The use of traditional medicines among mycetoma patients

Hope amidst neglect: Mycetoma Research Center, University of Khartoum. A holistic management approach to achieve the United Nations' Sustainable Development Goals

Mycetoma is a debilitating neglected tropical disease that affects individuals worldwide, particularly in regions where there is poverty and limited health care access. The Mycetoma Research Center (MRC), based in Khartoum, Sudan, provides a sustainable, holistic approach to patient care as the only World Health Organization collaborating center for mycetoma. We describe MRC activities that align with the United Nations' Sustainable Development Goals to control mycetoma in Sudan and globally.

The Mycetoma Research Center, University of Khartoum, Sudan's experience in community engagement initiatives spans 3 decades

Mycetoma profoundly affects marginalised communities, especially in impoverished and remote areas with limited access to healthcare. This chronic and debilitating inflammatory disease highlights the typical issues of neglected tropical diseases (NTDs), such as insufficient attention, funding, and resources, which perpetuate neglect and suffering. Patients often delay seeking medical help, leading to advanced disease stages, severe complications, and lasting disabilities. The lack of medical infrastructure and skilled healthcare professionals worsens the situation, causing delays in diagnosis and inadequate treatment. Engaging affected communities in tailored interventions is essential to tackle these challenges, promote collaboration, raise awareness, and mobilise resources to improve healthcare access and enhance diagnostic and treatment capabilities. Since 1991, the Mycetoma Research Center (MRC) at the University of Khartoum, Sudan, has led community engagement initiatives aimed at improving the quality of life for mycetoma-affected individuals through education, advocacy, and local collaboration. In this communication, the MRC shares its extensive experience in community engagement to benefit mycetoma-affected communities.

The pipeline for drugs for control and elimination of neglected tropical diseases: 2. Oral anti-infective drugs and drug combinations for off-label use

In its 'Road map for neglected tropical diseases 2021-2030', the World Health Organization outlined its targets for control and elimination of neglected tropical diseases (NTDs) and research needed to achieve them. For many NTDs, this includes research for new treatment options for case management and/or preventive chemotherapy. Our review of small-molecule anti-infective drugs recently approved by a stringent regulatory authority (SRA) or in at least Phase 2 clinical development for regulatory approval showed that this pipeline cannot deliver all new treatments needed. WHO guidelines and country policies show that drugs may be recommended for control and elimination for NTDs for which they are not SRA approved (i.e. for 'off-label' use) if efficacy and safety data for the relevant NTD are considered sufficient by WHO and country authorities. Here, we are providing an overview of clinical research in the past 10 years evaluating the anti-infective efficacy of oral small-molecule drugs for NTD(s) for which they are neither SRA approved, nor included in current WHO strategies nor, considering the research sponsors, likely to be registered with a SRA for that NTD, if found to be effective and safe. No such research has been done for yaws, guinea worm, Trypanosoma brucei gambiense human African trypanosomiasis (HAT), rabies, trachoma, visceral leishmaniasis, mycetoma, T. b. rhodesiense HAT, echinococcosis, taeniasis/cysticercosis or scabies. Oral drugs evaluated include sparfloxacin and acedapsone for leprosy; rifampicin, rifapentin and moxifloxacin for onchocerciasis; imatinib and levamisole for loiasis; itraconazole, fluconazole, ketoconazole, posaconazole, ravuconazole and disulfiram for Chagas disease, doxycycline and rifampicin for lymphatic filariasis; arterolane, piperaquine, artesunate, artemether, lumefantrine and mefloquine for schistosomiasis; ivermectin, tribendimidine, pyrantel, oxantel and nitazoxanide for soil-transmitted helminths including strongyloidiasis; chloroquine, ivermectin, balapiravir, ribavirin, celgosivir, UV-4B, ivermectin and doxycycline for dengue; streptomycin, amoxicillin, clavulanate for Buruli ulcer; fluconazole and isavuconazonium for mycoses; clarithromycin and dapsone for cutaneous leishmaniasis; and tribendimidine, albendazole, mebendazole and nitazoxanide for foodborne trematodiasis. Additional paths to identification of new treatment options are needed. One promising path is exploitation of the worldwide experience with 'off-label' treatment of diseases with insufficient treatment options as pursued by the 'CURE ID' initiative.

Improving mycetoma case detection through the training of community health workers in Northern Uganda: protocol for a stepped-wedge cluster-randomized trial

Introduction

The World Health Organization acknowledges the need for countries to incorporate neglected tropical disease care into their routine health care system. However, low detection rates and late presentation of mycetoma to health facilities have been observed in endemic countries, including Uganda.

Objective

To empower community health workers (CHWs) in Northern Uganda to recognize and refer suspects of mycetoma to health facilities.

Design

This will be a stepped-wedge cluster-randomized trial based in Gulu and Pader districts over a period of 9 months with sequential crossover from intervention phase to the control phase at different time points until both districts are exposed to the intervention.

Methods and Analysis

The study will leverage on the ongoing partnership between Northern Uganda Medical Mission and the Uganda Ministry of Health that has trained over 300 CHWs in Gulu and Pader. The study evaluation will be done using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework. The expected outcome of the study is increased detection and referral of suspects of mycetoma. Data will be analyzed using STATA 17.0 and Friedman statistics or Analysis of Variance to determine increase in case identifications and referrals.

Ethics and Registration

The study was approved by Mulago Hospital Research and Ethics Committee (MHREC 2406) and registered with Pan African Clinical Trial Registry (PACTR202301534749787).

Dissemination

The results from this trial will be published in a peer-reviewed journal. In addition, the findings will be shared at conferences, with funders, and at other research meetings.

Estimating the burden of mycetoma in Sudan for the period 1991-2018 using a model-based geostatistical approach

Mycetoma is widespread in tropical and subtropical regions favouring arid areas with low humidity and a short rainy season. Sudan is one of the highly endemic countries for mycetoma. Estimating the population at risk and the number of cases is critical for delivering targeted and equitable prevention and treatment services. In this study, we have combined a large dataset of mycetoma cases recorded by the Mycetoma Research Centre (MRC) in Sudan over 28 years (1991-2018) with a collection of environmental and water and hygiene-related datasets in a geostatistical framework to produce estimates of the disease burden across the country. We developed geostatistical models to predict the number of cases of actinomycetoma and eumycetoma in areas considered environmentally suitable for the two mycetoma forms. Then used the raster dataset (gridded map) with the population estimates for 2020 to compute the potentially affected population since 1991. The geostatistical models confirmed this heterogeneous and distinct distribution of the estimated cases of eumycetoma and actinomycetoma across Sudan. For eumycetoma, these higher-risk areas were smaller and scattered across Al Jazirah, Khartoum, White Nile and Sennar states, while for actinomycetoma a higher risk for infection is shown across the rural districts of North and West Kurdufan. Nationally, we estimated 63,825 people (95%CI: 13,693 to 197,369) to have been suffering from mycetoma since 1991 in Sudan,51,541 people (95%CI: 9,893-166,073) with eumycetoma and 12,284 people (95%CI: 3,800-31,296) with actinomycetoma. In conclusion, the risk of mycetoma in Sudan is particularly high in certain restricted areas, but cases are ubiquitous across all states. Both prevention and treatment services are required to address the burden. Such work provides a guide for future control and prevention programs for mycetoma, highly endemic areas are clearly targeted, and resources are directed to areas with high demand.

Role of socioeconomic factors in developing mycetoma: Results from a household survey in Sennar State, Sudan

BACKGROUND

Mycetoma is a chronic, progressively destructive disease of subcutaneous tissues and bones caused by certain species of bacteria or fungi. We conducted a cross-sectional community-based study alongside mapping of mycetoma in five administrative units with high mycetoma endemicity in the Eastern Sennar Locality, Sennar State, Sudan.

METHODS

A household survey was administered which included questions about the household members, household characteristics, economic activity and history of mycetoma. A clinical examination was conducted on all members of the household. If mycetoma was suspected, an individual questionnaire was completed collecting demographic, clinical and epidemiological data as well as information on the use of health care and associated costs. Geographical coordinates and photos of the lesions were taken, and the affected persons were referred to the medical centre for confirmation of the diagnosis and treatment. We compared the characteristics of households with confirmed cases of mycetoma with those without confirmed cases, and individuals with confirmed mycetoma with those in whom mycetoma was not confirmed.

RESULTS

In total 7,798 households in 60 villages were surveyed; 515 suspected cases were identified and 359 cases of mycetoma were confirmed. Approximately 15% of households with mycetoma had more than one household member affected by this disease. Households with mycetoma were worse off with respect to water supply, toilet facilities, electricity and electrical appliances compared to the survey households. Only 23% of study participants with mycetoma had sought professional help. Of these, 77% of patients travelled an average of six hours to visit a medical facility. More than half of patients had to pay towards their treatment. The estimated average cost of treatment was 26,957 Sudanese pounds per year (566 US dollars, exchange rate 2018).

CONCLUSIONS

Results of this survey suggest that agricultural practices and reduced access to sanitation and clean water can be risk factors in developing mycetoma. Poor access to health care and substantial financial costs were barriers to seeking treatment for mycetoma.

Systematic whole-genome sequencing reveals an unexpected diversity among actinomycetoma pathogens and provides insights into their antibacterial susceptibilities

Mycetoma is a neglected tropical chronic granulomatous inflammatory disease of the skin and subcutaneous tissues. More than 70 species with a broad taxonomic diversity have been implicated as agents of mycetoma. Understanding the full range of causative organisms and their antibiotic sensitivity profiles are essential for the appropriate treatment of infections. The present study focuses on the analysis of full genome sequences and antibiotic inhibitory concentration profiles of actinomycetoma strains from patients seen at the Mycetoma Research Centre in Sudan with a view to developing rapid diagnostic tests. Seventeen pathogenic isolates obtained by surgical biopsies were sequenced using MinION and Illumina methods, and their antibiotic inhibitory concentration profiles determined. The results highlight an unexpected diversity of actinomycetoma causing pathogens, including three Streptomyces isolates assigned to species not previously associated with human actinomycetoma and one new Streptomyces species. Thus, current approaches for clinical and histopathological classification of mycetoma may need to be updated. The standard treatment for actinomycetoma is a combination of sulfamethoxazole/trimethoprim and amoxicillin/clavulanic acid. Most tested isolates had a high IC (inhibitory concentration) to sulfamethoxazole/trimethoprim or to amoxicillin alone. However, the addition of the β-lactamase inhibitor clavulanic acid to amoxicillin increased susceptibility, particularly for Streptomyces somaliensis and Streptomyces sudanensis. Actinomadura madurae isolates appear to have a particularly high IC under laboratory conditions, suggesting that alternative agents, such as amikacin, could be considered for more effective treatment. The results obtained will inform future diagnostic methods for the identification of actinomycetoma and treatment.