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Jech.bmj.com

J Epidemiol Community Health 2000;54:79–80
Treatment with ivermectin: what works in onecommunity may not work in another O E Onwujekwe, E N Shu, C C Ndum, P O Okonkwo Nigeria is highly endemic for onchocerciasis, Study design
and seven million people are infected, 40 million at risk of infection and 0.2 million blind study sites with an estimated total population from the disease.1 Disease control is through size of 125 000. Interviewer administered mass distribution of ivermectin (Mectizan) “ a structured questionnaires were used to inter- drug that has revolutionized the treatment of onchocerciasis and other nematode diseases of selected household heads. Based on a table for man”.2 What is needed therefore, is to put in sample sizes,4 404, 393 and 214 household place an eVective system of drug delivery and distribution that can be sustained by the endemic countries themselves.3 An approachfor ivermectin distribution is through commu- Results and Discussion
nity self treatment, where the communities Men formed the majority of respondents in the themselves are actively involved in planning, three communities, and most respondents were designing and executing the ivermectin deliv- between 41 to 60 years in Achi and Nike com-munities, and 20 to 40 years in Toro commu- ery system. This has been termed community nity. Table 1 illustrates the community diVer- directed treatment with ivermectin (CDTI) by ences of who should distribute ivermectin; while community based distributors (CBDs) Control, APOC. CDTI schemes are currently from super family units were mostly preferred being tested in Africa to decide on the best approach. However, the danger lies in extrapo- workers were preferred in Achi (36%). How- lating results generated from some communi- ever, in aggregate terms, CBDs in various ties to all onchocerciasis endemic communi- forms were preferred in the three communites.
This result diVers from another study where characteristics and priorities, and what works only 26 of 97 villages treated with ivermectin in one community may not work in another.
preferred community based distribution to the Therefore, the preferences of individual com- “mobile” method by external agencies.5 Other munities must be a priori determined, and the results showed that: (1) fee for service was the results used to model and implement appropri- preferred payment mechanism in Achi (56%) and Nike (69%), while it was pre-payment in schemes. This pilot study investigated the pref- Toro (38%); (2) the three communities wanted the payments for the ivermectin delivery to be distributing ivermectin in three Nigerian com- collected and managed by the community but munities. This study should be of help to with the government supervising (Nike, 51%; Toro, 66%; and Achi, 56%); (3) in Achi, the establishing sustainable community based and majority preferred the government to fix the controlled systems for endemic disease(s) fees (47%), while in Nike it was the town union (29%), and in Toro it was a combination of the Preference of household heads for the diVerent channels for local ivermectin distribution Through CBDs to be selected from each extended family unit (umunna) Health Policy
Research Unit,
Through CBDs selected from all religious groups Department of
Through CBDs selected from age grades and schools Pharmacology and
Therapeutics, College
of Medicine,
Through a centrally located shop to be managed by nominated community members Option number 7 but with the shop managed by an external person University of Nigeria,
Through government health centers and hospitals.
PMB 01129 Enugu,
1 A super family unit refers to a group of extended family units that have a common ancestor. Among the Ibos of south eastern Nigeria where Achi and Nike are in, these are called the “umunna”.
2 A group of super family units comprise a village.
3 The term government workers is used loosely to imply all mobile health workers who go to the communities to distribute ivermec- tin. They could be from the government or from non-governmental organisations.
town union and the traditional ruling council in this paper will aid discussions about the (46%). The possible conclusion is that each most eVective and sustainable form of CDTI.
community has its unique characteristics andpreferences, and these must be determined We are grateful to the anonymous referee who provided very before CDTI is designed and implemented. No two communities are the same, and what works Funding: this study received financial support from the UNDP/ in one community may fail in another. It is World Bank/WHO Special Programme for Research and Train- ing in Tropical diseases.
Conflicts of interest: none.
know their communities very well before start-ing any programme, and a national CDTI 1 Edungbola LD. Onchocerciasis control in Nigeria. Parasitol policy must make provisions for the use of Today 1991;7:97–9.
2 Jenkins DC. Ivermectin in the treatment of filariasis and other nematode diseases of man. Trop Dis Bull 1990;87:R1–
that before using the results of surveys to embark on community action, in depth analysis 3 Amazigo U, Noma M, Boatin BA, et al. Delivery systems and cost-recovery in Mectizan treatment for onchocercia- sis. Ann Trop Med Parasitol 1998;92:S23.
general village assemblies, should be done so 4 Eddy KG. Sampling method and sampling size. WHO/IMR Regional in-service course on research design and method- that all areas of conflicts and vagueness about the scheme would be resolved. These will help 5 Biritwum RBI, Scylla M, Diarra T, et al. Evaluation of iver- mectin distribution in Benin, Cote d’Ivoire, Ghana and agenda in designing and implementing CDTI.
Togo: estimation of coverage of treatment and operationalaspects of the distribution system. Ann Trop Med Parasitol The result of the questionnaire survey reported 1997;91:297–305.

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