Buruli Ulcer

▪ Buruli ulcer is caused by Mycobacterium ulcerans, a bacteria belonging to the family which causes tuberculosis and leprosy ▪ The disease causes ulcers (mostly on limbs) which affect the skin and sometimes bone, and can lead to permanent disfigurement and long-term disability. ▪ The mode of transmission is not known and there is no prevention against the disease. BCG vaccination appears to provide limited protection. ▪ The bacteria produces a unique toxin – mycolactone – which causes tissue damage and inhibits the local immune response suppressing pain Disease and epidemiology


Summary of key actions to achieve targets
For effective morbidity control, it is essential to discover the disease early and to be able to treat it effectively. For this reason, the following three areas are critical to reach the targets: ▪ Build capacity of health workers to clinically diagnose and treat the disease and community health workers to detect and refer cases for treatment, furthering integration across skin NTDs ▪ Develop rapid diagnostic test for use at levels of the healthcare system closer to the patient ▪ Create comprehensive surveillance systems in all endemic countries including micro-mapping    ▪ Under-detection remains a concern ▪ Use data distribution and case mapping tools to improve targeting of case finding activities ▪ Secure financial and technical support for validation process ▪ Reinforce surveillance through setting up sentinel surveillance sites with trained staff and equipment

Current status
Bangladesh 100%, India 92%, Nepal 100% For more details, please visit: www.who.int/leishmaniasis/visceral_leishmaniasis/en/ HIGHLY PRELIMINARY SOURCE: All data sourced from WHO unless otherwise indicated 1 Bangladesh, Brazil, Ethiopia, Nepal, Somalia, South Sudan and Sudan 2 IHME Global Burden of Disease 3 Also referred to as non-endemic country 4 G-Finder report 2018 5 Assessment of endemicity in some districts in Nepal and sub-districts in Bangladesh has to be carried out; relapses and HIV-VL patients are not regularly included in the denominator in India which deflates the prevalence in India compared to other countries Insecticide spraying, insecticide-treated nets, and environmental management Vector control

N/A Veterinary public health
The treatment of leishmaniasis depends on several factors including type of disease, concomitant pathologies, parasite species and geographic location. Medicines include pentavalent antimonials, amphotericin B, paromomycin, among others

Case management
Early diagnosis (rapid diagnostic tests combined with clinical signs) and prompt treatment Other Target: disease control Leishmaniasis -visceral (VL) ▪ Outbreaks may overwhelm the capacity of existing health infrastructure/workforce ▪ Single manufacturers of medicines which are difficult to produce at the required quantity and quality ▪ Limited availability of treatments for concomitant diseases (e.g. anemia, malnutrition, co-infections) may increase case fatality rate ▪ Regular coordination meetings in-country and regionally occur although there is need for better dissemination of the minutes of those meetings to all stakeholders ▪ Cross-border meetings are not held ▪ Establish regular coordination mechanism in-country, regional and cross-border with dissemination of minutes to all stakeholders Collaboration and multisectoral action ▪ Although capacity building is done regularly, high turnover of staff causes gaps in training and some personnel is assigned to tasks without specific training ▪ Train community health workers and national health personnel for timely and adequate diagnosis and treatment ▪ Train newly deployed health personnel upon arrival to an endemic area on diagnosis and treatment of VL

Capacity building
▪ Key interventions such as provision of medical supplies or M&E are fully dependent on external donors in several countries ▪ Increase domestic funding to procure quality-assured medical supplies for diagnosis and treatment Advocacy and funding Enablers 1 Defined as an immunocompetent patient with no other concomitant condition which is not the result of VL (e.g. transplantation, HIV, cancer, immunosuppressive medicines, diabetes, renal failure, etc.)

Summary of key actions to achieve targets
The most devastating consequence of visceral leishmaniasis is death. There are currently patients dying who could be saved if early diagnosis and prompt treatment would be implemented. VL is a complex disease which manifests differently in various geographies and thus the response may need to be adapted to local context. Nevertheless, there are three key areas to be addressed: ▪ Early detection is essential in order to ensure prompt treatment, through, for example, active case detection ▪ Endemic areas have to remain well-supplied due to the epidemic nature of VL ▪ More user friendly treatment is needed, especially for East Africa ▪ National guidelines for VL control are in place ▪ Fully implement diagnostic and treatment algorithms in the field level Planning and governance ▪ Some countries do not report regularly and on time on medical supplies consumption which causes stocks out sometimes ▪ Some countries do not use WHO quality-assured medicines Supply and logistics ▪ ▪ Although capacity building is done regularly, the high turn over causes some gaps and some personnel is assigned to tasks without being specifically trained for ▪ Train community health workers and national health personnel for timely and adequate diagnosis and treatment Capacity building ▪ Key interventions such as provision of medical supplies or M&E are fully dependent on external donors in several countries ▪ Increase domestic funding to procure quality-assured medicines Advocacy and funding Enablers ▪ Regular coordination meetings in-country and regional occur although there is need to better dissemination the minutes of those meetings with all stakeholders ▪ Cross-border meetings not held Collaboration and multisectoral action ▪ Develop regular coordination mechanism in-country, regional and cross-border with dissemination of minutes to all stakeholders ▪ National guidelines for case management of CL are in place ▪ Distribute national guidelines at the local level to ensure implementation ▪ Reduce time elapsed between onset of symptoms and treatment by implementing activities aimed at early diagnosis and prompt treatment Planning and governance ▪ Several high burden countries lack the necessary medicines or physical treatment options for case management Supply and logistics ▪ Ensure availability of medicines and/or physical treatment for case management (procured or donated) in all countries ▪ Improve access to diagnosis and treatment for rural populations ▪ Most countries use aggregate data which does not allow for indepth analysis or struggle to accurately report ▪ Most countries lack comprehensive databases including disease and vector surveillance and control interventions data ▪ Establish electronic national databases with patient-based data for analysis, including vector surveillance and control interventions data ▪ Ensure cutaneous leishmaniasis is made notifiable and decouple roles dedicated to managing cases and reporting

▪
There is shortage of properly trained health personnel in several high endemic areas.

Summary of key actions to achieve targets
The precise burden of CL remains to be calculated. The treatment is complex. The key actions towards controlling the disease include: ▪ Develop and scale up easy-to-administer oral/topical treatment which could be used at a health centre level ▪ Improve the affordability and sensitivity of rapid diagnostic test for easy detection of cases ▪ Understand the burden of the disease through improving surveillance and establishing a patient database to ensure effective monitoring of the impact of the control interventions • Develop diagnostic test (preferably point-of-care) Diagnostics • Health promotion to increase use of protective clothes and wearing of shoes is ongoing • Separation of animals from human dwellings decreases incidence • Current treatment is either antibiotics, antifungals or a combination delivered for several months.
• Improve dwellings and living conditions • Develop better treatment (shorter duration and high efficacy) Effective intervention • The mechanism of transmission of mycetoma to be fully understood which limits the development of a sound preventive strategy.
• Understand transmission pathways Scientific understanding • Collaboration with various research institutes, drugs and diagnostics developers initiated

• Establish collaboration with various research institutions, drugs and diagnostics developers, manufacturers and donors required Collaboration and multisectoral action
• Continuing integration across skin NTDs • Peripheral health workers in many areas may not be able to recognize mycetoma early • In many endemic countries the majority of health workers lack the required knowledge and skill to manage cases • Train health workers and community health workers across skin NTDs to improve early detection • Improve the diagnostic and managing capacities of health care system in the endemic regions of the countries

Capacity building
• Only Sudan has a national control plan • Include mycetoma in their strategic plans against NTDs or develop specific plans in endemic countries Planning and governance Other ▪ Post-exposure prophylaxis (with the rabies vaccine as well as immunoglobulin for severe category 3 exposures) is needed immediately after exposure to a rabid animal ▪ Thorough wound washing Case management ▪ Access to water for wound washing (e.g. with soap and water) post-exposure can significantly decrease the viral load in the wound

Burden of disease
Progress against WHO 2020 targets

Impact indicator 2012
TBC 2020 target ▪ Bacterial infections can complicate the disease leading to serious consequences such as severe soft tissue infections, septicaemia, kidney disease and rheumatic fever.

Disease and epidemiology
▪ Accurate data on incidence and prevalence are not available   -Urogenital schistosomiasis results in blood in urine; in advanced stages also fibrosis of bladder and ureter, and kidney damage. Genital forms could manifest in pain of the testicle and blood in the sperm in men, abdominal and pelvic pain in women, pain during intercourse, ectopic pregnancies, and infertility; association with HIV transmission has been demonstrated in co-endemic areas.
▪ Transmitted to humans through contact with infested water (e.g. swimming, washing clothes, fishing); Inadequate hygiene increases risk of transmission