Controlling sleeping sickness - a review.

Following a period characterized by severe epidemics of sleeping sickness, restoration of effective control and surveillance systems has raised the question of eliminating the disease from sub-Saharan Africa. Given sufficient political and financial support, elimination is now considered a reasonable aim in countries reporting zero or less than 100 cases per year. This success may lead health authorities across the affected region to downgrade the disease from 'neglected' to simply being ignored. In view of the significant levels of under-reporting of sleeping sickness mortality in rural communities, this could be a short-sighted policy. Loss of capacity to deal with new epidemics, which can arise as a consequence of loss of commitment or civil upheaval, would have serious consequences. The present period should be seen as a clear opportunity for public-private partnerships to develop simpler and more cost-effective tools and strategies for sustainable sleeping sickness control and surveillance, including diagnostics, treatment and vector control.

Less is more: restricted application of insecticide to cattle to improve the cost and efficacy of tsetse control.

Studies were carried out in Zimbabwe of the responses of tsetse to cattle treated with deltamethrin applied to the parts of the body where most tsetse were shown to land. Large proportions of Glossina pallidipes Austen (Diptera: Glossinidae) landed on the belly ( approximately 25%) and legs ( approximately 70%), particularly the front legs ( approximately 50%). Substantial proportions of Glossina morsitans morsitans Westwood landed on the legs ( approximately 50%) and belly (25%), with the remainder landing on the torso, particularly the flanks ( approximately 15%). Studies were made of the knockdown rate of wild, female G. pallidipes exposed to cattle treated with a 1% pour-on or 0.005% suspension concentrate of deltamethrin applied to the (a) whole body, (b) belly and legs, (c) legs, (d) front legs, (e) middle and lower front legs, or (f) lower front legs. The restricted treatments used 20%, 10%, 5%, 2% or 1% of the active ingredient applied in the whole-body treatments. There was a marked seasonal effect on the performance of all treatments. With the whole-body treatment, the persistence period (knockdown > 50%) ranged from approximately 10 days during the hot, wet season (mean daily temperature > 30 degrees C) to approximately 20 days during the cool, dry season (< 22 degrees C). Restricting the application of insecticide reduced the seasonal persistence periods to approximately 10-15 days if only the legs and belly were treated, approximately 5-15 days if only the legs were treated and < 5 days for the more restricted treatments. The restricted application did not affect the landing distribution of tsetse or the duration of landing bouts (mean = 30 s). The results suggest that more cost-effective control of tsetse could be achieved by applying insecticide to the belly and legs of cattle at 2-week intervals, rather than using the current practice of treating the whole body of each animal at monthly intervals. This would cut the cost of insecticide by 40%, improve efficacy by 27% and reduce the threats to non-target organisms and the enzootic stability of tick-borne diseases.

Antioxidants promote establishment of trypanosome infections in tsetse.

Efficient, cyclical transmission of trypanosomes through tsetse flies is central to maintenance of human sleeping sickness and nagana across sub-Saharan Africa. Infection rates in tsetse are normally very low as most parasites ingested with the fly bloodmeal die in the fly gut, displaying the characteristics of apoptotic cells. Here we show that a range of antioxidants (glutathione, cysteine, N-acetyl-cysteine, ascorbic acid and uric acid), when added to the insect bloodmeal, can dramatically inhibit cell death of Trypanosoma brucei brucei in tsetse. Both L- and D-cysteine invoked similar effects suggesting that inhibition of trypanosome death is not dependent on protein synthesis. The present work suggests that antioxidants reduce the midgut environment protecting trypanosomes from cell death induced by reactive oxygen species.

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.

African trypanosomiasis.

Trypanosomiasis remains one of the most serious constraints to economic development in sub-Saharan Africa and, as a consequence, related research has been subject to strong social and political as well as scientific influences. The epidemics of sleeping sickness that occurred at the turn of the 20th Century focussed research efforts on what became known as 'the colonial disease'. This focus is thought to have produced 'vertical' health services aimed at this one disease, while neglecting other important health issues. Given the scale of these epidemics, and the fact that the disease is fatal if left untreated, it is unsurprising that sleeping sickness dominated colonial medicine. Indeed, recent evidence indicates that, if anything, the colonial authorities greatly under-estimated the mortality attributable to sleeping sickness. Differences in approach to disease control between Francophone and Anglophone Africa, which in the past have been considered ideological, on examination prove to be logical, reflecting the underlying epidemiological divergence of East and West Africa. These epidemiological differences are ancient in origin, pre-dating the colonial period, and continue to the present day. Recent research has produced control solutions, for the African trypanosomiases of humans and livestock, that are effective, affordable and sustainable by small-holder farmers. Whether these simple solutions are allowed to fulfil their promise and become fully integrated into agricultural practice remains to be seen. After more than 100 years of effort, trypanosomiasis control remains a controversial topic, subject to the tides of fashion and politics.

Extrachromosomal DNA of the symbiont Sodalis glossinidius.

The extrachromosomal DNA of Sodalis glossinidius from two tsetse fly species was sequenced and contained four circular elements: three plasmids, pSG1 (82 kb), pSG2 (27 kb), and pSG4 (11 kb), and a bacteriophage-like pSG3 (19 kb) element. The information suggests S. glossinidius is evolving towards an obligate association with tsetse flies.

Reanalyzing the 1900-1920 sleeping sickness epidemic in Uganda.

Sleeping sickness has long been a major public health problem in Uganda. From 1900 to 1920, more than 250,000 people died in an epidemic that affected the southern part of the country, particularly the Busoga region. The epidemic has traditionally been ascribed to Trypanosoma brucei gambiense, a parasite now confined to central and western Africa. The Busoga region still reports sleeping sickness, although it is caused by T.b. rhodesiense, commonly believed to have spread to Uganda from Zambia in the 1940s. Our analysis of clinical data recorded in the early 1900s shows that the clinical course of sleeping sickness cases during the 1900-1920 epidemic in Uganda was markedly different from T.b. gambiense cases, but similar to T.b. rhodesiense. These findings suggest that T.b. rhodesiense was present in Uganda and contributed to the epidemic. The historic context is reassessed in the light of these data.

Evidence for multiple origins of human infectivity in Trypanosoma brucei revealed by minisatellite variant repeat mapping.

In recent years a wide variety of biochemical and molecular typing systems has been employed in the study of parasite diversity aimed at investigating the level of genetic diversity and delineating the relationship between different species and subspecies. However, such methods have failed to differentiate between two of the classically defined subspecies of the protozoan parasite Trypanosoma brucei: the human infective, T. b. rhodesiense, which causes African sleeping sickness, and the non-human infective T. b. brucei. This has led to the hypothesis that T. b. rhodesiense is a host range variant of T. b. brucei. In this paper we test this hypothesis by examining highly polymorphic tandemly repeated regions of the trypanosome genome, i.e., minisatellite loci. We have employed the technique of minisatellite variant repeat mapping by PCR (MVR-PCR), which determines the distribution of variant repeat units along the tandem array of one minisatellite, MS42. The maps generated by this technique not only allow unequivocal allele identification but also contain within them cladistic information which we used to determine the possible genetic relationship between the different subspecies of T. brucei. Our findings revealed that human infective (T. b. rhodesiense) isolates from Uganda are more closely related to the local non-human infective isolates (T. b. brucei) than they are to other human infective stocks from different regions, suggesting that human infectivity has originated independently in these different geographical regions. This would infer that the separate classification of all human infective stocks from East Africa into the subspecies T. b. rhodesiense is genetically inappropriate and it would be better to consider geographically separate populations as host range variants of T. brucei brucei or perhaps as a series of different subspecies. Based on these data, it is clear that MVR mapping is a very useful tool for the analysis of zoonotic eukaryotic pathogens where delineation of the origins of outbreaks of disease and definition of human infective strains are key questions.

Trypanosomiasis control.

In July 2000, Heads of State of the 36th Session of the Organisation for African Unity signed a potentially important declaration on African trypanosomiasis, urging member states "to act collectively to rise to the challenge of eliminating the problem through concerted efforts in mobilising the necessary human, financial and material resources required to render Africa tsetse-free within the shortest time possible". To many, such an ambitious dream is received with some scepticism, recalling the doubts that surrounded a similar declaration signed in Brasilia in 1991, which paved the way for the Southern Cone Initiative against American trypanosomiasis (Chagas disease). True, the two diseases are quite different. But the operational challenges are quite similar, and there are sufficient biological parallels to suggest that the Latin American experience in controlling Chagas disease may provide a useful model for the control of African trypanosomiasis.

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 Fèvre, 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.

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.

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.

Minisatellite marker analysis of Trypanosoma brucei: reconciliation of clonal, panmictic, and epidemic population genetic structures.

The African trypanosome, Trypanosoma brucei, has been shown to undergo genetic exchange in the laboratory, but controversy exists as to the role of genetic exchange in natural populations. Much of the analysis to date has been derived from isoenzyme or randomly amplified polymorphic DNA data with parasite material from a range of hosts and geographical locations. These markers fail to distinguish between the human infective (T. b. rhodesiense) and nonhuman infective (T. b. brucei) "subspecies" so that parasites derived from hosts other than humans potentially contain both subspecies. To overcome some of the inherent problems with the use of such markers and diverse populations, we have analyzed a well-defined population from a discrete geographical location (Busoga, Uganda) using three recently described minisatellite markers. The parasites were primarily isolated from humans and cattle with the latter isolates further characterized by their ability to resist lysis by human serum (equivalent to human infectivity). The minisatellite markers show high levels of polymorphism, and from the data obtained we conclude that T. b. rhodesiense is genetically isolated from T. b. brucei and can be unambiguously identified by its multilocus genotype. Analysis of the genotype frequencies in the separated T. b. brucei and T. b. rhodesiense populations shows the former has an epidemic population structure whereas the latter is clonal. This finding suggests that the strong linkage disequilibrium observed in previous analyses, where human and nonhuman infective trypanosomes were not distinguished, results from the treatment of two genetically isolated populations as a single population.

Trypanosoma brucei: identification of trypanosomes with genotypic similarity to human infective isolates in tsetse isolated from a region free of human sleeping sickness.

In previous work, we have developed a molecular method that defines genotypes of Trypanosoma brucei and allows distinction of the human-infective subspecies T. b. rhodesiense from the non-human-infective T. b. brucei without recourse to measurement of resistance to lysis by human serum. Using this approach, we are also able to determine the geographical range of specific genotypes associated with a particular focus. In this study, we have characterised T. brucei isolates collected from tsetse in a region where human sleeping sickness has never been reported and which is some 500 km from the Busoga sleeping sickness focus of Uganda. We show that some of the trypanosome isolates taken from tsetse in this region have considerable genotypic similarity to trypanosomes from the Busoga focus, demonstrating a surprisingly wide dispersal of these trypanosome genotypes. Furthermore, the similarity of these genotypes to human-infective trypanosomes in the Busoga focus suggest the possible circulation of human-infective trypanosomes in this location. We also demonstrate that the genetic diversity in trypanosomes isolated from tsetse is significantly higher than that in those isolated from humans, confirming other studies that show that there exists a significant restriction in the range of genotypes that can be transmitted to humans.

Tsetse-trypanosome interactions: rites of passage.

Trypanosomes that cause sleeping sickness (Trypanosoma brucei rhodesiense and T. b. gambiense) are entirely dependent on tsetse for their transmission between hosts, but the flies are not easily infected. This situation has not arisen by chance - the tsetse has evolved an efficient defence system against trypanosome invasion. In this review, Susan Welburn and Ian Maudlin chart the progress of trypanosomes through the fly and identify some of the hazards faced by both parasite and fly that affect vector competence of tsetse.

Sodalis gen. nov. and Sodalis glossinidius sp. nov., a microaerophilic secondary endosymbiont of the tsetse fly Glossina morsitans morsitans.

A secondary intracellular symbiotic bacterium was isolated from the haemolymph of the tsetse fly Glossina morsitans morsitans and cultured in Aedes albopictus cell line C6/36. Pure-culture isolation of this bacterium was achieved through the use of solid-phase culture under a microaerobic atmosphere. After isolation of strain M1T, a range of tests was performed to determine the phenotypic properties of this bacterium. Considering the results of these tests, along with the phylogenetic position of this micro-organism, it is proposed that this intracellular symbiont from G. m. morsitans should be classified in a new genus Sodalis gen. nov., as Sodalis glossinidius gen. nov., sp. nov. Strain M1T is the type strain for this new species.

Trypanosome infections and survival in tsetse.

The effect of trypanosome infection on vector survival was observed in a line of Glossina morsitans selected for susceptibility to trypanosome infection. The differential effects of midgut and salivary gland infections on survival were examined by exposing flies to infection with either Trypanosoma congolense which colonizes midgut and mouthparts or Trypanosoma brucei rhodesiense which colonizes midgut and salivary glands. A comparison of the survival distributions of uninfected flies with those exposed to infection showed that salivary gland infection significantly reduces tsetse survival; midgut infection had little or no effect on the survival of tsetse. The significance of these findings is discussed in relation to the vectorial capacity of wild flies.

Trypanosoma brucei: comparison of circulating strains in an endemic and an epidemic area of a sleeping sickness focus.

Human sleeping sickness in East Africa is characterized by periods of long-term endemicity interspersed with short-term epidemics. The factors generating these huge changes are largely uncharacterized but probably reflect complex interactions among socioeconomic factors, ecological factors, and the movement and diversity of trypanosome strains. To investigate the role of trypanosome strains in the generation of these epidemics, we addressed two important questions. (1) Are the trypanosome strains circulating within a focus the same during times of endemicity and during an epidemic? (2) How stable are trypanosome strains within a single animal reservoir host? Using restriction fragment length polymorphism analysis of repetitive DNA, we have examined the relationship between Trypanosoma brucei isolates, taken from the Busoga focus of human sleeping sickness, during an endemic period (Busia, Kenya, 1993-1994) and stocks isolated during an epidemic period (Tororo, Uganda, 1988-1990). We show that similar strains, including human infective strains, are circulating in domestic cattle (the most significant animal reservoir) in both epidemic and endemic areas of the Busoga focus. Furthermore, we show the important finding that individual animals harbor the same genotype of T. brucei for a period of time and may be clonal for a given parasite strain.

Control of Trypanosoma brucei brucei infections in tsetse, Glossina morsitans.

Numbers of immature Trypanosoma brucei brucei within a tsetse midgut remain remarkably constant after establishment throughout the course of an infection, irrespective of whether the infection eventually matures. These results suggest a system of self regulation of the parasite population in the insect gut based on a form of programmed cell death which would carry advantages for both the parasite and the vector.