Schistosomiasis

SUMMARY

Well-structured questionnaire on the perception, impression and response to genitourinary bilharziasis (Genitourinary schistosomiasis) was administered and explained in local languages: 'Igbo' 'Esan' 'Ezon' Itshekiri and Bini to 33815 inhabitants of selected endemic areas in south-eastern Nigeria from January, 1999 to December, 2001. Out of this number, 3815 (11.3%) were properly filled and returned. About 42.0% of the inhabitants admitted knowledge of the disease, while 14 (0.4%) knew about the aetiologic agent. About 181 (5.0%) who responded, admitted procuring treatment, while 100 (5.0%) declined to seek treatment of any sort. The relationships between water-bodies and human activities, and infection were well discussed. Amongst those who admitted knowledge of the disease but no knowledge of its etiologic agent, declined seeking treatment of any kind, but believe the disease is a natural phenomenon in ones developmental stage and therefore of no morbidity and mortality. Laboratory analysis of urine, faeces, semen and HVS was employed to assess questionnaire responses, and in some cases, physical examination was utilized to augment laboratory analysis in confirming urinal diagnosis. Haematuria was only directly related to egg count in the early part of life. Females were significantly haematuric and excreted more ova than males (p

KEY WORDS: Genitourinary bilharziasis; Perception; Impression; Response.

INTRODUCTION

Urinary schistosomiasis (bilharziasis) is reported to be endemic in some parts of Borno State, Nigeria14 with an average total prevalence rate of 12.3%. This is believed to be age-dependent, and Bulinus globosus and Bulimts truncatus rhofsi are discovered to be the intermediate hosts1-1. In some oilier parts of Nigeria with same ecological settings, these have been shown to be consistent9,10,13. Constrained as it may be to work out the best control measures and strategies suitable for the people due to customs and habits, concerted efforts are now being made in the direction of educational campaign enlightenment14 on the dangers of epidemics. Other options being considered for harnessing include; improved access to health care and basic living conditions. Various studies by some other workers have shown common relationship between bilharziasis, water supply and human behaviour2,12.

The prevalence of S. haematobium was influenced by an agedependent and exposure to cercariae-infected water14. Bathing/swimming and fetching of water for domestic purpose readily predispose subjects to infection. Differences in these relationships due to cultural and socioeconomic activities must be considered in any community-based control programme'. For a good recommendation to be made or suggested for a given community, it is pertinent to know how the inhabitants of that community perceive the disease and their responses due to the impression formed on those already infected. This has informed our study, and however, help to establish what the community knows about the infection, the aetiologic agent, transmission, treatment and control/prevention. This will in turn help one to test how readily or prepared the community would assimilate and embrace the unique control measures to be instituted later.

MATERIALS AND METHODS

Study areas: Following reports from the State Ministry of Health in Asaba and Benin, the capitals of Delta and Edo States, respectively on the status of urinary schistosomiasis, and the preliminary works in the Department of Zoology, Edo State University on this infection, we decided to carry out this study further between January, 1999 to December, 2001 so as to explain the reason for the spread by evaluating peoples' perception, impression, response and beliefs toward urinary schistosomiasis. Endemic areas were selected from the reports of the Ministry of Health and new endemic areas were identified from our previous studies and these were also included. Delta and Edo State of Nigeria are located between longitudes 5°00' E and 6°45' and latitudes 5°00'N and 6°30'N covers an area of about seventeen thousand and eleven square kilometres on land (17,011.00km^sup 2^); and longitudes 6°44'E and 6°43'E and latitudes 5°44'N 7°34'N, and covers about nineteen million six hundred and fifty six thousand and thirty five square kilometers on land (19656.35km^sup 2^) respectively (Fig. 1). Both states have forty-three (43, - Edo 18 and Delta 25) Local Government Areas (LGAs).

The communities in these local government areas are without potable pipe-borne water supply, and the inhabitants depend on the water-logged terrains scattered all over the areas for their domestic and economic water supply, which they compete with straying sheep and cattle. Farming is practiced at a very low subsistence level with food crops such as beans, yams groundnut and rice.

Well structured copies of questionnaire (Fig. 3) explained in local languages, was administered carefully from house to house amongst the inhabitants in the various Local Government Areas. The questionnaire was distributed with the help of health teams from each Local Government Area Health Department. Within the metropolis, the questionnaire distributed was coded in English language while those who could not read in English had the interpreted local language questionnaire given to them. Interpreters were assigned to those, who could not read nor write in either of the languages. Members of the Health team were indigenous and therefore served as local guides and recorders. The distribution was done in such a way that it cuts across all age groups, sexes and occupations. Responses were mainly by volunteers. Before this exercise was carried out, respective village/community heads, headmasters/headmistresses and principals of primary and secondary schools were consulted on the objectives of the study. Ethical permission was sought and gotten from the State Ministry of Health in both Edo and Delta States of Nigeria.

The questionnaire sought to obtain name, age, sex, previous residence, duration of stay in the present community, religion, occupation, history of anti schistosomal drugs, the existence of the genitourinary disease, and so on. The inhabitants in the communities were asked about the causative agent, evidence of awareness about infection and relationship between infection and water contact, fresh water snails and blood in urine. The questionnaire also sought to know those clinical symptoms the inhabitants considered to be signs of the disease, and information concerning water-related activities of the inhabitants. The inhabitants were asked of their perception, impressions and responses to the infection and their method of seeking treatment. Responses were confirmed through laboratory and clinical diagnosis from the urine, faeces, semen and high vaginal swab (HVS) for S. haemolobium ova. Physical examination was also carried out to confirm clinical diagnosis.

Laboratory analysis of urine, faeces semen and High Vaginal Swab (HVS): Permission and cooperation of the inhabitants were sought before collection of these samples. Inhabitants were enlightened on the purpose of the study and the public health implications of schistosomiasis, while the ethical permission to carry out this analysis was given by Irrua Specialist Teaching Hospital. Urine and semen samples were collected during the early periods of the day after 20-30 min physical exercise into 10 ml wide mouthed screw-capped plastic universal bottles. Plastic universal containers and swab sticks were used to collect faeces and HVS from those males and females respectively, who reported positive in their questionnaires. All the samples were collected by the participants while the long plastic swab stick was used by the health officers to collect cxudates from the lower genital tract - LGT e.g. Cervix (squamous columnar epithelium junction), vagina and vulva of the females. All samples collected each day were taken to the laboratory. Infection was confirmed by the presence of S. haematobium ova in the urine, faeces, semen or HVS. Each urine was observed for any visible macro haematuria and very turbid and haematuric urine sample was diluted with 175% normal physiological saline or phosphate buffered saline (pH 7.4) before ova count. Follow-up was done each month for the period of a year and six months and at each screening, samples were collected.

Visible haematuria was determined using one strip of commercially prepared reagent strip comb 19 (Macherey - Nagel, Ch. B Lot 32225), dipped into each urine sample and the colour change was matched with standard colours by the side of the container of the reagent strips. Urine samples were examined microscopically for S. haematobium ova using Nytrel filter, based on the method of WHO17. Urine samples were collected through a syringe filter holder (Swinnex type) containing a Nytrel filter; 12 mm in diameter, with a pore size of 20 µm. The chamber was opened and the filter was removed with forceps, placed on a glass slide and stained with a drop of 50% lugols iodine and examined under x40 light microscope. About a gram of the stool was suspended in 10 ml of 10% buffered formalin. The solution was poured through a two-layer gauze and left for 10 min. The sediments were resuspended and centrifuged for 2 min at 1000 rpm. The supernatant was discarded and pellet resuspended in 10 ml formalin. About 3 ml of ethyl acetate was added and the solution shaked vigorously for 30 sec, centrifuged for 2 min at 1000 rpm and the acetate debris water layer on top was discarded. WHO16 technique of 50 mg Kato-Katz cellophane thick smear was employed. The presence of S. haematobium ova was examined after 48 h. The liquefied semen produced by masturbation and coitus interruptus and vaginal cxudates were diluted with 75% normal physiological saline. About 0.25 ml of each was dropped on microscope slide and stained with 50% lugols iodine, examined under × 10 light microscope.

RESULT

Table 1 shows the respondents' perception of genitourinary schistosomiasis and the awareness of its aeliologic agent. One thousand, five hundred and eighty-nine, (42.0%) inhabitants agreed having the knowledge of urinary schistosomiasis amongst them. One thousand, and thirty-six 1036 (27.2%) of the inhabitants claimed to have been aware of the high prevalence rate, while 14 (0.4%) claimed to be aware of the correct aetiologic agent of the disease. Out of a total of 33815 questionnaires distributed, 3815 (1 1.3%) subjects responded.

Table 2 shows the respondents' reactions to genitourinary schistosomiasis. One hundred and twenty eight, 128 (3.4%) willfully had sought treatment in hospitals while 53 (1.4%) treated themselves at homes with traditional medications. However 100 (3.0%) did not seek treatment of any sort. One hundred and thirty-six, (4.0%) claimed to have been infected in the past one year, while 153 (11.30%) indicated of being currently infected. Of the 3815 (11.30%) that responded, out of which 1589 (42.0%) claimed knowledge of the disease, 368 (10.0%) accepted that they avoided coming in contact with water as a control measure. That is to say, they are aware that the aetiologic agent hails from water but are ignorant of that correct aetiologic agent.

Table 3 shows the respondents' relationship with water-bodies vis-a-vis their daily domestic activities. The most frequent domestic activity which leads the inhabitants having contact with water-bodies was the constant fetching of drinking water, in which 782 (21.0%) of the respondents had indicated. This is followed by washing in stream 753 (20.0%), and bathing/swimming in stream 704 (19.0). However, there is no significant difference between these activities at p > 0.05. Respondents were observed to indicate more than one option.

Table 4 shows the age-specific prevalence of haematuria and ova in the studied population. Haematuria (60.0%) was recorded most within the ages of 5-14 years old. The presence of ova (66.0%), in the urine samples was also highest within these age bracket. The level of prevalence was significant between the age groups at p

Table 5 shows the sex specific prevalence of haematuria and ova in the responded studied population. The females had more haematuria (44.0%) and recorded more of the eggs (41.0%) in their urine samples than the males. The difference between sexes was significant at p

Table 6 shows the age specific prevalence of some clinical signs observed by physical examination, confirmed by laboratory diagnosis amongst the studied population. Headache was observed and recorded to be the most occurring clinical sign (43.0%). This was followed by dysuria, fever, frequency of micturition

Table 7 shows the age-specific impression of 1426 positive female subjects, about their spouses having haemaluria, dysuria and sexual pains. About 246 (17.3%) reported having no impression at all, while 21.0% and 20.12% recorded of the infection being part of human development and a natural phase i n puberty respectively. About 137(10.0%) reported of the infection leading to infidelity amongst the females immediately after contact on visiting the infected bodies of water, while 291 (20.4%) agreed that sickness ensues, i.e. haematuria is caused by water gods. However, 123 (9.0%) agreed that the sickness does not lead to divorce even when there is no child from the spouses.

Table 8 shows the age specific impression of 668 (41.1%) positive male subjects out of 1627 (43.0%) males who responded in the studied population on their spouses having haematuria, dysuria and sexual pains. Twenty-nine 29 (4.3%) of the positives showed S. haematobium eggs in their semen. Respondents' indicated 55.4% and 46.4% of their belief that, the infection is part of human development and therefore a natural phase in puberty respectively. Twenty-nine percent (29.0%) of the male respondents believed that the infection is caused by their gods of the rivers after visiting the bodies of waters at the early stage in ones life. This is an indication that one has grown. Twenty-one (3.1%) had the belief that, it becomes sickness if this puberty stage becomes associated with infidelity (7.2%).

Table 9 shows the occupational prevalence of urinary schistosomiasis amongst the subjects after laboratory analysis of their urine, faeces, semen and HVS samples. About 37.0% have primary school certificate while 50.0% of the subjects do not have any formal western education, however 3.1% and 1.0% have secondary and tertiary education respectively. About 55.0% engage in other business such as hunting, farming and fishing as their chief occupation, while 10.0% are government workers or have engaged in other paid jobs outside government service. About 56% of those in paid civil service possess primary school certificate while 39.0% and 5.0% possess secondary and tertiary certificates respectively.

Fig. 1 shows the map of Nigeria indicating locations of Edo/Delta States.

Fig. 2 shows the respondents awareness of the relationship between infection, water-contact, fresh water snails and presence of blood in urine (haematuria). The awareness rose sharply from 12 years of age and peaked on the age-groups i 9-24 years old, before declining.

Fig. 3 shows the details of the questionnaire administered.

DISCUSSION

The perception of the genitourinary schistosomiasis in some selected endemic areas in southeastern Nigeria is very high. One thousand, five hundred and eighty-nine (42.0%) of the respondents admitted having the knowledge of the existence of the disease and about 1036 (27.2%) indicated a high prevalence rate of disease. These findings contrasted with that of NDAMBA et [alpha]/.8 and ROBERT et al." who had similar observations in Zimbabwe and Cameroun respectively. The former established an awareness of 80.0% in Zimbabwe, and respondents had no knowledge of the causative agent of urinary schistosomiasis. The lack of knowledge of the current aetiologic agent in this study is principally due to ignorance and illiteracy of the inhabitants as most of the inhabitants are peasant farmers without western education. An epidemiological map was prepared in Tanzania using the perception of schistosomiasis by inhabitants as a guide to diagnosis and control, and this may be equally useful in Nigeria". This method can be used to determine and establish the public health status of the disease taking into consideration the whole population of Nigeria.

The 42.0% awareness recorded did not reflect the treatment profile in which only 181 (5.0%) sought mediation. The 100 (3.0%) cases which were untreated may consequently lead to serious pathological abnormalities like bladder calcification, uteri stricture, hydronephrosis and eventually death. This has been described before by EDINGTON et [alpha]/.4 and CHUGH et al.1. The study has established 153 (4.0%) to have had the infection during the period of study. This is comparable to the earlier averaged prevalence of 12.3% recorded in Borno Sate14 (p = 0.05).

Abstaining from water-bodies as one of the control measures was practiced by 368 (10.0%) and this is not reflected in the water-related activities of the inhabitants. Seven hundred and four (19.0%), 753 (20.0%) and 782 (21.0%) of inhabitants were involved in bathing/ swimming, washing in streams and fetching of water from streams for various domestic reasons. The 10.0% degree of abstention could not have resulted in the high average rate of prevalence of 12.3% recorded earlier14. This directly presupposed that provision of potable pipe born water would drastically reduce the prevalence rate and intensity of the disease. But this would have to be militated against when you consider the main pre-occupation of rice farming being practiced largely by inhabitants.

The high prevalence of hacmaturia and presence of S. haematobium ova as we observed was evident within the age bracket of 5-14 years old. It can be suggested that, this possibility was observed because of the low response of the immune status of these age groups. However, presence of ova is linearly proportional to haematuria. Haematuria, later increased with decrease in ova output. However, immunology could have been used to explain this but we suggested the expense of bladder-tissue architecture UKWANDU etal.]\ We believe that, haematuria was aresult of much contraction of the bladder tissue in forcing urine out. Normal tissue architecture would have been lost due to calcification of the ova within the tissues. The degree of infection is high amongst the females than males and lhc reason for this was not immediately deduced, because both sexes have equal rale of visiting infected water bodies in this age group. Our further studies on immunopathology of genitourinary schislosomiasis may explain this later. Although HABERBERGER et cil.3; and HAGAN el al6; adduced low response from CD8T-lymphocytes in females to be responsible for this.

The inter-relationship between infection rate, water contact, fresh water snails and the presence of blood in urine was very high amongst the age-groups of 15-20 years old. This has actually accounted and explained why there was a lower prevalence rate and intensity of infection seen in this age group in our previous study14.

Dysuria and frequent micturition > or = 6 times per day was recorded. The pressure applied on the bladder to squeeze urine out could have explained for dysuria and the low volume of urine voided out intermittently can explain for the frequency of micturition. The infection was observed to affect, although of little significance p = 0.05 the duration of menstrual flow and cycle. We could relate the occurrence of this infection with stillbirth, abortion, infertility and early stoppage of menstrual cycle. However, the preponderance of morbid effect of sexually transmitted diseases, largely due to secondary effects of bacterial action as a result of schistosomal legions, may be responsible for the morbidities observed above'.

The study noted with disappointment, the impression given by few inhabitants that their condition was a stage in the course of their human development and therefore, it is a natural stage in the course of existence. They have learnt to live with it until it disappears on its own or they die with it. However, they do not believe in divorce even when there is no child. The opinions of 5-14 years age groups augment information from other age groups. This is because we used their opinions to ascertain the extent of tenacity which they hold their cultural beliefs. Infidelity scores for those who believe that the infection is not water related. It is to be suggested that, advocating for the integrated method of control of urinary schistosomiasis3,14; for which mass educational enlightenment has been emphasized by UKWANDU & BUKBUK14 in Borno State, especially which for now, has seemed inassimilable by lew inhabitants, it can be assured that the high rale of perception would encourage understanding and compliance by this large number of inhabitants who perceive highly and would cooperate massively if the next step of mass chemotherapy using molluscicidal plant extracts on the intermediate host is advised.

RESUMO

Pcrcepção, crcnças c práticas sobre a esquistossomo.se genitourinária de habitantes de áreas endêmicas selecionadas (Edo/ Estados Delta) no sudeste da Nigeria

Um questionário bcm cstruturado sobre a pcrccpção e práticas e crenças sobre a esquislossomose genilo-urinária foi adminislrado e cxplicado em dialetos locais: "Igbo" "Esan" "Ezon" Itshekiri c Bini a 33815 habitantes de áreas endêmicas selecionadas no sudeste da Nigéria, de Janeiro de 1999 a dezembro de 2001. Deste total, 3815 (11,3%) foram prccnchidos adequadamente e devolvidos. Cerca de 42,0% dos habitantes admitiram conheccr a doença, enquanto 14 (0,4%) conheciam o agente etiologico. Cerca de 181 (5,0%) dos que respondcram admitiram ter procurado tratamento, enquanto 100 (5,0%) não procuraram tratamento de qualqucr tipo. A relação entre as coleções de águas e atividades humanas e infccção foram discutidas. Entre os que admitiram conhecer a doença mas não o scu agcnte etiológico não procuraram nenhum tratamento, mas acrcdilam que a doença é um fenômeno natural nos cstágios de desenvolvimcnio e portante não apresentam morbidade c morlalidadc. A análise laboratorial da urina, fezes, semen e HVS foi empregada para as resposlas dos qucslionários e em alguns casos o exame lísico foi utilizado para aumentar a análise laboratorial c confirmar o diagnoslico urinário. Hemalúria foi diretamcntc relacionada a contagcm de ovos na primeira parte da vida. As mulheres foram significativamenle mais hcmaturicas e excretaram mais ovos que os homcns (p

ACKNOWLEDGEMENTS

Wc wish to acknowledge the immense contributions of the following: Drs. L.T. Popo, Toby Majoroh and Alhaji S.L. Otokiti of the Ministry of Health Asaba, Delta State, and Benin, Edo State for their support and approval of ethical permission. More especially lrrua Specialist Teaching Hospital for allowing us assess to the Laboratories. We are highly indebted to all the Headmasters/Headmistresses and Principals within the affected communities for their cooperation, especially the village and communities' heads who helped in assembling their subjects. We also remember the help rendered by those who volunteered to act as interpreters.

REFERENCES

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6. HAGAN, P.; WILKINS, H.A.; BLUMENTHAL, UJ.; HAYES, RJ. & GREENWOOD, B.M. - Eosinophilia and resistance to .V. \\aiiniuiobhini in man. Paras, lmmunol., 7: 625-632, 1985.

7. LENGEELIiR, C.; KILIMA, P.; MSHINDA, H. el a/. - Rapid, low-cost, two step method to screen for urinary schistosomiasis at the district level: the Kilosa experience. Bull. WId. Hlth. Org., 69: 179-189, 1991.

8. NDAMBA, J; CHANDIWANA, S.K. & MAKAZA, N. - Knowledge, attitude and practices among rural communities in Zimbabwe in relation to Phytoldt'ca dcodecandra, a plant molluscicidc. Soc. Sei. Med., 28: 1249-1253, 1989.

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10. OKAI1OR, 1''.C. - Scliixiotoitifi liaeiiifilobinni cercariac transmission patterns in freshwater systems of Anambra Slate, Nigeria. Angew Parasit, 31: 159-166, 1990.

11. ROBERT, C.E.; BOUVIER, G. & ROUGEMONT, A. - Epidemiology of schistosomiasis in the riverine population of Lagdo lake, Northern Cameroon: mixed infections and ethnic factor. Ann. trop. Med. Parasit., 40: 153-158, 1989.

12. TAYO, M.A.; PUGH, R.N.A. & BRADLEY, A.K. - Water-contact activities in the schistosomiasis study area. Malumfashi Endemic Diseases Research Project, XI. Ann. trop. Mcd. Parasit., 74: 347-354, 1980.

13. UKOLI, RM.A. & ASUMU, D.T. - Ecological studies on snails in relation to the transmission of schistosomiasis and other snail borne disease in Kanji Lake, Nigeria. Nig. J. nat. Sei., 2: 59-68, 1980.

14. UKWANDU, N.C.D. & BUKBUK, D.N. - A study of the menace of urinary schistosomiasis (urinary Bilharziasis) in Borno State, Nigeria. West Afr. J. biol. Sei., (i): 31-37, 1996

15. UKWANDU, N.C.D.; NMORSl, O.P.G.; OYAKHIRE, O.K. el al. - The evaluation of non specific cellular immunological parameters amongst children with Sckiuowma haemalobhim infection in Nigeria. J. trop. Pacdiat., 47: 260-265, 2001.

16. WHO - Basic laboratory methods in medical Parasitology. Geneva, WHO, 1991.

17. WHO - Urine nitration technique for S. haematobium infection. Geneva, WHO, 1983. (PDP/83.4).

Received: 20 May 2002

Accepted: 26 July 2004

Nnamdi Callistus D. UKWANDU(1) & O. P. G. NMORSI(2)

1) Department of Medical Microbiology, Faculty of Clinical Sciences, College of Medicine, Edo State University, P.M.B. 14, Ekponut, Nigeria.

2) Department of Zoology, Faculty of Natural Sciences, Edo State University, P.M.B. 14, Ekpoma, Nigeria.

Correspondence to: N.C.D. Ukwandu, Department of Medical Microbiology, Faculty of Clinical Sciences, College of Medicine, Edo State University, P.M.B. 14, Ekpoma, Nigeria. E-mail: ncdukwandu@yahoo.com.

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