REASSESSMENT OF HELMINTH INFECTIONS IN GULU MUNICIPALITY NOTHERN UGANDA AFTER THE TWENTY YEARS OF INSURGENCY: USING THREE DIAGONOSTIC METHODS TO COMPARE THEIR SENSITIVITY.

BACKGROUND: During the period of insurgency there were several internally displace people camps all over the Northern Uganda. People who lived within ten kilometers from Gulu Municipality were forced to evacuate their villages and re-locate and build huts for themselves in areas identified for them by the government. There were several of such camps within the municipality creating influx of people from the villages to the municipality for security. Now with the situation restored to normal, there is need to re-assess and update information on the prevalence of helminth infections in Gulu municipality where many of the internally displaced people (IDP) settled. OBJECTIVE: To find out if S. mansoni and soil transmitted nematode infections are so prevalent and very common in children aged betweenfive to 20 years. In Gulu municipality and that additional preventive and curative measure need to be considered. Further is there a strong need to reconsider more sensitive diagnostic methods at the hospitals or does the standard approach of direct smear examination recognise at least most heavy infected children with any of the parasites. Setting. The study was carried out in Gulu municipality. DESIGN: Purposive and random sampling methods were used. Study Population: Mainly Primary school children aged between five to 20 years randomly selected from four primary schools purposively selected around Gulu municipality were recruited for the study. For control 20 staff of each school randomly selected were also studied. RESULTS: Of the 582 samples tested, 117(20.1%) were found positive for Schistosoma mansoni. Fifteen (2.6%) other samples were found positive for other helminths like Ascaris lumbricoides, Trichuris trichiura H.nana Hookworm. The comparison between the methods showed that the results obtained by the three methods were similar for field research. There is a low intensity of infection with soil transmitted helminths found in the primary schools around Gulu municipality. CONCLUSION: We concluded that the prevalence and intensity of infection with soil transmitted helminths was low among the children aged between 5 to 20 years in the four primary school studied (2.6%) but there was medium infection with S.mansoi (20.1%). The sensitivity in detecting the helminthes eggs in the stool specimen were similar. Though the original Kato/Katz method recorded lowest egg count than the Polderman and Odongo-Aginya methods. This could be due to the fact that the slides were read immediately.

Healthcare-seeking strategies among displaced children in war-ridden northern Uganda: the case of malaria.

A field study was performed to examine suffering and treatment seeking from the perspective of children aged 8-16 years living in war-affected northern Uganda. Various techniques for collecting qualitative and quantitative data were used, including a semi-structured questionnaire about illness experiences and medicine use over a 1-month recall period. The 165 children who were interviewed were attending primary schools for displaced children and/or commuters' night shelters. The children frequently attributed their common febrile ailments to malaria and used a variety of pharmaceuticals and herbal remedies, as self-medication, for their self-diagnosed malarial episodes. Misdiagnosis of febrile illnesses by the children (as well as by the local healthcare providers) and frequent misuse of medicines in the treatment of these illnesses appeared to be very common. Improvement of the health conditions of these children requires a change of focus. Firstly, children above the age of 5 years who are not under adult care and who are often no longer welcome in the local hospital's paediatric ward need to be accepted at the outpatient clinics currently intended for adults. Secondly, the local diagnostic system needs to be improved, not only so that malaria can be reliably diagnosed but also so that alternative diagnoses can be confirmed or rejected, otherwise the current over-consumption of antimalarial drugs may simply be replaced with an over-consumption of antibiotics.

Quality-quantity trade-off of human offspring under adverse environmental conditions.

A central paradigm in life-history theory is the trade-off between offspring number and quality. Several studies have investigated this trade-off in humans, but data are inconclusive, perhaps because prosperous socio-cultural factors mask the trade-off. Therefore, we studied 2461 offspring groups in an area under adverse conditions in northern Ghana with high fertility and mortality rates. In a linear mixed model controlling for differences in age and tribe of the mother and socioeconomic status, each additional child in the offspring group resulted in a 2.3% (95% CI 1.9-2.6%, P < 0.001) lower proportional survival of the offspring. Furthermore, we made use of the polygamous population structure and compared offspring of co-wives in 388 households, thus controlling for variation in resources between compounds. Here, offspring survival decreased 2.8% (95% CI 2.3-4.0%, P < 0.001) for each increase in offspring number. We interpret these data as an apparent quality-quantity trade-off in human offspring.

Morphological variability within Oesophagostomum bifurcum among different primate species from Ghana.

Adult Oesophagostomum bifurcum (Nematoda: Strongylida) from human and non-human primates from Ghana were compared in order to investigate the extent of morphological variability within the species. Using analysis of variance and principal component analysis, significant differences in morphological characters (such as parasite length, width, length of the oesophagus and length of spicules) were demonstrated between O. bifurcum worms from humans, the Mona, Patas or Green monkey and/or Olive baboons. These findings suggest that O. bifurcum from different species of primate host represent distinct population variants, also supported by recent epidemiological and genetic studies of O. bifurcum from such hosts.

Annual mass treatment with albendazole might eliminate human oesophagostomiasis from the endemic focus in northern Ghana.

As a follow-up to the study by Ziem et al., in this issue, efforts to control human oesophagostomiasis and hookworm infections in northern Ghana were pursued, and the results evaluated in collaboration with the Lymphatic Filariasis Elimination Programme. This phase of evaluation of the impact of mass treatment was no longer limited to a small-scale research setting: it was done both in the context of an operationally viable national control programme and as a continuation of the Oesophagostomum Intervention Research Project (OIRP). The methods of evaluation included classical stool examination with Kato thick smears, stool culture and ultrasound examination of the colon wall. The results showed that yearly population-based albendazole-ivermectin treatment in 11 villages scattered over north-eastern Ghana, with a treatment coverage of 70-75%, resulted in a reduction of Oesophagostomum prevalence from about 20% pre-intervention to less than 1% after 2 years of mass treatment. Simultaneously, hookworm prevalence went down from 70% to approximately 15%. The data, however, cannot be readily compared with those of Ziem et al. because of the relatively crude diagnostic (single stool cultures) screening system that had to be used for the evaluation of the large-scale control programme. In the research area of the OIRP, interruption of mass treatment resulted in a rising hookworm prevalence. The Oesophagostomum prevalence, on the other hand, continued to go down. Transmission of human oesophagostomiasis appears interruptible and small numbers of persistent cases of Oesophagostomum infection were shown insufficient to serve as a nucleus of renewed spread of the infection. The data suggest that both the infection with and the pathology due to human oesophagostomiasis can be eliminated and that elimination is likely to be achieved through operationally feasible albendazole-ivermectin treatment as used by the Global Alliance for the Elimination of Lymphatic Filariasis.

Mass treatment with albendazole reduces the prevalence and severity of Oesophagostomum-induced nodular pathology in northern Ghana.

Previous surveys conducted in northern Ghana where Oesophagostomum bifurcum is endemic showed that O. bifurcum-induced nodular pathology could be detected in up to 50% of the inhabitants. The impact of albendazole-based mass treatment to control both infection and morbidity is assessed and compared with the situation in a control area where no mass treatment has taken place. A significant reduction in the prevalence of infection based on stool cultures was achieved following two rounds of mass treatment in one year: from 52.6% (361/686) pre treatment to 5.2% (22/421) 1 year later (chi(1)(2)=210.1; P<0.001). At the same time, the morbidity marker of ultrasound-detectable nodules declined from 38.2% to 6.2% (chi(1)(2)=138.1; P<0.001). There was a shift from multinodular pathology, often seen in heavy infections, to uninodular lesions. In the control villages where no treatment took place, O. bifurcum infection increased from 17.8% (43/242) to 32.2% (39/121) (chi(1)(2)=9.6; P<0.001). Nodular pathology decreased slightly from 21.5% to 19.0%, but a higher proportion of these subjects developed multinodular pathology compared with baseline (chi(1)(2)=5.5; P=0.019). It is concluded that repeated albendazole treatment significantly reduces O. bifurcum-induced morbidity.

Distribution and clustering of Oesophagostomum bifurcum and hookworm infections in northern Ghana.

Human Oesophagostomum infections are locally common in northern Ghana. The present study describes the results of a cross-sectional survey involving 1011 subjects, selected by a compound-based random sampling method from 1227 compounds in 24 villages. Selected persons were examined by both Kato and coproculture methods. Hookworm-like eggs, representing ova of Oesophagostomum bifurcum and hookworm were detected in 87.5% of the Kato smears. The geometric mean egg count of the infected subjects was 1018. Upon coproculture, third-stage larvae of O. bifurcum and hookworm were detected in 53.0% and 86.9% of subjects respectively. Oesophagostomum infections were clustered but no clear explanation for aggregation of infections could be found as yet. Subjects infected with hookworm had a 5-fold higher risk of being infected with O. bifurcum. Infection rates in adult women were higher than in adult men. No association was found with family size, level of hygiene or with the presence of animals in the compounds. Representatives of the Bimoba-tribe were significantly more infected than those of the other tribes. It appears, however, that this tribal association is a geographical phenomenon: Bimoba are mostly living in villages with the highest infection rates.

Insights into the epidemiology and genetic make-up of Oesophagostomum bifurcum from human and non-human primates using molecular tools.

The nodule worm Oesophagostomum bifurcum (Nematoda: Strongylida) is a parasite of major human health importance predominantly in northern Togo and Ghana. Currently, it is estimated that 0.25 million people are infected with this nematode, and at least 1 million people are at risk of infection. Infection with this parasite causes significant disease as a consequence of encysted larvae in the wall of the large intestine. In spite of the health problems caused by O. bifurcum, there have been significant gaps in the knowledge of the biology, transmission and population genetics of the parasite. This review provides an account of some recent insights into the epidemiology and genetics of the parasite from human and non-human primate hosts in specific regions of Africa using molecular tools. Recent research findings are discussed mainly in relation to non-human primates being reservoirs of infection, and the consequences for the prevention and control of oesophagostomiasis in humans are briefly discussed.

Oesophagostomum bifurcum in non-human primates is not a potential reservoir for human infection in Ghana.

In northern Togo and Ghana, human infection with the parasitic nematode Oesophagostomum bifurcum is of major health importance. Elsewhere, oesophagostomiasis is considered a zoonotic infection, non-human primates being the natural host. We examined 349 faecal samples of the olive baboon, mona monkey and black and white colobus monkey from two geographically distinct areas in Ghana, outside the region endemic for O. bifurcum in humans. Using both microscopy and species-specific PCR, we found a high prevalence of O. bifurcum (75-99%) in olive baboons and mona monkeys. The majority of the test-positive faecal samples contained large numbers of larvae after copro-culture (>100). No O. bifurcum was detected in the faeces of the black and white colobus monkeys. Observational studies on the behaviour of the non-human primates, focusing on defecation, food consumption and the sharing of habitat with the local human population, indicated favourable conditions for zoonotic transmission. Given that no human infection with O. bifurcum has been reported from either study area, the present findings support the hypothesis that O. bifurcum from humans in the north of Ghana, and O. bifurcum from olive baboons and/or mona monkeys are distinct.

Definition of genetic markers in nuclear ribosomal DNA for a neglected parasite of primates, Ternidens deminutus (Nematoda: Strongylida)--diagnostic and epidemiological implications.

Ternidens deminutus (Strongylida) is a parasitic nematode infecting non-human and human primates in parts of Africa, Asia and the Pacific islands. The present study genetically characterized T. deminutus and defined genetic markers in nuclear ribosomal DNA (rDNA) as a basis for developing molecular-diagnostic tools. The sequences of the second internal transcribed spacer (ITS-2) of rDNA were determined for adult specimens of T. deminutus (Nematoda: Strongylida: Oesophagostominae) from the Olive baboon and the Mona monkey. The length and G+C content of the ITS-2 sequences was 216 bp and approximately 43%, respectively. While there was no sequence variation among individual T. deminutus specimens from the baboon, 6 (2.8%) nucleotide differences were detected in the ITS-2 between the parasite from baboon and that of the Mona monkey, which is similar to the difference (3.2%) between 2 other species of Oesophagostominae (Oesophagostomum bifurcum and O. stephanostomum) from non-human primates, suggesting significant population variation or the existence of cryptic (i.e. hidden) species within T. deminutus . Pairwise comparisons of the ITS-2 sequences of the 2 operational taxonomic units of T. deminutus with previously published ITS-2 sequences for selected members of the subfamilies Oesophagostominae and Chabertiinae indicated that species from primates (including those representing the subgenera Conoweberia and Ihleia) are closely related, in accordance with previous morphological studies. The sequence differences (27-48.3%) in the ITS-2 between the 2 taxonomic units of T. deminutus and hookworms (superfamily Ancylostomatoidea) enabled their identification and delineation by polymerase chain reaction (PCR)-based mutation scanning. The genetic markers in the ITS-2 provide a foundation for improved, PCR-based diagnosis of T. deminutus infections and for investigating the life-cycle, transmission patterns and ecology of this parasite.

Oesophagostomum bifurcum-induced nodular pathology in a highly endemic area of Northern Ghana.

Human infection with Oesophagostomum bifurcum is rare globally, but focally endemic and common in Ghana and Togo. Two clinical presentations are identified: uni-nodular disease, which may be recognized as a 'Dapaong Tumour', and multi-nodular disease. Here, we describe the prevalence of O. bifurcum infection and the association with nodular pathology in northern Ghana. The study was performed in October 2002. Out of a well-defined population of approximately 18000, 928 subjects of all ages were randomly selected for parasitological and ultrasound examination. In stool cultures, 44% had detectable third-stage O. bifurcum larvae present. Females were more often infected than males (P<0.05). In 34% of the samples, nodules were detected along the colon wall, with the ascending and the transverse colon being the most affected regions. Significant correlations existed between the intensity of infection and the presence of nodules, both at the village and the individual level (P<0.001 for both). Patients with multi-nodular pathology had significantly higher larval counts than patients with uni-nodular pathology. The present data suggest that nodular pathology, and probably the severity of the disease, are directly related to intensity of the infection.

High resolution DNA fingerprinting by AFLP to study the genetic variation among Oesophagostomum bifurcum (Nematoda) from human and non-human primates from Ghana.

An AFLP approach was established to investigate genetic diversity within Oesophagostomum bifurcum (order Strongylida) from human and non-human primates. Evaluation of different combinations of restriction enzymes (n = 8) and primers (n = 29) demonstrated that the use of HindIII/BglII digested templates and primers with the selective nucleotides + AG/ +AC, respectively, was the most effective for the analysis of O. bifurcum DNA. A total of 63 O. bifurcum adults from human, Patas monkey, Mona monkey and Olive baboon hosts from different geographical regions in Ghana were subjected to analysis using this method. Cluster analysis revealed 4 genetically distinct groups, namely O. bifurcum from the Patas monkey (I), from the Mona monkey (II), from humans (III) and from the Olive baboon (IV). These findings were concordant with those achieved previously using RAPD analysis and supports population genetic substructuring within O. bifurcum according to host species. The results demonstrated the effectiveness of the present AFLP method for establishing genetic variation within O. bifurcum, and indicates its applicability to other parasitic nematodes of human and/or veterinary health importance.

Distribution of human Oesophagostomum bifurcum, hookworm and Strongyloides stercoralis infections in northern Ghana.

A cross-sectional study was carried out in 216 randomly selected, representative rural villages in the northeastern part of Ghana from March 1995 to May 1998. Inhabitants of randomly selected households, stratified by age and gender, were included. The geographical position of villages was recorded with a global positioning system (GPS). The prevalence of Oesophagostomum, hookworm and Strongyloides stercoralis infections in a study population of 20250 people was determined by microscopic examination of larvae in stool cultures. The overall prevalence was 10.2, 50.6 and 11.6% for the three nematodes, respectively. Hookworm infections were seen in all but one (99.5%) and S. stercoralis in 88.4% of the 216 villages, while Oesophagostomum infections were found to be common in a limited area with prevalences varying from 0 to 75%. An association was found between Oesophagostomum and hookworm infection, both at the individual and at the village level. Spatial analysis of the prevalence data indicated that the endemic area is relatively clearly demarcated to the south of the study area.

The short-term impact of albendazole treatment on Oesophagostomum bifurcum and hookworm infections in northern Ghana.

In November-December 2002, stool samples from a random sample of the human population (N = 190) in the Garu area of northern Ghana were checked for intestinal helminths, using a single Kato smear and duplicate coprocultures for each subject. All 190 subjects were subsequently treated with a single, 400-mg dose of albendazole and 146 of them were successfully re-examined 21-28 days post-treatment. Prior to treatment, 75.5% of the Kato smears were found to contain 'hookworm-like' eggs (with a geometric mean egg count among the positives of 578 eggs/g faeces), and the third-stage larvae of Oesophagostomum bifurcum and hookworm were found in the cultures of stools from 34.2% and 77.4% of the subjects, respectively. Among the subjects who had positive Kato smears before treatment, albendazole treatment led to a cure 'rate' of 79.0% and an egg-reduction 'rate' of 73.5%. The results from the coprocultures indicated cure 'rates' of 98.0% for O. bifurcum but only 51.3% for hookworm. Only one subject was still positive for O. bifurcum after treatment. Among those still positive for hookworm after treatment, the larva-reduction 'rate' was 79.8%. The egg-/larva-reduction 'rates' among those with heavy infections prior to treatment were >90%, whether the data analysed came from the Kato smears or the coprocultures. It may be concluded that a single dose of albendazole is very likely to cure an O. bifurcum infection and to reduce greatly the intensity (but not the prevalence) of any hookworm infections.

The use of real-time PCR to identify Entamoeba histolytica and E. dispar infections in prisoners and primary-school children in Ethiopia.

In Ethiopia, it is generally unknown what proportion of the amoebic infections commonly found, by microscopy, in humans are caused by non-invasive Entamoeba dispar rather than the potentially invasive E. histolytica. Faecal samples were therefore collected from 363 primary-school students and 409 prisoners from various regions of Ethiopia. Each of these samples was checked for Entamoeba infection by the microscopical examination of formol-ether concentrates. DNA was then extracted from the 213 samples (27.6%) found Entamoeba-positive, and run in a real-time PCR with primers, based on the SSU-rRNA gene sequences of E. histolytica and E. dispar, that allow DNA from the two species to be distinguished. Although E. dispar DNA was identified in 195 (91.5%) of the 213 samples checked by PCR, no E. histolytica DNA was detected. This finding is consistent with the conclusion of a previous, smaller investigation: that many amoebic infections in Ethiopia are incorrectly attributed to E. histolytica and then treated, unnecessarily, with amoebicidal drugs.

[Migrating subcutaneous swellings due to dirofilariasis after a visit to the South of France]. / Migrerende subcutane zwellingen door dirofilariasis na een bezoek aan Zuid-Frankrijk.

In two women, aged 59 and 31 years, who suffered from an itching cutaneous nodule, subcutaneous dirofilariasis was diagnosed. The disease is characterised by recurrent migrating subcutaneous nodules and swellings. Both patients recently visited the South of France. Laboratory examination revealed a moderate eosinophilia. In both patients, filaria antibodies were demonstrated during the course of the disease and a nodule was eventually resected. Parasitological examination revealed Dirofilaria repens. After this the swellings did not recur. Dirofilariasis is a zoonosis common in dogs and cats, and is transmitted by mosquitoes. In humans, the most common clinical manifestation is a migrating subcutaneous nodule in the case of D. repens, and a pulmonary infiltrate (coin lesion on radiographs) in the case of Dirofilaria immitis. Filarial serology is often positive. The diagnosis is confirmed by parasitological examination of the excised nodule. Dirofilariasis is usually innocuous; it disappears after the worm has died but can cause patients to worry.

Screening for haplotypic variability within Oesophagostomum bifurcum (Nematoda) employing a single-strand conformation polymorphism approach.

Genetic markers in the mitochondrial genome have proven useful for population genetic studies because of their maternal inheritance and relatively high evolutionary rates. In this study, we exploited the high resolution capacity of PCR-coupled single-strand conformation polymorphism (SSCP) to screen for sequence variation in part of the cytochrome c oxidase subunit 1 gene (p cox 1) among individuals of the parasitic nematode, Oesophagostomum bifurcum from human or Mona monkey hosts from Africa. SSCP analysis revealed distinct profiles among some of the individuals, and subsequent sequence analysis of representative samples defined 10 different haplotypes. For comparative purposes, the p cox 1 sequences for representatives of four other species of Oesophagostomum from livestock were included. While there were high levels (11.5-13.7%) of sequence difference among the latter species, there was no fixed nucleotide difference between O. bifurcum individuals from humans and those from monkeys. The data support the proposal that O. bifurcum from the two primate hosts represents a single species and that the haplotypic variability in p cox 1 represents population variation. The results reinforce the usefulness of the SSCP-sequencing approach for studying genetic variation in nematode populations using mitochondrial markers.

Intraobserver and interobserver variation of ultrasound diagnosis of Oesophagostomum bifurcum colon lesions.

Infection by the nematode Oesophagostomum bifurcum is focally distributed in Africa and causes a syndrome of abdominal pain, obstruction, or abdominal mass because of its predilection for invasion of colonic mucosa. To determine the reliability of ultrasound for the detection of colon pathology induced by this parasite, three studies to assess the intraobserver and interobserver variation of the technique were performed. In an area of northern Ghana endemic for O. bifurcum, 181 people from a low-prevalence village and 62 people from a high-prevalence village were examined twice by the same observer, and 111 people were independently examined by two observers in a moderately endemic village. The kappa statistics for the prevalence observations in the three studies were 0.82, 0.87, and 0.81, respectively, and kappa values for the intensity observations were 0.66, 0.63, and 0.71, respectively. The upper 95% confidence intervals of the average absolute difference in nodule size measurements in Study 1 and Study 3 were 3.6 and 4.5 mm, respectively. Therefore, ultrasound is useful in the diagnosis and management of O. bifurcum colon infection.

The risk of Strongyloides stercoralis transmission from patients with disseminated strongyloidiasis to the medical staff.

To assess the risk of Strongyloides stercoralis transmission from two patients with disseminated strongyloidiasis to medical staff who had been in close contact with the patients, blood and stool specimens were obtained from medical staff two to three months after close contact with the patients. Antibodies to S. stercoralis were determined in blood. Stool specimens were tested for parasites with three different procedures.Forty-one medical staff were included. Culture and stool examination were negative in all subjects. Serology was negative in all subjects but one who had a borderline titer without signs or symptoms of strongyloidiasis. No evidence of transmission of S. stercoralis from patients with disseminated strongyloidiasis to medical staff was found.

Parasite-specific antibody and cellular immune responses in human infected with Necator americanus and Oesophagostomum bifurcum.

In this study parasite-specific antibody, cellular reactivity and Thl-type or Th2-type cytokine responses were investigated in humans concurrently infected with Necator americanus and Oesophagostomum bifurcum. The prospects for O. bifurcum-specific serodiagnosis based on IgG4 and IgE were evaluated. IgG4 showed low specificity for O. bifurcum due to antigen cross-reactivity with N. americanus, while IgE specifically distinguished between hookworm and O. bifurcum, and, in doubly infected patients, levels of O. bifurcum-specific as well as N. americanus-specific IgE were significantly elevated compared to those with N. americanus mono-infections. Cellular immunity was not strictly dominated by a Thl- or Th2- type reactivity. In co-infected patients cellular unresponsiveness to parasite antigens was observed, while cellular production of tumour necrosis factor alpha (TNF-alpha) and gamma-interferon (IFN-gamma) was greater in those doubly infected. Th2-type cytokines (interleukin-5 and interleukin-10) were produced in equal amounts by peripheral blood mononuclear cells from individuals with mono- and coinfections. Such mixed Thl-type and Th2-type immune responsiveness associated with persisting gastrointestinal parasitic nematodes may reflect a state of infection at which parasite-induced inflammatory and enteropathogenic responses co-exist, and furthermore, helminth coinfection will not only suppress parasite-specific cellular responsiveness but may also direct cytokine production towards a "permissive Th1-type cytokine profile" that favours parasite persistence.