Human African Trypanosomiasis (African Sleeping Sickness)

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Overview

Human African trypanosomiasis (HAT), or sleeping sickness, is caused by trypanosome parasites that are transmitted by tsetse flies. HAT is found only in sub-Saharan Africa. Two subspecies of Trypanosoma brucei cause disease: T. b. gambiense in West and Central Africa, and T. b. rhodesiense in East Africa.


This life-threatening disease mostly affects poor rural populations, causing significant harm. Travellers to endemic regions may also be at risk of infection.


HAT transmission requires the interaction of humans, tsetse flies and parasite reservoirs (humans, and domestic and wild animals). The animal reservoir is very important in T. b. rhodesiense and less so in T. b. gambiense, although it could explain the long-term endemicity in some foci despite control interventions.


Transmission can be interrupted by depleting the parasite reservoirs through detection and treatment of infected people and/or domestic animals and by reducing the tsetse fly population and human–tsetse contact.


In 1995, about 25 000 cases were detected, 300 000 undetected cases were estimated and 60 million people were estimated to be at risk of HAT infection. In 2001, WHO launched an initiative to reinforce control and surveillance, and HAT decreased markedly in the ensuing years. In 2019, fewer than 1000 cases were found. This reduction does not reflect a lack of control efforts as in general active and passive screening has been maintained at similar levels (around 2.5 million people screened per year).


Symptoms

After infection, trypanosomes multiply in the blood and lymph (first-stage, haemolymphatic) and, following a variable incubation period (from days to months), unspecific symptoms and signs such as headache, fever, weakness, joint pain, and lymphadenopathy appear. Over time, the parasites cross the blood–brain barrier to invade the central nervous system (second-stage, meningoencephalitic), causing various neurological disturbances including sleep disorders (excessive daytime sleepiness, nocturnal insomnia), deep sensory disturbances, abnormal movements, tremor, ataxia, walking difficulties, speech difficulties, psychiatric disorders, seizures, coma and ultimately death. Most signs and symptoms are common to both stages, and sleep disorders in particular can appear already during the first stage.


Rhodesiense HAT is typically acute, progressing to second-stage within a few weeks, and to death within 6 months. Gambiense HAT progresses slowly over around 3 years (highly variable).


An inoculation chancre (dermal reaction of 3–4 cm at the tsetse bite site) may appear 2–3 days after infection with rhodesiense HAT in up to 25% of local patients, but more frequently in patients from non-endemic regions. It is rare with gambiense HAT.


Sleeping sickness is diagnosed in several steps: after a clinical suspicion, serological tests (card agglutination trypanosomiasis test or HAT rapid diagnostic tests) can reinforce the suspicion, which should be confirmed by parasitological findings (in chancre exudate, lymphatic juice, blood and cerebrospinal fluid). Unfortunately, the usual serological tests are only applicable to T. b. gambiense. Stage is determined by the number of white blood cells and the presence of trypanosomes in cerebrospinal fluid examination.

Causes

African trypanosomiasis, also known as sleeping sickness, is a disease spread by an infected tsetse fly, found in rural areas of sub-Saharan Africa. Sleeping sickness is caused by two different parasites, Trypanosoma brucei rhodesiense and Trypanosoma brucei gambiense.

Risk factors

Risk factors for African trypanosomiasis include residence in Central or South America, living in old houses with mud and stick wall constructions or straw roofs, ingestion of contaminated water, or receiving blood transfusions or organ donation from individuals in regions with high endemicity.

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Complications

Anemia and fatigue.

Wasting syndrome.

Aspiration pneumonia.

Meningoencephalitis and seizures.

Stupor or coma (sleeping sickness)

Death.

Perinatal death or abortion (after congenital infection)

Prevention

Wear protective clothing, including long-sleeved shirts and pants. The tsetse fly can bite through thin fabrics, so clothing should be made of medium-weight material. Wear neutral-colored clothing.