Assessment of schistosomiasis and soil-transmitted helminths prevalence in school-aged children and opportunities for integration of control in local health services in Kwilu Province, the Democratic Republic of the Congo.

OBJECTIVE: To determine the prevalence of schistosomiasis (SCH) and soil-transmitted helminths (STH) in the Democratic Republic of Congo, and to assess the capacity of the local health centres for diagnosis and treatment. METHODS: Cross-sectional school-based survey in two health districts in the Province of Kwilu. We collected a stool and a urine sample for parasitological examination. Urine filtration and duplicate Kato-Katz thick smears were used for the diagnosis of SCH. Health centres were evaluated using a structured questionnaire. RESULTS: In total, 526 children participated in the study and the overall prevalence of Schistosoma mansoni infection was 8.9% (95% CI: 3.5-13.2) in both districts. The prevalence was higher in Mosango (11.7%; 95% CI: 8.9-14.8) than Yasa Bonga district (6.2%; 95% CI: 1.1-11.4). Urine filtration showed that Schistosoma haematobium infection was not present. The combined STH infection prevalence was 58.1% in both districts; hookworm infection was the most common STH found in 52.9% (95% CI: 29.3-62.4) of subjects, followed by Ascaris lumbricoides 9.3% (95% CI: 5.8-15.5) and Trichuris trichiura 2.1% (95% CI: 0.9-4.9). Mixed STH infections were observed as well as SCH-STH coinfection. CONCLUSION: Further mapping of both SCH and STH burden is needed, and coverage of preventive chemotherapy in school-aged children should be increased.

Integration of diagnosis and treatment of sleeping sickness in primary healthcare facilities in the Democratic Republic of the Congo.

BACKGROUND: Control of human African trypanosomiasis (HAT) in the Democratic Republic of Congo (DRC) has always been a vertical programme, although attempts at integration in general health services were made in recent years. Now that HAT prevalence is declining, the integration question becomes even more crucial. We studied the level of attainment of integration of HAT case detection and management in primary care centres in two high-prevalence districts in the province of Bandundu, DRC. METHODS: We visited all 43 first-line health centres of Mushie and Kwamouth districts, conducted structured interviews and inspected facilities using a standardised checklist. We focused on: availability of well trained staff - besides HAT, we also tested for knowledge on tuberculosis; availability of equipment, consumables and supplies; and utilisation of the services. RESULTS: All health centres were operating but most were poorly equipped, and attendance rates were very low. We observed a median of 14 outpatient consultations per facility (IQR 8-21) in the week prior to our visit, that is two patients per day. The staff had good knowledge on presenting symptoms, diagnosis and treatment of both HAT and tuberculosis. Nine centres were accredited by the national programme as HAT diagnosis and treatment centres, but the most sensitive diagnostic confirmation test, the mini-anion exchange centrifugation technique (mAECT), was not present in any. Although all nine were performing the CATT screening test, only two had the required cold chain in working order. CONCLUSION: In these high-prevalence districts in DRC, staff is well-acquainted with HAT but lack the tools required for an adequate diagnostic procedure. Attendance rates of these primary care centres are extremely low, making timely recognition of a resurgence of HAT unlikely in the current state of affairs.

Onchocerciasis control in the Democratic Republic of Congo (DRC): challenges in a post-war environment.

OBJECTIVE: To evaluate onchocerciasis control activities in the Democratic Republic of Congo (DRC) in the first 12 years of community-directed treatment with ivermectin (CDTI). METHODS: Data from the National Programme for Onchocerciasis (NPO) provided by the National Onchocerciasis Task Force (NOTF) through the annual reports of the 21 CDTI projects for the years 2001-2012 were reviewed retrospectively. A hypothetical-inputs-process-outputs-outcomes table was constructed. RESULTS: Community-directed treatment with ivermectin expanded from 1968 communities in 2001 to 39 100 communities by 2012 while the number of community-directed distributors (CDD) and health workers (HW) multiplied. By 2012, there were ratios of 1 CDD per 262 persons and 1 HW per 2318 persons at risk. More than 80% of the funding came from the fiduciary funds of the African Programme for Onchocerciasis Control. The cost of treatment per person treated fell from US$ 1.1 in 2001 to US$ 0.1 in 2012. The therapeutic coverage increased from 2.7% (2001) to 74.2% (2012); the geographical coverage, from 4.7% (2001) to 93.9% (2012). Geographical coverage fell in 2005 due to deaths in loiasis co-endemic areas, and the therapeutic coverage fell in 2008 due to insecurity. CONCLUSIONS: Challenges to CDTI in DRC have been serious adverse reactions to ivermectin in loiasis co-endemic areas and political conflict. Targets for personnel or therapeutic and geographical coverages were not met. Longer term funding and renewed efforts are required to achieve control and elimination of onchocerciasis in DRC.

Treatment outcomes for human African Trypanosomiasis in the Democratic Republic of the Congo: analysis of routine program data from the world's largest sleeping sickness control program.

OBJECTIVE: To enable the human African trypanosomiasis (HAT) control program of the Democratic Republic of the Congo to generate data on treatment outcomes, an electronic database was developed. The database was piloted in two provinces, Bandundu and Kasai Oriental. In this study, we analysed routine data from the two provinces for the period 2006-2008. METHODS: Data were extracted from case declaration cards and monthly reports available at national and provincial HAT coordination units and entered into the database. RESULTS: Data were retrieved for 15 086 of 15 741 cases reported in the two provinces for the period (96%). Compliance with post-treatment follow-up was very poor in both provinces; only 25% had undergone at least one post-treatment follow-up examination, <1% had undergone the required four follow-up examinations. Relapse rates among those presenting for follow-up were high in Kasai (18%) but low in Bandundu (0.3%). CONCLUSIONS: High relapse rates in Kasai and poor compliance with post-treatment follow-up in both provinces are important problems that the HAT control program urgently needs to address. Moreover, in analogy to tuberculosis control programs, HAT control programs need to adopt a recording and reporting routine that includes reporting on treatment outcomes.

Health care-seeking behaviour and diagnostic delays for Human African Trypanosomiasis in the Democratic Republic of the Congo.

OBJECTIVE: About half of the patients with Human African trypanosomiasis (HAT) reported in the Democratic Republic of the Congo (DRC) are currently detected by fixed health facilities and not by mobile teams. Given the recent policy to integrate HAT control into general health services, we studied health seeking behaviour in these spontaneously presenting patients. METHODS: We took a random sample from all patients diagnosed with a first-time HAT episode through passive case finding between 1 October 2008 and 30 September 2009 in the two most endemic provinces of the DRC. Patients were approached at their homes for a structured interview. We documented patient delay (i.e. time between onset of symptoms and contacting a health centre) and health system delay (i.e. time between first contact and correct diagnosis of HAT). RESULTS: Median patient delay was 4 months (IQR 1-10 months, n = 66); median health system delay was 3 months (IQR 0.5-11 months). Those first presenting to public health centres had a median systems delay of 7 months (IQR 2-14 months, n = 23). On median, patients were diagnosed upon the forth visit to a health facility (IQR 3rd-7th visit). CONCLUSIONS: Substantial patient as well as health system delays are incurred in HAT cases detected passively. Public health centres are performing poorly in the diagnostic work-up for HAT, mainly because HAT is a relatively rare disease with few and non-specific early symptoms. Integration of HAT diagnosis and treatment into general health services requires strong technical support and well-organized supervision and referral mechanisms.

A new format of the CATT test for the detection of human African Trypanosomiasis, designed for use in peripheral health facilities.

OBJECTIVES: To test the reproducibility and thermostability of a new format of the Card-Agglutination Test for Trypanosomiasis (CATT) test for Human African Trypanosomiasis (HAT), designed for use at primary health care facility level in endemic countries. METHODS: A population of 4217 from highly endemic villages was screened using the existing format of the CATT test (CATT-R250) on whole blood. All those testing positive (220) and a random sample of negatives (555) were retested in the field with the new format (CATT-D10). Inter-format reproducibility was assessed by calculating kappa. All samples testing positive on whole blood with either method were further evaluated in Belgium by CATT titration of serum by two observers, using both old and new format. CATT-D10 test kits were incubated under four temperature regimens (4, 37, 45 degrees C and fluctuating) with regular assessments of reactivity over 18 months. RESULTS: Inter-format reproducibility of CATT-D10 vs. CATT-R250 on whole blood performed by laboratory technicians in the field was excellent with kappa values of 0.83-0.89. Both inter- and intra-format reproducibility assessed by CATT titration were excellent, with 96.5-100% of all differences observed falling within the limits of +/-1 titration step. After 18 months, reactivity of test kits incubated under all four temperature regimens was still well above the minimum threshold considered acceptable. CONCLUSION: The CATT-D10 is thermostable and can be used interchangeably with the old format of the CATT test. It is highly suitable for use in peripheral health facilities in HAT-endemic countries.

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.

Maternal determinants of diarrhea in children under five in Lubumbashi, Democratic Republic of the Congo.

Diarrheal diseases are one of the leading causes of death among children younger than 5 years of age in the world in general and in sub-Saharan Africa in particular. Mothers are predominantly responsible for child care and housekeeping in this region. The objective of this study was to determine the prevalence of diarrhea and identify its maternal determinants in children under five in the city of Lubumbashi. A cross-sectional study conducted throughout March 2018 collected data from 299 mothers through a household survey. A pretested structured questionnaire was used to collect data in face-to-face interviews. The prevalence of diarrhea in children under 5 in Lubumbashi was 35.8%. In the univariate analysis, the variables associated with diarrhea were single motherhood, soap-free handwashing after latrine use, and the presence of feces around the latrines. Multivariate analysis revealed that the presence of feces around latrines (OR adjusted = 2.12 [1.18-3.80]) was associated with diarrhea. Defective cleaning by mothers, specifically their failure to keep latrine areas clean and free of feces, is associated with the risk of diarrhea in children under five in the study area. A hygiene intervention program must be designed to promote healthy behavior to alleviate the burden of diarrhea in children.

Small angle light scattering assay for the detection of malaria infection.

The diagnosis of malaria, caused by Plasmodium spp., still remains a challenging process. Especially in low-income countries, a rapid user-friendly method is needed for the efficient care of the patient. A small-angle light scattering device consisting of hardware and software was developed. Using the DNA-binding dye SYBR Green, malaria infections could be distinguished in healthy red blood cells infected with Plasmodium. Subsequently, samples from parasite positive and negative patients living in a hyper-endemic area of Kinshasa, DRC were assessed. The scatter profiles were distinct and malaria infection could be detected using the Giemsa stain. Although these results are preliminary, they indicate that the device has the potential to be used as a new diagnostic tool for the detection of Malaria infection.

Fatal Chromobacterium violaceum bacteraemia in rural Bandundu, Democratic Republic of the Congo.

We describe the first case of bacteraemia caused by Chromobacterium violaceum in the Democratic Republic of the Congo. This diagnosis was made in an apparently healthy adult who was admitted to a rural hospital of the province of Bandundu with severe community-acquired sepsis. The patient developed multi-organ failure and died; to our knowledge, this is the first reported fatal case in an adult in Africa.

[Prevalence of geohelminth infections in children living in Kinshasa]. / Prévalence des géohelminthiases chez les enfants à Kinshasa.

BACKGROUND: Data on geohelminth infections in children in the Democratic Republic of Congo are sparse. The objective of this study was to document and compare the profile and prevalence in children living in Kinshasa. METHODS: A prospective cohort study was conducted from May to October 2009 in children in the Biyela health area in Kinshasa, Democratic Republic of Congo. Stool samples were collected from representative members of these two populations and analyzed for geohelminths (GH) using the Kato-Katz technique. RESULTS: In this series, 438 school-age children were included. There were 235 children recruited in schools and 203 in households (77.8%). Overall prevalence of geohelminths was 66.9%. The specific prevalence was 69.4% in children recruited in schools and 64.0% in children recruited in households. The frequency of Ascaris lumbricoides, Trichuris trichiura, and Ancylostoma species were, respectively, 56.2%, 38.7%, and 1.7% in schools and 39.9%, 51.7%, and 1.0% in households. A. lumbricoides was significantly more prevalent in schools (56.2% vs 39.9%; OR=2.0; 95%CI: 1.3-3.0), T. trichiura was significantly less prevalent in schools (38.7% vs 51.7%; OR=0.6; 95% CI: 0.4-0.9). There were no significant differences in the prevalence of Ancylostoma between schools and households. CONCLUSION: GH is a health problem among Biyela children. Preventive measures and education of the population need to be emphasized in attempts to reduce the prevalence of geohelminths in these children.

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.

[Validity, cost and feasibility of the mAECT and CTC confirmation tests after diagnosis of African of sleeping sickness]. / Validité, coût et faisabilité de la mAECT et CTC comme tests de confirmation dans la détection de la Trypanosomiase Humaine Africaine.

OBJECTIVES: To evaluate the validity, cost and feasibility of two parasitological tests for the confirmation of Human African Trypanosomiasis (HAT): the mini Anion-exchange Centrifugation Technique (mAECT) and Capillary Tube Centrifugation (CTC). METHODS: During a sleeping sickness screening campaign in 2004 we screened 6502 people in Kwamouth, DRC. Those with a positive result in the Card Agglutination Test for Trypanosomiasis (CATT) had a gland puncture, fresh blood examination, stained thick blood film, mAECT, CTC and CATT titration. Sensitivity and specificity of the confirmation tests were calculated using the combination of all parasitological tests as a reference standard. Each method was costed and its feasibility was assessed with structured interviews of the technicians. RESULTS: Sensitivity of classical parasitological methods was 44.8% (36.8-53.0), of CTC 56.5% (48.3-64.5) and of mAECT 75.3% (95% CI: 67.7-81.9). Cost per test was 2.82 Euro for mAECT and 0.76 Euro for CTC. Time per test was 29.78 min for mAECT and 18.25 min for CTC. These two tests were judged feasible in field conditions. CONCLUSION: CTC and mAECT used alone or in combination would bring a considerable improvement to HAT active case finding when used as confirmation tests in CATT-whole blood-positive persons. They proved feasible in operational conditions if a 220 V power supply can be guaranteed. As mAECT is more sensitive but also considerably more expensive, efficiency as well as feasibility considerations will have to guide the choice of the best algorithm.

Trypanosomiasis in Kinshasa: distribution of the vector, Glossina fuscipes quanzensis, and risk of transmission in the peri-urban area.

Abstract. Because human and animal cases of African trypanosomiasis have been reported in and around the city of Kinshasa for a long time, the likelihood of local transmission was examined. A georeferenced image of the city was produced, based on a satellite image (SPOT 4). Urban, peri-urban and rural areas were delineated. All recent data on captures of Glossina fuscipes quanzensis Pires (Diptera: Glossinidae) between 1999 and 2004, as well as epidemiological data on a 1999 outbreak of human trypanosomiasis by Trypanosoma brucei gambiense in the Kisenso District, were entered in a geographical information system (GIS). Tsetse flies were mainly found along some of the major rivers in the rural and peri-urban area of Kinshasa. Unsupervised classification of the satellite image allowed identification of riverine habitats suitable for tsetse flies and indicated sites where further entomological surveys were needed. The study produced strong indications that local transmission of human trypanosomiasis had occurred in the recent past in the peri-urban zone of Kinshasa.

[Sleeping sickness in the region of the town of Kinshasa: a retrospective analysis during the surveillance period 1996-2000]. / La maladie de sommeil dans la région Ville de Kinshasa: une analyse rétrospective des données de surveillance sur la période 1996-2000.

In the Democratic Republic of Congo, the re-emergence of sleeping sickness is no longer limited to rural areas. Over the course of the past decade, more and more cases have been reported from urban centres such as Kinshasa, Mbuji-mayi, Matadi and Boma. This paper presents a retrospective analysis on the region of Kinshasa over the period 1996-2000, using epidemiological surveillance, individual case files and available entomological data. There are 22 health districts in total; they were classified as urban when the population exceeded 5000 per square kilometre. The Human African Trypanosomiasis (HAT) control programme reported 2451 parasitologically confirmed new cases between 1996 and 2000, in the entire region of Kinshasa. Affected people (66%) were aged 15-49 years. Cases occurred in every health district, and 956 (39%) occurred in urban residents. Glossina captures in 1999 established the presence of Trypanosoma spp. Local HAT transmission is plausible but not proven. The high number of urban cases necessitates development of control strategies adapted to cities.

Human African trypanosomiasis amongst urban residents in Kinshasa: a case-control study.

BACKGROUND: Increasing numbers of human African trypanosomiasis (HAT) cases have been reported in urban residents of Kinshasa, Democratic Republic Congo since 1996. We set up a case-control study to identify risk factors for the disease. METHODS: All residents of the urban part of Kinshasa with parasitologically confirmed HAT and presenting for treatment to the city's specialized HAT clinics between 1 August, 2002 and 28 February, 2003 were included as cases. We defined the urban part as the area with contiguous habitation and a population density >5000 inhabitants per square kilometre. A digital map of the area was drawn based on a satellite image. For each case, two serologically negative controls were selected, matched on age, sex and neighbourhood. Logistic regression models were fitted to control for confounding. RESULTS: The following risk factors were independently associated with HAT: travel, commerce and cultivating fields in Bandundu, and commerce and cultivating fields in the rural part of Kinshasa. No association with activities in the city itself was found. DISCUSSION: In 2002, the emergence of HAT in urban residents of Kinshasa appears mainly linked to disease transmission in Bandundu and rural Kinshasa. We recommend to intensify control of these foci, to target HAT screening in urban residents to people with contact with these foci, to increase awareness of HAT amongst health workers in the urban health structures and to strengthen disease surveillance.