Entamoeba Histolytica Outbreak in Buhoma, Uganda 06/09/2005

Prevalence:
E. Histolytica is endemic in most countries with low social economic conditions. Global mortality is estimated to be about 70,000 deaths per annum. Recently, in Buhoma and surrounding areas, there has been a rise in the number of E. Histolytica cases. Although exact numbers can not be calculated due to poor reporting, there has been an increase in the overall number of cases seen. In dealing with this situation, we need to address the factors enabling the spread of this disease and the strategies to stop it.

Spread:
E. Histolytica is spread via the oral-fecal route and thus sanitation/waste removal must be addressed first and foremost. In addition, many diseases in Uganda are at least partially caused by poor sanitation, thus if sanitation can be improved, over all health will improve as well. In a report done by the Kanungu District Health Inspector in 2004, 80% of the Disease burden in Kanungu was due to poor sanitation, with 440 children dieing of diarrhea each week. In terms of socio-economic costs; the Uganda government pays over 30 billion shillings a year for treatment of sanitation related diseases. In addition, 2.7 % of all pupils time in Uganda is lost to sickness from sanitation related illnesses. In view of this information, it is important to address the issues preventing good sanitation in Uganda, and specifically in Kanungu district.

Challenges:

1. Awareness. Many people do not understand the effects that poor sanitation has on health and do not make sanitation a priority.
2. Poor legislation, budgeting and coordination. Sanitation is neglected in most governmental budgets. The laws governing the sanitation promotion are outdated. There are little resources set aside in local budgets for sanitation. Because local governmental monies may be hard to come by, outside grant money must be considered in order to fund various sanitation programs.
3. Lack of skilled health workers. Sanitation work is usually left to extension or community health workers, of which there are too few of, and most do not have enough time to spend in the communities to achieve the behavioral change and participation needed to improve sanitation. Again, because governmental money may be hard obtain to pay for additional health workers, outside grant money must be sought to achieve improved sanitation.
4. Lack of clearly defined technical solutions. There are no clear guidelines for waste management and sanitation. Solutions including latrines, clean water and soap usage must be implemented to stop the spread of E. Histolytica.

Solutions:
Awareness/skilled workers: More health workers need to be trained in order for there to be a fairly regular presence in the villages. The health workers should meet with the village leaders regularly to address the changing sanitation situation and needs of the community. They should agree on roles and responsibilities for achieving proper sanitation and hygiene. These meetings should include collecting baseline information on sanitation and hygiene and agreeing on minimum sanitation standards. They should work on a plan together with the leaders, which the members will accept and be invested in. Once a sanitation program has been agreed upon, the health workers should return regularly (i.e. weekly) to assess the progress of the sanitation plan. These health workers should also train the teachers of the local schools, in topics of sanitation to better disseminate the message. The may develop a sanitation day at school or different contests for the students addressing sanitation issues. The health workers may also carry on sensitization programs, i.e. theater shows, songs, sanitation campaigns etc. In order for more health workers to be trained, a grant can be written, to pay for the salary of at least 2 more health workers to cover the areas of Makuna and Kikero parishes. Attempts to allocate funds can be directed at the U.S. embassy, international and local NGOs. The cost for two additional community health workers will be 300,000 shillings a month.

Technical solutions:
A. Latrines/waste removal is the first and foremost in the stopping of E. Histolytica spread. The health workers should go the different communities and ask the local people about the prevalence of latrines in the community, how many people use the latrines, their feelings about using the latrines, alternatives to latrines for waste removal, and water source distance from waste removal sites. If it is decided that there is a need for latrines, the local people must decide on what type of latrine( mud, cement etc.) they should build, how many latrines will be built, who will build them, and how to allocate funds if need be. Costs: Mud latrines with grass roof will cost approximately: 30,000 shillings per latrine. Mud latrines with metallic roof will cost @ 50,000 shillings per latrine. Cement latrine will cost about 1.8 million shillings. Shovels will cost @ 7,000 shillings each: Once the type and number of latrines is decided upon, a budget must be worked out. A grant can then be written to ask for the funds for the basic materials to construct the latrines. The local people should be involved with the constructing of the latrines, so they may be invested in the project. Attempts to allocate funds can be directed at the U.S. embassy, international and local NGOS. B. Water supply. This must also be addressed when dealing with the spread of E. Histolytica. The health workers should assess where the communities are getting their water supply. It also should be assessed whether people are willing to boil their drinking water, and if they have the pots to boil the water. It should be assessed if they are willing to dig wells and if so, if they have the supplies to do this. It should also be assessed if they have an alternative more way to obtain clean drinking water i.e. rain water, iodine etc. It should also be assessed if the local people understand the importance of clean water. If the local people decide to boil water and need supplies: a pot costs 6,000 shillings and a container to keep the water is @ 2,500 shillings. The prices for other alternatives will be calculated at that time, if other alternatives are agreed upon. Once the number and type of supplies needed are agreed upon a grant can then be written to ask for the funds. C. Soap usage/availability. This must also be addressed when dealing with the spread of E. Histolytica. Many people in Kanungu district do not use soap to wash their hands or their utensils, plate wares etc... The health workers need to address the reasons behind this. The health workers need to assess if the local people do not have enough money for the soap, or if there are other reasons why people are not using soap. If the problem is financial, a soap program may be undertaken, teaching the local people how to make soap, which can then be used for hygiene and as a source of profit. If a soap program was decided on, funds must be found to start the program. As of this time, it is not sure how much this would cost to begin. There would be money needed to buy the raw materials and to pay someone to teach the soap making. Once this budget was calculated a grant could be written to allocate funds for this. To buy soap would cost 800 shillings per bar. For a soap making program to be successful, it must cost less to make a bar of soap then to buy one.

Current Strategy:
Implementation: Once a grant has been written to hire more public health workers and these workers are trained, they need to visit the local communities and meet with the leaders. They must assess the local peopleÕs understanding of the various sanitation issues, and their feelings on latrines/waste removal, clean drinking water and soap, and the different solutions can begin to be implemented. They must start sensitization campaigns and education, so that if solutions are implemented they are optimally used. They can use questionnaires to assess the sanitation needs of the community and their willingness to accept technical solutions. If latrines are decided on, the number of latrines needed can be calculated and a grant written to obtain the funds. Depending on the clean water stategy agreed upon (i.e. boiling water, wells etc.) a grant can be written to allocate funds for whatever supplies are needed. If a soap program is agreed upon, a grant may be written to obtain the funds to start this.

Sample Questionnaire for Local Households

1. Have you ever had bloody diarrhea? If so, how many times?
2. How many people are in your household?
3. Does your household have a latrine? If yes, how many people use one latrine? If no, do you have an alternative form of waster removal?
4. Do you think it is important to use a latrine or remove of waste? If yes, why is it important?
5. What would be the ideal way for your household to remove waste? (Latrine or alternate way) If it is a latrine-what type would you prefer-mud/cement?
6. If you were to build a latrine, what supplies would you need? How much would this cost? Would you be able to find the money to do this? Who would build it?
7. Where do you remove your waste? / How far is it from a water source?
8. Where do you get your drinking water? Do you boil it? If not, why do you not like to boil it?
9. Do you have clean containers to collect your water in?
10. Do you use soap to wash your hands? If not, why not?
11. Do you use soap to clean your utensils/plate ware? If not, why not?
12. Is soap affordable?
13. Would you be interested in learning how to make soap, both to sell and to use?
14. Do you think it is important to use soap?

Sample Questionnaire for Village Leaders:

1. How many people live in your community?
2. How many latrines are in your community?
3. Do the majority of people in your community use latrines? If not, what do you think are the obstacles to this?
4. Where are the latrines in relation to the water source?
5. If the community were to build latrines, do you think the people would prefer mud or cement?
6. Do you think the local people would build the latrines? Would they be able to afford it?
7. Do you feel that the local people understand the importance in latrine use?
8. How many people in your community boil drinking water?
9. What do you think are the obstacles to this?
10. Do you feel that the local people understand the importance in boiling water?
11. Do people have the pots to boil the water?
12. Do you feel that the people would prefer alternatives to boiling water? (i.e. clean containers for rain water?)
13. How many people in your community use soap for washing hands/utensils.?
14. What do you think the obstacles to this are?
15. Would the local people be interested in learning to make soap? Could they afford the supplies to start this?