Factors affecting the attrition of community-directed distributors of ivermectin, in an onchocerciasis-control programme in the Imo and Abia states of south-eastern Nigeria.

In areas of Nigeria where onchocerciasis is endemic, community-directed distributors (CDD) distribute ivermectin annually, as part of the effort to control the disease. Unfortunately, it has been reported that at least 35% of the distributors who have been trained in Nigeria are unwilling to participate further as CDD. The selection and training of new CDD, to replace those unwilling to continue, leads to annual expense that the national onchocerciasis-programme is finding difficult to meet, given other programme priorities and the limited resources. If the reported levels of attrition are true, they seriously threaten the sustainability of community-directed treatment with ivermectin (CDTI) in Nigeria. In 2002, interviews were held with 101 people who had been trained as CDD, including those who had stopped serving their communities, from 12 communities in south-eastern Nigeria that had high rates of CDD attrition. The results showed that, although the overall reported CDD attrition was 40.6%, the actual rate was only 10.9%. The CDD who had ceased participating in the annual rounds of ivermectin blamed a lack of incentives (65.9%), the demands of other employment (14.6%), the long distances involved in the house-to-house distribution (12.2%) or marital duties (7.3%). Analysis of the data obtained from all the interviewed CDD showed that inadequate supplies of ivermectin (P<0.01), lack of supervision (P<0.05) and a lack of monetary incentives (P<0.001) led to significant increases in attrition. Conversely, CDD retention was significantly enhanced when the distributors were selected by their community members (P<0.001), supervised (P<0.001), supplied with adequate ivermectin tablets (P<0.05), involved in educating their community members (P<0.05), and/or involved in other health programmes (P<0.001). Although CDD who were involved in other health programmes were relatively unlikely to cease participating in the distributions, they were more likely to take longer than 14 days to complete ivermectin distribution than other CDD, who only distributed ivermectin. Data obtained in interviews with present and past CDD appear vital for informing, directing, protecting and enhancing the performance of CDTI programmes, in Nigeria and elsewhere.

The Carter Center's assistance to river blindness control programs: establishing treatment objectives and goals for monitoring ivermectin delivery systems on two continents.

Periodic mass treatment with ivermectin in endemic communities prevents eye and dermal disease due to onchocerciasis. As part of an international global partnership to control onchocerciasis, The Carter Center's Global 2000 River Blindness Program (GRBP) assists the ministries of health in ten countries to distribute ivermectin (Mectizan, donated by Merck & Co.). The GRBP priorities are to maximize ivermectin treatment coverage and related health education and training efforts, and to monitor progress through regular reporting of ivermectin treatments measured against annual treatment objectives and ultimate treatment goals (e.g., full coverage, which is defined as reaching all persons residing in at risk villages who are eligible for treatment). Since the GRBP began in 1996, more than 21.2 million ivermectin treatment encounters have been reported by assisted programs. In 1999, more than 6.6 million eligible persons at risk for onchocerciasis received treatment, which represented 96% of the 1999 annual treatment objective of 6.9 million, and 78% of the ultimate treatment goal in assisted areas.

Dracunculiasis eradication: delayed, not denied.

By the end of 1998, Asia was free of dracunculiasis (Guinea worm disease), with Pakistan, India, and Yemen having interrupted transmission in 1993, 1996, and 1997, respectively. Transmission of the disease was also interrupted in Cameroon and Senegal during 1997. Chad reported only 3 cases during 1998. Dracunculiasis is now confined to only 13 countries in Africa. The overall number of cases has been reduced by more than 97% from the 3.2 million cases estimated to have occurred in 1986 to 78,557 cases reported in 1998. Because the civil war in Sudan remains the major impediment to eradication of dracunculiasis, the interim goal is to stop all transmission outside that country by the end of 2000. The most important operational need now is for national programs to improve the frequency and quality of supervision of village-based health workers in order to enhance the sensitivity of surveillance and effectiveness of case containment.

Perspectives from the dracunculiasis eradication programme.

After a slow beginning in association with the International Drinking Water Supply and Sanitation Decade (1981-1990), the global Dracunculiasis Eradication Programme has reduced the incidence of dracunculiasis by nearly 97%, from an estimated 3.2 million cases in 1986 to less than 100,000 cases in 1997. Over half of the remaining cases are in Sudan. In addition, the programme has already produced many indirect benefits such as improved agricultural production and school attendance, extensive provision of clean drinking-water, mobilization of endemic communities, and improved care of infants. Most workers in the campaign have other responsibilities in their communities or ministries of health besides dracunculiasis eradication.

Four-week supplementation with a natural dietary compound produces favorable changes in body composition.

The purpose of this study was to determine whether a natural dietary supplement produced favorable changes in body composition during a 4-week diet- and-exercise program. The active compound contains a patented combination of chromium picolinate, inulin, capsicum, L-phenylalanine, and other lipotropic nutrients. A double-blind, weight-loss intervention design was used. Participants were randomly assigned to either a diet/exercise/supplement group (n = 56) or a diet/exercise/placebo group (n = 67). Caloric intake was reduced to 1500 kcal/d and participants walked for 45 minutes, 5 days a week, to attain between 60% and 80% of predicted maximal heart rate. Analysis of covariance (ANCOVA) showed significant differences (P < .05) between groups in percent body fat, fat mass, and fat-free mass; no significant differences were found (P > .05) in body weight, body mass index, or energy intake. Independent t tests showed no significant differences (P > .05) in diet composition between groups. Results indicate that the addition of a natural dietary supplement during a 4-week diet-and-exercise weight-loss program accelerates the rate of body fat loss and helps maintain fat-free mass (lean tissue), thereby producing favorable changes in body composition.

Dracunculiasis eradication: almost a reality.

The idea of a global campaign to eradicate dracunculiasis was first proposed by the Centers for Disease Control and Prevention in 1980, during the advent of the International Drinking Water Supply and Sanitation Decade (IDWSSD) (1981-1990). In 1981, the Steering Committee of the IDWSSD adopted eradication of dracunculiasis as a subgoal of their efforts to provide safe drinking water to unserved populations. In 1988, African ministers of health voted to eradicate dracunculiasis by the end of 1995, a target date that was endorsed by UNICEF in 1989 and the World Health Assembly in 1991. Although nine of 18 endemic countries, India (1980), Pakistan (1987), Nigeria and Cameroon (1988), Ghana (1989), and Mauritania, Benin, Burkina Faso, and Togo (1990) completed national searches for cases of the disease, only four countries, India (1983), Pakistan (1988), Ghana (1989), and Nigeria (1989), actually started eradication programs during the 1980s. The remaining 14 endemic countries began their eradication programs between 1991 and 1995. At the end of 1996, dracunculiasis had not been entirely eradicated, but its incidence had been reduced by 95%, from an estimated 3.2 million cases in 1986 to 152,805 cases in 1996. Sudan reported a total of 118,578 (78%) of the 152,805 cases of dracunculiasis reported during 1996. Insufficient funding and the civil war in Sudan continue to be the major obstacles to overcome. A primary aim of the eradication program in 1997 is to seek to ensure that all cases of dracunculiasis outside of Sudan are contained. In Sudan the challenge is to pursue all appropriate control measures in all accessible areas as vigorously as possible until political circumstances allow access to all of the remaining affected areas.

Eradication of dracunculiasis from Pakistan.

In 1986 the World Health Organization targeted dracunculiasis (Guinea-worm disease), which seriously impairs socioeconomic development in 16 African countries, India, Pakistan, and Yemen, to be eradicated globally. The target date for eradication by the end of 1995 was established in 1991. Pakistan eradicated dracunculiasis from the country in October, 1993, after a national campaign which began in 1987 with a nationwide village-by-village search for cases. The infection, which is transmitted by drinking water from ponds containing infected water fleas, was eradicated by using health education, cloth filters, and the cyclopsicide, temephos; and in the later stages, by case containment. Methods pioneered in Pakistan's National Guinea Worm Eradication Program are now being applied in remaining endemic countries.

PIP: Dracunculus medinensis larvae expelled into drinking water may be ingested by water fleas, copepods, in which they undergo two moults before becoming infectious to humans. A person consuming unboiled or unfiltered water infested with larvae-ridden copepods will contract dracunculiasis. The disease is manifest one year later by the emergence from the human host of one-meter-long adult worms of Dracunculus medinensis. Infected people are often incapacitated for several weeks by secondary infections associated with the emergence of the worm, although less than 1% of victims suffer permanent disability. The disease is rarely fatal, but it prevents large numbers of people from farming or attending school. Dracunculiasis, Guinea-worm disease, can be prevented by boiling drinking water or filtering it through a cloth to remove the larvae's copepod hosts, by educating villagers not to contaminate their sources, by providing clean drinking water from underground sources such as borehole wells which cannot be contaminated, or by using a larvicide, temephos, to kill the copepods while leaving the water safe for human consumption. In 1986, the World Health Organization targeted dracunculiasis for global eradication. From an estimated total of more than three million cases in 1986, only 165,000 cases were reported worldwide in 1994. Pakistan, however, is the first country endemic for dracunculiasis to eradicate the disease during the ongoing global campaign. The goal of countrywide eradication was reached in October 1993 after a national campaign which began in 1987 with a nationwide village-by-village search for cases. Health education, cloth filters, temephos, and case containment were used together to achieve success. Methods pioneered in Pakistan's guinea-worm eradication program are being applied in the remaining endemic countries.

Dracunculiasis eradication: March 1994 update.

Substantial progress has been realized in the global campaign to eradicate dracunculiasis by the end of 1995 since a previous review of the subject was published in this journal a year ago. All known endemic countries are now engaged in the eradication effort, and one or more control measures are now in place in 93% of endemic villages. Despite improved surveillance for the disease, the number of reported cases of the disease has been reduced by 41% (to about 221,000), and the number of known endemic villages has been reduced by 28% (to about 16,500) in the past year. Priorities for national eradication programs in 1994 include increasing the use of vector control and intensifying the case containment strategy in endemic villages. It is still possible to achieve the eradication target of December 1995, but greatly intensified efforts this year will be required to do so.

Dracunculiasis eradication: beginning of the end.

Beginning with the International Drinking Water Supply and Sanitation Decade (1981-1990), an increasingly broad coalition of international and bilateral agencies, organizations, private companies, and other institutions have joined forces to eradicate dracunculiasis (Guinea worm disease). From an estimated annual incidence of 10 million persons just before the campaign began, the remaining incidence of cases is now less than two million. More than 23,000 villages are known to be endemic. All 18 countries where the disease is still endemic have completed or begun nationwide searches to identify endemic villages, except Kenya. Dracunculiasis is nearly eradicated in Asia, where Pakistan found only 23 cases in 1992, and India found 1,081 cases. Cameroon and Senegal are close to achieving eradication in Africa, where the two formerly highest endemic countries, Nigeria and Ghana, reduced their combined total of cases from approximately 820,000 in 1989 to less than 240,000 in 1992. Much remains to be done, however, in francophone West Africa and especially in East Africa. The most serious current obstacles to eradicating dracunculiasis by 1995 are the civil war in Sudan, apathy of some national and international health officials, and inadequate funding for the campaign.

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.