Burden of onchocerciasis-associated epilepsy: first estimates and research priorities

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ivermectin 16 infectiousdiseasesdrugs
malaria 3 infectiousdiseases
onchocerciasis 91 infectiousdiseases
toxoplasmosis 3 infectiousdiseases
AIDS 1 infectiousdiseases
cysticercosis 2 infectiousdiseases

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ivermectin 3243 targeted for elimination, using preventive chemotherapy through mass drug administration (MDA) with ivermectin as the primary intervention strategy [[1]]. Onchocerciasis is transmitted by the bite of infected blackflies
ivermectin 9288 epilepsy cases in an onchocerciasis-endemic area are to be caused by onchocerciasis. The effect of ivermectin on preventing new OAE cases or on reducing the seizure frequency of prevalent epilepsy cases is to be
ivermectin 9460 frequency of prevalent epilepsy cases is to be further investigated, although recent studies suggest that ivermectin has a positive effect on epilepsy incidence [[26], [27]]. It is also reported that ivermectin can reduce
ivermectin 9554 that ivermectin has a positive effect on epilepsy incidence [[26], [27]]. It is also reported that ivermectin can reduce severity and frequency of epileptic seizures [[28]], but it is yet unclear if this is due
ivermectin 9702 epileptic seizures [[28]], but it is yet unclear if this is due to the anticonvulsant properties of ivermectin or due to flaws in the methodology of the respective study. More studies are currently underway to assess
ivermectin 11128 of recurrence is unknown and may depend on the mf load and whether the person has been treated with ivermectin . Nonetheless, the chances of epilepsy being caused by onchocerciasis are more likely in areas with high
ivermectin 13324 Additional file 2).We first estimated the number of prevalent OAE cases prior to initiation of MDA with ivermectin (gradually introduced in the region since 1995, with exception of Kaduna, Nigeria (1991)). This was
ivermectin 16814 non-optimal MDA) on the basis of studies that suggest a reduction in the incidence of epilepsy after ivermectin treatment [[26], [27], [71]]. We further assumed that once incidence of OAE is zero, the number of prevalent
ivermectin 17621 analyses were performed around our assumption of survival probability and number of years of suboptimal ivermectin before OAE incidence drops to zero (Additional file 2).Fig. 1Used published relationships and onchocerciasis
ivermectin 20186 only due to lower incidence for areas with MDA and excess mortality (i.e. assuming no direct effect of ivermectin on curing epilepsy, hence prevalent OAE cases). We predict that in 2015, there were approximately 117 000
ivermectin 33596 by the weighted mean of annual treatment costs of AEDs. No added cost is attributed to account for ivermectin as it is freely distributed by the Mectizan® Donation Programme [[54]]. We estimate that the total
ivermectin 42631 of epilepsy patients (irrespective of the cause of the epilepsy). Community-directed distributors of ivermectin could be trained to identify potential epilepsy cases and refer them to the general health system, to
ivermectin 45993 resource settings to identify suspected epilepsy cases, which can be used by community distributors of ivermectin and local primary healthcare workers so that these cases are timely referred to local health facilities.5Conduct
ivermectin 46221 prospective, longitudinal community intervention trials on the impact of MDA on the incidence of OAE in ivermectin -naïve areas with high onchocerciasis transmission with individual-level follow-up recording O. volvulus
ivermectin 46375 transmission with individual-level follow-up recording O. volvulus infection status, epilepsy onset, and ivermectin usage. Compare alternative onchocerciasis control strategies on reducing OAE incidence, e.g. different
ivermectin 46520 onchocerciasis control strategies on reducing OAE incidence, e.g. different frequencies of distribution of ivermectin , use of new macrofilaricidal drugs in development, and vector control where feasible.6Determine the
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AIDS 35974 necessities more frequently than unaffected women. This sexual assault also increases their risk for HIV/ AIDS and other sexually transmitted infections [[62]] and if they become pregnant, they may be left with
cysticercosis 6148 early in life [[9]]. Some parasitic infections are known to be associated with epilepsy, including neuro cysticercosis (NCC) (due to Taenia solium), toxoplasmosis (due to Toxoplasma gondii), and malaria, among others [[9]].
cysticercosis 15374 assume to be uncorrelated with other important causes of epilepsy in developing countries, like neuro cysticercosis Next, the pre-control number of OAE cases was estimated by multiplying the average OAE prevalence in
malaria 6238 including neurocysticercosis (NCC) (due to Taenia solium), toxoplasmosis (due to Toxoplasma gondii), and malaria , among others [[9]]. For example, T. solium in particular is endemic in many African countries where
malaria 12115 medical/neurological history and examination as well as diagnosis of various parasitic infections, including NCC, malaria , and toxoplasmosis, among others.Quantifying the number of OAE cases in sub-Saharan AfricaIn order to
malaria 45650 Such studies should tempt to include diagnosis of various other parasitic infections, including NCC, malaria , and toxoplasmosis. Muslim or Orthodox Ethiopian-Christian areas where pigs are not raised but endemic
onchocerciasis 47 Title: Infectious Diseases of PovertyBurden of onchocerciasis -associated epilepsy: first estimates and research prioritiesNatalie V. S. Vinkeles MelchersSarah MollenkopfRobert
onchocerciasis 508 /2018AbstractBackgroundSince the 1990s, evidence has accumulated of an increased prevalence of epilepsy in onchocerciasis -endemic areas in Africa as compared to onchocerciasis-free areas. Although the causal relationship between
onchocerciasis 562 accumulated of an increased prevalence of epilepsy in onchocerciasis-endemic areas in Africa as compared to onchocerciasis -free areas. Although the causal relationship between onchocerciasis and epilepsy has yet to be proven,
onchocerciasis 630 areas in Africa as compared to onchocerciasis-free areas. Although the causal relationship between onchocerciasis and epilepsy has yet to be proven, there is likely an association. Here we discuss the need for disease
onchocerciasis 769 be proven, there is likely an association. Here we discuss the need for disease burden estimates of onchocerciasis -associated epilepsy (OAE), provide them, detail how such estimates should be refined, and discuss the
onchocerciasis 1040 for anti-epileptic drugs.Main bodyProviding OAE burden estimates may aid prevention of epilepsy in onchocerciasis - endemic areas by inciting and informing collaboration between onchocerciasis control programmes and
onchocerciasis 1118 prevention of epilepsy in onchocerciasis- endemic areas by inciting and informing collaboration between onchocerciasis control programmes and mental health services. Epilepsy not only massively impacts the health of those
onchocerciasis 1392 burden for the households and communities involved. We used previously published geospatial estimates of onchocerciasis in Africa and a separately published logistic regression model quantifying the association between onchocerciasis
onchocerciasis 1506 in Africa and a separately published logistic regression model quantifying the association between onchocerciasis and epilepsy to estimate the number of OAE cases. We then applied disability weights for epilepsy to
onchocerciasis 1810 the cost of treatment. We estimate that in 2015 roughly 117 000 people were affected by OAE across onchocerciasis -endemic areas previously under the African Programme for Onchocerciases control (APOC) mandate where
onchocerciasis 2000 control (APOC) mandate where OAE has ever been reported or suspected, and another 264 000 persons in onchocerciasis -endemic areas where OAE has never been investigated before. The total number of YLDs due to OAE was
onchocerciasis 2292 disability weight of 0.336. The burden of OAE is approximately 13% of the total YLDs attributable to onchocerciasis and 10% of total YLDs attributable to epilepsy. We estimated that by 2015 the total costs of treatment
onchocerciasis 2674 burden of OAE in Africa. The treatment and care for people with epilepsy, especially in hyperendemic onchocerciasis areas with high epilepsy prevalence thus requires more financial and human resources.Electronic supplementary
onchocerciasis 3599 nearly all cases occurring in sub-Saharan Africa (SSA). Since the 1990s, high prevalence of epilepsy in onchocerciasis highly-endemic areas has increasingly been reported, especially in localised foci across Africa [[2]–[8]].In
onchocerciasis 4359 CI: 2.15–3.28) attributed to epilepsy, and 0.99 million DALYs (95% CI: 0.45–1.72) attributable to onchocerciasis in SSA [[11]]. Various studies have estimated the number of people with active epilepsy in SSA with
onchocerciasis 4610 4.5 million [[10]–[12]]. Only a fraction of these epilepsy cases may potentially be attributed to onchocerciasis -associated epilepsy (OAE) [[13]]. An early, crude assessment of the burden of OAE in SSA estimated approximately
onchocerciasis 5251 [[16]] if left untreated.In this review, we discuss the current evidence of an association between onchocerciasis and epilepsy, and provide the first estimates of OAE burden in terms of expected number of cases, years
onchocerciasis 5443 expected number of cases, years of life lived with disability (YLDs), and socioeconomic consequences for onchocerciasis -endemic areas previously under the African Programme for Onchocerciasis Control (APOC) mandate. Furthermore,
onchocerciasis 5768 research agenda and the diligence of human and financial resources required to prevent new OAE cases.Are onchocerciasis and epilepsy associated?Many well-known, non-infectious causes of epilepsy may contribute to the burden
onchocerciasis 5902 associated?Many well-known, non-infectious causes of epilepsy may contribute to the burden of epilepsy in onchocerciasis -endemic areas, including perinatal trauma, genetic factors, environmental/toxic factors or nutritional
onchocerciasis 6918 established. Although several cross-sectional and case-control studies show an association between onchocerciasis and epilepsy [[3], [4], [19], [20]], it is challenging to interpret such studies and demonstrate causality
onchocerciasis 7280 confounding factors.On the population-level, there is evidence of an association between epilepsy and onchocerciasis . A meta-analysis by Pion et al. [[4]] found an association between onchocerciasis and epilepsy using
onchocerciasis 7362 between epilepsy and onchocerciasis. A meta-analysis by Pion et al. [[4]] found an association between onchocerciasis and epilepsy using population-based surveys; on average there was a 0.4% increase in epilepsy for each
onchocerciasis 7496 population-based surveys; on average there was a 0.4% increase in epilepsy for each 10% increase in onchocerciasis prevalence. This association is based on studies from eight communities in seven African countries.
onchocerciasis 9068 [[25]]. These results suggest a dose-response relationship wherein the risk of developing epilepsy in onchocerciasis patients is higher with increasing O. volvulus mf density, supporting the hypothesis that a proportion
onchocerciasis 9210 increasing O. volvulus mf density, supporting the hypothesis that a proportion of epilepsy cases in an onchocerciasis -endemic area are to be caused by onchocerciasis. The effect of ivermectin on preventing new OAE cases
onchocerciasis 9258 hypothesis that a proportion of epilepsy cases in an onchocerciasis-endemic area are to be caused by onchocerciasis . The effect of ivermectin on preventing new OAE cases or on reducing the seizure frequency of prevalent
onchocerciasis 9930 of MDA on OAE [[29]].There is still no definitive pathophysiologic explanation for the link between onchocerciasis and epilepsy. Studies in children with nodding syndrome (a childhood epilepsy disorder described in
onchocerciasis 10317 volvulus [[30]]. Further research herein would be strongly recommended.The challenges of defining an onchocerciasis -associated epilepsy caseIn spite of the population-level association between onchocerciasis and epilepsy,
onchocerciasis 10409 defining an onchocerciasis-associated epilepsy caseIn spite of the population-level association between onchocerciasis and epilepsy, it is difficult to attribute individual epilepsy cases to onchocerciasis. Epilepsy is
onchocerciasis 10496 association between onchocerciasis and epilepsy, it is difficult to attribute individual epilepsy cases to onchocerciasis . Epilepsy is a condition characterised by recurrent (two or more) afebrile epileptic seizures at least
onchocerciasis 11193 whether the person has been treated with ivermectin. Nonetheless, the chances of epilepsy being caused by onchocerciasis are more likely in areas with high onchocerciasis transmission rates, evidence of O. volvulus infection,
onchocerciasis 11243 Nonetheless, the chances of epilepsy being caused by onchocerciasis are more likely in areas with high onchocerciasis transmission rates, evidence of O. volvulus infection, and onset of epilepsy at young age (~ 5–18 years
onchocerciasis 12414 been reported or suspected (independent on whether the study found a significant association between onchocerciasis and epilepsy). We identified 19 areas in nine countries across SSA; Uganda [[5], [26], [34], [35]],
onchocerciasis 13920 the approach and the underlying assumptions are described in Table 1.Table 1Methods for calculating onchocerciasis -associated epilepsy (OAE) cases in the African Programme for Onchocerciasis Control (APOC) countries
onchocerciasis 14513 with zero O. volvulus microfilariae prevalence was removed from the analysis. The prevalence of OAE in onchocerciasis -endemic areas was calculated by subtracting the predicted prevalence of all-cause epilepsy for APOC-areas
onchocerciasis 15237 between all-cause epilepsy and microfilariae prevalence was entirely driven by geographical variation in onchocerciasis prevalence, which we assume to be uncorrelated with other important causes of epilepsy in developing
onchocerciasis 17728 ivermectin before OAE incidence drops to zero (Additional file 2).Fig. 1Used published relationships and onchocerciasis map to calculate the pre-control prevalence of onchocerciasis-associated epilepsy. a Community-level
onchocerciasis 17790 (Additional file 2).Fig. 1Used published relationships and onchocerciasis map to calculate the pre-control prevalence of onchocerciasis -associated epilepsy. a Community-level all-cause epilepsy prevalence versus corrected onchocerciasis
onchocerciasis 17891 onchocerciasis-associated epilepsy. a Community-level all-cause epilepsy prevalence versus corrected onchocerciasis microfilariae prevalence, as published by Pion et al. [[4]]. b Map of the estimated pre-control prevalence
onchocerciasis 19081 all other APOC-areas). We further estimated that approximately 61.5% of all OAE cases were located in onchocerciasis hyperendemic areas (nodule prevalence in adult males ≥40%), 28.7% in mesoendemic areas (20–40% nodule
onchocerciasis 19300 nodule prevalence), and 9.8% in hypoendemic areas (< 20% nodule prevalence).Table 2Estimated number of onchocerciasis -associated epilepsy cases with 95% confidence intervals in the African Programme for Onchocerciasis
onchocerciasis 20068 cases increased over time due to population growth and that OAE prevalence declined during control of onchocerciasis only due to lower incidence for areas with MDA and excess mortality (i.e. assuming no direct effect
onchocerciasis 20448 cases, with an overall OAE prevalence of 0.74% (Table 2). If we assume that OAE is also present in onchocerciasis -endemic areas previously under the APOC mandate and where OAE has not (yet) been investigated, we predict
onchocerciasis 21115 to skin snipping. Secondly, the logistic functional relationship for prediction of OAE prevalence by onchocerciasis infection, as reported by Pion et al., includes the at that time available literature for which various
onchocerciasis 22861 0.049 (95% CI: 0.031–0.072) (Table 3).Table 3Different sequela of epilepsy that could be applied to onchocerciasis -associated epilepsy (adapted from [[72]])SequelaeHealth StateLay DescriptionDisability WeightSevere
onchocerciasis 24309 information is not widely reported in literature. A study in an area of Cameroon highly-endemic for onchocerciasis found that 47% of epilepsy cases in the area experienced at least one seizure in the 6 months prior
onchocerciasis 25493 Table 5.Table 4Frequency of different health states (indicating different severity levels) of epilepsy in an onchocerciasis hyperendemic area, associated disability weights for each health state (GBD), and calculation of the
onchocerciasis 26073 the proportion of cases in each health state0.336Table 5Methods for calculating YLDs attributable to onchocerciasis -associated epilepsy (OAE)The disability weight associated with epilepsy depends on the disease severity
onchocerciasis 26536 of cases in each health state is derived from clinical data of epilepsy severity and frequency in an onchocerciasis hyperendemic area [[44]]. We assume that the weighted mean disability weights are also applicable to
onchocerciasis 27478 0.336 × 264 000 = 88 700 (95%CI: 36 600–401 500)This total estimation of YLDs is based on onchocerciasis -endemic areas previously under the APOC mandate where OAE has not been reported or suspected.There are
onchocerciasis 28294 different O. volvulus species with differing pathogenic potential, such is the case for blindness due to onchocerciasis [[45]]. Variation is also expected by level of healthcare access, given that a lower disability weight
onchocerciasis 28703 the different assigned severity weights among especially children and young adults with epilepsy in onchocerciasis -endemic areas, as they are the ones with highest OAE prevalence. Ultimately, with so little available
onchocerciasis 29036 truth. However, the burden of OAE can be substantial as compared to other clinical manifestations of onchocerciasis . If we assume that OAE occurs throughout all onchocerciasis-endemic countries previously under the APOC
onchocerciasis 29096 compared to other clinical manifestations of onchocerciasis. If we assume that OAE occurs throughout all onchocerciasis -endemic countries previously under the APOC mandate, the total YLD attributable to OAE would be 128 000
onchocerciasis 29318 YLDs (39 300 + 88 700 = 128 000 YLDs) in 2015. The GBD estimated 989 653 YLDs due to onchocerciasis (i.e. skin disease, visual impairment, blindness) in the year 2015 for SSA [[11]]. The actual onchocerciasis
onchocerciasis 29427 onchocerciasis (i.e. skin disease, visual impairment, blindness) in the year 2015 for SSA [[11]]. The actual onchocerciasis burden (in terms of YLDs) would be approximately 12% higher if we would also take account of OAE. Out
onchocerciasis 29656 million prevalent epilepsy cases in SSA (GBD estimate for 2015 [[11]]), 11% would be associated with onchocerciasis . Using the weighted mean disability weight for epilepsy, the YLDs due to OAE in APOC-areas forms about
onchocerciasis 29950 1.31 million YLDs [[11]]).Estimating the socioeconomic burden of OAESimilar to the distribution of onchocerciasis , OAE occurs almost exclusively in remote areas where people are already disenfranchised by their socioeconomic
onchocerciasis 31102 expenditures reduce the amount of basic financial resources available to the household [[48], [49]]. Unlike onchocerciasis which has one drug of choice for its control, epilepsy treatments are multiple and their indications
onchocerciasis 33742 Mectizan® Donation Programme [[54]]. We estimate that the total cost for treating all OAE cases in onchocerciasis -endemic areas where OAE has previously been reported or suspected would have been approximately US$12.4
onchocerciasis 36939 become available and that the infrastructure can be set in place to target interventions in high-risk onchocerciasis -endemic communities.Towards more accurate burden estimatesWe have described the major challenges and
onchocerciasis 37473 is needed on the prevalence of O. volvulus and epilepsy at the community-level of various levels of onchocerciasis endemicity. While some data has already been collected and published [[4]], there are a number of challenges
onchocerciasis 37922 sensitivities and specificities. For epilepsy, an adapted case definition applicable in remote areas, including onchocerciasis -endemic areas, to establish aetiology of epilepsy in absence of neuroimaging would help in making study
onchocerciasis 38370 order to capture age- and sex-specific trends in prevalence and disease burden estimates. Epilepsy in onchocerciasis -endemic areas may have a different age pattern in the onset of epilepsy as compared to onchocerciasis
onchocerciasis 38472 onchocerciasis-endemic areas may have a different age pattern in the onset of epilepsy as compared to onchocerciasis non-endemic areas, with a peak onset of epilepsy between ages 10 and 15 years [[7], [8], [64]]. Age-
onchocerciasis 39055 data, however, may be quite challenging without the ability to confirm that the epilepsy is caused by onchocerciasis .Thirdly, there is limited data available about the premature mortality due to epilepsy. In a study in
onchocerciasis 39175 onchocerciasis.Thirdly, there is limited data available about the premature mortality due to epilepsy. In a study in an onchocerciasis -endemic region in Cameroon the relative risk of death among PWE was 6.2 times (95% CI: 2.7–14.1) than
onchocerciasis 39885 the current incidence and prevalence of OAE in the majority of sub-Saharan African countries where onchocerciasis is endemic. The available data is concentrated in limited and very focal study sites. This both limits
onchocerciasis 41063 globally from 1980 to present [[32]]. Mathematical models may better capture transmission dynamics of onchocerciasis [[65]–[67]], such that OAE development is dependent on mf-production with a damage trigger after which
onchocerciasis 42022 and treatment with AED through decentralised services) is urgently needed [[10]]. The link between onchocerciasis and epilepsy may be exploited in two ways.Firstly, the possible effect of onchocerciasis control efforts
onchocerciasis 42111 link between onchocerciasis and epilepsy may be exploited in two ways.Firstly, the possible effect of onchocerciasis control efforts on the incidence of epilepsy may be reason to put in extra resources for the intensification
onchocerciasis 42238 efforts on the incidence of epilepsy may be reason to put in extra resources for the intensification of onchocerciasis elimination activities in highly endemic onchocerciasis areas where high prevalence rates of epilepsy
onchocerciasis 42294 extra resources for the intensification of onchocerciasis elimination activities in highly endemic onchocerciasis areas where high prevalence rates of epilepsy are found [[32]]. Secondly, health systems can be strengthened
onchocerciasis 42451 epilepsy are found [[32]]. Secondly, health systems can be strengthened in (often remote) highly endemic onchocerciasis areas with high epilepsy prevalence, to enhance timely referral of epilepsy patients (irrespective of
onchocerciasis 42941 impact on the total epilepsy prevalence in SSA, but it would even so have adjuvant advantages for both onchocerciasis and epilepsy control and may even prevent the potentially significant impact of OAE. In some areas,
onchocerciasis 43821 precise (Table 7). These priorities should be included in the research and policy agendas of both onchocerciasis and epilepsy programmes in Africa. Sustained and intensified funding is required to prompt onchocerciasis
onchocerciasis 43927 onchocerciasis and epilepsy programmes in Africa. Sustained and intensified funding is required to prompt onchocerciasis elimination efforts in general, with special focus on high transmission zones (often associated with
onchocerciasis 44465 fundamental research is required to investigate the biological mechanisms of a potential relationship between onchocerciasis and epilepsy. Fundamental evidence of causality could assist in the establishment of burden estimates
onchocerciasis 44785 previous performed meta–analysis by Pion et al. [[4]] including recently performed epilepsy surveys in onchocerciasis -endemic regions to incorporate new information. Sources of bias of included studies should be tracked
onchocerciasis 45176 epilepsy potentially initiated by other causes.3Perform epilepsy incidence or prevalence surveys in onchocerciasis -endemic areas where no data is yet available, using standardised tools for O. volvulus and epilepsy
onchocerciasis 45470 OAE cases (including age of onset of the epilepsy) and the co-prevalence of other sequelae including onchocerciasis associated skin disease (including itching) and ocular disease. Such studies should tempt to include
onchocerciasis 45765 toxoplasmosis. Muslim or Orthodox Ethiopian-Christian areas where pigs are not raised but endemic for onchocerciasis could be included in such surveys.4Design, implement and evaluate a simple tool for ubiquitous use in
onchocerciasis 46255 intervention trials on the impact of MDA on the incidence of OAE in ivermectin-naïve areas with high onchocerciasis transmission with individual-level follow-up recording O. volvulus infection status, epilepsy onset,
onchocerciasis 46413 follow-up recording O. volvulus infection status, epilepsy onset, and ivermectin usage. Compare alternative onchocerciasis control strategies on reducing OAE incidence, e.g. different frequencies of distribution of ivermectin,
onchocerciasis 46967 the number of persons with OAE in 2015 is estimated to be 117 000 (95% CI: 50 000–441 000) in onchocerciasis -endemic areas where OAE has been reported or suspected and 264 000 (95% CI: 109 000–1 195 000)
onchocerciasis 47089 areas where OAE has been reported or suspected and 264 000 (95% CI: 109 000–1 195 000) in onchocerciasis -endemic areas where OAE has not yet been investigated. An educated analysis of the burden of OAE is
onchocerciasis 47576 quantifying the burden of OAE that we can expect today. These numbers are useful for policy-makers and onchocerciasis and epilepsy programme managers who need to be aware of the public health impact caused by epilepsy
onchocerciasis 47694 epilepsy programme managers who need to be aware of the public health impact caused by epilepsy in onchocerciasis -endemic areas. Intensification of onchocerciasis control efforts and/or increases in resources for epilepsy
onchocerciasis 47743 of the public health impact caused by epilepsy in onchocerciasis-endemic areas. Intensification of onchocerciasis control efforts and/or increases in resources for epilepsy healthcare services would then be imperative
onchocerciasis 47904 for epilepsy healthcare services would then be imperative for most affected areas. People living in onchocerciasis -endemic regions need to understand the full implication and potential gains of supporting and adhering
toxoplasmosis 6192 are known to be associated with epilepsy, including neurocysticercosis (NCC) (due to Taenia solium), toxoplasmosis (due to Toxoplasma gondii), and malaria, among others [[9]]. For example, T. solium in particular is
toxoplasmosis 12128 history and examination as well as diagnosis of various parasitic infections, including NCC, malaria, and toxoplasmosis , among others.Quantifying the number of OAE cases in sub-Saharan AfricaIn order to estimate the potential
toxoplasmosis 45663 should tempt to include diagnosis of various other parasitic infections, including NCC, malaria, and toxoplasmosis . Muslim or Orthodox Ethiopian-Christian areas where pigs are not raised but endemic for onchocerciasis

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