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Van Cutsem G, Siewe Fodjo JN, Hadermann A, Amaral LJ, Trevisan C, Pion S, Colebunders R. Onchocerciasis-associated epilepsy: Charting a path forward. Seizure 2024:S1059-1311(24)00123-7. [PMID: 38677953 DOI: 10.1016/j.seizure.2024.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 04/17/2024] [Accepted: 04/18/2024] [Indexed: 04/29/2024] Open
Abstract
This narrative review intends to inform neurologists and public health professionals about Onchocerciasis-Associated Epilepsy (OAE), a neglected public health problem in many remote onchocerciasis-endemic areas. For epidemiological purposes, we define OAE as sudden-onset of convulsive and non-convulsive seizure types, including head nodding seizures (nodding syndrome) in a previously healthy child aged 3 to 18 years in the absence of any other obvious cause for epilepsy, all happening within an area with high ongoing Onchocerca volvulus transmission. Several OAE pathophysiological mechanisms have been proposed, but none has been proven yet. Recent population-based studies showed that strengthening onchocerciasis elimination programs was followed by a significant reduction in the incidence of OAE and nodding syndrome. Treating epilepsy in onchocerciasis-endemic regions is challenging. More advocacy is needed to provide uninterrupted, free access to anti-seizure medication to persons with epilepsy in these remote, impoverished areas. It is crucial todevelop policies and increase funding for the prevention and treatment of OAE to reduce the associated burden of disease, notably via the establishment of morbidity management and disability prevention programs (MMDP). Moreover, effective collaboration between onchocerciasis elimination and mental health programs is imperative to alleviate the burden of OAE. This synergy promises reciprocal advantages and underscores the need for a comprehensive approach to address this multifaceted challenge.
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Affiliation(s)
- G Van Cutsem
- Department of Neurology, Centre Hospitalier de Luxembourg, Luxembourg; Faculty of Science, Technology and Medicine, University of Luxembourg, Luxembourg; Centre for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa
| | - J N Siewe Fodjo
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - A Hadermann
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - L-J Amaral
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - C Trevisan
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - S Pion
- Institute of Research for Sustainable Development, Montpelier, France
| | - R Colebunders
- Global Health Institute, University of Antwerp, Antwerp, Belgium.
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Metanmo S, Winkler AS. Response to "Nodding Syndrome Associated with Onchocerciasis". Neuroepidemiology 2024:1-4. [PMID: 38631300 DOI: 10.1159/000538697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 04/02/2024] [Indexed: 04/19/2024] Open
Affiliation(s)
- Salvatore Metanmo
- Inserm U1094, IRD U270, University of Limoges, CHU Limoges, EpiMaCT - Epidemiology of Chronic Diseases in Tropical Zone, Institute of Epidemiology and Tropical Neurology, Omega Health, Limoges, France
| | - Andrea Sylvia Winkler
- Department of Neurology, Center for Global Health, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
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Tshimbombu TN, Shin M, Thesen T, Mesu’a Kabwa L, Blackmon K, Kashama JMKW, Jobst BC, Fontaine D, Olarinde I, Okitundu‐Luwa E‐Andjafono D. Review of epilepsy care in the Democratic Republic of the Congo. Epilepsia Open 2024; 9:467-474. [PMID: 38243880 PMCID: PMC10984300 DOI: 10.1002/epi4.12904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 01/04/2024] [Accepted: 01/11/2024] [Indexed: 01/22/2024] Open
Abstract
Epilepsy imposes a substantial burden on the Democratic Republic of Congo (DRC). These challenges encompass the lack of comprehensive disease surveillance, an unresolved understanding of its pathophysiology, economic barriers limiting access to essential care, the absence of epilepsy surgical capabilities, and deeply ingrained societal stigmas. Notably, the national prevalence of epilepsy remains undetermined, with research primarily concentrating on infectious factors like Onchocerca volvulus, leaving other potential causes underexplored. Most patients lack insurance, incurring out-of-pocket expenses that often lead them to opt for traditional medicine rather than clinical care. Social stigma, perpetuated by common misconceptions, intensifies the social isolation experienced by individuals living with epilepsy. Additionally, surgical interventions are unavailable, and the accessibility of anti-seizure medications and healthcare infrastructure remains inadequate. Effectively tackling these interrelated challenges requires a multifaceted approach, including conducting research into region-specific factors contributing to epilepsy, increasing healthcare funding, subsidizing the costs of treatment, deploying mobile tools for extensive screening, launching awareness campaigns to dispel myths and reduce stigma, and promoting collaborations between traditional healers and medical practitioners to enhance local understanding and epilepsy management. Despite the difficulties, significant progress can be achieved through sustained and compassionate efforts to understand and eliminate the barriers faced by epilepsy patients in the region. This review outlines essential steps for alleviating the epilepsy burden in the DRC. PLAIN LANGUAGE SUMMARY: There are not enough resources to treat epilepsy in the DRC. PWEs struggle with stigma and the lack of money. Many of them still use traditional medicine for treatment and hold wrong beliefs about epilepsy. That is why there is a need for more resources to make the lives of PWEs better in the DRC.
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Affiliation(s)
| | | | - Thomas Thesen
- Geisel School of Medicine at DartmouthHanoverNew HampshireUSA
| | - Luabeya Mesu’a Kabwa
- Department of Neurology and Neuropsychiatry, Center for Neuro‐Psycho‐Pathology of Mont‐Amba, Faculty of MedicineUniversity of KinshasaKinshasaDemocratic Republic of Congo
- Centre Hospitalier ValisanaBrusselsBelgium
| | - Karen Blackmon
- Department of Psychiatry and PsychologyMayo ClinicJacksonvilleFloridaUSA
| | - Jean Marie Kashama wa Kashama
- Department of Neurology and Neuropsychiatry, Center for Neuro‐Psycho‐Pathology of Mont‐Amba, Faculty of MedicineUniversity of KinshasaKinshasaDemocratic Republic of Congo
| | - Barbara C. Jobst
- Department of Neurology, Geisel School of Medicine at DartmouthDartmouth‐Hitchcock Medical CenterLebanonNew HampshireUSA
| | | | - Immanuel Olarinde
- Richmond Gabriel University College of MedicineBelairSaint Vincent and the Grenadines
| | - Daniel Okitundu‐Luwa E‐Andjafono
- Department of Neurology and Neuropsychiatry, Center for Neuro‐Psycho‐Pathology of Mont‐Amba, Faculty of MedicineUniversity of KinshasaKinshasaDemocratic Republic of Congo
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Kegele J, Wagner T, Kowenski T, Wiesmayr M, Gatterer C, Alber M, Matuja W, Schmutzhard E, Lerche H, Winkler AS. Long-term clinical course and treatment outcomes of individuals with Nodding Syndrome. J Neurol Sci 2024; 457:122893. [PMID: 38278097 DOI: 10.1016/j.jns.2024.122893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 12/28/2023] [Accepted: 01/13/2024] [Indexed: 01/28/2024]
Abstract
Nodding Syndrome is a poorly understood epilepsy disorder in sub-Saharan Africa. The cause(s) of the disease, risk factors and long-term outcomes are unknown or controversial. The objectives of this study were to describe the long-term clinical course and treatment outcomes of individuals suffering from Nodding Syndrome. In addition, we aimed to provide a comprehensive characterization of the epileptological and social features of patients with Nodding Syndrome. From 11/2014 to 4/2015, we conducted a hospital-based, cross-sectional and observational study in Mahenge, Tanzania. Seventy-eight individuals (female:male ratio: 40:38, age at examination: 21.1 ± 6.39 (SD) years) have been enrolled, of whom 38 (49%) had also been examined in 2005 and in 2009. The 10-year clinical course analysis of this revisited subgroup revealed a calculated case fatality of 0.8-2.3%. Progressive physical or cognitive deterioration has not been observed in any of the 78 individuals and more than half of the people studied (38/69; 55%) managed to live and work independently. 14/78 individuals (18%) were seizure-free, (no head nodding, no other seizure types), 13 of whom were taking antiseizure medication. Phenytoin was more effective against head nodding seizures (14/19 (74%)) than monotherapy with other available antiseizure medication (phenobarbitone 12/25 (48%) and carbamazepine 7/22 (32%), p = 0.02, chi-square test). Our ten-year clinical outcome data show that Nodding Syndrome is not a fatal disease, however, the response to treatment is worse than in epilepsy patients in general. Phenytoin may be more effective than carbamazepine and phenobarbitone, but further studies are needed to confirm this observation.
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Affiliation(s)
- Josua Kegele
- Department of Neurology and Epileptology, Hertie Institute of Clinical Brain Research, University of Tübingen, Hoppe-Seyler Straße 3, 72076 Tuebingen, Germany.
| | - Thomas Wagner
- Centre for Pediatric and Adolescent Medicine, University Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Teresa Kowenski
- Medical University of Innsbruck, Innrain 52, 6020 Innsbruck, Austria
| | - Matthias Wiesmayr
- Medical University of Innsbruck, Innrain 52, 6020 Innsbruck, Austria
| | | | - Michael Alber
- Pediatric Neurology and Developmental Medicine, University of Tübingen, Hoppe-Seyler Straße 3, 72076 Tuebingen, Germany.
| | - Wiliam Matuja
- Department of Neurology, Muhimbili University of Health and Allied Sciences, United Nations Rd, Dar es Salaam, Tanzania
| | - Erich Schmutzhard
- Department of Neurology, Medical University of Innsbruck, Innrain 52, 6020 Innsbruck, Austria.
| | - Holger Lerche
- Department of Neurology and Epileptology, Hertie Institute of Clinical Brain Research, University of Tübingen, Hoppe-Seyler Straße 3, 72076 Tuebingen, Germany.
| | - Andrea S Winkler
- Department of Neurology, Center for Global Health, School of Medicine, Technical University of Munich, Ismaninger Straße 22, 81675 Munich, Germany; Department of Community Medicine and Global Health, Institute of Health and Society, University of Oslo, Forskningsveien 3A, 0373 Oslo, Norway; Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.
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5
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Metanmo S, Dossa D, Ahmat DN, Winkler AS, Boumediene F. Mapping, Associated Factors, and Pathophysiology of Nodding Syndrome in Africa: A Systematic Review. Neuroepidemiology 2024; 58:92-119. [PMID: 38171341 DOI: 10.1159/000536013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 12/08/2023] [Indexed: 01/05/2024] Open
Abstract
INTRODUCTION Nodding syndrome (NS) remains a poorly understood disorder. For a long time, it has been thought to be restricted to East Africa; however, cases in Central Africa have been increasing over time. The objective of this systematic review (SR) was to provide a summary of the state of knowledge on NS to date. METHODS All original articles published on NS up to November 2021 were searched in four major databases and in the gray literature. Commentaries, editorials, book chapters, books, conference paper, qualitative studies that mentioned NS cases were also included. Data retrieved included study location (with GPS coordinates searched), year of study and publication, population characteristics, definition and diagnosis of NS, associated factors, and treatment if applicable. A meta-analysis of associated factors was performed where possible, and results were presented as odds ratios (ORs) and visualized as forest plots. Geographic information systems were used for cartographic representations. The quality of the articles included was assessed. RESULTS Of the 876 articles initially identified, 67 (corresponding to 59 studies) were included in the SR. NS is only present in Central and East Africa. Interestingly, there were reports of NS in Central Africa prior to 2010, earlier than previously thought. The way NS diagnosis was established varies according to studies, and the 2012 WHO classification was used in only 60% of the studies. Approximately 11% of the articles did not meet the quality requirements set for this review. In our meta-analysis, the main factor associated with NS was onchocerciasis (OR = 8.8 [4.8, 15.9]). However, the pathophysiology of the disease remains poorly understood. The lack of common anti-epileptic drugs is a significant barrier to the management of head nodding and associated epileptic seizures. DISCUSSION/CONCLUSION The lack of an operational definition of NS is an obstacle to its diagnosis and, thus, to its appropriate treatment. Indeed, diagnostic difficulties might have led to false positives and false negatives which could have altered the picture of NS presented in this article. Treatment should take into account nutritional and psychological factors, as well as associated infections. Some risk factors deserve further investigation; therefore, we suggest a multicentric study with an etiological focus using a more operational definition of NS.
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Affiliation(s)
- Salvatore Metanmo
- Inserm U1094, IRD U270, Univ. Limoges, CHU Limoges, EpiMaCT - Epidemiology of Chronic Diseases in Tropical Zone, Institute of Epidemiology and Tropical Neurology, Omega Health, Limoges, France
| | - Djamirou Dossa
- Inserm U1094, IRD U270, Univ. Limoges, CHU Limoges, EpiMaCT - Epidemiology of Chronic Diseases in Tropical Zone, Institute of Epidemiology and Tropical Neurology, Omega Health, Limoges, France
| | - Djibrine Nassir Ahmat
- Inserm U1094, IRD U270, Univ. Limoges, CHU Limoges, EpiMaCT - Epidemiology of Chronic Diseases in Tropical Zone, Institute of Epidemiology and Tropical Neurology, Omega Health, Limoges, France
| | - Andrea Sylvia Winkler
- Department of Neurology, Center for Global Health, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- Centre for Global Health, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Farid Boumediene
- Inserm U1094, IRD U270, Univ. Limoges, CHU Limoges, EpiMaCT - Epidemiology of Chronic Diseases in Tropical Zone, Institute of Epidemiology and Tropical Neurology, Omega Health, Limoges, France,
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Mushi V, Mmbando BP, Colebunders R. Integration of onchocerciasis morbidity management and disability prevention services in the healthcare system in Tanzania: a call for action and recommendations. Trop Dis Travel Med Vaccines 2024; 10:1. [PMID: 38167350 PMCID: PMC10759408 DOI: 10.1186/s40794-023-00211-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 11/16/2023] [Indexed: 01/05/2024] Open
Abstract
Onchocerciasis is among the Neglected Tropical Diseases (NTDs) responsible for dermatological, ophthalmological, and neurological manifestations. With the ongoing burden of onchocerciasis clinical manifestations, morbidity management, and disability prevention services are required to alleviate the suffering of the affected populations. Unfortunately, despite the ongoing transmission of onchocerciasis, morbidity management, and disability prevention services are limited in Tanzania. Therefore, this article highlights the concept of onchocerciasis morbidity management and disability prevention, along with the significance of its adoption in the healthcare system in Tanzania. We further provide recommendations on where and how to start.
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Affiliation(s)
- Vivian Mushi
- Department of Parasitology and Medical Entomology, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
- Department of Zoology and Wildlife Conservation, College of Natural and Applied Sciences, University of Dar es Salaam, Dar es Salaam, Tanzania.
| | - Bruno P Mmbando
- National Institute for Medical Research, Tanga Research Centre, Tanga, Tanzania
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Hedtke SM, Post RJ, Feleke SM, Gebretsadik FS, Boakye DA, Krueger A, Grant WN, Wilding CS. Cytotaxonomic characterization and estimation of migration patterns of onchocerciasis vectors (Simulium damnosum sensu lato) in northwestern Ethiopia based on RADSeq data. PLoS Negl Trop Dis 2024; 18:e0011868. [PMID: 38175836 DOI: 10.1371/journal.pntd.0011868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 01/17/2024] [Accepted: 12/17/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND While much progress has been made in the control and elimination of onchocerciasis across Africa, the extent to which vector migration might confound progress towards elimination or result in re-establishment of endemism in areas where transmission has been eliminated remains unclear. In Northern Ethiopia, Metema and Metekel-two foci located near the Sudan border-exhibit continuing transmission. While progress towards elimination has been faster in Metema, there remains a problematic hotspot of transmission. Whether migration from Metekel contributes to this is currently unknown. METHODOLOGY/PRINCIPLE FINDINGS To assess the role of vector migration from Metekel into Metema, we present a population genomics study of 151 adult female vectors using 47,638 RADseq markers and mtDNA CoI sequencing. From additional cytotaxonomy data we identified a new cytoform in Metema, closely related to S. damnosum s.str, here called the Gondar form. RADseq data strongly indicate the existence of two distinctly differentiated clusters within S. damnosum s.l.: one genotypic cluster found only in Metema, and the second found predominantly in Metekel. Because blackflies from both clusters were found in sympatry (in all four collection sites in Metema), but hybrid genotypes were not detected, there may be reproductive barriers preventing interbreeding. The dominant genotype in Metema was not found in Metekel while the dominant genotype in Metekel was found in Metema, indicating that (at the time of sampling) migration is primarily unidirectional, with flies moving from Metekel to Metema. There was strong differentiation between clusters but little genetic differentiation within clusters, suggesting migration and gene flow of flies within the same genetic cluster are sufficient to prevent genetic divergence between sites. CONCLUSIONS/SIGNIFICANCE Our results confirm that Metekel and Metema represent different transmission foci, but also indicate a northward movement of vectors between foci that may have epidemiological importance, although its significance requires further study.
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Affiliation(s)
- Shannon M Hedtke
- Department of Environment and Genetics, School of Agriculture, Biomedicine and Environment, La Trobe University, Bundoora, Victoria, Australia
| | - Rory J Post
- School of Biological and Environmental Sciences, Liverpool John Moores University, Liverpool, United Kingdom
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Fikre Seife Gebretsadik
- Neglected Tropical Disease Prevention and Control Program, Federal Ministry of Health, Addis Ababa, Ethiopia
| | - Daniel A Boakye
- Parasitology Department, Noguchi Memorial Institute for Medical Research, Accra, Ghana
| | - Andreas Krueger
- Military Hospital Hamburg, Department Tropical Medicine, Hamburg, Germany
| | - Warwick N Grant
- Department of Environment and Genetics, School of Agriculture, Biomedicine and Environment, La Trobe University, Bundoora, Victoria, Australia
| | - Craig S Wilding
- School of Biological and Environmental Sciences, Liverpool John Moores University, Liverpool, United Kingdom
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Bhwana D, Siewe Fodjo JN, Amaral LJ, Vandevenne L, Francis F, Challe DP, Mmbando BP, Colebunders R. Disability assessment among persons with epilepsy in Mahenge, an onchocerciasis-endemic area in Tanzania: A cross-sectional study. Epilepsy Behav 2023; 146:109367. [PMID: 37523798 DOI: 10.1016/j.yebeh.2023.109367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 07/17/2023] [Accepted: 07/20/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND A high prevalence of epilepsy has been observed in the onchocerciasis-endemic focus of Mahenge, Tanzania. This study sought to assess the degree of disability experienced by persons with epilepsy (PWE) in Mahenge and identify associations with sociodemographic and clinical features. METHOD This cross-sectional study was conducted in Mahenge, Tanzania, between February and July 2020. PWE were recruited from the Mahenge epilepsy clinic and four neighbouring rural villages (Mdindo, Mzogezi, Mzelezi and Sali). Data were collected using the 36-item version of the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) questionnaire for adults. For children aged 5-17 years, we used the Module on Child Functioning developed by UNICEF and the Washington Group. Questionnaires were administered by trained research assistants. Descriptive statistics were performed, and multivariable analyses (gamma and logistic regressions) were conducted. RESULTS A total of 321 adults (45.5% males) and 48 children (55.3% males) with epilepsy participated. The overall median WHODAS 2.0 score was 4.8% (IQR: 0.9-18.9). The most affected disability domain was 'participating in the society' (median score: 12.5%, IQR: 0-29.2). Fifteen (31.3%) of the children with epilepsy had a disability in at least one domain of the child functioning module, with the 'accepting change' domain harbouring the highest proportion of disabled children (12.5%). Higher seizure frequency and longer epilepsy duration were associated with more disability. CONCLUSION PWE in Mahenge experience variable degrees of disability. The affected domains indicate the need for societal rehabilitation of PWE in various community and/or social activities. Peer-support groups were instituted at the study sites to address these needs.
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Affiliation(s)
- Dan Bhwana
- National Institute of Medical Research, Tanga, P.O Box 5004, Tanzania.
| | | | - Luís-Jorge Amaral
- Global Health Institute, University of Antwerp, 2610 Antwerp, Belgium.
| | - Lauren Vandevenne
- Global Health Institute, University of Antwerp, 2610 Antwerp, Belgium.
| | - Filbert Francis
- National Institute of Medical Research, Tanga, P.O Box 5004, Tanzania.
| | - Daniel P Challe
- National Institute of Medical Research, Tanga, P.O Box 5004, Tanzania.
| | - Bruno P Mmbando
- National Institute of Medical Research, Tanga, P.O Box 5004, Tanzania.
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Otabil KB, Ankrah B, Bart-Plange EJ, Donkoh ES, Avarikame FA, Ofori-Appiah FO, Babae TN, Kudzordzi PC, Darko VA, Ameyaw J, Bamfo JG, Sakibu RA, Antwi-Berko D, Fodjo JNS, Basáñez MG, Schallig HDFH, Colebunders R. Prevalence of epilepsy in the onchocerciasis endemic middle belt of Ghana after 27 years of mass drug administration with ivermectin. Infect Dis Poverty 2023; 12:75. [PMID: 37587500 PMCID: PMC10433588 DOI: 10.1186/s40249-023-01117-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 06/29/2023] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND In onchocerciasis-endemic areas with high ongoing Onchocerca volvulus transmission, a high prevalence of epilepsy has been reported. This study aimed to determine the prevalence and clinical characteristics of epilepsy in the Bono Region of Ghana following 27 years of implementation of ivermectin mass drug administration (MDA). METHODS Between October 2020 and August 2021, cross-sectional surveys were conducted in nine communities in the Tain District and Wenchi Municipality of the Bono Region of Ghana. In the first stage, a random door-to-door approach was used to screen the population for epilepsy using a pre-tested questionnaire. Persons suspected of having epilepsy were invited for a second-stage neurological examination for case verification. Community O. volvulus microfilarial infection status and Ov16 seropositivity were also determined. Ninety-five confidence intervals (95% CI) for prevalence values were calculated using the Wilson Score Interval. RESULTS Of the 971 participants, 500 (51.5%) were females, and the median age (interquartile range) was 26 (15‒43) years. Fourteen participants (1.4%, 95% CI: 1.0‒2.0) were diagnosed as having epilepsy with generalized seizures being the most frequent seizure type (85.7%, 12/14). The overall microfilarial prevalence of O. volvulus was 10.3% (November 2020) and 9.9% (August 2021); the Ov16 seroprevalence was 22.2% (June 2021). Only 63.2% took ivermectin in the last round of MDA distribution in March 2021. CONCLUSIONS The 1.4% prevalence of epilepsy in the Bono region is similar to the median epilepsy prevalence in sub-Saharan Africa. However, the persistent microfilarial prevalence and low ivermectin study coverage call for the Ghana Onchocerciasis Elimination Programme to step up its efforts to ensure that the gains achieved are consolidated and improved to achieve the elimination of onchocerciasis by 2030.
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Affiliation(s)
- Kenneth Bentum Otabil
- NeTroDis Research Group, Centre for Research in Applied Biology, School of Sciences, University of Energy and Natural Resources, Bono Region, Sunyani, Ghana.
- Department of Biological Science, School of Sciences, University of Energy and Natural Resources, Bono Region, Sunyani, Ghana.
- Global Health Institute, University of Antwerp, Antwerp, Belgium.
| | - Blessing Ankrah
- NeTroDis Research Group, Centre for Research in Applied Biology, School of Sciences, University of Energy and Natural Resources, Bono Region, Sunyani, Ghana
| | - Emmanuel John Bart-Plange
- NeTroDis Research Group, Centre for Research in Applied Biology, School of Sciences, University of Energy and Natural Resources, Bono Region, Sunyani, Ghana
- Department of Medical Laboratory Science, School of Sciences, University of Energy and Natural Resources, Bono Region, Sunyani, Ghana
| | - Emmanuel Sam Donkoh
- Department of Medical Laboratory Science, School of Sciences, University of Energy and Natural Resources, Bono Region, Sunyani, Ghana
| | - Fiona Amoabil Avarikame
- Department of Medical Laboratory Science, School of Sciences, University of Energy and Natural Resources, Bono Region, Sunyani, Ghana
| | - Fredrick Obeng Ofori-Appiah
- Department of Medical Laboratory Science, School of Sciences, University of Energy and Natural Resources, Bono Region, Sunyani, Ghana
| | - Theophilus Nti Babae
- NeTroDis Research Group, Centre for Research in Applied Biology, School of Sciences, University of Energy and Natural Resources, Bono Region, Sunyani, Ghana
| | - Prince-Charles Kudzordzi
- NeTroDis Research Group, Centre for Research in Applied Biology, School of Sciences, University of Energy and Natural Resources, Bono Region, Sunyani, Ghana
| | - Vera Achiaa Darko
- NeTroDis Research Group, Centre for Research in Applied Biology, School of Sciences, University of Energy and Natural Resources, Bono Region, Sunyani, Ghana
- STU Clinic, Sunyani Technical University, Bono Region, Sunyani, Ghana
| | - Joseph Ameyaw
- Happy Family Hospital, Bono East Region, Nkoranza, Ghana
| | | | - Raji Abdul Sakibu
- Department of Biological Science, School of Sciences, University of Energy and Natural Resources, Bono Region, Sunyani, Ghana
| | - Daniel Antwi-Berko
- Department of Medical Laboratory Science, School of Sciences, University of Energy and Natural Resources, Bono Region, Sunyani, Ghana
| | | | - María-Gloria Basáñez
- Department of Infectious Disease Epidemiology, MRC Centre for Global Infectious Disease Analysis (MRC GIDA), and London Centre for Neglected Tropical Disease Research, School of Public Health, Imperial College London, London, UK
| | - Henk D F H Schallig
- Department of Medical Microbiology, Experimental Parasitology Unit, Amsterdam University Medical Centres, Academic Medical Centre at the University of Amsterdam, Amsterdam, The Netherlands
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Jada SR, Amaral LJ, Lakwo T, Carter JY, Rovarini J, Bol YY, Logora MY, Hadermann A, Hopkins A, Fodjo JNS, Colebunders R. Effect of onchocerciasis elimination measures on the incidence of epilepsy in Maridi, South Sudan: a 3-year longitudinal, prospective, population-based study. Lancet Glob Health 2023; 11:e1260-e1268. [PMID: 37474232 DOI: 10.1016/s2214-109x(23)00248-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 05/15/2023] [Accepted: 05/19/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND High onchocerciasis transmission predisposes endemic communities to a high epilepsy burden. The 4·4% epilepsy prevalence documented in 2018 in Maridi, South Sudan, prompted the strengthening of onchocerciasis elimination measures. Community-directed treatment with ivermectin was implemented annually in 2017, 2018, and 2019, interrupted in 2020, and re-implemented biannually in 2021. We aimed to assess the effect of these interventions, along with slash and clear vector control on the incidence of epilepsy, including nodding syndrome. METHODS In this longitudinal, prospective, population-based study, we did a two-stage house-to-house epilepsy survey before (May 10-30, 2018) and after (March 9-19, 2022) the strengthening of onchocerciasis elimination interventions in South Sudan. Strengthening also included the implementation of a community-based slash and clear vector control method that we initiated in 2019 at the Maridi dam (the main blackfly breeding site). Eight sites were surveyed near the Maridi dam and inclusion required residence in one of these sites. All household residents were first screened by community workers, followed by confirmation of the epilepsy diagnosis by trained clinicians. The primary outcome was epilepsy incidence, including nodding syndrome, which was assessed via self-reported new-onset epilepsy in the previous 4 years of each survey, confirmed by clinician assessment. FINDINGS The preintervention survey included 17 652 people of whom 736 had epilepsy (315 female and 421 male), and the post-intervention survey included 14 402 people of whom 586 had epilepsy (275 female and 311 male). When biannual community-directed treatment with ivermectin was initiated in 2021, the intervention's coverage rose by 15·7% (95% CI 14·6-16·8); although only 56·6% of the population took ivermectin in 2021. Between 2018 and 2022, epilepsy incidence decreased from 348·8 (307·2-395·8) to 41·7 (22·6-75·0) per 100 000 person-years. Similarly, the incidence of nodding syndrome decreased from 154·7 (127·6-187·3) to 10·4 (2·7-33·2) per 100 000 person-years. The identified risk factors for epilepsy were: living closer to the Maridi dam, being aged between 6 and 40 years, not taking ivermectin, and being male. INTERPRETATION In onchocerciasis-endemic areas with high epilepsy prevalence, strengthening onchocerciasis elimination interventions can decrease the incidence of epilepsy, including nodding syndrome. Additional efforts are needed to increase community-directed treatment with ivermectin coverage and sustain blackfly control in Maridi. FUNDING Research for Health in Humanitarian Crisis, European Research Council, Research Foundation-Flanders, Research Foundation-Flanders, the Italian Agency for Development Cooperation, and La Caixa Foundation.
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Affiliation(s)
| | | | - Thomson Lakwo
- Division of Vector Borne and Neglected Tropical Diseases Control, Ministry of Health, Kampala, Uganda
| | | | - Jacopo Rovarini
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - Yak Yak Bol
- Neglected Tropical Diseases Unit, Ministry of Health, Juba, South Sudan
| | - Makoy Yibi Logora
- Neglected Tropical Diseases Unit, Ministry of Health, Juba, South Sudan
| | - Amber Hadermann
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - Adrian Hopkins
- The Onchocerciasis Elimination Advisory Committee, Juba, South Sudan
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Van Cutsem G, Siewe Fodjo JN, Dekker MCJ, Amaral LJ, Njamnshi AK, Colebunders R. Case definitions for onchocerciasis-associated epilepsy and nodding syndrome: A focused review. Seizure 2023; 107:132-135. [PMID: 37023626 DOI: 10.1016/j.seizure.2023.03.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/28/2023] [Accepted: 03/31/2023] [Indexed: 04/03/2023] Open
Abstract
Onchocerciasis-associated epilepsy (OAE) is an important but neglected public health problem in onchocerciasis-endemic areas with insufficient or inadequate onchocerciasis control. Hence, there is a need for an internationally accepted, easy-to-use epidemiological case definition of OAE to identify areas of high Onchocerca volvulus transmission and disease burden requiring treatment and prevention interventions. By including OAE as a manifestation of onchocerciasis, we will considerably improve the accuracy of the overall onchocerciasis disease burden, which is currently underestimated. Hopefully, this will lead to increased interest and funding for onchocerciasis research and control interventions, notably the implementation of more effective elimination measures and treatment and support for affected individuals and their families.
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Hadermann A, Amaral LJ, Van Cutsem G, Siewe Fodjo JN, Colebunders R. Onchocerciasis-associated epilepsy: an update and future perspectives. Trends Parasitol 2023; 39:126-138. [PMID: 36528471 DOI: 10.1016/j.pt.2022.11.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/22/2022] [Accepted: 11/24/2022] [Indexed: 12/23/2022]
Abstract
Onchocerciasis-associated epilepsy (OAE) is an important neglected public health problem in areas with high ongoing onchocerciasis transmission. The risk that children in such areas develop epilepsy is related to their Onchocerca volvulus microfilarial (mf) load. Before the implementation of mass treatment with ivermectin, microfilariae were detected in cerebrospinal fluid (CSF). More recently, neither O. volvulus microfilariae nor DNA were detected in CSF or brain tissue; however, these samples were obtained years after seizure onset. It is possible that during fever-induced increased blood-brain barrier permeability, microfilariae enter the brain and, upon dying, cause an inflammatory reaction inducing seizures. Including OAE in the onchocerciasis disease burden estimation may mobilise extra resources for onchocerciasis disease elimination and treatment/care of OAE-affected persons/families.
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Affiliation(s)
- Amber Hadermann
- Global Health Institute, University of Antwerp, Antwerp, Belgium
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13
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Abd-Elfarag GOE, Emmanuel L, Edridge AWD, van Beers S, Sebit MB, van Hensbroek MB, Rood EJJ. Epidemiology of nodding syndrome in the Greater Mundri area, South Sudan: Prevalence, spatial pattern and environmental risk factors. PLoS Negl Trop Dis 2022; 16:e0010630. [PMID: 35901184 PMCID: PMC9362928 DOI: 10.1371/journal.pntd.0010630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 08/09/2022] [Accepted: 07/01/2022] [Indexed: 11/19/2022] Open
Abstract
Background
Nodding syndrome (NS) is a progressive neurological disease that has been described in several sub-Saharan African counties, but South Sudan is considered the most affected. However, knowledge about the exact burden and the epidemiological risk factors of NS in South Sudan is lacking.
Objective
To determine the prevalence, distribution and epidemiological risk factors of NS in the Greater Mundri area, the epicenter of NS in South Sudan.
Methods
A NS prevalence house-to-house survey was conducted in multiple villages between February 2018 and November 2019. Geographical distribution and clustering of NS cases was identified using spatial and binomial regression analysis. Epidemiological risk factors of NS were identified using univariate and multivariate models.
Results
Of the 22,411 persons surveyed in 92 villages, 607 (2.7%) persons with NS were identified, of which 114 (19%) were new-onset cases. The highest prevalence was found in Diko village with a prevalence of 13.7%. NS showed a significant spatial pattern with clustering of cases between adjacent households and along rivers. Risks factors for NS include all behaviors around rivers (drinking, cooking, handwashing and bathing) and exposure to poultry. On the other hand, ownership of mobile phone decreased the risk of NS. Many other factors, including prior ivermectin treatment and internal displacement were not associated with NS.
Conclusion
Our study demonstrates a very high burden of the NS disease in the Greater Mundri area, strengthens the association with rivers, and identified possible new clues for an underlying cause.
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Affiliation(s)
- Gasim Omer Elkhalifa Abd-Elfarag
- Amsterdam Center for Global Health, Department of Pediatrics and Department of Global Health, Amsterdam UMC, Amsterdam, the Netherlands
- * E-mail:
| | - Lukudu Emmanuel
- Access for Humanity (AFH), Monitoring and Evaluation Unit, Juba, the Republic of South Sudan
| | - Arthur W. D. Edridge
- Amsterdam Center for Global Health, Department of Pediatrics and Department of Global Health, Amsterdam UMC, Amsterdam, the Netherlands
- Laboratory of Experimental Virology, Department of Medical Microbiology, Amsterdam UMC, Amsterdam, the Netherlands
| | - Stella van Beers
- Kit-Royal Tropical Institute, Epidemiology, Center for Applied Spatial Epidemiology (CASE), Amsterdam, the Netherlands
| | - Mohamed B. Sebit
- Department of Psychiatry, College of Medicine, University of Juba, Juba, the Republic of South Sudan
| | - Michaël B. van Hensbroek
- Amsterdam Center for Global Health, Department of Pediatrics and Department of Global Health, Amsterdam UMC, Amsterdam, the Netherlands
| | - Ente J. J. Rood
- Kit-Royal Tropical Institute, Epidemiology, Center for Applied Spatial Epidemiology (CASE), Amsterdam, the Netherlands
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Dusabimana A, Siewe Fodjo JN, Ndahura MM, Mmbando BP, Jada SR, Boven A, De Smet E, Ukety T, Njamnshi AK, Laudisoit A, Abrams S, Colebunders R. Surveillance for Onchocerciasis-Associated Epilepsy and OV16 IgG4 Testing of Children 6–10 Years Old Should Be Used to Identify Areas Where Onchocerciasis Elimination Programs Need Strengthening. Pathogens 2022; 11:pathogens11030281. [PMID: 35335605 PMCID: PMC8949980 DOI: 10.3390/pathogens11030281] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 02/17/2022] [Accepted: 02/18/2022] [Indexed: 01/27/2023] Open
Abstract
To eliminate onchocerciasis-associated morbidity, it is important to identify areas where there is still high ongoing Onchocerca volvulus transmission. Between 2015 and 2021, door-to-door surveys were conducted in onchocerciasis-endemic villages in Cameroon, the Democratic Republic of Congo (DRC), Nigeria, South Sudan, and Tanzania to determine epilepsy prevalence and incidence, type of epilepsy and ivermectin therapeutic coverage. Moreover, children aged between six and 10 years were tested for anti-Onchocerca antibodies using the Ov16 IgG4 rapid diagnostic test (RDT). A mixed-effect binary logistic regression analysis was used to assess significantly associated variables of Ov16 antibody seroprevalence. A high prevalence and incidence of epilepsy was found to be associated with a high Ov16 antibody seroprevalence among 6–10-year-old children, except in the Logo health zone, DRC. The low Ov16 antibody seroprevalence among young children in the Logo health zone, despite a high prevalence of epilepsy, may be explained by a recent decrease in O. volvulus transmission because of a decline in the Simulium vector population as a result of deforestation. In the Central African Republic, a new focus of O. volvulus transmission was detected based on the high Ov16 IgG4 seropositivity among children and the detecting of nodding syndrome cases, a phenotypic form of onchocerciasis-associated epilepsy (OAE). In conclusion, Ov16 IgG4 RDT testing of 6–10-year-old children is a cheap and rapid method to determine the level of ongoing O. volvulus transmission and to assess, together with surveillance for OAE, the performance of onchocerciasis elimination programs.
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Affiliation(s)
- Alfred Dusabimana
- Global Health Institute, University of Antwerp, Doornstraat 331, 2610 Antwerp, Belgium; (A.D.); (J.N.S.F.); (A.B.); (E.D.S.); (S.A.)
| | - Joseph Nelson Siewe Fodjo
- Global Health Institute, University of Antwerp, Doornstraat 331, 2610 Antwerp, Belgium; (A.D.); (J.N.S.F.); (A.B.); (E.D.S.); (S.A.)
- Brain Research Africa Initiative (BRAIN), Yaoundé P.O. Box 25625, Cameroon;
| | - Michel Mandro Ndahura
- Provincial Health Division Ituri, Ministry of Health, Bunia P.O. Box 57, Ituri, Democratic Republic of the Congo;
| | - Bruno P. Mmbando
- National Institute for Medical Research, Tanga Centre, Tanga P.O. Box 5004, Tanzania;
| | | | - Annelies Boven
- Global Health Institute, University of Antwerp, Doornstraat 331, 2610 Antwerp, Belgium; (A.D.); (J.N.S.F.); (A.B.); (E.D.S.); (S.A.)
| | - Eric De Smet
- Global Health Institute, University of Antwerp, Doornstraat 331, 2610 Antwerp, Belgium; (A.D.); (J.N.S.F.); (A.B.); (E.D.S.); (S.A.)
| | - Tony Ukety
- Centre de Recherche en Maladies Tropicales (CRMT), Bunia P.O. Box 143, Ituri, Democratic Republic of the Congo;
| | - Alfred K. Njamnshi
- Brain Research Africa Initiative (BRAIN), Yaoundé P.O. Box 25625, Cameroon;
- Neuroscience Laboratory, Faculty of Medicine and Biomedical Sciences, The University of Yaoundé I, Yaoundé P.O. Box 25625, Cameroon
- Neurology Department, Yaoundé Central Hospital, Yaoundé P.O. Box 25625, Cameroon
| | - Anne Laudisoit
- EcoHealth Alliance, 520 8th Ave Ste. 1200, New York, NY 10018, USA;
- Evolutionary Ecology Group (EVECO), University of Antwerp, Universiteitsplein 1, 2610 Antwerp, Belgium
| | - Steven Abrams
- Global Health Institute, University of Antwerp, Doornstraat 331, 2610 Antwerp, Belgium; (A.D.); (J.N.S.F.); (A.B.); (E.D.S.); (S.A.)
- Interuniversity Institute for Biostatistics and statistical Bioinformatics, Data Science Institute, UHasselt, Agoralaan Building D, 3590 Diepenbeek, Belgium
| | - Robert Colebunders
- Global Health Institute, University of Antwerp, Doornstraat 331, 2610 Antwerp, Belgium; (A.D.); (J.N.S.F.); (A.B.); (E.D.S.); (S.A.)
- Correspondence:
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Community perception of epilepsy and its treatment in onchocerciasis-endemic villages of Maridi county, western equatoria state, South Sudan. Epilepsy Behav 2022; 127:108537. [PMID: 35026562 DOI: 10.1016/j.yebeh.2021.108537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 12/27/2021] [Accepted: 12/27/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To assess the community's perception of epilepsy and its treatment in onchocerciasis-endemic villages of Maridi County, Western Equatoria State, South Sudan. The study was conducted prior to the setting up of a community-based intervention to manage the important disease burden caused by onchocerciasis-associated epilepsy in these villages. METHOD Five focus group discussions (FGD) were conducted with community leaders and with persons with epilepsy (PWE) and their families between November and December 2019. RESULTS Villages close to the Maridi dam were considered to be most affected by epilepsy. Misconceptions about the cause and treatment of epilepsy were identified. Most people believed that epilepsy is caused by bad spirits and is contagious, transmitted through saliva, air, and contact with PWE. Very few participants were aware of the link between onchocerciasis and epilepsy. Persons with epilepsy are restricted in their day-to-day activities and children with epilepsy are often denied going to school. Persons with epilepsy are stigmatized and seen as unfit for marriage. Most participants considered both traditional and medical treatment as ineffective. Uninterrupted anti-seizure treatment continuously was unaffordable for most families with one or more PWE. CONCLUSION There is a need to establish a comprehensive epilepsy treatment program which addresses misconceptions about epilepsy and reduces epilepsy-related stigma. Explaining the link between onchocerciasis and epilepsy could lead to a reduction in epilepsy-related stigma.
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Abd-Elfarag GOE, Edridge AWD, Spijker R, Sebit MB, van Hensbroek MB. Nodding Syndrome: A Scoping Review. Trop Med Infect Dis 2021; 6:tropicalmed6040211. [PMID: 34941667 PMCID: PMC8703395 DOI: 10.3390/tropicalmed6040211] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 12/06/2021] [Accepted: 12/08/2021] [Indexed: 12/23/2022] Open
Abstract
Nodding syndrome (NS) is a debilitating yet often neglected neurological disease affecting thousands of children in several sub-Saharan African countries. The cause of NS remains unknown, and effective treatment options are lacking. Moreover, knowledge regarding NS is scarce and is based on a limited number of publications, with no comprehensive overview published to date. Therefore, the aim of this scoping review was to summarise the current evidence and identify existing knowledge gaps in order to help clinicians, scientists, and policymakers develop guidelines for prioritising this severe condition. We searched the Medline (Ovid), Embase (Ovid), Scopus, and Global Health Library databases in accordance with the PRISMA extension for scoping review guidance and in accordance with the Joanna Briggs Institute guidelines and methodology for a scoping review, using keywords describing NS. We then extracted and presented the original data regarding the epidemiology, aetiology, pathophysiology, clinical features, diagnosis, management, and outcomes of NS, as well as community perceptions and the psychosocial and economic impact of NS. Out of 1470 identified articles, a total of 69 were included in this scoping review. Major gaps exist in understanding the aetiology and pathogenesis of NS. Future research is urgently needed not only to address these gaps, but also to study the treatment options, epidemiology, and psychosocial and economic impacts of NS. Innovative interventions and rehabilitation programmes designed to address the psychosocial and economic burdens associated with NS are also urgently needed.
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Affiliation(s)
- Gasim Omer Elkhalifa Abd-Elfarag
- Amsterdam Center for Global Health, Department of Pediatrics and Department of Global Health, Amsterdam UMC, 1105 AZ Amsterdam, The Netherlands; (A.W.D.E.); (M.B.v.H.)
- Correspondence:
| | - Arthur Wouter Dante Edridge
- Amsterdam Center for Global Health, Department of Pediatrics and Department of Global Health, Amsterdam UMC, 1105 AZ Amsterdam, The Netherlands; (A.W.D.E.); (M.B.v.H.)
- Laboratory of Experimental Virology, Department of Medical Microbiology, Amsterdam UMC, 1105 AZ Amsterdam, The Netherlands
| | - René Spijker
- Amsterdam Public Health, Medical Library, Amsterdam UMC, 1105 AZ Amsterdam, The Netherlands;
| | - Mohamed Boy Sebit
- Department of Psychiatry, College of Medicine, University of Juba, Juba P.O. Box 82, Sudan;
| | - Michaël B. van Hensbroek
- Amsterdam Center for Global Health, Department of Pediatrics and Department of Global Health, Amsterdam UMC, 1105 AZ Amsterdam, The Netherlands; (A.W.D.E.); (M.B.v.H.)
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Vieri MK, Logora MY, Rafiq K, Colebunders R. The World Health Organization road map for neglected tropical diseases 2021-2030: implications for onchocerciasis elimination programs. Infect Dis Poverty 2021; 10:70. [PMID: 34001286 PMCID: PMC8127298 DOI: 10.1186/s40249-021-00848-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 04/21/2021] [Indexed: 12/28/2022] Open
Abstract
In its new roadmap for neglected tropical diseases, the World Health Organization proposes three important strategic shifts: (i) Stronger accountability which shifting from process to impact indicators; (ii) Intensified cross-cutting approaches; and (iii) Stronger country ownership. In this paper we discuss the implementation of these three strategies in the setting of a high onchocerciasis disease burden in South Sudan. ![]()
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Affiliation(s)
- Melissa Krizia Vieri
- Global Health Institute, University of Antwerp, Kinsbergen Centrum, Doornstraat 331, 2610, Antwerp, Belgium.
| | - Makoy Yibi Logora
- Neglected Tropical Diseases Unit, Ministry of Health, Juba, Republic of South Sudan
| | - Kamran Rafiq
- The International Society for Neglected Tropical Diseases, London, UK
| | - Robert Colebunders
- Global Health Institute, University of Antwerp, Kinsbergen Centrum, Doornstraat 331, 2610, Antwerp, Belgium.
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Incidence and risk factors associated with the development of epilepsy in patients with intracranial alveolar echinococcosis. Epilepsy Res 2021; 174:106643. [PMID: 33964794 DOI: 10.1016/j.eplepsyres.2021.106643] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 03/17/2021] [Accepted: 04/14/2021] [Indexed: 02/08/2023]
Abstract
Parasitic infection remains a critical health problem in Ganzi Tibetan Autonomous Prefecture of China. The association of epilepsy and intracranial alveolar echinococcosis (IAE) is still largely unclear. This study primarily aimed to assess both the incidence and possible risk factors of epilepsy in patients with IAE. According to the occurrence of seizures, patients were separated into two different groups consisting of patients with epilepsy and those without epilepsy. Univariate and multivariate logistic regression analysis was used to identify the potential risk factors associated with the development of epilepsy in patients with IAE. A total of 97 patients (42 women, 55 men; age 19-76 years) were enrolled. Epilepsy was observed in almost 20 % of patients with IAE. The use of anti-seizure medications was not standardized, as 83.3 % of female patients of childbearing age used sodium valproate. It was observed that cortical lesions (hazard ratio (HR) = 29.740, P = 0.006) were significantly associated with development of epilepsy. In addition, epilepsy had no significant effect on the overall survival rate of patients with IAE.
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Onchocerciasis Prevalence among Persons with Epilepsy in an Onchocerciasis Hypo-Endemic Area in the Democratic Republic of Congo: A Cross-Sectional Study. Pathogens 2021; 10:pathogens10040389. [PMID: 33805016 PMCID: PMC8063918 DOI: 10.3390/pathogens10040389] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/16/2021] [Accepted: 03/16/2021] [Indexed: 11/17/2022] Open
Abstract
A high epilepsy prevalence has been reported in onchocerciasis meso- and hyper-endemic regions in sub-Saharan Africa, including in the Democratic Republic of Congo (DRC). We investigated whether onchocerciasis-associated epilepsy can also be suspected in onchocerciasis hypo-endemic regions. Stored serum samples from 342 patients admitted with recent onset neurological symptoms admitted to Mosango general hospital, in the Kwilu province, DRC, between 2012 and 2015 were screened for onchocerciasis (OV16) antibodies by ELISA and Taenia solium antigen (using an in-house B158/B60 antigen test). Eighty-one (23.7%; 95% CI 19.5-28.5%) of these samples were positive for OV16 antibodies and 43/340 (12.6%; 95% CI 9.5-16.6%) were positive for T. solium antigen. Of the 58 persons clinically diagnosed with late onset epilepsy of unknown etiology, 19 (32.8%) were OV16 positive and nine (16%) T. solium antigen positive. In total, 16 persons with epilepsy were OV16 positive and T. solium negative, of whom 12 (75%) were between the ages seven to 31 years old, an age rage in which onchocerciasis-associated epilepsy is observed. Our study suggests that in onchocerciasis hypo-endemic areas, in T. solium antigen negative persons with epilepsy, onchocerciasis should be considered as a potential trigger of epilepsy.
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Vieri MK, Hotterbeekx A, Raimon S, Abd-Elfarag G, Mukendi D, Carter JY, Kumar-Singh S, Colebunders R. Cytokines and Onchocerciasis-Associated Epilepsy, a Pilot Study and Review of the Literature. Pathogens 2021; 10:310. [PMID: 33799934 PMCID: PMC7998365 DOI: 10.3390/pathogens10030310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/04/2021] [Accepted: 03/05/2021] [Indexed: 12/03/2022] Open
Abstract
Neuro-inflammation may be associated with onchocerciasis-associated epilepsy (OAE) but thus far very few immunological studies have been performed in children with this form of epilepsy. In a pilot study we measured the cytokine levels in cerebrospinal fluid (CSF) of persons with OAE from Maridi, South Sudan, and from Mosango, Democratic Republic of the Congo (DRC) and compared these results with cytokine levels in CSF of Africans with non-OAE neurological disorders, and Europeans with epilepsy or other neurological conditions. The following cytokines were studied: IL-6, TNF-α, IL1-β, IL-5, IL-4, IL-13, CCL3 (Mip-1α), VEGF-C, VCAM-1. No cytokine was significantly associated with OAE, although a lower IL-13 level was observed in CSF of persons with OAE compared to African controls. Observed cytokine profiles and neuro-inflammation may be the consequence of long-standing epilepsy, concomitant infections and malnutrition. Ideally cytokine levels should be determined in a prospective study in serum and CSF collected at the time of onset of the first seizures.
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Affiliation(s)
| | - An Hotterbeekx
- Global Health Institute, University of Antwerp, 2610 Antwerp, Belgium;
- Molecular Pathology Group, Laboratory of Cell Biology & Histology, Faculty of Medical and Health Sciences, University of Antwerp, 20610 Antwerp, Belgium;
| | | | - Gasim Abd-Elfarag
- Academic Medical Center, Global Child Health Group, Department of Paediatrics and Department of Global Health, University of Amsterdam, 1105 Amsterdam, The Netherlands;
- Amsterdam Institute for Global Health and Development, 1105 Amsterdam, The Netherlands
| | - Deby Mukendi
- Institut National de Recherche Biomédicale, Av. De la Démocratie N°5345, Kinshasa 1197, Congo;
- Centre Neuro-Psycho Pathologique, Universite’ de Kinshasa, Kinshasa P.O. Box 127, Congo
| | - Jane Y. Carter
- Amref International Headquarters, Nairobi P.O. Box 27691−00506, Kenya;
| | - Samir Kumar-Singh
- Molecular Pathology Group, Laboratory of Cell Biology & Histology, Faculty of Medical and Health Sciences, University of Antwerp, 20610 Antwerp, Belgium;
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In pursuit of a cure: The plural therapeutic landscape of onchocerciasis-associated epilepsy in Cameroon - A mixed methods study. PLoS Negl Trop Dis 2021; 15:e0009206. [PMID: 33621233 PMCID: PMC7946181 DOI: 10.1371/journal.pntd.0009206] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 03/10/2021] [Accepted: 02/04/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND A high prevalence of epilepsy has been observed in several onchocerciasis-endemic villages in the Sanaga River basin, Cameroon. Recent studies suggest that ivermectin, a drug that is distributed annually with the aim of eliminating onchocerciasis, may have a protective effect against acquiring onchocerciasis-associated epilepsy (OAE). This study, therefore, provides an in-depth understanding of both the complex therapeutic landscape for epilepsy as well as the experiences related to the 'community-directed treatment with ivermectin' (CDTI) campaign in order to identify a more trenchant path forward in the fight against epilepsy. METHODOLOGY/PRINCIPAL FINDINGS Based on a mixed methods study combining a qualitative strand with a quantitative survey, we found that epilepsy was perceived to have had an epidemic emergence in the past and was still considered an important health issue in the study area. Socio-economic status, availability and accessibility of drugs and practitioners, as well as perceived aetiology shaped therapeutic itineraries for epilepsy, which included frequenting (in)formal biomedical health care providers, indigenous and/or faith healing practitioners. Ivermectin uptake for onchocerciasis was generally well known and well regarded. The CDTI faced structural and logistical bottlenecks undermining equal access and optimal adherence to the drug. CONCLUSIONS/SIGNIFICANCE Locally accessible, uninterrupted, sustainable and comprehensive health-service delivery is essential to help alleviate the epilepsy burden on afflicted households. Addressing structural challenges of CDTI and communicating the potential link with epilepsy to local populations at risk could optimize the uptake of this potentially significant tool in OAE prevention.
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Vieri MK, Hendy A, Mokili JL, Colebunders R. Nodding syndrome research revisited. Int J Infect Dis 2021; 104:739-741. [PMID: 33556614 DOI: 10.1016/j.ijid.2021.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 01/29/2021] [Accepted: 02/01/2021] [Indexed: 12/11/2022] Open
Abstract
Nodding syndrome is one of several forms of onchocerciasis-associated epilepsy (OAE) seen among children in areas formerly hyperendemic for the transmission of Onchocerca volvulus. These forms of epilepsy are highly prevalent and clustered in certain villages located close to blackfly (Diptera: Simuliidae) breeding sites. OAE presents with a wide spectrum of seizures, including generalized tonic-clonic and head nodding seizures, impaired cognitive function, growth stunting and delayed puberty. In 2014, the present authors published a perspective paper in this journal which hypothesized that nodding syndrome may be caused by either a neurotropic virus transmitted by blackflies or an endosymbiont present within the O. volvulus parasite. Seven years later, this critical review presents progress in nodding syndrome research, and assesses whether it is still plausible that a neurotropic virus or endosymbiont could be the cause.
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Affiliation(s)
- Melissa Krizia Vieri
- Department of Epidemiology and Social Medicine, University of Antwerp, Antwerp, Belgium; Molecular Pathology Group, Laboratory of Cell Biology and Histology, University of Antwerp, Antwerp, Belgium
| | - Adam Hendy
- Department of Pathology, University of Texas Medical Branch, Galveston, TX, USA
| | - John L Mokili
- Viral Information Institute, Department of Biology, San Diego State University San Diego, CA, USA
| | - Robert Colebunders
- Department of Epidemiology and Social Medicine, University of Antwerp, Antwerp, Belgium.
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23
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Shey RA, Ghogomu SM, Shintouo CM, Nkemngo FN, Nebangwa DN, Esoh K, Yaah NE, Manka’aFri M, Nguve JE, Ngwese RA, Njume FN, Bertha FA, Ayong L, Njemini R, Vanhamme L, Souopgui J. Computational Design and Preliminary Serological Analysis of a Novel Multi-Epitope Vaccine Candidate against Onchocerciasis and Related Filarial Diseases. Pathogens 2021; 10:99. [PMID: 33494344 PMCID: PMC7912539 DOI: 10.3390/pathogens10020099] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 01/14/2021] [Accepted: 01/18/2021] [Indexed: 11/16/2022] Open
Abstract
: Onchocerciasis is a skin and eye disease that exerts a heavy socio-economic burden, particularly in sub-Saharan Africa, a region which harbours greater than 96% of either infected or at-risk populations. The elimination plan for the disease is currently challenged by many factors including amongst others; the potential emergence of resistance to the main chemotherapeutic agent, ivermectin (IVM). Novel tools, including preventative and therapeutic vaccines, could provide additional impetus to the disease elimination tool portfolio. Several observations in both humans and animals have provided evidence for the development of both natural and artificial acquired immunity. In this study, immuno-informatics tools were applied to design a filarial-conserved multi-epitope subunit vaccine candidate, (designated Ov-DKR-2) consisting of B-and T-lymphocyte epitopes of eight immunogenic antigens previously assessed in pre-clinical studies. The high-percentage conservation of the selected proteins and epitopes predicted in related nematode parasitic species hints that the generated chimera may be instrumental for cross-protection. Bioinformatics analyses were employed for the prediction, refinement, and validation of the 3D structure of the Ov-DKR-2 chimera. In-silico immune simulation projected significantly high levels of IgG1, T-helper, T-cytotoxic cells, INF-γ, and IL-2 responses. Preliminary immunological analyses revealed that the multi-epitope vaccine candidate reacted with antibodies in sera from both onchocerciasis-infected individuals, endemic normals as well as loiasis-infected persons but not with the control sera from European individuals. These results support the premise for further characterisation of the engineered protein as a vaccine candidate for onchocerciasis.
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Affiliation(s)
- Robert Adamu Shey
- Department of Biochemistry and Molecular Biology, Faculty of Science, University of Buea, Buea 99999, Cameroon; (R.A.S.); (S.M.G.); (C.M.S.); (D.N.N.); (N.E.Y.); (M.M.); (J.E.N.); (R.A.N.); (F.N.N.)
- Department of Molecular Biology, Institute of Biology and Molecular Medicine, IBMM, Université Libre de Bruxelles, Gosselies Campus, 6040 Gosselies, Belgium;
| | - Stephen Mbigha Ghogomu
- Department of Biochemistry and Molecular Biology, Faculty of Science, University of Buea, Buea 99999, Cameroon; (R.A.S.); (S.M.G.); (C.M.S.); (D.N.N.); (N.E.Y.); (M.M.); (J.E.N.); (R.A.N.); (F.N.N.)
| | - Cabirou Mounchili Shintouo
- Department of Biochemistry and Molecular Biology, Faculty of Science, University of Buea, Buea 99999, Cameroon; (R.A.S.); (S.M.G.); (C.M.S.); (D.N.N.); (N.E.Y.); (M.M.); (J.E.N.); (R.A.N.); (F.N.N.)
- Frailty in Ageing Research Group, Vrije Universiteit Brussel, Laarbeeklaan 103, B-1090 Brussels, Belgium;
- Department of Gerontology, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Laarbeeklaan 103, B-1090 Brussels, Belgium
| | - Francis Nongley Nkemngo
- Department of Microbiology and Parasitology, Faculty of Science, University of Buea, Buea 99999, Cameroon;
- Centre for Research in Infectious Diseases (CRID), Department of Parasitology and Medical Entomology, Yaounde BP 13591, Cameroon
| | - Derrick Neba Nebangwa
- Department of Biochemistry and Molecular Biology, Faculty of Science, University of Buea, Buea 99999, Cameroon; (R.A.S.); (S.M.G.); (C.M.S.); (D.N.N.); (N.E.Y.); (M.M.); (J.E.N.); (R.A.N.); (F.N.N.)
| | - Kevin Esoh
- Division of Human Genetics, Health Sciences Campus, Department of Pathology, University of Cape Town, Anzio Rd, Observatory, Cape Town 7925, South Africa;
| | - Ntang Emmaculate Yaah
- Department of Biochemistry and Molecular Biology, Faculty of Science, University of Buea, Buea 99999, Cameroon; (R.A.S.); (S.M.G.); (C.M.S.); (D.N.N.); (N.E.Y.); (M.M.); (J.E.N.); (R.A.N.); (F.N.N.)
| | - Muyanui Manka’aFri
- Department of Biochemistry and Molecular Biology, Faculty of Science, University of Buea, Buea 99999, Cameroon; (R.A.S.); (S.M.G.); (C.M.S.); (D.N.N.); (N.E.Y.); (M.M.); (J.E.N.); (R.A.N.); (F.N.N.)
| | - Joel Ebai Nguve
- Department of Biochemistry and Molecular Biology, Faculty of Science, University of Buea, Buea 99999, Cameroon; (R.A.S.); (S.M.G.); (C.M.S.); (D.N.N.); (N.E.Y.); (M.M.); (J.E.N.); (R.A.N.); (F.N.N.)
| | - Roland Akwelle Ngwese
- Department of Biochemistry and Molecular Biology, Faculty of Science, University of Buea, Buea 99999, Cameroon; (R.A.S.); (S.M.G.); (C.M.S.); (D.N.N.); (N.E.Y.); (M.M.); (J.E.N.); (R.A.N.); (F.N.N.)
| | - Ferdinand Ngale Njume
- Department of Biochemistry and Molecular Biology, Faculty of Science, University of Buea, Buea 99999, Cameroon; (R.A.S.); (S.M.G.); (C.M.S.); (D.N.N.); (N.E.Y.); (M.M.); (J.E.N.); (R.A.N.); (F.N.N.)
- Department of Molecular Biology, Institute of Biology and Molecular Medicine, IBMM, Université Libre de Bruxelles, Gosselies Campus, 6040 Gosselies, Belgium;
| | - Fru Asa Bertha
- Department of Public Health and Hygiene, Faculty of Health Science, University of Buea, Buea 99999, Cameroon;
| | - Lawrence Ayong
- Malaria Research Unit, Centre Pasteur Cameroon, Yaoundé Rue 2005, Cameroon;
| | - Rose Njemini
- Frailty in Ageing Research Group, Vrije Universiteit Brussel, Laarbeeklaan 103, B-1090 Brussels, Belgium;
- Department of Gerontology, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Laarbeeklaan 103, B-1090 Brussels, Belgium
| | - Luc Vanhamme
- Department of Molecular Biology, Institute of Biology and Molecular Medicine, IBMM, Université Libre de Bruxelles, Gosselies Campus, 6040 Gosselies, Belgium;
| | - Jacob Souopgui
- Department of Molecular Biology, Institute of Biology and Molecular Medicine, IBMM, Université Libre de Bruxelles, Gosselies Campus, 6040 Gosselies, Belgium;
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Luna J, Metanmo S, Boumediene F, Mbelesso P, Auditeau E, Ajzenberg D, Preux PM. Onchocerciasis in tropical neurology: A scoping review. J Neurol Sci 2021; 421:117314. [PMID: 33493958 DOI: 10.1016/j.jns.2021.117314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 01/05/2021] [Accepted: 01/06/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Onchocerciasis is a serious problem in tropical areas. The role of the parasite as a factor associated with neurological diseases needs to be addressed because it might involve a reduction of the risk via elimination strategies. We performed a systematic scoping review to identify available studies on this association and put into perspective the different methodological approaches for interpreting the evidence. METHODOLOGY A literature search was conducted using MEDLINE (Pubmed) through October 1, 2020. We included all the studies evaluating the association between onchocerciasis and four neurological diseases (epilepsy, nodding syndrome, Nakalanga syndrome, and encephalitis) in tropical countries. A descriptive and critical summary of the results was conducted to provide an overview of the findings. RESULTS Overall, 161 articles were identified in the literature search. After full-length examination, we included twelve articles for epilepsy and three for nodding syndrome. Two meta-analyses of case-control studies found a modest strength of the association between O. volvulus and epilepsy. Recent meta-analyses and original studies support a significant association. Epidemiological studies suggest an association between onchocerciasis and nodding syndrome, however, the level of evidence from case-control studies was relatively low. No measure of association was reported for Nakalanga syndrome. There was no specific study on the association between O. volvulus and encephalitis. CONCLUSION The association between onchocerciasis and epilepsy seems increasingly likely. However, there are still many unanswered questions about the different clinical presentations of this epilepsy. Strong international collaboration is essential to improve our understanding of risk factors and physiopathological mechanisms of these intriguing conditions.
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Affiliation(s)
- Jaime Luna
- INSERM, Univ. Limoges, CHU Limoges, IRD, U1094 Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, GEIST, Limoges, France
| | - Salvatore Metanmo
- INSERM, Univ. Limoges, CHU Limoges, IRD, U1094 Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, GEIST, Limoges, France
| | - Farid Boumediene
- INSERM, Univ. Limoges, CHU Limoges, IRD, U1094 Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, GEIST, Limoges, France
| | - Pascal Mbelesso
- Department of Neurology, Amitié Hospital, Bangui, Central African Republic
| | - Emilie Auditeau
- INSERM, Univ. Limoges, CHU Limoges, IRD, U1094 Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, GEIST, Limoges, France
| | - Daniel Ajzenberg
- INSERM, Univ. Limoges, CHU Limoges, IRD, U1094 Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, GEIST, Limoges, France
| | - Pierre-Marie Preux
- INSERM, Univ. Limoges, CHU Limoges, IRD, U1094 Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, GEIST, Limoges, France.
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Colebunders R, Njamnshi AK, Menon S, Newton CR, Hotterbeekx A, Preux PM, Hopkins A, Vaillant M, Siewe Fodjo JN. Onchocerca volvulus and epilepsy: A comprehensive review using the Bradford Hill criteria for causation. PLoS Negl Trop Dis 2021; 15:e0008965. [PMID: 33411705 PMCID: PMC7790236 DOI: 10.1371/journal.pntd.0008965] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The possibility that onchocerciasis may cause epilepsy has been suggested for a long time, but thus far, an etiological link has not been universally accepted. The objective of this review is to critically appraise the relationship between Onchocerca volvulus and epilepsy and subsequently apply the Bradford Hill criteria to further evaluate the likelihood of a causal association. METHODS PubMed and gray literature published until September 15, 2020, were searched and findings from original research were synthesized. Adherence to the 9 Bradford Hill criteria in the context of onchocerciasis and epilepsy was determined to assess whether the criteria are met to strengthen the evidence base for a causal link between infection with O. volvulus and epilepsy, including the nodding syndrome. RESULTS Onchocerciasis as a risk factor for epilepsy meets the following Bradford Hill criteria for causality: strength of the association, consistency, temporality, and biological gradient. There is weaker evidence supporting causality based on the specificity, plausibility, coherence, and analogy criteria. There is little experimental evidence. Considering the Bradford Hill criteria, available data suggest that under certain conditions (high microfilarial load, timing of infection, and perhaps genetic predisposition), onchocerciasis is likely to cause epilepsy including nodding and Nakalanga syndromes. CONCLUSION Applying the Bradford Hill criteria suggests consistent epidemiological evidence that O. volvulus infection is a trigger of epilepsy. However, the pathophysiological mechanisms responsible for seizure induction still need to be elucidated.
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Affiliation(s)
- Robert Colebunders
- Global Health Institute, University of Antwerp, Antwerp, Belgium
- * E-mail:
| | - Alfred K. Njamnshi
- Neurology Department, Yaoundé Central Hospital, Yaoundé, Cameroon
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé Cameroon
- Brain Research Africa Initiative (BRAIN), Yaoundé, Cameroon
| | - Sonia Menon
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - Charles R. Newton
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom
| | - An Hotterbeekx
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - Pierre-Marie Preux
- Institute of Epidemiology and Tropical Neurology, INSERM UMR1094, University of Limoges, Limoges, France
| | - Adrian Hopkins
- Neglected and Disabling Diseases of Poverty Consultant, Kent, United Kingdom
| | - Michel Vaillant
- Competence Center in Methodology and Statistics, Luxembourg Institute of Health, Strassen, Luxembourg
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26
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Dusabimana A, Tsebeni Wafula S, Raimon SJ, Fodjo JNS, Bhwana D, Tepage F, Abd-Elfarag G, Hotterbeekx A, Abrams S, Colebunders R. Effect of Ivermectin Treatment on the Frequency of Seizures in Persons with Epilepsy Infected with Onchocerca volvulus. Pathogens 2020; 10:pathogens10010021. [PMID: 33396221 PMCID: PMC7824398 DOI: 10.3390/pathogens10010021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/24/2020] [Accepted: 12/28/2020] [Indexed: 11/16/2022] Open
Abstract
A clinical trial performed in the Democratic Republic of Congo (DRC), among persons with epilepsy (PWE) infected with Onchocerca volvulus treated with anti-seizure medication suggested that ivermectin reduces the seizure frequency. We assessed the effect of ivermectin treatment on seizure frequency in PWE with and without anti-seizure medication in three onchocerciasis endemic areas (Maridi, South Sudan; Aketi, DRC; and Mahenge, Tanzania). Pre- and 3–5 months post-ivermectin microfilariae densities in skin snips and seizure frequency were assessed. After ivermectin, the median (IQR) percentage reduction in seizure frequency in the study sites ranged from 73.4% (26.0–90.0) to 100% (50.0–100.0). A negative binomial mixed model showed that ivermectin significantly reduced the seizure frequency, with a larger decrease in PWE with a high baseline seizure frequency. Mediation analysis showed that ivermectin reduced the seizure frequencies indirectly through reduction in microfilariae densities but also that ivermectin may have a direct anti-seizure effect. However, given the short half-life of ivermectin and the fact that ivermectin does not penetrate the healthy brain, such a direct anti-seizure effect is unlikely. A randomized controlled trial assessing the ivermectin effect in people infected with O. volvulus who are also PWE on a stable anti-seizure regimen may be needed to clarify the causal relationship between ivermectin and seizure frequency.
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Affiliation(s)
- Alfred Dusabimana
- Global Health Institute, University of Antwerp, Doornstraat 331, 2610 Antwerp, Belgium; (S.T.W.); (J.N.S.F.); (A.H.); (S.A.)
- Correspondence: (A.D.); (R.C.); Tel.: +32-486-920-149 (R.C.)
| | - Solomon Tsebeni Wafula
- Global Health Institute, University of Antwerp, Doornstraat 331, 2610 Antwerp, Belgium; (S.T.W.); (J.N.S.F.); (A.H.); (S.A.)
- Department of Disease Control and Environmental Health, Makerere University, Kampala P.O. Box 7072, Uganda
| | | | - Joseph Nelson Siewe Fodjo
- Global Health Institute, University of Antwerp, Doornstraat 331, 2610 Antwerp, Belgium; (S.T.W.); (J.N.S.F.); (A.H.); (S.A.)
| | - Dan Bhwana
- National Institute of Medical Research, Tanga Centre, Tanga P.O. Box 5004, Tanzania;
| | - Floribert Tepage
- Ministry of Health, Bas Uélé Province, Buta B.P. 105, Democratic Republic of Congo;
| | - Gasim Abd-Elfarag
- Amsterdam Institute for Global Health and Development, Paasheuvelweg 25, 1105 BP Amsterdam, The Netherlands;
| | - An Hotterbeekx
- Global Health Institute, University of Antwerp, Doornstraat 331, 2610 Antwerp, Belgium; (S.T.W.); (J.N.S.F.); (A.H.); (S.A.)
| | - Steven Abrams
- Global Health Institute, University of Antwerp, Doornstraat 331, 2610 Antwerp, Belgium; (S.T.W.); (J.N.S.F.); (A.H.); (S.A.)
- Data Science Institute, Interuniversity Institute for Biostatistics and Statistical Bioinformatics, Hasselt University, 3590 Diepenbeek, Belgium
| | - Robert Colebunders
- Global Health Institute, University of Antwerp, Doornstraat 331, 2610 Antwerp, Belgium; (S.T.W.); (J.N.S.F.); (A.H.); (S.A.)
- Correspondence: (A.D.); (R.C.); Tel.: +32-486-920-149 (R.C.)
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27
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Dusabimana A, Bhwana D, Raimon S, Mmbando BP, Hotterbeekx A, Tepage F, Mandro M, Siewe Fodjo JN, Abrams S, Colebunders R. Ivermectin Treatment Response in Onchocerca Volvulus Infected Persons with Epilepsy: A Three-Country Short Cohort Study. Pathogens 2020; 9:pathogens9080617. [PMID: 32751060 PMCID: PMC7460326 DOI: 10.3390/pathogens9080617] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/24/2020] [Accepted: 07/27/2020] [Indexed: 11/16/2022] Open
Abstract
Despite a long history of community-directed treatment with ivermectin (CDTI), a high ongoing Onchocerca volvulus transmission is observed in certain onchocerciasis-endemic regions in Africa with a high prevalence of epilepsy. We investigated factors associated with higher microfilarial (mf) density after ivermectin treatment. Skin snips were obtained from O. volvulus-infected persons with epilepsy before, and 3 to 5 months after ivermectin treatment. Participants were enrolled from 4 study sites: Maridi (South Sudan); Logo and Aketi (Democratic Republic of Congo); and Mahenge (Tanzania). Of the 329 participants, 105 (31.9%) had a post-treatment mf density >20% of the pre-treatment value. The percentage reduction in the geometric mean mf density ranged from 69.0% (5 months after treatment) to 89.4% (3 months after treatment). A higher pre-treatment mf density was associated with increased probability of a positive skin snip after ivermectin treatment (p = 0.016). For participants with persistent microfiladermia during follow-up, a higher number of previous CDTI rounds increased the odds of having a post-treatment mf density >20% of the pre-treatment value (p = 0.006). In conclusion, the high onchocerciasis transmission in the study sites may be due to initially high infection intensity in some individuals. Whether the decreasing effect of ivermectin with increasing years of CDTI results from sub-optimal response mechanisms warrants further research.
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Affiliation(s)
- Alfred Dusabimana
- Global Health Institute, University of Antwerp, Doornstraat 331, 2610 Antwerp, Belgium; (A.D.); (A.H.); (J.N.S.F.); (S.A.)
| | - Dan Bhwana
- National Institute Medical Research, Tanga Centre, P.O. Box 5004 Tanga, Tanzania; (D.B.); (B.P.M.)
| | | | - Bruno P. Mmbando
- National Institute Medical Research, Tanga Centre, P.O. Box 5004 Tanga, Tanzania; (D.B.); (B.P.M.)
| | - An Hotterbeekx
- Global Health Institute, University of Antwerp, Doornstraat 331, 2610 Antwerp, Belgium; (A.D.); (A.H.); (J.N.S.F.); (S.A.)
| | - Floribert Tepage
- Ministry of Health, Bas Uélé province, B.P. 105 Buta, Democratic Republic of Congo;
| | - Michel Mandro
- Provincial Health Division Ituri, Ministry of Health, Bunia, P.O. Box 57 Ituri, Democratic Republic of Congo;
| | - Joseph N. Siewe Fodjo
- Global Health Institute, University of Antwerp, Doornstraat 331, 2610 Antwerp, Belgium; (A.D.); (A.H.); (J.N.S.F.); (S.A.)
| | - Steven Abrams
- Global Health Institute, University of Antwerp, Doornstraat 331, 2610 Antwerp, Belgium; (A.D.); (A.H.); (J.N.S.F.); (S.A.)
- Interuniversity Institute for Biostatistics and statistical Bioinformatics, Data Science Institute, Hasselt University, 3590 Diepenbeek, Belgium
| | - Robert Colebunders
- Global Health Institute, University of Antwerp, Doornstraat 331, 2610 Antwerp, Belgium; (A.D.); (A.H.); (J.N.S.F.); (S.A.)
- Robert Colebunders, Global Health Institute, Gouverneur Kinsbergencentrum, University of Antwerp, Doornstraat 331, 2610 Wilrijk, Belgium
- Correspondence: ; Tel.: +32-486920149
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28
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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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29
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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: 16] [Impact Index Per Article: 4.0] [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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30
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Siewe Fodjo JN, Mubiru F, Ukaga C, Logora MY, Mmbando BP, Mandro M, Njamnshi AK, Colebunders R. Low ivermectin use among 5- to 6-year-old children: observations from door-to-door surveys in onchocerciasis-endemic regions in Africa. Int Health 2020; 12:72-75. [PMID: 31251354 PMCID: PMC6964214 DOI: 10.1093/inthealth/ihz044] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/02/2019] [Accepted: 06/06/2019] [Indexed: 12/03/2022] Open
Abstract
During door-to-door surveys in onchocerciasis-endemic regions in Africa, the age-specific ivermectin coverage in 29 722 individuals was assessed. Children 5–6 y of age had significantly lower coverage compared with older participants. Insufficient ivermectin intake among young children could prolong onchocerciasis elimination prospects, as they may serve as human reservoirs of Onchocerca volvulus; moreover, it increases the risk of developing onchocerciasis-associated epilepsy (OAE). The causes of the low ivermectin coverage observed among children 5–6 y of age need to be explored. Integrating ivermectin distribution into chemoprophylaxis strategies for other neglected diseases could increase coverage in a cost-effective manner.
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Affiliation(s)
- J N Siewe Fodjo
- Global Health Institute, University of Antwerp, Doornstraat 331, 2610 Wilrijk, Antwerp, Belgium
| | - F Mubiru
- Infectious Disease Institute, Makerere University, P.O. Box 22418, Kampala, Uganda
| | - C Ukaga
- Imo State University, PMB 2000, Okigwe Rd, Ugwu Orji, Owerri, Nigeria
| | - M Y Logora
- Neglected Tropical Diseases Unit, Ministry of Health, Ministry of Health Ministerial Complex, P.O. Box 88, Juba, South Sudan
| | - B P Mmbando
- National Institute for Medical Research, Tanga Center, P.O. Box 5004, Tanga, Tanzania
| | - M Mandro
- Provincial Health Division Ituri, Ministry of Health, P.O. Box 185, Bunia, Democratic Republic of Congo
| | - A K Njamnshi
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Cameroon & Brain Research Africa Initiative (BRAIN), P. O. Box 87, Yaounde, Cameroon
| | - R Colebunders
- Global Health Institute, University of Antwerp, Doornstraat 331, 2610 Wilrijk, Antwerp, Belgium
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Single versus Multiple Dose Ivermectin Regimen in Onchocerciasis-Infected Persons with Epilepsy Treated with Phenobarbital: A Randomized Clinical Trial in the Democratic Republic of Congo. Pathogens 2020; 9:pathogens9030205. [PMID: 32164367 PMCID: PMC7157533 DOI: 10.3390/pathogens9030205] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 02/25/2020] [Accepted: 03/07/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND There is anecdotal evidence that ivermectin may decrease seizure frequency in Onchocerca volvulus-infected persons with epilepsy (PWE). METHODS In October 2017, a 12-month clinical trial was initiated in rural Democratic Republic of Congo. PWE with onchocerciasis-associated epilepsy experiencing ≥2 seizures/month were randomly allocated to receive, over a one-year period, ivermectin once or thrice (group 1), while other onchocerciasis-infected PWE (OIPWE) were randomized to ivermectin twice or thrice (group 2). All participants also received anti-epileptic drugs. Data was analyzed using multiple logistic regression. RESULTS We enrolled 197 participants. In an intent-to-treat analysis (data from group 1 and 2 combined), seizure freedom was more likely among OIPWE treated with ivermectin thrice (OR: 5.087, 95% CI: 1.378-19.749; p = 0.018) and twice (OR: 2.471, 95% CI: 0.944-6.769; p = 0.075) than in those treated once. Similarly, >50% seizure reduction was more likely among those treated with ivermectin twice (OR: 4.469, 95% CI: 1.250-16.620) and thrice (OR: 2.693, 95% CI: 1.077-6.998). Absence of microfilariae during the last 4 months increased the odds of seizure freedom (p = 0.027). CONCLUSIONS Increasing the number of ivermectin treatments was found to suppress both microfilarial density and seizure frequency in OIPWE, suggesting that O. volvulus infection plays an etiological role in causing seizures.
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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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Colebunders R, Stolk WA, Siewe Fodjo JN, Mackenzie CD, Hopkins A. Elimination of onchocerciasis in Africa by 2025: an ambitious target requires ambitious interventions. Infect Dis Poverty 2019; 8:83. [PMID: 31578157 PMCID: PMC6775645 DOI: 10.1186/s40249-019-0593-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 09/04/2019] [Indexed: 11/10/2022] Open
Abstract
To achieve the elimination of onchocerciasis transmission in all African countries will entail enormous challenges, as has been highlighted by the active discussion around onchocerciasis intervention strategies and evaluation procedures in this journal.Serological thresholds for onchocerciasis elimination, adapted for the African setting, need to be established. The Onchocerciasis Technical Advisory Subgroup of the World Health Organization is currently developing improved guidelines to allow country elimination committees to make evidence-based decisions. Importantly, onchocerciasis-related morbidity should not be forgotten when debating elimination prospects. A morbidity management and disease prevention (MMDP) strategy similar to that for lymphatic filariasis will need to be developed. This will require collaboration between the onchocerciasis elimination program, the community and other partners including primary health and mental health programs.In order to reach the goal of onchocerciasis elimination in most African countries by 2025, we should prioritize community participation and advocate for tailored interventions which are scientifically proven to be effective, but currently considered to be too expensive.
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Affiliation(s)
| | - Wilma A Stolk
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | | | - Adrian Hopkins
- Neglected and Disabling Diseases of Poverty Consultant, Gravesend, Kent, UK
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Colebunders R, Kugler M, Fodjo JNS. Analysis of the RIMDAMAL trial. Lancet 2019; 394:1006. [PMID: 31544741 DOI: 10.1016/s0140-6736(19)31814-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 06/26/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Robert Colebunders
- Global Health Institute, University of Antwerp, Doornstraat 331, 2610 Antwerp, Belgium.
| | - Marina Kugler
- Global Health Institute, University of Antwerp, Doornstraat 331, 2610 Antwerp, Belgium
| | - Joseph N Siewe Fodjo
- Global Health Institute, University of Antwerp, Doornstraat 331, 2610 Antwerp, Belgium
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Schwartz RA, Al-Qubati Y, Zieleniewski Ł, Shah R, Kapila R. Onchocerciasis (river blindness): larva-induced eczema (onchodermatitis) from an important oculocutaneous tropical disease spilling over into North America and Europe. Int J Dermatol 2019; 59:1065-1070. [PMID: 31513297 DOI: 10.1111/ijd.14614] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 08/05/2019] [Accepted: 08/09/2019] [Indexed: 11/28/2022]
Abstract
Onchocerciasis is a leading cause of blindness in the world. It may be seen in temperate climates of the United States and Europe in immigrants and travelers from endemic regions, often linked to poverty and war. One should be aware of an incubation period that can be up to 15 months. In its early stage and throughout its course, onchocerciasis has noteworthy skin findings, facilitating diagnosis, as onchodermatitis resembles common eczema with variable degrees of papular, lichenoid, atrophic, and pigmentary alterations, features not suggestive if one is unaware of an individual's immigration and travel history. The same concept applies for the encysted worms (onchocercomas), as they tend to appear as common skin cysts and benign neoplasms. New methods can be employed to increase diagnostic sensitivity and specificity. Ivermectin is the gold standard of therapy, the use of which has almost miraculously eliminated this disease from large areas of the earth. However, its effect remains isolated to microfilariae and can be devastating in those coinfected with Loa loa. Recently, the symbiotic relationship between adult worms and Wolbachia bacteria has been discovered and, with it, the possibility of adding doxycycline as a treatment option. We also discuss coinfection with HIV and other diseases.
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Affiliation(s)
- Robert A Schwartz
- Professor & Head, Dermatology, Rutgers New Jersey Medical School, Newark, NJ, USA
| | | | - Łukasz Zieleniewski
- Nicolaus Copernicus University Ludwig Rydygier Medical College, Bydgoszcz, Poland
| | - Radhika Shah
- Professor & Head, Dermatology, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Rajendra Kapila
- Professor & Head, Dermatology, Rutgers New Jersey Medical School, Newark, NJ, USA
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Makenga Bof JC, Mansiangi P, Nsangi H, Mafuta É, Aujoulat I, Coppieters Y. Community Participation in and Perception of Community-Directed Treatment with Ivermectin in Kinshasa, DRC. Trop Med Infect Dis 2019; 4:E109. [PMID: 31330958 PMCID: PMC6789872 DOI: 10.3390/tropicalmed4030109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 07/09/2019] [Accepted: 07/13/2019] [Indexed: 02/02/2023] Open
Abstract
The success of community-directed treatment with Ivermectin (CDTI) depends on active community participation. We conducted a case study nested in a cross-sectional study in the Binza Ozone Health Zone (ZS) in Kinshasa, Democratic Republic of Congo, in order to investigate community's knowledges and perceptions of onchocerciasis and on all CDTI's aspects. We interviewed 106 people aged 20 and over, purposively selected, through eight individual interviews and 12 focus groups. Themes used for collecting data were drawn for the Health Belief Model and data were analyzed using a deductive thematic approach. The term onchocerciasis was unknown to participants who called it "Mbitiri", the little black fly, in their local language. This disease is seen as curse put on the sufferer by a witch and perceived as a threat because of the "Mbitiri" bites. The afflicted participants were reluctant to seek treatment and preferred traditional practitioners or healers. CDTI is considered devastating because of adverse effects of ivermectin as well as inefficient after occurrence of deaths. This explains the low level of community adhesion and participation to this strategy. Recruitment procedures for community distributors are poorly understood and awareness and health education campaigns are either non-existent or rarely carried out. Nevertheless, the latter should be regularly done.
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Affiliation(s)
- Jean-Claude Makenga Bof
- School of Public Health, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070 Brussels, Belgium.
| | - Paul Mansiangi
- School of Public Health, Faculty of Medicine, Université de Kinshasa (UNIKIN), Avenue de l'Université, Lemba, Kinshasa, Democratic Republic of the Congo
| | - Horlyne Nsangi
- School of Public Health, Faculty of Medicine, Université de Kinshasa (UNIKIN), Avenue de l'Université, Lemba, Kinshasa, Democratic Republic of the Congo
| | - Éric Mafuta
- School of Public Health, Faculty of Medicine, Université de Kinshasa (UNIKIN), Avenue de l'Université, Lemba, Kinshasa, Democratic Republic of the Congo
| | - Isabelle Aujoulat
- Faculty of Public Health, Université Catholique de Louvain (UCL), Clos Chapelle-aux-Champs 30, 1200 Woluwe-Saint-Lambert, Brussels, Belgium
| | - Yves Coppieters
- School of Public Health, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070 Brussels, Belgium
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Siewe Fodjo JN, Mandro M, Mukendi D, Tepage F, Menon S, Nakato S, Nyisi F, Abhafule G, Wonya’rossi D, Anyolito A, Lokonda R, Hotterbeekx A, Colebunders R. Onchocerciasis-associated epilepsy in the Democratic Republic of Congo: Clinical description and relationship with microfilarial density. PLoS Negl Trop Dis 2019; 13:e0007300. [PMID: 31314757 PMCID: PMC6663032 DOI: 10.1371/journal.pntd.0007300] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 07/29/2019] [Accepted: 06/13/2019] [Indexed: 11/21/2022] Open
Abstract
Background High epilepsy prevalence and incidence were observed in onchocerciasis-endemic villages in the Democratic Republic of Congo (DRC). We investigated the clinical characteristics of onchocerciasis-associated epilepsy (OAE), and the relationship between seizure severity and microfilarial density. Methods In October 2017, ivermectin-naive persons with epilepsy (PWE) were recruited from onchocerciasis-endemic areas in the Logo health zone in the DRC. Additional PWE were enrolled in the Aketi health zone, where ivermectin had been distributed annually for 14 years. Past medical history, clinical characteristics and skin snips for Onchocerca volvulus detection were obtained from participants. Bivariate and multivariable analyses were used to investigate associations with microfilarial density. Results Of the 420 PWE in the Logo health zone, 392 were skin snipped (36.5% positive). Generalized motor seizures were most frequent (392 PWE, 93.3%), and nodding seizures were reported in 32 (7.6%) participants. Twelve PWE (3.1%) presented Nakalanga features. Sixty-three (44.1%) skin snip-positive PWE had a family history of epilepsy, compared to only 82 (32.9%) skin snip-negative PWE (p = 0.027). Eighty-one onchocerciasis-infected PWE were recruited in the Aketi health zone. Positive correlations between seizure frequency and microfilarial density were observed in Logo (Spearman-rho = 0.175; p<0.001) and Aketi (Spearman-rho = 0.249; p = 0.029). In the multivariable model adjusted for age, gender, and previous treatment, high seizure frequency was associated with increasing microfilarial density in Aketi (p = 0.025) but not in Logo (p = 0.148). Conclusion In onchocerciasis-endemic regions in the DRC, a wide spectrum of seizures was observed. The occurrence of Nodding seizures and Nakalanga features, as well as an association between seizure severity and O. volvulus microfilarial density suggest a high OAE prevalence in the study villages. Trial registration ClinicalTrials.gov NCT03052998. Several epidemiological surveys suggest that onchocerciasis (a disease resulting from an infection with the parasite Onchocerca volvulus) is a cause of epilepsy. We conducted a study to describe the clinical characteristics of persons with epilepsy (PWE) living in onchocerciasis-endemic villages in the Democratic Republic of Congo. In some study sites, the frequency of seizures increased with increasing number of O. volvulus microfilariae detected in the skin snips of participants. A wide spectrum of seizures was observed, including generalized tonic-clonic seizures, absence seizures, and focal seizures. Growth retardation and household clustering of PWE were common. Specific clinical presentations such as nodding seizures and Nakalanga features were encountered. These results suggest a high prevalence of onchocerciasis-associated epilepsy (OAE) in the study villages.
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Affiliation(s)
| | - Michel Mandro
- Ministry of Health, Ituri, Democratic Republic of Congo
| | - Deby Mukendi
- Mont Amba Neuropsychopathologic Center, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | | | - Sonia Menon
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - Swabra Nakato
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - Françoise Nyisi
- Centre de Recherche en Maladies Tropicales de l'Ituri, Rethy, Democratic Republic of Congo
| | - Germain Abhafule
- Centre de Recherche en Maladies Tropicales de l'Ituri, Rethy, Democratic Republic of Congo
| | | | - Aimé Anyolito
- Hôpital Général de Référence de Logo, Ituri, Democratic Republic of Congo
| | - Richard Lokonda
- Mont Amba Neuropsychopathologic Center, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - An Hotterbeekx
- Global Health Institute, University of Antwerp, Antwerp, Belgium
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O’Neill S, Irani J, Siewe Fodjo JN, Nono D, Abbo C, Sato Y, Mugarura A, Dolo H, Ronse M, Njamnshi AK, Colebunders R. Stigma and epilepsy in onchocerciasis-endemic regions in Africa: a review and recommendations from the onchocerciasis-associated epilepsy working group. Infect Dis Poverty 2019; 8:34. [PMID: 31109376 PMCID: PMC6526597 DOI: 10.1186/s40249-019-0544-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 04/21/2019] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND In onchocerciasis-endemic areas, particularly in those with a sub-optimal onchocerciasis control programme, a high prevalence of epilepsy is observed. Both onchocerciasis and epilepsy are stigmatizing conditions. The first international workshop on onchocerciasis-associated epilepsy (OAE) was held in Antwerp, Belgium (12-14 October 2017) and during this meeting, an OAE alliance was established. In this paper, we review what is known about epilepsy-associated stigma in onchocerciasis-endemic regions, and present the recommendations of the OAE alliance working group on stigma. MAIN BODY For this scoping review, literature searches were performed on the electronic databases PubMed, Scopus and Science Direct using the search terms "epilepsy AND onchocerciasis AND stigma". Hand searches were also undertaken using Google Scholar, and in total seven papers were identified that addressed epilepsy-related stigma in an onchocercisasis-endemic area. Due to the limited number of published research papers on epilepsy-associated stigma in onchocerciasis-endemic areas, other relevant literature that describes important aspects related to stigma is discussed. The thematic presentation of this scoping review follows key insights on the barriers to alleviating the social consequences of stigma in highly affected onchocerciasis-endemic areas, which were established by experts during the working group on stigma and discrimination at the first international workshop on OAE. These themes are: knowledge gaps, perceived disease aetiology, access to education, marriage restrictions, psycho-social well-being, burden on the care-giver and treatment seeking behaviour. Based on the literature and expert discussions during the OAE working group on stigma, this paper describes important issues regarding epilepsy-related stigma in onchocerciasis-endemic regions and recommends interventions that are needed to reduce stigma and discrimination for the improvement of the psycho-social well-being of persons with epilepsy. CONCLUSIONS Educating healthcare workers and communities about OAE, strengthening onchocerciasis elimination programs, decreasing the anti-epileptic treatment gap, improving the care of epilepsy-related injuries, and prioritising epilepsy research is the way forward to decreasing the stigma associated with epilepsy in onchocerciasis-endemic regions.
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Affiliation(s)
- Sarah O’Neill
- CRISS – School of Public Health, Université Libre de Bruxelles and LAMC Faculté de Philosophie et de Sciences Sociales Université Libre de Bruxelles, Brussels, Belgium
| | - Julia Irani
- Department of Public health, Institute of Tropical Medicine, Antwerp, Belgium
| | | | - Denis Nono
- Department of Mental Health, Austrian Partnership Programme in Higher Education and Research for Development (APPEAR) Project & AVSI Foundation, Gulu University, Gulu, Uganda
| | - Catherine Abbo
- Department of Psychiatry, Makerere University, Kampala, Uganda
| | - Yasuaki Sato
- Department of Environmental Science and Technology, Osaka Sangyo University, Osaka, Japan
| | | | - Housseini Dolo
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - Maya Ronse
- Department of Public health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Alfred K. Njamnshi
- Department of Neurology, Yaoundé Central Hospital/FMBS, The University of Yaoundé I, Brain Research Africa Initiative (BRAIN), Yaoundé, Cameroon
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Siewe Fodjo J, Tepage F, Colebunders R. Epidemiological evidence concerning the association between onchocerciasis and epilepsy. Int J Infect Dis 2019; 82:77-78. [DOI: 10.1016/j.ijid.2019.03.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 03/11/2019] [Indexed: 11/29/2022] Open
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Abbo C, Mwaka AD, Opar BT, Idro R. Qualitative evaluation of the outcomes of care and treatment for children and adolescents with nodding syndrome and other epilepsies in Uganda. Infect Dis Poverty 2019; 8:30. [PMID: 31036087 PMCID: PMC6489326 DOI: 10.1186/s40249-019-0540-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 04/09/2019] [Indexed: 11/10/2022] Open
Abstract
Background In 2012, the Ugandan Government declared an epidemic of Nodding Syndrome (NS) in the Northern districts of Gulu, Kitgum, Lamwo and Pader. Treatment guidelines were developed and NS treatment centres were established to provide symptomatic control and rehabilitation. However, a wide gap remained between the pre-defined care standards and the quality of routine care provided to those affected. This study is to qualitatively assess adherence to accepted clinical care standards for NS; identify gaps in the care of affected children and offer Clinical Support Supervision (CSS) to Primary Health Care (PHC) staff at the treatment centres; and identify psychosocial challenges faced by affected children and their caregivers. Methods This case study was carried out in the districts of Gulu, Kitgum, Lamwo and Pader in Uganda from September to December in 2015. Employing the 5-stage approach of Clinical Audit, data were collected through direct observations and interviews with PHC providers working in public and private-not-for-profit health facilities, as well as with caregivers and political leaders. The qualitative data was analysed using Seidel model of data processing. Results Clinical Audit and CSS revealed poor adherence to treatment guidelines. Many affected children had sub-optimal NS management resulting in poor seizure control and complications including severe burns. Root causes of these outcomes were frequent antiepileptic drugs stock outs, migration of health workers from their work stations and psychosocial issues. There was hardly any specialized multidisciplinary team (MDT) to provide for the complex rehabilitation needs of the patients and a task shifting model with inadequate support supervision was employed, leading to loss of skills learnt. Reported psychosocial and psychosexual issues associated with NS included early pregnancies, public display of sexual behaviours and child abuse. Conclusions Despite involvement of relevant MDT members in the development of multidisciplinary NS guidelines, multidisciplinary care was not implemented in practice. There is urgent need to review the NS clinical guidelines. Quarterly CSS and consistent anticonvulsant medication are needed at health facilities in affected communities. Implementation of the existing policies and programs to deal with the psychosocial and psychosexual issues that affect children with NS and other chronic conditions is needed. Electronic supplementary material The online version of this article (10.1186/s40249-019-0540-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Catherine Abbo
- Department of Psychiatry, School of Medicine 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
| | | | - Richard Idro
- Department of Paediatrics, School of Medicine College of Health Sciences, Makerere University, Kampala, Uganda
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Nodding syndrome research, lessons learned from the NSETHIO project. Glob Ment Health (Camb) 2019; 6:e26. [PMID: 31807310 PMCID: PMC6880249 DOI: 10.1017/gmh.2019.24] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 09/04/2019] [Accepted: 09/19/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Until recently, nodding syndrome (NS) was considered as a mysterious disease of unknown etiology. A link between onchocerciasis and epilepsy was suspected for a long time. However, onchocerciasis was not considered as the cause of NS because NS was believed to occur only in onchocerciasis-endemic regions in Uganda, South Sudan, and Tanzania. In October 2015, with funding from the European Research Council, the NSETHIO group launched a trans-disciplinary, multi-country research project to identify the cause of NS and to study the link between onchocerciasis and epilepsy. METHODS We reviewed NSETHIO activities as well as all published papers, and compared project findings with results of previous research on NS. RESULTS Findings from the NSETHIO project showed that NS is only one of the clinical manifestations in the wide spectrum of onchocerciasis-associated epilepsy (OAE) that could be prevented by strengthening onchocerciasis elimination programs. NSETHIO demonstrated that OAE is an important neglected public health problem in onchocerciasis-endemic areas with no or a sub-optimally functioning onchocerciasis control strategies. CONCLUSIONS Today there is overwhelming evidence that NS together with the Nakalanga syndrome is clinical presentations of OAE, a condition that could be prevented by strengthening onchocerciasis elimination programs. While research needs to continue to elucidate the pathophysiological mechanisms causing NS, new strategies to accelerate onchocerciasis elimination coupled with community-based surveillance and treatment programs for epilepsy are urgently needed in areas of high Onchocerca volvulus transmission.
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