Resurgence of sleeping sickness in Tambura County, Sudan

Influence of Pastoralists' Sociocultural Activities on Tsetse-Trypanosome-Cattle Reservoir Interface: The Risk of Human African Trypanosomiasis in North-Central Nigeria

The study investigated socio-cultural characteristics of pastoralists that influenced on the tsetse-trypanosome-cattle reservoir interface thereby predisposing them to HAT in Niger State, North-central Nigeria. It was a cross-sectional survey of adult pastoral herders, aged 30 years and above, and conducted between October 2012 and February 2013. A face-to-face structured questionnaire was administered on the pastoralists nested in 96 cattle herds with questions focused on pastoralists' socio-cultural activities and behavioral practices related to HAT risk. Descriptive and analytic statistics were used to describe the obtained data. A total of 384 pastoralists participated, with mean age of 49.6  ± 10.76 SD years. Male respondents constituted 86.7% of gender, while pastoralists of age group 40-49 years constituted 35.4% of respondents. About 59.4% of the pastoralists had knowledge about HAT and its symptoms and only 33.9% of them believed that cattle served as reservoir of HAT trypanosome. Knowledge/belief levels of the pastoralists about African trypanosomiasis occurrence in humans and animals were statistically significant. Males were four times more likely to be exposed to HAT (OR = 3.67; 95% CI: 1.42, 9.52); age group 60-69 was also four times more likely to be exposed (OR = 3.59; 95% CI: 1.56, 8.28); and nomadic pastoralists were two times more likely to be exposed to HAT (OR = 2.07; 95% CI: 1.37, 3.14). All cultural practices significantly influenced exposure to HAT with extensive husbandry system three times more likely to predisposed pastoralists to HAT (OR = 3.21; 95% CI: 1.65, 6.24). Socio-cultural characteristics of pastoralists influenced exposure to HAT risk and, therefore, there is a need to sensitize them to bring changes to their socio-cultural practices and perceptions to achieve effective and long term sustainable HAT control. Elimination strategies of parasites in animals and vectors should be considered to avoid reintroduction from animal reservoirs.

Epidemiology of human African trypanosomiasis

Human African trypanosomiasis (HAT), or sleeping sickness, is caused by Trypanosoma brucei gambiense, which is a chronic form of the disease present in western and central Africa, and by Trypanosoma brucei rhodesiense, which is an acute disease located in eastern and southern Africa. The rhodesiense form is a zoonosis, with the occasional infection of humans, but in the gambiense form, the human being is regarded as the main reservoir that plays a key role in the transmission cycle of the disease. The gambiense form currently assumes that 98% of the cases are declared; the Democratic Republic of the Congo is the most affected country, with more than 75% of the gambiense cases declared. The epidemiology of the disease is mediated by the interaction of the parasite (trypanosome) with the vectors (tsetse flies), as well as with the human and animal hosts within a particular environment. Related to these interactions, the disease is confined in spatially limited areas called “foci”, which are located in Sub-Saharan Africa, mainly in remote rural areas. The risk of contracting HAT is, therefore, determined by the possibility of contact of a human being with an infected tsetse fly. Epidemics of HAT were described at the beginning of the 20th century; intensive activities have been set up to confront the disease, and it was under control in the 1960s, with fewer than 5,000 cases reported in the whole continent. The disease resurged at the end of the 1990s, but renewed efforts from endemic countries, cooperation agencies, and nongovernmental organizations led by the World Health Organization succeeded to raise awareness and resources, while reinforcing national programs, reversing the trend of the cases reported, and bringing the disease under control again. In this context, sustainable elimination of the gambiense HAT, defined as the interruption of the transmission of the disease, was considered as a feasible target for 2030. Since rhodesiense HAT is a zoonosis, where the animal reservoir plays a key role, the interruption of the disease’s transmission is not deemed feasible.

Priorities for the elimination of sleeping sickness

Sleeping sickness describes two diseases, both fatal if left untreated: (i) Gambian sleeping sickness caused by Trypanosoma brucei gambiense, a chronic disease with average infection lasting around 3 years, and (ii) Rhodesian sleeping sickness caused by T. b. rhodesiense, an acute disease with death occurring within weeks of infection. Control of Gambian sleeping sickness is based on case detection and treatment involving serological screening, followed by diagnostic confirmation and staging. In stage I, patients can remain asymptomatic as trypanosomes multiply in tissues and body fluids; in stage II, trypanosomes cross the blood-brain barrier, enter the central nervous system and, if left untreated, death follows. Staging is crucial as it defines the treatment that is prescribed; for both forms of disease, stage II involves the use of the highly toxic drug melarsoprol or, in the case of Gambian sleeping sickness, the use of complex and very expensive drug regimes. Case detection of T. b. gambiense sleeping sickness is known to be inefficient but could be improved by the identification of parasites using molecular tools that are, as yet, rarely used in the field. Diagnostics are not such a problem in relation to T. b. rhodesiense sleeping sickness, but the high level of under-reporting of this disease suggests that current strategies, reliant on self-reporting, are inefficient. Sleeping sickness is one of the 'neglected tropical diseases' that attracts little attention from donors or policymakers. Proper quantification of the burden of sleeping sickness matters, as the primary reason for its 'neglect' is that the true impact of the disease is unknown, largely as a result of under-reporting. Certainly, elimination will not be achieved without vast improvements in field diagnostics for both forms of sleeping sickness especially if there is a hidden reservoir of 'chronic carriers'. Mass screening would be a desirable aim for Gambian sleeping sickness and could be handled on a national scale in the endemic countries - perhaps by piggybacking on programmes committed to other diseases. As well as improved diagnostics, the search for non-toxic drugs for stage II treatment should remain a research priority. There is good evidence that thorough active case finding is sufficient to control T. b. gambiense sleeping sickness, as there is no significant animal reservoir. Trypanosoma brucei rhodesiense sleeping sickness is a zoonosis and control involves interrupting the fly-animal-human cycle, so some form of tsetse control and chemotherapy of the animal reservoir must be involved. The restricted application of insecticide to cattle is the most promising, affordable and sustainable technique to have emerged for tsetse control. Animal health providers can aid disease control by treating cattle and, when allied with innovative methods of funding (e.g. public-private partnerships) not reliant on the public purse, this approach may prove more sustainable. Sleeping sickness incidence for the 36 endemic countries has shown a steady decline in recent years and we should take advantage of the apparent lull in incidence and aim for elimination. This is feasible in some sleeping sickness foci but must be planned and paid for increasingly by the endemic countries themselves. The control and elimination of T. b. gambiense sleeping sickness may be seen as a public good, as appropriate strategies depend on local health services for surveillance and treatment, but public-private funding mechanisms should not be excluded. It is timely to take up the tools available and invest in new tools - including novel financial instruments - to eliminate this disease from Africa.

Human African trypanosomiasis in South Sudan: how can we prevent a new epidemic?

Human African trypanosomiasis (HAT) has been a major public health problem in South Sudan for the last century. Recurrent outbreaks with a repetitive pattern of responding-scaling down activities have been observed. Control measures for outbreak response were reduced when the prevalence decreased and/or socio-political crisis erupted, leading to a new increase in the number of cases. This paper aims to raise international awareness of the threat of another outbreak of sleeping sickness in South Sudan. It is a review of the available data, interventions over time, and current reports on the status of HAT in South Sudan. Since 2006, control interventions and treatments providing services for sleeping sickness have been reduced. Access to HAT diagnosis and treatment has been considerably diminished. The current status of control activities for HAT in South Sudan could lead to a new outbreak of the disease unless 1) the remaining competent personnel are used to train younger staff to resume surveillance and treatment in the centers where HAT activities have stopped, and 2) control of HAT continues to be given priority even when the number of cases has been substantially reduced. Failure to implement an effective and sustainable system for HAT control and surveillance will increase the risk of a new epidemic. That would cause considerable suffering for the affected population and would be an impediment to the socioeconomic development of South Sudan.

Should I get screened for sleeping sickness? A qualitative study in Kasai province, Democratic Republic of Congo

Background

Control of human African trypanosomiasis (sleeping sickness) in the Democratic Republic of Congo is based on mass population active screening by mobile teams. Although generally considered a successful strategy, the community participation rates in these screening activities and ensuing treatment remain low in the Kasai-Oriental province. A better understanding of the reasons behind this observation is necessary to improve regional control activities.

Methods

Thirteen focus group discussions were held in five health zones of the Kasai-Oriental province to gain insights in the regional perceptions regarding sleeping sickness and the national control programme's activities.

Principal Findings

Sleeping sickness is well known among the population and is considered a serious and life-threatening disease. The disease is acknowledged to have severe implications for the individual (e.g., persistence of manic periods and trembling hands, even after treatment), at the family level (e.g., income loss, conflicts, separations) and for communities (e.g., disruption of community life and activities). Several important barriers to screening and treatment were identified. Fear of drug toxicity, lack of confidentiality during screening procedures, financial barriers and a lack of communication between the mobile teams and local communities were described. Additionally, a number of regionally accepted prohibitions related to sleeping sickness treatment were described that were found to be a strong impediment to disease screening and treatment. These prohibitions, which do not seem to have a rational basis, have far-reaching socio-economic repercussions and severely restrict the participation in day-to-day life.

Conclusions/Significance

A mobile screening calendar more adapted to the local conditions with more respect for privacy, the use of less toxic drugs, and a better understanding of the origin as well as better communication about the prohibitions related to treatment would facilitate higher participation rates among the Kasai-Oriental population in sleeping sickness screening and treatment activities organized by the national HAT control programme.

Active screening strategies are common disease control interventions in the context of poor and remote rural communities with no direct access to healthcare facilities. For such activities to be as effective as possible, it is necessary that they are well adapted to local socio-economic and cultural settings. Our aim was to gain insight into the barriers communities in the Kasai-Oriental province of the Democratic Republic of Congo experience in relation to their participation in active screening activities for African sleeping sickness. Participation rates seem to be especially low in this province compared to other endemic regions in the country. We found several important factors to be in play, a number of which could be addressed by adapting the operational procedures of the mobile teams that perform the active screening activities (e.g., improved confidentiality during the screening procedure). However, more profound considerations were found in the form of regional beliefs related to the treatment of the disease. Although not based on rational grounds, these prohibitions seem to pose a significant barrier in a person's decision to seek diagnosis and treatment. A better understanding of these prohibitions and their origin could lead to improved participation rates for sleeping sickness screening in Kasai-Oriental.

Socio-economic aspects of neglected diseases: sleeping sickness and visceral leishmaniasis

Several tropical diseases that are essentially poverty-related have recently gained more attention under the label of 'neglected tropical diseases' or NTD. It is estimated that over 1000 million people currently suffer from one or more NTD. Here, the socio-economic aspects of two NTD - human African trypanosomiasis and human visceral leishmaniasis - are reviewed. Both of these diseases affect the poorest of the poor in endemic countries, cause considerable direct and indirect costs (even though the national control programmes tend to provide free care) and push affected households deeper into poverty.

The Atlas of human African trypanosomiasis: a contribution to global mapping of neglected tropical diseases

BACKGROUND

Following World Health Assembly resolutions 50.36 in 1997 and 56.7 in 2003, the World Health Organization (WHO) committed itself to supporting human African trypanosomiasis (HAT)-endemic countries in their efforts to remove the disease as a public health problem. Mapping the distribution of HAT in time and space has a pivotal role to play if this objective is to be met. For this reason WHO launched the HAT Atlas initiative, jointly implemented with the Food and Agriculture Organization of the United Nations, in the framework of the Programme Against African Trypanosomosis.

RESULTS

The distribution of HAT is presented for 23 out of 25 sub-Saharan countries having reported on the status of sleeping sickness in the period 2000-2009. For the two remaining countries, i.e. Angola and the Democratic Republic of the Congo, data processing is ongoing. Reports by National Sleeping Sickness Control Programmes (NSSCPs), Non-Governmental Organizations (NGOs) and Research Institutes were collated and the relevant epidemiological data were entered in a database, thus incorporating (i) the results of active screening of over 2.2 million people, and (ii) cases detected in health care facilities engaged in passive surveillance. A total of over 42 000 cases of HAT and 6 000 different localities were included in the database. Various sources of geographic coordinates were used to locate the villages of epidemiological interest. The resulting average mapping accuracy is estimated at 900 m.

CONCLUSIONS

Full involvement of NSSCPs, NGOs and Research Institutes in building the Atlas of HAT contributes to the efficiency of the mapping process and it assures both the quality of the collated information and the accuracy of the outputs. Although efforts are still needed to reduce the number of undetected and unreported cases, the comprehensive, village-level mapping of HAT control activities over a ten-year period ensures a detailed and reliable representation of the known geographic distribution of the disease. Not only does the Atlas serve research and advocacy, but, more importantly, it provides crucial evidence and a valuable tool for making informed decisions to plan and monitor the control of sleeping sickness.

The past and present threat of vector-borne diseases in deployed troops

From time immemorial, vector-borne diseases have severely reduced the fighting capacity of armies and caused suspension or cancellation of military operations. Since World War I, infectious diseases have no longer been the main causes of morbidity and mortality among soldiers. However, most recent conflicts involving Western armies have occurred overseas, increasing the risk of vector-borne disease for the soldiers and for the displaced populations. The threat of vector-borne disease has changed with the progress in hygiene and disease control within the military: some diseases have lost their military significance (e.g. plague, yellow fever, and epidemic typhus); others remain of concern (e.g. malaria and dengue fever); and new potential threats have appeared (e.g. West Nile encephalitis and chikungunya fever). For this reason, vector control and personal protection strategies are always major requirements in ensuring the operational readiness of armed forces. Scientific progress has allowed a reduction in the impact of arthropod-borne diseases on military forces, but the threat is always present, and a failure in the context of vector control or in the application of personal protection measures could allow these diseases to have the same devastating impact on human health and military readiness as they did in the past.

Southern Sudan: an opportunity for NTD control and elimination?

Southern Sudan has been ravaged by decades of conflict and is thought to have one of the highest burdens of neglected tropical diseases (NTDs) in the world. Health care delivery, including efforts to control or eliminate NTDs, is severely hampered by a lack of infrastructure and health systems. However, the post-conflict environment and Southern Sudan's emerging health sector provide the unprecedented opportunity to build new, innovative programmes to target NTDs. This article describes the current status of NTDs and their control in Southern Sudan and outlines the opportunities for the development of evidence-based, innovative implementation of NTD control.

Sleeping sickness in Uganda: revisiting current and historical distributions

BACKGROUND

Sleeping sickness is a parasitic, vector-borne disease, carried by the tsetse fly and prevalent in sub-Saharan Africa. The disease continues to pose a public health burden in Uganda, which experienced a widespread outbreak in 1900-1920, and a more recent outbreak in 1976-1989. The disease continues to spread to uninfected districts.

OBJECTIVES

This paper compares the spatial distributions of sleeping in Uganda for the 1900-1920 outbreak period with current disease foci, and discusses information gaps and implications arising for future research, prevention and control.

METHODS

Population census records for 1911 and sleeping sickness records from Medical and Sanitary Reports of the Ugandan Protectorate for 1905-1936 were extracted from the Uganda Archives. Current sleeping sickness distribution data were provided by the Ministry of Health, Uganda. These were used to develop sleeping sickness distribution maps for comparison between the early 1900s and the early 2000s.

RESULTS

The distribution of sleeping sickness from 1905-1920 shows notable differences compared to the current distribution of disease. In particular, archival cases were recorded in south-west and central Uganda, areas currently free of disease. The disease focus has moved from lakeshore Buganda (1905-1920) to the Busoga and south-east districts.

CONCLUSIONS

Archival sleeping sickness distributions indicate the potential for a much wider area of disease risk than indicated by current disease foci. This is compounded by an absence of tsetse distribution data, continued political instability in north-central Uganda, continued spread of disease into new districts, and evidence of the role of livestock movements in spreading the parasite. These results support concerns as to the potential mergence of the two disease foci in the south-east and north-west of the country.

Differential expression of fat body genes in Glossina morsitans morsitans following infection with Trypanosoma brucei brucei

To determine which fat body genes were differentially expressed following infection of Glossina morsitans morsitans with Trypanosoma brucei brucei we generated four suppression subtractive hybridisation (SSH) libraries. We obtained 52 unique gene fragments (SSH clones) of which 30 had a known orthologue at E-05 or less. Overall the characteristics of the orthologues suggest: (i) that trypanosome infection has a considerable effect on metabolism in the tsetse fly; (ii) that self-cured flies are mounting an oxidative stress response; and (iii) that self-cured flies are displaying increased energy usage. The three most consistently differentially expressed genes were further analysed by gene knockdown (RNAi). Knockdown of Glossina transferrin transcripts, which are upregulated in self-cured flies compared with flies infected with trypanosomes, results in a significant increase in the number of trypanosome infections establishing in the fly midgut, suggesting transferrin plays a role in the protection of tsetse flies from trypanosome infection.

Civil conflict and sleeping sickness in Africa in general and Uganda in particular

Conflict and war have long been recognized as determinants of infectious disease risk. Re-emergence of epidemic sleeping sickness in sub-Saharan Africa since the 1970s has coincided with extensive civil conflict in affected regions. Sleeping sickness incidence has placed increasing pressure on the health resources of countries already burdened by malaria, HIV/AIDS, and tuberculosis. In areas of Sudan, the Democratic Republic of the Congo, and Angola, sleeping sickness occurs in epidemic proportions, and is the first or second greatest cause of mortality in some areas, ahead of HIV/AIDS. In Uganda, there is evidence of increasing spread and establishment of new foci in central districts. Conflict is an important determinant of sleeping sickness outbreaks, and has contributed to disease resurgence. This paper presents a review and characterization of the processes by which conflict has contributed to the occurrence of sleeping sickness in Africa. Conflict contributes to disease risk by affecting the transmission potential of sleeping sickness via economic impacts, degradation of health systems and services, internal displacement of populations, regional insecurity, and reduced access for humanitarian support. Particular focus is given to the case of sleeping sickness in south-eastern Uganda, where incidence increase is expected to continue. Disease intervention is constrained in regions with high insecurity; in these areas, political stabilization, localized deployment of health resources, increased administrative integration and national capacity are required to mitigate incidence. Conflict-related variables should be explicitly integrated into risk mapping and prioritization of targeted sleeping sickness research and mitigation initiatives.

Drug toxicity and cost as barriers to community participation in HAT control in the Democratic Republic of Congo

INTRODUCTION

Active case-finding programmes by mobile teams are the cornerstone of West African Human African Trypanosomiasis (HAT) control. Low attendance rates of screening and low uptake of treatment after diagnosis are major problems. The objectives of this survey were to explore community perception of HAT, to assess acceptability of control activities and to identify barriers amenable to intervention.

METHODS

In September 2004, we conducted 33 focus group discussions with beneficiaries of the HAT control programme among various ethnic groups in two ecological settings (savannah and fluvial) of the Democratic Republic of Congo.

RESULTS

The population had a very detailed knowledge and understanding of HAT transmission, utility of screening, symptoms and treatment. Melarsoprol treatment was feared for its side effects. The sudden death of previously asymptomatic people during treatment was attributed to witchcraft, to which one becomes more vulnerable when the diagnosis is disclosed in public. Lack of confidentiality was also a problem because HAT carries a stigma as a mental disease. Lumbar punctures, especially when performed in public, were disliked but less feared. Financial barriers were a major obstacle for many patients.

CONCLUSION

Less toxic drugs, lowering financial barriers and improving confidentiality would have considerable impact on the participation in population screening for HAT.

Trypanosomiasis control, Democratic Republic of Congo, 1993-2003

Efforts to control human trypanosomiasis, which sharply reduced the disease, must be sustained.

In the Democratic Republic of Congo (DRC), human African trypanosomiasis (HAT) reached unprecedented levels in the 1990s. To assess recent trends and evaluate control efforts, we analyzed epidemiologic and financial data collected by all agencies involved in HAT control in DRC from 1993 to 2003. Funds allocated to control populations, as well as to the population screened, doubled from 1993 to 1997 and from 1998 to 2003. The number of cases detected decreased from 26,000 new cases per year in 1998 to 11,000 in 2003. Our analysis shows that HAT control in DRC is almost completely dependent on international aid and that sudden withdrawal of such aid in 1990 had a long-lasting effect. Since 1998, control efforts intensified because of renewed donor interest, including a public-private partnership, and this effort led to a major reduction in HAT incidence. To avoid reemergence of this disease, such efforts should be sustained.

L'impact de la guerre sur l'evolution de la THA dans le centre-ouest de la cote d'ivoire

OBJECTIVE

To evaluate the situation of sleeping sickness in west-central Côte d'Ivoire from 2000 to 2003, in view of the war which broke out in September 2002.

METHODS

Active surveys by medical teams and passive case detection.

RESULTS

Between 2000 and 2003, 250 patients were diagnosed with sleeping sickness. At first it appeared that sleeping sickness prevalence had fallen since the beginning of political troubles. But this apparent drop was due to poor population coverage. Participation in medical surveys differed according to ethnic group, reflecting land use conflicts between ethnic communities. Such conflicts are common in this area, but have been exacerbated by the war.

CONCLUSION

In war, assessing the importance of sleeping sickness by medical surveys only is very difficult. But detection of sleeping sickness cases by passive surveillance increased.

Human African Trypanosomiasis: Epidemiology and Control

Human African trypanosomiasis (HAT), or sleeping sickness, describes not one but two discrete diseases: that caused by Trypanosoma brucei rhodesiense and that caused by T. b. gambiense. The Gambian form is currently a major public health problem over vast areas of central and western Africa, while the zoonotic, Rhodesian form continues to present a serious health risk in eastern and southern Africa. The two parasites cause distinct clinical manifestations, and there are significant differences in the epidemiology of the diseases caused. We discuss the differences between the diseases caused by the two parasites, with an emphasis on disease burden, reservoir hosts, transmission, diagnosis, treatment and control. We analyse how these differences impacted on historical disease control trends and how they can inform contemporary treatment and control options. We consider the optimal ways in which to devise HAT control policies in light of the differing biology and epidemiology of the parasites, and emphasise, in particular, the wider aspects of control policy, outlining the responsibilities of individuals, governments and international organisations in control programmes.

Sleeping sickness in Uganda: a thin line between two fatal diseases

OBJECTIVE

To determine, through the use of molecular diagnostic tools, whether the two species of parasite that cause human African trypanosomiasis have become sympatric.

DESIGN

Blood sampling of all available patients between June 2001 and June 2005 in central Uganda and between July and September 2003 in northwest Uganda and analysis of subcounty sleeping sickness records in Uganda between 1985 and 2005.

SETTING

Sleeping sickness treatment centres in central and northwest Uganda and in south Sudan.

PARTICIPANTS

Patients presenting at the treatment centres and diagnosed as having sleeping sickness.

MAIN OUTCOME MEASURE

Classification of parasites from patients from each disease focus as either Trypanosoma brucei rhodesiense (acute form) or T b gambiense (chronic form).

RESULTS

Blood from 231 patients with sleeping sickness in central Uganda and from 91 patients with sleeping sickness in northwest Uganda and south Sudan were screened for T b rhodesiense (detection of SRA gene) and T b gambiense (detection of TgsGP gene). All samples from central Uganda were classified as T b rhodesiense, and all samples from northwest Uganda and south Sudan were identified as T b gambiense.

CONCLUSIONS

The two focuses of human African trypanosomiasis remain discrete, but the area of Uganda affected by the acute form of human sleeping sickness has increased 2.5-fold since 1985, spreading to three new districts within the past five years through movement of infected livestock. Without preventive action targeted at the livestock reservoir of this zoonotic disease, it is likely that the two disease focuses will converge. This will have a major impact on diagnosis and treatment of this neglected disease. Real time monitoring is recommended, using molecular diagnostic tools (at a regional surveillance centre, for example) targeted at both livestock and human patients.

A case for a Glossina genome project

Given the medical and agricultural significance of Glossina, knowledge of the genomic aspects of the vector and vector-pathogen interactions are a high priority. In preparation for a full genome sequence initiative, an extensive set of expressed sequence tags (ESTs) has been generated from tissue-specific normalized libraries. In addition, bacterial artificial chromosome (BAC) libraries are being constructed, and information on the genome structure and size from different species has been obtained. An international consortium is now in place to further efforts to lead to a full genome project.

Interactions among multiple genomes: tsetse, its symbionts and trypanosomes

Insect-borne diseases exact a high public health burden and have a devastating impact on livestock and agriculture. To date, control has proved to be exceedingly difficult. One such disease that has plagued sub-Saharan Africa is caused by the protozoan African trypanosomes (Trypanosoma species) and transmitted by tsetse flies (Diptera: Glossinidae). This presentation describes the biology of the tsetse fly and its interactions with trypanosomes as well as its symbionts. Tsetse can harbor up to three distinct microbial symbionts, including two enterics (Wigglesworthia glossinidia and Sodalis glossinidius) as well as facultative Wolbachia infections, which influence host physiology. Recent investigations into the genome of the obligate symbiont Wigglesworthia have revealed characteristics indicative of its long co-evolutionary history with the tsetse host species. Comparative analysis of the commensal-like Sodalis with free-living enterics provides examples of adaptations to the host environment (physiology and ecology), reflecting genomic tailoring events during the process of transitioning into a symbiotic lifestyle. From an applied perspective, the extensive knowledge accumulated on the genomic and developmental biology of the symbionts coupled with our ability to both express foreign genes in these microbes in vitro and repopulate tsetse midguts with these engineered microbes now provides a means to interfere with the host physiological traits which contribute to vector competence promising a novel tool for disease management.

Nutritional impact of intestinal helminthiasis during the human life cycle

Poor people in developing countries endure the burden of disease caused by four common species of soil-transmitted nematode that inhabit the gastrointestinal tract. Disease accompanying these infections is manifested mainly as nutritional disturbance, with the differing infections having their deleterious effects at different phases during the human life cycle. Reduced food intake, impaired digestion, malabsorption, and poor growth rate are frequently observed in children suffering from ascariasis and trichuriasis. Poor iron status and iron deficiency anemia are the hallmarks of hookworm disease. The course and outcome of pregnancy, growth, and development during childhood and the extent of worker productivity are diminished during hookworm disease. Less is known about the impact of these infections in children under 2 years of age. The severity of disease caused by soil-transmitted nematodes has consistently been found to depend on the number of worms present per person. Cost-effective measures based on highly efficacious anthelminthic drugs are now available to reduce and control disease caused by these infections.

Recent developments in human African trypanosomiasis

PURPOSE OF REVIEW

Sleeping sickness has re-emerged as a serious problem in sub-Saharan Africa, with an estimated 100000 deaths each year. South Sudan, the Democratic Republic of Congo and Angola have experienced serious epidemics of the Gambian form of the disease. The control of Gambian sleeping sickness, which relies primarily on active case finding followed by chemotherapy, is being threatened by problems of drug resistance. Recently, Rhodesian sleeping sickness has also posed a health risk to travellers visiting game parks in East Africa.

RECENT FINDINGS

Because of war-related constraints, which have prevented case detection, the prevalence of Gambian sleeping sickness commonly exceeds 5% and reached 29% in one focus in south Sudan. The incidence of Gambian infections refractory to melarsoprol treatment has also risen sharply in northern Uganda, northern Angola and southern Sudan, with failure rates as high as 26.9%. Molecular techniques based on the gene for human serum resistance (SRA) have enabled the identification of human infective parasites in the domestic animal reservoir. This molecular tool has shown that the Rhodesian form of the disease is being carried in cattle northwards in Uganda towards areas endemic for the Gambian form. The coalescence of distributions of the chronic and acute forms of the disease will present problems for both control and treatment.

SUMMARY

This review surveys the molecular tools that are improving our understanding of the epidemiology of sleeping sickness, and highlights the search for new diagnostics and drugs to deal with the disease.

Homology modeling and molecular dynamics study of NAD-dependent glycerol-3-phosphate dehydrogenase from Trypanosoma brucei rhodesiense, a potential target enzyme for anti-sleeping sickness drug development

Sleeping sickness and Chagas disease are among the most severe diseases in Africa as well as Latin America. These two diseases are caused by Trypanosoma spp. Recently, an enzyme of a glycolytic pathway, NAD-dependent glycerol-3-phosphate dehydrogenase, of Leishmania mexicana was crystallized and its structure determined by x-ray crystallography. This structure has offered an excellent template for modeling of the homologous enzymes from another Trypanosoma species. Here, a homology model of the T. brucei enzyme based on the x-ray structure of LmGPDH has been generated. This model was used as the starting point for molecular dynamics simulation in a water box. The analysis of the molecular dynamics trajectory indicates that the functionally important motifs have both a very stable secondary structure and tertiary arrangement.

Host age and time of exposure in Trypanosoma brucei gambiense Human African Trypanosomiasis

Human African Trypanosomiasis is related to behavioural risk factors but complex interactions exist between (i) environmental and behavioural risk factors, (ii) vector and (iii) human host. Our aim was to investigate the interrelationships between previously analysed risk factors and the roles of age and time of exposure according to ethnic group and migration status. However, this descriptive and retrospective study is based on cases only (no controls) and our results must therefore be regarded as hypothesis-generating. Individuals originating from areas where sleeping sickness is absent and who settle in an endemic area seem to develop the disease after a shorter time of exposure than native subjects from endemic areas. Our results emphasise the complexity of vector-transmitted disease epidemiology, involving behavioural and/or environmental risk factors on the one hand, and more individual ones such as ageing, immunity and genetic background on the other hand.

Trapping the vector: community action to curb sleeping sickness in southern Sudan

South Sudan experienced a resurgence of trypanosomiasis (sleeping sickness) in the 1990s. In 1997 in Tambura County, public health officials combined standard mass screening and treatment techniques for infected persons with an additional component-trapping the vectors of the disease. The intent of this integrated approach was to lower the number and concentration of the tsetse flies that spread the disease while reducing the level of infection in the human population to make the likelihood of transmission extremely low. Because the trapping project depends on village participation (making, setting, and maintaining the traps), village volunteers and their neighbors learned more about the causes and prevention of sleeping sickness and became much more willing to participate in serosurveys and to seek treatment.

Re-emergence of epidemic sleeping sickness in southern Sudan

A resurgence of sleeping sickness developed in southern Sudan during the past decade. Prevalence of confirmed Trypanosoma brucei gambiense infection in humans now exceeds 5% in several foci. From 1997 to 1999, trypanosomiasis control programmes in three counties of Western Equatoria Province detected 3785 new cases among 67 181 persons screened. A major contributing factor in the re-emergence of epidemic sleeping sickness was the lack of active case-finding throughout the 1990s. Although the situation is improving in sites where trypanosomiasis programmes have been recently implemented, co-ordination and additional international assistance are needed to bring sleeping sickness under control in Sudan.

An unexpected extended conformation for the third TPR motif of the peroxin PEX5 from Trypanosoma brucei

A number of helix-rich protein motifs are involved in a variety of critical protein-protein interactions in living cells. One of these is the tetratrico peptide repeat (TPR) motif that is involved, amongst others, in cell cycle regulation, chaperone function and post-translation modifications. So far, these helix-rich TPR motifs have always been observed to be a compact unit of two helices interacting with each other in antiparallel fashion. Here, we describe the structure of the first three TPR-motifs of the peroxin PEX5 from Trypanosoma brucei, the causative agent of sleeping sickness. Peroxins are proteins involved in peroxisome, glycosome and glyoxysome biogenesis. PEX5 is the receptor of the proteins targeted to these organelles by the "peroxisomal targeting signal-1", a C-terminal tripeptide called PTS-1. The first two of the three TPR-motifs of T. brucei PEX5 appear to adopt the canonical antiparallel helix hairpin structure. In contrast, the third TPR motif of PEX5 has a dramatically different conformation in our crystals: the two helices that were supposed to form a hairpin are folded into one single 44 A long continuous helix. Such a conformation has never been observed before for a TPR motif. This raises interesting questions including the potential functional importance of a "jack-knife" conformational change in TPR motifs.

Prospects for control of African trypanosomiasis by tsetse vector manipulation

The extensive antigenic variation phenomena African trypanosomes display in their mammalian host have hampered efforts to develop effective vaccines against trypanosomiasis. Human disease management aims largely to treat infected hosts by chemotherapy, whereas control of animal diseases relies on reducing tsetse populations as well as on drug therapy. The control strategies for animal diseases are carried out and financed by livestock owners, who have an obvious economic incentive. Sustaining largely insecticide-based control at a local level and relying on drugs for treatment of infected hosts for a disease for which there is no evidence of acquired immunity could prove extremely costly in the long run. It is more likely that a combination of several methods in an integrated, phased and area-wide approach would be more effective in controlling these diseases and subsequently improving agricultural output. New approaches that are environmentally acceptable, efficacious and affordable are clearly desirable for control of various medically and agriculturally important insects including tsetse. Here, Serap Aksoy and colleagues discuss molecular genetic approaches to modulate tsetse vector competence.

Micronutrients and infection: interactions and implications with enteric and other infections and future priorities

Symposium presentations have focused on the elegant molecular science and the biologic mechanisms by which micronutrients play critical roles in cellular and humoral immune responses, cellular signaling and function, and even in the evolution of microbial virulence. The concluding session examined the practical issues of how best to evaluate the nutritionally at-risk host, especially in the areas of greatest need-an analytical model of nutrient-immune interactions, implications of nutritional modulation of the immune response for disease, and the implications for international research and child health. This overview illustrated how malnutrition may be a major consequence of early childhood diarrhea and enteric infections, as enteric infections may critically impair intestinal absorptive function with potential long-term consequences for growth and development. The potentially huge, largely undefined DALY (disability-adjusted life years) impact of early childhood diarrheal illnesses demonstrates the importance of quantifying the long-term functional impact of largely preventable nutritional and infectious diseases, especially in children in developing areas.

A potential target enzyme for trypanocidal drugs revealed by the crystal structure of NAD-dependent glycerol-3-phosphate dehydrogenase from Leishmania mexicana

BACKGROUND

NAD-dependent glycerol-3-phosphate dehydrogenase (GPDH) catalyzes the interconversion of dihydroxyacetone phosphate and L-glycerol-3-phosphate. Although the enzyme has been characterized and cloned from a number of sources, until now no three-dimensional structure has been determined for this enzyme. Although the utility of this enzyme as a drug target against Leishmania mexicana is yet to be established, the critical role played by GPDH in the long slender bloodstream form of the related kinetoplastid Trypanosoma brucei makes it a viable drug target against sleeping sickness.

RESULTS

The 1.75 A crystal structure of apo GPDH from L. mexicana was determined by multiwavelength anomalous diffraction (MAD) techniques, and used to solve the 2.8 A holo structure in complex with NADH. Each 39 kDa subunit of the dimeric enzyme contains a 189-residue N-terminal NAD-binding domain and a 156-residue C-terminal substrate-binding domain. Significant parts of both domains share structural similarity with plant acetohydroxyacid isomeroreductase. The discovery of extra, fatty-acid like, density buried inside the C-terminal domain indicates a possible post-translational modification with an associated biological function.

CONCLUSIONS

The crystal structure of GPDH from L. mexicana is the first structure of this enzyme from any source and, in view of the sequence identity of 63%, serves as a valid model for the T. brucei enzyme. The differences between the human and trypanosomal enzymes are extensive, with only 29% sequence identity between the parasite and host enzyme, and support the feasibility of exploiting the NADH-binding site to develop selective inhibitors against trypanosomal GPDH. The structure also offers a plausible explanation for the observed inhibition of the T. brucei enzyme by melarsen oxide, the active form of the trypanocidal drugs melarsoprol and cymelarsan.