Intestinal Schistosomiasis on the Shoreline of Lake Albert - Uganda: Through the Prism of Tropical Medicine Students
*Guest Bloggers from the East African Diploma of Tropical Medicine & Hygiene class of 2016: Rodgers Rodriguez, Felicity Cooksey, Tina Kindole, Angelika Masao, Anita Baine, Bonnie Mpondo, Shireen McVicker, Max Kelen, Tendai Marimwe)
There is a field camp at Bugoigo village on the Lake Albert shoreline that is overseen by Vector Control Division, Ministry of Health, Uganda. Extensive work conducted by Dr Amaya Bustinduy and Prof. Russ Stothard used this camp for applied research on schistosomiasis over the years. Several studies conducted there have helped change national and international policies on disease control. Less well-known is that the camp at Bugoigo also hosts students for teaching purposes and provides them with first-hand experiences of the local reality of Schistosomiasis.
As part of the East African Diploma in Tropical Medicine and Hygiene (Class of 2016), we were under the supervision of Dr Bustinduy and travelled to Bugoigo. Our intention was to learn about the ongoing battle for control of schistosomiasis and discover why the area continues to be hyper-endemic for this disease despite ongoing control interventions. Being taught previously in Uganda’s capital city Kampala, we prepared ourselves for the field camp with no electricity or running water.
After a five-hour drive from Kampala, we arrived at the lakeside location and experienced its vibrant community. It quickly became apparent that Lake Albert was of major importance to everyone; as a source of income, for drinking water, place to catch fish or bathe, as well as a children’s playground. It was also clear that ‘not going in the lake’ was impossible. Even with a local bore hole, nearly all locals and ourselves included, depended on the lake for domestic water. We were told that the local borehole water was considered ‘too salty’ for daily use. We were lucky in our camp to be able to put in place simple water hygiene measures, resting water and use of disinfectants.
Our second observation was that the community, especially the school children were familiar with Praziquantel, the current and only drug of choice for treatment of Schistosomiasis. In line with the national control campaign, the Ugandan government endorses a programme of Mass Drug Administration (MDA) with this drug. MDA takes place in all primary schools where the disease is endemic. Despite Praziquantel being an effective treatment, it is known locally as ‘mbaya’ which translated from Swahili means ‘bad.’ This is due to the side effects suffered considering disease burdens here are tremendously high and children frequently experience pain after taking treatment as the worms react. Further education is often needed to better explain this. We put on an outdoor play for the local school children, re-enforced with a song and a dance proving that their enjoyment is universal no matter where you are in the world.
Our main task at Bugoigo was to gain an appreciation of the clinical burden of schistosomiasis. This we gained in our survey of two schools and two communities nearby. The most startling result, novel to us was that pre-school children were heavily infected but are not targeted within the MDA campaigns. Sadly, 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) test. We also found complications in school children with 80% of the sampled school children having anaemia.
For us as doctors in the tropics where our daily 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, in particular schistosomiasis, have become a reality to us.
We had been informed there were concerns regarding giving young children Praziquantel tablets due to fears of choking as there is no suitable paediatric formulation available. However, at the end of the testing we offered treatment to all and for the young; we crushed the tablets and mixed them with a small amount of water to make a suspension. Although younger children were initially apprehensive, they swallowed the medicine with minimal difficulty.
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 administrations be done?
While there might be challenges in gaining ethical approval for a paediatric formulation, is it ethical to continue MDA with existing tools when young children from the same area are left out? The research COUNTDOWN is carrying out could provide possible answers and wait to see if it will provide answers to these questions.
We left Lake Albert feeling inspired by the local teams who are striving to improve the health of these communities and were empowered to join in this battle.
By not adequately controlling schistosomiasis here or elsewhere in sub-Saharan Africa, we are depriving children of their health and therefore communities of their future!