High prevalence of cysticercosis in people with epilepsy in southern Rwanda

The Vicious Worm education tool improves the knowledge of community health workers on Taenia solium cysticercosis in Rwanda

The pork tapeworm Taenia solium causes human taeniasis and cysticercosis when ingested as viable cysts and eggs, respectively. Despite its high health burden in low-income countries, knowledge of the parasite in endemic areas such as Rwanda is often limited. Here, we assess whether The Vicious Worm education software can increase knowledge in endemic areas of Rwanda. A cross-sectional mixed-methods study was conducted to evaluate knowledge about T. solium among community health workers trained using the Vicious Worm education software. Knowledge was assessed before, immediately after, and four weeks after the training. The health workers perceptions of the software were analysed thematically. A total of 207 community health workers were recruited from Nyamagabe district in Southern Province, Rwanda. Participants were composed of males (33.5%) and females (66.5%), aged between 22 and 68 years, and most (71%) had only completed primary education. Knowledge of cysticercosis at baseline was low, particularly knowledge of human cysticercosis and neurocysticercosis. The overall knowledge score increased significantly after training and was maintained four weeks after the training. Overall, insufficient knowledge was associated with neurocysticercosis-related questions, which after the training, remained relatively lower compared to questions of other categories. Participants reported the software to be user-friendly and educational. Digital illiteracy and the lack of smartphones were among the critical challenges highlighted in responses. This study has shown gaps in knowledge regarding T. solium infections within rural Rwanda, particularly neurocysticercosis. Health education using the Vicious Worm education software should be considered in integrated control programs.

Very high epilepsy prevalence in rural Southern Rwanda: The underestimated burden of epilepsy in sub-Saharan Africa

OBJECTIVES

Up to 85% of people living with epilepsy (PwE) reside in low-and middle-income countries. In sub-Saharan Africa, the lifetime prevalence of epilepsy is 16 per 1000 persons. In Northern rural Rwanda, a 47.7 per 1000 prevalence has been reported. As variations in prevalence across geographical areas have been observed, we studied the prevalence in Southern rural Rwanda using the same robust methodology as applied in the North.

METHODS

We conducted a three-stage, cross-sectional, door-to-door survey in two rural villages in Southern Rwanda from June 2022 to April 2023. First, trained enumerators administered the validated Limoges questionnaire for epilepsy screening. Second, neurologists examined the persons who had screened positively to confirm the epilepsy diagnosis. Third, cases with an inconclusive assessment were separately reexamined by two neurologists to reevaluate the diagnosis.

RESULTS

Enumerators screened 1745 persons (54.4% female, mean age: 24 ± 19.3 years), of whom 304 (17.4%) screened positive. Epilepsy diagnosis was confirmed in 133 (52.6% female, mean age: 30 ± 18.2 years) and active epilepsy in 130 persons. Lifetime epilepsy prevalence was 76.2 per 1000 (95% CI: 64.2-89.7‰). The highest age-specific rate occurred in the 29-49 age group. No gender-specific differences were noted. In 22.6% of the PwE, only non-convulsive seizures occurred. The treatment gap was 92.2%, including a diagnosis gap of 79.4%.

CONCLUSION

We demonstrated a very high epilepsy prevalence in Southern rural Rwanda, with over 20% of cases having only non-convulsive seizures, which are often underdiagnosed in rural Africa. In line with previous Rwandan reports, we reiterate the high burden of the disease in the country. Geographic variation in prevalence throughout Africa may result from differences in risk and aetiological factors. Case-control studies are underway to understand such differences and propose adapted health policies for epilepsy prevention.

The prevalence of and contributors to neurocysticercosis in endemic regions

BACKGROUND

Neurocysticercosis is one of the most common causes of acquired epilepsy worldwide. Caused by Taenia solium, the infection uses pigs as an intermediate host and thus is often associated with proximity to and consumption of pigs.

OBJECTIVE

This review explores the epidemiology of neurocysticercosis in endemic regions across Africa, Asia, and Latin America and examines common risk factors in these areas.

METHODS

A literature review was conducted using pubmed to search for articles with key words including neurocysticercosis, Taenia, solium, epidemiology, and the names of countries and continents in the regions of interest.

FINDINGS

Multiple risk factors for neurocysticercosis were identified, including inadequate regulation of pig farms and food safety, poor sanitation, and water contamination. In addition, additional barriers to appropriate diagnosis and management were found, including resource limitations and poor health literacy.

CONCLUSION

Despite its global prevalence, effective limitation of neurocysticercosis is still achievable through projects which address common risk factors.

Prevalence of Epilepsy, Human Cysticercosis, and Porcine Cysticercosis in Western Kenya

Cysticercosis is the leading cause of acquired epilepsy worldwide and has been shown to be highly prevalent in pig populations in western Kenya. We conducted a community-based door-to-door survey in a region of western Kenya with a high proportion of pig-keeping households. Persons with epilepsy (PWE) were determined using a screening questionnaire followed by a neurologist evaluation. Cysticercosis serum apDia antigen ELISAs and Western blot for LLGP and rT24h antigen were performed on all PWE and 2% of screen-negative patients. All PWE or people with positive apDia underwent contrast-enhanced brain computed tomography (CT). Of a sample of 810 village residents, 660 (81%) were present in the homestead, of whom 648 (98%) participated. Of these, 17 were confirmed to have lifetime epilepsy, an estimated crude prevalence of 2.6%. No humans with (N = 17) or without (N = 12) epilepsy had serological evidence of cysticercosis infection. Fourteen PWE and one individual with borderline positive apDia antigen ELISA underwent brain CT; none had radiographic findings consistent with neurocysticercosis. Nearly 30% of households kept pigs, with 69% always tethered in both wet and dry seasons. More than 8% (6/72) of pigs had palpable lingual cysts; these pigs all originated from homesteads with latrines, one-third of which were free-ranging at least some of the time. Epilepsy prevalence in our study was greater than the national prevalence, but we found no individuals with epilepsy attributable to cysticercosis. Additional studies are required to identify causes of epilepsy, human and porcine cysticercosis, the role of spatial clustering, and protective factors like host-pathogen immunity.

Using a Value Chain Approach to Map the Pig Production System in Rwanda, Its Governance, and Sanitary Risks

Rwanda has a fast growing pig production sector projected to continue expansion, due to rising local and regional demand. We undertook a value chain analysis to establish the flows of pigs and pork in Rwanda and the roles of various actors involved, and to understand governance and sanitary risks in the value chain. Cross-sectional qualitative data were collected through focus group discussions and key informant interviews with farmers, brokers, butchers, abattoir managers, and veterinarians. Data were collected on pig production methods and inputs, the source and destination of live and slaughtered pigs, value-adding infrastructures (abattoirs and processing factories), the people involved and interactions between them, governance, and challenges. Pig production in Rwanda is dominated by smallholders, mainly as a source of supplementary income and secondarily for manure. Emerging medium-sized and large pig farms were also identified, located mainly around urban areas. Live pig markets are the main mechanism allowing various actors to buy/sell pigs. Brokers have an important role in pig transactions: they are key in setting prices at markets, examining pigs for disease, organising the supply of pigs for abattoirs and for export. Only a few formal pig abattoirs were identified, which mainly supply to pork processing factories based in Kigali and/or export to customers. Local consumers rely on informal slaughtering at farm or bar/restaurant backyards, with irregular veterinary inspection. Formal abattoirs were attended by a veterinary inspector, however a lack of record keeping was noted. Sanitary risks identified were a lack of biosecurity throughout the chain and poor hygiene at slaughter places. Lingual palpation was practised in pig markets to identify cysticercosis infection, however cyst-positive pigs were not destroyed, but were sold for reduced prices in the same market or later informally sold by the owner. There are few veterinarians attending farms, with most services provided by less qualified technicians or self-treatment of pigs by farmers. Overall, this production system is characterised by a high degree of informality at all nodes, combined with the rapid growth trajectory in the sector. These findings provide a basis to plan interventions tailored to vulnerabilities identified in the Rwanda pig value chain.

High prevalence of neurocysticercosis among patients with epilepsy in a tertiary care hospital of Assam, India

Background:

Neurocysticercosis (NCC) is a parasitic disease of the central nervous system, which is caused by the metacestode of the pork tapeworm, Taenia solium. The present unicentric, hospital-based, cross-sectional study was undertaken to assess the contribution of NCC as a cause of active epilepsy among patients attending a tertiary health care center in Assam, India.

Materials and Methods:

Over a period of 2 years, 152 active epilepsy patients were investigated based on clinical, epidemiological, neuroimaging (contrast-enhanced computerized tomography), and immunological techniques to establish the diagnosis of NCC. A precoded questionnaire was administered to patients and/or guardians to collect detailed medical history.

Results:

Ninety-three cases (61.2%) fulfilled either definitive or probable diagnostic criteria for NCC. Anti-cysticercus immunoglobulin G antibodies were detected by ELISA and enzyme electro-immune transfer blot in 69 (45.4%) active epilepsy patients. Seroprevalence was higher in males, 46.6% (54/116); than in females, 41.7% (15/36), and increased significantly with age; peaking in the 20–39 years age group (36/76; χ² = 5.64; P = 0.02). Among the seropositive cases, 54 (78.3%) were diagnosed with NCC. A significantly higher number of seropositive individuals were diagnosed with NCC in the 20–39 years age group as compared to the 40 years and above age group (χ² = 6.28; P = 0.01). The association between seropositivity for NCC, and the number of lesions in the brain was statistically significant (χ² = −8.33; P = 0.003).

Conclusions:

This study indicates that NCC is a major cause of active epilepsy in Assam. A high prevalence of pediatric NCC is also a major concern.

Seroprevalence of Cysticercosis among Epileptic Patients Attending Neurological Units in the Urban Area of Abidjan

Cysticercosis is one of the main causes of secondary epilepsy in sub-Saharan Africa. To estimate the seroprevalence of cysticercosis among epileptic patients, we conducted a cross-sectional study of patients attending neurology consultation in Abidjan, Côte d'Ivoire. Methods: Patients' socio-demographic and lifestyle data were collected as well as blood samples for serological testing using ELISA and Western blot based on IgG antibodies detection. For qualitative variables comparison, Chi2 or Fisher tests were used; a Student's t-test was used to compare quantitative variables. A multivariate logistic regression model was fit to identify risks factors. Results: Among 403 epileptic patients included in the study, 55.3% were male; the median age was 16.9 years; 77% lived in Abidjan; 26.5% were workers. Most patients included in the study had tonic-clonic seizures (80%), and 11.2% had focal deficit signs. The seroprevalence of cysticercosis was 6.0%. The risk was higher in patients over 30 years old (aOR = 5.1 (1.3-20.0)) than in patients under 16. The risk was also considerably high in patients who reported epileptics in the family (aOR = 5 (1.7-14.6)). The risk was three-fold less in females than in males. Conclusions: This study highlighted the exposure of epileptic patients to Taenia solium larvae in an urban area. The risk of positive serology was increased with age, male gender, and family history of epilepsy.

Evidence for Transmission of Taenia solium Taeniasis/Cysticercosis in a Rural Area of Northern Rwanda

Cysticercosis is a parasitic infection caused by the metacestode larval stage (cysticercus) of Taenia solium. In humans, cysticercosis may infect the central nervous system and cause neurocysticercosis, which is responsible for over 50,000 deaths per year worldwide and is the major cause of preventable epilepsy cases, especially in low-income countries. Cysticercosis infection is endemic in many less developed countries where poor hygiene conditions and free-range pig management favor their transmission. A cross-sectional study was conducted in 680 children from a rural primary school in Gakenke district (Northern province of Rwanda). Stool samples were collected from participants and analyzed using the Kato-Katz method (KK), formol-ether concentration (FEC), and/or copro-antigen enzyme-linked immunosorbent assay (CoAg-ELISA) to detect taeniasis. Blood samples were collected and analyzed using enzyme-linked immunoelectrotransfer blot (EITB) and antigen enzyme-linked immunosorbent assay (Ag-ELISA) to detect human cysticercosis. The overall proportion of taeniasis positivity was 0.3% (2/680), and both cases were also confirmed by CoAg-ELISA. A total of 13.3% (76/572) of the children studied were positive to cysticercosis (T. solium-specific serum antibodies detected by EITB), of whom 38.0% (27/71) had viable cysticercus (T. solium antigens by Ag-ELISA). This study provides evidence of the highest cysticercosis prevalence reported in Rwanda in children to date. Systematic investigations into porcine and human cysticercosis as well as health education and hygiene measures for T. solium control are needed in Gakenke district.

A Novel, Highly Sensitive Quantitative Polymerase Chain Reaction Assay for the Diagnosis of Subarachnoid and Ventricular Neurocysticercosis and for Assessing Responses to Treatment

BACKGROUND

Treatment of subarachnoid neurocysticercosis (NCC) is complicated, and assays that can guide treatment are not widely available. The reproducibility and scalability of molecular-based biomarkers would be of great use.

METHODS

The Taenia solium genome was mined and primers and probes were designed to target repeats with the highest coverage; the most sensitive, specific, and efficient repeat (TsolR13) was selected for clinical testing. We tested 46 plasma samples and 36 cerebral spinal fluid (CSF) samples taken from patients with subarachnoid or ventricular disease using quantitative polymerase chain reaction (qPCR).

RESULTS

The analytic sensitivity of TsolR13 was 97.3% at 240 attograms (ag) of T. solium genomic DNA and 100% analytic specificity. The clinical sensitivity in detecting active subarachnoid or ventricular disease in symptomatic patients was 100% in CSF and 81.3% in plasma. The predictive ability to distinguish active from cured disease was better for CSF (94.4% of those cured had negative qPCR results) than for plasma (86.7% of those cured tested negative). Some subjects also had plasma DNA detectable intermittently for years after being cured. Overall, the test performance was equivalent to T. solium antigen detection.

CONCLUSIONS

A qPCR test for the detection of the highly repetitive Tsol13 sequence has been developed and shown to be highly sensitive and specific for NCC, but also useful as a test of cure in CSF and for the definitive diagnosis of NCC in plasma.

Prevalence of Swine Gastrointestinal Parasites in Nyagatare District, Rwanda

While pig farming has been growing rapidly in Rwanda, its potential contribution to the prevalence of zoonotic infections is not well known. Pig production is usually affected by gastrointestinal parasites, some of which are zoonotic and can threaten human health. The knowledge about the status of such infections is essential for policy decisions and interventions. We aimed to investigate the prevalence of swine gastrointestinal parasites in Nyagatare district, Rwanda. A cross-sectional study involved collecting 104 faecal samples from apparently healthy pigs. The floatation technique was used to identify the parasites and frequency distribution analysis, and Pearson chi-square tests of association were conducted for this study data. Overall, the prevalence of swine gastrointestinal parasites was 84.6%, and the predominant species were Strongyle-type helminths representing 70.2%, followed by coccidia (55.8%), Strongyloides ransomi (39.4%), and Ascaris suum (10.6%). Of all parasitized pigs (n = 88), 84.1% developed coinfections involving 2, 3, or 4 different parasite species. The results showed a statistically significant correlation between the location of pigs and parasitic infections and that some prevalent parasites are zoonotic. Interventions among pig farmers in Nyagatare should aim to improve awareness and to provide information on the negative impacts of swine gastrointestinal parasites on pig production and human health.

Unique Characteristics of Epilepsy Development in Neurocysticercosis

The parasitic helminth infection neurocysticercosis (NCC) is the most common cause of adult-acquired epilepsy in the world. Despite the serious consequences of epilepsy due to this infection, an in-depth review of the distinct characteristics of epilepsy due to neurocysticercosis has never been conducted. In this review, we evaluate the relationship between NCC and epilepsy and the unique characteristics of epilepsy caused by NCC. We also discuss recent advances in our understanding of NCC-related epilepsy, including the importance of anti-inflammatory therapies, the association between NCC and temporal lobe epilepsy, and the recent discovery of biomarkers of severe epilepsy development in individuals with NCC and seizures.

Taenia solium cysticercosis and taeniasis in urban settings: Epidemiological evidence from a health-center based study among people with epilepsy in Dar es Salaam, Tanzania

In Africa, urbanization is happening faster than ever before which results in new implications for transmission of infectious diseases. For the zoonotic parasite Taenia solium, a major cause of acquired epilepsy in endemic countries, the prevalence in urban settings is unknown. The present study investigated epidemiological, neurological, and radiological characteristics of T. solium cysticercosis and taeniasis (TSCT) in people with epilepsy (PWE) living in Dar es Salaam, Tanzania, one of the fastest growing cities worldwide. A total of 302 PWE were recruited from six health centers in the Kinondoni district of Dar es Salaam. Serological testing for T. solium cysticercosis-antigen (Ag) and -antibodies (Abs) and for T. solium taeniasis-Abs was performed in all PWE. In addition, clinical and radiological examinations that included cranial computed tomography (CT) were performed. With questionnaires, demographic data from study populations were collected, and factors associated with TSCT were assessed. Follow-up examinations were conducted in PWE with TSCT. T. solium cysticercosis-Ag was detected in three (0.99%; 95% CI: 0–2.11%), -Abs in eight (2.65%; 95% CI: 0.84–4.46%), and taeniasis-Abs in five (1.66%; 95% CI: 0.22–3.09%) of 302 PWE. Six PWE (1.99%; 95% CI: 0.41–3.56%) were diagnosed with neurocysticercosis (NCC). This study demonstrates the presence of TSCT in Dar es Salaam, however, NCC was only associated with a few cases of epilepsy. The small fraction of PWE with cysticercosis- and taeniasis-Abs may suggest that active transmission of T. solium plays only a minor role in Dar es Salaam. A sufficiently powered risk analysis was hampered by the small number of PWE with TSCT; therefore, further studies are required to determine the exact routes of infection and risk behavior of affected individuals.

Taenia solium cysticercosis and taeniasis is a zoonotic disease complex which affects thousands of people in sub-Saharan Africa. This parasite has a human-pig life cycle and has been considered a public health problem mainly in rural areas. As African towns and suburbs grow rapidly and disproportionally, adequate infrastructure such as sewage systems and clean water often lack while population density, trade, and travel increase. This may lead to the appearance of parasitic diseases formerly considered `rural´ in urban settings. In this study, we searched for evidence of T. solium infections in the Kinondoni district of Dar es Salaam, Tanzania. We focused on people with epilepsy (PWE) since epilepsy is one of the most common and severe disorders associated with T. solium neurocysticercosis and tested all of them serologically for T. solium cysticercosis and taeniasis. We further investigated neurological and radiological characteristics. Our findings show that in our study area in Dar es Salaam 2.65% of PWE had contracted T. solium infection at some stage. Neurocysticercosis, as confirmed by neuroimaging, was found only in 1.99% of PWE. This, in combination with the relatively small number of PWE detected with taeniasis antibodies (1.66%), points towards the fact that active transmission of T. solium seems to play only a minor role in this urban setting, suggesting that infections may mainly be contracted in rural areas. Further large-scale studies are required to investigate the infection pathways and risk behavior related to T. solium infections within urban areas of sub-Saharan Africa.

Taenia solium cysticercosis in West Africa: status update

Cysticercosis is caused by the larvae of the cestode Taenia solium. Few data are available on the prevalence of this disease in pigs and humans in West African countries. The aim of this study was to provide an overview of existing data concerning the spread of this parasitosis in the countries of the Economic Community of West African States (ECOWAS) on the basis of the literature published over the last five decades. Systematic searches for publications were carried out on PubMed and Google Scholar, as well as in certain regional and local journals. From a total of 501 articles initially retrieved concerning T. solium cysticercosis in West African countries, only 120 articles were relevant for this review and therefore finally retained. For pigs, only eight out of sixteen countries of the region have reported porcine cysticercosis. Post-mortem examination of carcasses at slaughterhouses, meat inspection at butcheries or tongue inspection in herds have been the main source of data, but may not entirely reflect actual parasite distribution. For humans, only five out of sixteen countries reported epidemiological data on neurocysticercosis. Most data referred to neurocysticercosis prevalence among epileptic patients or isolated clinical cases. Furthermore, existing data are often old. Overall, T. solium cysticercosis remains largely neglected in West Africa, and its prevalence appears not to be affected by any religion in particular. There is an urgent need to promote and implement health partnerships and programs on this disease in order to collect more data and identify sensitive populations in the countries of the ECOWAS area.

An epidemiological survey of the magnitude and local perceptions of porcine cysticercosis by two methods in Nyaruguru district, Rwanda

This study investigated the magnitude of porcine cysticercosis (PC), its risk factors, economic effects and the perceptions of 80 pig farmers from Nyabimata (n = 38) and Muganza (n = 42) and 20 registered butchers in the Nyaruguru district of Rwanda. January to December 2013 slaughter records from Kamirabagenzi market were also analysed for PC diagnoses based on the tongue test and meat inspection. During this period, the responding farmers' records showed a tongue test-based PC magnitude (3.9%, n = 984) which was lower than the collective tongue test-based PC magnitude of 9.2% (n = 1720) at Kamirabagenzi (p < .05). The overall magnitude of PC based on routine meat inspection diagnosis at Kamirabagenzi was 4%. The overall magnitude of PC for respondents using Free-range production systems (7.9%) was significantly greater than for those in Semi-intensive (2.1%) and Intensive production systems (1.5%) (p < .05). Though most farmers (90%) knew that PC is zoonotic, only 22.5% of the farmers opted for treatment of PC-infected pigs and 52.5% were willing to seek veterinary inspection while the rest (25%) opted to circumvent veterinary inspection (P > .05). Most butchers (70%) indicated they would circumvent veterinary inspection and continue to slaughter PC-positive animals whilst the rest (30%) indicated they would resell PC positive animals to defray costs (P < .05). The low sensitivity and specificity of methods used for PC detection in the study, implies that this may just be the tip of an iceberg and the actual magnitude is most likely to be much higher. In conclusion, PC is endemic in the Nyaruguru district of Rwanda with a high proportion of positive animals. The condition has public health implications and is worsening the economic plight of the impoverished Nyaruguru community.

A Stratified Analysis of Clinical Manifestations and Different Diagnostic Methods of Neurocysticercosis-Suspected Tamilian Population Residing in and Around Puducherry

INTRODUCTION

Human beings are accidental hosts for Cysticercus cellulosae showing varied clinical manifestations based on the site harbored by the parasitic cyst because of which disease profile remains unexplored at large. Besides this, diagnosis of the disease with a single conventional method is problematic due to lack of specificity and sensitivity.

AIM

To assess the varied clinical manifestations and stratify based on imaging and serological methods for diagnosis of Neurocysticercosis (NCC) in our study population.

MATERIALS AND METHODS

A hospital-based study was carried out at Jawaharlal Institute of Post-Graduate Medical Education and Research (JIPMER), the tertiary care centre caters patients from Puducherry and surrounding regions of Tamil Nadu. This is a cross-sectional analysis of clinically and radiologically suspected cases of NCC (n=119) for a period of three years (2012 to 2015). The collection of detailed clinical history and imaging findings (MRI or CT) along with the lifestyle parameters was done after obtaining informed consent. Enzyme-Linked Immune-Electro Transfer Blot (EITB) was carried out for the samples collected from study subjects.

RESULTS

Based on dietary and environmental factors non-vegetarians, pork eaters, raw vegetable consumers and open-field defecation showed significant seropositivity. The clinical manifestations like seizures, blurring of vision and chronic headache with nausea followed by neck pain, cognitive deficits and movement disorder have higher seropositivity respectively. Generalized seizures were found to be more than focal seizures. While comparing the imaging and serological tests for NCC diagnosis, the positivity rate was 46.2% considering positive by both methods; but 18.5% of sero-positive cases were imaging negative, and 16% of the sero-negative cases were imaging positive. The study showed a predominance of multiple cysts (62%) in cases with cystic lesions.

CONCLUSION

This study is first of its kind in associating varied and less commonly explored clinical manifestations with two different diagnostic measures in practice and its importance among our study settings. These manifestations must be considered as strong disease entities of NCC, which has to be suggested for differential diagnosis, and cannot be left ignored. Combinatorial diagnostic methods like serology and imaging techniques should be followed in diagnosis and assessing the disease burden.

Health service provision for people with epilepsy in sub-Saharan Africa: A situational review

BACKGROUND

Epilepsy is a public health issue in sub-Saharan Africa (SSA) where many people with the condition receive no treatment. Health-care services for epilepsy in this region have not been comprehensively assessed. We examined key features of epilepsy health services provided in SSA.

METHODOLOGY

This was a scoping review conducted using pre-specified protocols. We implemented an electronic search strategy to identify relevant citations using PUBMED, EMBASE, Web of Science, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), African Index Medicus (AIM), Open Grey, Cochrane database, and Google Scholar. Articles eligible for full-text review were screened and data of interest were reported.

RESULT

The search identified 81 eligible articles, forty-nine from East Africa, 19 from West Africa, 8 from South Africa, and 5 from Central Africa. A variety of care services were identified, with reporting of rural epilepsy care in 75% of retrieved articles mainly from East and South African countries. The majority of the rural epilepsy clinics were health worker- or nurse-led, reporting good seizure control in about two-thirds of patients using phenobarbital as the most commonly prescribed antiepileptic drug. Funding for rural epilepsy care came mainly from external donor agencies.

CONCLUSION

We attempted to provide a 'snapshot' of epilepsy care services in SSA. The successes achieved in some of the centers are due to the use of existing primary health-care systems and employing non-physician health-care personnel. The true picture of epilepsy care coverage is not apparent due to the lack of data and proper health system structure in most parts of SSA. As more individuals begin to receive care, the long-term funding for epilepsy care in African countries will depend on the commitment of their respective governments.

Validity of a PCR assay in CSF for the diagnosis of neurocysticercosis

Objective:

To prospectively evaluate the validity of a PCR assay in CSF for the diagnosis of neurocysticercosis (NC).

Methods:

We conducted a multicenter, prospective case-control study, recruiting participants from 5 hospitals in Cuenca, Ecuador, from January 2015 to February 2016. Cases fulfilled validated diagnostic criteria for NC. For each case, a neurosurgical patient who did not fulfill the diagnostic criteria for NC was selected as a control. CT and MRI, as well as a CSF sample, were collected from both cases and controls. The diagnostic criteria to identify cases were used as a reference standard.

Results:

Overall, 36 case and 36 control participants were enrolled. PCR had a sensitivity of 72.2% (95% confidence interval [CI] 54.8%–85.8%) and a specificity of 100.0% (95% CI 90.3%–100.0%). For parenchymal NC, PCR had a sensitivity of 42.9% (95% CI 17.7%–71.1%), and for extraparenchymal NC, PCR had a sensitivity of 90.9% (95% CI 70.8%–98.9%).

Conclusions:

This study demonstrated the usefulness of this PCR assay in CSF for the diagnosis of NC. PCR may be particularly helpful for diagnosing extraparenchymal NC when neuroimaging techniques have failed.

Classification of evidence:

This study provides Class III evidence that CSF PCR can accurately identify patients with extraparenchymal NC.

Risk factors, perceptions and practices associated with Taenia solium cysticercosis and its control in the smallholder pig production systems in Uganda: a cross-sectional survey

BACKGROUND

Prevalence studies report Taenia solium cysticercosis in pig and human populations in Uganda. However, the factors influencing occurrence in smallholder pig production systems are not well documented and little is known about farmers' perceptions of T. solium cysticercosis or farmer practices that could reduce transmission.

METHODS

To determine the risk factors, perceptions and practices regarding T. solium cysticercosis, a household survey using a semi-structured questionnaire was conducted in 1185 households in the rural and urban pig production systems in Masaka, Mukono and Kamuli Districts. Logistic regression was used to measure associations of risk factors with infection. Performance scores were calculated to summarise perceptions and practices of farmers regarding taeniosis, human cysticercosis and porcine cysticercosis as well as farmer behavior related to control or breaking transmission.

RESULTS

Pig breed type, farmers' knowledge about transmission, sources of water used, and pig keeping homes where family members were unable to use the latrine were all significantly associated with T. solium cysticercosis in pigs. Performance scores indicated that farmers were more aware of taeniosis (63.0%; 95% Confidence Interval 60.0-65.8) than human or porcine cysticercosis; only three farmers (0.3%, 95% CI = 0.1-0.8) had knowledge on all three conditions. More farmers reported that they dewormed pigs (94.1%) than reported deworming themselves and their family members (62.0%). Albendazole was the most commonly used drug for deworming both pigs and humans (85.0 and 81.5% respectively). Just over half (54.6%) of the farmers interviewed had clean water near the latrines for washing hands. Of these, only 41.9% used water with soap to wash hands after latrine use.

CONCLUSION

Factors that significantly influenced occurrence of T. solium cysticercosis in pigs were identified. Farmers had some knowledge about the disease but did not link taeniosis, human cysticercosis, and porcine cysticercosis. Therefore, there is need to employ strategies that raise awareness and interrupt transmission.

Seroprevalence and risk factors of human cysticercosis and taeniasis prevalence in a highly endemic area of epilepsy in Bangoua, west Cameroon

Cysticercosis caused by the larvae of Taenia solium is a serious and emerging threat to public health in the endemic areas as well as in the non-endemic areas.　Neurocysticercosis, an affection of the central nervous system is a leading cause of epilepsy in endemic areas. This study was carried out to investigate human cysticercosis, taeniasis and risk factors, and also their association with epilepsy in Bangoua, west Cameroon where epilepsy is highly prevalent. Out of 384 people investigated, 12 (3.1%) exhibited antibody response against low molecular weight antigens of T. solium by ELISA. Immunoblot revealed that six persons (1.6%) were seropositive with the same antigens. Among 61 epileptic patients, only one was seropositive by immunoblot and the study did not find any statistically significant difference (P>0.05) in seropositivity to T. solium between epileptic persons (1/61, 1.6%) and non-epileptic group (5/323, 1.5%). In addition, cysticercosis was associated with households eating pork meat from pigs slaughtered at home, but not with other factors. The risk factors including pig farming, the consumption of pork meat, vegetables, and non-drinkable water were attenuated by the relatively good hygiene and pig husbandry practices of the population. No egg of Taenia was found in stool by microscopic examination. All data obtained in this study suggested that cysticercosis might not be the principal causative agent of epilepsy in this area.

Neurocysticercosis among patients with first time seizure in Northern Namibia

INTRODUCTION

Neurocysticercosis is a common cause of seizures in low resource countries. There is a paucity of data regarding the extent of this infection in Namibia. There are multiple causes of First-time seizure including electrolyte abnormalities, infections, trauma, drugs, alcohol and many times no apparent cause can be found. We sought to describe the burden of Neurocysticercosis among individuals with a first-time seizure in Namibia.

METHODS

We recruited 221 patients with a First-time seizure who presented to the Intermediate Hospital Oshakati between August 2012 and March 2014. Patients with seizures due to identifiable causes like trauma, electrolytes, intoxications and meningitis were excluded. Brain CT scans were done, blood serological testing of Neurocysticercosis antibodies, Physical examination and demographic variables were collected. Data was entered into Epidata version 3.1 and transferred to stata version for analysis.

RESULTS

Ninety-six (96) of the participants had evidence of Neurocysticercosis on Brain CT scan representing a prevalence of 51.41%. Consumption of pork and rearing of pigs in the homestead were significant factors associated with Neurocysticercosis in our study population with odds of 3.48(1.45-8.33) and 2.07(1.11-3.86) respectively. Serological testing for Cyticercosis IgG had a sensitivity of 65.93% and Specificity of 96.51%. The positive and negative predictive values were 95.2% and 72.81% respectively.

CONCLUSION

Neurocysticercosis is a common cause of Index seizures in Northern Namibia, living in a rural area, rearing pigs in homesteads, eating pork and poor sanitary practices are the major risk factors for this illness.

The challenge of managing headache disorders in a tertiary referral neurology clinic in Rwanda

OBJECTIVE

To determine the pattern, management, and outcome of headaches among patients treated at Outpatient Neurology Clinic.

METHODS

A retrospective study was conducted at the Out-Patient Neurology Clinic of the Butare University Teaching Hospital, University of Rwanda, Butare, Rwanda between February and May 2015. We extracted the demographic data, headache characteristics, and associated conditions, prior pain-relieving medication use, waiting time before consultation, the results of paraclinical investigations, final diagnosis according to the International Classification of Headache Disorders, management, and 3-month clinical outcome from the medical records of all patients who consulted for headache over 36-month period. Epi Data and Statistical package for Social sciences software version 21.0 (SPSS Inc, Chicago, IL, USA) software were used for data processing.

RESULTS

Headache disorders represent a quarter of all neurological consultations. Patients were predominantly female (67%) and young (78% <45 years old). One-third (34%) presented with chronic tension-type headache. Neuroimaging demonstrated an abnormality in a significant minority (14%). Amitriptyline was the most commonly used drug (60%) in management. Forty percent of those patients followed for 3 months did not experience any clinical improvement.

CONCLUSION

Headache is among the most common medical complaints in the Outpatient Neurology Clinic, with a wide array of underlying diagnoses, and a significant yield on neuroimaging. A significant proportion of those suffering from headache disorders have poor short-term outcomes. Novel approaches, such as headache support groups and alternative pharmacological agents, should be investigated for these patients.

Recent advances and perspectives in molecular epidemiology of Taenia solium cysticercosis

Cysticercosis caused by accidental ingestion of eggs of Taenia solium is spreading all over the world through globalization and is one of the most neglected, neglected tropical diseases (NTDs) or neglected zoonotic diseases (NZDs). In the present study, the reason why T. solium cysticercosis has been neglected is discussed at first, and followed with an overview on the most recent advances and perspectives in molecular approaches for epidemiology of T. solium taeniasis/cysticercosis, since although taeniasis does not constitute recognized zoonoses, transmission and complete development are dependent on human definitive hosts. Main topics are discussions on (1) the two, Asian and Afro/American, genotypes of T. solium, (2) comparative analysis of mitochondrial (haploid) and nuclear (diploid) genes, and (3) the presence of hybrids of these two genotypes which indicates out-crossing of two genotypes in hermaphrodite tapeworms in Madagascar. Additional topics are on (4) the usefulness of phylogeographic analyses to discuss where the infection was acquired from, and (5) miscellaneous unsolved topics around these genetic diversity of T. solium.

Taenia solium taeniosis/cysticercosis and the co-distribution with schistosomiasis in Africa

Background

This study aimed to map the distribution of Taenia solium taeniosis/cysticercosis and the co-distribution with schistosomiasis in Africa. These two major neglected tropical diseases are presumed to be widely distributed in Africa, but currently the level of co-distribution is unclear.

Methods

A literature search on T. solium taeniosis/cysticercosis was performed to compile all known studies on the presence of T. solium and apparent prevalence of taeniosis and porcine cysticercosis in Africa. Studies were geo-referenced using an online gazetteer. A Bayesian framework was used to combine the epidemiological data on the apparent prevalence with external information on test characteristics to estimate informed district-level prevalence of taeniosis and porcine cysticercosis. Districts with T. solium taeniosis/cysticercosis presence were cross-referenced with the Global Neglected Tropical Diseases Database for schistosomiasis presence.

Results

The search strategies identified 141 reports of T. solium in Africa from 1985 to 2014 from a total of 476 districts in 29 countries, 20 with porcine cysticercosis, 22 with human cysticercosis, and 16 with taeniosis, in addition to 2 countries identified from OIE reports. All 31 countries were considered, on national scale, to have co-distribution with schistosomiasis. Presence of both parasites was confirmed in 124 districts in 17 countries. The informed prevalence of taeniosis and porcine cysticercosis were estimated for 14 and 41 districts in 10 and 13 countries, respectively.

Conclusions

With the paucity of data, T. solium infection is grossly under-reported and expected to be more widespread than this study suggests. In areas where co-distribution occurs there is a need for increased emphasis on evaluation of integrated intervention approaches for these two helminth infections and allocation of resources for evaluating the extent of adverse effects caused by mass drug administration.

Electronic supplementary material

The online version of this article (doi:10.1186/s13071-015-0938-7) contains supplementary material, which is available to authorized users.

Occurrence of porcine cysticercosis in free-ranging pigs delivered to slaughter points in Arapai, Soroti district, Uganda

Poverty, hunger and the need for production of pigs with meagre or zero inputs have made most farmers release their pigs to range freely, thus creating a pig-human cycle that maintains Taenia solium, the pig tapeworm and cause of porcine cysticercosis, in the ecosystem. A preliminary study was designed to establish the prevalence of porcine cysticercosis by postmortem examination of the tongue and carcass of free-range pigs from February to April 2014 in Arapai subcounty, Soroti district, eastern Uganda. The tongue of each pig was extended and examined before deep incisions were made and the cut surfaces were examined. The rest of the carcasses were examined for cysts. Out of 178 pigs examined, 32 were qualitatively positive for porcine cysticercosis, representing a prevalence of 18.0%. This high prevalence represents a marked risk to the communities in the study area of neurocysticercosis, a debilitating parasitic zoonosis. Proper human waste disposal by use of pit latrines, confinement of free-range pigs and treatment with albendazole and oxfendazole are recommended.

Addressing the treatment gap and societal impact of epilepsy in Rwanda--Results of a survey conducted in 2005 and subsequent actions

This study, supported by the Rwandan Ministry of Health and the World Health Organization, was conducted in 2005 to determine the prevalence of epilepsy and its sociocultural perception in Rwanda, as well as epilepsy-related knowledge and practices of health-care professionals (HCPs). A cross-sectional, nationally representative survey was conducted throughout Rwanda by trained investigators. Participants were recruited by random cluster sampling based on the organization of administrative units in the country. Overall, 1137 individuals (62% from rural areas) were interviewed. The prevalence of epilepsy was estimated to be 49 per 1000 people or 41 per 1000 for active epilepsy. Onset of epilepsy before the age of 2years was reported in 32% of the cases. Family history of epilepsy, head trauma, and premature delivery were reported in 53%, 50%, and 68% of the cases, respectively. Most (68%) patients did not receive any medical treatment for epilepsy; 21.5% had received some form of traditional treatment. According to responses from the general population, people with epilepsy should not be entitled to schooling (according to 66%), to work (according to 72%), to the use of public places (according to 69%), or to marriage (according to 66%). Furthermore, 50% believed that epilepsy was untreatable, and 40% thought that it was transmissible. Of the 29 HCPs interviewed, the majority knew the definition of epilepsy and status epilepticus, as well as basic treatment options and side effects. However, 90% believed that treatment was only necessary in the first week after a seizure. Living with epilepsy was associated heavily with stigma, and a significant treatment gap (68%) was identified. Following this study, numerous actions have been taken by the Rwandan government, the Rwandan League Against Epilepsy, and several nongovernmental organizations to increase awareness about epilepsy and to close the treatment gap. An overview of these activities is provided.

Clinical symptoms, diagnosis, and treatment of neurocysticercosis

The infection of the nervous system by the cystic larvae of Taenia solium (neurocysticercosis) is a frequent cause of seizure disorders. Neurocysticercosis is endemic or presumed to be endemic in many low-income countries. The lifecycle of the worm and the clinical manifestations of neurocysticercosis are well established, and CT and MRI have substantially improved knowledge of the disease course. Improvements in immunodiagnosis have further advanced comprehension of the pathophysiology of this disease. This knowledge has led to individualised treatment approaches that account for the involvement of parenchymal or extraparenchymal spaces, the number and form of parasites, and the extent of degeneration and associated inflammation. Clinical investigations are focused on development of effective treatments and reduction of side-effects induced by treatment, such as seizures, hydrocephalus, infarcts, and neuroinjury.

Immunology of Taenia solium taeniasis and human cysticercosis

The life cycle of Taenia solium, the pork tapeworm, is continuously closed in many rural settings in developing countries when free roaming pigs ingest human stools containing T. solium eggs and develop cysticercosis, and humans ingest pork infected with cystic larvae and develop intestinal taeniasis, or may also accidentally acquire cysticercosis by faecal-oral contamination. Cysticercosis of the human nervous system, neurocysticercosis, is a major cause of seizures and other neurological morbidity in most of the world. The dynamics of exposure, infection and disease as well as the location of parasites result in a complex interaction which involves immune evasion mechanisms and involutive or progressive disease along time. Moreover, existing data are limited by the relative lack of animal models. This manuscript revises the available information on the immunology of human taeniasis and cysticercosis.