Switched off: Sleeping Sickness in conflict

September 10, 2009
Dr Francois Chappuis and Bruno Jochum

Sustained political instability and violence have massive impacts on the health of affected populations. Studies show that more people die of treatable diseases during conflict than they do of conflict-related casualties. This is because the already poor state of health care facilities is often further degraded to a point where diseases that require only basic interventions – such as malaria or diarrhoea – cannot be cured.

Human African trypanosomiasis – or Sleeping Sickness as it is more commonly known – is a particularly problematic disease which tends to surge during conflict. Unlike malaria or diarrhoea, it demands difficult diagnostics and treatment, and is 100 percent fatal if left untreated.

Sleeping Sickness is transmitted to humans by the tsetse fly. It comes in 2 forms: Trypsanosoma brucei (t.b.) gambiense (west and central Africa) and rhondeniense (east African). It is estimated that 50-70,000 people are affected by the disease each year in 36 countries, with 7 countries representing 97% of all reported cases. But surveillance is poor in many areas so the true size of the problem is unknown.

Stage 1 symptoms begin with fever, headaches, and joint pains. If untreated, the disease slowly overcomes the defenses of the infected person then the parasite passes through the blood-brain barrier. The symptoms of stage 2 give the disease its name; besides confusion and reduced coordination, the sleep cycle is disturbed with bouts of fatigue punctuated with manic periods progressing to daytime slumber and night-time insomnia. Even if treated the damage caused in the neurological phase can be irreversible.

Sleeping Sickness is problematic because laboratory facilities are required to diagnose the disease. A lumbar puncture may also be needed to differentiate between stages 1 and 2. Treatment is relatively less complicated and still effective for patients at stage 1. However, most cases present at stage 2; this is when the treatment becomes very difficult. One option is to use a drug which is extremely toxic (melarsoprol) and kills 3-10% of patients, but this has limited effectiveness. The other option only works for one form of the disease (gambiense) and needs 56 intravenous infusions over 14 days. This requires specialized staff and infrastructure. Vector control is not enough to contain Sleeping Sickness; it is essential to diagnose and treat those affected to break the cycle of transmission.

The disease ravaged Africa over the last century with severe epidemics in Kenya, Tanzania, Uganda, Nigeria and the Democratic Republic of Congo (DRC). By the 1960s, the disease was bought under control but complacency and neglect led to its re-emergence in the mid-1970s and outbreaks continued until early this century. Fortunately, recent data shows that Sleeping Sickness has been bought more-or-less under control again. However, certain disease ‘hot-spots’ remain. These ‘hot spots’ have a common theme; in general they are areas of high insecurity and/or conflict.

One ‘hot spot’ is in Haut-Uélé, Province Orientale in the DRC where Medecins Sans Frontieres (MSF) had projects to detect and treat Sleeping Sickness from June 2007 until March 2009. During this period they found areas of high infection – approximately 3.4% of the 46,601 people screened were positive and treated, with some small pockets as high as 10%. For this particular disease, these rates are serious.

Haut-Uélé borders Uganda and Southern Sudan, is notoriously under-resourced, and has been subject to sporadic conflict and political tension for many years. Since September 2008, this insecurity and violence, which has been exacerbated by the joint military operations against the Lord’s Resistance Army (LRA), has caused almost all MSF activities to be shut down. This is particularly concerning since it is feared that over 5000 people will die within the next 2 years if they cannot access treatment.

Even more concerning is that the affected population is on the move. Refugees are entering new regions, raising the risk of reactivating historically cleared pockets or creating new foci. Moreover, the conflict is pushing the LRA to expand its territory into areas of the Central African Republic (CAR) which already has worrying rates of the disease.

WHO has expressed hope that Sleeping Sickness can be eliminated if detection and treatment can be integrated into primary health care services. However, in some contexts, there is very little capacity to do this and more radical, targeted interventions with active case finding are the best method to get the disease under control. Given these messy realities, total elimination is not feasible in many areas.

Sleeping Sickness is not a health problem that can be classified as a scourge of the past. Vigilance needs to be maintained along with specialised projects in politically unstable contexts. If victims are neglected once again, there is the potential for history to repeat itself.


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