In a three-room schoolhouse in Nasarawa state, Nigeria, 60 students uniformed in faded pink shirts and khaki shorts and skirts are making their way to a private place in the high grass surrounding the school grounds. Clutched in each student’s hand are two clear vials with red caps. The load roar of a generator can be heard as the students return with their samples. With no light bulbs or outlets, the portable generator is not being used for the school itself, but rather to power two electronic microscopes sitting on plastic tables in one of the classrooms. The children hang through the frameless windows and cluster around the door to watch as a specialized unit of scientists and public health practitioners work together to analyze the contents of each and every vial.
These health professionals are members of a disease mapping team supported by the ENVISION project through The Carter Center in partnership with the Federal Ministry of Health. Their task is to determine the prevalence and intensity of soil transmitted helminthes (STH) and schistosomiasis (SCH) among school age children in the program area by examining samples of urine and stool.
This team is one among multiple mapping teams working to complete STH/SCH mapping across nine Nigerian states (Plateau, Nasarawa, Abia, Edo, Imo, Anambra, Enugu, Delta, and Ebonyi) by August 2013. This substantial effort is supported by USAID and the ENVISION project, with technical assistance from The Carter Center, and will serve to establish a disease baseline in preparation for mass drug administration (MDA). The mapping teams always include two microscopists, two lab technicians, a recorder, a health consultant from the state, and one or two program supervisors. A zonal coordinator from the Ministry of Education (MOE) is included to help inform and mobilize the targeted school.
Dr. Obiageli Nebe, FMOH Program Manager for STH and SCH in the FMOH, often joins the team in a supervisory capacity and reflects on the challenges the mapping teams face. Each day, teams aim to visit two schools, managing rough terrain and inclement weather in order to avoid delays.
Teams set up the mobile lab only at the second school of the day, so that samples from both schools are examined at once. Hookworm eggs begin to breakdown after four hours so examining stool samples on site and on time is important for accurate results.
A Day of Mapping
Upon arriving at a targeted school, all of the children from grades 3 through 6 are assembled together. Teachers help to count the children present and explain what is needed to retrieve the necessary samples to the students randomly assigned for testing.
Headmaster Philip Bayaro of Kubwaru Primary School reflects, “We realize how important it is to have a child healthy. Today he will be in school, but tomorrow he won’t be because he is too weak or sick. The success of a school depends on the health of the students.”
Once the children have been given their instructions, they stand in line to receive their vials and to be registered. Augustine Nwoye, a Senior Scientific Officer for the FMOH, is the recorder of this team and is responsible for registration and data entry. Augustine and all of the recorders working in the ENVISION-supported mapping project are using new advances in technology to streamline and revolutionize their work. Augustine places a barcode on each vial and then scans it using his Android phone. The number on this barcode will act as a unique identifier for the student as his or her samples are tested and the status is uploaded to a cloud database maintained by Global Health Task Force in Atlanta. There, the data is reviewed and cleaned before gaining final approval from the FMOH.
It is Augustine’s first time to use this technology. “We used do everything on paper forms which was a huge time constraint.” In similar assessments Augustine has participated in, all of the information was handwritten on forms and then double entered into computers once the mapping was complete. Now the data can be instantly cleaned and feedback is available if any mistakes come up while the mapping is underway. “We still keep a paper copy, just in case, but we are much more efficient now that we don’t have to enter them into a computer.”
Once the samples are collected, vials of urine are tested for S. hematobium with a special dipstick that measures blood levels in urine. Dr. Nebe holds up a few vials which speak for themselves. The urine inside is a pinkish crimson, possible evidence of heavy hematuria caused by this type of SCH.
The vials with the fecal samples are given to a team comprised of two microscopists and two lab technicians. The lab technicians, wearing gloves and surgical masks, prepare slides from the samples at one table which are then passed to the microscopists at the second table for further examination. Rita Urude, one of the team’s microscopists, spends two to three minutes looking over each slide for the eggs of S. Mansoni, roundworm (Ascaris lumbricoides), whipworm (Trichuris trichiura) and hookworms (Ancylostoma duodenale).
She spots eight S. Mansoni eggs in the slide sample with their tell-tale “spine” protruding from the top of each oval egg. In the same slide, Rita also finds numerous hookworm eggs. To give an idea of the intensity of infection this suggests, each slide contains a feces sample roughly the size of a pea.
The team usually examines more than a hundred samples per day and often do not return to their base of operation until late in the evening. Dr. Eigege, Program Manager from Plateau and Nassarawa state for The Carter Center comments, “The work can be exhausting and tedious. We go from early in the morning to the evening without stopping for lunch or even breaks. [For] anyone in public health, these are the challenges you face. You need people who are rugged and adapted to field work.” These teams recognize that expediency is necessary in this mapping initiative. The sooner the prevalence of a disease is understood, the sooner it can be targeted for treatment and enable these children to live happy, healthy lives.