LETTERS

References Buruli Ulcer, health offi cials, was divided into 2 1. Migliori GB, Loddenkemper R, Blasi F, groups. Group A visited Akwa Ibom Raviglione MC. 125 years after Robert Nigeria and Cross Rivers States, and group B Koch’s discovery of the tubercle bacil- To the Editor: Buruli ulcer (BU), visited Anambra, Ebonyi, and Enugu lus: the new XDR-TB threat. Is “science” States. enough to tackle the epidemic? Eur Respir a neglected tropical disease caused by J. 2007;29:423–7. Mycobacterium ulcerans, is character- Based on the WHO case defi ni- 2. Laszlo A, Rahman M, Espinal M, Ravi- ized by necrosis of subcutaneous tis- tions (1), 14 of 37 patient examined glione M; WHO/IUATLD Network of sue, leading to chronic, painless, and were considered likely to have BU (9 Supranational Reference Laboratories. active and 5 inactive cases); 9 were Quality assurance programme for drug progressive ulcers. Without proper susceptibility testing of Mycobacterium treatment, BU results in severe and children <15 years of age. Eight pa- tuberculosis in the WHO/IUATLD Supra- permanent disability in more than a tients were female, and 6 were male. national Laboratory Network: fi ve rounds quarter of patients. Most patients are One of the patients with active disease of profi ciency testing 1994–1998. Int J Tu- had the edematous form, 1 had osteo- berc Lung Dis. 2002;6:748–56. children <15 years of age. BU has 3. World Health Organization. Extensively been reported in >30 countries (1). The myelitis and ulcer, and the other 7 had drug-resistant tuberculosis (XDR-TB): World Health Organization (WHO) ulcers (Figure). Ten of the patients recommendations for prevention and has described the epidemiology, clini- had lesions on the lower limbs, 3 on control. Wkly Epidemiol Rec. 2006;81: the upper limbs, and 1 on the face. All 430–2. cal features, diagnosis, and treatment 4. Shah NS, Wright A, Bai G-H, Barrera of BU (1–3). cases were documented by registra- L, Boulahbal F, Martín-Casabona N, et In 1967, Gray et al. described tion on a modifi ed version of the BU al. Worldwide emergence of extensively 4 BU cases in the Benue River Val- 02 form (1) and photography. Swab drug-resistant tuberculosis. Emerg Infect specimens were taken from all active Dis. 2007;13:380–7. ley in Nigeria (4). The authors also 5. Ferrara G, Richeldi L, Bugiani M, Cirillo described unpublished reports of the ulcerative lesions. A fi ne-needle as- D, Besozzi G, Nutini S, et al. Management disease in Banbur, Adamawa State, piration technique was used to obtain of multidrug-resistant tuberculosis in Italy. in the upper part of the Benue River specimens from the edematous pa- Int J Tuberc Lung Dis. 2005;9:507–13. tient. In 4 (44%) of the 9 patients with 6. Gandhi NR, Moll A, Sturm AW, Pawinski Valley. In 1976, Oluwasanmi et al. R, Govender T, Lalloo U, et al. Extensive- described 24 BU cases in and around active cases, the clinical diagnosis was ly drug-resistant tuberculosis as a cause of Ibadan (5). Since then, there has been confi rmed by the IS2404 PCR at the death in patients co-infected with tuber- no offi cial report of BU in Nigeria. Institute of Tropical Medicine. culosis and HIV in a rural area of South The locations and number of Africa. Lancet. 2006;368:1575–80. However, unoffi cial reports indicate that the disease is still present in the cases identifi ed in each are as follows: Ifi te Ogwari village, Ayamelum Local Address for correspondence: Giovanni Battista country. For example, between 1998 Government Area (LGA), Anambra Migliori, WHO Collaborating Centre for TB and and 2000, BU cases from the Lep- State (4 cases); Ndo Etok village, Ogo- Lung Diseases, Fondazione S. Maugeri, Care rosy and Tuberculosis Hospital in ja LGA, Cross River State (3 cases); and Research Institute/TBNET Secretariat/Stop Moniaya-Ogoja, Cross River State, Nkpo Hamida village, Igbo-Eze North TB Italy, via Roncaccio 16, 21049, Tradate, were bacteriologically confi rmed at LGA, Enugu State (1 case); Iburu vil- Italy; email: [email protected] the Institute of Tropical Medicine in Belgium (6). More recently, patients lage, Ohaozora LGA, Ebonyi State from Nigeria have been treated in the (1 case); Akofu village, Ikwo LGA, neighboring countries of Benin (7) Ebonyi State (1 case); Amagunze vil- and Cameroon (8). lage, Nkanu East LGA, Enugu State To clarify the BU situation in Ni- (1 case); Okro Mbokho village, East- geria, the government, with technical ern Obolo, Akwa Ibom State (1 case); assistance from WHO, carried out a Oron village, Oron LGA, Akwai Ibom rapid assessment in the southern and State (1 case); and Ugwu Tank, Awka southeastern states of the country, South LGA, Anambra State (1 case). where cases had been previously re- In conclusion, 30 years after the ported. Preassessment sensitization last publication (5) of cases in south- workshops for health workers within western Nigeria, BU cases have been the selected states were held in June found in the southern and southeastern and July 2006. The assessment took parts of the country. A similar phenom- place November 15–19, 2006. The enon occurred in Cameroon, where team, which was made up of interna- a case search in 2001 in 2 districts tional experts and national and state where cases had last been reported 24

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References 1. Asiedu K, Raviglione M, Scherpbier R, editors. Buruli ulcer: Mycobacterium ulcerans infection. (WHO/CDS/CPE/ GBUI/2000.1). Geneva: World Health Or- ganization; 2000. 2. Buntine J, Crofts K, editor. Buruli ulcer. Management of Mycobacterium ulcerans disease. A manual for health care provid- ers. (WHO/CDS/CPE/GBUI/2001.3).Ge- neva: World Health Organization; 2001. 3. World Health Organization. Provisional guidance on the role of specifi c antibiot- ics in the management of Mycobacterium ulcerans disease (Buruli ulcer). (WHO/ CDS/CPE/GBUI/2004.10). Geneva: The Organization; 2004. 4. Gray HH, Kingma S, Kok SH. Mycobac- terial skin ulcers in Nigeria. Trans R Soc Trop Med Hyg. 1967;61:712–4. 5. Oluwasanmi JO, Solankee TF, Olurin EO, Itayemi SO, Alabi GO, Lucas AO. Mycobacterium ulcerans (Buruli) skin ul- Figure. A typical Buruli ulcer in a 17-year-old boy identifi ed during the assessment. ceration in Nigeria. Am J Trop Med Hyg. 1976;25:122–8. 6. Janssens PG, Pattyn SR, Meyers WM, Portaels F. Buruli ulcer: an historical over- years earlier found 436 active and in- Acknowledgments view with updating to 2005. Bull Séances active cases (8). These fi ndings dem- We thank the following persons for Acad R Sci Outre-Mer. 2005;51:165–99. onstrate that BU has not disappeared their support: Ngozi Njepuome, Mansur 7. Debacker M, Aguiar J, Steunou C, Zinsou from Nigeria and that the absence of C, Meyers WM, Guedenon A, et al. Myco- Kabir, Peter Eriki, Michael Jose, Chijioke bacterium ulcerans disease (Buruli ulcer) any regular reporting should be inves- Osakwe, Ogban Ikpoti, Valerie Obot, N.A. in rural hospital, southern Benin, 1997– tigated. Although the assessment team Ojika, and O. Jaiyesimi. We also thank all 2001. Emerg Infect Dis. 2004;10:1391–8. was able to visit only 5 of the 36 states the patients and others who facilitated this 8. Noeske J, Kuaban C, Rondini S, Sorlin P, (8 of 774 LGAs and 10 communities), Ciaffi L, Mbuagbaw J, et al. Buruli ulcer work at federal, state, LGA, and commu- disease in Cameroon rediscovered. Am J it concluded that BU is still present in nity levels. Trop Med Hyg. 2004;70:520–6. Nigeria and may be more prevalent This work was supported by the WHO than had been previously thought. The Address for correspondence: Kingsley Asiedu, Global Buruli Ulcer Initiative through lack of familiarity with the disease by Global Buruli Ulcer Initiative, Department of funds provided by The Nippon Founda- health workers may also have contrib- Control of Neglected Tropical Diseases, World tion, Tokyo, Japan. uted to poor reporting. Health Organization, Geneva, Switzerland; The assessment team recom- email: [email protected] mended 5 measures: 1) inclusion of Okechukwu Chukwuekezie,* BU treatment and control activities in Edwin Ampadu,† Ghislain Letters the Tuberculosis and Leprosy Control Sopoh,‡ Ange Dossou,‡ Letters commenting on recent articles Program at federal, state, and LGA Alexandre Tiendrebeogo,§ Lola as well as letters reporting cases, out- levels to enhance surveillance of the Sadiq,¶ Françoise Portaels,# breaks, or original research are wel- come. Letters commenting on articles disease; 2) training of health workers and Kingsley Asiedu** should contain no more than 300 at all levels; 3) a detailed assessment *Federal Ministry of Health, Abuja, Nigeria; words and 5 references; they are more of the extent of BU in the 5 states vis- †Ministry of Health, Accra, Ghana; ‡Centre likely to be published if submitted ited as well as in other states; 4) ap- de Dépistage et de Traitement de l’Ulcère within 4 weeks of the original article’s publication. Letters reporting cases, proaching partners supporting tuber- de Buruli d’Allada, Cotonou, Benin; §World outbreaks, or original research should culosis and leprosy control activities Health Organization, Libreville, Gabon; contain no more than 800 words and in Nigeria to include BU; and 5) in- ¶World Health Organization, Abuja, Nige- 10 references. They may have one corporating BU into the national sur- ria; #Institute of Tropical Medicine, Antwerp, Figure or Table and should not be di- veillance system to allow better data Belgium; and **World Health Organization, vided into sections. All letters should contain material not previously pub- collection. Geneva, Switzerland lished and include a word count.

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