Knowledge, attitudes and practices during a community-level ivermectin distribution campaign in Guatemala.

Community acceptance and participation are essential for the success of mass ivermectin chemotherapy programmes for onchocerciasis (river blindness). To explore the local understanding of the purpose of ivermectin and willingness to continue taking the drug, we performed questionnaire surveys in four communities with hyperendemic onchocerciasis after each of three ivermectin treatment rounds. More than 100 respondents participated in each KAP survey, representing the heads of 30% of the households in each community. The respondents rarely stated that the goal of the ivermectin treatment programme was to prevent visual loss. Instead, they said they were taking the drug for their general well-being, to cure the onchocercal nodule (filaria), or to cure the microfilaria, a term newly introduced by agents of the treatment programme. The principal reason identified for refusal to take ivermectin was anxiety about drug-related adverse reactions, and there were marked differences between communities in acceptance of treatment. In one community over 50% of residents initially refused to take ivermectin, although participation rates improved somewhat after programmatic adjustments. We recommend that ivermectin distribution programmes establish surveillance activities to detect where acceptance is poor, so that timely and community-specific adjustments may be devised to improve participation.

Knowledge, attitudes and perceptions (KAP) of onchocerciasis: a survey among residents in an endemic area in Guatemala targeted for mass chemotherapy with ivermectin.

If ivermectin distribution programs are to have maximum impact on the morbidity and transmission of human onchocerciasis there must be broad and sustained acceptance within the endemic communities. Educational activities, developed with careful consideration of community attitudes, should promote positive treatment seeking behavior while simultaneously addressing local reservations about the control effort. To better understand the ambient knowledge, attitudes, and practices concerning onchocerciasis in the context of ivermectin use in Guatemala, we conducted a survey among 145 heads of households in five endemic communities. Given the country's long-standing nodulectomy program, it was not surprising that 100% of persons interviewed had heard of the disease 'la filaria', which they defined as a skin nodule that could cause blindness. Ninety-five percent of respondents identified surgery as the only cure for the condition. Relatively few (39%) knew that la filaria was caused by a worm, although slightly more (50%) knew that the condition was acquired by the bite of an insect. The term microfilaria was not broadly recognized. We also determined that onchocerciasis was not perceived as a serious health problem: few persons (12%) mentioned la filaria when requested to provide a complete list of illnesses that occurred in the community, and the gravity of infection (based on rank ordering of common illnesses) was similar to that of a bad cold. Recommendations were made which might assist long-term acceptance of a national chemotherapy initiative against onchocerciasis in Guatemala.

IgM rheumatoid factors in Guatemalan onchocerciasis.

The possible presence of IgM Rheumatoid factors (RF) and anti-DNA antibodies was investigated in sera of patients with Guatemalan onchocerciasis. The mean value of IgM RF in the patients was found to be significantly higher than that in controls and 10 out of 57 patients had increased levels of IgM RF. In addition, serum IgM levels in those 10 patients with increased levels of IgM RF were significantly elevated. In contrast, no significant increase of serum anti-single-stranded (ssDNA) and double-stranded DNA (dsDNA) antibodies were found in the patients.

Circulating immune complexes and their possible relevance to other immunological parameters in Guatemalan onchocerciasis.

Circulating immune complexes (CIC) were demonstrated in sera of Guatemalan patients with onchocerciasis by Raji cell radioimmunoassay. 44% of patients but none of controls had abnormally high concentrations of CIC in their sera. The increased concentrations of CIC were found more frequently in patients with lower density of microfilariae in their skin biopsies. Patients with higher concentrations of CIC appeared to have increased titers of serum antibodies to Onchocerca volvulus. A depression of both humoral immune response to tetanus toxoid and delayed hypersensitivity reaction to PPD were found in patients with onchocerciasis. CIC may be involved in modulation of the immune response in onchocerciasis.

Dermatological survey of onchocerciasis in Guatemala.

A comprehensive survey of onchocerciasis was performed on 1259 inhabitants in San Vicente Pacaya and the surrounding area. The total number of inhabitants examined was 1259, 763 males and 496 females. An examination of microfilarial density was carried out by the skin snip method. There were 610 microfilarial positives (50.4%) out of 1211 persons, 448 males (60.9%), and 162 females (34.1%). Nodules were examined by palpation, and there were 404 (32.8%) positives for nodule out of 1232 persons, 299 males (40.3%), and 105 females (21.4%). Eczematous dermatitis was seen in 149 persons, the generalized type in 13, and other types in 136. Depigmentation on the lower extremities was seen in 290 persons, the severity was graded from 0 to 4, and grade 1 depigmentation was seen in 91; grade 2, in 143; grade 3, in 52 and grade 4 in 4 persons out of 1159 individuals examined. The positives for lymphadenopathy (above grade 2) were 464 (41.2%) out of 1127 individuals. Itching was seen in 129 (18.3%) of 705 individuals examined by the inquiry card method. The correlation between skin changes and onchocerciasis was also analyzed. Those individuals who were microfilarial positive in the skin snip and eyes, and who had palpable nodules were defined as being onchocerciasis patients. There was a high frequency of eczematous dermatitis, depigmentation on the lower extremities and lymphadenopathy in the onchocerciasis infected group, compared with the non-infected group, but there was no difference in the rate of itching between them. Hanging groin, elephantiasis and "erisipela de la costa" were not seen in this endemic area, and the degree of skin changes was slight, compared with that reported in Africa thus far.