A Critical Appraisal of the Ideology of Monogamy’s Influence on HIV Epidemiology

The linked ideas that all members of society should only engage in monogamous relationships and that these should all be based on romantic love are decided outliers from a historical perspective. Despite this, there is a widespread contemporary belief that monogamy based on love is the most ethical and natural form of partnering for humans—mononormativism. It has long been accepted that our values influence how we frame and interpret scientific questions. In the article we ask, using the example of mononormativism, how does an individual’s sexual ethics influence how they pursue HIV epidemiology? Using a Social Intuitionalist theoretical framework, we argue that a belief in monogamy-as-normative has contributed to certain researchers dismissing the evidence that the generalized HIV epidemics in parts of Africa are due to higher rates of non-monogamy.

Abdominal Sonographic Findings in Severely Immunosuppressed Human Immunodeficiency Virus-Infected Patients Treated for Tuberculosis

Objective: We describe the abdominal sonographic findings among patients with HIV-tuberculosis (TB) co-infection with advanced immune suppression before initiation of ART and relate these findings to the patients’ abdominal symptoms and CD4 T-cell count. Methods: Consecutive HIV-TB co-infected patients, qualifying for ART, were prospectively enrolled in a cohort study at the Mulago National Tuberculosis and Leprosy Programme clinic in Kampala, Uganda. An abdominal ultrasound was performed at enrolment. Results: A total of 209 HIV-TB co-infected patients (76% with pulmonary, 19% with extrapulmonary TB and 5% with extrapulmonary and pulmonary TB) underwent an abdominal ultrasound scan. Only 49 patients (23.4%) had a normal abdominal ultrasound. The following sonographic abnormalities were found: multiple lymphadenopathy (38%), splenomegaly (18%), renal abnormalities (14%), gastro-intestinal tract abnormalities (thickened bowel loops, appendicitis) (13%), splenic abscesses (13%) and ascites (6%). The commonest groups of enlarged lymph nodes were in the porta-hepatis (19%) and peripancreatic (17%) area and 80% of the enlarged lymph nodes were hypoechoic. Conclusion: Most patients with advanced immune suppression and HIV-TB co-infection have sonographic evidence of generalized TB with abdominal involvement, therefore Ultrasound may assist in the early diagnosis of disseminated TB.

Treatment and prevention of epilepsy in onchocerciasis-endemic areas is urgently needed

Background There is increasing epidemiological evidence supporting the association between onchocerciasis and seizures, reinforcing the concept of onchocerciasis-associated epilepsy (OAE). The aim of this paper is to provide an update on the new knowledge about OAE and to propose recommendations to the World Health Organization how to address this public health problem.Main text During the 2nd International Workshop on OAE held on 19-21 September, 2023, in Antwerp, Belgium, participants recognised OAE as a substantial yet neglected public health problem, particularly in areas of sub-Saharan Africa where onchocerciasis remains hyperendemic. Evidence from prospective population-based studies suggest that strengthening onchocerciasis elimination efforts leads to a significant reduction of OAE incidence. There is a need to validate an OAE case definition to estimate the burden of disease and identify onchocerciasis-endemic areas requiring intensification of onchocerciasis elimination programmes and integration of epilepsy care. It is expected that raising awareness about OAE will boost the population uptake of ivermectin. The implementation of a community-based epilepsy treatment programme offering free anti-seizure medications (ASMs) has shown high effectiveness in reducing the frequency of seizures and improving the overall quality of life of people with epilepsy.Conclusions To reduce OAE burden, enhanced collaboration between onchocerciasis and mental health programmes at community, national, and international levels is required. Urgent efforts are needed to ensure the uninterrupted provision of free ASMs in onchocerciasis-endemic areas. Furthermore, OAE should be included in the quantification of the onchocerciasis disease burden.

Burden of onchocerciasis-associated epilepsy:first estimates and research priorities

Background:Since the 1990s,evidence has accumulated of an increased prevalence of epilepsy in onchocerciasisendemic areas in Africa as compared to onchocerciasis-free areas.Although the causal relationship between onchocerciasis and epilepsy has yet to be proven,there is likely an association.Here we discuss the need for disease burden estimates of onchocerciasis-associated epilepsy(OAE),provide them,detail how such estimates should be refined,and discuss the socioeconomic impact of OAE,including a cost-estimate for anti-epileptic drugs.Main body:Providing OAE burden estimates may aid prevention of epilepsy in onchocerciasis-endemic areas by inciting and informing collaboration between onchocerciasis control programmes and mental health services.Epilepsy not only massively impacts the health of those affected,but it also carries a high socioeconomic burden for the households and communities involved.We used previously published geospatial estimates of onchocerciasis in Africa and a separately published logistic regression model quantifying the association between onchocerciasis and epilepsy to estimate the number of OAE cases.We then applied disability weights for epilepsy to quantify the burden in terms of years of life lived with disability(YLD)and estimate the cost of treatment.We estimate that in 2015 roughly 117000 people were affected by OAE across onchocerciasis-endemic areas previously under the African Programme for Onchocerciases control(APOC)mandate where OAE has ever been reported or suspected,and another 264000 persons in onchocerciasis-endemic areas where OAE has never been investigated before.The total number of YLDs due to OAE was 39300 and 88700 in these areas respectively,based on a weighted mean disability weight of 0.336.The burden of OAE is approximately 13%of the total YLDs attributable to onchocerciasis and 10%of total YLDs attributable to epilepsy.We estimated that by 2015 the total costs of treatment with antiepileptic drug for OAE cases would have been a minimum of 12.4 million US$.Conclusions:These estimates suggest a considerable health,social and economic burden of OAE in Africa.The treatment and care for people with epilepsy,especially in hyperendemic onchocerciasis areas with high epilepsy prevalence thus requires more financial and human resources.

High prevalence of epilepsy in onchocerciasis endemic health areas in Democratic Republic of the Congo

Background:A high prevalence of epilepsy has been observed in many onchocerciasis endemic regions.This study is to estimate the prevalence of active epilepsy and exposure to Onchocerca volvulus infection in a rural population in Ituri province,Democratic Republic of Congo.Methods:In August 2016,a community-based cross-sectional study was conducted in an onchocerciasis endemic area in the rural health zone of Logo,Ituri Province.Households within two neighbouring health areas were randomly sampled.To identify persons with epilepsy,a three-stage approach was used.In the first stage,all individuals of the selected households were screened for epilepsy by non-medical field workers using a validated 5-item questionnaire.In the second and third stage,suspected cases of epilepsy were examined by non-specialist medical doctors,and by a neurologist,respectively.A case of epilepsy was defined according to the 2014 International League Against Epilepsy(ILAE)guidelines.Exposure to O.volvulus was assessed by testing for IgG4 antibodies to an O.volvulus antigen(OV16 Rapid Test,)in individuals aged 3 years and older.Results:Out of 1389 participants included in the survey,64 were considered to have active epilepsy(prevalence 4.6%)(95%confidence interval[CI]:3.6-5.8).The highest age-specific epilepsy prevalence estimate was observed in those aged 20 to 29 years(8.2%).Median age of epilepsy onset was 10 years,with a peak incidence of epilepsy in the 10 to 15 year-old age group.OV16 test results were available for 912 participants,of whom 30.5%(95%CI,27.6-33.6)tested positive.The prevalence of OV16 positivity in a village ranged from 8.6 to 68.0%.After adjusting for age,gender and ivermectin use,a significant association between exposure to onchocerciasis and epilepsy was observed(adjusted odds ratio=3.19,95%CI:1.63-5.64)(P<0.001).Conclusions:A high prevalence of epilepsy and a significant association between epilepsy and exposure to O.volvulus were observed in the population in Ituri province,Democratic Republic of Congo.There is an urgent need to implement a CDTI programme and to scale up an epilepsy treatment and care programme.

High prevalence of epilepsy in two rural onchocerciasis endemic villages in the Mahenge area,Tanzania,after 20 years of community directed treatment with ivermectin

Background:Epilepsy is a neurological disorder with a multitude of underlying causes,which may include infection with Onchocerca volvulus,the parasitic worm that causes human onchocerciasis.A survey carried out in 1989 revealed a high prevalence of epilepsy(1.02%overall,ranging from 0.51 to 3.71%in ten villages)in the Mahenge area of Ulanga district,an onchocerciasis endemic region in south eastern Tanzania.This study aimed to determine the prevalence and incidence of epilepsy following 20 years of onchocerciasis control through annual community directed treatment with ivermectin(CDTI).Methods:The study was conducted in January 2017 in two suburban and two rural villages in the Mahenge area.Door-todoor household visits were carried out by trained community health workers and data assistants to screen for persons suspected of having epilepsy,using a standardised questionnaire.Persons with suspected epilepsy were then interviewed and examined by a neurologist for case verification.Onchocerciasis associated epilepsy was defined as epilepsy without an obvious cause,with an onset of seizures between the ages of 3-18 years in previously healthy children.In each village,fifty males aged≥20 years were tested for onchocerciasis antibodies using an OV16 rapid test and were examined for presence of onchocerciasis nodules.Children aged 6-10 years were also tested using OV16 tests.Results:5117 individuals(median age 18.5 years,53.2%female)from 1168 households were screened.244(4.8%)were suspected of having epilepsy and invited for neurological assessment.Prevalence of epilepsy was 2.5%,with the rural villages having the highest rate(3.5%vs 1.5%),P<0.001.Overall incidence of epilepsy was 111 cases(95%CI:73-161)per 100000 person-years,while that of onchocerciasis associated epilepsy was 131(95%CI:70-223).Prevalence of OV16 antibodies in adult males and among children 6-10 years old was higher in rural villages than in suburban villages(76.5%vs 50.6,and 42.6%vs 4.7%respectively),(P<0.001),while overall prevalence of onchocerciasis nodules was 1.8%.Conclusions:This survey revealed a high prevalence and incidence of epilepsy in two rural onchocerciasis endemic villages in the Mahenge area.Despite 20 years of CDTI,a high prevalence of OV16 antibodies in children aged 6-10 years suggests on-going O.volvulus transmission.Reasons for the persistence of on-going parasite transmission in the Mahenge area need to be investigated.

Epidemiology of onchocerciasis-associated epilepsy in the Mbam and Sanaga river valleys of Cameroon:impact of more than 13 years of ivermectin

Background:A high epilepsy prevalence has been reported in several onchocerciasis-endemic villages along the Mbam and Sanaga river valleys in Cameroon,including Bilomo and Kelleng.We sought to determine the prevalence of epilepsy in these two villages following more than 13 years of community-directed treatment with ivermectin(CDTI).Methods:Door-to-door surveys were performed on the entire resident population in the villages in August 2017 and January 2018.Epilepsy was diagnosed using a 2-step approach:administration of a standardized 5-item questionnaire followed by confirmation by a neurologist.Previously published diagnostic criteria for onchocerciasis-associated epilepsy(OAE)were used.Ov16 serology was done for children aged 7-10 years to assess onchocerciasis transmission.Findings were compared with previous data from these two villages.Results:A total of 1525 individuals(1321 in Bilomo and 204 in Kelleng)in 233 households were surveyed in both villages.The crude prevalence of epilepsy was 4.6%in Bilomo(2017)and 7.8%in Kelleng(2018),including 12(15.6%of cases)persons with epilepsy(PWE)with nodding seizures.The age and sex-standardized prevalence in Kelleng decreased from 13.5%in 2004 to 9.3%in 2018(P<0.001).The median age of PWE shifted from 17(IQR:12-22)years to 24(IQR:20-30)years in Bilomo(P<0.001);and slightly from 24(IQR:14-34)years to 28(IQR:21.25-36.75)years in Kelleng(P=0.112).Furthermore,47.6%of all tested children between 7 and 10 years had Ov16 antibodies.Conclusions:There is a decrease in epilepsy prevalence after 13 years and more of CDTI in both villages.The age-shift observed in PWE suggests that ivermectin may prevent OAE in younger residents.Ov16 seropositivity in children indicates ongoing onchocerciasis transmission possibly due to suboptimal control measures.Our findings support the existence of OAE in Cameroon and highlight the need to strengthen onchocerciasis elimination programs.

Low prevalence of epilepsy and onchocerciasis after more than 20 years of ivermectin treatment in the Imo River Basin in Nigeria

Background:High epilepsy prevalence and incidence have been reported in areas with high onchocerciasis transmission.Recent findings suggest that proper community-directed treatment with ivermectin(CDTI)is potentially able to prevent onchocerciasis-associated epilepsy(OAE).We assessed the epilepsy prevalence and onchocerciasis transmission in two Nigerian villages following more than 20 years of CDTI.Methods:A cross-sectional door-to-door survey was performed in two villages in the Imo River Basin reported to be mesoendomic for onchocerciasis(Umuoparaodu and Umuezeala).Individuals were screened for epilepsy using a validated 5-item questionnaire.Persons suspected to have epilepsy were examined by a neurologist or a physician with training in epilepsy for confirmation.Onchocerciasis was investigated via skin snip microscopy and rapid diagnostic tests for Ov16 antibodies.Results were compared with previous findings from the Imo river basin.Results:A total of 843 individuals from 257 households in the two villages were encountered.We detected four persons with epilepsy(PWE)giving a crude epilepsy prevalence of 0.5%.This finding differs from observations reported 14 years ago which showed an epilepsy prevalence of 2.8%in the neighbouring village of Umulolo(P=0.0001),and 1.2%from 13 villages in the Imo river basin(P=0.07).The seroprevalence of Ov16 antibodies was found to be 0%.Only 4.6%of skin snips were positive compared to 26.8%in previous surveys(P<0.0001).Ivermectin mass distribution coverage in the study sites in 2017 was 79.7%.Conclusions:A low epilepsy and onchocerciasis prevalence was observed following more than 20 years of CDTI in the Imo River Basin.Absence of Ov16 antibodies indicates minimal transmission of onchocerciasis.These results contrast with observations from areas of high onchocerciasis transmission,where epilepsy prevalence and incidence remain high.Findings from this study suggest that sustained efforts could eventually achieve elimination of onchocerciasis in these villages.

Community perceptions of epilepsy and its treatment in an onchocerciasis endemic region in Ituri,Democratic Republic of Congo

Background:A recent study in the Logo and Rethy health zones in the Ituri Province in the Democratic Republic of Congo(DRC)reported that the majority of the persons with epilepsy(PWE)had not been treated with anti-epileptic medication(AEM)or had stopped treatment.Prior to the implementation of an epilepsy treatment programme in these health zones,this study investigated the perceptions and experiences regarding epilepsy and its treatment amongst community leaders,PWE and/or their families,traditional healers and health professionals.Methods:A total of 14 focus group discussions(FGD)and 39 semi-structured interviews(SSI)were conducted with PWE and/or their family members,community leaders,traditional healers,and health professionals in the Logo and Rethy health zones during February 2-19,2017.Results:In the two health zones,the clinical signs of convulsive epilepsy were recognized by community members.However,a variety of misconceptions about epilepsy were identified including the beliefs that epilepsy is a family-related condition,a contagious disease,is transmitted by insects,saliva or by touching a person of the same sex during seizures,or is caused by evil spirits and witchcraft.The role of traditional healers in spreading these beliefs was revealed.The study also reported sexual abuse on PWE,stigmatisation of PWE and loss of productivity of PWE and their families.Some PWE had been using AEM and traditional treatment but were not convinced about the efficacy of these treatment options.The lack of training of health providers about epilepsy care,financial barriers in obtaining AEM,and the shortage of AEM at primary health facilities were revealed.As remedies,the community requested access to a decentralized center for epilepsy treatment.They also proposed using churches and community health workers as communication channels for information about epilepsy.Conclusions:Clinical signs of convulsive epilepsy were recognized by the community in the Logo and Rethy health zones but many misconceptions about epilepsy were identified.A comprehensive community-based epilepsy treatment programme with an affordable uninterrupted AEM supply needs to be established.Such a programme should address stigma,misconceptions,sexual abuse and foster the rehabilitation of PWE to alleviate poverty.

From river blindness control to elimination:bridge over troubled water

Background:An estimated 25 million people are currently infected with onchocerciasis(a parasitic infection caused by the filarial nematode Onchocerca volvulus and transmitted by Simulium vectors),and 99%of these are in sub-Saharan Africa.The African Programme for Onchocerciasis Control closed in December 2015 and the World Health Organization has established a new structure,the Expanded Special Project for the Elimination of Neglected Tropical Diseases for the coordination of technical support for activities focused on five neglected tropical diseases in Africa,including onchocerciasis elimination.Aims:In this paper we argue that despite the delineation of a reasonably well-defined elimination strategy,its implementation will present particular difficulties in practice.We aim to highlight these in an attempt to ensure that they are well understood and that effective plans can be laid to solve them by the countries concerned and their international partners.Conclusions:A specific concern is the burden of disease caused by onchocerciasis-associated epilepsy in hyperendemic zones situated in countries experiencing difficulties in strengthening their onchocerciasis control programmes.These difficulties should be identified and programmes supported during the transition from morbidity control to interruption of transmission and elimination.

The World Health Organization road map for neglected tropical diseases 2021-2030:implications for onchocerciasis elimination programs

In its new roadmap for neglected tropical diseases,the World Health Organization proposes three important strategic shifts:(i)Stronger accountability which shifting from process to impact indicators;(ii)Intensified cross-cutting approaches;and(iii)Stronger country ownership.In this paper we discuss the implementation of these three strategies in the setting of a high onchocerciasis disease burden in South Sudan.

Report of the first international workshop on onchocerciasis-associated epilepsy

Background:Recently,several epidemiological studies performed in Onchocerca volvulus-endemic regions have suggested that onchocerciasis-associated epilepsy(OAE)may constitute an important but neglected public health problem in many countries where onchocerciasis is still endemic.Main text:On October 12-14th 2017,the first international workshop on onchocerciasis-associated epilepsy(OAE)was held in Antwerp,Belgium.The workshop was attended by 79 participants from 20 different countries.Recent research findings strongly suggest that O.volvulus is an important contributor to epilepsy,particularly in meso-and hyperendemic areas for onchocerciasis.Infection with O.volvulus is associated with a spectrum of epileptic seizures,mainly generalised tonic-clonic seizures but also atonic neck seizures(nodding),and stunted growth.OAE is characterised by an onset of seizures between the ages of 3-18 years.Multidisciplinary working groups discussed topics such as how to 1)strengthen the evidence for an association between onchocerciasis and epilepsy,2)determine the burden of disease caused by OAE,3)prevent OAE,4)improve the treatment/care for persons with OAE and affected families,5)identify the pathophysiological mechanism of OAE,and 6)deal with misconceptions,stigma,discrimination and gender violence associated with OAE.An OAE Alliance was created to increase awareness about OAE and its public health importance,stimulate research and disseminate research findings,and create partnerships between OAE researchers,communities,advocacy groups,ministries of health,non-governmental organisations,the pharmaceutical industry and funding organizations.Conclusions:Although the exact pathophysiological mechanism underlying OAE remains unknown,there is increasing evidence that by controlling and eliminating onchocerciasis,OAE will also disappear.Therefore,OAE constitutes an additional argument for strengthening onchocerciasis elimination efforts.Given the high numbers of people with epilepsy in O.volvulus-endemic regions,more advocacy is urgently needed to provide anti-epileptic treatment to improve the quality of life of these individuals and their families.

Prevalence and incidence of nodding syndrome and other forms of epilepsy in onchocerciasis-endemic areas in northern Uganda after the implementation of onchocerciasis control measures

Background:Around 2007,a nodding syndrome(NS)epidemic appeared in onchocerciasis-endemic districts of northern Uganda,where ivermeain mass distribution had never been implemented.This study evaluated the effect of community-directed treatment with ivermectin(CDTI)and ground larviciding of rivers initiated after 2009 and 2012 respectively,on the epidemiology of NS and other forms of epilepsy(OFE)in some districts of northern Uganda.Methods:In 2012,a population-based community survey of NS/epilepsy was carried out by the Ugandan Ministry of Health in Kitgum and Pader districts.In August 2017,we conducted a new survey in selected villages of these districts and compared our findings with the 2012 data.In addition,two villages in Moyo distria(where CDTI was ongoing since 1993)served as comparative onchocerciasis-endemic sites in which larviciding had never been implemented.The comparison between 2012 and 2017 prevalence and cumulative incidence were done using the Fisher's and Pearson's Chi-square tests at 95%level of significance.Results:A total of 2138 individuals in 390 households were interviewed.In the seleaed villages of Kitgum and Pader,there was no significant decrease in prevalence of NS and OFE between 2012 and 2017.However,the cumulative incidence of all forms of epilepsy decreased from 1165 to 130 per 100000 persons per year(P=0.002);that of NS decreased from 490 to 43 per 100000 persons per year(P=0.037);and for OFE from 675 to 87 per 100000 persons per year(P=0.024).The median age of affeaed persons(NS and OFE)shifted from 13.5(IQR:11.0-15.0)years in 2012 to 18.0(IQR:15.0-20.3)years in 2017;P<0.001.The age-standardized prevalence of OFE in Moyo in 2017 was 4.6%,similar to 4.5%in Kitgum and Pader.Conclusions:Our findings support the growing evidence of a relationship between infection by Onchocerca volvulus and some types of childhood epilepsy,and suggest that a combination of bi-annual mass distribution of ivermectin and ground larviciding of rivers is an effective strategy to prevent NS and OFE in onchocerciasis-hyperendemic areas.

Stigma and epilepsy in onchocerciasisendemic regions in Africa:a review and recommendations from the onchocerciasisassociated epilepsy working group

Background:In onchocerciasis-endemic areas,particularly in those with a sub-optimal onchocerciasis control programme,a high prevalence of epilepsy is observed.Both onchocerciasis and epilepsy are stigmatizing conditions.The first international workshop on onchocerciasis-associated epilepsy(OAE)was held in Antwerp,Belgium(12-14 October 2017)and during this meeting,an OAE alliance was established.In this paper,we review what is known about epilepsy-associated stigma in onchocerciasis-endemic regions,and present the recommendations of the OAE alliance working group on stigma.Main body:For this scoping review,literature searches were performed on the electronic databases PubMed,Scopus and Science Direct using the search terms"epilepsy AND onchocerciasis AND stigma".Hand searches were also undertaken using Google Scholar,and in total seven papers were identified that addressed epilepsy-related stigma in an onchocercisasis-endemic area.Due to the limited number of published research papers on epilepsyassociated stigma in onchocerciasis-endemic areas,other relevant literature that describes important aspects related to stigma is discussed.The thematic presentation of this scoping review follows key insights on the barriers to alleviating the social consequences of stigma in highly affected onchocerciasis-endemic areas,which were established by experts during the working group on stigma and discrimination at the first international workshop on OAE.These themes are:knowledge gaps,perceived disease aetiology,access to education,marriage restrictions,psycho-social well-being,burden on the care-giver and treatment seeking behaviour.Based on the literature and expert discussions during the OAE working group on stigma,this paper describes important issues regarding epilepsy-related stigma in onchocerciasis-endemic regions and recommends interventions that are needed to reduce stigma and discrimination for the improvement of the psycho-social well-being of persons with epilepsy.Conclusions:Educating healthcare workers and communities about OAE,strengthening onchocerciasis elimination programs,decreasing the anti-epileptic treatment gap,improving the care of epilepsy-related injuries,and prioritising epilepsy research is the way forward to decreasing the stigma associated with epilepsy in onchocerciasis-endemic regions.

Would ivermectin for malaria control be beneficial in onchocerciasis-endemic regions?

Background:There is accumulating evidence supporting the use of ivermectin as a malaria control tool.Recent findings from the repeat ivermectin mass drug administrations for control of malaria trial demonstrated a reduced incidence of malaria in villages which received repeated ivermectin mass drug administration(MDA;six doses)compared to those who had only one round of ivermectin.Several other studies investigating the benefits of ivermectin for malaria purposes are ongoing/planned.Main text:While ivermectin MDA offers promising perspectives in the fight against malaria,we highlight the added benefits and anticipated challenges of conducting future studies in onchocerciasis-endemic regions,which are confronted with a substantial disease burden including onchocerciasis-associated epilepsy.Increasing the frequency of ivermectin MDA in such places may reduce the burden of both malaria and onchocerciasis,and allow for more entomological investigations on both the Anopheles mosquitoes and the blackflies.Upfront,acceptability and feasibility studies are needed to assess the endorsement by the local populations,as well as the programmatic feasibility of implementing ivermectin MDA several times a year.Conclusions:Onchocerciasis-endemic sites would doubly benefit from ivermectin MDA interventions,as these will alleviate onchocerciasis-associated morbidity and mortality,while potentially curbing malaria transmission.Involving onchocerciasis programs and other relevant stakeholders in the malaria/ivermectin research agenda would foster the implementation of pluri-annual MDA in target communities.

Prevalence of epilepsy in the onchocerciasis endemic middle belt of Ghana after 27 years of mass drug administration with ivermectin

BackgroundIn onchocerciasis-endemic areas with high ongoing Onchocerca volvulus transmission,a high prevalence of epilepsy has been reported.This study aimed to determine the prevalence and clinical characteristics of epilepsy in the Bono Region of Ghana following 27 years of implementation of ivermectin mass drug administration(MDA).MethodsBetween October 2020 and August 2021,cross-sectional surveys were conducted in nine communities in the Tain District and Wenchi Municipality of the Bono Region of Ghana.In the first stage,a random door-to-door approach was used to screen the population for epilepsy using a pre-tested questionnaire.Persons suspected of having epilepsy were invited for a second-stage neurological examination for case verification.Community O.volvulus microfilarial infection status and Ov16 seropositivity were also determined.Ninety-five confidence intervals(95%CI)for prevalence values were calculated using the Wilson Score Interval.ResultsOf the 971 participants,500(51.5%)were females,and the median age(interquartile range)was 26(15‒43)years.Fourteen participants(1.4%,95%CI:1.0‒2.0)were diagnosed as having epilepsy with generalized seizures being the most frequent seizure type(85.7%,12/14).The overall microfilarial prevalence of O.volvulus was 10.3%(November 2020)and 9.9%(August 2021);the Ov16 seroprevalence was 22.2%(June 2021).Only 63.2%took ivermectin in the last round of MDA distribution in March 2021.ConclusionsThe 1.4%prevalence of epilepsy in the Bono region is similar to the median epilepsy prevalence in sub-Saharan Africa.However,the persistent microfilarial prevalence and low ivermectin study coverage call for the Ghana Onchocerciasis Elimination Programme to step up its efforts to ensure that the gains achieved are consolidated and improved to achieve the elimination of onchocerciasis by 2030.

The effect of bi-annual community-directed treatment with ivermectin on the incidence of epilepsy in onchocerciasis endemic villages in South Sudan:a study protocol

Background:Nodding syndrome(NS)is a devastating epileptic illness of unknown aetiology mainly affecting children 5-15 years of age.Head nodding distinguishes NS from other forms of epilepsy.Other manifestations of the illness include mental and physical growth retardation.Many children die as a result of falling in fires or drowning.Recently,it was shown that NS is only one of the phenotypic presentations of onchocerciasis associated epilepsy(OAE).Despite the strong epidemiological association between epilepsy and onchocerciasis,the causal mechanism is unknown.After implementation of bi-annual community directed treatment with ivermectin(CDTi)and larviciding of rivers in northern Uganda,new cases of NS have ceased,while new cases continue to emerge in South Sudanese onchocerciasis-endemic areas with an interrupted CDTi programme.This study is designed to evaluate the potential effects of bi-annual CDTi on reducing the incidence of NS/OAE in onchocerciasisendemic areas in South Sudan.Methods:A pre-intervention door-to-door population-based household survey will be conducted in selected onchocerciasis-endemic villages in Mundri and Maridi Counties,which have a high prevalence of epilepsy.Using a validated questionnaire,the entire village will be screened by community research assistants for suspected epilepsy cases.Suspected cases will be interviewed and examined by a trained clinical officer or medical doctor who will confirm or reject the diagnosis of epilepsy.Bi-annual CDTi will be implemented in the villages and a surveillance system for epilepsy set up.By implementing an epilepsy onchocerciasis awareness campaign we expect to obtain>90%CDTi coverage of eligible individuals.The door-to-door survey will be repeated two years after the baseline survey.The incidence of NS/OAE will be compared before and after bi-annual CDTi.Discussion:Our study is the first population-based study to evaluate the effect of bi-annual CDTi to reduce the incidence of NS/OAE.If the study demonstrates such a reduction,these findings are expected to motivate communities in onchocerciasis-endemic regions to participate in CDTi,and will encourage policy makers,funders and other stakeholders to increase their efforts to eliminate onchocerciasis.

Elimination of onchocerciasis in Africa by 2025: an ambitious target requires ambitious interventions

To achieve the elimination of onchocerciasis transmission in all African countries will entail enormous challenges,as has been highlighted by the active discussion around onchocerciasis intervention strategies and evaluation procedures in this journal.Serological thresholds for onchocerciasis elimination,adapted for the African setting,need to be established.The Onchocerciasis Technical Advisory Subgroup of the World Health Organization is currently developing improved guidelines to allow country elimination committees to make evidence-based decisions.Importantly,onchocerciasisrelated morbidity should not be forgotten when debating elimination prospects.A morbidity management and disease prevention(MMDP)strategy similar to that for lymphatic filariasis will need to be developed.This will require collaboration between the onchocerciasis elimination program,the community and other partners including primary health and mental health programs.In order to reach the goal of onchocerciasis elimination in most African countries by 2025,we should prioritize community participation and advocate for tailored interventions which are scientifically proven to be effective,but currently considered to be too expensive.

Onchocerca volvulus as a risk factor for developing epilepsy in onchocerciasis endemic regions in the Democratic Republic of Congo:a case control study

Background:A high prevalence of epilepsy has been observed in onchocerciasis endemic areas in the Democratic Republic of Congo(DRC).With this study we aimed to investigate whether Onchocerca volvulus infection is a risk factor for developing epilepsy in onchocerciasis endemic regions in the DRC.Methods:Between October and December 2015,a multi-centre case control study was performed in onchocerciasis endemic health zones(HZ)in the DRC:one study site was situated in Tshopo Province in the HZ of Wanierukula(village of Salambongo)where there had been 13 annual community distributions of treatment with ivermectin(CDTI),a second was situated in Ituri Province in the HZ of Logo(village of Draju)where ivermectin had never been distributed and in the HZ of Rethy(village of Rassia)where there had been THREE CDTI annual campaigns before the study.Individuals with unprovoked convulsive epilepsy of unknown etiology were enrolled as cases(n=175).Randomly selected healthy members of families without epilepsy cases from the same village and age-groups and were recruited as controls(n=170).Results:Onchocerciasis associated symptoms(e.g.,itching and abnormal skin)were more often present in cases compared to controls(respectively,OR=2.63,95%CI:1.63-4.23,P<0.0001 and OR=3.23,95%CI:1.48-7.09,P=0.0034).A higher number of cases was found to present with microfilariae in skin snips and with O.volvulus IgG4 antibodies in the blood compared to controls.Moreover,the microfilariae load in skin snips was 3-10 times higher in cases than controls.Conclusions:This case control study confirms that O.volvulus is a risk factor for developing epilepsy in onchocerciasis endemic regions in the DRC.

Comprehensive management of epilepsy in onchocerciasis-endemic areas:lessons learnt from community-based surveys

Background:Onchocerciasis-endem ic regions are known to have a high epilepsy prevalence.Limited resources in these areas and poor access to healthcare by persons with epilepsy(PWE)result in a wide anti-epileptic treatment gap,poor seizure control and a high burden of seizure-related complications.Recent comm unity-based surveys highlight the need for epilepsy managem ent strategies suitable for remote onchocerciasis-endemic villages to ensure better health outcom es for PWE.In this paper,we propose a feasible approach to manage PWE in such settings.Main text:Improved management of PWE in onchocerciasis-endemic areas may be achieved by decentralizing epilepsy care.Simplified approaches for the diagnosis and treatment of epilepsy may be used by non-physicians,under the supervision of physicians or specialists.To reduce the treatment gap,a regular supply of subsidized anti-epileptic drugs(AED)appropriate for different types of onchocerciasis-associated epilepsy should be instituted.Setting up a communitybased epilepsy surveillance system will enable early diagnosis and treatment of PWE thereby preventing complications.Community awareness programs on epilepsy must be implemented to reduce stigma and facilitate the social rehabilitation of PWE.Finally,strengthening onchocerciasis elimination programs by optimizing community-directed treatment with iverm eain(CDTI)and considering alternative treatment strategies might reduce the incidence of epilepsy.Conclusions:A community-based approach with task-shifting of epilepsy care from specialists to non-physician health workers will reduce epilepsy-associated morbidity.Increased advocacy and collaboration with various stakeholders is needed to establish a sustainable,cost-effective chronic care model for epilepsy that will significantly improve the quality of life of PWE in onchocerciasis-endemic regions.