COMMUNITY DIRECTED INITIATIVES IN DISEASE PREVENTION AND CONTROL

The True Spirit of Alma Ata Declaration on Primary Health Care

Apr - Jun 04 Achievements, Challenges & Strategies - Some Spotlights on Onchocerciasis Control in Peace Habomugisha* Introduction “Onchocerciasis endemic districts will continue in partnership with other in- stitutions and individuals committed to fight the disease. They will endeavor to make sure that the people know and un- derstand their roles in this battle.” This was said by the LC V Chairperson of District, Mrs. Josephine Kasya, while opening a meeting of the political and technical leaders of “phases 3 and 4 districts”, which was held on 29 April 2004 in the district’s council hall. Present also were such other resource persons as Dr. Andrew Byamungu and Peace Habomugisha. This text’s pages bring us the briefest of summaries of what was the most out- standing dimension of the seminar. Namely the addresses that were given by Kasya, Byamungu, Habomugisha and various District Onchocerciasis Some of the participants who attended sustainability workshop in Coordinators (DOCs), which we present in that order. Our highlights close with • A budget has been allocated for activi- I. Execution of the activities is very a list of challenges typical of almost all ties of the program. expensive. She therefore appealed the different districts in question, a roll • A radio talk show has been sponsored to the workshop participants to of proposals for the road ahead and an on the local FM station (Radio Kinkizi) look for ways of sustaining the overview of the workshop. Before delv- to educate people about the matter; and work. ing into the particulars, let us note that the response, judging by the many II. There is need for concerted effort Kanungu lies in Western Uganda. On phone calls during the programs, has to inform people about the treat- its northern and eastern ends it is bor- been good. ment of onchocerciasis, especially dered by Rukungiri, by to the • The council works hand in hand with where and how they fit in this South, Kisoro in the Southwest and the the technical staff to realize the activi- scheme. Democratic Republic of Congo on its ties. III. Achievements made so far stand western front. threatened by the possible pull out, The Chairperson, however, cited and elabo- Focus on Major Speakers rated on challenges they were faced with: Pg 2

Kasya against her Background as Po- Published by: Global 2000 litical Leader In this Issue: River Blindness Program Despite that Kanungu District was only Achievements, Challenges & Strategies and Vector Control Division, about 3 years old, said Kasya, it had (Habomugisha)…Pg. 1 Ministry of Health, Plot 15 Bombo Road managed to carry out a number of on- Community-Perceived Benefits Typeset by: Global 2000, chocerciasis-related activities, to wit: (Ndyomugyenyi)... Pg. 4 River Blindness Program; • The DOC has sensitized the News Flash...... Pg. 7 P. O. Box 12027, district’s council members about Treatment Updates ... Pg. 7 Tel: 256-41-251025 the magnitude of the problem. Fax: 256-41-349139

* An earlier draft of this compilation received from Julie Gipwola much-needed support. For this help, the compiler is most grateful. This newsletter is supported by The Carter Center, Global 2000 and Ministry of Health - Uganda by some parties, from the partner- CDTI within the primary health care (PHC) Projects, which are likely to be sustain- ship. She appealed to such bodies, structure means implementation of CDTI ac- able, she said, are judged not only ac- however, not to withdraw abruptly tivities using resources earmarked for other cording to their effectiveness, efficiency, but gradually so that the district PHC interests such that limited or no re- simplicity and integration into the rou- council can best plan how to inte- sources would be required exclusively to tine running activities of health services. grate the onchocerciasis program fulfill CDTI goals. Their potential also is considered in into its routine. terms of two other things: staff willing- Byamungu said that it is therefore impor- ness to accept CDTI as a regular activ- Byamungu on Sustainability and In- tant for district health managers to integrate ity, which they would continue to do even in the absence of additional mate- tegration CDTI activities in the PHC structure both rial rewards; and readiness, by a given In his opening remarks, Dr. Andrew at the planning and the implementation lev- community, to see, as their own, the Byamungu, of Uganda’s onchocerciasis els, highlighting areas within the structure control department, under the Health onchocerciasis project in their area and where integration is feasible. Furthermore, Ministry, hailed Kanungu district for her to assume responsibility for it. he made mention of the many opportunities high level of commitment, by word and deed, to the control of onchocerciasis. that the health systems and service mangers Sustainability, according to He called upon other Ugandan districts, could exploit to have CDTI integrated within Habomugisha, is promoted by several where the disease is also to be found, to the PHC edifice. As examples, he cited de- interrelated factors, among them the emulate Kanungu. centralization and poverty eradication and following: our individual and corporate action plan (PEAP) as well as the existence understanding of health care, adminis- trative and community structures and A paper, “Sustainability of CDTI in the of community-based organizations (CBOs) their functional linkages, our guarantee Post-APOC Era – Challenges of Inte- and other community programs that offer that each level in the health care system grating CDTI within the Primary Health health-related services. He, however, noted Care Structure”, was presented by him. is committed to the responsibilities with that there were various threats and weak- The objective of the African Program which it is charged, our use of a moni- nesses within and outside local governments, for Onchocerciasis Control (APOC), by toring tool annually to collect data and the end of the project’s 5th tyear, he said, which could seriously hamper the prospects learn from it what works and what does is to establish an effective and self-sus- of CDTI integration into the PHC order. not (in order to do such things as gener- taining community-based ivermectin Such, clearly, are constraints that can ob- ating new ideas), our integration of com- distribution system throughout on- struct CDTI sustainability for years long munity-based health care services and chocerciasis endemic societies. The after APOC’s withdrawal. development programs into community- project aims, if possible, to eliminate the directed approaches, as well as ensur- blackfly, and hence the disease, by us- Habomugisha with More on Matters of ing bi-annual or annual meetings, which ing environmentally safe vector-control Sustainability include stakeholders at higher and lower methods in selected foci. Also speaking at the Kanungu conference, levels of different administrative, health the Uganda Country Representative of The care and community structures. Sustaining CDTI after APOC has ceased Carter Center Global 2000, Peace to fund it, noted Byamungu, was going Habomugisha, commended the district lead- On evaluation of CDTI projects, she to be a real challenge to the national and ers, attending the gathering, for their hard explained the need for doing so as a way district health system managers because work. Because they are policy makers and of ensuring sustainability once APOC of limited resources, considerable lack implementers, she expressed concern about funding comes to an end. A style of plan- of political will, poor community mobi- their low participation in advocacy meetings, ning, it facilitates mobilization of re- lization, and limited technical manage- however. She wondered how the Kanungu sources and sets in place the routines ment of the program, especially at the and similar meetings could make big impact that ensure the continuation of on- district level. Integration of CDTI pro- without input from the majority of leaders chocerciasis control. According to grams, in the mainstream routine of the of the different onchocerciasis-infected dis- APOC, projects can successfully be district health team (DHT), was certainly tricts. evaluated using specific monitoring in- the way forward for the sustainability of dicators. These are some of the traits of these activities in post-APOC time, he Sustainability of CDTI, during the post- CDTI – challenges, weaknesses, fail- emphasized. APOC epoch, was the subject of ures, strengths and successes included Habomugisha’s study, which she delivered – as it is implemented and as it grows The speaker observed that integration is to the workshop. Following APOC’s defi- or diminishes in size and viability terms, a dynamic and fluid process that requires nition of sustainability, she explained that namely: planning, leadership, observa- constant innovations so as to address the “CDTI activities in an area are sustainable tion and supervision, health mobiliza- challenges of the day. During the post- when they continue to function effectively tion (by education and sensitization), APOC period, he underscored, CDTI for the foreseeable future, with high treat- Mectizan procurement and distribution, execution was likely to differ from area ment coverage, integrated into available training, financing, transport, human re- to area and, at times, from the recom- health care services, with strong community sources and coverage. mendations stipulated in the CDTI ownership, using resources mobilized by the implementation guidelines made by community and the government” (APOC, Habomugisha revealed that APOC APOC. He noted that integration of Feb. 2004). would not support problematic projects

2 beyond five years after taking them on. Integration of onchocerciasis activities ciasis control, at every health unit. Those that show progress towards in PHC is in evidence. This has enabled the program to be sustainability will, however, not be One focal person at each health sub- more effective. abandoned completely: to them APOC district (HSD) as well as many health Implementation of CDTI is now be- may give additional backing in techni- workers, community-directed health ing done through decentralized cal terms. This may include assistance supervisors (CDHS) and community- health, political and other structures. with replacement of capital equipment, directed health workers (CDHWs) CDTI activities have been integrated capacity building to strengthen have had training in CDTI. with other health programs such as sustainability, advocacy with the aim of Operational research, on sustainability sleeping sickness, schistosomiasis committing African governments to the of CDTI in the district, has been con- and malaria. fight of the disease, external monitor- ducted; and a report is yet to be made ing and evaluation, and operational re- available. search. For the financial year 2003/04, the Funds have been released for integra- district released funds for CDTI at Participants were further briefed, by the tion of the onchocerciasis program in two levels: the district level, shil- presenter, on possible extra APOC sup- the district’s work plan. lings 1 million; and the sub-county port for the 6th, 7th and 8th years. Quali- 35 communities have done community level, for the five sub-counties of fying districts have to meet these re- self-monitoring using their own moni- Kango, Nyapea, Wadelai, quirements: they must have a 3-year, tors and indicators. Jangokoro and Paidha, shillings post-APOC sustainability plan; a 857,000. district’s national government must be The district, which has 9 onchocercia- CDTI has been integrated into the able to release funds budgeted by it for sis endemic communities, last year health care delivery structure. CDTI activities; evidence that funds and (2003) achieved 99.5% coverage of 112 health workers have had train- other resources set aside for CDTI have ultimate treatment goal (UTG) due to ing in CDTI. been used for planned programs; as well a high level of commitment of the dif- Sub-counties have integrated CDTI as implementation of recommendations ferent stakeholders at all levels. into their budgets. by external monitors for the 5th year, Intensive health education was carried and, where applicable, for year three. out through video shows. General Challenges to CDTI at Dis- Advocacy meetings have been held trict Level District Highlights and facilitated by the Chief Adminis- Some community members still do Besides Kanungu, other districts repre- trative Officer (CAO). not know about their role within sented at the April 29 seminar were Onchocerciasis has been integrated in CDTI. Hence the need for more Adjumani, Apac, Moyo, Yumbe as well the district’s work scheme; and mon- health education. as Nebbi (all in northern Uganda), etary and other contributions are al- Rebel activities in some districts, Mbarara and Kibale in western Uganda. ready forthcoming from the district. such as Adjumani and Apac, are a Yumbe and Kibale, unfortunately, never hindrance to CDTI work. had time to highlight their program per- 77 health workers have been trained. Data collection from communities formance. For the whole of the first lot, A village health team (VHT) for inte- is becoming a problem as most sub- which were able to do so, it is to their grated disease control has been cre- counties have not honored their DOCs, as hinted before, that we are ated in each community; and the ma- pledge to support community super- particularly indebted: From Kanungu jority of the CDHS and CDHW have visors. we had Lauriano Hakiri, Mbarara been absorbed into it. Little political support, especially at (Benard Abwang), Apac (Charles Apat), Primary health care (PHC) funds are the LC 1 level, e.g. in Aliba, Gimara Adjumani (Richard Amola), Moyo used to cater for all health-related ac- and Itula sub-counties in Moyo Dis- (Nicholas Ogweng) and Nebbi (Dickson tivities including CDTI. trict, is a notable drawback. Unoba). To the highlights we now go. Advocacy for CDTI has been done While the district health teams jointly with the DHT and the Assis- (DHT) usually participate in pro- Kanungu District tant Chief Administrative Officer grams where they are facilitated fi- Health education has been carried (ACAO). The resulting impact has nancially, onchocerciasis activities out effectively with the help of the been felt: for example, 2 sub-counties, often have meager or no funds as- DHT using information, education Adropi and Adjumani Town Council, signed to them. and communication (IEC) materi- have fulfilled their pledges of 84,000/ There are programs that still pay als that were distributed for the = and 132,000/= respectively. some community members for drug purpose. This has partly been re- Ivermectin procurement and supply is delivery, for example the mass im- sponsible for the attainment of high done through the health service deliv- munization campaigns against treatment coverage. ery system. measles and polio. This tends to Workshops with district and sub- demoralize CDTI drug distributors county leaders have been held. The district has recruited more health who are generally never paid for This has enhanced awareness and personnel – thereby reducing the their services. increased interest in supporting workload of the DOC. Transport is not readily available CDTI work. There is a focal officer, for onchocer-

3 for CDTI supervision across vil- ness to the affliction and the need to rein in trol into the public health care system. lages, which are too numerous. the disease. Health workers are too few and, References because they are heavily loaded The Kanungu meeting, like many a compa- APOC, Feb. 2004. Guidelines for De- with their routine duties, they make rable forum in older years, also partook in veloping a CDTI Sustainability Plan of little or no time for CDTI work, another trait of clearly important interest. the 5th Year Projects, Ouagadougou. which is partially or barely inte- It was yet one more avenue by which CDTI grated in their regular schedules. fostered the now more urgent call for inte- gration of community-directed disease con- Way Forward At the end of the workshop, participants suggested possible solutions to CDTI problems and challenges: Community-Perceived Benefits of Ivermectin Treatment in some Onchocerciasis Endemic Local governments should solicit Communities of Uganda funds from other sources to sustain CDTI in their districts. Dr. Richard Ndyomugyenyi National Onchocerciasis Task Force (NOTF) ought to consult with dis- et al., 1989). Since 1987, a private phar- tricts on how CDTI can be properly Introduction maceutical company based in the implemented. Onchocerciasis is a parasitic disease of man U.S.A., Merck & Inc., has provided In the interest of effective service, caused by onchocerca volvulus. It is a clas- ivermectin free of charge to all on- the procurement, storage and distri- sic end of the road disease, which affects chocerciasis endemic countries. The bution of ivermectin should involve rural, impoverished people with little ac- the various stakeholders at the rel- cess to health care and no political clout. In company has pledged to continue do- evant district levels. Uganda, the disease causes onchocercal nating free ivermectin as long as is NOTF should continue conducting skin disease characterized by severe skin needed. Ivermectin is a microfilaricidal advocacy meetings for district lead- itching and ugly skin lesions (Kip et al., drug and by reducing microfilarial load ers and lobbying in order to make 1992). Itching can be so severe that it dis- in the infected individuals, ivermectin them more informed about integra- turbs sleep, concentration and work (WHO, reduces transmission of the infection and tion and sustainability of CDTI. 1995). Other complications of the disease prevents onchocercal blindness and skin Nebbi District will host the next meeting in 2004.

Overview of Workshop Workshop proceedings give mixed but by no means surprising signals of the status of onchocerciasis control in the given districts. Strides, minor or great, have been taken in some areas. Achieve- ments, dazzling and promising or other- wise, are boasted. Problems and chal- lenges, of varying magnitude, do, how- ever, still stalk the anti-onchocerciasis course. All these, nonetheless, are basi- cally no new indices. Previous monitor- ing and evaluations, by internal and/or external personnel, show a generally similar trend for the northern and west- ern, as for other onchocerciasis endemic, Ugandan districts. Ivermectin records for Dr. Richard Ndyomugyenyi Uganda, over the past decade and more, copies of which are deposited in the country’s Ministry of Health, bear out that have been observed in high numbers disease. Repeated ivermectin treatment this observation. The one inspiring thing, in onchocerciasis endemic areas of Uganda is also believed to have an effect on the for each of the onchocerciasis-affected are epilepsy and retarded growth (Ovuga fecundity of the female adult O. volvu- districts, stands out: Any treatment cov- et al., 1992; Fischer et al., 1993). The mani- lus worm (Schulz-Key et al., 1986). To erage achieved, any advocacy and as- festations of the disease are caused by mi- eliminate onchocerciasis as a public sessments undertaken within and with- crofilariae and are directly related to the health and socio-economic problem in out workshops – these and other phe- intensity of the infection in the community endemic communities, ivermectin treat- nomena like them increase public alert- (Thylefors and Brinkmann, 1997; Remme ment must continue for at least 15 years,

4 with stable annual treatment coverage of Data Analysis were coming from Byeya village at least 65% of the total population. Non-computerized analysis was used to because of our bad skins. People Therefore long-term compliance is im- analyze qualitative data. A code sheet was used to think that our skins were portant to achieve elimination of the dis- created following the focus group guide, bad because we were eating wild ease. Some studies have examined the and data were coded. Then a master sheet animals, which were not supposed impact of ivermectin treatment on com- analysis was done, giving all the responses to be eaten by human beings. munity microfilariae load from the focus group discussions and in- People had started refusing to (Ndyomugyenyi, 1998; Remme et al., depth interviews. Responses were inter- emigrate to this village because 1989; Boatin et al., 1998) but few stud- preted by looking at the patterns in the re- whenever they would come and ies have examined community-perceived sponses and formulating ideas, which could find people with bad skins and benefits of ivermectin, which is impor- account for those responses. Methods used scratching themselves, they would tant for sustained high treatment cover- included content analysis, ethnographic wonder what was happening to us age. This study was conducted to exam- summaries and use of quotations. Analysis and they would continue to Kibale ine the perceived benefits of ivermectin also gave consideration to the actual words District and settle there. People treatment in rural onchocerciasis commu- used by the respondents, the context, inter- would refuse to eat with us and nities of Uganda, where ivermectin dis- nal consistency and the specific responses. would not like to marry girls from tribution was ongoing for the past 11 Quantitative data were analyzed using ver- this area. People are now marry- years, to provide information that could sion 6.0 of the Epi-info software package, ing from here because girls have be used in designing appropriate health a creation of the Centers for Disease Con- good skins. education messages that could enhance trol and Prevention, Atlanta, GA, USA. continued ivermectin treatment. Another man had this to say about the Results discrimination of people with bad skins Materials and Methods Perceived benefits of ivermectin treatment and itchiness: Study Area Overall, 151 adults were interviewed and Some people were being discrimi- The study was conducted in Kyenjojo of those 83 (55%) were females. The age nated because people thought that district where ivermectin treatment had in years ranged from 19-84 with a mean they had Acquired Immune-Defi- been the only intervention to control on- age of 39.9. The number of years during ciency Syndrome (AIDS) due to chocerciasis since 1991 – an effort that which the respondents had received hair changes and bad skins. After was supplemented with vector elimina- ivermectin treatment ranged from 0-15 with taking the drug, their hair and tion in 1995. Onchocerciasis in the area, a mean of 9 years. Nearly all, 149 (98.7%), skins become okay and are now before ivermectin treatment started, was perceived onchocerciasis to be a danger- settled well with other people. 80% and the disease manifested itself as ous disease and the reasons for perceiving onchocercal skin disease characterized so are summarized in table 1. However, Although most people perceived on- by severe itching, ugly skin lesions and after several years of ivermectin treatment, chocerciasis to be no longer a major epilepsy (Kipp et al., 1992). The inhab- 75.5 % of the respondents perceived that health problem due to the reasons sum- itants of the area are Batoro (who are the onchocerciasis was no longer a major health marized in table 1, nearly all, 145 indigenous people) and Bakiga and problem due to stoppage of skin itchiness (96%), were willing to continue tak- Bafumbira who have immigrated from (table 1). A woman aged 35 years, who had ing the drug as long as necessary until Kabale and Kisoro districts, respectively. taken ivermectin for 11 years, had this to they are completely cured. “Our skins The main economic activity is agricul- say: had turned like that of a frog. People ture with emphasis on food crops such still want to take medicine so that they as sweet potatoes, maize, , beans, I had severe persistent skin itchiness do not get bad skins again,” observed groundnuts and bananas. The cash crops and I used stones to scratch myself and a man who had taken ivermectin for are mainly and tea. sometimes I would tear my clothes 17 years. On the economic aspect of while scratching. I could not dig. It was ivermectin treatment, 129 (85%) of the Methods terrible. I used to spend a lot of money respondents perceived that people are A questionnaire was developed and pre- going to hospital in Fort Portal to get now strong enough to cultivate land tested before it was used. It was admin- medicine for my skin disease. Now I and grow crops, which they could sell istered to randomly selected adults to am cured, I can dig and get some and get money. A man aged 50 years, assess peoples’ perceived benefits of money from my crops. who had taken ivermectin for 11 years, ivermectin treatment. The questions in- had this to say: “No more skin itchi- cluded perceived severity of the disease, The disease, before control, did not only ness. Itchiness was severe and women benefits of ivermectin treatment in terms cause distressful skin itchiness, but also had would spend the whole day scratching of disease control, socio-economic fac- socio-economic implications and a stigma themselves and could not cultivate the tors and whether people were willing to to the affected individuals. A man aged 35 land effectively. Now they are okay and continue taking the drug. Focus group years, from Byeya village, who had re- strong and are growing a lot of crops, discussions were also conducted for ceived ivermectin for 11 years, had this to which we sell and get money.” males and females separately using a fo- say: cus group discussion guide. Discussion Our skins were very bad. Wherever we The disease, prior to control, caused would go, people would know that we distressful skin itchiness (Fischer et al.,

5 1993), had socio-economic implications sequences on growth and development, Long Qi, X., Ze-Xiao, J., Sen-Hai, Y., Xiao- and a stigma to the affected individuals of the rural poor populations with in- Ming, D., Xin-Hui, B., Hui-Fung, Y., Hai Qing, as previously observed in other studies Z., Chang-Song, K., Qing-Wei, C., Chang- adequate health services. Hai., Yimng, F., Zu You, T. & Qing Wen, C. (Amazigo, 1994; Vlassoff et al., 2000). (1992). Treatment of soil transmitted helminth Onchocercal dermatitis is known to in- Conclusion infections by anti-helminthics in current use. terfere with people’s concentration and Chinese Journal of Parasitology and Para- Community members perceived that after ability to work (WHO, 1995) and when sitic Diseases, 10, 95-99. 10 years of ivermectin treatment, trouble- highly prevalent, local people often at- Marti, H., Savioli, L., Chwaya, H.M., Ameir, some skin itchiness had stopped and that tribute the symptoms of the disease to J.S. & Hatz, C. (1996). A comparative study this stoppage had increased their ability to of a single dose of ivermectin versus three days witchcraft and move, often to less fer- grow more crops, which they could sell and of albendazole for treatment of Strongyloides tile areas, so reducing productivity fur- get money. Despite the members’ percep- stercoralis and other soil-transmitted helminth ther, causing shortage of food and eco- infections in children. American Journal of tions that onchocercal skin itchiness, and nomic collapse (Ndyomugyenyi, 1998). Tropical Medicine and Hygiene, 55, 477-481. onchocerciasis in general, was no longer a Ivermectin treatment relieves the af- Ndyomugyenyi, R. (1998). The burden of public health problem, people were still Onchocerciasis in Uganda. Annals of Tropi- fected people from onchocercal derma- willing to continue taking the drug until they cal Medicine and Parasitology, 92, S133-137. titis and reverses acute dermatitis to are assured that they are completely cured. Njoo, F.L., Belling, A.C., Oosting, J., Vetter, normal skin. Community compliance Health education, on the need for contin- J.C.M., Stilma, J.S. & Kijlsta, A. (1993). Con- and the effects of ivermectin on skin current parasitic infections in onchocerciasis ued ivermectin treatment, should continue disease have been described. Most re- and the occurrence of adverse reactions after for sustained high treatment coverage. spondents perceived that there was no ivermectin treatment. American Journal of Tropical Medicine and Hygiene, 48, 652-657. more skin itchiness and people were Nnoruka, E.N. & Agu, C.E. (2001). Success- strong enough to cultivate land more effectively and grow crops, which they Table 1: Perceived reasons for onchocerciasis as a dangerous disease could sell and get money. Although on- and why it is no longer a major health problem 11 years after chocerciasis is known not to cause blind- ivermectin treatment in Western Uganda ness in this region (Fischer et al., 1993), a big proportion of the people perceived that ivermectin had improved their sight. Although people perceived that ivermectin treatment had stopped itchi- ness and improved their ability to work, other extra health benefits of the drug, such as its anti-scabetic activity (Nnoruka and Agu, 2001) and its de- worming effect, could have also played a big role. Intestinal helminths flourish where poverty, poor nutrition, shortage of drinking water and minimal health care prevail (WHO, 1994), which are the typical conditions where onchocer- ciasis is also endemic. Intestinal helm- inths play an important role in the cause References of iron deficiency anaemia due to ful treatment of scabies with oral ivermectin in Nigeria. Tropical Doctor, 31, 15-18. chronic blood loss and reduced nutri- Amazigo, U.O. (1994). Detrimental effects of Onchocerciasis on marriage age and breast-feed- Ovuga,E., Kipp, W., Mungerera, M. & Kasoro, ent intake (Santiso, 1997). Effectiveness ing. Tropical and Geographical Medicine, 46, S. (1992). Epilepsy and retarded growth in of ivermectin, against ascaris 322-325. hyperendemic focus of Onchocerciasis in ru- lumbricoides, has been reported to be Boatin, B.A., Hougard, J.M., Alley, E.S., ral western Uganda. East African Medical 100% (Njoo et al., 1993) and 11-100% Akpobouna, L.K., Yame’ogo, L., Demb’le’, N., Journal, 69, 554-547. Sk’ke’te’li,.A..& Dadzie, K.Y. (1998). The impact Remme, J., Baker, R.H.A., DeSole, G., Dadzie, effective against T. trichiura (Njoo et al., K.Y., Adams, M.A., Alley, E.S., Avissery, 1993; Mart et al., 1996) and 0-20% of Mectizan on the transmission of Onchocercia- sis. Annals of Tropical Medicine and Parasitol- H.S.K. & Walsh, J.F. (1989). A community trial against hookworm (Richard et al., ogy, 92, (Suppl. 1), S46-S60. of ivermectin in the Onchocerciasis focus of 1995). Therefore, the effort of the Afri- Fischer, P., Kip, W., Bamuhiiga, J., Binta-Kahwa, Asubende, Ghana. 1. Effect on microfilarial can Program for Onchocerciasis Con- J., Kiefer, A. & Büttner, D.W. (1993). Parasito- reservoir and the transmission of Onchocerca trol, to eliminate onchocerciasis as a logical and clinical characterization of Simulium volvulus. Tropical Medicine and Parasitology, 40, 367-347. public health and socio-economic neavei-transmitted Onchocerciasis in western Uganda. Tropical Medicine and Parasitology, 44, Richard, J.C., Behma, J.M.& Duce, I.R. problem through annual mass 311-321. (1995). In vitro studies on the relative sensi- ivermectin distribution, could in the Kipp, W., Bamuhiiga, J. T. & Kwered, M.E. tivity to ivermectin of Nector americanus and long term improve the quality of life, (1992). Onchocerciasis prevalence in previously Ancylostoma caninum. International Journal known foci in Western Uganda: results from a pre- of Parasitology, 25, 1185-1191. by controlling intestinal parasites liminary survey in . Tropical Santiso, R. (1997). Effects of chronic para- and their associated negative con- Medicine and Parasitology, 43, 80-82. sites on women health. International Journal

6 Treatment Updates (Apr-Jun 2004)

of Gynaecology and Obstetrics, 58, 129-136. May 5-8, 2004: Stella Agunyo flew to Arua health “in-charges” on their involvement Schulz-Key et al., (1986). Efficacy of District where she spent two days attend- in and support for onchocerciasis con- ivermectin on the reproductivity of female On- ing a post-APOC workshop, for the districts trol. For a period of time, Ochaka was chocerca volvulus. Tropical Medicine and Parasitology, 37, 20. of Arua, Yumbe and Nebbi, on integration in Gulu for a follow-up on his earlier Thylefors, B. & Brinkman, U.K. (1997). The and sustainability of CDTI programs. efforts (May 18-21, 2004) to drum up microfilarial load in the anterior segment of the May 18-21, 2004: Justin Ochaka camped support for CDTI activities in the dis- eye. A parameter of the intensity of infection of in Gulu. He held talks with the District trict. Onchocerciasis. Bulletin of the World Health Director of Health Services on how the health June 14-21, 2004: Only one or so days Organization, 55, 731-737. team of the district together with its opinion, after returning from Adjumani, Peace Vlassoff, C., Weiss, M., Ovuga, E.B.L., Eneanya, Nwel, P.T., Babalola, S.S., Awedoba, political and other leaders could be involved Habomugisha was once more on the A.K., Theophilus, B., Cofie, P. & Shetabi, P. in, and support, CDTI. Again, he met the ad- move, this time to Nebbi District. Her ob- (2000). Gender and the stigma of onchocercal ministration of Bungatira sub-county. This jective was to see how treatment was go- skin disease in Africa. Social Science & Medi- area, he discovered, did, in September 2003, ing on there. She tracked ivermectin from cine, 50, 1353-1368. release Uganda shillings 100,000 to support the district stores through the various World Health Organization (1994). Report of the WHO Informal Consultation on Hookworm its community supervisors in CDTI work. health levels down to the communities Infection and Anaemia in Girls and Women, 5- Ochaka also visited the Palenga Internally where treatment is ongoing. She was able 7 December. Displaced People’s Camp, a CDTI benefi- to interact with some of the people re- World Health Organization (1995). The impor- ciary. ceiving treatment. In addition, she vis- tance of Onchocercal Skin Diseases. Document May 25-30, 2004: Peace Habomugisha, on ited the office of the District Director of TDR/ONCHO/95.1. Geneva: WHO. foot and by car, traveled parts of Kisoro Health Services as well as offices of and Kasese, on APOC’s fact-finding mis- some of the district administrators where sion, to find out how these two districts have issues pertaining to integration and News Flash – April- been managing their CDTI activities with- sustainability of CDTI were discussed out external support. She was one of a group with her. June 2004 of monitors drawn from such institutions June 24-29, 2004: Stella Agunyo, Jus- as Makerere University and the Vector tin Ochaka and Harriet Sengendo did Working visits, major details of which Control Division of Uganda’s Health Min- fieldwork in District. Their ac- we now give you, engaged, as always, istry. tivities, by and large, aimed to initiate the Uganda arm of The Carter Center June 9-12, 2004: Peace Habomugisha ar- the area’s new DOC. The team together Global 2000 during the just ended quar- rived and stayed in Adjumani for a 2-day with the DOC retrained 217 community ter. post-APOC workshop, for the districts of supervisors and 15 health workers from Adjumani and Moyo, on integration and 4 health units. These people were re- April 29-30, 2004: Peace Habomugisha sustainability of CDTI activities. educated in several vital things: the roles was among the many invitees, in June 14-21, 2004: Justin Ochaka under- of various partners in the CDTI program, Kanungu District, for a follow-up work- took duties in Apac and Gulu districts. In matters of its sustainability and integra- shop on post-APOC CDTI sustainability. Apac, he had talks with members of the tion into Uganda’s public health system, A paper, relevant to the subject, was pre- district health team, its political adminis- as well as record keeping. sented by her. trative officers as well as with sub-district

Chief Editor: Peace Habomugisha Editorial Board: Richard Ndyomugyenyi, A.W. Onapa, Stella Agunyo, Julie Gipwola, Harriet Sengendo 7 The Carter Center Global 2000 River Blindness Program, Uganda P. O. Box 12027, Kampala. Plot 15 Bombo Road Vector Control Building Ministry of Health Tel: 256-41-251025/345183 Fax: 256-41-349139 Email: [email protected]

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