Buruli ulcer situation in Cameroon - minsante-cdnss.cm

Swiss TPHBURULI ULCER INCAMEROON:Buruli ulcer Advocacy Day.FMBS, UYI2nd November 2011Dr. Earnest NJIH TABAH, MD, MPH.SP-CNLP2LUB, MINSANTÉ, CAMEROON.

Definition of BU:♦♦♦♦Buruli ulcer disease is caused by Mycobacterium ulcerans, the 3 rdpathogenic mycobacterium after tuberculosis and lepraeInfection leads to extensive destruction of skin and soft tissue, largeulcersIf not detected and treated early, the results in long term functionaldisabilityEarly diagnosis and treatment is vital in preventing such disabilities

Clinical diagnosis of Buruli ulcerNodulePlaqueEdemaUlcer

Laboratory confirmation of BUTypes of specimencollected:♦♦SwabFine needle aspiration (FNA)Tests conducted:♦♦Ziehl Neelsen staining to lookfor AFBPCR♦Punch biopsy♦Culture♦Surgical biopsy♦Histology

Laboratory confirmation of BUAFB in ZNcolorationSpecific MUDNA seen inPCRMU incultureHisto-pathof BUlesion

Management of BU♦♦♦♦♦♦♦Specific antibiotic treatment Rifampicin/ Streptomycin once daily for56 daysWound careSurgical treatment (excision, skin grafting)Prevention of disabilityNutritionPsychosocial supportFunctional rehabilitation

Epidemiology of BUFrequently occurs near water bodiesAll ages and sexes are affected but over 60% of case are in childrenbelow 15 years90% of lesions occur on the limbs, especially the lower limbs(60%)Exact mode of transmission not knownNo evidence of person to person transmissionExact prevalence of the disease is not known.

History of BU Control: World♦♦♦♦♦♦♦Mycobacterium ulcerans first isolated in 1948 by MacCallum andcollaboratorsA large number of cases occurred in the Buruli county in Uganda inthe 1950s, hence the name Buruli ulcerIn 1998, the WHO established a Global Initiative against Buruli ulcerIn 2004, adoption of resolution WHA 57.1 on surveillance and controlof BU.In 2005, WHO introduced a medical treatment for BU with specificantibiotic (Rifampicin and Streptomycin)In 2009, the Cotonou Declaration on BU by Heads of States andgovernments of BU endemic countries in AfricaToday, over 30 countries around the world, with 13 in Africa known tobe endemic for BU

BU situation in Africa♦14 Confirmed endemic:Angola, Benin,Cameroon, CAR,Congo, C Ivoire, DRC,Gabon, Ghana, Guinea,Nigeria, Sudan, Togo &UgandaConfirmed endemic countriesSuspected endemic countriesNon-endemic countries♦9 Suspected endemic:Burkina Faso, Chad,Equatorial Guinea,Liberia, Malawi, Mali,Sierra Leone, Tanzania& Zambia

BU Control: Cameroon (1)♦♦♦♦♦First cases described in Cameroon in 1969 by Ravisse andcollaborators among in the Nyong valley (47 cases)Around 1999, District leprosy officers of Akonolinga and Ayos notifiedlarge ulcers in children and adults that would not respond totreatmentIn 2000, Noeske; Kuaban and collaborators carried out a survey in thehealth districts of Akonolinga and Ayos, that confirmed 436 cases ofBU.Commencement of BU care activities in 2002 by FAIRMED (formerALES) in Ayos and MSF-CH in Akonolinga.In the same year, the ministry of public health reorganized thenational leprosy control program to include Buruli ulcer control

BU Control: Cameroon (2)♦♦In 2004, Dr Um Boock carried out a national survey, which revealed thepresence of Buruli ulcer in 4 other regions in Cameroon: Adamawa,East, Far North, and South west.New endemic foci are being discovered year by year

Locations of BU endemic healthdistricts in Cameroon in 2010LAGDOSEMRIUNVDAMBOOPLAINS

Locations of BU endemic healthdistricts in Cameroon in 2010FAIRMED:BankimFAIRMED:MbongeFAIRMED:AyosFAIRMED:MbalmayoMSF-CH:Akonolinga

BU control strategies♦♦Objective:Diagnosed and treat all cases of BU according the WHOrecommendations free of charge.Strategies:Early detection of cases at the community level, and information,education and communicationTraining of health workers and village health workersCase management (a combination of antibiotics, surgery andprevention of disability/rehabilitation)Laboratory confirmation of casesStandardized recording and reporting system using forms BU 01 andBU 02Strengthening of health facilitiesMonitoring and evaluation of control activitiesResearch

New BU clinical cases since 2001Evolution of new cases of BU in Cameroon since 200110008006004002000914265 271312 323287223230132602001 2002 2003 2004 2005 2006 2007 2008 2009 2010•A cumulative numberof 3017 new casesbetween 2001 – 2010•287 cases in 2010

Case notification by BU DTC944 buruli ulcer cases notified between 2008 - 2010Case notification by BU DTC50%40%30%20%10%2008200920100%Akonolinga Ayos Bankim Mbonge Ngoantet

Age & sex distribution of BU casesAge distribution of cases 2008 - 2010Sex distribution of BU case60%60%50%50%40%30%20%10%0%2008 2009 201050yrs40%30%20%10%0%2008 2009 2010FemaleMale

Distribution by clinical forms andcategoriesDistribution of Clinical forms at diagnosisCategory of BU cases 2008 - 2010100%60%80%60%40%20%NoduleOedemaPlaqueUlcer50%40%30%20%10%Cat ICat IICat III0%2008 2009 20100%2008 2009 2010

Localisation of lesionLocalisation of lesionLimitation of joint movement at diagnosis70%60%50%40%30%20%10%0%Lower limbs Upper limbs Head/ neck Buttock/PerineumBody20102009200880%60%40%20%0%31% 28%37% 37%2007 2008 2009 2010NoYes

Treatment of BU in 2010Treatment of BU in 2010♦85% underwent ATBtreatment100%85%♦11% enrolled for heattreatment trial80%60%♦2% either delayed orrefused treatment40%20%0%11%2% 1%ATB Delay /Refusal Dressing Heat Rx Trial♦Average length ofhospital stay Cat 1: 12 weeks Cat 2: 16 weeks Cat 3: 24 weeks

Functional rehabilitation♦♦♦33 and 22 victims of BU who healed with disabilities benefitedplastic/corrective surgery from a team of Swiss plastic surgeons in2009 and 2010 respectivelyThis brought to 127, the number of victims who have benefited from theproject since 2007.Some indications of plastic/reconstructive surgery are as below

Research♦A number of research activities are ongoing in the domains of:Treatment (Antibiotherapy, heat treatment trial, clinical score)TransmissionSocio-anthropologic and economic aspects

Major Challenges♦Poor estimation of the real magnitude of Buruli ulcer in the country♦High cost of treatment♦Poor coverage of known endemic health districts♦Health personnel not properly trained in BU care (total absence ofinitial training in faculties of medicine and training schools for nurses)♦Only 3 development partners involved in BU care in Cameroon

Perspective♦♦♦♦♦♦♦Intensification of advocacy for increase government resources for BUcareSearch for new development partners to support BU control inCameroonSurveys to confirm new suspected endemic areasActualize the cartography of Buruli ulcer in the CameroonScale up coverage of new endemic health districtsIntroduce courses on BU in training schools for nurses and facultiesof medicineDiversify research areas

Acknowledgements