Main conclusions and recommendations Technical Advisory Group and Annual Meeting on Buruli ulcer Geneva, Switzerland 13 – 17 March 2006

Buruli ulcer 8-point control strategy 1. Early case detection at the community level and information, education and communication (IEC) 2. Training of health workers, schoolteachers and village health workers 3. Standardized case management [antibiotics, surgery and prevention of disability (POD)] 4. Laboratory confirmation of cases 5. Strengthening of health facilities 6. Standardized recording and reporting using forms BU 01 and BU 02 and the HealthMapper software 7. Monitoring and evaluation of control activities 8. Advocacy, social mobilization and partnerships

Community education and early detection of cases Training and involvement of village health workers, schoolteachers and local leaders. Active screening of populations at risk, particularly schoolchildren, during community education activities. Widespread distribution and use of IEC materials at villages, schools and health facilities to enhance case detection. Regular screening of WHO Buruli ulcer video in endemic villages, at schools and among health facilities. Ensuring availability of televisions, DVD players and portable generators at district and health-facility levels to support community education.

Despite the progress made in many countries, Buruli ulcer remains poorly understood, leading to misdiagnosis and mismanagement of cases. Training and retraining are essential in building knowledge and skills of health workers and others to improve diagnosis and treatment of the disease. Necessary materials should be available to support training. Training should be adapted to local contexts and optimize community participation, including that of schoolteachers and village health workers. Governments of endemic countries, WHO, NGOs and other partners are urged to support countries to accelerate progress in this area. Training – ongoing at country level

Training – surgery Antibiotic treatment is reducing the reliance on surgery in management of the disease. However, in some cases, surgery is needed to remove necrotic tissue and cover skin defects. To ensure the standardization of surgical management, a 4-week training programme is expected to start in May 2006 at which 10 countries will participate. NGOs are welcome to support this training programme and help provide basic equipment to facilities from which trainees are sent to participate.

Antibiotics treatment in the field Increasing evidence shows that the combination of rifampicin and streptomycin heals small- and medium- sized lesions and reduces the extent of surgery in large lesions. New evidence shows that in osteomyelitis cases, previous antibiotic treatment is beneficial and should be given for at least 4 weeks before surgical intervention. The widespread use antibiotics is recommended in the management of all forms of the disease. Careful monitoring of patients and proper documentation of treatment outcomes should be carried out according to WHO guidelines. WHO will provide drugs to endemic countries upon request.

Prevention of disability Important progress has been made in this area over the past 2 years, including the development of a POD manual and other materials. National programmes should identify a POD expert to assist in training and supervision of POD activities. All health workers involved in BU management should receive basic training in POD. NGOs should continue to assist countries in developing the basic capacity to implement POD activities in various centres and communities as well as rehabilitation for those in need. Essential that the implementation POD activities is well coordinated among different partners. WHO will organize a training-of-trainers for national POD supervisors and programme managers in 2006.

Better organization of laboratory confirmation of cases in national programmes. Direct smear examination at any health facility where TB microscopy is done. Quality control using other methods, particularly PCR, is highly recommended. Identification of laboratory networks to support PCR, culture and histopathology confirmation and quality assurance. Evaluation of feasibility of using needle aspiration to obtain specimens from non-ulcerative disease for direct smear examination and PCR (research proposal). Development of a guideline for laboratory confirmation of cases (after the evaluation of needle aspiration). Laboratory diagnosis

Strengthening of health facilities NGOs are contributing to the improvement of health facilities as a means of improving access to treatment, and this effort should continue.

Endemic countries are urged to use form BU 02 to register cases. All countries should report data to WHO using form BU 02. Cases should be mapped using prevalence data at village level (derived from form BU 02). WHO should assist endemic countries to develop capacity to use the HealthMapper software to analyse and report data. Surveillance

Classification of endemic countries Group 1. National programmes implementing the 8- point strategy (Benin, Cameroon, Ghana, Guinea). However, these countries need to intensify and increase coverage of their activities. Group 2. Need to strengthen the national programme and begin to actively implement the 8-point strategy (Togo, Gabon, Congo, Democratic Republic of the Congo, Côte d'Ivoire). Group 3. Need to improve surveillance to identify endemic foci to assist in targeting activities (Equatorial Guinea, Liberia, Malawi, Nigeria, Papua New Guinea, Peru, Sierra Leone, Sudan, Uganda).

Global indicators (core indicators) All endemic countries should use the following indicators in reporting to the annual meetings: number of new and recurrent cases (analysed by age, sex and place); proportion of cases confirmed by at least one method (if possible by PCR for quality control); proportion of non-ulcerative cases out of the total number of cases detected; proportion of cases healed with antibiotic treatment only; proportion of cases healed with deformity.

National and local-level indicators number of IEC campaigns carried out; proportion of patients completing the 8-week antibiotic treatment (compliance); proportion of positive results out of total number of samples examined; number of health workers, schoolteachers and village health workers trained; coverage – number of health facilities equipped to manage cases and implementing at least antibiotic treatment; number of districts and health facilities using forms BU 01 and 02; number of monitoring visits carried out by the national programme.

Working groups and networks 1. Advocacy, communication and social mobilization 2. Country monitoring and evaluation team (assists countries to build or strengthen national programmes) 3. Surgery (aimed at promoting and developing national capacities in surgery) 4. POD (aimed at promoting and developing national capacities) 5. Socioeconomic research (network to promote and coordinate work in this area) 6. Drug development (working group to research into new treatment options) 7. Basic science (network to promote and coordinate research on diagnostics, vaccines and pathogenesis) 8. Epidemiology/transmission – (network to coordinate epidemiological and transmission studies)

Country monitoring and evaluation team Establishment of an international monitoring and evaluation team (comprising WHO and selected TAG members) to:  Assist countries to develop, implement and sustain BU control using the 8-point strategy adopted in March  Continuously review the status of implementation, measure progress in countries and stimulate action when necessary.  Share the results of country evaluation visits with national authorities, relevant partners, experts and others so that the appropriate response can be mobilized to help the country concerned.