John C Martin Foundation.

Mycobacterium ulcerans disease is common in some humid tropical areas, particularly in parts of West Africa, and current management is by surgical excision of skin lesions ranging from early nodules to extensive ulcers (Buruli ulcer). Antibiotic therapy would be more accessible to patients in areas of Buruli ulcer endemicity. We report a study of the efficacy of antibiotics in converting early lesions (nodules and plaques) from culture positive to culture negative. Lesions were excised either immediately or after treatment with rifampin orally at 10 mg/kg of body weight and streptomycin intramuscularly at 15 mg/kg of body weight daily for 2, 4, 8, or 12 weeks and examined by quantitative bacterial culture, PCR, and histopathology for M. ulcerans. Lesions were measured during treatment. Five lesions excised without antibiotic treatment and five lesions treated with antibiotics for 2 weeks were culture positive, whereas three lesions treated for 4 weeks, five treated for 8 weeks, and three treated for 12 weeks were culture negative. No lesions became enlarged during antibiotic treatment, and most became smaller. Treatment with rifampin and streptomycin for 4 weeks or more inhibited growth of M. ulcerans in human tissue, and it provides a basis for proceeding to a trial of antibiotic therapy as an alternative to surgery for early M. ulcerans disease.

We have evaluated the clinical efficacy of the combination of oral rifampin at 10 mg/kg of body weight and intramuscular streptomycin at 15 mg/kg for 8 weeks (RS8), as recommended by the WHO, in 160 PCRconfirmed cases of Mycobacterium ulcerans disease. In 152 patients (95%) with all forms of disease from early nodules to large ulcers, with or without edema, the lesions healed without recourse to surgery. Eight patients whose ulcers were healing poorly had skin grafting after completion of antibiotics. There were no recurrences among 158 patients reviewed at the 1-year follow-up. The times to complete healing ranged from 2 to 48 weeks, according to the type and size of the lesion, but the average rate of healing (rate of reduction in ulcer diameter) varied widely. Thirteen subjects had positive cultures for M. ulcerans during or after treatment, but all the lesions healed without further antibiotic treatment. Adverse events were rare. These results confirm the efficacy of RS8 delivered in a community setting.Mycobacterium ulcerans disease, known as Buruli ulcer, is a chronic subcutaneous infection which is common in humid rural tropical areas. The majority of patients are children aged less than 15 years living in rural areas remote from a hospital (29). Infection initially manifests as a painless nodule or plaque which breaks down centrally to form an ulcer with undermined edges (11). In a small proportion of lesions, there is edema around the ulcer which spreads rapidly, resulting in a very large ulcer. Significant morbidity results from Mycobacterium ulcerans disease when there is extensive scarring or functional limitation from contractures at joints, and there is occasionally a need for amputation of a limb. Ulcers or scars rarely undergo malignant transformation (12).Until recently, the mainstay of treatment for Buruli ulcer was excision of lesions with a wide margin to ensure complete removal of infected tissue. Recurrence rates after surgery varied between 6 and 17%, depending on the type and extent of the lesion and on the experience and skill of the surgeon (1,6,22). Recent evidence that antibiotics are effective has shifted the balance between surgery and antibiotics. In vitro, M. ulcerans has been shown to be susceptible to rifampin (13), aminoglycosides (7), macrolides (21), and quinolones (26). Infection of mouse footpads has been used as a model for susceptibility testing, and after treatment with the same antibiotics, the lesions became smaller and the total number of M. ulcerans organisms in tissue was reduced (2,8,25). The combination of rifampin with amikacin or streptomycin for 8 weeks has been the most effective in reducing the bacterial load in a number of studies, and the low relapse rate after treatment suggested that this combination was bactericidal (2, 15). An important reason for using more than one drug is that resistant mutants were found after rifampin monotherapy in mice (16).The bactericidal effect of rifampin at 10 mg/kg of body weight orally combined with streptomycin at 15 mg/k...

Abstract-Hypertension and stroke are important threats to the health of adults in sub-Saharan Africa. Nevertheless, detection of hypertension is haphazard and stroke prevention targets are currently unattainable. Prevalence, detection, management, and control of hypertension were assessed in 1013 men (nϭ385) and women (nϭ628) In a recent study, the prevalence of hypertension was found to be 28% in North America and 44% in western Europe. 1 Until recently, hypertension was thought to be rare in rural Africa 3-4 ; on the other hand, hypertension and its complications, including stroke, heart failure, and renal failure, have been reported in blacks all over the world. Hypertension is now being widely reported in Africa and is the most common cause of cardiovascular disease on the continent. 5 It is also a major factor in the high mortality of adults in sub-Saharan Africa. 6 In Ghana, hypertensive renal disease is a common complication in both Kumasi and Accra. [7][8] In Ghana, earlier studies revealed a hypertension prevalence of 4.5% among rural dwellers and of 8% to 13% in the town. 9 This was part of an evaluation of the health burden of cardiovascular diseases in Accra and was to form the basis for setting up a hypertension control program. More recently, the prevalence of hypertension in urban Accra was found to be 28.3% (crude) and 27.3% (age-standardized). 10 Hypertension is becoming more common as urbanization increases, and this has been shown in several studies in Africa. 11 A number of studies of urban African populations have shown a positive correlation between blood pressure, age, and gender. The prevalence of hypertension in Accra was much higher in men than in women aged Ͻ40 years but similar above that age. 9 On the other hand, in a recent study prevalence was higher in women than in men. 10 In the developed world, the detection, treatment, and control of hypertension have been characterized by the "rule of halves," 12 although recent evidence suggests that there has been a general improvement. 13 However, in much of sub-Saharan Africa, due to scarce resources and inadequate healthcare provision, detection, treatment, and control are very poor. 9,10,14 The aim of our study was to assess the prevalence, detection, management, and control of hypertension among men and women living in rural and semi-urban villages in the Ashanti Region of Ghana, West Africa. 15 It was part of a community-based study of the prevention of hypertension and stroke in the same region.

Hypertension and stroke are important threats to the health of adults in sub-Saharan Africa. Nevertheless, detection of hypertension is haphazard and stroke prevention targets are currently unattainable. Prevalence, detection, management, and control of hypertension were assessed in 1013 men (nϭ385) and women (nϭ628), both aged 55 [SD 11] years, living in 12 villages in Ashanti, Ghana. Five hundred thirty two lived in semi-urban and 481 in rural villages. The participants underwent measurements of height, weight, and blood pressure (BP) and answered a detailed questionnaire. Hypertension was defined as BP Ն140 and/or Ն90 mm Hg or being on drug therapy. Women were heavier than men. Participants in semi-urban areas were heavier and had higher BP (129/76 [26/14] versus 121/72 [25/13] mm Hg; PϽ0.001 for both) than in rural areas. Prevalence of hypertension was 28.7% overall and comparable in men and women, but higher in semi-urban villages (32.9% [95% CI 28.9 to 37.1] versus 24.1% [20.4 to 28.2]), and increased with age. Detection rate was lower in men than women (13.9% versus 27.3%; Pϭ0.007). Treatment and control rates were low in both groups (7.8% and 4.4% versus 13.6% and 1.7%). Detection, treatment, and control rates were higher in semi-urban (25.7%, 14.3%, and 3.4%) than in rural villages (16.4%, 6.9%, and 1.7%). Hypertension is common in adults in central Ghana, particularly in urban areas. Detection rates are suboptimal in both men and women, especially in rural areas. Adequate treatment of high BP is at a very low level. There is an urgent need for preventive strategies on hypertension control in Ghana.

A year of genomic surveillance reveals how the SARS-CoV-2 pandemic unfolded in Africa

SummaryBackgroundHepatitis D virus (also known as hepatitis delta virus) can establish a persistent infection in people with chronic hepatitis B, leading to accelerated progression of liver disease. In sub-Saharan Africa, where HBsAg prevalence is higher than 8%, hepatitis D virus might represent an important additive cause of chronic liver disease. We aimed to establish the prevalence of hepatitis D virus among HBsAg-positive populations in sub-Saharan Africa.MethodsWe systematically reviewed studies of hepatitis D virus prevalence among HBsAg-positive populations in sub-Saharan Africa. We searched PubMed, Embase, and Scopus for papers published between Jan 1, 1995, and Aug 30, 2016, in which patient selection criteria and geographical setting were described. Search strings included sub-Saharan Africa, the countries therein, and permutations of hepatitis D virus. Cohort data were also added from HIV-positive populations in Malawi and Ghana. Populations undergoing assessment in liver disease clinics and those sampled from other populations (defined as general populations) were analysed. We did a meta-analysis with a DerSimonian-Laird random-effects model to calculate a pooled estimate of hepatitis D virus seroprevalence.FindingsOf 374 studies identified by our search, 30 were included in our study, only eight of which included detection of hepatitis D virus RNA among anti-hepatitis D virus seropositive participants. In west Africa, the pooled seroprevalence of hepatitis D virus was 7·33% (95% CI 3·55–12·20) in general populations and 9·57% (2·31–20·43) in liver-disease populations. In central Africa, seroprevalence was 25·64% (12·09–42·00) in general populations and 37·77% (12·13–67·54) in liver-disease populations. In east and southern Africa, seroprevalence was 0·05% (0·00–1·78) in general populations. The odds ratio for anti-hepatitis D virus detection among HBsAg-positive patients with liver fibrosis or hepatocellular carcinoma was 5·24 (95% CI 2·74–10·01; p<0·0001) relative to asymptomatic controls.InterpretationFindings suggest localised clusters of hepatitis D virus endemicity across sub-Saharan Africa. Epidemiological data are needed from southern and east Africa, and from patients with established liver disease. Further studies should aim to define the reliability of hepatitis D virus testing methods, identify risk factors for transmission, and characterise the natural history of the infection in the region.FundingWellcome Trust, Royal Society.

Punch biopsy specimens from Mycobacterium ulcerans disease lesions were used to compare the sensitivities and specificities of direct smear, culture, PCR, and histopathology in making a diagnosis of M. ulcerans disease in a field setting. PCR for the insertion element IS2404 was modified to include uracil-N-glycosylase and deoxyuridine triphosphate instead of deoxythymidine triphosphate to reduce the risk of cross contamination. The "gold standard" for confirmation of clinically diagnosed Buruli ulcer was a definite histological diagnosis, a positive culture for M. ulcerans, or a smear positive for acid-fast bacilli (AFB), together with a possible histological diagnosis. For 70 clinically diagnosed cases of M. ulcerans disease, the modified PCR was 98% sensitive and gave a rapid result. The sensitivities of microscopy, culture, and histology were 42%, 49%, and 82%, respectively. The use of a 4-mm punch biopsy specimen was preferred to a 6-mm punch biopsy specimen since the wound was less likely to bleed and to need stitching. Given adequate technical expertise and the use of controls, the PCR was viable in a teaching hospital setting in Ghana; and in routine practice, we would recommend the use of Ziehl-Neelsen staining of biopsy specimens to detect AFB, followed by PCR, in AFBnegative cases only, in order to minimize costs. Histology and culture remain important as quality control tests, particularly in studies of treatment efficacy.Mycobacterium ulcerans disease (Buruli ulcer) manifests as a nodule, papule, plaque, or edematous lesion prior to ulceration (5). The disease has been reported in more than 31 countries, mostly countries with a tropical climate (2). The recommended treatment has been surgical excision, but areas of endemicity in tropical countries are often rural, with unmade roads and relatively poor health care facilities (5).The clinical diagnosis of Buruli ulcer is relatively easy when a child from an area of endemicity presents looking well with a painless ulcer eroding into subcutaneous fat and the ulcer has undermined edges (2); but the disease can affect people of any age, and other ulcers can be mistaken for Buruli ulcer, particularly when they are around the ankles, for example, venous ulcer, cutaneous leishmaniasis, neurogenic ulcer, yaws, tropical ulcer, fungal lesions, and squamous cell carcinoma (7). Diagnosis is more difficult in the case of nodules, and the sensitivity of clinical diagnosis in experienced hands was 48% to 52% in one study (5). Confirmation of the clinical diagnosis of Buruli ulcer is becoming increasingly important now that there is growing evidence of a beneficial effect from treatment with antibiotics (4), which is beginning to replace excision surgery as the standard treatment. In the case of an ulcer, the diagnostic technique most often available in areas of endemicity is ZiehlNeelsen (ZN) staining for acid-fast bacilli (AFB) of a smear from a swab taken from below the undermined edge of the ulcer base, but its sensitivity is low (40%) (16) and the technique cann...