Rapid epidemiological mapping of onchocerciasis (REMO) in Southern Sudan, March 1-28, 2003: mission report

RAPID EPIDEMIOLOGICAL MAPPING OF ONCHOCERCIASIS (REMO) IN SOUTHERN SUDAN, MARCH t-28,2003 MISSION REPORT FOR woRLD HEALTH ORGANZATTON (WHO) AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL (APOC) OUAGADOUGOU, BURKINA FASO BY Dr. Mounkaila Noma Chief of Epidemiology & Vector Elimination WHO/APOC Ouagadougou, Burkina Faso Prof. B.E.B. Nwoke; Dr. I.N.S Dozie & C. M.U. Ajero WHO/APOC REMO Temporary Advisers Imo State University Nigeria PMB 2000 Oweri/I.{ igeria .D/ f A l! ' r.r l:;l : ^^ !'. .l a -{ i '':- i -i ,'_, '.,1 AP'-,'- lUlR Il4anch 27,2003 I LIST OF CONTENT 1.0 Summary 2.0 Introduction 3.0 Materials and Methods 3.1 Study Area 3.2 REMO Training 3.3 REMO Field Exercise 4.0 Results and discussion 5.0 References 6.0 Acknowledgements 7 .0 Appendix 7 .l Mission Schedule 7 .2 List of Nationals Trained 7.3 REMO Data 2 1.0 SUMMARY Rapid Epidemiological Mapping of onchocerciasis (REMo) was conducted in Southern Sudan, March l- 28,2003 with the support of African Programme for Onchocerciasis Control (APOC). During this study, a total of 300 villages (both from REA and REMO 2003) were selected. out of this, 1 18(39.3%) of them were either inaccessible andl or insecure at the time of the study. REMO exercise was successfully conducted or validated in 182(60.7%) of the villages selected. The result showed that onchocerciasis was absent in 6(3.3%) of the examined villages while in 176(96.7%) of the villages, varying degrees of the disease intensity were observed. Out of the 176 villages positive for onchocercal nodule, 33(18.8%) had nodule rates of 1- 9%; aa(25.0%) had 10- 19% nodule rates while 82(46.6%) and 17(9.7%) had 20- 39% and 40- 100% nodule rates respectively. The integration of the data into Atlas Geographical Information System (Atlas GIS) helped to define the Community Directed Treatment with Ivermectin(CDTl) priority zones, where REMO needs to be refined or carried out as well as non-CDTI zones. 3 2.0 INTRODUCTION From the grim background of the seriousness of the public health implications of human onchocerciasis and its socio- economic impact in endemic areas, it became clear that it is no longer a disease that can be taken for granted. This encouraged WHO (as executing agency) in 1974 with donor agencies and eleven (1 1) endemic countries in West Africa to establish Onchocerciasis Control Programme (OCP). OCP, the largest single and most successful tropical disease control progralnme was solely based on aerial spraying of breeding sites (rivers) with biodegradable larvicides to kill the aquatic larvae of the flies which transmit the disease. The success story of OCP has been reported severally (Duke, 1990; WHO, 1994; APOC, 2000). To sustain this success, and to confiol the disease in other endemic country outside the OCP area, global efforts continued in search of complementary strategy for the disease control. Recent years have seen considerable progress in the control of human onchocerciasis and the dramatic change of emphasis in strategy. The opportunity presented by the discovery and registrations of ivermectin (Mecttzan) as a safe and effective microfilaricide for large-scale (mass) oral treatment of onchocerciasis was a remarkable breakthrough. This development revolutionised the disease control strategy. Infact, repeated, annual single-dose treatment with Mectrzan reduces the development of clinical illness, visual impairment, disfiguring skin conditions and significantly decreases vector infectivity, thus reducing fransmission (APOC, 2000). On October 21, 1989, Merk & Co.Inc. at a press conference took an unprecedented decision and announced that it would supply Mectizan free for the treatment of onchocerciasis to any one who needed it, for as long as necessary. This commitment, provided agencies, organisations like OCP and endemic countries not only with incentive but also with formidable challenge. This open a new chapter and opportunity; and WHO 4 African Programme for Onchocerciasis Control (APOC) was launched in 1995 to take up this challenge to control the disease in l9 endemic African countries outside the OCP area. A massive consortium comprised of governments of 19 parhrer nations, donor countries, WT{O, Merk & Co. Inc., TDR/WHO, World Bank, NGDOs, UNDP and FAO all came together to help established and support a novel prograrnme-APOC-to oversee the distribution of Mectizan and to ensure it reached those populations most at risk. And the objective of APOC "is to establish, within a period of 12-15 years, effective, self- sustainability and Community Directed Treatment with Ivermectin (CDTD throughout the endemic areim in the geographical scope of the programme." By this, APOC's goal is to treat 50 million people per year by 2010 through CDTI strategy (APOC, 2000). Furthermore, in selected and isolated foci, APOC aims to eradicate the vector, wherever possible, by using environmentally safe methods (WHO, 1996). From its inception, the philosophy of APOC has been to provide Mectizan treatment to the people at the highest risk of developing the most severe complications (W-HO, 1995 a). In this concept, the general agreement is that ivermectin should be distributed first to communities thatare at risk of developing the severe and disabling ocular and dermal complications (Taylor et al, 1992; WHO, 1992). And the level of community's risk is directly related to the intensity of the disease in the community (Remme et al, 1989). This according to WHO (1992, 1995 a) and Ngoumou &Walsh (1993) is usually determined epidemiologically using Rapid Epidemiological Mapping of Onchocerciasis (REMO). In view of the foregoing, APOC requires comprehensive epidemiological data on onchocerciasis using the WHO recommended REMO from all APOC countries for effective CDTI strategy. The REMO data help to delineate the areas lzones tlrat need CDTI priority and at the same time ensure adequate coverage of the high risk areas. 5 In Southern Sudan, the first clinical observation of onchocerciasis was made by Ensor in 1908. Ensor described what was then known aS "craw craw" in soldiers stationed in Meridi in Bahr El-Ghazal Region. About three decades after Ensor's observation, Bryan (1935) reported a definite association of Onchocerca volvulus infection with blindness and onchocercal skin diseases. Infact, Bryant called oncho- blindness, "Jur blindness" because the disease was prevalent between the Jur and the Balanda near the Jur river tributaries. Since these initial studies, other works identified onchocerciasis and its vectors in the different parts of Southern Sudan, including Kirk (1937), Lewis (1957), Haseeb et al (1962), Satti (1985), Williams et al (1985), Kaneene at al (1985), and Baker & Abdeinur (1986). These results though not coordinated showed that onchocerciasis and its vector species are prevalent and widespread in Southern Sudan. However, there arc a lot of more areas where the prevalence and distribution of onchocerciasis is yet unknown. Furthermore, the available data are not comprehensive enough to give the needed spatial distribution of the disease. The absence of complete epidemiological information on the disease in Southern Sudan till now has limited APOC's complete implementation of CDTI in all the high-risk communities. It is against this background and in consideration of the current cease-fire that APOC sponsored this study with the following objectives:(a) To train the Southern Sector onchocerciasis Task Force (SSOTF) members on REMO procedures and techniques(b) To assist the Task Force conduct REMO exercise in selected villages and also appraise and validate the existing REA/REMO results-that will generate comprehensive epidemiological data that will enable APOC delineate areas that need CDTI priority and at the same time ensure adequate coverage of all the high risk communitie g/vi llages. 6 3.0 MATERHLS AND METHODS 3.1 STUDY AREA The study area of this mission is Southern Sudan. Southern Sudan is bordered on the west by Central Africa Republic (CAR), on the East by Ethiopia and on the southern boundaries by Democratic Republic of Congo (DRC), Uganda and Kenya. It is administratively divided into three regions; Equatorial Region on the South, Bahr El-Ghazal Region on the north west and the Upper Nile on the north east. Each region is divided into counties (Fig 1,2). The major topographical feature of Southern Sudan is the White Nile which constitutes the main drainage system. It transverses the three regions from the southern border with Uganda, DRC and CAR. In the Upper Nile region, the main tributaries of the White Nile are; Baro, Pibor, Bahr El-Jebel rivers; in the Bahr El Gazal, the main rivers are the Jur, Kiir, Pongo, and Chel while the main tributaries of the White Nile in Equatoria Region are Wau, Kideopo, Sue, Ibba, and Yei rivers. These rivers arise from the water shade or headwaters of the White Nile, and therefore are fast flowing with a lot of rapids. These characteristics create favourable breeding sites for the Simulium vectors. The climate of Southern Sudan is fropical with average annual temperature of about29C (about85F). The rainy season months are April-september with annual rainfall of more than 1000 mm (40 inches). In Southern Sudan, the vegetation varies from typical rainforest in the southern part to Guinea/derived Savannah in the northern area. There is a vast swampy and or flood plain in the Jonglei area of the Upper Nile. Human settlement, though seriously affected by many yea.rs of civil war is basically rural. Farming and livestock production are the main occupationp of the rural communities. Exposure to infection in Southern Sudan is by way of village proximity to breeding sites and occupational activities. In endemic 7 .''$ ; ;' a16,)i{t';" ' \'r'*' i' ,klk'l' ',1..:!r,iS'. ,4r" .'r.{. A;q; , , f rr -. ,,,*l 'SrFrHffi w-n mr o N r C!! m n z F m aC -{o n F sr+'fr*fifiiE#d*$EJH#Sd#ttrr#EfWffiiffiffiflrii..o?,tr .y*, a 3 I a =C a a o I ol C' oI oq S o o ar o a- o { aA aa oI -n =t e o6 A =LoH =.PEJE.?aF!oD9s :r-i.j. 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No o6 r]or 6-;!. ^'6oE.B A (6 c. !t o- {-.(- tL ).. x = o Oo N)oo { i .dd)i1r.,,.+.., +ii 't:i'fl ,-t-i"'i :l .!il ( \ i\ { communities, both old and young are exposed to infection such that the disease prevalence gradually increases with advancing age. 3.2 REMO TRAII{ING One of the major objectives of this mission was capacity building - to enable the Southern Sector Onchocerciasis Task Force (SSOTF) of Sudan have a pool of well trained manpower that will train the Regional and County control teams as well as possess the capacrty to continue successful REMO exercise in areas that are inaccessible or insecure at the time of the present exercise. To achieve this, a26-man SSOTF team (see appendix 7 .2) was trained for four days (March 10-14,2003) in Rumbek on all aspects of the WHO recommended Rapid Epidemiological Mapping of Onchocerciasis (REMO) documents (Ngoumou and Walsh, 1993 WHO, 1995 b). In addition, the team was exposed to the biology and ecology of the disease vectors, epidemiology, clinico-pathological aspects and the socio-economic impacts of the disease on the population. The team wim also taught the current disease control strategy adopted by WHO/APOC. At the end of the theoretical training at Rumbek, all the team members were taken to a known endemic community, Wulu in the Lakes County for a one day intensive practical (March 15,2003) on community mobilisation, use of REMO forms, clinical examination and identification of onchocercal nodule. The fraining was very successful. 3.3 REMO FEILD EXERCISE At the end of the practicum, six groups were formed (with a member of SSO]F as goup leader) to carry out field REMO exercise in the accessible and secure selected (REMO )villages based on the UN security advise. For obvious logistic and 8 \J *.- ,-1.I ,'H ldtd secu'ty reasons, the team tg-u.nner Nile region (Boma) had toflv for this exercise with a uN oiiisnut.J pi;r, where possibreand secure, the Apoc team fac,itited ;;l;rpervised the fierdexercise- Having established the time-tabte, and uN securityclearance for the vilrages to be r*urir.o, lo.qrut, logistic andmaterial supports incruding communication system (radio andmobile phone), all the groups went ahead with theimplementation of the fierd REMO exercise (March 15_262,2003). At the end of the fierd ,*...ir., irr, ,","ted resurts wereimpressive and consistent with previousry describedepidemiorogicar patterns of the disease. ih.r, is no doubt therefore that this Rruo exercise in Southern Sudan is a hugesuccess, notwithstanding the inherent difficurties associated wrttrextensive community bised-studies in an u.a ,noer civ, warconditions. 4.0 RBSULTS AND DISCUSSION with the support of wHo/Al9t, Rapid EpidemiorogicalMapping of onchocerciasis (REl,ro; *u, .iraucted in SouthernSudan, March r-29, 2003. It_ is irpo.turi to note here thatREMO as an operational procedure is ur"J io determine througha rapid and simple method the approximate distribution andseverity of onchocerciasis in the iria anw or varioate existinginformation and resurts or pi.uious mapping exercise. This iscarried out in order to provide a rationut u^I, for pranning andimplementation of costiffective and sustainabre onchocercias iscontrol. Against this background, on arrival at Nairobi the Apoc teamhad to study and appraise ttre hirto.irur epidemiorogical data ononchocerciasis from r 90g and the nrvro'r*.r.ise conducted byHealth net Internationar rrn ro *o oflr". ilao, in southernsudan, 1998-2002. It was observed that the previous REMOexercise was rerevant but the ,rrpr.i- villages lackedgeographicar co:ordinates (ratitudes uro-tongitudes) and werenot strictly serected in accordance wittr" wHo/ REMOprocedure. 9 However, the results were consistent with known epidemiological and entomological data in Southern Sudan. When the selection of the REMO villages for the present exercise was completed, their geographical co-ordinates were directly calculated using topographical maps as the use of Geographical Positioning System (GPS) was prohibited in Southern Sudan at the time of the exercise. Before the field exercise, consistent results of the previous REMO exercise which corresponded to villages selected in the present study were adopted and validated where possible. Infact, the endemic onchocerciasis village used for the practical was primarily selected to help validate the previous REMO exercise. A total of 300 REMO villages (both from REA and REMO 2003) were selected in this exercise. Out of this , I 18(39.3%) of them were either insecure andl or inaccessible at the time of the present study. REMO exercise was successfully conducted or validated in 182(60 .7%) of the selected villages. By the present result, onchocerciasis is absent in 6(3.3%) of the villages examined while in 176(96.7%) villages, varying degrees of disease intensity were observed. Of the 176 villages positive for oncho cercal nodule, 33(18.8%) had nodule rate of l-9%; 44(25.0%) villages had 10-19% nodule prevalence while 82(46.6%) and 17(9.7%) of the villages had 20-398% and 40- 100% nodule rate respectively. The distribution and intensity of Onchocerciasis in the exercise was integrated into Atlas Geographical Information System (Atlas GIS) (Fig 3) and it was observed to be consistent with known epidemiological information of the disease in Southern Sudan. Furthermore, the same software was used to define the CDTI priority areas, no CDTI areas and where REMO should be performed or refined (Fig. 4). From here it is clear that Onchocerciasis is endemic in Southern Sudan but more REMO data are urgently, needed to actually define the boundaries of CDTI priority zones. l0 ri -r{ o t' ) \ ) t':,' /( t , z o CLE 6'o s \ eeooo Af\rO ooo.I-tllvF(,)He\o\oo Ioo Noo t a laE a I o a CCt oL e S E ocI e.D\as a a aEo: aq. E Gt a .A to oa 't to:5 o a S oo aC' o s oI o Lt oo aa 3 F@FqO F}\J TF\-froH= d9?CL -- !,u= i/ Eonlrjoo--'= < ==tD'EsE a ! =.;t-(Doa=tcl o=.o -rEr=U1 ECL o19aq i:6dts 't (Dtr, EL ONEO o. It!o(DLA Cn r"'iataaaa x = ,5 i( b a' a, i ". ;{-, tto ooEI + CN og I r.l (D t,) og .+ - J o - -J Eop o a{ ? -CL 9' -JoEtE oa Ft (D D?(o o eeooo at F!ie?"?iolr(..)-'erag e z o CLc o o s ir I ,/-; ir ')r ';" l- -.ii' f > -o0 / 6r\ + -tbF ( t I I I P € c .J, 1i \ o \ Hq\-,\ +\ E 0t (/)1 ro(o o CL It{ o :e o N o (lq |$IdzoFaoEqSaii'Otr'0" o-5' E!9 rtrDn='E g<l!aft =(Dc3) -20 & H I tr onO I o ot u:. E! ot o0 o a o (! (n -l ;t]o \P) \I aE l o =o ot:q E a - a E o i' aq E o 66 o{T EtfI I oo EE of o o !oo nI \. \ \ F, i) =3Et I o olo5 sr o z oI o uDltr a-o -{ tsFl-t \ ->" tL F tl * \-- 6\\ -\tn+ 6Rir .L l'/nt C1fi\ Tt II :^i,r- tt .c_ -t. :el f c- -rl .cl -c. -s- .c s. ,* .c. ,(l3 -\r -+' c c c_ a. t. j :^- .-,f a a_ \-; ,+,(' c .l e ,c c t-. 'r- lcl:fl ia -c, c ..,., ?l c-f .e. ---c ) ,i _\/ 5.0 REFERENCES APOC(2000). Empowering Partnerships and Communities : APOC and the fight to get rid of Africa of River Blindness--- WHO African Prosramme for Onchocercias is Control (APOC), Ouagadou gou/B urkina Faso. Baker, RHA &Abdeinur, OM(1986). Onchocerciasis in Sudan: The distribution of the disease and its vectors. Troo. Med. Parasitot. 37: l -355 Bryant, J( I 93 5 ). Endemic retino-choroiditis in Anglo-Egyptian Sudan, and its possible relation to On0hocerca volvulus. Trans. Rov. Soc. Trop. Med. Hve. 28. 523-532 Duke, BOL(1990). Human Onchocerciasis: An overview of the Disease. Acta Leidensia- 59(l &2)'. 9-24 Ensor, H (1908). The advent of craw-craw in the Anglo- Esrytian Sudan. J. Roy. Army Medical Corp. 10:140-143 Haseeb, MA; Satti, MH & Sherifl M(1962). Onchocerciasis in Sudan. Bult wHo 27.609-615 Kaneene, JB et al (1985). An epidemiological study of Onchocerciasis in Bahr El-Gazal province. Sudan Med. J. 21(suppl .). 65-71 Kirk, R (1947). Observations on onchocerciasis in the Bahr El- Gazal province of Sudan. Ann Trop. Med. Parasitol 41.357' 364 Lewis, DJ(1957). Simuliidae and their relation to Onchocerciasis in Sudan. BuIt wHo. 16:671474 1l Ngoumou, P& Walsh, JF(1993). A Manual for Rapid Epidemiological Mapping of Onchocerciasis (REMO). TDR/TDE/ONCHO/93.4 WHO Geneva Remme, HJ et al (1989). Ocular Onchocerciasis and intensity of infection in the community.l. West African savannah. Trop. Med. Parasitol. 40:340-347 . Satti, MH(l985). A historical account of Onchocerciasis in Sudan Med.J 21.5-8 Taylor, HR; Duke, BOL & Munoz,BC (1992). The selection of communities for treatment of Onchocerciasis with ivermectin. Trop. Med. Paraiitol. 43:267-270 WHO (1992). Methods for community diagnosis of Onchocerciasis to guide ivermectin-based control in Africa. TDR/TDE/ONCHO/92 .2, Genev a WHO (1994). Twenty years (197 4-1994) of onchocerciasis control Programme in West ffiica. WHO Geneva. WHO (1995a). Onchocerciasis and its control: Report of a WHO Expert Committee on Onchocerciasis Control. WHO Tech Rep..Ser-Nejl2 WHO (1995b). The importance of onchocercal Skin disease: Report of a multy county study. TDR Applied Fietd Research Report, No 1 Geneva. WHO (1996). African Programme for Onchocerciasis Control (APOC). Programme document for phase 1. APOC Ouagadougou. Williams et al (1985). Current distribution of Onchocerciasis in Sudan. Sudan Med. J. 2l:9-17 . l2 6.0 AKNOWLEDGEMENT We are grateful to APOC for the opportunity given to us to serve in this exercise and to WHO Lagos, Southern Sudan and Kenya for their efforts to facilitate our mission. We are indebted to the chairman and members of SSOTF for their support and goodwill through out the study. The success of this exercise was made comparatively easier by the expertise and professionalism as well as commitment exhibited by HealthNet International (HNI) in generating the REA results even in the mist of civil war. The contributions of the field teams, village heads and drivers are highly appreciated. To all that contributed to the success of this study, we say thank you. l3 7.0 APPENDIX 7.1 MISSION SCHEDULE AGENDA Period Activities Feb.28th 2oo3 o Arrival of APOC Team Mar.l-8th 2oo3 a Meeting with SS OTF,WHO/Southern SudarL WHO/I(enya Collection of maps, reports and materials Planning of REMO exercise (training & field exercise) Travel clearance a O a Mar. 8-9th 2oo3 o Departure for Lokichoggio o Arrival in Lokichoggio o Security briefing by OLS o Orientation of APOC and HNI team members (By WHO) o Departure for Rumbek r Arrival in Rumbek Mar. 1o-14'h 22003 a Training on REMO methods and techniques Selection of REMO villages/ (sampling of villages) Preparation for field exercise a a Mar. 15-21" 2003 o Practicals o Field REMO exercise o Preliminary data analysis Mar.22N a Departure for Nairobi Mar.23-29'n 2oo3 o Dataentry, analysis o Mission report o Planning completion of REMO in Southern Sudan o Debriefing SSOTF, WHO/Southern Sudan o Deparhre of APOC team l4 7.?LIST OF SSOTF TRAINED 1. Dr. Samson Paul Baba/SSOTF Coordinator 2. Dr. Samuel Patti 3. Dr. Pius Subek 4. Dr. Angok Gordon 5. Dr. Margarret Itto 6. Mrs Esther Poni 7 . Mrs. Agum Isaac 8. Mrs. Merry Lucy 9. Mrs. Irene Mueller 10. Mr. David Bido I l. Mr. Mathew Guaso 12. Mr. Evans Ariko 13. Mr. Remijo Amule 14. Mr. Michael Luggalla 15. Mr. Emmanuel Ezama 16. Mr. Nek Martin 17. Mr. Daniel Dut 18. Mr. Cornelius Ndungu 19. Mr. Mario Deng 20. Mr. Phillip Makuach 21. Mr. Martin Mande 22.Mr. John Samuel Marko 23.Mr. Wisley B. Court 24.Mr. Jonathan Sebit 25. 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