1A9bnbK

70 THIRD WHO REPORT ON NEGLECTED TROPICAL DISEASES
***
4.1 Buruli ulcer
Introduction
Buruli ulcer is a chronic necrotizing skin disease caused by infection with Mycobacterium
ulcerans. Historically, the disease has been reported from 33 countries, 15 of which
continue to report cases to WHO annually (1). Globally, there is no clear pattern in the
distribution of cases, but an increasing trend has recently been found in Australia (2), Gabon
(3) and Ghana (4).
Although in areas without ready access to reference laboratories, diagnosis by experienced
clinicians may suffice to initiate treatment, increasingly countries are expected to ensure that
at least 70% of reported cases are laboratory-confirmed. In 2014, WHO published a manual on
the laboratory diagnosis of Buruli ulcer to guide health workers in the field (5).
WHO recommends combined antibiotic treatment using rifampicin and streptomycin,
with or without surgery and physiotherapy, depending on the stage, location and extent of
the disease (6). Since the publication of WHO treatment guidelines in 2004, more than 50
000 people have benefited from combination antibiotic therapy, almost halving the need for
surgery, the mainstay of treatment in the past.
The main challenges associated with management of the disease are the long periods needed
for healing, a process that includes hospitalization, and the contractures resulting from late
healing, especially when lesions cross joints and treatment is inadequate. At least 25% of
healed cases have some degree of disability. Death in patients is related to sepsis and tetanus.
Coinfection with HIV is an emerging issue for which optimal clinical management has yet to
be defined. Provisional guidance has been published until more data are accumulated (7).
The Global Buruli Ulcer Initiative comprises academic and research institutions, donor
agencies, nongovernmental organizations, Member States and WHO. Its aims are to raise
awareness of the disease, improve access to early diagnosis and treatment, and promote the
development of better tools for treatment and prevention. The strategy, which is based on the
Cotonou Declaration adopted in Benin in 2009 (8), is designed to minimize morbidity and
prevent disability through early detection and treatment. Opportunities to implement control
measures for Buruli ulcer together with other public-health programmes should be seized.