The disappearance of onchocerciasis from the Itwara focus, western Uganda after elimination of the vector Simulium neavei and 19 years of annual ivermectin treatments.

The Itwara onchocerciasis focus is located around the Itwara forest reserve in western Uganda. In 1991, annual treatments with ivermectin started in the focus. They were supplemented in 1995 by the control of the vector Simulium neavei, which was subsequently eliminated from the focus. The impact of the two interventions on the disease was assessed in 2010 by nodule palpations, examinations of skin snips by microscopy and PCR, and Ov16 recombinant ELISA. There was no evidence of any microfilaria in 688 skin snips and only 2 (0.06%) of 3316 children examined for IgG4 were slightly above the arbitrary cut off of 40. A follow up of the same children 21 months later in 2012 confirmed that both were negative for diagnostic antigen Ov-16, skin snip microscopy and PCR. Based on the World Health Organization (WHO) elimination criteria of 2001 and the Uganda onchocerciasis certification guidelines, it was concluded that the disease has disappeared from the Itwara focus after 19 years of ivermectin treatments and the elimination of the vector around 2001. Ivermectin treatments were recommended to be halted.

Ugandan HIV/AIDS orphans in charge of their households speak out: a study of their health-related worries.

The number of children orphaned due to HIV/AIDS in sub-Saharan Africa was estimated in 2007 by UNAIDS at upwards of 12 million. In Uganda alone, 800,000 of the estimated 1.6 million orphans are said to be orphaned due to this cause. These children suffer life-long consequences from the loss of their parents. This study explores the situation of children living in child-headed households in Uganda's western Kabarole district. Through qualitative research, including in-depth interviews with 20 child heads of households, the health concerns of these children are documented. The interview data were analysed using qualitative research techniques. The study reveals that the psychological and physical effects of orphanhood are magnified for those living in child-headed households. In particular, it highlights the fears of theft and abuse which are a constant source of anxiety for these children. It reports that illness episodes among younger siblings are also particularly worrisome for child heads of households. The article concludes with recommendations for addressing this urgent problem in sub-Saharan Africa.

Fourteen years of surveillance of HIV-1 prevalence among pregnant women attending antenatal care clinics in western Uganda.

This study monitored long-term temporal trends in HIV-1 prevalence in antenatal clinic attendees living in western Uganda. Semi-annual data collection was done from 1991 to 2004. For each woman the following data were recorded: HIV-1 status, age, educational status, marital status, occupation and parity. The results show that the overall HIV-1 prevalence was 15.3% during the entire time period (urban 21.3%, semi-urban 12.7% and rural 7.1%). Between 1991 and 2004, we observed a gradual decline in the HIV-1 prevalence. The decline was most pronounced in urban women aged 15-19 years old and least pronounced in rural women aged 20-24 years. Women above 25 years of age did not show any decline in HIV-1 prevalence over time. The declining HIV-1 prevalence in the younger age groups (15-24 years) likely represents a declining risk for acquiring HIV infection as we have previously shown in the urban sub-sample of this data set.

The elimination of the vector Simulium neavei from the Itwara onchocerciasis focus in Uganda by ground larviciding.

The Itwara focus of onchocerciasis covers an area of approximately 600 km(2) in western Uganda about 20 km north of Fort Portal. The vector is Simulium neavei, whose larvae and pupae live in a phoretic association on freshwater crabs. The phoretic host in the Itwara focus is the crab Potamonautes aloysiisabaudiae. Before any onchocerciasis control, ATPs were estimated to reach between 4500 and 6500 infective larvae per person per year. S. neavei was found to be a very efficient vector with 40% of parous flies harbouring developing larvae of Onchocerca volvulus. After 4 years of community-based distribution of ivermectin transmission was still considerable and in 1995 monthly treatment of streams with the larvicide temephos commenced in the first of three sub-foci, and was gradually extended to the whole focus. Biting S. neavei disappeared from the first sub-focus (Itwara main) in June 1996, and the last infested crab was caught in November 1996. In the second sub-focus (Siisa) treatment commenced towards the end of 1995, and the last biting fly was caught in March 1997, but a deterioration in the security situation interrupted the programme (after only three treatments in the third sub-focus). Monthly treatments restarted in the second and third sub-foci (Aswa) in September 1998, and when the situation was reassessed in 2003 no biting flies were found anywhere, and the flies had not reinvaded the first sub-focus, but infected crabs were found in the second and third sub-foci. The last treatments were carried out in April-June 2003, and since then no infested crabs have been found. In summary, no S. neavei-infested crabs have been found anywhere in the focus since June 2003 and the vector is considered eliminated from that date. However, transmission had already been halted since February 2001, when the last biting flies had been collected. The parasite reservoir should die out in the human population by 2016.

Mortality from epilepsy in an onchocerciasis-endemic area in West Uganda.

Mortality from epilepsy was investigated in a rural area of West Uganda where epilepsy is found to be closely linked to onchocerciasis. Thirty-three female and 28 male patients (age range 4-58 years, median 15 years) were identified in a population-wide prevalence survey and were followed from June 1994 to March 2001 (observation period 3,929 person-months). Patients had continuing access to antiepileptic drug (AED) treatment with phenobarbital. Eighteen patients died during the period of observation, corresponding to a standardised mortality ratio (SMR) of 7.2 (95% CI 4.4-11.6; P<0.0001). Adherence to treatment was considered good in 36 of 56 patients receiving regular AEDs, with a SMR of 7.4 in this group compared with a SMR of 8.0 for those 20 patients considered poorly adherent. These findings show high mortality in patients with onchocerciasis-associated epilepsy despite regular AED treatment. Epilepsy appears to have a dramatic impact on this community with high Onchocerca volvulus infestation. If the suspected causal relationship between epilepsy and infection with O. volvulus could be confirmed, this would further underline the importance of sustained control efforts against onchocerciasis.

Adverse reactions to the ivermectin treatment of onchocerciasis patients: does infection with the human immunodeficiency virus play a role?

To assess and compare the adverse effects resulting from ivermectin treatment of onchocerciasis patients with and without infection with human immunodeficiency virus (HIV-1), 1256 Ugandan cases of onchocerciasis were investigated as they were treated for the first time with the drug. Treatment followed the protocol of the Mectizan Expert Committee (i.e. a single dose of 150 mug/kg body weight). Adverse reactions to the ivermectin were determined, within 48 h of treatment, through questioning and clinical examinations during house-to-house visits. The HIV-1 status of each patient aged >15 years was initially determined using indirect ELISA, and any ELISA-positives were then confirmed in a western-blot assay. Among the cases aged >15 years, the frequency of adverse reactions to ivermectin was higher among those seropositive for HIV-1 (53.4%) than among the seronegative (45.7%) but the difference was not statistically significant (P = 0.25). The severity of the adverse reactions observed was, however, significantly lower in the HIV-1-positive patients than in the seronegative patients, with median scores of 1.37 and 1.68, respectively (P = 0.044). The conclusion is that ivermectin can be safely used for mass treatment in areas where the prevalences of onchocerciasis and HIV-1 infection are both high.

Attitude of women in western Uganda towards pre-packed, unit-dosed malaria treatment for children.

In the context of a larger study on malaria related knowledge, attitudes, practices and beliefs in western Uganda 813 women aged 15-49 years were shown a sample of a pre-packed, unit-dosed malaria treatment for children, its use was explained and attitudes of the women were investigated. Of all women, 90.5% (86% urban, 92% rural) said they would prefer the pre-packed over the conventional type of treatment and 93.9% of these were willing to pay between 0.17 (rural) and 0.29 (urban) US dollars more for this treatment. Two-thirds (67.8%) thought that they would not have to ask their spouses before making a decision on the kind of treatment and 59.5% said they would rather stock the treatment at home than buy it when a child gets sick. The most mentioned reason for preferring pre-packs was their safety and cleanliness, while ease of application, dosing and compliance were secondary. We conclude that pre-packed, unit-dosed malaria treatment is accepted by the caretakers of children in the area studied and that they readily understand and accept its concept. This indicates a high potential for this approach to improve the home management of malaria fevers and reduce malaria-related morbidity and mortality if adequate coverage can be achieved and if the intervention is embedded into an appropriate programme of behavioural change communication and provider training.

User fees, health staff incentives, and service utilization in Kabarole District, Uganda.

OBJECTIVE: To determine the impact of user fees on the utilization of health services in a community-based cost-sharing scheme in Kabarole District, western Uganda. METHODS: Of the 38 government health units that had introduced user-fee financing schemes, 11 were included in the study. Outpatient utilization was assessed as the median number of visits per month before and after cost sharing began. FINDINGS: After the introduction of cost sharing, overall utilization of general outpatient services, assessed by combining the data from all the participating units, dropped by 21.3%. Utilization increased, however, in facilities located in remote areas, while it decreased in those located in urban or semi-urban areas. The increased utilization in remote facilities was considered to be largely attributable to health workers' incentive payments derived from cost-sharing revenues. CONCLUSIONS: Incentive payments led the health workers to offer improved services. Other factors may also have been influential, such as an improved drug supply to health facilities and increased public identification with community projects in remote areas.

The Simulium damnosum complex in western Uganda and its role as a vector of Onchocerca volvulus.

The status of onchocerciasis vectors in the former Ruwenzori focus in western Uganda was re-examined some 15 years after control measures against Simulium damnosum s.l. were suspended. The four cytoforms S. kilibanum, 'Sebwe', 'Nkusi' and S. pandanophilum were found. While the nonanthropophilic 'Sebwe' was still widely distributed in rivers north, east and south of the Ruwenzori, the only anthropophilic species and vector, S. kilibanum, had disappeared from most of its former habitats and was now restricted to two limited foci, where high biting densities were encountered. It was still a vector south of the Ruwenzori (Kasese focus), where 15.4% of the parous flies were infected with larval stages of Onchocerca volvulus and 34 infective larvae were found in the heads of 1000 parous flies. In the second focus along the Mahoma and Nsonge rivers, a chromosomally highly polymorphic population of S. kilibanum had replaced the former vector S. neavei, but does not act as a vector. Only 2.3% of the parous females were infected and just 1 infective larva was found in the heads of 1000 parous flies.

T cell responses in coinfection with Onchocerca volvulus and the human immunodeficiency virus type 1.

Onchocerca volvulus and the human immunodeficiency virus (HIV) are two immunocompromising infectious agents of major public health concern in Uganda. To examine the effect of coinfection with O. volvulus and HIV on cellular immune responses, lymphocyte proliferative responses and cytokine production of peripheral blood mononuclear cells (PBMC) from persons infected with O. volvulus with and without HIV type 1 infection were compared. Proliferation of PBMC to PHA and tuberculin (PPD) in coinfection was less (P = 0.08, P < 0.01) than in O. volvulus infection. O. volvulus extract stimulated lymphocyte proliferation in microfilaria-negative and HIV-negative O. volvulus infection while only an inconspicuous response was observed in microfilaria-negative coinfection. After stimulation of PBMC with PPD, the production of interferon-gamma (IFN-gamma), interleukin (IL)-4 and IL-5-demonstrated in O. volvulus infection-were reduced in coinfection with HIV (P < 0.01). While both groups failed to produce IFN-gamma in response to O. volvulus extract, only O. volvulus infected persons generated pronounced IL-5 and low IL-4 levels (0.01 > P = 0.02). The cellular immune responses in coinfection suggested an HIV-related lack of specific reactivity to O. volvulus antigen and impairment of IL-4 and IL-5 production in addition to the lack of IFN-gamma response on antigenic stimulation.

Antiepileptic drug treatment in rural Africa: involving the community.

The vast majority of patients with epilepsy in developing countries do not receive adequate medical treatment and an estimated percentage of 80-90% are without any treatment. Poor infrastructure, insufficient availability of drugs and scarcity of trained medical personnel are relevant factors for this situation. Traditional concepts about epilepsy may also affect acceptance and compliance to modern treatment. We report our experience with anti-epileptic drug (AED) treatment in a rural African community with a high prevalence of epilepsy. After identification of the patients during a prevalence survey on epilepsy, the input of the medical service of the district to the treatment scheme was reduced to a 6-monthly medical visit to the area and long-term provision of AED to the patients. Members of the community were integrated as assistants in the distribution of the drugs and community participation was gradually enhanced over the first year of the programme. A cost-sharing system for the financing of the community assistants was introduced and a self-help committee of epilepsy patients and their families was founded. Within the first 20 months the patients showed good compliance as indicated by a growing number of patients presenting for treatment and a low rate of discontinuation of the treatment. A marked improvement could be observed for most of the patients treated with phenobarbitone in terms of reduction of seizure frequency although complete seizure control was achieved in only a few.

PCR and DNA hybridization indicate the absence of animal filariae from vectors of Onchocerca volvulus in Uganda.

In order to identify Onchocerca volvulus larvae from vectors, DNA of filaria larvae from dissected blackflies was isolated, and a 150-bp long tandemly repeated DNA sequence (0-150), which occurs in many Onchocerca species, was amplified using polymerase chain reaction (PCR). Subsequently, the PCR product was blotted onto a nylon membrane and hybridized with DNA probes specific for O. volvulus or Onchocerca ochengi. Filaria larvae from 395 infected Simulium neavei were examined and 259 samples produced detectable PCR products. Among these samples, 239 (92%) reacted with an O. volvulus-specific oligonucleotide. A sample of 69 PCR products was tested using an O. ochengi DNA probe, but all failed to hybridize. Filaria larvae from 64 infected Simulium damnosum, presumably of the cytotypes "Nyamagasani" and "Nkusi" were studied and 0-150 was amplified from 38 samples. From these samples, 35 (92%) hybridized specifically with an O. volvulus probe but none with the O. ochengi-specific DNA sequence. Nonamplified samples were obtained mainly from blackflies that contained only 1 or 2 filaria larvae, and therefore, an insufficient DNA extraction was assumed. It can be concluded that few, if any, filaria species of animal origin were transmitted by S. neavei and S. damnosum s.l. in Kabarole and Kasese districts in Uganda.

Demonstration of immunoglobulin G antibodies against Onchocerca volvulus excretory-secretory antigens in different forms and stages of onchocerciasis.

The excretory-secretory (E-S) products of helminths are considered to comprise immunogenic molecules of high diagnostic value. In the present study, the serodiagnostic potential of the E-S products released in vitro by cultured female Onchocerca volvulus was investigated by enzyme-linked immunosorbent assay (ELISA) and Western blotting using 190 serum samples from persons infected with O. volvulus and unexposed persons. The sensitivity of detection of anti-O. volvulus E-S antibodies was 94% for sera from patients with the generalized form of onchocerciasis and 100% for sera from patients with the chronic hyperreactive form (sowda). 95% of the sera from amicrofilaridermic persons, who subsequently became microfilaridermic within 2 years, reacted with O. volvulus E-S antigens and the donors were therefore regarded as having had a prepatent infection when first examined. These sera gave higher (P < 0.05) ELISA optical densities than sera from the same persons obtained when they had become patent, indicating a loss of antibody reactivity after emergence of microfilariae. The specificity of the E-S ELISA was 100% when sera of subjects infected with Wuchereria bancrofti were used, and at least 88% for Mansonella perstans sera. In Western blot analysis, the sera of persons with generalized onchocerciasis recognized 7 protein bands. Many E-S proteins were stained less intensely by the sera of subjects with generalized onchocerciasis than by the sera of sowda patients. Similar antigen bands were demonstrated using sera from the persons with prepatent infections.

Sensitivity of a polymerase chain reaction-based assay to detect Onchocerca volvulus DNA in skin biopsies.

A polymerase chain reaction (PCR) of a 150-bp tandem repeat of Onchocerca volvulus (O-150) combined with Southern-blot hybridization to species-specific DNA probes was employed for DNA detection. O-150 was amplified from parasites originating from Uganda, Benin, Cameroon, Liberia, Ghana, Burkina Faso, Mali, and Zaire and was successfully hybridized to digoxigenin-labeled oligonucleotides. To investigate the sensitivity of the PCR, 2 skin biopsies were taken from each of 227 persons from Uganda with proven O. volvulus infections but with low microfilaria (mf) densities due to ivermectin treatment. One biopsy was tested by PCR and the other was digested using collagenase to assess the total number of mf. The PCR revealed 76.2% of the samples to be positive, and the collagenase method showed that 78.9% were positive, indicating similar sensitivity for the two methods. It is probable that for both techniques the biopsy must contain at least one live mf or fragments of a dead mf. In this study, no free or circulating O. volvulus DNA could be detected in skin biopsies by PCR.

HIV-preventive cognitions amongst secondary school students in Uganda.

A self-completion questionnaire was used to survey HIV-preventive cognitions among secondary school students in Kabarole district, Uganda. An encouraging pattern of HIV-preventive beliefs was observed, suggesting that health education efforts have been effective in establishing basic transmission knowledge, accurate risk perception and an understanding of effective precautions. Further analysis explored the prerequisites of men and women's HIV-preventive self-efficacy, and intentions and tolerance of people with AIDS. Approximately a third of variance in men and women's condom use self-efficacy, half the variance in women's condom use intentions and a quarter of the variance in men's condom use intentions was accounted for by specified variables. Results offered support for psychological relationships proposed by social cognition models and suggested specific health education targets for young Ugandan men and women.

PIP: Questionnaires administered to 387 young people (mean age, 18.8 years) from nine randomly selected rural and urban secondary schools in Uganda's Kabarole District confirmed the effectiveness of acquired immunodeficiency syndrome (AIDS) health education efforts in this population. 84.7% of students indicated they had received school-based AIDS education and the overall knowledge level was high, exemplified by the fact that 83% were aware that individuals infected with human immunodeficiency virus (HIV) can appear healthy. 37.1% of students perceived themselves as at risk of HIV infection in the next five years. On the other hand, 80.6% expressed the intent to use condoms and 73.1% felt able to acquire them. 73.1% opposed discrimination against persons with AIDS. Regression analysis indicated that about 25% of the variance in perceived condom use self-efficacy was accounted for by perceptions as to condom effectiveness. 49% of the variance in female's intention to use condoms was explained by self-efficacy, perceived condom effectiveness, perceived susceptibility to HIV, perceptions of AIDS severity, condom acquisition self-efficacy. and confidence in terms of partner discussions about sexual histories. In males, however, these six variables explained only 25% of the variance, suggesting that there are unidentified determinants of condom use. These findings did indicate a need for school-based skills development, possibly through role play, to reduce young people's discomfort with condom purchasing and discussions of sexual histories.

Facing the challenge: role of women community based organisations in the support of AIDS widows and orphans

With the increasing effects of HIV/AIDS in the two districts of Kabarole and Bundibugyo; the need to support widows and orphans has become more evident. To promote this support GTZ in collaboration with GDS introduced an NGO office to assist AIDS afflicated households through the women's community based organisations. The NGO/CBO aims at working with women at the grassroot to ensure sustainability of their activities and also to network with other organisations involved in similar activities. The NGO Office uses participatory techniques to monitor and evaluate the groups' income generating activities. The results; to date show that 45 women's groups have submitted requests for financial and technical assistance. 12 groups composed of 134 widows and 170 orphans have received funds for income generating projects. Activities include poultry; agriculture; brick making; zero grazing; purchase and sell of agricultural produce and small scale retail trade. Most of the groups lack the knowledge in financial management. Therefore; they require close supervision which is too expensive given the way they are spread out in the two districts. Secondly; a number of the hard hit areas are not easily accessible. Thirdly; the number of the existing community self help groups may not be satisfied due to limitation of funds. Experience shows that supporting such womens' self help community initiatives seems to be way of alleviating the consequences of HIV/AIDS on communities

Monitoring of primary health care services: an example from western Uganda.

Results from baseline and follow-up surveys of the Basic Health Services Program in Kabarole District, Western Uganda carried out in 1989 and 1991 are presented. Indicators in relation to management capability, infrastructure, levels of basic knowledge and skills of health staff, community involvement and utilization of health services were measured. Subjectivity of the data collection was minimized through use of a randomized study design, and external supervision. Comparability of results between the two surveys was assured by employing the same rapid assessment methodology, using a fixed set of indicators. The results suggest a marked improvement of the health services in Kabarole district since implementation of specific project activities and in direct response to action taken following review of information from the original survey work. Overall, it is felt that this particular method of project monitoring, and using the specific method, Systems' Analysis, generates data particularly useful to national governments and other health organizations.

Facing the challenge:role of women community based organisations in the support of AIDS widows and orphans

With the increasing effects of HIV/AIDS in the two districts of Kabarole and Bundibugyo; the need to support widows and orphans has become more evident. To promote this support GTZ in collaboration with GDS introduced an NGO office to assist AIDS afflicated households through the women's community based organisations. The NGO/CBO aims at working with women at the grassroot to ensure sustainability of their activities and also to network with other organisations involved in similar activities. The NGO Office uses participatory techniques to monitor and evaluate the groups' income generating activities. The results; to date show that 45 women's groups have submitted requests for financial and technical assistance. 12 groups composed of 134 widows and 170 orphans have received funds for income generating projects. Activities include poultry; agriculture; brick making; zero grazing; purchase and sell of agricultural produce and small scale retail trade. Most of the groups lack the knowledge in financial management. Therefore; they require close supervision which is too expensive given the way they are spread out in the two districts. Secondly; a number of the hard hit areas are not easily accessible. Thirdly; the number of the existing community self help groups may not be satisfied due to limitation of funds. Experience shows that supporting such womens' self help community initiatives seems to be way of alleviating the consequences of HIV/AIDS on communities