In the heart of darkness: sleeping sickness in Zaire.

PIP: Human African trypanosomiasis (HAT) control programs existed during the colonial era in the Belgian Congo. HAT cases peaked in 1930 at 33,562. They declined gradually to about 1000 cases in 1959. The civil war that erupted after Zaire's independence in 1960 crippled the public health system. During 1960-1967, no active case finding was conducted and notification of HAT cases fell greatly. Mismanagement and corruption maintained a severe social and economic crisis after the civil war. At the end of the 1980s, the number of new HAT cases began to increase from the relatively stable numbers of 4000-6000 during 1969-1981 to almost 10,000. Socioeconomic conditions deteriorated quickly in the 1990s. The withdrawal of foreign aid in 1991 devastated many governmental health facilities that had been dependent on these funds. In much of Zaire, Catholic and Protestant missions were the only health care providers. The breakdown of the health system contributed to epidemics of Ebola fever, dysentery, the plague, and cholera. The specialized mobile teams providing trypanocidal drugs to HAT patients could no longer operate, resulting in drug shortages and thousands of deaths. The teams were somewhat remobilized during 1993-1994, when some foreign aid was again available. A return to neglected areas in 1994 found the HAT prevalence to be 15.4/1000 in the Equator region. In Kimbanzi, Bandundu region, it was 718/1000 among 241 persons examined. Had the teams not arrived when they did, the entire village of Kimbanzi could have disappeared within 1-2 years. The high prevalence rates in neglected areas were the highest rates recorded this century. The neglect brought about an increase in the number of infectious people, an increase in transmission, and a higher cost and toxicity of treatment due to an increase in late-stage HAT cases. The estimated true total incidence of HAT in Zaire in 1994 was about 34,400 new cases. The number of HAT deaths in 1994 was probably at least 80 times higher than that of Ebola deaths in 1995. Proper HAT control methods need to be fully funded and implemented to control this curable disease.^ieng

[Control of Trypanosoma gambiense trypanosomiasis. Evaluation of a strategy based on the treatment of serologically suspected cases with a single dose of diminazene]. / Contrôle de la trypanosomiase à T. b. gambiense. Evaluation d'une strategie basée sur le traitement des suspects sérologiques par une dose unique de diminazène.

A novel method for the control of T.b. gambiense trypanosomiasis was evaluated in an endemic focus of Zaïre where a high incidence had persisted despite massive participation in active case-finding surveys based on lymph node puncture. All inhabitants of 3 villages were examined with a card agglutination serological test (CATT), and parasitological examinations were performed on those who were CATT+. Individuals in whom we detected trypanosomes were treated as usual. A lumbar puncture was carried out on CATT+/parasitology- subjects; those whose cerebrospinal fluid showed more than 3 white blood cell (WBC) per mm3 were treated with a full course of melarsoprol while those with a CSF WBC count between 1 and 3 per mm3 were given a single injection of diminazene (7 mg/kg). Three such surveys were performed, with a 6-month interval, during which 282 "serological suspects" received diminazene, 39 "clinical cases" were given melarsoprol and 82 "parasitological cases" were treated according to standard protocols. The annual incidence of trypanosomiasis decreased rapidly from 10.4-41.1/1.000 inhabitants (mean: 17.6/1.000) during the 10 years before the intervention to 1.1-2.6/1.000 (mean: 1.7/1.000) in the 3 years following the intervention. No major adverse effect was seen with diminazene. Among the 282 serological suspects, an elevated CSF WBC count was later documented in 12 individuals, who were all cured with melarsoprol. The incidence increased 5 years after the intervention (7.1/1.000 in 1992), which may have been avoided had we carried out similar interventions in adjacent foci.

[A strategy to control Trypanosomiasis due to Trypanosoma brucei gambiense in an endemic region of Zaire. Association of a serological test and early treatment of suspected cases. Preliminary results]. / Une stratégie de lutte contre la trypanosomose à Trypanosoma brucei gambiense dans un foyer du Zaïre. Association d'un test sérologique et d'un traitement précoce des cas suspects. Résultats préliminaires.

The authors report results obtained after combination of a serological diagnostic test and the early treatment of suspected cases (a person with a positive serological test without parasitological confirmation) in an area in Zaire where sleeping sickness caused by Trypanosoma brucei gambiense is endemic. The serological test used was Testryp CATT, having a very high sensitivity and quite a high specificity, which is easy to handle in the field and which permits results to be obtained on the spot. The treatment employed was a medication active in the first stage of the disease (hematolymphatic stage), safe to handle, with few side effects and easy to administer (diminazine). This strategy was applied for one year in the area from Fankana-Kalakitini in the Bandundu region in Zaire. The entire population was examined with the classical methods, combined with the serological test Testryp CATT, and this every six months. People positive for the serological test (but negative for the parasite) received one injection of the proposed medication; but people in whom parasites were found got classic treatment. After this period, we were able to demonstrate a clear decline in the incidence rate of new cases (parasite positive), but also in seropositivity rates in the general population. The authors believe that in a circumscribed area where the disease is endemic, the combination of a serological test and early treatment of suspected cases can rapidly diminish the incidence of the disease to an acceptable level.

[Treatment of sleeping disease caused by trypanosoma brucei gambiense with alpha-difluoromethylornithine (DFMO) in a rural hospital in Zaire]. / Traitement de la maladie du sommeil à trypanosoma brucei gambiense avec le DL-alpha-difluoromethylornithine (DFMO) dans un hôpital rural au Zaïre.

The authors report the results of 32 patients with sleeping sickness due to Trypanosoma brucei gambiense treated with DFMO (DL-alpha-difluoromethylornithine), an inhibitor of polyamine biosynthesis. Between those patients, there were 5 new cases, 1 reinfection, and 26 cases with a primary, a secondary resistance or a relapse. 26 cases got DFMO only per os, but six others received first DFMO for two weeks by the intravenous way, followed by three weeks of DFMO per os. The secondary effects were never very severe and never prompted a definitive discontinuation of treatment. 12 cases were followed for a period of 24 months, 16 for a period between 1 and 18 months and 4 patients died during the study (3 during treatment and one 8 months afterwards), but we don't think that DFMO was the cause of death. Out of the 12 cases followed for two years, 11 were in perfect health at the end of this period (one case can be considered as a secondary resistance to DFMO, but it could have been a reinfection as well). For the 16 cases followed for a period less than two years, we found a very fast disappearance of trypanosomes from body fluids, immediately after the beginning of treatment, and a significant amelioration of clinical signs. After this study, the authors estimate that DFMO given orally provides as good results as DFMO given in a combined therapy. But the oral way seems much easier to administer and much cheaper in rural areas.(ABSTRACT TRUNCATED AT 250 WORDS)

An open clinical trial of nifurtimox for arseno-resistant Trypanosoma brucei gambiense sleeping sickness in central Zaire.

Twenty-five patients with arseno-resistant Trypanosoma brucei gambiense sleeping sickness were treated with oral nifurtimox, 12-17 mg/kg/d for 60 d. During treatment, trypanosomes disappeared from the cerebrospinal fluid (CSF) of 7/7 patients; the CSF infections; leucocyte was significantly lower at the end of treatment than before it was begun (pre-nifurtimox: 124.2 (+/- 149.3) per microliter; post-nifurtimox: 11.9 (+/- 12.1) per microliter; P less than 0.001). Nifurtimox was well tolerated, with gastro-intestinal disturbances in 6 patients and a reversible cerebellar syndrome in 2 patients. Among the 19 patients seen at least once at follow-up, 12 (63%) relapsed. The other 7 patients have been followed for 3-18 months, and the CSF remained completely normal in 4 of them. This study confirms that nifurtimox has some activity against T.b. gambiense, but a daily dosage higher than 15 mg/kg/d will be necessary to achieve cure of most patients.