Epidemiological surveillance of a village in onchocerciasis control: volume 3, Community Directed Treatment with Ivermectin for health professionals

EPIDEMIOLOGICAL SURVEILLANCE OF A VILLAGE IN ONCHERCIASIS CONTROL Useful Manual for Training And for Field Workers To use in their day-to-day Work Volume 3, Community Directed Treatment with Ivermectin for Health Professionals WORLD HEALTH ORGANIZATION Onchocerciasis Control Programme in West Africa (OCP) Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals ii INDEX VOLUME 3, COMMUNITY DIRECTED TREATMENT............................................I WITH IVERMECTIN FOR HEALTH PROFESSIONALS .............................................I WORLD HEALTH ORGANIZATION...................................................... i INDEX ..........................................................................................................ii PREFACE ....................................................................................................iii INTRODUCTION........................................................................................1 EDUCATIONAL OBJECTIVES..................................................................4 PRACTICAL ARRANGEMENTS ...............................................................8 DETAILED COURSE TIMETABLE ......................................................... 13 ONCHOCERCIASIS AND ITS MANAGEMENT ................................... 30 SYMPTOMS AND SIGNS OF ONCHOCERCIASIS..................................................33 DIAGNOSIS OF ONCHOCERCIASIS....................................................................36 TREATMENT OF ONCHOCERCIASIS..................................................................36 CONTROL OF ONCHOCERCIASIS......................................................................38 Approaches to ivermectin distribution in the community .......... 42 The first contact with the Community ............................................. 46 ASSESSMENT PLAN................................................................................ 74 Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals iii PREFACE This module is intended for the following categories of worker : • Nurses in charge of primary level clinics/ health centres. • District level supervisors of these nurses. • Officers from NGOs who are running community based ivermectin distribution programmes. Trainers for this module should: • Have considerable field experience of community based ivermectin distribution. • Have had previous experience as trainers. NOTE: • This module is also suitable for in-service training. In such a case only the relevant sessions are used. Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals iv • The training of village level distributors, and general information about onchocerciasis, are the subjects of other modules. Epidemiological Surveillance of a Village in Onchocerciasis Control INTRODUCTION Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 1 INTRODUCTION The elimination of onchocerciasis as a disease of public health importance is achieved by two major strategies: • interruption of transmission by the blackfly - this is achieved through larviciding • yearly treatment of villagers in affected areas with ivermectin. At first ivermectin was distributed in the villages by teams of health workers working directly for OCP. These teams visited each affected village yearly, and themselves gave out the treatment. They have now been discontinued, since it was decided that countries needed to start organising this programme themselves, in preparation for the year 2002. This approach has now been replaced by the so-called CDTI (Community Directed Treatment with Ivermectin) approach. In this approach: • Villagers choose whether to take ivermectin regularly, and if they do, plan themselves how they want to do it. Epidemiological Surveillance of a Village in Onchocerciasis Control INTRODUCTION Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 2 • Villagers selected by their villages are trained as distributors, and they administer the ivermectin in their village yearly, or twice yearly. • These villagers are trained and supervised by nurses working in the frontline primary health centres, who also order and supply the ivermectin that is needed. • The nurses themselves are supervised and supported in this activity by their district and regional managers, and also by the person in charge of the national onchocerciasis programme. Each level orders and supplies the ivermectin that is needed. • The decision about which villages and areas need the programme is made by the person in charge of the national onchocerciasis programme. This person informs the regional and district managers, who in turn inform the health centre nurses. • In some places non-government organisations, like Sight Savers, manage the ivermectin programme on behalf of the government. They use the same district level nursing staff to run it. Epidemiological Surveillance of a Village in Onchocerciasis Control INTRODUCTION Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 3 • The ivermectin is supplied free of charge by the manufacturer, but countries have to order it. The health workers on whom the success of this programme most depends are the nurses in the frontline health centres or clinics, in the areas where village ivermectin distribution must take place. This training manual is primarily intended for them. However such nurses have supervisors, at the level of the health district. These officers also need to know how the CDTI programme functions, and some have attended training about the implementation of CDTI before. This module is therefore also written for them - whether they train together with the nurses, or separately. Although we have done our best to prepare a really useful manual, one that should be easy to use, we would appreciate your comments after you have used it. They will help us to make it better. Please write to: PET Unit OCP POBox 549 Ouagadougou 01 BURKINA FASO Epidemiological Surveillance of a Village in Onchocerciasis Control EDUCATIONAL OBJECTIVES Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 4 EDUCATIONAL OBJECTIVES At the end of the module: 1. All trainees have to be able to perform the following tasks: • Make a list of all villages and hamlets in his/ her catchment area which qualify for ivermectin distribution, and coordinating this activity with the nurses in neighbouring health centres. • Approach villages to take part in the CDTI programme - the 'first visit'. • Communicate the essential facts about the CDTI programme effectively, to villagers and village distributors. • Train village distributors to conduct a yearly census in their village, and to distribute ivermectin to all eligible villagers yearly at the same time (sometimes twice yearly). • Manually prepare a page in a village distributor’s notebook, to serve as an example of how the distributor should continue. • Perform the hand-ear test to determine whether a child has reached the age of five years. Epidemiological Surveillance of a Village in Onchocerciasis Control EDUCATIONAL OBJECTIVES Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 5 • Make a plan to monitor and support village distributors yearly. • Calculate the amount of ivermectin needed for the villages his/ her catchment area for the year, and order it from the district office. • Stock the ivermectin in a secure place, and keep a record of receipts, issues and balances. • Using information provided by the village distributors, write: ! yearly village reports ! a yearly report about the CDTI programme for his/her catchment area • using the standard forms provided. • Treat persons suffering from severe reactions after taking ivermectin. • Fill in a specific report for each case of severe reaction to ivermectin, and send it to the district office. • File copies of all reports (received and sent) in a safe, retrievable place. Epidemiological Surveillance of a Village in Onchocerciasis Control EDUCATIONAL OBJECTIVES Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 6 2. District managers need to be able to perform the following additional tasks: • Make and implement a plan to monitor and support the ivermectin distribution activities of health centres in their district yearly, through including the CDTI programme in the ‘minimum package of activities’ for that level. • Motivate health centre nurses to continue with the CDTI programme. • Calculate the amount of ivermectin needed for the sub-districts in his/ her district for the year, and order it from the regional headquarters. • Write a yearly report about the CDTI programme for his/ her catchment area, using the standard forms provided. 3. All trainees have to be able to: • Discuss briefly how onchocerciasis is caused; its symptoms and signs; its treatment and prevention. • Describe in detail how a CDTI programme is supposed to operate. Epidemiological Surveillance of a Village in Onchocerciasis Control EDUCATIONAL OBJECTIVES Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 7 • Discuss the difference between community based and community directed ivermectin distribution, and their relative advantages and disadvantages. • List the three criteria whereby successful ivermectin distribution programmes are judged. • Discuss the following aspects of the drug ivermectin: formulation; dosage schedule; indications and contra- indications; side-effects and their management; duration of treatment. Epidemiological Surveillance of a Village in Onchocerciasis Control PRACTICAL ARRANGEMENTS Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 8 PRACTICAL ARRANGEMENTS Being a motivator and organiser for village level ivermectin distribution is a skill or more precisely, a group of skills. Trainees learn skills by: • seeing them demonstrated by someone who is an expert • performing them themselves under supervision • getting feedback on their performance, so they can improve. Some of the skills are office based (planning, reporting, ordering) while others are village based (training, educating). The overall module timetable will therefore look like this: • preparatory classroom work • field trip to a village • further classroom work and assessment. A detailed timetable is given in the next section. The content must be considered more or less fixed, but the timing should be altered to fit in with the local situation. Epidemiological Surveillance of a Village in Onchocerciasis Control PRACTICAL ARRANGEMENTS Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 9 NOTES: • It is assumed that a team of at least two (preferably three) experienced trainers from Head Office and/or the regional office will be conducting the training. • An important skill the trainees learn here is that of training. Each has to get a turn to train distributors in the village, which means that the trainee group cannot be too big. About four is probably the maximum in a village - so if larger numbers of trainees are taken, more than one village will have to be used simultaneously. • The course is 3½ days long and looks like this: • It is likely that the classroom training will be done at the district headquarters, so there should be a suitable village nearby. This should make it possible to fit the training into four days. two days in class one full day in the field half a day in class. Epidemiological Surveillance of a Village in Onchocerciasis Control PRACTICAL ARRANGEMENTS Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 10 • Two visits are needed to start up the programme in a village: one to introduce the CDTI proramme, and another to train the distributors ! Ideally trainees should practise both of these in the field. However the time interval between the two visits may be quite long, since the villagers need time to make their decisions. ! How to undertake the first visit will therefore be learned in a role play. The second visit will be practised in the field, in a village. • Before this training takes place the trainers will therefore have to do the first visit to a suitable village, to motivate them to become part of the CDTI programme; to ask them if they want to participate; to ask them to decide how to run it, and to select distributors; to ask them to prepare for a second visit when training will take place. Note that: ! The date for the training of the distributors is set to coincide with the training course for the nurses and their managers. ! There should be another visit a few days before the return visit, to make sure that everything is still in order. ! Villagers should be clear that they have to provide a notebook, a pen and a stick 2 metres long. Epidemiological Surveillance of a Village in Onchocerciasis Control PRACTICAL ARRANGEMENTS Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 11 • The choice of village for the training is important. CDTI should not be in operation there yet; but if it is, new distributors must be trained. • In case the first village doesn’t work out (e.g. because of an unexpected event like a funeral) it is as well to make arrangements with a second village, just in case. • Arrangements for transport and meals for the field trip have to be made well in advance. • We assume that nurses learn certain skills during their basic training, and practise them continually. It is therefore not necessary to include them in this course. Examples: ! Treating common ailments. ! Communicating health messages effectively. • There are plenty of materials to be prepared before the course starts: ! Trainers are advised to go through the plan for each session, where the materials needed are clearly stated, and make sure they have everything ready that is needed. Epidemiological Surveillance of a Village in Onchocerciasis Control PRACTICAL ARRANGEMENTS Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 12 ! They need to get copies of handouts, checklists, and the training manual 'Community directed treatment with ivermectin - CDTI (for village distributors)' ready for each trainee as well. ! At the beginning of the course each trainee gets a copy of the manual to work with and to keep. • The nurses who are coming on the course also need to prepare. Specifically, they need to find out the names and, if possible, the populations of all the villages in their catchment area. • This is more than a training exercise - it is also an exercise in planning and administration: ! The different levels of the health service plan how to cooperate in the new programme. ! The health centre nurses make lists of the villages they have to deal with. ! Each level plans how it will support the next. ! Specific plans are made for ordering and distributing ivermectin. ! Issues like transport are addressed. Epidemiological Surveillance of a Village in Onchocerciasis Control DETAILED COURSE TIMETABLE Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 13 DETAILED COURSE TIMETABLE DAY 1 MORNING: CLASSROOM SESSION SESSION 1 Introduction to the course Time : 08h00 – 08h50 Content : • Course objectives, practical arrangements Method : • Introductions - trainers and trainees. • Trainer introduces the objectives of the course ! time for trainees to ask questions, discuss, clarify. • Trainer hands out course timetable, goes through it with trainees. • Trainer discusses practical arrangements with trainees: accommodation, transport etc. Materials : • Handout of course timetable. SESSION 2 Onchocerciasis Time : 09h00 – 09h50 Content : • Onchocerciasis: how it is caused and spread. • Onchocerciasis: symptoms and signs. • The treatment of onchocerciasis. • The control of onchocerciasis. Method : • This sessions is best done as a discussion, since the trainees may know a lot already about onchocerciasis. The trainer introduces each of the topics above; asks what students know; adds what they don’t know. • At the end he asks: ‘So what is the part that ivermectin plays in onchocerciasis? And why is it so important?’ Materials: • Handout: ‘Onchocerciasis and its management’. Epidemiological Surveillance of a Village in Onchocerciasis Control DETAILED COURSE TIMETABLE Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 14 SESSION 3 Approaches to ivermectin distribution Time : 10h00 – 10h50 Content : • The three approaches: ! teams of health workers going to villages ! community based: 'owned' by health workers ! community directed: 'owned' by villagers. • The advantages/ disadvantages of each approach. • Choosing the 'community directed' approach. Method : • Short input from trainer, OR gives handout to trainees to read. • Then discussion about the differences between the three approaches - especially between (2) and (3). • Discussion about the advantages/diadvantages of each. • Trainer asks: why we are using the 'community directed' approach? Trainees debate and one of them summarises at the end. Materials: • Handout: 'Approaches to ivermectin distribution in the community'. SESSION 4 Organisation of the CDTI programme Time : 11h00 – 12h00 Content : • Starting up the programme in the villages in an area. • Continuing with the programme year by year. Method : • Trainer gives out handout: 'How the CDTI programme works'. Trainees read it through together in groups of two or three. • Trainer leads discussion on each point, until everyone is quite clear. Materials: • Handout: 'How the CDTI programme works' Epidemiological Surveillance of a Village in Onchocerciasis Control DETAILED COURSE TIMETABLE Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 15 AFTERNOON:CLASSROOM SESSION SESSION 5 Ivermectin and it side-effects Time: 15h00-16h30 Content : • Appearance, cost, source, storage. • How it works. • Indications/ contra-indications. • Frequency of administration, dosage, route of administration. • Community views and misconceptions. • Side-effects and their treatment. • Reporting severe reactions to ivermectin. Method : • Trainer gives out handouts: 'Ivermectin: general information' and 'Side-effects of ivermectin'. • Trainer and trainees work through each point together, discussing it until everyone is clear. • Trainer gives each trainee 2 copies of the form 'Report of serious side-effects due to ivermectin' - one to keep as an example, one to use now in the exercise. • Each trainee prepares such a report, using information read out by the trainer. Afterwards they and the trainer check each other's efforts and give feedback. • Short discussion on how the completed form must be sent to the district office, then to Head Office. Materials: • Handouts: 'Ivermectin: general information' and 'Side-effects of ivermectin'. • Enough copies of the form: 'Report on serious side- effects due to ivermectin'. • Information about a case with serious side-effects due to ivermectin, to read out for the exercise above. Epidemiological Surveillance of a Village in Onchocerciasis Control DETAILED COURSE TIMETABLE Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 16 SESSION 6 Making a list of villages Time : 16h40-17h30 Content : If an area is designated for ivermectin distribution by the National Office, all the villages and hamlets in it must be covered. The health centres who will run the CDTI programme have to divide up the villages between them, so that no village is left out. Method : • Trainers (who are also Head Office staff) present the information about which areas and villages are to be covered. • The nurses come with prepared information about the population of the villages in their catchment area. • Using their local knowledge, the health centre nurses and district managers allocate specific areas and villages to each health centre. A rough list is made for each health centre. • Each list is presented to the group. Discussion follows under these headings: are we leaving out any villages/ hamlets? is there any duplication? • At the end, each nurse makes a neat, final list. A copy is given to the district managers. Materials : • Head Office information about the area and the villages that have to be covered (from the era of mass distribution by teams or datas from recent Rapid Epidemiological Mapping of Oncho - REMO). • Paper and pens. Epidemiological Surveillance of a Village in Onchocerciasis Control DETAILED COURSE TIMETABLE Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 17 SESSION 7 Making the first order of ivermectin Time: 17h40 – 18h15 Content : Calculating what is needed systematically. Method : • Trainer explains: nurses have to have enough ivermectin with them before they can start implementing CDTI. • Trainers present available information about the population of the villages concerned. • Trainees use this knowledge, and their own knowledge of their area, to allocate a population to each village on their list. They work out the total population of the villages of their health centre catchment area. • They work out the number of ivermectin tablets they need: • population x 3. • They fill in the routine national order form if applicable, or make their own 'Yearly sub-district ivermectin order' for ivermectin. They make a copy, and hand the original to the district managers. (NOTE: this ivermectin should be handed to the nurses at the end of the course, before they leave). • The trainer points out that a different system is used for the yearly orders - this is going to be learnt in Session 15. Materials : • Head Office information about the area and the villages that have to be covered (from the era of mass distribution by teams or datas from recent Rapid Epidemiological Mapping of Oncho - REMO). • Paper and pens. Epidemiological Surveillance of a Village in Onchocerciasis Control DETAILED COURSE TIMETABLE Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 18 DAY 2 MORNING: CLASSROOM SESSION SESSION 8 The first visit to a village. Time : 07h00 – 09h50 Content : • The importance of doing the first visit well: good and bad approaches. • The information the village needs to have. • Exactly what the villagers are going to be asked to do. Method : • Trainer asks trainees to recap what they learnt in Session 2 about the 3 approaches to ivermectin distribution. • Trainees get handouts: 'First contact with the community' and 'How the CDTI programme works'. • All read the first one quietly - followed by a disussion of its main points. • Second handout: all work through the section on 'The first visit' together. • Short discussion about different kinds of authority in villages in the area, and how to approach each. • Group discussion about what to tell the villagers about CDTI at the first visit - trainer summarises on blackboard. • Group discussion about what to ask villagers to do for CDTI - trainer summarises on blackboard. • Each trainee prepares a little memo they can use to guide themselves during such a meeting. • Role play: one trainee plays a nurse arriving at a village, trainers and other trainees play chief and villagers (the trainee uses the memo s/he has prepared). After the play the trainee gets feedback from the others, using the material in 'The first visit' as a checklist. • If there is time repeat the play to give other trainees a chance. • Trainer asks a trainee to summarise the lessons learnt. Epidemiological Surveillance of a Village in Onchocerciasis Control DETAILED COURSE TIMETABLE Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 19 Materials : • Handouts: 'How the CDTI programme works'; 'First contact with the community'. • Blackboard and chalk. SESSION 9 Key messages for the village distributors Time : 10h00 – 10h50 Content : • Distributors need to know more than the other villagers. • The facts they need to know deal with: onchocerciasis in general; ivermectin. Method : • Trainees use their village distributor training manuals. Each trainee reads through the two handouts: ‘Ivermectin - the medicine for onchocerciasis’ and ‘Onchocerciasis and its management’. • Discussion about what they have read - whether they think more or fewer key messages are needed; which are the most important. Materials : • The manual:'Community directed treatment with ivermectin - CDTI (for village distributors)'. Epidemiological Surveillance of a Village in Onchocerciasis Control DETAILED COURSE TIMETABLE Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 20 SESSION 10 Les aptitudes que les distributeurs communautaires doivent acquérir. Time : 11h00 – 12h00 Content: • The distributor's record system - the notebook. • The hand-ear test for determining children's age. • Preparing a measuring rod. Method : • Trainees use their village distributor training manuals. They look at the checklist: 'How to complete the notebook properly.' A demonstration notebook is passed around for them to see. • They discuss any problems they have. • Each trainee prepares a page for 'Recording ivermectin distributed to a family.' The trainer reads out a few examples from a family, which the trainees fill in on the pages they have prepared. They check each other. • The trainer summarises: the important thing is to have a simple, reliable system. • A quick demonstration of the hand-ear test for children - the arm must go over the head. • Trainees are shown a rod villagers can use to measure height. Using the tape measure and knife, each makes their own. The trainer points out that they will use the one they make now as an example when they conduct training themselves back home. Material : • The manual:'Community directed treatment with ivermectin - CDTI (for village distributors)'. • A demonstration notebook with an example of each of the two kinds of pages villagers need to complete, prepared by hand. • A notebook page for each trainee. • A demonstration measuring rod. • Enough straight sticks to make a rod for each trainee. • A measuring tape and a knife. Epidemiological Surveillance of a Village in Onchocerciasis Control DETAILED COURSE TIMETABLE Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 21 AFTERNOON: CLASSROOM SESSION SESSION 11 Stocking and dispensing ivermectin Time: 15h00 – 15h50 Content: • Keeping record of ivermectin • Making and keeping a stock book. Method : • Short input from trainer: ivermectin can't just follow the same system as the other drugs, since it is specially donated and is dispensed by villagers. • Discussion: ask trainees how they plan to do and record receiving, stocking, issuing. Show examples of receipt, register for comments. • Finally group makes definite decision on how they are going to keep the records. They prepare examples of the necessary forms for themselves there and then. • Trainer stresses importance of keeping copies of everything. Materials : • Paper and pens. • Examples of receipt and stock sheet. SESSION 12 Preparing to train the distributors Time: 16h00 – 18h00 Content : • How to use the village distributor training manual Method : • Trainees work in pairs, under supervision of trainers: • First they familiarise themselves with the training manual 'Community directed treatment with ivermectin - CDTI (for village distributors)'. • This is discussed with the trainers to clarify any problems. • Then (if there is time) each trainee ‘teaches’ the other some of the sessions. • Finally the trainer makes practical arrangements for the next day: • When to leave, who is going to which village, what they have to take with them. • Who is going to teach which session (there are 8 sessions to be taught). • That evening each trainee prepares thoroughly for the Epidemiological Surveillance of a Village in Onchocerciasis Control DETAILED COURSE TIMETABLE Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 22 sessions s/he will teach - also the materials s/he will use. Materials : • The manual:'Community directed treatment with ivermectin - CDTI (for village distributors)'. IN THE EVENING : • Trainees prepare their teaching sessions for the next day. • Trainers assess the skills trainees learnt during Day 2, using the skills assessment form. Epidemiological Surveillance of a Village in Onchocerciasis Control DETAILED COURSE TIMETABLE Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 23 Day 3 ALL DAY: PRACTICAL IN THE VILLAGE SESSION 13 Training village distributors Time : The whole day will be needed - get there early!. Content : • Training the village distributors. • Assessing the village distributors. Method : • Upon arrival the team goes to greet the village chief, and to meet the chosen distributors. They find out what method of treatment the village has decided to use. A suitable place for the training is agreed upon. The trainees take the initiative; the trainers observe. • Each trainee in turn teaches the sessions s/he has prepared. The trainers and the other trainees observe. At the end of each session feedback is given to the 'trainer'. • During Session 5 'Doing the census and treatment' they use the method of arranging treatment that the village has decided upon. • Before leaving arrangements are made with the distributor to complete the job, and to visit the health centre with his/her notebook to report when they are through. Materials : • Each trainee has his/ her copy of the manual: 'Community directed treatment with ivermectin - CDTI (for village distributors)'. • Enough ivermectin tablets, demonstration measuring rod, handouts and checklists to leave in village. IN THE EVENING : • Trainees learn for their test the next day • Trainers prepare test questions for the written test. • Trainers assess the skills trainees learnt during Day 3, using the skills assessment form Epidemiological Surveillance of a Village in Onchocerciasis Control DETAILED COURSE TIMETABLE Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 24 DAY 4 MORNING : CLASSROOM SESSION SESSION 14 Préparation du rapport annuel pour les infirmiers des centres de santé Time : 07h00-08h00 Content : • Completing the two kinds of yearly report form required. • Completing the yearly order form for ivermectin. Method : • Short input from trainer about the information system for CDTI, using the handout 'The information system for the CDTI programme'. • Trainer gives each trainee two copies of each form. One must be kept (since trainees will copy them each year when making their reports) and one will be used now in the exercises in class. • Trainer shows an example of a completed 'Yearly village report form'. • Each trainee prepares such a form, using the data from a village distributor's notebook. • Trainer shows an example of a completed 'Yearly sub- district report form'. • Each trainee prepares such a form, using the data from the form they prepared above, as well as about 5 other 'Yearly village report forms' supplied by the trainer. • Trainees (and trainer) check each other's forms and give feedback. Materials : • Enough examples of each blank form. • Enough examples of each form correctly completed. • Photocopy of one complete village distributor's notebook for each trainee. • 'Yearly village report forms' from 5 other villages for each trainee. • Handout: 'The information system for the CDTI programme'. Epidemiological Surveillance of a Village in Onchocerciasis Control DETAILED COURSE TIMETABLE Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 25 SESSION 14 Préparation du rapport annuel pour les responsables de district Time : 07h00-08h00 Content: • Completing the yearly report form required. • Completing the yearly order form for ivermectin. Method : • Short input from trainer about the information system for CDTI, using the handout 'The information system for the CDTI programme'. • Trainer gives each trainee two copies of thir report form. One must be kept (since trainees will copy them each year when making their reports) and one will be used now in the exercises in class. • Trainer shows an example of a completed 'Yearly district report form'. • Each trainee prepares such a form, using the data from about 5 'Yearly sub-district report forms' supplied by the trainer. • Trainees (and trainer) check each other's forms and give feedback. • Since there will be some time left, trainees may now join the other half of the class to see what has to be done at sub- district level. Materials : • Enough examples of each blank form. • Enough examples of each form correctly completed. • 'Yearly sub-district report forms' from 5 sub-districts for each trainee. • Handout: 'The information system for the CDTI programme'. Epidemiological Surveillance of a Village in Onchocerciasis Control DETAILED COURSE TIMETABLE Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 26 SESSION 15 Making a yearly order for ivermectin Time : 08h10 – 08h50 Content : • Calculating the amount of ivermectin needed for the coming year. • Completing the yearly order form for ivermectin. Method : Trainer gives each trainee two copies of the 'Yearly sub- district ivermectin order'form (or the form that is being routinely used for ordering drugs in the country). One must be kept (since trainees will copy it each year when making their order) and one will be used now in the exercise in class. Trainer gives out handout: 'Calculating the amount of ivermectin to order' and goes through it with the trainees. Each trainee prepares such an order, using the following information: * the 'Yearly sub-district report form' they prepared in Session 14 * information given by the trainer: about a village that didn't participate properly, and about the present amount of ivermectin in the health centre dispensary. Trainees and trainer check each other's orders and give feedback. A short discussion about how district managers will make their order (simply adding together the sub-district orders). Materials : • Examples of the blank order form. • The completed 'Yearly sub-district report forms' from the previous session. • Information about a village that didn't cooperate, and present stock levels, to give to trainees during the exercise. Epidemiological Surveillance of a Village in Onchocerciasis Control DETAILED COURSE TIMETABLE Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 27 SESSION 16 Monitoring and supporting Time : 09h00 – 09h50 This is a parallel session - the class splits into two groups. Content : • Monitoring the CDTI programme. • Motivating village distributors to continue with the programme. Method : • Discussion with trainees about problems that could arise with CDTI at village level; how one would become aware of them; what one could do about them. • Practical monitoring: trainees work out together: • how they can fit in monitoring CDTI with their other village visits • what exactly they must monitor for CDTI • if they have a special checklist for village visits, how they can add CDTI to it. • Discussion with trainees about motivating villages and distributors who are doing well, and those who are not. Materials : • None. SESSION 16 Suivi et appui au programme de TIDC pour les responsables de district Time: 09h00 – 09h50 This is a parallel session - the class splits into two groups. Content : • Monitoring the CDTI programme. • Motivating health centre nurses to continue with the programme. Method : • Discussion with trainees about problems that could arise with CDTI at health centre level; how one would become aware of them; what one could do about them. • Practical monitoring: trainees work out how they can fit in monitoring CDTI with their supervisory visits to the health centres. • In particular they discuss how to add CDTI to the supervisory checklists they use. • Discussion with trainees about motivating health centre nurses who are doing well, and those who are not. Materials : • None. Epidemiological Surveillance of a Village in Onchocerciasis Control DETAILED COURSE TIMETABLE Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 28 SESSION 17 Written test Time : 10h00 – 10h50. Content : • Questions covering all the knowledge and decisions trainees have to learn - dealing with 'must knows' rather than 'nice to knows'. Method: • Written test. • While the trainees are writing the trainers meet to finally assess all the trainees' practical skills, using the skills assessment sheet, and work out a total mark. They decide who passes and fails the practical. • One trainer goes to take Session 17, the others stay behind to mark the papers and to prepare the sheet with the final results. Materials : • Prepared questions. • Skills assessment forms. Epidemiological Surveillance of a Village in Onchocerciasis Control DETAILED COURSE TIMETABLE Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 29 SESSION 18 Funding, materials and transport Time : 11h00-11h50 Content : • Practical arrangements for the resources the programme will need. Method : NOTE: one trainer takes this session while the others mark the tests. • This is the time for everyone present to plan exactly how to proceed. This will take the form of a discussion, on the following topics: • ways in which the nurses can integrate the visits to the villages for CDTI, with the other visits that they already do (e.g. EPI). • transport to get to the villages: where it will come from, who will pay for fuel • subsistence (if any) when the nurse is out in the field • the timetable for ivermectin ordering and supply • any other practical arrangements needed to implement CDTI in that area. • The trainer's task is to make sure all these areas are covered, and that there is a clear way forward in all of them. If possible, each nurse gets the ivermectin s/he needs now. • Finally each nurse makes a timetable for his/ her two visits to the villages on his/ her list. The district manager gets a copy. Materials : • Enough ivermectin for all nurses attending. • Paper and pens. SESSION 19 Closing ceremony Time : 12h00-12h20 Method : • The results are put up on a notice board before the ceremony. • The usual: thank yous, handing out of attendance certificates and enjoying a snack. Epidemiological Surveillance of a Village in Onchocerciasis Control ONCHOCERCIASIS AND ITS MANAGEMENT Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 30 ONCHOCERCIASIS AND ITS MANAGEMENT Onchocerciasis is a disease caused by the macrofilaria Onchocerca volvulus, which invades the subcutaneous tissues of the body. The life cycle of Onchocerca volvulus The female worm produces millions of microfilariae, which migrate to the skin of the infected person When the blackfly bites a human again, the larvae are introduced into the skin of this individual. The larvae grow into adulthood in the subcutaneous tissues of the new victim, and within about a year start producing microfilariae again. The adult worms live for about 14 years. The microfilariae go through three larval stages in the blackfly, the last of which migrates to the head and mouthpiece of the fly. The female blackfly Simulium needs blood meals before it can lay its eggs. When it bites an infected person it ingests some of the microfilariae together with the blood. Epidemiological Surveillance of a Village in Onchocerciasis Control ONCHOCERCIASIS AND ITS MANAGEMENT Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 31 The life cycle of the blackfly Simulium The adult female fly lays a large number of eggs every 4 to 5 days of her short life. Between every egg laying she has to take a blood meal. She will therefore bite several humans, at an interval of a week or so. This makes her an ideal vector for the parasite. The blackflies clearly prefer living close to rivers, and that is where most cases of onchocerciasis are found (hence the old name ‘river blindness’). However a single fly can migrate a hundred kilometres or more, especially if assisted by strong winds. After taking a blood meal the female backfly lays her eggs at the edge of fast flowing streams and rivers. The eggs hatch and the larvae live in the water, attached to objects like leaves, sticks and stones. They need oxygen rich water to thrive, which is why the fly lays her eggs next to fast flowing water. After going through a few larval stages and a pupal stage, the adult flies emerge from the water 7-10 days after the eggs were laid. Epidemiological Surveillance of a Village in Onchocerciasis Control ONCHOCERCIASIS AND ITS MANAGEMENT Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 32 A female blackfly taking a blood meal Blackfly's eggs attached to a stick Epidemiological Surveillance of a Village in Onchocerciasis Control ONCHOCERCIASIS AND ITS MANAGEMENT Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 33 Symptoms and signs of onchocerciasis Almost all the symptoms and signs are caused by the microfilariae, and not by the adult worm. • The most common symptom is itching, which is caused by body’s reaction to microfilariae dying in the skin. It is severe and continues day and night. This leads to the following clinical signs: - an onchocercal dermatitis - small papules - ‘lizard skin’ - areas of roughening - ‘leopard skin’ - areas of depigmentation (especially on the lower limbs). • As the number of microfilariae in the body increases, increasing numbers find their way to the eyes. Every part of the eye is eventually affected by inflammation, tissue damage and scarring. This leads to a gradual loss of vision, and eventually to irreversible blindness - often by as early as the age of thirty-five. • The adult worms may cause painless nodules under the skin. These are especially noticeable over bony parts such as the skull and pelvis. Epidemiological Surveillance of a Village in Onchocerciasis Control ONCHOCERCIASIS AND ITS MANAGEMENT Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 34 Symptoms and Signs of onchocerciasis Itching Onchocercal dermatitis "Lizard skin" "Leopard skin" Nodule on the face Loss of vision Epidemiological Surveillance of a Village in Onchocerciasis Control ONCHOCERCIASIS AND ITS MANAGEMENT Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 35 • The constant itch (leading to lack of sleep), the slow loss of vision, and the effect of the high parasite load together have a profound effect on the quality of life of the sufferers. They become weak, debilitated and depressed. In small children the heavy parasite load can interfere with growth and development, leading to a clinical syndrome refered to as ‘onchocercal cretinism’. As a result of the disease many fertile river basins were abandoned by their populations, with profound economic consequences for the countries concerned. Epidemiological Surveillance of a Village in Onchocerciasis Control ONCHOCERCIASIS AND ITS MANAGEMENT Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 36 Diagnosis of onchocerciasis The diagnosis is made by taking two small skin biopsies (over the left and right iliac crests respectively) and examining them microscopically. The living microfilariae are easily observed emerging from the biopsies. Taking of skin biopsies Treatment of onchocerciasis Before 1987, there was no effective treatment known. A drug called diethyl-carbamazine (DEC) was tried, but it had many serious side- effects. The only drug we now have available is ivermectin. This is non-toxic well tolerated compound: Epidemiological Surveillance of a Village in Onchocerciasis Control ONCHOCERCIASIS AND ITS MANAGEMENT Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 37 Mectizan® or Ivermectin, the drug used to treat onchocerciasis Epidemiological Surveillance of a Village in Onchocerciasis Control ONCHOCERCIASIS AND ITS MANAGEMENT Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 38 • It is highly effective as a microfilaricide. For this reason it immediately relieves the itching, and also causes early eye lesions to be reversed. It achieves these effects by being administered once a year. • It does not however kill the adult parasite, although it appears to lower the fertility of the female worm. More detailed information about ivermectin and its use is given in a separate handout. Control of onchocerciasis In order to control the disease we have to break its cycle of transmission (man blackfly man). Two ways have been worked out of achieving this: 1. Larviciding. The goal here is to eliminate the vector Simulium by killing its larvae: ! Each river where it breeds has to be identified, and an insecticide administered to each breeding site in those rivers once a week. ! This has mostly been done by helicopter, but also on the ground and with boats. Epidemiological Surveillance of a Village in Onchocerciasis Control ONCHOCERCIASIS AND ITS MANAGEMENT Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 39 Larviciding by helicopter Ground larviciding Epidemiological Surveillance of a Village in Onchocerciasis Control ONCHOCERCIASIS AND ITS MANAGEMENT Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 40 Larviciding with boat ! The process has to be continued for at least 15 years, until all the adult worms have died out and there are no microfilariae left in skins of the population. 2. Community directed treatment with ivermectin (CDTI). Ivermectin is administered to the whole population of the affected areas once a year (sometimes twice): ! Such infrequent administration is sufficient since all microfilariae are killed, and the fertility of the female worm is diminished for a susbstantial period. Epidemiological Surveillance of a Village in Onchocerciasis Control ONCHOCERCIASIS AND ITS MANAGEMENT Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 41 ! As a result transmission of the parasite is cut down by 75% (but not halted completely). ! The administration is achieved done by enlisting the help of the villagers themselves. ! Even those who feel well must be treated, since although their parasite load may be low they can still be sources of infection for others. Larviciding is the most reliable and effective way of eliminating the disease. CDTI helps the larviciding to take effect more quickly, but is not sufficient in itself to achieve control where there is a high prevalence of the disease. In situations where the parasite load is low CDTI will probably be sufficient to control the disease, but it will have to continue yearly for many years. Since 1974 the Onchocerciasis Control Programme (OCP) has been using these strategies to control the disease in West Africa - first only larviciding, then later CDTI as well. We now have a situation where the disease is no longer a public health threat. In addition, many thousands of hectares of fertile land in river basins have been resettled. Epidemiological Surveillance of a Village in Onchocerciasis Control APPROACHES TO IVERMECTIN DISTRIBUTION IN THE COMMUNITY Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 42 Approaches to ivermectin distribution in the community Since it became known that mass treatment of villages with ivermectin was essential for controlling onchocerciasis, three approaches have been used. Treatment of villages by mobile teams of health workers This was the strategy first used by the Onchocerciasis Control Programme (OCP). Teams of health workers were employed by the programme and given transport and other ressources. They visited all the villages in the area assigned to them every year, and gave the treatment to the villagers. Advantages of this approach ! The great advantage is that one can be sure that the work is being done. ! Because team members were all health workers (nurses for example) they could also treat other illnesses when they were in a village. This made villagers very happy about the visits. Epidemiological Surveillance of a Village in Onchocerciasis Control APPROACHES TO IVERMECTIN DISTRIBUTION IN THE COMMUNITY Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 43 Disadvantages of this approach ! It is very costly and countries cannot afford it. ! Because they do not come from the area, the teams sometimes miss isolated villages. ! If someone is absent, or pregnant, or sick during the team's visit, they miss the treatment. ! As soon as the teams stop operating the ivermectin stops being distributed. Community based treatment In this approach health workers no longer go around and give out the ivermectin themselves. In stead, local health workers from the health centres go to the villages and ask the villagers to help with distributing the ivermectin every year. They tell them exactly how to go about it, and train someone to do it that way. The programme still 'belongs' to the health workers - they are responsible for it, and the villagers just help them to do it. Advantages of this approach ! The great advantage is that it is much cheaper - the country can afford it long term. Epidemiological Surveillance of a Village in Onchocerciasis Control APPROACHES TO IVERMECTIN DISTRIBUTION IN THE COMMUNITY Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 44 ! People who were absent, pregnant or sick can be given the treatment later, by the distributor in the village - and still in the same year. Disadvantages of this approach ! It takes a while to get it going. In the meantime, the disease is not standing still. ! Sometimes the villagers do not cooperate well and abandon the programme. After all, they are being asked to help the nurses to do their job, and get no reward for that. ! It places a new burden on health workers who may already be overcommitted - they have to do the visits for motivation, training and follow-up. Community directed treatment This approach is similar to the second one, but with one important difference. In stead of being told how to go about the treatment, villagers are approached and asked if they want to have this programme in their village, on their own terms. If they do, they themselves have to decide how they want to tackle it. The health worker will only provide the necessary technical information and training. The programme therefore 'belongs' to the village. Epidemiological Surveillance of a Village in Onchocerciasis Control APPROACHES TO IVERMECTIN DISTRIBUTION IN THE COMMUNITY Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 45 Advantages of this approach ! This system has all the advantages of the second one. ! In addition, research has shown that compliance is much better with this approach than with the second one. This is not surprising - the villagers have accepted responsibility for the programme in their village, and have ownership of it. Disadvantages of this approach These are the same as for the second one, but to a lesser degree: ! The villagers are much less likely to abandon the programme. ! It takes less of the health workers' time because it is more sustainable. It should be clear why the third approach, the community directed one,is the one now being used in CDTI programmes throughout Africa Epidemiological Surveillance of a Village in Onchocerciasis Control THE FIRST CONTACT WITH THE COMMUNITY Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 46 The first contact with the Community The very first contact with the community is the most difficult and yet the most critical. This is when the first interactions between the healthworkers and the community members occuras for as CDTI is concerned. It is the time for first impressions. It therefore provides an opportunity for the health worker to learn about how the community rates him/her. The community would use the behaviour of the health worker to judge or recognize his functionand status. The community first regards the health worker as a person rather than as a worker and their opinion of him will depend on the rules and conduct in the social environment concerned. It is therefore important that before the first meeting is made health worker seeks to collect information which sets out the priority rules of that social environment, the hierarchy he/she will have to deal with, prohibited behaviours and hospital rules in the community. It is not necessary for the health worker to wear the hospital/health centre gown since the medical treatment will not be carried out by him/her. On the other hand, he/she should be simply dressed avoiding any attire that we attract too much attention to himself/herself. The costumary rules in the villages should be complied with when the visit is made. Epidemiological Surveillance of a Village in Onchocerciasis Control THE FIRST CONTACT WITH THE COMMUNITY Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 47 For example, it must recognized that the first thing to observe is that every visitor or stranger in a community needs to secure a place to settle. He/she should also recognize that she is someone’s visitor in the first instance before being a guestof the community . The health worker should avoid being a socially unknown visitoror stranger in the community for whose actions nobody in the community feels getting committed to. The choice of the person to stay is with is an an action which may have community implications and is therefore a delicate act for someone who is not on a private visit. It is therefore necessary to have a host or a landlord even if it is just for symbolic purposes, who will be the index representative of the village. In this case the village chief could be targeted, but it must be realised that the community representative variesfrom place to place. By choosing the index representative as a host means that there is recognation and legitimation of an authority which one would submit to.This submission is total no matter what institutional power the health worker may be vested with for justifying his/her presence in the community. The choice of a representative may be a difficult one in communities that may be experiencing a conflict of authority. Since the health worker should neither be a judge nor side with any particular group, the selection of a host should not be with the exclusion of any portion of the community which does not recognize the authority. Epidemiological Surveillance of a Village in Onchocerciasis Control HOW THE CDTI PROGRAMME WORKS Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 48 How the CDTI programme works The CDTI programme is not very complicated. From years of experience with onchocerciasis control, we now know that it is necessary for the inhabitants of the villages in certain river basins to take ivermectin regularly every year for a long time. This will not only make those who have the disease much better, but will also cut down the transmission of onchocerciasis by 75% in those villages, and in the country as a whole. For this to work well: ! 100% of the villages in those areas have to participate ! at least 65% of the inhabitants of each village have to take the treatment ! the treatment has to be taken once a year (in some cases twice a year) If these targets are not reached the onchocerciasis may come back. Epidemiological Surveillance of a Village in Onchocerciasis Control HOW THE CDTI PROGRAMME WORKS Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 49 Starting up the CDTI programme in an area The district manager receives the names of the area and villages where CDTI is needed.S/he then has to do three things : 1. Arrange with the officer in charge of conchocerciasis control at national level, to come and conduct training courses for the nurses from all the health centres in that area. 2. Inform all the health centres of the training, and making sure at least one nurse from each health centre attends it. 3. Make sure the training team from Head Office brings along a large supply of ivermectin tablets, because the nurses get their supply for the coming year on that occasion. The training lasts a week and takes place at the beginning of the year. During training each nurse will be expected to make a list of the villages and hamlets s/he is going to be responsible for. The nurses check with each other that no village or hamlet is left out. The first visit After they have been trained, the nurses make a first visit to each village to explain the programme, and to request their cooperation. This visit is of great importance, and has to be done carefully. Here are some guidelines: Epidemiological Surveillance of a Village in Onchocerciasis Control HOW THE CDTI PROGRAMME WORKS Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 50 • Villages are being asked to join the scheme voluntarily - they cannot be forced. The nurse has to be very polite and respectful throughout. • Village authority structures are different: ! Some are more autocratic, with the chief in council making decisions on behalf of the village. In such a case the nurse will expect decisions to come from the chief. ! Some are more democratic, with decisions being made by discussion and eventual consensus in a meeting. ! In some there is a conflict of leadership, in which case the nurse faces a difficult situation. It is probably best in such a case try for a meeting with many villagers present, as a forum to explain the programme and ask for decisions. Nurses have to draw on their knowledge of the local community to decide which approach to use. • Upon arrival the village authorities (chief, council) are first contacted. However the cooperation of the whole village is going to be needed. Epidemiological Surveillance of a Village in Onchocerciasis Control HOW THE CDTI PROGRAMME WORKS Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 51 • Therefore the nurse asks politely if as many villagers as possible can be called, so that s/he can explain more about onchocerciasis and CDTI. This is important, since it is part of the process to give ownership of the programme to the village, which is a key feature of the 'community directed' approach. It also helps to legitimise the programme in the village. • When the villagers have come together, the nurse explains carefully about onchocerciasis and about CDTI: ! S/he finds out what they know about the disease: cause, symptoms and signs, treatment, prevention - adding what they don't know. ! S/he explains about CDTI: - why it is necessary - the village will receive the treatment free of charge - what is being asked of the village. Epidemiological Surveillance of a Village in Onchocerciasis Control HOW THE CDTI PROGRAMME WORKS Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 52 ! S/he gives ample opportunity for questions. • When the discussion is done s/he asks whether they would like to take part in the programme. • If the villagers agree that they would like to take part: ! S/he explains that they themselves have to decide how they would like the distribution to take place in their village. ! S/he explains that someone has to learn on behalf of the village how to give out the medicine, otherwise it won't be safe - two or three persons. ! S/he asks the villagers to set criteria for choosing these persons (if necessary s/he adds: willing to work for free, acceptable to all the families, able to read and write a bit). • An agreement is made that the villagers will make these two decisions in the near future. • An appointment is made for the next visit, when the training (and the first treatment) will take place. The villagers are asked to supply the notebook and pen that the distributors will use in their work, and that will be needed at the time of the training - also a stick 2 metres long for a measuring rod. Epidemiological Surveillance of a Village in Onchocerciasis Control HOW THE CDTI PROGRAMME WORKS Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 53 The second visit At the second visit the nurse first goes to the chief again. S/he meets the persons who have been selected to be trained, and finds out what system they are going to use for the treatment. They negotiate for a suitable place for the training to be done, and a time for the treatment to start. The distributors are trained to administer ivermectin safely, and to keep the necessary records. The nurse leaves sufficient ivermectin for the whole village to be treated. The distributors agree to finish the job within a month, and to bring their records to the health centre when they are done. After receiving the reports of all the villages the nurse writes his/ her reports for the year. S/he also calculates how much ivermectin is needed for the following year, and orders it from the district office. Once the programme is going In January each year the health centre nurse has a look at the list of the villages/ hamlets s/he is responsible for. S/he updates the list if necessary. The distributors should arrive spontaneously to fetch their ivermectin. Some will and some will not - the latter have to be contacted and reminded. Between January and March the distributors in all the villages distribute the ivermectin, as they have been taught. Epidemiological Surveillance of a Village in Onchocerciasis Control HOW THE CDTI PROGRAMME WORKS Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 54 In March the nurse gets to see the records of this distribution from each village. S/he writes the village and summary reports. Again s/he sends the summary report to the district office, and keeps a copy for her/ his records. At the same time the nurse calculates how much ivermectin will be needed for the following year, and orders it from the district office. If there are villages with problems (i.e. not participating at all, or less than 65% uptake) the nurse tries to solve the problem on routine visits during the year. Epidemiological Surveillance of a Village in Onchocerciasis Control THE INFORMATION SYSTEM FOR THE CDTI PROGRAMME Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 55 The information system for the CDTI programme To ensure sustainability all forms are to be handwritten. Examples are given to every officer to keep, at the time of his/ her training. 1. The village distributor S/he writes down all his information in his/ her notebook, and takes it to the health centre once a year when he fetches his ivermectin. 2. The health centre level nurse • S/he makes a yearly summary of each village on the 'Yearly village report form', and keeps it. (If the village distributors are literate and keen, the nurse can teach them to do it). • S/he makes a yearly summary of his/ her whole sub-district (including villages which didn't comply) on a 'Yearly sub-district report form' and sends a copy to the district office. • At the same time s/he sends an order for ivermectin by means of the routine form s/he uses to order drugs from the district office (if that is not acceptable, s/he simply makes his/ her own 'Yearly sub- district ivermectin order'). The amount is calculated by summarising the data from the villages. Epidemiological Surveillance of a Village in Onchocerciasis Control THE INFORMATION SYSTEM FOR THE CDTI PROGRAMME Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 56 3. The district manager • S/he makes a yearly summary of all the sub-districts (including villages that didn't comply) on a 'Yearly district report form' and sends a copy to the regional office and/or to Head Office (depending on the system in the country). • At the same time s/he sends an order for ivermectin, based on that summary, by means of the routine form s/he uses to order drugs from the regional office or Head Office (if that is not acceptable, s/he simply makes his/ her own 'Yearly district ivermectin order'). 4. The regional manager S/he does the same summary (of districts this time) and ordering (for the region), if this is required of him/ her in his/ her country's system. Epidemiological Surveillance of a Village in Onchocerciasis Control IVERMECTIN :GENERAL INFPORMATION Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 57 Ivermectin: general information Ivermectin is a general anti-helminthic drug. The discovery of its effect against the parasite Onchocerca volvulus was a major breakthrough in the fight to control the scourge of onchocerciasis. It is used in two ways: • It relieves the symptoms and halts progression of the disease. • It helps to limit the spread of the disease. This only happens though if entire village populations are systematically treated over many years. Ivermectin has the following effects: • It kills all the microfilariae of O. volvulus instantly. Because of this it arrests the pathological processes they cause in the eye and the skin. The intractable itching which is a hallmark of the disease also stops. • It does not kill the adult worms, although there is evidence that it interferes with the fertility of the female worm. This means that: - ivermectin has to be given repeatedly, until all the adult worms are dead - about 15 years Epidemiological Surveillance of a Village in Onchocerciasis Control IVERMECTIN :GENERAL INFPORMATION Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 58 - ivermectin only needs to be given yearly (or twice if necessary), because the microfilariae now accumulate very slowly. • It kills most helminths in the bowel, which are then evacuated. This is an effect greatly appreciated by communities. As a result of the relief of symptoms and the shedding of a load of parasites, sufferers report a great sense of wellbeing after taking the drug. Mectizan® is a trade name of the drug ivermectin. This is what is used in West Africa to combat onchocerciasis, and it is sponsored by the manufacturer Merck, which also provides it free of charge. It is provided in tablets of 3 mg strength, which are white, unsecured and tasteless. • It is important to know that it previously came in tablets of 6 mg strength. This was discontinued because tablets often had to be broken in half to get the correct dosage. • Because it is tasteless it can either be chewed or swallowed with water. • Before ivermectin became available the drug diethyl-carbamazine (DEC) was used. In view of its serious side-effects its use has been completely suspended. Epidemiological Surveillance of a Village in Onchocerciasis Control IVERMECTIN :GENERAL INFPORMATION Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 59 An important characteristic of ivermectin is its very low toxicity. Millions of people have been treated with it so far, and no serious side- effects like death or permanent disability have been reported. This means that the drug can safely be administered by lay persons in the community, which is extremely important from the point of view of achieving good coverage. Mild side effects are fairly common though, and are the subject of a second handout. The decision about which areas and villages should be treated is made at national level. Such treatment continues yearly for many years, until the decision is made, again at national level, that it is safe to stop. When it has been decided that a village should be treated, it means everyone in that village, with the following exceptions: Children under the age of five years or less than 90 cm in height. They start taking the yearly dose as soon as they turn five. Pregnant women. They can take the dose a week after delivery. Women who are breastfeeding a baby who is less than a week old. They can take the tablets with them, to take as soon as the as the baby is a week old. People who are very sick. They can take the dose as soon as they are better. There is a simple test (the hand ear-test) one can do to find out if a child has turned five yet. The child is asked to try to reach with his arm over the top of his head, and to catch hold of his ear on the other side. Epidemiological Surveillance of a Village in Onchocerciasis Control IVERMECTIN :GENERAL INFPORMATION Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 60 If he can do that he is probably five years old or more, and can safely be given ivermectin. For practical reasons, the dose is determined by a person's height, as follows: between 90 and 119 cm 1 tablet between 120 and 140 cm 2 tablets between 141 and 158 cm 3 tablets 159 cm or more 4 tablets Finally, yearly ivermectin treatment in villages (in some cases twice a year) is the only practical way we have of controlling recrudescence of onchocerciasis - that is, if it reappears in areas where it was thought to have been eliminated. Epidemiological Surveillance of a Village in Onchocerciasis Control SIDE-EFFECTS OF IVERMECTIN Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 61 Side-effects of ivermectin These are usually mild, and are mostly caused by the reaction of the body to millions of dead microfilariae - a sign therefore that the treatment has worked. Interestingly community members spontaneously have this perception too. In the vast majority of cases the side-effects appear within 24 hours of the ivermectin being given, and clear up spontaneously, without further treatment, within a day or two. The most common side-effects are: Itching This can be very harsh but only lasts for a few days. It is considered severe if it stops the person from working or sleeping. It should then be treated with an antihistamine. Oedema This is sometimes generalised but is usually localised in some part of the body, often the face. It disappears a few days later. It is considered severe if it interferes with normal movement of the affected part. Aspirin should be given. Epidemiological Surveillance of a Village in Onchocerciasis Control SIDE-EFFECTS OF IVERMECTIN Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 62 Fever This is usually mild and of short duration. It is considered severe if it lasts longer than a day. In that case the patient should be investigated further, and the real cause (e.g. malaria) should be treated. Pain This can be located in any part on the body, may be localised in the swollen parts, may involve the joints, or take the form of a headache. If it is severe it should be treated with aspirin. Dizziness or syncope This comes on fairly quickly after taking the ivermectin. The patient should be encouraged to rest, and to take extra fluids. Diarrhoea This is a very rare complaint. If it is severe it should be treated with the usual rehydration solution. All severe reactions must, if possible, be seen by a doctor or nurse at a health centre. There is a specific form that has to be completed in such a case. This form will be passed on to the manufacturers of Mectizan® for their records. Epidemiological Surveillance of a Village in Onchocerciasis Control CACULATING THE AMOUNT OF IVERMECTIN TO ORDER Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 63 Calculating the amount of ivermectin to order If you are a nurse in a health centre, you will be responsible for ordering ivermectin yearly for the villages in the CDTI programme in your area. Don't worry about the first year you run the programme - the onchocerciasis person from Head Office will visit you and give you enough, or it will be decided upon during your training. For the following years you have to order it yourself. Here is an example of the calculation you have to do: You find the number of tablets that was used in the villages by adding the amounts for each village on the 'Yearly sub-district report form': 7513 There may be some villages which should have been taking the ivermectin, but for some reason did not do so.You know from your records how much ivermectin they need, and how much they should still have. You work out how much each one probably still needs: Batétou - they never fetched, need about 600, have a stock of 36 564 Youmé - they never fetched, need about 750, have no stock 750 TOTAL NEEDED BY VILLAGES 8 827 You subtract your present stock 972 So the minimum you need to order is : 7 855 To be safe you add 10% 785 NEW TOTAL 8 640 SO FINALLY YOU ORDER 8 600 Epidemiological Surveillance of a Village in Onchocerciasis Control CACULATING THE AMOUNT OF IVERMECTIN TO ORDER Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 64 You place the order around the end of March, when you do the yearly report. That means you will receive the new order in good time for the next year's issuing to the villages. Remember you have to issue old stock first, and tell the village distributors to do the same. For district managers the task is simple – they just add the totals from the sub-district together . Epidemiological Surveillance of a Village in Onchocerciasis Control EXAMPLES OF REPORT FORMS Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 65 Examples of report forms 1. Yearly sub-district ivermectin order NOTE : • This is a home-made form, to use of there is no routine health service form that can be used for this purpose. • The same form, slightly adapted, can be used for the district. IVERMECTIN ORDER FOR THE YEAR ___________ Sub-district: District: Quantity of ivermectin received the previous year Quantity distributed to villages Quantity left in stock to carry out our present activities we need ----------------- additional tablets. Name of health centre nurse making order:------------------------- Signature:----------------------------------------- Date:------------------------------------------------ Epidemiological Surveillance of a Village in Onchocerciasis Control EXAMPLES OF REPORT FORMS Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 66 2. Yearly village report form NOTE : If the village distributors are literate they learn to produce this report themselves, thus saving the health centre nurse a lot of trouble. CDTI PROGRAMME: YEARLY VILLAGE REPORT Year: Village: Health centre: Sub-district: District: Name(s) of village distributor(s): Number of inhabitants: Number of people treated: Number of people not treated: with 1 tablet children under 5 years with 2 tablets pregnant women with 3 tablets very sick with 4 tablets refusing TOTAL TREATED absent TOTAL NOT TREATED Ivermectin used: Number of tablets left at start of year Number of tablets given to village Number of tablets used Number of tablets lost/ spoilt Number of remaining tablets Name of health centre nurse making report: Signature : Date : Epidemiological Surveillance of a Village in Onchocerciasis Control EXAMPLES OF REPORT FORMS Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 67 3. Yearly sub-district report form NOTE : In your country you may be given a slightly different form. It should contain the same information though. CDTI PROGRAMME: YEARLY SUB-DISTRICT REPORT Sub-district: Name of village population counted population treated coverage: % of population treated quantity of ivermectin received quantity of ivermectin used quantity of ivermectin lost/spoilt Quantité d’ivermectine restant Epidemiological Surveillance of a Village in Onchocerciasis Control EXAMPLES OF REPORT FORMS Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 68 4. Report on serious side effects One report is written by the health centre nurses for every case of serious side-effects that they see, or that the village distributors report to them. This form has to be forwarded to the district, then to Head Office. Head Office will send the information to the manufacturers Merck in in the USA. REPORT ON SERIOUS SIDE-EFFECTS DUE TO IVERMECTIN 1. Information about the patient Name: Age: Sex: Name of home village: Sub-district: District: What was his/ her health like before? Good fair poor Which other illnesses does s/he have? Which other medicines has s/he been taking? 2. Information about the treatment with ivermectin Date s/he took the ivermectin: Patient's height: Number of tablets given: Was this the first time s/he got ivermectin? Yes no Epidemiological Surveillance of a Village in Onchocerciasis Control EXAMPLES OF REPORT FORMS Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 69 3. Description of the side-effects Date the side effects started: Describe the side-effects: Treatment given for the side-effects: 4. What happened to the patient Did s/he go to hospital? Yes no If s/he did, what happened there? Did s/he die? Yes no Name of health centre nurse making report: Signature: Health Centre: Date: Epidemiological Surveillance of a Village in Onchocerciasis Control EXAMPLES OF REPORT FORMS Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 71 5. Yearly district report form NOTE: In your country you may be given a slightly different form. It should contain the same information though. CDTI PROGRAMME: YEARLY DISTRICT REPORT District: Region: villages with CDTI quantity of ivermectinSub-district total number of villages number of villages with CDTI % of villages with CDTI total population population treated % of population treated received used lost/ spoilt left Name of district officer making report: Signature: Date: Epidemiological Surveillance of a Village in Onchocerciasis Control EXAMPLES OF REPORT FORMS Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 72 6. Example of a receipt form for issuing ivermectin to a village KÉROU HEALTH CENTRE Receipt number: Number of ivermectin tablets received: Name of nurse issuing: Signature of nurse issuing: Name of receiver: Address of receiver: Signature of receiver: Date: Epidemiological Surveillance of a Village in Onchocerciasis Control EXAMPLES OF REPORT FORMS Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 73 7. Example of a stock register for ivermectin Kérou Health Centre Ivermectin stock register tablets received tablets issued date receive from delivery note number amount issued to receipt number amount balance Epidemiological Surveillance of a Village in Onchocerciasis Control ASSESSMENT PLAN Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 74 ASSESSMENT PLAN It is very important that the trainees must learn especially the skills in this module to a high degree of competence. The plan for conducting such assessment is as follows: SKILLS In this module skills are learnt both in the classroom and in the field - in a village. The ‘classroom skills’ have to do with planning and writing. There are two possible ways of assessing the skills learnt: 1. At the end of each day’s practical the trainers meet to assess whether each trainee has mastered each skill s/he has to learn. This is done by using the assessment form below. Trainees who are not coping are given further opportunities to practice, under supervision, after hours. 2. For the ‘classroom skills’, the documents produced in class are collected and corrected. If the quality is good enough the trainee passess; is not, s/he has to re-do it. An average final skills mark of 2 or more is a pass. Epidemiological Surveillance of a Village in Onchocerciasis Control ASSESSMENT PLAN Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 75 KNOWLEDGE AND DECISIONS On the last day of the course a short written exam is conducted to see if the trainee has mastered essential knowledge and can make decisions with that knowledge. This test should cover the following areas: • How the CDTI programme works (including the three criteria whereby success is evaluated). • Ivermectin: formulation; dosage schedule; indications and contra- indications; side-effects and their management; duration of treatment. • The headings on a page in a village distributor’s notebook. • Community based and community directed ivermectin distribution: their advantages and disadvantages. A 50% mark for the test is a pass. DECISION TO PASS OR FAIL A trainee must pass both the practical and the test to pass. As usual, the practical part of the course is more important than the theory, although there are a number of important facts that trainees have to get to know well. Epidemiological Surveillance of a Village in Onchocerciasis Control ASSESSMENT PLAN Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 76 Finally the question is: are the trainer2s happy that a particular trainee will be able to perform the job, once s/he goes back to her/ his health centre? If the answer if ‘yes’ s/he passes; if not, s/he fails and has to re- do the module at some stage. Surveillance épidémiologique d’un village dans la lutte contre l’onchocercose PLAN D’EVALUATION Volume 3 – Community Directed Treatment With Ivermectin for Health Professionals 77 CDTI module - skills assessment sheet Date: trainees’ names 3 = excellent 2 = good - pass 1 = poor - needs more practice Write the score in pencil in the relevant block. This means you can change it later when the trainee has improved. 1. All trainees: • Make a list of villages and hamlets. • Perform the first visit to a village. • Prepare page in village distributor’s notebook. • Perform hand-ear test on a child. • Make and use a measuring rod. • Train village distributors using the manual. • Stock and dispense ivermectin. • Calculate ivermectin needed for a year. • Order ivermectin from the district office. • Write a yearly village report. • Write a yearly sub-district report. • Plan to monitor/ support distributors. 2. District managers only: • Plan to monitor/ support nurses in sub-districts. • Calculate ivermectin needed for district for the year. • Order ivermectin from the next level. • Write a yearly district report. average mark for skills (1, 1½, 2, 2½, 3) Assessors: