established all around the wound, we progress
to the scarring procedure that will be described in a separate document.

42
3. Results and comments

Very quickly, the therapeutic properties of clay minerals that I had recognized for a long time were once
more demonstrated, even on Mycobacterium ulcerans infections; I was totally amazed!... Not being an
expert in this disease, I had anticipated that the clay treatment might only be effective in dealing with the
secondary infection. I had never envisioned that it might be so effective in attacking the mycobacterium
itself.
I reviewed the available literature and attended the March 2001 WHO meeting in Geneva as an
observer… But nothing is better than one’s own experience, at the side of the patient, to begin to
understand what you are dealing with. At this stage, reading is very valuable and it becomes much more
constructive as it allows comparison of one’s own results with what has been achieved elsewhere, and
provides explanations. Nevertheless, it is obvious that the behavior of the mycobacterium, as observed
over several months in hundreds of patients, has not yet been described in medical literature.
When you have it in front of you, the situation is not so simple, because this mycobacterium is vicious,
artful, tough, full of surprises, and biologically primary as it reacts and vigorously regenerates. It has an
extraordinary ability to survive. In addition, the evolution of Mycobacterium ulcerans infection cannot
be predicted from the state of the infection when the patient is admitted to hospital, but depends on the
particular reaction of individuals.
I undertook to remove the bandages myself in order to check it and better observe it… And yet, it
constantly surprises me. I follow its actions in the development of the ulcers, without always being able
to predict all its reactions. Seeing, with your own eyes, the débridement of the ulcer while it is taking
place, in all its phases, is very enlightening, particularly when accompanied by regeneration of tissue in
other areas of the ulcer (a phenomenon which happens frequently with this method of treatment). Clay
respects living tissues and stimulates their regeneration, which is one of its utmost qualities.
When applying powdered clay minerals hydrated with water to successive evolution stages of the
Mycobacterium ulcerans infection, I have been able to observe spectacular results, clearly visible on the
digital photographs that were taken during treatment. The following part of this document contains a
detailed presentation of the results achieved in the treatment of the infection with clay, in terms of:
1. Rapid resolution of oedema
2. Action on nodules
3. Action on plaques
4. Powerful but non-aggressive cleaning action on the ulcer and on satellite lesions
5. Absorption of foul odors
6. Neutralization of mycobacterium and its toxins
7. Expulsion of “ramifications” (?)
8. Absorption effect via the lymphatic system
9. Action on severe “blazing” cases
10. Action on recurrences
11. Transition from treatment with illite to treatment with montmorillonite
12. Role of water
13. Absence of haemorrhage
14. Granulation tissue growth
15. The purple-colored scarring edge
16. Scarring
17. Risk of dissemination via the bloodstream
18. Testing for the HIV virus

Generally speaking, if the ulcer is recent, débridement is rapid from the very beginning of the treatment.
On the contrary, in long-standing infections, new ulcers may burst in the early stages.

43
Rapid resorption of oedema
Treatment with clay results in rapid and spectacular resorption of oedema (in 2 to 3 days, sometimes
less).

Action on nodules
Clay has an effect on nodules, sometimes resulting in their disappearance, sometimes by stimulating
them to burst; they then follow the same evolution process as the ulcer.

Action on plaques
Clay acts on plaques by achieving a full débridement. In fact, it appears that, as soon as clay packs are
applied, the mycobacterium is activated again and is stimulated. This is a painful stage, psychologically
speaking for the patient, who sees the ulcer appear, spread, then burst, producing purulent matter with
the foul odor of “rotten cassava” (as described by the patients themselves).

Vigorous but non-aggressive débridement of ulcer and its satellite ulcers

It is important to distinguish between “satellite” ulcers and “ramified” ulcers. Satellite ulcers occur
around the initial ulcer and result in an enlargement of the lesion; ramified nodules can arise anywhere
at a distance from the initial ulcer and may break out to form a new ulcer.

The clay treatment activates a vigorous (although not over-aggressive) débridement of the
ulcer and its satellite ulcers, removing contaminated tissues, no longer blood vascularized
tissues and necrotic tissues without affecting healthy tissues. This results in a lesion with
irregular edges and occasionally with islets of healthy dermis in the centre of the ulcer
(which are of considerable value subsequently).

This non-surgical débridement phase (also known as lesion trimming) to decontaminate the
ulcer may appear prolonged compared with surgery, but it is crucial. This treatment phase
is always disappointing, never gratifying, but it won’t tolerate imperfection. It is essential to
explain to the patient the nature of the different phases of the débridement episode.

Absorption of foul odors

After a few applications, thanks to the clay’s exceptional absorptive properties, the stench of “rotten
cassava” which characterizes Mycobacterium ulcerans infections is eliminated. (Thank God!)

Neutralization of Mycobacterium ulcerans and its toxins

I will not expand on the effects of Mycobacterium ulcerans’ toxins, which, as we know, result in the
destruction of adipocytes. The latter, unfortunately, are never renewed, making the scarring process
more difficult.
Clay absorbs toxins and decomposed adipocytes without difficulty. In some long established cases, this
takes time, and patience and persistence are needed. The result is worth the effort and the long wait.

Expulsion of “ramifications” (?)

On granulating and apparently clean ulcers, clay, thanks to its exceptional absorbing properties,
succeeds in “spitting-out” what I believe to be “ramifications”. The expulsed blackened necrotic matter
is accompanied by the same odor of “rotten cassava” mentioned previously. This event is very painful
for the patient, comparable to the pains of childbirth.
This is an astonishing phenomenon which leaves new nursing staff recruits totally speechless…

44
Analysis of samples of this black matter confirms the presence of the BAAR (alcohol-acid-fast bacilli).
There is little more I could say on this subject because our laboratory is brand new, equipped with state-
of-the-art equipment, but unfortunately we do not have, as yet, skilled staff available to operate it.
The expulsion phenomenon is often accompanied by a deterioration of the patient’s general condition,
occasionally triggering an outbreak of malaria, probably as a result of immuno-deficiency. In such cases,
the malaria is treated by the Centre’s medical staff (after confirmation by laboratory testing).
Alternatively and according to the patient’s general condition, antibiotic treatment may be given. If the
child is otherwise well, no medical treatment will be needed, although plenty of cuddles and sweeties are
welcome!
This expulsion episode doesn’t last long, only a few days, but it can recur several times, fortunately with
diminishing severity. During this period, the clay packs have to be replaced up to 3 times a day. When
you hold the “beast’s tail”, you don’t let it go!
At the end of the expulsion episode, the patients start smiling and the children become cheerful again.
The expulsion, as I described it, can occur when the lesion is clean and “good-looking” (even sometimes
when the staff is considering skin-grafting), while still being controlled with illite or montmorillonite
(gauze dressings impregnated with clay water and/or clay packs around the lesion). This phenomenon is
frequently observed in the course of patients’ treatment.

Absorption effect via the lymphatic system

I have personally observed that any alien matter or matter that became alien, such as decomposed
adipocytes, mycobacteria, thorns, even small stones or pieces of metal pins (observed lots of times) are
attracted by clay. Clay acts as a magnet to draw out these foreign substances. Clay is smart; it knows
how to “drive the wolves out of the wood”.
I can only think that this phenomenon must involve the lymphatic system; how else can we explain this
expulsion of matter laden with mycobacteria and decomposed adipocytes, which are expulsed out from
the centre or from on the edge of a perfectly “clean” lesion? Where do they come from? The episode
lasting only two or three days, is this possibly the expulsion of a distant ramification of the initial ulcer?
We are amazed by this demonstration of the potency of this natural clay and we are always astonished
when witnessing the demise of our enemy (or so we hope). We still have a lot to learn about this
infection!

Effect on severe “blazing” cases

Concerning this phenomenon, we have no real understanding of what is going on. The patient speaks
about a mere itchy pimple or boil, which did not really hurt and that appeared only 3 to 6 weeks earlier.
Two of those cases arrived at the “Oasis” Hospital of the Sisters of Mother Theresa in Abidjan (in the
town centre), where the severe cases of HIV are treated. They were treated for a few days with illite clay
packs (following the method I had taught them) while waiting to be picked up by the ambulance from
our Centre. Arms and legs sections were torn into shreds, as if lacerated or bitten by a vicious dog, and
the odor was atrociously foul (real stench). These cases were first infection cases, not recurrences. How
can such a quick and severe outbreak of the disease be explained?
The HIV tests on both patients were negative. In these two cases, clay has proved very effective, and
this from the very beginning of the treatment. As I write this, both patients are ready to go back home in
Abidjan (2 months for the first one after admission, and 3 months for the second one).

Effect on recurrences
Among the patients admitted at the Centre that I have personally examined, what struck me most is the
high proportion of recurrences. Recurrent cases are considerably more resistant than first infection cases;
ulcers emerge from under the scars hence dissolving them and even at times totally lifting grafted skin.

45
This set my mind thinking, and I pictured the mycobacterium as a kind of hydra with tentacles invading
the body through he lymphatic system, clutching at any part and promoting the formation of new
nodules. When you use surgery and cut its head, this vicious hydra has the power to regenerate itself
from its disseminated tentacles. The tentacles are likely the origin of new nodules. These ulcers burst
where you least expect them, more fiercely so as the “beast has been disturbed” and the human terrain it
infects suits it so well. It can nourish itself, prosper and multiply comfortably as the human body is the
ideal host… This became the turning point whereby I understood that it was necessary to do more than
simply place the clay on the lesion itself, by “attacking” both above and below the lesion with a thick
and far-reaching layer of clay, unlike what I would normally do on a sore, a varicose ulcer or a burn.
The beast must be bullied, drawn out, absorbed and digested.

Transition from treatment with illite to treatment with montmorillonite

During the débridement phase of the ulcer, the observation of the appearance of “filaments” of
coagulated blood on the lesion, does warn us that thromboses are receding and that we must stop using
green illite clay which is too absorptive and we must start using montmorillonite clay instead.
Montmorillonite clay which has excellent adsorption properties and has a greater transfer of ions than
illite clay, re-mineralizes, detoxifies and promotes healing. Montmorillonite stimulates tissue
regeneration and wound healing.

The role of water

I have no knowledge of which element in the clay is responsible for its active therapeutic properties;
however, I discern that “dry” clay has no action at all, while when hydrated with water, its properties
develop and become activated. We know already that water is a key factor, that is, an ideal transport
medium that infiltrates everywhere, consequently enabling elements to act. Water almost certainly has
other properties (to be exposed in a future essay).

Absence of hemorrhage
There is no bleeding during débridement using clay; we only see small filaments of coagulated blood
when the thrombosis stops.

Granulation tissue growth

Extreme care is needed during the granulation tissue growth phase. It is absolutely crucial to prevent any
damage to the granulation tissue and ensure it remains intact, avoiding any aggression by antiseptics and
by removal of dressings insufficiently soaked with saline serum or removed too quickly. Again this
phase is crucial and negligence is not permissible. Any bleeding, no matter how small, will warn us that
we have made a mistake and have damaged a precious marvel… When we reach this phase, we start
using “home-made” shea butter dressings (our shea butter comes from a laboratory in Burkina Faso).

The purple-colored edge

After the expulsion episode, scarring begins. Nevertheless, as long as the little “purple edge” which
appears on the lesion’s edges is not uniform on its entire perimeter, ANYTHING can still happen…

Scarring
Following ulcer débridement and lesion cleaning using clay packs and clay water dressings, we enter the
scarring phase wherein we benefit of clay’s remarkable healing properties. For this, we use clay water
dressings together with adjacent shea butter dressings or alternatively “Tulle Gras Lumière” dressings
made with “Balm of Peru” combined with Vaseline (petroleum jelly). The results of the work on the
scarring phase are documented in a separate document.

46
Scarring may be accelerated by surgery. Surgery is valuable above all when the lesions are substantially
large and cannot scar quickly on their own.

Risk of dissemination via the bloodstream

We must bear in mind that Mycobacterium ulcerans infection is an infectious disease and as such, it
cannot be cured by surgery; this statement was uttered by an eminent surgery Professor who will
recognize himself… It may be difficult, under particular circumstances, to question dogma which one
has been taught!

Testing for the HIV virus

In extremely severe cases like those mentioned above in this document, rapid tests for the HIV virus
were carried out; results were negative.
To my knowledge, we have had only two HIV positive patients affected by Buruli ulcer; a woman who
has since died and a young man who is still undergoing treatment as of this writing.

Conclusions
The method presented, inherited from ancestral practices but with proven effectiveness and classified as
traditional medicine, is a powerful demonstration of the force of nature and its healing power.

Advantages compared with the current methods

The advantages of using clay minerals to achieve débridement are the following:
a. Neutralization of Mycobacterium ulcerans and its toxins
b. Sparing of healthy tissue
c. Accelerate granulation tissue growth
d. Avoid fear of surgery
e. Avoid general anaesthesia and its well-know risks
f. Avoid haemorrhage
g. Eliminate the need for blood transfusion and its associated risks
h. Lessen the risk of contamination, as well as any further sepsis risk
i. Substantial pain reduction when dressing and undressing the wound
j. Lower treatment costs (clay is very inexpensive; so is our home-made equipment)

Disadvantages of the method described

a) Anxiety for the patient who sees his ulcer grow and substantial matter ooze out during the
débridement phase; therefore the patient must definitely be made aware of what is going on and
what is about to happen (fortunately, very often, patients near to be discharged, can provide
reassurance).
b) The substantial weight of clay packs, sometime in the order of several kilograms, especially if the
lesion has spread to the entire arm or leg in an adult patient.
c) It is anticipated that modern medicine will receive the results of this studies with unreserved
skepticism. The therapeutic benefits of physical application of hydrated clay minerals have never
been thoroughly researched; consequently, to my knowledge, the active components which could
explain the effectiveness on Mycobacterium ulcerans infections have not been identified.

Therapeutic properties of clay minerals

My research has been focused on the débridement properties of clay minerals on Mycobacterium
ulcerans infections and their ramifications. If only we could confirm the absorptive action of clay on
Mycobacterium ulcerans, then, possibly, we could prevent the recurrences of the disease, which are so
painful for the patient and discouraging for the medical staff. Moreover, we might be able to prevent the
severe associated osteomyelitis for which there is, as yet, no really effective treatment.

47
Infection recurrence
Infection recurrences or relapses are not unavoidable; I am convinced that these preliminary studies
could be improved by increasing the frequency of clay pack application and by nursing done by skilled,
dependable, motivated, ingenious, meticulous, and determined staff.

Early detection
Unfortunately most patients have reached an advanced stage of infection when they are admitted to the
Centre.

Bringing-in pinpointed cases

The patients under treatment in our Centre often tell us of other cases in their village. We have launched
an information campaign in order to prepare for the visit of our Centre ambulance to pick people up.
Beforehand, Father Jean-Louis, Director of the Catholic Mission, informs the village Chiefs by letter, so
that “messengers” can be sent to the campsites in advance to inform the inhabitants about our visit.
Nevertheless, we have never been able to bring-in the pinpointed cases, even though the ambulance,
board, lodging and medical care during treatment are free of charge. The Village Chief, unfortunately,
lacks the authority to force the infected individuals to undergo treatment and cannot even force them
come out of their huts. Making these trips, over a range of about 100 kilometres on very poorly
maintained dirt roads, without bringing back the patients, are very frustrating and costly.
How can we force them to be treated? How can we make them understand that as soon as the symptoms
are detected, they should immediately come for treatment to ensure quick and complete recovery?
We have designed posters to alert and inform the population of the problem; yet we still lack the money
to print them and distribute them.
I think it would be wise to classify Buruli ulcer infection as a mandatory reportable disease. Perhaps,
proceeding this way, it would make it possible to counter the popular belief attributing this disease to
witchcraft, and enable us to start treatment at an early stage of the infection.

Transmission of the infection

So far, we have been unable to start our campaign for collecting samples of water-insects and flying
insects, in order to identify the carrier of the mycobacterium. This is because, as yet, we have not been
given necessary permission by the sanitary district to drive through the villages for that purpose. Such
administrative barriers are very discouraging.

Digital photographs library

The results presented herein can all be examined on the digital photographs taken during the various
stages of this study. A library of over 2000 photographs taken with a professional digital camera has
been compiled. A commented slideshow will be presented at the WHO Meeting in March 2002.
In the meantime, portions of these slide collection are available upon request.

OUR HOPE: Never to see these patients again for a relapse.

48
Preliminary studies on débridement and scarring of Mycobacterium ulcerans
infections using natural hydrated aluminum silicates

Line Brunet de Courssou, Infirmière D.E. et son équipe d’infirmiers, Missillac, France

Devastating Buruli ulcers are caused by Mycobacterium ulcerans’s necrotic toxin. When arriving at the
hospital, the patient may present a small skin opening most often surrounded by a large edema taking an
entire arm or leg, the extent of which usually reflects the actual extent of the infection. Common
treatment is surgical débridement: the skin covering the entire infected zone is removed such as to gain
access to necrotic tissues and scrape them off. A large excision is made, muscles, tendons and
articulations are exposed and cleaned up and then new skin from the patient is grafted over the lesion.
Healing is fastidious, keloids and retractions occur quite frequently, articulations end up twisted and
movements are restricted. Nosocomial infections and new attacks of mycobacteria infestation
(recurrences) result in more functional disability, and sometimes end up with amputation.
We have experimented a new protocol at the Zouan-Hounien center, Ivory Cost, during the year 2001
(January 2001 to January 2002), and have successfully treated a hundred patients. We are here today to
communicate our results.
There are two distinct phases in that treatment: first the débridement phase, and then the scarring phase.
The first phase is aimed at neutralizing Mycobacterium ulcerans and toxins, removing necrotic tissues
and cleansing the derm, hypoderm and subcutaneous tissues. We manage to achieve this result without
the help of surgery. The immediate advantage is that every bit of healthy tissues is preserved to
participate in the scarring process. Moreover, tissue regeneration is stimulated to such an extent that
quite often skin grafts don’t have to be performed.
Débridement is achieved with natural hydrated aluminum silicates (illite and smectite) applied in direct
contact with the lesions. These ion-exchanging dressings suck-away all necrotic tissues, and drain them
out through the opening. The minerals are applied in thick packs and renewed up to three times a day. A
thorough washing preceds every new dressing, with water first, and then with a 10% solution of the
mineral. We continue on with this protocol until the arm or leg is ridden of the infectants, and the
solution injected far under the skin returns serous and odorless. This cleansing phase usually lasts five to
six days. Then the healthy skin would spontaneously start to reactivate and gradually stick to the
underlying muscle, resulting usually in itching. A purple sealing edge would appear all around the
wound that testifies of the adhesion to underlying structures. When the purple edge forms a uniform
seal, the « scarring protocol » (second phase) is initiated. We noticed that if the purple edge cannot
consolidate and expand well, thus leaving unsealed edges, it testifies of the need for a new discharge of
mortified tissues; subsequently, a second series of thick stench fluids (or “deep throat spit”) come out
within a few days, probably originating from a remote nest of mycobacteria. After this second
spontaneous discharge has completed, the purple edge completes rapidly the sealing around the wound,
and general scarring would then progress normally. This “secondary” discharge is probably the success
factor that prevents later infection recurrence.
In the second phase, the wound is cleaned solely with physiologic serum between applications. Initially,
dressings are also made with natural aluminum silicates which maintain ideal conditions for vigorous
tissue growth and for preventing dreaded retractions. Cell proliferation is impressive, but don’t worry, at
the right time derm granulations will subside and new skin will start to cover the opening. Shea butter
dressings are progressively introduced adjacent to the natural aluminum silicates dressings in order to
bring essential cell nutrient supplements (mostly A2 vitamin) to promote skin regeneration and better
texture. The entire lesion becomes covered with a regular and healthy scar which progressively darkens
(due to melanin) and becomes vascularized. What’s totally new about this scarring treatment is that the
new skin has a good and supple texture, free from retractions and keloids. Moreover, articulation
mobility and functionality is completely preserved. Only adiposytes are missing. Skin graft is indeed of
great help to speed up the scarring process when the lesion area is extensive.

49
This protocol was found to be totally successful with primo-infection cases, but significantly more
difficult with infection recurrences. As damages to functional limbs and articulations are minimized,
mobility impairment is minimized.
Let us conclude with this proposal: this protocol should be supplemented with a two year study in
Zouan-Hounien, and ideally in several other places, in order to confirm or infirm its practicability and
usefulness. Material and supplies cost is minimal, therefore local nurses may be trained by qualified
regional supervising doctors. We must give it a try: remember, Mycobacterium ulcerans infection is a
dreadful disease affecting mostly children and young adults, resulting in disabling scars or amputation,
gloomily impairing their family and economic future.

50
Update on Buruli Ulcer activities for 2001 in Ghana

Dr. George Amofah, Director Public Health, Ghana Health Service, Accra, Ghana

The year under review saw Ghana once again being used as a ‘field laboratory’ for major projects with
far reaching consequences for Buruli ulcer control and management worldwide.

1. Cultured epidermis project in Ghana

The year 2001 saw the operationalisation of the major pioneering work on cultured epidermis for BU
that had been in preparation for some time now. The project is a collaborative effort among MOH,
Ghana; Plastic Surgery Unit of Korle Bu Teaching Hospital, Ghana; Sasakawa Memorial Health
Foundation, Japan; J-Tec Company, Japan; Noguchi Memorial Institute, Ghana; WHO BU Global
Initiative; and Nippon Foundation, Japan.
The exercise was conducted in Accra, from 21 May to 8 June 2001. Seven patients with BU were
operated upon using cultured tissue skin for skin grafting. 100 sheets of cultured epidermis were brought
to Ghana from Japan and 30 were used for the skin grafting, with the remaining 70 stored at Noguchi.
Initial results were very encouraging.
The findings were presented to the media and the public later at a press conference, which was broadcast
widely as a publicity stint for advocacy.

2. Training

The principal investigator at Korle Bu used some of the remaining cultured epidermis to train surgeons
and some medical officers later during the year with permission from the Japanese counterparts.
Additional training is planned for February 2002 in Ashanti region.

3. Clinical trial

Another major undertaking during the year was the beginning of a clinical trial study involving three
sites in Ghana to assess the efficacy of Streptomycin and Rifampicin for early BU lesions. This is under
the auspices of WHO BU Initiative with sponsorship from Association Francaise Raoul Follereau,
France and Nippon Foundation, Japan. A minimum of 24 patients is expected to be recruited for
different treatment regimens according to a randomisation process.

4. Risk factors project

The collaborative project with CDC and Emory University, Atlanta on identifying risk factors of Buruli
ulcer is yet to be finalised even though the fieldwork has been completed. All samples have been sent to
Atlanta and we are waiting for analysis and report writing.

51
5. Capacity building workshop

Four Regional representatives each from all the 10 regions were taken through BU ulcer control and data
management during the year. They were taken through the BU1, BU2 and other reporting forms, and
quantities of the forms were given to the regions for use on trial basis.
In line with the ministry’s policy of integrated disease control at the district level, we have incorporated
aspects of BU reporting and surveillance in the Integrated Disease Surveillance and Response guidelines
that have just been developed. DHMTs shall be taken through the guidelines in 2002.

6. Seminar on infectious diseases

The medical and Dental Council of Ghana organised a seminar on infectious diseases for scientists,
health professionals and the academia. Buruli ulcer featured prominently and I had the privilege of
presenting a paper on the BU situation in Ghana, based on the national case search results. The seminar
generated a lot of interest about the disease.

• Two consultants from Ghana BU programme took part in the development of training modules for
BU control in the African region in Harare during the year.
• A new programme manager has been appointed recently to manage BU control in Ghana.

7. Collaboration with partners

The MOH has been collaborating with a number of agencies.

a) The Japanese Embassy provided a grant in March 2001 to support the School of Medical Sciences,
Kumasi with its BU project at Amansie West district.
b) A representative of the American Leprosy Mission undertook a visit to the country to explore
avenues for mutual collaboration. The Mission has agreed to support BU activities in some districts
in Ashanti region with particular focus on mission facilities.
c) The President of the Nippon Foundation, Mr Yohei Sasakawa, visited the country in connection
with the cultured epidermis collaborative project during the year. He and his team paid a courtesy
call on His Excellency, the President of the Republic of Ghana. The President used the occasion to
express his government’s commitment to BU control in Ghana.
d) University, Atlanta undertook a mission in Ghana to carry out preliminary assessment to identify
priority areas of concern for future work on economic aspects of BU.
e) He encouraged countries to document all costs associated with treatment of the disease, examine
cost-effectiveness of role of volunteers in reducing number of patients with advanced cases, and to
develop formal measures of effectiveness in terms of QALYs and DALYs.
f) HART: The NGO has now established a permanent presence in Ga district of Greater Accra region.
It once again organised a mission of surgeons and nurses to undertake surgical operations on many
BU patients in the district.
g) AILO representative in Ghana, Rev Fr. George Abraham, mobilised funds from the organisation and
elsewhere to construct a theatre with admission facility at Amasaman health Centre in Ga district of
Greater Accra region. The facility is to be used for providing surgical and other services for BU
patients in the district and elsewhere. Fr. Abraham also prepared a very colourful advocacy
document on the project that has been widely disseminated.

52
Update on Buruli ulcer control activities in Guinea
Dr Adama Marie Bangoura, National Buruli Ulcer Programme, Ministry of Health, Conakry, Guinea

1. Brief description of Guinea

The Republic of Guinea is located in West Africa, 10° north of the Equator. It is surrounded to the
north-west by Guinea Bissau, to the north by Senegal and the Republic of Mali, to the east by Côte
d'Ivoire and Mali, to the south by Liberia and Sierra Leone and to the west by the Atlantic ocean.
The country has a 300 km coastline and extends 800 km from east to west and 500 km from north to
south. Its total area is 245 857 km2.
In terms of geography and ecology, the country may be subdivided into the following natural regions:
Ÿ Basse or maritime Guinée: this 150 km-wide alluvial basin formed by the coastal rivers runs along
the Atlantic. It has a warm, humid sub-Guinean climate and is heavily influenced by the monsoon.
There is abundant rainfall, with an annual average of from 2000 to 3000 mm. It is ideally suited to
subsistence and commercial farming (rice, bananas and pineapples) and sea fishing.
Ÿ Moyenne or Fouta-Djallon Guinée: a region of mountains and plateaux which, together with the
Guinean ridge, is the water reserve of western Africa. It possesses a Foutan-type climate,
characterized by a mountain microclimate situated between 600 and 1500 metres. Rainfall varies
from 1500 to 2000 mm. It is a region of grazing, citrus fruit and vegetable gardens.
Ÿ Haute Guinée or the savannah region: this is a rice-growing region that is frequently flooded
during the rainy season. Average rainfall is 1200 mm. It is an area of river fishing and stock raising
par excellence and occupies 40% of the national territory.
Ÿ Guinée Forestière: this area is noteworthy for its dense vegetation and its mountains, which are a
continuation of the Fouta range. Rainfall is heavy, from 1700 to 3000 mm and is present for 8
months of the year. This is an area of subsistence and commercial farming (rice, bananas, tea, cocoa,
coffee and oil palm).

Guinea has a dense drainage system. It comprises several rivers belonging to the Niger basin, among
them the Djoliba, Bafing, Konkouré, Gouan and Makoni-Melli network.
These rivers branch out and form numerous marshes and swamps which have been developed to form
large reservoirs that are responsible for major ecological changes in several regions. Large dams have
been built, including the Garafiri, Kinkon and Kalé, and the so-called dry region is flooded each year.

2. Administrative structure

Since 1994, Guinea has been divided into 7 administrative regions (Kindia, Kankan, Labé, N'Zérékoré,
Mamou, Faranah and Boké) and the special area of Conakry, the capital.
The seven administrative areas and that of Conakry are subdivided into 33 prefectures, 347 sub-
prefectures, 38 urban district and 303 rural development districts (CRD).

• Population
At the beginning of 2000, Guinea had an estimated population of 7 842 792. The annual growth rate is
3.1%, giving an estimated population of 10.6 million by 2010.

Principal demographic indicators:

53
- total fertility rate 5.6%
- annual growth rate 3.1%
- under-five population 45.6%
- male population 49%
- female population 51%
- economically active pop. 52%

Social and cultural features

Literacy rate: the population has a low literacy rate, which also varies from one area to the next (from
40 to 50%); there is a significant difference between men and women, 41 and 22% respectively.
This is detrimental to the adoption of healthy lifestyles and to the success of IEC campaigns that rely on
the written word.
Practices and behaviour linked to custom, as well as attitudes among the population are not always
conducive to health.

Social and economic features

On the basis of the energy intake norms of WHO and FAO, 40% of the population lives below the
poverty threshold and as a result has poor access to health care.
Poverty is much deeper in rural areas and is unevenly distributed among the country's regions.
Despite its rich subsoil, Guinea counts among the world's least-developed countries.
The main economic activities are agriculture, fisheries and stock-raising, trade and crafts.

Health system
A three-tier pyramidal system: national, intermediate and peripheral. The system's strengths lie in:
– the Government's clear political determination to improve the population's health, as a result of
which health has been assigned priority as a sector of national development policy;
– the match between the health system's structure and the country's administrative division; this
favours decentralization and hence better integration of the health system into the local development
process.
– the ongoing process of territorial administrative decentralization with the support of partners, which
could help to accelerate the decentralization of the health sector and create a favourable environment
for cross-sectoral actions at the peripheral level.

Health situation
The health system operates in a deteriorating environment in which there is a range of diseases,
characterized by the prevalence of endemic and epidemic diseases, the most common of which are
malaria, acute respiratory infections, intestinal parasite disorders, diarrhoeal diseases, injuries, oral and
dental conditions, eye diseases, onchocerciasis, schistosomiasis, sexually transmitted infections and
AIDS. Besides these conditions, there are also chronic disorders such as leprosy and tuberculosis, as
well as a number of emerging diseases including Buruli ulcer.

Selected health indicators

- Birth rate
- Life expectancy at birth
- Maternal mortality rate
- Infant mortality rate
- Crude mortality rate
- Infant and child mortality rate
: 36.9 per thousand;
: 54 years;
: 528 (per 100 000 live births)
: 98 (per 100 000 live births)
: 14.2 per thousand
: 177 (per 100 000 live births)

54
3. Buruli ulcer situation

The first clinically observed cases of Buruli ulcer date back to 1993, and the scale of the problem
nationwide is unknown. An evaluation has been made only in Guinée Forestière (22% of the territory),
through a situation analysis conducted in 1999 with the assistance of WHO. The analysis showed that
N'Zérékoré administrative region is highly affected (5 out of 6 prefectures), as are Faranah and Mamou
(7 out of 33 prefectures).
Currently, although Guinée Forestière is the only endemic zone to have been systematically evaluated,
cases originating in other regions have been reported: these include Kissidougou (Guinée Forestière),
Dalabe (moyenne Guinée), Kindia and Forécariah (basse Guinée) and Kérouané (haute Guinée)
prefectures.
This increases the number of prefectures affected from 7 to 12.
It should be mentioned that dozens of the cases notified come from the Kissidougou refugee camps.
These figures suggest that the population as a whole is at risk from the disease, on account of
epidemiological factors resulting from the ecological disturbances in the four geographical regions, the
presence of the agent in the country and the presence of large numbers of refugees from countries in
which the disease is endemic (Liberia and Sierra Leone).
Between 1993 and the end of 2001, there was an aggregate total of 324 cases (221 of which were still
active, at Nzérékoré, Lola and Yomou (221 cases), 73 at the two university teaching hospitals and 30 at
the Phil Africaine mission medical centre at Macenta.
• 80.99% of cases were detected at a late stage, and 11.3% had retractile scars.
• the case detection rate ranged from 9.8 to 155 cases per 100 000 inhabitants.

On account of the following factors, these data are in no way indicative of the actual situation:
• failure to notify cases to SNIS on account of health workers' ignorance of the disease;
• the influence of social and cultural factors (taboos, witchcraft, other beliefs);
• ignorance among the populations of the possibilities offered by modern treatment techniques, which
limits the use made of modern medicine and leads to patients consulting traditional healers as a first
resort.
Consequently, we should not underestimate the number of cases that are undetected or not notified in
localities where no evaluation has been carried out; on the contrary, their number could be far higher
than the number of cases detected.
Case management is enormously handicapped by:
• the lack of facilities specialized in treating Buruli ulcer, the shortage of beds and the under-
equipment of the country's surgical departments;
• the lack of health workers trained to recognize and treat cases;
• the high cost of treatment, contrasting with the extreme poverty of patients;
• the lack of drugs and consumables in health facilities;

The 221 cases detected since the survey have not yet been treated.

4. Update on Buruli ulcer control in Guinea

In response to this growing endemic, and in conformity with the recommendations adopted by the
Yamoussoukro Conference, in February 2001 the Government of the Republic of Guinea decided to
establish the National Buruli Ulcer Control Programme.

55
In May 2001, the Ministry of Health designated a team to be responsible for coordinating national
activities by the different actors, whether specialized services or regular health service departments,
engaged in BU control.
The National Buruli Ulcer Control Programme is a new programme in Guinea; consequently, its
activities have been programmed in two phases:

1. a preparatory phase covering 2001, during which the following activities were to be carried out:
• laying the Programme's foundations;
• resource mobilization to fit out and equip the coordinating office's headquarters with computers,
audiovisual equipment and teaching facilities, to purchase logistic equipment (i.e. vehicles, the
endemic zone being 1000 km away), and to manage cases detected in Guinée Forestière.
• preparation of the different documents (PAO 2001 and 2002, national Buruli ulcer control policy
document, strategic five-year plan 2002–2006, framework and organizational instruments).
• validation of the national policy documents and of the plan of action 2002–2006;
• submission of the various documents to the different partners;
• training for health workers operating in the endemic zone.

Activities carried out

• *Acquisition of a headquarters for the national coordinating office at Donka national hospital; the
premises were neither fitted out nor equipped with computers, audiovisual and teaching facilities.
• *Inclusion of the National Buruli Ulcer Control Programme among the programmes assigned
priority by the National Health Development Plan and classification of the disease as one of the 24
priority diseases for purposes of integrated epidemic surveillance;
• *preparation of the different documents; the policy and programme documents, however, have not
yet been prepared;
• *organization of three training workshops for 19 district officials, 16 surgeons and 15 laboratory
technicians at N'Zérékoré;
• *selection of 10 focal points and 15 relay centres on the basis of selection criteria to provide case
management for the cases detected;
• beginning of case management at Nzérékoré hospital and at the Phil Africaine mission for 8 cases
complicated by osteomyelitis.

2. Implementation phase
This will cover a five-year period (2002–2006).

Overall objective:
• to reduce morbidity and the sequelae of Buruli ulcer.

Specific objectives:
• To provide satisfactory case management by the end of 2006 for at least 70% of the cases detected
in Guinea;
• To increase the case-detection rate of non-ulcerative forms from 7.69 to 30% by the end of 2006:
• To reduce the proportion of disabled patients from 11.31% to 5% by the end of 2006;
• To rehabilitate 10% of patients with disabilities detected between 2002 and 2006
• To set up five centres providing specialized case management by 2006 in the endemic areas
identified;
• To integrate BU activities into the minimum package of health centre activities and into the
supplementary package of hospital activities, depending on the level of treatment provided;
• To provide proper treatment for 90% of BU patients already identified;
• To promote operational research focusing on epidemiology, diagnosis, treatment and prevention;

56
5. Strategy and activities

In order to attain these objectives, we have chosen 8 lines of strategy for developing the different
activities:

1. Advocacy and resource mobilization

− amendment and adoption of documents;
− raising awareness among political and administrative authorities;
− organizing a round table in connection with resource mobilization.

2. Human resources development

This will be done in two stages:
a) Building up the skills of the coordination team in the fields of programme management, research,
communication, epidemiology and information technology.
b) Selecting and training health and social workers to identify the disease, with priority for health
workers in endemic zones and those working on the spot in centres providing treatment and
responsible for epidemiological surveillance, community health workers, traditional healers,
education workers and agricultural development workers, to provide early treatment and referral.
The training will be provided on the spot or through traineeships abroad. Study trips will also be made to
countries where the disease is endemic, to exchange experience.

3. Infrastructure development
− Construction and equipment of the coordinating office headquarters and of five treatment centres;
− Improvement of the equipment of the selected relay centres and focal points and their laboratories
with small surgical and laboratory equipment;
− Equipping the dermatology service's operating theatre (referral centre)

4. Correct case management

− Regular supply of drugs for treatment centres and of reagents and consumables for laboratories;
− Provision of food for hospitalized patients;
− Treatment of cases by level;
− Post-operative surveillance;
− Provision of rehabilitation;
− Organization of case detection sessions in villages.

5. Development of communication to change behaviour

− Raising awareness among the population by means of educational sessions, through the media and
health centres;
− Production of a documentary on BU in Guinea.

6. Operational research
− Risk evaluation in at least two geographical regions and in refugee camps.

7. Supervision/evaluation of activities
− Quarterly supervision of the intermediate and half-yearly of the central levels;
− Mid-term evaluation of the Programme.

57
8. Development of cross-sectoral partnership

Indicators:
• Prevalence
• Case detection rate
• Disability ratio
• Cure ratio
• Proportion of patients rehabilitated.

Difficulties encountered
The lack of material and financial resources, and particularly of equipment and logistic resources for
coordination, of drugs and consumables required for treatment and of information material to secure the
population's commitment to control measures, hampered all the activities planned;

6. Prospects

Validation of the documents by April 2002

Implementation of the 2002 PAO through:
a) Fitting out and equipment of the coordinating office headquarters:
b) Purchase of two vehicles for the coordinating office;
c) Provision of small surgical kits and of drugs, consumables and laboratory reagents for the focal
points and relay centres,
d) Situation assessment in Faranah and Kindia administrative districts and in the Kolla and Kounkan
refugee camps;
e) Community information to bring about a change in behaviour in endemic zones;
f) Training for district officials and health and welfare workers;
g) Integration of BU control activities at all levels;
h) Supervision of activities by the central level;
i) Continuation of study trips to exchange experience;
j) Building up the skill of the coordination team through courses abroad in communication techniques,
programme management and operational research.
k) Organization of the workshop to validate the monitoring and evaluation tools.

7. Advocacy

The creation of the Programme is proof of the political will and commitment of our Government and of
every political and health authority to Buruli ulcer control. However, Buruli ulcer is but one of the
manifold health problems faced by Guinea, whose solution places a heavy burden on our limited
resources and requires the assistance of the international community.
Consequently, we request the help of WHO with our advocacy efforts aimed at mobilizing the resources
needed to implement control activities in Guinea. We also appeal to every country, agency and
institution to support Guinea's efforts to control this disease and to strengthen cooperation between
countries to enable Guinea to benefit from their experience.

Lastly, our sincere thanks are due to WHO for its technical and financial support and for having given
me the opportunity to describe to you the Buruli ulcer situation in my country.
Thank you.

58
Situation in Togo

Prof. Komlanvi James and Dr Napo Tignoka, Programme national de lutte contre l’ulcère de Buruli,
Ministère de la Santé publique, Togo

1. Introduction

Buruli ulcer, an emerging disease caused by Mycobacterium ulcerans, is a public health problem in
several west African countries.
In Togo, since the first two cases were described by MEYERS et al. in 1996, several cases have been
treated in health facilities, including the St Jean de Dieu Hospital at Afagnan and the Tokoin university
teaching hospital (CHU) in Lomé. However, little is known about the prevalence of the disease.
Out paper provides statistics from the Buruli ulcer registers which the National Buruli Ulcer Control
Programme (PNLUB) has introduced in Togolese health facilities since 1999.

2. Methodology

After the August 1999 meeting in Lomé, which confirmed that Buruli ulcer was present in lagoon and
swampy regions of Togo, PNLUB set about studying the disease burden from the Buruli ulcer in
Togolese health facilities. The working methodology involved:

1. Informing physicians and medical assistants in university teaching hospitals (CHU), regional
hospitals (CHR) and provincial hospitals (CHP) to enable them to identify and manage Buruli ulcer
cases, by the use of posters on the disease produced by WHO.
2. Introducing a Buruli ulcer register in the main health facilities (CHU, CHR and CHP). Cases
registered must satisfy clinical (hyperpigmented ulcers with loose, undermined edges,
communicating with satellite ulcerations by subcutaneous passages), bacteriological (presence of
AFB on smears after Ziehl-Neelsen staining) and histopathological (presence of AFB on anatomical
specimens with undermining of the dermis, necrosis of the skin, dermis and hypodermis) criteria.
Those cases to be eliminated include leg ulcers in diabetic patients and patients with sickle-cell
anaemia; varicose ulcers, phagedenic ulcers presenting fusospirochetal flora on histopathological
examination and ulcerated cold abscesses caused by Mycobacterium abscessus, characterized on
histopathological examination by AFB in vacuoles, with purulent granulomatous reaction.
3. Collecting data on cases notified in the registers each quarter.

3. Results

1. Cases notified
The number of cases notified between 2000 and 2001 is shown in table 1. The highest number of cases
each year were reported in Golfe, Lacs, Sio and Avé prefectures. Golfe and Lacs prefectures are lagoon
areas, while Tsévié and Avé are marshy. A large number of cases are also reported in Tchaoudjo
prefecture, thanks to the assistance of GTZ in identifying and treating the disease there. The cases
recruited during this biennium are new cases, except in Afagnan, where former patients return to consult
for a relapse or for sequelae.

59
Table I: Number of cases

Prefecture Hospital Number of cases Total

2000 2001
Golfe CHU - Lomé 19 35 54
Lacs CHP - Aného 11 17 28
Zio-Avé CHP - Tsévié 06 10 16
Yoto-Vo H. Afagnan 12* 08* 20*
Haho CHP - Notsé 05 04 09
Ogou CHR - Atakpamé 01 05 06
Kloto CHP - Kpalimé 0 04 04
Sotoboua CHP - Sotoboua - 08 08
Tchaoudjo CHR - Sokodé 04 13 17
Tchamba CHP - Tchamba - 07 07
Koza CHR - Kara 04 04 08
Oti CHR - Mango 01 02 03
CHR - Dapaong 00 00 00
TOTAL 63 117 180

2. Sex and age

Table II indicates the cumulative distribution of cases by sex and age. There is virtually no
predominance of either sex; however the disease seems to affect men more than twice as frequently in
the 21 to 30 year age-group. The table shows that children of school age, adolescents and adults are most
affected.

Table II: Distribution of cases by sex and age

Age group Men Women Total

0 – 10 yrs 07 05 12
11 – 20 yrs 22 19 41
21 – 30 yrs 32 16 48
31 – 40 yrs 21 15 36
41 – 50 yrs 05 08 13
51 – 69 yrs 09 08 17
over 60 yrs 06 07 13
Total 102 78 180

60
 3. Location of lesions
The lesions are located on the lower limbs; lesions on the trunk, neck and head are rare (figure).

4. Social and economic status of patients

Patients in our cohort are from the most disadvantaged social group. They are mainly farmers,
gardeners, fishermen and schoolchildren. Patients from Lomé live in the city's teeming quarters on the
edge of the lagoon. The fishermen in the cohort work in the Lacs prefecture, while most of the farmers
with the disease are from the marshy rice-growing areas.

Table III: Social and economic status of patients

Profession Number Percentage

Farmer 76 42.22
Cook 02 1.11
Pupil 21 11.67
Gardener 27 21.11
Builder's labourer 06 3.33
Shopkeeper 02 1.11
Carpenter 01 0.56
Fisherman 38 15
Without a profession 07 3.89
Total 180 100

5. Stage of evolution
In most cases, our patients were examined at the late ulcerative stage; the ulcers measured more than
twenty centimetres at their widest point. In some patients, the ulcer affected the whole of the lower
limbs and was superinfected. Patients attended for consultation because of the long time taken for the
ulcer to heal.(photograph)

6. Treatment
Before attending for consultation at a hospital, 153 patients had first of all been treated by traditional
healers (n = 139) or by health workers who were uninformed about the disease (n = 14).
Surgery is the only form of treatment provided in hospital. It involves two phases:
– Excision-debridement of the lesion under general or conduction anaesthetic, depending on the site of
the lesion; all the necrosed and devitalized tissue is removed, exposing all the subcutaneous
galleries, but without sacrificing large areas of cutaneous tissue. Excision is followed by careful
cleansing of the lesions with oxygentated water, and the lesion is dressed with honey. The dressings
are changed daily until granulation suitable for grafting has developed;
– A dermo-epidermic grafting phase; this is carried out with an electric dermatome and covers the
granulation with wide strips of skin harvested from the front thigh.
The length of hospitalization depends on the size of the lesion, whether it is superinfected, and on the
patient's general condition.

61
4. Comments
Our approach is open to criticism because of certain distorsions:
• Training has not been provided for all health workers, especially those on the periphery, who are in
closest contact with people at risk from the disease;
• The registers are kept only in the CHU and CHR, but not in the medical and welfare centres (CMS)
or the peripheral medical centres (USP) which are the population's first-line health facilities.
• The bacteriological laboratories at the CHR are not always operational throughout the year because
of stockouts of material required for examinations.
• The only histopathology laboratory, in Lomé, does not always receive samples sent from inside the
country and has great difficulty sending the results to those who need them there.

For all the above reasons, there is no doubt that many Buruli ulcers are unreported, and the number of
cases declared is short of the actual number. However, the gradual increase in the number of cases
declared each year, the spread of the disease to other regions of Togo and our country's position in the
same ecosystem as Benin and Ghana, where prevalence of the disease is high, have led the Togolese
health authorities to classify Buruli ulcer as a public health problem and to charge the National Buruli
Ulcer Control Programme (PNLUB) with the control of the disease in Togo.

5. Activities of PNLUB
Training activities
Ÿ In training schools
Introduction of training on Buruli ulcer in schools whose curriculum does not yet include training on the
disease (Togolese National School of Midwifery, National Medical Auxiliaries College, Specialized
Diplomas (DES) in Surgery, Paediatrics and Internal Medicine).
More teaching time for Buruli ulcer in establishments where the disease is already on the programme
(Medical Faculty).
Ÿ In-service training
Training physicians, medical assistants and nurses already working in Togolese health facilities to
diagnose and manage Buruli ulcer.

Data collection
Introduction of case notification forms in all Togolese health facilities. The leprosy supervisors in
Togo's health prefectures are responsible for checking entries and collecting the forms every quarter.

Education and information activities among the population

Ÿ Radio programmes for the population on State and private radio stations in Lomé and in the interior;
Ÿ Televised chat shows on the disease;
Ÿ Publication of information on Buruli ulcer in State-owned and private newspapers.

Conclusion

In Togo, Buruli ulcer is currently considered to be a public health problem on account of the increase in
the number of patients registered each year in hospitals, the spread of the disease towards the country's
interior and the proximity of countries in which the disease is highly prevalent. The Togolese PNLUB
needs to intensify disease surveillance by the leprosy supervisors and focus on screening for pre-
ulcerative forms, which are hard to identify. Suitable surgical equipment (dermatome) should be
provided for surgical facilities; because they are poor, patients should be treated free of charge. Research
into traditional drugs should be encouraged to identify drugs capable of taking over from surgery.

62
Mycobacterium ulcerans infection in French Guyana – Situation on 31
December 2001

Dr Roger Pradinaud, Centre Hospitalier Général de Cayenne, Cayenne, French Guyana

This dermatological condition was for the first time identified in our French Amazonian department in
1969 under the name of "para-tuberculous ulcer" (Pradinaud, Basset, Grosshans).
The first positive culture confirming M. ulcerans was made by professor Tacquet in 1974 in Lille,
France, when we presented our first research at the Tropical Dermatology Congress in São Paulo, in the
presence of Wayne Meyers.
The first doctoral thesis in medicine on the subject was by Michel Gabaudan (1975, Bordeaux II):
"Mycobacterial skin infections in French Guyana"
The second thesis was that of Anne Morel, married name Labouche (1991, Brest): "Atypical
mycobacterial infections in French Guyana: study of 113 cases". A third thesis is being written, by
Michèle Golzak.
In 1980, Dr Roger Pradinaud wrote an entry for the Encyclopédie médico-Chirugicale, Paris, 12510,
B10, 2 on " Atypical mycobacterial infections".
The article has recently been re-written for the Encyclopédie médico-Chirugicale, Infectious diseases,
under the heading "Cutaneous environmental mycobacterial infections in dermatology, including
Mycobacterium ulcerans infection ("Buruli ulcer"). R. Pradinaud, P. Couppie and J. Versapuech (in
preparation).
For 18 years, we have been giving a presentation at the Curso Nacional de Dermatopatologia Tropical
in Brazil on what have become known as "environmental mycobacterial infections". This has enabled
our colleagues from all Brazil's major universities to be fully informed on the topic: they have not yet
found any foci, although 1 case has been identified in Surinam and 8 in Peru. There is no mention in any
article of the Bolivian case, and Professor Luis Valda-Rodriguez of La Paz has affirmed that it has
undoubtedly been confused with the Peruvian cases, because only M. fortuitum has been identified in
skin ulcers in Bolivia. This was confirmed to us by Professor Bravo from Peru, whom we met in
February 2002 at the American Academy of Dermatology in New Orleans.
By July 1997, a total of 132 cases had been registered in French Guyana and reported to the WHO
Yamoussoukro conference. No cases were observed in 1998, 4 in 1999, 9 in 2000 and 7 in 2001,
bringing the total to 152. Seventy-eight cases affect men and seventy-four women. The figures have
been provided by the dermatology department of Cayenne hospital.
Clinical features, distribution by ethnic group, foci and treatment will be described in a separate paper.
Noteworthy events in our epidemiological study are:
1. The sharp decline in the number of cases among people under 20: of the 39 most recent cases, (114
to 152, from 1993 to 2001) only eight are respectively aged 14, 5, 5, 12, 4, 2, 14 and 5, i.e. 20.51%
of cases aged under 20; in the previous series, the proportion of persons under 20 was 63.3%.

It is possible that the administration of improved BCG vaccine in coastal villages in French Guyana
(Mana, Organabo, Iracoubo and Sinnamary), where a majority of cases affected children, may be one
factor that has helped to improve the situation: a study is under way in collaboration with the
Departmental vaccination service to assess this possible improved anti-mycobacterial immunization,
although it has yet to be proved at the global level that "satisfactory primary infection" with BCG offers
relative protection against the whole range of mycobacteria.

63
2. Examination of 19 cases observed at St Laurent du Maroni by a surgeon, Dr Jean-François Klein,
who had had the privilege of working at Yamoussoukro and who, noting the presence of ulcers with
undermined edges, performed excisions which made it possible to confirm the disease by
histopathological examination.

The total number of cases recorded in French Guyana should include the case described by De Gentile
(skin ulcer caused by Mycobacterium ulcerans: observation of a case from French Guyana. Bull. Soc.
Pathol. Exot. 1992; 85: 212–214) and the two cases described by army physicians in the January 2002
issue of the Bulletin de l'ALLF. This brings the total number of confirmed cases in our department to
152 + 19 + 3 = 174 on 31 December 2001 (three cases have already been identified in 2002). As French
Guyana's population is 175 000, prevalence is 1%.
Another noteworthy feature is the excellent contribution made by Professor Bernard Carbonelle's service
at Angers to our bacteriological research involving Bactec and Lowenstein cultures, mice inoculations
and lastly PCR using the techniques described in: Ross BC, Marino L, Hayman J, Leslie DE, Robins-
Browne RM, Johnson PD. Development of a PCR assay for rapid diagnosis of Mycobacterium
ulcerans infection. J. Clin. Microbiol. 1997; 35: 1696–1700.
Since 2000, Dr Pascal Launois and Dr Ghislaine Prévot-Linguet have been able to perform this PCR
technique in French Guyana, at the Pasteur Institute in Cayenne. This makes it possible to diagnose the
infection extremely rapidly, with of course, Ziehl-Neelsen staining, which is not however, always
positive.
As regards treatment, we must stress the importance of heat treatment, which renders M. ulcerans less
active. However, if the mycolactone toxin proves not to be thermolabile, the explanation will need to be
reconsidered. In 2001, we abandoned the rifampycin + clofazimine association in favour of
clarithromycin, with equally favourable results; this drug therapy is used after surgical excision and in
association with heat treatment, which hinders a proper assessment.
As regards the name "Buruli ulcer" it might suggest that Buruli was a famous physician who described
the disease, leading to a fruitless search for his forename and nationality; probably an Italian (Antonio
Buruli?, Marcello Buruli?
All geographical names for diseases are a fearsome source of confusion, and the list is regrettably long:
Clou de Bishra, pied de Madura, maladie de Meleda, ulcère de Mozambique, which was also observed
at the beginning of the last century in French Guyana where it was, of course known as ulcère de
Cayenne!
Moreover, since disease caused by M. ulcerans involves oedematous, cotton wool-like and ulcerative
stages, occasionally with bone involvement, it would be preferable to adopt the name " Mycobacterium
ulcerans infection, and to class it among environmental mycobacterial infections, which are becoming
increasingly typical and less atypical, both in terms of their clinical and biological features and their
specific responsiveness to treatment, falling within increasingly precise ecosystems which are aptly
described as "environmental".
As early as in 1975, in the chapter on "skin ulcers caused by acid-fast bacilli" (pp. 265–295) written
by P.G. Janssens for Essays on Tropical Dermatology, volume 2, edited by James Marshall, Excerpta
Medica, the Belgian author, who was one of the most eminent specialists of the time, drew attention to
the value of using the name "ulcers caused by M. ulcerans".
“It should be obvious that there is no reason for making a distinction between Bairnsdale,
Kakerifu, Kasongo and Buruli ulcers. The term "Buruli ulcer", always low on the priority list, is
widely used in English literature on the subject. This is unfortunately based purely on ethnic
considerations, so that even M. ulcerans ulcerations in the Lower Congo, (Zaire) come to be
called "Buruli ulcers". (Smith, 1970) Common sense dictates that only M. ulcerans should be
used, or if an African name is wanted, "Kakerifu ulcer".
… … … …”

64
However, there is a logical contradiction here, since the author proposes the name "Kakerifu ulcer", a
regional name which is no more suited to the other African foci, than to those in French Guyana,
Malaysia, Australia, New Guinea, or even less so China. This is quite a mind-bender!
Finally, without wishing to criticize the impressive role played by religious or charitable institutions, it
would be preferable for our WHO group to ensure that these diseases are properly included in medical
training, in particular in dermatology, infectious diseases and surgery, and to prevent the media from
employing vague terminology, as was recently the case on TF1, a French TV channel and in a major
newspaper, which referred to "Buruli ulcer, a new leprosy"

65
Update on MBU in Papua New Guinea, March 2002
Sister Joseph, Wewak General Hospital Private Bag Wewak East Sepin Province, Papua New Guinea

Papua New Guinea lies south of the Equator just north of Australia.
Administratively it is divided into 18 provinces.
There are great Geographical variations in the region, with savannah, tropical forest, swamp forest,
mangrove swamp, grassland, and mountains, great plains, a huge coastal area and many islands.
Mycobacterial infection patterns coincide very accurately with places where swamp forest and grassland
combine. These are the Sepik- provinces of East Sepik and Sandaun, Western Province, Oro province,
and localized parts of Central province around Marshall Lagoon and Cape Rodney, with a tiny area in
central New Ireland.
At the third Annual Meeting of the task force, recommendations were made about surveillance and
training. Surveillance was recommended at the community level, health centre, hospital, regional, and
national levels. In accordance with this, surveys were done as detailed below.

1998: Upper and middle Sepik from Gahom to Angoram.

1999: Sandaun- Bewani
2000: Western Papua as far as Jaya Pura
2000: Chambri Lakes and Blackwater.
2001: Gahom through the Hunstein range.
2002: Western province- North Fly. Tabubil, Ningerum, Matkomnei, Rumginae and Kiunga.

As far as possible local, regional and national statistics have been compiled.

Hunstein Range: 6–10 April 2001

Place Population Patients Seen MBU

Gahom 200 90 0
Kigara 81 1 old case
Bitara < 100 64 0
Bugapuku 36 1 old case
Wagu 109 0
Yigai 125 0

It can be seen there were no new cases, and only two old ones.

Maprik: 15 February 2002

No new cases, none in hospital records.

67
North Fly : 18–25 February 2002

Date Place MBU cases

18 Tabubil 0
19 Ningerum 0
19 Matkommnei 0
19 Rumginae 1 yearly
19 Kiunga 1 yearly

Statistics from the rest of Papua New Guinea showed that there was no cases appearing in previously unrecorded
areas.

Areas of known occurrence 2001

Wewak East Sepik Province

Sex Age Site Type of infection

Female 3 Back 1
Male 2 Back 1
Male 12 Arm 1
Male 5 R forearm 1
Female 7 Elbow 1
Male 4 L. leg 1
Male 7 Groin 2
Male 5 Groin 2
Female 9 L. foot 1
Female 5 L. leg 1
Female 1 R. elbow 1
Female 2 R. leg 1
Female 15 L. knee 1

Total: 13 Females: 7 Males: 6 Limbs:12 Post traumatic: 2 Children: 12

68
Popondetta-Oro Province

Sex Age Site Type of Infection

Male 38 R leg 1
Female 35 R. foot 2
Male 55 L. foot 2
Male 10 L. knee 1
Male 10 R. knee 1
Male 15 R. knee 1
Male 13 Flank 2
Male 1 R. leg 1
Male 7 R. leg 1

Total: 9 Males: 8 Females: 1 Leg: 8 Post Traumatic: 3 Children: 5

Sandaun Vanimo: Nine cases unspecified.

Raihu: Child 1 leg 1

Adult arm 1
Adult Shoulder 2

69
 Sepik Seasonal Incidence

Year Jan. Feb. Mar. Apr. May June July Aug. Sept. Oct. Nov. Dec. Total
71 7 2 1 2 4 3 19
72 5 3 8 2 2 3 2 3 2 2 0 2 34
73 2 0 2 1 3 1 2 3 0 1 3 2 20
74 0 1 4 2 1 2 1 2 1 2 1 1 18
75 1 4 1 6
77 2 2 1 1 1 2 3 1 4 17
78 1 2 1 2 5 0 2 2 7 4 1 0 27
79 3 7 7 4 4 25
87 3 5 2 1 1 1 0 0 0 13
88 0 0 2 2 1 0 0 2 2 3 8 5 25
89 3 2 2 4 2 2 1 0 0 1 2 1 20
90 0 1 1 0 0 2 2 4 1 3 1 2 17
91 2 0 0 0 0 4 1 2 0 1 1 1 12
92 1 0 2 0 0 1 1 0 1 0 0 2 8
93 5 4 1 4 0 0 1 3 1 1 3 1 24
94 2 6 3 2 1 1 3 0 3 1 3 1 26
95 1 2 2 1 3 6 0 1 0 0 0 0 16
96 0 1 0 3 0 0 2 1 1 3 0 4 15
97 3 5 4 3 4 0 2 3 2 4 0 0 30
98 1 1 0 0 0 0 0 0 0 0 0 2 4
99 0 0 1 1 2 0 0 0 0 0 0 1 5
2000 0 0 1 1 1 2 1 0 1 0 0 1 8
2001 2 1 1 1 1 0 1 1 1 2 2 0 13
Tota 32 40 43 38 37 27 31 31 27 33 30 33 402
l

As far as the training is concerned, in Wewak General Hospital to date three resident medical officers
have been trained in surgery of MBU lesions, and five registrars. By the end of this year, a further
resident medical officer and two Health Extension residents should have been added to that number.
There has been widespread distribution of books pamphlets and posters within the regions.
Papers presented:

1. MBU a precancerous lesion, Wewak General Hospital Grand Round. August 2001
2. MBU a precancerous lesion, Association of Surgeons of PNG annual conference Sept 2001
3. MBU A precancerous lesion, National PNG Annual Medical Symposium 2001.

A Section on MBU has been introduced into the National Surgical Handbook for Health Extension
Officers at the revision meeting of the editorial board 4–11 December 2001.

70
Future
Field surveys.

1. Lower Sepik from Angoram to the Madang border where the Sepik goes into the sea
2. Oro province
3. Intensive Angoram- focus of cases

Continued awareness raising, practical training of field personnel.

71
Buruli Ulcer situation in Congo
Dr Hilaire Bassakouou, Ministry of Health, Solidarity and humanitarian action, Republic of Congo

1. Background information on the Republic of the Congo

Located in central Africa, astride the Equator

Area: 342 000 square kilometres
Population: 3 million
Economy: timber, oil, fishing, coffee and cocoa
Health system: based on cost recovery

Basic indicators:
Ÿ Crude rate of natural increase: 3.47
Ÿ Infant mortality rate 82‰
Ÿ Maternal mortality rate 120‰

2. Kouilou region

Located in the west, on the Atlantic coast

An administrative district covering 18 600 square kilometres
Population: approximately 800 000
Administrative structure: 6 districts and 1 commune (Pointe Noire) the regional administrative capital
(2/3 of the population)
Economy: timber, oil, fishing and gold

Kakamoeka district:
This district, with a population of 9 200, is located in the north of the region, 180 km from Pointe Noire.
Buruli ulcer and urinary schistosomiasis are endemic in the district
It is a major drainage basin: the Kouilou river, lakes N'dinga and Kitina.

3. Buruli ulcer: historical background

1970 Buruli ulcer cases reported in the village of Filou, but wrongly diagnosed as yaws.
1980 Case fatalities caused by the disease. They were blamed on bewitchment, with the
concomitant social consequences (witch hunt and large-scale population movement).
1990 Renewed upsurge of cases at Loaka and Magne (Kakamoeka district) and new foci
identified in Madingo-Kayes district (in the villages of M'boukoumassi and Tchisseka).
These two districts are watered by two large lakes, N'dinga and Naga, and by the
Kouilou river. Until this date, there had been a problem with diagnosis.
2000 Epidemiological survey in Loaka village (Kakamoeka district).
The survey made it possible to detect AFB in the samples taken (01/21 positive
samples).
April 2001 prevalence survey (see, survey results).
July 2001 Consultation to WHO for confirmation of the diagnosis.

73
4. Results of the prevalence survey

A total of 89 old and new cases detected;

68 of them active, i.e. 75.5% with ulcerative disease and 21 inactive i.e. 24.5% of the total.
In September 2001, 17 new BU cases detected, including:
11 cases in Kakamoeka (Kouilou region)
2 cases in Niari and 4 cases in Bouenza

4. Plan of action

Overall objective
To improve the quality of health care and health services in order to provide case management for BU
patients in Kakamoeka and Madingo-Kayes districts.

Specific objectives
1. To rehabilitate the Kakamoeka, Sexo and Filou health centres by 2004;
2. To make these three health centres operational;
3. To set up a centre to provide screening and treatment of BU (CDTUB) in Loaka, the village most
affected by BU, whose health centre is very run-down;
4. Assign the staff required for the centres to operate;
5. Organize monthly supervision by the regional surgeon.

Strategies
1. Advocacy and resource mobilization
2. Staff training
3. Early case detection
4. Case management
5. Monitoring and evaluation
6. Operational research
7. IEC

Conclusion

BU is an authentic public health problem in Kouilou region, and especially in Kakamoeka and Madingo-
Kayes districts.
A draft plan of action has been prepared and is to be submitted to MSSAH officials for adoption and
implementation, with the assistance of social and development partners.
It is planned to carry out a national survey to determine the actual prevalence of the disease.

74
Buruli ulcer situation in Malawi
Prof. O O Komolafe, Department of Microbiology, College of Medicine, Blantyre, Malawi

Until recently, the presence of Buruli ulcer in Malawi was purely speculative. During the Annual
Meeting on Buruli ulcer Control in the Africa Region held in Cotonou, Benin Republic from 6–9 August
2001, I presented the bacteriological evidence of the first cases of Buruli ulcer in Malawi. In that
meeting, a country-specific Buruli ulcer key activity chart for Malawi was developed as follows:
i) Sensitize the Secretary (Permanent Secretary) for Health and Population and other policy
makers in the health sector.
ii) WHO Buruli ulcer experts to visit Malawi for continued advocacy.
iii) Buruli ulcer case search activity to begin.

While activities (ii) and (iii) are yet to commence, the sensitization of key players in the health sector in
Malawi has been accomplished. In addition, WHO-prepared awareness materials on Buruli ulcer are
now in all the 27 District hospitals, 4 referral hospitals and other health facilities and institutions in
Malawi.
The net effect of this exercise is that more cases of non-healing ulcers are now being referred to the
Queen Elizabeth Central Hospital (QECH), Blantyre – the largest referral hospital in Malawi and the
Teaching Hospital of the College of Medicine. In the last six months of 2001, two more cases of Buruli
ulcer presented to the hospital.

75
Trends of Buruli ulcer in Uganda
Dr Henry Wabinga, Department of Pathology, Makerere University, Kampala, Uganda.

Introduction
Buruli ulcer disease caused by Mycobacterium ulcerans was first reported in Uganda in 1961 and was
found to have a peculiar epidemiological distribution occurring mainly around certain areas on banks of
River Nile (Clarcey et al 1961).
This disease which culminates into a devastating skin ulcer involve mainly lower limbs and usually not
missed by basic health workers.
However after sometime it has been noticed that the disease has become meticulously rare in Uganda
and the aim of this study was therefore to determine the trends of this disease and probably seek
explanation for the observed trend.

Methods and materials

The department of Pathology Makerere University, until recently, has been the sole centre undertaking
biopsy diagnostic services for the entire country Uganda. During the period 1965–1990 biopsy reports
were retrieved from the records units of the department and those reports with a diagnosis of Buruli
ulcer (ICD Code No 716) were analysis.

Results
A total of 2 020 cases were diagnosed in the 30 years period and over 80% occurred between 1965 and
1975. The disease was slightly more in male than females from birth up to 20 years and between 20 and
50 more in females than males.
Buruli ulcer was mainly of people of Lango but also Nyarwanda, Ganda, Nyoro, Madi, Soga and
“Buruli” The commonest areas have been on the banks of River Nile and Lake Kyoga. The commonest
site was lower limbs followed by upper limbs and head neck and trunk.

Discussion
In recent years increasing numbers of Buruli ulcer cases have been reported in West Africa whereas in
Uganda the disease appears to be on the decline. No explanation has been brought forward for the
observed trend in Uganda but there are several theories. The most outstanding is that probably the
transmission route, which is not well known, has been interrupted. Extensive BCG coverage and
probably use of antibiotic may be other factors. However research is needed to try and understand this
trend and certainly re-visit these endemic areas to critically determine the prevalence of the disease,
study the current socio-economic feature of these communities and probably BCG coverage and drug
use.

Reference
• Clancy JK, Dodge OG, Lunn HF, Odurori ML . Mycobacterial skin ulcer in Uganda. Lancet, 1961,
2: 951–954.
• Buruli ulcer Mycobacterium ulcerans infection Asiedu K, Scherpbies PD Raviglione M (eds.) WHO
Global Buruli Ulcer Initiative, 2000.

77
Application of cultured epidermis in surgical treatment of Buruli ulcer
patients in Ghana (hereinafter called the Project) – Preliminary results
Mr Fabian Mork, Reconstructive Plastic Surgery and Burns Center Korle-Bu Teaching Hospital,
Accra

Study site: Reconstructive Plastic Surgery and Burns Unit, Korle-Bu Teaching
Hospital, Accra, Ghana

Time frame: May 2001 to April 2002.

Sponsors
Ministry of Health, Republic of Ghana, Accra, Ghana and the Nippon and Sasakawa Memorial Health
Foundations, Tokyo, Japan.

Principal Investigators
• Prof. Minoru Ueda, Department of Oral Surgery, Nagoya University Graduate School of Medicine,
Nagoya, Japan
• Mr Fabian Mork, Reconstructive Plastic Surgery and Burns Unit, Korle-Bu Teaching Hospital,
Accra, Ghana

Co-investigators
• Dr. Shuuhei Torii, MD, Ph.D, Professor, Department of Plastic Surgery, Nagoya University
Graduate School of Medicine, Nagoya, Japan
• Dr. Ken-ichiro Hata, Department of Tissue Engineering, Nagoya University Graduate School of
Medicine, Nagoya, Japan
• Dr. Kazuhiro Toriyama, Department of Plastic Surgery, Nagoya University Graduate School of
Medicine, Nagoya, Japan
• Dr. Takashi Hasegawa, Plastic Surgeon, Chuubu Rosai Hospital, Nagoya, Japan
• Dr. Yoshitaka Hibino, Department of Tissue Engineering, Nagoya University Graduate School of
Medicine, Nagoya, Japan
• Dr. Katsumi Ebisawa, Department of Plastic Surgery, Nagoya University Graduate School of
Medicine, Nagoya, Japan
• Dr Kensuke Sakai, Department of Oral Surgery, Nagoya University Graduate School of Medicine,
Nagoya, Japan

Collaborators
• Professor David Ofori-Adjei, Director, Noguchi Memorial Institute for Medical Research, Accra
• Dr Tettey, Department of Pathology, Korle-Bu Teaching Hospital, Accra
• Professor Françoise Portaels, Department of Microbiology, Institute of Tropical Medicine, Antwerp,
Belgium
• Dr Wayne M. Meyers, Division of Microbiology, Armed Forces Institute of Pathology, Washington
DC, USA

79
Background information and rationale of the trial

In February 2000, The Nippon Foundation, a major donor to Global Buruli Ulcer Initiative (GBUI) of
WHO enquired from Professor Minoru Ueda of Nagoya University about the possibility of applying the
cultured epidermis that had been developed by his department, in the surgical treatment of Buruli ulcer
patients. In June 2000, Professor Ueda made a brief visit to Ghana to evaluate the needs and resources to
carry out the an initial trial. The Government of the Republic of Ghana, who had been aware of the
magnitude of the problem among its population and devastating suffering of the patients, also expressed
its willingness to support the possible improvement in its surgical treatment.
During the 4th Meeting of the WHO Advisory Group on Buruli ulcer on 5–7 March 2001, Dr. Ken-ichiro
Hata, Department of Tissue Engineering, Nagoya University Graduate School of Medicine, presented
the proposed study.

History of the cultured epidermis

During 1980s, Professor Shuuhei Torii, Professor Ueda and a team from the Nagoya University
developed the culture epidermis technique and has applied them clinically on a number of cases. It is
now a confirmed effective treatment method for reconstruction of various skin defects (Gallico et al.
1981; O’Connor et al. 1981; Hefton et al. 1983; Madden et al. 1986; Carter et al. 1987; Leigh et al.
1987; Aubock et al. 1988; Kumagai et al. 1988; Hansbrough et al. 1989; Phillips et al. 1989; Teepe et al.
1990; De Luca et al. 1992; Boyce et al. 1995; Gentzkow et al., 1996; Ueda et al. 1998; Braye et al.
2000). Japan Tissue Engineering Co. Ltd. (J-TEC) established in 1999 systematically produce cultured
epidermis.

Information on cultured epidermis transplantation

The cultured human epithelium (autografts) has been used successfully since 1981 as a permanent cover
for large skin defects. It is now an already established and available technology in many countries as a
useful method for reconstruction of any kind of dermatological and mucosal defects, particularly for
benefit to patients in shortening the duration of treatment, reduces the need of taking large amount skin
from donor sites for grafting of healthy skin, and also for cosmetic effect. The cultured epidermis is
impregnated with growth factors which stimulate growth of new skin.

Types of cultured epidermis

1. Autograft: transplantation of cultured epidermis produced by the patient’s own cells
2. Allograft: transplantation of third person’s (donor’s) cells. This trial used allograft in combination
with split thickness skin grafting

Advantages
• Enhancement of re-epithelialisation compared to split thickness skin grafting alone
• It enhances the graft-taking rate of patient’s own meshed skin
• Shortening the healing time of skin ulcer (epithelium defect)

Manufacturing of epidermis
The cultured epidermis used in this project was produced by J-TEC following strict Good
Manufacturing Practice (GMP) and other necessary procedures. Approved by J-TEC Internal Ethics
Committee and donors of tissue were free from infections e.g. Mycoplasma, HIV, HTLV, HBV, HCV,
TPHA. The cultured epidermis were transported in a Dry-shipper’ containers with liquid nitrogen at
–140 oC and stored at the Noguchi Memorial Institute for Medical Research, Accra.

80
Objectives of the trial
The objective was to conduct a preliminary study to assess the therapeutic applicability of allogenically
cultured epidermis transplantation (allograft) when used in conjunction with meshed skin grafting, in
healing of M. ulcerans ulcer.

Ethical aspects
The study approved by the Ministry of Health, Ghana and the WHO Ethical Committee. Written
informed consent was obtained from each patient and the treatment was free.

Method

Patient inclusion criteria include:

• Clinically diagnosed new M. ulcerans disease preferably plaque and oedematous forms. Cases
confirmed later
• Males or females aged more than 18 years
• Size not exceeding 20 cm by 20 cm or 20 cm in diameter (maximum width)
• Lesion(s) does not cross an articulation

Patient exclusion criteria include:

• No confirmation retrospectively from the excised lesion, for the presence of M. ulcerans infection
by histopathology, culture and PCR
• Tested and positive for HIV, HTLV, HBV, HCV, TPHA
• Has not developed good granulation tissue after debridement
• Lack of ability or willingness to give informed consent.
• Anticipated non-availability for follow-up visits/procedures.

Patient withdrawal criteria include:

• Withdrawal of consent/non-compliance
• Deterioration in clinical condition

Results (slides)

• Project at Korle-Bu Teaching Hospital, Accra – 7 cases treated in June 2001

• Project at Korle-Bu Teaching Hospital, Accra – 2 cases treated in September 2001
• Project at Komfo Anokye Teaching Hospita, Kumasi – 3 cases treated in February 2002

Conclusion

• This technology could be useful in the management of Buruli ulcer by speeding up the healing
process and thus reducing the duration of hospitalization
• Quality of this type of skin graft appear to be better than ordinary skin graft
• It could be used in the field situations, e.g. district hospitals
• Possibility of locally manufacturing the skin in Ghana at Noguchi Memorial Institute of Medical
Research in Accra in the future may be considered in the future

81
 Flow chart of the activities during the trial

Screening
Week-1/D0

If eligible
Informed consent for surgical excision + grafting with cultured skin

D1 (1day) Excision of the infected lesions

2 weeks

Week-3/D0- Transplantation of cultured epidermis

1 (1st transplantation)

Post-operation care 1 week

Week-4 Initial Assessment

If satisfactory If unsatisfactory

Clinical & lesion Re-transplantation*

assessment (2nd transplantation)
(at 3, 6, 12 months)
1 week

Assessment Week-5

If satisfactory If unsatisfactory

Split thickness skin grafting

82
Diagnosis and treatment of osseous forms of the disease and its complications
Dr Giovani Battista Priuli, St Jean de Dieu Hospital, Afagnan, Togo and Tanguieta, Benin

In the surgical treatment of lesions caused by Mycobacterium ulcerans infection, bone involvement
constitutes a separate chapter. The bone lesions provoked by BUD (Buruli Ulcer Disease) are a
particularly serious example of chronic forms of multifocal disseminated disease.

Clinical forms

Reactive or contiguous osteitis:

This form of bone infection occurs when the skin infection extends down to the bone. The less
malignant forms are characterised by an acute periosteal reaction accompanied by induration of the
cortical bone. Osteitis develops once the periosteum is affected: the cortical bone is exposed and dies.
The appearance of the bone is hard and lifeless. Several weeks later a sequester forms, which can be
either expelled or encysted in the granulation tissue of the ulcer; the healthy bone is hollowed and often
weakened, easily fractured, and covered by granulation tissue.

Metastatic or disseminated osteomyelitis:

It is caused by the hematogenous spread of M. ulcerans, in patients suffering or having suffered from
BU, in its ulcerated or non ulcerated form, or in subjects bearing large scars of old BU lesions, which
have healed spontaneously after traditional treatment, or more often after surgery. These osteomyelitic
forms of BU are reported fairly frequently in various studies by the authors, but on average they
constitute 10% to 20% of Buruli ulcer cases.
The features of metastatic osteomyelitis are similar to those of bone involvement in tuberculosis,
because of their appearance on the epiphysis and metaphysis of both long and small bones. Symptoms
are initially mild (slightly painful swelling, articular pain); later on the swelling increases and oedema
develops. Fistulisation appears progressing to ulceration. Radiography reveals thinning of the bone shaft
and an irregular induration which becoming increasingly visible and localised, resulting in the
production of a sequestrum surrounded by an irregular wide edge separating it from the healthy bone.
The macroscopic aspect of an early stage lesion is similar to that of bone tissue underneath the
periosteum. During excision or curettage it does not bleed, and rows of whitish, necrotic segments are
exposed, while the spongy bone tissue, normally a bright red, now appears yellowish-white, of friable
consistency, rather resembling the caseous tissue of the osteomyelitic lesions due to tuberculosis.
If the osteomyelitis is a few weeks or months old, geodes covered by fibrin can be observed, while the
bottom of the lesion is completely covered by granulation tissue. When the metaphyseal portion of the
bone is affected, a sequestration of the diaphysis may occur without adequate periosteal regeneration,
which means that the infected bone will be irreparably destroyed.

Surgical Treatment

1. Treatment of early stages

Radiographs of both former and current sufferers of BU complaining of pain and bruising near a joint
reveal a bone injury almost invariably epiphyseal, or which points to and articular lesion. Treatment
consists of a wide excision that reaches down to the bone. The wide excision is essential to facilitate
efficient drainage of the wound and consequent rapid recovery. After the removal of the surrounding

83
soft tissue and jelly-like substance that can resemble caseous tissue, the next step is a moderately severe
bone curettage. The lesion is then rinsed several times with hydrogen peroxide or a mixture of hydrogen
peroxide and iodised povidone (Betadine®), followed by a final rinse with distilled water. The wound is
then covered by granulated sugar (or honey) covered by gauze smeared with vaseline, and packed with
cotton wool and gauze compresses to make a thick dressing. This is held in place by a loosely bound
bandage which allows for maximum suspension of the limb, without the unnecessary discomfort caused
by a tourniquet and tightly compressed muscle. The dressing is changed every 2 to 4 days. Surgical
monitoring is needed every 8 to 10 days under anaesthesia, mainly by a series of bone curettages which
will finally get rid of all the infected bone.
The procedure described above can be be altered by certain modifications:
a) good results can be obtained by introducing deep into the osteomyelitic foci a small CH12-14 type
suction probe (see photograph), through which 2–3 mm of hydrogen peroxide and Betadine solution,
or of hydrogen peroxide and rifamycin can be injected into the wound without undoing the dressing.
The dressing should be changed every 4 or 5 days.
b) whenever the toes, metacarpal or metatarsal bones are affected, surgery should involve the excision
of large segments of necrotized bone, if not the bone in its entirety. The residual cavity in the bone
should be protected with the same type of packed-gauze dressing until grafting of the wound is
feasible.

2. Treatment of chronic forms

Old bone lesions of both metastatic or contiguous origin are always localized in variably extensive foci
of ulceration; the dead bone is sometimes exposed and frequently it is covered by granulation tissue.
Radiographs show that sequestration occurs in epi-diaphyseal areas with subsequent covering by
indurated periosteal tissue. It is essential to check for the presence of a healthy layer of periosteal bone
before proceeding to the excision of the sequesters. This method may prevent the occurrence of
complications such as debilitating pseudo-arthritis.
Surgical treatment then consists of a total or gradual sequestrotomy, first by enlarging the bone fistula
with scissors, followed by a curettage of the residual bone cavity. The curettage is accompanied by
irrigation of the ulcer with hydrogen peroxide, pure or mixed with Betadine®, and by rinsing with
distilled water. The final step is the application of a sugar and rifamycin covered by a hemostatic
dressing. If the whole limb is affected, it should be suspended in order to minimize bleeding, oedema
and pain, and to maximise hygiene.
Contiguous osteitis is often aggravated by the formation of a sequestrum, which considerably diminishes
the chances to treat the ulcer by means of skin grafting.
In order to accelerate the healing process, it is advisable to make multiple small perforations in the
exposed cortical bone, using a small grid (size nº 2, 5–3), in order to allow drainage of fluid secretions
and to facilitate granulation of the what is left of the still healthy spongy bone, and to encourage the
spontaneous expulsion of necrotic bone.
The perforations are made exclusively on the exposed surface of the cortical bone, and have an analgesic
effect as a result of fluid drainage.

Use of external support equipment

Before or during a sequestrectomy, the bone may be stabilized by external mechanical supports until the
bone becomes strengthened by the formation of a bone callus. Such extra support is necessary because a
large bone excision considerably weakens the bone structure. External supports are also used in order to
avoid the development of articular contractures caused by the scarring of ulcers and osteomyelitic
lesions.

84
The fixture in such cases is applied to the limb only after the first debridement or first surgical
intervention under anaesthesia, subsequently it will be left in place until the skin grafts have healed
completely, at least 15 days after cicatrisation of the grafts.
The removal of the external support should be accompanied by progressive mobilization of the articular
joint, which normally occurs without complications (see photograph).

How to deal with significant loss of bone

In the case of epiphyseal osteomyelitis of the proximal or distal tibia with vast loss of bone tissue, the
large residual cavity in the healthy bone can only be repaired partially or at least very slowly, hence the
reason to employ external supports, either in the form of implants of spongy bone taken from the iliac
bone, or by the implant of pedicellate strips of muscle or cutaneous tissue, or even of muscle tissue onto
which a skin graft is applied later on.

Conclusion

Bone involvement by hematogenous dissemination or by contact with adjacent surface lesions is a

tremendous complication of chronic ulcerated forms of Buruli ulcer disease. This condition necessitates
highly specialized treatment if the patient wishes to avoid permanent bone damage. Clinical expertise,
patience, prudence and timely intervention are essential to ensure beneficial results.

85
Protective effect of BCG vaccination in children against severe forms of
Mycobacterium ulcerans disease (Buruli ulcer)

Portaels F1,*, Aguiar J2, Debacker M1, Steunou C2, Zinsou C1,2, Guédénon A3, Meyers WM4
1
Institute of Tropical Medicine, Mycobacteriology Unit, Department of Microbiology, Nationalestraat 155, B-2000 Antwerp,
Belgium
2
Centre Nutritionnel et Sanitaire, Gbemoten, Zagnanado, Benin
3
PNLUB, Cotonou, Benin
4
AFIP, Washington DC, USA

Summary

Mycobacterium ulcerans disease, also known as Buruli ulcer (BU), is an increasingly important cause of
morbidity, especially in West Africa. Approximately 75% of all BU patients are children with up to 14%
of them suffering osteomyelitis in Benin. In our sample of 150 consecutive patients with laboratory
confirmed BU in Benin, 77 children (< 15 years old) and 50 adults (> 15 years old) had a BCG neonatal
vaccination scar. Only 4 of 77 vaccinated children had osteomyelitis (5.2%) while 3 of 7 unvaccinated
children had osteomyelitis (42.9%). BCG vaccination seems to offer significant protection against
dissemination of BU in children.
Mycobacterium ulcerans disease, also known as Buruli ulcer (BU), is the third most frequent
mycobacterial disease after tuberculosis and leprosy (1).
In recent times, BU has emerged as an increasingly important cause of morbidity, particularly in West
Africa. This emergence of BU is most likely related to environmental changes. In some endemic areas,
incidence of the disease may exceed that of leprosy and tuberculosis (2). Most patients are children
under 15 years. Contrary to the connotation of the name Buruli ulcer, microbiological and
histopathological analyses of cases in Benin confirm that 50% of the BU cases present in nonulcerative
forms. Severe forms of the disease, such as osteomyelitis are not uncommon with reported incidences as
high as 14% in Benin (2).
The epidemiology of BU is poorly understood. Some evidence exists for an environmental reservoir
associated with slow-flowing and stagnant water (3).
The only widely accepted treatment is surgical excision of the lesion and subsequent skin grafting.
Control of BU, like most public health problems, involves multiple, often interrelated socioeconomic,
environmental and biomedical issues. Because BU is not contagious, early identification and treatment
of cases alone will not control the disease. Elimination of the etiologic agent depends on environmental
factors, and transmission of the disease is influenced by socioeconomic factors. In endemic areas,
neither of these factors is likely to improve significantly in the near future. Therefore, the only approach
to control is prevention. In practical terms this can only be accomplished by immunoprophylaxis.
It is well known that BCG vaccine confers some protection against tuberculosis and leprosy. The
protective efficacy of BCG has been amply demonstrated for prevention of severe tuberculosis in
children (tuberculous meningitis and miliary tuberculosis).
The protective effect of single and booster BCG vaccination has been recently evaluated in an extensive
study (involving 121 020 individuals) in Malawi over a 5 to 9 year follow up for both leprosy and
tuberculosis (4). While a single BCG vaccination gave 50% protection, a second BCG vaccination gave
a further protection of about 50% for leprosy, but not for tuberculosis. All age groups were included in
this study, but protection appeared greatest in those receiving booster vaccinations before 15 years of
age.

87
Only two prospective clinical trials (5) have been carried out to determine the effect of BCG vaccination
for BU. These studies showed that BCG vaccination conferred a short-term protection against BU. The
overall protection rate was 47% for up to one year, with a range of 18% to 74% in different groups of
subjects. In addition, these trials demonstrated that vaccinated patients were more likely to develop less
severe forms of the disease, and that histologically the lesions showed more reactive cellular responses.
Given the protective effect of BCG against disseminated tuberculosis in children we were prompted to
analyze the possible protective effect of neonatal BCG vaccination against severe forms of BU such as
osteomyelitis in children in Benin. Thus, 150 consecutive patients confirmed as BU cases by
microbiological (direct smear examination, culture, IS2404 PCR) and histopathological analyses were
examined for the presence of a BCG scar.
A BCG scar was found in 127 patients (84.7%) and 23 patients (15.3%) had no BCG scar.
The frequency of osteomyelitis in BCG vaccinated and non-vaccinated patients was examined among
children under 15 years of age (Table 1) and among patients of 15 years or older (Table 2).

Table 1. Relationship between frequency of osteomyelitis in children under 15 years and BCG
vaccination at birth

BCG scar Osteomyelitis

present absent TOTAL
present 4 (5.2%) 73 (94.8%) 77 (100%)
absent 3 (42.9%) 4 (57.1%) 7 (100%)
TOTAL 7 77 84

Table 2. Relationship between the frequency of osteomyelitis in patients aged ≥ 15 years and BCG
vaccination at birth

BCG scar Osteomyelitis

present absent TOTAL
present 11 (22.0%) 39 (78.0%) 50 (100%)
absent 6 (37.5%) 10 (62.5%) 16 (100%)
TOTAL 17 49 66

Among the 84 children under 15 years, 77 had a BCG scar and 7 had no BCG scar. The frequency of
osteomyelitis was 42.9% in BCG non-vaccinated children and 5.2% in BCG vaccinated children (Table
1). This difference is statistically significant (Fisher exact: p = 0.01).
As shown in Table 2, among the 66 patients of 15 years or older, the frequency of osteomyelitis in BCG
non-vaccinated (37.5%) and in BCG vaccinated patients (22.0%) was not statistically significant (Fisher
exact: p = 0.30).
These results indicate that, like in tuberculosis, BCG vaccination at birth may protect children under 15
years old against the development of severe forms of BU (e.g. osteomyelitis) in patients with skin
lesions of BU.
Our observations in Benin suggest that BCG vaccination at birth confers significant protection against
the development of severe forms of BU in children under 15 years of age. BCG vaccination presently

88
remains the only ethically acceptable intervention for the prevention of BU and of severe forms of the
disease in children. We believe that BCG vaccination with a booster vaccination may represent the best
readily available and currently acceptable strategy for controlling Buruli ulcer. Its clinical efficacy in
large populations at risk of BU must be assessed.
This study was supported by the Directorate General for International Cooperation (Belgium) and by the
Damien Foundation (Brussels, Belgium).

References

1. World Health Organization (WHO)(2000). Buruli ulcer: Mycobacterium ulcerans infection

(K. Asiedu, R. Scherpbier & M. Raviglione, eds). WHO/CDS/CPE/GBUI/1. WHO, Geneva, 118 pp.
2. Lagarrigue V, Portaels F, Meyers WM, Aguiar J. L'ulcère de Buruli: Attention aux atteintes
osseuses ! A propos de 33 cas observés au Bénin. Médecine Tropicale, 2000; 60:262–266.
3. Portaels F, Elsen P, Guimaraes-Peres A, Fonteyne P-A, Meyers WM. Insects in the transmission
of Mycobacterium ulcerans infection (Buruli ulcer). The Lancet, 20 March 1999; 353: 986.
4. Karonga Prevention Trial Group. Randomized controlled trial of single BCG, repeated BCG, or
combined BCG and killed Mycobacterium leprae vaccine for prevention of leprosy and tuberculosis
in Malawi. Lancet, 1996; 348: 17–24.
5. Smith PG, Revill WDL, Luwago E, Rykushin YP. The protective effect of BCG against
Mycobacterium ulcerans disease: a controlled trial in an endemic area of Uganda. Transactions of
the Royal Society of Tropical Medicine and Hygiene, 1976; 70: 449–457.

89
Risk factors for Buruli ulcer: age, sex and Schistosoma haematobium
infection
J.T. Scott1, C.R. Johnson2, Guédénon 3, B. Gryseels1, F. Portaels1
1
Institute of Tropical Medicine, Antwerp, Belgium
2
Centre de Dépistage et de Traitement des ulcères de Buruli de Lalo, Bénin
3
PNLUB, Cotonou, Bénin

The study investigated three potential risk factors for the mycobacterial infection, Buruli ulcer, age, sex
and concurrent infection with Schistosoma haematobim. Despite the fact that in January 2002 the annual
meeting of health workers engaged in treating Buruli ulcer patients unanimously considered adolescent
boys to be a higher risk group than other ages, or young girls, a comparison of the number of cases of
Bu over a year, reflected the age/sex distribution of the general population. There was therefore no
evidence that either age or sex is a risk factor in Benin.
S. haematobium was considered a potential risk factor, because the disease exists in the same areas of
West Africa as Buruli ulcer. S. haematobium is contracted on contact with infected water, the probable
source of M. ulcerans infection and it is possible that Schistosoma sp. Skews the immune response
towards TH2m, putatively not considered helpful with regard to Buruli ulcer. A case control study in
Benin, showed 9.3% prevalence of S. haematobium infection in controls, compared with 10.4% in BU
cases. This indicates that S. haematobium is not a risk factor for BU in Benin.

Buruli ulcer risk factors in Benin

Three principle risk factors were investigated

− Age
− Sex
− Schistosoma haematobium infection

Age and sex

The annual meeting of health workers dealing with Buruli ulcer in Benin in January 2002, unanimously
considered young boys as the most “at risk” group.

– Age as risk factor

For schistosomiasis, age is the single greatest risk factor.
Prevalence and intensity of infection peaks between 8 and 15 years.
The “age/intensity” curve.
Intensity of S. mansoni infection in this population in Senegal retained this classical relationship with
age.
This despite the fact that in this population all people had been exposed for the same number of years
(not more than 3) and there was not difference in the quantity of water contact behavious between age
groups.
Maturity of host is in its own right a risk factor for S. mansoni
– Age and sex as a risk factor for Buruli ulcer
As distinct from investigations of age as a risk factor for schistosomiasis, perceptions of age and sex as
risk factors for Buruli ulcer are based on number of cases.

91
– Method
% of BU cases at each age and sex was compared to % of people in the same groups in a sruvey of the
total population of 4 “Hameaus” in the village of Yamatou.

– Sample size
Cases: 296 cases between 0 and 83 years presenting in Zagnanado center in 1997
618 people between 0 and 122 years old (NB very old people were classified as “over 60”)
The distribution of age and sex in BU cases reflects that of the general population
Age and sex as risk factors for BU, tested with logistic regression analysis

S. haematobium
S. haematobium was considered a potential risk factor because:
• The disease exists in the same areas of West Africa as Buruli ulcer
• S. haematobium is contracted on contact with infected water, the probable source of M. ulcerans
infection
• Speculation with regard to the putative skewing of the immune response by Schistosoma sp. towards
Th2, also putatively not considered helpful with regard to Buruli ulcer

Methods
• Cases were recruited from patients in two centers of BU treatment in Benin: Zagnanado and Lalo.
• Controls were chosen by random number selection from 8 settlements, from which current or
recently past BU patients are resident. Past or current BU cases were excluded from the “lottery”
Parasitlolgy: three urine samples given in the morning from each subject was tested for S. haematobium
by filtration of 10 ml urine.
NB: Neither cases nor controls were asked to exercise (as is usual) before giving urine samples, because
many BU cases were immobile and were not able to exercise.

Sex and age distribution in the study population:

Control: 483
Cases: 117

Results
P = 0,774 ou 1.1
NB: prevalence of S. haematobium =
11% - Lalo
9.3% - Zagnanado
p = 0,764

Was the sample too small?

In order to have an 80% chance of finding significant difference (p<0.05), with these prevalences of S.
haematobium, one would require:
14074 controls and 14074 cases
or
24891 controls and 9287 cases

Conclusion

We have no evidence that age, sex or S. haematobium infection are risk factors for Buruli ulcer

92
Acknowlegments
Residents of Yamatou and Ahouada
Malades de Lalo et Zagnanado
Dr Guédénon, Sister Julia, Dr de Schacht, Dr Johnson, Pere Ayiou

Next study

Contact with M. ulcerans

(water?) Genetics

M. ulcerans Individual
infection UB susceptibility

Immuno-suppressed
Root of entry
- puncture Concurrent Nutrition
- wound infection
- scarification Stress? (family
tension, etc.)

93
Acquired anergy following Mycobacterium ulcerans infection
Travis M. Gooding,1,3 Andrew S. Kemp,2,3,5 Paul D. R. Johnson,1,3,4 May Smith,6 and Roy M. Robins-
Browne1,3

Departments of Microbiology and Immunology1, and Paediatrics2 University of Melbourne, and Murdoch Children’s Research
Institute3, Parkville; Department of Infectious Diseases, Austin and Repatriation Medical Centre, Heildelberg4; Department of
Immunology, Royal Children’s Hospital, Parkville, Victoria5, and Mossman Hospital, Mossman6, Queensland, Australia.

We have shown previously that subjects who develop M. ulcerans disease have a profound systemic
anergy to M. ulcerans and M. bovis organisms (1). However it is not clear whether subjects who develop
clinical disease have an inherent inability to generate a strong TH1 response to mycobacterial antigens
or whether M. ulcerans organisms somehow induce this anergic state.
We studied the immune response to M. ulcerans in two groups of residents in the Douglas Shire of far
north Queensland, Australia, where M. ulcerans is endemic (2). Twenty three patients with Buruli ulcer
confirmed by culture (affected) and 25 subjects with no history of Buruli ulcer who lived in the same
house or who had close, ongoing contact with an affected individual (unaffected) were studied. In the
affected group one subject had active disease and the remainder had had Buruli ulcer between 6 months
and more than 40 years previously (mean: 9.4 years). One of the unaffected group subsequently
developed M ulcerans disease 27 months after the initial assessment, allowing us to compare her
immune response before and after she developed Buruli ulcer.
The 3 year old son of a 34 year old female developed a cutaneous M. ulcerans lesion on his left thigh in
October 1998 which was excised in December 1998. The lesion recurred, and was further excised 4
weeks later without recurrence. In May 2001 his mother developed a cutaneous ulcer on her left arm
which was excised in June 2001. The diagnosis was confirmed by PCR. She had never had BCG
immunisation. At the first assessment of her immune response in April 1999 she demonstrated gamma
inteferon (GIFN) release in response to live M.bovis and M. ulcerans organisms which was just below
the mean level of the unaffected controls (figure), but considerably higher than all results obtained from
patients with past or current M. ulcerans infection. Cytokine PCR following stimulation of her
peripheral blood lymphocytes with M. ulcerans showed the presence of messenger RNA for IL12, IL10
and GIFN but not IL4, IL5 or IL6. Antibodies to M. ulcerans and M. bovis were not detected. Repeat
studies in June 2001, 2 days prior to surgery for Buruli ulcer, demonstrated a marked reduction in GIFN
release with levels similar to other subjects with disease, the appearance of antibodies to M. ulcerans
and M. bovis, and a Th2 cytokine response with detection of IL4 and IL10 but not GIFN and IL12, IL5
and IL6.
We postulated previously that mycobacterial anergy contributes to the pathogenesis of M. ulcerans
disease (1). There is significant homology between important protective mycobacterial antigens in M.
bovis and M. ulcerans (3), which could account for the markedly reduced GIFN responses to both
organisms. M. ulcerans also secretes a lipid toxin, mycolactone, which has immunosuppressive activity
in vitro (4). It has been postulated that local secretion of this toxin reduces the cutaneous inflammatory
response and may cause the development of the ulcer. It is possible the mycolactone or other molecules
contribute to the development of the anergy that we have observed. However, an alternative hypothesis
is that the innate presence of this specific anergy underlies natural susceptibility to Buruli ulcer, and
explains why only some people who live in endemic areas are affected, while the majority remain
healthy.
Our observation in this case that GIFN secretion has decreased and that the cytokine profile has changed
from a TH1 to a TH2 response following the development of Buruli ulcer indicates that the anergy is
acquired rather than innate. New therapeutic approaches based on the systemic or topical use of
cytokines such as IL2 that can re-direct the cell mediated immune response back towards a TH1
response may be worth investigating as treatment options for Buruli ulcer.

95
Methods
Peripheral blood mononuclear cells (PBMC) were stimulated with whole living M. ulcerans (Chant
strain, a human isolate) or M. bovis BCG (CSL Limited, Parkville, Victoria, Australia) and interferon
gamma production was determined by enzyme immunoassay after 6 days stimulation as described
previously [1].Reverse transcriptase (RT)-PCR was performed for cytokines gamma interferon (GIFN),
interleukin (IL)-4, IL-5, IL-6, IL-10 and IL-12, using the Titan One Tube RT-PCR System (Roche
Diagnostics, Australia). Serum antibodies to M. ulcerans were detected by immunoblotting as described
previously [1].

References
1. Gooding TM, Johnson PD, Campbell DE, et al. Immune response to infection with
Mycobacterium ulcerans.Infect Immun, 2001 Mar;69(3):1704-7.
2. Jenkin JA, Smith M, Fairley M, Johnson PDR. Acute, oedematous Mycobacterium ulcerans
infection in a farmer from far north Queensland. Med J Aust, 2002;176:180–182.
3. Tanghe A, Content J, Van Vooren JP, Portaels F, Huygen K. Protective efficacy of a DNA
vaccine encoding antigen 85A from Mycobacterium bovis BCG against Buruli ulcer. Infect Immun,
2001;69(9):5403–11
4. Pahlevan AA, Wright DJ, Andrews C, George KM, Small PL, Foxwell BM. The inhibitory
action of Mycobacterium ulcerans soluble factor on monocyte/T cell cytokine production and NF-
kappa B function. J Immunol, 1999;163(7):3928–35.

Footnote: Informed consent was obtained from all participants in this study or their parents or guardians. The research plan was
approved by the Human Ethics Committee of the Murdoch Children’s Research Institute, the Royal Children’s Hospital,
Melbourne and Mossman Hospital (through Cairns Base Hospital), north Queensland. The study was conducted in accordance
with the committees' guidelines for clinical research.

Figure

Figure. Gamma interferon production from lymphocytes of subjects who have had M. ulcerans disease
("affected" open circles ¦ [n=23]) and unaffected contacts ("unaffected" black circles l [n = 25]),
following stimulation with live M. ulcerans and M. bovis organisms. The results from our patient 27
months before, and then later with Buruli ulcer are joined by the lines.

96
Mycobacterium ulcerans infection – Drug treatment: 3 illustrative cases
Paul Johnson, John Hayman, Melbourne, Autralia

Drug treatment

Surgery is the preferred treatment for M. ulcerans infection but we also prescribe drug therapy with the
aim of limiting the extent of surgery, and to reduce the risk of relapse. We present 3 cases with clinical
photographs, which support this approach.

Case 1
An 11-year-old boy from coastal Victoria, presented with a 10-week history of a large, painless
necrotising ulcer on the shin of his right leg. A biopsy showed necrosis, large numbers of acid-fast
bacilli (AFBs) but no granulomata. PCR confirmed the diagnosis of M. ulcerans infection. Surgery was
recommended, but was delayed for family reasons. He was therefore treated with oral clarithromycin
250 mg orally twice daily and oral rifampicin 450 mg daily for the 17 days immediately prior to surgery.
At the time of surgery the ulcer appeared unchanged and was excised and grafted. Carefully, histological
examination of the excised tissue failed to reveal any acid-fast bacilli, but numerous granulomata were
now present.
Conclusion: use of oral clarithromycin and rifampicin for two weeks was associated with a marked
reduction in number of M. ulcerans cells and a shift towards granulomatous inflammation.

Case 2
A 78-year-old man from coastal Victoria presented with a history of a non-healing painless ulcer over
his right elbow. Biopsy showed the presence of granumlomatous inflammation and AFBs. PCR
confirmed M. ulcerans infection. Resection and full-thickness skin grafting was carried out but the
surgeon resected only a small rim of surrounding healthy tissue. One of the resection margins was PCR
and culture positive for M. ulcerans. From the first post-operative day, he was treated with oral
azithromycin 500 mg daily and rifampicin 600 mg daily for 3 months. The patient was incidentally
noted to have multiple myeloma, although this has not yet required treatment. He has been followed up
for 4 months after ceasing antibiotic treatment without relapse.
Conclusion: Use of oral azithromycin and rifampicin in combination for 3 months has prevented relapse
of M. ulcerans infection despite the presence of viable M. ulcerans at the surgical resection margin.

Case 3
An 18 month child from coastal Victoria developed a necrotising lesion on his right pin. Initial histology
showed granulomatous inflammation and numerous AFBs. PCR and culture for M. ulcerans were
positive. For cosmetic reasons, surgery was limited to the debridement of obviously necrotic tissue. The
child was commenced on intravenous amikacin (30 mg/kg/day), oral azithromycin (10 mg/kg/day) and
oral rifampicin (10 mg/kg/day). Amikacin was ceased after 3 weeks but the other two drugs were
continued. Six weeks later, while still taking oral medication, the ear wound appeared moist and he
developed an large swelling near the site of the previous intravenous catheter insertion on his right
forearm, which subsequently ulcerated. This area was surgically resected and closed without grafting.
No additional surgery was performed on the pinna. Histology of the forearm lesion showed
granulomatous inflammation without acid fast bacilli, but PCR was positive for M. ulcerans.

97
Intravenous amikacin was again added to the continued two oral drugs and continued for 3 further
weeks. Rifampicin and azithromycin were then continued alone for a further 3 months. As the ear
wound failed to settle fully, heat therapy was added. The clinical impression was that heat led to rapid
improvement. The child has now been off all therapy for 2 months without relapse.

Conclusion:
1. Conservative debridement combined with drug and heat therapy has led to an apparent cure in a
child with M. ulcerans infection of the pinna.
2. New lesions may develop at distant sites while on active drug therapy, although it is not clear
whether this represents true drug failure or a “treatment reaction” (as sometimes seen in leprosy).

98
Buruli ulcer research at Noguchi Memorial Institute for Medical Research
Dr David Ofori-Adjei, Noguchi Memorial Institute for Medical Research, University of Ghana,
Legon, Ghana

I. Approach

Comprehensive research proposal

• Setting up field station
• Social & economic research
• Epidemiology
• Pathogenesis, virulence
• Clinical & pathological studies
• Diagnosis
• Nutritional studies
Collaborative research
WHO Collaborating Centre

II. Collaboration

• CDC
• Emory University
• Sasakawa Memorial Health Foundation
• Ministry of Health, Ghana
• WHO
• Swiss Tropical Institute
• Institute of Tropical Medicine, Antwerp

III. Activities

• Support : Preparation & distribution of transport and storage media

• Case confirmation
- Culture
- PCR
- Microscopy

• Storage
- Cultures
- Tissue
- Skin

• Graduate training
- Swiss Tropical Institute
- Institute of Tropical Diseases, Antwerp

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IV. Future

• WHO Collaborating Centre

- Research
- Training
- Bank–data, specimen, tissue & isolates
- Epidemiological surveillance
- Dissemination of information

• Establish field station for research

• BU research coordination in Ghana

• Skin culture

100
The use of DNA micro-arrays to investigate the host reponse to mycolactone;
how this data may lead to novel therapies for Buruli ulcer

Pam Small and Brian Ranger, University of Tennessee-Knoxville, and Karen Guilleman, Stanford
University, United States of America

Immunosuppression and cell damage are prominent features of Buruli ulcer. Much of this pathology
appears to be mediated by a lipid, polyketide-derived toxin, mycolactone.
In our laboratory we have used DNA micro-array technology to begin to understand how human cells
respond to mycolactone. In this study cultured human macrophages, THP-1 cells were treated with
mycolactone in order to identify host cells that were induced or repressed by mycolactone. The
experimental design is shown below (Fig. 1) RNA was isolated from both control cells and mycolactone
treated cells and differentially labeled with flourescent dyes. Labeled RNA populations from both sets of
cells were mixed and hybridized to an array of 41 000 genes on a glass slide. By determining the ratio
between results from control and test cells it was possible to determine whether genes were induced or
repressed by exposure to mycolactone. The numbers of genes repressed or induced by exposure to
mycolactone is shown in figure 2.

Effects of Mycolactone on Gene Expression in Human THP-1 Derived Macrophages

Experimental design
THP1 human macrophages differentiated with PMA

Mycolactone* Untreated control cells

2h isolate RNA

8h isolate RNA

*15 ng (low) and 100 ng (high) in separate experiments

Experimental Total # # Induced % Induction # Repressed % Repression

condition Arrayed
Low [myco] @ 2hr. 40 241 1 378 3.4% 411 1.0%
Low [myco] @ 8hr. 37 039 1 950 5.3% 152 0.4%
High [myco] @ 2hr. 40 347 1 889 4.7% 133 0.3%
High [myco] @ 8hr. 42 129 1 784 4.2% 284 0.7%

101
We are still in the process of analyzing data generated by the micro-array experiment. A summary of
data before is shown in figures 3, and 4 below. At 8 hours following addition of mycolactone there were
many shared responses with 2 h treatment however many fewer cytoskeletal genes or ion transport genes
were induced and there was up regulation of many non-specific stress proteins. It was of particular
interest to note that mycolactone induced the expression of many proteins associated with the
immunosuppressant FKK506. FK506 is a powerful macrolide immunosuppressant. The expression of
many FK506 binding proteins was induced in response to mycolactone suggesting that mycolactone and
FK506 may share similar pathways which result in immunosuppression.

Some genes induced at 2 h by 15 ng mycolactone (greater than 5X)

• FK506 binding proteins • Keratin 8
• Ion transporters • Desmoglein-2
• Actin associated proteins • Annexin 10
• cell cyle proteins • Vasodialation-stimulated phosphoprotein
• cell adhesion molecules • Kerotinocyte growth factor
• coagulation pathway genes • PAWR (PRKC, apoptosis, WT1, regulator)
• Dermatan-4-sulfotransferase • TGF-ß

Some genes repressed by exposure to 15 ng mycolactone for 2 h (greater than 3X)

• Interferon receptor
• Atpase class V
• Kalikrein 3
• Cell devision cycle 2 (G1/S)
• Endothelial monocyte activating cytokine
• Leukostatin
• Interferon induced protein
• Il-1 receptor protein
• CD8
• Chemokine receptor 1 (C-X3)
• Complement receptor 3, CD11b macrophage antigen
• Interleukin enhancer BF3
• Il-15

The data presented here are the results of a single microarray experiment using two concentrations of
mycolactone and observing the effects on macrophages 2 h and 8 h after addition. Both the high and low
level mycolactone are well within the range of toxin concentration that would be expected within a
Buruli ulcer lesion. At this point we plan to repeat this experiment, extend kinetic studies, and confirm
gene expression results using RT-PCR and Western blot analysis. The work presented here suggests that
mycolactone plays an important role as an immunosuppressant in Buruli ulcer. One corrolary of this
work is that anti-toxin could have a very important role both in the treatment and possibly prevention of
Buruli ulcer. We are particularly interested in determining whether anti-mycolactone antibody might
neutralize toxin present in a lesion so that the host immune response could function normally to clear
Mycobacterium ulcerans from the lesion. A similar strategy is used with considerable success in treating
cutaneous Leishmaniasis.

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Histopathologic characteristics of the PGL-1 immunostaining in lesions of
Buruli ulcer – specificity of the monoclonal antibody used
Milanga Mwanatambwe1, Mikihisa Yajima 2, Samuel Etuaful3, Yukiko Fukunishi4, Kingsley Asiedu5,
Keiji Susuki2, Nobutaka Yamada1 and Goro Asano1
1
Nippon Medical School, Tokyo, Japan
2
National Leprosarium, Tama, Japan
3
Agroyesum St Martin Hospital, Ashanti, Ghana
4
National Sanatorium, Matsuoka, Aomori, Japan
5
Buruli Ulcer Initiative

Phenolic glycolipids (PGLs), due to the strong antigenic capacity of their oligosaccharide constituents,
have given rise to hope regarding their possible use in the serological differentiation of mycobacteria.
The unique sugar configuration of PGL-1 from M. leprae gives the antigen tremendous potential in term
of specificity. Also, demonstration has been done that the antigen is implicated in the pathogenesis of
mycobacterial diseases, especially in lepromatous leprosy, through its capacity to scavenge oxygen free
radicals. The immunostaining of PGL-1 has been observed in clinically and histologically confirmed
lesions of Buruli ulcer, a skin disease mainly endemic in tropical and subtropical areas. The observation
of the PGL-1 immunoreactivity in lesions of Buruli ulcer was made on histological specimens by
immunohistochemical methods. While the serological relevance of the antigen’s presence in Buruli ulcer
patients is awaiting demonstration, in the following lines, we show the design of the monoclonal
antibodies used in our study.
Accurate investigations on the precise binding site of monoclonal antibodies directed against PGL-1
have been going on for the last 2 decades. These efforts for improvement have culminated in the
synthesis of sugars with structures closely related to the trisaccharide of PGL-1 (slide). Experiments
were done both with synthetic antigens having the same structure as the trisaccharide of PGL-1 (NT-P-
BSA in table 1) and those with deletion of the phenol group of the sugar (NT-H-BSA in table 1), by
ELISA assays and ELISA inhibition assays. The monoclonal antibodies (table 2) were then immunized
with these chemically well-defined different part of the PGL-1 trisaccharide. This has lead to the epitope
mapping of twelve binding site on the sugar molecule. We proceeded in different experiments by ABC
methods and by Direct EnVision methods recently designed using the DZ-1 monoclonal antibody (Table
1), immunized against the whole PGL-1 molecule. Similar to the immunophenotypic demonstration of
PGL-1 exhibited at the last year gathering, here are more micrographs of that immunoexpression in
lesion of Buruli ulcer of different ages.

Discussion
The very high specificity of the monoclonal antibodies used is evident. If cross reactivity between the
PGL-1 of M. ulcerans and that of other mycobacteria is confirmed very little, this antigen may be usefull
in the subclinical diagnosis of early cases of Buruli ulcer.

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Genome sequence analysis of Mycobacterium ulcerans

Timothy Stinear1, Thierry Garnier1, Roland Brosch1, Karin Eiglmeier1 Laurence Ma2, Stéphane
Ferris2, Stéphanie Duthoy2, Christiane Bouchier2
and Stewart T. Cole1.
1
Unité de Génétique Moléculaire Bactérienne and 2Génopole, Institut Pasteur, Paris, France

In February 2001 work commenced to determine the complete genome sequence of M. ulcerans. The
project is on track and expected to be at or near completion by the end of this year. A summary of the
milestones achieved to date is provided.
A strain of Mycobacterium ulcerans (designated Agy98), isolated in 1998 from a patient in Ghana, was
selected for sequencing. This strain was confirmed by genotype analysis to be the epidemic, West
African genotype. Two types of genotype analysis were performed; multilocus sequence typing (MLST)
and 2426-PCR genotyping. MLST analyses genotype by comparing nucleotide sequences at 7
independent loci with the same loci in other strains. The 2426-PCR technique exploits differences in the
spatial distribution of the two M. ulcerans, high-copy number repeated sequences, IS2404 and IS2606,
between strains. Thus each method is an independent measure of genotype. Both methods produced
exact matches with other West African isolates of M. ulcerans.
The next step was to construct a bacterial artificial chromosome library (BAC). There are approximately
300 clones in this library with an average insert size of 60kb. These clones have been end-sequenced and
will provide the scaffold for assembly of the genome from the smaller DNA fragments of the shotgun
library.
The small-insert, random, shotgun library is the main resource for determining the genome sequence.
This library has been constructed and all clones have been end-sequenced. The library contains
approximately 29 000 clones. To minimize cloning artifacts a non-palindromic cloning strategy was
followed. The clones were prepared within the size ranges of 2–3kb (6300 clones), 3–5kb (21000
clones) and 5–10kb (1500 clones). Restriction enzyme analysis of a selection of the clones indicated that
greater than 95% of clones contained inserts of the expected size ranges and preliminary sequencing of
2000 clones verified the randomness of the library and confirmed its suitability for determining the
genome sequence. Interestingly, despite a close phylogenetic relationship to M. tuberculosis, sequence
homology searches of the 2000 M. ulcerans clones against the genome sequence of M. tuberculosis
H37Rv identified less than 10% of clones with obvious synteny to H37Rv.
Sequencing of the 29000 clones in the shotgun library commenced in mid September 2001 and was
completed in November 2001. Quality control analysis indicated that approximately 43000 good
sequence reads had been obtained, representing a theoretical 6-fold genome coverage (an estimated
99.7% of the entire genome sequence assuming a genome size of 4.6 Mb).
Assembly of the sequences commenced in November. At this stage a database has been constructed that
contains approximately 1800 contigs with an average length of 3kb. Around 20% of these contigs
contain one or more copy the insertion sequences (IS) IS2404 and IS2606. The presence of such large
amounts of repetitive DNA has produced smaller contigs than could theoretically be expected and is
demanding rigorous treatment to ensure contig assemblies are correct. It is likely that the presence of the
IS have facilitated considerable genome plasticity and this may partly explain the reduced synteny with
M. tuberculosis.
Gap closure and finishing will commence once the contigs have been further assembled and verified
correct and at this point a publicly accessible list server (proposed name BuruList) will be established.
The server is expected to be available by July 2002. The annotation phase of the project will also
commence at this stage.
It is now time to start considering the next stage of investigation. Obvious examples will be to search for
the genes involved in the biosynthesis of mycolactone and the genes producing known immunodominant

105
and M. ulcerans-specific antigens. Other avenues of investigation will no doubt include studies of the
M. ulcerans transcriptomes and proteomes. Equally, comparative genomics with other mycobacterial
pathogens should identify genes and loci implicated in the different pathways of pathogenesis in each
species. At the Institut Pasteur plans are underway to commence such studies.

106
Immunological cross-reactivity between Mycobacterium ulcerans and other
mycobacteria
Gerd Pluschke1, Diana Diaz1, Simona Rondini1, Thomas Bodmer2 and Ernestina Mensah3
1
Swiss Tropical Institute, Basel, Switzerland
2
University of Bern, Switzerland
3
Ga District Health Management Team, Ghana MOH

Broad antigenic overlap between mycobacterial species complicates the analysis of adaptive immune
responses to Mycobacterium ulcerans. This immunological cross-reactivity hampers the development of
specific serodiagnostic tests for M. ulcerans disease suitable for areas where TB is also endemic. On the
other hand the associations described between BCG vaccination and a lower incidence of M. ulcerans
disease has raised interest in the nature of the cross-reactive immune responses.
In spite of a profound T cell anergy to mycobacterial antigens, patients with M. ulcerans infection seem
to be able to raise antibody responses against a broad range of M. ulcerans antigens. Our Western blot
analyses demonstrated heterogeneous antibody responses in sera from M. ulcerans patients from the Ga
district in southern Ghana. Comparisons of reaction patterns of these patient sera with lysates of
M. ulcerans, M. tuberculosis, M. marinum and BCG gave indications for a small proportion of
antibodies that recognise non-crossreactive M. ulcerans antigens. However, the complexity of reaction
patterns complicates the identification of these M. ulcerans specific antigens. To dissect the humoral
immune response, we have started to generate panels of monoclonal antibodies (mAbs) against
M. ulcerans antigens. We observed that the nature of humoral immune responses of mice to M. ulcerans
antigens strongly depends on the type of immunisation, which facilitates generation of mAbs against a
broad enough range of antigens. Some of the vaccination schedules induced predominantly broadly
cross-reactive humoral immune responses. In some other cases, antibodies reacted either predominantly
with both M. ulcerans and M. marinum or only with M. ulcerans. Among the first mAbs isolated, both
cross-reactive and non-crossreactive specificities were observed. Some of these are also identifiable in
patient sera. The description of the complete M. ulcerans genome will soon be available and will
facilitate identification of the antigens recognise by these mAbs. Characterisation of antigenic structures
unique for M. ulcerans will contribute to the understanding of host-pathogen interaction and help to
investigate the feasibility of developing a field-compatible assay for early diagnosis of M. ulcerans
disease.

107
Update on the activities of the Bernhard Nocht Institute for Tropical
Medicine in establishing a diagnostic unit for Mycobacterium ulcerans
Siegmund V1, Drosten C1, Adjei O2, Racz P1, Bretzel G1
1
Bernhard Nocht Institute for Tropical Medicine (BNITM), Hamburg, Germany
2
Kumasi Center for Collaborative Research in Tropical Medicine (KCCR), Kumasi, Ghana

Strain collection

Thirty-nine M. ulcerans strains from Africa, Asia and Australia were kindly provided by Prof. Francoise
Portaels (Institute of Tropical Medicine, Antwerp, Belgium), David Dawson (Queensland
Mycobacterium Reference Center, Brisbane, Australia), and Prof. Ohene Adjei KCCR, Kumasi, Ghana).

Diagnostic PCR

All 39 strains were tested with the diagnostic PCR by Stinear et al. (1) targeting the IS2404 element of
M. ulcerans. For 38 specimens positive PCR results were obtained.

Diagnostic specimens

In collaboration with KCCR and the HART surgical team clinical specimens (swabs and biopsies) from
25 patients obtained during the HART Spring 2001 Amasaman Project in Ghana were collected.
Primary cultures on LJ were done at KCCR, swabs and biopsies were forwarded to BNITM for
histopathological and PCR analysis. Furthermore, based on an observation made in our laboratory 24
serum samples from BU patients from Ghana and were tested in PGL-1 ELISA.
PCR results:
25 biopsies and 25 swabs were tested with the diagnostic PCR (1). 22 out of 25 swabs were positive, 21
out of 25 biopsies were positive.
Serum samples: 9 out of 24 samples were tested positive with titres ranging from 1: 300 – 1: 1200.

Sequence analysis of a flanking region to the IS2404 like element of

M. ulcerans

In an attempt to establish a combined method to detect and genotype isolates of M. ulcerans in one step,
a flanking region to the IS2404 like element of M. ulcerans was sequenced from 21 isolates of African,
Asian, and Australian origin.
Three variable residues and an insertion/deletion polymorphism were identified within this region,
which however did not allow genotypic discrimination by the real-time/hybridization probe PCR
method. Sequencing a large number of isolates of M. ulcerans may however increase the reliability of
detection by PCR.

109
Diagnostic 5‘nuclease PCR

Currently a diagnostic real-time PCR targeting a sequence located in IS2404 is being developed in our
PCR-Laboratory. It is scheduled to be evaluated in comparison with the established protocol by Stinear
et al. (1), which we consider the reference method.

“Field Laboratory”

It can be assumed that the implementation of diagnostical PCR procedures in developing countries will
comprise special difficulties in the storage of reagents and laboratory practice. An appropriate PCR
formulation will hence involve stable reagents that are easy to handle. In collaboration with the
department of Virology, our PCR laboratory has developed a dry-reagent based PCR formulation for the
detection of Filoviruses. The protocol has been successfully installed in the Ugandan Virus Reasearch
Institute, Entebbe, and was found to be very reliable and sensititve in the hands of non-trained laboratory
staff. Efforts are going on to adapt the system to the detection of M. ulcerans. It is scheduled to install
the system in a Ghanaan laboratory once ready for use. The laboratory has yet to be specified.

Pilot study on external quality assessment (EQA) of M. ulcerans AFB smear

microscopy and the sensitivity of different diagnostic techniques used for the
detection of M. ulcerans

In analogy with the standardized methods developed for external quality assessment of TB smear
microscopy (2) it is planned to carry out a pilot study on EQA of M. ulcerans AFB smear microscopy in
a selected region in Ghana in collaboration with KCCR. Therefore, a laboratory network including
different level laboratories shall be established, providing a wide range of diagnostic techniques (AFB
smear microscopy, culture, histopathology, PCR) for the diagnosis of Mycobacterium ulcerans. First,
diagnostic sildes shall be re-checked on different reference levels within this network according to the
established principles of EQA. Second, clinical specimens shall be subjected on a large scale to different
diagnostic techniques in order to obtain information on the sensitivity and specificity of the methods
routinely applied in the diagnosis of Buruli ulcer.

References

1. Stinear et al. Identification and characterization of IS2404: Two distinct repeat sequences for
detection of Mycobacterium ulcerans by PCR. J Clin Microbiol, 2001,37 (4):1018
2. Guidelines on External Quality Assessment for AFB Smear Microscopy. IUATLD,WHO CDC,
KNCV, APHL, in press

110
Susceptibility to Mycobacterium ulcerans infection; impact of co-infection
with schistosomes on the development of Buruli ulcer
Stienstra Y, van der Werf TS, van der Graaf WTA, Groningen University Hospital, Groningen, The Netherlands
Raghunathan PL, Whitney EAS, Secor WE, Guarner J, Tappero JW, Ashford DA, National Center for
Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
Asamoa K, Ministry of Health, Accra, Republic of Ghana
Kihlstrom SL, Dobos KM, King CH, Division of Infectious Diseases, Emory University School of Medicine,
Atlanta, GA

Background

The influence of parasitic diseases on the immune system and on the development of other myco-
bacterial diseases, as well as the similar epidemiological characteristics of schistosomiasis and
M. ulcerans infection, raise the question whether schistosomiasis leads to an increased susceptibility to
M. ulcerans infection.

Methods

A case-control study was conducted in three districts in Ghana endemic for M. ulcerans infection,
autumn 2000. One hundred and six patients with confirmed M. ulcerans infection and 106 matched
community controls without M. ulcerans infection were included. Schistosome worm burden of these
patients and controls was measured by an ELISA detecting circulating anodic antigen in serum.1

Results

Fifty percent of the participants were positive for schistosomiasis by the circulating antigen test. There
was no difference in positivity rates amongst patients and controls. No difference in intensity of worm
burden was measured amongst patients and controls with a positive worm load.

Conclusions

Schistosomiasis is highly prevalent in this mainly rural population. Susceptibility to M. ulcerans

infection can not be explained by a co-infection with schistosomes. Other environmental, immunological
and genetic factors should be studied to elucidate susceptibility for this emerging disease.

1
Deelder et al. Am J Trop Med Hyg,1989; 40:268–272

111
Functional limitations caused by Buruli Ulcer
Debora E. Ellen 1, Ymkje Stienstra 1, Margreet A. Teelken 1, Pieter U. Dijkstra 2, Winette T.A. van der
Graaf 1, Tjip S. van der Werf 1

Departments of 1 Internal Medicine; and 2 Rehabilitation, Groningen University Hospital, POBox 30 001, 9700 RB Groningen,
the Netherlands

Background

Buruli ulcer leaves patients with considerable sequelae, but formal studies assessing severity have not
been published.

Methods

Follow-up study of Buruli ulcer patients in Ghana, identified in the records of two different hospitals in
highly endemic areas, treated between 1994 and July 2000. Assessment of late sequelae by measuring
limitations of movement in joints using a goniometer.

Results

Out of 433 patients, 78 (18%) were retrieved; 58% (n = 45) had a reduction in the range of motion of
one or more joints. The range of motion measured was translated into a predicted score for functional
limitations. Of our population, 30% (n = 23) had a predicted functional limitation of the leg and 21%
(n = 16) of the arm. Of all patients examined, 49% (n = 38) had a functional limitation. Of all patients
with affected knees, the predicted average extent of limitation was 63%. In patients with affected ankles,
limitation was 78% on average; in those with elbow involvement, this was 76% on average, and in
wrists involved, 65%. All of the hands involved were markedly restricted.

Discussion

More than half of treated patients had functional limitations. For future studies, we propose a simplified
and functional scoring system that should be tested for validation in a second patient sample, and, if
properly validated and adjusted, be used in future intervention trials.

113
Extent of excision impacts on healing of Buruli ulcer

M.A. Teelken 1, Y. Stienstra 1,2

, D.E. Ellen 1, E. Quarshie 3, E. Klutse 4, W.T.A. van der Graaf 1, T.S.
van der Werf 1
1
Department of Internal Medicine, Groningen University Hospital, the Netherlands
2
Department of Infectious Diseases, Emory School of Medicine, Atlanta Ga, USA
3
Agogo Hospital, Agogo, Ashanti Region, Ghana
4
Dunkwa Hospital, Dunkwa, Central Region, Ghana

Background

Surgery is considered pivotal in the treatment of Buruli ulcer. There is however no evidence from formal
studies evaluating surgical techniques in the management of Buruli ulcer.

Methods

Follow-up of patients treated for Buruli ulcer, identified from hospital records between 1994 and July,
2000. In two different hospitals, 432 patients were identified that were treated for Buruli ulcer. We
retrieved and examined 78 of these patients. In these two hospitals, surgical practice had differed
considerably; in one hospital, Buruli ulcer was excised until normal skin and subcutaneous tissue were
reached using a safety margin of one or more centimetres; in the other hospital the ulcer was excised
until just into the healthy tissue.

Results

In a univariate analysis, treatment in hospital A; the use of rifampin (P = 0.013); time lapsed between
treatment and assessment (P = 0.01); and BCG vaccination status (P = 0.04) were all significantly
associated with ulcer healing. The length of stay in hospital A was significantly longer (P = 0.002), and
more operations on average were done per patient (P = 0.002). Using a logistical regression model for
multivariate analysis, only treatment as given in hospital A, with standard practice of wide surgical
excision, appeared to predict ulcer healing independently (P = 0.02).

Discussion

This study provides evidence, that extent of surgical treatment is critical for healing in Buruli ulcer.

115
Latent Class Analysis (LCA) evaluation of four diagnostic tests for Buruli
ulcer disease
Whitney EAS1, Phelan M1, Raghunathan PL1, Stienstra Y2, Dobos K3, Guarner J1, Kilhstrom S3,
Ablordey A4, Etuaful S5, Klutse E6, Quarshie E7, Ofori-Adjei D4, van der Werf TS2, van der Graaf
WTA2, Asamoa K8, Amofah G8, King CH3, Ashford DA1
1
National Center for Infectious Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA
2
Groningen University Hospital, Groningen, The Netherlands
3
Emory University School of Medicine, Atlanta, GA
4
Noguchi Memorial Institute, Accra, Ghana
5
St. Martins Catholic Hospital, Agroyesum, Ghana
6
Dunkwa Government Hospital, Upper Denkyira District, Ghana
7
Presbyterian Hospital, Agogo, Ghana
8
Ministry of Health (MOH), Republic of Ghana, Accra, Ghana

Abstract

Diagnosis of Buruli ulcer disease (BUD) is complicated by the absence of a diagnostic “gold standard”
and a resulting lack of clarity regarding the sensitivity and specificity of different laboratory diagnostic
assays. Currently, BUD is diagnosed by clinical characteristics of lesions: nodules, papules, plaques,
oedema, ulcers and osteomyelitis. Culture has been considered a possible, yet imperfect gold standard
on empiric evidence alone.
During the fall of 2000, a case-control study was performed in Ghana to identify the risk factors
associated with BUD. As part of this study, clinical samples including swabs and tissue samples of
lesions were collected from suspect BUD patients who met the WHO case definition for BUD. Samples
were collected one week post-enrollment during surgical excision of the lesion and placed in either 10%
buffered formalin or transport media. Four laboratory tests were performed on these samples to confirm
the clinical diagnosis of BUD: microscopic examination of smears from swabs of lesions for acid fast
bacilli (AFB) performed at time of excision, polymerase chain reaction (PCR) amplification of
Mycobacterium ulcerans DNA in tissue from lesions, histopathologic study of tissue biopsies, and
culture of M. ulcerans from tissue or swab of the lesion (pending HPLC confirmation). Of 158 patients
enrolled in the case control study, we obtained results from all four tests in 63 (40%) of patients.
We calculated the sensitivity of four diagnostic tests for BUD using Latent Class Analysis (LCA). LCA
examines the patterns of responses, detects interrelatedness of each test, and determines the probability
of outcome, which gives insight into the utility of the individual tests for the confirmation of BUD.
The results from the LCA for sensitivity are presented in Table 1. They suggest that sensitivity is
greatest for histopathology and PCR. Because our clinical samples were collected only from a sample
population that suffered from clinically-compatible disease (a high prior probability of truly being cases
if BUD), specificity and predictive values of these assays can not be calculated with confidence from
these data. From our data, when the following combination of two test results are positive the probability
of being a case reaches 100%: culture and AFB; culture and histopathology; AFB and histopathology.
Using any combination of three tests or all four tests results in 100% probability.

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Table 1 – Sensitivity for diagnostic tests for Buruli Ulcer Disease

Test Sensitivity 95% confidence interval

Culture
(Pending HPLC confirmation) 82% (59%, 100%)
AFB 23% (9%, 36%)
PCR 89% (80%, 99%)
Histopathology 100% (100%, 100%)

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Histopathologic features of Mycobacterium ulcerans infection
Guarner J1, Bartlett J1, Whitney EAS1, Raghunathan PL1, Stienstra Y2, Asamoa K3, Etuaful S4,
Klutse E5, Quarshie E6, Amofah G3, King CH7, Ashford DA1
1
Infectious Diseases Pathology Activity, and Meningitis and Special Pathogens, National Centers for Infectious Diseases,
Centers for Disease Control and Prevention, Atlanta, GA;
2
Groningen University Hospital, the Netherlands;
3
Ministry of Health, Ghana; Emory University, Atlanta, GA
4
St. Martins Catholic Hospital, Agroyesum, Ghana
5
Dunkwa Government Hospital, Upper Denkyira District, Ghana
6
Presbyterian Hospital, Agogo, Ghana
7
Emory University School of Medicine, Atlanta, GA

Abstract

M. ulcerans produces an indolent skin infection known as Buruli ulcer (BU). During a study of risk
factors for BU in Ghana, 145 excisional skin biopsy specimens were obtained from clinically suspicious
lesions at different stages (preulcerative, and ulcerative). A comparative study of histopathologic
features of definitive and suspect BU cases has not been reported. Of the 145 specimens, 124 had
adequate tissue for histopathological examination. Cases where acid fast bacilli (AFB) were found in
histologic sections, were considered definitive BU; cases with negative AFB were considered suspect
BU (SBU) unless they presented other diagnoses. Non-BU cases included 7 nodules (3 filarial nodules,
2 deep fungi, 1 keratin cyst, and 1 lymph node) and 2 ulcers (both squamous cell carcinoma). We
confirmed 78 cases as BU (18 nodules, 5 plaques, and 55 ulcers), while 37 were considered SBU (5
nodules, 1 plaque and 31 ulcers). The proportion of nodules with a histopathologic diagnosis was higher
compared to that of ulcers (83% versus 65%). Coagulative necrosis of subcutaneous tissues and necrotic
collagen in the dermis were found more frequently in BU cases compared to SBU (p < 0.001). Patients
with definitive BU preulcerative lesions had less epidermal hyperplasia than those with ulcers (42%
versus 78%; p = 0.005), lower amounts of chronic inflammation (17% versus 49%; p = 0.01), less
granulomas (13% versus 49%; p = 0.005), and higher concentrations of AFB in the subcutaneous tissues
(78% versus 56%; p = 0.07). In summary, a histopathologic diagnosis was more frequent in nodules
compared to ulcers. Coagulative necrosis is the most reliable histologic feature for diagnosis of BU;
however, the histopathologic features are not unique, thus diagnosis of BU requires clinico-pathologic
correlation.

119
A case control study to identify Modifiable Risk Factors for Buruli Ulcer
Disease, Ghana, 2000

Pratima L. Raghunathan, Ellen A. Whitney, Thomas H. Taylor Jr., Jeannette Guarner, Jordan W.
Tappero, David A. Ashford

National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
Sam Bugri, George Amofah, Kwame Asamoa, Ministry of Health, Accra, Republic of Ghana
David Ofori-Adjei, Daniel Boakye, Anthony Ablordey, Noguchi Memorial Institute for Medical Research, Accra, Ghana
Y. Stienstra, W. van der Graaf, T. van der Werf, Groningen University Hospital, Groningen, the Netherlands
K. Dobos, S. L. Kihlstrom, C. King, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA

Background

Buruli ulcer disease (BUD), a cutaneous infection caused by Mycobacterium ulcerans, is a major
contributor to long-term disability in rural West Africa. Prevalence has been reported to range from 4%
to 22% in endemic villages. Prevention strategies cannot be developed, because the source and mode of
transmission remain unknown, and risk factors for the disease are not well-characterized.

Methods

To identify modifiable risk factors for BUD, we conducted a case-control study in three endemic
districts of Ghana. We enhanced hospital- and community-based surveillance for BUD by providing
training and modest incentives to village health volunteers. A suspected BUD case was defined as a
person who presented to one of the three study hospitals from August 29, 2000 through November 30,
2000, and who was clinically diagnosed with 1) a painless nodule, plaque, or diffuse nonpitting edema
evolving into an ulcer with undermined edges characteristic of active BUD, or 2) a depressed stellate
scar characteristic of healed, inactive BUD. We enrolled 158 suspected BUD case-patients and 149 age-
and community-matched controls, and obtained skin biopsies from suspected case-patients. A confirmed
case of BUD was defined according to WHO criteria as a suspected BUD case with laboratory evidence
of M. ulcerans infection by at least one of the following four methods: 1) presence of Ziehl-Neelsen
stained acid-fast bacilli (AFB) in the lesion, 2) characteristic histopathology, 3) M. ulcerans culture, or
4) polymerase chain reaction (PCR) detection of M. ulcerans DNA. In addition, we obtained blood and
urine specimens from all enrolled subjects. We administered standardized questionnaires regarding
behaviors and water exposures, and analyzed responses using conditional logistic regression for matched
case-control data.

Results

Of 158 suspected case patients, 144 had skin biopsies performed; 121 cases (84%) were confirmed by at
least 1 method. PCR confirmed the highest proportion of cases (105/143, or 73%), followed by
histopathology (79/144, or 55%), culture (56/144, or 39%), and AFB in the lesion (13/102, or 13%).
Case confirmation rates did not differ by disease stage (Wilcoxon rank sum, p = 0.7117): we found
laboratory evidence of M. ulcerans infection in 82% (28/34) of patients with preulcerative lesions,
compared to 78% (89/114) of patients with ulcers. The median age of all confirmed case-patients was 12
(range 2 to 53 years); sexes were approximately equally distributed (64/121, or 53% female). Females
had an older age distribution than males (mean age of females = 16.8 years, mean age of males = 12.9

121
years; Wilcoxon rank sum, p = 0.0388). Most confirmed case-patients had lesions on the leg (49%) or
the arm (36%), and relatively few presented with lesions on the trunk (15%). However, males were more
likely to have a lesion on their trunk compared to females (Fisher’s Exact Test, p = 0.009).

Among the 149 matched case-control sets, we analyzed the 116 pairs containing confirmed cases. By
univariate analysis, confirmed cases were strongly associated with a burulin skin test reaction greater
than 8 mm (OR = 12.3, 95% CI = 3.8, 40.0; p < 0.0001) and also with a tuberculin skin test reaction
greater than 8.5 mm (OR = 4.5, 95% CI = 1.9, 10.9; p = 0.0009). Preliminary multivariate analysis for
modifiable risk factors revealed that cases were more likely to have a high distance to their primary
drinking water source, and to have swum, waded, or bathed in a river. In contrast, controls were more
likely to have used toilet soap while bathing. Analysis of other potential risk factors, and derivation of a
final multivariate model, is in progress. (NB: I haven’t reported ORs or p-values here because the
models are still in flux. We don’t have a final model, and I don’t feel comfortable reporting numbers we
will change later. In fact, I am not sure we want to report anything from the multivariate analysis yet!)

Conclusions

Using laboratory confirmation of M. ulcerans infection, we demonstrated that clinical diagnosis for
Buruli ulcer has a high positive predictive value (84%) in these three endemic districts of Ghana.
Misdiagnosis of Buruli ulcer lesions appears independent of the stage of disease. The location of lesions
on the extremities, or in males, on the trunk, suggests disease transmission may require exposed areas of
skin. Environmental exposure to river water is implicated as a risk factor, and the use of toilet soap may
be protective against BUD.

122
Experimental chemotherapy of Buruli ulcer: where do we stand?
Jacques Grosset, Center for Tuberculosis Research, Johns Hopkins University School of Medicine,
Baltimore, MD, United States of America

The growth of Mycobacterium ulcerans in the foot pad of mice was first reported by Fenner in 1956 (5).
The following year, streptomycin was demonstrated to be efficacious in treating infection of the mouse
foot pad (4), a finding confirmed in 1965 (7). In the 70’s, several authors found that rifampicin had a
bactericidal activity on M. ulcerans in the foot pad model (6, 10). Despite these results, antimicrobial
therapy has largely been considered ineffective in the treatment of M. ulcerans infection, and large
surgical excision of the necrotic ulcer followed by skin grafting was the only effective treatment (11).

Drugs and drug regimens active against M. ulcerans

1. In 1998, clarithromycin was demonstrated to be active in vitro against M. ulcerans (8). When tested
in mice with a method (Figure 1) derived from the Fenner mouse foot pad model (5) and with
Shepard’s kinetic method (9), clarithromycin exhibited only bacteriostatic activity, comparable to
that of minocycline (MINO) and sparfloxacin (SP). As shown in Figure 2, in mice infected with
5x105 AFB of M. ulcerans the swelling of 50% of the foot pads occurred 15 weeks after infection. In
mice treated daily with each of these drugs for 8 weeks the swelling of foot pads occurred with less
than 8 weeks’ delay compared to control mice (3). Conversely, daily treatment with either
rifampicin (RIF), or rifabutin (RBT), or amikacin (AMK) completely prevented the swelling of foot
pad, through 17 weeks of follow-up after completion of treatment, suggesting that these antibiotics
have bactericidal activity against M. ulcerans.

2. A subsequent mouse experiment (Fig. 3) tested several 4-week long daily treatments for their ability
to prevent the foot pad swelling in mice infected with 105 AFB of M.ulcerans (3). The drug
regimens evaluated were: streptomycin (SM) alone, AMK alone, RIF alone, and the combination
AMK+RIF. Clarithromycin (CLAR) alone was used as a positive control and untreated mice served
as negative controls. As previously observed, CLAR exhibited bacteriostatic activity. However, in
contrast to previous observation with 8-week therapy, 4-week monotherapy with RIF, SM, AMK,
and dual therapy with AMK+RIF were not sufficiently bactericidal to prevent the swelling of foot
pad. The combination AMK+RIF given for 4 weeks was more active than any monotherapy.

3. Because of its potent activity in preventing the swelling of foot pad infected with M. ulcerans, the
daily combination AMK + RIF was tested in mice with established foot pad infections (1). Mice
infected with 3x104 AFB (3x103 CFU) of M.ulcerans were left without treatment for 5 weeks up to
the swelling of their hind foot pads. They were then daily treated for 12 weeks with one of the 3
daily regimens: AMK + RIF, a fully oral three-drug combination (RIF + CLARI + SP), or RIF
alone. As shown in figure 4, all untreated control mice were dead with extensive lesions of the foot
and leg by the eight weeks after the onset of treatment. Conversely, all mice treated with AMK +
RIF, or RIF + CLARI + SP or RIF alone remained alive. In mice treated with AMK + RIF, the foot
pad swelling progressively disappeared over 4 weeks and the foot pads remained apparently cured
up to the 28th week from the initiation of treatment [e.g., after16 weeks of follow-up after treatment
completion (data not shown)]. In mice treated with RIF + CLARI + SP, the foot pad swelling
increased during the first 3 weeks of treatment, before slowly decreasing and eventually
disappearing by the 12th week of treatment. However the foot pads remained thicker (fibrotic scar?)
than those in mice treated with AMK + RIF, and the swelling progressively returned after the 20th
week (data not shown), suggesting active relapse. In mice treated with RIF alone, the swelling
increased during the first 3 weeks of treatment, before stabilizing without regression up to the end of
the experiment. No clear relapse was observed up to the 28th week.

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The results of CFU counts performed during the first 8 weeks of the experiment were in full agreement
with the macroscopic evolution of the foot pads. As shown in figure 5, the CFU counts fell from 5.26
log10 to 0.34 log10, a 5 log10 decline, between week 2 and week 8 in the foot pads of mice treated with
AMK + RIF. During the same period of time, they fell from 5.89 log10 to 1.72 log10, a 4 log10 decline, in
mice treated with RIF + CLARI + SP, indicating the potent bactericidal activity of this oral combination.
In mice treated with RIF alone, the fall in CFU began after week 4 and was of limited magnitude, from
5.90 to 4.02 log10 [e.g., of less than 2 logs (data not shown)]. Curiously, with all drug regimens, the
decline in the CFU counts was not accompanied by a decline in the AFB counts. The AFB counts
remained unchanged throughout the entire treatment period as though there was an immune paralysis in
the foot pads of mice infected with M. ulcerans, as observed in the skin lesions of patients with
lepromatous leprosy.

4. Because daily treatment of M. ulcerans infection is not easy to implement in the field, the
comparative activities of once weekly, twice weekly, and five times weekly (daily) treatments with
AMK + RIF were tested in the mouse foot pad modelmice (1) by the proportional bactericidal test
(2). As shown in figure 6, the bactericidal activity of the combination AMK + RIF was directly
related to the frequency of its administration. The more frequent the administration, the greater the
bactericidal activity.

Conclusions

1. The aminoglycosides, streptomycin and amikacin and, to a much lesser degree rifampicin, have
exhibited bactericidal activity against M. ulcerans.
2. The combination of an aminoglycoside (streptomycin or amikacin) with rifampicin has greater
bactericidal activity against M. ulcerans than either antibiotic alone. Given for two months, each
drug alone was able to prevent the late swelling of the mouse foot pad infected with M. ulcerans.
Given for three months, the combination of amikacin with rifampicin was able to cure swollen foot
pads infected with M. ulcerans without late relapses during follow-up after completion of treatment.
The bactericidal potency of the daily combination amikacin-rifampicin was significantly decreased
by intermittent administration.
3. The oral 3-drug combination, rifampicin-clarithromycin-sparfloxacin, is only slightly less potent
than the amikacin-rifampicin combination and deserves careful consideration for field use.
4. The following main issues have to be addressed:
– in case the on-going Ghana trial confirmed the experimental findings, what will be the next
move? Test the role (period, duration) of the amikacin (or streptomycin) plus rifampicin
combination in the treatment of ulcerated lesions? Test a fully oral drug regimen, supplemented
or not with an aminoglycoside during the initial phase?
– how to promote research on oral drug(s) active against M. ulcerans?

References

1. Bentoucha A, Robert J, Dega H, Lounis N, Jarlier V, Grosset J. Activities of new macrolides

and fluoroquinolones against Mycobacterium ulcerans infection in mice. Antimicrob agents
Chemother, 2001; 45:3109–3112.
2. Colston MJ, Hilson GRF, Bannerjee DK. The proportional bactericidal test, a method for
assessing bactericidal activity of drugs against Mycobacterium leprae in mice. Lepr Rev, 1978; 49:
7–15.
3. Dega H, Robert J, Bonnafous P, Jarlier V, Grosset J. Activities of several antimicrobials against
Mycobacterium ulcerans infection in mice. Antimicrob agents Chemother, 2000; 44:2367–2372.
4. Feldman WH, Karlson AG. Mycobacterium ulcerans infections: response to chemotherapy in
mice. Am Rev Tuberc, 1957; 75:266–279.

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5. Fenner F. Pathogenic behavior of Mycobacterium ulcerans and Mycobacterium balnei in mouse
and developing chick embryo. Am Rev Tuberc, 1956; 73:650–673.
6. Havel A, Pattyn SR. Activity of rifampicin on Mycobacterium ulcerans. Ann Soc Belge Med Trop,
1975; 55:105–108.
7. Pattyn SR, Royackers. Traitement de l’infection experimentale de la souris par Mycobacterium
ulcerans et Mycobacterium balnei. Ann Soc Belge Med Trop, 1965; 45:31–38.
8. Portaels F, Traore H, De Ridder K, Meyers WM. In vitro susceptibility of Mycobacterium
ulcerans to clarithromycin. Antimicrob agents Chemother, 1998; 42:2070–2073.
9. Shepard CC. A kinetic methog for the study of the activity of drugs against Mycobacterium leprae.
Int. J. Lepr, 1967; 35:429–436.
10. Stanford JL, Phillips I. Rifampicin in experimental Mycobacterium ulcerans infection. Med
Microbiol, 1972; 5:39–45.
11. Van der Werf T, Van der Graaf WTA, Tappero JW, Asiedu K. Mycobacterium ulcerans
infection. Lancet, 1999; 354:1013–1018.

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WHO antibiotic trial
Dr Mark Wansbrough-Jones, Division of Infectious Disease, St George’s Hospital Medical School,
London, United Kingdom

At the 2001 meeting of the WHO Advisory Group on Buruli ullcer a trial protocol was presented, the
objectives of which was to evaluate the efficacy and safety of antibiotic therapy with rifampicin and
streptomycin given at different durations in early stage M. ulcerans infection (Buruli ulcer) in Ghanaian
patients. The goals was to gather preliminary information for a future larger trial, as part of the serach
for an effective alternative to surgery. Specific objectives were (1) to evaluate the efficacy of antibiotic
therapy with rifampicin/streptomycin combination given at different durations of 2, 4, 8 and 12 weeks,
in terms of (I) clinical improvement of the lesion (complete healing of significant reduction of lesion
size), (ii) histopathological improvement in the lesion, (iii) evidence of antibactericidal activity, i.e.,
complete clearance or significant reduction of total viable M. ulcerans in the lesion, (iv) recurrence rate
after complete healing within 6 months follow-up period, and (2) to assess the safety and tolerability of
the combination given for different lengths of time in patients with early stage M. ulcerans infection.

The initial proposal was to include 5 groups of 5 patients of both sexes (aged > 5 years) all with early
M. ulcerans lesions diagnosed clinically by the principal investigator. Those willing to participate in the
trial would be randomised to receive one of the following 5 treatments:
Group I: immediate lesion excision without antibiotic therapy
Group II: antibiotic therapy for 2 weeks, followed by excision
Group III: antibiotic therapy for 4 weeks, followed by excision
Group IV: antibiotic therapy for 8 weeks, followed by excision
Group V: antibiotic therapy for 12 weeks, followed by excision

Antibiotic therapy in all cases is the combination of rifampicin 10mg per kilogram body weight orally
per day and streptomycin 15 mg per kilogram body weight intramuscularly per day to be given once
daily at the same time. Patients would be admitted to hospital during antibiotic treatment, at surgery and
for 10 days after surgery. They would be advised to come back to the hospital for follow-up at 6 weeks
and once every 2 months up to 6 months after surgery or whenever recurrence occurs. During antibiotic
treatment, clinical assessment as well as monitoring of adverse events would be performed daily; lesion
and laboratory (clinical chemistry, urinalysis) assessments would be done weekly; a hearing test would
be done every two weeks. Tissue samples would be collected after lesion excision (immediately after
excision in Group-II, III, IV and IV) for histology, molecular marker for viable M. ulcerans, PCR for
M. ulcerans and bacteriology. Assessment of lesions would be performed 3 days, 1 and 6 weeks, and 2,
4 and 6 months after surgery to detect any sign of recurrence of lesion.
The trial was approved by the local ethical committee in Kumasi and by the WHO ethical committee but
the latter recommended that the lower age limit be increased to 15 years which has had a serious impact
on recruitment. Also the group were changed following concern about the accuracy of clinical diagnosis.
Group II was removed and the number of patients in each of the other groups was increased to 10 (total
40). Randomisation was arranged in groups of 4 to ensure even recruitment to the groups.
By February 2002, 16 patients had been recruited to the trial. The rate of correct diagnosis has been high
and work has begun on microbiological analysis in the laboratory of Professor Carbonnelle. The current
state of recruitment will be reported at the meeting.

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The role of water bugs in the transmission of Mycbacterium ulcerans
Laurent Marsollier,1* Jacques Aubry,2 Timothy Stinear,3 Raymond Robert,4 Jean-Paul Saint André,5
Henri Kouakou,6 Pierre Legras,1 Anne-Lise Manceau,1 Mahaza Chetaou,1 Henri Asse,6 Bernard
Carbonnelle1
1
Laboratoire de Bactériologie-Virologie-Hygiène, CHU, 49033 Angers, France.
2
INSERM U435, Institut de Biologie & Faculté de Pharmacie 44035 Nantes, France.
3
Unité de Génétique Moléculaire Bactérienne, Institut Pasteur, rue du Docteur Roux, 75724 Paris cedex 15 France2
4
Laboratoire de Parasitologie, Faculté de Pharmacie, 49000 Angers, France.
5
Laboratoire d'Anatomie Pathologique, CHU, 49033 Angers, France.
6
Laboratoire de Bactériologie, Institut Raoul Follereau, Adzopé, Côte d'Ivoire.

*To whom correspondence should be addressed. E-mail: laurentmarsollier@hotmail.com

Mycobacterium ulcerans is an environmental mycobacterial species that is the etiologic agent of Buruli
ulcer, a disease that usually begins with a painless nodule or papule in the skin which, in the absence of
effective treatment, results gradually in extensive skin ulceration. Given that the drug treatment is still
disappointing (1), the only effective care is surgical excision of necrotized and infected tissues. Such a
treatment requires long hospital stays and cannot prevent functional invalidities. Prevalence of Buruli
ulcer has been dramatically increasing in West Africa for the last ten years so that it is now the third
most common mycobacterial human infection, after tuberculosis and leprosy (2).
Since the work of the Uganda Buruli Group (3), it is assumed that the infection by M. ulcerans is related
to swampy areas of tropical countries. Interestingly M. ulcerans has been detected by direct polymerase
chain reaction (PCR) in environmental waters (4-6) and in water bugs (5), suggesting that people living
in swampy areas of tropical countries, get infected through minor wounds or skin abrasions in contact
with infected water. An attractive hypothesis for a possible mode of transmission to humans was
recently proposed by Portaels et al. (7): water-filtering hosts (fish, molluscs) concentrate M. ulcerans
present in water or mud , which are then ingested by aquatic predators such as beetles or water bugs. In
turn these insects could transmit the disease to humans by biting. Despite studies identifying by PCR the
presence of M. ulcerans in aquatic environment, the role of water insects as an intermediate host has
remained so far elusive. In the present report, we demonstrate that :
i) contaminated aquatic bugs were able to transmit M. ulcerans into mice by biting;
ii) after experimental infection of the bugs, M. ulcerans was localized in salivary glands and
iii) those of aquatic bugs collected in an area endemic for Buruli ulcer were naturally harbouring
M. ulcerans as assessed by PCR and positive cultures.

Aquatic bugs are insects abundant in freshwater rich in vegetation throughout the temperate and tropical
regions. Classified in many families of the order Hemiptera (Naucoridae, Belostomidae, Nepidae…)
most of them are carnivorous. Whether they are found in temperate countries like France or tropical
ones like Côte d'Ivoire, they have the same way of life and prey, according to their size, on molluscs,
fishes, and the adults and larvae of other insects that they catch with their raptorial front legs and their
rostrum.
Naucoris cimicoides, fed with grubs experimentally infected with M. ulcerans, can transmit the bacilli to
mice by biting. Seven out ten Balb/c mice the tail of which had been bitten by N. cimicoides fed with
these grubs developed 59 to 87 days later, a non ulcerative inflammatory lesion with oedema at the point
of bite. Cultures and PCR performed from tail lesions were positive for M. ulcerans. No lesion occurred
in mice bitten by control bugs. Histological sections were made on bugs fed with grubs experimentally
infected by M. ulcerans. AFB were observed in the accessory and main salivary glands. The presence of
M. ulcerans in insect tissues was confirmed by PCR, culture and immunochemistry.
When aquatic bugs were fed with grubs experimentally infected with other mycobacteria known to be
present in aquatic environment, M. kansasii a slowly growing species, M. marinum, M. chelonae and

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M. fortuitum, both rapidly-growing species, no AFB was observed in salivary glands or in other tissues.
Surpringsly the presence of M. ulcerans in salivary glands was not temporary but permanent. Till the
105th day after being fed with infected grubs, sections of N. cimicoides salivary glands stained either by
Ziehl-Neelsen or by specific antibodies exhibited an extremely large number of M. ulcerans. Moreover
M. ulcerans not only did survive in the salivary glands of the bugs but also did multiply locally as
suggested by the presence of mycobacterial clusters. In three N. cimicoides fed with grubs containing
106 AFB of M. ulcerans, we harvested 105 days later about 108 AFB in the accessory salivary glands
using the method developed by CC Shepard to enumerate M. leprae in the footpad of mice (8). Together
these findings demonstrate that aquatic bugs are not just a passive vector of M. ulcerans infection, but
enabled M. ulcerans to multiply in their salivary glands.
In Côte d'Ivoire, an endemic country for Buruli ulcer, the aquatic bugs are present in swamps or river
locations with intensive human activity like farming, fishing or bathing. This prompted us to capture in
the endemic area of Daloa eighty aquatic bugs. Since in our preceding findings M. ulcerans was
restricted to salivary glands, PCR and cultures were performed on these tissues. M. ulcerans was
detected by PCR in five out of 80 Naucoridae. Two of them, gave a positive culture on Löwenstein-
Jensen medium at 30 °C only. The PCR performed on the two isolates demonstrated specific sequences
of M. ulcerans. About 104 bacilli of each isolate were subcutaneously inoculated into the tail of five
mice, and height weeks later, signs of infection were observed; PCR performed on infected tissues were
positive for M. ulcerans. These results confirmed that the aquatic bugs could be naturally contaminated
by M. ulcerans. For the first time, M. ulcerans was isolated directly from environment.
The waters bugs may become good flyers, so they could colonize new swampy areas and create new foci
at Buruli ulcer. However it does not exclude other ways of transmission or even other environmental
reservoirs.

References

1. H. Darie, S. Djakeaux, A. Cautoclaud, Bull Soc Pathol Exot, 1994, 87:19–21.

2. K. Asiedu, R. Sherpbier, M. C. Raviglione, Report 2000 Word Health Organisation Geneva
Switzerland (2000).
3. Ugangd Buruli Group, Trans R Soc Trop Med Hyg, 1971, 65:763–75.
4. B. Roberts, R. Hirst, J. Clin.Microbio, 1997, 35:2709–2711.
5. F. Portaels, P.-A. Fonteyne, W. M. Meyers, The Lancet, 1999, 353:986.
6. T. Stinear et al., J Clin Microbiol, 38:1482–7. (2000).
7. F. Portaels et al., Rev Sci Tech Of. int Epi, 2001, 20:252–64.
8. C. C. Shepard, D. H. M. Rae, Int. J. Lepr, 1968, 36:78–82.

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Advocacy, social mobilization and training for Buruli Ulcer

Dr Elil Renganathan, Coordinator, Social Mobilization and Training, Programme for Communicable
Diseases, World Health Organization

Social mobilization and training Unit (SMT)

The mandate of SMT

• Social mobilization
Objective: To develop social mobilization strategies and tools, and build capacity in social
mobilization in order to mobilize broad support for disease control and prevention.
• Advocacy
Objective: To develop messages and strategies to raise public awareness and increase political and
financial support.
• Training
Objective: To coordinate training as a basis for capacity building for the control, prevention and
eradication of communicable diseases

Key Action Areas for the GBUI

• Global Advocacy
• Health and Allied Workers Training
• Social Mobilization and Communication

2001: Achievements

Social mobilization
− Social mobilization guidelines being developed
− Comic book targeting school children published (cross-sectoral distribution)
− Draft COMBI plan to tackle BU at country level developed

Advocacy
− BU advocacy brochure produced
− Development of the “strategic areas for support and action” document
− Support to resource mobilization efforts

Training
− BU training manuals for health workers completed
− Training videos for health staff under development

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 Capacity building for Buruli Ulcer

Three key areas:

• provision of enabling environment
• intensification of training and retraining
• technical support mechanisms

Major goals of capacity building for GBUI

• advocate and support the development of effective Human Resources Development policies and systems
• strengthen capacity to plan and manage programmes
• improve and maintain service provider capacity
• build community capacity
• strengthen research capability
• partnerships and resource mobilization

Training plan for 2002

Key activities
• Finalisation of training tools (e.g. Video)
• Regional training of surgeons as resource persons
• In country training workshops (7 priority countries)
• Promotion of early detection and treatment in schools

Partnerships: working together

• A shared vision and common goals

• The need for leadership and strong coordination, especially the stewardship role of governments
• A clear public health orientation with clear targets, community ownership and effective
interventions
• Building on specific comparative advantages of each partner
• And accountability through transparent reporting, monitoring and evaluation

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Contribution of ANESVAD

Mrs Verónica Malda and Mr Andrés Ginés, ANESVAD, Bilbao, Spain

Ladies and Gentlemen,

The ANESVAD Foundation is a Spanish non-governmental organization which since 1968 has
been engaged in health and welfare projects on behalf of the world's neediest groups. At present, it
is active in 28 countries in Asia, Latin America and Africa.
Among all the challenges which ANESVAD has constantly taken up over the past 34 years, its principal
objective has always been efforts to control leprosy. Since 1999, it has also included Buruli ulcer
control.
In order to control Buruli ulcer, ANESVAD operates in the following three major fields of activity:
1. direct care for Buruli ulcer patients;
2. research;
3. information and awareness campaigns.

1. Direct care for Buruli ulcer patients

In Côte d'Ivoire, between March 2001 and March 2002, ANESVAD carried out approximately 20
projects to improve care for Buruli ulcer patients. We shall briefly describe them below.

Treichville hospital dermatology centre

The rehabilitation and equipment of the surgical units at Treichville Hospital dermatology centre, which
were inaugurated in April, is now complete. Under the agreement which the Government of Côte
d'Ivoire entered into with ANESVAD, through a framework cooperation agreement signed in November
1999, Buruli ulcer patients will receive treatment free of charge in this centre.

Kongouanou clinic
Also in April, the surgical unit of the Kongouanou clinic was inaugurated. ANESVAD has built this unit
and rehabilitated other parts of the clinic. Because of problems of space in the operating theatre's
sterilization room, it needed to be enlarged, the cost of which was met by ANESVAD. In addition,
ANESVAD pays the wages of the Centre's staff and the cost of feeding patients.

The demi-Emile Centre in Zouan-Hounien

Anaesthesia, which is necessary to perform operations on Buruli ulcer patients is now provided in the
operating theatre. Funding has also been provided for the purchase and installation of an autoclave. In
addition, ANESVAD contributes to the centre's operating expenses, staff wages, pharmaceutical
expenditure and pays part of the cost of feeding patients.

Sakassou clinic
ANESVAD has financed the purchase of a vehicle to enable the Sisters responsible for Sakassou clinic
to conduct early detection programmes in villages in the region of Sakassou. In addition, because the
number of Buruli ulcer cases is constantly increasing in this zone, it has become necessary to build a
hospital for 30 patients. Consequently, ANESVAD has financed the building of the hospital, which has
treatment rooms, a pharmacy, a room for perfusions, three wards, bathrooms, a refectory, kitchen,

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laundry and store. The hospital, which will treat Buruli ulcer patients, especially patients from the most
remote villages, has also been equipped.

Saint-Michel Health Center in Zoukougbeu

The Saint-Michel health centre in Zoukougbeu has been provided with a vehicle for early detection
campaigns and to help with transport of drugs and other supplies from Abidjan (450 kilometres away).
The Centre also receives assistance with staff wages and with its operating and maintenance costs.

National Buruli Ulcer Control Programme (PNUM)

Throughout this year, ANESVAD has funded the following projects, through PNUM:

− Surgical missions for Buruli ulcer patients in treatment centres which ANESVAD has rehabilitated
and equipped, including Kongouanou, Zoukougbeu and Zouan-Hounien. Teams of surgeons from
Abidjan or Manikro have carried out these missions. Each team, comprising two surgeons and two
nurses, operates on approximately 20 patients each month in each centre.

− Early detection and treatment missions for Buruli ulcer cases in 8 endemic zones. These seven-day
missions are carried out at the rate of one per month in each centre. The health workers participating
in the missions comprise a team of PNUM physicians and another local team with a physician, two
nurses and two community health workers from each region in which the mission is carried out.
ANESVAD finances expenditure on personnel and support, drugs and fuel. These missions have
been particularly successful both for the personnel involved in them and for the patients and
inhabitants of the endemic zones visited.

During the visit organized by ANESVAD to Côte d'Ivoire at the end of April 2001, we held a number of
meetings with Professor Kanga, Executive Director of the National Buruli Ulcer Control Programme,
who described to us the financial situation of the programme as a result of the country's current political
circumstances.
As a result of the conversations, and because of ANESVAD's commitment to Buruli ulcer control, it was
decided, on an exceptional basis, to provide financial support to PNUM for one year and to pay off all
its accumulated debts and expenses.
St Martin Hospital in Agroyesum, Ghana

* In addition to the above, and in line with its commitment to Buruli ulcer control, ANESVAD has
expanded its assistance to Ghana where, at the beginning of this year, building began on a new surgical
theatre at the St Martin hospital in Amansie West district, Ashanti. The five-year development plan
drawn up by the hospital includes the construction of this surgical unit, in which it will be possible to
carry out operations on Buruli ulcer patients, who currently occupy 50% of its beds.

2. Research

* Research is another field of action in which ANESVAD is involved. The general lack of knowledge
about how to control Buruli ulcer, the fact that at present there is only one effective form of treatment
(surgery) and the manifest limitations of this, have led ANESVAD to support the clinical trial directed
by professor Kanga. The results of this research, involving a sample of 100 patients, will be described by
Professor Kanga in his presentation.

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3. Information campaigns

As we already explained last year, providing information is one of ANESVAD's main tasks. To this end,
during the past year, ANESVAD has continued its major effort to inform and educate the population,
both in Spain and in endemic countries, about this growing problem.

Internationally, ANESVAD has significantly increased its cooperation with WHO, and has
collaborated in the following projects:
Ÿ A Spanish language video on Buruli ulcer produced by WHO;
Ÿ Manuals on the treatment of Buruli ulcer, in English, French and Spanish;
Ÿ A Spanish-language monograph on Buruli ulcer;
Ÿ A comic strip on Buruli ulcer, in French.

In Spain, in order to inform different media about the disease, ANESVAD has:
Ÿ published numerous information leaflets which have been sent to all the Spanish media and to its
145 000 Members and collaborators in Spain;
Ÿ Organized different lectures, press conferences and photographic exhibitions on Buruli ulcer;
Ÿ Taken part in different radio and TV broadcasts.

As far as its future activities are concerned, ANESVAD reiterates its resolute support for Buruli ulcer
control, and intends to do everything possible to support control efforts in all areas and countries
affected.
To conclude, we should simply like to say, following the recommendation made last year at this
meeting, that ANESVAD has ceased to describe Buruli ulcer as the leprosy of the twenty-first century,
in order to avoid undesirable stigmas and associations.
On behalf of all the ANESVAD team, thank you very much.

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The intervention of AIFO to help in the fight against Buruli ulcer in Ghana

Dr Sunil Deepak, AIFO, Associazione Italiana Amici di Raoul Follereau, 4 via Borseli, 40135
Bologna, Italy

AIFO interest in the work against Buruli Ulcer goes back to 1999, after a visit by Prof. Nunzi to Ghana,
and encouraged by the deep concern regarding the problem of their Local Representative Dr. George
Abram.
Initially it was thought that AIFO should include in its intervention two districts, Akwapim South and
Amasaman. But for the time being only Amasaman has been selected. The reason for the choice was
that the latter needed more help and more urgently. Amasaman is the administrative centre of Ga Rural
District, located in the rural area not far from the outskirts of Accra, the capital city of Ghana. The Ga
District has been created quite recently and therefore lacks many essential commodities, like buildings
for the administration and health centres.
This rural area, besides the congenital problems of lack of roads, electricity and pipe-borne water, is
constantly being degraded due to uncontrolled excavation of sand: the greenery is removed, the sand
carried away, and all that is left is just barren soil which turns into marshes during the rainy season and
slowly becomes a swamp.
When AIFO studied the problem, not many serious steps were taken in Ghana towards the prevention
and cure of Buruli Ulcer, notwithstanding the rapid and wide spread of the disease in the last decade,
and the seriousness of the Ministry of Health in this regard. Both the patients and their families have
been very reluctant to refer to the health authorities. Some of the reasons for this noncompliant
behaviour and neglect may be rooted in the belief that such a disease is linked to a supernatural cause,
which is reminiscent of the former attitude of the population to leprosy. Therefore people have been
referring to shrines and shamans rather than doctors and hospitals. The experience that official medicine
could not do much to heal the wounds was another cause of distrust and it deepened the superstitious
belief. Another drawback is the fact that the nodules and ulcers are usually painless, and so the patient is
not urged to seek relief, and not from a doctor in any case.
We know that the ulcer can be prevented by early surgery and may also be successfully treated, after its
inset, with the standard procedures requiring daily care. It was therefore decided, in accord with the
Ministry of Health of Ghana, to build a small hospital and furnish it with all the necessary facilities,
because in the Ga District there was only one health centre, without a theatre and wards where Buruli
patients may be admitted after the intervention to remove the nodule or any other kind of surgical
treatment to clear and reduce the ulcer, or to avoid further damage caused by the disease.
The plan includes an integrated programme for the overall running of the project. It spans from health
education activities to training of rural health personnel, to domiciliary management of ulcers. The
building of the hospital is in finished, and plans for the other aspects of the project are being studied and
prepared together with the Directorate of the Ministry of Health. Thanks to the untiring efforts and
selfless work of the Director of the District, Dr. Ernestina Mensah, and the support of the surgeon at the
hospital of Ankaful (the headquarters of the Leprosy Programme) Dr. Ekow Otabir, many patients have
been helped, and the situation in the district is no more one of emergency.
In the meantime AIFO sponsored a survey to identify the villages in dear need of clean water, and the
feasibility of sinking wells in their premises. This will part of the intervention of AIFO for the current
year 2002, together with some forms of support in the medical field: medicines, disinfectants, material
for the operating room, dressing, vehicle maintenance, training courses and material.
Dr. George Amofah will illustrate the epidemiological data concerning the Ga Rural District. I would
like to add only the number of cases treated at the main hospital of Ankaful: during the 2001 a total of
25 little patients were admitted for intensive treatment, ending up with skin grafting and skin transplant.

137
The average stay of each patient was of about 105 days. Taking young patients to Ankaful however
creates a great many problems for the families, even if in this hospital we provide for all the needs of
those affected by the Buruli Ulcer, including the meals. The major problem is the distance factor, about
200 km. A new hospital complex is foreseen at Amasaman. The work is already in progress thanks to
the interest and intervention of other NGO’s, including some members of ILEP.
The financial commitment of AIFO for the year 2000 was US$ 121,523.39, and US$ 56,909.30
for 2001, for a total amount of US$ 178,432.69.

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Leprosy Relief Emmaüs – Switzerland (ALES)

Patricia Beauverd, ALES, Switzerland

Leprosy Relief Emmaüs – Switzerland, a non-governmental organization founded in 1960, has its
headquarters in Bern. For approximately 40 years it has specialized in efforts to control leprosy, and is
active mainly in India, Cameroon and the Central African Republic. In 1998, TB control activities were
associated with leprosy control in Cameroon. As the leprosy control network covers the whole country,
it can easily undertake other tasks. When the presence of Buruli ulcer was suspected in some areas of
Cameroon, it was quite normal for us to turn our attention to the problem.
After having been informed by the leprosy controllers in Ayos and Akonolinga health districts of the
presence of an endemic of chronic mutilating ulcers that were unresponsive to treatment, we decided in
agreement with the Cameroonian Ministry of Health, to undertake an official survey between 20 and 21
August 2001.
Ÿ The endemic affects Centre province
Ÿ A joint survey was carried out with Médecins Sans Frontières Suisse and the Ministry of Health in
Ayos and Akonoliga health districts
Ÿ The survey covered 12 health areas in which a total of 85 villages with a population of 98 000 were
visited, i.e., 75% of the districts' total population
Ÿ A total of 438 cases were identified within a radius of 40 km

Table 1 – Survey

Health areas Villages Population N° of cases Prevalence

Ayos 5/7 35 40 000 = 81% 97 2.4
Akonolinga 7 / 11 50 56 000 = 70% 331 5.9
Abong Mbang 1 (partly) 2500 = 3.8% 10 2.5
Total 98 500 438 4.4

Table 2 – Buruli ulcer, active phase

Number of cases 199

Age: 0 to 15 years 107
Age: 15 and above 92
Male 113
Female 86

A total of 152 samples were analysed by the Swiss Tropical Institute in Basel. Ninety of them proved
positive, 24 negative and 39 required further analysis to confirm the diagnosis.
Ÿ Detection makes it possible to inform the population and ensures access to treatment
Ÿ Case management of patients identified reduces the disability rate
Ÿ Community case management ensures early detection and primary prevention
Ÿ Accompanied research leads to progress in our understanding of the disease

Our long experience of leprosy control in the field has taught us that it is not possible to address a
problem of this scale solely from the emergency angle. If Buruli ulcer control activities are to be viable,
a comprehensive and general approach must be adopted from the outset. Each successive stage needs to
be planned until the programme is operational.

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A Swiss partnership comprising:
Ÿ Médecins Sans Frontières Suisse
Ÿ the Swiss Tropical Institute
Ÿ Geneva University Hospital, and
Ÿ Leprosy Relief Emmaus – Switzerland, working in close collaboration with the
Ÿ Cameroonian Ministry of Health and the
Ÿ World Health Organization

Cooperation between various agencies should make it possible to carry out the activities step by step.
Funding is currently being sought in order to secure the long-term management of the programme. All
the organizations involved have been active in Cameroon for many years and have a wealth of
experience in their respective areas. For Médecins Sans Frontières Suisse and Geneva University
Hospital, the priorities are:
Ÿ To strengthen existing structures; an audit has shown them to be wholly inadequate;
Ÿ To plan and carry out surgery;
Ÿ To ensure the quality of local skills by training those involved in providing hospital care.

In practical terms, Médecins Sans Frontières Suisse will provide case management for the patients, in
collaboration with Geneva University Hospital. In order to ensure the quality of the surgery and of local
skills, the referral structures will first of all need to be reinforced.
Ÿ Health education ensures that community care is provided
Ÿ Early detection is vital in order to prevent disabilities
Ÿ Primary-level prevention requires awareness-raising, mobilization and communication to change
behaviour
Ÿ Case management for patients presenting the first symptoms of the disease is ensured by training
primary-level health workers

Early detection and primary-level prevention through health education and training of primary-level
health workers will be the responsibility of Leprosy Relief Emmaus-Switzerland, which has the
necessary skills and experience for this type of action. The leprosy-control network is ideally suited to
all these activities. The objective of the Swiss Tropical Institute is to improve the health of populations;
to achieve this:
Ÿ Its field of research will enable it to answer all the questions posed about the disease, which has
very significant social and economic consequences
Ÿ Epidemiology should make it possible to determine factors responsible for the emergence of the
disease
Ÿ Knowledge of the biology and immunology of M. ulcerans are fields of research that may lead to
the development of a vaccine
Ÿ The development of diagnostic tools is intended to facilitate care for patients.

Accompanied research to develop a better knowledge of how the disease is understood by the
populations, of its social and cultural and socio-economic aspects, and of the epidemiology, biology and
immunology of M. ulcerans is the responsibility of the Swiss Tropical Institute, the overall aim being to
develop cheap and easy-to-use diagnostic tools and an efficacious and simple treatment. It may even be
possible to develop a vaccine.

Conclusion
It has been possible to imagine and set up a programme of this scope thanks to the commitment of
partners who are deeply involved in humanitarian action. At present, all that is needed is funding to
enable the project to start up, and we are hopeful that this will rapidly be found. Follereau Foundation of
Luxembourg, which will nevertheless have a seat on the Board of Directors, but by the Ministry of
Public Health. the Centre will act as a referral centre for detecting and treating Buruli ulcer. I shall now
play the video cassette showing how far the work has progressed.

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Communication from the Raoul Follereau Foundation of Luxembourg (FFL)
Professor Henry-Valère T. Kiniffo, Mr Robert Kohll, FFL, Luxembourg

Mr President, the Director of the Global Buruli Ulcer Initiative, dear colleagues, Ladies and Gentlemen
At the Group's fourth meeting in July last year, the Raoul Follereau Foundation of Luxembourg
presented its project to build a Buruli ulcer screening and treatment centre (CDT/BU) on a 4673 m2 site
at the health centre in Allada sub-prefecture, 56 kilometres from Cotonou, Benin's economic capital (see
map).
The centre comprises the following:
1. Four main buildings: a technical building, an operating theatre, a hospitalization building, an
administrative block
2. Annexes: grass huts, a shelter for two vehicles, a shelter for the generating unit, a kitchen for people
accompanying patients, a room for people accompanying patients, a room for medical fluids, a
drying room, a washroom
3. The roads, infrastructure and connections with public utility systems comprise fences, toilet
facilities, huts, showers, gardens, paths, pavements and sanitation works.

Building work, under the triple supervision of the Department of Infrastructure, Equipment and Material
(DIEM/SMP), which determines the required norms, of the architect and the consultant engineer
appointed by FFL, has been divided into three lots assigned to three different firms to save time.
The cost of the building work amounts to CFAF 422 384 900 i.e. € 643 922. If the cost of the various
studies, of supervision and control are included, the total cost of the work amounts to CFAF 452 396
518 i.e. € 689 674
4. FFL has also financed CFAF 400 000 000 i.e. € 609 796 worth of equipment and drugs. These
comprise:
• a four-wheel-drive vehicle (twin cab pick-up)
• a Toyota Land Cruiser ambulance
• two Yamaha 80cc motorcycles
• office furniture
• medical and rehabilitation equipment
• drugs
• a 30 kW generating unit

In all, if we include the additional consultants required, such as the engineer to carry out an energy
requirements assessment, the specific additional items of equipment, the forwarding agent, the reduced
import charges and transport, the overall FFL funding amounts to 1 thousand million CFA francs, i.e.
€1 524 490.

Plans

As you shall see, the work is already 87% complete, and delivery is scheduled to take place within three
weeks. The inauguration of the Centre by the Minister of Public Health is scheduled for June 2002. The
Centre will not be managed by the Raoul Follereau Foundation of Luxembourg, which will nevertheless
have a seat on the Board of Directors, but by the Ministry of Public Health. the Centre will act as a
referral centre for detecting and treating Buruli ulcer.
I shall now play the video cassette showing how far the work has progressed.

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Medical Assistance (MAP) International
Mr Edouard Yao, West Africa Regional Office, MAP International, Abidjan, Côte d’Ivoire

MAP International is a religious nongovernmental organiztaion that was founded in the United States of
America in 1954 in the State of Illinois which today comprises four regional offices: Latin America
(Quito, Ecuador), North America (Brunswick, Georgia), Eastern Africa (Nairobi, Kenya), West and
Central Africa (Abidjan, Côte d’Ivoire).

Presentation of West Africa MAP

Objective
A world in which people, families and communities have the hope and the ability to create the optimal
conditions to reach their “total health”.
“Total health” is defined by MAP International as the ability of individuals, families and communities to
work together to provide a sustainable basis for their physical, social, psychological, economic,
environmental and spiritual well-being.

Mission
Respond to the health community needs: physical, psychological, environmental, social, economic and
spiritual.

Areas of intervention of the Abidjan office

• Promotion of health community development
− Training, medical consultation, operational research
− Local health promotion
• Provision and rational use of essential drugs
• Prevention and eradication of the disease
− HIV/AIDS programme with the churches
− Guinea Worm Eradication Programme in Côte d’Ivoire
− Programme of drinking water supplies
− National Buruli Ulcer Control Programme

Support Programme to Buruli ulcer control

In 2001, MAP and ALM decided to join their efforts to support the Buruli ulcer Programmes in Côte
d’Ivoire and Ghana
ALM: American Leprosy Missions, American religious NGO working on leprosy elimination
MAP West Africa is responsible for the implementation of common actions

Objectives
Main objective: to support national programmes in their efforts to reduce the morbidity and the
mortality due to Buruli ulcer and its consequences

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Specific objectives:
• To support the planning, operation, follow-up and evaluation of activities
• To develop a holistic approach
• To provide with medico-surgical equipment and pharmaceuticals

Implementation
• Bringing to completion the development of the national strategic plan of Côte d’Ivoire : funding,
organization, operation
• Finalisation of 2002 operational plans of support to the 4 management sites : Kongouanou,
Sakassou, Zouan-Hounien, Zoukougbeu
Planned activities :
− Community-based early detection of cases and treatment
− Physiotherapy
− Socio-economic rehabilitation of cured patients
Acquired funding, starting of activities in early April 2002
• Provide medico-surgical equipment and pharmaceuticals : preparation of 2 containers for the
Programmes of Côte d’Ivoire and Ghana
• Health education : contribution to the financing of the Buruli ulcer comic
• Social mobilization : « Truth » (musical band) tour

Perspectives
To continue to support Côte d’Ivoire towards the extention of the model of the four operational sites to
the endemic health districts
Research of KAP (Knowledge, Attitude and Practices) towards the spiritual, socio-economic aspects
Opening of a multi-purpose center in Adjame (Abidjan)
Openinig to other endemic countries starting with the reinforcement of the management capacities of the
national programmes (planning, follow-up and evalutation) and the medico-surgical equipment and
pharmaceuticals support.

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