Abstract

BackgroundActive screening by mobile teams is considered the most effective method for detecting gambiense-type human African trypanosomiasis (HAT) but constrained funding in many post-conflict countries limits this approach. Non-specialist health care workers (HCWs) in peripheral health facilities could be trained to identify potential cases for testing based on symptoms. We tested a training intervention for HCWs in peripheral facilities in Nimule, South Sudan to increase knowledge of HAT symptomatology and the rate of syndromic referrals to a central screening and treatment centre.Methodology/Principal FindingsWe trained 108 HCWs from 61/74 of the public, private and military peripheral health facilities in the county during six one-day workshops and assessed behaviour change using quantitative and qualitative methods. In four months prior to training, only 2/562 people passively screened for HAT were referred from a peripheral HCW (0 cases detected) compared to 13/352 (2 cases detected) in the four months after, a 6.5-fold increase in the referral rate observed by the hospital. Modest increases in absolute referrals received, however, concealed higher levels of referral activity in the periphery. HCWs in 71.4% of facilities followed-up had made referrals, incorporating new and pre-existing ideas about HAT case detection into referral practice. HCW knowledge scores of HAT symptoms improved across all demographic sub-groups. Of 71 HAT referrals made, two-thirds were from new referrers. Only 11 patients completed the referral, largely because of difficulties patients in remote areas faced accessing transportation.Conclusions/SignificanceThe training increased knowledge and this led to more widespread appropriate HAT referrals from a low base. Many referrals were not completed, however. Increasing access to screening and/or diagnostic tests in the periphery will be needed for greater impact on case-detection in this context. These data suggest it may be possible for peripheral HCWs to target the use of rapid diagnostic tests for HAT.

Highlights

  • Found in remote sub-Saharan areas where health systems are often weak and/or destabilised by armed conflict, human African trypanosomiasis (HAT, or sleeping sickness) is one of the world’s most neglected tropical diseases (NTDs)

  • In an era where approaches to HAT case detection and control must increasingly be integrated into health referral systems, it is vital to understand the opportunities and challenges associated with syndromic case detection in first line facilities to design effective interventions

  • We present the results of a syndromic HAT training intervention which targeted health care workers (HCWs) in peripheral facilities in the Nimule focus of South Sudan with the objective of increasing the rate of syndromic referrals to a central screening and treatment centre

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Summary

Introduction

Found in remote sub-Saharan areas where health systems are often weak and/or destabilised by armed conflict, human African trypanosomiasis (HAT, or sleeping sickness) is one of the world’s most neglected tropical diseases (NTDs). It is caused by infection with trypanosome parasites that are transmitted primarily by tsetse flies (Glossina) and is nearly always fatal if untreated. HAT caused by Trypanosoma brucei gambiense represents more than 90% of global HAT burden and is endemic in geographically limited foci in west and central Africa [1] In these areas, humans are assumed to be the main reservoir of infection. We tested a training intervention for HCWs in peripheral facilities in Nimule, South Sudan to increase knowledge of HAT symptomatology and the rate of syndromic referrals to a central screening and treatment centre

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