1

CHAPTER ONE
1.0 Introduction
Communities in the tropics notably Africa South of the Sahara are still plaqued by a myriad of
infections and infestations. According to a report by World Health Organization (WHO), 2004.
A number of factors such as the insanitary living conditions, poor personal hygiene to mention
but a few account for this. Inappropriate Solid Waste Management is a major contributory factor
in the outbreak and spread of infections and infestations in the tropics (Amuda et al., 2014).
Communities in Africa both and rural are characterized by unsightly refuse heaps, unevacuated
waste, open dumps, street litters, clogged gutters etc. A common site in some coastal
communities is the indiscriminate defecation (improper management of human wastes) etc.
These wastes abound in and around dwelling places, markets, schools/ institutions, streets etc. As
a matter of fact, these human wastes are sometimes disposed in water in these communities
without fear of the repercussions because of the belief that water would get rid of the waste and
whatever is contained in it. Some human waste consists of helminth eggs, cysts of parasites and
bacteria etc. that could be a source of infections and infestations via the contamination e.g.
cholera, typhoid. Apart from faeces other wastes are dumped into water by residents of the
coastal communities (Kaoje et al., 2015). These too could serve as source of infections and
infestations to coastal community dwellers. Worthy of mention is the fact that these wastes
consist of substances that are capable of providing suitable habitats and breeding ground for
either disease - causing organisms/ agents as their vectors. Some of the vectors serve in the
mechanical or biological transmission of disease- causing organisms or agents which often
enhance the outbreak and spread of infections and infestations in communities (Olukanmi and
Akinyinka, 2012).
Infections according to Garcia (2009), is defined as the invasion and multiplication of organisms
such as bacteria, viruses, and parasites that are not normally present within the body. An
infection may remain localized or it may spread through the blood or lymphatic vessels to
become systemic (body wide). Microorganism that live naturally in the body are not considered
as infections for example, bacterial that normally live within the mouth and intestines are not
infections. Example of infection are common cold, severe acute respiratory syndrome (SARS),
Dengue, Hepatitis A, hand, foot and mouth disease.
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Infestations according to (Petrovska and Cekovsca, 2010), is defined as the condition of being
invaded or inhabited by ectoparasites such as lice, mites or ticks. The term infestation refers to
the parasitic diseases caused by animals such as arthropods (i.e. mites, ticks and lice) and worms
but excluding condition caused by protozoa, fungi, bacteria and virus which are called infections.
Infestations can also be defined as the presence of an unusually large number of insects or
animals in a place, typically to cause damage or disease.
Infections and infestations are similar in that they are both capable of causing illness or disease
to person. However, the difference between an infections and infestations is that infections are
caused by micro-organisms or germs like bacteria, protozoa and viruses while infestations is the
inflection by larger complex organisms than germs especially arthropods which reproduce on the
exterior surface of the body or invasion of the gastrointestinal tract by Parasitic worm (Reddy
and Fried, 2008).

1.1 Objective
The objective of this seminar was to highlight the role of proper Solid waste Management in the
control of community infections and infestations.
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CHAPTER TWO
2.0 Some Community Infections and Infestations
2.1 Community Infections
Several Community infections exist, however common Community infections in the tropical
Africa include malaria, lymphatic filariasis (elephantiasis), yellow fever, typhoid, cholera,
amoebic dysentery, Lassa fever etc (Lozano et al., 2012).

2.1.1 Malaria
Malaria is a mosquito-borne infectious disease that affects humans and other animals. Malaria
causes symptoms that typically include fever, tiredness, vomiting, and headaches. In severe
cases, it can cause yellow skin, seizures, coma, or death. Symptoms usually begin ten to fifteen
days after being bitten by an infected mosquito. If not properly treated, people may have
recurrences of the disease months later. Malaria is caused by single-celled microorganisms of the
Plasmodium group. The disease is most commonly spread by an infected female Anopheles
mosquito. The mosquito bite introduces the parasites from the mosquito's saliva into a person's
blood. The parasites travel to the liver where they mature and reproduce. Five species of
Plasmodium can infect and be spread by humans. Most deaths are caused by P. falciparum,
whereas P. vivax, P. ovale, and P. malariae generally cause a milder form of malaria. The
species P. knowlesi rarely causes disease in humans (Barman, 2012).
The risk of disease can be reduced by preventing mosquito bites through the use of mosquito nets
and insect repellents or with mosquito-control measures such as spraying insecticides and
draining standing water. Several medications are available to prevent malaria in travelers to areas
where the disease is common. Occasional doses of the combination medication sulfadoxine/
pyrimethamine are recommended in infants and after the first trimester of pregnancy in areas
with high rates of malaria. As of 2020, there is one vaccine which has been shown to reduce the
risk of malaria by about 40% in children in Africa (Fenwick, 2012).
The disease is widespread in the tropical and subtropical regions that exist in a broad band
around the equator. This includes much of sub-Saharan Africa, Asia, and Latin America. In
2019 there were 229 million cases of malaria worldwide resulting in an estimated 409,000
deaths. Approximately 94% of the cases and deaths occurred in Sub-Saharan Africa. Rates of
disease have decreased from 2010 to 2014 but increased from 2015 to 2019, during which there
 4

were 229 million cases. Malaria is commonly associated with poverty and has a significant
negative effect on economic development. In Africa, it is estimated to result in losses of US$12
billion a year due to increased healthcare costs, lost ability to work, and adverse effects on
tourism. Malaria is caused by Plasmodium parasites. The parasites are spread to people through
the bites of infected female Anopheles mosquitoes, called "malaria vectors." There are 5 parasite
species that cause malaria in humans, and 2 of these species – P. falciparum and P. vivax – pose
the greatest threat (Wang et al., 2016).
plate 1: Anophelles mosquito that transmit plate 2: Malaria Parasite
malaria parasite

Source: (Wang et al., 2016). Source: (Wang et al., 2016).

Symptoms
Malaria is an acute febrile illness. In a non-immune individual, symptoms usually appear 10–15
days after the infective mosquito bite. The first symptoms – fever, headache, and chills – may be
mild and difficult to recognize as malaria. If not treated within 24 hours, P. falciparum malaria
can progress to severe illness, often leading to death. Children with severe malaria frequently
develop one or more of the following symptoms: severe anaemia, respiratory distress in relation
to metabolic acidosis, or cerebral malaria. In adults, multi-organ failure is also frequent. In
malaria endemic areas, people may develop partial immunity, allowing asymptomatic infections
to occur (WHO, 2011a).
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Transmission
In most cases, malaria is transmitted through the bites of female Anopheles mosquitoes. There
are more than 400 different species of Anopheles mosquito; around 30 are malaria vectors of
major importance. All of the important vector species bite between dusk and dawn. The intensity
of transmission depends on factors related to the parasite, the vector, the human host, and the
environment. Anopheles mosquitoes lay their eggs in water, which hatch into larvae, eventually
emerging as adult mosquitoes. The female mosquitoes seek a blood meal to nurture their eggs.
Each species of Anopheles mosquito has its own preferred aquatic habitat; for example, some
prefer small, shallow collections of fresh water, such as puddles and hoof prints, which are
abundant during the rainy season in tropical countries. Transmission is more intense in places
where the mosquito lifespan is longer (so that the parasite has time to complete its development
inside the mosquito) and where it prefers to bite humans rather than other animals. The long
lifespan and strong human-biting habit of the African vector species is the main reason why
approximately 90% of the world's malaria cases are in Africa (WHO, 2005).
Transmission also depends on climatic conditions that may affect the number and survival of
mosquitoes, such as rainfall patterns, temperature and humidity. In many places, transmission is
seasonal, with the peak during and just after the rainy season. Malaria epidemics can occur when
climate and other conditions suddenly favour transmission in areas where people have little or no
immunity to malaria. They can also occur when people with low immunity move into areas with
intense malaria transmission, for instance to find work, or as refugees. Human immunity is
another important factor, especially among adults in areas of moderate or intense transmission
conditions. Partial immunity is developed over years of exposure, and while it never provides
complete protection, it does reduce the risk that malaria infection will cause severe disease. For
this reason, most malaria deaths in Africa occur in young children, whereas in areas with less
transmission and low immunity, all age groups are at risk (Boss et al., 2016).

Prevention
Vector control is the main way to prevent and reduce malaria transmission. If coverage of vector
control interventions within a specific area is high enough, then a measure of protection will be
conferred across the community WHO recommends protection for all people at risk of malaria
with effective malaria vector control. Two forms of vector control – insecticide-treated mosquito
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nets and indoor residual spraying – are effective in a wide range of circumstances (Ravina,
2011).

Insecticide-Treated Mosquito Nets

Sleeping under an insecticide-treated net (ITN) can reduce contact between mosquitoes and
humans by providing both a physical barrier and an insecticidal effect. Population-wide
protection can result from the killing of mosquitoes on a large scale where there is high access
and usage of such nets within a community. In 2019, an estimated 46% of all people at risk of
malaria in Africa were protected by an insecticide-treated net, compared to 2% in 2000.
However, ITN coverage has been at a standstill since 2016. Indoor spraying with residual
insecticides. Indoor residual spraying (IRS) with insecticides is another powerful way to rapidly
reduce malaria transmission. It involves spraying the inside of housing structures with an
insecticide, typically once or twice per year. To confer significant community protection, IRS
should be implemented at a high level of coverage (Sold and Holland, 2011).

Antimalarial Drugs
Antimalarial medicines can also be used to prevent malaria. For travelers, malaria can be
prevented through chemoprophylaxis, which suppresses the blood stage of malaria infections,
thereby preventing malaria disease. For pregnant women living in moderate-to-high transmission
areas, WHO recommends at least 3 doses of intermittent preventive treatment with sulfadoxine-
pyrimethamine at each scheduled antenatal visit after the first trimester. Similarly, for infants
living in high-transmission areas of Africa, 3 doses of intermittent preventive treatment with
sulfadoxine-pyrimethamine are recommended, delivered alongside routine vaccinations
(Litchtensteger et al., 1999).

Surveillance
Surveillance entails tracking of the disease and programmatic responses, and taking action based
on the data received. Currently, many countries with a high burden of malaria have weak
surveillance systems and are not in a position to assess disease distribution and trends, making it
difficult to optimize responses and respond to outbreaks. Effective surveillance is required at all
points on the path to malaria elimination. Stronger malaria surveillance systems are urgently
 7

needed to enable a timely and effective malaria response in endemic regions, to prevent
outbreaks and resurgences, to track progress, and to hold governments and the global malaria
community accountable (Fenwick, 2012).

Elimination
Malaria elimination is defined as the interruption of local transmission of a specified malaria
parasite species in a defined geographical area as a result of deliberate activities. Continued
measures are required to prevent re-establishment of transmission. Malaria eradication is defined
as the permanent reduction to zero of the worldwide incidence of malaria infection caused by
human malaria parasites as a result of deliberate activities. Interventions are no longer required
once eradication has been achieved (Lazano et al., 2012).

WHO Response
The WHO Global technical strategy for malaria 2016-2030 – adopted by the World Health
Assembly in May 2015 – provides a technical framework for all malaria-endemic countries. It is
intended to guide and support regional and country programmes as they work towards malaria
control and elimination. The Strategy sets ambitious but achievable global targets, including:
reducing malaria case incidence by at least 90% by 2030; reducing malaria mortality rates by at
least 90% by 2030; eliminating malaria in at least 35 countries by 2030; preventing a resurgence
of malaria in all countries that are malaria-free.

2.1.2 Lymphatic Filariasis

Lymphatic filariasis is a human disease caused by parasitic worms known as filarial worms.
Most cases of the disease have no symptoms. Some people, however, develop a syndrome called
elephantiasis, which is marked by severe swelling in the arms, legs, breasts, or genitals. The skin
may become thicker as well, and the condition may become painful. The changes to the body
have the potential to harm the person's social and economic situation. The worms are spread by
the bites of infected mosquitoes. Three types of worms are known to cause the disease:
Wuchereria bancrofti, Brugia malayi, and Brugia timori, with Wuchereria bancrofti being the
most common. These worms damage the lymphatic system. The disease is diagnosed by
microscopic examination of blood collected during the night (Jia et al., 2012). Prevention can be
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achieved by treating entire groups in which the disease exists, known as mass deworming. This
is done every year for about six years, in an effort to rid a population of the disease entirely.
Medications used include antiparasitics such as albendazole with ivermectin, or albendazole with
diethylcarbamazine. The medications do not kill the adult worms but prevent further spread of
the disease until the worms die on their own. Efforts to prevent mosquito bites are also
recommended, including reducing the number of mosquitoes and promoting the use of bed nets
(Albanese et al., 2001).

Plate 3: person infected by Lymphatic Filariasis

Source: (Albanese et al., 2001).

Cause and Transmission

Lymphatic filariasis is caused by infection with parasites classified as nematodes (roundworms)
of the family Filariodidea. There are 3 types of these thread-like filarial worms: Wuchereria
bancrofti, which is responsible for 90% of the cases, Brugia malayi, which causes most of the
remainder of the cases and Brugia timori, which also causes the disease. Adult worms nest in the
lymphatic vessels and disrupt the normal function of the lymphatic system. The worms can live
for approximately 6–8 years and, during their life time, produce millions of microfilariae
(immature larvae) that circulate in the blood. Mosquitoes are infected with microfilariae by
ingesting blood when biting an infected host. Microfilariae mature into infective larvae within
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the mosquito. When infected mosquitoes bite people, mature parasite larvae are deposited on the
skin from where they can enter the body. The larvae then migrate to the lymphatic vessels where
they develop into adult worms, thus continuing a cycle of transmission. Lymphatic filariasis is
transmitted by different types of mosquitoes for example by the Culex mosquito, widespread
across urban and semi-urban areas, Anopheles, mainly found in rural areas, and Aedes, mainly in
endemic islands in the Pacific (Wu and Jones, 2000).

Symptoms
Lymphatic filariasis infection involves asymptomatic, acute, and chronic conditions. The
majority of infections are asymptomatic, showing no external signs of infection while
contributing to transmission of the parasite. These asymptomatic infections still cause damage to
the lymphatic system and the kidneys and alter the body's immune system. When lymphatic
filariasis develops into chronic conditions it leads to lymphoedema (tissue swelling) or
elephantiasis (skin/tissue thickening) of limbs and hydrocele (scrotal swelling). Involvement of
breasts and genital organs is common. Such body deformities often lead to social stigma and sub-
optimal mental health, loss of income-earning opportunities and increased medical expenses for
patients and their caretakers. The socioeconomic burdens of isolation and poverty are immense
(Hall et al., 2008). Acute episodes of local inflammation involving skin, lymph nodes and
lymphatic vessels often accompany chronic lymphoedema or elephantiasis. Some of these
episodes are caused by the body's immune response to the parasite. Most are the result of
secondary bacterial skin infection where normal defenses have been partially lost due to
underlying lymphatic damage. These acute attacks are debilitating, may last for weeks and are
the primary cause of lost wages among people suffering with lymphatic filariasis.

WHO Response
World Health Assembly resolution WHA50.29 encourages Member States to eliminate
lymphatic filariasis as a public health problem. In response, WHO launched its Global
Programme to Eliminate Lymphatic Filariasis (GPELF) in 2000. WHO’s strategy is based on 2
key components: stopping the spread of infection through large-scale annual treatment of all
eligible people in an area or region where infection is present; and alleviating the suffering
caused by lymphatic filariasis through provision of the recommended essential package of care.
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WHO now recommends the following MDA regimen in countries without onchocerciasis:
ivermectin (200 mcg/kg) together with diethylcarbamazine citrate (DEC) (6 mg/kg) and
albendazole (400 mg) in certain settings. The impact of MDA depends on the efficacy of the
regimen and the coverage (proportion of total population ingesting the medicines). MDA with
the two-medicine regimens have interrupted the transmission cycle when conducted annually for
at least 4–6 years with effective coverage of the total population at risk. Salt fortified with DEC
has also been used in a few unique settings to interrupt the transmission cycle.

2.1.3 Yellow Fever

Yellow fever is a viral disease of typically short duration. In most cases, symptoms include fever,
chills, loss of appetite, nausea, muscle pains – particularly in the back – and headaches.
Symptoms typically improve within five days. In about 15% of people, within a day of
improving the fever comes back, abdominal pain occurs, and liver damage begins causing yellow
skin. If this occurs, the risk of bleeding and kidney problems is increased. Yellow fever is an
acute viral haemorrhagic disease transmitted by infected mosquitoes. The "yellow" in the name
refers to the jaundice that affects some patients. Symptoms of yellow fever include fever,
headache, jaundice, muscle pain, nausea, vomiting and fatigue (Keiser and Utzinger, 2008).
The virus is endemic in tropical areas of Africa and Central and South America. Large epidemics
of yellow fever occur when infected people introduce the virus into heavily populated areas with
high mosquito density and where most people have little or no immunity, due to lack of
vaccination. In these conditions, infected mosquitoes of the Aedes aegypti species transmit the
virus from person to person. Yellow fever is prevented by an extremely effective vaccine, which
is safe and affordable. A single dose of yellow fever vaccine is sufficient to grant sustained
immunity and life-long protection against yellow fever disease (Fung and Cairncross, 2009).
Good supportive treatment in hospitals improves survival rates. There is currently no specific
anti-viral drug for yellow fever. The Eliminate Yellow Fever Epidemics (EYE) Strategy
launched in 2017 is an unprecedented initiative. With more than 50 partners involved, the EYE
partnership supports 40 at-risk countries in Africa and the Americas to prevent, detect, and
respond to yellow fever suspected cases and outbreaks. The partnership aims at protecting at-risk
populations, preventing international spread, and containing outbreaks rapidly. By 2026, it is
expected that more than 1 billion people will be protected against the disease (Bolbol, 1992).
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Plate 4: Aedes aegypti mosquito that causes yellow fever

Sources: (Bolbol, 1992).

Causes
Yellow fever virus spread by mosquitoes. The disease is caused by yellow fever virus and is
spread by the bite of an infected mosquito. It infects only humans, other primates, and several
types of mosquitoes. In cities, it is spread primarily by Aedes aegypti, a type of mosquito found
throughout the tropics and subtropics. The virus is an RNA virus of the genus Flavallia. A safe
and effective vaccine against yellow fever exists, and some countries require vaccinations for
travelers. Other efforts to prevent infection include reducing the population of the transmitting
mosquitoes. In areas where yellow fever is common, early diagnosis of cases and immunization
of large parts of the population are important to prevent outbreaks. Once a person is infected,
management is symptomatic; no specific measures are effective against the virus. Death occurs
in up to half of those who get severe disease. The disease originated in Africa and spread to
South America in the 17th century with the Spanish and Portuguese importation of enslaved
Africans from sub-Saharan Africa. Since the 17th century, several major outbreaks of the disease
have occurred in the Americas, Africa, and Europe. In the 18th and 19th centuries, yellow fever
was considered one of the most dangerous infectious diseases; numerous epidemics swept
through major cities of the US and in other parts of the world (Hagel and Giuati 2010).

Signs and Symptoms

Once contracted, the yellow fever virus incubates in the body for 3 to 6 days. Many people do
not experience symptoms, but when these do occur, the most common are fever, muscle pain
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with prominent backache, headache, loss of appetite, and nausea or vomiting. In most cases,
symptoms disappear after 3 to 4 days. A small percentage of patients, however, enter a second,
more toxic phase within 24 hours of recovering from initial symptoms. High fever returns and
several body systems are affected, usually the liver and the kidneys. In this phase people are
likely to develop jaundice (yellowing of the skin and eyes, hence the name ‘yellow fever’), dark
urine and abdominal pain with vomiting. Bleeding can occur from the mouth, nose, eyes or
stomach. Half of the patients who enter the toxic phase die within 7 - 10 days.

Transmission
The yellow fever virus is an arbovirus of the flavivirus genus and is transmitted by mosquitoes,
belonging to the Aedes and Haemogogus species. The different mosquito species live in different
habitats - some breed around houses (domestic), others in the jungle (wild), and some in both
habitats (semi-domestic). There are 3 types of transmission cycles: Sylvatic (or jungle) yellow
fever: In tropical rainforests, monkeys, which are the primary reservoir of yellow fever, are
bitten by wild mosquitoes of the Aedes and Haemogogus species, which pass the virus on to
other monkeys. Occasionally humans working or travelling in the forest are bitten by infected
mosquitoes and develop yellow fever. Intermediate yellow fever: In this type of transmission,
semi-domestic mosquitoes (those that breed both in the wild and around households) infect both
monkeys and people. Increased contact between people and infected mosquitoes leads to
increased transmission and many separate villages in an area can develop outbreaks at the same
time. This is the most common type of outbreak in Africa. Urban yellow fever: Large epidemics
occur when infected people introduce the virus into heavily populated areas with high density of
Aedes aegypti mosquitoes and where most people have little or no immunity, due to lack of
vaccination or prior exposure to yellow fever. In these conditions, infected mosquitoes transmit
the virus from person to person (Ziegelbaner et al. 2012).
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Prevention
Vaccination
Vaccination is the most important means of preventing yellow fever. The yellow fever vaccine is
safe, affordable and a single dose provides life-long protection against yellow fever disease. A
booster dose of yellow fever vaccine is not needed. Several vaccination strategies are used to
prevent yellow fever disease and transmission: routine infant immunization; mass vaccination
campaigns designed to increase coverage in countries at risk; and vaccination of travelers going
to yellow fever endemic areas. In high-risk areas where vaccination coverage is low, prompt
recognition and control of outbreaks using mass immunization is critical. It is important to
vaccinate most (80% or more) of the population at risk to prevent transmission in a region with a
yellow fever outbreak.

Vector control
The risk of yellow fever transmission in urban areas can be reduced by eliminating potential
mosquito breeding sites, including by applying larvicides to water storage containers and other
places where standing water collects. Both vector surveillance and control are components of the
prevention and control of vector-borne diseases, especially for transmission control in epidemic
situations. For yellow fever, vector surveillance targeting Aedes aegypti and other Aedes species
will help inform where there is a risk of an urban outbreak. Historically, mosquito control
campaigns successfully eliminated Aedes aegypti, the urban yellow fever vector, from most of
Central and South America. However, Aedes aegypti has re-colonized urban areas in the region,
raising a renewed risk of urban yellow fever. Mosquito control programmes targeting wild
mosquitoes in forested areas are not practical for preventing jungle (or sylvatic) yellow fever
transmission. Personal preventive measures such as clothing minimizing skin exposure and
repellents are recommended to avoid mosquito bites. The use of insecticide-treated bed nets is
limited by the fact that Aedes mosquitos bite during the daytime.

WHO Response
In 2016, two linked urban yellow fever outbreaks – in Luanda (Angola) and Kinshasa
(Democratic Republic of the Congo), with wider international exportation from Angola to other
countries, including China – have shown that yellow fever poses a serious global threat requiring
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new strategic thinking. The Eliminate Yellow Fever Epidemics (EYE) Strategy was developed to
respond to the increased threat of yellow fever urban outbreaks with international spread. Steered
by WHO, UNICEF, and Gavi, the Vaccine Alliance, EYE supports 40 countries and involves
more than 50 partners. The global EYE Strategy is guided by three strategic objectives: protect
at-risk populations. prevent international spread of yellow fever. contain outbreaks rapidly.
These objectives are underpinned by five competencies of success: affordable vaccines and
sustained vaccine market; strong political commitment at global, regional and country levels;
high-level governance with long-term partnerships; synergies with other health programmes and
sectors; and research and development for better tools and practices. The EYE strategy is
comprehensive, multi-component and multi-partner. In addition to recommending vaccination
activities, it calls for building resilient urban Centre’s, planning for urban readiness, and
strengthening the application of the International Health Regulations (2005).

2.1.4 Typhoid
Typhoid fever is a life-threatening infection caused by the bacterium Salmonella typhi. It is
usually spread through contaminated food or water. Once Salmonella typhi bacteria are eaten or
drunk, they multiply and spread into the bloodstream. Urbanization and climate change have the
potential to increase the global burden of typhoid. In addition, increasing resistance to antibiotic
treatment is making it easier for typhoid to spread through overcrowded populations in cities and
inadequate and/or flooded water and sanitation systems (Nakona et al. 2006).
Typhoid fever, also known as typhoid, is a disease caused by Salmonella serotype Typhi
bacteria. Symptoms may vary from mild to severe, and usually begin 6 to 30 days after exposure.
Often there is a gradual onset of a high fever over several days. This is commonly accompanied
by weakness, abdominal pain, constipation, headaches, and mild vomiting. Some people develop
a skin rash with rose colored spots. In severe cases, people may experience confusion. Without
treatment, symptoms may last weeks or months. Diarrhea is uncommon. Other people may carry
the bacterium without being affected, but they are still able to spread the disease to others.
Typhoid fever is a type of enteric fever, along with paratyphoid fever. Rose spots on the chest of
a person with typhoid fever. The bacterium enters the intestines, then invades the body through
M cells covering the Peyer's patches. Resident phagocytes then take up the bacteria and may
traffic it to distant locations, such as the mesenteric lymph nodes, and blood stream - causing a
 15

primary bacteremia. The bacteria in the blood stream may then reach and multiply in phagocyes
in the spleen, liver, and bone marrow. To transmit the disease, the bacteria re-seeds the intestinal
tract through bile in the gall bladder. The bacterium is then shed in the feces.

Symptoms
Salmonella typhi lives only in humans. Persons with typhoid fever carry the bacteria in their
bloodstream and intestinal tract. Symptoms include prolonged high fever, fatigue, headache,
nausea, abdominal pain, and constipation or diarrhea. Some patients may have a rash. Severe
cases may lead to serious complications or even death. Typhoid fever can be confirmed through
blood testing.

Epidemiology, Risk Factors, and Disease Burden

Improved living conditions and the introduction of antibiotics resulted in a drastic reduction of
typhoid fever morbidity and mortality in industrialized countries. In developing areas of Africa,
the Americas, South-East Asia and the Western Pacific regions, however, the disease continues
to be a public health problem. WHO estimates the global typhoid fever disease burden at 11-20
million cases annually, resulting in about 128 000–161 000 deaths per year. Typhoid risk is
higher in populations that lack access to safe water and adequate sanitation. Poor communities
and vulnerable groups including children are at highest risk.

Treatment
Typhoid fever can be treated with antibiotics. As resistance to antibiotics has emerged including
to fluoroquinolones, newer antibiotics such as cephalosporins and azithromycin are used in the
affected regions. Resistance to azithromycin has been reported sporadically but it is not common
as of yet. Even when the symptoms go away, people may still be carrying typhoid bacteria,
meaning they can spread it to others through their faeces. It is important for people being treated
for typhoid fever to do the following: Take prescribed antibiotics for as long as the doctor has
prescribed Wash their hands with soap and water after using the bathroom, and do not prepare or
serve food for other people. This will lower the chance of passing the infection on to someone
else (WHO, 2009a).
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Prevention
Typhoid fever is common in places with poor sanitation and a lack of safe drinking water.
Access to safe water and adequate sanitation, hygiene among food handlers and typhoid
vaccination are all effective in preventing typhoid fever. Two vaccines have been used for many
years to protect people from typhoid fever: an injectable vaccine based on the purified antigen
for people aged over 2 years a live attenuated oral vaccine in capsule formulation for people aged
over 5 years. These vaccines do not provide long-lasting immunity and are not approved for
children younger than 2 years old.
A new typhoid conjugate vaccine, with longer lasting immunity, was prequalified by WHO in
December 2017 for use in children from the age of 6 months. All travelers to endemic areas are
at potential risk of typhoid fever, although the risk is generally low in tourist and business
centres where standards of accommodation, sanitation and food hygiene are high. Typhoid fever
vaccination should be offered to travelers to destinations where the risk of typhoid fever is high.
The following recommendations will help ensure safety while travelling: Ensure food is properly
cooked and still hot when served. Avoid raw milk and products made from raw milk. Drink only
pasteurized or boiled milk Avoid ice unless it is made from safe water.
When the safety of drinking water is questionable, boil it or if this is not possible, disinfect it
with a reliable, slow-release disinfectant agent (usually available at pharmacies). Wash hands
thoroughly and frequently using soap, in particular after contact with pets or farm animals, or
after having been to the toilet. Wash fruits and vegetables carefully, particularly if they are eaten
raw. If possible, vegetables and fruits should be peeled (UNICEF and WHO, 2012).

WHO Response
In December 2017, WHO prequalified the first conjugate vaccine for typhoid. This new vaccine
has longer-lasting immunity than older vaccines, requires fewer doses and can be given to
children from the age of 6 months. This vaccine will be prioritized for countries with the highest
burden of typhoid disease. This will help reduce the frequent use of antibiotics for typhoid
treatment, which will slow the increase in antibiotic resistance in Salmonella typhi. In October
2017, the Strategic Advisory Group of Experts (SAGE) on immunization, which advises WHO,
recommended typhoid conjugate vaccines for routine use in children over 6 months of age in
typhoid endemic countries. SAGE also called for the introduction of typhoid conjugate vaccines
 17

to be prioritized for countries with the highest burden of typhoid disease or of antibiotic
resistance to Salmonella typhi.

Table 1: List of Vector-Borne Diseases, According to their Vector

The following table is a non-exhaustive list of vector-borne disease, ordered according to the
vector by which it is transmitted. The list also illustrates the type of pathogen that causes the
disease in humans.

VECTOR DISEASE CAUSED TYPE OF PATHOGEN

Mosquito Chikungunya Virus
Aedes Dengue Virus
Lymphatic filariasis Parasite
Rift Valley fever Virus
Yellow Fever Virus
Zika Virus

Anopheles Lymphatic filariasis Parasite

Malaria Parasite
Culex Japanese encephalitis Virus
Lymphatic filariasis Parasite
West Nile fever Virus
Aquatic snails Schistosomiasis (bilharziasis) Parasite
Blackflies Onchocerciasis (river blindness) Parasite
Fleas Plague (transmitted from rats to humans) Bacteria
Tungiasis Ectoparasite
Lice Typhus Bacteria
Louse-borne relapsing fever Bacteria
Sandflies Leishmaniasis Parasite
Sandfly fever (phlebotomus fever) Virus
Ticks Crimean-Congo haemorrhagic fever Virus
Lyme disease Bacteria
Relapsing fever (borreliosis) Bacteria
Rickettsial diseases (eg: spotted fever and Q Bacteria
fever) Virus
Tick-borne encephalitis Bacteria
Tularaemia
Triatome bugs Chagas disease (American trypanosomiasis) Parasite
Tsetse flies Sleeping sickness (African trypanosomiasis) Parasite
Source: WHO, 2005
 18

2.1.5 Cholera
Cholera is an infection of the small intestine by some strains of the bacterium Vibrio cholerae.
Symptoms may range from none, to mild, to severe. The classic symptom is large amounts of
watery diarrhea that lasts a few days. Vomiting and muscle cramps may also occur. Diarrhea can
be so severe that it leads within hours to severe dehydration and electrolyte imbalance. This may
result in sunken eyes, cold skin, decreased skin elasticity, and wrinkling of the hands and feet.
Dehydration can cause the skin to turn bluish. Symptoms start two hours to five days after
exposure. Cholera is caused by a number of types of Vibrio cholerae, with some types producing
more severe disease than others. It is spread mostly by unsafe water and unsafe food that has
been contaminated with human feces containing the bacteria. Undercooked seafood is a common
source. Humans are the only animal affected. Risk factors for the disease include poor sanitation,
not enough clean drinking water, and poverty. There are concerns that rising sea levels will
increase rates of disease. Cholera can be diagnosed by a stool test. A rapid dipstick test is
available but is not as accurate (WHO and UNICEF, 2004).

Plate 5: Vibrio cholerae that causes cholera

Source: (WHO and UNICEF, 2004).

 19

Symptoms
Cholera is an extremely virulent disease that can cause severe acute watery diarrhea. It takes
between 12 hours and 5 days for a person to show symptoms after ingesting contaminated food
or water. Cholera affects both children and adults and can kill within hours if untreated. Most
people infected with V. cholerae do not develop any symptoms, although the bacteria are present
in their faeces for 1-10 days after infection and are shed back into the environment, potentially
infecting other people. Among people who develop symptoms, the majority have mild or
moderate symptoms, while a minority develop acute watery diarrhea with severe dehydration.
This can lead to death if left untreated.

Mode of Transmission
Cholera transmission is closely linked to inadequate access to clean water and sanitation
facilities. Typical at-risk areas include peri-urban slums, and camps for internally displaced
persons or refugees, where minimum requirements of clean water and sanitation are not being
met. The consequences of a humanitarian crisis – such as disruption of water and sanitation
systems, or the displacement of populations to inadequate and overcrowded camps – can increase
the risk of cholera transmission, should the bacteria be present or introduced. Uninfected dead
bodies have never been reported as the source of epidemics. The number of cholera cases
reported to WHO has continued to be high over the last few years. During 2019, 923 037 cases,
1911 deaths were notified from 31 countries. The discrepancy between these figures and the
estimated burden of the disease is since many cases are not recorded due to limitations in
surveillance systems and fear of impact on trade and tourism (WHO, 2007).

Prevention and Control

Prevention methods against cholera include improved sanitation and access to clean water.
Cholera vaccines that are given by mouth provide reasonable protection for about six months.
They have the added benefit of protecting against another type of diarrhea caused by E. coli. The
primary treatment is oral rehydration therapy—the replacement of fluids with slightly sweet and
salty solutions. Rice-based solutions are preferred. Zinc supplementation is useful in children. In
severe cases, intravenous fluids, such as Ringer's lactate, may be required, and antibiotics may be
beneficial. Testing to see which antibiotic the cholera is susceptible to can help guide the choice.
 20

Cholera affects an estimated 3–5 million people worldwide and causes 28,800–130,000 deaths a
year. Although it is classified as a pandemic as of 2010, it is rare in high income countries.
Children are mostly affected. Cholera occurs as both outbreaks and chronically in certain areas.
Areas with an ongoing risk of disease include Africa and Southeast Asia. A multifaceted
approach is key to control cholera, and to reduce deaths. A combination of surveillance, water,
sanitation and hygiene, social mobilization, treatment, and oral cholera vaccines are used
(UNICEF and WHO, 2012).

Surveillance
Cholera surveillance should be part of an integrated disease surveillance system that includes
feedback at the local level and information-sharing at the global level. Cholera cases are detected
based on clinical suspicion in patients who present with severe acute watery diarrhea. The
suspicion is then confirmed by identifying V. cholerae in stool samples from affected patients.
Detection can be facilitated using rapid diagnostic tests (RDTs), where one or more positive
samples triggers a cholera alert. The samples are sent to a laboratory for confirmation by culture
or PCR. Local capacity to detect (diagnose) and monitor (collect, compile, and analyze data)
cholera occurrence, is central to an effective surveillance system and to planning control
measures. Countries affected by cholera are encouraged to strengthen disease surveillance and
national preparedness to rapidly detect and respond to outbreaks. Under the International Health
Regulations, notification of all cases of cholera is no longer mandatory. However, public health
events involving cholera must always be assessed against the criteria provided in the regulations
to determine whether there is a need for official notification (UN, 2010).

Water and Sanitation Interventions

The long-term solution for cholera control lies in economic development and universal access to
safe drinking water and adequate sanitation. Actions targeting environmental conditions include
the implementation of adapted long-term sustainable WASH solutions to ensure use of safe
water, basic sanitation and good hygiene practices in cholera hotspots. In addition to cholera,
such interventions prevent a wide range of other water-borne illnesses, as well as contributing to
achieving goals related to poverty, malnutrition, and education. The WASH solutions for
 21

cholera are aligned with those of the Sustainable Development Goals (SDG) (UNICEF and
WHO, 2012).

Treatment
Cholera is an easily treatable disease. The majority of people can be treated successfully through
prompt administration of oral rehydration solution (ORS). The WHO/UNICEF ORS standard
sachet is dissolved in 1 litre (L) of clean water. Adult patients may require up to 6 L of ORS to
treat moderate dehydration on the first day. Severely dehydrated patients are at risk of shock and
require the rapid administration of intravenous fluids. These patients are also given appropriate
antibiotics to diminish the duration of diarrhea, reduce the volume of rehydration fluids needed,
and shorten the amount and duration of V. cholerae excretion in their stool.
Mass administration of antibiotics is not recommended, as it has no proven effect on the spread
of cholera may contribute to antimicrobial resistance. Rapid access to treatment is essential
during a cholera outbreak. Oral rehydration should be available in communities, in addition to
larger treatment centres that can provide intravenous fluids and 24-hours care. With early and
proper treatment, the case fatality rate should remain below 1%. Zinc is an important adjunctive
therapy for children under 5, which also reduces the duration of diarrhea and may prevent future
episodes of other causes of acute watery diarrhea. Breastfeeding should also be promoted
(Albanese et al. 2001).

Hygiene Promotion and Social Mobilization

Health education campaigns, adapted to local culture and beliefs, should promote the adoption of
appropriate hygiene practices such as hand-washing with soap, safe preparation and storage of
food and safe disposal of the faeces of children. Funeral practices for individuals who die from
cholera must be adapted to prevent infection among attendees. Further, awareness campaigns
should be organized during outbreaks, and information should be provided to the community
about the potential risks and symptoms of cholera, precautions to take to avoid cholera, when
and where to report cases and to seek immediate treatment when symptoms appear. The location
of appropriate treatment sites should also be shared. Community engagement is key to long term
changes in behaviour and to the control of cholera.
 22

Oral Cholera Vaccines

Currently there are three WHO pre-qualified oral cholera vaccines (OCV): Dukoral®,
Shanchol™, and Euvichol-Plus®. All three vaccines require two doses for full protection.
Dukoral® is administered with a buffer solution that, for adults, requires 150 ml of clean water.
Dukoral can be given to all individuals over the age of 2 years. There must be a minimum of 7
days, and no more than 6 weeks, delay between each dose. Children aged 2 -5 require a third
dose. Dukoral® is mainly used for travellers. Two doses of Dukoral® provide protection against
cholera for 2 years. Shanchol™ and Euvichol-Plus® have the same vaccine formula, produced
by two different manufacturers. They do not require a buffer solution for administration. They
are given to all individuals over the age of one year. There must be a minimum of two weeks
delay between each dose of these two vaccines. Two doses of Shanchol™ and Euvichol-Plus®
provide protection against cholera at least for three years, while one dose provides short term
protection.

WHO Response
In 2014 the Global Task Force on Cholera Control (GTFCC), with its Secretariat based at WHO,
was revitalised. The GTFCC is a network of more than 50 partners active in cholera control
globally, including academic institutions, non-governmental organizations and United Nations
agencies. Through the GTFCC and with support from donors, WHO works to: promote the
design and implementation of global strategies to contribute to capacity development for cholera
prevention and control globally; provide a forum for technical exchange, coordination, and
cooperation on cholera-related activities to strengthen country capacity to prevent and control
cholera; support countries for the implementation of effective cholera control strategies and
monitoring of progress; disseminate technical guidelines and operational manuals; support the
development of a research agenda with emphasis on evaluating innovative approaches to cholera
prevention and control in affected countries; and increase the visibility of cholera as an important
global public health problem through the dissemination of information about cholera prevention
and control, and conducting advocacy and resource mobilization activities to support cholera
prevention and control at national, regional, and global level.
 23

2.1.6 Dysentery
The cause of dysentery is usually the bacteria Shigella, in which case it is known as shigellosis,
or the amoeba Entamoeba histolytica. Other causes may include certain chemicals, other
bacteria, other protozoa, or parasitic worms.t may spread between people. Risk factors include
contamination of food and water with feces due to poor sanitation. The underlying mechanism
involves inflammation of the intestine, especially of the colon (WHO, 2009a). Efforts to prevent
dysentery include hand washing and food safety measures while traveling in areas of high risk.
While the condition generally resolves on its own within a week, drinking sufficient fluids such
as oral rehydration solution is important. Antibiotics such as azithromycin may be used to treat
cases associated with travelling in the developing world. While medications used to decrease
diarrhea such as loperamide are not recommended on their own, they may be used together with
antibiotics. Shigella results in about 165 million cases of diarrhea and 1.1 million deaths a year
with nearly all cases in the developing world. In areas with poor sanitation nearly half of cases of
diarrhea are due to Entamoeba histolytica.

2.1.7 Lassa Fever

Lassa fever, also known as Lassa hemorrhagic fever (LHF), is a type of viral hemorrhagic fever
caused by the Lassa virus. Many of those infected by the virus do not develop symptoms. When
symptoms occur they typically include fever, weakness, headaches, vomiting, and muscle pains.
Less commonly there may be bleeding from the mouth or gastrointestinal tract. The risk of death
once infected is about one percent and frequently occurs within two weeks of the onset of
symptoms. Of those who survive, about a quarter have hearing loss, which improves within three
months in about half of these cases (Brird et al. 1986). The disease is usually initially spread to
people via contact with the urine or feces of an infected multimammate mouse. Spread can then
occur via direct contact between people. Diagnosis based on symptoms is difficult. Confirmation
is by laboratory testing to detect the virus's RNA, antibodies for the virus, or the virus itself in
cell culture. Other conditions that may present similarly include Ebola, malaria, typhoid fever,
and yellow fever. The Lassa virus is a member of the Arenaviridae family of viruses. There is no
vaccine. Prevention requires isolating those who are infected and decreasing contact with the
mice. Other efforts to control the spread of disease include having a cat to hunt vermin, and
storing food in sealed containers. Treatment is directed at addressing dehydration and improving
 24

symptoms. The antiviral medication ribavirin has been recommended, but evidence to support its
use is weak. Descriptions of the disease date from the 1950s. The virus was first described in
1969 from a case in the town of Lassa, in Borno State, Nigeria. Lassa fever is relatively common
in West Africa including the countries of Nigeria, Liberia, Sierra Leone, Guinea, and Ghana.
Lassa fever is an acute viral haemorrhagic illness caused by Lassa virus, a member of the
arenavirus family of viruses. Humans usually become infected with Lassa virus through
exposure to food or household items contaminated with urine or faeces of infected Mastomys
rats. The disease is endemic in the rodent population in parts of West Africa. Lassa fever is
known to be endemic in Benin, Ghana, Guinea, Liberia, Mali, Sierra Leone, Togo and Nigeria,
but probably exists in other West African countries as well. Person-to-person infections and
laboratory transmission can also occur, particularly in health care settings in the absence of
adequate infection prevention and control measures. Diagnosis and prompt treatment are
essential. The overall case-fatality rate is 1%. Among patients who are hospitalized with severe
clinical presentation of Lassa fever, case-fatality is estimated at around 15%. Early supportive
care with rehydration and symptomatic treatment improves survival. About 80% of people who
become infected with Lassa virus have no symptoms. 1 in 5 infections result in severe disease,
where the virus affects several organs such as the liver, spleen and kidneys (UN, 2010).

Plate 6: Mastomys Rat that causes lassa fever Plate 7: lassa fever virus

Source: (UN, 2010). Source: (UN, 2010).

 25

2.2 Community Infestations

Common community infestations in tropical Africa include ascariasis (round worms),
enterobiasis (pin worms), hook worms, pediculosis and lice infestations, scabies due to human
itch mite etc.

2.2.1 Ascariasis
Ascariasis is a disease caused by the parasitic roundworm Ascaris lumbricoides. Infections have
no symptoms in more than 85% of cases, especially if the number of worms is small. Symptoms
increase with the number of worms present and may include shortness of breath and fever in the
beginning of the disease. These may be followed by symptoms of abdominal swelling,
abdominal pain, and diarrhea. Children are most commonly affected, and in this age group the
infection may also cause poor weight gain, malnutrition, and learning problems. Infection occurs
by eating food or drink contaminated with Ascaris eggs from feces. The eggs hatch in the
intestines, the larvae burrow through the gut wall, and migrate to the lungs via the blood. There
they break into the alveoli and pass up the trachea, where they are coughed up and may be
swallowed. The larvae then pass through the stomach for a second time into the intestine, where
they become adult worms. It is a type of soil-transmitted helminthiasis and part of a group of
diseases called helminthiases (Sold and Holland, 2010).
Prevention is by improved sanitation, which includes improving access to toilets and proper
disposal of feces. Handwashing with soap appears protective. In areas where more than 20% of
the population is affected, treating everyone at regular intervals is recommended. Reoccurring
infections are common. There is no vaccine. Treatments recommended by the World Health
Organization are the medications albendazole, mebendazole, levamisole, or pyrantel pamoate.
Other effective agents include tribendimidine and nitazoxanide. About 0.8 to 1.2 billion people
globally have ascariasis, with the most heavily affected populations being in sub-Saharan Africa,
Latin America, and Asia. This makes ascariasis the most common form of soil-transmitted
helminthiasis. As of 2010 it caused about 2,700 deaths a year, down from 3,400 in 1990. Another
type of Ascaris infects pigs. Ascariasis is classified as a neglected tropical disease (WHO,
2009a).
 26

Helminthiasis Signs and Symptoms

In populations where worm infections are widespread, it is common to find that most people are
infected by a small number of worms, while a small number of people are heavily infected. This
is characteristic of many types of worm infections. Those people who are infected with only a
small number of worms usually have no symptoms.

Migrating Larvae
As larval stages travel through the body, they may cause visceral damage, peritonitis and
inflammation, enlargement of the liver or spleen, and an inflammation of the lungs. Pulmonary
manifestations take place during larval migration and may present as Loeffler's syndrome, a
transient respiratory illness associated with blood eosinophilia and pulmonary infiltrates with
radiographic shadowing.

Intestinal Blockage
Piece of intestine, blocked by worms, surgically removed from a 3-year-old boy in South Africa.
The worms can occasionally cause intestinal blockage when large numbers get tangled into a
bolus or they may migrate from the small intestine, which may require surgery. More than 796 A
lumbricoides. worms weighing up to 550 g [19 ounces] were recovered at autopsy from a 2-year-
old South African girl. The worms had caused torsion and gangrene of the ileum, which was
interpreted as the cause of death. The worms lack teeth. However, they can rarely cause bowel
perforations by inducing volvulus and closed loop obstruction (Berman, 2012).

Bowel Obstruction
Bowel obstruction may occur in up to 0.2 per 1000 per year. A worm may block the ampulla of
Vater, or go into the main pancreatic duct, resulting in acute pancreatitis with raised serum levels
of amylase and lipase. Occasionally, a worm can travel through the billiary tree and even into the
gallbladder, causing acute cholangitis or acute cholecystitis.

Prevention
 27

Prevention is by improved access to sanitation which includes the use of properly functioning
and clean toilets by all community members as one important aspect. Handwashing with soap
may be protective; however, there is no evidence it affects the severity of disease. Eliminating
the use of untreated human faeces as fertilizer is also important. In areas where more than 20%
of the population is affected treating everyone is recommended. This has a cost of about 2 to 3
cents per person per treatment. This is known as mass drug administration and is often carried
out among school-age children. or this purpose, broad-spectrum benzimidazoles such as
mebendazole and albendazole are the drugs of choice recommended by WHO.

2.2.2 Pinworm Infection

Pinworm infection, also known as enterobiasis, is a human parasitic disease caused by the
pinworm. The most common symptom is itching in the anal area. This can make sleeping
difficult. The period of time from swallowing eggs to the appearance of new eggs around the
anus is 4 to 8 weeks. Some people who are infected do not have symptoms. Pinworms
(Enterobius vermicularis), the disease is spread between people by pinworm eggs. The eggs
initially occur around the anus and can survive for up to three weeks in the environment. They
may be swallowed following contamination of the hands, food, or other articles. Those at risk are
those who go to school, live in a health care institution or prison, or take care of people who are
infected. Other animals do not spread the disease. Diagnosis is by seeing the worms which are
about one-centimetre-long or the eggs under a microscope. Treatment is typically with two doses
of the medications mebendazole, pyrantel pamoate, or albendazole two weeks apart. Everyone
who lives with or takes care of an infected person should be treated at the same time. ashing
personal items in hot water after each dose of medication is recommended. Good handwashing,
daily bathing in the morning, and daily changing of underwear can help prevent reinfection
(Burkhart and Burkhart, 2005). Pinworm infections commonly occur in all parts of the world.
They are the most common type of worm infection in the developed world. School-aged children
are the most commonly infected. In the United States about 20% of children will develop
pinworm at some point. Infection rates among high-risk groups may be as high as 50%. It is not
considered a serious disease. Pinworms are believed to have affected humans throughout history
(Nakano et al., 2006).
 28

Plate 8: image of pinworm Plate 9: Image of Pinworm

Source: (Nakano et al., 2006) Source: (Nakano et al., 2006)

Spread
Pinworm infection spreads through human-to-human transmission, by swallowing infectious
pinworm eggs. The eggs are hardy and can remain infectious in a moist environment for up to
three weeks, though in a warm dry environment they usually last only 1–2 days. They do not
tolerate heat well, but can survive in low temperatures: at −8 degrees Celsius (18 °F), two-thirds
of the eggs are still viable after 18 hours. After the eggs have been initially deposited near the
anus, they are readily transmitted to other surfaces through contamination. The surface of the
eggs is sticky when laid, and the eggs are readily transmitted from their initial deposit near the
anus to fingernails, hands, night-clothing and bed linen. From here, eggs are further transmitted
to food, water, furniture, toys, bathroom fixtures and other objects. Household pets often carry
the eggs in their fur, while not actually being infected. Dust containing eggs can become airborne
and widely dispersed when dislodged from surfaces, for instance when shaking out bed clothes
and linen. Consequently, the eggs can enter the mouth and nose through inhalation, and be
swallowed later. Although pinworms do not strictly multiply inside the body of their human host,
some of the pinworm larvae may hatch on the anal mucosa, and migrate up the bowel and back
into the gastrointestinal tract of the original host. This process is called retro-infection.
According to Burkhart (2005), when this retro-infection occurs, it leads to a heavy parasitic load
and ensures that the pinworm infestation continues. This statement is contradictory to a statement
by Caldwell, who contends that retro-infection is rare and not clinically significant. Despite the
limited, 13-week lifespan of individual pinworms, autoinfection (infection from the original host
to itself), either through the anus-to-mouth route or through retro infection, causes the pinworms
to inhabit the same host indefinitely (WHO, 2006).
 29

Life cycle
The life cycle begins with eggs being ingested. The eggs hatch in the duodenum (first part of the
small intestine). The emerging pinworm larvae grow rapidly to a size of 140 to 150 micrometres,
and migrate through the small intestine towards the colon. During this migration they moult
twice and become adults. Females survive for 5 to 13 weeks, and males about 7 weeks. The male
and female pinworms mate in the ileum (last part of the small intestine), where after the male
pinworms usually die, and are passed out with stool. The gravid female pinworms settle in the
ileum, caecum (beginning of the large intestine), appendix and ascending colon, where they
attach themselves to the mucosal and ingest colonic contents. Almost the entire body of a gravid
female becomes filled with eggs. The estimations of the number of eggs in a gravid female
pinworm ranges from about 11,000 to 16,000. The egg-laying process begins approximately five
weeks after initial ingestion of pinworm eggs by the human host. The gravid female pinworms
migrate through the colon towards the rectum at a rate of 12 to 14 centimetres per hour. They
emerge from the anus, and while moving on the skin near the anus, the female pinworms deposit
eggs either through (1) contracting and expelling the eggs, (2) dying and then disintegrating, or
(3) bodily rupture due to the host scratching the worm. After depositing the eggs, the female
becomes opaque and dies. The reason the female emerges from the anus is to obtain the oxygen
necessary for the maturation of the eggs (Petrovska and Cekovska, 2010).

Prevention
Pinworm infection cannot be totally prevented under most circumstances. This is due to the
prevalence of the parasite and the ease of transmission through soiled night clothes, airborne
eggs, contaminated furniture, toys and other objects. Infection may occur in the highest strata of
society, where hygiene and nutritional status are typically high. The stigma associated with
pinworm infection is hence considered a possible over-emphasis. Under ideal conditions, bed
covers, sleeping garments, and hand towels should be changed. Simple laundering of clothes and
linen disinfects them. Children should wear gloves while asleep, and the bedroom floor should
be kept clean. Food should be covered to limit contamination with dust-borne parasite eggs.
Household detergents have little effect on the viability of pinworm eggs, and cleaning the
bathroom with a damp cloth moistened with an antibacterial agent or bleach will merely spread
 30

the still-viable eggs. Similarly, shaking clothes and bed linen will detach and spread the eggs
(Litchtensteger et al., 1999).

2.2.3 Hookworm Infection

Hookworm infection is an infection by a type of intestinal parasite known as a hookworm.
Initially, itching and a rash may occur at the site of infection. Those only affected by a few
worms may show no symptoms. Those infected by many worms may experience abdominal
pain, diarrhea, weight loss, and tiredness. The mental and physical development of children may
be affected. Anemia may result. Ancylostoma duodenale (old world hookworm), Necator
americanus (new world hookworm) (WHO, 2006).
Two common hookworm infections in humans are ancylostomiasis and necatoriasis, caused by
the species Ancylostoma duodenale and Necator americanus respectively. Hookworm eggs are
deposited in the stools of infected people. If these end up in the environment, they can hatch into
larvae (immature worms), which can then penetrate the skin. One type can also be spread
through contaminated food. Risk factors include walking barefoot in warm climates, where
sanitation is poor. The disease can be prevented on an individual level by not walking barefoot in
areas where the disease is common. At a population level, decreasing outdoor defecation, not
using raw feces as fertilizer, and mass deworming is effective. Treatment is typically with the
medications albendazole or mebendazole for one to three days. Iron supplements may be needed
in those with anemia (Habbari et al., 2006).

Plate 10: Image of Hookworm

Source: (Habbari et al., 2006).

 31

Cause
Hookworm infections in humans include ancylostomiasis and necatoriasis. Ancylostomiasis is
caused by Ancylostoma duodenale, which is the more common type found in the Middle East,
North Africa, India, and (formerly) in southern Europe. Necatoriasis is caused by Necator
americanus, the more common type in the Americas, sub-Saharan Africa, Southeast Asia, China,
and Indonesia. Other animals such as birds, dogs, and cats may also be affected. A. tubaeforme
infects cats, A. caninum infects dogs, and A. braziliense and Uncinaria stenocephala infect both
cats and dogs. Some of these infections can be transmitted to humans.

Hookworm Life Cycle

The hookworm thrives in warm soil where temperatures are over 18 °C. They exist primarily in
sandy or loamy soil and cannot live in clay or muck. Rainfall averages must be more than 1000
mm (40 inches) a year for them to survive. Only if these conditions exist can the eggs hatch.
Infective larvae of N. americanus can survive at higher temperatures, whereas those of A.
duodenale are better adapted to cooler climates. Generally, they live for only a few weeks at
most under natural conditions, and die almost immediately on exposure to direct sunlight or
desiccation. Infection of the host is by the larvae, not the eggs. While A. duodenale can be
ingested, the usual method of infection is through the skin; this is commonly caused by walking
barefoot through areas contaminated with fecal matter. The larvae are able to penetrate the skin
of the foot, and once inside the body, they migrate through the vascular system to the lungs, and
from there up the trachea, and are swallowed. They then pass down the esophagus and enter the
digestive system, finishing their journey in the intestine, where the larvae mature into adult
worms. Once in the host gut, Necator tends to cause a prolonged infection, generally 1 to 5 years
(many worms die within a year or two of infecting), though some adult worms have been
recorded to live for 15 years or more (Mas arini-Serra, 2011).
 32

Plate 11: Life cycle of Hookworm

Source: (Mas arini-Serra, 2011).

WHO Strategy for Control

In 2001, delegates at the World Health Assembly unanimously endorsed a resolution
(WHA54.19) urging endemic countries to start seriously tackling worms, specifically
schistosomiasis and soil-transmitted helminths. The strategy for control of soil-transmitted
helminth infections is to control morbidity through the periodic treatment of at-risk people living
in endemic areas. WHO recommends periodic medicinal treatment (deworming) without
previous individual diagnosis to all at-risk people living in endemic areas. This intervention
reduces morbidity by reducing the worm burden. In addition, health and hygiene education
reduces transmission and reinfection by encouraging healthy behaviours; and provision of
adequate sanitation is also important but not always possible in resource-poor settings.
Periodically treatment aims to reduce and maintain the intensity of infection, and to protect
infected at-risk populations from morbidity. Deworming can be easily integrated with child
health days or supplementation programmes for preschool children, or integrated with school
health programmes. In 2018, over 676 million school-aged children were treated with
anthelminthic medicines in endemic countries, corresponding to 53% of all children at risk.

WHO Recommended Medicines

The WHO recommended medicines –albendazole (400 mg) and mebendazole (500 mg) – are
effective, inexpensive and easy to administer by non-medical personnel (e.g. teachers). They
have been through extensive safety testing and have been used in millions of people with few
 33

and minor side-effects. Both albendazole and mebendazole are donated to national ministries of
health through WHO in all endemic countries for the treatment of all children of school age.
Ivermectin for the control of S. stercoralis is expected to be available at affordable price from
2021.

2.2.4 Pediculosis
Pediculosis is an infestation of lice (blood-feeding ectoparasitic insects of the order
Phthiraptera). The condition can occur in almost any species of warm-blooded animal (i.e.
mammals and birds), including humans. Although pediculosis in humans may properly refer to
lice infestation of any part of the body, the term is sometimes used loosely to refer to pediculosis
capitis, the infestation of the human head with the specific head louse (Gunning et al., 2012).
Plate 12: human lice

Source: (Gunning et al., 2012).

Classification
Pediculosis may be divided into the following types: Pediculosis capitis (Head lice infestation),
Pediculosis corporis (Pediculosis vestimenti, Vagabond's disease) and Pediculosis pubis (Crabs)

Head Lice: Pediculosis Capitis

Pediculosis in the head of a 6-year-old boy caused by the head louse, as confirmed by optical (c)
and electron microscopy (d). Head-lice infestation is most frequent on children aged 3–10 and
their families. Approximately 3% of school children in the United States contract head lice.
Females aged 3–12 years are most commonly infested. Those of African descent rarely suffer
infestation due to differences in hair texture. Head lice are spread through direct head-to-head
contact with an infected person. From each egg or "nit" may hatch one nymph that will grow and
develop to the adult louse. Lice feed on blood once or more often each day by piercing the skin
 34

with their tiny needle-like mouthparts. While feeding they excrete saliva, which irritates the skin
and causes itching (Verma am Namdeo, 2015).

Body Lice: Pediculosis Corporis

This condition is caused by body louse (Pediculus humanus humanus, sometimes called
Pediculus humanus corporis), a louse which infests humans and is adapted to lay eggs in
clothing, rather than at the base of hairs, and is thus of recent evolutionary origin. Pediculosis is a
more serious threat due to possible contagion of diseases such as typhus. Epidemiology and
treatment of human body lice is described in the article on body lice.

Pubic Lice: Pediculosis Pubis

The pubic or crab louse (Pthirus pubis) is a parasitic insect which spends its entire life on human
hair and feeds exclusively on blood. Humans are the only known host of this parasite, although it
is more closely related to the louse parasites in other primate species, than are human head or
body lice which probably evolved from it as the "original" louse infestation of humans.
Epidemiology and treatment of pubic lice is discussed in the article on pubic lice.

Other Animals
Pediculosis is more common in cattle than any other type of domesticated animal. This is a
significant problem, as it can cause weight loss of 55 to 75 pounds per animal. Some species of
lice infesting cattle include the cattle biting louse (Bovicola bovis), the shortnosed cattle louse
(Haematopinus eurysternus), the longnosed cattle louse (Linognathus vituli), and the little blue
cattle louse (Solenopotes capillatus) (Maunder, 1983).

UKNHS and AHA Report

The United Kingdom's National Health Service, and many American health agencies report that
lice "prefer" clean hair, because it's easier to attach eggs and to cling to the strands. Head lice
(Pediculus humanus capitis) are not known to be vectors of diseases, unlike body lice (Pediculus
humanus humanus), which are known vectors of epidemic or louse-borne typhus (Rickettsia
 35

prowazekii), trench fever (Rochalimaea quintana) and louse-borne relapsing fever (Borrelia
recurrentis).

2.2.5 Scabies
Scabies (also known as the seven-year itch is a contagious skin infestation by the mite Sarcoptes
scabiei. The most common symptoms are severe itchiness and a pimple-like rash. Occasionally,
tiny burrows may appear on the skin. In a first-ever infection, the infected person will usually
develop symptoms within two to six weeks. During a second infection, symptoms may begin
within 24 hours. These symptoms can be present across most of the body or just certain areas
such as the wrists, between fingers, or along the waistline. The head may be affected, but this is
typically only in young children. The itch is often worse at night. Scratching may cause skin
breakdown and an additional bacterial infection in the skin (Grumming et al. 2012).
Scabies is caused by infection with the female mite Sarcoptes scabiei var. hominis, an
ectoparasite. The mites burrow into the skin to live and deposit eggs. The symptoms of scabies
are due to an allergic reaction to the mites. Often, only between 10 and 15 mites are involved in
an infection. Scabies is most often spread during a relatively long period of direct skin contact
with an infected person (at least 10 minutes) such as that which may occur during sex or living
together. Spread of the disease may occur even if the person has not developed symptoms yet.
Crowded living conditions, such as those found in child-care facilities, group homes, and
prisons, increase the risk of spread. Areas with a lack of access to water also have higher rates of
disease. Crusted scabies is a more severe form of the disease. It typically only occurs in those
with a poor immune system and people may have millions of mites, making them much more
contagious. In these cases, spread of infection may occur during brief contact or by contaminated
objects. The mite is very small and usually not directly visible. A number of medications are
available to treat those infected, including permethrin, crotamiton, and lindane creams and
ivermectin pills. Sexual contacts within the last month and people who live in the same house
should also be treated at the same time. Bedding and clothing used in the last three days should
be washed in hot water and dried in a hot dryer. As the mite does not live for more than three
days away from human skin, more washing is not needed. Symptoms may continue for two to
four weeks following treatment. If after this time symptom continue, retreatment may be needed
(Stermer et al., 2009).
 36

Scabies is one of the three most common skin disorders in children, along with ringworm and
bacterial skin infections. As of 2015, it affects about 204 million people (2.8% of the world
population). It is equally common in both sexes. The young and the old are more commonly
affected. It also occurs more commonly in the developing world and tropical climates. The word
scabies is from Latin: scabere, 'to scratch'. Other animals do not spread human scabies. Infection
in other animals is typically caused by slightly different but related mites and is known as
sarcoptic mange.

Plate 13: infected skin with scabies

Source: (Stermer et al., 2009).

Signs and Symptoms

The characteristic symptoms of a scabies infection include intense itching and superficial
burrows. Because the host develops the symptoms as a reaction to the mites' presence over time,
typically a delay of four to six weeks occurs between the onset of infestation and the onset of
itching. Similarly, symptoms often persist for one to several weeks after successful eradication of
the mites. As noted, those re-exposed to scabies after successful treatment may exhibit symptoms
of the new infestation in a much shorter period—as little as one to four days. In most people, the
trails of the burrowing mites are linear or S-shaped tracks in the skin often accompanied by rows
of small, pimple-like mosquito or insect bites. These signs are often found in crevices of the
body, such as on the webs of fingers and toes, around the genital area, in stomach folds of the
skin, and under the breasts of women. Symptoms typically appear two to six weeks after
infestation for individuals never before exposed to scabies. For those having been previously
 37

exposed, the symptoms can appear within several days after infestation. However, symptoms
may appear after several months or years (Horak, 1992).

Crusted scabies
Crusted scabies in a Person with AIDS
The elderly, disabled, and people with an impaired immune system, such as those with
HIV/AIDS, cancer, or those on immunosuppressive medications, are susceptible to crusted
scabies (also called Norwegian scabies). On those with weaker immune systems, the host
becomes a more fertile breeding ground for the mites, which spread over the host's body, except
the face. The mites in crusted scabies are not more virulent than in noncrusted scabies; however,
they are much more numerous (up to two million). People with crusted scabies exhibit scaly
rashes, slight itching, and thick crusts of skin that contain large numbers of scabies mites. For
this reason, persons with crusted scabies are more contagious to others than those with typical
scabies. Such areas make eradication of mites particularly difficult, as the crusts protect the mites
from topical miticides/scabicides, necessitating prolonged treatment of these areas.

Transmission
Scabies is contagious and can be contracted through prolonged physical contact with an infected
person. This includes sexual intercourse, although a majority of cases are acquired through other
forms of skin-to-skin contact. Less commonly, scabies infestation can happen through the
sharing of clothes, towels, and bedding, but this is not a major mode of transmission; individual
mites can survive for only two to three days, at most, away from human skin at room
temperature. As with lice, a latex condom is ineffective against scabies transmission during
intercourse, because mites typically migrate from one individual to the next at sites other than the
sex organs. Healthcare workers are at risk of contracting scabies from patients, because they may
be in extended contact with them.

Prevention
Mass-treatment programs that use topical permethrin or oral ivermectin have been effective in
reducing the prevalence of scabies in a number of populations. No vaccine is available for
scabies. The simultaneous treatment of all close contacts is recommended, even if they show no
 38

symptoms of infection (asymptomatic), to reduce rates of recurrence. Since mites can survive for
only two to three days without a host, other objects in the environment pose little risk of
transmission except in the case of crusted scabies.

Management
A number of medications are effective in treating scabies. Treatment should involve the entire
household, and any others who have had recent, prolonged contact with the infested individual.
Options to control itchiness include antihistamines and prescription anti-inflammatory agents.
Bedding, clothing and towels used during the previous three days should be washed in hot water
and dried in a hot dryer.

Permethrin
Permethrin, a pyrethroid insecticide, is the most effective treatment for scabies, and remains the
treatment of choice. It is applied from the neck down, usually before sleep, and left on for about
eight to 14 hours, then washed off in the morning. Care should be taken to coat the entire skin
surface, not just symptomatic areas; any patch of skin left untreated can provide a "safe haven"
for one or more mites to survive. One application is normally sufficient, as permethrin kills eggs
and hatchlings, as well as adult mites, though many physicians recommend a second application
three to seven days later as a precaution. Crusted scabies may require multiple applications, or
supplemental treatment with oral ivermectin (below). Permethrin may cause slight irritation of
the skin that is usually tolerable.

Ivermectin
Oral ivermectin is effective in eradicating scabies, often in a single dose. It is the treatment of
choice for crusted scabies, and is sometimes prescribed in combination with a topical agent. It
has not been tested on infants, and is not recommended for children under six years of age.
Topical ivermectin preparations have been shown to be effective for scabies in adults, though
only one such formulation is available in the United States at present, and it is not FDA-
approved as a scabies treatment. It has also been useful for sarcoptic mange (the veterinary
analog of human scabies). One review found that the efficacy of permethrin is similar to that of
systemic or topical ivermectin. A separate review found that although oral ivermectin is usually
 39

effective for treatment of scabies, it does have a higher treatment failure rate than topical
permethrin. Another review found that oral ivermectin provided a reasonable balance between
efficacy and safety. Since ivermectin is more convenient than permethrin, many have turned to
veterinary sources of the drug to obtain assurance of a cure at an affordable price (WHO, 2009b).

Communities
Scabies is endemic in many developing countries, where it tends to be particularly problematic in
rural and remote areas. In such settings, community-wide control strategies are required to
reduce the rate of disease, as treatment of only individuals is ineffective due to the high rate of
reinfection. Large-scale mass drug administration strategies may be required where coordinated
interventions aim to treat whole communities in one concerted effort. Although such strategies
have shown to be able to reduce the burden of scabies in these kinds of communities, debate
remains about the best strategy to adopt, including the choice of drug. The resources required to
implement such large-scale interventions in a cost-effective and sustainable way are significant.
Furthermore, since endemic scabies is largely restricted to poor and remote areas, it is a public
health issue that has not attracted much attention from policy makers and international donors.

Scabies in animals: Sarcoptic mange and Acariasis

Scabies may occur in a number of domestic and wild animals; the mites that cause these
infestations are of different subspecies from the one typically causing the human form. These
subspecies can infest animals that are not their usual hosts, but such infections do not last long.
Scabies-infected animals suffer severe itching and secondary skin infections. They often lose
weight and become frail. The most frequently diagnosed form of scabies in domestic animals is
sarcoptic mange, caused by the subspecies Sarcoptes scabiei canis, most commonly in dogs and
cats. Sarcoptic mange is transmissible to humans who come into prolonged contact with infected
animals, and is distinguished from human scabies by its distribution on skin surfaces covered by
clothing. Scabies-infected domestic fowl suffer what is known as "scaly leg". Domestic animals
that have gone feral and have no veterinary care are frequently afflicted with scabies and a host
of other ailments. Nondomestic animals have also been observed to suffer from scabies. Gorillas,
for instance, are known to be susceptible to infection by contact with items used by humans
(WHO, 2009a).
 40

Plate 14: Infected dog with scabies

Source: (WHO, 2009a).

 41

CHAPTER THREE
3.0 Inappropriate Solid Waste Management and the Occurrence of Community
Infections and infestations
3.1 Waste as Breeding Ground for Disease Causing Organisms
The practice of indiscriminate and improper dumping of Municipal Solid Waste (MSW) is on the
increase in Agbowo and Bodija communities areas in particular and Nigeria in general and it is
compounded by a cycle of poverty, population explosion, decreasing standard of living, poor
governance and low level of environmental awareness, and the end product of it all is the
dumping of these waste in any available open space (Rachel et al. 2009). Abd’Razack et al. 2013
stated that it has been observed that because of poor or improper land use planning in some part
of many organically developed cities has results into the creation of informal settlement with
narrow streets, which makes it difficult for waste collection trucks to access such areas (Nabegu
2010; Swapan 2008). Waste are dumped into the drainages that block the free flow of runoff
water and this practice gives rise to flooding and the communities are adversely affected, some
people dumped their waste to the road side, thereby reducing the width of the road and esthetics
of the cities especially in Nigeria. This is evident as one walk across the nook and the crannies of
Nigeria; you find heaps of refuse littering the entire landscape, road sides, parks, gardens,
commercial centres and other land use (Danbuzu 2011; Imam et al. 2007; Amuda et al. 2014).
Waste as breeding ground for disease causing organisms or vectors of disease- causing
organisms/agents such as empty cans, water proofs, coconut hull, shells, bottles, jars, tyres etc.
serves as breeding ground for mosquitoes and decomposing waste are breeding grounds for filth
flies, bacteria, viruses etc. In addition, Olukanni and Akinyinka 2012 join other researchers to
conclude that there are potential risks to the environment and human health from improper
handling of solid wastes. Direct health risks concern mainly the workers in this field, who need
to be protected, as far as possible, from contact with wastes. This further reveals other
epidemiological studies that shows that a high percentage of workers who handle refuse, and of
individuals who live near or on disposal sites, are infected with gastrointestinal parasites, worms
and related organisms. Disease transmission by houseflies is greatest where inadequate refuse
storage, collection and disposal is accompanied by inadequate sanitation (Olukanni and
Akinyinka, 2012). The mountainous heaps of solid wastes that deface Nigerian cities and the
continuous discharges of industrial contaminants into streams and rivers without treatment
 42

motivated the federal government of Nigeria to promulgate Decree 58 for the establishment of a
Federal Environmental Protection Agency (FEPA) in 1988. Nevertheless, research studies since
1988 has generally revealed the bankruptcy of the FEPA establishment and how largely Nigeria
communities have suffered from poor environmental governance and the subsequent public
health challenges which has constituted great threats to the population health.

Plate 15: Open dump site

(Olukanni and Akinyinka, 2012)

3.2 Waste as Source of Food for pathogens and Other Vectors

Urban zoonoses, specifically those transmitted by rodent and canine reservoirs, are associated
with solid waste, especially when garbage accumulates over time creating burrowing sites and
food for reservoirs. In a review of neglected tropical diseases and their impact on global health
and development, Hotez states of zoonoses: “Of relevance to the NTDs, the poorest favelas do
not benefit from regular garbage collection or sewage treatment, thereby creating excellent
niches for rats and stray dogs.” Rodents and canines directly transmit disease of importance to
urban zoonosis. Solid waste accumulation is an important factor for urban rodent and canine
feeding and sheltering strategies and can be used as a proxy in the absence of reliable data on
rodent distribution in the city. Presence Bonfante-Cabarcas et al. (107) speculate that
accumulated garbage favors breeding of T. cruzi reservoirs (rats, mice, and opossum) and
provides long-term refuge with immediate food sources for insects to reproduce and colonize the
house for a long time, increasing the probability of intra-domiciliary vector transmission of T.
cruzi.
 43

3.3 Waste as Source of Contamination of Water

A wide range of chemicals can contaminate our water, land, or air, impacting the environment
and our health. Most contaminants enter the environment from industrial and commercial
facilities; oil and chemical spills; non-point sources such as roads, parking lots, and storm drains;
and wastewater treatment plants and sewage systems. Many hazardous waste sites and industrial
facilities have been contaminated for decades and continue to affect the environment.
Contaminants in the environment can look and smell pretty nasty, but their impacts go beyond
just aesthetics (WHO, 2012c). Harmful chemical pollution and excess nutrient runoff are serious
threats to the coastal environment. When contaminants threaten or harm aquatic species, make
them unsafe to eat, or degrade their habitat. Solid waste impacts water quality through the release
of leachate from landfills into water sources. As water comes in contact with decomposing solid
waste, it will dissolve together with soluble inorganic and organic wastes producing polluted
liquid known as leachate or waste juice. The concentration of leachate increases as it seeps into
deeper layers of the landfill; this contributes to the light brown/black colour of leachate and it's
horrible stench (which is pretty similar to the smell you get from our drains due to the rotting
waste that people have thrown in there). It has a high polluting potential impact due to its high
concentrations of organic contaminants and high ammonical nitrogen. Once leachate is
discharged into water bodies or/and aquatic environment, it will have an acute and chronic
impact. If toxic metals are present, this can lead to chronic toxin accumulation in organisms that
depend on it and may consequently affect humans if we feed on these organisms (e.g. fish,
prawns, crabs etc.), Waste as source of water contamination causes oral- faecal contamination,
dysentery, diarrhea, cholera etc. when used by human.
 44

CHAPTER FOUR
4.0 The Role of Appropriate Solid Waste Management in the Control of Community
Infections and Infestations
4.1 Solid Waste Management Methods in Control of Community Infections and
Infestations
Abul (2010) classified solid waste into different types, depending on their source; household
waste is generally classified as municipal waste, industrial waste as hazardous waste, and
biomedical waste or hospital waste as infectious waste. The term “solid waste” means any
garbage, refuse, or sludge from a waste treatment plant, water supply treatment plant, or air
pollution control facility and other discarded material, including solid, liquid, semisolid, or
contained gaseous material resulting from industrial, commercial, mining, and agricultural
operations (Salam Abul 2010; US Law-Solid Waste Act 2 1999). This wastes are disposed at the
very outskirts of the cities. Waste generated from households, shops, supermarkets, and open
market places are therefore termed as Municipal waste. This wastes are either properly disposed
in landfills, incinerators or open dumpsites. Salam (2010) further add that solid waste disposal
sites are found on the outskirts of the urban areas, turning into the child sources of contamination
due to the incubation and proliferation of flies, mosquitoes, and rodents; that, in turn, are disease
transmitters that affect population’s health, which has its organic defenses in a formative and
creative state. The said situation produces gastrointestinal, dermatological, respiratory, genetic,
and several other kind of infectious diseases (Salam, 2010).
However, increasing population levels, booming economy, rapid urbanization and the rise in
community living standards have greatly accelerated the municipal solid waste generation rate in
developing countries (Debnath et al. 2015; Minghua et al. 2009) and urban cities such as Ibadan
and Lagos. In the face of this increasing population levels and rapid urbanization, the major
urban environmental concerns- municipal waste management, sanitation and associated adverse
health impacts- the increased urbanization with large population density can further intensify
these concerns, unless we take urgent effective steps to improve sanitation and solid waste
management. In the words of Debnath et al. (2015) and Taylor (2003), landfilling is the simplest
and normally cheapest method for disposing of waste. However, this claim may not be true for
waste management methods in developed countries. For instance, landfilling is a very expensive
method of managing waste in industrialized countries like China, Netherlands and Germany
 45

(Lam and Chaudry 2005). Improper management of municipal waste has become one of the
problems facing developing urban cities across the world. Little attention is given to waste
management practices as it is common to see heaps of waste in the major cities littering the
streets, dumped indiscriminately in drainages, vacant plots and open space especially in the
developing cities and our study areas in particular. This has contributed not only to the spread of
communicable diseases in the affected areas; it has effect on flooding and other environmental
problems (Abd’Razack et al. 2013; Babalola et al. 2010; Wilson et al. 2009). A typical solid
waste management system in developing countries displays an array of problems among which
include low collection coverage and irregular collection services (Abd’Razack et al. 2013;
Nwaka 2005; Omran et al. 2007).

4.2 Strategies that Should Be Adopted in the Control of Community Infections and
Infestations
4.2.1 The Global Burden of Infectious Disease
In 2008, a total of 8.8 million children died before their fifth birthday – half of them in Sub-
Saharan Africa. Pneumonia, diarrhea, malaria, HIV/AIDS and measles caused 44% of these
deaths in children under five years. Newborn deaths from sepsis and tetanus in the first four
weeks of life accounted for a further 7%, and many of the 17% of deaths attributed to ‘other
causes’ were also due to infection, including TB and meningitis exacerbated by malnutrition,
which contributes to over one-third of all child deaths. (Note that the ‘non-infectious neonatal
causes’ depicted in the figure refer to deaths resulting from prematurity, birth asphyxia, trauma
and congenital abnormalities.) (Ye-Obong and Uduak, 2013).

4.2.2 The Public Health Approach

The term public health refers to the ‘science and art of preventing disease, prolonging life, and
promoting health’ and encompasses everything affecting the health of a population as a whole,
rather than the individuals of which it is composed. A population may be all members of a nation
or geographical region, or a defined group, for example all children under five years of age, all
members of a minority ethnic group, or all women during the potential childbearing years. Public
health is also concerned with non-communicable diseases, for example cancers, cardiovascular
diseases and diabetes.
 46

4.2.3 Levels of Infectious Disease Prevention

The prevention of disease obviously has a potentially greater impact on public health than
medical treatment, although – with the exception of vaccination programmes – infectious disease
prevention has always been far less well funded or researched. This section examines a hierarchy
of public health interventions, which are traditionally considered to operate at three different
‘levels of prevention’. Although you should be aware that there is some artificiality in separating
them in this way, they provide a useful framework to illustrate the diversity of public health
strategies for preventing infectious disease which are primary prevention Strategies, secondary
prevention strategies and tertiary prevention strategies.

4.2.4 Public Health Successes in Controlling Infectious Disease

In this section you will explore some major successes in public health interventions to control
infectious disease, and see how these encouraging indicators of progress have been achieved.
This will involve studying an additional resource: a slide cast about infectious diseases and
public health in Ethiopia.

4.2.5 The Guinea Worm Eradication Campaign

Guinea worm disease, or dracunculiasis, is caused by the nematode worm Dracunculus
medinensis – literally the ‘little dragon of Medina’. It is the largest tissue parasite to affect
humans and the only exclusively waterborne pathogen. Note that the terms ‘guinea worm
disease’ and ‘dracunculiasis’ are used interchangeably in the literature on this condition; you will
also find ‘Guinea worm’ capitalized in some sources.

4.2.6 The Millennium Development Goals, Infectious Disease and Public Health
While there have been enormous strides in improving public health in all countries worldwide
during the twentieth century, through the approaches described and illustrated in this course,
there is still a huge gap between the health of the poorest people and the rest. In this century,
public health approaches, including slum clearance, are central to achieving the Millennium
Development Goals (MDGs) adopted by the United Nations at its Millennium Summit in
2000(Hefny et al., 2009).
 47

CHAPTER FIVE
5.0 Conclusion and Recommendations
5.1 Conclusion
Public health strategies aim to prevent disease or reduce its impact by taking actions to protect or
promote the health and wellbeing of the population as a whole, in contrast to medical strategies
for treating disease in its individual members. The global burden of infectious disease remains a
significant threat to health, economic development and equity of opportunity, particularly (but
not exclusively) in low- and middle-income countries and disproportionately among young
children. A systematic and evidence-based approach to addressing threats to public health began
with the sanitarian movement in England in the nineteenth century and remains the basis for
public health strategies today. Public health approaches to infectious diseases focus on one or a
combination of: screening, surveillance, monitoring and reporting of disease outbreaks
community education to promote health-related behaviour change increasing the resistance of the
human host to infection, e.g. through vaccination and nutritional support community
mobilization to tackle sources of infection in the environment case finding, case containment and
(where necessary) isolation of infectious individuals. Vaccination, the provision of clean
drinking water and improved sanitation, the promotion of personal and institutional hygiene
(particularly the importance of handwashing with soap), and the organization of surveillance and
response strategies to detect and control disease outbreaks are integral to the public health
approach. Raising sustainable living standards, improving the quality of housing, nutrition and
education, and promoting gender equality and personal security are also important public health
goals. International health regulations (IHRs), including trade and travel agreements, and the
work of international organizations (e.g. the WHO) contribute at a global level to public health
approaches to infectious disease. Three levels of prevention of infectious diseases can be
identified in a public health context. Primary prevention aims to prevent new cases from
occurring; secondary prevention aims to treat the disease at the earliest stage to prevent it from
spreading; and tertiary prevention aims to alleviate the worst effects of an established disease in
an individual, which may indirectly benefit the rest of the community. Community participation
and community health workers with minimal training and equipment are central to the success of
infection-control campaigns in many parts of the world, and particularly in low- and middle-
income countries.
 48

5.2 Recommendations
Community Infections and Infestations free could be achieved through environmental Sanitation,
vector control via breaking route of transmission, proper waste management, mass treatment
campaign and public health enlightenment about Infections and Infestations in order to create
awareness etc.
 49

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