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Nodding syndrome (NS) is a poorly understood form of childhood-onset epilepsy that is characterized by the pathognomonic ictal phenomenon of repetitive vertical head drops. To evaluate the underlying ictal neurophysiology, ictal EEG features were evaluated in nine participants with confirmed NS from South Sudan, Tanzania, and Uganda and ictal presence of high frequency gamma oscillations on scalp EEG were assessed. Ictal EEG during the head nodding episode predominantly showed generalized slow waves or sharp-and-slow wave complexes followed by electrodecrement. Augmentation of gamma activity (30-70 Hz) was seen during the head nodding episode in all the participants. We confirm that head nodding episodes in persons with NS from the three geographically distinct regions in sub-Saharan Africa share the common features of slow waves with electrodecrement and superimposed gamma activity. ANN NEUROL 2022;92:75-80.

With an estimated lifetime prevalence of epilepsy of 7.6 per 1,000 people, epilepsy represents one of the most common neurological disorders worldwide, with the majority of people with epilepsy (PWE) living in low-income and middle-income countries (LMICs). Adequately treated, up to 70 % of PWE will become seizure-free, however, as many as 85% of PWE worldwide, mostly from LMICs, do not receive adequate treatment.To assess the impact of the presence of a neurologist on the management of PWE in Tanzania.Two epilepsy clinics in rural Tanzania, one continuously attended by a neurologist, and one mainly attended by nurses with training in epilepsy and supervised intermittently by specialist doctors (neurologists/psychiatrists) were comparatively analyzed by multivariable linear and logistic regression models with regard to the outcome parameters seizure frequency, the occurrence of side effects of antiepileptic medication and days lost after a seizure.The presence of a neurologist significantly reduced the mean number of seizures patients experienced per month by 4.49 seizures (p 0.01) while leading to an increase in the occurrence of reported side effects (OR: 2.15, p = 0.02).The presence of a neurologist may play a substantial role in reducing the burden of the disease of PWE in LMICs. Hence, specialist training should be encouraged, and relevant context-specific infrastructure established.

Background Neurocysticercosis (NCC), a zoonotic disease caused by the pork tapeworm T. solium, represents one of the most common causes of secondary epilepsy but remains often undiagnosed due to lack of awareness and diagnostic facilities. Methodology We pooled data from four cross-sectional studies on epilepsy and NCC in eastern Africa. Study sites were in Uganda, Malawi and in Tanzania (Dar es Salaam and Haydom). The study in Uganda and Malawi were community-based, the two studies in Tanzania were hospital-based. The same questionnaire was used for assessment of clinical characteristics of patients with epilepsy. Computed tomography (CT) scans and serological testing were performed in order to diagnose NCC. Results Overall, 1,179 people with epilepsy were included in our analysis. Of those, 941 PWE underwent CT scanning and were pooled for NCC analysis. Seventy patients were diagnosed with NCC, but NCC prevalence differed considerably between sites ranging from 2.0% (95%CI 0.4% to 3.6%) in Dar es Salaam to 17.5% (95%CI 12.4% to 22.6%) in Haydom. NCC prevalence did not show any association with sex but increased with age and was higher in rural than urban settings. In addition, being a farmer, non-Muslim, eating pork and living with pigs close by was associated with a higher NCC prevalence. PWE with NCC experienced their first epileptic seizure around 3 years later in life compared to PWE without NCC and their epileptic seizures seemed to be better controlled (p Conclusions NCC is prevalent among PWE in eastern Africa, although it may not be as common as previously stated. Demographic characteristics of PWE with NCC differed from those without NCC, but semiological characteristics and results on neurological examination did not differ compared to PWE without NCC. Interestingly, seizures seemed to be less frequent in PWE with NCC. Being aware of those differences and similarities may help triaging PWE for neuroimaging in order to establish a diagnosis of NCC.

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).The study was conducted in January 2017 in two suburban and two rural villages in the Mahenge area. Door-to-door 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.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 100 000 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%.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.

Objectives Epileptic seizures and epilepsy in urban settings of low-income and middle-income countries (LMIC) are largely under-researched, but their prevalence is necessary for good healthcare planning. This study aimed to determine the lifetime prevalence of epileptic seizures and epilepsy in urban Dar es Salaam. Methods Nearly 50,000 people in former Kinondoni district, Dar es Salaam, were screened for epileptic seizures using a set of nine questions. Answers to these nine questions were categorized into generalized, focal, and unspecified seizures. Screening positivity rates were adjusted for questionnaire inaccuracy using two scenarios to analyse true epilepsy prevalences. Results Overall, 1085 (2.23%) people fulfilled the criteria for ever having had at least one type of epileptic seizure. Two-hundred-ninety-six (0.60%) people screened positive for generalized seizures, 986 (2.02%) for focal seizures, and 32 (0.07%) for unspecified seizures. Women more commonly screened positive than men (2.61% versus 1.72%, p, Highlights • Data on epilepsy in urban African populations are scarce • Reliable prevalence estimates for epilepsy are important for healthcare planning but difficult to obtain • Epilepsy screening tools need to be developed carefully in a participatory approach • Focal and non-convulsive seizures are often overlooked in studies • Epilepsy prevalence in urban Tanzania is similar to other parts of Africa

To describe the clinical manifestations of epilepsy and access to antiseizure treatment in Mahenge in Central Tanzania, an onchocerciasis endemic area with a high prevalence of epilepsy. A door-to-door epilepsy prevalence survey was conducted in four rural and two sub-urban villages. Trained community workers used five screening questions to identify persons suspected to have epilepsy. Such individuals were interviewed and examined by a neurologist or a medical doctor with additional training in epilepsy, and were tested for Onchocerca volvulus antibodies. A total of 221 out of 8,062 (2.74%) surveyed individuals were confirmed to have epilepsy. The median age at seizure onset was 12 years (interquartile range: 7-16). Seventy-nine persons with epilepsy (PWE) (36.1%) had a family member with epilepsy, which was a sibling in 52.1%. Tonic-clonic seizures (142 individuals; 64.2%) were the most common seizure type. Nodding seizures were reported in 12.7% of PWE; the majority of them living in rural villages. Persons with nodding seizures reported more frequent seizures, presented with more psychiatric symptoms, and more often had onchocerciasis antibodies than those with other seizure types. The high rate of individuals with a seizure onset at between seven and 16 years is characteristic of onchocerciasis-associated epilepsy (OAE). Of the PWE, 77.9% met the criteria for the clinical case definition of OAE. Eighty-three PWE (37.6%) were not taking any antiepileptic medication. Phenobarbital was the antiepileptic drug most commonly prescribed in 76.1% of treated PWE. The high prevalence of epilepsy in rural villages in Mahenge most likely is related to the high prevalence of OAE. To prevent children developing OAE, strengthening the onchocerciasis elimination programme in Mahenge is urgently needed. Moreover, a decentralised epilepsy treatment programme is also needed to provide uninterrupted access to affordable antiepileptic drugs for the many PWE living in rural villages in the Mahenge area.

Introduction The spectrum of meningitis pathogens differs depending on the age of patients and the geographic region, amongst other. Although meningitis vaccination programs have led to the reduction of incidence rates, an imbalance between low- and high-income countries still exists. Methods In a hospital-based study in rural northern Tanzania, we consecutively recruited patients with confirmed meningitis and described their clinical and laboratory characteristics. Results A total of 136 patients with meningitis were included. Fever (85%), meningism (63%) and impairment of consciousness (33%) were the most frequent clinical symptoms/signs. Nearly 10% of all patients tested were positive for malaria. The majority of the patients with bacterial meningitis (39%), especially those under 5years of age, were confirmed to be infected with Haemophilus influenzae (26%), Streptococcus pneumoniae (19%) and Neisseria meningitidis (15%). Haemophilus influenzae represented the dominant causative organism in children under 2years of age. Conclusion Our study emphasizes the importance of recognizing warning symptoms like fever, meningism and impairment of consciousness, implementing laboratory tests to determine responsible pathogens and evaluating differential diagnoses in patients with meningitis in sub-Saharan Africa. It also shows that Haemophilus influenza meningitis is still an important cause for meningitis in the young, most probabaly due to lack of appropriate vaccination coverage.

In Africa, urbanization is happening faster than ever before which results in new implications for transmission of infectious diseases. For the zoonotic parasite Taenia solium, a major cause of acquired epilepsy in endemic countries, the prevalence in urban settings is unknown. The present study investigated epidemiological, neurological, and radiological characteristics of T. solium cysticercosis and taeniasis (TSCT) in people with epilepsy (PWE) living in Dar es Salaam, Tanzania, one of the fastest growing cities worldwide. A total of 302 PWE were recruited from six health centers in the Kinondoni district of Dar es Salaam. Serological testing for T. solium cysticercosis-antigen (Ag) and -antibodies (Abs) and for T. solium taeniasis-Abs was performed in all PWE. In addition, clinical and radiological examinations that included cranial computed tomography (CT) were performed. With questionnaires, demographic data from study populations were collected, and factors associated with TSCT were assessed. Follow-up examinations were conducted in PWE with TSCT. T. solium cysticercosis-Ag was detected in three (0.99%; 95% CI: 0–2.11%), -Abs in eight (2.65%; 95% CI: 0.84–4.46%), and taeniasis-Abs in five (1.66%; 95% CI: 0.22–3.09%) of 302 PWE. Six PWE (1.99%; 95% CI: 0.41–3.56%) were diagnosed with neurocysticercosis (NCC). This study demonstrates the presence of TSCT in Dar es Salaam, however, NCC was only associated with a few cases of epilepsy. The small fraction of PWE with cysticercosis- and taeniasis-Abs may suggest that active transmission of T. solium plays only a minor role in Dar es Salaam. A sufficiently powered risk analysis was hampered by the small number of PWE with TSCT; therefore, further studies are required to determine the exact routes of infection and risk behavior of affected individuals., Author summary Taenia solium cysticercosis and taeniasis is a zoonotic disease complex which affects thousands of people in sub-Saharan Africa. This parasite has a human-pig life cycle and has been considered a public health problem mainly in rural areas. As African towns and suburbs grow rapidly and disproportionally, adequate infrastructure such as sewage systems and clean water often lack while population density, trade, and travel increase. This may lead to the appearance of parasitic diseases formerly considered `rural´ in urban settings. In this study, we searched for evidence of T. solium infections in the Kinondoni district of Dar es Salaam, Tanzania. We focused on people with epilepsy (PWE) since epilepsy is one of the most common and severe disorders associated with T. solium neurocysticercosis and tested all of them serologically for T. solium cysticercosis and taeniasis. We further investigated neurological and radiological characteristics. Our findings show that in our study area in Dar es Salaam 2.65% of PWE had contracted T. solium infection at some stage. Neurocysticercosis, as confirmed by neuroimaging, was found only in 1.99% of PWE. This, in combination with the relatively small number of PWE detected with taeniasis antibodies (1.66%), points towards the fact that active transmission of T. solium seems to play only a minor role in this urban setting, suggesting that infections may mainly be contracted in rural areas. Further large-scale studies are required to investigate the infection pathways and risk behavior related to T. solium infections within urban areas of sub-Saharan Africa.

The prevalence of febrile seizures (FSs) and epilepsy are often reported to be higher in sub-Saharan Africa. Furthermore, several studies describe complex features of FSs as risk factors for the development of subsequent epilepsy. During the period from 2002 to 2004 door-to-door studies with supplementary data collection were conducted in three different areas of Tanzania, examining the prevalence of FSs in 7,790 children between the age of 2 mo and 7 y at the time of the interview. The information on the presence of FSs of 14,583 children, who at the time of the interview were younger than 15 y, was collected in order to describe reported seizures, if any. Overall, 160 children between 2 mo and 7 y with a prevalence rate of 20.5/1,000 (95% confidence interval: 17.5–23.9/1,000) met the criteria for FSs. The average age at onset was 2.2 (SD: 1.8) y and ~42% had complex FSs. Respiratory tract infections and malaria were the most frequent concomitant diseases. Our findings do not confirm the assumption of an increased prevalence of FSs in sub-Saharan Africa. However, the elevated number of complex FSs emphasizes the necessity of more reliable studies about FSs and its consequences.

Background The frequency of Taenia solium, a zoonotic helminth, is increasing in many countries of sub-Saharan Africa, where the prevalence of the human immunodeficiency virus (HIV) is also high. However, little is known about how these two infections interact. The aim of this study was to compare the proportion of HIV positive (+) and negative (−) individuals who are infected with Taenia solium (TSOL) and who present with clinical and neurological manifestations of cysticercosis (CC). Methods In northern Tanzania, 170 HIV+ individuals and 170 HIV– controls matched for gender, age and village of origin were recruited. HIV staging and serological tests for TSOL antibodies (Ab) and antigen (Ag) were performed. Neurocysticercosis (NCC) was determined by computed tomography (CT) using standard diagnostic criteria. Neurological manifestations were confirmed by a standard neurological examination. In addition, demographic, clinical and neuroimaging data were collected. Further, CD4+ cell counts as well as information on highly active antiretroviral treatment (HAART) were noted. Results No significant differences between HIV+ and HIV– individuals regarding the sero-prevalence of taeniosis-Ab (0.6% vs 1.2%), CC-Ab (2.4% vs 2.4%) and CC-Ag (0.6% vs 0.0%) were detected. A total of six NCC cases (3 HIV+ and 3 HIV–) were detected in the group of matched participants. Two individuals (1 HIV+ and 1 HIV–) presented with headaches as the main symptom for NCC, and four with asymptomatic NCC. Among the HIV+ group, TSOL was not associated with CD4+ cell counts, HAART duration or HIV stage. Conclusions This study found lower prevalence of taeniosis, CC and NCC than had been reported in the region to date. This low level of infection may have resulted in an inability to find cross-sectional associations between HIV status and TSOL infection or NCC. Larger sample sizes will be required in future studies conducted in that area to conclude if HIV influences the way NCC manifests itself.

Objective.— One goal of the campaign “Lifting the burden: The global campaign against headache” is to highlight existing evidence about headache worldwide. In this context, the aim of our study was to report the migraine-related headache burden in northern Tanzania. Methods.— From December 2003 until June 2004 a community-based door-to-door survey was undertaken in northern Tanzania, using multistage cluster sampling. Based on the criteria of the International Headache Society, 7412 individuals were enrolled in this survey. Results.— Migraine patients' average annual attack frequency was 18.4 (n = 308, standard deviation [SD] ± 47.4) with a mean duration of 16.4 hours (SD ± 20.6). The average headache intensity per patient was 2.65 (SD ± 0.59) with a calculated loss of 6.59 (SD ± 26.7) working days per year. Extrapolation of data to the investigated population (n = 7412) resulted in annual migraine burden of 281.0 migraine days per 1000 inhabitants. Conclusions.— To our knowledge, this study reports for the first time the burden that arises from migraine headache in a rural population of sub-Sahara Africa (SSA). As the presented migraine-related burden is considerable, we hope that our data will increase the awareness among local decision makers in allocating resources for treatment and research on headache.

The aim of the study was to assess the prevalence of headache with special attention to tension-type headache (TTH) in a rural area in northern Tanzania. A door-to-door study was performed using a standardized and validated questionnaire. A total of 7412 participants were screened. The total headache prevalence during the past year was 12.1%; the overall 1-year prevalence of TTH was 7%; 5% reported episodic TTH and 0.4% chronic TTH. Borderline cases (International Headache Society code 2.3) were described in 1.6%. The prevalence of headache was highest in the 41-50-year-old group in women and in the 61+ age group in men. This is the first account of the prevalence of TTH in a rural Tanzanian population, and shows that headache in general and, more specifically, TTH are prevalent disorders that deserve attention. However, the prevalence of primary headache seems to be lower than in Western countries.

Summary Background: Rapid diagnosis and adequate therapy are crucial to prevent development of severe disease and death in children suffering from malaria. A reliable but easy system for disease severity assessment would help to fast track seriously ill children and provide suitable therapies for different patient groups. Objectives: To examine risk factors and appropriate scoring systems in children suffering from malaria for outcome in terms of morbidity and mortality. Methods: A prospective, consecutive study in children admitted to the Muhimbili Medical Centre in Dar es Salaam was conducted to evaluate risk factors and test appropriate scoring systems. The simplified Multi-Organ Dysfunction Score (sMODS), a severity of disease classification consisting mainly of clinical data, was applied. Chosen outcome parameters were morbidity and mortality. Results were compared to those obtained from the World Health Organisation (WHO) classification of severe malaria, the Blantyre Coma Scale (BCS) and selected single clinical parameters. Results: Seventy-five children were recruited into the study. Mean age was 28 months ranging from 6 months to 8 years. ‘Severe Malaria’, according to WHO criteria was evident in 57 patients (76%). Mean sMODS on admission was 15.6 � 2. Seven patients (9%) died. Among single symptoms, impaired consciousness and respiratory distress predicted both, fatal outcome and morbidity. In terms of scoring systems, the sMODS correlated with both outcome parameters. In comparison, the WHO criteria did not correlate with any of the two parameters, the BCS correlated with mortality only. Conclusion: In our study, sMODS has been shown to represent a useful quantitative approach towards disease severity classification in resource poor settings and can be used for risk estimation in children suffering from malaria in terms of both morbidity and mortality.

Background: Nodding syndrome (NS) is a seemingly progressive epilepsy disorder of unknown underlying cause. We investigated association of pyridoxal-phosphate serum levels and occurrence of anti-neuronal antibodies against N-methyl-D-aspartate (NMDA) receptor and voltage gated potassium channel (VGKC) complex in NS patients.Methods: Sera of a Tanzanian cohort of epilepsy and NS patients and community controls were tested for the presence of anti-NMDA-receptor and anti-VGKC complex antibodies by indirect immunofluorescence assay. Furthermore pyridoxal-phosphate levels were measured.Results: Auto-antibodies against NMDA receptor or VGKC (LG1 or Caspr2) complex were not detected in sera of patients suffering from NS (n=6), NS plus other seizure types (n=16), primary generalized epilepsy (n=1) and community controls without epilepsy (n=7). Median Pyridoxal-phosphate levels in patients with NS compared to patients with primary generalized seizures and community controls were not significantly different. However, these median pyridoxal-phosphate levels are significantly lower compared to the range considered normal in Europeans.Conclusions: In this pilot study NS was not associated with serum anti-NMDA receptor or anti-VGKC complex antibodies and no association to pyridoxal-phosphate serum levels was found.Key words: nodding syndrome, epilepsy, anti-neuronal antibodies, pyridoxal-phosphate

Summary We have previously described a seizure disorder characterized by head nodding (HN). In a prospective study in southern Tanzania, we evaluated 62 patients with HN. Here, we report the patients’ clinical characteristics and those of their seizures, which indicate high seizure frequency, unsatisfactory seizure control, a high burden of cognitive impairment and disease-associated barriers to education.

Objectives Restless legs syndrome (RLS) is one of the most common neurological disorders in Caucasian populations with prevalence rates between 5% and 15%. A recent study conducted in rural northern Tanzania documented a prevalence of only 0.013%. This result requires further investigation of the epidemiology of RLS in Africa, as prevalence rates seem to vary among different ethnicities. Patients/methods We conducted a community-based door-to-door study in an urban environment in eastern Africa (Kinondoni district, Dar es Salaam, Tanzania), where 35.008 people aged 14 years and above were screened for RLS according to the essential diagnostic criteria. Sampling was performed by the method of cluster sampling with probability-proportional-to-size. Results One hundred and sixty-four people screened positively for RLS (0.47%). Ninety-two of those were subject to detailed history taking and physical examination. Four people could finally be diagnosed with RLS, yielding a RLS prevalence rate of 0.037% (95% CI 0.015%; 0.059%) among the people in Kinondoni. Conclusion These results support previous findings that RLS has a very low prevalence in Tanzania despite the fact that only part of the questionnaire-positive RLS people could be interviewed face-to-face, and show that this is independent of whether assessed in a rural or an urban population. According to our results it seems that indigenous Tanzanian people (which are considered representative for the population of Eastern Africa) are less prone to RLS compared to Caucasian populations. Whether the reasons for this discrepancy in prevalence are primarily genetic, environmental or have a cultural/social component remains to be determined. In addition, the study points to a limited application of the essential diagnostic criteria in settings of non-Caucasian populations. Irrespective of ethnic origin, we support the necessity of detailed history and physical examination as performed in the second part of our study to exclude RLS mimics and verify the diagnosis of RLS.

Summary Objectives Nodding syndrome (NS), a new epilepsy disorder of sub-Saharan Africa, has only recently been classified. In a study conducted in southern Tanzania in 2005, 62 patients with NS were analyzed in great detail. The present study, a follow-up investigation, was conducted to evaluate the progression of NS over time and to obtain serial electroencephalography (EEG) data. Methods Of the 62 NS patients, 53 (85.5%), the majority of whom were currently on some form of antiepileptic treatment, could be reevaluated in 2009 with a standardized questionnaire. A subset of these patients (25/53) underwent EEG investigation. Results In patients with “head nodding (HN) only” in 2005, 10 (43.5%) of 23 remained with the same diagnosis, whereas 5 (21.7%) of 23 had developed “HN plus” (i.e., HN and generalized tonic–clonic seizures). Six patients (26.1%) had seizures other than HN only, and two patients (8.7%) had fully recovered. In the “HN plus” group of 2005, 9 (30.0%) of 30 patients remained “HN plus,” and 15 patients (50.0%) had seizures other than HN only. Four patients (13.3%) reverted to “HN only,” and two patients (6.7%) stopped all seizures. In 11 (44.0%) of 25 patients, electroencephalography (EEG) showed generalized slowing. Six (54.6%) of these 11 abnormal EEG studies further showed generalized epileptiform discharges: (1) ictal electroencephalographic pattern with generalized 2.5 Hz spike and waves in two patients and (2) interictal bursts of 1.5–2 Hz spike and waves in four patients. Significance This follow-up study confirms that HN represents an epilepsy disorder, possibly of the atypical absence type with dynamic development over time.

Background: Onchocerciasis has been implicated in the pathogenesis of epilepsy. The debate on a potential causal relationship between Onchocerca volvulus and epilepsy has taken a new direction in the light of the most recent epidemic of nodding syndrome.Objective: To document MRI changes in people with different types of epilepsy and investigate whether there is an association with O. volvulus infection.Methods: In a prospective study in southern Tanzania, an area endemic for O. volvulus with a high prevalence of epilepsy and nodding syndrome, we performed MRI on 32 people with epilepsy, 12 of which suffered from nodding syndrome. Polymerase chain reaction (PCR) of O. volvulus was performed in skin and CSF.Results: The most frequent abnormalities seen on MRI was atrophy (twelve patients (37.5%)) followed by intraparenchymal pathologies such as changes in the hippocampus (nine patients (28.1%)), gliotic lesions (six patients (18.8%)) and subcortical signal abnormalities (three patients (9.4%)). There was an overall trend towards an association of intraparenchymal cerebral pathologies and infection with O. volvulus based on skin PCR (Fisher’s Exact Test p=0.067) which was most pronounced inchildren and adolescents with nodding syndrome compared to those with other types of epilepsy (Fisher’s Exact Test, p=0.083). Contrary to skin PCR results, PCR of CSF was negative in all patients.Conclusion: The observed trend towards an association of intraparenchymal cerebral pathological results on MRI and a positive skin PCR for O. volvulus despite negative PCR of CSF is intriguing and deserves further attention.Key words: Epilepsy, head nodding, magnetic resonance imaging, cerebrospinal fluid. Onchocerca volvulus

Neurocysticercosis (NCC) is a major cause of epilepsy in regions where pigs are free-ranging and hygiene is poor. Pork production is expected to increase in the next decade in sub-Saharan Africa, hence NCC will likely become more prevalent. In this study, people with epilepsy (PWE, n = 212) were followed up 28.6 months after diagnosis of epilepsy. CT scans were performed, and serum and cerebrospinal fluid (CSF) of selected PWE were analysed. We compared the demographic data, clinical characteristics, and associated risk factors of PWE with and without NCC. PWE with NCC (n = 35) were more likely to be older at first seizure (24.3 vs. 16.3 years, p = 0.097), consumed more pork (97.1% vs. 73.6%, p = 0.001), and were more often a member of the Iraqw tribe (94.3% vs. 67.8%, p = 0.005) than PWE without NCC (n = 177). PWE and NCC who were compliant with anti-epileptic medications had a significantly higher reduction of seizures (98.6% vs. 89.2%, p = 0.046). Other characteristics such as gender, seizure frequency, compliance, past medical history, close contact with pigs, use of latrines and family history of seizures did not differ significantly between the two groups. The number of NCC lesions and active NCC lesions were significantly associated with a positive antibody result. The electroimmunotransfer blot, developed by the Centers for Disease Control and Prevention, was more sensitive than a commercial western blot, especially in PWE and cerebral calcifications. This is the first study to systematically compare the clinical characteristics of PWE due to NCC or other causes and to explore the utility of two different antibody tests for diagnosis of NCC in sub-Saharan Africa., Author Summary Neurocysticercosis, a preventable and treatable disease, is one of the main causes of epilepsy in low income countries. In these countries, the diagnosis of epilepsy is often based on clinical presentation and interviews as neuroimaging is rarely available. It is crucial to distinguish people with epilepsy due to neurocysticercosis from other people with epilepsy by clinical symptoms and/or serology, because the former warrants a specific approach both in terms of diagnosis and treatment. The authors compared the demographic and clinical data of the two groups and found that people with epilepsy due to neurocysticercosis are older, more likely to consume pork, and respond better to anti-epileptic treatment. Additionally, the authors compared two antibody tests for cysticercosis with computed tomography images, which showed a higher sensitivity of the CDC electroimmunotransfer blot compared to a commercial western blot. The number of neurocysticercosis lesions was significantly associated with a positive antibody result in both tests. In summary, this research describes clinical characteristics of people with epilepsy and neurocysticercosis and assesses the usefulness of two immunoblots in those patients. This has implications not only for the diagnosis of neurocysticercosis in low income countries, but also for future epidemiological research.

SUMMARYIntroduction.Several reports indicate high prevalences of both onchocerciasis and epilepsy in some regions of Africa. This raises the question of whether these diseases are associated. We therefore investigated people with epilepsy and/or onchocerciasis living in an area in Tanzania endemic forOnchocerca volvulus(O. volvulus).Methods.We collected clinical information, skin snips, and blood from 300 individuals, and cerebrospinal fluid (CSF) from 197. Participants were allocated to 4 groups consisting of people with epilepsy and onchocerciasis (n=135), those with either epilepsy (n=61) or onchocerciasis only (n=35), and healthy individuals (n=69). Samples were evaluated for microfilaria, IgG4antibodies againstO. volvulus,O. volvulusantibody index (CSF/serum), and CSF routine parameters. Polymerase chain reaction (PCR) was performed on skin snips and CSF.Results.No difference was found in microfilarial density between participants with and without epilepsy (P=0·498). The antibody index was raised in 2 participants. CSF PCR was negative in all samples tested.Discussion.Our results do not give evidence of a relationship betweenO. volvulusand epilepsy. Despite the fact that 2 participants had raised antibody index, the existence of cerebral onchocerciasis caused by migration of microfilariae into the CSF appears unlikely. However, to date unexplored reactions to the infestation withO. volvuluscausing epilepsy cannot be excluded.

Summary Purpose: In developing countries, neurocysticercosis (NCC) is a common cause of epilepsy. Most of the work on NCC and epilepsy has been compiled in Latin America. To date, comprehensive neuroimaging studies are missing in sub-Saharan Africa. Methods: In our study, we interviewed 212 people with epilepsy (PWE) and performed cerebral computed tomography (CT) at the Haydom Lutheran Hospital in northern Tanzania. Control cerebral CT scans were selected from 198 consecutive individuals without epilepsy. Sera of PWE with lesions indicating NCC (n = 20), PWE without NCC lesions (n = 20), and healthy individuals (n = 20), as well as cerebrospinal fluid (CSF) samples of PWE with NCC lesions (n = 11) were investigated for anticysticercal antibodies. Results: Definite NCC lesions were present in five (2.4%), lesions highly suggestive of NCC in 24 (11.3%), and lesions compatible with NCC in nine (4.2%) PWE. This compares to two (1.0%) people with definite NCC lesions, two (1.0%) with lesions highly suggestive of, and six (2.9%) with lesions compatible with NCC in the control group. NCC lesions were significantly more frequent in PWE compared to controls (p

Summary Purpose: In the 1960s in Tanzania, L. Jilek-Aall observed a seizure disorder characterized by head nodding (HN). Decades later, “nodding disease,” reminiscent of what was seen in Tanzania, was reported from Sudan. To date this seizure disorder has not been classified and possible causes still remain obscure. Methods: In a prospective study in southern Tanzania, we evaluated 62 patients with HN. Selected patients underwent blood (n = 51) and cerebrospinal fluid (CSF) (n = 48) analyses. Others were chosen for MRI (n = 12) and EEG (n = 10). Results: Seizure type was classified as “head nodding only” and “head nodding plus,” the latter being combined with other types of seizure (n =34). During HN, consciousness was impaired in 11 patients (17.7%) and supportive signs of epileptic seizures were described by 15 (24.2%) patients. Precipitating factors were confirmed by 11 (17.7%) patients. Fifty-six (90.3%) patients had at least one relative with epilepsy. EEG confirmed interictal epileptic activity in two patients and unspecific changes in four patients. MRI showed hippocampus pathologies (n = 5) and gliotic changes (n = 5). Skin polymerase chain reaction (PCR) positivity for Onchocerca volvulus was significantly associated with lesions on MRI. However, PCR of the CSF was negative in all cases. Conclusions: We present a comprehensive clinical description of the “HN syndrome,” possibly a new epilepsy disorder in sub-Saharan Africa. MRI lesions and their association with positive skin PCR for O. volvulus despite negative PCR of the CSF is intriguing and deserves attention. Furthermore, the high prevalence of hippocampus sclerosis and familial clustering of epilepsy may point toward other potential pathogenetic mechanisms.

In developing countries, especially Latin America, neurocysticercosis (NCC) is a common cause of epilepsy. Recently, neurotoxocariasis has also been implicated in the pathogenesis of epilepsy. In sub-Saharan Africa data on parasitic disease and epilepsy are scarce. We therefore conducted a study in a rural hospital in northern Tanzania and analysed serum samples for anticysticercal and antitoxocaral antibodies for 40 people with epilepsy (PWE), 20 of whom had confirmed NCC on cranial computed tomography (CT) and 20 healthy individuals. Cerebrospinal fluid (CSF) of 11 PWE with NCC lesions on cranial CT was also investigated. Antibodies were determined using ELISA and Western blot. Six PWE with NCC lesions showed anticysticercal antibodies in serum. Of those, five had active lesions. Anticysticercal antibodies were significantly more frequent in PWE with active NCC than in those with inactive NCC (P

Background : Taenia solium metacestodes/cysts obtained from pig carcasses constitute a primary source for diagnostic tools used for the detection of human cysticercosis. Data on T. solium cyst preparation in Africa is still scarce but required to establish independent reference laboratories. Objectives : The aim of the present study is a) to present the likely yield of T . solium cyst material by the use of two different preparation methods in the field and b) to investigate its suitability for immunodiagnosis of human cysticercosis. Methods: In Zambia, Uganda and Tanzania 670 pigs were screened for T. solium infection. Cysts were prepared by `shaking method´ and ‘washing method’. Generated crude antigens were applied in a standard western blot assay. Results : 46 out of 670 pigs (6.9%) were found positive for T. solium (Zambia: 12/367, 3.3%; Uganda: 11/217, 5.1%; Tanzania 23/86, 26.7%). Mean values of 77.7 ml whole cysts, 61.8 ml scolices/membranes and 10.9 ml cyst fluid were obtained per pig. Suitability of collected material for the use as crude antigen and molecular diagnostic techniques was demonstrated. Conclusion : This study clearly shows that T. solium cyst preparation in African settings by simple field methods constitutes an effective way to obtain high quality material as source for diagnostic tools and research purposes. Keywords : Taenia solium, cysticercosis, neurocysticercosis, antigen, immunoblot

Taenia solium causes significant economic and public health impacts in endemic countries. This study determined effectiveness of a health education intervention at improving school children's knowledge and attitudes related to T. solium cysticercosis and taeniasis in Tanzania. A cluster randomised controlled health education intervention trial was conducted in 60 schools (30 primary, 30 secondary) in Mbulu district. Baseline data were collected using a structured questionnaire in the 60 schools and group discussions in three other schools. The 60 schools stratified by baseline knowledge were randomised to receive the intervention or serve as control. The health education consisted of an address by a trained teacher, a video show and a leaflet given to each pupil. Two post-intervention re-assessments (immediately and 6 months post-intervention) were conducted in all schools and the third (12 months post-intervention) was conducted in 28 secondary schools. Data were analysed using Bayesian hierarchical log-binomial models for individual knowledge and attitude questions and Bayesian hierarchical linear regression models for scores. The overall score (percentage of correct answers) improved by about 10% in all schools after 6 months, but was slightly lower among secondary schools. Monitoring alone was associated with improvement in scores by about 6%. The intervention was linked to improvements in knowledge regarding taeniasis, porcine cysticercosis, human cysticercosis, epilepsy, the attitude of condemning infected meat but it reduced the attitude of contacting a veterinarian if a pig was found to be infected with cysticercosis. Monitoring alone was linked to an improvement in how best to raise pigs. This study demonstrates the potential value of school children as targets for health messages to control T. solium cysticercosis and taeniasis in endemic areas. Studies are needed to assess effectiveness of message transmission from children to parents and the general community and their impacts in improving behaviours facilitating disease transmission.

We set out to assess the prevalence during the previous year of migraine in a rural area surrounding the Mnero Diocesan Hospital in Southern-Tanzania. A door-to-door survey from August until December 1999 using a questionnaire based on the criteria of the International Headache Society (IHS), including 1047 households with 3351 persons, was done, consisting of a screening dialogue with a representative family member followed by a face-to-face interview with the affected subject. Of the 3351 participants (female 1876; male 1475; age > 10 years), 23.1% had suffered from headache during the past year; overall prevalence of migraine was 5.0% (female 7.0%; male 2.6%); 1.4% reported migraine without aura (female 1.8%; male 0.9%); and 3.6% reported migraine with aura (female 5.2%, male 1.6%). The peak prevalence was found in female persons in the fourth (11.1%), in male persons in the third decade of life (3.8%). Compared with other African surveys, the prevalence rate of migraine headache in South Tanzania is slightly higher than among Ethiopian and Zimbabwean Africans.

Limited data are available on the stroke subtypes in Tanzania and sub-Saharan Africa. The present study was aimed at determining retrospectively the pattern of confirmed strokes in all patients in our hospital who had been given a computerized tomography (CT) brain scan during the study period (April 2001 to May 2002). Over the 12-month period 371 CT brain scans were taken, of which 148 showed stroke, 89 (60.1%) showed haemorrhage and 59 (39.9%) showed infarcts ( P

IntroductionWorldwide, there are an estimated 50 million people affected by epilepsy. Its aetiology is manifold, and parasitic infections play an important role, specifically onchocerciasis. In onchocerciasis endemic areas, a distinctive form of epilepsy has been described as nodding syndrome, affecting children and causing nodding seizures, mental retardation and debilitating physical development. Onchocerciasis control programmes using community-directed treatment with ivermectin (CDTI) are implemented in endemic countries. This study is designed to contribute to a better understanding of the linkage between the onset of epilepsy, onchocerciasis and CDTI. Comparing the epidemiological data on epilepsy and onchocerciasis from pre-CDTI and 20 years after its introduction will allow identifying a potential impact of ivermectin on the onset of epilepsy.Methods and analysisThe study will be conducted in the Mahenge highlands in Tanzania. Study site selection is based on an in-depth study on epilepsy in that area dating from 1989. CDTI was introduced in 1997. By a door-to-door approach, the population will be screened for epilepsy using a validated questionnaire. Suspected cases will be invited for a neurological examination for case verification. Onchocerciasis prevalence will be assessed by a rapid epidemiological assessment. As an indicator for ongoing transmission, children younger than 10 years of age will be tested for Ov16 antibodies. Ivermectin use will be assessed at household level. Epilepsy data will be analysed in comparison with the 1989 data to reveal pre-CDTI and post-CDTI prevalence and incidence.Ethics and disseminationThe protocol has received ethical approval from the ethics committees of the University of Antwerp, Belgium, and of the National Institut of Medical Research, Dar es Salaam, Tanzania. The findings will be published in peer-reviewed journals, and presented to the health authorities in Tanzania, at national, regional and village level.