article: Cameroon is endemic for Buruli ulcer (BU) and organised institutional BU control began in 2002. The objective was to describe the evolution, achievements and challenges of the national BU control programme (NBUCP) and to make suggestions for scaling up the programme. We analysed collated data on BU from 2001 to 2014 and reviewed activity reports NBUCP in Cameroon. Case-detection rates and key BU control indicators were calculated and plotted on a time scale to determine trends in performance. A linear regression analysis of BU detection rate from 2005–2014 was done. The regression coefficient was tested statistically for the significance in variation of BU detection rate. In 14 years of BU control, 3700 cases were notified. The BU detection rate dropped significantly from 3. 89 to 1. 45 per 100 000 inhabitants. The number of BU endemic health districts rose from two to 64. Five BU diagnostic and treatment centres are functional and two more are planned for 2015. The health system has been strengthened and BU research and education has gained more interest in Cameroon. Although institutional BU control Cameroon only began 30 years after the first cases were reported in 1969, a number of milestones have been attained. These would serve as stepping stones for charting the way forward and improving upon control activities in the country if the major challenge of resource allocation is dealt with.
  Buruli ulcer (BU), caused by Mycobacterium ulcerans, is the third most common mycobacterial infection, after tuberculosis and leprosy. M. ulcerans infection leads to chronic necrotizing ulcers [1], resulting in deformities, functional limitation and social stigma, if left untreated [2; 3]. BU occurs in tropical and sub-tropical regions near stagnant or slow flowing water bodies and marshlands [4; 5], and worldwide, this association has been shown to be a risk factor for the infection. The mode of transmission however is unclear, although some studies have suggested the involvement of an animal reservoir or of insect vectors [6]. BU affects people of all ages and both sexes, but mostly children below 15 years of age. However, children below five years seem to be underrepresented among patients [7] and less exposed to M. ulcerans than older children [8]. Although all body parts may be involved, about 90% of lesions occur on the limbs [7], which may reflect the mode of transmission. Since M. ulcerans is thermosensitive, it is primarily causing skin lesions. BU presents in two major clinical forms: non-ulcerative (papule, nodule, plaque, and oedema) and ulcerative lesions (Fig 1). The WHO has defined three categories of lesions based on their sizes and location on the body [9]. BU can be diagnosed clinically by experienced and skilled health workers in endemic areas [10]. Four standard laboratory methods can be used to confirm BU [11], however, polymerase chain reaction (PCR) targeting the multi-copy insertion segment (IS) 2404 of M. ulcerans is the most commonly used because it has the highest sensitivity and results can be available within 48 hours [12]. The treatment of BU has evolved from exclusively surgical [13] to the use of specific antibiotics [10; 14] in association with, simple surgery for controlled wound healing, physiotherapy, nutritional and psychosocial support if required. Today, major surgery is reserved only for treatment of BU complications. Effective BU control began in Cameroon in 2002. In this article, we describe the national BU control programme (NBUCP) in Cameroon from its creation to 2014, based on a review of reports and data from 2001 to 2014 compiled at the NBUCP. The objective is to describe the evolution, achievements, and challenges of the NBUCP, and make suggestions for improvement and expansion of BU programme activities. The paper shall be useful for advocacy to mobilize resources for implementation of BU control programme activities worldwide.
  This study was instructed by the Cameroon Ministry of Public Health Decision No 0486/D/MINSANTE/CAB and was approved the National Ethics Committee of Cameroon through the authorisation No 041/CNE/DNM/09. All data were anonymized and confidentiality was strictly respected in the data handling and analysis.
  Although BU was first reported in Cameroon in 1969 [17], control activities only began effectively 33 years later, in 2002. The triggers for control activities in Cameroon were the new momentum to BU control following the 1998 Yamoussoukro Declaration [18] and the reconfirmation of the Nyong Basin in Central Cameroon as a BU endemic area by Noeske and colleagues in 2001, when they identified 436 clinical cases of BU, 162 of whom were sampled and 135 confirmed by IS2404 PCR [19]. Noeske’s findings led to the creation of the first two BU-DTCs in the country in 2002, in Ayos and Akonolinga both of which are located within the Nyong basin. These BU-DTCs were set-up with the support of two NGOs: FAIRMED (former Aide aux Lépreux Emmaüs Suisse) and Médecins Sans Frontières Suisse (MSF-CH), respectively. The effectiveness of the treatment of BU in these pioneer centres quickly led Cameroon’s Ministry of Public Health to create the NBUCP in 2004, underlying the important role of research in health development policy. The initial goals and objectives of the NBUCP largely reflected those of the WHO GBUI as stated in the Yamoussoukro Declaration” [18]. The NBUCP objectives have however evolved over time, to suit new developments and orientations in the domain as charted by the 2004 WHA resolution on BU and the 2009 Cotonou Declaration on BU. The current goal of the NBUCP is to reduce the suffering of the population due to BU. The global objective is to ensure accessibility to quality health services in endemic areas in order to reduce morbidity and disability linked to BU in Cameroon. Specifically, the NBUCP aims to detect cases of BU early, preferentially as non-ulcerative forms and category 1 lesions; to confirm 70% of clinical BU cases by PCR; to treat all active cases of BU according to standard guidelines; and to heal at least 95% of BU patients without limitation of joint movement. BU is an expensive condition to treat and occurs primarily in poor and remote parts of Cameroon. Partner resources, upon which NBUCP activities largely depended, are becoming rarer leading to cutting down on activities and consequent drop in performance indicators. The Government of Cameroon funding for recurrent costs of programme activities is very limited and cannot cover the gap. This situation does not allow for rapid expansion of BU activities to new endemic districts. There is a lack of diagnostic and management skills for BU among the health personnel. BU care is not taught in all faculties of medicine and training schools for health personnel. Consequently, health personnel may only learn about BU on the job, if they get posted to a BU-DTC, through workshops and refresher courses organised by the NBUCP and partners. A series of workshops on the management of chronic wounds and BU are being organised since 2013 in collaboration with MSF-CH, Hôpitaux Universitaires de Genève and the Faculty of Medicine and Biomedical Sciences of the University of Yaounde 1 (FMBS-UY1). Many unanswered questions about BU still prevail. The mode of transmission, the exact prevalence and incidence, the relationship between BU and HIV/AIDS, the role of beliefs and customs surrounding BU, economic costs of BU treatment and the effect of M. ulcerans infection on nerve conduction are a few of the concerns. These questions call for well planned and executed research projects. Most research projects in Cameroon so far were championed by expatriates. However, this trend is changing as more Cameroonian researchers are now involved, and the FMBS-UY1 has now introduced a course on BU in its curriculum. Furthermore, some Cameroonian researchers and care providers have recently founded the Cameroon Wound Management Society with the aim, among others, of promoting BU research. Much experience has been acquired in 12 years of BU control in Cameroon. Capitalizing on these experiences and lessons learned should prepare the NBUCP to be more effective and efficient. This will require dealing with the identified challenges. The NBUCP is intensifying advocacy to get more partners on board as well as secure more resources from traditional partners of the programme. The Cameroon’s Ministry of Public Health is aware of the dwindling partner resources and has begun to put in some additional resources for recurrent costs since 2013. The remaining faculties of medicines of the various state universities as well as the training schools for health personnel in Cameroon should follow the example of FMBS-UY1 to include courses on BU in their training programmes and be more involved in research activities on the disease. This review shows that significant progress has been made in BU case detection and management, health system reinforcement, capacity building and research in Cameroon, although institutional BU control Cameroon only began 30 years after the first cases were reported. However the reduction in programme resources and activities by the major support partners has led to a steady drop in performance indicators since 2010. More effort needs to be made in resource mobilization for expansion and scaling up of the programme activities.
summary: Organised control of Buruli ulcer (BU), the third most common mycobacterial disease, began in Cameroon in 2002. We used 2001–2014 data and activity reports from the National BU Control Programme, to describe the onset, evolution, achievements and challenges of BU control in Cameroon, and make suggestions for improvement and expansion of programme activities. A cumulative number of 3700 BU cases have been detected and treated free-of-charge in five functional BU diagnostic and treatment centres. Sixty-four BU-endemic districts are now confirmed in Cameroon. Furthermore, Cameroon has actively participated in several BU research activities. However major challenges regarding demanding and costly surveillance, education, diagnostic and treatment activities remain to be addressed. Capitalizing on experiences and lessons learned in the past 14 years of activities, the National BU control programme should however be prepared to move forward.
title: Buruli Ulcer in Cameroon: The Development and Impact of the National Control Programme