University of Nigeria Research Publications

EMEJULU, Chinyelu Angela Author PG/M.Sc/90/9564

Epidemiology of Urinary Schistosomiasis in Title Agulu Lake Area of Anambra State, Nigeria

Biological Sciences Faculty

Zoology Department

July, 1992 Date

Signature

EPIDEMIOLOGY OF URINARY SCH ISTOSOMIASIS IN AGULU LAKE AREA UF ANAMBRA STATE, NIGERIA

EMEJULU, CHINYELU ANGELA PG/M.Sc./90/9564

A DISSERTATION SUBMITTED TO'THE UNIVERSITY OF NIGERIA NSUKKA, IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF MASTERS OF SCIENCE (M.Sc.) DEGREE IN ZOOLOGY (PARASITOLOGY) *

SUPERVISOR: DR. F.C. OWOR

JULY 1992

iii

DEDICATION

This thesis is dedicated with love to my little nephew

Chidiebele Emejulu. ACKNOWLEDGEMENT

MY greatest thanks and gratitude are directed to my upervisor, Dr. F.C. Okafor for his interest, encoiurage- ment, advice, constructive criticisms, providing neces- sary materials and for painstakingly reading through the entire manuscript and making useful suggestions.

My immense gratitude also goes to Dr. J.C. Ezigbo and my brother-inlaw, Dr. C.E. Iloegbu for their encouragement and for making available to me laboratory materials and equipment used for the work.

I am also grateful to my daddy's drivers, Isaac and

Ikechukwu who helped in making things easier for me during collection of the snail and urine samples used for the work. I am equally indebted to Rev. Prof. E.U. Iheagwam and Dr. Ezenwaji both of Zoology Department, University of Nigeria, Nsukka for their various advice and interest in the progress of the work which spurred me to greater activity. I thank all the academic and non-academic staff of the Department of Zoology, University of Nigeria, Nsukka, for their various forms of assistance each rendered to me.

Finally, I am highly indebted to my parents who without their financial and moral support, this work would not have been possible.

EMEJULU, C.A. TABLE OF CONTENTS

Page Title Page . . . . i Certification . . ii Dedication . . -. iii Acknowledgement . . iv Table of Contents . . vi List of Figures . . viii List of Plates . . ix List of Tables . . X Abstract . . . . xii

CHAPTER ONE: INTRODUCTION AND LITERATURE REVIEW ...... 1 Introduction .. 1 Distribution . . 1 The Disease Schistosomiasis, thc Parasite and Life Cycle 2 Epidemiology and Socio-cul- tural ~s~ects . . . . 5 Objectives of Study . . 11

CHAPTER TWO: MATERIALS AND METHODS .. 13 2.1 The Study Area . . . . 13 2.2 Human Ecology . . . . 13 2.3 Study Techniques .. . . 25 2.3.1 Epidemiology . . . . 25 i School ...... 25 ii) Community ...... 26 iii) Collection of snails and Analysis ...... 28 vii

2.3.2 KAP ......

CHAPTER THREE : RESULTS ...... 3.1 Epidemiology ...... i School ...... ii) Commmity ...... 3.2 Related Concurrent Studies i Visible Haematuria .. . . ii) Snail Study ...... iii) Distance and Domestic Water Supply ...... KAP ...... Characteristics of the Respondents ...... Knowledge of the Disease .. Local ~erminologiesfor Urinary Schistosomiasis . . ii) Theory of Causation and Transmission ...... iii) 3.3.3 Attitude ...... 3.3.4 Practices ......

CHAPTER FOUR: DISCUSSION ...... CHAPTER FIVE: CONCLUSION ......

REFERENCES ......

APPENDICES ...... viii

LIST OF FIGURES

Pigurc 1: The Lifc Cycle of -S. hzcmatohi.1.1rn-- and -S. rrmnsoni ...... 4 Fiqurc 2: M7p of Anambra Statc showing the Local Govcrnmcnt Arcas . . .. 14

Pigurc 3: Map of Awka Local Governmcnt Arca showing s tudics coirmuni tics . . 15

Pigure 4: Map of Njikoka Local Governmcnt Area showing studiec! conmxnitics 1G

Figure 5: Plap of Annocha Local Govcrnrncnt Area showing stud.icd cornr;lunities 17

Pigure 6: Agulu Lakc Rcgion showing vill-2gcs in NL~imd Ayulu with case of Urinary Schistoso~niasis . . . . 18

Figure 7: Prevalences of S. --hacmatobium by Scx, Age and ~cEoolAIfliation .. 36

Figurc 8: Prevalenccs of --S. -----hq3cmatobium .-- by Sex, Age and Community Affiliation 41

Figure 9: Age Preval.cncc and Tntcnsity (egg output)- of Inf cc tion wiL!l -S . hnema tobium in the Enilemic ~ommunitics ...... 43 Figure 10: Occupationzl Variation among Schools infected with Urinary Schistosomiasis in the Endemic Communities ...... 46 Pigure 11: Prevalence Rate and Domestic Water Supply Distance ...... 54 LIST OF PLATES

Plate 1: Ezunwani Stream at Awba-Ofcmili (Awka L,GA) showing human activities

Plate 2: Aliulo Stream at Nawgu (Njikoka LGA) showing hulnan activities . .

Part of Ulasi Strcarn i.n Nri (Anaochn LGA) ......

Plate 4: Part of Agul-u Lake showing Vegetation ......

Arm 1 of Agulu Lake (Agulu siclc) showing human activities . . . .

Plate 6: Arm 2 of Agulu Lake (Agulu sidc)

Plate 7: Arm 5 of Agulu Lakc (Nri sidc)

Platc 0: Shell of Blllinus (Physopsis) globosus ......

Plate 9: Shcll of Dulinus truncatus var pp rohlfsi. . P ......

Furcocercous Cercaria of -S. haanntobium ...... LIST OF TABLES Page Tablc Distrihution of Urinary Schistosomiasis in thc LGAs and Prevalcncc Ratc in Affcctcd Schools

TCLlJlc Prevalence Rate of Infection by Scx in thc Affected Schools in Anaocha LGA ...... Tdble Prcvalcnce of Infcction and Gcomc- tric mcan of the cgg outpui (from those infcctcd in thc varjous Schools) by Agc ...... Tablc Distribution of Urinary Scliistoso- miasis in thc LGAs and Pzcvalencc Ratc in thc Various Cornmnitics

Table Prevalence Rate of Infection by Sex in t.hc Endcniic Corrmuni tics

Table Prevalence of S. hacmatohium and Ccomctric mean-of the cg7 0u!tPut

Table Geometric mean of egq Output per 10 ml urine from those Inicctcd by Sex, Age and Community . . . . Table Prevalence of S. haematobiurn in Occupational ~rou~sin endemic

Tablc Visible haematuria and Intensity of egg Output ...... Table Visible haematuria as a Diagnostic Test ...... Table No. of Snails Collected, No. Infec- ted and Infection Rates in 1991 and 1992 ...... Tab1 e Prevalence Rate and Natural Domestic Water Distance ...... Page

Table 13: Community and Sex Specific Characteristics of Respondents .. 55 Table 14: Age and Sex Specific Characteris- tics of Respondents ...... 56

Table 15: Definition of -S. haematobiurn by Cornmuni ty ...... 57 Table 16: Responses on Symptoms of Urinary Schistosomiasis ...... 58 xii ABSTRACT

The presence of -S. haematobium infection was investigated in school children and in 16 communities in Anambra State, Nigeria. The disease was prevalent in 4 schools and found endemic in

3 communities.

Out of the 200 pupils examined in the 4 schools, 104 (52.0%;o I were infected. Out of the 128 males involved in the school study, 76 (59.4%) were infected while out of the 72 females examined, 28 (38.9%) were infected. Interestignly however., the infection rates difference between males and females was not statistically significant at 5% level. In the community study, Nri and Agulu had similar prevalence rates (37.2% and 29.4%). Adazi-Nnukwu had a very low prevalence rate (6.0%). The overall geometric mean egg output in the cornrnunity study was 22.4/10m1 Urine. The number and levels of visible haematuria were measured

in relation to' the presence and intensity of -S.haematobium - egg output in the urine of individuals in the endemic communities. It was found that 61 individuals passed reddish (bloody) urine while 164 individuals passed brown urine (tending towards red). Visible haematuria as a diagnostic test for the presence of the infection was statistically highly sensitive (97%) but showed low specificity (20.6%). There were variations in the xiii intensity of egg output within the same shade of haematuria of different individuals. There was also a lot of overlap in egg output between the different shades.

However there was a noticeable increase in egg output as the colour of urine deepened into frank red. Malacological surveys show that snail distribution is focal especially at human water contnct sites at arms of the lake and a stream (Ulasi) in Nri.

A study to examine the effect of distance of rural water supply on prevalence showed that households tend to use water from nearest sources. The prevalence rate showed a significant decrease (P=0.05) with increasing household distance to natural water source (c.g. 71.4% at < 250m and 22.2% prevalence at> 2,000m).

The knowledge, Attitudes and Practices (KAP) of people in relation to the disease in the endcmic communities was carried out. Of the 200 respondcnts, 67

(22.3%) were previously infected while 233 (77.7%) were never infected. All the respondents associated the disease with passing of blood in urine. Oya obalz (disease with blood), Mgbu obala (pain with blood), Mamiri obala (urine with blood) are various terminologies for the disease in these communities. The presence of the disease was linked with the Nigerian-Biafran civil war of 1967-1970. Although majority 98.3% of the xiv respondents did not believe it is a killing disease, 73.7% believed that it is a serious disease. A good number

129 (438) prefer&oing to hospital for treatment. CHAPTER ONE

INTRODUCTION AND LITERATURE REV1 EW

INTRODUCTION Schistosomiasis is widespread with a relatively low mortality rate but accompanied by a high mobidity rate - causing severe debilitating illness in millions of people. The disease afflicts over 271 million people in the world, 168 million of them in

Africa (Peters, 1978). Estimated mortality rate is less than 200,000 per year and the number of people considered a risk is 500 - 600 million while number of countries affected is 76 (WHO 1990). It is often associated with water development projects, such as dams and irrigation schemes, where the snail intermediate hosts of the parasite breed in water where people swim, wash and fish. The disease is essentially one of rural communities, where there exists ignorance, poverty, poor personal and community hygiene and poor sewage disposal systems.

DISTRIBUTION Each of the established species of Schistosoma infecting man has a specific geographic distribution.

Both S. mansoni and -S. haematobium are wide-spread in Africa. S. haematobium alone occurs in Tunisia, Algeria, Niger, Morocco, Guinea-Bissau, Mauritania, Congo Republic (Brazzaville), Somalia and the Island of Mauritus. Only -S. mansoni occurs in the endemic areas of the New World, Brazil has the largest number of cases (Wilson, 19'75; WHO, 1980) estimated at 8 million cases. -S. japonicum occurs in the Orient and is found in China, Taiwan, Japan, the Phillipines and New Sulawesis (Mahmoud, 1979).

-S. intercalatum occurs in small foci in Africa while 2. mekongi is found in the Mekongi river basin of S.E. Asia (Ukoli, 1990; WHO, 1990).

In the West Coast of Africa, the disease has been reported in Ghana (0sei-tutu and England 1983); in Mali (Brinkmann and Werter 1988); and in Nigeria

where the disease is known to be very common (Ramsay, 1934; Okpala, 1961; Cowper, 1963; Gilles, 1965;

Nnochiri, 1966; Ndifon, 1983; Okafor, 1984).

1.3 THE DISEASE SCRISTOSOMIASIS, THE PARASITE AND LIFE CYCLE

The causative agent is the trematode flat worm (fluke) of the genus Schistosoma, transmitted from infected snails. Adult male and female Schistosomes

(fig. 1) lives together in blood vessels of different organs where they release egg - some of which are passed out in the urine (S.- haematobium) or stools

(S. mansoni, -S. japonicum). S. mansoni occurs in the veins of the capillaries of the portal veins drain- ing the large intestine. -S. haematobiurn lives in the veins of the vescical~plexussurrounding the urinary bladder of man while -S. japonicum occurs in capillaries of the mesentric veins draining the small intestine in man (Ukoli, 1990).

In water, larval stages of Schistosrnes (cercaria) are shed from infected snails and penetrate the skin of people in the water. The snails become infected by another larval stage of the schistosome (miracidia) which hatch from eggs passed in the urine or' stool of infected people. -S. haematobium is mainly transmitted by Bulinus snails, -S. mansoni by

Riophalaria, and -S japonicum by the amphibious Oncomelania.

Reactions to Schistosome eggs lodged in the tissues are the cause of disease in schistosomiasis. In urinary schistosomiasis (S.haematobium), there are no defined symptoms upto about the tenth to twelfth week when eggs begin to appear in the urine. The clinical symptoms at this stage are dysuria, increased frequency of micturition, and Fig.1 The life cycle of S.haematobium andI 5.manson\ haematuria (Nnochiri, 1966). Progressive damage to the bladder, ureter and kidney due to calcified eggs

leads to hydroureter, hydronephrosis, and uraemia (Ukoli 1990). Bladder cancer is quite common in advanced cases. Intestinal schistosomiasis (S.-

mansoni, -S. japonicum and -S. mekonqi) is slower to develop. There is progressive enlargement of the liver and spleen as well as damage to the intestine

due to fibrotic lesions around the schistosorne eggs

lodged in these tissues and hypertension of the abdominal blood vessels. Repeated bleeding from these vessels leads to blood in the stool and can be

fatal. Few eggs carried to the spinal cord have been known to produce severe neurological defects.

In general pathological effects of -S. -rnansoni are more 'severe than those of -S. haematobiurn-

1.4 EPIDEMIOLOGY AND SOCIO-CULTURAL ASPECTS There have been many schistosomiasis surveys

in Nigeria since Ramsay (1934) studied intestinal schistosomes in Northern Nigeria and observed that the incidence of the disease amongst school children

ranged between 9 - 39%. Blair (1956) reported that

-S. haematobiurn infection was widespread especially in Northern and Western Nigeria with an infection rate of about 95% in Kastina, Northern Nigeria. In

Epe, Western Nigeria, Okpala (1961) found u~ to 91% of school children infected. -S. haematobium predominates in the dry, northern regions where the infection is focal and acquired in seasonal pools.

As far back as 1953, WHO reported -S. haematobiurn infections only in Abeokuta, Epe, Lagos, Igarra, all in the Western part of Nigeria. Recently, Ukoli and Asumu (19791, Ogunbo (19811, Ndifon (19831, reported the occurence of both -S. haematobium and -S. -mansoni in their studies in various parts of Western, Nigeria and Tiga area of Kano State. In the Eastern Nigeria,

-S. haematobiurn in man has been reported (Cowper, 1963; Onubogu, 1978; Anya and Okafor, 1986; Ozumba --et al, 1989). No report of -S. mansoni-inEastern Nigeria is yet available in the literature.

The epidemiology of -S. haematobium in man has been described in terms of age-specific prevalence. School children, who usually represent the age groups

. - at greatest risk and with greatest intensity of infections have often been studied; thus providing convenient baseline data for the whole population (Forsyth, 1969; Wilkins, 1977). Advances in the methodology of epidemiological research on schistoso- miasis are based on a growing recognition of field. Since the introduction of quantitative methods for urinary examination in schistosomiasis by Barlow (1931) and after -S. mansoni and -S. haemato- bium egg counts were shown to be relatively constant in the same individual over short periods of time (Scott, 1938; Stimmel and Scott, 1956) egg counting techniques have increasingly been used in epidemiolo- gical studies on these parasitic infections. Stimrnel and Scott (1956) observed that egg output is greatest between noon and 2 p.m. while Brad]-ey (1963) observed that egg output is least variable between noon- and 2 p.m. The ex-gencies of field work have led many workers to examine a 10 ml aliquot from the entire urine passed at the peak period and usually data obtained have been used as an index of community egg output. The relationship between intensity of infection and morbidity of -S. mansoni infection was assessed by quantitative stool examination (Kloetzel, 1962). Since that time, World Health Organization (WHO, 1967; 1980) has repeatedly advocated the use of quantitative methods in all aspects of epidemiolo- gical studies on Schistosomiasis. In general, successful control programmes for Schistosomiasis have been based on sound epidemiolo- gical studies using standardized, if not quantitative methods (Jordan, 1977). The detection and counting of schistosome eggs in heavily infected individuals do not present any statistical or practical problems (Mott and Cline, 1980). In such cases, a small sample of urine or stool is sufficient to classify the individual as infected or uninfected and if a quantitative method is used, the minimum number of eggs per gram can be estimated. Quantitative techniques have a measurable variability and thus the inherent differencies in their application from one area to another by different personnel can be taken into account. This increases the accuracy of epidemiological measurements such as prevalence and incidence, and also improves confidence in the validity of conclusions drawn from these data. In endemic areas of -S.haematobium, haernaturia of various grades, is one of the commonest manifesta- tions of the infection especially among the young age groups (Jordan and Webbe, 1969). It* not until very recently that interest has risen for the use of haematuria in screening for the infection (Pugh --et a1 1980). However, the methods in use are relatively sophisticated, expensive and time consum- ing to be adopted for large scale application, especially by health workers in rural areas who are often called upon to diagnose numerous health problems, including schistosomiasis, under constrained circumstances. Rutasitara -et --a1 (1984) reported that visible haematuria could be used for the screening of -S. haematobium infections. However there is the need for more studies to evaluate the validity of using visible haematuria for the rapid screening of the presence and intensity of --S.haemato- bium infection. From such studies, a practical method which can easily and inexpensively be adopted for use under those circumstances could be recom- mended. Geographical distribution of snails influence the effective transmission of urinary schistosomiasis McCullough (1964) reported that transmission takes place only where suitable snail host is found in relatively compact bodies of water visited frequently by the inhabitants of a village. Thus a village may be almost free from the infection while another dl'ib9 e within a distance of few kilometers may show a very high incidence. Composition of water, temperature, light, season, predators are factors which influence distribution of snails (Ramsay, 1934; Cowper, 1959; Okpala, 1961; Asumu, 1975; Wilcocks and Manson-Bahr, 1978; Ndefon, 1980, Okafor, 1984). In general the snails are not found in heavily shaded or fast flowing water (Wilcocks and Manson-Bahr, 1978). Blum --et a1 1987 reported that one of the imported determinants of a households choice of water source is likely to be distance. The distance beyond which people had negligible c'ontact with Lake Volta (Ghana) was found by Jones (1973) to be 5 km. Appleton and Bruton (1979) also reported that only about & of the people who live within 5 km of Lake Sibaya (South Africa) probably depend on it or its adjacent ponds for water and so have frequent contact with these habitals. The remaining $'s they reported use streams or pans for domestic purposes although some of those people may have to use the lake or ponds during winter or dry years. There is the need for more studies on this to evaluate if distance to water source in endemic areas influence the prevalent rates of Schistosomiasis. Throughout history, the cause or causes of disease have been ascribed to a variety of factors.. These being influenced by changing human thought and diverging interpretations of man's observations on the circumstances surrounding the development of disease. The Knowledge, Attitudes and Practices (KAP)'

of people play a major role in the epidemiolcgy of a disease. Knowledge is the cultural definition of the causation, transmission and symptomatology of a

disease. Attitudes refers to the feeling people have towards the disease. Practices include the social behavioural patterns of the people relating to the transmission, treatment and preventicn of a disease (Lu --et a1 1988). One of the great attractions of KAP studies had been that they offered a simple formula to researches with little experience in research design and little time to develop new research strategies (Ware, 1978).

Other socio-cultural aspects of schistosomiasis on water contact pattern (practices) in relation to its transmission are reported by Dalton and Pole

(1978) in Late Volta Ghana, Tayo --et a1 (1980) and Ozumba --et a1 (1989) in Nigeria.

1.5 OBJECTIVES OF STUDY Although it is generally known that schi-stoso-

miasis exists in Nigeria, yet accurate information is lacking concerning its exact distribution and infection rates in many parts of the country. The

present study concentrates on urinary schistosomiasis around Agulu Lake area in Anambra State of Eastern

Nigeria. The general objective of the study is to: 1. identify the communities and villages around Agulu Lake where Schistosomiasis is endemic and to accurately document the extent of its endemicity which will promote further understand-

ing of the relationship between the intensity of , infection and morbidity;

2. provide reliable baseline data for the evaluation of the potential for a possible local/state Schistosomiasis control and eradication programme;

3. evaluate the validity of using visible haematuria for the rapid screening of the disease under constrained circumstances;

4. determine the villager's indigenous and tradi- tional knowledge of the cause and transmission of schistosomiasis;

5. describe their cultural definition of schistosomiasis in an attempt to identify the local attitudes towards the disease and the prevalent customary practices and preventive measures. CHAPTER TWO

MATER I ALS AND METHODS

2 -1 THIS STUDY AREA Anambra State is located in the south eastern region of Nigeria. The State extends between latitudes 5" 43' and 6O 45' North; longitudes 6" 38' and 7" 20' east. It is bordered on the North by Kogi and Enugu States, on the south by Imo State, on the west by Delta State and on the east by Enugu State. The areas covered by this investigation are Awka, Anaocha and Njikoka Local Government Areas all around Agulu Lake. The three local government areas are contiguous. Awka Local Government Area lie between latitudes 6O 07' and 6' 26' North, and

longitudes 6" 57' and 7" 10' East. The Njikoka

Local Government Area falls within latitudes 6" 08' and 6' 18' North and longitudes 6" 55' and 7" 03' East. While Anaocha Local Government Area falls

within 6" 01' N and 6" 10' N latitudes and between longitudes 6O 55' E and 7O 04' E (figures 2 - 6). ANAMBRA OY I' C I x

t .

GBARU .' lHlALA

~i~,2:MAP OF ANAMBRA STATE SHOWINGTHE L.G. A'S ,P-.-. .A'- -. / &ob. -. , Oba %mulokpa Ofemili '. EZEAGU \

NJIKOKA L

. . Fig.3 '. MAP OF AWKA LOCAL GOVERNMENT AREA i ~ig.4 : MAP OF NJIKOKA LOCAL GOVERNMENT AREA ~ig.5: MAP OF ANAOCHA LOCAL GOVT. AREA. , I PO 6'10N-L

\

/

I -.

-

'.

a ~~05'~. 743

Fig.6 : Agulu Lake Region of Anornbro State (Nigeria) showing villoges i'n Nri & Agulu with cases of Urinary Sc~istosomiosis. Agulu itself is in Anaocha Local Government

Area. It is located between latitude 6" 06' N and longitude 7" 03' E. The land is generally a gentle slope, sloping towards the lake. It enjoys tropical type of climate. It is located in the rain forest belt of North Equatorial region of West Africa but dut to over cultivation and extensive constant clear- ing for erection of buildings, the rain forest has degenerated into an open palm forest.

2.2 HUMAN ECOLOGY The topography of the study local government areas are identical and promotes an even distribution of human population of relatively high density. For studied communities in Awka Local Government Area, the population is predominantly rural with mud huts especially Awba Ofemili where everybody excrete in the bush. Achalla, Isuanaocha, Nise and Umuawulu have both mud and cement houses with occasionally pit toilets. They have their houses surrounded by farms and are mainly rice farmers. In these communities are many free flowing water; streams, rivers (Plate 1) and spring water. The selected communities in Njikoka Local Government Area (Abagana, Ukwulu, Nawgu, ~nugu-~gidi, I

------Plate 1: Ezunwani Stream a$ Awba-Ofemili (Awka LGA) showing human activities Nawfia) are like those in Awka Local Government Area except that Abagana is a semi-urban area with civil servants who work in the Local Government headquarter. This area has so many water bodies. Pipe borne water is found in some parts too. In Anaocha Local Government ~rea,Ichida, Agulu- Uzoigbo and Adazi-Ani have no natural body of water. They use constructed wells, tap and tanks. Others: Agulu, Agukwu-Nri (or Nri), Adazi-Nnukwu have different water bodies. In this area is also the lake which has six arms (fig. 6). Two. big major arms are in Agulu, across which is a bridge and a wide tarred road. Other arms extended into Nri.and a little portion into Adazi-Nnukwu. This is probably why the lake is referred to as Miri-Agukwu('Agukwu water') by some people. Nri community is actually surrounded by * water (Plates 2 - 7). ~guldis a very large community and is semi-urban with pipe borne water in some parts which are far away from the lake. Most primary and secondary schools in this Local Government Area are situated very close to the big lake. The inhabitants of the area are mainly yam and cassava farmers with few traders. 1' Plate 2: Aliulo Stream at Nawgu (~jikokaLGA) showing human activities

Plate 3: Part of Ulasr Stream in Nri tAnaocha LGA) Plate 4: Part of Agulu Lake showing Vegetation

Plate 5: Arm 1 of Agulu Lake (Agulu side) showing human activities -- Plate 6: Arm L of Agulu Lake (Agulu s-de)

Lrm 5 of Agulu Lak (Nri side) 2.3 STUDY TECHNIQUES

2.3.1 Epidemiology

(i) School On the 11th of January, 1991, 3 local government headquarters (Anaocha, Awka, Njikoka) around Agulu Lake were visited to ascertain: (a) the communities in each Local Government Area;

(b) population of people in each community.

Randomly, five communities from each of the 3 local government areas were selected (Appendix 1). Then on the 17th of January, 1991, the Education Commission and Primary School Board in Enugu were visited to get the list of all secondary and primary schools in the selected communities. Two primary schools in each community and 2

I secondary schools in each lo%al government area with- in selected communities were randomly selected. Agulu community is included as a special area (because major portion of the lake easily accessible to villagers is in the community) with 2 primary and 1 secondary school also randomly selected in it (Appendix 2). Then 50 children each were randomly selected from these primary and secondary schools. Involved in the study are 16 communities, 32 -primary schools, 7 secondary schools giving a total of 1,950 pupils. The co-operation of the,headmasters, principals and teachers in the selected schools was obtained before the case-search commenced. A questionnaire (Appendix 3) was used to obtain the personal information, social activities and for identification of each pupil involved in this study.

(ii) Community On the 12th of July, 1991, the Primary Health Care (PHC) Units of the 3 local government areas were visited to get the number of households and numbers assigned to them during primary health care activities. By random selection, 30 households in each previously selected communities were used for the study. Agulu was a.lso used as a special area. Questionnaire (Appendix 4) was used and collection and analysis of urine was same procedure as in school children. Every member of a household that was present was involved in the study. Involved in this study are 16 communities, 480 households with a total of 2,246 individuals. The distance from each household (in afflicted communities) to domestic water sources was recorded too. the distance was recorded using the mileage indicator of the vehicle where it could be motored and a measuring tape where it could not. In most cases the distance was partially measured with the tape and partially motored.

Collection of Urine Wide-mouthed screw cap containers with numbers which tally with those on the questionnaires were used to collect urine samples from each selected person in different schools on visitation. The time of collection of urine was between 12.00 p.m. - 2.00 p.m. The visitations were made to two schools on two different days of every week each and the urine samples taken straight to the laboratory for analysis that particular day.

Urine Analysis A simple centrifugal sedimentation procedure

(5 min. at 5000 rpm) of 10 ml aliquot urine sample drawn from each specimen was used (Clivier and

Uemura, 1973). Schistosoma haematobium ova in the sediment poured on a MacMaster slide were counted under lox microscope eye piece. Calculation of geometric mean egg count was done using the method

of WHO (1987). Also the colour of 342 randomly selected urine samples were observed and recorded.

(iii) Collection of Snails and Analysis Collection of snails was done between December 1991 and Ju~e1992. A preliminary investigation was carried out to identify the species of Bulinid snails in the area. Collected snails were identified using the field guide from the Danish Bilharziasis Laboratory in Denmark and confirmed by Dr. F.C. Okafor. The snails were mostly found on the bottom side of the leaves of the grass and water lilies. They were also found on wood trunks and logs used in holding fermenting cassava sacks at a place and on decaying Leaves of the surrounding palms which are in contact with water. In view of this, two sampling techniques were used. One was with a scoopnet and involves sampling a fixed area for a standard time (usually 15 minutes in 10mZ of site area). The other was the hand picking technique from vegetation (decaying palm fronts) using gloves and involves searching for snail for a fixed period of time in a fixed area. Non bulinid snails collected were placed back from collected sites. Bulinid snails (Plates 8 - 9) collected were taken to the laboratory and screened for cercarial (Plate 10) shedding after 2 - 3 hours exposure to sunlight in test-tube.

2.3.2 KAP After the afflicted communities were identified,

the household numbers obtained from PHC Unit in Anaocha (the only afflicted LGA) was used in this study. Some 50 households were randomly selected in all identified communities. Two persons (one male and one female) of the ages 15 years and above in each household who must have lived in the communities for not less than 15 years were interviewed to provide knowledgeable responses to the interview questions. Two coached primary school.teachers in the different communities helped in interviewing the respondents. Altogether, 300 respondents were involved in the investigation. The interview utilised a questionnaire. The interview schedule consisted of a series of closed and open-ended questions composed of discriminatory statements on popular beliefs and practices on ' urinary schistosomiasis in which agreement or dis- agreement is required (Appendix 5). The interview

schedule8~~4t to obtain the following : (a) the respondents understanding of the causation, transmission mode and symptomatology of urinary schistosomiasis based on their indigenous body of facts, experiences and observations;

(b) the belief system of the community members 5nd feeling surrounding the causation, transmission, treatment and prevention of the disease;

(c) local habits and customs of the people in relation to transmission, treatment and prevention of urinary schistosomiasis. CHAPTER THREE

RESULTS

3.1 EPIDEMIOLOGY (i) Schools A total of 1,950 pupil in the 39 schools in the 3 Local Government Areas provided urine specimen. The table 1 below shows the distribution of the disease.

Table 1: Distribution of Urinary Schistosomiasis in the Local Government Areas and Preva- lence Rate in Affected Schools

No. No. ", School Examined Infected Infected Eqede Primary Sch. Achalla 0 Central School Achalla 0 Community Second- ary Sch. Achalla 0 Central School Awba-Ofemili 0 Progressive School Awba-Ofemili 0 Central School Isuanaocha 0 Community School Isuanaocha 0 Central School Nise 0 School No. NO. Examined Infected

Community School Nise 50 0 Central School Umuawu lu 50 0 Community School Umuawulu 50 0 Girls Secondary School, Umuawulu 50 0

Central School Adazi-Ani Community Primary Sch., Adazi-Ani Ojiako Memorial Prim. Sch. Adazi- Nnukwu Bubendorf Girls Sec. Sch. Adazi-Ani Union Primary Sch. Adazi-Nnukwu Community School Agulu-Uzoigbo Igweamaka Primary Sch. Agulu-Uzoigbo Azudo Primary School Ichida Mgbudu Primary School Ichida Community Secondary School Ichida LGA School No. No. 8 Examined Infected Infected

Central School Nri 50 34 68.0 a- - Ebede Primary 4J C School Nri 50 21 42.0 0 U - Obe Primary Sch. 4 Agulu 50 0 0 X U 0 Umuowelle Primary Sch. Agulu 50 33 66.0 4 Girls High Sch. Agulu 50 0 0

Hill Top Primary Sch. Abagana 50 0 0 Akpu Abagana Prim. School 50 0 0 Girls Secondary School Abagana 50 0 0 x Anadurnma Primary Sch. Enugu-Agidi 0 '30 0 0 Obioma Central Sch. Enugu-Agidi 50 o o Uruorji Primary Sch.I Nawf ia :-,0 0 0 OjokoMemorial Prim.I School Nawfia 50 0 0 Z I Comprehensive Secon- dary Sch. Nawfia 50 0 0 Community School Nawgu Go 0 0 Examined Infected Infected

-V Iruka Primary c cr G School Nawgu 0 U - Central Primary School Ukwulu Udodimrna Pr imaiy 1 1 School Ukwulu

Table 1 shows that the disease occured only in Anaocha Local Government Area, The prevalence rate w4s highest (68%) in Central Primary School Nri. Ebede Primary School Nri recorded 428 while Orjiako Memorial Primary School Adazi-Nnukwu recorded 32% prevalence rate. Umuowelle Primary School Agulu recorded 66% prevalence. 35

Table 2: Prevalence Rate of Infection by Sex in the affected Schools in Anaocha LGA rota1 No./% Infected Total School 3xami- No. /% Female ned Female Infected

Central Sch.Nri 50 Ebede Prim. Sch. Nri 50

Ox jiako P/Sch. Adazi- Nnukwu 50 Umu- owelle P/Sch. Agulu 50

Total 200

9 Table 2 shows that higher number of infection occur in males than in females in all the schools. In Agulu, the trend is same, UmuoweZle Primary School recorded prevalence of 75% and 50% in males and females respectively. However the difference in overall prevalence rate found among maleand femalesin these schools is not statistically significant at 5% Level.

Fig. 7 show5the relationship between degree of infection and age in both sexes Schoo\ Nri , E bed. ~rilsrhNri

Orjiakor Adazi Nnukwu UrnrnII~ Schod Agulu. 100

Ap Groyl (in years)

Fig.7: Rwo\ences of A,Hmrmtobitxn By SQX ,A~Q And Schoot Affiliation. in the various schools. It shows that in males and females of all the endemic primary schools, heavy infections occur within the 10 - 14 age group.

Table 3: Prevalence of Infection and Geometric mean of the egg output (from those infected in the various school) by.age No. Geometric mean of egg TGroup Examined Infected Prevalence % output/lO ml urfne Ce Ob Or Urn --- -

63415

27 18 12 17

100 1

--t--Total 50 50 50 50 34 21 16 33

The geometric mean egg output/lO ml urine in the various schools follow the same trend as prevalence, 30.4 for Central, 25.9 for Obede, 24.6 for Orjiakor and 31.4 for Umuowelle.

Ce = Central School Nri

Ob = Obede Primary School Nri

Or =.Orjiakor Primary School Adazi-Nnukwu

Um = Umuowel le Primary School Agul u (ii) Community

A total of 2,246 individuals in 480 households

in the 3 Local Government Areas provided urine

specimens. Table 4 below shows the distribution of the disease.

Table 4: Distribution of Urinary Schistosomiasis in the Local Government Geas 'and.Prevalence Rate in the various Communities

No. of No. (%) Total no: house- house- of Ind. Communities hold hold wi- Exam, in sampled th infe- household ction Achalla Awba Of ernili Isuanaocha Nise Umuawulu Adazi-Ani

I Agulu-Uzoigbo 30 lchida 1 30 Nri 1 30

Abagana 30 Enugu-Agidi 30 Nawfia 30 Nawqu 30 Ukwulu 30 Total 1 480 In table 4 above, the Local Government Area endemic with urinary schistosomiasis is Anaocha. The endemic communities in this Local Government Area are Adazi-Nnukwu, Nri and Aqulu. Out of 30 households from each community, 6(20.0%) in Adazi-Nnukwu and 19(63.3%) in Nri had individuals with urinary schistosomiasis. In Agulu,

12(40.0%) households had people with infection.

Table 5: Prevalence Rate of Infection by Sex In the endemic communities

Commu- Examined Total No.[%) Infected Total Exami- Male Female Infected Nnity Male1 Femalc ned 40(38.1) 27(36.0) Adazi- Nnukwu 80 71 6(7.5) 3(4.2)

Aqulu 90 72 27(30.0.) lg(26.1)

1 I Total 1275 1 218 73(26.5) 49(22.5)

Table 5 shows that among the infected people,

40(38.1%), 6(7.5%) and 27(30.0%) were males in Nri, Adazi-Nnukwu and Agulu respectively while 27(36.0%), 3(4.2%) and 19(26.1%) were females, given an average infection of 73(26.5%) and 49(22.5%) in males and females in these communities. Infection rate in relation to sex show no clZ3sex difference in the prevalence rate of in£ection in these communities,

Fig. 8 shows that prevalence in male followed the

normal trend (increase with peak at 10-14 year group) in the three communities. However, in f,emales,the

peak was in 20-39 age groups in Nri cornunity and 15-29 age groups in Agulu. Nri

I Adni Nnukwu

Age Groy, in Ymrs FI g. 8: Rwabm Of S. !-h~rratobium By Sox, Age And Community Affiliation. Table 6: Prevalence of S. haematobium and geometric mean of the egg output in the endemic Comm- unities by Age

. Infec zd 1 % Prevalence f 6.m : egg utput Adazi- I I \dazi- Nnukw~ Aqulu IPri iinukwu Aqul u

0 7.1 14.7 0.0 6.0

1 25.0 31.5 14.0 23.9

6 36.2 39.7 14.8 41.4

2 33.3 24.2 11.0 23.5

0 30.8 20.2 0.0 21.3

0 25.0 19.2 0.0 19.0

0 14.3 18.0 0.0 22.0

Total 1 493 122

The prevalence rate of urinary schistosomiasis in the total population was 24.7% and the geometric

mean egg output was 2 2.4 /,Q mi li*', *e : 1 Table 6 and Pig. 9 show that prevalence rate and geometric egg output rise rapidly in the early years to a peak level in the 10-14 year age group and

then falls. In Fig. 9 egg output falls sharply and then more slowly while prevalence declines from its peak level slowly and relatively steadily with advancing years. 0-4 5-9 10-14 15-79 23-29 3-39 4y

Age Group kn y~rs)

Fig. 9: Aga Prevabnce And lntemity (egg out put) of lnfoction ' With in the Endemic Comnunities. Table 7: Geometric Mean of egg output per 10 ml from those infected, by sex, age and community Male Female (Yrs. ) I Adazi- Adazi- I Agulul Nri I Nnukwu Agulu Nri Nnukwu

In table 7, a sex differential, with higher values in males than in females, first becomes apparent in the egg output in the 5-+age group, however, after 10-14 age group, the egg output in 4ktn IM MQ~~S females became higher,$rom 15-lgjl,age group up.

Infection in Occupational Groups Urinary schistosomiasis was wide spread in many occupational groups but certain vocations appeared to predispose individuals to attack by the parasite due to differential exposure (table 8, Fig. 10). The farming population had the highest infection rate of 35.7%. This was followed by school children with prevalence rate of 27.7%. 21.18 of housewives were found to be infected during the survey period. Civil servants had the lowest prevalence rate of 7.18.'

Nri community recorded the highest number of

infections among farmers (59.5%) and'housewives (33.3%) while Agulu community recorded the highest among

school children (36.8%) and traders (20.0%). Low infection rateswe found in the various occupational groups in Adazi community.

Table 8: Prevalence of S. haematobiwn in Occu~ational* qrou~sin endezic communities Communi tv Occupa- Agulu . Nri Adazi Total tional No. No. No. No. No''X No./% No./% Category Exami Exami- Exami- Exani- - Infected Infected Infected Infected ned ned ned ned

Traders 10 2(20.0) 12 2(16.7) 10 l(10.1) 32 -5l15.5)

Pupi 1 s 57 Zl(36.8) 69 24(34.8) 47 3(6.4) 173 48(27.7)

Farmers 35 13137.1) 42 25(59.5) 38 3(7.9) 115 41135.7)

Housewives 30 7(23.3) 33 ll(33.3) 27 l(3.7) 90 19(21.1)

Ci vi 1 Servants 14 l(7.1) 6 l(16.7) 8 O(O.0) 28 2(7.1)

Others 15 2(16.7) 23 4(17.4) 17 l(5.9) 55 7(12.7) Fig. 10 Variation Among IndivSdual of Various Occupational Groups Infected,With Urinary Schistosomiasis in the Endemic Communities.

.< 3-2 RELATED CONCURRENT STUDIES (i) Visible Haematuria 342 urine specimens were randomly picked for analysis in studying the possibility of using visible

haematuria as a diagnostic test in urinary schistoso- miasis.

Table 9: Visible haematuria and intensity of egg output

I Egg output per LO ml Urine Urine Colour 0 1-50 51-100 100' Total

Clear Yellow 14 4 2 1 21 Ambar 34 33 28 1 96 Brown 17 65 80 2 164

(frank) 3 13 41 4 61 Red ( blood)

Total 68 115 151 8 342

Table 10: Visible haematuria as a diagnostic test

Positive Negative Total True Method ' (Microscopic)I 261 274 I T4 68

Altogether, 61 urine samples out of 342 were red

in colour (Table 9), the deeper colours of urine contain higher egg counts i.e. over 100 eggs per 10 ml urine. Of the 342 urine samples, 321 were rnacroscopi-

cally assumed positive (i.e. containing -S. haemato- hium ova) but only 267 were found positive microscopically. Of the 21 specimens which were presumed negative macroscopically only 14 were found negative microscopically. Thus there were 7 false negative specimens. Of the 68 microscopically negative specimens, 54 were falsely assumed positive macroscopically (table 10). Thus visual haematuria when used as a diagnos-

tic test, the probability of getting a false negative is 0.0255. Thus the sensitivity of the test -274 - is 1 - 0.0255 = 0.9745 (or 97%). Also the probability of getting a false positive with the test method is

54 0.794. Thus the specificity is 1 0.794 -68 = - = 0.206 (or about 20.6%),

(ii) Snail Study During the same period (1991/92) research was undertaken in the study area on the snail intermediate host (B~linus~species).This study emphasised the

focality of -S. haematobium at human water-contact sites at Ulasi Stream in Nri and along different arns of Agulu Lake. Snail sampling data are shown in Table 11, where the numbers of Bulinus qlobosus and Bulinus truncatus collected, the numbers infected with mature cercaria, and the infection rates are presented.

Table 11: Nos.of Snails Collected, Infection Rates in 1991 and 1992

Type/No. - Infection Site No. of Bulinus Infected Rate Collected (%)

Agulu Lake (Arm 1) -B. globosus ! 317 19 6.0 Agulu -B. truncatus 182 9 4.9 Agulu Lake (Arm 2) qlobosus 161 5.0 truncatus 671 I 1.5 Agulu Lake (Arm 3) B. glsbosus 217 11 6.1 Nri 1;. - trunciltus 106 1 3 1 2.8 Agulu Lake (Arm 4) B. qlobosus 157 14 8.9 Nri 1,. 1,. truncatus 1001 4 1 4.0 Agulu Lake (Arm 5) B qlobosus 312 12 3.8 Nri 1;. -ncatus 1281 6 1 4.7 Agulu Lake (Arm 6) -B. qlobosus 112 4 3.6 Agulu/ Adazi-Nnukwu -B. truncatus 37 3 8.1

Ulasi Stream (Nri) -B. qlobosus 278 15 5.4 lee truncatus 1491 8 1 5.4 Total 2323 117 5.0

In the above table, more -B, globosus than -B. truncatus were collected from the different water sites. Both species were found shedding -schistosoma

haematobium- cercariae.

The least infection rate of 1.5% was recorded

from 8. truncatus while the highest

(8.9%) was recorded from -B. globosus. However, the

table shows overall low infection rate of 5.0% in both snail species.

Plate 8: Shell of Bulinus globosus Plate 9: Shell of Bulinus truncatus

Plate 10: Purcocercous cercaria of 5. haematobium [iii) Distance and Domestic Water Supply The prevalence rate of infection and the distri- bution of the 90 households studied in the endemic comn~unitieswith respect to distance to their main domestic water source is shown below. ,Table 12: Prcvalcncc ratc and natural domentic water distancc relationship. . . . .

~singeach souxcc/ oE Domcstic in mctere ,000-1999 1>2000 PI . -

Tanker l7

Lokc Arm l* I Lakc Arm 2* I 3

Lakc Arm 4* ( 2 Lakc Arm 5* 4 Lakc Arm G* I Ulasi Strc- - - 'I'oLa 1 - - Total using natural aourcc - - No. using nat . .source - - Z

-k

* Sourcc with inEccLcd bulinu~ + u3c altcrnativc natural water source of cqual distance Main water sourcc - Any main natural Source (rain exclusive) Table 12 shows that most households use water source very close to them (between 1-500 meter). Very few use sources up to 2 km (2,000 m) away from home. The number of positive cases of urinary

schistosomiasis decreases as one moves away from qt.,%'e t infected site (Fig. ll), 71.4% prevalence at (250 m and 22.2% prevalence at &2,000 m. Correlation analy- sis confirm this to be significant at 5% level. The investigation also show that no household use natural source more than 2,500 m (2% km). Fig. l I: Prevalence Me And Domestic Wer . Suppty Distance. -.4 3.3 KAP 3.3.1 Characteristics of the Respondents Three hundred respondents from 150 households constituted the cohort population from the three communities afflicted with the disease - namely, Agulu, Nri and Adazi-Nnukwu. One hundred (50 males and 50 females) were drawn from each of the sttaka (Table 13). Sixty-seven (22.3%) respondents from all the study areas had previously been attacked by urinary schistosomiasis and 233(77.7%) had not suffered from the disease infection. The age-specific characteristic table of res- pondents indicate that individuals aged between 20 years and 40 years formed the bulk (59.3%) of the respondents (Table 14). The respondents were relatively young with a mean age of 33.33 years (33.28 for male and 33.37 female) see Appendix12.

Table 13: Community and Sex Specific characteristics of Respondents - Never Respondents Prevlously infected . Infected Comnunity Male(%) Female(%) Total Male Female . Total Male Female T

Agulu 50(50) 50(50) 100 18 9- 27 32 41 73 Nri 50(50) 50(50) 100 21 8 29 29 42 71 Adazi-Nnukwu 50(50) 50[56] 100 6 5 11 44 45 89 150(50 150(50) 300 45 22 67(22.3%) 105 128 233( Table 14: Age and Sex Specific Characteristics of Respondents Age group(yrs.) Male Female Total

15-19 19 16 35 20-29 40 43 83 30-39 46 49 95 40-49 35 30 65 50 above 10 12 22

Total 150 300 150 I

3.3.2 Knowledge of the Disease In the 3-study communities, all the respondents positively affirmed that urinary schistosomfasis is very well known by them. The respondents associated the disease with the passing of blood with urine. Ninety-seven (32.3%) of the respondents could give the English name of the disease - Bilharzia. In response to the open-ended question "from whom did you learn about the disease", 67(22.3%) answered that they had been previously attacked by the parasitic

infection, 72(24%) had family members who had suf- fered from the disease while 161 (53.7%) learnt about the infection from discussions and stories. Investigations revealed that this last group of respondents live in villages very far from the transmission foci (Agulu Lake).

(i) Local Terminologies for Urinary Schistosomiasis Urinary schistosomiasis is well defined in the three communities with different but related terms -

Oya obala (disease with blood), Mgbu obala (pain with '. blood.), Mamiri obala (urine with blood), or Oya mamiri (urine illness). These names are derived from the fact that afflicted ones pass blood with urine at a certain stage of the disease (Table 15).

Table 15: Definition of -S. haematobiurn by Community Community Terminology for -S. haernatobiurn Agulu I Oya obala, Mgbu obala Nri Oya mamiri, Marniri obala Adazi-Nnukwu I Oya obala

(ii) Theory of Causation and Transmission It was common knowledge that -S. haematobium affects mostly children of both sexes. However, there were considerable variations in response to the question on how the disease get into the body. One hundred and twenty-two respondents (40.78) attributed the disease tc drinking contaminated water. Ninety- seven (32.3%) associated the disease with swimming in infected water, and 30 (10%) believed that the

r7i cnzca nrnhlam i c P~IYCP~hw pza+infl wafer qnni 1 whi 1~ 51(17.0%) of the respondents could not attribute the cause of the disease to anything. Eighty-five of the respondents (28.3%) linked the sudden appearance of the disease to civil war, 82(27.3%) linked it to God's wish while 87(298) did not know what was responsible.

(iii) Symptomatology Generally the symptom - !?passing.of' blood1 with urine was known by all respondents. Also more of those who had been previously attacked by the parasite associated the disease with painful urination [Table

Table 16: Responses on Symptoms of Urinary

No./% of Respondents Symptom I Previously Never Infected(%) Infected(%) Total I%)

Bl.ood in urine 67 (100 233 (100) 300 (100) Painful urination1 45(67.2) 1 51(21.9) 1 96(32.0)

~izziness/weakness 9 (13.4 ) ll(3.7) Don1t know lO(14.9) 3.3.3 ~ttitude In response to the question "is urinary schistosomiasis a serious disease," majority 73.7% are of the affirmative. It is interesting to note that among these people, 40(59.7%) were previously

infected while 18(77.7%) were not. Some 98.3 percent of the respondent did not believe that urinary schistosomiasis is a killing disease, while all the respondent believed that it is not contagious and so they do not avoid people with the disease. However, they do not envy people who pass blood with urine. Majority (97%) of the respondents were positive about the potential curability of -S. haematobiurn. Also a significant majority (68.7%) of the res- pondents felt that the disease problem could be prevented.

3.3.4 Practices

While 23% of the respondents go for swimming,

in Agulu Lake, 40.7% and 23% of the respondents do same in various streams and ponds near to them respectively. It is remarkable that while 4.3% of the respondents prefer Agulu Lake for domestic water supply during the rainy season, 20% prefer itduring the dry season. Though majority (80.7%) prefer rain water during rainy season, they usually resort to streams, ponds and lake during dry season for domestic water. Seventy-eight percent of the respondents had '. no pit or water system laterine and as such, 82.3% of them use open bushes and road paths near and away the bank of the lake for toilet.

Only 9(3%)of the respondents favoured the use of local herbs in the treatment of -S. haematobiurn infection. Thirty-seven percent preferred chemist shop where they are given antibiotics and some pain relieving tables like panadol and novalgin. Some 43% of respondents prefer hospital treatment. However, it is interesting to note that 17% favoured leaving the patient alone without treatment. This group of people believe that the passing of blood stops and comes back on its own. CHAPTER FOUR

DISCUSSION

Out of the 15 communities of Awka, Anaocha and Njikoka Local Government Areas involved in this survey, 6 have common boundaries with Agulu community while 2 (~riand Adazi-Nnukwu) have common boundaries with the lake. The establishmczt of p~tentschistosomiasis in some school children and community members in Nri and Adazi-Nnukwu communities including Agulu confirmsthe endemic nature of the disease problem in this region that depends on Agulu Lake for domestic water supply. Okafor (19841 reported that a village may be almost free from infection while another within a distance of one to three kilometers may show a very high incidence. This could be linked with several factors but effective transmission takes place only where a suitable snail host is found in relatively compact bodies of water visited frequently by inhabitants of a village (McCullough, 1964). Observations on S. haematobium infection in primary schools and some communities in Anaocha LGA alone indicate that there is a significant variation in the prevalence rate of the infection between schools within same and different villages and within communities in a local government area. Infection rate in Central School ~ri and Umuowelle Primary School Agulu are higher than that in Ebede Primary School Nri and Orjiako School Adazi- Nnukwu. This could be as a result of different locations of the schools around Agulu Lake and other infected sites and their lake related activities. The between community infection rates showed that two communities Nri and Agulu recorded higher rates than Adazi-Nnukwu. Investigations revealed that Nri community is surrounded by natural bodies of water (about 3 arms of the lake and many streams), while ACazi-Nnukwu has few streams and a little portion of the Lake at the outskirts of the town. The various arms of the Lake habour snail host of the disease. This could be a major reason for the differences observed in the community infection rates. The overall school and community prevalence rates are higher than the figure reported by ~jezieand Ade-Serrano (1981) in Nigeria but lower than higher figures established by Scott --et a1 (1982) and ~kpala(1961). These variations may be due to the type and nature of water and human activities in relation to the disease transmis- sion in the studied area. More males were shown to have higher rate of infec- tion than females in the endemic schools and communities although the difference is not statistically significant. This is in.agreement with the findings of Pugh --et a1 (1980) and Scott et a1 (1982) in Northern Nigeria and Lake Volta Ghana respectively. However, this is at variance with other existing literature. Thus Anya and Okafor (1986) in parts of former Anambra State of Eastern Nigeria and Okpala (1961) in Epe Western Nigeria, reported higher prevalence of the infection among females. The between sex difference in prevalence may also be attributed to variation in the degree of exposure to various transmission foci. Sexual differences in prevalence

rates and intensity have not been previously found to be significant:. (Forsyth and Bradley, 1966; Wilkins, 1977), although in ibadan Western Nigeria, Edington et a1 (1970) found it to be significantly higher in males than in females. The age group differences in infection rates with usually age group 10-14 being more susceptible to infection appears to be a common feature of urinary schistosomiasis (Okpala, 1961; Bradley and McCullouyh, 1973). Bradley and McCullough (1973) explained that people begin life uninfected and gradually become infected as they expose themselves over the first 10 years of life. Then by the age of 10 years most children have been infected for a variable number of years and have acquired substanti;

concomitant immunity, so that the 10-14 age group are both heavily infected and protected from further infection. HOwzver, Anya and Okafor (i986) reported the age groups with peak infection as 15-19 years in males and 20-29 years in females.

They explained that people within this age groups were farmers in their study population and are the members of the population with a higher risk of infection. Due to the nature of their work, they are always in contact with small pools of infected water. Though the overall peak was in the age group 10-14 years in this study, an observation similar to Anya and Okaforls (1986) report was found in Nri and Agulu communities. In these commu- nities, the peak in females were in older women, 15-19, 20-29 years. This is probably because women in this age . group are housewives who carryout domestic work (fetching of water, washing of cloths, fermenting of cassava etc.) which takes them frequently to infected natural water sites. This could also be? to role reversals as these women now farm as much as and some even more than men in these communities. In general, prevalence and egg output go together.

The most significant association is with age. Both egg output and prevalence rise rapidly in the early years to a peak level in the 10-14 years age group and then declines slowly with advancing years. The overall geometric mean of egg output (22.4) obtained in this study is lower than 54.0 and 47.3 established by Scott --et a1 (1982). This could be termed law endemicity since quantitative analysis (egg output level) provides a better sensitive index in the measurement of the level of transmission than the prevalent rate. The low endemicity may be due to the fact that afflicted indivi- dual visit hospitals for treatment. The farming population constitute the occupational group at greatest risk. This is in agreement with the findings of Okafor (1984). This group bath in the fresh water streams and or pools near their farms after each days work. School children are next to farmers with prevalence rate of 27.7%. This is probably because they join their mothers to carry out domestic activities which usually take them to transmission sites. Okafor

(1984) also observed that school children spend most of the break periods swimming in streams adjacent to their school especially during the dry season when the sun can be scorching. Thus high infections observed in these socio-economic groups could be explained in terms of their prolonged exposure to unprotected or infected sources of water. Civil servants were the least infected his suggests upati at ion group in the study communities. that rnmm~~ni tv mot i rrated hea 1 th edncat i on ramna i on on Among the various shades of haematuria, there is a wide range of egg output within each shade and a lot of overlap between the different shades of haematuria. However, there was a tendency for deeper colours of urine to contain higher egg counts. Earlier studies (Macdonald, 1973; Pugh --et al, 1980) demonstrated that

severe sequelae of -S. haematobium infection were more common among those infected individuals passing more than 240 ova per 10 ml of urine. This is probably why more individuals in this study who passed out red urine

(frank blood) excreted about 100' ova/lO rnl urine. For any diagnostic method to be valid, it must be sensitive, specific and reproducible. The result of the analysis for visible haematuria is highly sensitive. The reason for its low specificity could be because the shade of urine passed by an infected individual often varies from time to time. This affects reproducibility of tests. However, for practical purposes, the test is an appro- priate indicator of the presence and intensity of -S. haematobium infection suitable for use in areas of high endemicity (though this study is in a low endemic area). It is instant and needs no special equipment and can easily be adopted for use by the less trained health workers engaged in control schemes in rural areas. The six arms of Agulu Lake and a stream known as Ulasi habour snail host of the disease. Some snails collected from human water contact paints in these water bodies were infected. Thus this study emphasised the focality of -S. haematobium transmission on these points. The prevalence rate of infection showed a signifi- cance decrease with increasing household to natural water source distance. This suggest that with rain, the prevalence rate of the infection will fall drastically since rain water is collected at home. Because this study was carried out in the dry season, rain was not included as a water source. Blum --et al (1987) in Imo State of Nigeria, reported that in wet season when the availability of water sources was much greater, rain water was the main source for 64% of household while only 318 use borehole. Distance will determine the time spent in collecting water and so it affects travel times. Saving of time for other chores could be one of the reasons why the villagers resort to nearest water source, no matter the type. The results of the KAP study indicate that within a small geographically contagious area and even within the same linguistic group, differing perceptions of a specific disease sroblem may exist. In the study, urinary schistosomiasis appear to be well known with diverging views about it. The disease, it is asserted, is by God's wish, which is why there is the civil war which brought about the evil lake (Agulu Lake) to be polluted. Studies of individuals with special exposure characteristics, such as migrants who have left an endemic area abound (Warren, 1974; rem million -et e, 1978). This finding afford important opportunities to study the natural history of urinary schistosomiasis in this area.

While the disease was widely recognised with the :I, ; lake as the transmission foci and its symptomatology fairly understood, its mode of transmission was viewed with scepticism. The recognition that the lake is the transmission foci by some individuals may be probably why some refer to the lake as Miri bilharzia (Bilharzia water). And because of this some people do not drink it, yet they bath and carry out other domestic activities in the lake. Even still, some defecate in open bushes around the lake and urinate virtually anywhere. This suggests the need to develop concise method to convey the real life cycle and mode of transmission of the disease. Health education efforts which draw the link between susceptibility to infection and swimming in contaminated water could be instrumental in dispelling notions of preordained susceptibility.

The passing of blood with urine is well known to the villagers in the study communities. The perception of the disease as a serious problem probably arose from this. This is because in this part of the country, anything that can cause blood to come out from a human body must be serious. This fear must have led to the low prevalence rate of the disease in the area. The communities expressed general optimism on the curability of schistosomiasis which is why most of them go to hospitals an2 chemists Eor treatment. Such practice may also have led to the low geometric egg count and prevalence rate of the disease and indicate that the communities are not too rural or timid. However, few emphasised that it is not curable probably because that after treatment one go back to the lake to get reinfected. This could be why some insisted that the disease should be left to heal on its own probably when one gets older. This suggests why some (31.3%) of the respondents feel it could not be prevented. This perception is not surprising especially when viewed against the background of general lack of knowledge of the mode of transmission and of the causative organism. Result also shows that the lake is frequented by people from nearby households with no alternative source of water. Villages far from the lake have their own streams, ponds and even tank where they can swim and collect domestic water. Pipe borne water is also located at different parts of some communities like Agulu and

Adazi-Nnukwu. Howsver, beca~sethe lake is big, it attracts people from far places for recreational activities. CHAPTER FIVE

CONCLUSION

It is evidenced from the study that Urinq 3 $j,.&&3mas~~ is not very widespread in the Agulu Lake area and that the endemicity is still low. This is probably because the disease is not very old in the area and must have been introduced during the ~igerian/~iafrancivil war when soldiers and refugees from endemic area contaminated the lake. The findings of this research emphasise the need for a country-based, well defined and locally acceptable intervention and preventigr, program. Usually, the successful introduction and implementation of control programs depend largely on a thorough understanding of the epidemiology of the disease. In this case a more plausible, more rapid and cheap approach in the control should be through health education and individual and community participation. This must focus on the cause, prevention and control of the disease. As this is going on, provision of safe sources of domestic water will be embarked upon. This sources should be very close to household especially those using the lake and Ulasi stream, since they prefer near water sources. When this must have been done, then these sites which habour snail host of the disease could be pronounced out of bounds for 2-3 years since the communities are not necessarily fishermen. During this period, molluscides could be used to treat the focal points. Treatment of the small group of infected individuals with drugs of choice (praziquantel and metrifonate) becomes necessary at this stage. If not they will likely pollute other sites, increase in number and involve other members in the community. REFERENCES

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W.H.O. (1990). Schistosomiasis in Tropical Diseases 1990 UNDP/World Bank/WHO special Programme for Research and Training in Tropical Diseases (TDR). 6 - 7. APPENDIX 1

RANDOMLY SELECTED COMMUNITIES IN THE THREE LOCAL GOVERNMENT AREAS (LGAs)

Awka L.G.A. Achalla

Awba-Ofemili

Isuanaocha Nise

Umuawulu

Njikoka L.G.A.

Abagana

Enugu-Agidi

Nawf ia

Nawgu Ukwulu

Anaocha L.G.A.

Adazi-Ani Adazi-Nnukwu

~qulu-Uzoigbo

Ichida Nri

Aqulu (Special area) APPENDIX 2

SELECTED .SCHOOLS IN THE VARIOUS COMMUNITY IN TI-IE THREE LOCAL GOVERNKENT AREAS

AWKA ANAOCIIA I'rima-~'y Primnrv Egede Prim. Sch. Akpu Abagana Prim. Obe Prim. Sch. Agulu Achalla School Central School Hill-top Prim. Umuowcllc Prim. Achalla Sch. Abagana Sch. Acjulu Ccntral School Central School Anadumma Prim. Awba-Ofemili Sch. Enugu-Agidi Adazi-Ani Conununi ty Prim. Progressive Sch. Obioma Ccntral Sch Enugu-Agidi Sch. Adazi-Ani Orjiako Memorial Community Sch. Uruorji Prim. Sch. Isuanaocha Nawl ia Sch. Adazi-Nnukwu Union Sch. Central School Ojoko Memorial Prim. Isuanaocha Sch. Nawfia ~dazi-Nnukwu Community School Central School Conununity Sch. Nise Nawcju Agulu-Uxoigbo Prim, Community Sch. Iruka Prim. Sch. Igwearnako Nise Nnwgu Sch. Agulu-Uzoigbo Central School Azudo Prim. Sch. Central School Ichida Umuawulu Ukwulu Central School Mgbudu Prim. Sch. Udodimma Prim. Ichida Umuawulu Sch. Ukwulu Central School Secondarv Secondary Nri Community Sec. Girls Sec. Sch. Ebede Prim. Sch. Sch. Achalla Abagana Nri Girls Sec. Comprehensive Sec. Secondary Sch. Umuawulu Sch. Nawfia Bubendorf Girls Adazi-Ani Community Sec. Sch. Ichida Girls High School Agulu APPENDIX 3 81

INDIVIDUAL INFORMATION FORM FOR URINARY SCHI STOSOMIASI S SURVEY IN SCHOOL CHILDREN

PERSONAL DATA/IDENTIFICATION

Name :

L.G.R. :

Age : Sex:

I (In the following questions tick ( ) as appropriate) 1 LEVEL OF EDUCATION Attends Primary School Water Supply - Drains Well Attends Sec. School Pipe Borne Water Stream/River OTHER BACKGROUND INFORMATION Have you been to Agulu Lake? Others Yes Swimming - Ponds No Stream/river id you wade into the wat Others

Yes Washing Clothes and .. utensils - NO I Pond Was there a time you passed ~ell/Tank blood with urine? Pump Yes Stream No Others HOME AND SANITATION Fishing - Pond Type of house - Mud Stream Cement River others others Latrine - Pit EXAMINATION OF URINE Water System Urine: In the bush Data/Time of Collection Farm - far from habitation DateiTime Examined Under water Colour of Urine near a pond -S. haematobiurn ova: Positive No. of Egg APPENDIX 4 QUESTIONNAIRE HOUSEROLD SCHEDULE (List all Bousehold Members) Uouschold No,

First Name Urine Ova or Initial Sex Colour +ve/No ,.

Main natural domestic water source apart from rain Distance of water supply to the house

Recorded by: Name : Signature: Date: ATPENDIX 5

URINARY SCHI STOSOMIASIS' A STUDY OF THE KMWLEDGE, ATTITUDE AND PRACTICES IN AFFLICTED COMMUNITIES IN AMAOCHA LOCAL GOVERNMENT AREA OF AMRMBRA STfiTE, NIGERIA INTERVIEW QUESTIONNAIRE NAME OF RESPONDENT COMMUNITY 3. VILLAGE AGE 5. SEX NUMBER OF YEARS LIVED IN THE VILLAGE (In the following questions tick ( ) as appropriate) Do you know of a disease which causes passing of blood with urine? i) Yes ii) No Which is the local name for the disease? i) Oya obala ii) Ngbu obala iii) Mamiri obala iv) Oya Mamiri v) Don ' t know Which is the English name for the disease? i Malaria ii) Schistosomiasis/Bilharzia

iii) ' Gonorrhoea iv ) Don't know Have you suffered from this disease? i) Yes ii) No Have you seen a person with the disease? i Yes ii ) No From whom did you learn about the disease? i From stories and discussions ii ) Saw victim in your household iii) Suffered it yourself Which is the conunon symptom of the disease? i) Headache ii) Dlood in urine iii j Don" know W!-.ich is another symptom of the disease?

i) , Painful urination ii ) lIeadache/fevcr iii ) Dizzincss/wealcness iv) Don't know Bow does the disease get into the human body? i) ~rinkinccontaminated water ii) Swimming in infected water iii) Eating snail iv) Don't know What led to the presence of the disease in this area? i) Civil war ii) Evil lake (Agulu Lake) iii) God's wish iv) Don't know Who is usually affected by the disease? a) -Sex: i) Male b) se:- i) Children ii) Female ii) Adult iii) Both sexes iii) Both Why are some people more susceptible to the disease? i) Destiny ii) Swimming in water iii) Don't know Is schistosomiasis a serious disease? i) Yes ii) No Do people die from bilharzia disease? i) Yes ii) No Can it be prevented? i) Yes ii) No 23. Is it curable? i) Yes ii) No 24. Do you avoid people with the disease? i) Yes ii) No 25. Do you regard people that pass blood with urine as lucky ones? i) Yes ii) No 26. How is the disease treated? i) Use of herbs ii) Visit chemist shop for medicine iii) Visit hospital for treatment iv) Leave it to heal on its own 27. Where do you g3 to swim? i) Stream ii) Agulu Lake iii) Pond iv) No where 28. Which is your preferred domestic water supply during rainy season? i) Rain water ii) Stream iii) Tank/Well/Tap iv) Agulu Lake 29. Prom which do you collect domestic water during dry season? i) Stream/pond ii) Tanker/well/tap iii) Agulu Lake 30. Do you have pit latrine or water toilet system? i) Yes ii) No 31. Where do you normally excrete/urinate? i) Latrine/water toilet system ii) Bush/bush paths/road sides APPENDIX 6a

School children Male Female 71.4 60 46.9 33.3 41.4 13.0

SD = 16.985 SD = 18.116

Vnriancc 288.502, 3: = 328.189 5' nl = Infection independent on sex (i.c. diff. not Ho : significant) 2 2 s* = am ("-1) +-sf (n-1) - 280.502x3+328.109~3 308.346 - _ df = 2(n-1) 6

APPENDIX Sb OR. Chi- Square

Male- - Female Total 0 E 0 E Central Nri 74.4 (77.68) 60.0 (53.72) 131.4 Ebede Nri 46.9 (47.41) 33.3 (32.79) 80.7 Orjiako Adazi 41.4 (35.71) 19.0 (24.69) 60.4 Umuowelle AguguL?.O (73.89) 50.0 (512) --125.0 Total 234.7 162.3 337.0

Decision rule : Reject Ho if xXfcal> *tab 2 2 Test Statistics : df (r-l&-3=, x2= f(o-e)-- , N = 397.0 2 (71.4-77.681~ 2 Calculation =c)C = 77.68 + ... (50-51.1)51.1 = 3.63

since%!-, < q-,we accept H- (Infection is indepen- APPEFDIX 7 Prevalences of bmatobiwn by Scx, Age and School Affliation S, & - - Sc1100l Age group in years Male Pemalc

I. Central School Nri

2. Ebede Primary School. Nri

3. Orjiako Primary School Aclazi- Nnukwu

4. Umuowelle Primary School APPENDIX 9 Age Prevalence and Intensity of Infection with S. huernatdU.um in the endemic commit ies

Age group Total % Preva- Geometric mean lence Egg Count in years Examined Infccted

APPENDIX 9b Prevalences of S,h-aema-tt&m by Sex, Age and Cornunity Affiliation

Nri Adazi-Nnukwu Agulu Age group in years Male Female Malc Female Male Pcmale 0-4 20.0 16.7 0.0 0.0 0.0 20.0 5-9 50.0 33.3 10.0 0.0 33.3 15.8 10 - 14 51.4 37.5 16.0 9.0 42.9 26.3 15-19 36.4 45.0 5.0 6.2 27.8 40.0 20 - 29 0.0 50.0 0.0 0.0 25 .'O 40.0 30 - 39 16.7 50.0 0.0 0.0 25.0 25.0 40 + 11.1 0.0 0.0 0.0 0.0 20.0 APPENDIX 10 OccupationaI Variation Among infected individuals in the endemic countries

Occupational No. Examined No. Infected % Infected Catet-ory

Traders Pupils

Farmers

Housewives

Civil Servants

Others

Total APPENDIX 11 Correlation Analysis

Distance to H20 Prevalence (%)

Hypothesis: There is no correlation between distance from home to natural source of domestic water and prevalence rate of urinary Schistosomiasis.

Conclusion: Because tcal > toc we reject the null hypothesis of no correlation and conclude that at 5% level of significant that distance from home to natural domestic H20 source has influence on prevalence rate of urinary schistosomiasis. APPENDIX 12 KAP': Mean age and sex characteristics of respondents - - Mean age for all respondents X age for Male X age for Respondents Female Res- pondents

Class ~ark[l) ~req.CF) fx req. --f 17 35 595

24.5 83 2033.5 APPENDEX 13 Comnuni ty-Speci f ic responses to selected survey questions Adazi- AWlu(%) Nri(%) ----Nnukwu (8) Total(%) 1. What led to the presence of this disease in your area? , . i) eibil war ii) Evil Lake (Agulu Lake iii) God's wish iv) Don't know 2. Why are some people more susceptible to the disease than others? i) Destiny ii) Swimming in water iii) Don't know 3. Who is usually affected by the disease? Sex i) Male ii) Female iii) Both sexes Age i) Children ii) Adult iii) Both 4. Can Urinary schistoso- miasis be prevented? i) Yes ii) No 5. Do you avoid people with the disea,se? i) Yes ii) No 6. Do you regard people that pass blood with urine as lucky ones? i) Yes ii) No Adazi- Aqulu(%) Nri(%) Nnukwu ( % ) TotaL( % ) 7. Where do you go to swim? i) Stream ii) Agulu Lake (Miri Agukwu) iii) Pond iv) No where 8. Which is your pre- ferred domestic water supply during rainy season? i) Rain water ii) Stream iii) Tank$well/Tap iv) Agulu' Lake 9. From which do you collect domestic water during dry season?

iii) Agulu Lake 10. Do you have pit latrine or water system toilet? i) Yes ii) No 11. Where do you normally excrete/ urinate? i) ~atrine/ water system ii) Bush, bush paths/road- sides APPENDIX 14 Infected and Never Infected Individual responses to selected survey questions

Previously Never Totalf%) Infected(%) Infected(%) _ 1. Which is the common symptom of the disease? i) Headache iil Blood in urine iii) Don't know 2. Which is another symptom of the disease? i) Paidul urination ii) Neadache/fever iii) Dissincss/weakncss iv) Don't know 3. How does the disease get into the human body? i) Drinking contamina- ted water ii) Swimming in infec- ted water iii) Eating snail iv) Don't know 4. Is urinary schistoso- miasis a serious disease? i) Yes ii) No 5. DO people die from it i) Yes ii) No 6. Is it contagious? i) Yes ii) No 7. IS it curable/ i) Yes ii) No Previously. Never Total(%) infected(%) Infected(%) a. How is the disease treated? i) Use of herbs 3(4.5) 6(2.6) 9(3) ii) Visit chemist shop for medicine 24(35.8) 87(37.31 lll(37) iii) Visit hospital for treatment 29t43.3) lOO(42.91 129(43) iv) Leave it to heal .. . on its own 11 (16.4) 40(17.2) 51(17)