healthyliving Neglected Tropical Diseases

Battling elephantiasis
The Minsitry of Health
says more than 11 million
Ugandans are suffering from
Neglected Tropical Diseases
(NTD). Starting today,
Healthy Living will run a
series of stories on NTDs. We
begin with elephantiasis, a
disease that leads to massive
swelling of body parts.


nguish, pain, immobility and
stigma, is what Peter Oyuki and
Patrick Balikoba have. The two
have been abandoned by their wives
because of their large deformed legs
and feet, that are a result of elephantiasis.
Oyuki, who has lived with elephantiasis for 31 years, says he lost his
wife, the mother of their three children, to his neighbour in Lukindu B
Village, Bukatube Sub-County in Mayuge District in eastern Uganda.
“My wife left me three years ago.
My handsome neighbour took her
away after convincing her that she
should not live with a sick, disabled
and ugly man like me,” Oyuki, 51, says
in sad low tone.
Unlike Oyuki, Balikoba, a 47-yearold resident of Buseera B Village in
Busakira Sub-County, Mayuge District, is still wondering what forced

his spouse with whom he had five
children to move out of their marital
home. “My wife left a month ago and
she did not give a reason for leaving.
I don’t know if it was due to my illness,” Balikoba wonders.
Oyuki recalls that the disease
started in 1983. “It began with itching then I started feeling cold and
difficulty in walking. My legs became
painful and heavy to carry. I have
tried to get this illness treated and
failed. I do not know what causes this
disease,” he shares.
In search for a remedy, Oyuki
went to Buluba Leprosy Hospital in
Mayuge District where the doctors
recommended amputation. “When
I went to Buluba Hospital, I thought
I had leprosy but when the doctors
suggested amputating me, I left because I feared losing my legs. Then
I tried traditional medicine which
failed. Meanwhile, the symptoms
have increased and I have lived like
this since,” he says.
Balikoba started suffering from elephantiasis a year ago. “It began with
itching and swelling of my legs. The
pain comes with heat and sweating
all over my body, mainly during the
rainy season. The itching happens
only in the dry season,” Balikoba
“I don’t know what caused this disease. I have not yet got any form of
medication because I wasn’t aware
that I could get treatment in hospital,” Balikoba adds.
Oyuki’s leg develops wounds on
which he applies Procaine Benzyl
Penicillin (PPF) or amoxyl capsule


Also, the victim’s skin stretches
so much that it hardens, thus turning into a habitat for organisms like
bacteria, fungi and viruses resulting
in full blown elephantiasis.
The disease derives its name “elephantiasis” from the fact that the
legs and feet swell a lot.


Prevalence rate
According to the Drugs for Neglected Diseases Initiative (DNDI),
elephantiasis affects an estimated
120 million people living in tropical
areas. The ministry reports that elephantiasis mostly affects the poorest
Ugandans. It is a major public health
and socio economic problem with 4.7
million people in 54 districts out of
the 112 suffering from the disease.
Another 14.5 million are at a risk of
being infected.
In some communities in eastern
and northern Uganda, up to 25 per
cent of adults show chronic signs of
LF; mainly hydroceles.


powder. He continues to take the
Ivermectin tablets, which are given
free of charge by the Ministry of
Health once every year. Extreme heat
and coldness cause Oyuki a lot of discomfort. “I usually experience a lot
of pain when it is very hot or cold. I
get so uncomfortable that I can’t even
move around,” he says.
According to the Mayuge District
Vector Control Officer, Juma Nabonge, Oyuki’s condition is in the irreversible stage of elephantiasis and
he will have to live in this sad state.
“We shall make sure Balikoba
starts getting drugs from the Village
Health Team,” Nabonge promised,
adding, “The drug will kill the worm
but unfortunately the size of his legs
will remain the same.”
“I do not know if I will ever heal.
My hopes are in the doctors. Otherwise, I have no option but to look after my children until the time I leave
this world. My extended family will
take care of my children when I die,”
Oyuki says.
Victim’s plea
“My wish is government should
treat me so that I can heal and other
sufferers,” Balikoba says, adding
rather optimistically: “If I heal, I will
marry again.”
The plight of Oyuki and Balikoba
is an example of the social stigma
and discrimination that victims of
Neglected Tropical Diseases (NTDs)
face in Uganda. It is not only the male
victims who suffer, but the women
too, are chased from their matrimonial homes by their husbands.

Peter Oyuki has lived with elephantiasis for 31 years. PHOTO BY PAUL MENYA

What causes elephantiasis?
Elephantiasis, an NTD, scientifically known as lymphatic filariasis
(LF), is caused by tiny thread-like parasitic filarial nematode worms called
wuchereria bancrofti transmitted by
mosquitoes to humans. Infection is
acquired early in life but gradually
begins to cause internal damage.
Adult worms are found in the
lymphatic vessels (used for carrying waste body fluids), where they
cause damage, leading to elephantiasis (swelling of the legs and feet),
hydroceles (swelling of the scrotum),
the vulva in women and other parts
of the body. However, the majority of
infected individuals show no physical signs.
According to the elephantiasis/
podoconiosis Programme Manager in
the ministry of health, Gabriel Matwale, the symptoms filarial fevers,
which are often mistaken for malaria.
One will have general body weakness
and body pains.

Treatment coverage
The NTD Control Programme
provides annual drug treatments to
nearly 13 million people in affected
areas under its Mass Drug Administration (MDA) activity.
MDAs occur annually in districts
endemic with NTDs that can be controlled with medicine. The first MDA
with Ivermectin and Albendazole
against elephantiasis was carried
out in 2002 in two districts (Katakwi
and Lira), reaching coverage rates of
about 75 per cent.
The MDA has been scaled up to
cover all the 54 affected districts.
Health workers also conduct hydrocele surgeries. There are plans
to scale up the number of surgeries
conducted by implementing surgical
Those with elephantiasis get health
education to control secondary infections and alleviate pain. Health officials refute claims that elephantiasis
is caused by witchcraft and hydroceles are hereditary. Matwale says
treating elephantiasis in Uganda is
not clear-cut like treating malaria.
“This is chronic infection where
obvious signs (elephantiasis and
hydrocele) appear later in life. Our
strategy is to interrupt transmission
where by people are given medicines
(Mectizan and Albendazole) despite
their infection status. By doing that,
those who have it will have reduced
the worm load, which can’t be picked
by the mosquito.”
“The major challenge is to convince those without the signs to take
the medicine. Also, there is little focus or help for those already infected
because the medicine has little effect.
Lastly, we lack transport and operation funds to intensify supervision
of village health team members who
are our frontline service providers,”
Matwale adds.
According to the ministry more
than 11 million Ugandans are suffering from NTDs. Uganda has 12 NTDs.
World Health Organisation says NTDs
such as leprosy, elephantiasis and
leishmaniasis (kala-azar) are feared
and the source of strong social stigma
and prejudice. As a result, these diseases are often hidden – out of sight,
poorly documented and silent.

MONDAY, MARCH 24, 2014 7

Daily Monitor

Have you ever had a painful
cavity and all you can do is
go for extraction to relieve
yourself of the pain? The
next few days before healing
might have been so bad that
you questioned what went
wrong because the wound
was as painful as the cavity.
Dr Victoria Nanziri, a dental
administrator at Nakasero
Hospital says: “The pain
only comes either because
the person who extracted
the tooth did not give
proper instructions or you
simply never followed the
After the tooth has been
extracted, you must not
brush immediately because
the toothbrush may
accidentally hit the gum
causing it to bleed.
Dr Nanziri also warns
against immediate rinsing
because it washes away the
platelet clotting responsible
for quicker healing of the
“The pain comes due to
infections because you did
not follow instructions and
proper medication. The area
must be healed within four
days,” adds Dr Nanziri. The
medication given includes
painkillers to reduce pain
and antibiotics to kill the
If the pain persists, you
must see a dentist who
will make it bleed and
dress it again and give you
medication that will help
you heal.
•Eat soft foods
•Take lukewarm fluids
•Take the medicine as
instructed by the dentist.
•Rinse the mouth with
lukewarm water and salt the
following day.
•Take a lot of fluids on day
•Eat hard foods
•Roll your tongue on the
•Brush or rinse immediately
after the extraction.
•After a day, you may brush
but be careful not to hit
the affected area to avoid
By Beatrice Nakibuuka

healthyliving Neglected Tropical Diseases

Water is life, but not
when bilharzia walks in
Are you a fan of swimming in
fresh waters? Watch your back,
for bilharzia could just snatch you.



mmanuel Kizito has been forced to
abandon swimming, his favourite
sport, after he contracted bilharzia
in Lake Victoria where he indulged in his
“I developed a lot of stomach pains
sometime in 2012. I immediately informed
my teachers at school who gave me medicine. I took the drugs up to August 2013.
After the completion of the dose, my stomach stopped paining me. I advise children
to stop swimming in the lake, I got bilharzia while swimming there,” says. Kizito, a
14-year-old Primary Seven pupil .
“15-year-old Sylvia Natukunda, also a
Primary Seven pupil, who has also suffered
from bilharzia says: “I had severe stomach
pain in April 2013. My teachers started giving me drugs in September 2013 and now
I feel better.”
Both Kizito and Natukunda are pupils of
Katosi Church of Uganda Primary School
in Ntenjeru Sub-County, Mukono District.
Katosi Landing Site is famous for fishing.
David Keuber, a teacher at Katosi Church
of Uganda Primary School confirmed that
bilharzia is prevalent in the area.
“Most of our learners play in Lake Victoria and get infected by bilharzia. We advise
them not to play in the lake and that they
should boil the water they fetch from the
lake before drinking it,” Keuber says.
How it is spread
Schistosomiasis commony, known as
bilharzia, ( entumbi in Luganda is spread
by a parasitic worm called schistosome.
Its infection can damage the urinary and
intestinal tracts.
According to the Ministry of Health,
bilharzia larvae are released in water by
fresh water snails. As people enter water,
the larvae penetrate their skin and move
through the body to the urinary and intestinal tracts, where they develop to maturity. The cycle is complete when infected
people urinate or defecate the bilharzia
eggs back into fresh water.
The Carter Centre health programme
notes that the parasite can live for years
in the veins near the bladder or intestines,
laying thousands of eggs that tear and scar
tissues of the intestines, liver, bladder, and
The majority of infected people in
Uganda do not have initial symptoms. If
untreated, infected individuals can experience stunted growth, cognitive impairment and severe damage of internal organs which can lead to death. In children,
bilharzia can cause anaemia and reduced
ability to learn, health experts warn.
According to the World Health Organisation (WHO), people are infected during
routine agricultural, domestic, occupational and recreational activities which expose them to infested water. Poor hygiene
and certain play habits of children such
as swimming or fishing in infested water
make them vulnerable to infection.
The ministry says individuals who
spend more time in fresh water bodies
have a higher risk of infection. Bilharzia

can be reduced to a level where it is no
longer a public health problem by treating risk-prone people in all endemic areas
every year.
According to WHO, bilharzia affects almost 240 million people worldwide, and
more than 700 million people live in endemic areas. The infection is prevalent in
tropical and sub-tropical areas, in poor
communities without potable water and
adequate sanitation. In Sub Saharan Africa, it has been estimated that more than
200,000 deaths per year are due to bilharzia.
According to the Ministry of Health, bilharzia is in 74 districts in Uganda, mostly
those with large fresh-water bodies. Approximately four million people are at risk
of getting infected. And an additional 17
million people risk getting infected.
“…In such heavily-infected areas, many
people acquire infections at a young age
and either suffer early severe disease
which either leads to death, or to severe
complications later. If detected and treated
early, these complications can however, be
prevented,” the health ministry says.
The Ministry of Health NTD programme
provides annual school and communitybased drug treatments to risk prone populations during Mass Drug Administration

“A number of
people have
resisted taking
the drugs
because some
claim that if
they do, they
will not have
children in






Fishermen at Katosi
landing site prepare
to go fishing. Wading
through fresh lake
water puts people
at risk of Bilharzia

(MDA) exercises. Fishing communities are
typically targeted for treatment.
David Oguttu, the parasitologist in the
Vector Control Division, Ministry of Health,
says praziquantel is very effective against
bilharzia. The side effects (abdominal
pain, vomiting, dizziness, diarrhoea and
skin rushes), he says, are as a result of the
body’s reaction to the dying worms.
“If you have more worms, you will have
greater side effects. The side effects will
also depend on one’s immunity,” he says,
adding: “These side effects are short lived.
We don’t expect them to last more than
three hours after taking the medicine.
Some people don’t follow the instructions.
We tell teachers not to give praziquantel to
children who have not had meals. We advise adults not to take alcohol immediately
after taking the drug.”
Why it keeps spreading
James Kaweesa, the Mukono District Vector Control Officer observed that schools
have reported the highest rates of compliance in regards to taking drugs.
“Compliance is the highest in schools
than in the communities because some
adults don’t take the drugs in fear of false
side effects like impotence. And because
bilharzia is a slow killer disease, infected
adults will continue with their normal life
unlike malaria that weakens and puts one
down,” Kaweesa says. He adds: Adults also
think that a single dose against bilharzia is
enough to heal the illness. They don’t know
that they get reinfected whenever they return to the water in the lake. We have to
continue telling them that whenever you
return to the stagnate water, you pick other
water bodies.”
“A number of people have resisted taking
the drugs because some politicians claim
that if they do, they will not have children
in future,” says Godfrey Nsereko, a member
of the Katosi Village Health Team (VHT).
“The good thing is that those who have
taken the drugs have healed. We have also
discovered that those who complained of
side effects in the beginning of the programme did not follow the proper procedures,” Nsereko adds.
The VHT supervisor in Bunakiffa Parish
in Ntenjeru Sub County, Bakari Walakira
says: “Some even believe that they will not
be able to work when they take the drugs.
We advise them to take water whenever
they get side effects.”
According to Nsereko, since the recruitment of VHTs, bilharzia cases have been
reducing because the VHTs are able to administer the drugs. Sanitation in homes has
also improved.
To wipe out bilharzia, the ministry is
raising funds to improve sanitation, including the construction of latrines near water

MONDAY, MARCH 31, 2014 7

Daily Monitor


Heartburn is a painful burning
sensation just below or
behind the breastbone. Most
of the time, it comes from the
esophagus. The pain often
rises in your chest from your
stomach and may spread to
your neck or throat.
In addition to a burning
sensation in the chest, other
symptoms of heartburn
include a sour, acidic or salty
tasting fluid at the back of
the throat or a feeling of food
being stuck in the throat.
There can also be chest pain
especially after bending
over, lying down or eating.
Sometimes it also comes
with nausea and difficulty in
According to Dr Enoth
Nahamya of Ultimate Medical
Centre, if the symptoms are
accompanied by shortness of
breath, radiation to the arms
or neck, dizziness or sweat
and fatigue, the person needs
to see a doctor. Dr Nahamya
says when one swallows,
the esophageal sphincter,
a circular band of muscle
around the bottom part of
your esophagus, relaxes to
allow food and liquid to flow
down into your stomach and
it then closes again. However,
if it relaxes abnormally or
weakens, stomach acid
can flow back up into
your esophagus, causing
heartburn. Some foods and
beverages such as garlic,
onions, chocolates, coffee,
oranges and other acidic
juices fatty foods, fried foods,
grapefruits, tomatoes and
spicy foods, are responsible
for the abnormal relaxation
because they stimulate
overproduction of stomach
acid which causes heartburn.
Alcohol and smoking can also
cause heartburn. However, he
adds that every person reacts
differently to specific food
groups and therefore, in order
to track what foods worsen
your symptoms, keep a food
journal where you keep track
of what you eat and the time.
Dr Nahamya recommends
drinking plenty of water,
avoiding over eating and
taking your time while eating,
wearing loose fitting clothes,
not going to bed with a full
stomach, avoiding smoking
and drinking alcohol and
staying away from foods that
trigger heartburn. However,
even if the pain lessens,
go for a thorough medical
evaluation. If not controlled,
heartburn can result into
serious complications such
as esophagitis, esophageal
bleeding and ulcers
and increase the risk of
esophageal cancer. It can also
lead to chronic cough, sore
throat or chronic hoarseness.
By Rose Rukundo

healthyliving Neglected Tropical Diseases

When walking barefoot and
sharing food spreads worms
In our third series on
neglected tropical diseases,
we look at worms, which
continue to infect many
people, yet they can be easily
prevented with good hygiene


t first sight, Raymond Kabenge
and Juliet Kisakye look like any
normal pupil in their school.
But hidden behind their innocent
faces is the pain of suffering from intestinal worms.
Kabenge, 11, a Primary Four pupil of
Buseera Primary School in Busakira
Sub County, Mayuge District, recalls
developing painful stomach ache towards the end of last year. “Whenever I slept, I felt painful movement
in my stomach. I did not know what
it was. I later noticed white worms
in my stool before I started taking

medication at school,” he says.
“Last term, I took tablets (Albendozole) and the stomach pain has been
reducing ever since,” Kabenge says,
adding: “I am willing to take more
medication to heal.”
On her part, 12-year-old Kisakye,
who is also in Primary Four, says she
feels pain stretching from her stomach to the chest. “I have taken drugs
twice so far, given out by our teachers
and I feel better now.
“I do not know what caused this
problem which started when I was in
Primary Two. I get pain especially before I have had a meal and it only reduces after eating,” Kisakye laments.
David Wakaka, a science and mathematics teacher at Buseera Primary
observes that cases of worms shoot
up during the wet season when children share mangoes.
“We get a lot of reports during the
rainy season because it is the period
when mangoes ripen. So the children
will share mangoes or other snacks
such as pancakes among themselves,
and those with long dirty nails will
spread the worms,” Wakaka ob-

Raymond Kabenge
(above) admits
he does not know
what causes
intestinal worms.
(left) hookworms
are one of the
common types
of worms that
Ugandans suffer

•According to the Ministry of Health,
hookworm is the most common of all
worm infections, and it is homogenously
distributed in the country exceeding 60
per cent prevalence in 85 per cent of the
schools surveyed.
•On the other hand, roundworm
and whipworm are concentrated in
southwestern Uganda, where up to 9 out of
10 people are said to be infected.
•The health ministry estimates that
about 17 million Ugandans are infected
with worms and 33 million are at risk of
becoming infected.
•The latest estimates from WHO indicate
that worldwide, more than 880 million
children are in need of treatment for these
Intestinal worms include roundworm (ascaris lumbricoides), whipworm (trichuris trichiura) and
hookworm (necator americanus and
ancylostoma duodenale). They are
commonly transmitted through poor
hygiene and sanitation.
The worms enter the body through
bare feet or ingestion of contaminated foods.
Their eggs are released through
the faeces of infected individuals into
the environment, hence the collective
name of Soil Transmitted Helminthes
(STH). They are also one of the neglected tropical diseases.
According to the World Health Organisation, STH live in the intestine
of infected individuals where they
produce thousands of eggs each day,
which are then passed out in faeces.
Humans become infected when
ingesting infected roundworm and
whipworm eggs or hookworm larvae
in contaminated food (for example,
vegetables that are not thoroughly
cooked, washed or peeled), hands or
utensils or through penetration of the
skin by infective hookworm larvae in
contaminated soil.
There is no direct person-to-person
transmission or infection from fresh
faeces because eggs passed in faeces
need about three weeks in the soil before they become infectious.
According to WHO, the more the
number of worms an infected person
has, the greater the severity of disease.
The worms impair the nutritional
status of those infected in many
ways, including causing intestinal
bleeding, loss of appetite, diarrhoea
or dysentery and sometimes causing
complications that require surgical
Hookworms for instance can cause
chronic intestinal blood loss that may
result in anaemia.
According to the Ministry of Health,
worm infection in pregnant women
can lead to underweight babies and
complications for the mother.
WHO notes that worm infections
are among the most common infections worldwide, and affect mainly

deprived communities.
Pregnant women at risk
According to WHO, pre and schoolgoing children and women of childbearing age (including pregnant
women in the second and third trimesters, and those who are breastfeeding face higher risk of suffering
from worms.
Infections are common in tropical
and subtropical areas and, since they
are linked to lack of sanitation, they
occur wherever there is poverty.
The parasitologist in the Vector
Control Division at the Ministry of
Health, David Oguttu attributes the
high burden of intestinal worms in
Uganda to the ignorance about transmission and prevention.
“There is poor sanitation especially if somebody infected with
hookworms openly defecates in the
gardens, other people will also be infected. We also have poor food handling and hand-washing culture and
hygiene,” Oguttu says.
The Mayuge District Vector Control Officer, Juma Nabonge notes that
containing the disease that is spread
across the district requires a combination of interventions including
construction of latrines. “As far as
sanitation is concerned we emphasise wearing of shoes to reduce the
transmission rate and continued usage of drugs,” Nabonge says.
WHO’s control interventions are
based on the periodic administration
of anthelminthics to groups of people
at risk, supported by the need for improvement in sanitation and health
The health ministry treats all children aged one to 15 years twice a year,
under the Mass Drug Administration
(MDA) programme with medicine
(Albendazole and Mebendazole) donated by WHO.
The government and its partners
observe that school-based MDA to
treat bilharzia and STH has proven
to be a cost-effective intervention.
Reasons for this include the reduced
price of the drug and the use of nonhealth volunteers to distribute the
Government admits in the National
Master Plan for Neglected Tropical
Diseases Programme 2013-2017 that
sanitation management remains dismal, with latrine coverage still below
the expected level.
As a result, after successful treatment of worms, majority of the people quickly get re-infected, thus compromising the impact of Mass Drug
Administration. It is therefore vital to
undertake sanitation improvement,
behaviour change among communities and snail (the vector for bilharzia) control, all of which are currently
not being given adequate attention
due to limited funding.
Latrine construction especially in
public places such as landing sites,
schools, health facilities, worship
places and markets should be made

MONDAY, APRIL 7, 2014 7

Daily Monitor

Are you watching too much
television? Well, in the long
run, it could have negative
consequences for your eyes.
According to Charles
Mainga, an optician at
Eye-to-Eye Optical Centre,
watching television generally
does not damage the eyes,
but rather strains it over a
period of time.
He explains that there is no
defined distance from which
either adults or children
should be while watching TV,
but generally, being four to
five metres away from the
set is recommended.
“Children have the ability to
focus very well at close range
because they have a shorter
distance between their eyes
than adults, hence they
prefer sitting closer,” Mainga
He, however, adds that
if a child has the habit of
watching TV while sitting
closer to the set, the parents
should consider undertaking
tests to eliminate possible
refractive error, especially
“What happens is when
people are watching
television, the muscles
around the eyes get worked
up and the longer the person
watches the screen, the
more tired the eyes get,”
explains Mainga.
Other activities that cause
eye strain may include sitting
behind computers over long
periods of time.
“It is not advisable to watch
television in a dark room
where it acts as the only
source of light because
eyes quickly get fatigued.
The sitting posture should
be upright and not on the
bed or lying on one’s back
because it can lead to severe
backache and neck pain,”
says Mainga.
Dr Ronald Kiweewa of Kadic
Hospital Bukoto, explains
that when light enters the
eye, it has to be refracted
or reflected, which involves
sending impulses to the
brain thus affecting the
eye nerves. And when a
person consistently watches
television over a long period
of time, say four to five
years, the cornea and iris
(parts of the eye) tire out
and therefore cause damage
to the eyes.
By Roland Nasasira

healthyliving Neglected Tropical Diseases

Fighting river blindness
along fastflowing streams
River blindness continues to
affect several communities
in Uganda. In our series on
neglected tropical diseases,
we explore interventions that
are helping to address the



fter 17 years of living with river
blindness, Tereza Akulu’s wish
is to see development of strong
drugs that can heal the disease faster.
“I have taken medicine for so long. I
am only lucky that I sought medical
attention in time which helped me
retain my eyesight,” she says.
“Government should bring enough
drugs for everyone in our area because this disease is causing blindness in many people,” she adds.
Akulu, 65, a mother of five, lives in
Lamacha South Village, Awere Sub
county, Pader District in northern
She was diagnosed with river
blindness in 1997 at Lacor Hospital,
Gulu District. It was from here that
she was referred to Awere Health
Centre III, where she continues to get
When she first developed the disease, she recalls getting a feeling of
burning body pain, which was followed by itching and subsequently
the disfigurative skin malady that
developed on her legs and scalp.
Whenever Akulu runs out of medicine, she has to walk three kilometers
to Awere Health Centre III to pick a
new dose. But even though she was
lucky to be able to access treatment,
it did not come without challenges.
“When I started treatment in 1997, I
developed rashes, although they later
disappeared as I continued with the
medicine,” she says.
“But I am not happy because the
skin disease has not normalised.
It has now spread to my scalp and
caused grey hair around the affected
area,” Akulu explains.
She is grateful though, that treatment is provided for free by government. “It would have been very expensive for me to buy the drugs.”
Like Akulu, 40-year-old Angulleta
Lanyero first developed body rash
and itching in 2006. She later developed painful lumps around her waist
and was unable to see clearly. She
went to Lacor Hospital.
“Doctors at the hospital discovered that I had worms in my eyes.
They told me I had contracted river
blindness. But I was not convinced
that I could have got this disease, so
I went to Gulu Hospital, which also
confirmed the same.
It is then that I started treatment,”
Lanyero says. “The doctors told me
the extent of the damage in my eyes
will neither increase nor improve
because the nerves were damaged.
They said I am going to live like this
forever. My only problem is the eyes.

I continue to see worms in my vision.
I have a blurred vision. I cannot see
distant objects,” she says.
Inadequate drugs
However, Lanyero decries the inadequate supply of the medicines.
Asked if she would be willing to
shift to another place that is not affected by river blindness, Lanyero
says she has nowhere to go.
“Besides, where would I get the
money to buy land? This is the place
where I will be buried.” Many people
who have been affected or infected by
river blindness also have to contend
with stigma in the community.
“This arises from some people who
believe that the disease is contagious.
They fear interacting with us during
social gatherings and sharing food
and drinks,” Akulu observes.
River blindness, also known as onchocerciasis, is an eye and skin infection caused by a worm (filaria) known
scientifically as Onchocerca volvulus.
According to the World Health Organisation, river blindness is transmitted to humans through the bite of
a black fly (Simulium species).
These flies breed in fast-flowing
streams and rivers in the inter-tropical zones, increasing the risk of blindness to individuals living nearby,
hence the commonly known name,
river blindness.
Within the human body, the adult
female worm (macrofilaria) produces
thousands of baby or larval worms
(microfilariae), which migrate in the
skin and the eye.
The death of microfilariae is very
toxic to the skin and the eyes, producing terrible itching and various
lesions. After repeated years of exposure, these lesions may lead to
irreversible blindness, according to








Tereza Akulu speaks during the interview. (Below) She has developed a patchy skin
infection on her legs as a result of living with river blindness for several years.

WHO. Tom Lakwo, the manager in
charge of the Onchocerciasis programme in the Ministry of Health,
notes that the patchy skin condition
presents in those who have lived long
with the disease.
“This condition is not reversible
even when you take medication, and
this is common in older people.”
According to WHO, about 90 per
cent of the disease occurs in Africa.
The latest figures from the Ministry
of Health indicate that more than two
million people are infected with the
parasite that causes river blindness.
Most cases have been reported in the
western axis of the country bordering the Democratic Republic of Congo
and in areas around Mt Elgon in eastern Uganda.
Leading cause of blindness
According to the health ministry,
river blindness is a leading cause of
blindness and visual impairment in
In 2007, the National Onchocerciasis Control Programme (NOCP)
launched an elimination plan. The
programme is currently being run in
31 districts with the prevalence of the
disease through Mass Drug Administration (MDA), supplemented by vector elimination in some feasible areas. Bi-annual and annual treatment
programmes are being undertaken in
14 and 17 districts respectively.
To address the shortage of drugs,
Lakwo says: “The National Onchocerciasis Control Programme always
makes application for drugs based
on population figures provided by

the district. And it is this information
that is then used to deliver supplies.”
Lakwo says the Neglected Tropical
Diseases Programme has conducted
fresh registration in all districts to
obtain accurate numbers of people
who may be infected. This would be
used to minimise cases of drug shortages.
The health ministry says with a
good prevention and disease management plan, river blindness can
be reduced to a level where it is no
longer a public health threat, as long
as individuals living in the affected
areas receive treatment every year
for a period of 15 to 20 years.
“In some areas, where the programme treats all people twice a year,
river blindness can be eliminated in
less than seven years. With additional
blackfly control, it can take fewer
years,” the ministry adds.

MONDAY, APRIL 14, 2014 7

Daily Monitor

Nutritionists encourage
us to eat a well-balanced
diet. But how many of us
know what exactly entails a
balanced diet? According to
nutritionist Jamiru Mpiima
of Family Nutritionist
Uganda, people usually
misunderstand what a
balanced diet is and what it
should contain.
“It is sometimes referred
to as a coloured plate. This
means your plate of food
should have more than three
colours of food,” he says.
He explains that for a
meal to be balanced, it
should have at least five
food groups, each taken
differently, depending on the
requirement for the body.
These comprise starch
from grains such as cereals,
cassava, sweet potatoes and
plantains. It can also contain
proteins as a source of body
building. The proteins can
come from plant and animal
sources. Animal proteins can
be got from fish, eggs and
milk, while plant proteins
include soy beans and
ground nuts.
Therefore, a balanced diet
should include both animal
and plant proteins.
Fruits such as pineapples,
paw paws, oranges and green
vegetables should also be
included in one’s meal. Fatty
oils are also recommended,
although they should always
be taken in moderation.
Mpiima notes that a
balanced diet is important
because one type of food
cannot have all nutrients
needed for the proper
functioning of the body.
“Whereas fish and eggs have
particular nutrients, they
may not be able to cater for
fibres found in vegetables
and minerals,” he explains.
Without a balanced diet, a
person risks being either
over or under malnourished.
“You can see a person having
matooke and beans every day
and when they check with
the doctor, they are told that
they are malnourished. This
is not the best way to keep
healthy,” he notes. He adds
that eating a balanced meal
everyday also helps to reduce
the chance of developing
constipation and contributes
to better brain growth in
By Sandra Janet Birungi

MONDAY, APRIL 21, 2014 7

healthyliving Neglected Tropical Diseases

Daily Monitor

How untreated trachoma can
cause permanent blindness

Monika Nandego
(Left) has lived
with trachoma
since she was 10
years old. She says
the disease has
severely affected
her left eye and
causes her pain.

Trachoma is a preventable
disease which continues to
blind people in Uganda. In our
series on neglected tropical
diseases, today we look at
how it can be managed.


ealth experts estimate that 80
per cent of the population in
the developing world depends
on traditional medicine as their primary source of treatment. Indeed for
nearly 25 years, this is what Monika
Nandego used to treat her right eye
that had been infected with trachoma.
With hindsight now, she regrets
that by the time she abandoned the
herbs which she usually squeezed
into her eyes three years ago for
modern medicine, it was too late to
cure the illness. “The pain in my right
eye started when I was 10 years old.
I have grown up with this pain and
when it becomes too painful, I do not
touch or wash my face,” says the 38year-old mother of five.
When herbs caused more pain
“I used traditional medicine for a
long time but it did not cure my condition so I decided to switch to modern medicine, which I have now used
for the last three years. I apply Tetracycline eye ointment whenever I feel
the pain and it gives me great relief,”
Nandego explains.
She advises all those suffering
from eye problems to visit hospitals
and not rely on traditional healers or
medicine. Nandego lives in Ntafungirwa Village in Buwaya Sub county,
Mayuge District in eastern Uganda.

“I do not like to move a lot in the hot
season because I feel pain in the eye. I
prefer places with less sunshine,” she
says. Because Nandego’s case was in
the late stage of the disease, doctors
at Mayuge Hospital recommended an
eye operation, which she hopes to do
as soon as her children come home
for the holidays.
Free drugs changing lives
Nandego is grateful for the free
medicine she gets from the public
health facilities through the Village
Health Teams. While she admits
she does not know what causes trachoma, she hopes her condition will
be healed if she gets the right treatment.
On his part, 70-year-old Kefa Misango recalls when he first got trachoma in 1990. “I do not know what
caused this illness, but I immediately
went to hospital for treatment.”
“It has been on and off. I still get
blurred vision. Whenever my eyes are
painful, I buy Tetracycline eye ointment and apply,” says Misango who
lives in Ntafungirwa Village in Buwaya Sub county, Mayuge District.
The district vector control officer,
Juma Nabonge, says while Misango
has not been examined by an optician at the district hospital, he may
require an eye operation because his
condition is in the advanced stages.
According to the World Health Organisation, trachoma is caused by an
organism called chlamydia trachomatis. Through the discharge from
an infected child’s eyes, trachoma is
passed on by hands, through clothing or by flies that land on the face
of the infected child. It is frequently
passed from child to child and from
child to mother, especially in areas
with water shortage, numerous flies,
and crowded living conditions.
Infection usually begins during

infancy or early childhood, and can
become chronic if left untreated. The
infection eventually causes the eyelid
to turn inwards, which in turn causes
the eyelashes to rub on the eyeball,
resulting in intense pain and scarring of the front of the eye - a condition called trichiasis. This ultimately
leads to irreversible blindness, typically between the ages of 30 to 40,
without proper treatment.
According to Dr Patrick Turyaguma
who heads the trachoma control programme at the Ministry of Health,
people who develop the disease usually experience red and painful irritating eyes, discharge and tears and they
tend to fear light (photophobia).
Early treatment crucial
The recommended drugs by the
Ministry of Health are zithromax (a
trachoma-fighting antibiotic) and
Tetracycline eye ointment.
“If the disease is not treated early
enough, a person can go blind. Unfortunately, the blindness is permanent,” Dr Turyaguma says.
Trachoma is the world’s leading
cause of preventable infectious blindness. The disease is more common in
poor rural communities in developing countries. WHO estimates that six
million people worldwide are blind
due to trachoma and more than 150
million are in need of treatment.
According to latest figures from

“If the disease is not treated early
enough, a person can go blind.
Unfortunately, the blindness
is permanent. Trachoma is a
disease of poor hygiene and so
if you improve hygiene, it can be

the Ministry of Health, over 900,000
children under the age of 10 have trachoma, and 10 million people are at
risk of being infected. Another 47,000
people are said to be blind from the
disease. The trachoma control programme in Uganda follows the WHO
recommended use of the SAFE Strategy (Surgery, Antibiotics, Facial
Cleanliness, and Environmental Improvements) to eliminate the disease
by 2020.
Trachoma elimination through
mass treatment with Zithromax
started in seven districts in 2007.
Since then, there has been a steady
scale up of treatment coverage to
more districts with Mass Drug Administration. Currently, all the 36
districts with high prevalence of trachoma receive Zithromax drugs, and
about 20,000 surgeries have been
carried out to prevent blindness.
Since 2007, a cumulative total 12.8
million people have received treatments with Zithromax.
According to the Ministry of
Health, elimination of blindness from
trachoma is possible by treating everyone in areas where the disease is
prevalent over a period of three to
five years. This can be achieved by
operating all people with in-turned
eyelashes and improving hygiene and
sanitation. Dr Turyaguma is optimistic that trachoma can be eliminated
by 2020 in Uganda, if there is improvement in hygiene and the drugs
are made available to all those who
require it.
“Trachoma is a disease of poor hygiene and so if you improve hygiene,
it can be eliminated,” he adds.
Other ways to eliminate the disease
include reducing fly breeding sites,
encouraging the washing of children’s faces, improved access to clean
and safe water and proper disposal of
human and animal.

Nutritionists encourage
us to eat a well-balanced
diet. But how many of us
know what exactly entails a
balanced diet? According to
nutritionist Jamiru Mpiima
of Family Nutritionist
Uganda, people usually
misunderstand what a
balanced diet is and what it
should contain.
“It is sometimes referred
to as a coloured plate. This
means your plate of food
should have more than three
colours of food,” he says.
He explains that for a
meal to be balanced, it
should have at least five
food groups, each taken
differently, depending on the
requirement for the body.
These comprise starch
from grains such as cereals,
cassava, sweet potatoes and
plantains. It can also contain
proteins as a source of body
building. The proteins can
come from plant and animal
sources. Animal proteins can
be got from fish, eggs and
milk, while plant proteins
include soy beans and
ground nuts.
Therefore, a balanced diet
should include both animal
and plant proteins.
Fruits such as pineapples,
paw paws, oranges and green
vegetables should also be
included in one’s meal. Fatty
oils are also recommended,
although they should always
be taken in moderation.
Mpiima notes that a
balanced diet is important
because one type of food
cannot have all nutrients
needed for the proper
functioning of the body.
“Whereas fish and eggs have
particular nutrients, they
may not be able to cater for
fibres found in vegetables
and minerals,” he explains.
Without a balanced diet, a
person risks being either
over or under malnourished.
“You can see a person having
matooke and beans every day
and when they check with
the doctor, they are told that
they are malnourished. This
is not the best way to keep
healthy,” he notes. He adds
that eating a balanced meal
everyday also helps to reduce
the chance of developing
constipation and contributes
to better brain growth in
By Sandra Janet Birungi

healthyliving Neglected Tropical Diseases

Sleeping sickness
still thrives in
poor communities
Although many countries have
eliminated sleeping sickness,
it continues to affect several
communities in Uganda,
especially those who are poor,
with limited access to health
care services.



t did not occur to John Ocung that
he was suffering from sleeping
sickness because tests from the
clinics he visited always concluded
that he had malaria. Even though he
was on medication, it did not relieve
his pain.
Then, he developed severe headache, a visual blackout and paralysis
in his left leg. His wife, who was worried that he would not survive, suggested they turn to prayers. Ocung
resisted. Eventually, he ended up at
Lwala Hospital in Otuboi Sub-county,
Kaberamaido District.
“I did not know I had sleeping sickness because I was always diagnosed
with malaria. Their treatment never
healed me,” Ocung narrates from his
hospital bed at Lwala, where he has
spent a week receiving treatment
after doctors confirmed he was suffering from sleeping sickness.
“I suffered severe headache, I could
not see clearly and always felt my leg
was paralysed. I could not sleep at
night and could do so mostly during the day, between 8am and 2pm,”
Ocung recalls.
He adds: “I wish I had come to the
hospital earlier. I now feel better with
the medication I am receiving. My leg
is improving and I can now get some
sleep. However, I still get headache, a
cold, and pass urine frequently.”
Ocung, 55, a father of eight, is optimistic that he will be cured of the
disease soon.

Late-stage disease
Charles Elamu, the Kaberamaido
District vector control officer says in
Ocung’s case, the disease was already
at an advanced stage. It had therefore
affected his central nervous system.
During this stage, patients develop
visual problems, they feel sleepy
most of the time and their speech
becomes incoherent.
Like Ocung, Moses Eryengu initially relied on malaria drugs which
he got from his drug shop in Soroti
Town to treat his illness. Little did he
know, at the time, that it was sleeping sickness that was keeping him ill
most of the time.
“I was weak and could not even
stand up. I was admitted to hospital.
Tests confirmed I had sleeping sickness and not malaria. I felt relieved
because at least I now knew what it
was. I even thought I had been bewitched because of the on-and-off

fever and body weakness,” he says.
He adds that if he had remained in
Soroti treating malaria and typhoid,
he would have succumbed to sleeping
In Eryengu’s case though, when
the first tests were carried out, it
showed that his disease was in the
early stages. Subsequently, he started
treatment and after successful completion of the dose, further tests
showed he had been cured.
He was discharged from hospital
in January. “My only problem now is
that I spit a lot, even at night. When
I move long distances I become dizzy
and it becomes difficuly for me to
walk in the sun,” he says.
“This illness has set me back in my
business and the education of my
children and siblings because I have
no income to pay for their fees,” he
says, adding: “I am confident I will reorganise myself when I fully recover.”
Lwala Hospital is the only treatment
centre for sleeping sickness in Lango
Those with symptoms have to go
through two painful lumbar punctures where fluids are sucked from
their cerebral spinal code and taken
for analysis in the laboratory. The
second puncture is usually carried
out if one has not cured from the first
dose of medication.

“It is a painful injection that is
administered on the back and
because of the fear of the prick,
some patients have escaped from
the ward without waiting for the
second puncture that confirms
if they have completely healed
from the disease.” NELSON OGIDO,


When infection happens
In Kaberamaido District, the number of sleeping sickness cases is usually high between December and
January, and drops from February to
Eryengu has an appeal for government: “They should carry out an
aerial spray all over our sub region
to kill the tsetse flies. Otherwise the
traps set against the flies are shortlived and people vandalise them or
use them as clothes.”
According to the World Health Organisation (WHO), sleeping sickness
also known as Human African Trypanosomiasis (HAT) is a vector-borne
parasitic disease, which is caused by
infection with protozoan parasites
belonging to the genus trypanosoma.
It is transmitted to humans by tsetse
fly (glossina genus) bites, which acquire their infection from human beings or from animals that harbour the
parasites that cause the disease.
Symptoms of the disease include
fever, swollen lymph glands, aching

Control efforts
However, WHO says continuous
prevention control efforts over the
years have reduced the number of
new cases. In 2009, there were 9,878
new cases of the disease reported in
Uganda. This was also the first time
in 50 years that less than 10,000 cases
were reported.
And in 2012, this figure dropped
further to 7,216 cases.
“Sleeping sickness is prevalent in
about 40 districts, with 10 million
more people at risk. Because of concerted control efforts, we have been
reporting just a third of cases in the
past five years ago,” says Dr Charles
Wamboga, the programme manager
in-charge of sleeping sickness control
at the Ministry of Health.
The ministry notes that Uganda is
affected by mainly two types of the
diseases-trypanosoma brucei gambiense and trypanosoma brucei rhodesiense.
Trypanosoma brucei gambiense
predominantly occurs in the West
Nile region, which is bordered by the
Democratic Republic of Congo and
South Sudan- countries also known to

Daily Monitor


John Ocung (above) speaks during the interview. (Below) A campaign poster against
sleeping sickness hangs in a ward at Lwala Hospital PHOTOS BY PAUL MENYA
muscles and joints, headaches and
irritability. When left untreated, the
disease attacks the central nervous
system and can cause death.
According to WHO, sleeping sickness occurs only in 36 sub-Saharan
Africa countries where there is a high
prevalence of tsetse flies.
The population most exposed to
tsetse fly and affected by sleeping
sickness live in remote areas with
limited access to adequate health
services, which complicates the surveillance and therefore the diagnosis
and treatment of cases.
In addition, displacement of populations, war and poverty are common
factors that facilitate transmission, as
poor people with no access to health
services cannot be diagnosed early
enough and put on treatment.

MONDAY, APRIL 28, 2014 7

have a high prevalence of the disease.
Human beings are the main reservoir
for this form of sleeping sickness.
On the other hand, Trypanosoma
brucei rhodesiense was originally
limited to the South Eastern region of
the country. Recently, however, this
type of sleeping sickness has been
reported in some parts of Northern
Uganda such as Alebtong District.
Cattle are the main reservoir for
this acute form of sleeping sickness.
According to the Ministry of Health,
case detection, is mainly through passive and active screening (on a limited scale). All diagnosed cases are
treated with drugs such as suramin
and pentamidine for early stages of
the disease, and melarsoprol and nifurtimox/eflornithine combination
therapy for late stage cases.
The Health ministry management
centres have been established in several districts across the country to
treat cases of the disease.
With support from the Pan African
Tsetse and Trypanosomiasis Eradication Campaign (PATTEC), advocacy
and social mobilisation have also
been revitalised, with most of the
support for the programme funded
by WHO.

Diaper rash is a skin irritation
that occurs when a child’s
body reacts to the organisms
in a diaper. This results from
excess moisture that a child
has been exposed to, and
mostly affects the genital
areas. It makes the baby’s
skin to become sore, red or
Dr Ahmed Ddungu, a general
practitioner at Mulago
hospital, says the rash
occurs when a baby is kept
in a diaper that has urine
or faecal matter over long
periods of time.
When this happens, the
acidic content in the faeces
and the ammonia in the urine
burn the baby’s skin, hence
causing the rash. The rash
can be prevented by keeping
babies clean and dry at all
times. This means that if
a child wets their diapers,
they should be changed as
soon as possible before any
irritation or itching happens.
After a used-up diaper has
been removed, it is advisable
to wait a little bit longer the
baby is dressed in a new one,
as this gives an opportunity
for the child to get enough
fresh air and therefore
minimise the build-up of
Dr Ddungu says some
babies may however not
develop body rash from
the use of diapers. “There
is no particular reason for
this but children’s bodies
react differently to various
things,” he says.
He advises that the use
petroleum jelly in the area
around a child’s genitals can
help reduce the itching.
Here are quick ways to
prevent diaper rash:
•Change your baby’s soiled
or wet diapers as soon as
possible and clean the area
•Put diapers on loosely in
order to allow enough air
•Use absorbent diapers to
help keep the skin dry and
reduce the chance of getting
an infection.
•Occasionally soak the
baby’s bottom between
diaper changes with warm
•Allow your baby’s skin to
dry completely before you
change to another diaper
By Pauline Bangirana

MONDAY, MAY 5, 2014 7

healthyliving Neglected Tropical Diseases

Daily Monitor

Pastoral communities pay high
price for kala-azar disease

Benson Ruto (far
left) is excited that
he will go to school
after recovering
from kala-azar
disease. Nakor
Nawate (left) has
also benefited
from treatment at
Amudat Hospital.

In our series on neglected
tropical diseases, today we
look at kala-azar, a disease
that largely affects pastoral
communities and efforts
being made to eradicate it.


or two months, Nakor Nawate
relied on traditional medicine
to treat kala-azar, a disease she
had been suffering from over a long
period. By the time she was brought
to Amudat Hospital by a community
health worker, the blood in her body
was too low that she had to get transfusion and was put on a healthy diet
before embarking on medical treatment.
“I do not know what causes this
disease that sucks nearly all your
blood,” says Nawate.
Nawate, who does not know her age
is married with three children and
lives in Kosiroi Village in Katikekile
Sub-county in Moroto District.
Benson Ruto is another survivor
of kala-azar disease. He too cannot
tell how old he is, nor can his father,
Benson Lolingang. But he looks
about eight or nine. For four months,
Ruto’s parents treated their son using local herbs and coartem because
they thought he had malaria. “When
his condition did not improve, we
called the community health worker
who tested him at home. The results
confirmed he had kala-azar. He was
admitted here at Amudat Hospital,”
Lolingang says of his son who is recovering from his hospital bed.
“I developed fever, a swollen stomach and general body weakness before
I was admitted here. After the treatment, I now feel better. I can even run
around the ward,” says Ruto.
Not all Lolingang’s seven children
attend school. Ruta was one of those

who were herding livestock instead
of attending school.
“If I take all of my children to
school, who will look after our animals? Ruto has been herding cattle
but I have now decided to take him
back to school because he falls sick
frequently,” says Lolingang.
Ruto is excited about going to
school. “I want to become a doctor
and treat people in future,” he says
with a wide smile.
Mobile communities
The Amudat District community
mobilizer, Andrew Ochieng observes
that because of their pastoral nature,
the community in this region is mobile and difficult to mobilise.
“When I test them in their different
locations and find some are suffering
from kala-azar, they do not come to
hospital immediately. I have to plead
with them all the time. However,
those who know the values of a hospital do not hesitate to seek treatment
as soon as they can,” Ochieng says.
He adds that most young boys in
the region have to look after the family livestock even when they are sick.
“Unless parents get replacements,
the boys are not allowed to go tohospital, and only do so when they
have become too weak,” explains
According to the World Health
Organisation (WHO),kala-azar is
the most serious form of the disease
caused by leishmaniasis visceral.
Others are cutaneous and mucocutaneous.

“When people in these areas fall
sick, they do not seek medical
care from hospital immediately.
Their first call is usually the
traditional healers and when
this fails, they come to hospital,”

leishmaniasis is caused by a protozoa parasite from over 20 leishmania
species and is transmitted to humans
by the bite of infected female phlebotomine sandflies.
The disease is commonly associated with malnutrition, poor housing,
climate change and a weak immune
system. According to the Ministry
of Health, the disease is common in
remote villages of Uganda, Sudan,
Ethiopia and Kenya.
Kala-azar is characterised by irregular bouts of fever, weight loss,
enlargement of the spleen and liver,
and general body weakness.
Up to 90 per cent of people who
are not treated against the disease
die due to organ failure, anaemia and
other secondary infections. It can also
cause skin ulcers. People of all ages
are at risk of infection if they live or
travel in areas where the prevalence
of kala-azar is high, although male
teenager are said to be at a higher
risk of infection because they engage
more in animal herding.
The Leishmaniasis East Africa Platform (LEAP) clinical trial principle
investigator in Uganda, Prof. Joseph
Olobo observes: “At household level,
the impact of kala-azar is disastrous.
It is lethal if not treated. The disease
is mainly found in children, so families will lose their loved ones if it is
not treated on time.”
The Health ministry says the disease has predominantly been reported in Amudat District, which
forms part of Karamoja sub-region.
Termite mounds are a dominant
feature of the area and form the
main breeding and resting site for the
sand fly vectors which transmit the
disease. However, two cases were recently reported in Moroto and Kotido
districts, which are part of the Karamoja sub-region in north-eastern
“We do not know the extent of the
disease in Uganda. In the past, it was
mainly in Amudat District, but now
we are getting cases in neighbouring

districts. Mapping is important to establish the extent of the disease, however, we need to know where the vector is more prevalent. We also need to
have good diagnosis and treatment,”
Prof. Olobo notes.
A poor health seeking behaviour
and low literacy levels are some of the
challenges that make it easy for kalaazar disease to thrive in Amudat.
“When people in these areas fall
sick, they do not seek medical care
from hospital immediately. Their first
call is usually the traditional healers and when this fails, they come
to hospital,” says Lawrence Okello,
the medical officer in charge of the
management of kala-azar patients at
Amudat Hospital.
According to WHO, kala-azar is
most prevalent in the Indian subcontinent and in East Africa. An
estimated 200,000 to 400,000 new
cases of kala-azar occur worldwide
each year. Over 90 per cent of the new
cases occur in six countries of Bangladesh, Brazil, Ethiopia, India, South
Sudan, and Sudan.
Following a kala-azar disease assessment, Medecins Sans Frontiers
(MSF), which has been offering technical assistance to Amudat Hospital,
initiated a control programme in
2000, focusing on case detection and
Treatment of kala-azar usually involves the use of antimonial drugs
such as sodium stibogluconate (SSB),
which has also been included on the
essential drugs list of Uganda.
Research has also been conducted
in the past three years to see if drug
combinations are effective.
The health ministry admits there
is no established control programme
for kala-azar, with current diagnosis
and treatment largely supported by
the Drugs for Neglected Disease initiative (DNDi).

Salt (sodium chloride) is
essential for our bodies.
However, if consumed in
high quantities, it can cause
high blood pressure and also
damage the kidneys.
When there is too much salt
in the body, the kidneys pass
it through urine. However,
because of the high salt
level, the kidneys cannot
keep up with the salt level,
and most of it ends up in the
Salt also attracts water. And
as it draws more water into
the blood, this increases
the volume of blood, which
thereby raises blood
That is why eating salty food
tends to make us thirsty,
as we end up drinking and
retaining excess. With this,
the blood pressure also
continues to build as water
is consumed several hours
after salt is ingested.
The result can be a
temporary increase in blood
pressure, which persists
until the kidneys eliminate
both salt and water.
Foods that are high in salt
will increase blood pressure
over time. Fortunately,
limiting salt intake in the
diet can reverse these
effects. Discuss with your
nutritionist, the alternatives
you can use to reduce your
salt intake. These could
include adding lemons and
spices to your daily diet.
Also, some people are more
sensitive to salt than others
including the elderly, women
and people with diabetes.
These groups of people
need to control how much
salt they consume. Most of
the sodium we consume is
in the form of salt, and the
vast majority of it is found in
processed foods.
It is also recommended
that you consume more
potassium containing foods
because it is the balance
of the two minerals that
matter. A potassium-rich
diet includes a wide variety
of fruits, vegetables, and
Alternatively, discuss with
your nutritionist how to cook
delicious food without or
with limited salt.
By Jamiru Mpiima
The writer is a nutritionist

8 MONDAY, MAY 12, 2014

healthyliving Neglected Tropical Diseases

How rodents
are spreading
bubonic plague
Plague outbreaks are largely
unheard of in most parts of
the world. But in Uganda,
many communities are still
affected by this problem,
largely because prevention
programmes remain weak.



hen Jesila Ngoloru developed pain in her salivary
glands in 2013, she thought
the discomfort would go away by itself. She was wrong.
Ngoloru, who lives in Ewavini
village in Vurra Sub-county, Arua
District, recalls that when the pain
persisted, her family suspected she
had contracted the deadly plague
“By January, 2014, my left salivary aliva glands were swollen.
I developed fever, headache and
general body pain. When I went to
Opia Health Centre III in Vurra SubCounty, a blood test confirmed that I
had plague. I am now on treatment,”
says Ngoloru.
“Although I feel much better now, I
still experience some pain.”
At the time of this interview, Ngoloru had been on treatment for one
week, and was preparing to return
to Opia Health Centre III for medical
Ngoloru, a Primary Seven pupil at
Oyoo Primary School, says she could
have contracted the disease from the
many rats in their house.
“There are many rats at our home
and the only way we try to get rid of
them is through poisoning. We have
cleared the bushes around our home
because this is where most of the rats
breed from,” Ngoloru adds.
The district health team now plans
to spray the villages surrounding
Ngoloru’s home with chemicals to
kill the rats.
“We shall spray Ewavini, Opio Centre, Kongodo and Offa, which have
been most affected by the plague,”
says Nickson Anguyo, the district
vector control programme officer.
After the villages are sprayed, the
chemicals are expected to keep fleas
away for at least four months.
For Ruzalia Maturu, the story is
different. She is still mourning the
death of her granddaughter, Sabina
Ondoru, who succumbed to plague in
September last year.
“I never realised Ondoru had
been infected with plague after she
complained of fever, headache and
general body pain. We took her illness lightly thinking it was a simple
fever, only for her to succumb after
two days,” says Maturu, who is currently nursing her 10-month-old twin
daughters for respiratory tract infec-

tion and pneumonia at Opia Health
Centre III.
When a member of the Village
Health Team (VHT) heard of Ondoru’s
death, they alerted the Sub-county
health assistant, who stopped the
burial to conduct a test on the deceased. It confirmed that the eightyear-old had indeed died of plague.
“After the burial, the health assistant advised us not to return to the
house, and it was later sprayed with
chemicals. After a few days, dead rats
were falling from the roof top. We
have also cleared the bushes around
the homestead,” adds Maturu.
According to the World Health Organization (WHO), plague is a bacterial disease, caused by Yersinia pestis,
which primarily affects wild rodents.
It is spread among these rodents by
fleas. Humans bitten by an infected
flea usually develop bubonic plague,
which is usually characterised by a
swelling of the lymph node in the affected area.
If the bacteria reach the lungs,
the patient develops pneumonia
(pneumonic plague), which is then
transmitted from person to person
through infected droplets that can
spread from cough.
Initial symptoms of bubonic plague

“We advise people in these
communities to report high cases
of sudden deaths of rats in their
homes to VHTs. The VHTs will
then alert the nearest health
centre that will collect these rats
and bring them to the Uganda
Virus Research Institute for
appear between seven and 10 days after infection.
If diagnosed early, bubonic plague
can be successfully treated with antibiotics. Pneumonic plague, on the
other hand, is a deadly infectious
disease, and infected people can die
within 24 hours after infection. Cases
of plague are still prevalent in tropical and warm temperate countries.
Between 1989 and 2003, WHO says
an estimated 38,310 cases, including 2,845 deaths, were recorded in
25 countries with high prevalence of
human plague worldwide.
WHO observes that plague cases
remain largely under-reported
around the world for several reasons,
including the reluctance of countries
to declare cases, lack of timely and
accurate diagnosis and the absence of
laboratory confirmation equipment.
Arua and Zombo districts, bordering DR Congo have registered the
highest cases of plague in the last 40
years, with at least five outbreaks re-

Daily Monitor


Jesila Ngoloru shows the swollen lymph nodes caused by the plague. Below, Maturu
Ruzalia who lost her granddaughter to the the plague recently. PHOTOS BY PAUL MENYA
ported in the last 20 years.
And in the past 10 years alone,
more than 2,000 cases of plague have
been diagnosed in Arua and Zombo
districts. The health ministry has reported an average of 200 plague cases
per year from this region, with 30 per
cent resulting in death. Uganda accounts for 50 per cent of all plague
cases worldwide.
The flea species responsible for
transmission of the disease are Xenopsylla cheopis and Xenopsylla brasiliensis. If a person is infected with any
of these flea species, they experience
symptoms such as fever, headache,
body weakness and swollen lymph
Control plans
Plague outbreaks in Uganda typically occur as a result of cultivation of
grain crops, deforestation and poor
sanitation. The Ministry of Health,
Uganda Virus Research Institute and
the US Centres for Disease Control
and Prevention are collaborating
on plague research and control programmes in Arua and Zombo districts, as a result, have set up a test
laboratory in the area.
Beside laboratory testing programmes, the ministry also carries
out flea control programmes by
spraying affected areas during outbreaks and administering treatment
such as prophylaxis against those
who are infected.
Community Medicine Distributors (CMDs) or VHTs have also been
trained to identify cases and refer
them to health facilities.
Anguyo says seeking medical care
in time is crucial.
Rapid diagnostic kits and facilities
for diagnosis have been established
in the affected areas. Clinicians have
also been trained to manage cases in

a timely way, according to the Ministry of Health.
On the issue of vector control, the
ministry says habitat and household
modifications are being carried out
to decrease the number of rodents
that breed in houses.
“People need to raise their beds at
least one foot above the ground, so
that fleas to not fly from the ground
on to the beds” Anguyo says
According to Arua District Health
Inspector, Manaseh Anziku, sensitisation of the community has always
been a key priority.
“We advise people in the communities to report high cases of sudden
deaths of rats in their homes to VHTs.
The VHTs will then alert the nearest
health centre that will collect these
rats and bring them to the Uganda
Virus Research Institute for investigations,” Anziku says.
However, the health ministry admits cross border collaboration with
DR Congo, which also has a high prevalence of plague remains weak, making it hard to eliminate the disease
completely on the part of Uganda.

Children like to keep
active at all times, and
this is recommended for
their growth and social
development. However, some
children may end up playing
next to fire places, putting
them at risk of burns and
injuries from hot liquids such
as water and porridge.
A burn is an injury that may
be sustained from exposure
to heat or flames, or from
chemicals, electricity,
friction or radiation.
And yet, some parents may
not know what kind of first
aid to administer when
children suffer such burns.
As a result, it is common
for parents to apply sugar,
cooking oil or cold water to
burn wounds.
Dr Alfonse Omona of Mulago
National Referral Hospital
says it is important not to
attempt to treat burns on
your own, as this will only
make the condition worse.
The first step should be
to remove the child from
the accident scene, and
put them in a safe, clean
environment for observation.
Before administering first
aid, it is also crucial to
evaluate the extent of the
“If the child experiences
excessive pain, the parent
should apply warm water
on the burn. Warm water
is recommended because
it reduces pain, while cold
water, which many people
tend to use actually causes
more pain and swelling,” says
Dr Omona.
Prompt medical attention
to serious burns can help
prevent scarring, disability,
and deformity. Burns on
the face, hands, feet, and
genitals can be particularly
serious, as children have a
higher risk of complications
from severe burns. “However,
the child should be taken to
the hospital as soon as first
aid has been administered.
It is also dangerous to apply
herbal concoctions to burn
wounds because some may
cause bacterial infections,”
says Dr Omona.
He says as the child is being
taken to the health facility,
the burn should be covered
with a clean cloth to protect
against infection. Parents
are also advised against
using lotions, ointments or
creams on fresh burns.
By Joseph Kato

healthyliving Neglected Tropical Diseases

MONDAY, MAY 19, 2014 7

Daily Monitor


Martin Tako (inset) shows his scarred left leg which is healing after a buruli ulcer operation. His biggest complaint is that the leg still swells. Dr Dominic Drametu (R) says the disease
is very common during the rainy season. PHOTOS BY PAUL MENYA

Buruli Ulcer: A misunderstood
mycobacterial disease

Buruli ulcer is caused by a germ that mainly affects the skin
but which can also affect the bone. Left untreated, the disease
leads to functional disability, loss of economic productivity, and
social stigma.


ay 2012 evokes sad memories for Martin Tako. It was
the month when something
pricked the lower limb of his left leg,
resulting in buruli ulcer.
At the time, he did not know what
was ailing him even when the affected
spot got swollen and developed blisters which eventually turned into a
The father of eight says, “I then
sought medical attention. I first
used local herbs and therapeutic
cuts were done with no change.” He
was referred to Adjumani Hospital.
“I would feel pain right to my bones
in the affected leg. My left leg would
swell even after a short walk. The
swelling would only reduce when I
raised the leg.”
Moment of truth
On June 17, 2012, he was admitted
to Adjumani Hospital where he was
told he had buruli ulcer.
This diagnosis was then followed
with surgery and then skin grafting
was done. He was discharged on July
30, 2012. That gave him a new lease
of life because the pain disappeared
and he was able to wear closed shoes
Although he does not know what
causes buruli ulcer, his advice to victims is to seek medical attention.
Tako says he did not react to drugs
but he complains of the swelling of
his left leg. “I can’t say I have completely healed because my left leg occasionally swells. I hope for complete

recovery,” he says. As a result, Tako’s
farming activities have retarded yet
this is his only source of income.
He owns 11 acres of land, five in
Pakele Sub-county and six in Adjumani Municipality where he used to
grow ground nuts, rice, cassava and
“I can’t do anything on my farm
for fear of harming my leg. A stone or
any other object could hit the leg and
cause another wound,” Tako says.
According to the World Health
Organisation (WHO), buruli ulcer is
caused by infection with mycobacterium ulcerans, an organism which
belongs to the family of bacteria that
causes tuberculosis and leprosy. It is a
chronic debilitating skin and soft tissue infection that can lead to permanent disfigurement and disability.
Infection leads to destruction of
skin and soft tissue with large ulcers
usually on the legs or arms. Patients
who are not treated early suffer longterm functional disability. Early diagnosis and treatment are the only
ways to minimise morbidity and prevent disability.
Buruli ulcer has been reported
in 33 countries in Africa, America,
Asia and the Western Pacific. Most
cases occur in tropical and subtropical regions except in Australia, China
and Japan. Between 5,000 and 6,000
cases are reported annually from 15
of the 33 countries.
Most cases occur in rural communities in sub-Saharan Africa and
nearly half of the people affected are
children under 15. West Africa, Benin,
Côte d’Ivoire and Ghana report most

cases, with Côte d’Ivoire reporting
almost half of the global cases.
According to statistics from Ministry of Health, the disease is the third
most common mycobacterial infection after tuberculosis and leprosy. It
is also the most misunderstood of the
three human mycobacterial diseases.
The disease affects men and women
About 75 per cent of those affected
are children under 15 years of age and
90 per cent of the lesions are on the
limbs; mostly lower limbs. There is
little seasonal variation in the incidence of the disease.
The ministry adds that buruli ulcer imposes a serious economic burden on the affected household and
on health systems that are involved
in the diagnosis of the disease and
Although the disease was initially
identified in Buruli (Nakasongola District), a recent survey found no cases
there. They also add that the disease
is prevalent in areas near rivers,
swamps and wetlands. Some cases of
the disease, however, were recorded
in Adjumani and Moyo districts.
WHO observes that buruli ulcer
often starts as a painless swelling
(nodule). It can initially also present
as a large painless area of induration
(plaque) or a diffuse painless swelling
of the legs, arms or face (oedema).
Local immunosuppressive properties
of the mycolactone toxin enable the
disease to progress with no pain and
Without treatment or sometimes
during antibiotics treatment, the
nodule, plaque or oedema will ulcerate within four weeks with the
classical, undermined borders. Occasionally, the bone is affected causing
gross deformities.
The Adjumani Hospital Medical

Superintendent, Dr Dominic Drametu, says he has on average been
treating 2 – 3 people per month.
According to Drametu, cases of
buruli ulcer are common during the
rainy season between the months of
April and October. The disease is so
prevalent around the shores of River
Nile in Adjumani District and also
South Sudan.
“One of the features of a nodule
is that it is usually painless, unless
there is a secondary bacterial infection. Otherwise, people don’t come
for treatment. They usually dress the
wound themselves along with herbs
for a long time. It is only when the
wound fails to heal that they come to
hospital,” Drametu says.
A combination of rifampicin and
streptomycin/amikacin for eight
weeks as a first line treatment for all
forms of active disease is being used.
Nodules and uncomplicated cases
can be treated without hospitalisation. For complicated cases, the only
treatment available is surgery to remove the lesion, followed by a skin
graft if necessary. Health workers in
Adjumani and Moyo hospitals have
been trained in diagnosis and management, including skin grafting. In
addition, village health teams were
trained in case detection and referral
to health facilities.
WHO notes that the exact mode
of transmission of mycobacterium
ulcerans is still unknown. However,
it appears that different modes of
transmission occur in different geographic areas and epidemiological
There may be some role for living
agents as reservoirs and as vectors of
mycobacterium ulcerans, in particular aquatic insects, adult mosquitoes
or other biting arthropods.
The health ministry on its part admits that the major gap in the management of the disease is the absence
of a well-established national control
Currently, there is limited data
available on buruli ulcer. Routine surveillance needs to improve for early

Constipation is such a
common uncomfortable
condition that occurs
when one gets a problem
with their digestion. Dr
Alex Kakoraki, a general
practitioner at Murchison
Bay Hospital in Luzira
says that the condition
is also caused when the
muscle contractions in
the intestines are too slow
to push the stool out of
the body and sometimes,
it is lack of enough water
to soften the stool so as
to move it through the
intestines to the anus. Other
causes of constipation
include; cancer of the
intestines, local swelling
of the walls of the large
intestines, failure to drink
a lot of water, over eating
of fast foods like chips,
chapatis, and chicken,
among others.
Kakoraki further mentions
some of the ways one can do
to relieve the constipation.
•Take a soap enema with
warm water
•Take a lot of warm water.
As a start, try just drinking
a glass of water 3-4 times a
day in addition to what you
normally drink. after a heavy
•Take laxative tablets
•Aim to eat at least five
portions of a variety of fruit
and vegetables each day.
One portion is: one large fruit
such as an apple, pear.
• Keeping your body active
helps to keep your gut
moving. It is well known that
disabled people, and bedbound people (even if just
temporarily while admitted
to hospital) are more likely to
get constipated.
In children, the doctor
advises that one should rub
vaseline or oil on the middle
finger, push it into his or her
anus to remove the stool.
One can use gloves in this
case or rush the child to a
nearby hospital.
The doctor also cautions,
“you may notice an increase
in wind (flatulence) and
tummy (abdominal) bloating.
This is normal and tends
to settle down after a few
weeks as the gut becomes
used to the increase in fibre
(or bulk-forming laxative).”

By Christine Katende

healthyliving Neglected Tropical Diseases

When fertile soils spread
the deadly podoconiosis
Ploughing for many years
or going barefoot on
soils appears to trigger
inflammatory changes within
the lymph system in the legs
causing elephantiasis of the
lower limbs.


ne salient feature of neglected
tropical diseases is that they
are silent killers which pounce
on their victims when least expected.
William Bukoma’s story is true testament of this – having lived with
the deadly podoconiosis disease or
elephantiasis of the lower limbs for
54 years.
Bukoma was attacked by the disease in 1960 – the same year he underwent the Bamasaba initiation ritual of circumcision. He was 23 years
old then, meaning podoconiosis has
been part of his adulthood for 55
years. “This disease has been on and
off since 1960, but last year (2013) the
pain and itching intensified. The pain

always comes with burning and itching of my legs and feet. Once the pain
intensifies and I am eating, I have to
put the food aside and concentrate on
scratching my legs and feet,” Bukoma
The father of 10, thought he had
been bewitched, but quickly adds
that he has not tried traditional
medicine and is pinning all his hopes
of ever healing on modern medicine.
“I have now given up on getting cured
because I have suffered for so long.
I wish a cure could be got and the
drugs brought nearer to us,” he bitterly says.
What its all about
According to the World Health Organisation (WHO), podoconiosis is a
type of tropical lymphoedema clinically distinguished from elephantiasis (lymphatic filariasis) by being
ascending and commonly bilateral
but asymmetric. Research suggests
that podoconiosis is the result of a
genetically determined abnormal inflammatory reaction to mineral particles in irritant red clay soils derived
from volcanic deposits.
Podoconiosis is found in high-

William Bukoma
has lived with
Podoconiosis for
54 years. Below
is his left foot
with signs of
elephantiasis of
the lower limbs.

land areas of tropical Africa, Central
America and north-west India.
The disease occurs in highland red
clay soil areas, mainly among poor,
bare footed agricultural communities, who do not wear protective
shoes and, or wash the dust off their
feet using soap and water.
According to WHO, podoconiosis is characterised by a prodromal
phase before elephantiasis sets in.
Early symptoms commonly include
itching of the skin of the forefoot and
a burning sensation in the foot and
lower leg.
Early changes that may be observed are splaying of the forefoot,
plantar oedema with lymph ooze,
increased skin markings, hyperkeratosis with the formation of moss-like
papillomata (left) and rigid toes.
Podoconiosis starts in the foot and
progresses up the leg to the knee but
rarely involves the groin; conversely,
elephantiasis is found at lower altitudes and changes often are noticed
first in the groin.
As the disease progresses, the
swelling may be one of two types: soft
and fluid, or hard and fibrotic, often
associated with multiple hard skin
nodules. Acute adenolymphangitis
episodes occur in which the patient
becomes pyrexial and the limb warm
and painful. These episodes appear to
be related to progression to the hard,
fibrotic leg.
WHO says diagnosis is based on
location, history, clinical findings and
absence of microfilaria or antigen on
immunological card test. Podoconiosis occurs in populations living at
high altitudes (more than 1,000 metres above sea level).
Population-based surveys by WHO
suggest a prevalence of 5–10 per cent
in barefoot populations living on irritant soil. In Ethiopia, one million
people are estimated to be affected,
while in Cameroon, a further 500,000
people are estimated to be affected.
The economic consequences are severe: productivity losses per patient
amount to 45 per cent of working
days per year, thus economic losses
to a country such as Ethiopia exceed
$200m per year.
Most of the community-based
studies have shown onset of symptoms in the first or second decade
and a progressive increase in podoconiosis prevalence up to the sixth
Farmers who for cultural reasons
or through sheer poverty do not
wear shoes are at high risk, but the
risk extends to any occupation with
prolonged contact with soil.
In Uganda, the disease was first
documented in 1934. The Ministry
of Health says the number of cases in
Uganda is unknown, however, there is
a strong belief cases of this condition
are high in highland areas associated
with the Rift Valley Geological complex. A 2001 study on elephantiasis in

Kapchorwa District revealed a prevalence of 4.5 per cent in all age groups.
Another survey carried out by the
Programme to Eliminate Lymphatic
Filariasis in 2012 showed a prevalence of 7.2 per cent in the badly hit
sub-counties of Busiriba and Ntara
of Kamwenge District in western
The health ministry observes that
the socio-economic impact of the disease is high: Out of 10 patients, seven
to nine tend to belong to the economically active age group population.
The ministry further admits to
National Master Plan for Neglected
Tropical Diseases Programme 20132017, that despite the high prevalence,
high morbidity and enormous socioeconomic impact, little information
about the disease burden is available
in most parts of Uganda.
Consequently, little effort has been
made at national, district and community levels to control podoconiosis.
According to WHO, primary prevention consists minimising exposure
to irritant soils by wearing shoes or
boots and by covering floor surfaces
inside traditional huts.
Secondary prevention includes
daily foot-washing with soap, water
and antiseptic, use of a simple emollient, bandaging in selected patients,
elevation of the leg, controlled exercises, and use of socks and shoes.
Compression bandaging is highly effective in reducing the size of the soft
type of swelling.
Tertiary prevention encompasses
secondary prevention measures,
elevation and compression of the
affected leg, and, in some cases, removal of prominent nodules.
More radical surgery is no longer
recommended since patients unable
to avoid contact with soil experience
recurrent swelling which is more
painful because of scarring. Social
rehabilitation is vital, and includes
training treated patients in skills
that enable them to generate income
without contact to irritant soil.
According to the Action on Podoconiosis Association (APA) based
in Ethiopia, as a result of stigmatisation the sufferers are frequently
ostracised from their families and
communities, lonely and treated as
“…They are typically in constant
pain and discomfort from the condition and can smell offensively
through chronic infection. Only the
fortunate receive family support.
Some die early through starvation or
infection although, without help, all
are destined to a miserable, deprived
However, Bukoma says he has not
been shunned in his community. “I
have not been stigmatised by my
community because I always associate with them. I share my problem
with them and they always advise
me to go to Mbale Regional Referral

MONDAY, MAY 26, 2014 7

Daily Monitor

A migraine is a severe
headache which is
characterizsed by throbbing
or pulsating on the fore
head, on either side of
the head. Dr Umar Rashid
Gulooba of Makerere
University Business school
health centre says when
serotonin, a chemical in the
brain, reduces, the blood
vessels first contract and
then they dilate which
triggers the initial stages
of a migraine before severe
pain set in. He also says a
migraine is triggered by
emotional, physical, dietary,
environmental and medical
Under emotional situations,
Gulooba says, anxiety,
panic, stress from work
and depression triggers
a migraine; and physical
circumstances like
tiredness, fatigue and failure
to have enough sleep also
brings about migraines.
Poor dietary conditions
like dehydration, alcohol
and taking much tea or
coffee which has caffeines
that affect the serotonin
chemical in the brain and
environmental conditions
like bright light from
television and computer
and loud sound also triggers
migraines. Medically,
taking sleeping pills and
contraceptives frequently
act as triggers.
“When one side of one’s
vision is not clear and also
when there is an experience
of flash lights and blind
spots in the eyes, are all
symptoms of migraines.
Similarly, when someone
also smells weird things
when they actually aren’t
there is also a symptom
of migraines,” Gulooba
says. He adds that “when
you put a person in a dark
quiet room and give them
sedative pills to rest for
some time, by the time they
wake up, the migraine pain
will have reduced.” Using
pain killers and medicine
to stop vomiting also cures
As anyone who gets
headaches knows, certain
smells can trigger the pain.
But peppermint in particular
seems to have pain-reducing
effects. “It’s very individual,”
he says, and may not work
for everyone. Or, it could just
mask less pleasant smells.
By Roland Nasasira

healthyliving Neglected Tropical Diseases

Rabies management
in humans still
Rabies is a fatal disease
among humans with survivors
being only those who have
received vaccines before the
onset of the disease.


hen nine-year-old Bulema
Muwada attempted to chase
a cow from their potato garden in Bulonda Village in Bugoya
Sub-county, Buyende District in eastern Uganda, little did he know that he
would end up being bitten by a stray
Muwada shares how his life
changed on January 31. “I was at
home when I saw a cow eating potato leaves in our garden. I decided
to chase it away only to see a dog running after me. It first barked and then
went on to bite my hands and back
when I fell down,” Muwada recalls.
“I screamed and called out for
help. When the people at home came
to my rescue, the dog ran away but
was later killed in our compound,”
Muwada says as his father, Zaidi Muwiri nods in agreement. The Primary
Three pupil of Adiswale Primary
School, is still nursing injuries that
resulted from a rabid dog bite.
Muwada was admitted to Lubaga
Mission Hospital, a private facility
where he received a rabies vaccine
at Shs45,000.
According to hospital authorities,
the boy was supposed to have a total of three vaccines but so far he has
only got one.
When asked, his father says the
family could not afford Shs90,000 for
the remaining two shots. Muwada’s
father says, “the government offers
free rabies vaccines but they are not
available in hospitals around here.”
The Ministry of Health defines rabies as a viral disease that is caused
by the Rhabdovirus (Rabies Virus)
affecting all warm blooded animals.
It is a disease common among rural
and urban populations of low socioeconomic status.
How it is spread
According to the World Health Organisation (WHO), people are usually infected following a deep bite or
scratch by an infected animal.
But transmission can also occur
when infectious material – especially
saliva – comes into direct contact
with human mucosa or fresh skin
Human-to-human transmission by
bite is theoretically possible, but has
never been confirmed.
WHO reports indicate that rabies
occurs in more than 150 countries and
territories. More than 55,000 people
die of rabies every year mostly in
Asia and Africa.
Dogs are the source of most rabies
related deaths in humans although
40 per cent of people who are bitten

“While all the other diseases are
easily curable following onset
of clinical signs, rabies has no
cure and progression to death is
rapid once clinical signs including
encephalitis (“madness”),
abnormal behaviour, difficulties in
swallowing, staggering, paralysis,
altered vocalisation, and seizures
have manifested.” DR DOMINIC LALI

cats) is a major risk factor contributing to the spread of rabies to the
human population through bites of
rabid dogs and cats.
According to reports from WHO,
people living in rural areas are mostly
at risk, because human vaccines and
immunoglobulin are not readily available or accessible in such areas.
Reports show that the disease exists in two forms. The first form is
furious where victims exhibit signs
of hyperactivity (This is when more
active than is usual or desirable), excited behaviour, hydrophobia (a set
of symptoms of the later stages in
rabies) and sometimes aerophobia
(an abnormal and persistent fear of
flying). After a few days, death occurs
by cardio-respiratory arrest (the sudden and often unexpected stoppage
of effective heart action).
The other, paralytic rabies accounts for about 30 per cent of the
total number of human cases.
This form of rabies runs a less dramatic and usually longer course than
the furious form. The muscles gradu-

ally become paralysed, starting at the
site of the bite or scratch.
The patient slips into a coma and
eventually death occurs. The paralytic form of rabies is often misdiagnosed, contributing to the underreporting of the disease.

The Health ministry says the actual
prevalence of both human and animal rabies in Uganda is currently not
known because of inadequate surveillance system.
Therefore, there is a need to carry
out the surveillance to actually determine the magnitude of the disease in
the country.


Bulima Muwada (above) was attacked by a dog while chasing a cow from their potato
garden. (Below) His right hand healing from a dog bite PHOTOS BY PAUL MENYA

Expert analysis
According to the president of the
Uganda Veterinary Association, Dr
Dominic Lali Mundrugo-Ogo, rabies
is the only viral disease among the 12
Neglected Tropical Diseases (NTDs)
in Uganda, adding that it is not curable.
“Death is rapid once clinical signs
including encephalitis (“madness”),
abnormal behaviour, difficulties in
swallowing, staggering, paralysis, altered vocalisation, and seizures have
manifested,” Lali Mundrugo-Ogo observes.
With exception of buruli ulcer,
plague and trachoma which are bacterial, the rest (NTDs) are parasitic
and run a chronic course.
It is estimated that the population
of dogs in Uganda stands at three
million while that of cats is about
With the poor veterinary care given
to these animals, these pets pose a
big risk factor in rabies transmission,
health officials warn.
They add that the current dog vaccination coverage in Uganda is less
than 20 per cent and there is no regular centrally planned mass vaccination programme for dogs and cats

Daily Monitor


by suspect rabid animals are children
under the age of 15.
The incubation period for rabies
is typically one to three months, but
may vary from one week to one year.
The initial symptoms are fever and
often pain or an unusual or unexplained tingling, pricking or burning
sensation (paraesthesia) around the
site of the wound.
WHO adds that as the virus spreads
through the central nervous system,
progressive, fatal inflammation of
the brain and spinal cord develops.
Risk factors
The Health ministry says about
10–20 individuals die and 5,000 are
treated for rabies annually. More
than 95 per cent of rabies cases originate from rabid dog bites with most
cases being children aged between
five and 19.
Experts say children are vulnerable
as a result of their inclination to approach animals.
There is poor community awareness due to insufficient funding and
inadequate supply of medicine for
individuals bitten by rabid animals,
leading many people to seek care
from traditional healers.
The presence of many free-roaming and unvaccinated pets (dogs and

MONDAY, JUNE 2, 2014 7

Interventions in place
The Ministry of Health has put in
place a rabies control programme
that aims at improving the prevention and control of human rabies
in Uganda. This is to be achieved
through improvement of rabies surveillance in animals and humans,
diagnosis, creation of awareness,
regular vaccination of dogs and cats,
improvement of animal welfare and
treatment of people exposed to the
In the National Master Plan for Neglected Tropical Diseases Programme
2013-2017, this strategy is usually
successful if the vaccination of dogs
is carried out at least once a year and
with vaccination coverage of at least
75 per cent of the dog population.
The Ministry of Health together
with health education and community sensitisation on rabies control is
responsible for the execution of this
But already there are hiccups,
the health ministry admits, “However, the vaccination of dogs and
cats in Uganda and sensitisation
programmes are not regularly carried out because of lack of funds to
purchase rabies vaccines and other
logistics and carry out sustained sensitisation campaigns.”

As a way to help adolescents
living with HIV/Aids forge
a normal life as well as take
their medication has given
birth to a new project in
Masaka District. Dubbed
SUUBI Adherence Project
is funded by the American
government, SUUBI
Adherence is headed by Prof
Fred Ssewamala of Columbia
The five-year study project
seeks to establish if
economic empowerment for
HIV positive adolescents
helps them to adhere better
to antiretroviral therapy
According to Ms Jenifer
Nattabi, the project
coordinator, when an
adolescent or their
caretaker deposits savings
of Shs20,000 in a month,
SUUBI Adherence deposits
an equivalent amount on
the same account. They are
called matched savings. The
adolescent or the caretaker
may deposit any amount
as savings but SUUBI
Adherence can only match
savings of up to Shs25,000.
The period for the project’s
matched savings is two
years and the agreed upon
position is that the savings
can only be withdrawn to
pay fees, to start a money
generating project or to
settle an emergency health
“I don’t believe in cash
donations to orphans
without them making any
input,” says Prof Fred
Ssewamala who heads the
He adds, SUUBI is the
Luganda word for hope and
the study is named SUUBI
Adherence because its
ultimate aim is to restore
hope among the vulnerable
youths and is also in many
respects related to other
quite successful SUUBI
study projects that have
been carried out among HIV
orphaned children in the
region since 2004.
Launched in September
2013, SUUBI Adherence
study project has 736
HIV positive adolescents
aged between 10 and 16
years as its participants
in the districts of Rakai,
Lyantonde, Lwengo, Masaka,
Bukomansimbi, and Kalungu.
To ensure the adolescents
take their medicine regularly,
SUUBI Adherence has
given out Wise Pill boxes to
all the study participants.
These devices are almost
the size of a cell phone and
are used to store medicines.
Whenever pills are taken
out, the SUUBI Adherence
server receives an electronic
message which helps the
monitors and counsellors to
ascertain if the adolescent is
taking his medication at the
prescribed time.
Michael J Ssali

healthyliving Neglected Tropical Diseases

Six million people at risk
of contracting jiggers
Jigger infestation is a big
problem, especially in Busoga
sub-region. We examine why
the problem has persisted and
the health threats posed to
the community.



he risk for infestation from tungiasis or jiggers is high if feet
are not protected by shoes and
socks, either because people cannot
afford them or if wearing shoes is not
part of local custom, health scholars
This assertion is very true in the
case of sufferers in Busoga sub-region.
In Nabirama Village, Butansi Subcounty, Kamuli District, Adonia Babi
Kirevu and his mother, Ruth Nabirye,
are both suffering from Tungiasis or
jiggers, as this infection is popularly
His mother says, “I do not know
what causes this disease but my
neighbour’s children infected my
children with jiggers.”
She says ever since the family was
treated by the village health team and
sprayed with hydrogen peroxide and
jik, most members have healed, except Kirevu.
The mother of six believes this is
because he has stubbornly refused to
have the jiggers removed.
“I try to remove the jiggers every
after two days but he will not accept.
So I have to sweet talk him otherwise
he will run away,” Nabirye says.
Nabirye’s husband, a rice farmer,
abandoned them for his three other
wives yet she has no steady income
to fend for her big family.
How jiggers spread
Tungiasis is listed as a neglected
tropical inflammatory painful itching
skin disease caused by a female ectoparasitic sand flea that burrows into
the skin.
Once inside a person’s body, which
is usually the feet, jiggers suck blood
and grow while breeding at the same
time. Once the female flea expels 100200 eggs, the cycle of transmission
begins again.
Health experts say fleas require a
warm-blooded host to reproduce. Intense transmission is in the dry season (dust is ideal for survival).
In addition to humans, reservoir
hosts include pigs, dogs, cats, cattle,
sheep, horses, mules, rats, mice, and
some wild animals.
They add that symptoms of this
disease include; severe itching, pain,
skin inflammation and swelling,
desquamation of the skin, lesions
and ulcerations, with black dots in
the middle.
If left untreated, secondary infections, such as tetanus, gangrene and
bacteremia can occur. It can also lead
to severe disability and death.

Adonia Babi Kirevu (Left) has jiggers in
both his fingers and feet. (Above)Is the
foot infested with jiggers. PHOTOS BY PAUL


Most prone persons
It is estimated that more than six
million people are at risk and at least
2.4 million have jiggers, 50 per cent
of whom, are confined in eastern
Uganda, especially the Busoga subregion. A recent household survey in
Busoga found jiggers prevalence of
40.6 per cent in schools and communities.
The distribution of tungiasis is
thus patchy, and the disease occurs
predominantly in impoverished populations, the head of the Jiggers Focal
Point in Ministry of Health, Dr George
Mukone, says, adding, “ Mortality has
been reported but occurs indirectly
due to opportunistic infections.”
Case studies
According to Dr Mukone, as of
2009, tungiasis was present worldwide in 88 countries with varying
degrees of incidence.
He says as a result of heavy infestation, school children are unable to
attend school, leading to high school
absenteeism and poor academic per-

“The traditional methods of use of
unsterilised instruments such as
thorns for jiggers extraction puts
those infected at risk of infections
such as HIV/ AIDS and hepatitis,”’

formance. Severely affected farmers
are unable to reach their gardens
leading to malnutrition and further
poverty as their productivity is severely compromised. “Some people
have actually gone on to lose toes
and entire limbs to jiggers,” says Dr
“The traditional methods of use
of unsterilised instruments such
as thorns for jigger extraction puts
those infected at risk of infections
such as HIV/Aids and hepatitis,” Dr
Mukone warns.
The single most reliable mode to
stop jiggers or public health intervention is by breaking the flea breeding
cycle through rendering homesteads
This is practical during rainy seasons when rain clears dusty compounds, and house floors and verandahs are plastered repeatedly with
cow dung and sand mixtures.
Local studies have shown that Benzyl Benzoate Emulsion (BBE) is quite
effective in killing the embedded fleas
if applied in right concentration. Another drug of proven efficacy against
embedded fleas is Dimeticone, a topical application usually used to treat
head lice.
In the National Master Plan for Neglected Tropical Diseases Programme
2013-2017, the Ministry of Health observes that the disease is endemic in
most districts but it is intense in 20
districts of eastern region. Current
efforts to control it are based on social mobilisation.

The Busoga story
The Kamuli District vector control
officer, Moses Waiswa, observes that
the biggest challenge facing the district’s jigger treatment drive is the
non-participation of adults. “Adults
with jiggers feel stigmatised and do
not turn up for treatment. But the
children are free to talk about their
illness and come for treatment,” he
There are plans by the Ministry of
Health to get funding to implement
a comprehensive plan to eliminate
this problem once and for all by not
only targeting Busoga sub-region,
but scaling up to other districts in
the country affected by jiggers. It
particularly plans to carry out case
finding and treatment, environmental management and where necessary fumigation of homesteads and
rehabilitation of those cases found
severely disabled by the disease.
Issues at hand
Writing in the Bulletin of the World
Health Organization 2009; 87:152159, Hermann A. Feldmeier and Jorg
B. Heukelbach note that Epidermal
Parasitic Skin Diseases (EPSD) occur worldwide and have been known
since ancient times. Despite the considerable burden caused by EPSD,
this category of parasitic diseases
has been widely neglected by the scientific community and health-care
According to Feldmeier and Heukelbach, six EPSDs are of particular
importance: scabies, pediculosis
(head lice, body lice and pubic lice
infestation), tungiasis (sand flea disease) and hookworm-related cutaneous larva migrans (HrCLM). They are
either prevalent in resource-poor settings or are associated with important morbidity. They add that except
in epidemic circumstances, data on
EPSD are not recorded so there is no
reliable information on global disease
occurrence, changes in incidence
over time, and spatial distribution in
endemic areas.
The year 2018 is targeted by the
ministry for the elimination of tungiasis, but current statistics show that
the country is nowhere in eliminating
this scourge.

MONDAY, JUNE 9, 2014 7

Daily Monitor

Should you worry about
baby fat? Not so much.
While some recent studies
have found a link between
fattening up too fast during
infancy and childhood
obesity, your number one job
as a parent is to help your
baby gain weight. Indeed,
cutting calories during the
first year could interfere
with both your baby’s
physical growth and its brain
development. Instead, just
keep these guidelines in mind
so your little cherub develops
healthy eating habits:
• You will need to feed
a newborn often and on
demand. But an older baby
who fusses between meals or
not long after it has emptied
its mum’s breasts or finished
off a bottle does not always
need more food to feel better.
First try offering them a
pacifier, or help him relax
with rocking.
• During the first year, a
child’s primary source of
calories and nutrition should
be breast milk or formula.
Even though babies typically
start solids around six
months, the main function of
eating food at this point is to
get a child used to having it in
her mouth and to provide her
with a chance to “practice”
• Babies should double their
birth weight by about four
months, and triple it by their
first birthday. Talk to your
pediatrician if your baby is
exceeding these guidelines.
First foods first!

Introduce your baby to
simple, natural foods first.
Start with cooked vegetables
(such as parsnip, potato,
yam, sweet potato or carrot),
mashed banana, avocado,
pear or cooked apple, and
any fist-sized pieces of soft
fruit or veg. You can also try
cereals such as baby rice
mixed with milk.
What next?

Once your baby has got used
to eating simple, natural
foods, you can offer them
other healthy foods such as
meat, fish, pasta, noodles,
bread, chapatti, lentils, and
mashed rice. You can also
introduce them to wellcooked eggs, and full fat,
low sugar dairy products like
cheese, yoghurt, fromage
frais, or custard.

healthyliving Neglected Tropical Diseases

Why Uganda carries
heavy burden of neglected
tropical diseases
located towards their treatment,
control and elimination. That is why
they are called neglected tropical diseases.”
“These NTDs run a chronic course
because they are slow killers. Most
times victims only seek attention
when they feel pain. These factors
make them neglected diseases,” Dr
Turyaguma adds.
Both the cause and the result of
poverty and neglected diseases are
responsible for billions of dollars in
loss of productivity each year worldwide.

Village Health Teams have been engaged in helping with mass drug administration to
help adrress the problem of human resource shortage. FILE PHOTO

Research shows that more
than 11 million Ugandans
are suffering from neglected
diseases. In our last series on
neglected tropical diseases,
we look at factors that have
caused these diseases to


he neglected tropical diseases
(NTDs) are the most common
infections of the world’s poorest people living in developing countries. Uganda, which is listed among
the developing countries, is highly
endemic to NTDs which pose a heavy
burden on poor rural communities.
The effect of NTDs may lead to
chronic ill-health such as disability,
deformity, blindness, and retarded
physical or mental growth. If not
treated, they will lead to death.
World Health Organisation (WHO)
observes that NTDs affect more than
one billion people globally, and also
lists 171 diseases as NTDs.
Dr Monique Wasunna, the director, Drugs for Neglected Diseases
initiative (DNDi), Africa Regional
Office, says most NTDs have been
wiped out in parts of the world with
good living conditions and hygiene.
These diseases, however, still affect
the world’s poorest populations, with
little visibility and little voice.
Dr Patrick Turyaguma, one of the

programme managers at the National
NTD Secretariat, Ministry of Health,
says, “Until recently, NTDs had limited attention from the sufferers
themselves, the communities where
they live, national governments, and
the international community. There
have been inadequate resources al-

Why elimination is neccessary
“Controlling and eliminating these
diseases is a vital part of alleviating
poverty,” says Prof Joseph O. Olobo,
a lecturer at the Immunology Department, College of Health Sciences,
Makerere University, adding: “However, this is not an easy task. Finding adapted treatments is part of the
“However, in Africa, for patients to
be diagnosed and treated, they have
to leave their house, village, to walk,
sometimes for days, to the closest
health facility. There, they will need
to stay up to several weeks to receive
the treatment. All this time, they will
not work and not earn money to feed
their families, hence the burden on
productivity. This is why the ultimate
objective is to develop a treatment
that can be a pill, taken directly at the
community level,” Prof Olobo says.
Dr Miriam Nanyunja, the focal
person for NTD control at the WHO
Country Office believes effective interventions that could be deployed
to eliminate most NTDs are available,
but there is limited global funding to
scale up these interventions.
Research shows that in Uganda,
like elsewhere in Africa, many sufferers rely on traditional medicine
for treatment, even when traditional



he government has a goal of
eliminating Neglected Tropical Diseases (NTDs) as a public
health problem by 2020.
It has developed the “National Master Plan for Neglected
Tropical Diseases Programme
2013-2017” focusing on scaling
up NTD control efforts with
the eventual aim of achieving
prevention, control, elimination and/or eradication of these
diseases in line with the WHO
roadmap for elimination of
NTDs in Africa by 2020.
Currently, the focus is on
eliminating bilharzia, elephantiasis and hydrocele, river blindness, trachoma and intestinal
“We have advocacy and promotional activities that aim
at encouraging populations at
risk, to seek medical attention
in time but also to come and receive drugs during MDA activities,” Turyaguma says.

Turyaguma observes that like
other health programmes, there
are misconceptions about the
drugs that are given out.
He says the support for
NTD control and elimination
is mainly donor driven. He,
however quickly adds that the
government also supports the
Asked whether Uganda
will eradicate NTDs by 2020,
Turyaguma says: “The target
for elimination of NTDs is still
2020. However, this is likely to
be undermined by insufficient
resources, changing priorities,
and emerging situations that
may require urgent attention.”
As to how WHO rates Uganda’s efforts to eliminate NTDs,
the focal person for NTD control
at the WHO Country Office, Dr
Miriam Nanyunja commends
the strides the country has
taken to eliminate NTDs.
By Bamuturaki Musinguzi

medicine has not been proved to cure
Prof Olobo says, “Patients affected
by Kala-azar (a chronic and potentially fatal parasitic disease) have
been known to use traditional medicine. However, studies show that
these herbs are not effective.”
According to National Master Plan
for Neglected Tropical Diseases Programme 2013-2017, Uganda continues
to carry a heavy burden of NTDs due
to a number of factors which include
shortage of medical personnel, inequitable funding of the health sector, lack
of interest by pharmaceutical industries to develop drugs for NTDs and a
low literacy rate.
The government admits the shortage of medical personnel has greatly
compromised the delivery of quality
health services.
The ratio of medical doctor to population ranges from 1:12,500 to 1:50,000
in Uganda and that of nurse to population is 1:5,000.
The inequitable distribution of
human resources particularly affects
NTD areas that are generally hardto-reach and hard-to-stay for health
Assessing interventions
To bridge this gap, the government
makes use of Village Health Teams/
community medicine distributors for
mass drug administration. But still
this does not fill the void of qualified
health workers.
Dr Turyaguma admits: “When you
have shortage of human resource, you
are not going to properly execute your
plans. ”
Information from ministry of
Health indicates that about $30 - $40
(Shs76,000- Shs102,000) per capita
and an an increase on the health budget to at least 15 per cent over the next
years to adequately fund the implementation of the Uganda minimal
healthcare package.
However, the health financing is
overwhelmed by the major killers malaria, HIV/Aids and tuberculosis and
leaving little funding for NTDs.
A 2008 report by the Ministry
of Health showed that on average,
only 28 per cent of the health facilities in Uganda have a constant supply of medicines and health supplies
throughout the year.
Inadequate financial and human
resources, capital investment and
management issues have resulted in
the public sector being unable to fulfill
its mandate of providing medicines to
meet the requirement of universal access to health care.
Weaknesses in supply chain management such as poor quantification,
delays in procurement, inappropriate
and late deliveries, late orders from
facilities and poor record keeping
contribute to shortage and wastage
of medicines in the public sector and
do not help the cause.
“The other problem is the working
figures, especially district populations
that vary, making it difficult to have
accurate estimates of the required
drugs,” Dr Turyaguma says.
“For some of the diseases, for instance, sleeping sickness, the drugs
available for treatment are quite toxic
and very old, with no new or recent
research ongoing to find less toxic
drugs. Pharmaceutical industries
have not shown much interest in developing new products or drugs for
such diseases, yet new medicines for
malaria, HIV, among others, are being
worked on all the time,” Dr Nanyunja

MONDAY, JUNE 16, 2014 7

Daily Monitor

Due to different reasons,
people at times do not eat
well-done animal products.
This, health experts cautions
could cause brucellosis.
Dr Sam Thembo, a general
medical practitioner and the
director of Community Clinic
and Laboratories Limited,
says brucellosis is an
infectious disease caused by
bacteria of genus brucella.
He says humans get infected
with brucellosis when
they get into contact with
infected animals or when
they consume products from
infected animals like goats,
sheep and cattle.
Dr Gloria Akampa of Kairos
Hospital in Seeta, Mukono
District, further adds
that brucella abortus is
the commonest type of
brucellosis that human
beings suffer from.
She says, “Infants can also
be infected with brucellosis
through breastfeeding,
especially when the mother
has the disease and is not
on treatment.” it can also
be spread through sexual
Signs and symptoms

According to Dr Akampa,
brucellosis can show
symptoms like fever, joint
pain, loss of appetite, back
pain and general body
She adds that vomiting,
fever, nausea, backache,
chest pain, abdominal pain,
headache, heart palpitations,
burning sensation in the
legs and feet, sweat and
dizziness are soime of the
warning signs.
Other signs may include
sexual dysfunction,
miscarriages and severe
infection of the central
nervous systems.

Dr Akampa says brucellosis
can be diagnosed by
conducting the brucella
antigen test.
However, there is no specific
vaccine for brucellosis, but
the disease can be diagnosed
in a laboratory by using
samples of blood and in
bone marrow to find brucella

Dr Thembo recommends
to fully cook all animal
products. For herdsmen and
hunters, it is advised to use
rubber gloves when handling
bowels of animals.
By Joseph Kato

Some of the animal products. NET