AFETI ALEX.Pdf

KNOWLEDGE, ATTITUDE AND PRACTICES TOWARDS THE PREVENTION AND CONTROL OF SCHISTOSOMIASIS AMONGST THE COMMUNITY AT BUTIABA LANDING SITE, BULIISA DISTRICT

BY AFETI ALEX

(BMS/0056/91/DU)

A DISSERTATION SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS OF THE AWARD OF THE DEGREE OF BACHELLOR OF MEDICINE AND SURGERY OF KAMPALA INTERNATIONAL UNIVERSITY

SUPERVISED BY: DR. KINTU MUGAGGA

OCTOBER 2014

DECLARATION

I hereby declare that this research dissertation to the best of my knowledge has not been presented to any other institution before.

Signature………………………………………..Date………………………….

AFETI ALEX

(AUTHOR)

Produced, supervised and submitted with the approval of:

Signature………………………………………………Date……………………….. DR. KINTU MUGAGGA (SUPERVISOR)

DEDICATION This work is dedicated to my family members more especially my mother Semerita Zaru, brothers Musa Pariyo, Aaron Avutia, madam Harriet Kyamanywa and the children Opoa E, Ejoru N, and Ajedra; sisters Leah Apai and Fida Atibaru for their prayers and support in one way or the other during the study.

ACKNOWLEDGEMENT I thank the Almighty God for giving me health, guidance, protection and strength up-to-date. More thanks goes to Belgian Embassy in Uganda for sponsoring me throughout the course. I acknowledge the efforts of my supervisor Dr. Kintu Mugagga for his guidance and supervision during the preparation of this work. Am also greatly indebted to my family members for their moral and financial support, and encouragement. To Dr. Jino Abiriga of Masindi General Hospital for his endless teaching and guidance during my clinical practice. All my fellow students, friends and colleagues for their cooperation and togetherness during the course.

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TABLE OF CONTENTS Page CHAPTER ONE: INTRODUCTION………………………………………1 1.1 Background.……………………………………………………………1 1.2 Statement of the problem……………………………………………2 1.3 Broad objective…………………………………………………………2 1.4 Study questions……………………….……………………………….3 1.5 Significance of the study….………………………………………….3 1.6 Conceptual frame work……………………………………………….3 CHAPTER TWO: REVIEW OF RELATED LITERATURE……………..5 2.1 Life history and transmission of Schistosomiasis………………5 2.2 Knowledge about preventive and control practices…………….7 2.3 Prevention and control measures…………………………………..9 CHAPTER THREE: METHODOLOGY………………………………..….25 3.1 Study design…………………………………………………………….25 3.2 Study area……………………………………………………………….25 3.3 Study population……………………………………………………….27 3.4Sample size………………………………………………………………..27 3.5 Sampling method……………………………………………………….28 3.6 Data collection…………………………………………………………..28 3.7 Data analysis and presentation…………………….………………28 3.8 Data quality control……………………………………………………28 3.9 Inclusion criteria……………………………………………………….28 3.10 Exclusion criteria…………………………………………………….29 3.11 Ethical consideration…………………………………………………29 3.12 Study limitations………………………………………………………29 3.13 Dissemination of results……………………………………….……29 CHAPTER FOUR: RESULT…………………………………………………30 CHAPTER FIVE: DISCUSSION OF RESULTS………………………….40 CAPTER SIX: CONCLUSION AND RECOMMENDATIONS…………..45 REFERENCES…………………………………………………………………46

LIST OF TABLES, FIGURES AND CHARTS. Flow chart 1.6.1 for conceptual frame work…….…………..……………4 Table 4.1: Demographic characteristics…………………………………..30 Figures 4.2: According to the knowledge ..……………………….…..…..32 Figures4.3: According to the attitude and practices ……...……………36

LIST OF APPENDICES ………………………………………Page I. Letter of introduction………………………………………………49 II. Map of uganda showing buliisa district (study area)………50 III. Map of buliisa district showing butiaba landing site…..…51

LIST OF ABBREVIATIONS

CDC: Center for Disease Control. DHO: District Health Officer. Dr: Doctor. PZQ: Praziquantel. S. mansoni/haematobium: Schistosomiasis mansoni/haematobium. WHO: World Health Organisation. %: Percentage. ≥: Greater than. <: Less than.

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ABSTRACT Schistosomiasis is an “emerging tragedy in our new global health decade” being endemic in 76 countries of the world affecting about 200 million people of the 700 million people living in the endemic areas. Even with readily available drugs, the pervasiveness of the intermediate host snails and the ease at which re-infection occurs; its control still presents an important challenge for public health services around the world. The objective of the study was to assess the knowledge, attitudes and practices amongst the residents of Piida B village, Butiaba landing site towards the prevention and control of Schistosomiasis. I conducted a cross sectional qualitative study where a population of 246 respondents were interviewed using pre-coded questionnaires. The demographic characteristics, knowledge, attitude and practices were then established and data generated and presented using tables, graphs and charts. I found out that over 87% of the respondents had some general knowledge about Schistosomiasis although 206 (84%) had no or very low level (primary school dropout) of formal Education and fishing was the main occupation 101 (41%). There was also continuous contamination of the lake with faecal matter with 83 (74%) reported defaecating either in the lake or nearby bush at lakeshore while in water, as well as contact with lake water amongst 235 (96%) without the use of any protective gadgets amongst 190 (90%) with 197 (93%) accepted uptake of PZQ tablets during mass deworming. In conclusion in spite of the good general knowledge about Schistosomiasis, its prevention and control still possess a big challenge. I recommend continuous Health Education on proper disposal of human faeces and urine; avoid contact with lake water or use of protective gadgets as well as annual mass deworming.

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CHAPTER ONE: INTRODUCTION 1.1 BACKGROUND Schistosomiasis has been described as an “emerging tragedy in our new global health decade” with its control still presenting an important challenge for public health services around the world (Baker John, et al., 2007; Hotez and Fenwick, 2009; Standly et al, 2009; king, 2009; and WHO, 2010).

It is endemic in 76 countries of the world, affecting about 200 million people of the 700 million people living in the endemic areas with about 120 million people having symptomatic infection, 20 million develop severe disease and between 150,000-280,000 die as a consequence of the disease per year (Van der werf et al, 2003; WHO, 2010). About 7.1 million people are infected with S. mansoni in the Americas, 95% of which is in Brazil (WHO, 2010). Sub-Saharan Africa accounts for approximately 80-85% of the 200 million infected people worldwide with the overwhelming majority of human infections caused by S. mansoni or the S. haematobium group (Hotez et al., 2009; Steinmann et al, 2006; WHO, 2002).

In Uganda, an estimated 2 million people are infected, 13% of the population is at risk of infection commonly caused by S. mansoni found in 63 out of the 112 districts with the countrywide prevalence is just over 10%, but in selected foci there is almost 100% severe infection with the highest prevalence and intensity of Schistosomiasis in areas along the main water bodies especially in lakes Victoria, Albert, Kyoga, and Albert Nile (along River Nile) but it is focal There is no clear data on it’s the prevalence at Buliisa but is said to be endemic along Lake Albert ((Kabatereine et al., 2003, 2004; Tukahebwa, et al, 2013).

1.2 STATEMENT OF THE PROBLEM Since the official launch of the Uganda National Programme for the control of Bilharzia and Intestinal Worms at Pakwach, Nebbi District in March 2003 with mass drug treatment using Praziquantel (PZQ) (Kabatereine et al 2003), the intensity of Schistosomiasis was reduced by 70% and 98.2 in the first and the second year respectively. People later developed reinfections because of the continued contact with infected water suggesting that knowledge about prevention and control were not fully used in Uganda thus lead to raising an issue of health education by the Community Drug Distributors as a way forward (Kabatereine, et al, 2006). It was noted that infection and re-infection with Schistosomiasis can only be avoided if communities or individuals have good knowledge about the life cycle and control methods (Koukounari et al, 2007; Simonga 2009). The study therefore, intended to investigate the knowledge, attitudes and practices on prevention and control of Schistosomiasis amongst the community of Piida B village which findings shall tell how much Health Education has been implemented as an additional strategy.

1.3 OBJECTIVES 1.3.1 BROAD OBJECTIVES To assess the knowledge, attitudes and practices of the residents of Piida B village, Butiaba landing site towards the control and prevention of Schistosomiasis. 1.3.2 SPECIFIC OBJECTIVES a. To find out how much the people know about Schistosomiasis. b. To find out what prevention and control measures the community undertakes. c. To find the impact of the community practice on Schistosomiasis.

1.4 STUDY QUESTIONS 1. What do the residents of Piida B know about Schistosomiasis prevention and control? 2. Do these residents have any precautionary measures towards the prevention and control Schistosomiasis? 3. What might be the impact of people’s practices on the prevention and control Schistosomiasis?

1.5 SIGNIFICANCE OF THE STUDY This study was intended to identify the gaps, misconceptions, lack of knowledge, good and bad attitudes and practices towards the prevention and control of Schistosomiasis and help and guide the policy makers and implementers in formulation and incorporation of health education strategies specific to that community. In addition, the information will help the community on how fishing as their main economic activity and way of earning a living should best be practiced with minimal contact with the contaminated water.

1.6 CONCEPTUAL FRAME WORK It is concerned with how people interact socially with the ecological environment. It spells out the dependent, independent and intervening variables leading to the disease state as explained and shown on the flow chart below. Schistosomiasis does not only result from the presence of infected snails harbouring the Schistosomes that determine its distribution and people but also from the habits, customs and traditions of the local population. If human behaviour could be changed so that they stop contamination of water bodies with urine and faeces containing Schistosome eggs, and

contact with infected lake water is avoided, then transmission of the parasite would cease. Infection and re-infection with Schistosomiasis can only be avoided if communities or individuals have good knowledge about the life cycle and control methods. Figure 1.6.1: Flow chart for conceptual frame work.

Independent variables: Schistosomes and suitable intermediate host, Intervening Individuals variables: behaviour, socio- Knowledge, economic, Attitude and demographic Practices factors, and sanitation variables (watersupply and sewage disposal) Dependent variable: Schistosomiasis

CHAPTER TWO: LITERATURE REVIEW 2.1. LIFE HISTORY AND TRANSMISSION. The life cycle of Schistosomiasis consists of an asexual reproduction stage in the intermediate hosts (fresh water snails) and a sexual reproduction stage in the definitive hosts (man) which under favourable conditions takes 80 days (Katz & Almeida, 2003, Ministério da Saúde, 2005). The four major schistosome species responsible for human Schistosomiasis in the world are Bulinus for S. haematobium, Biomphalaria for S. mansoni, Oncomelania for S. japonicum and Neotricula for S. mekongi (Xu J-F, et al. 2013).

It is the distribution of the snails that determines the distribution of Schistosomiasis in any given areas or country. They typically live in rivers, streams, dams or ponds, but can inhabit virtually any body open water where there is appropriate vegetation, including large artificial or natural lakes. In Lake Albert in Uganda, for example, transmission occurs both close to the shore where Biompalaria lives on reeds close to the surface and at some distance into the lake where in lives on vegetation at the depths of several metres.

Much of the schistosome life cycle takes place in the aquatic environment. When eggs called ova excreted in large numbers in urine and/or faeces of infected individuals, reach freshwater, they hatch releasing a free swimming larva called miracidium which seek out and penetrate a suitable intermediate host (snail) in which to continue development (Rollinson and Southgate, 1987; Rollinson and Johnston, 1996). Those ova that do not reach water are soon desiccated and play no part in transmission.

Within the snail, the parasite develops and multiplies asexually into large numbers of fork-tailed infective forms called cercariae. The cercariae are shed from snail during the day, as water temperature rises and as light increases where they may survive for 2-3 days. Thus the peak cercarial densities are found dueing the middle of the day and it is the time when water containing infected snails is most infectious.

People get infected when they come into contact with water containing cercaria during bathing, washing clothes, collecting water, playing or swimming, while some adults such as fishermen/women, canal cleaners and boat transporters may be occupationally exposed at high levels (Enk et al. 2004; Massara et al. 2008). In about one minute upon contact, the cercariae penetrate directly through the skin, losing its tail and transforming into Schistosomula which stay in the skin for two days before migrating via the blood stream, first to the lungs and then to the liver, where they are about 10 days after infection. Here they mature into female and male adult worms and form pairs, migrating against the flow of hepatic portal blood to the small venules draining the large intestines in case of S. mansoni or the bladder in case of S. haematobium within 4-6 weeks of infection. Once established, adult worm have a mean lifespan of 3 years for S. haematobium to 7 years for S. mansoni (Fulford et al., 1995).

The female of the paired adult worm lays several hundred eggs per day starting at 6 for S. mansoni to 10 for S. haematobium weeks after infection and each contains a larval form called miracidium surrounded by a hard shell with a characteristic spine but many of the eggs fail to leave the body and get trapped in various tissues and organs such as the liver and bladder (Loker, 1983). The eggs that lodge in the tissues elicit the development of a cell mediated granulomatous reaction which with

its subsequent fobrosis is responsible for the chronic clinical manifestations of disease such as generalized lymphadenopathy, hepatosplenomegally, gastrointestinal bleeding, myelopathy. Acute Schistosomiasis is usually a mild, self-limiting condition but can be severe and symptoms may include fever, rigors, sweating, headaches, muscular aches, skin rashes, weakness, malaise, unproductive cough, abdominal pain, nausea, vomiting, diarrhoea and weight loss (Wilson et al 2008). Alternatively, the eggs are passed out through the intestine or bladder in faeces or urine. Upon cantact with water, the eggs then hatch, releasing the free living miracidium, which swim actively until they encounter an appropriate snail host (Ongom and Bradly, 1972; Wallace2000; Cook, 2003). In Africa, humans are mainly responsible for maintaining the infection in the environment through indiscriminate deposition of contaminated faeces and urine in the nearby bush or water bodies (Graeff – Teixeira et al.; 1999; Schistosomiasis prevention and hygiene, 2009), and the susceptibility of other mammalian species (non-human primates) to the infection (Alarcón De Noya et al., 1997.; Theron and Combes, 1995.; He et al., 2001.; Webster et al., 2006.; Crosby and Garnham, 2009.; Hanelt et al., 2010; Standley, CJ. et al 2011) .

2.2 KNOWLEDGE ABOUT SCHISTOSOMIASIS Assessing the knowledge, attitude and practice of residents of Schistosome endemic areas about Schistosomiasis is critical in prevention and control of the spread.

In other studies which examined the knowledge, attitude and practice of the locals on schistosomiasis, most people attributed it to contact with contaminated water and lack of sanitation, but they did not relate it to

the presence of suitable freshwater snails in the water and therefore continued with their basic survival activities such as agriculture, fishing and other essential activities like bathing, washing clothes, utensils (Ndamba, et al,1989; Rosenberg, 1994).

In Nigeria, Useh and Ejezie (1994) showed that 92% of respondents admitted knowledge of the disease (in their local language), although none of them knew about the etiologic agent. About 82% of the respondents admitted procuring medication while 15.2% did not seek treatment of any kind.

Coura-Filho. P, (1998) cited ineffectiveness of knowledge. He found that after two centuries in contact with water, the community was not aware of the role of water in the transmission of Schistosomiasis as only a small proportion (4.6%) attributed it to bathing and washing in the river.

According to Wagatsuma, et al (2003), there was discrepancy between knowledge and infection rates in Ghana, for which he said knowledge was necessary but not sufficient for the eradication in restricted areas. Educated and informed people were able to adopt control and preventive strategies at personal level even if it required reducing their contact with contaminated water source or making water safe for drinking (Medical ecology, 2009).

Similarly, Kabateraine (2006) found out that the local knowledge of the cause did not necessarily match with the biomedical understanding. Even the local informants and those associated with formal health care services were rarely able to explain or describe the life cycle and symptoms/signs associated with Schistosomiasis infection. Some communities have mistaken it for a local ailment.

In a related way an interview revealed that adults had inadequate knowledge of rational for repeated treatment for Schistosomiasis including those who distributed drugs. The low level of knowledge was justified by the continued exposure to contaminated water, high infection rate despite chemotherapy thus the need for more reinforced knowledge (Kabateraine, 2006). A similar study done about transmission risk of S. Japonicum in Brazil found that children less than 16 years had increased risk because of lack of knowledge (Xu J.F., et al. 2013).

A cross sectional study carried out in Jinja district of Uganda (2013) where a random sample of 1010 children in 12 primary schools was questioned about their uptake of PZQ , knowledge and perceptions about Schistosomiasis, support from taking preventive treatment and dangers of taking PZQ showed that uptake of PZQ in this population was very low. Fear of the side effects, lack of knowledge about Schistosomiasis transmission and prevention was rampant (Muhumuza, S.; et al., 2013).

2.3 PREVENTION AND CONTROL MEASURES The first Control Program for Schistosomiasis was initiated in 1913 in Egypt anchored on snail control where both local people and stationed soldiers were heavily infected. The effectiveness of the programme was based on the numbers of the snails killed and not reductions in the numbers of infections (Jordan, 2000). In the 1930s, sanitation was incorporated in the programme, but still the results were not convincing (Jordan and Rosenfield, 1983).

Blas et al (1989) report that the first Control Program that integrated research and systemic monitoring of its effect was implemented by Lyte in the Philippines from 1953- 1962 with the help of WHO with initial

objective of control aimed at stopping transmission. This could hardly be achieved and remains elusive even up till today.

WHO expert committee on epidemiology and control of Schistosomiasis took a holistic approach at the control of the disease and noted that comprehensive understanding of the factors of environment, demographic, social and human behavioral and economic factors is essential for the design of Control Programs that are successful in the long run (Davis, 1981; Kloos, 1985).

Before 2000, extensive and successful control measures where introduced in China, Brazil and Egypt as well as Morocco and Tunisia Since 2000 there has been a greater interest in the health and well-being of Africans, with the result that today there are more and more national programs to control Schistosomiasis. This lead to establishment of the Schistosomiasis Control Initiative (SCI) (www.schisto.org) in 2000 as a pilot program to develop national strategies for a number of African countries and in mid- 2002, SCI was awarded funds from the Bill and Melinda Gates Foundation (www.gatesfoundation.org).

In 2001, the World Health Assembly, in its resolution 54.19, proposed a target of 75-100% coverage of treatment of the at risk children by the year 2010. Six countries were selected with the support of SCI, Uganda (in 2002) and then Burkina Faso, Mali, Niger, United Republic of Tanzania and Zanzibar, and Zambia (in 2003) and made the following progress:- National plans have been developed; high level political commitment has been achieved and Schistosomiasis Control and school health were placed in Health Sector Strategic Plan; local government level administrators have been informed as to the effects of these infections and the value of treatment; teachers and community health workers were trained to administer these drugs to selected populations; 10

substantial reduction in infection and morbidity in six African countries (up-to one million children and adults have been treated in three of the poorest countries in West Africa Burkina Faso, Mali, Niger) and over two million, treated in Uganda, Uganda commenced annual deworming of children through “health days” scheduled in October but however both infection and disease are increasing in the continent as a whole (Fenwick et al, 2009).

Resolution CD49.R19 of the Pan American Health Organization (PAHO) (2009) a strategy for control of Schistosomiasis was approved. It urged Member States to commit themselves to eliminate or reduce neglected diseases and other infections related to poverty to levels so that these diseases are no longer considered public health problems 2015 with the cardinal objective of reducing morbidity and mortality to levels below public health significance by implementation of specific measures. Morbidity control will not only reduce the number of the infected but it will also drastically reduce environmental contamination with the eggs even when cure is not attained. A drastic reduction of the population of the environment with the eggs would also reduce the chances of transmission; should this occur at a level below public health importance, the probability of eventual elimination of the disease is certain with a sustained integrated approach. Such implementation may involve specific technical intervention and perhaps legislation to enforce compliance.

In researches done in Brazil, most control programs adapted an integrated approach of diagnosis, treatment and control of snails. This involved the use of boots during field work, public health education, sanitation, community based chemotherapy using PZQ and drinking safe clean water (boiling, filtering, and holding water in storage tanks and

containers for 24 hours), heating bathing water (WHO, 2002; CDC`s fact sheet on Schistosomiasis, 2009).

The most striking fact relevant to control is that if human behaviour could be changed so that they stop contamination of water bodies with urine and faeces containing Schistosome eggs, then transmission of the parasite would cease. This fact is central to many longer-term control efforts. In theory, the breaking of the Schistosome life cycle is remarkably easy, whereas in practice, it is extremely difficult at the community level among poor and underserved populations. In this regard, isolated or combined measures could be taken (Coura & Amaral 2004).

With the advent of praziquantel as a safe and efficacious drug for the treatment of Schistosomiasis, WHO 1991 reinforced its 1984 recommendation to shift from transmission control (focusing on the prevalence of infection) to morbidity control (lying emphasis on intensity of infection) (Bruun and Aagaard Hansen, 2008).

Majority of the 76 Schistosomiasis endemic countries of the world are still unable to adopt health policies that might reduce the transmission of the parasites due to lack of funds except Brazil, Chine, Philippines, Iran, Morocco, Egypt, Venezuela and Tunisia. China used three approaches of mass community deworming with PZQ, snail control and extensive health education program in place (CDC`s fact sheet on Schistosomiasis, 2009). Unlike China, Japan used good sanitary practices in controlling human excreta and health education that brought the number or the infected people below the limit necessary for transmission (Medical ecology, 2009).

The treatment campaign had been developed since 1999, but after training, implementation commenced in 2003 when the Vector Control

Division of the Ministry of Health received supplies of Praziquantel (PZQ) and Albendazole from Schistosomiasis Control Initiative (SCI) and this was integrated with Measles campaign in children (Ndyomugyenyi and Kabatereine, 2003). In one week, approximately 8 million children were de-wormed and received their measles vaccination, and this program has become an annual event. The control and preventive methods need coordinated health education, remarkable out reaches and extensive knowledge of ecology of the snails involved in the life cycle of the parasite, good political will and funding (Ndyomugyenyi and Kabatereine, 2003). Since then drug treatment using PZQ is the sole preventive and control method for Schistosomiasis in Uganda.

There is a consensus of opinion in the model of Schistosomiasis control and that it should be integrated with special emphasis on those methods that are accessible, affordable, acceptable and capable of yielding high levels of sensitivity and specificity as discussed below (King and Stothard et al, 2009; CDC`s fact sheet on Schistosomiasis, 2009)

2.3.1 POPULATION BASED CHEMOTHERAPY Medication treatment is still the most efficient method (Date et al., 2007). It is believed that the use of chemotherapy against Schistosomiasis started with Christopherson (1918) who reported a successful treatment for the urinary form of the disease caused by S. haematobium using tartar emetic. After that, several other antimony compounds were introduced for clinical use (Cioli et al., 1995, Parise-Filho & Silveira, 2001) and they were the most used medicines until the Second World War (Brindley, 1994). Chemotherapy has become the only widely used method at present in endemic areas for the control of morbidity due to Schistosomiasis.

At the beginning of the 1970’s, pyrazinoisoquinoline derivatives e.g. praziquantel were tested as antiparasitic drugs (Andrews, 1981). The first clinical studies took place in 1978 in cooperation with WHO, in endemic regions for S. mansoni, S. haematobium, S. japonicum and S. intercalatum (Katz et al., 1979, Davis et al., 1979, Ishizaki et al., 1979). In 1984, cure rates had improved over 80% for all the Schistosomiasis species (Wegner, 1984). It was also found out that praziquantel was well tolerated by patients of all ages with different clinical forms of Schistosomiasis (Frohberg, 1984, Bassily et al., 1985), having light side effects on them (Cioli, et al., 1995). Other studies indicated low toxicity and no mutagenic risks (Frohberg, 1984, Kramers et al., 1991). Those screenings clearly established praziquantel as the drug of choice in the treatment for Schistosomiasis (Cioli & Pica-Mattoccia, 2002). In addition, it was the first anthelmintic to fulfil the WHO requirements and recommended for the treatment for all the species of Schistosomiasis (Silva et al., 2005).

The WHO (1993) identified four approaches in the administration of chemotherapy program namely:-  Mass treatment: Treatment of the entire population. This is often limited by availability of finance.  Selective population treatment: Treatment of infected persons identified by a diagnostic survey of the whole population.  Selective population treatment: Treatment of all or infected members of a high risk age or occupational group.  Phased treatment: Use of the above strategies in a sequence of progressively greater selectivity. It is recommended that treatment should be administered to school children who are most vulnerable group through the school system.

Even with readily available drugs, the pervasiveness of the intermediate host snails and the ease at which re-infection occurs has hampered attempts to manage the disease in many places (Standley et al. 2009; Fenwick, 2009; King, 2009).

Results of the 2003 Uganda National Control Program in which some 400,000 individuals including both adults and children were treated annually for three years showed that awareness had increased many folds, prevalence of infection in the heavy infection group has been reduced, but most striking the prevalence of heavy intensity infections had fallen significantly . The Schistosomiasis Control Initiative and the Ugandan scientists were working out what to do next, and how many treatments need to be carried out in relation to pre-treatment prevalence and intensity in order to reduce morbidity (Brooker et al., 2004).

It is noteworthy that, although the side effects of PZQ are considered to be mild and transient (Coura & Conceição, 2010), they are a major factor discouraging people from taking the drug (Fleming et al., 2009; Garba et al., 2009; Souza-Figueiredo et al., 2010).

Similarly a cross sectional study carried out in Jinja district of Uganda (2013) in primary schoolchildren found that uptake of PZQ in this population was very low due to fear of the side effects (Muhumuza S., et al, 2013)

Due to the above, it is necessary to develop new effective Schistosomicidal drugs. The most recent researches on new compounds or drugs with Schistosomicidal activity have already been carried out the following researchers (Abdulla et al., 2007; Kuntz et al., 2007; Sayed et al., 2008; Caffrey, 2007; Xiao et al., 2007; Van Nassauw et al., 2008;

Keiser et al., 2009; El Ridi et al., 2010; Eissa et al, 2011). At the present moment there are no clinical assays with these compounds.

2.3.2 SNAIL CONTROL USING MOLLUSCICIDES. The intricate relationship between snail and Schistosome make this part of the life cycle vulnerable to control activities, and there is a long history of attempted snail control using chemicals (molluscicides) to kill snails (Paulini, 1958; Ferguson, 1961; Crossland, 1963; Go¨ nnert, 1967; Barnish, 1970; Sturrock, 1995). Biological and environmental manipulation of the habitat to reduce snail numbers has been considered and targeting of specific intermediate snail hosts is a challenge for the future (Berg, 1973; Frandsen, 1987; Ault, 1994; Pointier and Jourdane, 2000; Pointier and David, 2004). The efficiency of focal molluscicide treatment against Schistosomiasis re- infection in an irrigation scheme and in small dams’ area in Mali has been undertaken (Werler, 1989). The cost factor alone was sufficient to reject focal molluscicide treatment especially at the Plateau Dagon since transmission starts at the end of the rainy season if there is still water in the dams by then and slows down in the cool dry season.

There is currently no perfect molluscicide because it is not easy to develop a molluscicide with the basic requirements laid out by the WHO (1965).

Joubert and Precious (1991) noted that though molluscicides have a marked potential, there are a lot of problems mitigating against the application of chemical molluscicides particularly in sub-Saharan Africa. It is not likely that community participation would be guaranteed for the purpose of focal mollusciciding in endemic areas. The other problems are high illiteracy rate and cost of procurement of molluscicides.

2.3.3 MODIFICATION OF THE WATER-RELATED ACTIVITIES OF RESIDENTS OF AN ENDEMIC AREA Several studies have confirmed a strong link between the water related activities of residents of Schistosome endemic communities and the prevalence and intensity of infection.

In Nigeria, Useh & Ejezie (1999b) showed that intensity of infection was more closely correlated with the number of water contacts than with the total duration of exposure, emphasizing the importance of specific/multiple activities, and of the surface area of the body submerged in transmission. The application of the results of a study like this may change the attitude of the residents by encouraging them to avoid activities that expose them to infection.

In Zimbabwe a study by Chandiwana and Woolhouse (1991) showed that water contact rates were related to age (highest in 8-10 years old). Their results provide strong quantitative support for control programmes aimed at heavily infected sites (e.g. focal mollusciciding) or at the minority of individuals making most water contact (e.g. targeted chemotherapy).

Use of rubber boots during fieldwork practiced by few people may reduce the disease but transmission is not stopped as many people still come in contact with contaminated (WHO, 2002).

2.3.4 GOOD SANITATION AND PROVISION OF CLEAN SAFE WATER SOURCES. At the global level, the disability-adjusted life years (DALYs) from insufficient water, sanitation and hygiene (including contact with Schistosome infested waters) suggested that 4% of all deaths and 5.7% of the total disease burden can be attributed to these largely preventable 17

conditions. However, with the emphasis placed on morbidity control of Schistosomiasis using population-based chemotherapy, there is less focus on interventions related to safe water supply and sanitation, which in theory could contribute to controlling transmission of all helminthes and many other infections (Prus et al., 2002).

Bruun & Aagaard (2008) noted that the establishment of safe and adequate water supply and sanitation facilities at household and village levels has an effect on domestic utilization patterns, but the relationship to prevalence of Schistosomiasis remain complex.

2.3.4.1 Good Sanitation Quite often sanitation is viewed and accepted as being very expensive but it is not known what proportion it would make up compared with sums of money spent on classical measures for the control of Schistosomiasis.. Considering the high reproductive potentials of the parasite where a single miracidium produces thousands of cercariae means a small proportion of human waste containing parasite eggs, reaching snail infested water is sufficient to maintain effective transmission in an area and therefore sanitation has tremendous benefits not only in helping to control Schistosomiasis but other endemic tropical diseases associated with fecal-oral route of transmission (Hotez et al., 2006). The provision of latrine facilities does not imply that they are always used by everybody as intended (Asaolu & Ofoezie, 2003).

In a related study in Eygpt, el Katsha & Watt, (1997) showed that overall infection levels were higher in the village without a sewage system. When measured at household level, there was a statistical significant relationship between infection levels and the absence of sewerage connections, but in the better drained village, there was no similar significant correlation. Even though only a third of households were 18

connected to the sewerage system in this village, the system had contributed to lowering the water table to the benefit of the general village environment. Good sanitation and proper use of high quality latrines for disposal of excreta was not only a key in the control and prevention of a number of water borne infections and raise the sanitation standards but was also paramount in reducing infections from Schistosomiasis. A single annual dose of PZQ tablets was incorporated to prevent the transmission as the disease is not easy to eradicate (The Carter Centre Schistosomiasis Control Program, 2009).

Poor excreta disposal from contaminated persons in the bushes or in water has far reaching effect on the transmission of Schistosomiasis as majority (53%) had no pit latrines (Uganda Demographic Survey, 2000). In a related study in Brazil, Andrei et al (2006) found that 12.6% of the 153 participants (142 students and 11 teachers) reported no toilet and the bushes being cited as the place of defaecation.

2.3.4.2 Provision of clean safe Water sources The provision of alternative sources of safe water, such as piped water, wells, water tanks and laundry areas for domestic and recreational uses, contributed to effective reduction in the rate of transmission and re- infection in population of about 2000 that had previously been dependent on water from infected streams and rivers (Kloos et al., 2008). The authors concluded that an adequate, reliable, and convenient supply of water can reduce the transmission of S. mansoni and should be considered as a control measure in other endemic areas.

A comprehensive water delivery system consisting of a water outlet to each house, communal laundries, shower facilities, and play pools, coupled with health education were studied to determine the role they could play in the spread of Schistosomiasis in St Lucia, West Indies 19

(Jordan, 1988). After a 4 year period, the incidence of new S. mansoni infections among children aged 2-5 years fell from 19.3% to 4.5% while over the same period in villages served by a standpipe system the incidence fell only slightly from 16.5% to 14%.

In a related study in Cameroon, Ndamkou and Ratard (1990) investigated the role of sanitation, water supply and a Health Centre in the control of Schistosomiasis. The authors noted that these parameters were effective in reducing the prevalence of Schistosomiasis infection. In a different focus in Cameroon, Tchuem et al (2001) studied the impact of installation of a water pump on Schistosomiasis transmission. They concluded that Schistosomiasis focus evolve dynamically, and demonstrated that changes in water supply, in association with other actions such as repeated chemotherapy, may have a profound effect on disease transmission.

In Euthiopia, because of low quality drinking water and latrine coverage, helminthes infections are the 2nd most predominant cause of outpatient morbidity (Kumie A., Ali A., 2005; Tadesse, Z., et al, 2008). A cross sectional study in Zarima town among elementary schoolchildren in Euthiopia found a high prevalence of Schistosomiasis and still a major health problem in the study area (Kumie A, et al, 2009).

A study in Kenya that installed community standpipes and a shower unit at the local school observed that the new water sources had a great influence on some villagers water contact behaviour and very little on the rest of the villagers (Noda et al., 1997). El Kholy et al (1989) investigated the effects of borehole wells on water use in a high prevalence area in Kenya, which showed no short-term effect on the transmission of S. haematobium, but a significant number

of households changed to borehole water for drinking, cooking and dish washing. A clean source of water would limit the possibility of contacting parasitic, viral and bacterial diseases. Where borehole water is provided, no mechanism is often in place for the maintenance of the facility. When it malfunctions, the residents resort to infested water bodies and become infected and the cycle of infection continues. There is also the need to take care of the recreational needs of the residents where piped water is available.

Some people with safe water source have continued contact with the contaminated water source because these sources provide plenty of water for use and therefore eliminated the need to draw clean water from protected sources (Miranda et. al, 1998). The lack of clean protected water sources in some endemic areas means that there is no alternative but only to use the contaminated lake water. This was evidenced by Marandino (2002) in Brazil where he found out that use of contaminated water for consumption posed a risk for transmission as only 39.5% of the participants reported use of clean water. This is true for Butiaba landing site (Uganda Demographic Survey, 2000) but since then Uganda Red Cross has provided piped clean water source in the area at a user friendly rate but still the majority of the people use the lake water as others say they cannot afford to buy or connect water to their residence due to lack of money.

Livelihood is one of the contributing factors as people are involved in activities such as irrigation, fishing and boat transport on these infected water sources (Rozenberg, 1994). A similar report also cited people saying ‘’without fishing, they would die’’ (Kabateraine, 2007).

Water supply management and sanitation could also be effective, however the cost and lack of political will and community motivation has made these approaches difficult to implement in the majority of the endemic countries (Limae, et al 1987 and Closs, 1995).

2.3.5 HEALTH EDUCATION A systematical approach is required in order to properly educate the residents of Schistosomiasis endemic areas to buy into the project through health educational planning. Children are known to carry the greatest burden of Schistosomiasis and soil transmitted infections. To meet this objective, Bundy and Guyatt (1996) summarized the key points to be taken into consideration when addressing health education in schools. It should be aimed to: Create awareness about the existence of the diseases and build a bridge between scientific understanding of disease and children’s perception of the disease in their everyday lives; foster in children an understanding of what is healthy living, and what they can do to promote and practice this for themselves and their communities; give children practical skills in recognition of disease in themselves and their families, and in how to protect themselves and the community against such diseases; encourage children’s sense of responsibility for their own health and that of their families in the future. It is on this basis that the WHO recommended that the school system should be the focus in mounting intervention against these disorders (WHO, 1990).

Fleming et al, (2009) emphasized Health education as an essential component of any disease specific control programme that is receiving increasing attention especially when diagnosis and drug treatment is undertaken through the primary SCI

In Cameroon, Kamga et al (2003) assessed a health education strategy in the control of urinary Schistosomiasis. School children given health education were found to be significantly less infected than those who had no health education. The investigators concluded that health education through the framework of a school could be adopted as a national policy for urinary Schistosomiasis Control Programme in tropical developing countries, planned with school children as full partners, provided that they received appropriate orientation.

In Uganda an attempt was made to integrate chemotherapy with Health Education in 2004 but this was not repeated in 2005 and to-date, health education has not been prioritized (Kabatereine, 2006). Simonga, (2009) In a related study in Uganda recommended future efforts to include clean water, adequate sanitation as well as health educational issues in the control and prevention strategy.

2.3.6 DEVELOPMENT OF A SCHISTOSOME VACCINE Due to the slow progress towards controlling Schistosomiasis using effective chemotherapeutic agents and the possible development of resistance to PZQ and other compounds, as well as rapid re-infection and the overall economic cost, it is important that demand for other approaches like vaccination be pursued (Coles et al., 1987).

Butterworth et al (1992) argued that the aim of vaccination is to reduce morbidity as several investigations have confirmed that the severity of clinical disease is dependent on intensity of infection rather than simply the presence or absence of infection (Lehman et al, 1976 ; Chen and Mott, 1988) implying that even an incomplete immunity may be of considerable value. As noted by Curwen et al (2004) and Dillion et al (2006), current advances in post-genomic techniques are providing new avenues and 23

hope to identify the secreted and surface exposed antigens that mediate protection.

No vaccine is yet available, but a ‘therapeutic’ vaccine to prevent reinfection among infected and treated children against S mansoni using the antigen Sm28 GST is undergoing a phase 3 efficacy trial in Senegal (INSERM, 2009). Other candidate vaccine antigens exist and have been tested in animal models, while new ones are being identified through genome studies (McManus and Loukas, 2008)

CHAPTER THREE: METHODOLOGY 3.1 STUDY DESIGN This was a cross sectional qualitative study where data was collected using questionnaire which were directly answered or filled by the respondents living in Piida B village.

3.2 STUDY AREA 3.2.1 Location and Size The study was done at Piida B village in Butiaba landing site, Butiaba parish, Butiaba Subcounty, Buliisa District, in Western Uganda with its headquarters 320km from Kampala. Buliisa district was curved out of Masindi district in July 2006. The district mainly lies in the Western rift valley in the Albertine area where lots of oil deposits have been discovered, with the highest point being at 1800 meters and the lowest point (in Lake Albert) at 682 meters above sea level. It is situated between 1023 and 20210 North of the equator, longitude 310 241 and 330 24 east of Greenwich meridian and bordered by Nebbi and Nwoya districts to the North, Masindi and Kiryandongo Districts to the East, Hoima to the South, and Democratic Republic of Congo to the west. Buliisa District covers an area of 3200 square kilometers comprised of open water and land. It is surrounded by Lake Albert, with the bigger part of the land area occupied by Murchison falls national park, Bugungu game reserve and Budongo forest and many escarpments with steep slopes and wide valleys. Butiaba landing site where the study area is located used to be one of busy Ports in Uganda in the 1960s - 1980s. To date, it is still the busiest and 3rd populated Sub-county after Biiso and Ngwendo in the District as well as having almost all the tribes in Uganda

3.2.2 Topography and Climate The hydro geological conditions in some areas, covering about 70% of the district, do not allow simple low cost water supply using spring catchment or dug wells, and boreholes remain the only effective means to meet the water requirements in those parts of the district. Lying in the rift valley area and being surrounded by lake Albert and many escarpments with steep slopes and wide valleys, as well as having sandy soil which is unstable and easily collapses makes the whole of Butiaba Sub-county flood during the heavy rainy seasons. The District receives a bimodal rainfall pattern with totals ranging from about 800mm in the Lake Albertine rift valley rising rapidly further away to the East above the escarpment to between 1250 – 1500 mm per annum before tapering off to 1000mm in the Eastern border areas of the District with peak periods are between March – May and September to December. This presents a very important potential for agricultural development in the crop-growing areas. Majority of the population depend on subsistence farming, fishing and rearing animals (Source: community information system 2009). 3.2.3 Health services: Buliisa district has seven Government owned Health centres and 02 (two) private not for profit (PNFP) health units. Butiaba Parish has three health centre II with the study village having one health centre II (Source: District Director of health Services Office 2009). 3.2.4 Water and Sanitation Safe water coverage in the district is approximately 49%, but with wide disparities between the different sub-counties. Latrine coverage along the Lake Albert shore is low (47%) and easily collapse during heavy rainy seasons. Diarrhoea diseases rank the 3rd in the top ten disease burdens amongst admitted cases in the District pointing to serious water and sanitation related problems in the District. The rural people have little access to safe water compared to those in urban areas like Biiso centre, 26

Butiaba, Bugoigo, Wanseko and Buliisa Town Council. Along the lake shore areas despite being an urban area, the communities at Butiaba, Bugoigo, and Wanseko, sanitation is extremely poor with majority of the people using the lake as the main drinking water supply which is neither boiled nor treated because the safe water sources are sold. With all the above, intense sensitisation campaigns are required for any improvement to be reasonably expected (Source: community information system 2009).

3.3 STUDY POPULATION This consisted of all the residents of Piida B village from fifteen years of age and above.

3.4 SAMPLE SIZE The sample size was calculated using Kish and Leslie formula (1965).

2 2 n=Z PQ/d Where n = the required population size for the study. Z = 1.96 (A confidence interval of 95%). P = Proportion of the population with the desire characteristics (>15 years) of Piida B village with a total population of 3030 and 642 households (Source: community information system 2009) is :- From proportion of children <15 years old = 0.48 X Total population of the village = 0.48 X 3030 = 1454. Then those ≥ 15years and above is 3030 – 1464 = 1576, of which those with desired characteristic Is assumed to be = 0.2. Therefore P = 0.2 D (Degree of error or desired precision) = 5% (0.05) Q (Estimated proportion of study population without the desired characteristics) = 1- P. Therefore Q = 1.0 - 0.8 = 0.2 There n = 1.962 x 0.2 x 0.8/0.052 = 246 respondents.

3.5 SAMPLING METHOD In order to systematically select 246 of your 1576 respondents (sampling frame) with the desired characteristics, I divided the 1576 by total number of households (642 instead of 246respondents i.e. 1576/642 = 3, meaning I took every 3rd of the households. I chose number 2 which is between 1 and 3 as a starting point and took every 3rd household thereafter. I took household numbers 2, 5, 8, 11, 14, 17, 20……243.

3.6 STUDY TOOL Both closed and open ended questionnaires with three sections included for demographic, knowledge and attitude and practices and pre-coded for easy data entry into the computer, analysis and privacy of the participants.

3.7 DATA QUALITY CONTROL Pre-testing of the questionnaire was done involving 25 respondents of similar study group to test for reliability and validity of the study tools and adjustments were made accordingly.

3.8 DATA PROCESSING AND PRESENTATION Data was checked for completeness, organised, cleaned, entered and presented in form of tables, figures and charts.

3.9 DATA ANALYSIS Statistical Package for the Social Sciences (SPSS) and Excel were used to analyse the data.

3.10 INCLUSION CRITERIA All the residents of Piida B village fifteen years and above of age.

3.11 EXCLUSION CRITERIA  Children less than 15 years old.  Visitors  Health workers.

3.12 ETHICAL CONSIDERATION A letter of introduction was obtained from the Dean Faculty of Clinical Medicine and Dentistry, Kampala International University Western Campus after approval of my proposal by my supervisor. Permission for data collection was sought from the DHO-Buliisa District who gave me the go ahead. Written and verbal informed consent was obtained from the participants. Participants were assured of confidentiality by not including their names.

3.13 STUDY LIMITATIONS  Limited time frame allocated for the research  Some respondents refused to be interviewed.

3.14 DISSEMINATION OF RESULTS • District Health Officer - Buliisa District Local Government. • Department of Public Health and Community Development - Buliisa District Local Government. • Buliisa Health SubDistrict. • Butiaba Sub-County • Butiaba Health Center II • Local Council Chairperson 1 Piida B village • An appropriate journal for publication. • Belgian Technical Corporation • Supervisor.

CHAPTER FOUR: RESULT A total of 246 respondents were interviewed and the results categorised under demographic characteristics, knowledge and attitude and practices towards the prevention and control schistosomiasis. TABLE 4.1: DEMOGRAPHIC CHARACTERISTICS OF THE RESPONDENTS VARIABLES FREQUENCY PERCENTAGE Age group (Years) <20 49 20 20-29 84 34 ≥30 112 46 Sex Male 127 52 Female 119 48 Level of Education Non 46 19 Primary 160 65 Secondary 40 16 Tertiary 0 0 Occupation Housewife 70 28 Fishing 101 41 Business 56 23 Others 19 8 Years lived at Piida B village <1 years 7 3 1-5 years 71 29 ≥5 years 168 68 TOTAL 246 100

As noted from the table above, a total of 246 respondents with almost equal sex distribution of 127 (52%) males and 119 (48%) the females were interviewed of whom 168 (68%) have lived in Piida B village for over 5 years. The majority 196 (80%) were aged 20 years and above 206 (84%) had no or primary education dropout while 40 (16%) had secondary education with 101 (41%) having fishing as their main occupation followed by House wife 70 (28%).

4.2: KNOWLEDGE OF RESPONDENTS ABOUT SCHISTOSOMIASIS Figure 4.2.1a: Column showing if respondents ever heard about Bilharzia.

250 215 (87%) 200

150

100 31 (13%) 50

0 Yes No

Majority 215 (87%) of the respondents have heard about Bilharzia compared to 31 (13%) who have never heard about it

Figure 4.2.1b: Pie chart showing the source of information.

14 (7%)

Local Council

67 (31%) Health Worker

134 (62%) Media

Of the 215 respondents, 134 (62%) heard about Bilharzia from Local Council-1 compared to 67 (31%) from the health worker and 14 (7%) heard from the media.

Figure 4.2.2: Pyramid showing if Bilharzia exists.

228 (93%) 18 (7%) 100%

80%

60%

40%

20% 0 (0%)

0% Yes No Not sure

228 (93%) of the respondents believe that Bilharzia exists compared to 18 (7%) who were not sure about its existence.

Figure 4.2.3: Line graph showing if respondents are aware of Bilharzia worms in the lake water.

250 216 (88%) 200 150 100 50 20 (8%) 10 (4%) 0 Yes No Not sure

216 (88%) were aware of Bilharzia worms in the lake water, 20 (8%) not and 10 (4%) were not sure.

Figure 4.2.4: Column showing if Bilharzia is acquired by contact with infected water

225 (91%) 250 200 150 100 21 (9%) 50 0 0 TRUE FALSE NOT SURE

225 (91%) of the respondents reported contact with infected water predisposes one to get Bilharzia compared to 21(9%) who were not sure.

Figure 4.2.5: Cylinder showing if Bilharzia is spread by contamination of water with faeces and urine of infected persons.

208 (85%) 250

200

150

100 25 (10%) 13 (5%) 50

0 TRUE FALSE NOT SURE

208 (85%) reported that Bilharzia is spread by contamination of water by infected persons defaecating and urinating in the lake water or nearby bush.

Figure 4.2.6a: Cone showing if Bilharzia be prevented.

212 (86%) 300 200 7 (3%) 27 (11%) 100 0 Yes No Not sure

212 (86%) of the respondents say Bilharzia can be prevented compared to 7 (3%) who say no and 27 (11%) who are not sure.

Figure 4.2.6b: Line graph showing prevention and control methods.

214 212 (100%) 212 (100%) 212 210 209 (97%) 208 210 (99%) 206 204 202 201 (92) 200 198 196 194 Use Avoid Proper use of Use Use drugs protected contact with pit latrine protective water source infected gadgets water

Of the 212 respondents, over 201 (95%) reported that Bilharzia can be prevented by use of protected water sources, avoid contact with infected water, proper use of pit latrines for defaecation and urination, protective gadgets for fishing and treatment with drugs.

4.3 ATTITUDES AND PRACTICES TOWARDS PREVENTION AND CONTROL OF SCHISTOSOMIASIS Figure 4.3.1a: Pie chart showing respondents with of pit latrine in use at home.

Yes 60 (24%) No 186 (76%)

186 (76%) of the 246 respondents had pit latrines that where in use compared to 60 (24%) who did not have.

Figure 4.3.1b: Line graph showing where respondents without latrine defaecate and urinate.

100% 80% 60% 40% 20% 0% Neighbour's latrine Bush

All the 60 (100%) respondents without pit latrine reported using the neibgbour’s pit latrine for defaecation and urination.

Figure 4.3.2a: Pie chart showing if respondents had an urge to defaecate while in water.

Yes 63 (26%) No 183 (74%)

183 (74%) of the 246 respondents reported a feeling like to defaecate while in lake water compared to the 63 (26%) who had no urge.

Figure 4.3.2b: Line graph showing respondents had the urge and where do you defaecate/urinate.

160 140 141 (77%) 120 100 80 60 36 (20%) 40 20 6 (3%) 0 Lake water Bush at lakeshore Bucket

Of the 183 respondents with the urge to defaecate while in water, 141 (77%) did it in the lake water, 36 (20%) in the nearby lakeshore and 6 (3%) reported use of bucket which is emptied in the pit latrine when out of the lake.

Figure 4.3.3: Column showing why people continue contact with infected lake water.

250 235 (96%)

200

150

100

50 11 (4%) 0 (0%)

0 Source of Lack of No reason Livelihood knowledge

235 (96%) of respondents reported continuous contact with the infected lake water because it was their source of livelihood in term of plenty of free water for bathing, washing clothes and utensils, food while 11 (4%) gave reason of lack of knowledge about Schistosomiasis transmission.

Figure 4.3.4: Pyramid showing use of protective gadgets while in water.

190 (90%)

200

100 20 (10%)

0 Yes No

Of the 210 respondents who said Bilharzia can be prevented by use of protective gadgets (gum boots, long hand gloves) while in water, 190 (90%) reported no use of protective gadgets while in water compared to 20 (10%) who use protective gadgets.

Figure 4.3.5a: Doughnut showing acceptance to take drugs during mass deworming.

15 (7%)

Yes

197 (93%)

Of the 212 respondents who accepted that bilharzia can be prevented by treatment with drugs, 210 (93%) accepted to swallow the drugs while 15 (7%) say they would refuse because of the side effects and they don’t come in contact with lake water.

Figure 4.3.5b: Pie chart showing reasons for not taking the drugs.

Don’t enter lake water 7 (47%) 8 (53%) Sideeffects of drugs

Of the 15 (7%) respondents, 7(53%) say they would refuse because they don’t come in contact with lake water while 7 (47%) gave reason of side effects of the drug.

CHAPTER FIVE: DISCUSSION OF RESULTS. Of the 246 respondents, 112 (46%) were 30 years and above with almost equal sex distribution of 127 (52%) males and 119 (48%) the females. This was in line with prior studies done in fishing villages on Lake Albert which showed that older children and adults had very high levels of demonstrable exposure among adult fishermen but very much lower pattern of reinfection levels, arguing strongly for the development at, or shortly after puberty of immunity (Kabatereine et. al, 999). The age group 15-19 was least affected 49 (20%) probably because this is the age group are supposed to be at school or they are visitors and fear entering the lake water. 168 (68%) had lived in Piida B village for over 5 years meaning that they have had contact with the infected water for long and do not fear entering it followed by 71 (29%) who have lived between 1-5 years. 206 (84%) of the respondents did not have formal education or dropped out in primary school and continued contact with water due to limited knowledge while a few respondents 40 (16%) had secondary education and probably good knowledge on the transmission of Schistosomiasis and therefore avoided contact with the infected lake water. This agrees with other studies that found that educated and informed people were able to adopt control and preventive strategies at personal level even if it required reducing their contact with contaminated water source or making water safe for drinking (Wagatsuma, et al, 2003; Medical ecology, 2009). 101 (41%) of the respondents had fishing as the main occupation probably because the area has sandy soils which does not favour crop cultivation. This was followed by House wife 70 (28%) and business 58 (23%) because they are involved in domestic work and the business mostly is buying fish at the lakeshore meaning that they are at least

always in contact with the infected lake water as the lake is source of their livelihood.

Although the majority of the respondents 206 (84%) did not have formal education or were school dropouts, they had some general knowledge as evidenced by 215 (87%) having heard about Bilharzia from the Local Council 1, Health Worker and the media; 228 (93%) said it existed and 216 (88%) were aware of the Lake heavily contaminated with Bilharzia worms; 225 (91%) and 208 (85%) knew how it is acquired and spread respectively, and over 212 (86%) knew the its prevention and control measures such as use of protected water source, avoiding contact with infected water, proper disposal of excreta and good sanitation, use of protective gadgets while in water, and drugs. The good knowledge is probably due to continuous Health Education carried out yearly by the Health Workers, Local Council 1 and the Community Drug Distributors who are trained before mass deworming by the Health Workers and who then intensify door to door Health Education in their villages as they register eligible members who will receive the drugs before its distribution. This was in line with other studies done by, Ndamba et al (1989) in Zimbabwe, Aklil and Legesse (1989), Rosenberg (1994), Useh and Ejezie (1994) in Nigeria, where they found that a large proportion of the participants had some knowledge about Schistosomiasis but was in contrary to studies done by Coura- Filho- P (1998), Kabatereine (2006); Muhumuza, S, et al, (2013) and Xu J.F., et al. (2013) which cited inadequate knowledge on the role water plays in the transmission, prevention and control of Schistosomiasis. According to Wagatsuma, et al (2003), there was discrepancy between knowledge and infection rates in Ghana, for which he said knowledge was necessary but not sufficient for the eradication in restricted areas.

The study also found out that 186 (76%) of the respondents had their own pit latrines in use while 60 (24%) who did not have one but reported using that for neighbour’s, none reported use of the bush. However, investigator during the tour of the Lakeshore, noticed plenty of fecael matters in the nearby bushes thus confirming that much as people have latrines, it is not often used. This was in agreement with a similar study done by Asaolu & Ofoezie, (2003) where they found that the provision of latrine facilities does not imply that they are always used by everybody as intended. There was rampant contamination of the Lake with urine and faeces while in water as 183 (74%) reported the urge to defaecate and 177 (97%), actually did it in the lake water or nearby bush in lakeshore. Only 6 (3%) reported use of a bucket which is emptied in the pit latrine when they reach at home. This means there is continuous contamination of the lake despite the knowledge they have. This was in agreement with other studies done in Uganda and Brazil show, that poor excreta disposal by infected persons in the bushes or in water due to lack of latrine has far reaching effect on the transmission of Schistosomiasis (Uganda Demographic Survey, 2000; Andrei, et. al, 2006). Japan used good sanitary practices in controlling human excreta and health education that brought the number or the infected people below the limit necessary for transmission (Medical ecology, 2009). Therefore Good sanitation and proper use of high quality latrines for disposal of excreta was not only a key in the control and prevention of a number of water borne infections and raise the sanitation standards but was also paramount in reducing infections from Schistosomiasis. A single annual dose of PZQ tablets was incorporated to prevent the transmission as the disease is not easy to eradicate (The Carter Centre Schistosomiasis Control Program, 2009).

Despite 212 respondents saying that use of protective gadgets prevented and controlled Schistosomiasis transmission, it was found out that 190 did not use any and the majority questioned the use of gum boots while fishing citing the incidence of boot and canoe accidents and how one can swim with them on the legs. This means they are always in contact with the water. In researches done in Brazil, it was noted that use of rubber boots during fieldwork practiced by few people may reduce the disease but transmission is not stopped as many other people still come in contact with contaminated without protective gadgets (WHO, 2002; CDC`s fact sheet on Schistosomiasis, 2009).

235 (96%) of the respondents said they continued contact with lake water because it is source of their livelihood as it provides them with fish and plenty of water for their daily activities. This is evidenced by Rozenberg (1994) who found that livelihood was one of the contributing factors as people are involved in activities such as irrigation, fishing and boat transport on these infected water sources. A similar report by Kabatereine (2007) cited people say ‘without fishing they would die’. Lack of knowledge about Schistosomiasis transmission was also cited as the other reason for contact with infected water by 11 (4%) of the respondents. Miranda, et al, (1998), found that some people with safe water sources continued contact with infected water because it provided plenty of water for use and therefore eliminated the need to draw clean water from protected sources. Marandino (2002) in Brazil found out that lack or limited source of clean protected water in some endemic areas meant that there is no alternative but only to use the contaminated lake water which poses a risk for transmission as only 39.5% of the participants reported use of clean water. This was true for the community of Piida B who reported use of

protected water source for drinking only while for other domestic activities, they use lake water which is free and plenty. Bruun & Aagaard (2008) noted that the establishment of safe and adequate water supply and sanitation facilities at household and village levels has an effect on domestic utilization patterns, but the relationship to prevalence of Schistosomiasis remain complex.

A good proportion 197 (93%) accepted to take PZQ tablets when given. This could be true for this community because Uganda started with PZQ as the only preventive and control method (Kabatereine et. al, 2006). This was evidenced in other mass deworming reports using PZQ by Aklil and Legesse (1989), Useh and Ejezie (1994) where over 80% of the community members accepted to continue taking the drug, and in China and Uganda (CDC’s fact sheet on Schistosomiasis, 2009). However (7%) of the respondents said they cannot take the tablets because they don’t come in contact with Lake Water as well as the side effects of PZQ. This was in line with other independent studies done which cited side effects of PZQ as a major factor discouraging people from taking the drug (Fleming et al., 2009; Garba et al., 2009; Souza-Figueiredo et al., 2010; and Muhumuza S, et al, 2013.

CAPTER SIX: CONCLUSION AND RECOMMENDATIONS. 6.1 CONCLUSION In-spite of the good general knowledge about Schistosomiasis, its prevention and control still possess a big challenge because of the continued contact with the infected Lake as it is the source of their livelihood as well as contamination of lake with faeces and urine form infected individuals as reinfection rates remain very high.

6.2 RECOMMENDATIONS. 1. Continuous Health Education to human beings on the preventive and control measures especially to stop contamination of water bodies with urine and faeces containing Schistosome eggs so that transmission of the parasite ceases as well as the use of protective gadgets while entering in the lake. 2. Yearly mass deworming of the community using PZQ tablets should continue. 3. Having been confirmed as a zoonotic disease, there is need for human public initiatives and wildlife monitoring groups to work synergistically together to produce disease control strategies which are beneficial to all animals including humans at risk of contracting the disease.

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APPENDIX II: LETTER OF INTRODUCTION.

APPENDIX V: MAP OF UGANDA SHOWING BULIISA DISTRICT

APPENDIX VI: A SKETCH MAP OF BULIISA DISTRICT SHOWING BUTIABA LANDING SITE.