“Aboa Gbonyo”

I recently returned from Ghana, Africa, after checking on the clinical trial Dr. John Macdonald and I are helping with for the treatment of Buruli ulcer. I have mentioned Buruli ulcer here before, but to refresh your memory, it is an ulcerative disease of the skin caused by an infectious agent, Mycobacterium ulcerans. Ulcers comparable with what we call Buruli ulcers were first described in 1897 by Sir Albert Cook, a British physician in Kampala, Uganda. In the 1960s, many cases were reported from Buruli County in Uganda, thus the name. Although ulcers resembling Buruli ulcers have been encountered in Australia, the majority are seen in Sub-Saharan Africa. Even though the disease has been a problem for more than 100 years, no one is sure how the bacteria is transmitted to humans, although they do know it is not transmitted from person to person. The disease affects the extremities in 90% of cases, with the lower extremity being involved most of the time.¹ Unfortunately, children under 16 are the targets of this disease more than 70% of the time.¹ The ulcers caused by Mycobacterium ulcerans and its toxin, mycolactone, are devastating for everyone, but it is especially heartbreaking to see these young children missing most of the skin on a leg or arm, knowing that they will undergo 8 weeks of antibiotic therapy, and 80% of them will require a skin graft to attempt healing of the wound after their treatment is completed. Complications include osteomyelitis, limb contractures due to poor healing, amputation, and even death! One name for the ulcer in Ghanaian is Aboa gbonyo which means “dreadful disease.” 

Wound care for these patients while they were getting their antibiotic therapy has been almost nonexistent by our standards. Most wounds were treated by washing with acetic acid followed by placing gauze soaked in povidone-iodine solution on the wound with dressings being changed once or, at the most, twice per week. You can imagine why the wounds were not improving over the 8-week treatment period! When visiting and seeing patients with Buruli ulcer in 2007, Dr. Macdonald and I suggested more “modern” moist wound treatment techniques. Because extensive edema involved the extremities with ulcers, we also recommended a modified compression wrap. We were able to convince a few centers to try it and, thankfully, the outcomes were significantly better.² We were excited, but how does one change the thinking of an entire continent?

In 2013, a group from Amsterdam working with the World Health Organization was to undertake a large Buruli ulcer trial to find more effective antibiotics for the treatment of the bacteria. We were overjoyed when we were contacted about providing the wound management for the patients in the trial. Here was a chance to treat a large number of these patients with the “new” wound care. We just hoped the outcomes would be good. Since this was a randomized, controlled trial for the antibiotic portion, we wanted to do the same for the wound treatment. One thing we quickly learned when treating patients in Africa is that there is no control group. If 1 patient is to get the “old” dressing and another is to get the “new” dressing, there will be a revolt; everyone is going to get the “new” one. Because of that, both antibiotic treatment arms are receiving the same wound care—a nonadherent dressing followed by a hydroconductive dressing. The extremity is then wrapped with a modified short-stretch compression bandage. The dressings are changed 3 times per week.

The study has been ongoing for more than 2 years with 234 patients enrolled, and should be completed within another year and another 100 patients. Unfortunately, more than 50% of the patients are still younger than 15 years. The preliminary results to date look very good in terms of the healing rates when compared to the historical data. Skin grafting is rarely required now when it was close to 80% in previous studies.

Even though strides are being made in treating Buruli ulcer, we feel much needs to be done to stop this “dreadful disease.” Why can’t someone develop a vaccine or a way to stop the transmission of the bacteria? It has been going on for more than 100 years.

I am reminded of the quotation of General Zateb Kazim, a character in 2005 movie Sahara, who said, “Don’t worry. It’s Africa. Nobody cares about Africa.” I hope we can change that attitude about many diseases in Africa but especially Buruli ulcer. No matter where children live around the world, they deserve better than having to deal with a “dreadful disease.”