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Hotterbeekx A, Lammens M, Idro R, Akun PR, Lukande R, Akena G, Nath A, Taylor J, Olwa F, Kumar-Singh S, Colebunders R. Neuroinflammation and Not Tauopathy Is a Predominant Pathological Signature of Nodding Syndrome. J Neuropathol Exp Neurol 2020; 78:1049-1058. [PMID: 31553445 PMCID: PMC6839030 DOI: 10.1093/jnen/nlz090] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Indexed: 11/15/2022] Open
Abstract
Nodding syndrome (NS) is an epileptic disorder occurring in children in African onchocerciasis endemic regions. Here, we describe the pathological changes in 9 individuals from northern Uganda who died with NS (n = 5) or other forms of onchocerciasis-associated epilepsy (OAE) (n = 4). Postmortem examinations were performed and clinical information was obtained. Formalin-fixed brain samples were stained by hematoxylin and eosin and immunohistochemistry was used to stain astrocytes (GFAP), macrophages (CD68), ubiquitin, α-synuclein, p62, TDP-43, amyloid β, and tau (AT8). The cerebellum showed atrophy and loss of Purkinje cells with hyperplasia of the Bergmann glia. Gliosis and features of past ventriculitis and/or meningitis were observed in all but 1 participant. CD68-positive macrophage clusters were observed in all cases in various degrees. Immunohistochemistry for amyloid β, α-synuclein, or TDP-43 was negative. Mild to sparse AT8-positive neurofibrillary tangle-like structures and threads were observed in 4/5 NS and 2/4 OAE cases, preferentially in the frontal and parietal cortex, thalamic- and hypothalamic regions, mesencephalon and corpus callosum. Persons who died with NS and other forms of OAE presented similar pathological changes but no generalized tauopathy, suggesting that NS and other forms of OAE are different clinical presentations of a same disease with a common etiology.
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Affiliation(s)
- An Hotterbeekx
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - Martin Lammens
- Department of Pathology, Antwerp University Hospital, Antwerp, Belgium
| | - Richard Idro
- Department of Neuropathology, Born-Bunge Institute, University of Antwerp, Antwerp, Belgium
| | - Pamela R Akun
- Department of Paediatrics and Child Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Robert Lukande
- Department of Pathology, Makerere University, Medical School, Kampala, Uganda
| | | | - Avindra Nath
- Section of Infections of the Nervous System, National Institute of Neurological, Disorders and Stroke, National Institutes of Health, Bethesda
| | - Joneé Taylor
- Department of Forensic Medicine, New York University, School of Medicine, New York City Office of the Chief Medical Examiner, New York, New York
| | - Francis Olwa
- Department of Diagnostics, Faculty of Health Sciences, Lira University, Lira, Uganda
| | - Samir Kumar-Singh
- Molecular Pathology Group, Laboratory of Cell Biology & Histology, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Robert Colebunders
- Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
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Johnson TP, Sejvar J, Nutman TB, Nath A. The Pathogenesis of Nodding Syndrome. ANNUAL REVIEW OF PATHOLOGY-MECHANISMS OF DISEASE 2020; 15:395-417. [PMID: 31977293 DOI: 10.1146/annurev-pathmechdis-012419-032748] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Nodding syndrome is a rare, enigmatic form of pediatric epilepsy that has occurred in an epidemic fashion beginning in the early 2000s in geographically distinct regions of Africa. Despite extensive investigation, the etiology of nodding syndrome remains unclear, although much progress has been made in understanding the pathogenesis of the disease, as well as in treatment and prevention. Nodding syndrome is recognized as a defined disease entity, but it is likely one manifestation along a continuum of Onchocerca volvulus-associated neurological complications. This review examines the epidemiology of nodding syndrome and its association with environmental factors. It provides a critical analysis of the data that support or contradict the leading hypotheses of the etiologies underlying the pathogenesis of the syndrome. It also highlights the important progress made in treating and preventing this devastating neurological disease and prioritizes important areas for future research.
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Affiliation(s)
- Tory P Johnson
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA
| | - James Sejvar
- Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia 30329-4027, USA
| | - Thomas B Nutman
- Helminth Immunology Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland 20892, USA
| | - Avindra Nath
- Section of Infections of the Nervous System, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland 20892, USA;
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Zoonotic and vector-borne parasites and epilepsy in low-income and middle-income countries. Nat Rev Neurol 2020; 16:333-345. [PMID: 32427939 DOI: 10.1038/s41582-020-0361-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2020] [Indexed: 12/22/2022]
Abstract
Zoonotic and vector-borne parasites are important preventable risk factors for epilepsy. Three parasitic infections - cerebral malaria, Taenia solium cysticercosis and onchocerciasis - have an established association with epilepsy. Parasitoses are widely prevalent in low-income and middle-income countries, which are home to 80% of the people with epilepsy in the world. Once a parasitic infection has taken hold in the brain, therapeutic measures do not seem to influence the development of epilepsy in the long term. Consequently, strategies to control, eliminate and eradicate parasites represent the most feasible way to reduce the epilepsy burden at present. The elucidation of immune mechanisms underpinning the parasitic infections, some of which are parasite-specific, opens up new therapeutic possibilities. In this Review, we explore the pathophysiological basis of the link between parasitic infections and epilepsy, and we consider preventive and therapeutic approaches to reduce the burden of epilepsy attributable to parasitic disorders. We conclude that a concerted approach involving medical, veterinary, parasitological and ecological experts, backed by robust political support and sustainable funding, is the key to reducing this burden.
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Olum S, Scolding P, Hardy C, Obol J, Scolding NJ. Nodding syndrome: a concise review. Brain Commun 2020; 2:fcaa037. [PMID: 32954295 PMCID: PMC7425334 DOI: 10.1093/braincomms/fcaa037] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 02/19/2020] [Accepted: 02/21/2020] [Indexed: 12/12/2022] Open
Abstract
Nodding syndrome is an uncommon epileptic disorder of childhood onset, which appears to occur exclusively in clusters in sub-Saharan Africa. It was first reported in the 1960s, in what is now southern Tanzania, then in Liberia, and later in South Sudan and northern Uganda, with both epidemic and endemic patterns described. The cause remains unknown. Here we describe the background and development of descriptions of the disorder, review its clinical features and summarize current theories and studies concerning its cause, outlining the principal remaining research questions relating to this highly unusual disease.
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Affiliation(s)
- Sam Olum
- Faculty of Medicine, Gulu University, Gulu, Uganda
| | - Peter Scolding
- Department of Medicine, Imperial College Healthcare NHS Trust, London W12 0HS, UK
| | - Charlotte Hardy
- Faculty of Medicine, Gulu University, Gulu, Uganda.,Emergency Department, Royal United Hospital, Bath BA1 3NG, UK
| | - James Obol
- Faculty of Medicine, Gulu University, Gulu, Uganda
| | - Neil J Scolding
- Faculty of Medicine, Gulu University, Gulu, Uganda.,Institute of Clinical Neurosciences, University of Bristol, Learning and Research Building, Southmead Hospital, Bristol BS10 5NB, UK
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Dual-Targeted Autoimmune Sword in Fatal Epilepsy: Patient's glutamate receptor AMPA GluR3B peptide autoimmune antibodies bind, induce Reactive Oxygen Species (ROS) in, and kill both human neural cells and T cells. J Autoimmun 2020; 112:102462. [PMID: 32561150 DOI: 10.1016/j.jaut.2020.102462] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 04/03/2020] [Accepted: 04/03/2020] [Indexed: 11/22/2022]
Abstract
Nodding Syndrome (NS) is a fatal pediatric epilepsy of unknown etiology, accompanied by multiple neurological impairments, and associated with Onchocerca volvulus (Ov), malnutrition, war-induced trauma, and other insults. NS patients have neuroinflammation, and ~50% have cross-reactive Ov/Leiomodin-1 neurotoxic autoimmune antibodies. RESULTS: Studying 30 South Sudanese NS patients and a similar number of healthy subjects from the same geographical region, revealed autoimmune antibodies to 3 extracellular peptides of ionotropic glutamate receptors in NS patients: AMPA-GluR3B peptide antibodies (86%), NMDA-NR1 peptide antibodies (77%) and NMDA-NR2 peptide antibodies (87%) (in either 1:10, 1:100 or 1:1000 serum dilution). In contrast, NS patients did not have 26 other well-known autoantibodies that target the nervous system in several autoimmune-mediated neurological diseases. We demonstrated high expression of both AMPA-GluR3 and NMDA-NR1 in human neural cells, and also in normal human CD3+ T cells of both helper CD4+ and cytotoxic CD8+ types. Patient's GluR3B peptide antibodies were affinity-purified, and by themselves precipitated short 70 kDa neuronal GluR3. NS patient's affinity-purified GluR3B peptide antibodies also bound to, induced Reactive Oxygen Species (ROS) in, and killed both human neural cells and T cells within 1-2 hours only. NS patient's purified IgGs, or serum (1:10 or 1:30), induced similar effects. In vivo video EEG experiments in normal mice, revealed that when NS patient's purified IgGs were released continuously (24/7 for 1 week) in normal mouse brain, they induced all the following: 1.Seizures, 2. Cerebellar Purkinje cell loss, 3. Degeneration in the hippocampus and cerebral cortex, and 4. Elevation of CD3+ T cells, and of activated Mac-2+microglia and GFAP+astrocytes in both the gray and white matter of the cerebral cortex, hippocampus, corpus calossum and cerebellum of mice. NS patient's serum cytokines: IL-1β, IL-2, IL-6, IL-8, TNFα, IFNγ, are reduced by 85-99% compared to healthy subjects, suggesting severe immunodeficiency in NS patients. This suspected immunodeficiency could be caused by combined effects of the: 1. Chronic Ov infection, 2. Malnutrition, 3. Killing of NS patient's T cells by patient's own GluR3B peptide autoimmune antibodies (alike the killing of normal human T cells by the NS patient's GluR3B peptide antibodies found herein in vitro). CONCLUSIONS: Regardless of NS etiology, NS patients suffer from 'Dual-targeted Autoimmune Sword': autoimmune AMPA GluR3B peptide antibodies that bind, induce ROS in, and kill both neural cells and T cells. These neurotoxic and immunotoxic GluR3B peptide autoimmune antibodies, and also NS patient's NMDA-NR1/NR2A and Ov/Leiomodin-1 autoimmune antibodies, must be silenced or removed. Moreover, the findings of this study are relevant not only to NS, but also to many more patients with other types of epilepsy, which have GluR3B peptide antibodies in serum and/or CSF. This claim is based on the following facts: 1. The GluR3 subunit is expressed in neural cells in crucial brains regions, in motor neurons in the spinal cord, and also in other cells in the body, among them T cells of the immune system, 2. The GluR3 subunit has diverse neurophysiological role, and its deletion or abnormal function can: disrupt oscillatory networks of both sleep and breathing, impair motor coordination and exploratory activity, and increase the susceptibility to generate seizures, 3. GluR3B peptide antibodies were found so far in ~27% of >300 epilepsy patients worldwide, which suffer from various other types of severe, intractable and enigmatic epilepsy, and which turned out to be 'Autoimmune Epilepsy'. Furthermore, the findings of this study could be relevant to different neurological diseases besides epilepsy, since other neurotransmitter-receptors autoantibodies are present in other neurological and psychiatric diseases, e.g. autoimmune antibodies against other GluRs, Dopamine receptors, GABA receptors, Acetylcholine receptors and others. These neurotransmitter-receptors autoimmune autoantibodies might also act as 'Dual-targeted Autoimmune Sword' and damage both neural cells and T cells (as the AMPA-GluR3B peptide antibodies induced in the present study), since T cells, alike neural cells, express most if not all these neurotransmitter receptors, and respond functionally to the respective neurotransmitters - a scientific and clinical topic we coined 'Nerve-Driven Immunity'.
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Mandro M, Siewe Fodjo JN, Mukendi D, Dusabimana A, Menon S, Haesendonckx S, Lokonda R, Nakato S, Nyisi F, Abhafule G, Wonya’Rossi D, Jakwong JM, Suykerbuyk P, Meganck J, Hotterbeekx A, Colebunders R. Ivermectin as an adjuvant to anti-epileptic treatment in persons with onchocerciasis-associated epilepsy: A randomized proof-of-concept clinical trial. PLoS Negl Trop Dis 2020; 14:e0007966. [PMID: 31923177 PMCID: PMC6977765 DOI: 10.1371/journal.pntd.0007966] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 01/23/2020] [Accepted: 12/03/2019] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Recent findings from onchocerciasis-endemic foci uphold that increasing ivermectin coverage reduces the epilepsy incidence, and anecdotal evidence suggests seizure frequency reduction in persons with onchocerciasis-associated epilepsy, when treated with ivermectin. We conducted a randomized clinical trial to assess whether ivermectin treatment decreases seizure frequency. METHODS A proof-of-concept randomized clinical trial was conducted in the Logo health zone in the Ituri province, Democratic Republic of Congo, to compare seizure frequencies in onchocerciasis-infected persons with epilepsy (PWE) randomized to one of two treatment arms: the anti-epileptic drug phenobarbital supplemented with ivermectin, versus phenobarbital alone. The primary endpoint was defined as the probability of being seizure-free at month 4. A secondary endpoint was defined as >50% reduction in seizure frequency at month 4, compared to baseline. Both endpoints were analyzed using multiple logistic regression. In longitudinal analysis, the probability of seizure freedom during the follow-up period was assessed for both treatment arms by fitting a logistic regression model using generalized estimating equations (GEE). RESULTS Ninety PWE enrolled between October and November 2017 were eligible for analysis. A multiple logistic regression analysis showed a borderline association between ivermectin treatment and being seizure-free at month 4 (OR: 1.652, 95% CI 0.975-2.799; p = 0.062). There was no significant difference in the probability of experiencing >50% reduction of the seizure frequency at month 4 between the two treatment arms. Also, treatment with ivermectin did not significantly increase the odds of being seizure-free during the individual follow-up visits. CONCLUSION Whether ivermectin has an added value in reducing the frequency of seizures in PWE treated with AED remains to be determined. A larger study in persons with OAE on a stable AED regimen and in persons with recent epilepsy onset should be considered to further investigate the potential beneficial effect of ivermectin treatment in persons with OAE. TRIAL REGISTRATION Registration: www.clinicaltrials.gov; NCT03052998.
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Affiliation(s)
- Michel Mandro
- Provincial Ministry of Health, Bunia, Ituri, Democratic Republic of Congo
| | | | - Deby Mukendi
- Centre Neuro-Psycho Pathologique, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | | | - Sonia Menon
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | | | - Richard Lokonda
- Centre Neuro-Psycho Pathologique, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Swabra Nakato
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - Francoise Nyisi
- Centre de Recherche en Maladies Tropicales de l'Ituri, Rethy, Ituri, Democratic Republic of Congo
| | - Germain Abhafule
- Centre de Recherche en Maladies Tropicales de l'Ituri, Rethy, Ituri, Democratic Republic of Congo
| | - Deogratias Wonya’Rossi
- Programme National de Lutte contre l’Onchocercose, Bunia, Ituri, Democratic Republic of Congo
| | - Jean Marie Jakwong
- Hôpital Général de Référence de Logo, Logo, Ituri, Democratic Republic of Congo
| | | | - Jacques Meganck
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - An Hotterbeekx
- Global Health Institute, University of Antwerp, Antwerp, Belgium
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Stacey HJ, Woodhouse L, Welburn SC, Jones JD. Aetiologies and therapies of nodding syndrome: a systematic review and meta-analysis. JOURNAL OF GLOBAL HEALTH REPORTS 2019. [DOI: 10.29392/joghr.3.e2019066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Hotterbeekx A, Raimon S, Abd-Elfarag G, Carter JY, Sebit W, Suliman A, Siewe Fodjo JN, De Witte P, Logora MY, Colebunders R, Kumar-Singh S. Onchocerca volvulus is not detected in the cerebrospinal fluid of persons with onchocerciasis-associated epilepsy. Int J Infect Dis 2019; 91:119-123. [PMID: 31786246 PMCID: PMC6996151 DOI: 10.1016/j.ijid.2019.11.029] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 11/24/2019] [Accepted: 11/25/2019] [Indexed: 10/25/2022] Open
Abstract
OBJECTIVES Epidemiological evidence links onchocerciasis with the development of epilepsy. The aim of this study was to detect Onchocerca volvulus microfilariae or its bacterial endosymbiont, Wolbachia, in the cerebrospinal fluid (CSF) of persons with onchocerciasis-associated epilepsy (OAE). METHODS Thirteen persons with OAE and O. volvulus skin snip densities of >80 microfilariae were recruited in Maridi County (South Sudan) and their CSF obtained. Cytospin centrifuged preparations of CSF were examined by light microscopy for the presence of O. volvulus microfilariae. DNA was extracted from CSF to detect O. volvulus (O-150 repeat) by quantitative real-time PCR, and Wolbachia (FtsZ gene) by standard PCR. To further investigate whether CSF from onchocerciasis-infected participants could induce seizures, 3- and 7-day old zebrafish larvae were injected with the CSF intracardially and intraperitoneally, respectively. For other zebrafish larvae, CSF was added directly to the larval medium. RESULTS No microfilariae, parasite DNA, or Wolbachia DNA were detected in any of the CSF samples by light microscopy or PCR. All zebrafish survived the procedures and none developed seizures. CONCLUSIONS The absence of O. volvulus in the CSF suggests that OAE is likely not caused by direct parasite invasion into the central nervous system, but by another phenomenon triggered by O. volvulus infection.
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Affiliation(s)
- An Hotterbeekx
- Global Health Institute, University of Antwerp, Antwerp, Belgium.
| | | | - Gasim Abd-Elfarag
- Global Child Health Group, Department of Paediatrics and Department of Global Health, Academic Medical Center, University of Amsterdam, The Netherlands; Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands.
| | | | - Wilson Sebit
- National Public Health Laboratory, Juba, South Sudan.
| | | | | | - Peter De Witte
- Moleculaire bio-ontdekking, Katholieke Universiteit Leuven, Leuven, Belgium.
| | - Makoy Yibi Logora
- Neglected Tropical Diseases Unit, Ministry of Health, Juba, South Sudan.
| | | | - Samir Kumar-Singh
- Molecular Pathology Group, Laboratory of Cell Biology and Histology, Faculty of Medical and Health Sciences, University of Antwerp, Antwerp, Belgium.
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Spencer PS, Mazumder R, Palmer VS, Pollanen MS. Nodding syndrome phenotypes. Rev Neurol (Paris) 2019; 175:679-685. [PMID: 31753452 DOI: 10.1016/j.neurol.2019.09.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 09/10/2019] [Accepted: 09/12/2019] [Indexed: 10/25/2022]
Abstract
Nodding syndrome (NS) is a progressive encephalopathy of children and adolescents characterized by seizures, including periodic vertical head nodding. Epidemic NS, which has affected parts of East Africa, appears to have clinical overlap with sub-Saharan Nakalanga syndrome (NLS), a brain disorder associated with pituitary dwarfism that appears to have a patchy distribution across sub-Sahara. Clinical stages of NS include inattention and blank stares, vertical head nodding, convulsive seizures, multiple impairments, and severe cognitive and motorsystem disability, including features suggesting parkinsonism. Head nodding episodes occur in clusters with an electrographic correlate of diffuse high-amplitude slow waves followed by an electrodecremental pattern with superimposed diffuse fast activity. Brain imaging reveals differing degrees of cerebral cortical and cerebellar atrophy. Brains of NS-affected children with mild frontotemporal cortical atrophy display neurofibrillary pathology and dystrophic neurites immunopositive for tau, consistent with a progressive neurodegenerative disorder. The etiology of NS and NLS appears to be dominated by environmental factors, including malnutrition, displacement, and nematode infection, but the specific cause is unknown.
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Affiliation(s)
- P S Spencer
- Department of Neurology, Oregon Health & Science University, Portland, OR, USA.
| | - R Mazumder
- Department of Neurology, University of California Los Angeles, Los Angeles, CA, USA
| | - V S Palmer
- Department of Neurology, Oregon Health & Science University, Portland, OR, USA
| | - M S Pollanen
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Ontario, Canada
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Colebunders R, Siewe Fodjo JN, Hopkins A, Hotterbeekx A, Lakwo TL, Kalinga A, Logora MY, Basáñez MG. From river blindness to river epilepsy: Implications for onchocerciasis elimination programmes. PLoS Negl Trop Dis 2019; 13:e0007407. [PMID: 31318857 PMCID: PMC6638735 DOI: 10.1371/journal.pntd.0007407] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
| | | | - Adrian Hopkins
- Neglected and Disabling Diseases of Poverty Consultant, Kent, United Kingdom
| | - An Hotterbeekx
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - Thomson L. Lakwo
- Neglected Tropical Diseases Control Programme, Ministry of Health, Kampala, Uganda
| | - Akili Kalinga
- National institute for Medical Research, Ministry of Health, Dar es Salaam, Tanzania
| | - Makoy Yibi Logora
- Neglected Tropical Diseases Unit, Ministry of Health, Juba, South Sudan
| | - Maria-Gloria Basáñez
- London Centre for Neglected Tropical Disease Research and MRC Centre for Global Infectious Disease Analysis (MRC-GIDA), Imperial College London, London, United Kingdom
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Irani J, Rujumba J, Mwaka AD, Arach J, Lanyuru D, Idro R, Gerrets R, Grietens KP, O’Neill S. "Those who died are the ones that are cured". Walking the political tightrope of Nodding Syndrome in northern Uganda: Emerging challenges for research and policy. PLoS Negl Trop Dis 2019; 13:e0007344. [PMID: 31220081 PMCID: PMC6605670 DOI: 10.1371/journal.pntd.0007344] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 07/02/2019] [Accepted: 03/28/2019] [Indexed: 11/19/2022] Open
Abstract
Background Nodding Syndrome was first reported from Tanzania in the 1960s but appeared as an epidemic in Northern Uganda in the 1990s during the LRA civil war. It is characterized by repetitive head nodding, often followed by other types of seizures, developmental retardation and growth faltering with onset occurring in children aged 5–15 years. More than 50 years after the first reports, the aetiology remains unknown and there is still no cure. The recent hypothesis that Nodding Syndrome is caused by onchocerciasis also increases the relevance of onchocerciasis control. Northern Uganda, with its unique socio-political history, adds challenges to the prevention and treatment for Nodding Syndrome. This article aims to show how and why Nodding Syndrome has been politicised in Uganda; how this politicisation has affected health interventions including research and dissemination; and, the possible implications this can have for disease prevention and treatment. Methodology Ethnographic research methods were used triangulating in-depth interviews, focus group discussions, informal conversations and participant observation, for an understanding of the various stakeholders’ perceptions of Nodding Syndrome and how these perceptions impact future interventions for prevention, treatment and disease control. Principal findings Distrust towards the government was a sentiment that had developed in Northern Uganda over several decades of war and was particularly linked to the political control and ethnic divisions between the north and south. This coincided with the sudden appearance of Nodding Syndrome, an unknown epidemic disease of which the cause could not be clearly identified and optimal treatment had not clearly been established. Additionally, the dissemination of the inconclusive results of research conducted in the area lacked sufficient community involvement which further fueled this political distrust. Disease perceptions revolved around rumours that the entire Acholi ethnic group of the north would be annihilated, or that international researchers were making money by stealing study samples. This discouraged some community members from participating in research or from accepting the mass drug administration of ivermectin for prevention and treatment of onchocerciasis. Such rumour and distrust led to suspicions concerning the integrity of the disseminated results, which may negatively impact future disease management and control interventions. Conclusions and recommendations Trust must be built up gradually through transparency and by de-politicising interventions. This can be done by engaging the community at regular intervals during research and data collection and the dissemination of results in addition to involvement during service delivery for prevention and treatment. Maintaining a regular feedback loop with the community will help control rumours, build trust, and improve the preparations for adequate dissemination. Nodding Syndrome, a form of epilepsy that occurs in onchocerciasis-endemic areas has affected about 3000 children in Northern Uganda where the epidemic emerged at the time of the civil war. Although an association with onchocerciasis has been established, the disease etiology has not yet been identified. In conjunction with the area’s history of war, political conflict and ethnic divides, many affected people were suspicious of government health interventions and scientific studies. Furthermore, ambiguities around the disease etiology leaves room for several interpretations, which in addition to distrust leads to rumours, that may hinder future interventions. In view of improving adherence to health interventions, this article explains the socio-political nature of Nodding Syndrome in Northern Uganda. We show how and why this disease has been politicised in Uganda; how this politicisation has affected research and dissemination; and, the implications this has for disease control. The insights presented will be critical for reducing resistance to research, to treatment and to the dissemination of knowledge which is necessary for the prevention and control of Nodding Syndrome and onchocerciasis in Northern Uganda.
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Affiliation(s)
- Julia Irani
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- * E-mail:
| | - Joseph Rujumba
- Department of Pediatrics and Child Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Amos Deogratius Mwaka
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- The Ugandan Ministry of Health, Kampala, Uganda
| | - Jesca Arach
- Department of Pediatrics and Child Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Denis Lanyuru
- Department of Pediatrics and Child Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Richard Idro
- Department of Pediatrics and Child Health, College of Health Sciences, Makerere University, Kampala, Uganda
- The Ugandan Ministry of Health, Kampala, Uganda
| | - Rene Gerrets
- The Amsterdam Institute for Social Science Research, University of Amsterdam, Amsterdam, Netherlands
| | | | - Sarah O’Neill
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- CRISS, Ecole de Santé Publique and LAMC, Faculté de Philosophie et Sciences Sociales, Université Libre de Bruxelles, Brussels, Belgium
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Abstract
Nodding syndrome is a mysterious neurologic illness of unknown etiology, presenting with distinctive clinical features often at early age. Currently, it affects children in restricted geographical areas in South Sudan, Northern Uganda and Southern Tanzania and is associated with high mortality and morbidity, especially in the children with severe disease. In this paper, we will give an outline of what is known about nodding syndrome with respect to epidemiology, clinical presentation, etiology and treatment. In addition, a possible approach to resolving the mystery is presented.
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Mukendi D, Tepage F, Akonda I, Siewe JNF, Rotsaert A, Ndibmun CN, Laudisoit A, Couvreur S, Kabutako B, Menon S, Hotterbeekx A, Colebunders R. High prevalence of epilepsy in an onchocerciasis endemic health zone in the Democratic Republic of the Congo, despite 14 years of community-directed treatment with ivermectin: A mixed-method assessment. Int J Infect Dis 2019; 79:187-194. [PMID: 30711145 PMCID: PMC6353816 DOI: 10.1016/j.ijid.2018.10.021] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 10/14/2018] [Accepted: 10/26/2018] [Indexed: 11/24/2022] Open
Abstract
A high epilepsy prevalence in the Aketi health zone was observed despite 14 years of community-directed treatment with ivermectin. The high prevalence of OV16 antibodies in children is indicative of high ongoing onchocerciasis transmission. High onchocerciasis transmission is the consequence of high exposure to blackflies and low intake of ivermectin. Head nodding seizures were observed in 13.8% of the persons with epilepsy. Ivermectin coverage needs to be increased and bi-annual distribution should be considered.
Objectives To investigate the reasons for the high prevalence of epilepsy (>6%) discovered in 2015 in the Aketi health zone in the north of the Democratic Republic of the Congo. Methods Persons with epilepsy (PWE) diagnosed in a door-to-door survey in 2015 were traced and re-examined in 2017 by a neurologist. Confirmed PWE were paired with matched controls. For onchocerciasis assessment, children 7–10 years old were tested for IgG4 Onchocerca volvulus (OV16) antibodies, a rapid epidemiological mapping of onchocerciasis (REMO) study was performed, and ivermectin coverage was investigated. Results Forty-three (61.4%) previously diagnosed PWE were traced; the neurologist confirmed the epilepsy diagnosis in all of them. The overall OV16 positivity rate was 64.5%. Poor ivermectin coverage (55.9%) and a high prevalence of onchocercal nodules (>70%) were observed. The prevalence of epilepsy was 5.7% in Aketi rural town, with nine PWE (13.8%) experiencing head nodding seizures. A case-control study showed that PWE had lower body weight and higher ivermectin coverage in 2017 than healthy controls. Conclusions The high prevalence of epilepsy in the Aketi health zone, despite 14 years of community-directed treatment with ivermectin (CDTI), was found to be associated with high onchocerciasis transmission and low ivermectin use. An awareness programme to increase ivermectin coverage and the introduction of a bi-annual CDTI programme should be considered.
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Affiliation(s)
- Deby Mukendi
- Neuropsychopathologic Centre of Mont Amba, University of Kinshasa, Kinshasa, Congo.
| | | | | | | | - Anke Rotsaert
- Global Health Institute, University of Antwerp, Antwerp, Belgium.
| | | | - Anne Laudisoit
- Global Health Institute, University of Antwerp, Antwerp, Belgium; EcoHealth Alliance, New York, USA.
| | - Simon Couvreur
- Global Health Institute, University of Antwerp, Antwerp, Belgium.
| | - Blandine Kabutako
- School of Medicine, Bel-Campus Technological University, Kinshasa, Congo.
| | - Sonia Menon
- Global Health Institute, University of Antwerp, Antwerp, Belgium.
| | - An Hotterbeekx
- Global Health Institute, University of Antwerp, Antwerp, Belgium.
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Colebunders R, Titulaer MJ. Nodding syndrome: Preventable and treatable. Sci Transl Med 2019; 9:9/377/eaam8532. [PMID: 28202778 DOI: 10.1126/scitranslmed.aam8532] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 01/27/2017] [Indexed: 11/02/2022]
Abstract
New insights into the pathophysiology of nodding syndrome, a form of childhood epilepsy associated with onchocerciasis, provide new opportunities for disease treatment and parasite control (Johnson et al).
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Affiliation(s)
| | - Maarten J Titulaer
- Department of Neurology, Erasmus University Medical Center, Rotterdam, Netherlands
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Idro R, Anguzu R, Ogwang R, Akun P, Abbo C, Mwaka AD, Opar B, Nakamya P, Taylor M, Elliott A, Vincent A, Newton C, Marsh K. Doxycycline for the treatment of nodding syndrome (DONS); the study protocol of a phase II randomised controlled trial. BMC Neurol 2019; 19:35. [PMID: 30841858 PMCID: PMC6402111 DOI: 10.1186/s12883-019-1256-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 02/13/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Nodding syndrome is a poorly understood neurological disorder of unknown aetiology, affecting several thousand children in Africa. There has been a consistent epidemiological association with infection by the filarial parasite, Onchocerca volvulus and antibodies to leiomodin and DJ-1, cross-reacting with O.volvulus proteins, have been reported. We hypothesized that nodding syndrome is a neuro-inflammatory disorder, induced by antibodies to O.volvulus or its symbiont, Wolbachia, cross-reacting with human neuron proteins and that doxycycline, which kills Onchocerca through effects on Wolbachia, may be used as treatment. METHODS This will be a two-arm, double-blind, placebo-controlled, randomised phase II trial of doxycycline 100 mg daily for six weeks in 230 participants. Participants will be patients' ages≥8 years with nodding syndrome. They will receive standard of care supportive treatment. All will be hospitalised for 1-2 weeks during which time baseline measurements including clinical assessments, EEG, cognitive and laboratory testing will be performed and antiepileptic drug doses rationalised. Participants will then be randomised to either oral doxycycline (Azudox®, Kampala Pharmaceutical Industries) 100 mg daily or placebo. Treatment will be initiated in hospital and continued at home. Participants will be visited at home at 2, 4 and 6 weeks for adherence monitoring. Study outcomes will be assessed at 6, 12, 18 and 24-month visits. Analysis will be by intention to treat. The primary efficacy outcome measure will be the proportion of patients testing positive and the levels or titires of antibodies to host neuron proteins (HNPs) and/or leiomodin at 24 months. Secondary outcome measures will include effect of the intervention on seizure control, inflammatory markers, cognitive function, disease severity and quality of life. DISCUSSION This trial postulates that targeting O.volvulus through drugs which kill Wolbachia can modify the pathogenic processes in nodding syndrome and improve outcomes. Findings from this study are expected to substantially improve the understanding and treatment of nodding syndrome. TRIAL REGISTRATION Registered with clinicaltrials.gov ID: NCT02850913 on 1st August, 2016.
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Affiliation(s)
- Richard Idro
- College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda
- Centre for Tropical Neuroscience, P.O. Box 27520, Kampala, Uganda
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7FZ UK
| | - Ronald Anguzu
- College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda
- Centre for Tropical Neuroscience, P.O. Box 27520, Kampala, Uganda
| | - Rodney Ogwang
- College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda
- Centre for Tropical Neuroscience, P.O. Box 27520, Kampala, Uganda
| | - Pamela Akun
- College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda
- Centre for Tropical Neuroscience, P.O. Box 27520, Kampala, Uganda
| | - Catherine Abbo
- College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda
| | | | - Bernard Opar
- Ministry of Health, P.O Box 7272, Kampala, Uganda
| | | | - Mark Taylor
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L35QA UK
| | - Alison Elliott
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, P.O Box 49, Entebbe, Uganda
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9TH UK
| | - Charles Newton
- Department of Psychiatry, St John’s College, University of Oxford, St Giles, Oxford, OX1 3JP UK
| | - Kevin Marsh
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7FZ UK
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Angwafor SA, Bell GS, Njamnshi AK, Singh G, Sander JW. Parasites and epilepsy: Understanding the determinants of epileptogenesis. Epilepsy Behav 2019; 92:235-244. [PMID: 30711777 DOI: 10.1016/j.yebeh.2018.11.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 11/25/2018] [Accepted: 11/26/2018] [Indexed: 12/25/2022]
Abstract
There is a large body of evidence suggesting that parasites could be a major preventable risk factor for epilepsy in low- and middle-income countries. We review potentially important substrates for epileptogenesis in parasitic diseases. Taenia solium is the most widely known parasite associated with epilepsy, and the risk seems determined mainly by the extent of cortical involvement and the evolution of the primary cortical lesion to gliosis or to a calcified granuloma. For most parasites, however, epileptogenesis is more complex, and other favorable host genetic factors and parasite-specific characteristics may be critical. In situations where cortical involvement by the parasite is either absent or minimal, parasite-induced epileptogenesis through an autoimmune process seems plausible. Further research to identify important markers of epileptogenesis in parasitic diseases will have huge implications for the development of trials to halt or delay onset of epilepsy.
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Affiliation(s)
- Samuel A Angwafor
- NIHR University College London Hospitals Biomedical Research Centre, UCL Queen Square Institute of Neurology, London WC1N 3BG, United Kingdom; Chalfont Centre for Epilepsy, Buckinghamshire, United Kingdom
| | - Gail S Bell
- NIHR University College London Hospitals Biomedical Research Centre, UCL Queen Square Institute of Neurology, London WC1N 3BG, United Kingdom; Chalfont Centre for Epilepsy, Buckinghamshire, United Kingdom
| | - Alfred K Njamnshi
- Neurology Department, Central Hospital Yaoundé/Faculty of Medicine and Biomedical Sciences (FMBS), The University of Yaoundé 1, Cameroon; Brain Research Africa Initiative (BRAIN), Yaoundé, Cameroon
| | - Gagandeep Singh
- NIHR University College London Hospitals Biomedical Research Centre, UCL Queen Square Institute of Neurology, London WC1N 3BG, United Kingdom; Chalfont Centre for Epilepsy, Buckinghamshire, United Kingdom; Department of Neurology, Dayanand Medical College, Ludhiana, India
| | - Josemir W Sander
- NIHR University College London Hospitals Biomedical Research Centre, UCL Queen Square Institute of Neurology, London WC1N 3BG, United Kingdom; Chalfont Centre for Epilepsy, Buckinghamshire, United Kingdom; Stichting Epilepsie Instelligen Nederland (SEIN), the Netherlands.
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Siewe JNF, Ukaga CN, Nwazor EO, Nwoke MO, Nwokeji MC, Onuoha BC, Nwanjor SO, Okeke J, Osahor K, Chimechefulam L, Ogomaka AI, Amaechi AA, Ezenwa CI, Ezike MN, Ikpeama C, Nwachukwu O, Eriama-Joseph AI, Nwoke BEB, Colebunders R. Low prevalence of epilepsy and onchocerciasis after more than 20 years of ivermectin treatment in the Imo River Basin in Nigeria. Infect Dis Poverty 2019; 8:8. [PMID: 30670093 PMCID: PMC6343278 DOI: 10.1186/s40249-019-0517-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 01/06/2019] [Indexed: 12/02/2022] Open
Abstract
Background High epilepsy prevalence and incidence have been reported in areas with high onchocerciasis transmission. Recent findings suggest that proper community-directed treatment with ivermectin (CDTI) is potentially able to prevent onchocerciasis-associated epilepsy (OAE). We assessed the epilepsy prevalence and onchocerciasis transmission in two Nigerian villages following more than 20 years of CDTI. Methods A cross-sectional door-to-door survey was performed in two villages in the Imo River Basin reported to be mesoendomic for onchocerciasis (Umuoparaodu and Umuezeala). Individuals were screened for epilepsy using a validated 5-item questionnaire. Persons suspected to have epilepsy were examined by a neurologist or a physician with training in epilepsy for confirmation. Onchocerciasis was investigated via skin snip microscopy and rapid diagnostic tests for Ov16 antibodies. Results were compared with previous findings from the Imo river basin. Results A total of 843 individuals from 257 households in the two villages were encountered. We detected four persons with epilepsy (PWE) giving a crude epilepsy prevalence of 0.5%. This finding differs from observations reported 14 years ago which showed an epilepsy prevalence of 2.8% in the neighbouring village of Umulolo (P = 0.0001), and 1.2% from 13 villages in the Imo river basin (P = 0.07). The seroprevalence of Ov16 antibodies was found to be 0%. Only 4.6% of skin snips were positive compared to 26.8% in previous surveys (P < 0.0001). Ivermectin mass distribution coverage in the study sites in 2017 was 79.7%. Conclusions A low epilepsy and onchocerciasis prevalence was observed following more than 20 years of CDTI in the Imo River Basin. Absence of Ov16 antibodies indicates minimal transmission of onchocerciasis. These results contrast with observations from areas of high onchocerciasis transmission, where epilepsy prevalence and incidence remain high. Findings from this study suggest that sustained efforts could eventually achieve elimination of onchocerciasis in these villages. Electronic supplementary material The online version of this article (10.1186/s40249-019-0517-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Joseph N F Siewe
- Global Health Institute, University of Antwerp, Campus Drie Eiken, Doornstraat 331, 2610 Wilrijk, Antwerp, Belgium.
| | | | - Ernest O Nwazor
- Federal Medical Centre, Owerri, Nigeria.,Madonna University Teaching Hospital, Elele, Nigeria
| | | | | | | | | | - Joel Okeke
- Imo State Ministry of Health, Owerri, Nigeria
| | | | | | | | | | | | | | | | | | | | | | - Robert Colebunders
- Global Health Institute, University of Antwerp, Campus Drie Eiken, Doornstraat 331, 2610 Wilrijk, Antwerp, Belgium
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Abstract
As we learn more and more about the classes of organisms that infect humans, we are discovering that many organisms, including pathogenic organisms, may have a complex relationship with humans in which infection seldom results in the production disease. In some cases, infection may be just one biological event that occurs during a multievent process that develops sequentially, over time, and involves genetic and environmental factors that may vary among individuals. Consequently, the role of infectious organisms in the development of human disease may not meet all of the criteria normally required to determine when an organism can be called the cause of a disease. This chapter reviews the expanding role of infections in the development of human disease. We discuss prion diseases of humans, a fascinating example of an infectious disease-causing agent that is not a living organism. We also discuss the diseases of unknown etiology for which infectious organisms may play a role. In addition, this chapter reviews some of the misconceptions and recurring errors associated with the classification of infectious diseases that have led to misdiagnoses and have impeded our understanding of the role of organisms in the development of human diseases.
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Hotterbeekx A, Namale Ssonko V, Oyet W, Lakwo T, Idro R. Neurological manifestations in Onchocerca volvulus infection: A review. Brain Res Bull 2018; 145:39-44. [PMID: 30458251 PMCID: PMC6382410 DOI: 10.1016/j.brainresbull.2018.08.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 08/22/2018] [Accepted: 08/25/2018] [Indexed: 11/17/2022]
Abstract
Human onchocerciasis, caused by infection by the filarial nematode Onchocerca volvulus, is a major neglected public health problem that affects millions of people in the endemic regions of sub-Saharan Africa and Latin America. Onchocerciasis is known to be associated with skin and eye disease and more recently, neurological features have been recognized as a major manifestation. Especially the latter poses a severe burden on affected individuals and their families. Although definite studies are awaited, preliminary evidence suggests that neurological disease may include the nodding syndrome, Nakalanga syndrome and epilepsy but to date, the exact pathophysiological mechanisms remain unclear. Currently, the only way to prevent Onchocera volvulus associated disease is through interventions that target the elimination of onchocerciasis through community distribution of ivermectin and larviciding the breeding sites of the Similium or blackfly vector in rivers. In this review, we discuss the epidemiology, potential pathological mechanisms as well as prevention and treatment strategies of onchocerciasis, focusing on the neurological disease.
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Affiliation(s)
- An Hotterbeekx
- University of Antwerp, Global Health Institute, Antwerp, Belgium
| | | | | | - Thomson Lakwo
- Ministry of Health, Division of Vector Control, Kampala, Uganda
| | - Richard Idro
- Makerere University College of Health Sciences, Kampala, Uganda; Centre for Tropical Neuroscience, Kampala, Uganda; University of Oxford, Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford, UK.
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Abd-Elfarag G, Logora MY, Carter JY, Ojok M, Songok J, Menon S, Wit F, Lako R, Colebunders R. The effect of bi-annual community-directed treatment with ivermectin on the incidence of epilepsy in onchocerciasis endemic villages in South Sudan: a study protocol. Infect Dis Poverty 2018; 7:112. [PMID: 30424817 PMCID: PMC6234538 DOI: 10.1186/s40249-018-0496-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 10/19/2018] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Nodding syndrome (NS) is a devastating epileptic illness of unknown aetiology mainly affecting children 5-15 years of age. Head nodding distinguishes NS from other forms of epilepsy. Other manifestations of the illness include mental and physical growth retardation. Many children die as a result of falling in fires or drowning. Recently, it was shown that NS is only one of the phenotypic presentations of onchocerciasis associated epilepsy (OAE). Despite the strong epidemiological association between epilepsy and onchocerciasis, the causal mechanism is unknown. After implementation of bi-annual community directed treatment with ivermectin (CDTi) and larviciding of rivers in northern Uganda, new cases of NS have ceased, while new cases continue to emerge in South Sudanese onchocerciasis-endemic areas with an interrupted CDTi programme. This study is designed to evaluate the potential effects of bi-annual CDTi on reducing the incidence of NS/OAE in onchocerciasis-endemic areas in South Sudan. METHODS A pre-intervention door-to-door population-based household survey will be conducted in selected onchocerciasis-endemic villages in Mundri and Maridi Counties, which have a high prevalence of epilepsy. Using a validated questionnaire, the entire village will be screened by community research assistants for suspected epilepsy cases. Suspected cases will be interviewed and examined by a trained clinical officer or medical doctor who will confirm or reject the diagnosis of epilepsy. Bi-annual CDTi will be implemented in the villages and a surveillance system for epilepsy set up. By implementing an epilepsy onchocerciasis awareness campaign we expect to obtain > 90% CDTi coverage of eligible individuals. The door-to-door survey will be repeated two years after the baseline survey. The incidence of NS/OAE will be compared before and after bi-annual CDTi. DISCUSSION Our study is the first population-based study to evaluate the effect of bi-annual CDTi to reduce the incidence of NS/OAE. If the study demonstrates such a reduction, these findings are expected to motivate communities in onchocerciasis-endemic regions to participate in CDTi, and will encourage policy makers, funders and other stakeholders to increase their efforts to eliminate onchocerciasis.
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Affiliation(s)
- Gasim Abd-Elfarag
- Department of Global Health, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
| | - Makoy Yibi Logora
- Neglected Tropical Diseases Unit, Ministry of Health, Juba, Republic of South Sudan
| | | | | | | | - Sonia Menon
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - Ferdinand Wit
- Department of Global Health, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
| | - Richard Lako
- Policy, Planning, Budgeting and Research, Ministry of Health, Juba, Republic of South Sudan
| | - Robert Colebunders
- Global Health Institute, University of Antwerp, Kinsbergen Centrum, Doornstraat 331, 2610 Antwerp, Belgium
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Mutamba BB, Kane JC, de Jong J, Okello J, Musisi S, Kohrt BA. Psychological treatments delivered by community health workers in low-resource government health systems: effectiveness of group interpersonal psychotherapy for caregivers of children affected by nodding syndrome in Uganda. Psychol Med 2018; 48:2573-2583. [PMID: 29444721 PMCID: PMC6093795 DOI: 10.1017/s0033291718000193] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Despite increasing evidence for the benefits of psychological treatments (PTs) in low- and middle-income countries, few national health systems have adopted PTs as standard care. We aimed to evaluate the effectiveness of a group interpersonal psychotherapy (IPT-G) intervention, when delivered by lay community health workers (LCHWs) in a low-resource government health system in Uganda. The intended outcome was reduction of depression among caregivers of children with nodding syndrome, a neuropsychiatric condition with high morbidity, mortality and social stigma. METHODS A non-randomized trial design was used. Caregivers in six villages (n = 69) received treatment as usual (TAU), according to government guidelines. Caregivers in seven villages (n = 73) received TAU as well as 12 sessions of IPT-G delivered by LCHWs. Primary outcomes were caregiver and child depression assessed at 1 and 6 months post-intervention. RESULTS Caregivers who received IPT-G had a significantly greater reduction in the risk of depression from baseline to 1 month [risk ratio (RR) 0.25, 95% confidence interval (CI) 0.10-0.62] and 6 months (RR 0.33, 95% CI 0.11-0.95) post-intervention compared with caregivers who received TAU. Children of caregivers who received IPT-G had significantly greater reduction in depression scores than children of TAU caregivers at 1 month (Cohen's d = 0.57, p = 0.01) and 6 months (Cohen's d = 0.54, p = 0.03). Significant effects were also observed for psychological distress, stigma and social support among caregivers. CONCLUSION IPT-G delivered within a low-resource health system is an effective PT for common mental health problems in caregivers of children with a severe neuropsychiatric condition and has psychological benefits for the children as well. This supports national health policy initiatives to integrate PTs into primary health care services in Uganda.
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Affiliation(s)
- Byamah B. Mutamba
- Butabika National Mental Hospital, Kampala, Uganda., Amsterdam Institute of Social Science Research, Faculty of Social and Behavioural Sciences, University of Amsterdam
| | - Jeremy C. Kane
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health
| | - Joop de Jong
- Amsterdam Institute of Social Science Research, Faculty of Social and Behavioural Sciences, University of Amsterdam
| | - James Okello
- Department of Psychiatry, Gulu University, Uganda
| | - Seggane Musisi
- Department of Psychiatry, College of Health Sciences, Makerere University, Kampala, Uganda
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Nodding syndrome in Uganda is a tauopathy. Acta Neuropathol 2018; 136:691-697. [PMID: 30219940 PMCID: PMC6208726 DOI: 10.1007/s00401-018-1909-9] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 09/11/2018] [Accepted: 09/11/2018] [Indexed: 11/16/2022]
Abstract
Nodding syndrome is an epidemic neurologic disorder of unknown cause that affects children in the subsistence-farming communities of East Africa. We report the neuropathologic findings in five fatal cases (13–18 years of age at death) of nodding syndrome from the Acholi people in northern Uganda. Neuropathologic examination revealed tau-immunoreactive neuronal neurofibrillary tangles, pre-tangles, neuropil threads, and dot-like lesions involving the cerebral cortex, subcortical nuclei and brainstem. There was preferential involvement of the frontal and temporal lobes in a patchy distribution, mostly involving the crests of gyri and the superficial cortical lamina. The mesencephalopontine tegmental nuclei, substantia nigra, and locus coeruleus revealed globose neurofibrillary tangles and threads. We conclude that nodding syndrome is a tauopathy and may represent a newly recognized neurodegenerative disease.
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Kaiser C, Asaba G, Rubaale T, Tukesiga E, Kipp W. Onchocerciasis-Associated Epilepsy with Head Nodding Seizures-Nodding Syndrome: A Case Series of 15 Patients from Western Uganda, 1994. Am J Trop Med Hyg 2018; 99:1211-1218. [PMID: 30226148 PMCID: PMC6221207 DOI: 10.4269/ajtmh.18-0511] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Accepted: 08/05/2018] [Indexed: 11/07/2022] Open
Abstract
Nodding syndrome (NS) is an encephalopathy characterized by the core symptom of epileptic head nodding seizures, affecting children at the age between 3 and 18 years in distinct areas of tropical Africa. A consistent correlation with onchocerciasis was found, but so far, the causation of NS has not been fully clarified. With a systematic analysis of features of a cohort of epilepsy patients examined in the Itwara onchocerciasis focus of western Uganda in 1994, we provide evidence that NS actually occurred in this area at this time, and we demonstrate a correlation between prevalence of NS and that of onchocerciasis in different villages. Following the elimination of onchocerciasis by community-directed treatment with ivermectin and ground larviciding, our data provide a baseline to examine the question whether NS will disappear once its putative cause has been removed.
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Affiliation(s)
- Christoph Kaiser
- Basic Health Services Kabarole and Bundibugyo Districts, Fort Portal, Uganda; Vector Control Unit, Ministry of Health, Fort Portal, Uganda; Department of Public Health Sciences, University of Alberta, Edmonton, Canada
| | - George Asaba
- Basic Health Services Kabarole and Bundibugyo Districts, Fort Portal, Uganda; Vector Control Unit, Ministry of Health, Fort Portal, Uganda; Department of Public Health Sciences, University of Alberta, Edmonton, Canada
| | - Tom Rubaale
- Basic Health Services Kabarole and Bundibugyo Districts, Fort Portal, Uganda; Vector Control Unit, Ministry of Health, Fort Portal, Uganda; Department of Public Health Sciences, University of Alberta, Edmonton, Canada
| | - Ephraim Tukesiga
- Basic Health Services Kabarole and Bundibugyo Districts, Fort Portal, Uganda; Vector Control Unit, Ministry of Health, Fort Portal, Uganda; Department of Public Health Sciences, University of Alberta, Edmonton, Canada
| | - Walter Kipp
- Basic Health Services Kabarole and Bundibugyo Districts, Fort Portal, Uganda; Vector Control Unit, Ministry of Health, Fort Portal, Uganda; Department of Public Health Sciences, University of Alberta, Edmonton, Canada
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Ogwang R, Anguzu R, Akun P, Ningwa A, Kayongo E, Marsh K, Newton CRJC, Idro R. Asymptomatic malaria parasitaemia and seizure control in children with nodding syndrome; a cross-sectional study. BMJ Open 2018; 8:e023624. [PMID: 30341136 PMCID: PMC6196862 DOI: 10.1136/bmjopen-2018-023624] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE Plasmodium falciparum is epileptogenic and in malaria endemic areas, is a leading cause of acute seizures. In these areas, asymptomatic infections are common but considered benign and so, are not treated. The effects of such infections on seizures in patients with epilepsy is unknown. This study examined the relationship between P. falciparum infection and seizure control in children with a unique epilepsy type, the nodding syndrome. DESIGN This cross-sectional study was nested in an ongoing trial 'Doxycycline for the treatment of nodding syndrome (NCT02850913)'. We hypothesised that, in patients with epilepsy, infection by P. falciparum, including asymptomatic infections, increases the risk of seizures and impairs seizure control. SETTING AND PARTICIPANTS Participants were Ugandan children with nodding syndrome, age ≥8 years, receiving sodium valproate. All had standardised testing including documentation of the number of seizures in the past month, a rapid malaria test and if positive, the peripheral blood parasite density. OUTCOMES The primary outcome was the number of seizures in the past month (30 days). RESULTS A total of 164/240 (68%) had malaria. Asymptomatic infections (without fever) were seen in 160/240 (67%) and symptomatic infections in 4/240 (2.7%). In participants without malaria, the median (IQR) number of seizures in the past month was 2.0 (1.0-4.0) and it was 4.0 (2.0-7.5) in participants with malaria, p=0.017. The number of seizures in asymptomatic persons was 3.0 (IQR 2.0-7.3) and 6.0 (IQR 4.0-10.0) in symptomatic individuals, p=0.024. Additionally, in asymptomatic patients, a positive correlation was observed between the parasite density and number of seizures, r=0.33, p=0.002. CONCLUSION In patients with nodding syndrome, both asymptomatic and symptomatic malaria are associated with an increased risk of seizures and poorer seizure control. Similar effects should be examined in other epilepsy disorders. Malaria prevention should be strengthened for these patients and chemotreatment and prevention studies considered to improve seizure control.
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Affiliation(s)
- Rodney Ogwang
- Makerere University College of Health Sciences, Kampala, Uganda
- Centre for Tropical Neuroscience, Kitgum site, Uganda
| | - Ronald Anguzu
- Makerere University College of Health Sciences, Kampala, Uganda
- Centre for Tropical Neuroscience, Kitgum site, Uganda
| | - Pamela Akun
- Makerere University College of Health Sciences, Kampala, Uganda
- Centre for Tropical Neuroscience, Kitgum site, Uganda
| | - Albert Ningwa
- Makerere University College of Health Sciences, Kampala, Uganda
- Centre for Tropical Neuroscience, Kitgum site, Uganda
| | - Edward Kayongo
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Kevin Marsh
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Charles R J C Newton
- Kenya Medical Research Institute-Wellcome Trust Collaborative Programme, Kilifi, Kenya
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Richard Idro
- Makerere University College of Health Sciences, Kampala, Uganda
- Centre for Tropical Neuroscience, Kitgum site, Uganda
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
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Mandro M, Suykerbuyk P, Tepage F, Rossy D, Ngave F, Hasan MN, Hotterbeekx A, Mambandu G, Kashama JM, Laudisoit A, Colebunders R. Onchocerca volvulus as a risk factor for developing epilepsy in onchocerciasis endemic regions in the Democratic Republic of Congo: a case control study. Infect Dis Poverty 2018; 7:79. [PMID: 30293530 PMCID: PMC6174565 DOI: 10.1186/s40249-018-0465-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 07/18/2018] [Indexed: 02/08/2023] Open
Abstract
Background A high prevalence of epilepsy has been observed in onchocerciasis endemic areas in the Democratic Republic of Congo (DRC). With this study we aimed to investigate whether Onchocerca volvulus infection is a risk factor for developing epilepsy in onchocerciasis endemic regions in the DRC. Methods Between October and December 2015, a multi-centre case control study was performed in onchocerciasis endemic health zones (HZ) in the DRC: one study site was situated in Tshopo Province in the HZ of Wanierukula (village of Salambongo) where there had been 13 annual community distributions of treatment with ivermectin (CDTI), a second was situated in Ituri Province in the HZ of Logo (village of Draju) where ivermectin had never been distributed and in the HZ of Rethy (village of Rassia) where there had been THREE CDTI annual campaigns before the study. Individuals with unprovoked convulsive epilepsy of unknown etiology were enrolled as cases (n = 175). Randomly selected healthy members of families without epilepsy cases from the same village and age-groups and were recruited as controls (n = 170). Results Onchocerciasis associated symptoms (e.g., itching and abnormal skin) were more often present in cases compared to controls (respectively, OR = 2.63, 95% CI: 1.63–4.23, P < 0.0001 and OR = 3.23, 95% CI: 1.48–7.09, P = 0.0034). A higher number of cases was found to present with microfilariae in skin snips and with O. volvulus IgG4 antibodies in the blood compared to controls. Moreover, the microfilariae load in skin snips was 3–10 times higher in cases than controls. Conclusions This case control study confirms that O. volvulus is a risk factor for developing epilepsy in onchocerciasis endemic regions in the DRC. Electronic supplementary material The online version of this article (10.1186/s40249-018-0465-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Michel Mandro
- Provincial Health Division of Ituri, Ministry of Health, Bunia, Democratic Republic of Congo
| | | | | | - Degratias Rossy
- Programme national de lutte contre l'onchocercose, Kisangani, Democratic Republic of Congo
| | - Francoise Ngave
- Centre de Recherche en Maladies Tropicales de l'Ituri, Rethy, Democratic Republic of Congo
| | | | - An Hotterbeekx
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - Germain Mambandu
- Office of the governor of Tshopo, Kisangani, Democratic Republic of Congo
| | - Jean Marie Kashama
- Neuropsychopathologic Centre of Mont Amba (CNPP), University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Anne Laudisoit
- Global Health Institute, University of Antwerp, Antwerp, Belgium.,EcoHealth Alliance, New York, USA
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76
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Romo ML, Nash D. Onchocerciasis and epilepsy: a causal relationship? THE LANCET. INFECTIOUS DISEASES 2018; 18:1172-1174. [PMID: 30268644 DOI: 10.1016/s1473-3099(18)30488-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 07/25/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Matthew L Romo
- CUNY Institute for Implementation Science in Population Health & Department of Epidemiology and Biostatistics, CUNY Graduate School of Public Health and Health Policy, City University of New York, New York, NY 10027, USA.
| | - Denis Nash
- CUNY Institute for Implementation Science in Population Health & Department of Epidemiology and Biostatistics, CUNY Graduate School of Public Health and Health Policy, City University of New York, New York, NY 10027, USA
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77
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Chesnais CB, Nana-Djeunga HC, Njamnshi AK, Lenou-Nanga CG, Boullé C, Bissek ACZK, Kamgno J, Colebunders R, Boussinesq M. The temporal relationship between onchocerciasis and epilepsy: a population-based cohort study. THE LANCET. INFECTIOUS DISEASES 2018; 18:1278-1286. [PMID: 30268645 DOI: 10.1016/s1473-3099(18)30425-0] [Citation(s) in RCA: 97] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 06/13/2018] [Accepted: 07/04/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND Many studies have suggested that onchocerciasis might be associated with epilepsy. Therefore, we did a cohort study to assess the incidence of epilepsy relative to Onchocerca volvulus skin microfilarial density (MFD) measured during childhood and to assess the possibility of a temporal relationship. METHODS During onchocerciasis surveys undertaken in 25 villages in Cameroon during 1991-93, we measured MFD in individuals aged 5 years or older. In 2017, we revisited seven of these villages. With a standardised five-item questionnaire, we collected information on the occurrence of epilepsy in 856 individuals who were aged 5-10 years in 1991-93, and had MFD determined during the original surveys. We did multivariable analyses to assess the overall incidence and incidence ratios taking into account age, sex, individual MFD in 1991-93, and onchocerciasis endemicity level in the village. FINDINGS In 2017, we obtained data on the history of epilepsy for 85% (729 of 856) of individuals. Among these individuals, we classified 60 as being suspected cases of epilepsy. The overall incidence of epilepsy was 350 per 100 000 person-years (95% CI 270-450). The adjusted incidence ratio for developing epilepsy was 7·07 (95% CI 0·98-51·26; p=0·0530) in individuals with initial MFD of one to five microfilariae per skin snip (mf per snip), 11·26 (2·73-46·43) in individuals with six to 20 mf per snip, 12·90 (4·40-37·83) in individuals with 21-50 mf per snip, 20·00 (3·71-108·00) in individuals with 51-100 mf per snip, 22·58 (3·21-158·56) in individuals with 101-200 mf per snip, and 28·50 (95% CI 3·84-211·27; p=0·0010) in individuals with more than 200 mf per snip, compared with that of individuals without detectable densities of skin microfilariae. INTERPRETATION Individual O volvulus MFD in childhood was associated with the risk of either seizures or epilepsy in an onchocerciasis focus in Cameroon. This temporal relationship suggests a potential causal link between onchocerciasis and epilepsy. FUNDING European Research Council, NSETHIO Project.
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Affiliation(s)
- Cédric B Chesnais
- UMI 233, Institut de Recherche pour le Développement, Montpellier, France; Université Montpellier, Montpellier, France; INSERM Unité 1175, Montpellier, France
| | | | - Alfred K Njamnshi
- Neurology Department, University of Yaoundé I, Yaounde, Cameroon; Brain Research Africa Initiative, Yaounde, Cameroon
| | - Cédric G Lenou-Nanga
- Centre for Research on Filariasis and other Tropical Diseases, Yaounde, Cameroon
| | - Charlotte Boullé
- UMI 233, Institut de Recherche pour le Développement, Montpellier, France; Université Montpellier, Montpellier, France; INSERM Unité 1175, Montpellier, France; Centre Hospitalier Universitaire Nîmes, Nîmes, France
| | - Anne-Cécile Zoung-Kanyi Bissek
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaounde, Cameroon; Division of Health Operations Research, Ministry of Public Health, Yaoundé, Cameroon
| | - Joseph Kamgno
- Centre for Research on Filariasis and other Tropical Diseases, Yaounde, Cameroon; Public Health Department, University of Yaoundé I, Yaounde, Cameroon
| | | | - Michel Boussinesq
- UMI 233, Institut de Recherche pour le Développement, Montpellier, France; Université Montpellier, Montpellier, France; INSERM Unité 1175, Montpellier, France.
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Anguzu R, Akun PR, Ogwang R, Shour AR, Sekibira R, Ningwa A, Nakamya P, Abbo C, Mwaka AD, Opar B, Idro R. Setting up a clinical trial for a novel disease: a case study of the Doxycycline for the Treatment of Nodding Syndrome Trial - challenges, enablers and lessons learned. Glob Health Action 2018; 11:1431362. [PMID: 29382251 PMCID: PMC5795749 DOI: 10.1080/16549716.2018.1431362] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
A large amount of preparation goes into setting up trials. Different challenges and lessons are experienced. Our trial, testing a treatment for nodding syndrome, an acquired neurological disorder of unknown cause affecting thousands of children in Eastern Africa, provides a unique case study. As part of a study to determine the aetiology, understand pathogenesis and develop specific treatment, we set up a clinical trial in a remote district hospital in Uganda. This paper describes our experiences and documents supportive structures (enablers), challenges faced and lessons learned during set-up of the trial. Protocol development started in September 2015 with phased recruitment of a critical study team. The team spent 12 months preparing trial documents, procurement and training on procedures. Potential recruitment sites were pre-visited, and district and local leaders met as key stakeholders. Key enablers were supportive local leadership and investment by the district and Ministry of Health. The main challenges were community fears about nodding syndrome, adverse experiences of the community during previous research and political involvement. Other challenges included the number and delays in protocol approvals and lengthy procurement processes. This hard-to-reach area has frequent power and Internet fluctuations, which may affect cold chains for study samples, communication and data management. These concerns decreased with a pilot community engagement programme. Experiences and lessons learnt can reduce the duration of processes involved in trial-site set-up. A programme of community engagement and local leader involvement may be key to the success of a trial and in reducing community opposition towards participation in research.
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Affiliation(s)
- Ronald Anguzu
- a Department of Paediatrics and Child Health , Makerere University College of Health Sciences , Uganda.,b Department of Paediatrics and Child Health , Centre of Tropical Neuroscience , Kitgum Site , Uganda.,c Institute of Health and Equity , MoH, Medical College of Wisconsin , Kampala , USA
| | - Pamela R Akun
- a Department of Paediatrics and Child Health , Makerere University College of Health Sciences , Uganda.,b Department of Paediatrics and Child Health , Centre of Tropical Neuroscience , Kitgum Site , Uganda
| | - Rodney Ogwang
- a Department of Paediatrics and Child Health , Makerere University College of Health Sciences , Uganda.,b Department of Paediatrics and Child Health , Centre of Tropical Neuroscience , Kitgum Site , Uganda
| | - Abdul Rahman Shour
- c Institute of Health and Equity , MoH, Medical College of Wisconsin , Kampala , USA
| | - Rogers Sekibira
- a Department of Paediatrics and Child Health , Makerere University College of Health Sciences , Uganda.,b Department of Paediatrics and Child Health , Centre of Tropical Neuroscience , Kitgum Site , Uganda
| | - Albert Ningwa
- a Department of Paediatrics and Child Health , Makerere University College of Health Sciences , Uganda.,b Department of Paediatrics and Child Health , Centre of Tropical Neuroscience , Kitgum Site , Uganda
| | | | - Catherine Abbo
- a Department of Paediatrics and Child Health , Makerere University College of Health Sciences , Uganda
| | - Amos D Mwaka
- a Department of Paediatrics and Child Health , Makerere University College of Health Sciences , Uganda
| | | | - Richard Idro
- a Department of Paediatrics and Child Health , Makerere University College of Health Sciences , Uganda.,b Department of Paediatrics and Child Health , Centre of Tropical Neuroscience , Kitgum Site , Uganda.,e Nuffield Department of Medicine , University of Oxford , Oxford , UK
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79
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Chronic Toxoplasma gondii Infection Induces Anti- N-Methyl-d-Aspartate Receptor Autoantibodies and Associated Behavioral Changes and Neuropathology. Infect Immun 2018; 86:IAI.00398-18. [PMID: 30037790 DOI: 10.1128/iai.00398-18] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 07/13/2018] [Indexed: 12/27/2022] Open
Abstract
Anti-NMDA receptor (NMDAR) autoantibodies have been postulated to play a role in the pathogenesis of NMDAR hypofunction, which contributes to the etiology of psychotic symptoms. Toxoplasma gondii is a pathogen implicated in psychiatric disorders and associated with elevation of NMDAR autoantibodies. However, it remains unclear whether parasite infection is the cause of NMDAR autoantibodies. By using mouse models, we found that NMDAR autoantibody generation had a strong temporal association with tissue cyst formation, as determined by MAG1 antibody seroreactivity (r = 0.96; P < 0.0001), which is a serologic marker for the cyst burden. The presence of MAG1 antibody response, but not T. gondii IgG response, was required for NMDAR autoantibody production. The pathogenic relevance of NMDAR autoantibodies to behavioral abnormalities (blunted response to amphetamine-triggered activity and decreased locomotor activity and exploration) and reduced expression of synaptic proteins (the GLUN2B subtype of NMDAR and PSD-95) has been demonstrated in infected mice. Our study suggests that NMDAR autoantibodies are specifically induced by persistent T. gondii infection and are most likely triggered by tissue cysts. NMDAR autoantibody seroreactivity may be a novel pathological hallmark of chronic toxoplasmosis, which raises questions about NMDAR hypofunction and neurodegeneration in the infected brain.
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Vinkeles Melchers NVS, Mollenkopf S, Colebunders R, Edlinger M, Coffeng LE, Irani J, Zola T, Siewe JN, de Vlas SJ, Winkler AS, Stolk WA. Burden of onchocerciasis-associated epilepsy: first estimates and research priorities. Infect Dis Poverty 2018; 7:101. [PMID: 30253788 PMCID: PMC6156959 DOI: 10.1186/s40249-018-0481-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 08/30/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Since the 1990s, evidence has accumulated of an increased prevalence of epilepsy in onchocerciasis-endemic areas in Africa as compared to onchocerciasis-free areas. Although the causal relationship between onchocerciasis and epilepsy has yet to be proven, there is likely an association. Here we discuss the need for disease burden estimates of onchocerciasis-associated epilepsy (OAE), provide them, detail how such estimates should be refined, and discuss the socioeconomic impact of OAE, including a cost-estimate for anti-epileptic drugs. MAIN BODY Providing OAE burden estimates may aid prevention of epilepsy in onchocerciasis- endemic areas by inciting and informing collaboration between onchocerciasis control programmes and mental health services. Epilepsy not only massively impacts the health of those affected, but it also carries a high socioeconomic burden for the households and communities involved. We used previously published geospatial estimates of onchocerciasis in Africa and a separately published logistic regression model quantifying the association between onchocerciasis and epilepsy to estimate the number of OAE cases. We then applied disability weights for epilepsy to quantify the burden in terms of years of life lived with disability (YLD) and estimate the cost of treatment. We estimate that in 2015 roughly 117 000 people were affected by OAE across onchocerciasis-endemic areas previously under the African Programme for Onchocerciases control (APOC) mandate where OAE has ever been reported or suspected, and another 264 000 persons in onchocerciasis-endemic areas where OAE has never been investigated before. The total number of YLDs due to OAE was 39 300 and 88 700 in these areas respectively, based on a weighted mean disability weight of 0.336. The burden of OAE is approximately 13% of the total YLDs attributable to onchocerciasis and 10% of total YLDs attributable to epilepsy. We estimated that by 2015 the total costs of treatment with anti-epileptic drug for OAE cases would have been a minimum of 12.4 million US$. CONCLUSIONS These estimates suggest a considerable health, social and economic burden of OAE in Africa. The treatment and care for people with epilepsy, especially in hyperendemic onchocerciasis areas with high epilepsy prevalence thus requires more financial and human resources.
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Affiliation(s)
- Natalie V S Vinkeles Melchers
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. box 2040, 3000, CA, Rotterdam, The Netherlands.
| | - Sarah Mollenkopf
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Avenue, Suite 600, Seattle, WA, 98121, USA
| | | | - Michael Edlinger
- Department of Medical Statistics, Informatics, and Health Economics, Medical University Innsbruck, Vienna, Austria
| | - Luc E Coffeng
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. box 2040, 3000, CA, Rotterdam, The Netherlands
| | - Julia Irani
- Department of Public Health, Institute of Tropical Medicine Antwerp, Nationalestraat 155, 2000, Antwerp, Belgium
| | - Trésor Zola
- Department of Tropical Medicine, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Joseph N Siewe
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - Sake J de Vlas
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. box 2040, 3000, CA, Rotterdam, The Netherlands
| | - Andrea S Winkler
- Centre for Global Health, Institute for Health and Society, Oslo, Norway.,Center for Global Health, Department of Neurology, Technical University of Munich, Munich, Germany
| | - Wilma A Stolk
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. box 2040, 3000, CA, Rotterdam, The Netherlands
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81
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Mmbando BP, Suykerbuyk P, Mnacho M, Kakorozya A, Matuja W, Hendy A, Greter H, Makunde WH, Colebunders R. High prevalence of epilepsy in two rural onchocerciasis endemic villages in the Mahenge area, Tanzania, after 20 years of community directed treatment with ivermectin. Infect Dis Poverty 2018; 7:64. [PMID: 29921319 PMCID: PMC6009039 DOI: 10.1186/s40249-018-0450-3] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 06/07/2018] [Indexed: 11/10/2022] Open
Abstract
Background Epilepsy is a neurological disorder with a multitude of underlying causes, which may include infection with Onchocerca volvulus, the parasitic worm that causes human onchocerciasis. A survey carried out in 1989 revealed a high prevalence of epilepsy (1.02% overall, ranging from 0.51 to 3.71% in ten villages) in the Mahenge area of Ulanga district, an onchocerciasis endemic region in south eastern Tanzania. This study aimed to determine the prevalence and incidence of epilepsy following 20 years of onchocerciasis control through annual community directed treatment with ivermectin (CDTI). Methods The study was conducted in January 2017 in two suburban and two rural villages in the Mahenge area. Door-to-door household visits were carried out by trained community health workers and data assistants to screen for persons suspected of having epilepsy, using a standardised questionnaire. Persons with suspected epilepsy were then interviewed and examined by a neurologist for case verification. Onchocerciasis associated epilepsy was defined as epilepsy without an obvious cause, with an onset of seizures between the ages of 3–18 years in previously healthy children. In each village, fifty males aged ≥20 years were tested for onchocerciasis antibodies using an OV16 rapid test and were examined for presence of onchocerciasis nodules. Children aged 6–10 years were also tested using OV16 tests. Results 5117 individuals (median age 18.5 years, 53.2% female) from 1168 households were screened. 244 (4.8%) were suspected of having epilepsy and invited for neurological assessment. Prevalence of epilepsy was 2.5%, with the rural villages having the highest rate (3.5% vs 1.5%), P < 0.001. Overall incidence of epilepsy was 111 cases (95% CI: 73–161) per 100 000 person-years, while that of onchocerciasis associated epilepsy was 131 (95% CI: 70–223). Prevalence of OV16 antibodies in adult males and among children 6–10 years old was higher in rural villages than in suburban villages (76.5% vs 50.6, and 42.6% vs 4.7% respectively), (P < 0.001), while overall prevalence of onchocerciasis nodules was 1.8%. Conclusions This survey revealed a high prevalence and incidence of epilepsy in two rural onchocerciasis endemic villages in the Mahenge area. Despite 20 years of CDTI, a high prevalence of OV16 antibodies in children aged 6–10 years suggests on-going O. volvulus transmission. Reasons for the persistence of on-going parasite transmission in the Mahenge area need to be investigated. Electronic supplementary material The online version of this article (10.1186/s40249-018-0450-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bruno P Mmbando
- National Institute for Medical Research, Tanga Research Centre, Tanga, Tanzania.
| | | | | | | | - William Matuja
- Muhimbili University of Health and allied Sciences, Dar es Salaam, Tanzania
| | - Adam Hendy
- University of Texas Medical Branch, Galveston, TX, USA
| | - Helena Greter
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - Williams H Makunde
- National Institute for Medical Research, Tanga Research Centre, Tanga, Tanzania
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82
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Al Shareef SM, Basit S, Li S, Pfister C, Pradervand S, Lecendreux M, Mayer G, Dauvilliers Y, Salpietro V, Houlden H, BaHammam AS, Tafti M. Kleine-Levin syndrome is associated with LMOD3 variants. J Sleep Res 2018; 28:e12718. [PMID: 29923248 DOI: 10.1111/jsr.12718] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 05/16/2018] [Accepted: 05/16/2018] [Indexed: 11/30/2022]
Abstract
Kleine-Levin syndrome (KLS) is a rare periodic hypersomnia with associated behavioural abnormalities but with often favourable prognosis. There is excess risk of KLS in first-degree relatives, suggesting a strong genetic contribution. So far, no mutation is identified in KLS and comprehensive genetic analysis of affected individuals is lacking. Here we performed whole genome single-nucleotide polymorphism (SNP) genotyping and exome sequencing in a large family with seven affected members. The identified gene with a mutation was resequenced in 38 sporadic KLS patients and the expression of the gene product was mapped in the mouse brain. Linkage analysis mapped the disease locus to chromosome 3 and exome analysis identified a heterozygous missense variant in LMOD3 (p.E142D) in the linkage interval. The variant was found to segregate in all affected and one presumably unaffected member of the family. Resequencing LMOD3 in 38 other KLS patients and their families revealed three other low frequency or rare missense variants in seven cases that were inherited with incomplete penetrance. LMOD3 is expressed in the brain and colocalized with major structures involved in the regulation of vigilance states. LMOD proteins are structural proteins and seem to be developmentally regulated. Our findings suggest that KLS might be a structural/neurodevelopmental brain disease.
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Affiliation(s)
- Saad M Al Shareef
- Department of Internal Medicine, College of Medicine, Al Imam Mohammad Ibn Saud Islamic University (IMSIU), Riyadh, Saudi Arabia
| | - Sulman Basit
- College of Medicine, Taibah University, Almadinah Almunawwarah, Saudi Arabia
| | - Sha Li
- Department of Physiology, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Corinne Pfister
- Department of Physiology, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.,Faculty of Biology and Medicine, Center for Integrative Genomics, University of Lausanne, Lausanne, Switzerland
| | - Sylvain Pradervand
- Genomic Technologies Facility, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Michel Lecendreux
- AP-HP, Pediatric Sleep Center and National Reference Center for Orphan Diseases, Narcolepsy, Idiopathic Hypersomnia and Kleine-Levin Syndrome, Robert-Debré Hospital, Paris, France
| | - Geert Mayer
- Hephata Klinik, Scwalmstadt, and Philipps University of Marburg, Marburg, Germany
| | - Yves Dauvilliers
- Reference National Center for Narcolepsy, Department of Neurology, Gui-de-Chauliac Hospital, INSER U106, Montpellier, France
| | - Vincenzo Salpietro
- Department of Molecular Neuroscience, Institute of Neurology, University College of London, London, UK
| | - Henry Houlden
- Department of Molecular Neuroscience, Institute of Neurology, University College of London, London, UK
| | - Ahmed S BaHammam
- College of Medicine, University Sleep Disorders Center, King Saud University, Riyadh, Saudi Arabia.,The Strategic Technologies Program of the National Plan for Sciences and Technology and Innovation, Riyadh, Saudi Arabia
| | - Mehdi Tafti
- Department of Physiology, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.,Faculty of Biology and Medicine, Center for Integrative Genomics, University of Lausanne, Lausanne, Switzerland.,Center for Investigation and Research in Sleep (CIRS), Lausanne University Hospital (CHUV), Lausanne, Switzerland
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Valdes Angues R, Suits A, Palmer VS, Okot C, Okot RA, Atonywalo C, Gazda SK, Kitara DL, Lantum M, Spencer PS. A real-time medical cartography of epidemic disease (Nodding syndrome) using village-based lay mHealth reporters. PLoS Negl Trop Dis 2018; 12:e0006588. [PMID: 29906291 PMCID: PMC6021112 DOI: 10.1371/journal.pntd.0006588] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 06/27/2018] [Accepted: 06/06/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Disease surveillance in rural regions of many countries is poor, such that prolonged delays (months) may intervene between appearance of disease and its recognition by public health authorities. For infectious disorders, delayed recognition and intervention enables uncontrolled disease spread. We tested the feasibility in northern Uganda of developing real-time, village-based health surveillance of an epidemic of Nodding syndrome (NS) using software-programmed smartphones operated by minimally trained lay mHealth reporters. METHODOLOGY AND PRINCIPAL FINDINGS We used a customized data collection platform (Magpi) that uses mobile phones and real-time cloud-based storage with global positioning system coordinates and time stamping. Pilot studies on sleep behavior of U.S. and Ugandan medical students identified and resolved Magpi-programmed cell phone issues. Thereafter, we deployed Magpi in combination with a lay-operator network of eight mHealth reporters to develop a real-time electronic map of child health, injury and illness relating to NS in rural northern Uganda. Surveillance data were collected for three consecutive months from 10 villages heavily affected by NS. Overall, a total of 240 NS-affected households and an average of 326 children with NS, representing 30 households and approximately 40 NS children per mHealth reporter, were monitored every week by the lay mHealth team. Data submitted for analysis in the USA and Uganda remotely pinpointed the household location and number of NS deaths, injuries, newly reported cases of head nodding (n = 22), and the presence or absence of anti-seizure medication. CONCLUSIONS AND SIGNIFICANCE This study demonstrates the feasibility of using lay mHealth workers to develop a real-time cartography of epidemic disease in remote rural villages that can facilitate and steer clinical, educational and research interventions in a timely manner.
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Affiliation(s)
- Raquel Valdes Angues
- Department of Neurology, Oregon Health & Science University, Portland, Oregon, United States of America
| | - Austen Suits
- University of Washington, Seattle, Washington, United States of America
| | - Valerie S. Palmer
- Department of Neurology, Oregon Health & Science University, Portland, Oregon, United States of America
| | | | | | | | | | | | - Moka Lantum
- MicroClinic Technologies, Ltd, Nairobi, Kenya
| | - Peter S. Spencer
- Department of Neurology, Oregon Health & Science University, Portland, Oregon, United States of America
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84
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Greter H, Mmbando B, Makunde W, Mnacho M, Matuja W, Kakorozya A, Suykerbuyk P, Colebunders R. Evolution of epilepsy prevalence and incidence in a Tanzanian area endemic for onchocerciasis and the potential impact of community-directed treatment with ivermectin: a cross-sectional study and comparison over 28 years. BMJ Open 2018; 8:e017188. [PMID: 29605818 PMCID: PMC5884367 DOI: 10.1136/bmjopen-2017-017188] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION Worldwide, there are an estimated 50 million people affected by epilepsy. Its aetiology is manifold, and parasitic infections play an important role, specifically onchocerciasis. In onchocerciasis endemic areas, a distinctive form of epilepsy has been described as nodding syndrome, affecting children and causing nodding seizures, mental retardation and debilitating physical development. Onchocerciasis control programmes using community-directed treatment with ivermectin (CDTI) are implemented in endemic countries. This study is designed to contribute to a better understanding of the linkage between the onset of epilepsy, onchocerciasis and CDTI. Comparing the epidemiological data on epilepsy and onchocerciasis from pre-CDTI and 20 years after its introduction will allow identifying a potential impact of ivermectin on the onset of epilepsy. METHODS AND ANALYSIS The study will be conducted in the Mahenge highlands in Tanzania. Study site selection is based on an in-depth study on epilepsy in that area dating from 1989. CDTI was introduced in 1997. By a door-to-door approach, the population will be screened for epilepsy using a validated questionnaire. Suspected cases will be invited for a neurological examination for case verification. Onchocerciasis prevalence will be assessed by a rapid epidemiological assessment. As an indicator for ongoing transmission, children younger than 10 years of age will be tested for Ov16 antibodies. Ivermectin use will be assessed at household level. Epilepsy data will be analysed in comparison with the 1989 data to reveal pre-CDTI and post-CDTI prevalence and incidence. ETHICS AND DISSEMINATION The protocol has received ethical approval from the ethics committees of the University of Antwerp, Belgium, and of the National Institut of Medical Research, Dar es Salaam, Tanzania. The findings will be published in peer-reviewed journals, and presented to the health authorities in Tanzania, at national, regional and village level.
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Affiliation(s)
- Helena Greter
- Global Health Institute, University of Antwerp, Wilrijk, Belgium
| | - Bruno Mmbando
- National Institute of Medical Research, Tanga Research Centre, Tanga, Tanzania
| | - Williams Makunde
- National Institute of Medical Research, Tanga Research Centre, Tanga, Tanzania
| | - Mohamed Mnacho
- Department of Neurology, Muhimbili University of Health Sciences, Dar es Salaam, Tanzania
| | - William Matuja
- Department of Neurology, Muhimbili University of Health Sciences, Dar es Salaam, Tanzania
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85
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Colebunders R, Mandro M, Njamnshi AK, Boussinesq M, Hotterbeekx A, Kamgno J, O'Neill S, Hopkins A, Suykerbuyk P, Basáñez MG, Post RJ, Pedrique B, Preux PM, Stolk WA, Nutman TB, Idro R. Report of the first international workshop on onchocerciasis-associated epilepsy. Infect Dis Poverty 2018; 7:23. [PMID: 29580280 PMCID: PMC5868050 DOI: 10.1186/s40249-018-0400-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 03/06/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Recently, several epidemiological studies performed in Onchocerca volvulus-endemic regions have suggested that onchocerciasis-associated epilepsy (OAE) may constitute an important but neglected public health problem in many countries where onchocerciasis is still endemic. MAIN TEXT On October 12-14th 2017, the first international workshop on onchocerciasis-associated epilepsy (OAE) was held in Antwerp, Belgium. The workshop was attended by 79 participants from 20 different countries. Recent research findings strongly suggest that O. volvulus is an important contributor to epilepsy, particularly in meso- and hyperendemic areas for onchocerciasis. Infection with O. volvulus is associated with a spectrum of epileptic seizures, mainly generalised tonic-clonic seizures but also atonic neck seizures (nodding), and stunted growth. OAE is characterised by an onset of seizures between the ages of 3-18 years. Multidisciplinary working groups discussed topics such as how to 1) strengthen the evidence for an association between onchocerciasis and epilepsy, 2) determine the burden of disease caused by OAE, 3) prevent OAE, 4) improve the treatment/care for persons with OAE and affected families, 5) identify the pathophysiological mechanism of OAE, and 6) deal with misconceptions, stigma, discrimination and gender violence associated with OAE. An OAE Alliance was created to increase awareness about OAE and its public health importance, stimulate research and disseminate research findings, and create partnerships between OAE researchers, communities, advocacy groups, ministries of health, non-governmental organisations, the pharmaceutical industry and funding organizations. CONCLUSIONS Although the exact pathophysiological mechanism underlying OAE remains unknown, there is increasing evidence that by controlling and eliminating onchocerciasis, OAE will also disappear. Therefore, OAE constitutes an additional argument for strengthening onchocerciasis elimination efforts. Given the high numbers of people with epilepsy in O. volvulus-endemic regions, more advocacy is urgently needed to provide anti-epileptic treatment to improve the quality of life of these individuals and their families.
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Affiliation(s)
| | - Michel Mandro
- Provincial Health Division of Ituri, Bunia, Democratic Republic of the Congo
| | - Alfred K Njamnshi
- Department of Neurology, Yaoundé Central Hospital/University of Yaoundé 1, Brain Research Africa Initiative (BRAIN), Yaoundé, Cameroon
| | - Michel Boussinesq
- Institut de Recherche pour le Développement (IRD), Montpellier, France
| | - An Hotterbeekx
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - Joseph Kamgno
- Centre for Research on Filariasis and other Tropical Diseases (CRFilMT), and Faculty of Medicine and Biomedical Sciences, University of Yaoundé 1, Yaoundé, Cameroon
| | - Sarah O'Neill
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Adrian Hopkins
- Neglected and Disabling Diseases of Poverty Consultant, Kent, UK
| | | | - Maria-Gloria Basáñez
- London Centre for Neglected Tropical Disease Research, Imperial College London, London, UK
| | - Rory J Post
- London School of Hygiene & Tropical Medicine and Liverpool John Moores University, London, UK
| | - Belén Pedrique
- Drugs for Neglected Diseases initiative, Geneva, Switzerland
| | - Pierre-Marie Preux
- Preux Pierre-Marie, INSERM, University Limoges, CHU Limoges, UMR_S 1094, Tropical Neuroepidemiology, Institute of Neuroepidemiology and Tropical Neurology, CNRS FR 3503 GEIST, 87000, Limoges, France
| | - Wilma A Stolk
- Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Thomas B Nutman
- Laboratory of Parasitic Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Richard Idro
- Makerere University, College of Health Sciences, Kampala, Uganda
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86
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Blomberg J, Gottfries CG, Elfaitouri A, Rizwan M, Rosén A. Infection Elicited Autoimmunity and Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: An Explanatory Model. Front Immunol 2018; 9:229. [PMID: 29497420 PMCID: PMC5818468 DOI: 10.3389/fimmu.2018.00229] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 01/26/2018] [Indexed: 12/13/2022] Open
Abstract
Myalgic encephalomyelitis (ME) often also called chronic fatigue syndrome (ME/CFS) is a common, debilitating, disease of unknown origin. Although a subject of controversy and a considerable scientific literature, we think that a solid understanding of ME/CFS pathogenesis is emerging. In this study, we compiled recent findings and placed them in the context of the clinical picture and natural history of the disease. A pattern emerged, giving rise to an explanatory model. ME/CFS often starts after or during an infection. A logical explanation is that the infection initiates an autoreactive process, which affects several functions, including brain and energy metabolism. According to our model for ME/CFS pathogenesis, patients with a genetic predisposition and dysbiosis experience a gradual development of B cell clones prone to autoreactivity. Under normal circumstances these B cell offsprings would have led to tolerance. Subsequent exogenous microbial exposition (triggering) can lead to comorbidities such as fibromyalgia, thyroid disorder, and orthostatic hypotension. A decisive infectious trigger may then lead to immunization against autoantigens involved in aerobic energy production and/or hormone receptors and ion channel proteins, producing postexertional malaise and ME/CFS, affecting both muscle and brain. In principle, cloning and sequencing of immunoglobulin variable domains could reveal the evolution of pathogenic clones. Although evidence consistent with the model accumulated in recent years, there are several missing links in it. Hopefully, the hypothesis generates testable propositions that can augment the understanding of the pathogenesis of ME/CFS.
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Affiliation(s)
- Jonas Blomberg
- Department of Medical Sciences, Uppsala University, Clinical Microbiology, Academic Hospital, Uppsala, Sweden
| | | | - Amal Elfaitouri
- Department of Infectious Disease and Tropical Medicine, Faculty of Public Health, Benghazi University, Benghazi, Libya
| | - Muhammad Rizwan
- Department of Medical Sciences, Uppsala University, Clinical Microbiology, Academic Hospital, Uppsala, Sweden
| | - Anders Rosén
- Department of Clinical and Experimental Medicine, Division of Cell Biology, Linköping University, Linköping, Sweden
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87
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Hotterbeekx A, Menon S, Siewe JFN, Colebunders R. Onchocerciasis associated epilepsy: An important neglected public health problem. Seizure 2018; 60:205. [PMID: 29325732 DOI: 10.1016/j.seizure.2018.01.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 01/05/2018] [Indexed: 12/13/2022] Open
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88
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Boivin MJ. New evidence for nodding disease as an autoimmune reaction to Onchocerca volvulus. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:461. [PMID: 29285494 DOI: 10.21037/atm.2017.09.06] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Michael J Boivin
- Department of Psychiatry and Neurology & Ophthalmology, Michigan State University, East Lansing, MI, USA.,Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
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89
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Colebunders R, Nelson Siewe FJ, Hotterbeekx A. Onchocerciasis-Associated Epilepsy, an Additional Reason for Strengthening Onchocerciasis Elimination Programs. Trends Parasitol 2017; 34:208-216. [PMID: 29288080 DOI: 10.1016/j.pt.2017.11.009] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 11/21/2017] [Accepted: 11/27/2017] [Indexed: 10/18/2022]
Abstract
A high prevalence of epilepsy has been observed in onchocerciasis-endemic regions with high onchocerciasis transmission. Recent epidemiological studies suggest that Onchocerca volvulus infection is the trigger causing the seizures, which appear in previously healthy children between the ages of 3 and 18 years. Persons with onchocerciasis-associated epilepsy present with a wide spectrum of seizures, including atonic and myoclonic neck seizures; but also absences and most frequently generalized tonic-clonic seizures. Often individuals present with intellectual disabilities and psychiatric disorders and occasionally with 'Nakalanga' features such as severe stunting with delayed or absent external signs of sexual development. Onchocerciasis-associated epilepsy, because of its importance as a public health problem, is an additional reason for strengthening onchocerciasis elimination programs.
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Affiliation(s)
| | - F J Nelson Siewe
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - An Hotterbeekx
- Global Health Institute, University of Antwerp, Antwerp, Belgium
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90
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Kaiser C, Pion SDS. River blindness goes beyond the eye: autoimmune antibodies, cross-reactive with Onchocerca volvulus antigen, detected in brain of patients with Nodding syndrome. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:459. [PMID: 29285492 DOI: 10.21037/atm.2017.08.35] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | - Sébastien D S Pion
- UMI 233, Institut de Recherche pour le Développement (IRD) and University of Montpellier 1, Montpellier, France
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91
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Kakooza-Mwesige A. Unravelling the mysterious onchocerciasis-nodding syndrome link: new developments and future challenges. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:486. [PMID: 29299448 PMCID: PMC5750291 DOI: 10.21037/atm.2017.09.36] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Accepted: 09/20/2017] [Indexed: 01/18/2023]
Affiliation(s)
- Angelina Kakooza-Mwesige
- Department of Paediatrics & Child Health, Makerere University College of Health Sciences, Kampala, Uganda
- Astrid Lindgren Children's Hospital, Department of Women’s & Children’s Health, Neuropediatric Research Unit, Karolinska Institutet, Stockholm, Sweden
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92
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Rose NR. Negative selection, epitope mimicry and autoimmunity. Curr Opin Immunol 2017; 49:51-55. [DOI: 10.1016/j.coi.2017.08.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 08/26/2017] [Indexed: 12/17/2022]
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93
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Nath A. Grand Challenges in Neuroinfectious Diseases. Front Neurol 2017; 8:480. [PMID: 28959232 PMCID: PMC5603653 DOI: 10.3389/fneur.2017.00480] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 08/29/2017] [Indexed: 12/16/2022] Open
Affiliation(s)
- Avindra Nath
- Section of Neuroinfectious Diseases, National Institutes of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States
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94
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Lagoro DK, Arony DA. Nodding syndrome (NS) and Onchocerca Volvulus ( OV) in Northern Uganda. Pan Afr Med J 2017; 28:1. [PMID: 29138647 PMCID: PMC5681003 DOI: 10.11604/pamj.2017.28.1.13554] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 08/19/2017] [Indexed: 11/11/2022] Open
Abstract
Nodding Syndrome (NS) is a childhood neurological disorder characterized by atonic seizures, cognitive decline, school dropout, muscle weakness, thermal dysfunction, wasting and stunted growth. There are recent published information suggesting associations between Nodding Syndrome (NS) with cerebrospinal fluid (CSF) VGKC antibodies and serum leiomidin-1 antibody cross reacting with Onchocerca Volvulus (OV). These findings suggest a neuro-inflammatory cause of NS and they are important findings in the search for the cause of Nodding Syndrome. These observations perhaps provide further, the unique explanation for the association between Nodding Syndrome and Onchocerca Volvulus. Many clinical and epidemiological studies had shown a significant correlation between NS and infestation with a nematode, Onchocerca volvulus which causes a disease, Onchocerciasis, some of which when left untreated can develop visual defect ("River Blindness"). While these studies conducted in Northern Uganda and Southern Sudan indicate a statistically significant association with (OV infection (using positive skin snips), we observe that (OV is generally endemic in many parts of Sub Saharan Africa and Latin America and that to date, no NS cases have been recorded in those regions. This letter to the Editor is to provide additional information on the current view about the relationship between Nodding Syndrome and Onchocerca Volvulus as seen in Northern Uganda.
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Affiliation(s)
| | - Denis Anywar Arony
- Gulu University, Faculty of Medicine, Department of Biochemistry, Gulu, Uganda
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95
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Fowler VM, Dominguez R. Tropomodulins and Leiomodins: Actin Pointed End Caps and Nucleators in Muscles. Biophys J 2017; 112:1742-1760. [PMID: 28494946 DOI: 10.1016/j.bpj.2017.03.034] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 03/27/2017] [Accepted: 03/30/2017] [Indexed: 12/29/2022] Open
Abstract
Cytoskeletal structures characterized by actin filaments with uniform lengths, including the thin filaments of striated muscles and the spectrin-based membrane skeleton, use barbed and pointed-end capping proteins to control subunit addition/dissociation at filament ends. While several proteins cap the barbed end, tropomodulins (Tmods), a family of four closely related isoforms in vertebrates, are the only proteins known to specifically cap the pointed end. Tmods are ∼350 amino acids in length, and comprise alternating tropomyosin- and actin-binding sites (TMBS1, ABS1, TMBS2, and ABS2). Leiomodins (Lmods) are related in sequence to Tmods, but display important differences, including most notably the lack of TMBS2 and the presence of a C-terminal extension featuring a proline-rich domain and an actin-binding WASP-Homology 2 domain. The Lmod subfamily comprises three somewhat divergent isoforms expressed predominantly in muscle cells. Biochemically, Lmods differ from Tmods, acting as powerful nucleators of actin polymerization, not capping proteins. Structurally, Lmods and Tmods display crucial differences that correlate well with their different biochemical activities. Physiologically, loss of Lmods in striated muscle results in cardiomyopathy or nemaline myopathy, whereas complete loss of Tmods leads to failure of myofibril assembly and developmental defects. Yet, interpretation of some of the in vivo data has led to the idea that Tmods and Lmods are interchangeable or, at best, different variants of two subfamilies of pointed-end capping proteins. Here, we review and contrast the existing literature on Tmods and Lmods, and propose a model of Lmod function that attempts to reconcile the in vitro and in vivo data, whereby Lmods nucleate actin filaments that are subsequently capped by Tmods during sarcomere assembly, turnover, and repair.
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Affiliation(s)
- Velia M Fowler
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, California.
| | - Roberto Dominguez
- Department of Physiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
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96
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Levick B, Laudisoit A, Tepage F, Ensoy-Musoro C, Mandro M, Bonareri Osoro C, Suykerbuyk P, Kashama JM, Komba M, Tagoto A, Falay D, Begon M, Colebunders R. High prevalence of epilepsy in onchocerciasis endemic regions in the Democratic Republic of the Congo. PLoS Negl Trop Dis 2017; 11:e0005732. [PMID: 28708828 PMCID: PMC5529017 DOI: 10.1371/journal.pntd.0005732] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 07/26/2017] [Accepted: 06/20/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND An increased prevalence of epilepsy has been reported in many onchocerciasis endemic areas. The objective of this study was to determine the prevalence of epilepsy in onchocerciasis endemic areas in the Democratic Republic of the Congo (DRC) and investigate whether a higher annual intake of Ivermectin was associated with a lower prevalence of epilepsy. METHODOLOGY/PRINCIPLE FINDINGS Between July 2014 and February 2016, house-to-house epilepsy prevalence surveys were carried out in areas with a high level of onchocerciasis endemicity: 3 localities in the Bas-Uele, 24 in the Tshopo and 21 in the Ituri province. Ivermectin uptake was recorded for every household member. This database allowed a matched case-control pair subset to be created that enabled putative risk factors for epilepsy to be tested using univariate logistic regression models. Risk factors relating to onchocerciasis were tested using a multivariate random effects model. To identify presence of clusters of epilepsy cases, the Kulldorff's scan statistic was used. Of 12, 408 people examined in the different health areas 407 (3.3%) were found to have a history of epilepsy. A high prevalence of epilepsy was observed in health areas in the 3 provinces: 6.8-8.5% in Bas-Uele, 0.8-7.4% in Tshopo and 3.6-6.2% in Ituri. Median age of epilepsy onset was 9 years, and the modal age 12 years. The case control analysis demonstrated that before the appearance of epilepsy, compared to the same life period in controls, persons with epilepsy were around two times less likely (OR: 0.52; 95%CI: (0.28, 0.98)) to have taken Ivermectin than controls. After the appearance of epilepsy, there was no difference of Ivermectin intake between cases and controls. Only in Ituri, a significant cluster (p-value = 0.0001) was identified located around the Draju sample site area. CONCLUSIONS The prevalence of epilepsy in health areas in onchocerciasis endemic regions in the DRC was 2-10 times higher than in non-onchocerciasis endemic regions in Africa. Our data suggests that Ivermectin protects against epilepsy in an onchocerciasis endemic region. However, a prospective population based intervention study is needed to confirm this.
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Affiliation(s)
- Bethany Levick
- Institute of Integrative Biology, School of Biological Sciences, University of Liverpool, Liverpool, United-Kingdom
| | - Anne Laudisoit
- Institute of Integrative Biology, School of Biological Sciences, University of Liverpool, Liverpool, United-Kingdom
- CIFOR, Jalan Cifor, Situ Gede, Sindang Barang, Bogor Bar, Jawa Barat, Indonesia
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - Floribert Tepage
- National Onchocerciasis Control Program (PNLO), Ministry of Health, Buta, Democratic Republic of the Congo
| | - Chellafe Ensoy-Musoro
- Interuniversity Institute for Biostatistics and statistical Bioinformatics, University of Hasselt, Hasselt, Belgium
| | - Michel Mandro
- Ituri Provincial Health Division, Ministry of Health, Bunia, Democratic Republic of the Congo
| | - Caroline Bonareri Osoro
- Interuniversity Institute for Biostatistics and statistical Bioinformatics, University of Hasselt, Hasselt, Belgium
- Nanyuki Teaching and Referral Hospital, Nanyuki, Kenya
| | | | - Jean Marie Kashama
- Neuropsychopathologic Centre of Mont Amba (CNPP), University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Michel Komba
- Biodiversity Monitoring Centre, Faculty of Sciences, University of Kisangani, Kisangani, Democratic Republic of the Congo
| | - Alliance Tagoto
- National HIV program, Ministry of Health, Kisangani, Democratic Republic of the Congo
| | - Dadi Falay
- Department of Pediatrics, University of Kisangani, Kisangani, Democratic Republic of the Congo
| | - Michael Begon
- Institute of Integrative Biology, School of Biological Sciences, University of Liverpool, Liverpool, United-Kingdom
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97
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Johnson T, Nutman T, Dowell S, Nath A. Closing the Loop between Nodding Syndrome and Onchocerca Infection. Trends Parasitol 2017; 33:490. [PMID: 28596063 DOI: 10.1016/j.pt.2017.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 05/01/2017] [Indexed: 11/24/2022]
Affiliation(s)
- Tory Johnson
- Department of Neurology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Thomas Nutman
- Helminth Immunology Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Scott Dowell
- Bill and Melinda Gates Foundation, Seattle, Washington, USA
| | - Avindra Nath
- Section of Infections of the Nervous System, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA.
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98
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Spencer PS, Schmutzhard E, Winkler AS. Nodding Syndrome in the Spotlight - Placing Recent Findings in Perspective. Trends Parasitol 2017; 33:490-492. [PMID: 28596064 DOI: 10.1016/j.pt.2017.05.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 05/01/2017] [Indexed: 11/24/2022]
Abstract
Nodding syndrome (NS) is a debated scientific topic. A recently published study suggests that NS is an autoimmune disorder based on findings of cross-reacting antibodies between neuronal structures and a protein present in Onchocerca volvulus (OV). In our opinion, the proposed causal relationship between OV infection and NS has yet to be demonstrated and, instead, OV infection in NS may be opportunistic.
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Affiliation(s)
- Peter S Spencer
- Department of Neurology, School of Medicine, and Oregon Institute of Occupational Health Sciences, Oregon Health & Science University, Portland, OR, USA.
| | - Erich Schmutzhard
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Andrea S Winkler
- Centre for Global Health, Institute of Health and Society, University of Oslo, Oslo, Norway; Centre for Global Health, Department of Neurology, Technical University of Munich, Munich, Germany
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Colebunders R, Njamnshi AK, van Oijen M, Mukendi D, Kashama JM, Mandro M, Gumisiriza N, Preux PM, Suykerbuyk P, Idro R. Onchocerciasis-associated epilepsy: From recent epidemiological and clinical findings to policy implications. Epilepsia Open 2017; 2:145-152. [PMID: 29588943 PMCID: PMC5719844 DOI: 10.1002/epi4.12054] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2017] [Indexed: 11/12/2022] Open
Abstract
A high prevalence of epilepsy is reported in many onchocerciasis‐endemic regions. In this paper we discuss recent epidemiological and clinical aspects as well as public health implications of onchocerciasis‐associated epilepsy (OAE) and propose a strategy to reduce the burden of disease. OAE probably presents in a variety of clinical manifestations, including the nodding syndrome and the Nakalanga syndrome. The most common clinical presentation, however, is generalized (primarily tonic‐clonic) seizures. A characteristic of OAE is the onset of seizures between the ages of 3 and 18 years and clustering in certain families and villages close to rapid‐flowing black‐fly‐infested rivers. A strategy combining active surveillance for epilepsy with early treatment with antiepileptic drugs and prevention of onchocerciasis by increasing the geographical and therapeutic coverage of community‐directed treatment with ivermectin (CDTi) may considerably decrease the burden of disease.
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Affiliation(s)
| | - Alfred K Njamnshi
- Neurology Department Central Hospital Yaoundé Faculty of Medicine and Biomedical Sciences the University of Yaoundé IYaoundé IRepublic of Cameroon
| | - Marieke van Oijen
- Global Health Institute University of Antwerp Antwerp Belgium.,Department of Neurology Academic Medical Center Amsterdam the Netherlands
| | - Deby Mukendi
- Neuro-psycho-pathological Centre University of Kinshasa Kinshasa Democratic Republic of the Congo
| | - Jean Marie Kashama
- Neuro-psycho-pathological Centre University of Kinshasa Kinshasa Democratic Republic of the Congo
| | - Michel Mandro
- Provincial division of Health of Ituri Ministery of Health Bunia Democratic Republic of the Congo
| | | | | | | | - Richard Idro
- College of Health Sciences Makerere University Kampala Uganda.,Nuffield Department of Medicine Centre for Tropical Medicine and Global Health University of Oxford Oxford United Kingdom
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100
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Ben AF. Carphology. Pract Neurol 2017; 17:169. [PMID: 28315841 DOI: 10.1136/practneurol-2017-001642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- A Fo Ben
- Wales Epilepsy Research, Swansea, UK
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