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
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.