Buruli ulcer in West Africa: Strategies for early detection and treatment in the antibiotic era

OBJECTIVE: Buruli ulcer (BU), caused by Mycobacterium ulcerans infection, has become one of the most rapidly emerging diseases in West Africa in recent decades. Until recently, the definitive treatment involved wide surgical excision. Recent data suggest that antibiotic therapy with rifampin and streptomycin may reduce the extent or prevent excision when initiated during the early phases of the disease. New strategies for BU control are needed, emphasizing early detection and increasing public awareness about the disease and treatment. Here we review current knowledge about BU and examine clinical, public health and anthropological research in the context of this new treatment paradigm to identify potential strategies for more effective control of this disease. METHODS: A comprehensive literature search for articles in English or French using the Medline and INIST databases, World Health Organization publications, and bibliographical references was undertaken using key words Buruli ulcer. Mycobacterium ulcerans, community surveillance, and public health. CONCLUSION: Studies to identify factors contributing to delayed presentation indicate that awareness of the disease is generally good in endemic regions, but wide variation exists in perceived cause of the disease, and the role of sorcery in its transmission and treatment. The use of traditional healers as first line therapy also contributes to delayed treatment, as do lack of awareness about the availability of effective treatment and financial concerns. Epidemiological data from existing BU control programs indicate that active public awareness campaigns are succcessful in increasing understanding and decreasing treatment delay and disease progression. Community-based surveillance and health education modeled after the village health worker programs used in the eradication of Guinea worm may be successfully applied in BU endemic areas.