The Professional Diploma in Tropical Medicine & Hygiene (East African Partnership) is a three-month course taught by the School and colleagues in Tanzania and Uganda, for doctors planning to work in Africa. In this blog, students from the 2016 course describe their experiences studying the burden and treatment of Schistosomiasis in a community in Uganda.
By Rodgers Rodriguez, Felicity Cooksey, Tina Kindole, Angelika Masao, Anita Baine, Bonnie Mpondo, Shireen McVicker, Max Kelen & Tendai Marimwe
We were part of the East African Diploma in Tropical Medicine & Hygiene Class of 2016 and under the supervision of Amaya Bustinduy, we travelled to the shores of Lake Albert, in the Buliisa District of Western Uganda. Our intention was to learn about the ongoing battle for control of Schistosomiasis and to discover why, despite annual mass drug administration campaigns, the area continues to be hyperendemic for Schistosomiasis.
We packed a game of monopoly, wet wipes and prepared ourselves for no electricity or running water. We arrived in a picturesque location with a vibrant community. It quickly became apparent Lake Albert was the community hub; a source of income, drinking water, food, a place to bathe and a children’s playground. It was also clear simply ‘not going in the lake’ was not an acceptable choice for most. There was a local bore hole, but we were told the water was considered ‘too salty’ so it wasn’t being used as expected.
Our second observation was that the locals, especially school children, were familiar with the medication Praziquantel. A government program of Mass Drug Administration (MDA) of Praziquantel happens annually in primary schools where contact with most children in the community is made; hence pre-school children miss out. Despite Praziquantel being an effective treatment, it is known locally as ‘mbaya’ which translated from Swahili means ‘bad’. This view is due to the side effects suffered. Further education was needed, so we decided to put on a play for local school children. The experience demonstrated some of our colleagues could consider careers on the stage and also reinforced the fact that enjoyment of a song and a dance is universal, no matter where you are in the world.
Our main task though was to gain an appreciation of the burden of Schistosomiasis, and we surveyed two schools and two communities. The most startling result found was although pre-school children are not targeted in the mass drug administration campaigns, many had already developed complications with negative consequences for their growth and development. 18% of young children, under the age of five, had features of liver fibrosis on ultrasound. The average egg count on stool testing (Kato-Katz) was 500 eggs/gram and 80% had a positive urine sample using Circulating Cathodic Antigen (CCA) testing. We also found complications in school children. Despite receiving annual Praziquantel, 80% of the sampled school children had anaemia.
We had been informed there were concerns regarding giving young children Praziquantel tablets due to choking fears as there is no paediatric formulation available. However, at the end of the testing we offered treatment to all. For the young we crushed the tablets and mixed them with a small amount of water to make a suspension. We were initially apprehensive, however they swallowed the medicine with minimal difficulty.
For a doctor in the tropics where practice is hospital-centric battling malaria, HIV and helping mothers deliver, going out into the community was an eye-opener. To find a whole generation of children already weighed down by the burden of Schistosomiasis; not forgetting the frequent sights of children with pot-bellies due to environmental enteropathy and chronic malnutrition, made us appreciate the vital role of research and community health especially in hard-to-reach areas. Neglected Tropical Diseases became a reality to us.
A couple of us on the team were unfortunately exposed when the protective gear they were wearing while out in the lake shore collecting snails got leakages. There was so much panic of exposure after being in contact with the waters of Lake Albert for just less than 5 minutes. But how about the women, the men and children that spend hours daily in the lake swimming, fishing or fetching water? Having to take Praziquantel 2 months later and the side effects we felt was enough to give us insight into the worm burden we had accumulated over the weeks from our exposure.
Despite how much we learnt during the week, we were left with more questions: What is the right drug dose for pre-school children? How frequently should mass drug administration be done? There are often challenges to gaining ethical approval for research involving children, but is it ethical to continue to miss out young children from mass drug administration of Praziquantel given the growing evidence of harm from Schistosomiasis in this age group?
At the end of our week, we agreed a collective approach is needed, including the early detection and treatment of cases, provision of an alternative, safe and acceptable water source, and an environmental friendly approach to snail control. Lake Albert is a natural border between Uganda and the Democratic Republic of Congo, with daily movement of people to and fro. As such, collaborative efforts between the two countries would be key in controlling Schistosomiasis by ensuring that efforts on one side are not watered down by laxity on the other. Though we were only in the Buliisa district for a short time, it appeared in-order to improve outcomes, frequent treatment of all members of the community, including pre-school children, will be required.
By not adequately controlling Schistosomiasis, we are depriving children of their health and therefore communities of their future. We left Lake Albert feeling inspired by the teams who are striving to improve the health of these communities and empowered to join the battle.