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Keywords:

  • schistosomiasis;
  • onchocerciasis;
  • lymphatic filariasis;
  • praziquantel;
  • albendazole;
  • ivermectin
  • Esquistosomiasis;
  • oncocercosis;
  • filariasis linfática;
  • praziquantel;
  • albendazol;
  • ivermectina

Summary

  1. Top of page
  2. Summary
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Objectives  To compare (i) side effects associated with the simultaneous adminstration of praziquantel, albendazole and ivermectin with side affects associated with albendazole and ivermectin only and (ii) coverage by volunteers distributing three or two drugs.

Methods  Two-arm comparative study in northern Ghana integrated praziquantel distribution into an existing lymphatic filariasis and onchocerciasis control programme using Community Directed Distributors. The control arm continued to distribute only ivermectin and albendazole. Dosages of ivermectin and praziquantel were based on height. Treatment was directly observed, and all two/three drugs were co-administered. Adverse effects were recorded based on passive surveillance. Parasitological, anthropometric and haematological data were collected at baseline.

Results  Prevalence of Schistosoma haematobium infection among 1001 (boys: 47.9% girls: 52.1%) school-age children (6–15 years) [intervention: 30.0% (CI: 23.1–34.2); control: 23.0% (CI: 18.9–27.0)], mean haemoglobin, weight and age were similar among the intervention and control groups. While 1676 (99.1%) compounds in the control area were visited and 15 020 (96.58%) people were treated, only 1375 (88.5%) compounds in the intervention area were visited and 8454 (80.97%) people treated (P < 0.001). The numbers of adverse effects were similar (intervention: 50/6896; control: 130/15 020). The most reported adverse effects was headache (intervention: 14/50; control: 13/130), followed by body weakness, which was reported more from the intervention group (intervention: 13/50, 95% CI: 14.6–40.3; control: 6/130, 95% CI: 1.7–9.8]. Sixty-six per cent (6896/10 441) of the eligible population received praziquantel.

Conclusions  Reported adverse events were mild and managed at the subdistrict level with no cases of hospitalization; intensive health education will, however, be required to improve coverage.

Objetivos:  Comparar (1) los efectos secundarios asociados con la administración simultánea de pazicuantel, albendazol e ivermectina con los efectos secundarios asociados al albendazol e ivermectina solas; y (2) cobertura por voluntarios distribuyendo tres o dos medicamentos.

Métodos:  Estudio comparativo de dos brazos en el norte de Ghana integrando la distribución de prazicuantel en un programa existente de control de la filariasis linfática y oncocercosis utilizando distribuidores dirigidos por la comunidad. En el brazo control se continuó distribuyendo solo la ivermectina y el albendazol. Las dosis de ivermectina y prazicuantel se basaban en la altura. El tratamiento era de observación directa y todos los medicamentos (dos o tres) fueron co-administrados. Los efectos adversos se registraron basándose en una vigilancia pasiva. Los datos parasitológicos, antropométricos y hematológicos se recolectaron al inicio del estudio.

Resultados:  La prevalencia de la infección por S. haematobium entre 1,001 (niños: 47.9% niñas: 52.1%) niños en edad escolar (6-15 años) [intervención: 30.0% (IC: 23.1-34.2); control: 23.0% (IC: 18.9-27.0)], la hemoglobina media, el peso y la edad eran similares entre los grupos de la intervención y de control. Mientras que se visitaron 1,676 (99.1%) viviendas en el área de control y se trató a 15,020 (96.58%) personas, solo se visitaron 1,375 (88.5%) viviendas en el área de la intervención y se trataron 8,454 (80.97%) personas [P < 0.001]. El número de efectos adversos era similar (intervención: 50/6896; control: 130/15,020). Los efectos adversos más reportados eran el dolor de cabeza (intervención: 14/50; control: 13/130), seguido por la debilidad corporal que se reportó más en el grupo de intervención (intervención: 13/50, 95% CI: 14.6–40.3; control: 6/130, 95% CI: 1.7–9.8]. Un sesenta y seis por ciento (6,896/10,441) de la población elegible recibió praziquantel.

Conclusiones:  Los eventos adversos reportados eran leves y manejables a nivel del sub-distrito, sin casos de hospitalización; sin embargo, es necesario el que haya un fuerte compromiso en pos de la educación sanitaria si se quiere mejorar la cobertura.


Introduction

  1. Top of page
  2. Summary
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Community-directed annual mass drug administration is a pro-poor non-discriminatory and equitable intervention which serves all eligible people irrespective of socio-economic status (Mohammed et al. 2008). This provides an opportunity to improve the health of millions of people who harbour the parasites causing onchocerciasis, lymphatic filariasis and schistosomiasis. The strategy to control these three diseases is high coverage, long-term mass treatment with ivermectin for onchocerciasis and lymphatic filariasis, praziquantel for schistosomiasis and albendazole for intestinal helminths. These drugs have long been proved to be safe for mass treatment (Remme et al. 1989; Webbe 1999).

In Uganda, community-directed treatment is an effective way of integrating the distribution of praziquantel and mebendazole treatment for the control of schistosomiasis and intestinal helminths respectively without negatively affecting ivermectin coverage (Ndyomugyenyi & Kabatereine 2003). In this study, because of uncertainty of the safety of the co-administration of the three drugs, ivermectin and mebendazole were administered on Day 1 and praziquantel on Day 2. Such a treatment regimen was found to be time-consuming. There is also a high likelihood of non-compliance when such a regimen is followed, as some of the people may not avail themselves on Day 2 to receive the drugs.

A study by Na-Bangchang et al. (2006) in Thailand, which found no clinically relevant pharmacokinetic changes or adverse reactions when ivermectin, praziquantel and albendazole were given concurrently compared to when these drugs were given individually, resolved some of the uncertainties on safety of co-administration of the three drugs. The current report based on a study in northern Ghana investigated adverse reactions experienced when ivermectin, praziquantel and albendazole are given concurrently using the ComDT approach compared to when ivermectin and albendazole only are given.

Materials and methods

  1. Top of page
  2. Summary
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Study site and population

The study was conducted in the Kassena-Nankana District (KND) in northern Ghana. The district lies between 10°30′ and 11°00′ N, 1°00′ and 1°30′ W and covers about 1674 sq km of Sahelian savannah with an estimated population of 144 000 (NDSS 2009). This is a rural district with most of the people living in multifamily compounds, which form the basis of the address system used in the Navrongo Demographic Surveillance System (NDSS) and are separated from one another by agricultural land. Virtually all inhabitants engage in subsistence farming of millet, groundnut, rice, vegetables and livestock. The average annual rainfall is 850 mm, almost all of which occurs in the wet months of June to October, with the rest of the year being relatively dry. A large reservoir (Tono dam) in the middle of the district provides water throughout the year for irrigation.

For the purpose of research, the NDSS has divided the district into five zones (east, west, north, south and central) and settlements grouped into clusters as there are no district villages and settlement is dispersed. This study was carried out in the East and West zones of the district. The West zone has one health centre and four community health compounds where community health officers provide health services to the community members. The East zone has two health centres and four community health compounds.

Schistosomiasis, lymphatic filariasis and onchocerciasis are endemic in the district (Amankwa et al. 1994; Gyapong et al. 1994). There is an ongoing ivermectin and albendazole distribution programme in place which uses community-directed distributors (CDDs) in the distribution of the drugs annually. This programme has been in place since the year 2000.

Experimental design

The study was a two-arm comparative study, in which the East zone served as the intervention area and the West zone the comparison area. The intervention area integrated the distribution of praziquantel into the ivermectin and albendazole distribution programme. The same CDDs undertaking the distribution of ivermectin and albendazole added praziquantel and distributed the three drugs together. The control arm maintained the distribution of only ivermectin and albendazole.

Drug administration

Ivermectin and praziquantel dosages were determined using height (WHO dose poles). The two dose poles were harmonized on a single-dose pole by having the lines and corresponding number of tablets on opposite sides of the pole for the different parasites. This eliminated the problem of having to carry two poles about. Drug administration was by directly observed therapy (DOT) and all two/three drugs were taken concurrently. The height–dosage relationship for praziquantel was 94–109 cm = 1 tablet, 110–124 cm = 1½ tablets, 125–137 cm = 2 tablets, 138–149 cm = 2½ tablets, 150–159 cm = 3 tablets, 160–177 cm = 4 tablets and ≥178 cm = 5 tablets) and that for ivermectin was 90–119 cm = 1 tablet, 120–140 cm = 2 tablets, 141–158 cm = 3 tablets and ≥159 cm = 4 tablets).

The inclusion/exclusion criteria were the same as in the National Control Programme (Gyapong et al. 2001), which exclude pregnant women, children 4 years and younger and persons seriously ill, and so pregnant women were not given praziquantel (though it is now permissible, WHO 2002).

Data capture

The same registers used by the CDDs to collect data on the distribution of ivermectin and albendazole were used to capture the data in both the control and intervention areas. All relevant data on praziquantel distribution including adverse effects were captured in these registers. Two weeks of active distribution and 3 months of follow-up were allowed for the distribution of the drugs.

Safety monitoring and adverse effects management

All CDDs and health personnel at health facilities in the study area were trained in the handling of adverse effects. The documented side effects of the three drugs were discussed during the training. A study physician was available at the district hospital to attend any emergencies.

Selection of CDDs

Community meetings were held between the research team, the district health management team and community members including the chiefs and opinion leaders. The purpose of the research was explained to the community members. The CDDs were selected by the community members for the training.

Parasitological and anthropometric measurements

Stool and urine were collected from a randomly selected representative sample of children 6–15 years of age from the intervention and control areas. This age group carries the highest burden of schistosomiasis and forms a sensitive group for the assessment of the disease burden and evaluation of impact of intervention (King et al. 2005). All eligible participants were identified through the NDSS database and randomized at the individual level based upon being in-school or not-in-school. Stool sample containers were distributed to potential study participants in their homes or schools a day before sample collection for them to provide stool samples the next morning. Urine samples were collected between 10:00 and 12:00 h, as the excretion of Schistosoma haematobium ova in the urine is highest between 10:00 and 14:00 h, with a peak around midday.

To determine haemoglobin levels, a drop of blood was taken from a finger prick of each child. Sterile disposable lancets were used for the finger prick using aseptic techniques. Haemoglobin was determined using an automated HemoCue photometer (HemoCue AB, Sweden instruments). The children were weighed to the nearest 0.5 kg using a mechanical Seca floor weighing scale (Vogel & Halke, Hamburg, Germany).

Laboratory analysis

Stool and urine samples collected in the field were transported to Navrongo Health Research Centre laboratory, processed and examined by qualified laboratory technicians. All urine samples were processed on the same day. One aliquot of 10-ml urine sample was filtered through a 13-mm, 12-μm porosity polycarbonate membrane (Millipore, Company, through UNICEF Supply Division, Copenhagen) using a 10-ml syringe and the filter placed on a single slide labelled with the identification number of the child and date of collection. Intensity of infection was classified into three groups: light (1–49), moderate (50–99) and heavy (100 eggs and more in 10 ml of urine).

The Kato-Katz technique (cellophane faecal thick smear) was used for the stool sample examination. Schistosoma mansoni infection was determined by microscopically examining 41.7 mg of faecal material and systematically counting the eggs in the faecal specimens. To increase the visibility of the parasite eggs, the cellophane was soaked in a 3% methylene blue, glycerol/water solution for 24 h. The intensity of infection was expressed as eggs per gram (epg) of faeces by multiplying the number of eggs in the 41.7 mg specimen by 24. The intensity of S. mansoni infection was classified into three groups: light (1–99), moderate (100–399) and heavy (400 eggs and over per gram of faeces) (WHO 1998). Quality control was done by an independent technologist on 10% of all slides (both positive and negative) collected.

Data analysis

All data collected in the field or the laboratory were logged for traceability, and then batched for double data entry and processed using Microsoft® Visual FoxPro 6.0. Data analysis was performed using StataCorp Stata 9 (TX, USA) and Microsoft® Excel 2007. Continuous variables like age, weight and haemoglobin level were summarized using the mean, standard deviation, minimum and maximum values by allocated group. Categorical variables like sex and age group, presence of S. haematobium, S. mansoni, and reported side effects were described using proportions with 95% confidence intervals by allocated group. Egg density of S. haematobium, S. mansoni was summarized using the geometric mean egg count, the minimum and maximum values. All statistical tests were two-sided, and an alpha level <0.05 was considered a statistically significant result.

Ethical considerations

Ethical approval was obtained from the Ghana Health Service Ethical Review Committee and Navrongo Health Research Centre IRB before commencement of the study. Written informed consent was obtained from participants ≥18 years. Parental consent was obtained for children <18 years. Assent was obtained from children 10–17 years. Chemotherapy was provided for children who were found to be infected with schistosomiasis.

Results

  1. Top of page
  2. Summary
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Parasitological, haematological and anthropometric measurements

A total of 1001 school-age children (6–15 years) participated in the baseline survey: 479 boys (47.9%) and 522 girls (52.1%). The mean haemoglobin concentration was 11.9 g/dl (SD: 1.48; min: 5.9; max: 15.8), the mean body weight was 28.1 kg (SD: 8.51; min: 10; max: 58) and the mean age was 12 years (SD: 2.0; min: 6; max: 15). The prevalence of S. haematobium was 26.7% (267/1001); with a geometric mean egg density of 12 eggs per 10 ml of urine. Most of the children (77% 206/267) infected with S. haematobium had light infection, 27 (10%) had moderate and 35 (13%) had heavy infection. Infection with S. mansoni was rare (0.6%, 6/1001) with a geometric mean egg density of 53 eggs per gram (epg) of faeces. Five of the six children had light infection, one had moderate infection. Only two (both boys) had mixed infection (one each from the control and intervention areas).

The prevalence of infection (male: 27.8%, 133/479; female: 25.5%, 133/522) and geometric mean density of S. haematobium eggs (male: 13 eggs per 10 ml of urine; female: 11 eggs per 10 ml of urine) were similar among males and females. Children aged 13–15 years had the lowest prevalence of infection (20.1%) (Figure 1). The prevalence of infection among this age group (13–15 years) was significantly lower than that among 9–12 years old [31.6%].

image

Figure 1.  Baseline prevalence of Schistosoma haematobium infection by age group (N = 1001). The points plotted (inline image) indicate the percentage of infected children per age group, while the vertical lines show the corresponding 95% confidence intervals.

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The prevalence of S. haematobium infection (intervention: 30.0% [(CI: 23.1–34.2); control: 23.0% (CI: 18.9–27.0)] mean haemoglobin, weight and age were similar among participants from the intervention and control areas (Table 1).

Table 1.   Characteristics of school-age children (6–15 years) who participated in the baseline parasitological, haematological and anthropometric studies (N = 1001)
IndicatorsControlIntervention
Mean age in years [SD]12 [2.4]12 [2.0]
Mean Hb in g/dl [SD]12.0 [1.49]11.9 [1.48]
Mean Weight in kg [SD]28.2 [8.3]28.0 [8.9]
Prevalence of Schistosoma haematobium [95% CI]23.0% (114/495) [19.4–27.0]30.0% (152/506) [26.1–34.2]
Prevalence of Schistosoma mansoni [95% CI]0.81% (4/495) [0.2–2.1]0.40% (2/506) [0.05–1.4]
Geometric mean egg density of S. haematobium10.212.8
Geometric mean egg density of S. mansoni54.424

Drugs distribution

A total of 126 CDDs distributed the praziquantel, albendazole and ivermectin in the intervention area. They distributed a total of 18 843, 8454 and 23 721 tablets of praziquantel, albendazole and ivermectin, respectively. In all, 18 744 registered community members were expected in the area (Table 2). However, 8076 of them could not be given the drugs as they were not eligible at the time of the exercise (seriously ill = 76; pregnant = 102; height <94 cm = 683; migrated = 7057 and dead = 158); thus, 43.09% of the registered people could not be given the drugs. A total of 10 668 people were therefore eligible to receive the drugs in the intervention area during the 2008 program period, of whom 227 (2.13%) refused to take the drugs mainly because of fear of serious side effects. Of the total 10 668 eligible people, 6896 (66.05%) received praziquantel with 18.4% of those who received albendazole and ivermectin refusing to take praziquantel for fear of serious side effects. All persons who took albendazole also took ivermectin with the number of ivermectin tablets per person being 3. In all, 178 compounds were missed in the intervention area. Each CDD covered an average of 67 people (8454/126).

Table 2.   Showing registered compounds, community members and drug distribution
Study groupInterventionControl
Total registered people18 74421 848
 Seriously ill7699
 Pregnant102188
 Under height (<94 cm)683977
 Migrated70574559
 Dead158222
Non-eligible80766045
 Non-eligible (%)43.0927.67
Total eligible10 66815 803
 Refusals227251
 Refusals (%)2.131.59
Study population10 44115 552
 No. receiving Ivermectin/albendazole845415 020
 Ivermectin/albendazole coverage (%)80.9796.58
 Ivermectin tablets distributed23 72148 466
 No. of Ivermectin tabs/person2.813.23
 No. receiving praziquantel68960
 Praziquantel coverage (%)66.050
Registered compounds15531691
 No. of people per compound(18 744/1553) 12.1(21 848/1691) 12.9
 Compounds missed178/155315/1691
 Compounds missed (%)11.500.90

In the control area, 134 CDDs distributed 15 020 and 48 466 tablets of albendazole and ivermectin, respectively, to a total of 15 020 community members. Each CDD covered on the average 112 community members. There were 1691 compounds in the control area with only 15 compounds that could not be reached by the volunteers. A total of 6045 people could not be given the drugs as they were not eligible at the time of the exercise (seriously ill = 99; pregnant = 188, under height (<94 cm) = 977; migrated = 4559 and dead=222); thus, 27.67% of the registered people could not be given the drugs. A total of 15 803 people were therefore eligible to receive the drugs in the control area. Also, 251 (1.59%) people refused to take the drugs (albendazole and ivermectin).

Coverage of compounds in the intervention area was lower than that in the control area as about 11.50% of compounds could not be served during the period, while <1% of compounds were missed in the control area. Thus, while 99.10% of compounds in the control area were visited and 96.58% of the intended population served with ivermectin and albendazole, only 88.50% of compounds in the intervention area were visited and 80.97% of the population served with the two drugs (ivermectin and albendazole), a difference that was statistically significant (P < 0.001). The number of non-eligible people in the intervention area was much higher than the number in the control arm (43.09%vs. 27.67%) with most of the non-eligible persons (37.65%) having migrated from the area compared with the control group (20.87%), P < 0.001.

Reported side effects of the drugs

In all, 180 reports of side effects were recorded with no statistically significant difference in the number of reports between the intervention and control groups [prevalence 0.73% (50/6896) vs. 0.84% (130/15 552)] P > 0.05. (Table 3).The most reported side effect was headache, with more reports from the intervention area than the control (28.00%vs. 10.00%, P = 0.017). There were also more reports of body weakness from the intervention than the control area (26.00%vs. 4.60%, P < 0.001). There were 10 reports of body itching from the control area with none from the intervention area (P = 0.035), and nine reports of tiredness also from the control area with none from the intervention area (P = 0.045). The side effects reported were mild and managed at the subdistrict level by the CDDs, CHOs and Medical Assistants with no reported cases of hospitalization.

Table 3.   Prevalence of side effects reported after taking the drugs
Side effectsIntervention N = 6896Control N = 15 552Total N = 22 448
No.Prev. (1/1000)%No.Prev. (1/1000)%No.Prev. (1/1000)%
  1. *The difference in the number of reports was statistically significant.

Abdominal pains50.7310110.718.9160.718.9
Sore throat00.00010.060.810.040.6
Tender lymph nodes00.00020.131.520.091.1
Joint pains30.44680.516.2110.496.1
Dizziness60.8723100.647.7160.718.9
*Headache142.0328130.8410.0271.2015
Fever00.00070.455.470.313.9
Skin rash10.15240.263.150.222.8
*Itching00.000100.647.7100.455.6
Muscle pains10.152110.718.5120.536.7
Swelling of the limbs00.00040.263.140.182.2
Swelling of the face00.00030.192.330.131.7
*Tiredness00.00090.586.990.405
Reddening of eyes00.00080.516.280.364.4
*Body weakness131.892660.394.6190.8510.6
Diarrhoea00.00040.263.140.182.2
Blood in stool10.15250.323.860.273.3
Loss of appetite00.00020.131.520.091.1
Nausea40.58880.516.2120.536.7
Vomiting20.29440.263.160.273.3
Total507.251001308.361001808.02100

Discussion

  1. Top of page
  2. Summary
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

The current study was conducted in northern Ghana with the aim of developing ways of improving access to treatment of all those at risk of both overt and subtle morbidity because of schistosomiasis. The potential for integration of the distribution of praziquantel, for the control of schistosomiasis into an already functioning lymphatic filariasis and onchocerciasis control programme using CDDs was explored.

The coverage of the CDDs was about 75% of the total population (Gyapong et al. 2001) before the current study, with high hopes of sustainability as it is being implemented by the Ghana Health Service. This coverage rate was similar to that reported for Uganda by (Ndyomugyenyi et al. 2007). Although coverage of the two drugs by the CDDs in the intervention area (80.97%) of the current study was lower compared with the control area (96.58%), possibly as a result of the introduction of praziquantel, coverage had improved significantly over the period.

More people were non-eligible for taking albendazole and ivermectin in the intervention than in the control area. This was mainly as a result of migration of the people from their original compounds. Seasonal migration of young people from northern Ghana to the southern part of the country is well known (Awumbila & Ardayfio-Schandorf 2008) and therefore was not surprising. A slightly higher proportion of people in the intervention area also refused to take the drugs possibly for fear of serious side effects (Cantey et al. 2010). A recent study of the involvement of CDDs in other activities in two African countries (Katabarwa et al. 2010) has revealed that the more additional activities CDDs are to perform at the same time, the less likely they are to achieve very high levels of treatment coverage. Treatment coverage of 90% for example could be achieved only if volunteers worked within 1 km of their homes. The 2008 ivermectin and albendazole distribution exercise took place in November instead of the usual February/March, a period when people in the district usually harvest their crops and therefore were not at home to receive the drugs, necessitating revisits by the CDDs. The change in the distribution time was as a result of delays in procuring albendazole and ivermectin by the Ghana Ministry of Health for the programme.

Although the need for revisits to distribute drugs and/or record side effects could be the same for CDDs in both study areas, it was necessary for the CDDs in the intervention area to spend additional time on educating and allaying the fears of the people on the possible side effects of taking the three drugs simultaneously. This could have contributed to the lower coverage in the intervention area compared with the control area. Coverage (in intervention area) in the current study was similar to that reported by Ndyomugyenyi and Kabatereine (2003) in Uganda. Through the intervention, however, about 66.05% of the vulnerable population had access to praziquantel. This being the first of such an integration attempt in the district, some operational problems similar to those experienced by Richards et al. (2006) in Nigeria were anticipated. We are, however, very hopeful that through continuous health education by the District Health Management Team (DHMT), a significantly higher proportion of the population will be covered in subsequent programmes; as less time will be spent giving explanations to the populace. Increasing the duration of the distribution may not be necessary as improving access to information prior to the drug distribution exercise can lead to increase in coverage. Continuous health education therefore in our view can significantly improve the situation.

Passive surveillance during the current study, as is usually done in the national onchocerciasis and lymphatic filariasis control programme, revealed that co-administration of the three drugs by CDDs was safe, with no cases of hospitalization. Even though there were significantly more reports of headache and body weakness from the intervention area than the control, reports of body itching and tiredness came only from the control area. Simultaneous administration of ivermectin, albendazole and praziquantel has been reported in some earlier studies to be safe (Remme et al. 1989; Webbe 1999; Mohammed et al. 2008). A recent randomized controlled clinical trial on the safety of co-administration of the three drugs to infected schoolchildren in Uganda has also established that simultaneous administration is safe (Namwanje et al. 2011). Similarly, not too many side effects were reported from both the intervention and control areas of the current study.

The prevalence of urinary schistosomiasis among school-age children in both the intervention and control areas was high; a level similar to those reported by Agnew-Blais et al. (2010) for a peri-urban population in Lusaka, Zambia and Ndiaye et al. (2005) for Senegal. This level of infection would require annual drug administration to help reduce the prevalence. The level of infection could be higher in other parts of the district (the irrigated area) (Amankwa et al. 1994). The integration of praziquantel distribution into the lymphatic filariasis and onchocerciasis control programme will be a sure way of reaching vulnerable populations at reduced cost.

We believe that the addition of praziquantel to albendazole and ivermectin for simultaneous administration in Kassena-Nankana district will work. We do, however, recommend that before the integration, there should be intensive health education focusing on risk perception and dispelling misconceptions. There is also the need to motivate and support CDDs in the form of training and incentives to sustain their interest and improve compliance among the community members.

Acknowledgements

  1. Top of page
  2. Summary
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

We are most grateful to the chiefs and people of the Kassena-Nankana district, the community volunteers, the District Health Management Team, the Upper East Regional Health Directorate, the National Lymphatic Filariasis and Onchocerciasis Control Programme and staff of the Navrongo Health Research Centre. We also acknowledge the contributions of Messrs Edmond Tampugre and Patrick Aberinga. This investigation received financial support from UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR).

References

  1. Top of page
  2. Summary
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
  • Agnew-Blais J, Carnevale J, Gropper A, Shilika E & Bail RNgoma M (2010) Schistosomiasis haematobium prevalence and risk factors in a school-age population of peri-urban Lusaka, Zambia. Journal of Tropical Pediatrics 56, 247253.
  • Amankwa JA, Bloch P, Meyer-Lassen J, Olsen A & Christensen NO (1994) Urinary and intestinal schistosomiasis in the Tono Irrigation Scheme, Kassena/Nankana District, upper east region, Ghana. Tropical Medicine and Parasitology 45, 319323.
  • Awumbila M & Ardayfio-Schandorf E (2008) Gendered poverty, migration and livelihood strategies of female porters in Accra, Ghana. Norwegian Journal of Geography 62, 171179.
  • Cantey PT, Rout J, Rao G, Williamson J & Fox LM (2010). Increasing compliance with mass drug administration programs for lymphatic filariasis in India through education and lymphedema management programs. PLoS Neglected Tropical Diseases 4, e728. doi:10.1371/journal.pntd.0000728.
  • Gyapong JO, Magnussen P & Binka FN (1994) Parasitilogical and Clinical aspects of bancroftian filariasis in Kassena-Nankana District. Transactions of the Royal Society of Tropical Medicine and Hygiene 88, 555557.
  • Gyapong M, Gyapong JO & Owusu-Banahene G (2001) Community-directed treatment: the way forward to eliminating lymphatic filariasis as a public-health problem in Ghana. Annals of Tropical Medicine and Parasitology 95, 7786.
  • Katabarwa M, Habomugisha P, Eyamba A, Agunyo S & Mentou C (2010) Monitoring ivermectin distributors involved in integrated health care services through community-directed interventions-a comparison of Cameroon and Uganda experiences over a period of three years (2004–2006). Tropical Medicine and International Health 15, 216223.
  • King CH, Dickman K & Tisch DJ (2005) Reassessment of the cost of chronic helmintic infection: a meta-analysis of disabilityrelated outcomes in endemic schistosomiasis. Lancet 365, 15611569.
  • Mohammed KA, Haji HJ, Gabrielli AF et al. (2008) Triple coadministration of ivermectin, albendazole and praziquantel in zanzibar: a safety study. PLoS Neglected Tropical Diseases 2, e171.
  • Na-Bangchang K, Kietinun S, Pawa KK, Hanpitakpong W, NaBangchang C & Lazdins J (2006) Assessments of pharmacokinetic drug interactions and tolerability of albendazole, praziquantel and ivermectin combinations. Transactions of the Royal Society of Tropical Medicine and Hygiene 100, 335345.
  • Namwanje H, Kabatereine N & Olsen A (2011). A randomised controlled clinical trial on the safety of co-administration of albendazole, ivermectin and praziquantel in infected schoolchildren in Uganda. Transactions of the Royal Society of Tropical Medicine and Hygiene 105, 181188.
  • Navrongo Demographic Surveillance SystemAnnual report 2009.
  • Ndiaye D, Diouf M, Diedhiou Y, Toure M, Sembene M & Ndir O (2005) Prevalence of urinary schistosomiasis in the school population in Senegal in 2002. Dakar Medical 50, 198201.
  • Ndyomugyenyi R & Kabatereine N (2003) Integrated community-directed treatment for the control of onchocerciasis, schistosomiasis and intestinal helminths infections in Uganda: advantages and disadvantages. Tropical Medicine and International Health 8, 9971004.
  • Ndyomugyenyi R, Lakwo T, Habomugisha P & Male B (2007) Progress towards the elimination of onchocerciasis as a public-health problem in Uganda: opportunities, challenges and the way forward. Annals of Tropical Medicine and Parasitology 101, 323333.
  • Remme J, Baker RH, De Sole G et al. (1989) A community trial of ivermectin in the onchocerciasis focus of Asubende, Ghana. I. Effect on the microfilarial reservoir and the transmission of Onchocerca volvulus. Tropical Medicine and Parasitology 40, 367374.
  • Richards FO Jr, Eigege A, Miri ES, Jinadu MY & Hopkins DR (2006) Integration of mass drug administration programmes in Nigeria: the challenge of schistosomiasis. Bulletin of the World Health Organization 84, 673676.
  • Webbe G (1999) Community-wide treatment of schistosomiasis with praziquantel. Tropical Doctor 29, 172176.
  • WHO (1998) Guidelines for the Evaluation of Soil-Transmitted Helminthiasis and Schistosomiasis at Community Level. (WHO/CTD/SIP/98.1). WHO, Geneva.
  • WHO (2002) Report of the WHO Informal Consultation on the use of Praziquantel during pregnancy/lactation and Albendazole/Mebendazole in Children under 24 months. Geneva, 8–9 April 2002.