Mission to Mozambique to advise the Ministry of Health in the planning and the country implementation of the rapid epidemiological mapping/assessment (REMO/REA) of onchocerciasis March 23-April 8, 1998: mission report

Mission to Mozambique to advise the Ministry of Health in the planning and rhecoun'''*'1",:Ifl':il11?ile;ff B:?'5,:[:1'ffi i?,*icarMappins/ March 23-April 8, 1998 Report written by: Dr Piene Ngoumou Minisuy of Public Healtlr Yaounde, Cameroon 0 q RVR. 1998 I. Introduction and Background During our first visit to Mozambique in May 1996, the concern of the Ministry oif Health was to join the newly created African Progrmme for Onchocerciasis Control (APOC). At this time, there was no information whatsoever on the prevalence and distribution of onchocerciasis in Mozambique. No community-based survey(s) has ever been carried out, no report(s) from the Ministry of Health was available and the literau.rre was "generally" silent on the topic. At the end of our visit, it was recommanded that a proposal be drafted, and submitted to WHO/TDR for funding. The proposal was approved and in 1997, the study was conducted in the Milange district, Zambezia province. The study has revealed that onchocerciasis was present in Milange, though the endemicity levels were very low. The resuls of this preliminary investigation have suggested that the question now is no longer wtpher ? What there is onchocerciasis in Mozambique, rather where do you find the disease in the country is is extent? (the number of communities and the size of the population likely to be affected) From March 23 to April 8, we carry out a second visit to Mozambique. The objectives of our mission were to advise the Ministry of Healtlr (MOH) on the necessity of conducting a country wide Rapid Epidemiological Mapping/Assessment (REMO/REA) of Onchocerciasis in Mozambique; and to make with the MOH authorities and other partners a deuiled plan for these activities, if necessary. ll. Discussions with the authorities of the Ministry of Health During our visit, we held a series of meetings and discussions with Dr A. Barreto, Chief fi Epidemiologist, Ministry of Health, Dr L. Guiral(title?), and Pr. l. Pividal, from the Medical School, University of Maputo. During these meetingp topics were raised and when a consensus was found, the auhor of this repon will take note as the rappofteur. Any document produced during the visit is a result of a collaborative effort between the consultant, tlle partneru involved and the Ministry of Health authorities. March 23 -,27, 1998 We first reviewed and discused the report of the preliminary investigation canied out by Pr. Pividal at the beginning of 1997. The report revealed that onchocerciasis was found in the Milange district, Zambezia ProMnce, at hypgen-d_emiStY-lgygls (14.24o/o) in the area(s) surueyed. It was common agreement that: the question was no longer whether onchocerciasis was present or absent in Mozambique, but where to find it and the people who have the disease, and what is is severity and extent ? o there is therefore a need to carry out a nation-wide REA of the disease. However, priority would be given to the northern provinces of the counuy, because they share the same border(s) with Malawi and Tanzania, two onchocerciasis endemic countries a t/ (Tete, Niasa, Gbo Delgado), or because they are crossed by river rystem(s) likely to be breeding sites for the Simulium flies (Tete, Manica, Sofala, Zambezia, Nampula). We took note there have been serious modifications of the study methodology, and the execution of the survey. We recommanded that the protocole of the current study in preparation, be closely followed in order to avoid the collection of misleading information. lll. Elaboration of the REMO/REA Proiect Proposal in Mozambique March 28 - 30 1998 Once the decision was taken to carry out a REMO/REA exercise, we set out to write the proposal. A first draft of the document was circulated and reviewed at a meeting on March 30, 1 998. Few problems were raised with regard to the planning and execution of the REMO/REA exercise: J. t. Absence of the classical mapping team /!' -tr#rlyI /t'' The classical mapping team comprising a geographer, an epidemiologist and ail entomologist could not be formed. There is an entomologist worting with the malaria control plfigramme, but we were unabte to meet with him. At the same time, we suggested to the NOfFto identity a geographer in the Institute of Cartography and Teledetection, who can b?! pan of the mapping team. Because we are not certain that by the time the REMO/REA exercise start the team will be complete, we proposed a modification of the method of selection of communities to be surveyed (see Section 3.3.). Recommendation(s) We recommended to the National Team to continue the search for a geographer and an entomologist, who would be auailable duing the REMO/REA planning exercise. We also indicated to the National Team tltat tlte geographer and the entomologist should take paft in tlte training session of the National and REA field teams. a a J.2. Oryanisation of the REA surueys Three teams comprising two public health nurse(s)/technician(s), and a driver will carry out the REA survey(s). Each team will cover nruo provinces: Niasa e[ Cabo Delgado; Zambezia et Nampula. The third team will cover three provinces:Tete, Manica and Sofala. The fieldwor* will last 45 days. ldeally, each team should visit two villages per day, but because of the bad conditions of the roads in the northem provinces of Mozambique, and in addition to the long distances between villages, which are likely to have disappeared, the teams will be allowed to visit one village per day. This will make 35 days of fieldwork, and ten ( l0) extra days for travel time. The survey(s) are supposed to start as soon as possible, likely in May 1998 as the conditions allow and should last through mid lune. o't- J.3. Selection of communities to be surueyed The map shees to the scale of l:250,0OO are the ones available in Mozambique; however they are lacking a great deal of information. While the villages and the rivers are well depicted, the information on the relief, elevations, vegetation and some other details is lacking. ln the absence of a complete mapping team, we advised the Natjonal Team to use a modified method for the selection of communities to be surueyed. Communities to be surveyed will be selected using nvo procedures: Where no iver system is shown on the map, a gidline pattem, independent of the iver system, of 2O km of width will be used. In the presence of a maior iver system as indicated on the map, tlte selection of hish isk and secondary communities will be indicated We are anticipating that a minimum of 15 villages will be selected by province (if the REMO divisions/zones could not be obtained) to ascertain the presence or the absence of onchoceriasis. A totalof 105 villages will be visited. Each team will survey 35 villages for 35 days, the extra l0 days will cover the travel time between villages. Recommendation(s) i. We recommended to the National team to prepare a logbook to record all tlte steps uken duing tlte planning exercise, particularly during tlte exercise of selection of communities to be surueyed. 3.4. Training of the National Team in tlte planning and implementation REMO/REA surueys a a l Because of time constraints, we were unable to organize a training session for the National team However, the training of the National Team, the REA field teams, the geographer and the entomologist will take place before the surt of the fieldwork in ear{y May. ill J.5. Logistics At the central level, the MOH does not have dedicated transportation for the control program. At provincial level(s), it appears that tlrere are multipurpose used vehicles for EPl, Malaria control, MCH and other programs, etc. The vehicles cannot be mobilized for such a Iong period of time for the REA surveys. Recommendations a ) llf fnere are possibilities of renting a car in Malawi, but at a cosr of $2OO per day.,nFor the three ll[..rrr, *. *itl end up pavins izt,ooo. ) H,; )a i.- ,*l- 'F^" . ^e,tr t. , (,i A e We recommended that rather a slum sum of $ t SOOO be allocated for ttre)ll 4*f, I transportion i.e. the rental of vehicles for tlte fieldwork. ttl F We also suggested to tlte National Team to look for fi.tnds locally througlt WHO Office)11 for example, other potential donon and concemed paftnex. lll a April I - 6. 1998 3.6. Dau entry and analysis The MOH is provided with computing equipment and printer(s). There proiet coordinator and the deputy are computer literate. They will carry out the initial data entry and analysis, while preparing to send this data to APOC. 3.7. Report writing We advise the NOTF on the content of the repoft to be su[rgined to APOC at the end of the whole exercise. We advise d them that the report should fls comprehensive as possible, with detailed account(s) of difficulties encountered, villages selectdd and not surueyed and reasons for that, etc. The report should show areas of hyper and meso endemiciry eligible for communiry- directed treatment with ivermectin (CDTI) and those urgeted for clinic-based distribution. The report should also comment on the adequary of the sample coverage. 3.8. Follow up of the REA activities The proposal for the implementation of REMO/REA activities in Mozambique was finalized by Friday 3, 1998. Future activities are listed in annex ll. lt is expected that the training of the different percons and teams involved in the project will uke place in early May. The field wott is anticipated to start by early may. We requested the NOTF to prepare an ethical clearance form, and fax it as soon as posible to;f APOC, as the involvement of human beings in most WHO funded survey(s) requires that an// ethical clearance be given by the MOH, the ethical clearance committee, or any similar body. ll We furcher discussed activities in preparation to the elaboration of the National Plan of Action, and the readiness of the country to apply for funding to APOC. Table I summarizes the current situation as for the control of onchocerciasis in Mozambique. Recommendations APOC should provide technical suppon for the implemenation of the follow up activities: training of teams, superuision and validation of the REA results. a -lAJct tD (r, hJaC o oN A, g .o .D E aE O)td.o d .D OJE E. .) AJ trto o = o. ocl o -g oo oN EDC m ooc)q E -o 0c) -t .D Fm o o trl z o .D -E o rflO-ooq .)ot=- -4,5e-aD^ -o z o .D 1'dn .DUn+ drD-l =o 6'/D o. Eu, 4c)6(, *o oa .D OJ a o- m -.{ x.4,6 *E 'Tl a)o.DEo aD- A, I3> HE.n'o z?-tt6ts e a >hi cE HeJE -q7i.D E- Ee' o.= 3a 6' 7D- aD q)6=o.o. OJ .D o{ P. o' - 11 .D F rtl o Frtl I .D = z A)c.o J 9r = q)) o r) e.o5 Eq d' 6' J o o.o6E 3 .D o .E oo E8o -.rE-:9s9r cl qA vn oo IV. Summary of Conclusions and recommarylafons (a) There is a necessity to carry out rlation*iau RfVO/REA exercise in Mozambique. The obiectives of the exercise will be to de-Emine th-e prevalence, distribution, severity and extent of the disease, including the number of communities and the size of the population likely to be infected; to gather baseline data in preparation for the elaboration a the National Plan for the Control of Oncherciasis in Mozambique. (b) The mapping exercise would start in the northern provinces of the country because they are crossed by maior river rystems, likely to be breeding sites for Simulium flies or because they share the same borders with Malawi and Tanzania, two known onchocerciasis endemic countries. (c) During our visit, we were unable to identiff a mapping team (geographer, entomologist). We recommended to the NOTF to continue the search, and likely we will have the complete team during the planning of field activities in May. (d) Because of the absence of the mapping team, we also proposed a modification of the method of selection of communities to be surueyed. (e) It is anticipated that 105 villages will be selected and will be surveyed during 45 days by three teams (35 days of field work and l0 days of traveltime between villages). (0 The field work will be canied out by three REA field teams, and will staft in early May, and will include the training of the national and REA fietd teams, the geographer, the entomologist, and the superuisors (MOs) in the planning and the execution of REMO/REA field suruey(s). APOC will provide assistance for the training, the supervision and the validation of REA results; and will evaluate the performance of REA field teams. (g) Because of the high cost of transportation, it was the MOH concern and our suggestion to mobilize local funds to cover some items on the budget. (h) The superuision of the field activities will canied out by an expert from APOC and a MO, from the taryet provinces. As for the validation exercise, the NOTF will appoint one of is memben who will participate in the validation exercise. (i) We explained the purpose of the final report to the NOTF and recommended to the NOTF that the final report should be as comprehensive as possible. lt should give a detailled account of the difficulties encountered in the field, the number of villages selected but not surueyed, etc. The reporu should also indicate the levels of endemicity by areas and should highlight communities eligible for community-directed treatment with ivermectin (CDTI), and those urgeted for clinic-based distrpution. lf possible, the report should mention a word on the adequacy of the sample coverage. Annex I ltinerary of the Mission 23.O3.1998 24.O3.1998 25.03.1998 26.O3.1998 Anival in Maputo from Harare Meeting with Dr A. Barreto, preliminary discussions of the workplan Meeting with Dr A. Baneto, discussions of the worplan (continued) Review of WHO/TDR sponsored study report Discussions for the need to carry a REMO/REA exercise throughout the country: Drafting of REMO/REA proposal to APOC ? Meeting in the Ministry of Health with Dr A. Baneto, Dr J.Pividal, Dr L. Guiral Discussions on the planning and execution of REMO/REA activities in Mozambique 27.O3.98 - 29.O3.1998 Request of village base maps from Ouagadougou Drafting of REMO/REA proposal to APOC (continued) 30.03.1998 3 r .03.1998 Visit of the lnstitute of Cartography and Teledetection Updating of the proiect proposal I .04. r 998 Meeting with the MOH authorities (Dr A. Baneto, Dr L. Cuiral) 2.O4.1998 Meeting in the Ministry of Health Review of first draft of proposal Discussions on the selection of communities to be surveyed in the absence of a mapping team. Meeting with the Ministry of Health authorities, and DPC 3.04.1 998 4-5.O4.1998 6.O4.1998 Meeting with WR Meeting with the Ministry of Health authorities, and DPC Submission of the proposal to the MOH and the WR Report writing Finalisation of mission report Depamure for Yaounde, via lohannesbyrg, Abidjan and Douala J rDx -u oEo rD o- p- OJ =' uq o v rfl o F m AJ .1d. -t(D oNqJ Jg .oE .D E(t 3 2.o o 9r ID rc o T o to c) v .D o e{ =.c Jqq o o a' .D o .D OJe .D tA, ao OC' A,a .D B, (7 A) OJ .D q OJ o. AJ AJ o. .D I tD J o. .D g o. OJc. o5 o vm ? ID trl EE(D 3. 6' o q o.{o I - =E. .D 3 .D A,g. o o v rt| E ? .D -la P. =' oct o F rfi lD A) + oq .D o oc) o)E .Da F .D o 3 o oq9. -l -A, ='oq o z OJ o 9r +o O) 3 F rfl o PID 6- A, .D o e o.(t -v oo 2 OQ OJ a .D -tlrr 1/rcq d' 5' o E aE o 9r o 'U oo a)If. s. c. .D -{ AJ F \ I \o\o @ .g a =.oo. o to l.DtiI hJ oVt o z I n-\ N/)I\-