Am. J. Trop. Med. Hyg., 80(5), 2009, pp. 691–698
Copyright © 2009 by The American Society of Tropical Medicine and Hygiene
Perspective
Nigeria’s War on Terror: Fighting Dracunculiasis, Onchocerciasis,
Lymphatic Filariasis, and Schistosomiasis at the Grassroots
Ngozi A. Njepuome, Donald R. Hopkins,* Frank O. Richards Jr, Ifeoma N. Anagbogu, Patricia Ogbu Pearce,
Mustapha Muhammed Jibril, Chukwu Okoronkwo, Olayemi T. Sofola, P. Craig Withers Jr, Ernesto Ruiz-Tiben,
Emmanuel S. Miri, Abel Eigege, Emmanuel C. Emukah, Ben C. Nwobi, and Jonathan Y. Jiya
Federal Ministry of Health, Abuja, Nigeria; The Carter Center, Atlanta, Georgia; The Carter Center, Jos, Nigeria
Abstract. Africa’s populous country, Nigeria, contains or contained more cases of dracunculiasis, onchocerciasis, lymphatic filariasis, and schistosomiasis than any other African nation and ranks or ranked first (dracunculiasis, onchocerciasis, schistosomiasis) or third (lymphatic filariasis) in the world for the same diseases. After beginning village-based
interventions against dracunculiasis 20 years ago and confronting onchocerciasis a few years later, Nigeria has nearly
eliminated dracunculiasis and has provided annual mass drug administration for onchocerciasis to over three quarters
of that at-risk population for 7 years. With assistance from The Carter Center, Nigeria began treating lymphatic filariasis
and schistosomiasis in two and three states, respectively, over the past decade, while conducting pioneering operational
research as a basis for scaling up interventions against those diseases, for which much more remains to be done. This paper
describes the status of Nigeria’s struggles against these four neglected tropical diseases and discusses challenges and plans
for the future.
average of 4–8 weeks, reducing agricultural productivity and
school attendance.5
Nigeria’s national Guinea Worm Eradication Program
(NIGEP) got underway after a national conference in March
1985 publicized qualitative evidence that showed for the first
time that dracunculiasis was a problem throughout the country6,7 and underscored the fact that there were effective ways
to prevent it. Medical geographer Susan Watts8 estimated in
1986 that Nigeria (estimated 1986 population of 98 million)
accounted for 2.5 million (75%) of 3.32 million Africans with
dracunculiasis and 25% (30/120 million) of the African population at risk. Nigeria conducted the first quantitative nationwide village-by-village search for cases of the disease in Africa
in 1988–1989,9 which documented 653,492 cases of dracunculiasis (more than any other country) in 5,872 Nigerian villages
(Figure 1).7 Systematic interventions began immediately, and
starting in 1991 were based on village-based volunteers who
were trained to conduct health education, distribute cloth filters, and report cases monthly. ABATE larvicide was applied
monthly during the transmission season to water sources in
the most highly affected villages by special teams, and water
supply agencies were urged to give priority to villages where
Guinea worm disease was endemic. Supervision, surveillance, and supplies were organized around administrative levels from village to local government area (LGA), state, zone,
and nation.1 The political and financial leadership provided
by former Nigerian Federal Minister of Health, the late Prof
Olikoye Rasome-Kuti, resulted in several infusions of Nigerian
cash at key points during the program, including $2 million
donated to The Carter Center by the Federal Government of
Nigeria to help support NIGEP. The willingness of Nigeria to
invest in its program stimulated further investment by outside
donors.
Cases of dracunculiasis fell rapidly from 653,492 in 1989
to 39,774 by 1994, but this was followed by 5 years of inadequate funding and poor program execution, during which
reported annual incidence hovered between 12,000 and 17,000
cases. Progress resumed after The Carter Center appointed
a Nigerian country director in 1998, recruited former Nigerian
head of state General (Dr) Yakubu Gowon as the chief
INTRODUCTION
With ~20% of the population of sub-Saharan Africa,
Nigeria (estimated 2006 population of 140 million) is or once
was the most highly affected country in Africa for dracunculiasis (Guinea worm), onchocerciasis (river blindness), schistosomiasis (Bilharziasis), and lymphatic filariasis (elephantiasis)
in numbers of cases, while also ranking among the top three
endemic countries globally. Although effective ways to prevent dracunculiasis have been known since early in the 20th
century, practical annual mass drug administration (MDA) for
the other three diseases became available only in the past few
decades. Despite its significant political challenges in modern
times, Nigeria began waging war on two of these microbial terrorists (dracunculiasis and onchocerciasis) about two decades
ago and began a similar community-based combat against the
others subsequently.1–4 This paper describes the current status
of these four struggles in Nigeria and their implications for
Africa and the world.
COMBATTING THE FOUR TERRORISTS
Dracunculiasis. Two- or 3-ft long worms (Dracunculus medinensis) emerging through the skin are the painful hallmark of
dracunculiasis, which people contract by drinking water from
open sources such as stagnant ponds that contain immature
parasites in tiny copepods (water fleas). There is no treatment
or cure for dracunculiasis, but it can be prevented by filtering drinking water through a finely woven cloth, by teaching villagers to avoid entering water sources when a worm
is emerging, by using a mild larvicide (ABATE, temephos;
BASF, Mount Olive, NJ) to kill copepods and parasites in the
water, and by providing safe sources of clean water, such as
from borehole wells. Affected persons are incapacitated for an
* Address correspondence to Donald R. Hopkins, The Carter
Center, 453 Freedom Parkway, Atlanta, GA 30307. E-mail: sdsulli@
emory.edu
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NJEPUOME AND OTHERS
Figure 1. Mapping for dracunculiasis, onchocerciasis, LF, and schistosomiasis in Nigeria. A, Distribution of dracunculiasis 1987–1988. Source:
Nigerian Guinea Worm Eradication Program, National Plan of Action, Federal Ministry of Health, December 1988, p. 23. B, Distribution of
Onchocerciasis 2003. Source: www.who.int/apoc/countries/nga/en/index.html. Accessed October 24, 2008. C, Distribution of LF 1999–2008. Source:
Nigerian Federal Ministry of Health. D, Distribution of schistosomiasis 1987. Source: adapted from Doumenge and others.40 * Since the Doumenge
publication, both S. mansoni and S. hematobium have been reported in Nasarawa State.29
advocate for the program in 1999, and obtained adequate
external funding through a generous grant from the Bill &
Melinda Gates Foundation in 2000. General Gowon visited
local officials and affected communities to press for action
and also encouraged the water sector to focus more on provision of safe water points for endemic communities. By 2007,
Nigeria reported only 73 cases of dracunculiasis, from four villages, after a small unexpected outbreak that was discovered
early that year, while ~6.2 million Nigerians are still at risk of
the disease.10 A complete report of this campaign will be published later.
Onchocerciasis. Microscopic infectious larvae of the filarial worm Onchocerca volvulus enter humans with the bite
of tiny Simulium black flies, which breed in fast-flowing rivers. Onchocerciasis (river blindness) is manifest as the larvae
mature to adults, gather in nodules, mate, and produce millions
of microfilariae that migrate to the skin, where they cause
intense itching and are available to be picked up by subsequent black flies and continue the cycle, and to the eye, where
they may cause blindness after several years of repeated
infections. The itching may prevent victims from working, or
concentrating in school, and causes some to disfigure their skin
by repeated scratching.11 Onchocerciasis can be controlled by
annual MDA with ivermectin (Mectizan; Merck, Rahway, NJ)
at a dose of 150 μg/kg, estimated by height.12
Nigeria was not included in the regional Onchocerciasis
Control Program (OCP) that began helping control the disease by insecticidal spraying in 11 other West African countries
from 1974. After Merck began donating the microfilaricidal
drug Mectizan (ivermectin) for MDA of onchocerciasis in 1987,
however, several non-governmental organizations (NGOs)
started helping local Nigerian health authorities provide some
of the first MDA programs in Africa in 1989 after surveys
to determine the extent and intensity of onchocerciasis
began in Kaduna State in 1989.13 Plateau State launched its
program in 199214 (Plateau was divided into Plateau and
Nasarawa States in 1997). After Nigeria and 18 other African
countries were included in the new African Program for
Onchocerciasis Control (APOC), which was launched in
December 1995 to help support MDA of Mectizan,12 the
Rapid Epidemiological Mapping of Onchocerciasis (REMO)
methodology developed by APOC15 was completed nationwide
NIGERIA’S WAR ON WORM TERROR
in Nigeria with support from APOC in 2003 (Figure 1; www.who
.int/apoc/countries/nga/en/index.html). The APOC strategy is
to treat only communities in areas where REMO estimated
the prevalence of onchocerciasis skin nodules to be 20%
or more; populations living in villages where nodule prevalence is 19% or less are not eligible for mass treatment. Based
on that treatment threshold, it is estimated that 30 million
persons require MDA for onchocerciasis in Nigeria, which is
almost 36% of the 82 million Africans at risk of the disease,
making Nigeria the most endemic country in the world for
onchocerciasis.16
With APOC’s financial assistance to Nigeria beginning in
1996, the Nigerian Onchocerciasis Control Program (NOCP)
and its many NGO partners17,18 shifted from a strategy of
village-based volunteers that included some volunteers
inherited from the Guinea Worm Eradication Program,14
to the Community-Directed Treatment with Ivermectin
(CDTI) strategy advocated by APOC.2,19 Like their predecessors, volunteer CDTI workers educated their neighbors
about onchocerciasis and distributed the annual mass treatment with Mectizan, but unlike their predecessors, the CDTI
workers were chosen by the community (not by the village
chief or health workers), who also decided when and how
Mectizan would be distributed in their community.
The number of mass Mectizan treatments administered
in Nigeria increased from < 0.6 million in 1992 to > 20 million treatments in 2007 (Figure 2), thus reaching ~77% of the
estimated 30 million Nigerians who are at risk of onchocerciasis (Figure 3). Nigeria has administered a cumulative total
693
of > 175 million treatments for onchocerciasis in 1989–2007.
The Carter Center has helped document the impact of MDA
for onchocerciasis in a few sites in Nigeria (Figure 4), which
confirmed 95% reductions in onchocercal nodules between
1992/93 and 2005 in Plateau and Nasarawa States (Umaru J,
personal communication) and 94% reduction in poor visual
acuity between 1995 and 2002 in Imo State.20
Lymphatic filariasis. The swollen legs, arms, and scrotums of
persons affected by advanced lymphatic filariasis (LF), caused
in Africa by Wuchereria bancrofti, are a constant source of suffering and ostracism to its victims and an unforgettable sight
to others. These filarial worms are transmitted to humans in
Africa by bites of Anopheles (which also transmit malaria) and
Culex mosquitoes. Recognition that simultaneous annual oral
administration of ivermectin (Mectizan; donated by Merck for
treatment of LF in sub-Saharan Africa at 150 μg/kg, estimated
by height) and albendazole (donated by GlaxoSmithKline,
Brentford, Middlesex, UK; at 400 mg/dose) could suppress
microfilaremia and interrupt the transmission cycle by blocking vector infection, availability of rapid diagnostic tests
(immunochromatographic card tests [ICT])21 that detect specific filarial antigen and do not require nocturnal blood sampling (in Africa microfilariae only circulate at night), which
allowed for rapid mapping of the condition, together with
the large donation of mectizan and albendazole, allows great
opportunity for elimination of LF transmission.22,23 Of the estimated 400 million Africans at risk of LF,24 80 million (20%)
are believed to be Nigerians, and Nigeria contains 25 million
(54%) of the estimated 46 million Africans with the disease.25
Figure 2. MDA for onchocerciasis, LF, and schistosomiasis in Nigeria: absolute numbers of treatments provided in 1989–2008. Schistosomiasis
treatments with praziquantel began in 1999, and LF treatments with combined ivermectin and albendazole in 2000, although in amounts too small
to be easily seen relative to onchocerciasis treatments (with ivermectin) bars of graph. Overlapping LF and onchocerciasis treatments are counted
twice: once in the LF bar and again in the onchocerciasis bar. * Schistosomiasis and LF 2008 figures are provisional through July reports for Carter
Center–assisted programs. The 2008 national onchocerciasis treatment numbers are projections.
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NJEPUOME AND OTHERS
Figure 3. Intervention coverage of at-risk populations in Nigeria. Numbers in parentheses reflect known or estimated ultimate intervention
goals needed to reach full coverage.
Given the similar modes of intervention by annual MDA
and health education, The Carter Center and officials in
Plateau State and the Federal Ministry of Health began
planning in 1997 to study whether control measures against
LF and urinary schistosomiasis (see below) could be safely,
effectively, and more efficiently combined with interventions
against onchocerciasis3 as a pilot test for possible expansion
to other areas of the country. Mapping of lymphatic filariasis
began in Plateau and Nasarawa States in 1999 and extended
to other states beginning in 2001, with mobile teams using
ICTs on a sample up to 100 randomly chosen adults per village. LF mapping has now been completed in 33 of Nigeria’s
36 states and is underway in the 3 remaining states and Federal
Capital Territory, with a goal of completing the whole country
by early in 2009 (Figure 1). Mapping thus far has confirmed
that LF is more widespread than onchocerciasis. For example,
although 12 of the LGAs of Plateau and Nasarawa States met
APOC requirements for MDA for onchocerciasis, all 30 LGAs
required MDA with Mectizan and albendazole for lymphatic
filariasis.4
Health education and MDA for LF began in two LGAs
of Plateau and Nasarawa States in 2000 and expanded to all
30 LGAs by 2003, using the same village volunteers as for
onchocerciasis, where available, and training new volunteers
where necessary. In 2007, Plateau and Nasarawa (combined
population now ~4.5 million) administered > 3.4 million combined treatments with Mectizan and albendazole, a year that
was the fifth, sixth, or seventh year of MDA exceeding 85%
coverage of the treatment population. A cumulative total of
> 19 million treatments for LF have been administered in
2000–2007 (Figure 2). Assessments of impact in sentinel villages in Plateau and Nasarawa States showed that, as of 2007,
Figure 4. Impact in Nigeria. A, Dracunculiasis: number of cases. Source: Nigerian Guinea Worm Eradication Program, Federal Ministry of
Health, 2008. B, Onchocerciasis: nodule prevalence in adults. Source: unpublished data based on nodule palpation surveys of 30 adult samples in
each of 11 villages in Plateau 1992/93) and Plateau and Nasarawa States (2007), courtesy of J Umaru. C, LF: antigenemia in humans. Unpublished
data based on 2000 and 2007 surveys for LF antigenemia using ICT card tests3,4,8 in 10 sentinel villages (50 persons per village) in Plateau and
Nasarawa States, courtesy of A Eigege. D, urinary schistosomiasis: blood in urine (dipstick positivity) in school children. Source: based on rapid
heme dipstick reagent testing of school children, adapted from Hopkins and others.3
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NIGERIA’S WAR ON WORM TERROR
the prevalence of positive ICT serologic tests for LF had been
reduced by 83% (Miri E, personal communication) (Figure 4),
and average mosquito infection rates had been reduced by
92%.26 The program is actively assessing whether transmission
of LF in some LGAs has been interrupted and whether MDA
with Mectizan and albendazole might be able to be stopped in
those LGAs in 2009. More rapid and earlier national expansion of MDA for LF did not take place because of the absence
of additional funding to complete LF mapping and the initial difficulties in integrating LF activity with APOC-funded
nationwide MDA with Mectizan. In 2007, however, MDA
programs for LF (integrated within onchocerciasis program
areas) were finally launched in states outside of Plateau and
Nasarawa, beginning in Ekiti, Ondo, and Osun, but this still
represents only about 5% of the estimated at risk population
(Figure 3).24 In 2008, ~4.7 million persons (~6%) are expected
to be treated in the five states, and in 2009, LF MDA should
reach 7.5 million treatments, with expansion planned for
selected LGAs in Oyo, Bauchi, Benue, Gombe, Ogun, Taraba,
and Adamawa States.
Schistosomiasis. School-aged children playing in ponds and
rivers comprise the group most important to transmission of
schistosomiasis, which in Nigeria is caused mainly by infection with Schistosoma hematobium and S. mansoni, which
cause urinary and intestinal schistosomiasis, respectively.
Either or both forms of this parasite occur throughout Nigeria.
This disease is an occupational hazard for fishermen and rice
farmers and a potential threat to anyone exposed to freshwater that has been contaminated by human feces or urine containing the parasite’s eggs from previous victims. The larval
stages of this parasite emerge from specific snails that serve
as intermediate hosts, penetrate the skin, and mature in veins
serving the bladder (S. hematobium) or intestines (S. mansoni). Adult female worms lay thousands of tiny spiked eggs
that damage blood vessels before emerging in feces or urine
that may be deposited in fresh water where the eggs hatch,
and emerging parasites infect and multiply in the snails, thus
completing that parasite’s life cycle. Patients may experience
bloody urine or stools, and after several years, scarring of the
intestines, bladder, kidneys, liver, and/or lungs, with potential
complications of anemia, liver failure, heart failure, renal failure, or bladder cancer. Schistosomiasis can be controlled by
annual MDA with praziquantel (40 mg/kg). The estimated 101
million Nigerians at risk of schistosomiasis account for ~21%
of the estimated 477 million Africans at risk of that disease27;
this makes Nigeria the most endemic country in the world for
schistosomiasis.
Nigeria’s FMOH conducted a qualitative questionnaire survey of health officials, and teachers nationwide in 1991 aimed
at reporting bloody urine to determine crude distribution for
S. hematobium throughout the country.28 Plateau and Nasarawa
States began quantitatively mapping urinary schistosomiasis
with mobile teams using heme reagent dipstick tests of urine
(to detect hematuria) on randomly selected school children
5–14 years of age in each village in two LGAs in 1999, whereas
similar dipstick surveys began in Delta State in 2003 and in
Ekiti and Ondo States in 2008 (Figure 1). Mapping of intestinal schistosomiasis has lagged because of the absence of a
rapid diagnostic test and the requirement of a stool examination for eggs conducted by a trained microscopist, although
some S. mansoni mapping has recently taken place in Plateau
and Nasarawa.29
Health education and MDA with praziquantel against urinary schistosomiasis began in 1999 in Plateau and Nasarawa
States, in 2004 in Delta State, and in 2008 in Ekiti, integrated
with the existing network for combating onchocerciasis and
LF in Plateau and Nasarawa and onchocerciasis in Delta, using
WHO treatment criteria30 (communities with hematuria rates
in children of 20–49% receive mass treatment of school age
children, and communities where ≥ 50% of school age children have hematuria receive MDA for the entire community).
The integrated MDA program has ultimately evolved into a
complex mosaic of different drug combinations of mass treatments that were indicated for onchocerciasis, LF, and schistosomiasis (Figure 5).
Nigeria treated 202,941 persons for schistosomiasis using
praziquantel in 2007 and a cumulative total of 1 million treatments in 1999–2007 (Figure 3). A major donation of praziquantel from E-Merck (Germany) through WHO allowed
Nigeria to treat another one million school-aged children in
2008, which still comprises only ~1% of the estimated 101
million Nigerians believed to need treatment for schistosomiasis,27 which is more than any other country in the world.
MDA with praziquantel was provided at least 1 week before
or after MDA with Mectizan and albendazole (or Mectizan
alone), until October 2006, after WHO provided data showing
that simultaneous administration of all three drugs was safe.31
Monitoring of children in the first two districts where interventions began in Plateau and Nasarawa States has shown an
average reduction of 94% in the prevalence of bloody urine as
measured by dipstick (Figure 4).3
Other operational research conducted in Nigeria includes
rotation of praziquantel MDA to other schistosomiasisendemic communities after three to five annual rounds of
treatment in individual communities, assessment of missed
opportunities for mass treatment of S. mansoni in communities
that do not qualify for MDA because of absent or lower rates
of S. hematobium,29 and combined surveys for schistosomiasis
and trachoma.
DISCUSSION
Nigeria’s success and leadership in combating two of these
four diseases (dracunculiasis and onchocerciasis) by nationwide mapping, community-based interventions, monitoring
coverage and impact of the interventions, and conducting
operational research are significant in their own right, but gains
even more importance when Nigeria’s continental prominence
is considered. Dracunculiasis’ extensive prevalence, available
control measures, the early political and financial leadership
provided by former Nigerian Federal Minister of Health, the
late Prof Olikoye Ransome-Kuti, and later advocacy by former
Nigerian Head of State General (Dr) Yakubu Gowon were
critical ingredients in Nigeria’s success against dracunculiasis.
The fact that Nigeria has nearly eradicated dracunculiasis and
has provided treatment of onchocerciasis to over three quarters of its at-risk population for several years now (well above
APOC’s target threshold coverage of 65%), despite obvious
challenges, are noteworthy triumphs. Eradication of dracunculiasis will be assured in perpetuity, but sustaining MDA and
health education for onchocerciasis for as long as necessary is
a major ongoing challenge,32 because Nigeria’s onchocerciasis
program remains greatly dependent on support provided by
international NGOs and APOC.
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NJEPUOME AND OTHERS
Figure 5. Disease mapping for LF, onchocerciasis, and urinary schistosomiasis in Plateau and Nasarawa States, Nigeria, by LGAs. Named subdivisions of the two state area show LGAs with colors reflecting endemicity based on mapping activities. Parentheses in color legend show number
of LGAs conforming to that endemicity code. Onchocerciasis endemicity based on an estimated adult resident onchocercal nodule prevalence of
≥ 20%. LF endemicity based on ICT card test blood surveys of adults showing at least one village in the LGA had a prevalence of > 1% LF antigenemia.18 Urinary schistosomiasis prevalence based on finding villages in the LGA with urinary dipstick heme prevalences in school children of
> 20%.4
The successful dracunculiasis and onchocerciasis programs
and the demonstration of successful integrated interventions
against onchocerciasis, LF, and schistosomiasis should be the
foundation for rapid national scaling up MDA and health
education for LF and schistosomiasis.3,4 A successful national
attack on lymphatic filariasis and schistosomiasis will require
at least as much financial and political commitment as Nigeria
invested in its Guinea Worm Eradication Program, particularly because praziquantel, for the most part, still must be purchased. The cost to treat 101 million Nigerians annually (at
US$0.20/dose) would be more than US$20 million per year and
is the major constraint to scaling up schistosomiasis control.
Because schistosomiasis cannot be eradicated in the foreseeable future, this investment will need to continue indefinitely.
In contrast, medicines for LF are donated. In addition, if, in
the near future, LF is confirmed to be eradicable in sub-Saharan Africa, that could obviate the need to invest in nationwide
interventions against LF indefinitely.
The International Task Force for Disease Eradication was
the first international body to declare LF to be potentially
eradicable33 and is closely monitoring the possibility that
onchocerciasis might 1 day become eradicable.34 Scaling up
MDA with Mectizan and albendazole to eradicate LF also
would intensify impact on onchocerciasis by adding a second
anti-helminthic (albendazole) drug and extending MDA to
many untreated communities where onchocerciasis is below
APOC’s 20% prevalence threshold for MDA.12 The LF program would also extend the ancillary benefits of these antihelmintics by reducing the burden of ascariasis, hookworm
infection, and trichuriasis significantly, at least for the duration
of the LF program.29
Long-lasting insecticidal nets (LLINs) for malaria control, as
an adjunct to MDA for LF or alone, represent another tool to
help eliminate LF from Nigeria. Nigeria’s insecticide-treated
bed net use among children younger than 5 years old was 4%
in 2007,35 but village volunteers in Plateau and Nasarawa States
have proven to be very effective at distributing bed nets (provided by Nigeria’s Malaria Program) during LF MDA, having
increased coverage to 80% among households with vulnerable
groups (pregnant women or children younger than 5 years of
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NIGERIA’S WAR ON WORM TERROR
age) in two Nigerian LGAs in 2004.36 The challenge to scale
up distribution of LLINs to simultaneously fight malaria and
LF, both of which are widely endemic throughout Nigeria and
share the same Anopheles mosquito vector, by using village
volunteers, is a special opportunity that Nigeria intends to
seize, beginning in 2009, building on the largest ivermectin distribution system in the world for onchocerciasis. In southeastern Nigeria, where LF MDA cannot be used as yet because of
risk of adverse events associated with Mectizan treatment of
the co-endemic filarial parasite Loa loa there, LLIN alone at
full coverage (as opposed to targeting only vulnerable groups)
may also be useful to attack LF in the absence of MDA. Thus,
scaling up LF MDA wherever possible and providing full
LLIN coverage throughout the Federation conceivably would
have a better chance of eliminating LF from Nigeria than
either MDA or LLINs alone, while strengthening the war on
malaria and the fight against onchocerciasis.
The battle against schistosomiasis has the greatest scale up
challenges of the four diseases.4 Potential options are to undertake the expensive and labor-intensive approach to mapping
both intestinal and urinary schistosomiasis nationwide and
adopt a policy to administer praziquantel MDA presumptively
and broadly without mapping,29 or perhaps also use rotation of
MDA and health education to extend the benefits of limited
and costly praziquantel supplies to the maximal number of
communities. In any event, Nigeria will need to buy, manufacture, and/or secure adequate donated supplies of praziquantel
to attack schistosomiasis nationwide.
Much remains to be done to strengthen overall primary
health care services in rural areas of Nigeria that could facilitate the war on these four terrorizing worms.37 The full engagement of communities and use of village volunteers would be a
tremendous resource for helping people to rid themselves of
some of their microbial tormentors. Indeed, the communitydirected approach to integrated disease management as a way
of tackling up to four diseases efficiently and cost-effectively
was piloted in Kaduna, Ogun, and Taraba States and is being
replicated as another means of strengthening primary health
care.38 The important contributions of health education and
community mobilization to the success of all four programs in
Nigeria thus far must be emphasized, because these key elements tend to be overshadowed by the more tangible tools
such as miracle tablets and longlasting bednets, to the detriment of some programs elsewhere.39
The on-going work summarized in this paper provides the
knowledge and foundation for scaling up efforts throughout
Nigeria for LF and schistosomaisis and lends tested strategies
and tactics for potential use in other countries. Better tools are
still needed, and continued research in support of Nigeria’s
efforts is important. A macrofilaricide that would kill adult
Onchocerca parasites could bring to possibility the eradication
of river blindness.32 A less expensive test to diagnose LF infection (ICT tests cost more than USD$2.00 each) and a simple
inexpensive diagnostic test for S. mansoni infection would facilitate the struggles to verify LF elimination and map intestinal
schistosomiasis, respectively. However, the progress summarized
here shows that much can be done with the tools that are available right now, where there is the will and support to do so.
Received November 14, 2008. Accepted for publication January 21, 2009.
Acknowledgments: The authors thank Shandal Sullivan, Renn
McClintic-Doyle, and Lauri Hudson-Davis for assistance in preparing
this manuscript. We are deeply grateful for the support provided by
Past President and Mrs. Jimmy Carter, and by General Dr. Yakubu
Gowon in the work described here. We also acknowledge the work of
Dr. Munirah Y. Jinadu, former national coordinator for schistosomiasis control and LF elimination.
Financial support: Major external support for the dracunculiasis
eradication program was provided by The Carter Center, the World
Health Organization (WHO), the United Nations Children’s Fund
(UNICEF), Centers for Disease Control and Prevention (CDC), and
many other donors. The Japan International Cooperation Agency
(JICA) and UNICEF helped support safe water sources in some
dracunculiasis-endemic villages. Nigeria appreciates the support and
partnership with Lions Clubs, UNICEF, Africare, the River Blindness
Foundation, Helen Keller Worldwide, Christoffel Blindenmission,
SightSavers International, MITOSATH, IFESH, and The Carter
Center for Nigeria’s onchocerciasis activities. Additional support
for the onchocerciasis activities is provided by the African Program
for Onchocerciasis Control, with Mectizan donated by Merck.
Albendazole was donated by GlaxoSmithKline, and praziquantel was
donated by E-Merck (Germany) through WHO. GlaxoSmithKline
also provided financial support for LF work in Plateau and Nasarawa
States. The Izumi Foundation provided some support for schistosomiasis control in Plateau, Nasarawa and Delta States. The Bill and
Melinda Gates Foundation has provided some support for all four
programs. WHO’s Regional Office for Africa, the Mectizan Donation
Program, the Liverpool Lymphatic Filariasis Support Center, and The
Carter Center are helping to support mapping of LF.
Authors’ addresses: Ngozi Njepuome, HIV/AIDS/TB, Federal Ministry
of Health, Federal Secretariat, Abuja, Nigeria, Tel: 234-805-601-0207,
Fax: 234-9-523-7475, E-mail: [email protected]. Donald R. Hopkins,
The Carter Center, 453 Freedom Parkway, Atlanta, GA 30307, Tel:
404-420-3837, Fax: 404-874-5515, E-mail: [email protected]. Frank
Richards, River Blindness Control Program (including Lymphatic
Filariasis Control and Schistosomiasis Elimination), Malaria Control
Program, The Carter Center, 453 Freedom Parkway, Atlanta, GA
30307, Tel: 770-488-4511, Fax: 770-488-4521, E-mail: [email protected].
Ifeoma N. Anagbogu, National Guinea Worm Eradication Program,
Federal Ministry of Health, Abuja, Nigeria, E-mail: ifechuba@yahoo
.co.uk. Patricia Ogbu Pearce, National Onchocerciasis Control Program
and Lymphatic Filariasis Elimination Program, Federal Ministry of
Health, Abuja, Nigeria, E-mail: [email protected]. Mustapha
Muhammed Jibril, Schistosomiasis and Soil Transmitted Helminth
Control Program, Federal Ministry of Health, Abuja, Nigeria, E-mail:
[email protected]. Chukwu Okoronkwo, National Onchocerciasis
Control Program, Federal Ministry of Health, Abuja, Nigeria, E-mail:
[email protected]. Olayemi T. Sofola, National Malaria
Control Program, Federal Ministry of Health, Abuja, Nigeria, E-mail:
[email protected]. P. Craig Withers Jr, Health Programs, The Carter
Center, 453 Freedom Parkway, Atlanta, GA 30307, Tel: 404-420-3851,
Fax: 404-874-5515, E-mail: [email protected]. Ernesto Ruiz-Tiben,
Guinea Worm Eradication Program, The Carter Center, 453 Freedom
Parkway, Atlanta, GA 30307, Tel: 770-488-4509, Fax: 770-488-4532,
E-mail: [email protected]. Emmanuel Miri, Country Representative, The
Carter Center, 1 Jeka Kadima Street, Off Tudun Wada Ring Road, PO
Box 7772, Jos, Nigeria, Tel: 234-73-461-861 or -463-870, Fax: 234-73460-097, E-mail: [email protected]. Abel Eigege, Nasarawa
Integrated Programs, The Carter Center, 1 Jeka Kadima Street, Off
Tudun Wada Ring Road, PO Box 7772, Jos, Nigeria, Tel: 73-461-861
or -463-870, Fax: 73-460-097, E-mail: [email protected].
Emmanuel Emukah, Southeast Programs, The Carter Center, 1 Jeka
Kadima Street, Off Tudun Wada Ring Road, PO Box 7772, Jos, Nigeria,
Tel: 73-461-861 or -463-870, Fax: 73-460-097, E-mail: emukahe@yahoo.
com. Ben C. Nwobi, Control of Neglected Tropical Diseases, Federal
Ministry of Health, Abuja, Nigeria, E-mail: emekanwobi@hotmail
.com. Jonathan Y. Jiya, Federal Ministry of Health, Abuja, Nigeria,
E-mail: [email protected].
Reprint requests: Donald R. Hopkins, The Carter Center, 453 Freedom
Parkway, Atlanta, GA 30307.
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