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Stamping out sleeping sickness in Uganda

If the two forms collide, Uganda will be faced with a public health crisis (© Dr. Anna Okello)
If the two forms collide, Uganda will be faced with a public health crisis
© Dr. Anna Okello

A public-private partnership - "Stamp Out Sleeping Sickness" (SOS) - has been implementing a novel approach in Uganda to prevent the two forms of Human African Trypanosomiasis (HAT) occurring in the same area. Although HAT threatens more than 66 million people across 37 countries in Africa, Uganda is the only country to have T.b rhodesiense (acute form) in the south east, and T.b gambiense (chronic form) in the north west of the country. However, as a result of re-stocking of cattle carrying rhodesiense parasite, following years of civil war in northern Uganda, the disease spread to eight new districts in a ten year period, by which time only 150km separated the two forms of the disease.

"If the two forms collide, Uganda will be faced with a public health crisis," explains Dr. Anna Okello, a zoonotic disease researcher at the University of Edinburgh. "The only way we can tell which form of HAT a human being is infected with is by knowing which part of Uganda they come from, and the treatment is quite different. If the two forms merge we will not be able to treat patients effectively, and this disease is always fatal without treatment."

Avoiding a fateful collision

By bringing together Ugandan and international authorities, a private pharmaceutical company, Ugandan veterinary students and researchers, the SOS public-private partnership was established to "clean out" the parasite from the cattle reservoir in northern Uganda and reduce human incidence of the disease.

Cattle were sprayed on their legs and belly with an insecticide to prevent re-infection (© Dr. Anna Okello)
Cattle were sprayed on their legs and belly with an insecticide to prevent re-infection
© Dr. Anna Okello

With the knowledge that rhodesiense is carried in domestic cattle and is passed to humans by the bite of an infected tsetse fly, SOS targeted livestock, rather than tsetse, an approach that proved to be cheaper and more effective. Research from Zimbabwe also found that most tsetse feed from the legs and belly of cattle, indicating that spraying these areas with insecticide would be as effective as spraying the whole animal, and for a fraction of the cost. The added benefit to farmers is that they reduce nagana, the cattle form of the disease, which leads to reduced productivity, fertility, and draught power and often leads to death.

During late 2006, over an eight week period, SOS teams treated 250,000 cattle in five districts for free, to halt the northward spread of rhodesiense. Makerere University veterinary students initially treated cattle with a trypanocide and then, to prevent re-infection from tsetse, cattle were sprayed on their legs and belly with an insecticide. The combined treatment approach reduced the prevalence of trypanosomiasis in cattle by over 70 per cent. Once the immediate emergency was over, SOS turned its attention to encouraging monthly spraying of cattle to prevent re-infection from the tsetse population.

Sustainability

One of the greatest challenges with sleeping sickness is that the symptoms look much like malaria in the early stages, and HIV in its later stages. "It's difficult to convince people this is a disease they get from their cows," Okello says. In addition, cattle infected with human infective rhodesiense do not look sick, making it harder to convince farmers to pay for constant spraying of their animals. "Farmers have to be aware of the causes of sleeping sickness and the links between human and animal health," Okello adds. "Public engagement to raise awareness of the disease has been a big part of the intervention since the beginning, but ongoing political support is required to maintain advocacy long-term."

Five graduates set up private veterinary business in northern Uganda (© Dr. Anna Okello)
Five graduates set up private veterinary business in northern Uganda
© Dr. Anna Okello

For livestock keepers to regularly use insecticide, the sprays have to be cheap to purchase and easy to acquire. Farmers also require access to veterinary services. To build a permanent distribution chain for veterinary products and services in rural areas, the partnership developed the '3V Vet Initiative'*. Initially, five Makerere University graduates were supported financially to set up private veterinary business in northern Uganda. "We have all started and legalised our businesses, which have changed the lives of our farmers and ourselves," explains 3V vet Emanuel Isingoma. "By setting up private enterprises, we are ensuring sustainability," Okello says. "These 3V veterinary services have remained active despite the cessation of donor funds."

By providing clinics and distribution networks, the 3V network has improved animal health but natural shocks, including drought, have impacted the ability of livestock keepers to pay for sustained preventative treatment. So far, another five 3V vets have been set up in Soroti and Serere to ensure drug supply chains remain open.

Maintaining momentum

The working relationship between the SOS consortium partners has been one of the key reasons for the success of the project. But questions over who pays to control sleeping sickness in the absence of donors, and whether the Ugandan government will be able to maintain the momentum, will determine whether sleeping sickness continues to be contained. "Ideally animal treatment costs should be shared between the Ministry of Livestock and the Ministry of Health but this is unlikely to occur in the near future," Okello states. But she ends in warning, "This disease is just too devastating to have "hit and miss" adherence to policy."

* IKARE, CEVA Santa Animale, Coordinating Office for Control of Trypanosomiasis in Uganda (COCTU), World Health Organisation (WHO), Ministry of Health Uganda, Ugandan Ministry of Agriculture, Animal Industry and Fisheries (MAAIF), Makerere University, University of Edinburgh, DFID Research Into Use
* 3V: named after the three drugs used to control Nagana (Vectocid, Veriben, and Veridium)

Date published: November 2011

 

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