title: Environmental, dietary and case-control study of Nodding Syndrome in Uganda: A post-measles brain disorder triggered by malnutrition?
abstract: Nodding Syndrome (NS) is an epileptic encephalopathy characterized by involuntary vertical head nodding, other types of seizures, and progressive neurological deficits. The etiology of the east African NS epidemic is unknown. In March 2014, we conducted a case-control study of medical, nutritional and other risk factors associated with NS among children (aged 5-18years) of Kitgum District, northern Uganda (Acholiland). Data on food availability, rainfall, and prevalent disease temporally related to the NS epidemic were also analyzed. In NS Cases, the mean age of reported head nodding onset was 7.6years (range 1-17years). The epidemiologic curve of NS incidence spanned 2000-2013, with peaks in 2003 and 2008. Month of onset of head nodding was non-uniform, with all-year-aggregated peaks in April and June when food availability was low. Families with one or more NS Cases had been significantly more dependent on emergency food and, immediately prior to head nodding onset in the child, subsistence on moldy plant materials, specifically moldy maize. Medical history revealed a single significant association with NS, namely prior measles infection. NS is compared with the post-measles disorder subacute sclerosing panencephalitis, with clinical expression triggered by factors associated with poor nutrition.
authors.affiliation: Global Health Center (former), Oregon Health & Science University, Portland, OR, USA; Department of Neurology, School of Medicine, Oregon Health & Science University, Portland, OR, USA; Oregon Institute of Occupational Health Sciences, Oregon Health & Science University, Portland, OR, USA; Faculty of Medicine, Gulu University, Gulu, Uganda. Electronic address: spencer@ohsu.edu.
authors.forename: Peter S
authors.initials: PS
authors.lastname: Spencer
authors.affiliation: Global Health Center (former), Oregon Health & Science University, Portland, OR, USA.
authors.forename: Rajarshi
authors.initials: R
authors.lastname: Mazumder
authors.affiliation: Global Health Center (former), Oregon Health & Science University, Portland, OR, USA; Department of Neurology, School of Medicine, Oregon Health & Science University, Portland, OR, USA; Faculty of Medicine, Gulu University, Gulu, Uganda.
authors.forename: Valerie S
authors.initials: VS
authors.lastname: Palmer
authors.affiliation: Oregon Institute of Occupational Health Sciences, Oregon Health & Science University, Portland, OR, USA.
authors.forename: Michael R
authors.initials: MR
authors.lastname: Lasarev
authors.affiliation: Global Health Center (former), Oregon Health & Science University, Portland, OR, USA.
authors.forename: Ryan C
authors.initials: RC
authors.lastname: Stadnik
authors.affiliation: Global Health Center (former), Oregon Health & Science University, Portland, OR, USA.
authors.forename: Peter
authors.initials: P
authors.lastname: King
authors.affiliation: Department of Food Technology and Nutrition, College of Agricultural and Environmental Sciences, Makerere University, Kampala, Uganda.
authors.forename: Margaret
authors.initials: M
authors.lastname: Kabahenda
authors.affiliation: Oregon Institute of Occupational Health Sciences, Oregon Health & Science University, Portland, OR, USA.
authors.forename: David L
authors.initials: DL
authors.lastname: Kitara
authors.affiliation: Graduate Program in Human Nutrition, School of Medicine, Oregon Health & Science University, Portland, OR, USA.
authors.forename: Diane
authors.initials: D
authors.lastname: Stadler
authors.affiliation: Department of Public Health and Preventive Medicine, Oregon Health & Science University, Portland, OR, USA.
authors.forename: Breanna
authors.initials: B
authors.lastname: McArdle
authors.affiliation: Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Makerere University, Kampala, Uganda.
authors.forename: James K
authors.initials: JK
authors.lastname: Tumwine
mesh_terms: D000293:Adolescent; D000886:Anthropometry; D001927:Brain Diseases / Q000453:epidemiology / Q000209:etiology*; D016022:Case-Control Studies; D002648:Child; D004032:Diet / Q000009:adverse effects; D004777:Environment; D005260:Female; D006801:Humans; D008297:Male; D044342:Malnutrition / Q000150:complications* / Q000453:epidemiology; D008457:Measles; D064128:Nodding Syndrome / Q000453:epidemiology* / Q000209:etiology*; D011795:Surveys and Questionnaires; D014454:Uganda / Q000453:epidemiology
keywords: Abnormal sleep; Cognitive deficits; Epilepsy; Infection; Internment; Moldy food; Sub-acute sclerosing panencephalitis (SSPE); Tropical neurology