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.

Community-directed treatment of onchocerciasis with ivermectin in Takum, Nigeria.

A study to identify factors within the community that can ensure sustainable community-directed treatment (ComDT) with ivermectin compared the effectiveness of programme-designed (PD) and community-designed (CD) strategies in 37 villages in the Takum area of Nigeria. In a subset of PD villages, designated PD1, communities were asked to use the village heads as community-directed distributors (CDD), and the other communities (PD2) were asked to select female distributors, and both were instructed to use the house-to-house method of distribution. Community-designed communities, on the other hand, were asked to design their own approach. All study communities received health education, treatment guidelines, and training enabling them to determine appropriate dosage. A total of 1744 people were interviewed about their experiences after two treatment cycles. Communities preferred honest, reliable community members as CDDs, but few women were selected. The results show striking similarity between PD and CD villages in many respects. In the PD1 villages, where the programme designated the village head as CDD, the mode of distribution was changed from house-to-house to central point, and distribution took place in the compound of the village head. In the PD2 villages, where the programme specified distributors should be women, the women who were selected were replaced by their male children. These changes to the original design were consistent with the local cultural norms and made the arrangement for distribution more acceptable to the people. Programme-designed villages that used the village head as distributors performed better than those that used women, and the coverage in the former group compares well with that of CD villages. Only five villages achieved coverage > 60%, but dosage was correct in most cases (87.4%). Drug shortage was the most frequent reason for non-treatment. Communities devised means for ensuring equity and fairness in sharing their limited supply and freely altered the original designs to fit local norms and values. These changes to the original design were consistent with local norms and were acceptable to the people. The success of this strategy should be tested in other parts of Nigeria. Long-term success of ComDT, however, requires a reliable drug supply and inputs from professionals in the health system for minimal supervision. The core issues that determine sustainability of ComDT appear to be not so much in the structure, but in the process by which they are introduced. Communities will only sustain a programme where the process of implementation fits well with local norms and where communities are free to alter PD procedures that are inconsistent with local customs.

Community-perceived benefits of ivermectin treatment in northeastern Nigeria.

A 3-step approach involving focus group discussion, structured interviews and informal conversations with key individuals was used to investigate community usage and perceived benefits of ivermectin in nine Nigerian villages participating in a WHO-sponsored investigation of community-directed treatment with ivermectin (CDTI). Only 27% of 284 persons interviewed had received treatment. An under-estimation of the district's ivermectin needs led to inadequate supply of ivermectin to the communities, which was cited as the main reason (65%) for non-treatment. All those treated (N=76) were further interviewed using questionnaires. Worm expulsion (80%) and blindness prevention (68%) were the most frequently stated benefits. Other perceived benefits were an increase in vitality (68%), sexual drive and performance (29%). The sudden relief from a heavy burden of worms, which had built up over a long period, may have indirect effect on all aspects of an individual's health and account for the diverse experiences. The feeling of vitality, good appetite and general health following ivermectin treatment is an animating experience to many communities. Health planners face the challenge of preparing communities for fewer 'sensational' experiences and preventing a possible feeling of disappointment that may result from frequent usage.

Human behaviour, water usage and schistosomiasis transmission in a small settlement near Yola, Nigeria.

A study of the social, environmental and parasitological factors involved in the transmission of schistosomiasis among 1834 residents of a small settlement within an agricultural establishment near Yola, Nigeria, was carried out between June 1991 and May 1992. Water-contact rates and the prevalences of urinary schistosomiasis and intestinal schistosomiasis (40.0% of all contacts, 98% and 79%, respectively) were highest among children of 5-12 years, who were also the major contributors to the contamination of the Lake Geriyo environment with faeces and urine. The frequency and duration of water contact followed a seasonal pattern and seemed to be influenced by physiological and social needs such as defecation, urination and avoidance of harsh weather conditions. The interplay between a need for water contact, sanitation, freshwater snails and a supportive environment ensures a recycling of parasites within the studied community. This, in turn, helps to maintain a parasite bank from which infection is probably spread to other areas of the state. The present study is part of a series, on the dynamics of schistosomiasis transmission, which began with a study of the ecology of the freshwater snails in the same area.