Exposure to parasitic infections determines features and phenotypes of active convulsive epilepsy in Africa

Background: Epilepsy affects 70 million people worldwide, 80% of whom are in low-and-middle income countries (LMICs). Infections of the central nervous system (CNS) contribute considerably to the burden of epilepsy in LMICs, but the nature and presentation of epilepsy following these infections is not fully understood. We examined if epilepsy foutcomes are associated with the exposure to parasitic infections. Methods: This was a case-comparison study nested in a cross-sectional survey of people with active convulsive epilepsy, with cases as those exposed to parasitic infections, and comparison as those unexposed. Associations of exposure to parasites with clinical and electroencephalographic features of epilepsy were done using a modified mixed effects Poisson regression model across five sites in Africa. Multiplicative and additive scale (RERI) interactions were explored to determine the effect of co-infections on epilepsy features. Population attributable fractions (PAF) were calculated to determine the proportion of severe clinical and electroencephalographic features of epilepsy attributable to CNS infections. Results: A total of 997 participants with active convulsive epilepsy from the five African sites were analyzed, 51% of whom were males. Exposure to parasitic infections was associated with more frequent seizures in adult epilepsy (relative risk (RR)=2.58, 95% confidence interval (95%CI):1.71-3.89). In children, exposure to any parasite was associated with convulsive status epilepticus (RR=4.68, (95%CI: 3.79-5.78), intellectual disabilities (RR=2.13, 95%CI: 1.35-3.34) and neurological deficits (RR=1.92, 95%CI: 1.42-2.61). Toxoplasma gondii and Onchocerca volvulus interacted synergistically to increase the risk of status epilepticus (RERI=0.91, 95%CI=0.48-1.35) in the data pooled across the sites. Exposure to parasitic infections contributed to 30% of severe features of epilepsy as shown by PAF. Conclusions: Parasitic infections may determine features and phenotypes of epilepsy through synergistic or antagonistic interactions, which can be different in children and adults. Interventions to control or manage infections may reduce complications and improve prognosis in epilepsy

Magnitude and factors associated with nonadherence to antiepileptic drug treatment in Africa: A cross-sectional multisite study

Objectives: The epilepsy treatment gap is large in low- and middle-income countries, but the reasons behind nonadherence to treatment with antiepileptic drugs (AEDs) across African countries remain unclear. We investigated the extent to which AEDs are not taken and associated factors in people with active convulsive epilepsy (ACE) identified in cross-sectional studies conducted in five African countries. Methods: We approached 2,192 people with a confirmed diagnosis of ACE for consent to give blood voluntarily. Participants were asked if they were taking AEDs, and plasma drug concentrations were measured using a fluorescence polarization immunoassay analyzer. Information about possible risk factors was collected using questionnaire-based clinical interviews. We determined factors associated with nonadherence to AED treatment in children and adults, as measured by detectable and optimal levels, using multilevel logistic regression. Results: In 1,303 samples assayed (43.7% were children), AEDs were detected in 482, but only 287 had optimal levels. Of the 1,303 samples, 532 (40.8%) were from people who had reported they were on AEDs. The overall prevalence of nonadherence to treatment was 63.1% (95% confidence interval [CI] 60.5–65.6%) as measured by detectable AED levels and 79.1% (95% CI 73.3–84.3%) as measured by optimal AED levels; self-reported nonadherence was 65.1% (95% CI 45.0–79.5%). Nonadherence was significantly (p < 0.001) more common among the children than among adults for optimal and detectable levels of AEDs, as was the self-reported nonadherence. In children, lack of previous hospitalization and learning difficulties were independently associated with nonadherence to treatment. In adults, history of delivery at home, absence of burn marks, and not seeking traditional medicine were independently associated with the nonadherence to AED treatment. Significance: Only about 20% of people with epilepsy benefit fully from antiepileptic drugs in sub-Saharan Africa, according to optimum AEDs levels. Children taking AEDs should be supervised to promote compliance

A gentle push towards improved hygiene and food safety through ‘nudge’ interventions

Most of the perishable food in low- and middle-income countries is sold in informal markets where food handlers are not usually trained in good hygienic practices. There are different approaches to improve food safety in those markets, some of which include capacity building. However, one-off trainings are not usually sustainable as behaviours are deeply rooted and often lead to unconscious practices that can increase risk of food contamination. Close follow-up is intense in terms of human and financial resources. Nudges have been described to influence behaviour with varying results, partly depending on whether they have been imposed on or co-created with the end-users. In this study we describe the human-centred-design process from identifying critical control points between slaughter and retail to co-creating nudges that could potentially lead to better compliance of meat handlers in Uganda with good hygienic practices. Three of the WHO “Five Keys To Safer Food” were selected as the target behaviours to improve. The qualitative research was implemented in the greater Kampala area between October 2020 to December 2021 and involved 119 meat handlers, pork joint customers, food safety and veterinary technical experts and over 20 project stakeholders. Findings from the initial ‘explore’ phase generated a number of insights on meat handlers’ perceptions and attitudes that were later used to generate ideas and solutions in cocreating nudges during the ‘experiment’ phase: 1) Meat handlers eat the pork they handle at work and have low risk perception; 2) Meat handlers feel their practices are acceptable; 3) Meat handlers see ‘broken windows’ which set the norm for unhygienic behaviour; 4) Meat handlers follow the path of least resistance; 5) Meat handlers keep up appearances for customers; and 6) Owners want to see returns on hygienic investments. Fourty-two early prototypes were co-created with potential end users and after several iterations, two nudge kits emerged, e.g. the “Keep Clean Loop” and the “Tricolour Kitchen”. In a subsequent pilot test we assessed if the nudges help reducing the burden of foodborne pathogens and if behaviour of meat handlers changes sustainably