Dynamics of tuberculosis in Wau, South Sudan during a period of armed conflict.

BACKGROUND: South Sudan has endured decades of armed conflict, with the most recent in 2016. This has left the health system and infrastructure overstretched by a myriad of infectious diseases like tuberculosis. Our study aimed at quantitatively and qualitatively documenting TB dynamics and challenges with access to health care during a period of civil unrest in Wau. MATERIALS & METHODS: A cross sectional study was carried out between January and February 2016 at Wau Teaching Hospital (WTH). Sputum was randomly collected from 207 of the 1035 TB suspects and analyzed using Ziehl-Neelsen (ZN) and Fluorescent Microscopy (FM), Culture, Capilia MTBC Neo, and DST. The laboratory results and questionnaire metadata were used for descriptive statistics, logistic regression in R version 3.4.2. These results were presented along with results from a qualitative assessment of the situation at WTH. RESULTS: Of 207 TB suspects, 39 (18.8%) were positive on FM with bacilli growth on culture, later confirmed as Mycobacterium tuberculosis complex. Only 5.4% of the cases were resistant to Isoniazid. Age; 20-45 OR = 13 (95%CI = 2.4-25.6, p = 0.011), > 46 OR = 3 (95%CI = 0.5-58, p = 0.005) and raw milk consumption OR = 2.2 (95%CI = 0.37-42.48, p = 0.005) were associated with being TB positive. The qualitative evaluation reveals that gunfights in the surroundings of Wau influenced the number of patients attending WTH, with some travelling up to 545 km to seek medical attention. CONCLUSION: We report a high prevalence of tuberculosis among patients who presented at WTH, with approximately 1 out of 5 individuals testing positive for tuberculosis. This is likely an underestimation given the challenges patients had to endure as they sought medical attention. Tuberculosis epidemiology is likely to be driven by individual and household factors, but further investigations are needed to fully understand the risk profile. The tools in use were adequate for TB diagnostics and we observed a remarkably low prevalence of drug resistance, a statistic that is worth preserving. We therefore call for action from all stakeholders.

Taenia spp. infections in wildlife in the Bangweulu and Kafue flood plains ecosystems of Zambia.

Taenia spp. have an indirect life cycle, cycling between a definitive and an intermediate host with zoonotic species causing public health problems in many developing countries. During the course of 2 separate surveys in Zambia (2004 and 2009), the presence of Taenia larval stages (cysticerci) was examined in Kafue lechwe (Kobus leche kafuensis), Black lechwe (Kobus leche smithermani) and other wildlife species from the Kafue and Bangweulu flood plains. Examinations involved post-mortem inspection and serum specific antigen detection. The recovered cysts from seven carcasses were characterised using PCR and DNA sequence analysis. The overall proportion of infection in wildlife on post-mortem examination was 19.0% (95% CI: 9.1-29.0%). The proportion of infected wildlife based on post-mortem examinations in the Kafue flood plains was estimated at 28.6% (95% CI: 13.3-43.9%), while the seroprevalence was estimated at 25.0% (95% CI: 2.9-47.1%). The seroprevalence for cattle in the Kafue flood plains was estimated at 61.5% (95% CI: 42.0-81.0%) while that of Kafue lechwe in the same ecosystem was estimated at 66.6% (95% CI: 45.6-85.7%). Infection rates were higher in Kafue lechwe than in Black lechwe suggesting differences in the exposure patterns. The sequencing results indicated that none of the recovered cysts were either Taenia solium or Taenia saginata. We therefore conclude they most likely belong to a less studied (wildlife) Taenia species that requires further characterisation.

Bovine tuberculosis and brucellosis in traditionally managed livestock in selected districts of southern province of zambia.

A study was performed in 2008 to estimate the prevalence of tuberculosis and brucellosis in traditionally reared cattle of Southern Province in Zambia in four districts. The single comparative intradermal tuberculin test (SCITT) was used to identify TB reactors, and the Rose Bengal test (RBT), followed by confirmation with competitive enzyme-linked immunosorbent assay (c-ELISA), was used to test for brucellosis. A total of 459 animals were tested for tuberculosis and 395 for brucellosis. The overall prevalence of BTB based on the 4 mm and 3 mm cutoff criteria was 4.8% (95% CI: 2.6-7.0%) and 6.3% (95% CI: 3.8-8.8%), respectively. Change in skin thickness on SCITT was influenced by initial skin-fold thickness at the inoculation site, where animals with thinner skin had a tendency to give a larger tuberculin response. Brucellosis seroprevalence was estimated at 20.7% (95% CI: 17.0-24.4%). Comparison between results from RBT and c-ELISA showed good agreement (84.1%) and revealed subjectivity in RBT test results. Differences in brucellosis and tuberculosis prevalence across districts were attributed to type of husbandry practices and ecological factors. High prevalence of tuberculosis and brucellosis suggests that control programmes are necessary for improved cattle productivity and reduced public health risk.

A review of bovine tuberculosis at the wildlife-livestock-human interface in sub-Saharan Africa.

Infection of wild animals by bovine tuberculosis (bTB) is raising concern worldwide. This article reviews the current epidemiological situation, risk of emergence and control options at the wildlife­livestock­human interface in sub-Saharan Africa. In livestock, bTB has been confirmed in the majority of countries from all parts of the continent. Wildlife infection is confirmed in seven countries from southern and eastern Africa, apparently spreading in the southern Africa region. Mycobacterium bovis has been isolated from 17 wild mammal species, although only four are suspected to play a role as maintenance host. Zoonotic risks are a concern, but no direct spillover from wildlife to humans has been documented, and no case of bTB spillback from wildlife to livestock has been confirmed. In this paper we assess the main risk factors of bTB spillover at the wildlife­livestock­human interface and suggest several research themes which could improve the control of the disease in the African context.

Cost benefit analysis of tuberculosis control in wildlife-livestock interface areas of Southern Zambia.

This paper presents the results of an economic simulation model evaluating the costs and benefits of bovine tuberculosis (bTB) control in a wildlife-livestock interface area of Southern Zambia over a 10 year period, using test and slaughter in livestock and promotion of milk pasteurization amongst livestock keeping communities to reduce the zoonotic transmission of bTB through milk. Expected benefits included increased productivity and health in village resident and transhumant cattle, and averted human bTB treatment costs after the fourth year of the project. In monetary terms, at different bTB prevalence estimates in cattle, the simulation outcome showed that the costs of control never exceeded the few benefits considered over the simulated period. However, the benefits are likely to outweigh the costs if wider implications of bTB in humans (infirmity-related productivity losses), livestock and wildlife (reduced productivity and herd value in cattle and diminished tourism potential from bTB-related wildlife mortalities) are taken into account.

Brucella seroprevalence of the Kafue lechwe (Kobus leche kafuensis) and Black lechwe (Kobus leche smithemani): exposure associated to contact with cattle.

We investigated Brucella seroprevalence in Kafue (Kobus leche kafuensis) and Black (Kobus leche smithemani) lechwe antelopes to assess Brucella infections in relation to presence/absence of cattle interaction on the wetlands. Accordingly, two study populations based on cattle interaction were assesed: Kafue lechwe from Kafue flats which interact with cattle; and the Black lechwe with no known interaction with cattle from the Bangweulu swamps. Fourteen Kafue lechwe and thirty Black lechwe were slaughtered between October and December 2009 using special research licenses obtained from the Zambia wildlife authority to investigate diseases in lechwe antelope. For the purpose of this study, blood was collected and sera separated for Rose Bengal and indirect ELISA tests. Seroprevalence of Brucella in the Kafue lechwe was estimated at 42.9% [95% CI: 15.2-70.5] while that in Black lechwe was 0% [95% CI:0.0-11.6]. On the Kafue flats, cattle were spotted grazing in the same areas as lechwe while there was no evidence of cattle presence on the Bangweulu swamps. These differences in seroprevalence between Kafue lechwe and Black lechwe were assumed to be associated with interaction between Kafue lechwe and Brucella infected cattle, and no such contact existed between cattle and the Black lechwe. Our study suggests that brucellosis in the Kafue lechwe may have originated from cattle but has now established a reservoir in wild animals. It is also important to keep in mind that the Black lechwe can easily become infected with Brucella spp. once cattle are introduced in the surrounding areas.

Helminth parasites of the Kafue lechwe antelope ( Kobus leche kafuensis): a potential source of infection to domestic animals in the Kafue wetlands of Zambia.

The Kafue lechwe antelope (Kobus leche kafuensis), a medium-sized, semi-aquatic antelope, grazes extensively on pastures accessed by livestock in and around Lochinvar and Blue Lagoon national parks in the Kafue wetlands of Zambia. This interaction has a potential for bi-modal transmission of a wide range of parasitic helminths between lechwe and domestic ruminants. A survey was conducted to investigate the status of helminths in the Kafue lechwe during the 2008 (July-December) hunting season, involving 65 animals hunted under special research licences. Worm identification was based on morphological features using standard identification keys. Eleven different types of helminths were identified in the animals studied; namely, Oesophagostomum, Bunostomum, Cooperia, Dictyocaulus, Marshallagia, Stilesia, Setaria, Trichuris, Fasciola, amphistomes and Schistosoma. Amphistomes (100%) and Oesophagostomum (60.9%) were the most common while Fasciola (7.8%) and Stilesia (1.6%) were the least of the identified helminths. There was no evidence that helminths, at intensities observed, adversely affected the health of the lechwe. The degree of worm infection was observed to vary between the two study areas, with Blue Lagoon recording higher infection levels compared to Lochinvar. The host range of many of the helminths found in the Kafue lechwe is broad and could serve as a potentially stable source of infection to domestic animals such as goats and cattle. Therefore, issues concerning livestock management and conservation may arise.

Tuberculosis in Kafue lechwe antelopes (Kobus leche Kafuensis) of the Kafue Basin in Zambia.

Tuberculosis (TB) has been reported in the Kafue lechwe antelopes (Kobus leche Kafuensis) of Zambia. However, previous reports are restricted to the southern parts in Lochinvar, where only old male animals were investigated. This study was conducted to gather epidemiological information on TB in Lechwe antelopes across sexes and age groups in relation to other explanatory variables of disease occurrence in the Kafue Basin. Animals were hunted under a special licence to investigate diseases in the Kafue Basin during the 2004, 2005 and 2008 hunting seasons. Histopathology, acid-fast staining and mycobacterial culturing from tissue samples were conducted. A total of 119 animals were slaughtered with an estimated age range of 2.5-20 years. Of these, 29 (24.3% [95% CI: 16.5, 32.3%]) had necropsy lesions suggestive of tuberculosis, of which 21 (17.6% [95% CI: 10.7, 24.6%]) tested positive on acid-fast staining while 33 (27.7% [95% CI: 19.6, 35.9%]) showed culture and colony morphological characteristics suggestive of Mycobacterium species. On univariate analysis, animals with poor body condition were twice as likely to have tuberculosis associated lesions as those having good body conditions (OR=2.3, 95% CI: 0.6, 9.3%). Based on lesion distribution, a respiratory route of mycobacterial infection is intimated.

Effectiveness of Rose Bengal test and fluorescence polarization assay in the diagnosis of Brucella spp. infections in free range cattle reared in endemic areas in Zambia.

The effectiveness of Rose Bengal test (RBT) and fluorescence polarization assay (FPA) in diagnosing cattle brucellosis in endemic areas was assessed and RBT and FPA test agreement was compared (n = 319). The sensitivity of RBT and FPA in detecting low Brucella titres were evaluated in paired sera (n = 34). A logistic regression model was constructed to predict cattle test result in FPA using RBT as the main predictor and incorporating bio-data and animal history. There was 79.3% agreement between the RBT and FPA (Kappa = 0.59; Std error = 0.05; p = 0.000) and a high correspondence between high RBT scores and positive FPA results suggesting that sera with high RBT score may not require confirmation with tests such as competitive-ELISA or CFT. High FPA cut-off points were more likely to miss animals with low antibody titres. The RBT had a reduced ability in detecting low antibody titres compared to the FPA. FPA test interpretation was improved if a priori information, such as sex and age was used. Under the challenging disease surveillance conditions prevailing in rural Africa, field-testing methods that are sensitive and specific; allow single animal contact, low technical skills in data interpretation are suitable.

Prevalence of bovine tuberculosis and animal level risk factors for indigenous cattle under different grazing strategies in the livestock/wildlife interface areas of Zambia.

A cross-sectional study was conducted to investigate the prevalence and animal level risk factors for bovine tuberculosis (BTB) in indigenous cattle of the livestock/wildlife interface areas in Zambia. A total of 944 cattle from 111 herds were investigated. The comparative intradermal tuberculin test (CIDT) was used to identify reactor animals for BTB. Animal level data on sex, age, parity and body condition score were registered. The overall animal prevalence of BTB as determined by the CIDT was 6.8% (95% CI: 4.2, 9.5%). In Lochinvar and Blue Lagoon areas, animal level prevalence were observed at 5.2% (95% CI: 2.2, 8.2%) and 9.6% (95% CI: 6.1, 13.2%), respectively. Kazungula, an area outside the livestock/wildlife interface, had a prevalence of only 0.8% (95% CI: 0.0, 2.3%). The age of the animal, its body condition score and the type of management system, were predictive of its BTB status. The study revealed that BTB was relatively high in the livestock/wildlife interface areas of Lochinvar and Blue Lagoon compared to Kazungula. These findings should raise a serious public health concern considering the extent to which the communities of the study areas are in contact with their animals and the levels at which they use untreated milk.

Mortality and commercial off-take rates in adult traditional cattle of Zambia.

A cohort study was conducted in the livestock-wildlife interface areas of Zambia to determine cattle mortality and commercial off-take rates among adult cattle as well as factors influencing them. A total of 416 animals from 43 herds were followed up for one year and animals were individually identified and their fate was indicated as sold, slaughtered, dead or present as appropriate. The overall mortality incidence risk was estimated at 7.5%. Cattle in Kazungula were at a greater risk of dying compared to those in Blue Lagoon and Lochnivar. Annual off-take was estimated at 13.7% (8.1-19.3%), unadjusted values, and 16.4% (8.1-24.5%) after adjusting for sampling fraction in primary sampling units (herds) and area stratification. Area variations were observed with Kazungula recording the highest in both instances, which was attributed to a contagious bovine pleural pneumonia (CBPP) outbreak. Herd size and gender were observed to influence cattle mortality rates. Cattle in the middle-sized herds (50-150 cattle) recorded high mortality rates (OR = 3.91) compared to smaller herds (10-50) and so were females compared to males (OR = 4.16). The logistic regression model showed that cattle death was influenced by managerial factors and that off-take rates tend to increase in the face of disease outbreaks.

Risk factors associated with bovine tuberculosis in traditional cattle of the livestock/wildlife interface areas in the Kafue basin of Zambia.

We conducted a cross-sectional study from August 2003 to February 2004 to identify risk factors for bovine tuberculosis (BTB) in the Kafue basin of Zambia. We investigated a total of 106 herds of cattle for presence of BTB using the comparative intradermal tuberculin test (CITT) while an interviewer-administered questionnaire was used to gather epidemiological data on herd structure, management and grazing strategies. BTB prevalence at herd level was estimated and possible risk factors were investigated using the multiple logistic regression model. The true herd level prevalence of BTB was estimated at 49.8% (95% CI: 37.9, 61.7%). The logistic regression model showed that cattle herd BTB status was highly associated with area and husbandry practices. When compared to Kazungula, cattle herds in Blue Lagoon were more likely to test positive for BTB when other factors such as management practices were controlled (OR=10.5). In terms of grazing strategies, transhumant herds (TH) had higher odds (OR=3.0) of being positive compared to sedentary herds (OR=1.0). The results in this study provide preliminary information about potential risk factors that were found to be associated with BTB status in cattle.

Risk factors for brucellosis in indigenous cattle reared in livestock-wildlife interface areas of Zambia.

We conducted this cross-sectional study to investigate risk factors of Brucella seropositivity in cattle herds reared in livestock-wildlife interface areas of Blue Lagoon and Lochinvar National Parks in Zambia between August 2003 and September 2004. Sera were collected from cattle aged > or =2 years from 124 herds. Data on husbandry practices, grazing strategies, and herd structure (sex and age composition) were also collected. Sera were screened for anti-Brucella antibodies using the Rose Bengal test (RBT) as a presumptive test and a competitive-ELISA (c-ELISA) as a confirmatory test. A herd was classified as Brucella seropositive if at least one animal tested positive on both RBT and c-ELISA in series testing. Risk factors for herd-level brucellosis seropositivity were tested using multivariable logistic regression; risk factors for increases in the within-herd counts of seropositive cattle were analyzed using the negative binomial regression model with the number of seropositive animals as outcome and total number of cattle tested in a herd as the population at risk (exposure). Of the 110 herds tested, 68 (62; 95% CI: 53, 71% after adjusting for clustering by area) tested seropositive for exposure to Brucella spp. The final logistic-regression model identified geographical area, with Lochinvar (OR=3.4; CI: 0.97, 12) and Kazungula (OR=4.3; CI: 0.91, 20) recording higher odds of Brucella infections compared to Blue Lagoon. Herds coming in contact with wildlife had higher odds compared to those without contact (OR=3.4; CI: 1, 11). Similarly, the odds of Brucella infection were progressively higher in the larger herd categories (26-40 cattle, OR=2.6; CI: 0.70, 10; 41-82 cattle, OR=4.9; CI: 0.93, 26; >82 cattle, OR=9.4; CI: 1.7-51) compared to the smallest herd category (10-25). The negative binomial regression model identified geographical area, contact with wildlife, and herd size as having significant effect on counts of seropositive cattle in a herd.

Prevalence of antibodies to Brucella spp. and individual risk factors of infection in traditional cattle, goats and sheep reared in livestock-wildlife interface areas of Zambia.

A cross-sectional study was performed in the livestock-wildlife interface areas of Lochinvar and Blue Lagoon National Parks and the non-interface area of Kazungula to determine the prevalence of antibodies to Brucella spp. in domestic ruminants and identify individual animal risk factors of infection. A total of 1245 cattle from 124 herds and 280 goats and sheep from 29 flocks were tested sequentially for Brucella antibodies using the Rose Bengal test (RBT) and competitive ELISA. In cattle, individual seroprevalence ranged from 14.1% to 28.1%, while herd sero-prevalence ranged from 46.2% to 74.0% in the three study areas. No goat or sheep tested positive for Brucella antibodies. Three types of cattle grazing strategies were encountered: locally grazed herds (LGH), transhumantly grazed herds (TGH) and river flood plain grazed herds (FGH). Brucella seroprevalence was seen to vary according to area and grazing strategy: Lochinvar and transhumant grazed herds recorded the highest figures, respectively. Age, sex and history of abortion were found to have independent effects on individual seroprevalence. This study establishes that brucellosis is endemic in domestic animals in the livestock-wildlife interface areas of Blue Lagoon and Lochinvar national parks and the disease is also present in Kazungula. We observed that type of grazing strategy had significant impact on cattle Brucella seroprevalence and that transhumant herds were at high risk of being infected.