Integrating innovations:a qualitative analysis of referral non-completion among rapid diagnostic test-positive patients in Uganda’s human African trypanosomiasis elimination programme

Background:The recent development of rapid diagnostic tests(RDTs)for human African trypanosomiasis(HAT)enables elimination programmes to decentralise serological screening services to frontline health facilities.However,patients must still undertake multiple onwards referral steps to either be confirmed or discounted as cases.Accurate surveillance thus relies not only on the performance of diagnostic technologies but also on referral support structures and patient decisions.This study explored why some RDT-positive suspects failed to complete the diagnostic referral process in West Nile,Uganda.Methods:Between August 2013 and June 2015,85%(295/346)people who screened RDT-positive were examined by microscopy at least once;10 cases were detected.We interviewed 20 RDT-positive suspects who had not completed referral(16 who had not presented for their first microscopy examination,and 4 who had not returned for a second to dismiss them as cases after receiving discordant[RDT-positive,but microscopy-negative results]).Interviews were analysed thematically to examine experiences of each step of the referral process.Results:Poor provider communication about HAT RDT results helped explain non-completion of referrals in our sample.Most patients were unaware they were tested for HAT until receiving results,and some did not know they had screened positive.While HAT testing and treatment is free,anticipated costs for transportation and ancillary health services fees deterred many.Most expected a positive RDT result would lead to HAT treatment.RDT results that failed to provide a definitive diagnosis without further testing led some to question the expertise of health workers.For the four individuals who missed their second examination,complying with repeat referral requests was less attractive when no alternative diagnostic advice or treatment was given.Conclusions:An RDT-based surveillance strategy that relies on referral through all levels of the health system is inevitably subject to its limitations.In Uganda,a key structural weakness was poor provider communication about the possibility of discordant HAT test results,which is the most common outcome for serological RDT suspects in a HAT elimination programme.Patient misunderstanding of referral rationale risks harming trust in the whole system and should be addressed in elimination programmes.

Estimating the economic and social consequences for patients diagnosed with human African trypanosomiasis in Muchinga,Lusaka and Eastern Provinces of Zambia(2004-2014)

Background:Acute human African trypanosomiasis(rHAT)caused by Trypanosoma brucei rhodesiense is associated with high mortality and is fatal if left untreated.Only a few studies have examined the psychological,social and economic impacts of rHAT.In this study,mixed qualitative and quantitative research methods were used to evaluate the socio-economic impacts of rHAT in Mambwe,Rufunsa,Mpika and Chama Districts of Zambia.Methods:Individuals diagnosed with rHAT from 2004 to 2014 were traced using hospital records and discussions with communities.Either they,or their families,were interviewed using a structured questionnaire and focus group discussions were conducted with affected communities.The burden of the disease was investigated using disability adjusted life years(DALYs),with and without discounting and age-weighting.The impact of long-term disabilities on the rHAT burden was also investigated.Results:Sixty four cases were identified in the study.The majority were identified in second stage,and the mortality rate was high(12.5%).The total number of DALYs was 285 without discounting or age-weighting.When long-term disabilities were included this estimate increased by 50%to 462.The proportion of years lived with disability(YLD)increased from 6.4%to 37%of the undiscounted and un-age-weighted DALY total.When a more active surveillance method was applied in 2013-2014 the cases identified increased dramatically,suggesting a high level of under-reporting.Similarly,the proportion of females increased substantially,indicating that passive surveillance may be especially failing this group.An average of 4.9 months of productive time was lost per patient as a consequence of infection.The health consequences included pain,amnesia and physical disability.The social consequences included stigma,dropping out of education,loss of friends and self-esteem.Results obtained from focus group discussions revealed misconceptions among community members which could be attributed to lack of knowledge about rHAT.Conclusions:The social and economic impact of rHAT on rural households and communities is substantial.Improved surveillance and strengthening of local medical services are needed for early and accurate diagnosis.Disease prevention should be prioritised in communities at risk of rHAT,and interventions put in place to prevent zoonotic disease spill over from domestic animals and wildlife.Supportive measures to mitigate the long-term effects of disability due to rHAT are needed.

Evaluating the impact of targeting livestock for the prevention of human and animal trypanosomiasis,at village level,in districts newly affected with T.b.rhodesiense in Uganda

Background:Uganda has suffered from a series of epidemics of Human African Trypanosomiasis(HAT),a tsetse transmitted disease,also known as sleeping sickness.The area affected by acute Trypanosoma brucei rhodesiense HAT(rHAT)has been expanding,driven by importation of infected cattle into regions previously free of the disease.These regions are also affected by African Animal Trypanosomiasis(AAT)demanding a strategy for integrated disease control.Methods:In 2008,the Public Private Partnership,Stamp Out Sleeping Sickness(SOS)administered a single dose of trypanocide to 31486 head of cattle in 29 parishes in Dokolo and Kaberamaido districts.This study examines the impact of this intervention on the prevalence of rHAT and AAT trypanosomes in cattle from villages that had(HAT^(+ve))or had not(HAT^(-ve))experienced a recent case of rHAT.Cattle herds from 20 villages were sampled and screened by PCR,pre-intervention and 6-months post-intervention,for the presence or absence of:Trypanosoma brucei s.l.;human infective T.b.rhodesiense;Trypanosoma vivax;and Trypanosoma congolense savannah.Results:Post-intervention,there was a significant decrease in the prevalence of T.brucei s.l.and the human infective sub-species T.b.rhodesiense in village cattle across all 20 villages.The prevalence of T.b.rhodesiense was reduced from 2.4%to 0.74%(P<0.0001),with the intervention showing greater impact in HAT^(-ve) villages.The number of villages containing cattle harbouring human infective parasites decreased from 15/20 to 8/20,with T.b.rhodesiense infection mainly persisting within cattle in HAT^(+ve) villages(six/eight).The proportion of T.brucei s.l.infections identified as human infective T.b.rhodesiense decreased after the intervention from 8.3%(95%CI=11.1-5.9%)to 4.1%(95%CI=6.8-2.3%).Villages that had experienced a recent human case(HAT^(+ve) villages)showed a significantly higher prevalence for AAT both pre-and post-intervention.For AAT the prevalence of T.vivax was significantly reduced from 5.9%to 0.05%post-intervention while the prevalence of T.congolense increased from 8.0%to 12.2%.Conclusions:The intervention resulted in a significant decrease in the prevalence of T.brucei s.l.,human infective T.b.rhodesiense and T.vivax infection in village cattle herds.The proportion of T.brucei s.l.that were human infective,decreased from 1:12 T.brucei s.l.infections before the intervention to 1:33 post-intervention.It is clearly more difficult to eliminate T.b.rhodesiense from cattle in villages that have experienced a human case.Evidence of elevated levels of AAT in livestock within village herds is a useful indicator of risk for rHAT in Uganda.Integrated veterinary and medical surveillance is key to successful control of zoonotic rHAT.