Implementation of newly available diagnostic tools by national control programmes is ongoing in several HAT-endemic countries, with the help of FIND and other partners. Case detection and confirmation strategies include:
- Passive screening using RDT, microscopy & LAMP for T.b. gambiense
- Active screening by motorcycles with RDT b. gambiense
- Sustained control by passive screening using microscopy & LAMP T.b. rhodesiense
A major part of implementation includes capacity building projects designed to strengthen health facilities through installation of solar energy, procurement of laboratory equipment and consumables, training of personnel, quality assurance, advocacy and sensitization of communities. Collectively, this work is accelerating elimination of HAT by facilitating early detection of cases and preventing transmission of the disease.
New diagnostic tools
Three diagnostic tests for sleeping sickness have been developed in collaborations between FIND and academic, manufacturing and endemic country partners:
1. The SD HAT rapid diagnostic test (RDT):
– Simple to use and store
– Inexpensive (50 US cents)
– Very sensitive (92%)
– Imperfect specificity: 3 in 100 people who do not have HAT test positive for the disease, so positives must be confirmed by other tests
– Requires minimal expertise and training, and can be performed by staff at the smallest health-care facilities as well as by mobile teams
2. Primo Star iLED fluorescence microscope (iLED FM)
– Low power requirements and long-lasting light sources
– Slides are quick and easy to stain
– Versatile – can also be used for malaria and TB
– Does not require a dark room
– Low sensitivity – LED FM misses many cases
– LED FM can be used to perform all parasitological confirmation tests for HAT and can be powered from solar panels
3. Loop-mediated isothermal amplification (LAMP) of DNA
– Highly sensitive
– Identifies HAT suspects missed by microscopy
– Also works on blood samples dried on filter paper
– Requires reliable power and a reasonably well equipped lab
– Can be performed by technicians with no training in molecular biology and can be deployed at district- or microscopy level laboratories
One of the challenges in HAT elimination is the fact that the disease emerges in rural locations. HAT diagnostic tools capable of case confirmation and test-of-cure can only be deployed at district or microscopy level laboratories.
To overcome this, FIND and partners designed a new screening process that makes new diagnostic technologies more accessible to potential patients.
After implementation of new diagnostic tools in targeted endemic regions–strategically dispersed to minimize patient travel–symptomatic patients are screened as follows:
1. Patients with symptoms suggestive of HAT are tested with a malaria RDT because symptoms can be similar
2. If a patient is negative for malaria (or positive but still symptomatic after malaria treatment) a HAT RDT is performed
3. If the HAT RDT is positive, the patient is referred to the nearest facility for parasitological confirmation, including with LED fluorescent microscopy
4. If found positive by microscopy, the patient is staged and treated for HAT. When a patient is negative by microscopy, further testing is required at a facility equipped to perform LAMP. If the patient is at a facility that does not have LAMP, a blood sample is dried on filter paper and transported to the nearest LAMP facility by a motorcycle belonging to the project.
5. Patients found positive by LAMP are considered strong HAT suspects and undergo further tests by microscopy to demonstrate parasites, in line with WHO guidelines
*Screening process is adapted based on the particular resources, needs, geography and demography of different locations
The Trypa-NO! Partnership aims to drive Trypanosoma brucei gambiense HAT (gHAT) cases to zero in Côte d’Ivoire and Uganda, and to reduce them by 90% in Chad and Guinea over a three-year period.
The Trypa-NO! Partnership is a collaboration between FIND, the French National Research Institute for Sustainable Development (IRD), the Liverpool School of Tropical Medicine (LSTM), the Coordinating Office for Control of Trypanosomiasis in Uganda (COCTU), the National HAT Control Programmes of Chad and Guinea, the National HAT Elimination Programme of Côte d’Ivoire, the Institut Pierre Richet and the University of Daloa.
The integrated strategy developed by the Trypa-NO! partners aims to:
- Eliminate the reservoirs of T.b. gambiense within the human population
- Reduce numbers of the tsetse fly vectors in active gHAT focus areas in order to interrupt transmission
- Collect and map disease surveillance data to guide elimination planning
Trypanosoma brucei gambiense HAT (gHAT) is rapidly declining in Chad as a result of continuous control operations over several years. In 2016, only 53 cases of gHAT were identified, down from 510 cases in 2009. Closer than ever to elimination, in 2017 Chad’s National HAT Control Programme began implementing an integrated elimination programme called Trypa-NO! which pairs tsetse fly control methods with intensive screening, diagnosis and treatment to meet the World Health Organization’s (WHO) goal to eliminate HAT as a public health problem by 2020.
The Trypa-NO! Partnership in Chad is a collaboration between FIND, the French National Research Institute for Sustainable Development (IRD), the Liverpool School of Tropical Medicine (LSTM) and Vestergaard, in coordination with the Government of Chad’s Ministry of Public Health and Ministry of Livestock and Animal Production, through the National Control Programme against HAT and IRD.
The Trypa-NO! Partnership aims to reduce gHAT cases in Chad by 90% over a three-year period. FIND’s work in Chad has focused on increasing diagnostic capacity of health facilities by introducing rapid and molecular tests to identify suspected cases of gHAT, and by enhancing microscopy to perform confirmatory diagnosis
Complementary initiatives by WHO to improve access to treatment have helped ensure that gHAT patients receive necessary care. Active efforts led by Chad’s Ministry of Agriculture and supported by IRD and LSTM to interrupt gHAT transmission by tsetse flies are playing a key role in disease control.
Republic of Guinea
Guinea has the largest sleeping sickness burden in West Africa, with more than 800 cases of Trypanosoma brucei gambiense HAT (gHAT) reported between 2000 and 2009. Tsetse control activities by the National HAT Control Programme and IRD prevented a dramatic increase of gHAT during the Ebola outbreak in Guinea. In addition, the passive surveillance system that had initially been set up at the beginning of 2014, pre-Ebola, was revived.
The elimination strategy of the Trypa-NO! Partnership relies on a combination of active and passive screening activities, with the deployment of Tiny Targets – insecticidal “flags” to reduce human-tsetse contact – aiming to reduce gHAT cases in Guinea by 90% over a three-year period.
In Guinea, the Trypa-NO! Partnership is a collaboration between FIND, the French National Research Institute for Sustainable Development (IRD), the Liverpool School of Tropical Medicine (LSTM), and the National HAT Control Programme of the Ministry of health of Guinea.
The Trypa-NO! Partnership also includes activities to raise awareness on the disease, such as performing dramas in gHAT endemic villages prior to active screening campaigns.
In 2012, the London Declaration endorsed the roadmap for HAT elimination as a public health problem by 2020, as defined by the World Health Organization (WHO). The government of Uganda has responded by working with partners to implement a national initiative to accelerate elimination of the disease. In 2016, only four cases of Trypanosoma brucei gambiense HAT were identified in Uganda.
In Uganda, the Trypa-NO! Partnership is a collaboration between FIND, the Liverpool School of Tropical Medicine (LSTM) and the Coordinating Office for Control of Trypanosomiasis in Uganda (COCTU).
The Trypa-NO! Partnership pairs tsetse fly control methods with intensive screening, diagnosis and treatment, to go the last mile to zero cases, aiming to eliminate gHAT as a public health problem in Uganda over a three-year period. Though gHAT was previously thought to have been near elimination in Uganda, Trypa-NO! has identified several cases within the South Sudanese refugee population, executing a quick and immediate screening and vector control response.
Monitoring and technology services have also been effective in tracking cases. An SMS system of data transfer put in place in August 2016 is being used to follow the implementation of passive screening activities. The system also allows an easier follow-up of patients found positive with screening tests, but negative by microscopy.
In Côte d’Ivoire, significant efforts to control Trypanosoma brucei gambiense HAT (gHAT) over the past three decades have drastically reduced the incidence of gHAT. The Trypa-NO! Partnership pairs tsetse fly control methods with intensive screening, diagnosis and treatment, to go the last mile to zero cases, aiming to eliminate gHAT as a public health problem in Côte d’Ivoire over a three-year period.
The Trypa-No! Partnership in Côte d’Ivoire is a collaboration between FIND, the French National Research Institute for Sustainable Development (IRD), the Liverpool School of Tropical Medicine (LSTM), the National HAT Elimination Programme of the Ministry of Health, Institut Pierre Richet, and University of Daloa of Côte d’Ivoire.
The Democratic Republic of the Congo (DRC), Republic of Congo and Angola are partnering with FIND to implement a trans-boundary project aimed at accelerating elimination of human African trypanosomiasis (HAT) or sleeping sickness.
Due to environmental, biological, demographic and other poorly understood factors, infections with HAT tend to aggregate in spatially limited areas referred to as foci. While such foci are often located within individual countries and can be controlled by single national disease control programmes, others traverse neighboring countries and necessitate concerted, international control efforts. In a large endemic region known as Kongo Central (formerly the Bas-Congo province of DRC, the north of Angola and the south of the Republic of Congo), the prevalence of HAT is low.
Since this region is isolated from other endemic areas, intensified and sustained management of the disease could lead to its elimination. This transboundary project introduces new diagnostic tools and methods in health facilities across the entire area.
In the DRC, 600 health facilities have been equipped with the SD BIOLINE HAT RDT, 23 facilities have been upgraded to perform state-of-the-art parasitological methods, including LED fluorescence microscopy, while LAMP (loop-mediated isothermal amplification) has been introduced in 5 facilities. Such a network of health facilities can support the implementation of FIND’s game-changing diagnostic screening strategy.
Mapping health facilities
In the Republic of the Congo, characterization of health facilities is being carried out in eight HAT-endemic communes that border Kongo Central. Similarly, in Angola, characterization of health facilities is being carried out in endemic areas of the Zaire and Cabinda provinces, located next Kongo Central. The data from the characterization will be used to select health facilities to be strengthened for the implementation of new diagnostic solutions, thus enhancing control of HAT. The activities in the two countries will ensure full coverage of the endemic focus, complementing the efforts that are going on in Kongo Central. Strengthening diagnostic capacity in these three neighboring countries will have a significant impact on control of the disease, prevent its resurgence in the region and accelerate HAT elimination.
- Mapping health facilities
In 2013, the Ministry of Health of Malawi signed an agreement with FIND to strengthen the diagnostic capacity of health centres adjacent to the Vwaza Marsh Game Reserve to intensify control of sleeping sickness in Malawi by increasing the chances for early diagnosis.
Malawi is endemic for Trypanosoma brucei rhodesiense sleeping sickness or human African trypanosomiasis (HAT), an acute form of the disease.
The collaboration includes refurbishing health facilities and equipping them with LED fluorescent microscopes and LAMP to diagnose HAT and other diseases prevalent in the area, as well as training laboratory personnel. The initiative has reduced the time between infection and confirmatory diagnosis of the disease. This increases the chances of detecting cases in the early stage, when treatment is safer and more effective. It also reduces the burden on patients in time and costs of travelling to distant diagnostic services, which until recently, were only available at the district hospital more than 60 km from the game reserve.
This initiative has been supported by the government of Malawi, the Bill and Melinda Gates Foundation, the German Federal Ministry of Education and Research, the Department for International Development (DFID) of the United Kingdom and the Swiss Agency for Development and Cooperation (SDC).
In 2014, the Nigerian government, through the Nigerian Institute for Trypanosomiasis Research (NITR), signed an agreement with FIND to collaborate on the implementation of a strategy for intensified surveillance of sleeping sickness in Nigeria.
Though nationwide active surveillance of sleeping sickness has not been undertaken for a long time, recent reports have confirmed presence of sleeping sickness in and around Abraka in the Delta State. FIND and NITR conducted an in-depth analysis of all the health facilities in the Delta State and selected facilities for implementation of the new strategy. This included renovations, supplying equipment and consumables, and training laboratory technicians and health personnel in the use of the new technologies. These activities contributed significantly to strengthening the health system in the region.
Since intensive surveillance for sleeping sickness started in 2015, no sleeping sickness case has been identified, suggesting that the disease may have been eliminated in the region. FIND is working with NITR and the Ministry of Health of Nigeria to transition the project to post-elimination surveillance.
This project is supported by the government of Nigeria, the Bill and Melinda Gates Foundation, the German Federal Ministry of Education and Research, the Department for International Development (DFID) of the United Kingdom and the Swiss Agency for Development and Cooperation (SDC).
In 2013 and 2014, South Sudan reported the fourth highest number of cases of Trypanosoma brucei gambiense human African trypanosomiasis (gHAT). Due to lack of resources, there has been no active screening for gHAT, and many cases may have gone undiagnosed and untreated.
Implementation of the project to control gHAT in South Sudan, in collaboration with with Malteser International and the Ministry of Health of the Republic of South Sudan, started in the Yei River and Maridi Counties in 2013 and has expanded to Ibba, Kajo Keji, Magwi and Pegeri counties. The activities of the project include:
- Mapping and characterization of all health facilities
- Up-grading and equipping selected health facilities
- Training of technicians and health workers
- Advocacy and communication.
FIND and the Government of Uganda have been implementing a similar project to eliminate gHAT in the region bordering South Sudan. An extension of these activities to South Sudan is a great opportunity to sustain and accelerate control and eventually eliminate HAT in the region.
Malteser International, the relief agency of the Sovereign Order of Malta for humanitarian aid and the Ministry of Health are the lead implementing partners on this project, with support from WHO and Jhpiego, an international NGO dedicated to saving the lives of women and families worldwide. This project is supported by the Bill and Melinda Gates Foundation, the German Federal Ministry of Education and Research, the Department for International Development (DFID) of the United Kingdom, the Swiss Agency for Development and Cooperation (SDC) and the Republic and Canton of Geneva, Switzerland.