Schistosomiasis Control in Kwabeng Social, Environmental, and Engineering Challenges to Reducing Schistosomiasis Incidence in a Rural Town in Eastern Ghana Tufts University Department of Civil and Environmental Engineering Project Team Student Members: – Casey Caldwell, Robert Curry, Charline Han, Daron Kurkjian, Kelly Sanborn, and Katie Shuman Faculty Advisors: – John Durant and David Gute Tufts University, Dept. of Civil & Environmental Engineering 2 The Problem Schistosomiasis is water-borne parasitic disease that is contracted by coming into contact with contaminated water We hypothesized that hydraulic alterations to the river in Kwabeng have increased the incidence of schistosomiasis Source: Rob Curry Tufts University, Dept. of Civil & Environmental Engineering 3 Life Cycle of Schistosomiasis Source: http://www.payer.de/entwicklung/entw2039.gif Tufts University, Dept. of Civil & Environmental Engineering 4 Long Term Project Objective Decrease, if not eliminate, the incidence of schistosomiasis in Kwabeng, Ghana Promote better management of water resources in Kwabeng Assess the transportability of our approach to other affected communities Tufts University, Dept. of Civil & Environmental Engineering 5 First Year Project Objectives Research the nature and complexity of the problem Establish baseline data for Kwabeng Create relationships with community members Design a matrix to determine the best possible solutions Tufts University, Dept. of Civil & Environmental Engineering 6 Research Methods in Kwabeng Gathered water data – Velocity, Temperature, pH, Dissolved Oxygen, Specific Conductivity Average Max Min SpC (mJ/cm) 0.118 0.124 0.097 pH 7.20 7.80 6.86 Temp (oC) DO (mg/L) Source: Rob Curry 25.59 29.58 24.15 7.33 7.85 6.29 Tufts University, Dept. of Civil & Environmental Engineering 7 Research Methods in Kwabeng Identified presence of schistosomiasis in water and in children – Collected snails – Identified schistosomes in snails – Conducted school surveys to determine incidence of infection in children, along with river use habits Tufts University, Dept. of Civil & Environmental Engineering 8 Snail and Velocity Correlation 25 Number of snails 20 15 10 5 0 0 0.1 0.2 0.3 0.4 0.5 0.6 Velocity (meters/second) Tufts University, Dept. of Civil & Environmental Engineering 9 Research Methods in Kwabeng Met with community members and leaders – Gathered community acceptance and historical data for the town Helped establish a committee to continue project efforts in Kwabeng Source: Katie Shuman Tufts University, Dept. of Civil & Environmental Engineering 10 Research Methods in Kwabeng Made maps of the before and after mining company changes Used a GPS unit, measuring tape, and compass Digitized the maps for use in GIS Tufts University, Dept. of Civil & Environmental Engineering 11 Tufts University, Dept. of Civil & Environmental Engineering 12 Tufts University, Dept. of Civil & Environmental Engineering 13 Tufts University, Dept. of Civil & Environmental Engineering 14 Tufts University, Dept. of Civil & Environmental Engineering 15 Identifying Interventions Identified three types of interventions – Reduce number of snails in the river – Prevent people from exposure to parasites – Reduce the population of parasites in snails Tufts University, Dept. of Civil & Environmental Engineering 16 Selection Criteria Cost – Relative cost taking into account capital cost and O&M Feasibility – How possible the intervention technology is in Kwabeng • Access to equipment • Human health and safety concerns Community Acceptance – How well the proposed solution resonates with the community • Cultural, political and economic implications Tufts University, Dept. of Civil & Environmental Engineering 17 Selection Criteria Continued Efficacy – Success rate in decreasing the incidence of schistosomiasis • Can the intervention stand alone • Has it been successful in other areas Sustainability – Longevity of the intervention Tufts University, Dept. of Civil & Environmental Engineering 18 Tufts University, Dept. of Civil & Environmental Engineering 19 Numbering System Cost: • 1 = most expensive Feasibility: • 1 = least feasible 5 = very supported Efficacy: • 1 = not effective at decreasing infection 5 = most feasible Community Acceptance: • 1 = not supported 5 = least expensive 5 = very effective Sustainability: • 1 = not sustainable 5 = indefinitely sustainable Tufts University, Dept. of Civil & Environmental Engineering 20 All Possible Rated Interventions Specific Intervention Increase staff school visits Free schisto screening & drugs Public Latrines Town-wide education campaign Do nothing Increase Predators Increase Direct Snail Competitors Plants- for Shade Plants-in Water Increase slope of channel Reduce Cross-sectional area Restoring Flow or Modified Flow Herbicide Mollusicide Public showers Wells Public Taps Recreation Area Expand Household Distribution System Cost UW 10% 3 0.3 2 0.2 3 0.3 5 0.5 5 0.5 4 0.4 4 0.4 5 0.5 3 0.3 1 0.1 1 0.1 1 0.1 3 0.3 3 0.3 2 0.2 3 0.3 3 0.3 3 0.3 2 0.2 Feasibility Community Acceptance Efficacy UW 15% UW 15% UW 35% 4 0.6 3 0.45 3 1.05 2 0.3 4 0.6 4 1.4 5 0.75 2 0.3 4 1.4 3 0.45 4 0.6 3 1.05 5 0.75 1 0.15 1 0.35 2 0.3 3 0.45 1 0.35 2 0.3 3 0.45 1 0.35 3 0.45 3 0.45 3 1.05 4 0.6 3 0.45 3 1.05 1 0.15 2 0.3 4 1.4 1 0.15 2 0.3 4 1.4 4 0.6 4 0.6 5 1.75 2 0.3 1 0.15 3 1.05 2 0.3 1 0.15 2 0.7 3 0.45 3 0.45 2 0.7 4 0.6 2 0.3 2 0.7 4 0.6 4 0.6 2 0.7 4 0.6 3 0.45 1 0.35 4 0.6 4 0.6 2 0.7 Tufts University, Dept. of Civil & Environmental Engineering Sustainability Total Rating UW 25% (Max:5) 3 0.75 3.15 3 0.75 3.25 1 0.25 3.00 3 0.75 3.35 1 0.25 2.00 1 0.25 1.75 2 0.5 2.00 3 0.75 3.20 2 0.5 2.90 5 1.25 3.20 4 1 2.95 5 1.25 4.30 2 0.5 2.30 2 0.5 1.95 3 0.75 2.55 3 0.75 2.65 3 0.75 2.95 4 1 2.70 4 1 3.10 21 Snail Control: Reducing the amount of snails in the river Type of Intervention Specific Intervention Increase Predators Cost - Purchase cost Monitoring 4 Increase Direct Snail Competitors -Purchase cost -Monitoring 4 Biological Controls Plants- for Shade -Purchase cost -Monitoring 5 -Labor Plants-in Water 3 Sustainability - Talapia already present in the water, problem persists 1 -Acuta already present, Bulinus still present -Rebalancing effect of nature, would force restocking of competitors 2 -Depends on community education that trees need to protect river from becoming hospitable to plants that snails live on 3 -Need to constantly “weed” entire watershed 2 Community Acceptance People eat snails from the river, must be Bulinus specific 3 Unknown, likely to be neutral 3 High, restoration efforts good, some farmers close to rivers may oppose 3 Plants are part of river ecosystem 3 Efficacy Feasibility - Must teach people Low, ecologically to not eat the impractical predatory fish 1 2 Low, plant and algal food source would need to be highly degraded -Predators of competitors would be attracted to rivers 1 2 High, areas with less plants had few to no snails -Deforestation on banks could quickly revert situation to present conditions 3 3 Plants provide part of the surface snails live on, -Would expose branches and workers to river other submerged -Safety issues surfaces would need to be removed as well 3 Tufts University, Dept. of Civil & Environmental Engineering Total Weighted Score 1.75 2.00 3.20 2.90 4 22 Type of Intervention Specific Intervention Increase slope of channel Cost Labor: Construction: Overhead: Design: Volunteered 1 Increase Velocity – River Alteration Reduce Crosssectional area Labor: Construction: Overhead: Design: Volunteered 1 Increase Input through Restoring Original Flow or Modified Flow Labor: Construction: Overhead: Design: Volunteered 1 Herbicide -Purchase cost -Labor to apply 3 Sustainability Community Acceptance High, permanent structure - Need partnership with mining co. - Mining operations to resume June 04 -Reduces recreational use of river -Massive earth moving work may be opposed High, targets snail habitat 2 4 1 High, targets snail habitat - Mining co. has access to equipment and experience altering rivers -may interfere with river uses 5 -High, permanent structure -May require routine maintenance 4 -High, permanent features -Community & Government Vigilance in protection of river 5 - Need to continually reapply 2 Chemical Controls Mollusicide -Purchase cost -Labor 3 - Need to continually reapply 2 -Reduces recreational use of river -may impede water gathering - Need partnership with mining co. Efficacy 2 - Need partnership with mining co. - Support from some Assembly men and farmers 4 High, targets snail habitat 4 -Very low -Water supply would be contaminated with herbicides - Mining co. has access to equipment and experience altering rivers - Construction already done on Abudusu -Difficult to implement - Mining co. has access to equipment and experience altering the specific rivers -Dependent on Mining Co. Compliance 4 -High, depending on dose -Pesticide application could negatively impact agriculture on farms 3 2 -Neutral, dosages commonly used are ineffective to control snail population 1 Tufts University, Dept. of Civil & Environmental Engineering 2 Total Weighted Score 3.20 2.95 1 5 1 -Low -Adding pesticide to public water supply Feasibility -Some snails are food source, would have to prevent contaminating food supply 4.30 2.30 1.95 2 23 Biological Controls Adding Terrestrial Plants for Shade – Shade reduces aquatic plant life in river, habitat of the snails – Competing land requirements from farmers near banks of river – Correlation between high shade and low/no snail population Harvesting Aquatic Plants Source: http://www.kauai-vacationrentals.com/shadesofgreen/100shades.htm – High labor demand – Competing growth surfaces reduce efficacy – Continual removal of aquatic plants will lower biological productivity of river – Kwabeng community view option as drastic Tufts University, Dept. of Civil & Environmental Engineering 24 Biological Controls Increase Snail Predator Population – Fishing of beneficial predators would limit snail reduction gains – Ecological equilibrium would require constant addition of fish to effectively reduce snail populations – Risk of unintended consequences of species introduction – Population monitoring costs high Increase Direct Snail Competitors – Competitive species could be local foods (certain snail species) – Ecological equilibrium between species will require excessive competitor population Tufts University, Dept. of Civil & Environmental Engineering 25 Chemical Controls Herbicide – Ineffective long term solution – Risk to farmers who irrigate from river water – Town water supply impacted Molluscicide – Requires 8 hour contact time with river – Temporary solution – If implemented incorrectly could increase chemical resistance of snails – Towns water supply impacted Tufts University, Dept. of Civil & Environmental Engineering 26 Increasing the River Velocity Increase slope channel – – – – Effective, but impractical Major earth moving needed Water supply weir would need to be removed Changes to the water supply system drastic Reduce Cross-Sectional Area – Entire river would need width contraction – high expense – Maintenance against erosion could be high, with seasonal storm and flood events – Community skeptical of option Tufts University, Dept. of Civil & Environmental Engineering 27 Increasing the River Velocity Increase Input Through River Restoration – Rejoin the Awusu and the Abodusu Rivers – Partnership with Mining Co. necessary • Earth moving equipment in hands of Mining Co. • Experience in river alterations – Highly effective – Desired by many in community Source: Charline Han Tufts University, Dept. of Civil & Environmental Engineering 28 Alternatives to Using the River Specific Intervention Public showers Wells Cost -construction costs -pay attendant -maintenance -water costs 2 - pay attendant -construction with machinery -maintenance 3 Public Taps -expand of water system -pay attendant -maintenance -water costs 3 Recreation Area -construction -maintenance 3 Expand Household Distribution System Feasibility -would need land -need to have water co. bring in pipes 3 Community Acceptance - Children should shower for free b/c they use latrines for free 3 -don’t know depth to water table 4 - People prefer to get water from river or taps 2 - 9 taps already exist in town 4 -Are supplies available in Ghana? - Many people use public taps - Children in charge of getting water pocket money and go to river 4 -would children use it? 4 3 - Ghana Water -pay water co. to Co Ltd. not expand cooperating with - Very expensive -water costs secondary -maintenance(?) school 2 3 4 Efficacy Sustainability Total -Must be coupled with other intervention -doesn’t prevent river use -workmanship and maintenance 2.55 2 -Must be coupled with other intervention -doesn’t prevent river use 3 -too much use could effect water table 2 3 - Must be coupled with other intervention -doesn’t prevent river use -water co. must maintain water system and quality 2 -Must be coupled with other intervention -doesn’t prevent river use 1 3 -workmanship and maintenance -Must be coupled with other intervention -doesn’t prevent river use -water co. must maintain water system and quality 2 4 Tufts University, Dept. of Civil & Environmental Engineering 2.65 2.95 2.70 4 2.95 29 Public Showers Construction, operation, and maintenance costs Adults would be willing to pay a small fee, but children would have to be free. Attendant needed for maintenance and up keep. Need cooperation with Ghana Water Ltd. Does not prevent river use Must be coupled with other interventions Tufts University, Dept. of Civil & Environmental Engineering 30 Public Wells Construction, operation, and maintenance costs Don’t know depth to water table Small fee for usage (1-2¢) Community is resistant to using wells because they are usually hand dug and the water does not come from the river Does not prevent river use Must be coupled with other interventions Source: Charline Han Tufts University, Dept. of Civil & Environmental Engineering 31 Tufts University, Dept. of Civil & Environmental Engineering 32 Public Taps Construction, operation, and maintenance costs Many taps already in town Small fee for usage (1-2¢) Does not prevent river use Must be coupled with other interventions Tufts University, Dept. of Civil & Environmental Engineering 33 Recreation Area Construction cost and constructability. – Are supplies available in Ghana? Will Children use it? Does not prevent river use Must be coupled with other interventions Tufts University, Dept. of Civil & Environmental Engineering 34 Expand Household Distribution System Implementation costs high as are recurring costs Not everyone has a “house” Requires cooperation of Ghana Water Ltd. Does not prevent river use Must be coupled with other interventions Tufts University, Dept. of Civil & Environmental Engineering 35 Schistosome Control: Reducing parasite population in snails Specific Intervention Medical treatment – Increase staff for existing school visit treatment system Cost Salary of nurse Feasibility - 1 nurse has outings to schools three times per week over entire district for many illnesses (including schisto) - Cooperation of Ghana Health Services that runs clinic - Physical space availability at clinic 3 Medical treatment – Monthly free schisto screening & drug distribution day Diagnosis - Salary for a team of nurses/DRs/lab techs for 1 day Treatment - Praziquantel: $1.33 per dose for adult, $0.66 per dose for children 4 - Commitment from health personnel 2 Reducing egg return to river from humans – latrines Construction - $2-3 per day cost of labor - Equipment costs - Capital costs for building materials O&M - $10-12 per month Income - Children use for free - $0.10 per use 2 - Access to construction equipment 3 Children - Cost of teacher/health care professional’s time Town-wide education campaign Adults 5 Do nothing - Makes people feel weak and anemic 5 5 - 5 Primary schools - Teachers are qualified to teach health issues - Hard to teach very young children - Difficult to bring adults together physically to educate them - Differing levels of education and understanding within the community 3 Community Acceptance - Committee supports increased assistance at clinic - Accountability is a concern 3 - Committee ID poverty as a barrier - Committee recognized difficulties in accessing drugs - focused screening 5 - Double the rate of screening - Students are required to self diagnose symptoms 3 - People are constantly reinfected - One dose treatment 4 4 - Public latrines exist in town – new set just built - Drug problem at latrines - Must be free for children - Cost discourages use - Eggs could be entering the river if not designed properly - Proximity to residences - Cost discourages use 2 4 - District commissioner very helpful - Not all children go to school - Adults don’t prioritize schistosomiasis - Community resistance to behavioral changes 4 - Invested in finding a solution to the problem - Feasible Efficacy 1 Tufts University, Dept. of Civil & Environmental Engineering - Constant reeducation necessary - Comprehensive education program could greatly reduce (re)infection rates 3 - Current interventions are not very effective 1 Sustainability - Long term funding needed - Follow up needed Total Weighted Rating 3.15 3 - Praziquantel gives little to no immunity - Reduces return of eggs to river 3.25 3 - Finite life span 3.00 1 - Constant reeducation process as children enter/leave school 3.35 - Constant reeducation necessary 3 - Hypothesize that incidence will increase 2.00 1 36 Medical Treatment-Increase Staff for Existing School Visit Treatment System Currently one nurse conducts school visits to evaluate children’s health Students are required to self-assess illnesses Town clinic run by Ghana Health Services, therefore requires cooperation Community questions current system’s accountability and supports increased assistance Long term monitoring needed Tufts University, Dept. of Civil & Environmental Engineering 37 Medical Treatment-Monthly Free Schistosomiasis Screening and Drug Distribution Days Salary of nurse, MDs, and lab techs Cost of Praziquantel (most common drug used for treatment) Reinfection rate a concern Medication does not confer immunity Reduces egg return to the river, thus breaking life cycle Tufts University, Dept. of Civil & Environmental Engineering 38 Latrines - Reducing Egg Return to River from Humans Construction, operation, and maintenance costs Small income generated because adults would pay to use latrines Latrines already exist in town and are not widely used because of their cost to the users Finite life span, therefore lacks sustainability Reduces egg return to the river, thus breaking life cycle Tufts University, Dept. of Civil & Environmental Engineering 39 Town-wide Education Campaign Two target populations: children and adults Cost of educated health personnel Behavioral changes are often difficult to implement and sustain Constant reeducation necessary Preventing schistosomiasis is Source: Charline Han not presently a priority in Kwabeng Tufts University, Dept. of Civil & Environmental Engineering 40 No Action Alternative Side effect of schistosomiasis is anemia, which makes people feel weak and decreases worker productivity Community is invested in working with us to find a solution Hypothesis that incidence rates on the rise Tufts University, Dept. of Civil & Environmental Engineering 41 Conclusions and Recommendations Top three interventions 1. Increase river velocity by river restoration 2. Town-wide education campaign 3. Monthly schistosomiasis screening and treatment days Interventions can be used in conjunction with each other – Lower scoring interventions can be used to supplement main intervention Tufts University, Dept. of Civil & Environmental Engineering 42 Future Work Ongoing – Locate sources of funding – Identify international partners Year 2 – In depth data collection on the recommended interventions and selection of the best intervention Year 3 – Design of selected intervention Year 4 – Implementation Year 5 – Monitoring and evaluation Tufts University, Dept. of Civil & Environmental Engineering 43 Acknowledgements Professors John Durant and David Gute Kwabena Kyei-Aboagye Dr. Kwame Boadu Kwabeng District Superintendent of Schools Professor Manu, University of Ghana Provost Bharucha Tufts University Center for Children Department of Civil and Environmental Engineering Tufts University, Dept. of Civil & Environmental Engineering 44