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A terrifying disease stalks seaside Australia: Flesh-eating ulcers

SORRENTO, AUSTRALIA — To Rob Courtney, it looked like a sunburn. But after a few days, the redness and inflammation got worse. Soon, the skin on his right foot was split open, the wound oozing. His doctor sent him straight to the emergency room.

Then came the horrifying diagnosis: Courtney was infected with a species of flesh-eating bacteria.

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In recent years, cases of the disease, known as Buruli ulcer, have exploded in the seaside area where Courtney, 80, lives in southeastern Australia.

As he would learn, it is a fearsome intruder.

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The ulcer left the flesh on his foot corroded and gangrenous. It devoured a skin graft. Eventually, doctors prescribed the same powerful antibiotics used to treat leprosy and tuberculosis. The drugs made him feel nauseated and fatigued, and turned his sweat and tears orange. He spent nearly 50 days in the hospital.

“It’s been a bit of a journey,” Courtney said recently as he lay on an examination table at his local clinic, where he has endured a daily wound dressing for several weeks. “I wouldn’t recommend it.”

Buruli ulcer has been reported in 33 countries, primarily in Africa, where a lack of access to health care can mean that cases go on for months, sometimes resulting in disfigurement and disability.

In Australia, where cases of the ulcer have been recorded since the 1940s, the recent increase in infections has brought new attention to the neglected disease. That, along with a growing global interest in infectious diseases, has raised hopes that scientists might finally have the resources to crack its code.

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The area hit hardest in Australia is the Mornington Peninsula, in the state of Victoria. More than 180 cases per year have been reported in the state since 2016, peaking in 2018 at 340. In February, the disease crept further into the suburbs of Melbourne, a city of 5 million people.

No one knows exactly how the infection spreads or why it has flared on the Mornington Peninsula, an affluent region less than 50 miles from Melbourne where cafes line leafy boulevards and thousands of tourists visit each year.

The small town of Blairgowrie on the Mornington Peninsula in Australia on Feb. 27, 2021. No one knows exactly how the Buruli ulcer infection spreads or why it has flared in the region.
The small town of Blairgowrie on the Mornington Peninsula in Australia on Feb. 27, 2021. No one knows exactly how the Buruli ulcer infection spreads or why it has flared in the region. (Christina Simons/The New York Times)

Scientists think that Buruli ulcer — and up to 75% of emerging diseases, including the coronavirus — is zoonotic, meaning it jumps from animals to humans. They say zoonotic diseases are becoming more common in part because of human encroachment on wild environments.

As for the spike in cases in Victoria, the leading theory is that possums, a marsupial native to Australia, carry the bacteria, which are then transmitted to humans by mosquitoes that have come into contact with the animal’s feces.

The bacterium has long been present, but “what we’ve done is stumbled into it and maybe helped it to amplify and become the unwitting victims,” said Dr. Paul Johnson, a physician and professor of infectious diseases at Austin Health in Melbourne. “We’ve provided situations where it can expand rapidly and cause human disease.”

In recent years, as attention to the disease has increased funding for research, Johnson and others have been trying to figure out exactly how Buruli ulcer is transmitted. To test their theory, the scientists are working to reduce the number of mosquitoes on the Mornington Peninsula to see whether cases of Buruli ulcer drop as well.

On a Saturday in late February, Johnson and Tim Stinear, a professor of microbiology at the Doherty Institute at the University of Melbourne, led a troop of more than a dozen researchers — clad in yellow “Beating Buruli in Victoria” vests — as they set mosquito traps in the suburbs of the Mornington Peninsula.

The researchers have also been on the hunt for possum feces, which they say has given them a crucial map of hot spots where the bacteria are present. “Once you start looking for this stuff, you see it everywhere,” Stinear said as he knelt in a driveway, using a stick to scoop the scat into a sandwich bag. “Because it is everywhere.”

Stacey Lynch, left, and Tim Stinear, who are studying how Buruli ulcer is transmitted, preparing mosquito traps in the Mornington Peninsula of Australia on Feb. 27, 2021.
Stacey Lynch, left, and Tim Stinear, who are studying how Buruli ulcer is transmitted, preparing mosquito traps in the Mornington Peninsula of Australia on Feb. 27, 2021. (Christina Simons/The New York Times)

Despite possums’ ubiquitousness, they are protected as native creatures in Australia. That has tended to stall research and has stood in the way of culling programs that could reduce the spread of the disease. (Vaccinating the animals, though, is a possibility.) Efforts to cull mosquitoes with insecticide have also met pushback from environmentalists.

The opposition is hardly a surprise, researchers say, given the global wave of distrust in science. But funding work on obscure diseases like Buruli ulcer is crucial to halting outbreaks. “We never know when they will become important,” Stinear said. “This is a lesson that we learned with coronavirus.”

For those who contract Buruli ulcer, the journey can be arduous, leading to severe illness and sometimes even amputation and death in older and vulnerable patients. The wounds can take months to heal, scarring patients both physically and psychologically.

“It’s a huge illness to deal with,” said Dr. Daniel O’Brien, an infectious disease specialist based in Geelong, 50 miles southwest of Melbourne. “It becomes quite disconcerting for people in the community.”

Michael Steele, a Buruli ulcer patient, in Melbourne, Australia, on March 1, 2021, is waiting for a skin graft. He said he thought he had the Buruli ulcer disease in Sorrento last year.
Michael Steele, a Buruli ulcer patient, in Melbourne, Australia, on March 1, 2021, is waiting for a skin graft. He said he thought he had the Buruli ulcer disease in Sorrento last year. (Christina Simons/The New York Times)

On a Friday in March, O’Brien treated Courtney and more than a dozen other patients at a clinic in Sorrento on the Mornington Peninsula. When O’Brien began traveling there about a decade ago, he would see a handful of patients each week. Now he sees up to 50.

He has treated more than a thousand patients, both in Australia and overseas, for the disease. Many of those in Australia are older, but others are young teachers, laborers and even children.

He measures their lesions gently with a ruler, marking them to track their progression. Although ulcers look like the stuff of nightmares — some eat all the way to the bone — most patients describe them as painless. The flesh-eating toxin produced by the bacteria presents a peculiar horror: It both weakens the immune response and numbs the flesh it is consuming. It’s “quite an extraordinary organism, really,” O’Brien said of the bacterium, “and a formidable foe.”

In Courtney’s case, the ulcer had ravaged the top half of his foot before doctors could give a diagnosis. They have since performed surgeries to remove the necrotic, concrete-like tissue. “Unless you get rid of that dead flesh, the skin will never heal,” said Dr. Adrian Murrie, a physician at the clinic who has been treating Courtney.

Other patients with less severe cases sometimes decline treatment, instead opting for natural remedies like applying heat and clay. Although the body can occasionally fight off smaller ulcers, such treatments can pose a danger in serious cases, O’Brien said.

In most cases, the course of treatment is antibiotics. Previously, the disease was largely treated with surgery, but with better medications, the prognosis has vastly improved in recent years. “It was thought the antibiotics didn’t work,” O’Brien said, “because it actually gets worse before it gets better.”

Still, for now, prevention is close to impossible.

“We don’t know how to stop it,” he said. But if the answer is to be found anywhere, he said, it’s in Australia.

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For Courtney, his battle with the disease is far from over. Doctors expect his treatment to last at least another six months.

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“When you’re 80 years old and you lose a year,” he said, “you get really savage about it.”

A mosquito trap left by the researchers on the Mornington Peninsula of Australia on Feb. 27, 2021. As Buruli ulcer cases have risen, they have taken a physical and psychological toll but also offered hope that scientists can solve the bacteria’s many mysteries.
A mosquito trap left by the researchers on the Mornington Peninsula of Australia on Feb. 27, 2021. As Buruli ulcer cases have risen, they have taken a physical and psychological toll but also offered hope that scientists can solve the bacteria’s many mysteries. (Christina Simons/The New York Times)

c.2021 The New York Times Company

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