Nodding disease or nodding syndrome is a recent, little-known disease which emerged in Sudan in the 1960s. It is a fatal, mentally and physically disabling disease that only affects children, typically between the ages of 5 and 15. It is currently restricted to small regions in South Sudan, Tanzania, and northern Uganda. Prior to the South Sudan outbreaks and subsequent limited spread, the disease was first described in 1962 existing in secluded mountainous regions of Tanzania, although the connection between that disease and nodding syndrome was only made recently.
The symptoms of nodding disease are very peculiar. When children are affected by it, their growth is stunted completely and permanently. The growth of the brain is also stunted, leading to mental handicapping of the affected individual. The disease is named nodding syndrome due to the characteristic, pathological nodding seizure. The seizure often begins when the children begin to eat, or sometimes when they feel cold. These seizures are brief and halt after the children stop eating or when they feel warm again. These seizures can manifest themselves with a wide degree of severity. Neurotoxicologist Peter Spencer, who has investigated the disease, has stated that upon presentation with food, "one or two [children] will start nodding very rapidly in a continuous, pendulous nod. The child next door will suddenly go into a tonic–clonic seizure, others will freeze." Severe seizures can cause the child to collapse, leading to further injury. Sub-clinical seizures have been identified in electroencephalograms, and MRI scans have shown brain atrophy and damage to the hippocampus and glia cells.
A curious feature is that no seizures occur when victims are given an unfamiliar food; for example, a candy bar.
Diagnosis and treatment 
Diagnosis is not very advanced and is based on the telltale nodding seizures of the victims. When stunted growth and mental handicap are also present, probability of nodding syndrome is high. In the future, neurological scans may also be used in diagnosis. As there is no known cure for the disease, treatment has been directed at symptoms, and has included the use of anticonvulsants such as sodium valproate and phenobarbitol. Anti-malaria drugs have also been administered, to unknown effect.
Nodding syndrome is thought to be debilitating both physically and mentally. In 2004, Peter Spencer stated: "It is, by all reports, a progressive disorder and a fatal disorder, perhaps with a duration of about three years or more." While a few children are said to have recovered from it, many have died from the illness. Seizures can also cause children to collapse, potentially causing injury or death.
Possible causes 
It is currently not known what causes the disease, but it is believed to be connected to infestations of the parasitic worm Onchocerca volvulus, which is prevalent in all outbreak areas. O. volvulus, a nematode, is carried by the black fly and causes river blindness. In 2004, most children suffering from nodding disease lived close to the Yei River, a hotbed for river blindness, and 93.7% of nodding disease sufferers were found to harbour the parasite — a far higher percentage than in children without the disease. A link between river blindness and normal cases of epilepsy, as well as retarded growth, had been proposed previously, although the evidence for this link is inconclusive. Of the connection between the worm and the disease, Scott Dowell, the lead investigator into the syndrome for the US Centers for Disease Control and Prevention (CDC), stated: "We know that [Onchocerca volvulus] is involved in some way, but it is a little puzzling because [the worm] is fairly common in areas that do not have nodding disease". Andrea Winkler, the first author of a 2008 Tanzanian study, has said of the connection: "We could not establish any hint that Onchocerca volvulus is actually going into the brain, but what we cannot exclude is that there is an autoimmune mechanism going on." In the most severely affected region of Uganda, infection with microfilariae in epileptic or nodding children ranged from 70% to 100%.
The CDC is investigating a possible connection with wartime chemical exposure. The team is also investigating whether a deficiency in vitamin B6 (pyridoxine) could be a cause, noting the seizures of pyridoxine-dependent epilepsy and this common deficiency in disease sufferers. Older theories include a 2002 toxicology report that postulated a connection with tainted monkey meat, as well as the eating of agricultural seeds provided by relief agencies that were covered in toxic chemicals.
Prevalence and epidemiology 
While occurrences of the disease known as "nodding syndrome" have been relatively recent, it appears that the condition was first documented in 1962 in southern Tanzania. More recently, nodding syndrome was previously most prevalent in South Sudan, where in 2003 approximately 300 cases were found in Mundri alone. By 2009, it had spread across the border to Uganda's Kitgum district, and the Ugandan ministry of health declared that more than 2000 children had the disease. As of the end of 2011, outbreaks were concentrated in Kitgum, Pader and Gulu. More than 1000 cases were diagnosed in the last half of that year.
There were further outbreaks in early 2012, in South Sudan, Uganda, and Tanzania.
The spread and manifestation of outbreaks may further be exacerbated due to the poor health care of the region.
See also 
- Meredith Wadman (13 July 2011). "Box: A growing threat". Nature. Retrieved 11 July 2011.
- Lacey M (2003). "Nodding disease: mystery of southern Sudan". Lancet neurology 2 (12): 714. doi:10.1016/S1474-4422(03)00599-4. PMID 14649236.
- UGANDA: Nodding disease or "river epilepsy"? IRIN Africa. Accessed 19 October 2010
- "Nodding disease in East Africa". CNN. Retrieved 6 June 2011.
- Wadman, Meredith (13 July 2011). "African outbreak stumps experts". Nature. Retrieved 25 December 2011.
- 'Nodding disease' hits Sudan Andrew Harding BBC News 23 September 2003, Accessed 19 October 2007
- Ross, Emma (3 February 2004). "Sudan A Hotbed Of Exotic Diseases". CBS News (Rumbek, Sudan). Retrieved 25 December 2011.
- Bizarre Illness Terrifies Sudanese - 'Nodding Disease' Victims Suffer Seizures, Retardation, Death Emma Ross, CBS News, Jan. 28, 2004. Accessed 19 October 2007
- "WHO document describing disease with unusual observation re: unfamiliar food". World Health Organisation. WHO. Retrieved 25 December 2011.
- Abraham, Curtis (23 December 2011). "Mysterious nodding syndrome spreading through Uganda". New Scientist. Retrieved 25 December 2011.
- When Nodding Means Dying: A baffling new epidemic is sweeping Sudan. Lekshmi Santhosh The Yale Journal of Public Health Vol. 1, No. 1, 2004. Accessed 25 December 2011
- Druet-Cabanac M, Boussinesq M, Dongmo L, Farnarier G, Bouteille B, Preux PM (2004). "Review of epidemiological studies searching for a relationship between onchocerciasis and epilepsy". Neuroepidemiology 23 (3): 144–9. doi:10.1159/000075958. PMID 15084784.
- Ovuga E, Kipp W, Mungherera M, Kasoro S (1992). "Epilepsy and retarded growth in a hyperendemic focus of onchocerciasis in rural western Uganda". East African medical journal 69 (10): 554–6. PMID 1473507.
- Marin B, Boussinesq M, Druet-Cabanac M, Kamgno J, Bouteille B, Preux PM (2006). "Onchocerciasis-related epilepsy? Prospects at a time of uncertainty". Trends Parasitol. 22 (1): 17–20. doi:10.1016/j.pt.2005.11.006. PMID 16307906.
- Dan Michael Komakech (2011-11-07). "Nodding disease community dialogue meeting held in Pader district". Acholi Times.
- "East African Mystery Disease: Nodding Syndrome". Daily Kos. March 14, 2012. Retrieved March 14, 2012.