The distribution of dracunculiasis in Nigeria: a preliminary study.

This paper presents a preliminary assessment of the distribution and endemicity of dracunculiasis in Nigeria. The disease is found in all 19 States of the Federation and in the Federal Capital Territory of Abuja. It occurs in areas with a dry season of more than nine months as well as those with a dry season of less than four months; the seasonal distribution of rainfall influences the peak period of disease transmission and patency. Altogether, an estimated 2.5 million cases occur every year, and at least 30% of the entire rural population is at risk from the infection. The widespread distribution of dracunculiasis throughout the country indicates the need for a national control campaign and a sustained programme of international cooperation.

The clinico-epidemiological profile of guinea worm in the Ibadan district of Nigeria.

An epidemiological survey of guinea worm infection was carried out in 17 rural village communities north of Ibadan in western Nigeria from 1971 to 1975. The incidence was 13.5% in a population of 8,200. The sexes were equally affected although there were significantly more cases amongst boys than girls. A majority of the worms emerged from the lower limbs and the incidence of complications and disability was higher in those with lesions around the ankles and feet. The average duration of incapacity from effective work among this predominantly rural population was 100 days. A case is made for a concerted effort to eradicate this easily prevented disease by the provision of wholesome potable water to all persons.

Mebendazole in the treatment of dracontiasis.

In a controlled field trial of treatment for dracontiasis, mebendazole (Vermox) was found to be effective in eliminating the adult worm and preventing clinical relapses, but it did not achieve significant amelioration of symptoms, subsidence of inflammation, or healing of ulcers. The failure is attributed to poor absorption and lack of anti-inflammatory action of the drug. Mebendazole was well tolerated and although two patients reported mild gastrointestinal disturbances, which may be attributed to the drug, the study confirms that mebendazole is one of the safest anthelmintics in current use and is in that respect ideal for mass therapy.

Impact of guinea worm disease on children in Nigeria.

School attendance records of all primary schools in a guinea worm-endemic village in southwestern Nigeria were examined to determine the cause of missed school days and school drop-outs. At the time of the survey, 1,495 pupils (768 boys and 727 girls were registered in the 4 primary schools in the village, of which 21% of the pupils were infected with guinea worm disease (GWD). Female pupils had a higher infection rate than their male counterparts. Guinea worm-infected pupils missed up to 25% of school year days compared to a non-guinea worm-infected absence of 2.5%. At the height of guinea worm season in the study area, guinea worm-related absences contributed virtually all of the absenteeism recorded in the schools. Implications of the findings within the context of educational attainment of the pupils are discussed.

Mobilization strategy for guinea worm eradication in Nigeria.

The transformation of dracunculiasis from an obscure and neglected rural disease to the highly visible target of a national eradication campaign in Nigeria is described in this report. This process progressed through four overlapping stages: documentation of the extent and nature of the disease as a national problem, demonstration in Nigeria that dracunculiasis could be effectively prevented by targeted provision and use of protected rural water supplies, mobilization for community participation in, and political support of, the eradication effort, and implementation of interventions nationwide. The conduct of the first national village-by-village search for cases and documentation of the adverse socioeconomic impact of the disease (e.g., on rice production) in Nigeria were the key elements used to solicit greater attention to the problem and mobilize support for its eradication. The critical role of the mass media in this effort and other benefits of this mobilization strategy are also highlighted.

A method of rapid assessment of the distribution and endemicity of dracunculiasis in Nigeria.

This paper describes how information was collected at a national conference in Nigeria and a map compiled to give an initial assessment of the distribution and endemicity of dracunculiasis (guinea worm disease) throughout the country. The map provided a stimulus for further studies of the status of the disease and for the consideration of national control strategies. A map created along the same lines could be used for obtaining an initial assessment of the extent and endemicity of dracunculiasis, or other diseases, in countries for which such data was not readily available.

Guineaworm control case study: planning a multi-strategy approach.

The planned global eradication of guineaworm (dracunculiasis) offers opportunities to learn about relatively complicated disease control situations. Unlike smallpox, which was eradicated over 10 years ago through immunization, the guineaworm problem has no one solution, but must rely on a variety of technologies to protect, treat or replace existing unsafe community water supplies which harbour the disease. Experiences in rural Nigeria have shown that a multi-strategy approach is necessary to account for differences in geographical settlement patterns, local culture and beliefs, geology of the area, economy of the villages and political clout of town leaders among the five major segments of the community. Through a self-help primary health care programme, residents of the Idere community were able to dig wells, produce and distribute cloth water filters bringing a reduction in disease incidence in some areas. It was also seen that generally low standards of living exacerbated by scattered outlying settlements made self-help difficult. Unfortunately occasional government and private efforts did not succeed because of a lack of community participation. Programme planners must involve the consumers in diagnosing these community characteristics and in planning, supervising and maintaining the resulting projects. The multi-strategy approach will help avoid wasted resources and false expectations that arise when project staff attempt to apply a "magic bullet" solution to a complex problem.

Development of reactive onchocercal skin lesions during a placebo-controlled trial with ivermectin among persons without lesions at baseline.

Clinical trials of the effects of ivermectin on onchocercal skin disease have documented reduction in itching, but a less than clear benefit on reactive skin lesions. It has been suggested that one of the positive effects might be the prevention of new lesions. A study among a rural adult farming population in southwestern Nigeria provided ivermectin in three treatment groups and a placebo to community members who were examined and treated at 3-monthly intervals over a 15-month period. Among the 1206 people recruited for the study, 627 (52%) had no lesions at baseline examination. Atotal of 291 participants without baseline lesions attended all five follow-up examinations, and only their results were analysed. Members of all four groups developed new lesions, but those receiving ivermectin had a consistently lower proportion of lesions than the placebo group. This difference reached statistical significance at the 5% level in three of the five periods and was below the 10% level at the other two periods. These findings are suggestive of an inhibiting effect of ivermectin among those without lesions at the beginning of a community treatment programme, and justify community treatment as a way of limiting morbidity and social stigma associated with these lesions.

Epidemiology of dracunculiasis and its socio-economic impact in a village in south-west Nigeria.

An epidemiological survey of dracunculiasis conducted in a village in Oluyole Government Area of Oyo State, Nigeria, from January to June 1985 revealed that of a sample of 851 subjects interviewed and examined 52.2% had had infection at one time or the other while 28.7% were females (30.3%) than males (27.0%) were infected, the difference was not statistically significant. The prevalence increased with age and infection was found to be uncommon in children below one year of age. Reinfection after infancy is a common feature and all the infected people regularly drank untreated pond water. 85.8% claimed they knew that they were infected before the formation of the characteristics guineaworm bleb; of these 56.6% became aware of infection two to five days prior to the formation of the bleb. 70% had had more than one worm emerging at a time, mainly in the lower parts of the body. Most of the infected people (76.0%) became clinically ill in the dry season and 93.4% of these were incapacitated for an average of 26 days from each infection.

An assessment of national needs for community physician manpower in Nigeria: staff training needs and programmes.

This second part of a national survey was designed to identify the training needs and programmes considered most appropriate by the most senior health management staff of the state governments for the field practice of community medicine in Nigeria. The operation of the current primary health care programme and the field practice of community medicine although constitutionally a local government responsibility, effectively rests on the state governments at present because of economic and political constraints at the LG level. The main needs identified in the study are for a certifiable and appropriate generalist community physician training programme as well as the relative levels of emphasis needed in the different sub-specialty areas. While holders of the current fellowship diploma in public health of the National Postgraduate Medical College of Nigeria are welcome to practice in the field if they are available, many state governments and officials consider the programme ill-suited to the needs of field practice community physicians. Thirteen (68.4% of the) respondents, consider it suitable only for jobs at state employment levels and higher up. Twelve of the 17 physician respondents considered clinical practice essential for all community physicians. Eighteen of the 21 state governments would be ready to sponsor their physician candidates to local training programmes in public health as identified in this study, if different from the current postgraduate fellowship. Maternal and child health was the area of sub-specialty training considered most needed in the states. This was followed by epidemiology, environmental health, health education, health and biostatistics, health management, and occupational health in that order.(ABSTRACT TRUNCATED AT 250 WORDS)

An assessment of national need for community physician manpower in Nigeria.

This is a study of the government policy situation in all the 19 states of Nigeria in relation to the practice of community medicine in the context of primary health care and the movement for health-for-all by the year 2000, as well as the existing mechanisms for the achievement of those policies. The result of the study, which was carried out by means of mail questionnaires to all the 19 Ministries of Health (MOH) and each of the State Health Management Boards (SHMB) or Health Councils (SHC), show that only 8 of the states have actual or assumed policy for the provision of community medical officers ("Medical Officers of Health") for each of their local government areas. Only 3 states have a mechanism for operating the said policy. Details of the study methods and the responses, as well as other aspects of community medical practice in the states are discussed and suggestions made towards their improvement for the attainment of the health-for-all objectives in Nigeria in the foreseeable future.

Epidemiological survey of an outbreak of gastroenteritis in a rural community in Oyo State.

This report documents the investigation and control of an outbreak of gastro-enteritis in Lagun, Oyo State, Nigeria. Prior to the outbreak which occurred in 1981, there had been epidemics of gastro-enteritis, suspected to be cholera, in various parts of Nigeria. The investigations carried out included personal interviews of patients and their contacts, laboratory investigations of faecal specimens and analysis of water samples obtained from the village wells and stream. Available evidence indicates that the infection was probably introduced by one of the many visitors who had thronged the village for a festival. Neither Vibrio cholerae, Salmonella nor Shigella species were isolated from fecal specimens. However Vibrio metschnikovii organisms were present in water from the stream; and all the water samples tested revealed faecal contamination. The intervention consisted of intensive health education of various groups in the community, chlorination of water sources, treatment or referral of patients as necessary, with chemoprophylaxis and cholera immunization for contacts. A community environmental sanitation programme was also carried out, and recommendations have been made. This study highlighted what can be done at Primary Health Care level to investigate and control epidemics of gastro-enteritis which are common occurrence in the rural communities of this country.

A comparative trial of the anthelminthic efficacy of pyrantel pamoate (Combantrin) and thiabendazole (Mintezol).

The anthelminthic efficacy of pyrantel pamoate (Combantrin) in a single dose of 10 mg/kg body weight was compared with that of thiabendazole (Mintezol) in two doses each of 25 mg/kg body weight in a controlled trial. Follow-up examination, 6 weeks after treatment with Combantrin gave cure rates of 93.8%, and 29.1% for infection with Ascaris and the Hookworm respectively, and 44.3% and 27.3% in those treated with Mintezol. The reduction in hookworm egg counts was higher in patients treated with Combantrin than with Mintezol, and Combantrin was better tolerated. Neither drug was effective against the Trichuris. The results are compared with those from other parts of the world.

Epidemiology and treatment of dog bites in Ibadan: a 12-year retrospective study of cases seen at the University College Hospital Ibadan (1962-1973).

A retrospective epidemiological study was made of dog bite accidents seen at the Casualty department of the University College Hospital, Ibadan, between 1 January 1962 and 31 December 1973. A variety of host, agent and environmental factors were analysed. The incidence per 1000 attendances was 11.5 with a male/female ratio of 57:43. Majority of the bites occurred in the dry season and 75.4% of the victims were less than 20 years of age. 83.5% of the bites were inflicted on the extremities and 59.1% were moderately severe or severe. 50% of the bites were unprovoked and 80.3% of the biting dogs belonged to known owners. 86.9% of the victims reported for treatment within 24 hours of the accident but only 6.6% attended for follow up beyond four weeks. 73.5% of the victims received active immunization with rabies vaccine but only 50.2% of these completed the prescribed course. The findings in this study provides a factual basis for making recommendations to prevent, control and treat dog bites.

Controlled comparative study of the efficacy of pyrantel pamoate and a combined regimen of piperazine citrate and bephenium hydroxynaphthoate in the treatment of intestinal nemathelminthiases.

Pyrantel pamoate at a dose of 10 mg/kg body weight daily for 2 or 3 days was found to be more effective against Ascaris than both a regimen of bephenium hydroxynaphthoate (2.5 g base) and piperazine citrate (2-3 g) given daily for 2 days and a placebo-treated control group. The cure rates for pyrantel were about 95% compared to 90 and 20% for the other two groups respectively. None of the drug schedules was effective against the Trichuris. The bephenium/piperazine regimen was superior to both the 2-day and 3-day courses of pyrantel pamoate against the hookworm with aggregate cure rates of 58-60% for pyrantel pamoate and 68-85% for bephenium/piperazine. The results were better than those reported earlier in the series when a single dose of pyrantel pamoate (10 mg/kg of body weight) was used. Pyrantel pamoate was well tolerated and the drug merits further studies at higher doses, particularly against the hookworm.

Bowel habit in a Yoruba rural community: preliminary report.

The bowel habit of a rural population 80 kilometres outside Ibadan was examined. Based on the pattern of the diet there, 91% of the apparently healthy subjects have daily bowel actions, 60% have two or more motions a day and the stool was soft in 51% of them. There was no alteration in the frequency and consistency of the stool with advancing age. The range of bowel actions was two to three soft motions per day. Recognizable dietary factors producing this pattern include not only the bulky carbohydrate diet but also the vegetables, pepper, fruits and traditional as well as proprietary laxative products commonly taken by these subjects. The implication of the bowel habit on the prevalence of certain gastrointestinal disease on the basis of Burkitt's hypothesis was examined. Measurements of food transit time and stool weights will form the basis of subsequent studies.

Field trials of pyrantel pamoate (Combantrin) in Ascaris, hookworm and Trichuris infections.

In a trial involving 185 school children, pyrantel pamoate (Combantrin) at a dose of 20 mg/kg body weight for 1-3 days was found to be very effective against the Ascaris and moderately effective against the hookworm, with mean cure rates ranging from 93.3-96.7% and 53.3-73.3% respectively. No apparent action against the Trichuris was detected, a mean cure rate of between 34.2 and 46.1% being only slightly, but not significantly, better than the 33.8% cure for a placebo-treated control group. Single and multiple doses of the suspension and tablet formulations of the drug were well tolerated. From the series of randomized and controlled trials conducted, we recommend that, in this area, the appropriate dose of the drug to use for treating ascariasis is 10 mg/kg per day for 1 day, and for infections which include hookworm, 20 mg/kg per day for 3 days.

Rapid community identification, pain and distress associated with lymphoedema and adenolymphangitis due to lymphatic filariasis in resource-limited communities of North-eastern Nigeria.

Identification of communities with people that could benefit from adenolymphangitis (ADL) and lymphoedema morbidity management within Lymphatic Filariasis Elimination Programmes (NLFEP) in many African countries is a major challenge to programme managers. Another challenge is advocating for proportionate allocation of funds to alleviating the suffering that afflicted people bear. In this study we developed a rapid qualitative technique of identifying communities where morbidity management programme could be situated and documenting the pain and distress that afflicted persons endure. Estimates given by health personnel and by community resource persons were compared with systematic household surveys for the number of persons with lymphoedema of the lower limb. Communities in Northeastern Nigeria, with the largest number of lymphoedema cases were selected and a study of local knowledge, physical, psychosocial burden and intervention-seeking activities associated with the disease documented using an array of techniques (including household surveys, key informant interviews, group discussions and informal conversations). Health personnel gave a more accurate estimate of the number of lymphoedema patients in their communities than either the community leader or the community directed ivermectin distributor (CDD). Community members with lymphoedema preferred to confide in health personnel from other communities. The people had a well developed local vocabulary for lymphoedema and are well aware of the indigenous transmission theories. Although the people associated the episodic ADL attacks with the rains which were more frequent at that period they did not associate the episodes with gross lymphoedema. There were diverse theories about lymphoedema causation with heredity, accidental stepping on charmed objects and organisms, breaking taboos. The most popular belief about causation, however, is witchcraft (60.9%). The episodic attacks are dreaded by the afflicted, since they are accompanied by severe pain (18%). The emotional trauma included rejection (27.5%) by family, friends and other community members to the extent that divorce and isolation are common. Holistic approach to lymphoedema morbidity management should necessarily be an integral component of the ongoing transmission elimination programme. Any transmission prevention effort that ignores the physical and psychological pain and distress that those already afflicted suffer is unethical and should not be promoted.