ASSESSMENT OF PREVALENCE AND KNOWLEDGE OF HUMAN AFRICAN TRYPANOSOMIASIS (HAT) IN DELTA STATE, NIGERIA

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ABSTRACT
World Health Organization (WHO) earmarked Human African Trypanosomiasis for elimination from Nigeria in 2015, making it one of the Country’s (Nigeria) priority diseases listed for surveillance through integrated disease surveillance and response.  HAT is a major public health problem in sub-Saharan Africa, where it affects mainly the rural poor and is usually fatal when untreated.
The objective of the study was to assess the prevalence of HAT and the level of knowledge exhibited by the people about the disease, its risk factors among the residents of Delta State, Nigeria.
A cross sectional study was conducted in Delta State Nigeria from September to December 2011. Structured questionnaires were used to collect data on demographics, knowledge and attitude about HAT and also exposure to risk. Study population was 1,028 residents, aged five years and above, from seven Local Government Areas (LGAs) in the State. Blood samples of respondents were collected for HAT screening using the card agglutination Test for Trypanosoma brucei gambiense (CATT/T.b. gambiense) reagents and kits. Lymph node aspirates and cerebrospinal fluid of CATT positive respondents were examined for the parasite.
Out of the 672 respondents about the knowledge of HAT, 579 (86.2%) knew at least one correct symptom, 578 (86.0%) knew the cause and mode of transmission of HAT, 562 (83.6%) knew how to seek care while 612 (90.7%) knew how to protect themselves from the vector. 142 (21.1%) with knowledge about HAT got the information from several sources, 114 (17.0%) heard from the media while only 35 (5.2%) heard from health workers.
Out of the 1,028 respondents screened for HAT, 28 were CATT positive, seroprevalence of 2.7%,  19 (67.9%) had knowledge of HAT symptoms, 22 (78.6%) had knowledge of mode of transmission, 12 (42.9%) had knowledge of personal protection from tsetse flies and only 2 (7.1%) had knowledge of how to seek care. Analysis involving two variables (bi-variate analysis) showed that respondents of who know how to seek care were less likely to be sero positive to HAT (p = 0.02). Seropositivity to HAT infection was lower among respondents who had knowledge of how to protect themselves from the disease.
All the seven villages from seven Local Government Areas chosen through three stage random sampling in the three senatorial districts were mapped and their coordinates taken using the Global Positioning System (GPS)

HAT is endemic in Delta State, Nigeria. Prevalence rate was low but sero positive persons had high titres for CATT for T.b. gambiense. Risk factors for infection included ignorance about where to seek medical care when ill with HAT and knowledge about personal protection against HAT. Mass health education on preventive measures for HAT should be embarked upon and health care providers should be sensitized, for improved suspicion index for HAT diagnosis and management in Delta State and Nigeria.

TABLE OF CONTENTS

TITLE
TABLE OF CONTENTS
LIST OF TABLES
LIST OF FIGURES
APPENDICES
ABBREVIATIONS
ABSTRACT

Chapter 1       INTRODUCTION

Chapter 2       LITERATURE REVIEW

Chapter 3       METHODOLOGY

Chapter 4       RESULTS

Chapter 5       DISCUSSION

Chapter 6       CONCLUSION AND RECOMMENDATIONS
REFERENCES

APPENDICES


CHAPTER ONE

1.0       INTRODUCTION:
1.1   Background
Trypanosomiasis (Sleeping sickness) is a parasitic disease of livestock and humans in sub-Saharan Africa.  It is also one of the world’s most neglected tropical diseases that have re-emerged in Africa1-3. In the African Continent including Nigeria, trypanosomiasis has severe impact on humans, livestock and other agricultural production systems4.
Trypasosomiasis are two types; Animal African trypanosomiasis or nagana disease which affects only animals and Human African trypanosomiasis or sleeping sickness which is caused by two subspecies of T brucei gambiense and T bruceirhodiense.T. b. gambiense is responsible for the chronic form of sleeping sickness in West and Central Africa, whereas T. b. rhodiense gives rise to the acute form of the disease in East and Southern Africa. There are two distinct stages during the course of sleeping sickness. The first and early stage of the disease also known as the haemolymphatic stage is defined by the restriction of the trypanosome to the blood and the lymph system5.The symptoms of this stage are fever, headache, joint pains, itching. The second or late stage of the disease, also known as the neurological phase, is characterised by the presence of the parasite in thecerebrospinal fluid. In general this is when the typical signs of the disease occur; confusion, disturbed sleep pattern, extreme lethargy, poor condition and change in mental behaviour. If left untreated, sleeping sickness patients die within months when infected with the T. b. rhodiense or within years when infected with T. b. gambiese. The transmission is from one person to anotheror from animal to man by the bite of an infected tsetse fly. Infectioncould also be through blood transfusion and even laboratory accidents with infected blood6-7
In 1985, a hospital based study documented HAT for the first time in Niger Delta area of Southern Nigeria8. The hyper endemic status of these areas for HAT was later corroborated by some population based studies9. Reports of high catches of the riverine tsetse species (palpalis group) Glossina  tachinoides with serious complaints of fly bites nuisance were received from inhabitants of communities of Kaduna, Chamso Bachit, Bakin Kogi, Angware, Durbi and Federe Districts of Mangu, Barkin Ladi and Jos East LGAs of Plateau State respectively. These communities live and work near rivers and streams and were mostly involved in intensive agrarian conditions during the wet and dry seasons10. Trypanosomiasis in domestic animals including canine trypanosomiasis have been reported in Nigeria as common occurrence in T.b. gambiense belts11, assymptomatic individuals and some of these domestic animals are suspected to be reservoirs for HAT in endemic areas12.
1.2             Burden of the disease/Current Scientific Knowledge:
A significant portion of children are affected by the disease and many of them suffer considerable delay in mental development which impacts negatively on school performance and professional advancement13. According to the WHO, global burden of the estimates that HAT caused 1.5 million deaths in 200214. This was why at the 25th ISCTRC (International Scientific Council for Trypanosomiasis Research and Control) in Mombassa, Kenya, in October 1999, the idea of anAfrican-wide initiative to controltsetse and trypanosomiasis populations was discussed. During the 36th summit of the African Union in Lome, Togo in July, 2000, a resolution was passed to form the Pan African Tsetse and Trypanosomiasis Eradication Campaign (PATTEC). The campaign works to eradicate the tsetse vector population levels and subsequently the protozoan disease, by use of insecticide impregnated targets, fly traps, insecticide-treatedcattle, ultra low dose aerial/ground spraying (SAT) of tsetse resting sites and the sterile insect technique (SIT) 15. The use of SIT in Zanzibar proved effective in eliminating the entire population of tsetse flies but was expensive and is relatively impractical to use in many of the endemic countries afflicted with African trypanosomiasis16.
Regular active surveillance, involving detection and prompt treatment of new infections and tsetse fly control is the backbone of the strategy used to control sleeping sickness. Systematic screening of at risk communities is the best approach, because case by case screening is not practical in endemic regions. Systematic screening might be in the form of mobile clinics, or fixed screening centres where teams travel daily to areas of high infection rates. Such screening efforts are important because early symptoms are not evident or serious enough to warrant patients with gambiense disease to seek medical attention, particularly in very remote areas. Also diagnosis of the disease is very difficult and health workers may not associate such general symptoms with trypanosomiasis. Systematic screening allows early stage disease to be detected and treated before the disease progresses, and removes the potential human reservoir17. A single case of sexual transmission of West African sleeping sickness has been reported18.
The current treatment for the first stage disease is intravenous or intramuscular pentamidine (for T.b gambiense)19. For T. b. gambiense second stage, intravenouseflornithine orthe combination of nifurtimox and eflornithine appear to be more effective and easier to give20. These threatments may replace melarsoprol when available with the combination being the first line. Intravenous melarsoprol was previously the standard treatment for the second stage (neurological phase) disease and is effective for both types of Trypanosomiasis.u It is the only treatment for second stage T. b. rodesiense, however can cause death in 5% of people who take it. Resistance to melarsoprol can occur.....


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