Muhumuza's study brightens Jinja's war on bilharzia in schools

By Angel Nabweteme

When Dr. Muhumuza Simon pitched camp in Jinja in March 2011, little did he know that his PhD research could open up an effective blow against bilharzia.

His research in Walukuba Division could have been out of his passion for the control of bilharzia, but his findings have not only given the community a beam of hope but also made him a darling of the affected populations.

"Bilharzia is very treatable and preventable," he said. "But it is still a major concern in most parts of Uganda! The Ministry of Health actually distributes free bilharzia drugs to all the 73 affected districts and all school going children are given praziquantel on an annual basis. But the disease has failed to go and it is still affecting many children."

The doctor says bilharzia makes children stunted and reduces their physical and mental development, which combine to reduce education performance and future adult productivity. Yet pupils were shunning treatment or receiving it and throwing it away. When schools demanded that pupils take their doses in front of teachers, pupils began to miss school.



Laboratory personnel testing children’s stool for bilharzia

What is Bilharzia?

Bilharzia (also called schistosomiasis) is caused by parasitic worms that live in water. It is spread by poor human unsanitary practices such as urinating and defecating in open water sources. The worms penetrate human skin when one gets into contact with contaminated water. The early symptoms include fever, cough, general body weakness, abdominal pain and bloody diarrhoea. If left untreated, bilharzia can cause damage to internal body organs such as the liver, bladder and the kidneys, leading to death.

"But bilharzia is completely curable and even preventable," the doctor said. "My study was in 12 primary schools in Walukuba Division where bilharzia, locally known as Ekidaada, is highly endemic to discover why the drug praziquantel was failing to demonstrate visible success in the eradication of the disease. When I started the research in 2011, about 4 out of 10 school children were infected with bilharzia!"

In Uganda, bilharzia is found in 73 districts around such large water bodies as Lakes Victoria, Kyoga, Albert and River Nile. School children are the most affected because of their increased water contact through playing, bathing, swimming and fishing.



Some of the pupils drinking juice before taking the drug, Praziquantel, used in the treatment of bilharzia

The study

In his 41 month research, Muhumuza discovered that many children did not take the praziquantel drug they were given because of its related side effects. Praziquantel causes such undesirable effects as abdominal pain, vomiting and diarrhea especially when it is taken on an empty stomach.

With financial support from the Danish Ministry of Foreign Affairs, Muhumuza's study provided a pre-treatment snack to mitigate praziquantel's side-effects.

The children, who came for the snack, were also offered education messages about the dangers of bilharzia, the importance of taking treatment and information about taking the drug with food to reduce the side effects. Praziquantel was provided by the Vector Control Program, Ministry of Health.

The study was published in PLoS Medicine, a reputable science publications, from where other publications like www.sciencedaily.com, National Centre of Biotechnology Information (NCBI) and www.researchgate.net picked the information.



Muhumuza (in life jacket) and his research team arriving at one of the schools on Kisiima island in Walukuba division, Jinja

The findings

12 primary schools were divided into two equal groups: one group of about 3,000 children from 6 schools received the education messages about bilharzia prevention for two months prior to mass treatment with praziquantel.

The other group received the same messages plus the snack shortly before treatment. The snack consisted of one big high carbohydrate doughnut to mitigate the drug's side effects and 500 ml of mango juice.

After the study the drug adherence in both groups had improved. In the messages only group, 8 in 10 children took the treatment (78% adherence). But in the snack group, all the children took the treatment. Undesirable effects of praziquantel were measured in proportion to the pupils that did not get the side effects. 25% side effects were recorded in th snack group while 48% were in the non-snack group. Bilharzia infection in the snack group was negligible at 1% but 14% in the non snack group.

"My best news in all this was that, by the end of the study in 2013, bilharzia infection in those school children had reduced from 35% to 1% in 3 years!" Muhumuza said.

The findings suggested that giving food at the time of treatment improves treatment coverage for bilharzia among school children, reduces the undesirable effects of praziquantel and reduces bilharzia infection significantly among the children. Muhumuza therefore recommended that in addition to tailored education messages, provision of food should be integrated into school-based mass treatment programs for bilharzia in Uganda.

Implementation

After the study, Muhumuza organized a dissemination workshop for the leaders and schools that hosted his research to discuss his findings. The district hasn't adopted a policy to feed children during treatment but officials say something was in the pipeline.

Jinja district focal person for neglected diseases, Baayenda Gilbert, said they used the results to appeal to the donors of the praziquantel drug to adjust their budget and add snacks for the pupils.

"They promised to do so. Hopefully, they have adjusted their 2015/2016 budget. If they have, we shall definitely provide snacks with drugs," he said.

However, the district education officer, (DEO), Kamwana Jonathan, says parents should not wait for Government to implement the food snacks strategy. They should, in the meantime, give their children something to eat on drug days.

"I believe we can overcome bilharzia if we ensure adherence. We cannot force pupils to swallow drugs on empty stomachs because of the bad side effects they get, but we can motivate them with food which mitigates the effects of the drugs" he said.

Individual schools have innovated ways of supporting children on treatment. Magoma Samuel, the head teacher, Uganda Railway Primary School, says all pupils are now given mid-morning breakfast of porridge

"We can't afford giving out snacks but we ask parents to pack food for the pupils especially on days that bilharzia drugs are distributed," he said.

Magoma also said the school has asked the district to explore ways of accompanying the praziquantel drug they to schools with a snack and officials promised to work on it.

Nakibogo Florence Gwaka, Head teacher, Kirinya Primary school said the school had started giving pupils porridge every morning.

"The district officials have also assured us at a meeting that they were working on the logistics and, very soon, they will help us with special feeding on the drugs day."

Who is Dr. Muhumuza

Born 42 years ago in Kabale District, Muhumuza graduated from Mbarara University of Science and Technology with a Bachelors' Degree in Medicine and Surgery in 2001.

He served as an In-charge of Bukuku HC IV in Kabarole District and Acting Medical Superintendent for Kabarole Hospital.

After his Masters in Public Health in 2007, he worked as Monitoring and Evaluation Advisor for Makerere University Joint AIDS Program (MJAP), a PEPFAR funded program that provides comprehensive HIV/AIDS care, support and treatment.

Currently he works with Makerere University School of Public Health as a Monitoring and Evaluation Technical Advisor.

His PhD was a collaboration between Child Health and Development Centre, Makerere University and Copenhagen University, Denmark.

Voices

Baayenda Gilbert,Focal person for Neglected Diseases, Jinja District

Dr. Muhumuza really has a heart for the community. Not so many people would choose to come down and track a neglected disease but he did it successfully. I thank him for helping us in our efforts to lobby for funds. I would like him to come back and expand his research to other parts of Lake Victoria. He really works well with communities.

Kamwana Jonathan, DEO Jinja District

I participated in the doctor's study to popularize it among pupils who had a negative attitude towards drugs. I even swallowed the drug in front of the pupils because I also go to the lake often. I ask all concerned parties, especially donors, to take this study seriously.

Already, there is a big improvement in our schools that have started feeding pupils. Good health and better academic performance go hand in hand. I would like to thank Dr. Muhumuza for the impressive study and scientific results.

Magoma Samuel, Head teacher, Uganda Railway Primary School

We all knew about the problem. Drugs on empty stomachs are not a joke; some pupils would collapse after swallowing them, others would vomit but many more would miss school. Now, thanks to Dr. Muhumuza, attendance on drug days is high because we ask parents to pack food.

Pupils even demand for the food. Side effects have reduced, uptake of the drug has increased and performance is getting better. I would like to thank Dr. Muhumuza for choosing our school as a sample study site

Nakibogo Florence Gwaka, Head teacher, Kirinya Primary school

When Dr. Muhumuza first tested our students and the results showed 95% had bilharzia, I was shocked. I started blaming the pupils for not taking the drugs. But when the study came up with the strategy of giving something to eat before swallowing the drugs, I saw the solution clearly. I thank the doctor.

I liked the way he conducted the study. He was very friendly to the pupils and staff. He involved everyone despite the fact that he had a big team he came with. On some days he could come with a ball and play football with the pupils as he waited for his laboratory team to finish testing. All the pupils fell in love with his down-to-earth character.

Kyabanabwe Robinah, P 4 teacher, Kirinya Primary school

We used to have lots of absentees because of bilharzia. Some parents thought it was witchcraft and said the side effects were a result of mixing traditional diseases with foreign medicine. So, they would discourage their children from taking the treatment.

But ever since Dr. Muhumuza came into the picture, all pupils are participating and getting treatment. They are healthier and performing better. But they still go to the lake. If the government doesn't take Dr. Muhumuza's strategy seriously, especially on strategies to increase uptake of drugs, we are likely to go back to square one.