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ORIGINAL ARTICLE
Year : 2023 | Volume
: 22
| Issue : 3 | Page : 252-258
Household coverage of ivermectin distribution in birnin kudu local government area of Jigawa State, Nigeria
Lukman A Raji1, Olufemi E Babalola2, Danjuma Musa1, Amina Hassan1, Ismail Raji3, Murtala M Umar1, Jimoh A Ogungbenjo1, Mahmoud B Alhassan1
1 National Eye Centre, Kaduna, Nigeria
2 Bingham University, New Karu, Nigeria
3 Department of Community Medicine, Uthman Danfodio University Teaching Hospital, Sokoto, Nigeria
Correspondence Address:
Lukman A Raji
National Eye Centre, P.M.B. 2267, Kaduna
Nigeria
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/aam.aam_50_20
Abstract
Purpose: To assess community-directed treatment coverage with Ivermectin (CDTI) in Onchocerciasis-endemic communities in Birnin Kudu local government area (LGA) Jigawa state. Subjects and Methods: This was a community-based multistaged cross-sectional survey based on probability proportional to size. The study involved the administration of a questionnaire on 2021 respondents from 207 households. Also, 30 Community Leaders and Community Directed Distributors (CDDs) were purposively selected for interview from the communities visited. Results: Overall, 2021 respondents from the 2031 sampled population took part in the study giving a response rate of 99.6%. Slightly above half, 1130 (55.9%) were males. The geographic and therapeutic coverage of mass drug administration of Ivermectin achieved in the LGA was 100% and 79.9%, respectively. The key factors affecting coverage includes the unavailability of drugs (48.8%), absenteeism of some of the household members (31%), and inadequate incentives to the CDDs by the government and poor record keeping by the CDDs. Conclusion: This study found that the minimum geographic and therapeutic coverage of Ivermectin distribution was achieved by CDD as recommended by the World Health Organization for the control of onchocerciasis. For this to be sustained and to achieve elimination, there must be an adequate supply of ivermectin, training of CDDs, retraining of CDDs, adequate supervision in record keeping, and health education to the community.
Abstract in French Résumé
Objectif: Évaluer la couverture du traitement sous direction communautaire à l'ivermectine (TIDC) dans les communautés endémiques de l'onchocercose de la zone d'administration locale de Birnin Kudu (LGA) dans l'État de Jigawa. Sujets et méthodes: Il s'agissait d'une enquête transversale communautaire à plusieurs degrés basée sur une probabilité proportionnelle à la taille. L'étude a impliqué l'administration d'un questionnaire sur 2021 répondants de 207 ménages. De plus, 30 leaders communautaires et distributeurs dirigés par la communauté (CDD) ont été délibérément sélectionnés pour un entretien dans les communautés visitées. Résultats: Globalement, 2021 répondants sur la population échantillonnée de 2031 ont participé à l'étude, soit un taux de réponse de 99,6 %. Un peu plus de la moitié, 1130 (55,9 %) étaient des hommes. La couverture géographique et thérapeutique de l'administration massive d'ivermectine obtenue dans la LGA était de 100 % et de 79,9 %, respectivement. Les principaux facteurs affectant la couverture comprennent l'indisponibilité des médicaments (48,8%), l'absentéisme de certains membres du ménage (31%), et les incitations inadéquates aux DC par le gouvernement et la mauvaise tenue des dossiers par les DC. Conclusion: Cette étude a révélé que la couverture géographique et thérapeutique minimale de la distribution d'ivermectine était atteinte par le CDD tel que recommandé par l'Organisation mondiale de la santé pour le contrôle de l'onchocercose. Pour que cela soit durable et pour parvenir à l'élimination, il doit y avoir un approvisionnement adéquat en ivermectine, une formation des DC, un recyclage des DC, une supervision adéquate de la tenue des dossiers et une éducation sanitaire de la communauté.
Mots-clés: Distributeurs communautaires, TIDC, ivermectine, onchocercose
Keywords: Onchocerciasis, Ivermectin, CDD, CDTI
Introduction 
Onchocerciasis, a neglected tropical disease, is a parasitic disease of man, affecting the skin and eye, leading to visual impairment and blindness. It is caused by a filarial nematode worm (Onchocerca volvulus). It is transmitted from person to person by the bite of various subspecies of the black fly Simulum damnosum in Sub-Saharan Africa. It occurs in the communities near fast-flowing rivers, hence the name river blindness.[1]
Over 20 million people are projected to be infected, 1 million are blind, and 70 million at risk of infection worldwide.[2] Nigeria accounts for one-third of these estimates. The disease is found in all states of Nigeria, with varying degrees of endemicity and severity of clinical manifestations.[2] The savannah type associated with severe eye disorders and blindness and the forest type, which causes more skin damage are present and responsible for the divergent clinic – epidemiologic picture [Figuer 1].[2],[3],[4]
Furthermore, Onchocerciasis causes dermatological problems such as debilitating itching, depigmentation, and disfiguring lesions,[6],[7] leading to secondary skin infections.[8]
Stigmatization occurs with individuals who have skin disfiguration, especially in finding a marriage partner.[9],[10],[11]
Populations at risk include farmers, fishermen, ferrymen, and hunters who live and spend the most time around the breeding sites.[12],[13],[14],[15]
Onchocerciasis is the second leading cause of preventable blindness in the world.[6] People who have a high load of O. volvulus have been found to have a shorter life span.[12] They also possess psychosocial distress from either blindness or severe itching preventing them from work, thereby retarding their economic status.[15] Children living in households headed by individual suffering from Onchocerciasis are two times more likely to drop out of school than those living in households headed by a guardian who does not have this disease.[16],[17]
The activities of the Onchocerciasis Control Programme (OCP) commenced in 1974, and eleven West-African countries benefitted from this program.[18] It adopted an aerial larviciding method to eliminate vectors and ultimately eliminated the disease as a public health problem in endemic countries.[19]
The African Programme for Onchocerciasis Control (APOC) began in 1995 and expanded upon the efforts, knowledge, and experience of OCP to eliminate onchocerciases (as a public health problem) from Africa by the year 2007.[6],[19] APOC was coordinated under the World Health Organization (WHO). The program was active in 19 countries and depended on the involvement of Ministries of Health, Local and International nongovernmental organizations (NGOs).[20]
Community-Directed Treatment with Ivermectin (CDTI) is the primary strategy adopted by APOC to address the menace of Onchocerciasis,[6],[19] while vector control (a cost-effective method of control) is used in isolated and small communities where the vectors can be eliminated within a short period.[20] CDTI operates by the participation of community whereby the mesoendemic or hyperendemic communities/villages design and implement the treatment of their residents using the community-directed distributors (CDDs).[21],[22] The selected community members are chosen to be the CDD by Community Health Workers (CHW) or community and are trained to provide treatment and education to the community on Onchocerciasis.[23] APOC countries have implemented annual CDTI, whereas Onchocerciasis Elimination Programme for Americas (OEPA) countries have used semi-annual (twice yearly) or multi-annual (up to 8 times yearly) CDTI.[24],[25]
Ivermectin treatment for Onchocerciasis control should be monitored regularly to improve geographic and therapeutic coverage, which is an essential component of the sustainability of community-directed treatment with Ivermectin (CDTI).[26],[27],[28],[29] It is important to note that many people who require ivermectin treatment reside in poor rural communities beyond the end of the road in the bush.[30]
Jigawa state has been carrying out mass distribution of Ivermectin in Onchocerciasis-endemic areas of Birnin Kudu local government area (LGA) [Figure 1] for the past 20 years through CDTI strategy.[31],[32],[33],[34] However, no survey has been conducted to assess the household coverage of this treatment in this LGA. Factors that will facilitate adequate coverage or poor coverage in the community need to be identified to improve the successes recorded and communities with poor coverage to adopt similar methods to reach all eligible persons. Therefore, we assessed the coverage of CDTI in Onchocerciasis-endemic communities in Birnin Kudu LGA of Jigawa state and to identify the key factors influencing Ivermectin coverage.
Figure 1: Map showing Gigawa state and highlighting Birnin Kudu local government area[26] Subjects and Methods This is a community-based cross-sectional survey conducted from March 2015 to April 2015 in all the districts of Birnin Kudu LGA, Jigawa State, Northwest Nigeria.
Inclusion criteria
Household members aged 5 years and above resident in Birnin Kudu Community for at least one year.
Exclusion criteria
A person not currently enlisted for annual ivermectin treatment as a result of chronic debilitating disease.
Sample size and sampling
Using the Cochran's formula, we estimated a sample size of 2030. We used a systematic sampling technique to select the study population. We estimated a sample of fifty households in each of 40 clusters. A cluster is a collection of households within a single Onchocercal Community.
A household is a group of persons who live under the same roof and eat from a common pot.[35],[36]
A two-stage cluster random sampling was used, with probability proportional-to-size, we selected forty clusters using systematic selection. In each cluster, fifty households were selected using compact segment sampling.
Team training and fieldwork
There was a two-day training for the research team. The training included a basic introduction to the research area. The data collectors were also introduced to the study instrument and ethics of field work were discussed during the training. Following the training, we pretested the study instrument in a community outside the enumerated clusters to help the research team get acquainted with the research instrument.
In each household, the head of household or his representative listed the names of other eligible household members. The head of household also answered for the absentees and an underaged child who was not able to answer. We sought information on when last treatment was received, how many tablets were given, why were tablets not received, was tablet given the year before the last distribution, the heights of the eligible respondent was measured using a dosing pole and compared with the number of tablets given by the CDD to ascertain if the number of tablets given corresponds with the height of respondents. The community leaders and community drug distributors were interviewed in thirty purposively selected clusters using semi-structured questionnaire to seeking information on how many CDDs were present in the village, how many female CDDs (if none, what are the reasons?), how were the CDDs selected, why were they selected, involvement of CDDs in other health activities, shortage of the drug, record keeping, availability of register and community contribution to support the program.
Ethical considerations
Ethics and Research Committees of National Eye Centre Kaduna approved the Study. The Jigawa State Ministry of Health and Birinin Kudu Local Government Health Department granted an administrative permit. Verbal consent was obtained by the Research Assistant from each adult in a language he or she understood, and parents/guardians assented for their wards.
Data management
Data entry and analysis were done in IBM® SPSS version 22 (Kaduna, Nigeria). Data analysis involved running descriptive statistics of all variables. A general description of participants was done by calculating mean and standard deviation for continuous variables and frequencies and percentages for categorical data.
The district geographical coverage level was determined by the number of eligible communities that received ivermectin as a proportion of the total number of communities in the district. The therapeutic coverage level was analyzed as the total number of individuals in the community that took Ivermectin divided by the total number of eligible individuals.
Analysis of variance was used to test the relationship between age distribution and districts. Frequencies of factors influencing Ivermectin coverage were run. The maximum margin for error (alpha) in the statistical tests was set at 5% (0.05) level of significance. Any statistical test with a P < 0.05 was considered statistically significant.
Results Findings from the household survey within the districts
Overall, six districts were covered in this survey with 41 communities. Two thousand and thirty people were enumerated, out of which 2021 [Table 1] (response rate of 99.6%) granted the interview.
Table 1: Distribution of participants across communities in various districtsThe number of male and female respondents were 1130 (55.9%) and 891 (44.1%), respectively.
The male respondents were significantly older than the females (23.9 ± 17 years and 22.07 ± 14, respectively.) t = 2.6, P = 0.01.
The overall mean age for all respondents was 23.08 ± 15.7; Yalwan Damai had the smallest mean age of 21.62 ± 14.732 years, and Wurno had the Highest mean age of 25.53 ± 17.229 years; Birnin Kudu, Iggi, and Sundimina had a mean age of 23 years, and Bamaina had a mean age of 22.6 ± 17.2 years.
Analysis of variance
There was no statistically significant difference in the age groups in all the different districts F = 1.294, P = 0.26.
In 2013, 1618 (80.1%) respondents received Ivermectin tablets during the distribution, while 403 (19.9%) did not receive tablets, giving a therapeutic coverage of 80.1% [Table 2].
Table 2: Proportion of those that took drugs in each district the year 2013 and 2014 distributionDuring the 2014 MDA, 1614 (79.9%) respondents received Ivermectin tablets, while 407 (20.1%) did not. The geographic coverage is 100% for the period 2013/2014 [Table 2].
Among those that did not receive Ivermectin tablets, about half of them 201 (49.5%) did not receive the drug because it was not available. This was closely followed by being absent at the time of distribution 127 (31.2%) [Figure 2]. Only one person did not receive the drug because he was sick.
There was a statistically significant association between the number of correct drugs given to the respondents and the age, χ2 = 18.309, df = 3, P < 0.000. A majority, 777 (57.6%) of the respondents who received the correct doses of the drug were within the age group of 5 and 24 years, and majority of those that received incorrect dosages were also within the age group of 5 and 24 years.
There was no statistically significant relationship between the sex of the respondents and the number of correct tablets given χ2 = 1.847, df = 1, P = 0.174.
Among the respondents chosen as CDDs showed that 12 (40%) had good relationship, 2 (6.7%), had good human relationship and were educated, 13 (43.3%), good human relationship and were competent, while 3 (10.0%) were educated and competent [Table 3].
All the community leaders that were interviewed said the timing (month/season) for distribution and mode of distribution and the persons selected were decided at the village meeting. They also decided that the mode of distribution will be house-to-house.
Eleven of the community leaders said they only have one CDD while another 11 said they have 2 CDDs. One Community Leader reported that they have 7 CDDs in their community. Details are found in [Table 4]. All the CDDs were reported to be males. The reason for the nonparticipation of women was because it was not culturally and religiously acceptable.
Training, monitoring, and supervision
Twenty-eight of the community leaders reported that the CDDs had received training. All those who were trained were reported to have been trained by health staff. Most of them were trained before the first distribution. Only two Community Leaders reported CDDs were not trained. All the Community Leaders responded yes to the supervision of the CDDs in their community.
Community-directed distributors responses
Community participation and ownership
Among the CDDs, 21 (70%) reported that the time for distribution is decided at the community meeting, while 9 (30%) reported that it is decided by the health worker. In terms of distribution, 28 (93.3%) reported that the house-to-house strategy was used to distribute the drugs.
Forty percent (40%) of the CDDs have had to be replaced mainly because the incumbents left to seek further education, but some because they migrated from the area. Only 2 (6.7%) CDD reported that four CDDs have stopped working in their community, 6 (20%) CDDs reported that one CDD has stopped working in their community. All but one CDD reported they would be willing to continue as CDD.
Record keeping and availability of register
For record-keeping, only 2 (6.7%) reported problems with keeping records. All CDDs claimed they have an updated register; however, only two were sighted. The total population found in the register was 4764.
Drug distribution to absentees, refusals, and pregnant women after delivery
When asked what they do about individuals who were absent during the normal distribution period, the CDDs responded that they tended to revisit, except one who did not give any response. A majority, 96.7% of the CDDs said they counseled those who refused treatment. For those that refuse treatment, 26 (86.7%) of CDDs also said they tended to revisit initial refusals. For women who were pregnant, 23 (76.7) percent of them were treated after delivery.
Sustainability of program, challenges to work and how to improve program
Twenty-nine out of 30 CDDs reported active community participation in the CDTI exercise. Seventeen of the CDDs felt the program might be sustained over a long period by increasing community awareness, while 20 of them thought supporting the CDDs would help achieve the program goal.
Discussion All eligible persons in a community must receive Ivermectin treatment for 15 years for Onchocerciasis to be eliminated. There must be a sustainable geographic drug coverage of at least 90% as recommended by the World Health Organization.[1] It, therefore, implies that a high geographical and therapeutic coverage must be maintained throughout Ivermectin distribution.
The geographic coverage recorded in this study is 100%, while the therapeutic coverage varied across the six districts; with the least coverage of 74% and the highest coverage of 89.3%, which is consistent with the findings elsewhere.[27],[28] The therapeutic coverage in the year 2013 was better in all the districts except in Yelwan Damai district. However, all the districts met the minimum therapeutic coverage of 65% recommended by the WHO for control in two preceding cycles. Lower levels of female coverage compared to that of the male were noted in this study. This was also observed in a similar study in Oyo State, Nigeria, where a greater proportion of eligible males took Ivermectin than eligible females.[27] The reason could be due to exclusion of pregnant women and breastfeeding mothers from ingestion of Ivermectin.
One of the major barriers identified by the respondents affecting adequate coverage of Ivermectin MDAs in this study is the shortage of drugs. This was reported by 73% of the key informants and 80% of CDDs. The large proportion (49.5%) of nontreated individuals at the household level was due to inadequacy of drugs. This finding is consistent with the findings in Niger state, where 92.7% of non-treated individuals was due to unavailability of drugs.[29] Absenteeism is another factor affecting the distribution of Ivermectin. Over thirty percent (31.3%) of respondents that did not receive the drug were absent at the time of distribution. This is similar to what was observed in the study done in Oyo State, Nigeria, where 34.9% of respondents who did not receive the drug were reported to be absent during drug distribution.[28]
Pregnancy and lack of information ranked as the third reason ivermectin were not given, which is also similar to what was found in Niger state[29] and elsewhere.[28],[30] However, in this study, we recorded a higher number of pregnant women who did not receive ivermectin when compared to the study done in Niger state. Not informed as a reason for not taking the drug is slightly higher in our study when compared to what is obtained elsewhere.[28] This could be due to lack of adequate community awareness through routine channels such as town announcer, messages in religious institutions, radio jingles, among others.
The refusal rate reported in this study is extremely low, as only 9 (1.9%) people refused drug. This could mean that the ivermectin is accepted in most communities visited, and the CDDs are diligent in counseling those who refused drugs, as reported by 26 CDDs. This is similar to what is obtained in Niger state where only 1 (0.3%) person refused the drug. The finding differs from the one done in a multi-site study in 5 APOC sponsored projects in Nigeria and Cameroon in the year 2011, where 20.5% refused ivermectin.[28] The reason for this higher value could be attributed to the higher sample size when compared to our study and that of Niger state. It could also be due to the increased awareness in the intervening period, and the observation of benefit to those who accepted to be dosed.
The interview response of CDDs revealed poor record keeping. Only two villages had registers, and most of the information was incomplete. This could be due to inadequate training as only 50% of the CDDs interviewed had training on record keeping. This was the case of a previous study.[30] Research has shown that training of CDDs is essential for the planning, evaluation and success of the program and that record keeping makes the whole system transparent.[19],[27]
The year 2014 distribution of ivermectin was in the rainy season, because there was a delay with the supply of medications from the state coordinator. This might have affected the coverage of drugs that year because the occupation of the majority of the respondents and CDDs is farming. When compared to the distribution done the year before in the dry season, higher coverage was recorded in the local government [Figure 3].
Figure 3: Reasons why individuals did not receive tablets in the year 2014 distributionThe ratio of the CDD to the population in most of the studied communities was grossly inadequate. As recommended by the WHO/APOC treatment protocol, it should be a ratio of 1 CDD to 100 people.[31] Seventy-three percent of the key informants said they have two or fewer CDDs in their community, which implies that the duration of the treatment will be prolonged, making it difficult to give all members of the community drugs within a short period of time. However, those who were initially absent can be found.
The CDDs interviewed in all the districts said they do not have female CDDs because it is culturally and religiously unacceptable to do such work. This finding is similar to what is obtained in Niger State,[31] even though it was noticed that 33.3% of the key informants said women attend a general community meeting. A study has shown that where there is a female CDD in the village, the community recorded a higher coverage of ivermectin distribution compared to communities without any female CDD.[28]
The CDDs interviewed are all willing to continue to serve in that capacity, even though not all of them enjoy incentives from the community. In this study, only one CDD does not enjoy any form of incentive, while in the study done in Niger state, 3 out of the 6 CDDs do not enjoy any form of incentives.[31] These incentives enjoyed by most of the CDDs could be responsible for better coverage of ivermectin in this study compared to that of Niger State.
Suggestions were made on how to improve annual and long-term compliance during the interview of CDDs. From the findings, health education to the community ranked the highest, followed by support for CDDs and finally adequate provision of drugs. This finding is similar to what is obtained in a study done in Abia state, Nigeria, where health education/enlightenment ranked very high, followed by awareness through church/school, house-to-house distribution, and support of CDDs.[33]
Conclusion The therapeutic and geographic coverage of ivermectin distribution in Birinin Kudu LGA is high, being above the 65% minimum level by the WHO. The major challenges that need to be overcome to ensure effective Onchocerciasis control include: Enhancing CDDs motivation, breaking cultural and religious barriers to ensure female gender participation in drug distribution.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References 
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