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The knowledge, attitude and perception of onchoceriasi and ivermectin (mass) treatment by the people in okpuje, edo state, nigeria

International Journal of Biomedical and Health Sciences 2008 African Studies on Population and Health The knowledge, attitude and perception of onchocerciasis and ivermectin treatment by the people in Okpuje, Edo 1 Department of Basic Sciences, Benson Idahosa University, Benin City, Nigeria. 2 Department of Animal and Environmental Biology, University of Benin, Benin City, Nigeria. ABSTRACT: The study was carried out to determine the knowledge, attitude and perception of onchocerciasis and its
treatment with ivermectin by the people of Okpuje, an endemic community in Edo State, Nigeria. A four-step approach
involving: a structured questionnaire, personal interview, physical examination and group discussion, were used in the
study. Two hundred (200) volunteers, over ten years of age, were randomly chosen for the study. 61 persons (30.5%)
inadequate knowledge of the disease but 139 subjects (69.5%) were ignorant of onchocerciasis. Adequate knowledge
has a significant effect on the prevalence of onchocerciasis (P<0.005). Most respondents perceived the various
symptoms of onchocerciasis found in the area, namely; itching, nodules, leopard skin, lizard skin and ocular lesion as
separate diseases. Some symptoms were regarded as part of the ageing process while some respondents were not
bothered by the disease. Although 147 persons (73.5%) were given ivermectin during the yearly single-dose treatment,
only 117 respondents (58.5%) actually took the drug while the rest opted for local traditional method of treatment.
More females (51.28%) than males (48.72%) accepted ivermectin. The difference was not statistically significant
(P>0.05). Members of the community need to be educated and sufficiently mobilized to appreciate onchocerciasis as a
health problem so as to positively change their attitude, perception and level of awareness of the disease and the
efficacy of ivermectin treatment. That in turn should greatly increase the distribution coverage and acceptance level of
ivermectin used for the control of onchocerciasis in the community.
Keywords: Onchocerciasis; River blindness; Ivermectin; Okpuje; Edo State; Nigeria.
Introduction

Onchocerciasis is a chronic parasitic infection with a devastating burden of impaired vision and
blindness, and dermatitis on the afflicted (Abiose, 1993, WHO, 1997). About 125 million people world-
wide are estimated at risk of onchocerciasis and of these, 96% are in Africa. A total of 18 million people
are infected with the disease (WHO, 1995; Etyaale, 2001). It is estimated that the disease affects about 10
million people living in the savannah and rain forest regions of Nigeria. (Edungbola, 1991; Abiose, 1993).
Although a lot of attention has been paid to the clinical symptoms associated with oncherciasis, there is
little information on the knowledge, attitude and perception of local populations in most endemic areas
about the disease inadequate attention to this aspect of research could hinder the effective implementation
of strategies for the control of human onchocerciasi at the local level.
This paper report the findings of research on the knowledge attitude and perception of onchocerciasis
and the extent to which these would affect ivermectin distribution coverage and acceptance level of the
Int. J. Biomed. & Hlth. Sciences Vol. 4, No. 3 (2008) drug by the people in Okpuje, an onchocerciasis mesoendemic rural farming community in Owan West
L.G.A, Edo State, Nigeria.
Materials and Methods

The study was carried out in Okpuje, Owan West Local Government Area, Edo state, Nigeria. The study
area with its tropical climate lies between longitudes 5o 40’E and 6o 10’E and latitudes 6o 45’N and 7o 15’N.
It is located within the forest-savannah transition zone of Nigeria. Several streams which are tributaries of
River Owan transverse the community and provide breeding sites for Simulium damnosum, the vector of
Onchocerca volvulus.
Four methods were used in the study of the Knowledge, Attitude and Perception (KAP) of
onchocerciasis by the people. These were: a structured questionnaire, personal interview, participation
observation and group discussion.
Of the 655 persons enumerated in the community, two hundred (200) volunteers, ten years old and
above, were randomly chosen for the study. Besides their participation in the KAP studies, they were
examined for onchocercal signs and symptoms; and skin-snipped using corneo-scleral punch (2mm bite)
for the presence of microfilariae by a physician assisted by local health officials. After the physical
examination, each volunteer was given a structured questionnaire for the collection of information on his or
her knowledge, attitude and perception of onchocerciasis; and ivermectin treatment. This was followed up
with a friendly personal or group interview conducted in ora language, the ethnic language of the people.
Results

A total of 655 people aged five years and above were counted in the house-to-house census conducted at
the study site at Okpuje. Two hundred (200) volunteers (102 males and 98 females) of ten years of age and
above were randomly chosen for the study.
Knowledge of Onchocerciasis

Sixty one (61) respondents to (30.5%) named the disease correctly as onchocerciasis or river blindness;
caused by worms, and transmitted by Blackflies/insects. However, 139 persons (69.5%) responded with
wrong answers by stating one symptom such as itching, nodules, bad skin, eye sigh” as the name of the
disease. They could not name the causative agent or the vector of the disease.
From the response to the questionnaires, the entire volunteers were placed into two broad groups,
according to their knowledge or ignorance of Onchocerciasis (Table 1). The result showed that infection by
onchocerciasis occurred more among people who lacked aetiological knowledge (ignorant) of the disease
(29%) than among those who were knowledgeable (3.5%). Knowledge had a significance effect on the
prevalence of infection (P<0.005).
Attitude and perception of onchocerciasis.

Most male volunteers, who were farmers, admitted that they were usually thinly clothed with shorts and
sleeveless singles while at work on the farms. Thus, they exposed most parts of the body to bites of
blackflies. Also most males in the community often bathed in nearby streams reputed to be breeding sites
of blackflies in the area. Besides, no house was found screened with insect nets.
One hundred and thirty-nine persons (69.5%) regarded some recorded symptomatic effects of
onchoceriasis in the community, namely: itching, nodules, leopard skin, lizard skin and ocular lesion as
separate diseases, and not linked to the same causative nematode, onchocercea vulvulus 15 subjects (7.5%)
perceived leopard skin and lizard skin as part of the ageing process. 7 males (33.3%) infected with nodules,
stated that the disease neither incapacitated them nor prevented them from carrying out their routine work
and that They were not bothered about the disease. 25 individuals (12.5%) admitted using traditional herbal medicines for the treatment of onchocerciasis. Table 1: The Prevalence of infection in two broad groups respondents placed according to their aetiological knowledge or ignorance of onchocerciasis. GROUP Respondents Ignorant Knowledgeable about about Onchocerciasis Table 2: Ivermectin Distribution Coverage and acceptance level by sex at Okpuje. A: ACTUALLY TOOK B: DID NOT TAKE IVERMECTIN Attitude towards ivermectin treatment The National Onchocerciasis Control Programme (NOCP) using the Rapid Assessment Method (RAM) in 1996 declared the community as hyperendemic for onchocerciasis. However, during this study, the nodular prevalence at Okpuje was 10.5%. The overall prevalence of infection based on skin-snip positivity for Onchocerca volvulus microfilariae was 47.5%. Ivermectin distribution started in the community in 1996, using the community-based treatment (CBTI), which was later changed to the on-going community-directed treatment (CDTI). During this study, 147 persons (73.5%) received ivermectin during the yearly mass distribution exercise. Only 117 persons (58.5%) out of the 147 individuals who were given ivertmection, admitted to have actually taken the drug treatment. Of the 117 persons who took ivermectin 60 (51.28%) were females while 57 (48.72%) were males (Table 2). Out of the 30 individuals who were given ivermectin but did not take the treatment, 13 (43.3%) were females while 17 (56.7%) were males. Also, 23 persons (76.6%) out of the thirty, claimed that ivermectin had no effect or did not eliminate/cure the disease symptoms; 5 subjects (16.6%) felt that the period of treatment was too long; and 2 subjects (6.6%) feared adverse reactions. These individuals subsequently discontinued ivermectin treatment. However, 53 respondents (26.5%) were not given ivermectin during the yearly single-dose mass distribution exercise, 27 subjects (50.94%) in this category, claimed they were absent at that time. 11 persons (20.75%) alleged that the community drug distributor (CDD) omitted their names from the Int. J. Biomed. & Hlth. Sciences Vol. 4, No. 3 (2008) treatment list. 15 persons (28.3%) rejected the drug outright because they did not know the benefits of
ivermectin.
Discussion
According to Ukoli (1992) many authorities believe that the knowledge, attitude and practice (KAP) of
the peasants of rural Africa predispose them to infection. The results obtained from 200 volunteers in this
study showed that the people of Okpuje lacked adequate knowledge about onchocerciasis. Only 61 subjects
(30.5%) named the disease correctly; knew about the Onchocercia worms as the causative agents of the
disease, and black flies or insects as disease vectors. It was observed that infection by onchocerciasis
occurred more among respondents who lacked adequate knowledge of the disease than among those that
were knowledgeable. Consequently knowledge of onchocerciasis significantly affected the prevalence of
infection (P<0.005).
Richard et al., (1991) in a similar study to determine the knowledge attitude and perception of
onchocerciasis among subjects in an endemic area of Guatemala, found that although the people did not
perceive onchocerciasis as serious problems; 39% of the residents knew that the disease was caused by a
worm. 5% of the people knew that the condition was acquired through the bite of an insect. Nwoke et al.,
(1992) in Jos, Plateau State, Nigeria, reported that though villagers in endemic areas knew of the nuisance
of blackfly bites, the majority of them lacked aetiological knowledge of onchocercal lesion. In this study, it
was found that 24.5% of the respondents knew that onchocerciasis was acquired through the bites of
backflies, yet nobody had taken steps to prevent or reduce man-vector contact. For instance, male farmers
still exposed most parts of their bodies to blackfly bites in the farms, no house in the community was found
screened with insect nets. 25 person (12.5%) admitted using traditional herbal medicines for the treatment
of onchocerciasis. 33.3% of the males infected with nodules wee not bothered by the disease since they
were neither incapacitated nor prevented from carrying out their normal work and 7.5% of the respondents
perceived leopard skin and lizard skin as part of the ageing process. All these showed clearly poor attitude
towards the diseases in the community. Amazigo (1993) observed that culture had a lot of influence on the
attitude of rural dwellers towards the disease. He reported that women in a rural farming community in
Etteh, Nigeria, have traditional beliefs about onchocerciasis which differ from the concepts of modern
science. He concluded that recognizing these beliefs could allow health workers gain their confidence and
participate in control programmes.
Ivermectin, when taken annually, has the ability to bring about sustained reduction in skin and eye
microfilariae to very low levels with reduction in morbidity (WHO, 1997; Abiose 1998) and transmission
(Cupp et al., 1992; Remme, 2002).
According to Molyneux (1995), 65-80% coverage is necessary for significant and persistent regression
in morbidity. In this study at Okpuje, although ivermectin distribution coverage was high (73.5%), yet
ivermectin acceptance was only 58.5%. The prevalence of infection obtained during the study was 47.5%.
The high prevalence of onchocerciasis in Okpuje inspite of many years of annual dosing of the people with
ivermectin could be attributable to the low acceptance level of the drug. There are eligible individuals who
refused to take the drug whenever it was administered. There were others who initially took the drug but
refused to continue the treatment as a result of adverse reactions or absence of physical improvement on the
symptomatic effects. Others were absent during the time of treatment. These individuals constitute a
reservoir for infection and reinfection in the community. Also, in this study at Okpuje, more females,
(51.28%) than males (48.72%) accepted ivermectin treatment. However, the difference was not statistically
significant, (P>0.05). These findings are similar to the report of Wagbatsoma and Aisien (2001) who
observed ivermectin distribution coverage of 85.74% but a relatively high prevalence of onchocerciasis of
42.1% in Ekpan village, Edo State. They also reported that more females took ivermectin than the males.
Abanobi (2000) reported a high ivermectin coverage ranging from 71% to 92%, in nine communities
surveyed in Imo State, Nigeria. Richards et al., (1991) in a similar study in Guatemala reported that the
major reasons given for not taking ivermectin was fear about drug related adverse reactions. However, he
observed that general well being, improved energy level, improved visual acuity and cure of onchocercal
nodules and microfilariae were the motivating benefits for accepting ivermectin.
According to findings reported in TDR (2001), increased knowledge and awareness of onchocerciasis
had made it easier for health workers to engage endemic communities in the single-dose annual ivermectin
treatment programmes to obtain their commitment to carry out and support the treatment themselves.
Conclusion

Adequate knowledge of Onchocera volvulus; its mode of transmission; disease manifestation; and the
efficacy of ivermectin treatment would bring about the desired positive change of attitude and perception or
behaviour that would enhance individual and community acceptance of ivermectin at Okpuje. Besides the
door-to-door distribution method, the CDDIs should ensure that ivermectin is actually taken on delivery. In
addition, effective age-grade mobilization of the people would ensure a greater distribution coverage and
acceptance level of ivermectin treatment in order to make onchocerciasis control programme at Okpuje
very successful.
References

Abanobi, O.C. (2000). Community based mass distribution of ivermectin for the control of human onchocerciasis in
Ehime communities, Imo State, Nigeria. Eye and Vision, 41-56 Abiose, A. (1993). Operational research for ivermectin-based onchocerciasis control in Nigeria. Nigeria Journal of Abiose, A. (1998). Onchoceral eye disease and the impact of mectizan treatment. Ann. Trop. Med. Parasitol., 92: 511 – Amazigo, U.O (1993). Onchocerciasis and women’s reproductive health: indigenous and biomedical concepts. Trop. Cupp E. W., Ochoa J.O., Collins R.C., Cupp M.S., Gonzales – Peralta C., Castro J. and Zea-Florea G. (1992). The effects of repetitive community-wide ivermectin treatment on transmission of Onchocerca volvulus in Guatemala. Am. J. Trop. Med. Hyg. 47(2): 170 – 180. Edungbola, L.D. (1991). Onchocerciasis control in Nigeria. Parasitology Today. 7: 97 – 99. Etya’ale, D.E. (2001). Vision 2020: Update on onchocerciasis. J. Comm. Eye Health 14: 19 – 21. Molyneux, D.H (1995). Onchocerciasis control in West Africa: Current status and future of onchocerciasis control programme. Parasitology Today. 11(11): 399-402. Nwoke, B.E.B, Onwuliri, C.O. and Ufomadu, G.O (1992). Onchocerciasis in Plateau state, Nigeria: ecological background. Local disease perception and treatment, and vector/parasite dynamics. J. Hyg. Epidemiol. Microbiol. Immunol. 36 (2). 153 – 160. Remme Hans (2002). Effect of ivermectin on elimination of onchocerciasis transmission. TDR news. Feb., 67:4 Richards, F., Klein, R.E., Gonzales-Peralta, C., Flores, R.Z., Flores, G.Z and Ramirez, J.C. (1991). Knowledge, attitude and perceptions (KAP) of onchocerciasis: a survey among residents in an endemic area in Guatemala, targeted for mass chemotherapy with ivermectin. Soc. Sci. med., 32 (11): 275-281. TDR (2001). Onchocercal skin disease, in: Snippets of achievement, Mattock, N. (Ed) pp 6-7, TDR/GEN/01.1 Ukoli, F.M.A. (1992). Prevention and control of parasitic diseases in tropical Africa: The main issues. Ibadan, Wagbatsoma, V.A. and Aisien, M.S.O. (2001) Ivermectin distribution coverage and the associated factors in Ekpan Village, Edo State, Nigeria. The Nigerian Journal of Parasitology. 22 (122) pp 157-162. WHO (1995). Onchocerciasis and its control. Report of a who Expert Committee on Onchocerciasis. TRS No. 852. WHO (1997). Tropical disease Research progress 1995-96, Thirteenth Progress Report. UNDP/World

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