EVALUATION OF ONCHOCERCIASIS CONTROL PROGRAMME IN IGBOEZE NORTH LOCAL GOVERNMENT AREA OF ENUGU STATE

Abstract

This study evaluated the Onchocerciasis Control Programme in Igboeze North Local Government  Area  of  Enugu  State.  It  evaluated  the  availability  of  Onchocerciasis control services, the availability and adequacy of qualified services providers and materials, the level of utilization of Onchocerciasis control services and the level of sustainability of these services in the LGA. The factors evaluated  in relation to the utilization of the services included, the distance of people to the nearest health facility, age  and  gender  influences.  To  achieve  the  purpose  of  the  study,  seven  research questions were formulated and three null hypotheses postulated. The study adopted the descriptive survey research design. It covered the 49 villages/communities in Igboeze North LGA, of whom 662 community-directed  distributors, 245 community/opinion leaders,  35 Front-line health  facility staff and the three team members  of the local Onchocerciasis  control  team  were  studied.  There  was  no  sampling  as  the  entire population was studied through the use of three sets of questionnaires and programme data  stored  in  the  local  government  headquarters  and  the  health  facilities.  For the purpose  of  reaching  valid  conclusions,  data  collected  were  analyzed  quantitatively using  frequency  distribution  and  percentages  in  respect  of  research  questions  one through five and mean and standard deviation for research questions six and seven. The Student t-test and ANOVA statistics were used to verify the three hypotheses at .05 level of significance. Data generated from programme records were used to confirm

information  got  from  respondents.  The  study  revealed  that  Mectizan™   distribution, annual training and retraining of community-directed distributors and community self- monitors were available to a good extent, while health education and mobilization and

monitoring  of  community  self-monitors  were  available  to  a  lesser  extent.  It  also revealed that all the services personnel and materials were available but the adequacy remained a problem. The study further revealed that the distance of the people to the nearest health facility affected the utilization level of the services, while age did not. Further  on,  gender  affected  the  utilization  of  community  self-monitoring  services, while it did not affect Mectizan  distribution  and health education  and mobilization. Based on the major findings and conclusions, it was recommended that the state government and the local government should ensure the availability and adequacy of programme personnel and materials, and improve on the funding of the programme. The community was recommended to fully assume the ownership of the programme by meeting frequently to discuss programme strategies, select and compensate CDDs and also monitor the activities of such CDDs.

Background to the Study

CHAPTER ONE Introduction

Despite the several control efforts put in place regarding Onchocerciasis, it is still classified as a neglected tropical disease due to extreme fluid political and donor situations. Due to the epidemiological  characteristics of the disease, governments in endemic areas, owing to one political reason or the other (poverty, war, conflicts), do not pay attention  to  the disease  (Remme,  2004). Donor agencies  owing to  lack  of certain dedicated infrastructure that will enable committed control efforts merely adopt remedial control measures.

Before the Onchocerciasis Control Programme (OCP) got under way in 1974, Onchocerciasis was the second cause of infection-induced blindness in the world (Wikipedia,  2010).  It  affected  thirty-six  countries  in  Africa,  the  Yemen  and,  very locally,  Latin  America.  But  the  most  severely  hit  was  Africa,  where  it  was  a debilitating obstacle to settlement and economic and social development.

Today,  about  forty million  people  are  afflicted  worldwide  with  two  million blind (Njepuome, Ogbu-Pearce,  Okoronkwo & Igbe, 2009). They further stated that eighty-five and half million people in thirty-five countries live in endemic areas where the disease ravages. Further breakdown of the figure shows that twenty-eight countries are in Africa, six in Latin America and the other is Yemen. Some eighteen million are estimated to be infected, and of this, about ninety-nine percent live in Africa.

Onchocerciasis, also known as river blindness and Robles’ disease, is a parasitic disease  caused  by  infestation  by  Onchocerca  volvolus,  a  nematode  (roundworm) (WHO, 2010). It is got through the bite of a vector, the blackfly or Simulium species, through which its lifecycle may be traced.

Gaffar (2010) and Willey, Sherwood, Woolverton & Prescott, (2009) stated that a gravid female blackfly takes a blood meal meant for the maturation of its ova from an infested human host, ingesting the infective microfilariae of the nematode. The microfilariae enter the gut and thoracic flight muscles of the blackfly progressing into the first larval stage and move to the proboscis and into the saliva in their third larval stage. These take about seven days.

During another blood meal, the blackfly passes the larvae into the next human host. The larvae migrate to the subcutaneous tissues and undergo two more moults. They form nodules as they mature into adult worms over six to twelve months.

After maturing, adult male worms mate with the female worms in the subcutaneous  tissues  to  produce  between  700  and  1,500  microfilariae   per  day, according to Trattle and Gladwin (2007). The microfilariae migrate to the skin during the day, and blackfly only feed in the day, so the parasite is in a prime position for the female fly to ingest it. Blackfly takes blood meal to ingest these microfilariae to restart the cycle.

According to Willey et al. (2009), it is not the nematode but its endosymbiont, Wolbachia pipientis, which causes the severe inflammatory response that leaves many blind. When the worms die, their Wolbachia symbionts are released, triggering a host immune system response that causes intense itching and can destroy nearby tissues, such as the eye (Sightsavers International, 2007).

Rodolfo Robles’ study on patients in Guatemala in 1915 led to the discovery that the disease is caused by the filarial, Onchocerca volvolus and sheds light on the lifecycle and transmission of the parasite. According to Okulicz (2008), Robles, using case studies of coffee plantation workers in Guatemala hypothesized that the vector of the disease was a day-biting insect, and more specifically, two anthropophilic species of Simulium flies were found in the endemic areas.

James, Berger, Elston and Odom (2006) described the disease, Onchocerciasis, in the following phases or types:

Erisipela de la costa. This is an acute phase characterized by swelling of the face with erythema and itching. Onchocerciasis causes different kinds of skin changes  and  these  changes  vary  in  different  geographic  regions.  This  skin changes, erisipela de la costa, of acute Onchocerciasis is most commonly seen among victims in Central and South America.

Mal morando. This is a cutaneous condition  of the disease  characterized  by inflammation that is accompanied by hyper-pigmentation. This includes leopard skin – a term referring to the spotted de-pigmentation of the skin that may occur

in  Onchocerciasis;  lizard  skin  –  the  thickened,  wrinkled  skin  changes;  and

elephant skin – the thickening of the human skin.

According  to  Baldo,  Desjardins,  Russell,  Stahlhut  and  Warren  (2010),  adult worms remain  in  cutaneous  nodules, limiting access  to  the host’s  immune  system. Microfilariae, in contrast, are able to induce intense inflammatory responses, especially upon their death. Dying microfilariae,  according to Baldo et al., have been recently discovered to release Wolbachia Surface Protein that activates TLR2 and TLR4, triggering innate immune responses and producing the inflammation and its associated morbidity.  Wolbachia  species have been  found to be endosymbiont  of Onchocerca volvolus adult and microfilaria, and are thought to be the driving force behind most of the Onchocerca volvolus morbidity. The severity of the illness is directly proportional to the number of infected microfilariae  and the power of the resultant inflammatory response.

Skin   involvement   typically   consists   of   intense   itching,   swelling   and inflammation (Wanni, 2003). A grading system, according to Ali et al. (2003), has been developed to categorize the degree of skin involvement. This includes: acute popular onchodermatitis (scattered pruritic papules; chronic popular onchodermatitis (larger papules,   resulting   in   hyper-pigmentation);    lichenified   onchodermatitis   (hyper- pigmented papules and plaques with oedema, lymphadenopathy, pruritis and common secondary bacterial  infection); skin atrophy (loss of elasticity,  skin resembles tissue paper; lizard skin appearance); and de-pigmentation (leopard skin appearance, usually on the anterior lower leg).

Ocular  involvement  provides  the  common  name  associated  with Onchocerciasis, river blindness, and according to Wanni (2008) and may involve any part  of  the  eye  from  the  conjunctiva  and  cornea  to  uvea  and  posterior  segment including retina and optic nerve. Punctate keratitis occurs as the microfilariae migrate to the surface of the cornea. This clears up as the inflammation subsides. However, if the infection is chronic, sclerosis keratitis may occur, making the affected area to be opaque. Over time, the entire cornea may become opaque, leading to blindness. There is evidence, according to Baldo et al (2010), to suggest that the effect on the cornea is caused by an immune response to the bacteria present in the worms. This worrisome

state  of  blindness  provided  for  investigations  into  the  cause,  which  brought  about several intervention programmes.

There   have   been   various   control   programmes   that   aim   at   stopping Onchocerciasis from being a public health problem. The first was the Onchocerciasis Control Programme (OCP), which was launched in 1974 and at its peak covered thirty (30)  million  people  in  eleven  (11)  countries  (Remme,  2004).  Through  the  use  of larvicidal spraying of fast flowing rivers and streams to control blackfly population to treating infested people, the OCP strived to eliminate Onchocerciasis as a public health problem. The OCP, now APOC (African Programme for Onchocerciasis Control), a joint effort of the World Health  Organization  (WHO), the World Bank, the United Nations   Development   Programme   (UNDP)   and   the   United   Nations   Food   and Agricultural Organization (FAO) was considered a success because transmission was broken in the eleven original countries covered.

In  1995,  the  African  Programme  for  Onchocerciasis  control  (APOC)  was launched to cover another nineteen (19) countries and to take over from the OCP which was exited by 2002 and to use mass drug administration (MDA) already experimented upon by the OCP as its only strategy. The continued monitoring of the former OCP countries by APOC ensures that Onchocerciasis will not reinvade the OCP countries. This is by select treatment of rivers and streams with larvicides and treatment of select communities with the drug ivermectin.

Ivermectin kills the parasite by interfering with the nervous system and muscle function, in particular, by enhancing inhibitory neurotransmission. According to Rea, Zhang  and  Baras  (2010), the  drug binds  to  and  activates  glutamate-gated  chloride channels   (GluCls).  These  channels,  present  in  neurons  and  myocytes,   are  not invertebrate-specific, but are protected in vertebrates from the action of ivermectin by the blood-brain  barrier.  According  to  Wolesteholme  and  Rogers (2005), Yates  and Wolesteholme  (2004)  and  Harder  (2002),  ivermectin  irreversibly  activates  these channel receptors in the worms, eventually causing an inhibitory postsynaptic potential (IPSP). The chance of a future action potential occurring in synapses between neurons decreases and the nematode experiences flaccid paralysis followed by death.

Rea, Zhang and Baras (2010) said that ivermectin is directly effective against the larval stage microfilariae of Onchocerca volvolus, which it paralyzes so that they can be killed by eosinophils and macrophages. Ivermectin does not kill the adult female Onchocerca  volvolus,  but causes  them  to  cease  releasing  microfilariae,  perhaps  by paralyzing the reproductive tract.

It is upon this that APOC is using the mass drug administration (MDA) as its tool in the control of Onchocerciasis  in the nineteen other African  countries, which Nigeria is one, and in the containment of the eleven former OCP countries to prevent reinvasion; this is due to poor donor situation. By the MDA, infested people are treated with one or two doses of ivermectin  every year, repeated  between  fifteen  (15) and twenty-five (25) years, which corresponds to the expected average lifespan of the adult worm.  The  drug  paralyzes  and  kills  the  microfilariae,  causing  fever,  itching,  and possibly oedema, arthritis and lymphadenopathy. The intense skin itching is eventually relieved  and progression  towards blindness is halted. According  to Rea Zhang and Baras (2010), while the drug does not kill the adult worm, it does prevent them from producing additional offspring. The drug, therefore, prevents both morbidity and transmission.

Nigeria ranks as the highest endemic country of Onchocerciasis in the world. According to Stanford University (2006), of the over eighty-five (85) million people who live in endemic areas, half of this figure resides in Nigeria. During the APOC rapid epidemiological monitoring (REMO) conducted in 1995 to determine the level of endemicity, Enugu State had two of her local government areas as hypo-endemic; nine, meso-endemic;  and six hyper-endemic.  Igboeze North Local Government  Area falls into the six that were hyper-endemic beside, Oji River, Isiuzo, Uzouwani, Nkanu East and Ezeagu (Enugu State Ministry of Health, 2009).

According  to  the Onchocerciasis  update  of Enugu  State Ministry of Health, (2009), mass drug administration with ivermectin started in Igboeze North Local Government  Area  since 1999  and  continued  till date.  A programme  evaluation  for sustainability was carried out in August 2003 by APOC to measure the expected level of  sustainability  in  preparation  for  the  APOC  expected  winding  up  by  2008  and eventual pull-out by 2010. All the local government areas of the State were short of the levels of sustainability parameters expected at that time and she was given an extension

of two years before the next re-evaluation. The second expected by 2005 is yet to hold, though according Afriquejet (2011), the exit date of APOC is now expected to be 2015, and with numerous calls on the World Health Organization to extend it beyond this date.

Community-directed  treatment  with ivermectin (CDTI) is the APOC strategy for the mass drug administration. It is expected that a community-based and sponsored framework that can continue to distribute ivermectin, as long as it is available, is the feasible means to control the disease.

The hyper-endemicity of the disease in the Igboeze North Local Government Area is because the two traditional communities of Enugu-Ezike and Ette that form the LGA  lie  on  hillocks  that  harbour  fast-flowing  streams  and  rivulets.  The  major occupation of the people is subsistent agrarian farming and this factor has them spend most of their daytime in open fields with their body extremities exposed to the bite of the blackfly. The two communities lie between 6 °  57’N and 7° 05’N latitudes and 7°

26’E and 7° 36’ E longitudes (United Nations Jobs, 2011), and borders Olamaboro LGA

of Kogi State that shares similar terrain and is also hyper-endemic.

The evaluation of the community-directed treatment with ivermectin framework of the Onchocerciasis control programme in Igboeze North is essential to identifying shortcomings in the programme which may lead to its collapse and to conceptualize approaches  that  may improve  the  services.  This  according  to  Trochim  (2006)  will improve programme cost-effectiveness and long-term sustainability.

Evaluation, according to del Tufo (2002) is the process of assessing and judging the value of a piece of work or an organization to reflect on what it is trying to achieve, assessing how far it is succeeding and identifying required changes. This is by asking questions on the extent the inputs make impact, meeting the needs of beneficiaries, efficiency and effectiveness and quality of input compared to output. Evaluation in this work is the process of determining the worth or merit of something. This is by determining if it is achieving the goals by which it is set up.

Programme evaluation, according to McNamara (2010), is carefully collecting information  about a programme or some aspects of a programme in order to make necessary  decisions  about  the  programme.  Despite  a  variety  of  evaluation  types,

knowledge about programme decisions and accurate collection  and understanding of the information are the important factors in programme evaluation. Purpose, audience, kind of information, sources, method and resources are key considerations in designing a programme evaluation.

Evaluation of CDTI strategy for Onchocerciasis control in Igboeze North LGA is  a goal-based  evaluation.  According  to  McNamara  (2010),  goal-based  evaluation evaluates the extent to which programmes meet one or more specific goals described in the programme plan. CDTI as a strategy seeks to establish the mass drug administration of ivermectin  therapy as a control measure of Onchocerciasis  which will last up to twenty-five (25) years without external funding.

Mectizan  (ivermectin) is donated by Merk since 1988 as a means to control Onchocerciasis. According to Thylefors, Alleman and Twum-Danso (2008), Merk pledged to make available mectizan free-of-charge as long as it needed. Due to the fact that no organization pledges to fund the distribution, the WHO through the African Programme for Onchocerciasis Control seeks to establish a community-directed intervention as the means to sustain this distribution for the estimated long period of time.   This   CDTI  strategy   is   beneficial   because   health   programmes   based   on government sponsorship are politicized, which has led to their eventual collapse. The success of CDTI in Igboeze North LGA will create awareness to the people of the local government area that they can surmount their other health problems using the same intervention strategy.

Statement of the Problem

Community-directed treatment with ivermectin (CDTI) is a strategy adopted by the WHO through its African Programme for Onchocerciasis Control for the control of Onchocerciasis in the remaining nineteen African countries not covered by the World Bank/UNDP/FAO sponsored programme of the OCP. It is not supported by any other strategy, partly due to poor donor situation and because it is a good strategy on its own. The safety of the drug and the ease in handling it joins to promote the advantage of the strategy.

CDTI is established in every endemic community in the nineteen African countries, including Nigeria. This is through the supply of drugs and the training of

distributors (Community-directed distributors – CDD) selected by the community. The drug is distributed in various communities at the time and place dictated by the community such that the distribution will not disturb the occupational activities of the people (Hodgkin et al. (2007). The reduction in the severity of the onchocercal skin diseases (OSD) joins to the other motivating factors that bring about the community sustaining the distribution for the expected lifespan of the distribution.

The extension of APOC sponsorship for Enugu State CDTI by two years after the 2003 APOC evaluation (Enugu State Ministry of Health, 2009) is indicative that CDTI indicators in Enugu State did not reach the pass mark. Mectizan availability in Nigeria (Mbanefo et al. 2009) is not consistent. This goes to negate the concept of the community directing distribution time. By the report of Biu and Bitrus (2009) in the situation of Onchocerciasis  in Borno State, the disease is still prevalent despite the distribution   of  the  drug   in   the   State.  This  contrasts   Njepuome,   Ogbu-Pearce, Okoronkwo and Igbe (2009) on Onchocerciasis control situation in Nigeria, which they give a pass mark.

Because there is no effort on the part of the Nigeria government to complement the efforts of WHO by attempting vector control as another strategy to Onchocerciasis control,  drug  distribution  situation  is  poor  and  the  disease  is  still  prevalent.  It  is doubtful if the single control strategy is effective. It becomes pertinent to evaluate the Community-directed  treatment  with ivermectin  situation in Igboeze North, which  is one the hyper-endemic LGAs of Enugu State in order to understand the Onchocerciasis control situation in the State.

Purpose of the Study

The  purpose   of  this   study  was   to   evaluate   the   Onchocerciasis   control programme in Igboeze North Local Government Area of Enugu State. Specifically, this study sought to determine the:

1.  availability of Onchocerciasis control services in Igboeze North LGA;

2.  availability of qualified Onchocerciasis control services providers in Igboeze

North LGA;

3.  availability of materials for Onchocerciasis  control programme in Igboeze

North LGA;

4.  adequacy  of materials  for  Onchocerciasis  control  programme  in  Igboeze

North LGA;

5.  adequacy  of  qualified   staff  for  Onchocerciasis   control  programme   in

Igboeze North LGA;

6.  level  of  utilization  of  Onchocerciasis  control  services  in  Igboeze  North

LGA; and

7.  extent  of sustainability  of Onchocerciasis  control  programme  in  Igboeze

North LGA.

Research Questions

The following research questions were formulated to guide the study:

1.  What Onchocerciasis control services are available in Igboeze North LGA?

2.  What qualified  Onchocerciasis  control services  providers  are available  in

Igboeze North LGA?

3.  What materials  for Onchocerciasis  control are available  in Igboeze North

LGA?

4.  How  adequate  are  qualified  staff  for  Onchocerciasis  control  services  in

Igboeze North?

5.  How  adequate  are  materials  for  Onchocerciasis  control  programme  in

Igboeze North LGA?

6.  What  are  the  levels  of  utilization  of  Onchocerciasis  control  services  in

Igboeze North LGA?

7.  What is the extent of sustainability of Onchocerciasis control programme in

Igboeze North LGA?

Hypotheses

The following null hypotheses were formulated to guide the present study. Each null hypothesis was tested at .05 level of significance,  at the appropriate  degree of freedom.

1.  There is no significant difference in the utilization of Onchocerciasis control services based on the distance of the people of Igboeze North LGA to their nearest health facility.

2.  There is no significant difference in the utilization of Onchocerciasis control services between the various age groups in Igboeze North LGA

3.  There is no significant difference in the utilization of Onchocerciasis control services between the males and the females in Igboeze North LGA

Significance of the Study

The evaluation of Onchocerciasis  control programme in Igboeze North LGA went  a  long  way  in  establishing  the  existence  of  the  programme  in  the  local government area. Many a time, programmes are thought to be in existence in an area only in name. By providing information regarding the existence of the programme, it rested the question of its existence. Otherwise, efforts would have been geared towards establishing it. This will position the LGA to enjoy the benefits accruable to possible control of the debilitating disease of Onchocerciasis through ensuring that the standards of such a programme is in place. Agencies as the local government council, the state government and the international agencies of the WHO and the World Bank, who join in sponsoring, are among the beneficiaries of this evaluation.

Information generated by this evaluation has made clear to the local government council,  the  state  government  and  the  WHO  that  the  programme  is  running  with qualified personnel. It has also shown that these personnel were not adequate. This was done by examining the number of the service providers against the standards required for providing such services.

Furthermore, having qualified staff is one and their adequacy to the needs is the other; this evaluation examined and alerted the local government council and the state governments on the poor state of adequate qualified staff. This is of immense benefit to the  governments  and  the  programme  as  this  evaluation  has  cleared  the  issue  of adequacy of qualified staff towards the smooth running of the programme.

Sometimes, failure of programmes result from unavailability of some or all the materials required for the programme to run. This evaluation generated information to this end to enable the community and the health  service of the local  and the state governments regarding the absence of such important materials required for the programme to run, which may have been provided for, but did not reach the target.

Other times, failure of programmes result from inadequacy of programme materials, due to poor estimate of the population. This evaluation  has assessed this problem and has alerted, especially,  the assisting agencies of the non-governmental developmental organization (NGDO) and the donor agency, of such inadequacies. This will help to reduce the possible loss of the efforts which may result from the collapse of the programme.

Of great importance is the utilization of this Onchocerciasis control services. This evaluation has thrown open the levels of utilization and the factors responsible for such. By the direction given by this evaluation, the agencies of the community, the health service, NGDO and the donor will understand how to maintain their efforts or adjust strategies.

Utilization  of services provided by the Onchocerciasis  control programme in Igboeze North LGA is moderated by factors related to the population. This evaluation exposed these factors and how they affected the programme. This will be beneficial to the health service of the local and state governments that provide the services. It will help to keep the ship of the programme on sail.

Long  lasting  programmes  like  Onchocerciasis   control  is  best  maintained internally than from the outside. This evaluation has brought to foreground indicators of sustainability of the programme which are in place. This will indicate to the external bodies of the NGDO and the donor what will happen should they withdraw, and to put in more actions as the situations were not in good direction.

Generally, the evaluation of Onchocerciasis  is not only beneficial  to Igboeze North, but has thrown more light on the state of affairs of Onchocerciasis control in Enugu State and Nigeria in general, especially where no such evaluation has held. It has add to the body of knowledge towards the elimination of the disease as issues about vector  control,  environmental   control  has  been   raised   as  alternative   means  of controlling the menace. It will also be beneficial to other programme implementers, planners and funding agencies. Due to limited funding, the area on sustainability will be of immense benefit to financing agencies of programmes because it will motivate them in accepting to donate, knowing that the programme will grow to sustain itself.

Scope of the Study

The study was on the evaluation of the Onchocerciasis control programme in Igboeze North Local Government Area of Enugu State. It covered the two communities of  Enugu-Ezike   and   Ette,   which   comprise   the   local   government   area.   These communities comprised of forty-nine (49) villages with thirty-five (35) health facilities that cover them. Private health institutions are not involved because health services personnel are not remunerated.

The study covered the programme area of the African Programme for Onchocerciasis Control (APOC). This included the supply of mectizan by the donor, which the availability and adequacy will be evaluated and the transportation of same to the community health centres. It also included the training of health personnel and the community-directed distributors (CDD). The indicator of sustainability, which lies on the  principle  that  the  community  accepts  the  ownership  of  the  programme,  was inclusive.  These  indicators  included  the  selection  of  and  the  compensation  of  the CDDs, provision of registers and measuring sticks and carrying out community self- monitoring (CSM). The independent variables involved in this study were location, age and gender. The study was limited to goal-based  evaluation and was guided by the discrepancy model and Stufflebeam CIPP evaluation models.

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