Factors affecting the attrition of community-directed distributors of ivermectin, in an onchocerciasis-control programme in the Imo and Abia states of south-eastern Nigeria

In areas of Nigeria where onchocerciasis is endemic, community-directed distributors (CDD) distribute ivermectin annually, as part of the effort to control the disease. Unfortunately, it has been reported that at least 35% of the distributors who have been trained in Nigeria are unwilling to participate further as CDD. The selection and training of new CDD, to replace those unwilling to continue, leads to annual expense that the national onchocerciasis-programme is finding difficult to meet, given other programme priorities and the limited resources. If the reported levels of attrition are true, they seriously threaten the sustainability of community-directed treatment with ivermectin (CDTI) in Nigeria. In 2002, interviews were held with 101 people who had been trained as CDD, including those who had stopped serving their communities, from 12 communities in south-eastern Nigeria that had high rates of CDD attrition. The results showed that, although the overall reported CDD attrition was 40.6%, the actual rate was only 10.9%. The CDD who had ceased participating in the annual rounds of ivermectin blamed a lack of incentives (65.9%), the demands of other employment (14.6%), the long distances involved in the house-to-house distribution (12.2%) or marital duties (7.3%). Analysis of the data obtained from all the interviewed CDD showed that inadequate supplies of ivermectin (P<0.01), lack of supervision (P<0.05) and a lack of monetary incentives (P<0.001) led to significant increases in attrition. Conversely, CDD retention was significantly enhanced when the distributors were selected by their community members (P<0.001), supervised (P<0.001), supplied with adequate ivermectin tablets (P<0.05), involved in educating their community members (P<0.05), and/or involved in other health programmes (P<0.001). Although CDD who were involved in other health programmes were relatively unlikely to cease participating in the distributions, they were more likely to take longer than 14 days to complete ivermectin distribution than other CDD, who only distributed ivermectin. Data obtained in interviews with present and past CDD appear vital for informing, directing, protecting and enhancing the performance of CDTI programmes, in Nigeria and elsewhere.

The Carter Center's assistance to river blindness control programs: establishing treatment objectives and goals for monitoring ivermectin delivery systems on two continents

Periodic mass treatment with ivermectin in endemic communities prevents eye and dermal disease due to onchocerciasis. As part of an international global partnership to control onchocerciasis, The Carter Center's Global 2000 River Blindness Program (GRBP) assists the ministries of health in ten countries to distribute ivermectin (Mectizan, donated by Merck & Co.). The GRBP priorities are to maximize ivermectin treatment coverage and related health education and training efforts, and to monitor progress through regular reporting of ivermectin treatments measured against annual treatment objectives and ultimate treatment goals (e.g., full coverage, which is defined as reaching all persons residing in at risk villages who are eligible for treatment). Since the GRBP began in 1996, more than 21.2 million ivermectin treatment encounters have been reported by assisted programs. In 1999, more than 6.6 million eligible persons at risk for onchocerciasis received treatment, which represented 96% of the 1999 annual treatment objective of 6.9 million, and 78% of the ultimate treatment goal in assisted areas.

Dracunculiasis eradication: delayed, not denied

By the end of 1998, Asia was free of dracunculiasis (Guinea worm disease), with Pakistan, India, and Yemen having interrupted transmission in 1993, 1996, and 1997, respectively. Transmission of the disease was also interrupted in Cameroon and Senegal during 1997. Chad reported only 3 cases during 1998. Dracunculiasis is now confined to only 13 countries in Africa. The overall number of cases has been reduced by more than 97% from the 3.2 million cases estimated to have occurred in 1986 to 78,557 cases reported in 1998. Because the civil war in Sudan remains the major impediment to eradication of dracunculiasis, the interim goal is to stop all transmission outside that country by the end of 2000. The most important operational need now is for national programs to improve the frequency and quality of supervision of village-based health workers in order to enhance the sensitivity of surveillance and effectiveness of case containment.

Four-week supplementation with a natural dietary compound produces favorable changes in body composition

The purpose of this study was to determine whether a natural dietary supplement produced favorable changes in body composition during a 4-week diet- and-exercise program. The active compound contains a patented combination of chromium picolinate, inulin, capsicum, L-phenylalanine, and other lipotropic nutrients. A double-blind, weight-loss intervention design was used. Participants were randomly assigned to either a diet/exercise/supplement group (n = 56) or a diet/exercise/placebo group (n = 67). Caloric intake was reduced to 1500 kcal/d and participants walked for 45 minutes, 5 days a week, to attain between 60% and 80% of predicted maximal heart rate. Analysis of covariance (ANCOVA) showed significant differences (P < .05) between groups in percent body fat, fat mass, and fat-free mass; no significant differences were found (P > .05) in body weight, body mass index, or energy intake. Independent t tests showed no significant differences (P > .05) in diet composition between groups. Results indicate that the addition of a natural dietary supplement during a 4-week diet-and-exercise weight-loss program accelerates the rate of body fat loss and helps maintain fat-free mass (lean tissue), thereby producing favorable changes in body composition.

Perspectives from the dracunculiasis eradication programme

After a slow beginning in association with the International Drinking Water Supply and Sanitation Decade (1981-1990), the global Dracunculiasis Eradication Programme has reduced the incidence of dracunculiasis by nearly 97%, from an estimated 3.2 million cases in 1986 to less than 100,000 cases in 1997. Over half of the remaining cases are in Sudan. In addition, the programme has already produced many indirect benefits such as improved agricultural production and school attendance, extensive provision of clean drinking-water, mobilization of endemic communities, and improved care of infants. Most workers in the campaign have other responsibilities in their communities or ministries of health besides dracunculiasis eradication.

Dracunculiasis eradication: almost a reality

The idea of a global campaign to eradicate dracunculiasis was first proposed by the Centers for Disease Control and Prevention in 1980, during the advent of the International Drinking Water Supply and Sanitation Decade (IDWSSD) (1981-1990). In 1981, the Steering Committee of the IDWSSD adopted eradication of dracunculiasis as a subgoal of their efforts to provide safe drinking water to unserved populations. In 1988, African ministers of health voted to eradicate dracunculiasis by the end of 1995, a target date that was endorsed by UNICEF in 1989 and the World Health Assembly in 1991. Although nine of 18 endemic countries, India (1980), Pakistan (1987), Nigeria and Cameroon (1988), Ghana (1989), and Mauritania, Benin, Burkina Faso, and Togo (1990) completed national searches for cases of the disease, only four countries, India (1983), Pakistan (1988), Ghana (1989), and Nigeria (1989), actually started eradication programs during the 1980s. The remaining 14 endemic countries began their eradication programs between 1991 and 1995. At the end of 1996, dracunculiasis had not been entirely eradicated, but its incidence had been reduced by 95%, from an estimated 3.2 million cases in 1986 to 152,805 cases in 1996. Sudan reported a total of 118,578 (78%) of the 152,805 cases of dracunculiasis reported during 1996. Insufficient funding and the civil war in Sudan continue to be the major obstacles to overcome. A primary aim of the eradication program in 1997 is to seek to ensure that all cases of dracunculiasis outside of Sudan are contained. In Sudan the challenge is to pursue all appropriate control measures in all accessible areas as vigorously as possible until political circumstances allow access to all of the remaining affected areas.

Eradication of dracunculiasis from Pakistan

In 1986 the World Health Organization targeted dracunculiasis (Guinea-worm disease), which seriously impairs socioeconomic development in 16 African countries, India, Pakistan, and Yemen, to be eradicated globally. The target date for eradication by the end of 1995 was established in 1991. Pakistan eradicated dracunculiasis from the country in October, 1993, after a national campaign which began in 1987 with a nationwide village-by-village search for cases. The infection, which is transmitted by drinking water from ponds containing infected water fleas, was eradicated by using health education, cloth filters, and the cyclopsicide, temephos; and in the later stages, by case containment. Methods pioneered in Pakistan's National Guinea Worm Eradication Program are now being applied in remaining endemic countries.

Dracunculiasis eradication: March 1994 update

Substantial progress has been realized in the global campaign to eradicate dracunculiasis by the end of 1995 since a previous review of the subject was published in this journal a year ago. All known endemic countries are now engaged in the eradication effort, and one or more control measures are now in place in 93% of endemic villages. Despite improved surveillance for the disease, the number of reported cases of the disease has been reduced by 41% (to about 221,000), and the number of known endemic villages has been reduced by 28% (to about 16,500) in the past year. Priorities for national eradication programs in 1994 include increasing the use of vector control and intensifying the case containment strategy in endemic villages. It is still possible to achieve the eradication target of December 1995, but greatly intensified efforts this year will be required to do so.

Dracunculiasis eradication: beginning of the end

Beginning with the International Drinking Water Supply and Sanitation Decade (1981-1990), an increasingly broad coalition of international and bilateral agencies, organizations, private companies, and other institutions have joined forces to eradicate dracunculiasis (Guinea worm disease). From an estimated annual incidence of 10 million persons just before the campaign began, the remaining incidence of cases is now less than two million. More than 23,000 villages are known to be endemic. All 18 countries where the disease is still endemic have completed or begun nationwide searches to identify endemic villages, except Kenya. Dracunculiasis is nearly eradicated in Asia, where Pakistan found only 23 cases in 1992, and India found 1,081 cases. Cameroon and Senegal are close to achieving eradication in Africa, where the two formerly highest endemic countries, Nigeria and Ghana, reduced their combined total of cases from approximately 820,000 in 1989 to less than 240,000 in 1992. Much remains to be done, however, in francophone West Africa and especially in East Africa. The most serious current obstacles to eradicating dracunculiasis by 1995 are the civil war in Sudan, apathy of some national and international health officials, and inadequate funding for the campaign.

Mobilization strategy for guinea worm eradication in Nigeria

The transformation of dracunculiasis from an obscure and neglected rural disease to the highly visible target of a national eradication campaign in Nigeria is described in this report. This process progressed through four overlapping stages: documentation of the extent and nature of the disease as a national problem, demonstration in Nigeria that dracunculiasis could be effectively prevented by targeted provision and use of protected rural water supplies, mobilization for community participation in, and political support of, the eradication effort, and implementation of interventions nationwide. The conduct of the first national village-by-village search for cases and documentation of the adverse socioeconomic impact of the disease (e.g., on rice production) in Nigeria were the key elements used to solicit greater attention to the problem and mobilize support for its eradication. The critical role of the mass media in this effort and other benefits of this mobilization strategy are also highlighted.

Surveillance for dracunculiasis, 1981-1991

In 1986 the World Health Organization (WHO) designated dracunculiasis (guinea worm disease) as the next disease scheduled to be eradicated (by 1995) after smallpox. Dramatic improvement in national and international surveillance has played a key role in the global eradication campaign, which was initiated at CDC in 1980. About 3 million persons are still affected by the disease annually, with adverse effects on their health as well as on agricultural production and education. Over 100 million persons are at risk of having the disease in more than 20,000 villages in India, Pakistan, and 17 African countries. At least one nationwide, village-by-village search to detect all villages with endemic dracunculiasis and count cases is recommended at the outset of each national campaign, followed by monthly reporting by village-based health workers in the targeted villages during the implementation phase. Rapid dissemination of the results of the surveillance is critical. Intensive case detection and containment--with rewards for reporting of cases--are most appropriate near the end of each campaign. Cameroon, Ghana, India, Nigeria, and Pakistan have pioneered the various surveillance methods for this disease in recent years. Methods for conducting surveillance of dracunculiasis and other important diseases must continue to be developed and improved as countries now believed to be free of dracunculiasis prepare to apply to WHO for certification of elimination of dracunculiasis.

Strategies for dracunculiasis eradication

In 1991 the Forty-fourth World Health Assembly declared the goal of eradicating dracunculiasis (guinea worm disease) by the end of 1995. This article summarizes the recommended strategies for surveillance and interventions in national dracunculiasis eradication programmes. It is based on personal experience with dracunculiasis programmes in Ghana, Nigeria and Pakistan. Three phases are described: establishment of a national programme office and conduct of a baseline survey; implementation of interventions; and case containment. The relevance of dracunculiasis eradication activities to strengthening of primary health care in the three countries is discussed briefly. Similar strategies would help eradicate this disease in the remaining endemic countries.

Dracunculiasis eradication: target 1995

Substantial progress has been achieved over the past 3 years by the campaign to eradicate dracunculiasis. The target of eradication by 1995 has been set by the African Regional Office of the World Health Organization and accepted by the United Nations Children's Fund (UNICEF) and the United Nations Development Program. India and Pakistan continue to reduce their cases of the disease dramatically. In Africa, Ghana and Nigeria conducted national village-by-village searches in 1988-1990 and, between them, found greater than 800,000 cases of the disease. Most African countries have now prepared national plans of action, appointed national coordinators, and intend to use UNICEF's assistance to conduct national searches by the end of 1990. An international donors' conference held in 1989 facilitated major new assistance for the initiative by UNICEF, the United Nations Development Program, the United States Agency for International Development, the Japanese International Cooperation Agency, the Peace Corps, the American Cyanamid Company, and DuPont. The World Health Organization held a meeting early in 1990 to draft criteria and recommend the process for certifying achievement of elimination of dracunculiasis in formerly endemic countries. The major remaining obstacles to eradication of dracunculiasis by 1995 are civil wars in northeastern Africa and the apathy of some national and international officials.

Effect of low-impact aerobic dance on the functional fitness of elderly women

To determine the effect of low-impact aerobic dance on sedentary elderly women (N = 53), functional fitness was measured by items from the proposed American Alliance of Health, Physical Education, Recreation, and Dance (AAHPERD) fitness test for older adults. After 12-weeks of low-impact aerobic dance, the group improved significantly on all functional fitness components except motor control/coordination, including cardiorespiratory endurance, strength/endurance, body agility, flexibility, body fat, and balance.

Smallpox: ten years gone

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Dracunculiasis eradication: a mid-decade status report

A campaign to eradicate dracunculiasis has been underway from the beginning of the International Drinking Water Supply and Sanitation Decade (1981-1990), since providing safe drinking water is the most effective means to prevent that disease. About 120 million persons are estimated to be at risk of the infection in Africa, and 20 million more in India and Pakistan. Both major endemic countries in Asia have begun efforts to eliminate the disease, and by the end of 1986, national anti-dracunculiasis programs were underway or planned in 8 of the 19 affected African countries. In May 1986, the World Health Assembly adopted a resolution on the elimination of dracunculiasis-the first such resolution since the successful Smallpox Eradication Program. India, which began its Guinea Worm Eradication Program in 1980, has already eliminated the disease from one of seven endemic states, and reduced the total number of cases found through active surveillance by 35% between 1983 and 1985. In Côte d'Ivoire (Ivory Coast), the only African country to conduct active surveillance for dracunculiasis so far, an aggressive combined program of rural water supply, health education, and active surveillance has reduced the disease from 4,971 cases in 1976 to 592 cases in 1985.

Public health measures for prevention and control of AIDS

The grave challenge posed by the recent pandemic of acquired immunodeficiency syndrome is not the first time mankind has faced such a threat. Useful lessons may be drawn from the successful global Smallpox Eradication Program and applied to the current campaign in the areas of surveillance, strategy, operations, and evaluation. The most important epidemiologic characteristic of this new infection is the unprecedented observation that virtually all asymptomatic infected persons are infectious and will remain so indefinitely. In combatting this infection we should concentrate our efforts in the United States on preventing transmission from the estimated 1.5 million persons who are already infected. We must make the best use we can of all the tools we already have: public information, health education, counseling and serologic testing of persons at high risk, treatment and prevention of intravenous drug abuse, and serologic screening of organ and tissue donors. Adequate confidentiality of test results needs to be secured in order to promote voluntary testing as an important means of achieving behavorial change among persons who are most likely to have been exposed to the infections. Persons whose sexual or drug abuse behavior puts them at higher risk of infection are the highest priority target group. They should be sought at every opportunity, whether seen in public clinics or private practice, and advised to be tested. In order to focus on preventing sexual, parenteral, and perinatal transmission of the virus we must avoid numerous potential distractions and irrelevant issues: we don't have time for them.

AIDS in minority populations in the United States

Among ethnic minorities in the United States, blacks and Hispanics, who compose 12 percent and 7 percent of the U.S. population, respectively, constitute 24 percent and 14 percent of the cases of AIDS. Seventy-eight percent of all children with AIDS are black or Hispanic, as are 71 percent of all women with AIDS. In the black and Hispanic communities, intravenous (IV) drug abuse is associated with much of the AIDS transmission, and parenterally acquired infections are spread secondarily by sexual and perinatal transmission. Almost two-thirds of black and Hispanic persons with AIDS in the United States reside in New York, New Jersey, or Florida. Important differences in the understanding of AIDS and human immunodeficiency virus infection and control measures in minority communities must be considered in devising information and intervention programs for those communities. Programs intended specifically for minorities, especially greatly intensified prevention and treatment of IV drugs abuse, are needed to supplement programs aimed at the U.S. population in general. Combatting AIDS offers black and Hispanic populations an opportunity to greatly reduce IV drug abuse, other sexually transmitted diseases, and teenage pregnancy.

A method of rapid assessment of the distribution and endemicity of dracunculiasis in Nigeria

This paper describes how information was collected at a national conference in Nigeria and a map compiled to give an initial assessment of the distribution and endemicity of dracunculiasis (guinea worm disease) throughout the country. The map provided a stimulus for further studies of the status of the disease and for the consideration of national control strategies. A map created along the same lines could be used for obtaining an initial assessment of the extent and endemicity of dracunculiasis, or other diseases, in countries for which such data was not readily available.

Impact of the control of endemic treponemal diseases in Ghana on other diseases

A program for control of yaws and yellow fever in the Republic of Ghana was initiated with the aims of reducing the sharp increase in the prevalence of yaws and preventing epidemics of yellow fever. In addition, the program included health education and mass immunization with single doses of measles, tetanus, and tuberculosis vaccines. An evaluation of the first three years of the program indicates that the multidisciplinary approach has benefited a large segment of the population, which previously has had little or no access to medical care. This control program has also had an impact on other diseases and conditions.

Yaws in Ghana

The final results of a three-year campaign against yaws in the Republic of Ghana, which was introduced in an attempt to reduce an unusually high prevalence, are summarized. The campaign started in January 1981 and officially ended in December 1983. Serious economic and technical constraints slowed the progress of work after the first year and reduced the total population covered. In spite of the shortcomings, the program provided penicillin treatment to 77,818 patients with active yaws (4.04% of those examined during the campaign) as well as chemoprophylaxis for an additional 1,556,360 contacts. The campaign staff compiled detailed information on the epidemiology of yaws in Ghana. A second attack phase using simple equipment and vehicles such as motorcycles and bicycles could be implemented with greater efficiency and could reduce costs.

Control of yaws and other endemic treponematoses: implementation of vertical and/or integrated programs

Previous mass campaigns against the endemic treponematoses have taught investigators several lessons that, along with current constraints and altered circumstances, must be considered in the formulation of a contemporary strategy for the control or eradication of yaws, endemic syphilis, or pinta. A time-limited, vertical approach is necessary in highly endemic areas initially to reduce the level of transmission. Elsewhere, control activities should be integrated into other primary health care interventions, especially health education, water and sanitation programs, maternal and child health care, and provision of essential drugs. Control of the endemic treponematoses is an ideal means of strengthening primary health care in endemic areas.

The spread of Jenner's vaccine: social mobilization in the early nineteenth century

Several books have been devoted in the past to the history of smallpox, for instance the classic "Smallpox" by C. W. Dixon, published in 1962 by J. and A. Churchill Ltd., London, which endeavors to present both the clinical and public health aspects of the disease. More recently, 2 very important books have been written on the history of smallpox, one in the United States, by Donald R. Hopkins, assistant surgeon general of the United States and deputy director of the Centers for Disease Control, Atlanta, entitled "Princes and Peasants, Smallpox in History," published in 1983, the other one in France, by Yves-Marie Berce, professor of modern history at the University of Reims, entitled "Le Caudron et la Lancette, Croyances Populaires et Medecine Preventive (1798-1830), "published in 1984. Among the many topics which these 2 recent books address, a most important question for today's strategies is extensively documented: how did the Jenner vaccine spread over the world in 10 years? Some of the significant answers which the works of Donald R. Hopkins and Yves-Marie Berce provide are excerpted and adapted in this article.

Beyond smallpox eradication

This paper highlights 2 important, under-recognized lessons of the Smallpox Eradication Program (SEP). The 1st lesson is that the discipline and enthusiasm of that vertical campaign could be applied to an attack on several high priority diseases or conditions simultaneously, to great advantage. The 2nd lesson is that eradication of selected diseases remains a uniquely useful tool for advancing the public's health.

Resurgence of yaws in Ghana

This paper reports on the first 1 1/2 years of a new effort to control yaws in Ghana, where the disease has been resurgent since a previous mass campaign ended over 10 years ago.

Dracunculiasis: an eradicable scourge

As an incapacitating disease which has a direct negative effect on the self-sufficiency of rural populations in parts of Asia and Africa, dracunculiasis is a serious, but neglected, hindrance to economic development. It is the only communicable disease that is transmitted solely by drinking contaminated water. Several intervention measures have been shown to be effective in reducing or interrupting transmission, the most effective of which is provision of safe drinking water. Its vulnerability to well planned control measures has been demonstrated in India, the Ivory Coast, Nigeria, the Soviet Union, and elsewhere. The International Drinking Water Supply and Sanitation Decade (1981-1990) presents an unparalleled opportunity to eradicate dracunculiasis, and linking the Decade and an effort to eradicate dracunculiasis would be mutually beneficial. Additional epidemiologic studies to document further the economic impact of the disease on affected populations, the changes in incidence which result when effective interventions are made, and the role of subgroups in affected villages as transmitters of the infection, would be very useful in the struggle to eradicate another scourge of mankind.

Benzodiazepine withdrawal in general practice

A study of benzodiazepine prescribing in a single-handed general practice was carried out over a period of three months. It seemed that the existing pattern of prescribing was indiscriminate and ineffective, and that repeat prescriptions were poorly controlled. A programme of controlled withdrawal was instituted for patients whose consumption of benzodiazepines was felt to be no longer appropriate. Of 103 patients identified who had been taking benzodiazepines for longer than three months, 78 were entered into the programme. On completion, 45 patients (58 per cent) had discontinued benzodiazepines completely, and a further 13 (17 per cent) were taking less than half their original dose. Four patients had failed to reduce consumption at all and two were lost to follow-up. At follow-up between three and five months later, 49 patients (63 per cent) had discontinued benzodiazepines completely and only two had restarted treatment. The median time taken to complete the programme was 3.2 weeks, with 95 per cent of patients completing within six weeks. Withdrawal was generally well tolerated, with a temporary increase in insomnia as the main symptom. Two patients experienced severe symptoms, but both had stopped treatment abruptly.