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BURULI ULCER (Mycobacterium
ulcerans disease)
Margaret Hughes, Oxford
Buruli Ulcer is the third most frequent mycobacterium
disease after tuberculosis and leprosy, but it is not a notifiable disease
and has not been considered a public health problem. Patients mainly receive
care from private volunteer/mission hospitals or traditional healers.
In May 2004 the World Health Assembly (WHA) expressed its deep concern
about the spread of Buruli ulcer disease, especially among children, and
its impact upon poor rural communities in the thirty-two countries affected.
The diagnosis of Buruli ulcer is confirmed by the finding of the acid-fast
bacilli.
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Figure 1: Countries
where Buruli Ulcer is present (areas in red).
Democratic Republic of Congo
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The WHA, aware that early detection and treatment minimises
the adverse consequences of the disease, urges its Member States in which
the disease is endemic to assess the burden, establish a control programme
and accelerate efforts to detect and treat cases at an early stage. Further,
the Assembly calls upon the international community, the United Nations
and Non-Government Organizations to co-operate and support these approaches
in the countries concerned.
Figure 2: Buruli ulcer, IME Hospital,
Kimpese, DRC.
Treatment of Buruli ulcer with antibiotics and surgery.
Figures 2a and 2b (above,
and below left)
Buruli ulcer before treatment.
Figure 2c (below right).
Buruli ulcer after excision.
The disease is usually transferred via minor
scratches and if not treated it develops into an ulcer involving the sub-cutaneous
fat tissue and spreads to other tissue, produces a toxin that causes necrosis
and can result in osteomyelitis, deformity, disability and death. There
have been several reports of Buruli ulcer with concurrent HIV infection.
One centre that is endeavouring to follow an approach similar to that
recommended by the WHA is the Institut Medical Evangélique (IME)
[Protestant Medical Institute] Kimpese hospital in south-west Congo. A
summary of a recent article from that centre is given below.
Buruli ulcer in the Democratic
Republic of Congo: epidemiology, presentation and outcome
A E Bafende MD, MD Phanzu MD and BB
Imposo MD
IME/Kimpese Hospital, Kimpese,
Congo Democratic Republic
Mycobacteria are the cause of tuberculosis and leprosy.
In the tropical regions of the world another strain, mycobacterium ulcerans,
causes the Buruli ulcer, so named after a district in Uganda where it
was investigated in the 1960s. Buruli ulcer has been reported in twenty-seven
tropical countries in Africa, America, Asia and the west Pacific. The
most common site of occurrence is on the legs.
In Congo the first case was reported in 1950 in an American boy living
in the Kwilu and later it was reported in the Bas-Congo and Kivu provinces.
Bafende et al report on the occurrence of this type of ulcer in the Kimpese
region from 1989 to 2002 and have set up a project to fight the infection
in the Bas Congo.
In 2002 the population of DRC was estimated to be 50 million, seventy
percent of people live in rural areas. 57% of the population are under
19 years and 39% are aged between 20 and 50 years old. There is one doctor
for every 22,637 people and one nurse for every 1,714 people. The Bas-Congo,
one of eleven provinces, has a population of about 2.5 million. The IME
Kimpese hospital has 400 beds and serves 150,000 people in the local area
and a further 600,000 in the surrounding district. From 1989 to 1999 45
skin ulcers in the hospital were Buruli ulcers, an average of four cases
per year. During 2000 and 2001 there were 62 cases, average 31 per year
and in the first ten months of 2002 there were 14 cases. The mean duration
of hospitalisation was six months in 1989–1999; five months in 2001–2202
and decreased to three months in 2002. During 2000–2001 50% of patients
were under 15 years old and 44% between 16 and 20 years old. The ulcer
occurred more often in males than females increasing from 55% in males
in the earlier period to 79% in males in 2002. Bafende et al suggest that
this could be explained by the fact that most of the boys would be playing
and swimming in the swamps while the girls helped their mothers in the
village! In Kimpese itself where the water supply is good there were fewer
cases.
The number of cases of the Buruli ulcer showed a big increase in 2000–2001,
and a decrease in 2002. However, Bafende consider that the number of cases
in the area is considerably higher, a research team having reported 20
cases following a single day’s investigation. Many patients cannot
reach a hospital or medical centre and many cannot afford the treatment.
The direct cost per patient (drugs and medical and nursing care is estimated
to be US $466 which is 2.5 times the average annual income in the area.
The decrease of hospitalisation time from six months to three months is
attributed to the implementation of a protocol for the management of BU
ulcer introduced in the IME Kimpese hospital in 2000 and, since 2002,
the management of the ulcer by excision of the lesion and the use of antibiotics.
The mortality rate decreased from 7% between 1989 and 1999, to 3% in 2000–2001
and 0% in 2002.
Figures 2d. Site of Buruli ulcer, post-grafting.
Figure 3. Buruli ulcer, comparison
of cases per annum in Kimpese,
and percentage of deaths, for the period 1989 to 2002
References
Buruli ulcer: global situation. www.who.int/gtb-buruli
Surveillance and control of Mycobacterium ulcerans disease (Buruli ulcer).
WHA 57.1, May 2004.
Bafende AE, Phanzu MD and Imposo BB. Buruli ulcer in the Democratic Republic
of Congo: epidemiology, presentation and outcome. Tropical Doctor
2004; 34: 82–84.
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