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The Challenge of Schistosomiasis Frank O Richards Jr,A Abel Eigege,B Emmanuel S Miri,B MY Jinadu,C & Donald R Hopkins A

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The Challenge of Schistosomiasis Frank O Richards Jr,A Abel Eigege,B Emmanuel S Miri,B MY Jinadu,C & Donald R Hopkins A Integration of mass drug administration programmes in Nigeria: the challenge of schistosomiasis Frank O Richards Jr,a Abel Eigege,b Emmanuel S Miri,b MY Jinadu,c & Donald R Hopkins a Problem Annual mass drug administration (MDA) with safe oral anthelminthic drugs (praziquantel, ivermectin and albendazole) is the strategy for control of onchocerciasis, lymphatic filariasis (LF) and schistosomiasis. District health officers seek to integrate treatment activities in areas of overlapping disease endemicity, but they are faced with having to merge different programmatic guidelines. Approach We proceeded through the three stages of integrated MDA implementation: mapping the distribution of the three diseases at district level; tailoring district training and logistics based on the results of the mapping exercises; and implementing community- based annual health education and mass treatment where appropriate. During the process we identified the “know–do” gaps in the MDA guidelines for each disease that prevented successful integration of these programmes. Local setting An integrated programme launched in 1999 in Plateau and Nasarawa States in central Nigeria, where all three diseases were known to occur. Relevant changes Current guidelines allowed onchocerciasis and LF activities to be integrated, resulting in rapid mapping throughout the two states, and states-wide provision of over 9.3 million combined ivermectin–albendazole treatments for the two diseases between 2000 and 2004. In contrast, schistosomiasis activities could not be effectively integrated because of the more restrictive guidelines, resulting in less than half of the two states being mapped, and delivery of only 701 419 praziquantel treatments for schistosomiasis since 1999. Lessons learned Integration of schistosomiasis into other MDA programmes would be helped by amended guidelines leading to simpler mapping, more liberal use of praziquantel and the ability to administer praziquantel simultaneously with ivermectin and albendazole. Bulletin of the World Health Organization 2006;84:673-676. ميكن اﻻطﻻع عىل امللخص بالعربية يف صفحة Voir page 675 le résumé en français. En la página 675 figura un resumen en español. .676 Background Community-based annual mass albendazole, praziquantel is not donated drug administration (MDA) with safe and costs approximately US$ 0.20 per Pablos-Mendez et al., in their October and effective oral drugs is the principal treatment. 2005 editorial in the Bulletin entitled: strategy for the control of onchocer- Knowledge translation in global health 1 ciasis, lymphatic filariasis (LF) and argued that research must be part of a Context of the translation schistosomiasis.3 Annual treatment with strategic process that moves evidence- microfilaricide ivermectin (Mectizan, of knowledge: is there based, cost-effective interventions to true donated by Merck & Co., Inc.) prevents a know–do gap in the practice. Barriers to the implementation the severe eye and skin manifestations integration of mass drug of effective interventions lead to what of onchocerciasis. Transmission of LF by the authors called the “know–do” gap. mosquitoes can be interrupted in Africa by administration? Research should help us to understand annual single-dose combination therapy When the Global Alliance to Eliminate those barriers that prevent bringing with ivermectin (also donated by Merck LF (GAELF) was launched in 1998, we what we know to the logical conclusion & Co.) and albendazole (donated by noted the potential synergy and cost of action in the field and resultant bet- GlaxoSmithKline).4 Schistosomiasis in savings to be made in Nigeria from ter health or better health services. The Africa is usually caused by Schistosoma linking the LF activities to those being Carter Center-assisted mass treatment mansoni or S. haematobium. School-aged supported by the African Programme for programmes in Nigeria 2 provided an children are the most heavily infected, Onchocerciasis Control (APOC).6,7 Both opportunity to demonstrate how dif- and the most frequent symptom of WHO initiatives were based on World ferences in mass treatment guidelines urinary schistosomiasis (infection with Health Assembly-approved strategies and resources create a know–do gap S. haematobium) is blood in the urine. of annual MDA and health education; presenting a barrier to the integration of Mass distribution of praziquantel can both were working in many of the same programmes that should logically work significantly reduce schistosomiasis mor- countries; both had access to donated together synergistically. bidity.5,6 However, unlike ivermectin and drugs; and both used ivermectin. This a The Carter Center, 1 Copenhill, Atlanta, GA 30307, USA. Correspondence to this author (email: [email protected]). b The Carter Center, Jos, Plateau State, Nigeria. c Federal Ministry of Health, Lagos, Nigeria. Ref. No. 06-029652 (Submitted: 3 January 2006 – Final revised version received: 9 March 2006 – Accepted: 11 May 2006) Bulletin of the World Health Organization | August 2006, 84 (8) 673 Special Theme – Knowledge Translation in Global Health Mass administration of schistosomiasis drugs in Nigeria Frank O Richards Jr et al. was an excellent opportunity to link the launch point for the urinary schistoso- questionnaires to be used to ask children two multicountry WHO programmes miasis programme in 1999 and the LF if they have blood in their urine — as in Nigeria. The approach taken was to programme in 2000. Working through a less expensive alternative for mapping launch the LF programme from within the ministries of health of the state and — but in our pilot study of this ques- the mature APOC-supported pro- the LGAs, the partners added each new tionnaire we found its sensitivity to be gramme. Albendazole tablets would be MDA programme in three phases: only 50% that of urine reagent dipsticks given concurrently with the ivermectin • mapping distribution of the diseases; (Eigege, unpublished data).) Guidelines tablets already being delivered, together • tailoring training and treatment logis- also require stratification of villages into with additional health education. tics based on results of the mapping; three groups: But we hoped for more than the and • those who do not qualify for praziqu- obvious linkage of onchocerciasis and • implementing community-based antel mass treatment (under 20% LF. Efforts to control schistosomiasis annual health education and MDA urine blood prevalence); were (and are) lagging behind the LF where appropriate according to the • mass treatment of school-aged chil- and onchocerciasis initiatives in Nigeria. WHO guidelines.6 dren (20–49%); and The Schistosomiasis Control Initiative,4 • community-wide treatment (50%). another large regional initiative similar The results of the LF and schis- to APOC and GAELF, had not chosen tosomiasis mapping were the key to This complex operational treatment Nigeria as a one of its programme coun- the decision-making and action plans recommendation differed considerably tries. We wondered if linking the LF and of the LGAs. Because ivermectin and from that of “treat or not treat”; used in onchocerciasis programmes with urinary albendazole are donated, guidelines for the onchocerciasis and LF programmes. schistosomiasis control could invigorate the distribution of these medicines are Lastly, praziquantel is not approved for this MDA programme as well. A suc- “liberalized”, calling for blanket treat- combined treatment with ivermectin cessful know–do programme with three ment within the LGAs; this made LF and albendazole. Thus, schistosomiasis drugs for three diseases in “triendemic mapping relatively easy. Only one village treatment had to be temporally separated areas” might show national and global per LGA (on average there are 100 per from MDA activities for the control of decision-makers how they could expand LGA) needed to be visited, and in total LF and onchocerciasis by at least one integrated helminthic disease control to only 30 villages needed to be visited to week. include schistosomiasis and therefore completely map the two states for LF. Thirteen LGAs need MDA and stimulate new thinking, new policy, new A sample of 100 adult residents in each health education for LF only; eight investments and partnerships, and per- of the villages visited submitted to a need integrated LF and onchocerciasis haps even a donation of praziquantel. finger-prick blood test that detected LF activities; five need integrated LF and circulating antigen;8 guidelines called schistosomiasis activities; and four need Information collected for MDA of the whole LGA when one all three. All nine LGAs mapped so far for schistosomiasis have villages that The large-scale integration project is a of these 100 tests was positive (i.e. an were in all three mass praziquantel treat- combined effort by the Federal Ministry LF antigen prevalence of 1%). All 30 ment schemes (not treat, treat school- of Health and The Carter Center and is villages sampled were found to be above aged or treat community-wide), and situated in Plateau and Nasarawa States, this threshold, and LF mapping was 21 LGAs have yet to be mapped for an area which has an estimated popula- completed by the end of 1999. schistosomiasis. tion of 4 million inhabitants and com- In contrast, as praziquantel is not Not surprisingly, a know–do gap prises 30 administrative districts (local donated, mapping guidelines for schis- has been identified as to how to link government areas (LGAs)), all of which tosomiasis are designed
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