Martin Odiit

Identification of human-infective trypanosomes in animal reservoir of sleeping sickness in Uganda by means of serum-resistance-associated (SRA) gene

BACKGROUND The expansion of sleeping sickness caused by Trypanosoma brucei rhodesiense beyond its traditional focus in southeast Uganda has been linked with large-scale livestock restocking. To assess the risk presented to the human population by domestic livestock, human-infective T b rhodesiense must be distinguished from non-human-infective T brucei brucei, since both parasites can be present in cattle. We investigated the use of a simple genetic marker to characterise parasites collected from cattle in villages within the new sleeping sickness focus in Soroti District, Uganda. METHODS 70 T brucei sl samples of known human infectivity status collected from human beings and cattle in Tororo District, Uganda, from 1989 to 1991 were screened for the presence of the human-serum-resistance-associated (SRA) gene by conventional PCR. In 2000-01, blood samples from 200 randomly selected cattle in six villages and two markets in Soroti District were screened for T brucei sl parasites by PCR; positive samples were screened for the presence of the SRA gene. FINDINGS The SRA gene was present in all 29 samples from patients with sleeping sickness in Tororo District. Of the 41 samples collected from cattle at the same time, the SRA gene was present in the eight samples that tested resistant to human serum in vitro, whereas it was absent from all 33 isolates that were sensitive to human serum in vitro. Of the 200 cattle sampled in Soroti District, we estimated that up to 18% (95% CI 12-23) were infected with T b rhodesiense. INTERPRETATION Detection of the SRA gene could provide the basis for a simple diagnostic test to enable targeted control of T b rhodesiense in the domestic livestock reservoir, thereby reducing the public-health burden of sleeping sickness in east Africa.

The origins of a new Trypanosoma brucei rhodesiense sleeping sickness outbreak in eastern Uganda

BACKGROUND Sleeping sickness, caused by two trypanosome subspecies, Trypanosoma brucei gambiense and Trypanosoma brucei rhodesiense, is a parasitic disease transmitted by the tsetse fly in sub-Saharan Africa. We report on a recent outbreak of T b rhodesiense sleeping sickness outside the established south-east Ugandan focus, in Soroti District where the disease had previously been absent. Soroti District has been the subject of large-scale livestock restocking activities and, because domestic cattle are important reservoirs of T b rhodesiense, we investigated the role of cattle in the origins of the outbreak. METHODS We identified the origins of cattle entering the outbreak area in the 4 years preceding the outbreak. A matched case-control study was conducted to assess whether the distance of villages from the main market involved with restocking was a risk factor for sleeping sickness. We investigated the spatial clustering of sleeping sickness cases at the start of the outbreak. FINDINGS Over 50% (1510 of 2796) of cattle traded at the market were reported to have originated from endemic sleeping sickness areas. The case-control study revealed that distance to the cattle market was a highly significant risk factor for sleeping sickness (p<0.001) and that there was a significant clustering of cases (27 of 28) close to the market at the start of the outbreak (p<0.001). As the outbreak progressed, the average distance of cases moved away from the cattle market (0.014 km per day, 95% CI 0.008-0.020 km per day, p<0.001). INTERPRETATIONS The results are consistent with the disease being introduced by cattle infected with T b rhodesiense imported to the market from the endemic sleeping sickness focus. The subsequent spread of the disease away from the market suggests that sleeping sickness is becoming established in this new focus. Public health measures directed at controlling the infection in the animal reservoir should be considered to prevent the spread of sleeping sickness.

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

Abstract 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.

Sleeping sickness: a tale of two diseases

Sleeping sickness presents clinically as two distinct diseases, reflecting the fact that two very different trypanosomes are responsible. The African Rift separating East and West Africa defines the distribution of the two diseases. In this review, Susan Welburn, Eric Fevre, Paul Coleman, Martin Odiit and Ian Maudlin discuss the biology and distribution of these two diseases in relation to the evolution of hominids in Africa.

Quantifying the level of under-detection of Trypanosoma brucei rhodesiense sleeping sickness cases

To formally quantify the level of under‐detection of Trypanosoma brucei rhodesiense sleeping sickness (SS) during an epidemic in Uganda, a decision tree (under‐detection) model was developed; concurrently, to quantify the subset of undetected cases that sought health care but were not diagnosed, a deterministic (subset) model was developed. The values of the under‐detection model parameters were estimated from previously published records of the duration of symptoms prior to presentation and the ratio of early to late stage cases in 760 SS patients presenting at LIRI hospital, Tororo, Uganda during the 1988–1990 epidemic of SS. For the observed early to late stage ratio of 0.47, we estimate that the proportion of under‐detection in the catchment area of LIRI hospital was 0.39 (95% CI 0.37–0.41) i.e. 39% of cases are not reported. Based on this value, it is calculated that for every one reported death of SS, 12.0 (95% CI 11.0–13.0) deaths went undetected in the LIRI hospital catchment area – i.e. 92% of deaths are not reported. The deterministic (subset) model structured on the possible routes of a SS infection to either diagnosis or death through the health system or out of it, showed that of a total of 73 undetected deaths, 62 (CI 60–64) (85%) entered the healthcare system but were not diagnosed, and 11 (CI 11–12) died without seeking health care from a recognized health unit. The measure of early to late stage presentation provides a tractable measure to determine the level of rhodesiense SS under‐detection and to gauge the effects of interventions aimed at increasing treatment coverage.

A burgeoning epidemic of sleeping sickness in Uganda

The epidemic of Trypanosoma brucei rhodesiense sleeping sickness in eastern Uganda, which began in 1998 as a result of movements of the livestock reservoir of the parasite, has continued to spread. An additional 133 000 people have been put at risk of infection in Kaberamaido, another newly affected district. The few resources committed to control interventions in Soroti district have failed to contain the epidemic. The high prevalence of the parasite in cattle presents a significant risk for transmission to human beings and further spread of this neglected zoonotic disease. Targeted interventions are urgently needed to control epidemics and reduce the high mortality resulting from sleeping sickness.

The diagnosis of trypanosome infections: applications of novel technology for reducing disease risk

Reliable DNA based methodologies to determine prevalence of trypanosome species in domestic livestock have been available for over 10 years. Despite this, they are rarely used to generate baseline data for control operations for these diseases in the field. Rather, such operations tend to rely on data which can be generated using low technology methods such as direct observation of parasites by light microscopy. Here we show the pitfalls of relying on such low tech methodology which, although simple in its application, can provide inaccurate and inadequate data on which to base control methodologies. Our analysis of 61 cattle selected for trypanosome carrier status by either microscopy, low PCV or poor condition score, showed that 90% were infected with trypanosomes while 84% of the total were infected with T. brucei. Diagnosis by PCR on buffy coat preparations on Whatman® FTA® matrices was the most sensitive methodology relative to the gold standard, whereas microscopy was the least sensitive. (African Journal of Biotechnology: 2002 1(2): 39-45)

Spatially and Genetically Distinct African Trypanosome Virulence Variants Defined by Host Interferon-γ Response

We describe 2 spatially distinct foci of human African trypanosomiasis in eastern Uganda. The Tororo and Soroti foci of Trypanosoma brucei rhodesiense infection were genetically distinct as characterized by 6 microsatellite and 1 minisatellite polymorphic markers and were characterized by differences in disease progression and host-immune response. In particular, infections with the Tororo genotype exhibited an increased frequency of progression to and severity of the meningoencephalitic stage and higher plasma interferon (IFN)- gamma concentration, compared with those with the Soroti genotype. We propose that the magnitude of the systemic IFN- gamma response determines the time at which infected individuals develop central nervous system infection and that this is consistent with the recently described role of IFN- gamma in facilitating blood-brain barrier transmigration of trypanosomes in an experimental model of infection. The identification of trypanosome isolates with differing disease progression phenotypes provides the first field-based genetic evidence for virulence variants in T. brucei rhodesiense.

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 100 000 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.

Focus-Specific Clinical Profiles in Human African Trypanosomiasis Caused by Trypanosoma brucei rhodesiense

Background Diverse clinical features have been reported in human African trypanosomiasis (HAT) foci caused by Trypanosoma brucei rhodesiense (T.b.rhodesiense) giving rise to the hypothesis that HAT manifests as a chronic disease in South-East African countries and increased in virulence towards the North. Such variation in disease severity suggests there are differences in host susceptibility to trypanosome infection and/or genetic variation in trypanosome virulence. Our molecular tools allow us to study the role of host and parasite genotypes, but obtaining matched extensive clinical data from a large cohort of HAT patients has previously proved problematic. Methods/Principal Findings We present a retrospective cohort study providing detailed clinical profiles of 275 HAT patients recruited in two northern foci (Uganda) and one southern focus (Malawi) in East Africa. Characteristic clinical signs and symptoms of T.b.rhodesiense infection were recorded and the degree of neurological dysfunction determined on admission. Clinical observations were mapped by patient estimated post-infection time. We have identified common presenting symptoms in T.b.rhodesiense infection; however, marked differences in disease progression and severity were identified between foci. HAT was characterised as a chronic haemo-lymphatic stage infection in Malawi, and as an acute disease with marked neurological impairment in Uganda. Within Uganda, a more rapid progression to meningo-encephaltic stage of infection was observed in one focus (Soroti) where HAT was characterised by early onset neurodysfunction; however, severe neuropathology was more frequently observed in patients in a second focus (Tororo). Conclusions/Significance We have established focus-specific HAT clinical phenotypes showing dramatic variations in disease severity and rate of stage progression both between northern and southern East African foci and between Ugandan foci. Understanding the contribution of host and parasite factors in causing such clinical diversity in T.b.rhodesiense HAT has much relevance for both improvement of disease management and the identification of new drug therapy.