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WHO guidelines on Buruli ulcer need adjustment

18 June 2010 Institute of Tropical Medicine Antwerp

Buruli ulcers, one of the ‘neglected tropical diseases’ left aside by big pharma and governments alike, are reasonably well treatable, also in poor regions. But then more attention has to be paid to early diagnosis and correct treatment. This means the rules of the World Health Organization urgently need to be changed. So say scientists of the Antwerp Institute of Tropical Medicine (ITM), based on ten years of research in Congo.

The disease is caused by Mycobacterium ulcerans, a nephew of the infamous tuberculosis bacterium. It occurs in tropical and subtropical countries, mainly in Africa. It causes hideously ulcerating ‘holes’ in the skin, that can dig to the bone and can outgrow to diameters of more than 10 centimetres. Much about the disease is unknown, for instance how exactly people get infected. It is assumed that water plays a role, but only in 2008 scientists – at ITM – succeeded in cultivating the bacterium from a water insect.

For a long time the only treatment consisted of caring for the wounds, and possibly a skin transplantation. Nowadays the WHO proposes a treatment analogous to tuberculosis, with two antibiotics, rifampicin and streptomycin. This works for light cases, but for lesions above 10 cm the effect was not documented. ITM scientist Anatole Kibadi Kapay collected cases in DR Congo from the previous five years, when surgery combined with antibiotics was used, and from the five year before that, when only surgery was used. In the process he discovered a new focus close to the Angolan border; he assumes it to be correlated to the working conditions in the illegal diamond mines there.

Kibadi Kapay noticed that the WHO guidelines for clinical diagnosis lead to a correct diagnosis in only 2 cases out of 3. As opposed to a Ziehl-Neelsen smear, a microscopic technique that is within reach of poor countries – and that, through a better diagnosis, prevents the needless use of antibiotics.

But when large wounds have to be treated, from a microscopically confirmed Buruli case, antibiotics indeed are of good use. With surgery only, 15% of patients relapse; with parallel use of antibiotics, less than 2% relapse. But antibiotics only, without surgery, make large wounds worse.

Kibadi Kapay – who today received a doctorate from Antwerp University for his work –  and his ITM colleagues advocate faster surgery of large ulcerating lesions, without four weeks of waiting with antibiotics only. The more because patients themselves already wait a long time before consulting a doctor – to them the ulcers are inflicted by witchcraft or fate.

The research by Kibadi Kapay demonstrates the need of a better education of the population, but more important, it shows that WHO guidelines for diagnosis and treatment of Buruli ulcers urgently need to be adapted.

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