Preliminary enquiry into the availability, price and quality of malaria rapid diagnostic tests in the private health sector of six malaria-endemic countries.

OBJECTIVES: This enquiry aimed to provide a snap-shot of availability, price and quality of malaria rapid diagnostic tests (RDTs) in private health facilities at selected sites in six malaria-endemic countries in Africa, South East Asia and South America. METHODS: In each study site, data collectors surveyed private healthcare facilities which were selected based on accessibility from their home institution. Using a questionnaire, information was recorded about the facility itself and the malaria RDT(s) available. Where possible, a small number of RDTs were procured and quality control tested using a standardized procedure. RESULTS: Of the 324 private healthcare facilities visited, 35 outlets (mainly private clinics and hospitals) were found to supply 10 different types of RDTs products. RDT prices across the six countries ranged from US$1.00 to $16.81. Five of the 14 malaria RDTs collected failed quality control testing. CONCLUSIONS: In the private outlets sampled, the availability of RDTs was limited. Some of the RDTs whose quality we tested demonstrated inadequate sensitivity. This presents a number of risks. Given the more widespread distribution of antimalarials currently planned for private sector facilities, parasite-based diagnosis in this sector will be essential to adhere to the WHO guidelines for effective case management of malaria. Considerable regulation and quality control are also necessary to assure the availability of accurate and reliable RDTs, as well as adequate case management and provider adherence to RDT results. Public sector engagement is likely to be essential in this process.

Knowledge, attitude, perception of malaria and evaluation of malaria parasitaemia among pregnant women attending antenatal care clinic in metropolitan Lagos, Nigeria.

BACKGROUND & OBJECTIVES: Little information exists on the compliance of pregnant women to malaria management in malaria endemic countries. This study was designed to access knowledge, attitude, perception and home management of malaria among consenting pregnant women attending antenatal care (ANC) clinic. METHODS: In total, 350 pregnant women were randomly recruited during their ANC Clinic in Lagos. Structured questionnaires were administered in a two-stages research design; first during their early months of ANC visit and the second approximately 1-2 months before delivery. Information on occupation, parity, symptoms used to recognise malaria, treatment sources, control measures, knowledge factors, anti-vector measures, health-seeking practices, malaria parasitaemia and packed cell volume (PCV) were recorded. RESULTS: The results revealed that 78.9% of the pregnant women identified infected mosquitoes as the cause of malaria while 86% of the pregnant women identified stagnant water as its breeding sites. Knowledge of the benefit of insecticide-treated mosquito bednets was less prominent as most of the selected subjects decried its high market price. Our data also showed that educational programme targeted on potential mothers is beneficial. Overall, 27.4% (96/350) of the pregnant women had peripheral malaria infection with 88.5% (85/96) of the parasite positive women infected with Plasmodium falciparum and 11.5% (11/96) with P. malariae. PCV ranged from 20-40% (median 33.9%) with 25.7% (90/350) of the pregnant women being anaemic with PCV <33%. We found an association between malaria infection and occupation, and this association was not influenced by parity. INTERPRETATION & CONCLUSION: Our findings revealed that improvement in knowledge and education of women of child-bearing age has an influential impact on malaria control.

The community-based treatment of onchocerciasis in Shao, Kwara State, Nigeria.

Community acceptance of and compliance with annual ivermectin treatment in Shao, a sub-urban community in Kwara State, Nigeria, were remarkably high. Of 890 subjects from 204 randomly selected households, 832 (93.5%) had taken ivermectin at least once during the six-year treatment period. An average community acceptance rate (ACAR) of 88.77% (range 85.4 - 91.9%) was recorded during this period; a community compliance rate (CCR) of 74.76% was recorded. Overt refusals, covert refusals and those excluded from treatment were low and insignificant (p > 0.05). The mean compliance age was 37.47 +/- 16.52 years. Of the subjects studied, 40.67% reported adverse reactions to ivermectin during the first round of treatment (Tx1); this number decreased significantly (p < 0.05) to 15.43% during the sixth round of treatment (Tx6). Though considerable adverse reactions were reported in the community, these did not seem to have negatively affected acceptance of and compliance with annual ivermectin treatment; in some cases, the adverse reactions were believed by the villagers to demonstrate the efficacy and effectiveness of the drug. The community showed great awareness of the disease, its treatment with ivermectin and the distribution of the drug. On the basis of the high acceptance and compliance rates, it was concluded that Shao will benefit greatly from the current African Program for Onchocerciasis Control Strategy: Community-Directed Treatment with Ivermectin (CDTI) using Community-Directed Distributors (CDDs).

Intestinal helminthiases and their control with albendazole among primary schoolchildren in riverine communities of Ondo State, Nigeria.

A study to establish the prevalence of intestinal helminthiases among schoolchildren of riverine communities in the Ilaje-Ese Odo Local Government Area of Ondo State, Nigeria was conducted. Ninety-four percent of the children studied were infected with intestinal helminths. Trichuris trichiura infection was the commonest (84%), followed by Ascaris lumbricoides (75.3 %) and hookworm (7.6 %). Dual helminthic infections were recorded, with Ascaris-Trichuris having the highest prevalence among the children. Poor environmental sanitation and personal hygiene combined with the absence of potable water and a lack of awareness of the effects of nematode infection were identified as the possible reasons for the high rate of infection. Treatment with albendazole (200 mg) brought about reductions in the level of Trichuris trichiura (to 41.7%), Ascaris lumbricoides (to 4.2%) and Hookworm (to 0.7%). The estimated rates of reduction were 94.4%, 49.7%, and 90.2% for Ascaris lumbricoides, Trichuris trichiura and hookworm respectively. Post-treatment helminthic reduction, as found in this study, is expected to enhance the mental and physical development of the children. Community mobilization with health education messages aimed at improving personal and community hygiene was initiated with an emphasis on creating a sustained reduction in the burden of helminthic infection.

Reduced prevalence of onchocerciasis following mass treatment with ivermectin.

The effect of four years of cummulative annual treatment with ivermectin just before the fifth round of dosing with the drug was studied in six endemic communities where pretreatment data had been collected in 1992. Significant reductions in prevalence of microfilaridermics (PMF), skin microfilarial density (MFD) and community microfilarial load (CMFL) was recorded. Remarkable reductions in PMF were recorded in Gbodongi (53.0%), Ndanako (80.1%) and others. In all the communities, the infection was reduced to a hypo endemic status except for Gbodongi. This was corroborated by the increase in amicrofilaridermics. CMFL was reduced in Gbodongi by 64.2%, Lata (53.1%) and the least in Bongi (11.0%). Reduction in clinical manifestations were variable.

Evaluation of community compliance with annual ivermectin treatment of onchocerciasis in Patigi, Nigeria.

A low community acceptance and compliance with annual ivermectin treatment was recorded in Patigi, Nigeria where ivermectin is being distributed centrally in designated centres for the fifth time. The average community acceptance rate (ACAR) for the treatment period was 53.48% while the community compliance rate (CCR) of 1.9% of the total subjects interviewed was recorded. Absenteeism from treatment was a major reason for non-treatment (average, 34.6%). Inadequate and poor mobilisation was identified as a major reason for the low ivermectin acceptance and compliance with treatment in this community. An intensive mobilisation with health education messages with the inclusion of religious/traditional institutions is advocated.

PIP: With regard to the treatment of onchocerciasis, studies have shown ivermectin to be well tolerated and effective in reducing microfilarial load, improving ocular and skin lesions, and reducing disease transmission. Nigeria is one of the world's worst onchocerciasis-affected countries. International agencies and nongovernmental organizations in Nigeria currently distribute ivermectin vertically to endemic communities, yet without involving the communities concerned. Although ivermectin is given free of charge to all users, not all eligible individuals in the communities receive annual doses of the drug. Low drug coverage and systematic noncompliance with treatment can result in the build-up of a reservoir population, while the drug's effectiveness depends upon long-term administration. Findings are presented from a study conducted to evaluate the efficiency and effectiveness of the ivermectin delivery program in Patigi, Patigi Local Government Area of Kwara State, Nigeria. A low level of community acceptance and compliance with annual ivermectin treatment was recorded in the study area, with an average community acceptance rate (ACAR) for the treatment period of 53.48%, and a community compliance rate (CCR) of 1.9%. Absenteeism from treatment was a major reason for nontreatment (average, 34.6%). Inadequate and poor mobilization was identified as a major reason for the low ivermectin acceptance and treatment compliance in the community. An intensive community mobilization with health education messages, involving religious/traditional institutions, is warranted.

Induced immunity to Plasmodium yoelli nigeriensis in albino mice by antigenic mice organs.

Antigenic materials prepared from parasite infected and non-infected tissue (blood), organs (spleen, liver, lung) and whole mouse burnt with or without Aframomum melegmeta (Alligator Pepper) were tested whether they could elicit immune response to Plasmodium yoelli nigeriensis in albino mice. This investigation is in line with the practice of traditional medicine in the western part of Nigeria where burnt herbal preparation are introduced into patient through body cuts known as "Gbere" for protection and therapy against infection. Results from the study unexpectedly showed that immune response was elicited against malaria parasite by the uninfected antigenic material prepared from spleen and whole mouse. Aframomum melegmeta on its own lysed the red blood cells and played a doubtful role in inducing immunity.

Disinfectant/antiparasitic activities of Jatropha curcas.

OBJECTIVE: To investigate the disinfectant/antiparasitic activities of Jatropha curcas as a first step in providing a cheap, readily available disinfectant and malaria vector control agent. DESIGN: Bacteriological and parasitologic tests were carried out on laboratory bench surfaces using the sap and crushed leaves of Jatropha curcas. Four rectangular areas labelled A, B, C and D were first swabbed and streaked onto McConkey and Nutrient agar plates. Section A was treated with "Hibiscrub", D with exterma germcloth, B and C with full strength sap and leaf extracts respectively. Effect of the sap was also tested on helminth ova, vector control on mosquito eggs and toxic effects of the sap on mice. SETTING: The study was carried out in the medical microbiology laboratory of the College of Medicine, University of Lagos, Lagos. RESULTS: Observation showed that the sap extracted germicidal actions on the growth of common bacteria of Staphylococcus, Bacillus and Micrococcus species on contact and retained such effects on treated laboratory bench surface for close to six hours after initial application. Ova of Ascaris Lumbricoides and Necator americanus incubated in 50% and 100 concentrations of the sap at room temperature showed either no evidence of embryonation after 21 days in the case of A. Lumbricoides, negation of hatchability in hookworm, or complete distortion in both. The sap also exhibited strong inhibitory effect on normal larval growth of mosquito, but was highly toxic to mice when administered through oral or intraperitoneal routes. CONCLUSION: J. curcas would provide a very cheap, readily available disinfectant and malaria vector control agent and should be commercially exploited.

Effect of repeated community-based ivermectin treatment on the intensity of onchocerciasis in Nigeria.

INTRODUCTION: Ivermectin (Mectizan) is an effective and well-tolerated microfilaricidal drug that has emerged as the drug of choice for large-scale treatment of onchocerciasis. Repeated doses of ivermectin is reported to lower the incidence of microfilardermia, while a single dose will markedly reduce skin microfilarial loads for up to 12 months with a transient fall in microfilarial level. AIM: The aim of the study was to evaluate the effect of repeated community-based ivermectin treatment on the intensity of onchocerciasis in 10 onchocerciasis-endemic communities of Lade District, Pategi Local Government Area of Kware State, Nigeria. METHODS: The participants, a cohort of 330 men from whom parasitologic pre-treatment data were collected before mass ivermectin distribution commenced in 1992, were evaluated just before the fifth round of annual ivermectin treatment in August-September 1996, and 12 months after the fifth round in August-September 1997. Two bloodless skin snips were obtained from participants' left and right iliac crests and incubated for 24 h in an 0.5 mL microfuge tube containing 0.2 mL normal saline, before microscopic examination and enumeration of microfilariae. The community microfilarial load (CMFL), the most sensitive parasitologic indicator, was computed. RESULTS: Following four rounds of repeated annual treatments of onchocerciasis with ivermectin in the 10 communities studied, varying degrees of reduction in CMFL were observed in six of the 10 communities. These reductions were significant in three of the six communities at the first evaluation carried out just before the fifth round of annual ivermectin treatment (p = or <0.05). There was an increase in the remaining four communities, mainly attributed to poor annual acceptance and compliance with annual ivermectin treatment due to the occurrence of severe adverse reactions and absenteeism. Post-treatment evaluation (12 months after the previous evaluation), just before the sixth round of annual ivermectin treatment was preceded by community mobilization (enlightenment on the usefulness of ivermectin an assurance on its safety), especially in the four affected communities. This brought about reductions in the CMFL in the four communities that were not previously affected. Although the CMFL of these four communities was reduced, the CMFL of three of the communities did not fall below the 1992 pre-treatment level but was below the level recorded 12 months earlier. One of these affected communities had its CMFL reduced below the 1992 pre-treatment CMFL. CONCLUSION: This study confirms the efficacy of ivermectin in the reduction of CMFL but exposes the danger of failing to monitor annual ivermectin treatment where community ivermectin-based control efforts are ongoing. The results obtained from this study are not as impressive as results reported from closely monitored scientific evaluations of ivermectin efficacy studies.

Malaria and HIV co-infection and their effect on haemoglobin levels from three health-care institutions in Lagos, southwest Nigeria.

BACKGROUND: Malaria and human immunodeficiency virus (HIV) are two major infections with enormous public health consequence. Together, they are endemic in many developing countries with anaemia being the most frequent haematological consequence of the infections. OBJECTIVES: To determine the prevalence of malaria and HIV co-infection as well as anaemia among selected patients from three health-care institutions in Lagos, Nigeria. METHODS: A cross-sectional study of 1080 patients was carried out to determine the prevalence of malaria and HIV co-infection as well as anaemia. Blood sera from each of the patients were screened for malaria parasites, HIV-1 and HIV-2 using Giemsa stain, Cambridge Biotech Recombigen HIV-1/HIV-2 rapid device, respectively while haemoglobin estimation was performed using cyanmethemoglobin method. RESULTS: Our data showed that the total number of malaria infected patients were significantly higher in HIV sero-positive patients 47.7% (31/65) when compared with their HIV sero-negative counterparts 25.8% (262/1015) P = 0.047. The result also revealed that 25.8% (8/31) of the patients co-infected with malaria and HIV had anaemia as compared to 11.1% (29/262) infected with malaria alone. Multivariable logistic regression analysis showed that patients with dual infection of malaria and HIV were twice likely to be anaemic than those infected with malaria alone [adjusted OR 2.4, 95% CI, 1.3 to 2.7, P = 0.014]. CONCLUSIONS: Our data indicated a higher prevalence of malaria in HIV infected patients and also revealed that patients co-infected with malaria and HIV were more likely to be anaemic.

The roles, challenges and institutionalization of institutional review boards.

Researches involving human participants are expected to be conducted professionally to ensure that the research participants are protected from any likely harm. In this regard, the Institutional Review Board (IRB) of an institution plays a very important role in ensuring the safety and rights of research participants. Though most institutions have an IRB that approves research protocols, official policy that all research must be approved is yet to be institutionalized. In addition, training and re-training of members of IRBs is not given sufficient attention. While noting that the functionality of an IRB is hinged on an efficient secretariat that serves as the clearing house for protocols to be approved, some of our IRBs do not have a working secretariat with dedicated staff. Indeed, there are a number of challenges that are capable of undermining the role of the IRBs. Other challenges in the operationalization of IRBs include: poor mechanisms of monitoring of research, financial constraints, poor data archival systems, lack of a standard operational procedure and guidelines for submission and evaluation of protocols etc. As the IRBs are expected to play important roles in research involving human participants especially in clinical and vaccine trials, this paper highlights the role, challenges and requirements for the institutionalization of IRBs.

Community response to repeated annual ivermectin treatment of onchocerciasis in Nigeria.

The evaluation of repeated annual treatment with ivermectin in onchocerciasis-endemic communities using output indicators such as acceptance rate (AR) and community compliance rate (CCR) are invaluable tools for assessing community response to onchocerciasis control measures. These indicators were employed in evaluating the responses to annual ivermectin treatment in ten communities in Lade District, Kwara State, Nigeria, where annual ivermectin treatment had reached the fourth round in 1995. The mean AR in all of the communities at the first round of treatment (Tx1) was 95.18% while the mean for Tx1-Tx4 varied between the communities and ranged from 62.82% to 98.49%. The CCR also differed between the communities and ranged from 38.56% to 96.97%. Adverse reactions to ivermectin treatment at Tx1 brought about non-compliance in Lile (CCR of 38.46%), one of the communities studied. AR in Lile also decreased from 94.87% at Tx1 to 61.54% at Tx2, 53.85% at Tx3 and 41.03% at Tx4. (The commencement of community mobilization in defaulting communities after Tx4 restored the acceptance at the next round of annual treatment. The drop in participation in Lile due to adverse reactions would have been averted if annual ivermectin treatment were properly monitored. This study advocates the need for the continuous monitoring and evaluation of onchocerciasis-endemic communities currently receiving treatment, especially in the implementation of the Community-Directed Treatment with Ivermectin (CDTI) programme, so that feedback from the communities can permit proper intervention if necessary.

Control of human African trypanosomiasis: trap and odour preference of tsetse flies (Glossina morsitans submorsitans) in the upper Didessa river valley of Ethiopia.

Ethiopia is one of the endemic countries for Human African Trypanosomiasis (HAT) as over 100,000 people are at risk of having the disease. The control of HAT using odour preference of tsetse flies (Glossina morsitans submorsitans) was studied in upper Didessa river valley of Ethiopia. No information exists on the effectiveness of attractants for these species of tsetse flies in Ethiopia. Three attractants and their combinations namely: acetone, octenol, cow urine, acetone + octenol, acetone + octenol + cow urine, were evaluated using biconical and NGU traps for their efficacy as a first step in developing a sustainable community-based HAT control initiative. The biconical traps baited with acetone, octenol or cow urine, or when combined, were more effective in catching G. m. submorsitans than the NGU traps (P < 0.05). However, the NGU traps caught more female tsetse flies than the biconical traps (P < 0.05). The acetone, octenol and cow urine combination was the most effective in attracting tsetse flies in both the biconical and NGU traps. Acetone was the best attractant while octenol was the least effective. Cow urine showed great promise for possible use in community-based HAT control activities, especially urine that has been kept for several days. The use of cow urine in HAT control in Ethiopia is likely to succeed in the future because of its sustainability.