Factors Affecting the Prevalence of Urinary Schistosomiasis in Giohar Town, Middle Shabelle Region, Somalia

Factors Affecting the Prevalence of Urinary

Schistosomiasis in Giohar Town, Middle Shabelle

Region, Somalia

BY:

HASSAN MOHAMED JIMALE

Thesis submitted to the University of Gezira in fulfillment of the

requirements for the degree of Master of Science

Medical Entomology and Vector Control

Blue Nile National Institute of Communicable Disease

University of Gezira

October 2016

Supervision Committee:

Name Position Signature

Prof. BakriYousif Mohamed Nour Main Supervisor ……………………….

Prof. Samira Hamid AbdelrahmanCo-supervisor ……………………….

Date: October, 2016

DECLARATION

I declare that this thesis hereby submitted to University Of Gezira, for the degree of master of Science in medical entomology and vector control has not previously been submitted to any other University; that is my work in design and in implementation, and all material contained has been accordingly acknowledged.

ACKNOWLEDGEMENT

First, I am very great full to my thesis advisor, Prof: Bakri M. Nour, for his guidance and constructive advice to conduct my research. The lesson that I have learnt during the interaction has not only helped me to accomplish my research work but will remain with me throughout my life.

My genuine appreciation is expressed to the Benadir university for its financial support specially prof. Dr: Abdullah Hussein (Bushkuleti.).In addition, Drs. Alaa Ibrahim from

Sudan who assist me for Data Analysis peace be upon her.

The contribution Mr. Umar Ahmed the head of Daryeel laboratory technicians for their unforgettable help and PHD student Dr. Mohamed Hassan Mohamud who helped me in one way or another and also head lady of Bilkhayr women empowerment and training center Mrs. Anab Mahamud Mohamed for her financial support.

Factors Affecting the Prevalence of Urinary Schistosomiasis in Giohar Town, Middle Shabelle Region, Somalia

HASSAN MOHAMED JIMALE

ABSTRACT

The main objective of the study was to determine the factors that affect the incidence of urinary Schistosomiasis in Giohar town. The study follows Crossectional survey involving 395 respondents was under taken to determine the prevalence of the urinary schistosomiasis in Giohar town, Middle Shabelle region in southern Somalia.

Malacolagical survey in both rainy and dry season shows as the enlarge number of bulinus abbysinicus was found in dry season.

The study found that Prevalence of urinary schistosomiasis among quraning schools in

Giohar Eylo Village and the total prevelance was 70.5% are males and 49.3% are females respectively.

العوامل المؤثرة على نسبت البلهارسيا في مدينت جيوهار, منطقت شابيلي الوسطى,الصومال

حسن محمد جمعالي

خالصت الدراست

خلفيت الدراست: وثبئيخ الجلهبسسيب الجىليخ وجذد مىز صمه ثؼيذ في جىىة الصىمبل, كمب مب صال اكزشبفهب في ثؤس جذيذح مسزمش. االهداف: اهذاف هزي الذساسخ كبوذ في رحذيذ الؼىامل الزي رؤثش ػلً وسجخ الجلهبسسيب الجىليخ في مذيىخ جيىهبس. الطريقت: ػيىخ اخزجبس احصبئيخ للطفيل و اسزجيبن مسحي ضم 593 مشزشك اخزوا لزحذيذ اوزشبس الجلهبسسيب الجىليخ مه اثشيل ليىليى 3105 في مذيىخ جيىهبس ,مىطقخ شبثيلي الىسطً في جىىة الصىمبل. مسح للشخىيبد في مىسم المطش و الجفبف اوضح ان ػذد كجيش مه قىقغ الجليىويس وجذ في مىسم الجفبف. وشبطبد الىبس مغ المبء رمذ دساسزهب. النتيجت: اوزشبس الجلهبسسيب الجىليخ في المذاسس القشآويخ في مذيىخ جيىهبس ايلى وجذ ان 51.3% كبوى ركىس و %39.5 كه وسبء. ػالقخ االوزشبس ثبلؼمش و الىىع اخزد ثؼيه االػزجبس . الشجبل اكثش اصبثخ مه الىسبء و االطفبل في الفئخ الؼمشيخ مه 9-03 هم اكثش اصبثخ رليهم الفئخ مه 03-01 ثم مه 1-6. الخاتمت: 093 طبلت في المذاسس القشآويخ رم رحليل ػيىبد الجىل و لم رىجذ فيهب ثلهبسسيب مؼىيخ . المؼشفخ ػه المشض لذي المشبسكيه كبوذ ضئيلخ جذا. الىقص في الميبي الىظيفخ, الجيئخ الصحيخ و الخذمبد الصحيخ هم اسبس االوزشبس الحبد.

TABLE OF CONTENTS

DECLARATION ...... iii ACKNOWLEDGEMENT ...... iv ABSTRACT ...... v CHAPTER ONE ...... 3 1.0 INTRODUCTION ...... 7 1.1 PROBLEM IDENTIFICATION AND JUSTIFICATION ...... 9 1.2-SCHISTOSOMIASIS IN SOMALIA ...... 10 1.3- OBJECTIVES ...... 12 1.4.1 General objectives ...... 12 1.4.2. Specific objectives ...... 12 CHAPTER TWO ...... 13 LITERATURE REVIEW ...... 13 2.1 INTRODUCTION ...... 13 2.2 DISTRIBUTION...... 16 2.3 TRANSMISSION, DISEASE PATTERN AND RISK EFFECTS ...... 18 2.4- FACTORS ASSOCIATED WITH SCHISTOSOMIASIS INFECTION ...... 19 2.5. MASS DRUG ADMINISTRATION ...... 19 2.6 LACK OF ENGAGEMENT WITH MASS DRUG ADMINISTRATION PROGRAMS ... 20 2.7- SNAIL CONTROL AND ENVIRONMENTAL MODIFICATION ...... 22 2.8 ELIMINATION ...... 24 CHAPTER THREE ...... 25 MATERIALS AND METHODS ...... Error! Bookmark not defined. 3.1. GENERAL DESCRIPTION OF THE STUDY AREA ...... 25 It should have been or still a potential active focus of the infection according to information collected from WHO (Mogadishu, Somalia)...... 28 3.3 STUDY POPULATION ...... Error! Bookmark not defined. Study Design...... 27 Sampling Techniques...... 28 3.4 QUESTIONNAIRE SURVEY ...... 29 3.5. ETHECAL CONSIDERATION ...... 29 3.6. DATA ANALYSIS ...... 29 CHAPTER FOUR ...... 30 RESULTS AND DISCUSSION ...... 30 4.1. RESULTS ...... 30 4.1.1 PARASITOLOGICAL SURVEY ...... 30 Table 1. Prevalence of Schistosomiasis infection among Quranic School children of Giohar Eylo village in Giohar town, categorized by age and gender ...... 30 4.1.2 MALACOLOGICAL SURVEY ...... 31 Table 2. Prevalence of Urinary Schistosomiasis by age group from 2007-2011 in South Somali...... 31 Table 3: Suspected habitats of Bulinus abyssinucus Surveyed around Giohar eylo village in Goihar Town during rainy season April 2013 ...... 31 Table 4: Suspected habitats of Bulinus abyssinucus Surveyed around Giohar eylo village in Goihar District during winter season December 2013...... 31 1

4.1.3 Questionnaire Survey ...... 32 Table 5- Socio-demographic factors and Schistosomiasis-related knowledge ...... 32 Table 6. Sanitation Characteristics of respondents (N=390) ...... 33 Table 7: Sex Respondent * Do you know the disease called bilharzia ...... 33 Table 8: Sex Respondent * Have you ever suffered from bilharzias ...... Error! Bookmark not defined. Table 9: Occupation of respondent * Can bilharzia be treated ...... 34 4.2. DISCUSSION ...... 35 4.2.1. PREVALENCE OF URINARY SCHISTOSOMIASIS ...... Error! Bookmark not defined. 4.2.2. FACTORS ASSOCIATED WITH SCHISTOSOMIASIS .. Error! Bookmark not defined. CHAPTER FIVE ...... 40 CONCLUSION AND RECOMMENDATION ...... 40 5.1. CONCLUSION ...... 40 5.2. RECOMMENDATION ...... 41 REFERENCES ...... 43

List of Tables No. Content Page Prevalence of Schistosomiasis infection among Quranic 4.1 School children of Giohar Eylo village in Giohar town, 29 categorized by age and gender Prevalence of Urinary Schistosomiasis by age group from 4.2 30 2007-2011 in South Somali. Suspected habitats of Bulinus abyssinucus Surveyed around 4.3 Giohar eylo village in Goihar Town during rainy season April 30 2013 Suspected habitats of Bulinus abyssinucus Surveyed around 4.4 Giohar eylo village in Goihar District during winter season 30 December 2013 Socio-demographic factors and Schistosomiasis-related 4.5 31 knowledge 4.6 Sanitation Characteristics of respondents (N=390) 32 4.7 Sex Respondent * Do you know the disease called bilharzia 32 4.8 Age Respondent * Do you know the disease called bilharzia 33 4.9 Residence of respondent * Can bilharzia be treated. 33 4.10 : Marital status of Respondent * Can bilharzia be treated 34

List of Figures No. Content Page 2.1 Life Cycle of Shistosomiasis CDC 2013 17 2.2 Distribution of S. haematobium in Africa 2008 18

List of Appendices No. Content Page Appendix 1 Authority acceptance to Conduct Research 45

Appendix 2 Giohar Map 46 Snail scooping activity 47

Appendix 3 During rainy season During dry season

Appendix 4 Urine collection activityin Giohar Eylo 48

Appendix 5 Snails Collected in Giohar Eylo 49

Appendix 6 Water Contact Activity 50 Appendix 7 QUESSIONNAIRE 56

List of Abbreviations Epg Egg per gram FT Filtration Technique PZQ Praziquantel P. value Probability value SPSS Statistical Package for Social Science WHO world health organizations

CHAPTER ONE

1. INTRODUCTION

Schistosomiasis is a chronic water- related parasitic disease caused by blood flukes of the genus

Schistosoma. It is the most important disease in terms of its public health and socioeconomic

Impact next to malaria and is still a major helminth infection at the beginning of the 21st century

In many developing countries of the tropics. The disease is endemic in 74 tropical developing

countries (Chitsuloet al., 2000). People become infected when coming in contact with water

containing schistosome-infected snails. There are five species of schistosomes that cause disease

in humans, namely S. mansoni, S. intercalatum S. haematobium, S. japonicum and S. mekongi

(Gurarie and Seto, 2009).

Among these, S. mansoni, S. japonicum and S.haematobium cause significant public health

problems (McManus and Loukas, 2008). S. mansoni, S. japonicumand S. intercalatum cause

intestinal schistosomiasis whereas S. haematobium is responsible for urinary schistosomiasis.

These worms deposit eggs in blood vessels surrounding the gut or bladder of the infected hosts.

There are also other minor non- human species that may also cause accidental infections, or

cercarial dermatitis (bird-infecting schistosomes e.g. Trichobilharzia spp.). Other schistosomes

of veterinary importance include S. bovis, S. mathei, S. hippopotami, S. sprinallis and S. rohhaini

(Okpalaet al., 2004).

In an attempt to measure the global burden of schistosomiasis, various estimates have been

made. Recent systematic review integrating results of several independent studies by Steinmann

et al. (2006) suggests that 779 million people are at risk of schistosomiasis and 207 million

people are infected worldwide.

According to Steinmann et al. (2006), earlier estimates of an annual loss of between 1·7 and 4·5 million DALYs due to schistosomiasis is underestimated and this figure could be many times greater in view of recent meta-analysis. Although, infection with schistosome parasite is mostly associated with morbidity, it also has considerable mortality effect resulting in death (King et al.,

2005). It is probably responsible for hundreds of thousands of deaths annually (Bergquist, 2001).

As many other tropical diseases, schistosomiasis is found much concentrated in Africa. It is endemic in 46 countries in the continent (Boelee and Madsen, 2006). In Africa again, the great majority (80-85%) of schistosomiasis is found in sub-Saharan Africa (Bergquist, 2002), where S. haematobium, S. intercalatum and S. mansoni are endemic.

However, the two main causative species of Schistosomiasis are Schistosoma haematobium and

Schistosoma mansoni. In this subcontinent, approximately 393 million people are at risk of infection from S. mansoni, of which 54 million are infected. For S. haematobium an estimated number of 436 million at risk, of which 112 million are infected (van der Werf et al., 2003).

However, this estimate is higher compared to the figure of the world mentioned above and this shows the inconsistency of various estimates.

Overall, annual mortality rate might exceed 200,000 people in Africa, mainly due to bladder cancer or renal failure caused by urinary schistosomiasis, and liver fibrosis and portal hypertension caused by intestinal Schistosomiasis (van der Werf et al., 2003). However, much of the morbidity associated with infection can be reversed with the use of effective drug treatments

(Keiser and Utzinger, 2008).

Schistosome infection during childhood causes substantial growth retardation and anemia (Olds et al., 1996). Infected children may also have cognitive impairment and memory deficits

(Nokeset al., 1999; Savioli et al., 2004). According to Nokeset al. (1999), the cognitive

impairment and memory deficits that may happen in infected children have been shown to impair

their school performance.

The disease is linked with anemia perhaps due to blood and nutrient loss in either the stool or

urine. More serious and very common complications include bladder or ureter calcification in

urinary schistosomiasis and an enlarged liver and spleen in intestinal Schistosomiasis. Prevalence

and intensity are related and, generally, populations with high prevalence of infection tend to

have high intensity (Hoffman et al., 1979).

Schistosomiasis mansoni morbidity (prevalence of hepatomegaly and splenomegaly), is directly

correlated to the prevalence and intensity of infection and explains the morbidity variation

between areas better than the prevalence of infection (Barreto and Loureiro, 1984).

Transmission potential of an area can be estimated through various techniques which focus on

monitoring the components of the human-snail-water interface, where transmission occurs.

These surveillance techniques include monitoring schistosome egg output by humans

Vercruysseet al., 2001), human water contact activities (Chandiwana and Woolhouse, 1991) and

snail infection rates (Sturrock, 2001).

1.1. Problem Identification and Justification

In southern Somalia Urinary Schistosomiasis is hyper-endemic and cause considerable health

and economic impact (World Schistosomiasis risk chart 29th edition 2008). More than four

million are believed to live along the two rivers (Jubba and Shabelle), where Urinary

Schistosomiasis is endemic (WHO, in Somalia, 2008). A total number of 15146 person of

clinically Urinary Schistosomiasis were diagnosed in which 8497 (56%), were Male and 62495

(44%) were Female. In 64 villages in lower and middle Shabelle regions during Jan-Dec (WHO,

Somalia 2009) (Cahill et al. 1968) reports that the survey conducted in Giohar town in Middle 9

Shabelle region, Somalia, Schistosoma antibodies were detected 57% o191 samples using

Bentonite flocculation test and 56% by the indirect fluorescent test.

New transmission foci are being discovered in different parts in South Somalia over-time. The

reasons of the spreading of the disease to new localities seem to be extensive internal

displacement population due to the civil war and lack of central Government since 1990.

Additionally in this era of Global warming and climatic change, the epidemiology of temperature

dependent infectious diseases could be changing implying the possibility of new transmission era

in the world in general and in Somalia in particular.

The present Epidemiological study was, therefore conducted in Giohartown, southern Somali, to

determine major factors that contribute the incidence of urinary Schistosomiasis in Giohar town.

1.2. Schistosomiasis in Somalia:

Schistosomiasis is the most neglected and prevalent parasitic disease in Somalia, especially in

south and central part, and it was solely attribute to Schistosoma haematobium infection and the

rest of the country is free from the disease (World Schistosomiasis Risk chart 29th Edition-

IAMAT, edition, 2012).

It estimated more than half of the population four million is believed to live along the two rivers

where Schistosomiasis is thought to be endemic due to availability of water bodies infecting

cercarial and human behavior of water contacts (WHO in Somalia, 2008).

A total number of 15146 of clinically diagnosed urinary Schistosomiasis in which 8497 (56%)

were male and 62495 (44%) were female in 64 villages in lower and middle shabelle regions

during Jan-Dec 2009 (WHO Somalia, 2009) (Cahill et al, 1968) reports that. In a survey

conducted in Giohar district in Somalia, Schistisoma antibodies were detected in 57% of 191

blood samples using the Bentonite flocculation test and in 56% by the indirect fluorescent antibody test.

A survey made on the prevalence of Schistosomiasis in 14 localities in four areas in Somalia has revealed the presence of Urinary bilharzias is among the inhabitants of all these localities, this being much higher in the two areas where water development has accomplished.

The mean prevalence of infection was found to be 27.2% and 58.1% in the two areas where water development has only be planned, while it was58.7% and 75.6% in the two areas where the extensions of irrigation was achieved years ago. Snails were collected from the inhabitants visited and these were identified. The role of Bulinus abyssinicus in the transmission of infection was proven.

A parastological study carried out among school children of the elementary and intermadite schools of golwayn, agricultural village in the region of lower shabelle (Somalia).A parasitological examination was effected on the feces and urine of 153 subjects consisting of 117 males and 36 females; giving the result that 136 children, or 88.9% of the sample considered, were found to be infested by parasites. A Number of different helminthes were found of which

13 (9.6) were positive with S. heamatobium, A. lubricoids 108(79.4), T. trichiura 20 (14.7) A. dudinal 4 (2.9) H. nana 1 (0.7) and as well as protozoa (G. intestinal and T. histolytica).

The results are reported on the bases of sex, age poly infection and the morphological, chronological and the weight group of each subject. The conclusion reached is that it is necessary to adopt measures of environmental control within the framework of community medicine.

Faculty of Medicine of Somali National University, June 1984).

S. haematobium is highly endemic in the southern provinces of Hiran, Benadir, Lower Jubba, and upper Jubba, especially in the irrigated agricultural areas of shabelle and Jubba Rivers

(World Schistosomiasis Risk chart. 2009 EDITION). A parasitological and serological survey of 11

Schistosomiasis in the Giohar town in the middle Shabelle region in southern province in

Somalia defines a hyper endemic zone of Urinary Schistosomiasis.

1.3. OBJECTIVES

1.4. General objectives

To determine major factors that contributes the incidence of Bilharzia in Giohar town related

villages

1.5. Specific objectives

To identify the potential environmental factors that contributes the incidence of Bilharzia in

Giohar town.

To investigate the behaviors of Giohar people about river water contact.

To determine the current urinary Schistosomiasis control measures in Giohar town.

CHAPTER TWO

LITERATURE REVIEW

2. Introduction:

Schistosomiasis is tropical parasite disease caused by blood swelled fluke worm of genus

Schistosoma. In urinary schistosomiasis, the Schistosoma’s live within the perivescal venous

plexus .the females produce eggs which are excreted in the urine and on contact with water. The

egg releases the micracidium.it searches for the intermediate host. Fresh water snails and after

penetrating and passing same developmental cycles start leaving the nail as cercaria. cercaria

penetrates the skin of human migrates in the blood via the lungs of the liver and transform into

yang worm which eventually reside in associated destination (mascara et al.,2004).

One case in Pont for most sub-Saharan Africa countries where schistosomiasis is endemic is that

control programmes based on oral drugs delivery have been developed and partially

implemented as a means to control morbidity within the effected populations. However,

questions remain about the long-term impact of the programmes on parasite transmutations.

Treatment of the most heavily infected segment of the pulation, i,e., school egg children, has

been suggested as the best practical means of reducing contamination of local water by

Schistosoma egg ( kapito-tempo et al.,2009). Although treatment has been shown to significantly

reduce Schistosoma egg output, by about in the case of S. haematobium among the treated

subjects over the short term.

(kapito-tempo et al., 2009) the actual impact of long-term, population based treatment

programmers on year-to-year transmissions of Schistosomiasis has not been fully explored the

public health significance of Schistosomiasis ids often underestimated partly because like all

helminthics infections, its distributions is usually wide-spread with view people have heavy infections and severe disease while the majority is symptomatic with lighter infections.

Schistosomiasis is a neglected tropical disease than can cause death although research shows that rather than mortality, the main outcome of infection is chronic disability (king et al.2005) (king - and Dangerfieldcha, 2006).

The degree of morbidity is usually related to both the intensity of infection and the total duration of the infection. Chi of school age usually the highly vulnerable group and represent the infection status in the population. according to the WHO expert committee report on Schistosomiasis, children should be first target group for interventions because of the detrimental effect the disease has on their growth and development (WHO, 1993) early diagnosis and treatment of children shortens the duration of heavy infections thereby reducing the risk of severe disease and childhood disability (king et .al.2005).

The world health organizations (WHO) classifies schistosomiasis as one of neglected tropical disease (NTD,S) it is believed that one billion people are effected with one or more neglected tropical disease (WHO.2002) yet. These diseases remain neglected at all levels, are called neglected because of the flowing reason, these disease persist exclusively in poorest and the most marginalized communities, and have been eliminated and thus forgotten in wealthier places.

They are not highly visible because they do not kill large numbers of people (Approx.500.000 death annually), they have to compete with visible disease like Hepatitis, TB and malaria with higher mortality rates and attract more attention nationally and internationally.

They do not cause explosive outbreak that attract public and media attent, they cause enormous misery but do not kill large number of people, and they effect the poorest of the poor so there is no incentive for the development of new diagnostic tools, drugs and vaccines for disease with a

market they cannot pay. Endemic courtiers have limited resources to invest in health and competition for fund is fierce.

Schistosomiasis is endemic in much of Africa, yet effected nations do not always treat it as a healthy priority. One person for this is the perceptions that squeal are mild, since infected people are often able to maintain an active lifestyle. According to Awototunde (2002), surveillance for Schistosomiasis is very important in establishing endemicity and in the planning of control operations. Is believed that many areas of the world

2.1. Historical Baground:

It was only fortunate that made Theodor Bilharz to discover the causative worm of urinary schistosomiasis in the mesenteric veins of a dead young man on whom he was performing an autopsy in Cairo in 1851. Bilharz called this blood parasite Distomum Haematobium. In 1855

Weil and suggested the name Schistosoma referring to gynaecophoric cleft (schistose) and body

(soma) of the male worm. (Warren, 1973).Farooq (1973) stated that it was Leiper who identified the Bulinus snail as the Intermediate host of Schistosoma haematobium in a village near Cairo in

1915. Leiper ascertained this by exposing mice to cercariae developing in the Bulinus snails and he could demonstrate that these cercariae always produce worms that shed the characteristic terminal-spined ova the urinary schistosomes.

In 1898 Manson postulated, on the basis of differences jn their geographical distribution, that the vesical and intestinal forms of the disease were attributed to separate species of the parasite.

This postulation, which was strengthened by his recovery of lateral-spined eggs in the faeces of a

West Indian in 1902, caused great dispute and controversy. It was Leiper who finally settled this

problem by demonstrating, in 1915, the presence of two distinct species of the parasite that had

two different intermediate snail hosts. (Farooq, 1973).

In 1847, Fujiidescribed the disease attributed to Schistosoma japonicas. The causative

Schistosoma was reported by kasturada in 1904 following his recovery of the worm from portal

system of an infected cat. The intermediate snail host.

Figure 2.1: Life Cycle of Shistosomiasis 2013 CDC.

2.2. Distribution of Schistosomiasis:

Schistosomiasis infections are generally widely distributed within populations at risk with few

individual harboring the majority of worms. A study done by Seto (2007), found that infection

levels are lower in adults than in children, which may be as a result of partially protective,

acquired immunity and/or changes in water contact behaviors with age. Numerous studies have

assessed the relationship between age, water contact and infection.

Some studies suggest that changes in exposure with age do not completely explain the infection

levels (Butterworth et al., 1992). A study by (Scott et al., 2003) in Senegal found that water

contact differed with age, sex and location, but was not related to infection intensity. In Brazil

Bethony (2001) found water contact to be weakly associated with infection, after adjusting for

household risk factors. It is however, a fact that exposure are largely related with fishing, tending

cattle, harvesting crops and swimming. Distribution of S. haematobium:

11 September 2009 Prof. Suad M. Sulaiman Figure 2.2: Distribution of S. haematobium in Africa 2008

2.3. Transmission, Disease Pattern and Risk Effects:

Schistosomiasis represents a significant health burden for many developing countries.

Accumulation of parasite eggs in host tissues and the consequent egg-induced inflammatory

response lead to both acute and chronic injury of the tract in the case of Urinary schistosomiasis.

Hematuria, anemia and under nutrition are clinical correlated of infection in childhood. Long-

term manifestations of infection include scaring and of the ureters and bladder, chronic bacterial

super infection, and kidney failure (King et.al2002) mention that while schistosomiasis infection

is chronic by nature and is unlikely to be directly lethal, its toll of morbidity is high in the

endemic areas, where health-care budgets are often limited.

Schistosomiasis thrives in places with unsafe water, poor sanitation, and limited access to basic

health. It is in the category of diseases that blind, debilitate, deform and maim (Talaat et.al.

2006). With schistosomiasis, severe impairments occur after years of virtually silent infection.

According to Engels et.al (2002), school aged children, particularly those between 10-15 years of

age, are at risk of contracting schistosomiasis. Understandably, this pattern is likely due to

multiple risk factors, such as higher rates of water activities, anatomical developmental changes

of the vasculature supplying genitourinary structures harbor the parasite and its eggs

(Bachleret.al. 2001). Because schistosomiasis rates peak I early adolescence, complication of

infection can affect integral aspects of adolescent life, such as growth and cognitive development

impairment thus reducing the child’s ability to learn and benefit from attending school. In adults,

it significantly reduces the economic productivity, thereby anchoring millions of people in

poverty.

2.4. Factors Associated with Schistosomiasis Infection:

Observations have been made in endemic regions, in Africa, Asia, Latin America and the

Caribbean, where socioeconomic and behavioral factors, as well as water-supply patterns, have

been shown to play a major roles in the transmission of the parasite causing human

Schistosomiasis (Barreto, 19991; Cautinhoet.al., 1997; Gazzinelliet.al., 2008; Rudge et.al.,

2008). Some other studies have reported like role of parental education and environmental

factors (Stothardet.al. 2006). Many other factors influence the epidemiology of Schistosomiasis.

Edungbol

2.5. Mass Drug Administration:

WHO recommends, that all school-aged children living in areas where schistosomiasis

transmission occurs be treated for Schistosomiasis. once a year, every two years, and twice

during their school years in areas where the prevalence of schistosomiasis in school aged

children is less or equal to 50%, less or equal to 10% but greater than 50% and 10%

respectively(World Health Organization 2006).

They also recommend that certain groups of at risk adults are treated in areas where the

prevalence in school aged children is less or equal to 10%, a World Health Assembly resolution

passed in 2001 set a goal of at least 75% treatment coverage of at risk school children by

2010(World Health Assembly 2001). Despite this, only 50% of countries where preventative

chemotherapy is needed had programs in place in 2010, and it is estimated that only 13% of

people at risk received treatment (World Health Organization 2012).

Treatment is with Praziquantel, taken orally. A single dose of 40mg/kg is typically used against

all species of schistosome. It has an initial cure rate of around 60-90%, with egg reductions of

around 90-99% in individuals where egg reductions are not 100 %( World Health Organization

1993). Minor adverse effects are common (including abdominal pain, headaches, nausea,

vomiting, general malaise, fever, loose bowel, itching, body pain and dizziness), but no serious

adverse effects have been reported in trials (Danso-Appiah, Utzinger et al.2008).

There is some evidence that mass treatment programs may be reducing the incidence of

Schistosoma infections in some areas. In Uganda, the prevalence of S. mansoni infection in

previously untreated six year olds fell from 35% at baseline, to 23% after two years of mass drug

administration (Zhang, Koukounari et al. 2007).

The mean intensity of infection fell from 171 epg to 72 epg. It is unclear if annual mass drug

administration will continue to reduce new infections in many areas however. In six sites in

Mali, the prevalence(mean intensity) of S. haematobium infection in seven year olds fell from

91%(195eggs/10ml urine) in 2004 to 47%(38eggs/10ml urine) in 2005, before rising to

59%(26eggs/10ml urine) in 2010 (Landoure, Dembele et al. 2012).

This is suggestive of increase in incidence, despite mass drug administration. However other

explanations cannot be ruled out. The seven year olds had not previously been treated at school,

should have been treated as part of the community mass drug administration program. Increases

in prevalence may therefore reflect poorer treatment coverage in the community. In addition,

drug administration did not occur in two years in two of the six sites tested.

2.6. Lack of Engagement with Mass Drug Administration Programs:

The impact of mass drug administration programs may be reduced by a lack of engagement in

some areas. It has been argued that treatment coverage can be low among some groups with the

highest need. This is particularly the case for fishermen, who often spend days or weeks fishing

away from their villages (Parker, Allen et al. 2012). Other people may refuse treatment. Several

anthropological studies have been conducted in Uganda since the start of the mass treatment 20

program in 2003, exploring reasons for resistance to treatment (Parker, Allen et al. 2008;

Fleming, Fenwick et al.2009; Parker and Allen 2011; Parker, Allen et al. 2012). A commonly reported reason for refusing treatment in one study was fear of side effects (Parker, Allen et al.

2008). For instance, one participant said “When I took the tablet,’Praziquantel (PZQ)’,[in 2004] it disturbed me for 2 to 3 weeks…I am a fisherman [and] I cannot afford not to fish. This is why

I did not take it [in 2005].” Other informants reported fears that treatment with PZQ could lead to infertility and miscarriage, with one even suggesting that some people think that mass treatment with Praziquantel is a Ministry of Health strategy to reduce birth rates. Accounts were also given of people dying after taking Praziquantel, sometimes linked to concerns that the fact that

Praziquantel doses are calculated by height not weight could lead to overdoses(this is not the case). Other studies found that participants were more accepting of side effects however and even questioned whether the drug was still working during later rounds when they experienced milder or no side effects (Fleming, Fenwick et al. 2009; Parker and Allen 2011).

Another Major barrier to treatment reported by the studies was belief in “awola” (Parker, Allen et al. 2008; Parker, Allen et al. 2012) or “ esidada”(Fleming, Fenwick et al. 2009), ailments with similar symptoms to schistosomiasis that are caused by witchcraft. This was reported to prevent people from seeking biomedical treatment, as they believed that it would be ineffective. In the case of awola, it was also reported to make people afraid to take PZQ due to a belief that individuals inflicted with awola could die if take medicine.

Finally, some respondents stated that they did not think it was appropriate to take Praziquantel when they felt well (Parker, Allen et al. 2008; Parker and Allen 2011). For instance, one man said, “It is not in our culture to take drugs unless we are sick. The idea of taking a drug when you are well is strange to people here…people do not wish to take it, especially as it can make you 21

sick.” (Parker, Allen et al. 2008). This view will not only prevent people who are not infected

from taking Praziquantel, but it is likely to also reduce treatment coverage among people with

asymptomatic schistosomiasis, and among infected people with symptoms that they attribute to

other causes. Schistosomiasis mass treatment programs often have the additional goal of

promoting treatment-seeking behavior among people with schistosomiasis. It is unclear if this

goal is feasible for S. mansoni infection, as few people may have the knowledge of disease

symptoms that are necessary if they are to seek treatment with Praziquantel. Booma village,

Uganda has been the site of multiple research projects into schistosomiasis since 1996, exposing

residents to far greater levels of education about schistosomiasis than is typical in the region

(Dunne, Vennervald et al. 2006).

When questioned about symptoms of schistosomiasis, 80% of people correctly identified a

distended abdomen as a symptom. Only 34% of people reported the next most commonly

reported symptom, diarrhea (Pinot de Moira 2008). This is problematic as visibly distended

abdomens only occur when the infection has already caused considerable morbidity (Balen,

Stothard et al. 2006). Furthermore, it was also reported that some individuals attribute distended

abdomens to `charms`, something for which they are unlikely to seek biomedical treatment. The

situation was found to be similar at another long-term S. mansoni study site. Only half of

residents in a village in Senegal were able to describe the symptoms of schistosomiasis following

seven years of research projects (Sow, de Vlas et al. 2003). Levels of knowledge away from sites

of repeated research programs are likely to be even lower.

2.7. Snail Control and Environmental Modification:

Mass drug administration programs are currently the principal means of Schistosomiasis control

employed in sub-Saharan Africa. Other methods have been used with some success in the past

however, and Schistosomiasis elimination is unlikely to be achieved using mass drug administration alone. Prior to the late 1970s, snail control through the application of molluscicides was the mainstay of Schistosomiasis control (Sturrock 2001). Repeated application of niclosamide successfully reduced transmission in many locations. In some areas, snail populations were eliminated and schistosome transmission halted. In southern Tunisia, Bu.

Truncates were eliminated from nearly 200 sites by the application of niclosamide (Rey,

Hachicha et al. 1982). In conjunction with a program of chemotherapy and water resource and agricultural infrastructure development, this led to countrywide elimination of S. haematobium by 1982 (Rollinson, Knoppet al. 2013).

In most areas, the repeated application of niclosamide had more temporary effects.

Schistosomiasis prevalence was often greatly reduce, while control programs were ongoing, however the costs of the programs were high, and snail populations and Schistosomiasis prevalence rapidly increased. When the programs were stop (Brown 1994). Application of niclosamide to seasonal rain pools over a period of three years in Ghana reduced Bu. Senegalese numbers to around 1% of the numbers found in control pools (Goll and Wilkins 1984).

The intensity of S. haematobium infection in a cohort of children fell by more than 50% over the three years, compared with a ten-fold increase in a similar cohort living in an untreated area.

Applications of niclosamide were stopped after three years, and in the following rainy season snail numbers in the previously treated pools reached levels close to those found in the untreated pools.

Environmental control has also been employed to control or eliminate snail populations, particularly in manmade water bodies such as irrigation canals. Methods employed include the

lining of irrigation ditches with cement (Minai, Hosaka et al. 2003; Ohmae, Iwanaga et al. 2003),

the introduction of predator species (Van Schayck 1986), seasonal drying out of canals (Yousif,

Kamel et al. 1993), and releasing stored water rapidly as a `flushing wave` (Fritsch 1992). These

methods can be extremely successful in controlling or eliminating snail populations, but have the

potential to cause environmental damage if employed in natural watercourses (Brown 1994).

2.8. Elimination of Diseases:

In recent years, there has been an increased interest in the possibility of achieving

schistosomiasis elimination in many low transmission areas. The WHO’s 2012 Neglected

Tropical Disease control `Roadmap for Implementation` (World Health Organization 2012) sets

a goal of regional elimination of schistosomiasis in the Eastern Mediterranean Region,

Caribbean, Indonesia, and the Mekong River Basin by 2015; regional elimination in regions of

the Americas and Western Pacific Region by 2020; and elimination in selected African countries

by 2020. Most endemic countries in sub-Saharan Africa are not currently in a position to work

towards countrywide elimination, due to a combination of high prevalence and a lack of

resources. It has nevertheless been suggested that local elimination could achieved in low

prevalence areas of many countries (Rollinson, Knoppet al. 2013).

In most cases, elimination will not be achieved through current control efforts. WHO guidelines

recommend infrequent treatment in low prevalence areas (World Health Organization 2006).

These areas are also likely to be accorded a low priority by resourcelimited programs focusing

on morbidity reduction. A conscious decision to switch to an elimination strategy, incorporating

active case finding and targeted treatment, will be needed to achieve local elimination. Snail

control may also play an important part, along with water, sanitation, and education programs.

It is crucial to consider the effects of climate change when deciding when and where to switch 24

from a control to an elimination strategy. In many areas, low prevalence maybe due, at least in part, to temperatures which are marginal for transmission? In some of these areas, increasing temperatures may make elimination goals increasingly feasible, making them attractive targets for elimination programs. On the other hand, the parasite and/or intermediate snail hosts may become extinct in these areas even in the absence of increased control efforts. In contrast, in cooler areas, warming temperatures may increase transmission, and control and elimination targets may not be met without increased resource allocation. Schistosomiasis may also spread to new areas, outside the boundaries of any current control efforts, impacting on local elimination

CHAPTER THREE

MATERIALS AND METHODS

3.1. Study Area:

Giohar town is the head quarter of the middle- shabelle region and situated 2’47N and 45 30 E in southern Somali. The region has borders Galgadud region in the north, Benadir region and lower shabelle to the south and the Indian Ocean to the East.The total population in the region pre-war census was 1.5 million and consists of seven districts: Giohar- regional capital, Balad, Adale,

Adanyabal, Warsheikh, Run-nirgod and Mahaday. The region supports live-stock production, rain-fed and irrigated agriculture and fisheries, covering an area of approximately 60,000 square kilometer, the region have 400 km coast-line of the Indian Ocean. The Shabelle River runs for

150 km through the region.

The region is composed low-land with agricultural river-line and also coastal-line with no high land or mountains. Shabelle River divides Giohar town in two parts eastern and western parts which both of them are agricultural areas with the total area of approximately 280 sq. km.Giohar is characterized by dry weather and high temperatures in winter (Jan-march), the 25

summer is cold (July-Sep) and the spring (April-Jun) is the best rainy season and autumn (Oct-

Dec.). The total amount of rainfall is about 150 – 500 mm. the relative humidity ranges 15 – 35% in summer and 70 – 90% in winter. The total number of population according to 2010 census was 35156 and the sex distribution is nearly equal although females are slightly more than males.

3.2. Study Design:

This is a community-based longitudinal studyto determine the burden of Urinary Bilharziasis and identify the potential contributing factors of Bilharzia incidence in Giohar town(Middle Shabelle

Region, Somalia) from July 2012 to July 2013

3.3. Study population:

The main occupation of the adult males is farming; cultivation of rice near farm extension areas around river banks and live-stock production, businessmen and others work in building places on both sides of the river. The Giohar town links Mogadishu, the capital of Somalia to central regions. Education: In Giohar town there are three secondary schools, four primary schools, and several Quranic schools. Water & sanitation: Giohar has the Shabelle River and the entire population depends on water supply for this river and the town has also man –made shallow wells drilled by Farjanno municipal company. Health services: Giohar town has only two hospital centers one of them supported by MSF Spain for medical supplies while others receive support from INTR (Italian). In addition, those remote areas close to Giowhar town are lack of health care, safe water supply and other humanitarian assistance due to their solitary situation and this made them most vulnerable to disease. For the above mentioned reasons, many of the families migrated from their relatively poor villages to Giohar town where chances of procuring better education and health care benefits which more favorable and abundant ..

Small villages, especially those in Giohar town which are at the sides of marshes and swamps depend for their water supply on ponds, ditches or small tributaries of the river Shabblle. The houses in large villages in Goihar town are constructed of long sticks and mud; the domestic

animals are kept in separate shelter. Small villages and hamlets of nomadic people are made of huts and they shelter both man and their animals side by side, Sanitation is generally poor and in most of the villages is lacking. In large villages shallow pit latrines dug, but the majority of people, especially nomads prefer to pass their defecation in the open.

Giohar town is the head quarter of the Giohar district of Middle Shabelle Region with a population of

35156. There are 32 villages in the district and most of the villages reside the Shebelle River bank. Apart from these villages, the Nomadic people are also served by this district. The internal population movement is unstable due to the ongoing armed conflict between the Transitional Federal Government and the opposition Islamist. (Jowhar District Polio officer 2009).

In order to determine the incidence of urinary Schistosomiasis in Giohar town we follow the following steps:

3.4. Study Design:

In reference to data records collected by WHO in Urinary Schistosomiasis in Giohar town (2009-

2011) MSF-spain 2012.

Cross-sectional survey Giohar eylo Village inGiohar town which was considered to be hyper- endemic in order to determine the degree of endemicity of the Disease and to assess the various ecological and environmental variables that are involved in the incidence of Schistosomiasis.

 Questionnaire survey

 Urine collection and examination

 Malacological surveys in search of Bulinusabbysinyus in the Giohar eylo village of

Giohar district where there is evidence of urinary Schistosomiasis

In order to determine the incidence of urinary bilharzias in Giohar Town and to assess the burden of the current incidence of urinary bilharzias. See the study units are village within the study area, whichsatisfies the following criteria:

(i) It should be accessible during the study period, and having water bodies throughout the year.

(ii) It should have at least 100 permanent resident populations.

It should have been or still a potential active focus of the infection according to information collected from WHO (Mogadishu, Somalia).

3.5. Sampling Techniques:

The number of people to be included this study was calculated by using the following formula. n= N 1+N (e) ²

(Cochran 1963:75)

Where n is the Sample size, N is the estimated total Population and e is the level of precision

(5%).

Therefore, Giohar town has a population of 35,156, applying the above equation we get the following sample size:

n= 35156

1+35156(0.05)²= 395

3.6. Data Analysis:

Data were analyzed by SPSS software version 20. Chi-square (X2) test was used to test possible association between variables. P-value of less than 0.05 was considered statistically significant.

3.7. Ethical Consideration:

The purpose of the study was explained to both parents and the chief of the village .Those that declined to participate in the study were not forced, but we assured of their protected privileges.

The respondents were interviewed in their homes and only urine specimens were students in

Quanic Schools as we children are most vulnerable to attract the disease.

Privacy and confidentiality was maintained. The names of the respondents did not appear anywhere in the forms. The respondents were thus assured of utmost confentiality. All children found with urinary schistosomiasis were referred to treat their homes by qualified nurse from

Bulo sheikh MCH.

3.8. PILOT STUDY:

The pilot study of this study was done at a village very close Giohar eylo village called Bulo sheikh. This helped test the tool and also helped determine the duration of each interview. Ten percent of the sample size (39) was interviewed during pilot study

3.9. Questionnaire Survey:

Information relating to factors associated with urinary bilharziasis in Giohar eylo village in

Giohar district the people was collected from the houses. Open-ended questionnaire schedule

(appendix) was used to collect quantitative data. The interview captured by demographic variables, knowledge of schistosomiasis and factors associated with Schistosomiasis infection.

The questionnaire was in most cases translated in the local language (Somali) as the village people are very conversant with the English language.

CHAPTER FOUR

RESULTS AND DISCUSSION RESULTS 4.1. Result: 4.1.1. Parasitological Survey: A total one hundred and ninety-two urine specimen were collected from Quranic School children in Giohar eylo village near Giohar town and microscopically examined for urinary Schistosomiasis. The age group and gender of the study participants are presented in table 1.A total of 192 pupils aged 6-18 years participated in the study out of which 119 (61.9%) were boys.

Table 1 details the prevalence of S. haematobium infection, stratified by age and gender. The 9- 14 years ago showed a high prevalence of schistosomiasis as compared to other age groups and also there is a remarkable difference as regards to gender in the study participants, 70.5% males and 49.3% females. Table 1. Prevalence of Schistosomiasis infection among Quranic School children of Giohar Eylo village in Giohar town, categorized by age and gender Factor No. of Examined No. of infected Prevalence (%) Age-group (years) 6 – 8 years 92 45 48.9 9 – 14 years 62 50 80.6 15 – 18 years 38 25 65.7 Gender Males 119 84 70.5 Females 73 36 49.3

4.1.2. Malacological Survey: Malacological survey in suspected habitats such as canals, ponds, ditches and rivers in Giohar eylo village both rainy and dry seasons.During Scooping we use standard scoop consist of flat wire-mesh of a metal frame (40x30cm) supporting a mesh (micro size 1.5 cm) and mounted to iron handle of 1.5 meter. The collecting materials including the vegetation and different species of snails including Bulinus abbysinicus were transferred to plastic powl and transported to the laboratory for further investigation.

Table 2.Prevalence of Urinary Schistosomiasis by age group from 2007-2011 in South Somali. Year 0-8 9-14 15-24 25-34 >35 Total 2007 906 2123 985 391 475 4880 2008 2317 4048 2461 1851 2260 12937 2009 2827 3989 2485 2147 3698 15146 2011 422 2418 3905 1293 2065 10103

4.1.3. Source of information: Quarterly report Bilharzia by WHO Somali for the years 2011-2012.Please note that no Data was entered in the table for the year 2010 as no survey were carried in that period.

Table 3: Suspected habitats of Bulinus abyssinucus Surveyed around Giohar eylo village in Goihar Town during rainy season April 2013 Name of village Standing water habitats Flowing water habitats Ponds Ditches Canals Rivers Giohar eylo 8B.aby 15B.aby 16B.aby 19B.aby

Table 4: Suspected habitats of Bulinus abyssinucus Surveyed around Giohar eylo village in Goihar District during winter season December 2013 Name of village Standing water habitats Flowing water habitats

Ponds Ditches Canals Rivers Giohar eylo Dry Dry 168B.aby 84B.aby

4.1.4. Questionnaire Survey: Table 5- Socio-demographic factors and Schistosomiasis-related knowledge Factor N % Age 13-18 180 45.6 19-25 120 30.4 26+ 95 24.1 Gender Male 240 60.8 Female 155 39..2 Occupation Farmer 321 81.3 Live stock 44 11.1 Business 30 7.6 Know what is Bilhaziasis is Yes 361 91.4 No 34 8.6 Have you ever suffered Bilharzia Yes 209 52.9 NO 186 47.1 Able to get medical advice Hospital 32 8.1 Traditional 32 8.1 Pharmacy 331 83.8 Were you given medicine?

Yes 161 40.8 No 142 35.9 Not applicable 92 23.3

4.1.5. Sanitation Characteristics: In sanitation, about 59% of the respondents (male) said they do not know more about the disease called Bilharzia, 79% of the respondents (male) said that they know the disease. 41% of the respondents (female) showed they don’t know Bilharzia disease, 20, 6% of the respondents

(female) said they know more about the disease and the table below shows

Table 6. Sanitation Characteristics of respondents (N=390)

Factor N % Are there toilets/ Pit latrines in your home Yes 340 87.1 No 50 0.25 When there is no Toilet facility what do you use Neighbor’s 25 6.3 Bush 154 39 Lake shore 182 46.4 Other 34 8.1 Where do you get water for drinking? Lake 265 67.1 River 98 24.8 Other 32 8.4 Where do you wash yourself? Lake 122 30.9 River 273 69.1 Where do you wash your clothes? Lake 136 34.4 River 259 65.6

Table 7: Sex Respondent * Do you know the disease called bilharzia

Sex Do you know the disease called Total P. value Respondent bilharzia

No Yes Male 240(59%) 27(79%) 213(60.8%) 0.02* Female 155(41%) 7(20.6%) 148(39.2%) Total (100%) 395 (100%) 34 (100%) 361

37% of the respondents aged of 13-18 and said that they know more about the disease called

Bilharzia, 30.4 % of the respondents aged of 19-25 and they showed to have known the disease.

24.1 % of the respondents aged above 26 and showed they know Bilharzia disease and the table below shows

Table 8: Age Respondent * Do you know the disease called bilharzia

Do you know the disease called Age bilharzia Total p. value Respondent No Yes 13-18 34(8.6) 146(37.0) 180(45.6%) 19-25 0(0%) 120(30.4%) 120(30.37%) 0.0* 26+ 0(0%) 95(24.1%) 95(24%) Total 34(8.6%) 361(91.4%) 395(100%)

69.8% of the respondents are rural 32, 4%, of 69.8% said: no” whereas the rest said “yes “.

26.9% of the respondents are nomad, 32, 4%, of 26.9% said: no” whereas the rest said “yes “..

33% of the respondents are IDPs 32, 4%, of 33% said: no” whereas the rest said “yes and the table below shows

Table 13: Residence of respondent * Can bilharzia be treated

Do you know the disease called Residence of bilharzia Total P. value Respondent No Yes

Rural 12(32.4%) 252 (69.8%) 264(66.8%) Nomad 11(32.4%) 97(26.9%) 108(27.3%) 0.000

IDPs 11(32.4%) 12(3.3%) 23(5.8%) Total 361(100.0%) 34(100.0%) 395(100.0%)

209 of the respondents were single. 80 of the respondents said: no” whereas 129 said “yes

“.103 of the respondents were married. 62 of the respondents said: no” whereas 41 said “yes,

83 of the respondents were divorced 42 of the respondents said: no” whereas 41 said “yes and the table below shows.

Table 12: Marital status of Respondent * Can bilharzia be treated

Marital Can bilharzia be treated status of Total P. value No Yes Respondent Single 80 129 209 Married 62 41 103 0.01* Divorced 42 41 83 Total 184 211 395

4.2. DISCUSSION:

Parasitological malacological and questionnaire survey were conducted in Giohar area, Middle shabelle region to determine the factors associated the prevalence of urinary Schistosomiasis.

The prevalence of urinary Schistosomiasis observed among qur’anic school was 70.5% in males and 40.3% in females. Moreover, the Schistosoma infected B. aby were very high and infected especially in dry season. All these practices and observation confirmed the transmission of urinary Schistosomiasis was very high.

It has been clear that population movement and internal displacement which may occur various reasons especially in civil war have led to an increase in the spread of urinary schistosomiasis.

Age was significantly associated with the disease in the current study. Satayathum. et al., (2006) also observed between age and urinary Schistosomiasis. Older age groups were more likely to be infected. The study revealed a peak prevalence among age groups 9-14 was 80.6%followed by

15-18 was 65.7% and 6-8 was 48.9%. The low prevalence in the age group 6-8 years observed in the present study and most other studies may be attributed to the low water contact behavior of children in this age range.

Study participants demonstrated a high level of knowledge (76.2%) on Schistosomiasis in terms of what the disease is. There were a significant proportion of Quranic school children had no knowledge on the transmission and treatment of the disease according to my observation.

Schistosomiasis is essentially tied to local water use behaviors. Some studies have revealed a strong association of human water contact and infection. King (2001). Watts et al., (1998) evaluated the frequency of water contact activities regarding the most common activities in their communities, such as washing clothes, taking paths, swimming, fishing and crossing the river and lakes. The significant relationship between water contact and infection in bivariate analysis significantly associated with infection.

Many surveys assured that the prevalence and intensity of Schistosomiasis are closely related to the socioeconomic conditions prevailing in any particular endemic area (Lima e costa et al.,

1985; Pugh & Gilles, 1978; Goll& Wilkins, 1984;EKeh &Adeniyi, 1988; Kloos, 1995;

Gwatirisaet al., 1999; Ofoezie, 2000; WHO, 2002). The most important factors among these are the accessibility to adequate clean water supply and sanitary facilities. The lack of sanitary facilities and safe water supply is the main cause of increasing the contamination of water bodies with the parasite's eggs as well as increasing the human water-contact activities.

The findings in this study revealed that all of the villagers used Lakes (67.1%) and River (24.8%) water for drinking, and the rest (8.9%).

Cheesbrough (1999) highlighted the essential factors that contribute to the spread and increase in incidence of parasitic infections. These include the inadequate sanitation and unhygienic living conditions, which ultimately lead to intensive faecal contamination of the environment, The lack of a serious health-education programme, the constrain of water-supply, which exaggerated the problem of water bodies’ contamination, absence of any programme for vector control due to the lack of resources and trained personnel and the medical services including the expenses of the drugs are beyond the financial means of the concerned communities. Schistosomiasis is spreading through water development projects ,thus, the number of human victims and those at risk is increasing. Since eradication of the disease is beyond the human and financial resources of 37

most endemic countries, the primary objective of schistosomiasis control, therefore, must be the reduction and then the elimination of transmission. In this way, a low level of transmission with limited disease problems must be accept. A stroke of a pen or even application of standard measures cannot achieve a real and meaningful control of any disease. Experience has shown that no single control method is likely to break the transmission cycle, and so all available methods should be consider and use concurrently. Thus, sound epidemiological surveys should be conducted for obtaining tangible and realistic figures of the infection parameters of any parasitic disease. In consistent with the above and based on the survey findings, some interventional tools were adopt: these include the chemotherapy, health education and community participation.

Large-scale chemotherapy programme usually would result in higher reductions in the levels of morbidity and transmission intensity. The health delivery system in the scheme is well found in the villages, but not in the camps. If a control strategy is to be implement in the scheme, it should be inject within the available health system, with particular consideration to the camps of the scheme.

It is very pity that the alphabetic knowledge of how the disease is transmitted is missing among the scheme inhabitants, where no effort was exert in real health education. Health-education programme is a necessity for maintaining full utilization of water provided and to motivate latrine construction and use. The launch of such programmes, especially among the schoolchildren, is an important measure in the control of schistosomiasis.

In conjunction with the above, intensive talks will be conducted to the residents in the schools, mosques and football clubs. These health education programmes will be support by effective audiovisuals for solidifying the health messages. Coloured posters illuminating how the disease transmission takes place as well as the complications, prevention and control of the disease, will 38

be distributed wherever the inhabitants accumulate. Although no latrines were installed, but, the campaign utilized "religious quotes" as an entry point for precluding of water bodies' contamination.

Water closets (WCs) and safe-water facilities are targeted the contamination reduction of the surrounding water bodies with Bilharzia eggs and as well as the reduction of water-contacts. The pivotal role of sanitation in Schistosomiasis control is well recognize, although some constrains like the cultural, religious traditions and sociological barriers might minimize the use of latrines.

However, upgrading of sanitation standard increases the probability of success of other control measures.

Snail control might play an influential role in morbidity control programme to be propose in

Giohar canals and rivers, since it maintains the low level of morbidity attained by chemotherapy.

Snail control strategies have relied almost exclusively on chemical control, molluscicides, which are apply through various techniques to the watercourses (Ahmed, et al., 2002). Usually the continuity and sustainability of the chemical snail control programmes are interrupt for a variety of causes. The cost of the routine mollusciciding programmes remains high and inevitable which is a major constrain at a time when per capita expenditure on health in developing countries is diminishing. In addition, the problem was further aggravated by other associated problems like resistance and the chemical risk hazards to drinking water.

CHAPTER FIVE

CONCLUSION AND RECOMMENDATION

5.1. CONCLUSION

In conclusion, to control the transmission of schistosomiasis in the scheme, safeadequate water supply should be secured for the villages and be provided to the camps. The residents should be motivated for both installment and usage of latrines or any suitable system for excreta disposal, especially in the camps. These previously mentioned two facilities, not important only for combating Schistosomiasis, but crucial for scaling down other water-related diseases. Many control trials stressed on health education and community participation as a potent tool for novating these cultural and social traditions, especially among the children. Finally, a mass treatment campaign is a necessitous intervention preceded by health education utilizing the local vernaculars and jargons

1) In this study, the prevalence of urinary Schistosomiasis in Giohar Eylo village Quranic

Schools was found 70.5% in Males and 49.3% were Female

2) 192 Quranic students screened none was found with S. mansoni.

3) Knowledge of the disease by the study participants was increasingly high.

4) Lack of clean water, poor environmental sanitation, lack of health services is the main

cause of high prevalence.

5.2. RECOMMENDATION

1) The fact that the study revealed only one type of Schistosomiasis implies that only one

drug Prazquentel should be considered for treatment of infected children in Giohar Eylo

village in Giohar Town.

2) School and Quranic age children who are out of Quranic Schools should be invited to

participate in future studies to produce more reliable estimate for the prevalence of

urinary Schistosomiasis.

3) Conduction of malacological survey all the middle shabelle region in search of Bulinus

abyssinicus in Micro- and macro habitats.

4) Since molluscuciding is practically impossible to apply the extensive water bodies, all

efforts must be directed towards the interruption of transmission by wide use of mass-

chemotherapy.

5) In terms of education starting health education programs are clearly needed to maintain

the observed levels of awareness of the disease in the community.

6) More collaboration between the state Ministries of Health and local community is

needed to manage and to reduce the danger of the disease

REFERENCES

Agnew-Blais J, Carnevale J, Gropper A, Shilika E Bail R and Ngoma M

(2010).Schistosmiasis JO haematobium prevalence and risk factor s in a school-age

population of peri-urban Lusaka , Zambia .Journal of Tropical Pediatrics .56:247-

253.

Awotunde JO, Okanla EO and AgbaBN(2002). Prevalence and socioeconomic factor

Schistosoma haematobium infection in a Ghanain Community.African Journal of

Biomedical Research .5:5-8.Of Schistosomamansoni in the urban area of northeast

Brazil .Bulletin of the World Health Organization. 69:93-102.

BethonyJ,Williams JT, KloosH,BlangeroJ,Alves-Franga L, Buck G Michalek A,William –

Blangero S, LoVerde PT, Correa-Oliveira R and Gazzine A(2001). Exposure to

Schistosomamansoni infection in rural area in Brazil .II:Household risk factors.

Tropical Medicine and International Health. 6:136-145.

BichlerKH,Feil G and Zumbragel A (2001).Schistosmiasis :a critical view.Current Opinion in

Urology .11:97-101.Brouwer KC, Munatsi A Ndhlovo PD, Wagatsuma Y and

Shiff CJ (2004).Urinary Schistosmiasis in zimbabwean School Children: predictors

of morbidity.

African Health Sciences. 4:115-118.

Boatin BA, Dukes P, Wurapa FK(1984).Parasitic infectIn North-eastern Zambia .Medical

Journal of Zambia18:2-7.Butterworth AE,DunneDw, fulford AJC, Thorne KJI,

GachuhiK,Ouma JH, and Sturrock RF (1992). Human immunity to

Schistomamansoni : observation on Mechanisms ,and implication of control

.immunological Investigations 21:391-407.

Caffrey CR (2007).Chemotherapy of Schistosmiasis :present and future . Current Opinion in

Chemical Biology . 11:433-439.

Cairncross S, Blumenthal U, KloskyP, Maores L, Tayeh A (1996). The public and domestic

Domains in the transmission of the disease .Tropical Medicine and International

Health .1:27-34.Central Statistics Office (2000). Census of population and hosting

county report,

Ministry of Health, Lusaka.

Coutinho EM, Abath FG, Barbosa CS, Domingues AL , MC, Melo MC, Montenegro SM,

Lucena MA Romani SA, Souza WV and Coutinho AD (1997). Factors involved

in SchistosomaMansoni infection in rural areas af Northeast Brazil

.MemoriasInstitutoOswaldo Cruz; 92:707-15.

Dalton PR and pole D (1978). Water contact patterns in relation to ScistosomaHaematobium

infection . Bulletin of the World Health Organization , 56,417-426.

Doehring E, FeldmeierH,Daffalla AA (1983). Day –to –day variation and circadian rhythm

ofEgg excretion in urinary schistosomiasis in the Sudan .Annals of Tropical Medicine

and Parasitology. 77:587-594.

Dunne D (2003). Factors affecting Schistosomaisis associated hapatosplenmegalyIn children and

adults. Proceeding of British Society for Parasitology . Spin meeting .6-9 April .

London.

EdungaLD(1980). Water utilization and and its health implication in Ilorin,KwaraState Nigeria

.Act Tropica . 37:79-81.

Engels D, chitsulo L, Montresor A and Savioli L(2002). The global epidemiological situation

of Schistosomiasis and new approaches to control and research .Act Tropica.82:139-

146.

Fenwick A, Savioli, Engels D, Berquist NR , and Todd MH (2003). Drugs for the Control of

parasitic disease :Current Status and Development in Schistosomais. TrendsIn

parasitology. 19:509-515.

Firmo JOA, Lima e Costa MF,Guerra HL and Rocha RS (1996).Urban Schistosomais

:Morbidity ,Sociodemographic Character istics and water tact patterns predictive

infection. International journal of Epidemiology. 25:1292-1300.

Fulford AJ, Ouma JH, Kariuki HC ,Thiongo FW, Klumpp R, Kloos H, Sturrock RF

andButterworth AE (1996). Water contact observation in keynyan communities

endemic for Schistosomaisis: methodology and pattern of behavior .

parasitology.113:223-241.

Garba A, Toure S, Dembele R, Busque-Oliva E and fenwick A (2006).Implementation of

National Schistosomais Control Progra Am in west Africa . Trends In parasitology.

22:322-326.

Gazzinilli, A Valasquez-Melendez AG, Crawford SB, LoVerde PT, Correa –Oliveira

RAnd KLoos H (2006). Socio-economic determinants of Schistosomaisis in a poor

rural area in Brazil .Act Tropica .99:36-271.

GryseelsB ,Polman K, Clerinx J and Kestens L(2006).Human Schistosomaisis.Lancet

368;1118.

Guimaraes MDC, Lima e Costa MFF, Lima LB, Moreira MA (1985).Clinical-

epidemiological study of schistosomiasismansoni in school children of Ilha, Arcos

Distirict, Minas Gerais, Brazil Revista se SaudePublicaSoa Paulo 19: 8-17.

Hustings EL (1983). Human water-contact activities related to the transmission of bilharzias

(schistosomiasis). Journal of Tropical Medicine and Hygiene. 86: 23-35.

Kapito-Tembo AP, Mwapasa V, Meshnick SR, Samanyika Y, Banda D, Bowie C and

Radke S (2009).Prevalence distribution and risk factors for

Schistosomaheamatobium infection among school children in Blantyre, Malawi

PLoS Neglected Tropical Diseases. 3: e361.

Katz N,Chaves and pellegrino JP(1972). A simple device for quantitative stool thick-smear

technique in schistosomiasismansoni. Revista do instituto de mrdicina Tropical de

soa Paulo. 14: 397-400.

King CH (2001). Epidemiology if schistosomiasis: determinants of transmissi of infection

Mahmoud AAF,ed. Schistosomiasis. London. Imperial Collage Press, 115-132.

King CH, Dangerfield-Cha M (2008). The unacknowledged impact of chronic

SchistosomiasisCronicHlness. 4:65-79.

King CH.Dickman K, Tisch DJ (2005). Reassessment of the cost of chronic Schistosomiasis

Lancet. 365: 1561-1569.

King CH, Sturrock RF, Kariuki HC and Hamburger J (2006). Transmission Control for

.Why it matters now. Trends in Parasitology. 22: 575-582ــ Schistosomiasis

Kloos H, Olivera R, Quites HFO, Souza MMC and GazzinelliA (2008). Socio economic

studies of schistosomiasis in Brazil: a review. ActaTropica 108: 194-204.

Lwihula GK (1987). Human water contact activities in relation to snail and cercariae densities

in kikwahila village, ifakara area. Parasitosis in Tanzania. 2: 19-46.

Mafe Ma, Stamm T, Utzinger J and N,Goran EK (2000). Control of urinaySchistosomiasis:

An investigation into the effective use of questionnaires to identify High-risk

communities and individuals in nager State, Niger Tropical Medicine and

International Health. 5 : 53-56.

Mascara CL, Peixoto SV, Heliton da silva B, Enk ME, Omar dos santos C and Schall V

(2004). Factors associated with Schistosomiasismansoni in a papulation from

Municipality of jaboticatubas, state of Minas Gerais,BrazilMemorias do

institutoOswaldo Cruz. 96:127-134.

Mubila L and Rollinson D (2002). Snail-Parasite Compatibility and Prevalence of

Schistosomiasisheamatobiumon the Shores of Lake Kariba, Zambia. Annals of

Tropical Medicine and Parasitology. 96:165-173.

Ndyomugyenyi R and Minjas JN (2001). Urinary Schistosomiasis in schoolchildren in der-es-

salaam, Tanzania, and fNigeractors influencing its transmission. Annals of Tropical

Medicine and Parasitology. 95:697-706.

Ogbeide O, Okojie O, Wagbastoma V and Isah E (1994).Schistosomaheamatobium in rural

school children in Nigeria. West African journal of medicine. 13:31-33.

Okanla EO (1991). Schistosomiasis: Influence of parental occupation and rural or urban

dwelling on prevalence. Nigerian journal of Pure and Applied Sciences. 6:154-159.

Opara KN, Udoidung NI, Ukpong IG (2007).GenitourniarySchistosomiasis among pre-

primary school children in rural community within cross river basin, Nigeria. Journal

of Helminthology. 81 : 393-397.

Rudge JW, Stothard JR, Basanez M, Ali FM, KhamisANandRollinson D (2008).Micro-

epidemiology of urinary Schistosomiasis in Zanzibar: local risk factors associated

with distribution of infections among school children relevance for control

ActaTropica. 105:45-54.

Satayathum SA, Muchiri EM, Ouma JH, Whalem CC and King CH (2006). Factors

effecting infection or re-infection with Schistosomaheamatobium in coastal Kenya:

Survival analysis during in a nine-year school-based treatment program. American

Journal of Tropical Medicine and Hygiene. 75:83-92.

Scott GW, Michaud CM and Reich MR (2003). The global burden of disease due to

Schistosomiasis (2003). DCCP working paper. (http://dep2.org /file/34/wp19.pdf).

Seto EYW, Lee YJ, Laing S and Zhong B (2007). Individual and Village-level study of water

contact patterns and SchistosomaJaponicuminfection in mountainous Rural china

tropical medicine and international Health. 12:1199-1209.

Simoonga C, Kazemble LN, Kristensen TK, Olsen A, Appleton CC mubita P and Mubila L

(2008). The epidemiology and small-scale spatial heterogeneity of Urinary

Schistosomiasis in Lusaka province, Zambia. Geospital Health. 3:57-67.

Siziya S, Mushanga M, Sichilima W, Sukwa T.Y, Lengeler C and Sala-diakanda DM

(1993). The distribution of Schistosomaheamatobium in the Isoka district, Zambia;

and a possible strategy for its control. Central Africa n Journal of Medicine. 39: 32-

37.

Siziya S and Mushanga M (1996). Importance of Schistosomiasis in the Isoka district of

Zambia: A pre-requisite for its control using community participation. Social Science

and medicine. 42:431-435.

Steinmann P, Kieser J, Bos R, Tanner M and Utzinger J (2006). Schistosomiasis and Water

resource development: Systematic review, meta-analysis, and estimates of people at

risk. Lancent . 6:411-425.

Stothard JR, Mook P, Mgeni AF, Khamis S, KhamisANandRollinson D (2006). Control of

urinary SchistosomiasisonZenzibar (Ungunja Island): pilot evaluation of the

educational impact of the jumanaKichacho health educational booklet with in

primary schools. Memorias do InstitutoOswaldo Cruz. 101: 119-124.

StothardJR, Mgeni AF, KhamisS,Seto S and Rollinson D (2002). Urinary Schistosomiasison

in school-children ofZenzibar Island (Ungunja), Tanzania A parasitological survey

supplemented with questionnaires. Transactions of the Royal Society of Tropical

Medicine and Hygiene. 96: 507-514.

Talaat M, Omar M and Evans D (1999). Developing strategies to control Schistosomiasison

morbidity in non-enrolled School-age children: Experience from Egypt Tropical

Medicine and International Health. 4:551-556.

USAID (2003). School health and nutritional interventions lead to positive behavior change.

Warren KS,Siongok TK, Houser HB, Ouma JH, peters PA (78). Quantification of infection

with Schistosoma haematobium in relation to epidemiology and selective population

chemotherapy. I. minimal number of daily egg counts in urine necessary to establish

intensity of infection. Journal of infectious disease. 138:849-855.

Watts S, Khallaayoune K, Bensefia R, laamrani H, and Gryseels B (1998). The study of

human behavior and Schistosomaisis transmission in an irrigated area in Morocco.

Social science and medicine. 46:755-765.

WHO (2006). Schistosomaisis and Soil-transmitted parasite infections:Preliminary estimates of

the number of children treated with albendazole or mebendazole WHO weekly

Epidemiological Report 16:145-164.

SomaliBilharzia control Programme prevalence surveys 2008-2012Prevalence baseline status for

Schistosomaisis.

Appendix – 1 : Authority acceptance to Conduct Research

Appendix -2: Giohar Map

Appendix -3: Snail scooping activity

During rainy season

During dry season

Appendix – 4: Urine collection activityin Giohar Eylo

Appendix -5: Snails Collected in Giohar Eylo

Appendix -6: Water Contact Activity

APPENDIX -7: QUESSIONNAIRE

1. Please do not indicate name of respondent on the form 2. Write responses by ticking in the box provided 3. For questions with no boxes write the responses on the space provided 4. Answer all questions

SECTION A-BACKGROUND INFORMATION 1. Date of interview ______2. Sex a. Male [ ] b. Female [ ] 3. Age 4-Residence a. Urban b. Rural c. Nomad d. IDPs 5-Marital status a. Single b. Married c. Divorced d. Widowed 6-Level for education a. None b. Quranic c. Primary d. Secondary e. Other (please specify……………………………….) [ ] 7-Occupation a. Farmer b. Livestock c. Business d. Other (Please specify…………………………..) [ ] 8-Types of housing a. Brick b. Thatched c. Hut d. Tent 9-Types of toilet facility a. Pit latrine b. Water closed c. VIP d. Other (please specify…………………………….) [ ] 4. Where do you urinate/defecate most of the times when you are not at home?

a. Neighbor’s b. Bush c. Lake shore d. River bank e. Other (Please specify………………………………) [ ] 5. Where do you get water for drinking? a. Lake b. Well c. River d. Tap e. Other (please specify……………………………..) [ ] 6. Where do you get water for washing your body? a. Lake b. Well c. Tap d. River 7. Where do you wash yourself? a. Lake b. Shower c. Pit latrine d. Path tap 8. Where do you wash your clothes? a. Lake b. Well c. Tap d. River 9. Do you swim in the lake? a. Yes b. No 10. Do you go fishing on the lake? a. Yes b. No

Section B Questions on Knowledge 11. Do you know the disease called bilharzias? a. Yes b. NO 17. Is bilharzias problem is your area? a. Yes b. No 18. Can bilharzias be treated? a. Yes b. No

19. Where do you get information on bilharzias? a. Friends b. Health worker c. Radio d. Journal Section C-questions on health seeking behavior 20. Have you ever suffered from bilharzias? a. Yes b. NO 21. Where did you go for medical advice? a. Hospital b. Traditional c. Self-medication d. Other (please specify………………..) [ ] 22. Where you give medicine? a. Yes b. NO c. Not applicable 23. How soon did you receive medical advice? a. Immediately b. After some time c. Did not seek medical d. Other (please specify…………………) [ ] 24. If you were given medicine, were you completely cured? a. Yes b. No c. Not applicable 25. Were you given any health education on bilharzias at the hospital? a. Yes b. NO