Nation-wide rapid epidemiological mapping of onchocerciasis (REMO) in Rwanda, July 24-August 22, 1999 : mission report

NATION-WIDE RAPID EPIDEMIOLOGICAL MAPPING OF ONCHOCERCIASIS (REMO) IN RWANDA. JULY 24-AUGUST 22,1999). MISSION REPORT FOR woRLD HEALTH ORDANIZATTON (WHO) AFRTCAN PROGRAMME FOR ONCHOCERCTASIS CONTROL (APOC) OUAGADOUGOU, BURIilNA FASO. DR. B.E.B. NWOKE, & Dr. AbCI NAMSSENMO, (wHo TEMPORARY ADVTSERS) 1. Professor of Medical/Public Health Parasitology & Entomology. Consultant, National Onchocerciasis Task Force (NOTF) Nigeria, School of Biological Sciences, Imo State University, Nigeria PMB 2000 Owerri, Nigeria. E-mail : ricdenis @ theobech.com 2. Medecin Epidemiologiste Chef de Service de Lutte contre les Maladies Endemo-Epidemiques DMPM/MS PP Bangui B.P.783 Bangui RCA. AUGUST 20 ,1999 BY a I.O SUMMARY 2.0 INTRODUCTION 3.0 MATERIALS AND METHODS LIST OF CONTENT 3.1 Study area 3.2 REMO Training and Implementation ,, 3 4 4 5 4.0 RESULTS AND DISCUSSION 5.0 REFERENCES 6.0 ACKNOWLEDGEMENT 7.0 APPENDIX 7.1 Mission Schedule 7.2List of Nationals Trained 7.3 REMO Data 6 8 9 10 10 11 t2 a2 SUMMARY In order to determine the existence of human onchoceerciasis, the levels of disease endemicity in different bioecological regions, and areas where Community Directed Treatement with Ivermectin ( C D T I ) disease control strategy should be implemented in Rwanda, African Onchocerciasis Control Programme (APOC) supported this nation-wide Rapid Epidemiological.Mapping of Onchocerciasis (REMO) July 24 - August22,l999.The principle of REMO developed by WHO and applied in this study is the use of percentage onchocercal nodule rates among randomly chosen resident adults farmers, aged > 20 years in selected villages within the river basins (possible breeding sites of vectors and disease transmission foci ) as indicators of disease endemicity. A total of 104 REMO sample villages from all the 12 Sanitory Regions of the country were selected for this exercise.Of this number 6 (5.8 %) of then were inaccessible/non-existing at the time of the study.REMO exercise was successfully conducted is 98 (94.2%) of showed that human onchocerciasis was apparently absent in 84 .0-5. o 1n 4 These results within epidemiological frame-work of the disease the selected villages.The results 7zo) ot,n. rr,rug", *iffi ry*i- ^ b4r.4W" ftcbl/il, ,/a,,l.ili^"2 ti lAanuuo.J. llA" % &o ah l.{&/te cf9 a tr 7 C./ b, A" il"'u' c, c- a- 0 / 32.0 .INTRODUCTION Human onchocerciasis is a chronic parasitic disease caused by filarial nematode, Onchocerca volvulus.It is transmitted to man by infected female black flies, Simulium species which breed in well oxygenated river. The vectors in west and Central Africa are mainly S.damnosum group which breed in fast flowing rivers-with the aquatic stages attached to trailing vegetation, sticks and rock. On the other hand, in East African countries transmission of the disease is mainly by S.neavel group whose aquatic stages have phoresy association with fresh water crabs. This debilitating disease is endemic in at least 37 countries : 30 coutries in Africa,6 in the Americas and 1 in Yemen. About 20-40 million people are infected by this disease, I million suffer severe visual loss, while 200,000-500,000 are blinded by it. And another 80 million people are at risk of being infected (WHO, 1995 a) River blindness as a common name for onchocerciasis draws the attention to the most overt, serious and feared consequences ofthe disease-causing different characteristic ocular lesions often leading to irriversible blindness in untreated patients. Hence the name river blindness because these blindness cases are more prevalent in villages around the rivers (the breeding sites of vectors and high transmission foci of the disease) . The villagers therefore believed that the gods of the river were responsible for the blindnessQ.{woke, 1990). In addition, onchocerciasis causes very severe and debilitating onchocercal skin diseases(OSD), disfiguring and worrisome hanging groin, genital distortion and elephantiasis of the genitalia as well as systemic complications. These non-ocular lesions which hitherto were not recognized as a public health problems to warrant control efforts, have recently been acknowledged to cause much more burden than blindness in most endemic areas in Africa, especially in the rainforest belt. It was in recognition of the fact that onchocerciasis is a major public health problem and impediment to socioeconomic development in endemic areas that encouraged WHO in 7974 to establish the Onchocerciasis Control Programme (OCP) in West Africa. OCP the largest and most successful tropical disease programme strategy was solely based on vector control larviciding of breeding sites with biodegradable insecticides. It started with 7 West African countries and extended to encompass a total of 1 1 countries. To sustain this success, global efforts continued in search of complementary strategy for the disease control. Recent years have seen considerable progress in the onchocerciasis control and dramatic change of emphasis in strategy. The oppostunity presented by the discovery and registration of ivermectin(Mectican@ ) as a safe and effective microfilaricide for large-scale (mass) treatment of onchocerciasis as well as the commitment of the manufacturers, Merk & Co to provide the drug free of charge revolutionizedthe control strategy. This development gave incentive to the establishment of WHO African Programme for Onchocerciasis(APOC) in l9 African countries outside OCP area. In parallel with APOC the programme for the elimination of onchocerciasis in the Americas (OEPA) is supporting the distribution of ivermectin in endemic countries of Mexico, Guatemala, Venezuela, Colombia, Ecuador, and Brazil (WHO, 19995 a ; Molyneaux &Davies, 1997). 4APOC strategy is based on partnerships between govemment of endemic countries and NGDOs (Boatin et al, 1997) to achieve sustainable delivery of ivermectin using Community Directed Treatment with Ivermectin (CDTI) strategy. The philosophy being to ensure adequate community involvement/ownership to sustain delivery after the support to projects has ceased after five years. In this concept, the general agreement is that ivermectin should be distributed first to communities that are at the risk of developing the severe and disabling ocular and dermal complications of the disease (Taylor et al,1992; WHO, 1992). And the level of community's risk is directly related to the intensity of disease infection in the community (Remme et al, 1989). This is usually determined epidemiologically using REMO (WHO, 1992). In view of the foregoing, APOC requires comprehensive epidemiological data on the disease using the WHO recommended Rapid Epidemiological Mapping of Onchocerciasis (REMO) from all APOC countries for effective CDTI strategy.The REMO results help to delineate the areas/zones that need C D T I priority and at the same time ensure adequate coverage of all the high risk (hyper- and meso-endemic) areas in the control programme. In Rwanda at the time of this report, there was no, records of any epidemiological studies on onchocersiasis.This was to the extent that one did not know whether the disease existed or not. This situation therefore created fundamental questions and difficulty to health planners in the country. Again, this complete absence of epidemiological information on the disease in the country made it difficult for APOC to extend her hand of partnership. The need to determine the existence of human onchocerciasis, the levels of endemicity and areas where CDTI should be implemented became very necessary and urgent. This was why the nation-wide REMO exercise was sponsored by APOC : a) To train Rwandan Nations on REMO procedure and b) To assist the National team to conduct nation-wide REMO exercise in the country c) 3.0 MATERIALS AND METHODS 3.1 s y Area This REMO exercise was conducted nation-wide, covering the whole country. Fermerly known as Ruanda (part of the Belgian-Administered territory of Ruanda-Urundi), Rwanda is geographocally located on the east-central Africa between Latitudes 1o and 2" 55' and Longitudes 28o 50' and 30"56'E (Fig1). It is boredered on the North by Uganda, on the East by Tanzania, on the South by Burundi and on the West by the Democratic Republic of Congo (DRC) . With a population of over 7 million, Rwanda occupies an area of 26,338 sq.km. (10,169 Sq.Mille).That is an average of 265.78 persons per Square Kilometer. Rwanda's relief is mountainous and the altitude declines from West to East with the highest peaks overlying the Western high reliefs, there are high plateau to the East which form more or less the centre of the country.East wards, towards Tanzania, there is a broad zone of hills and swampy lakes. 5Rwanda is located south of the Equator with temperatures influenced by altitude. Kigali, the capital city has an annual average temperature of 19oC. There is a temperate climate in area above 2 000 meters (6,562 ft) and low temperatures are experienced at night during the dry season. Rain fall in Rwanda is determined by the winds from the Indian Ocean. The Capital, Kigali, receives an anniual average rainfall of about 1,016 mm (40 inches ). There are two rainy seasons in the country : March-May and October-December. Also the country experiences two dry Season periods : January-February and June-september. Rwanda is mainly drained by the Akagera and Nyabarongo/Akanyaru rivers and their numerous tributaries. Also, there are many lakes in the country : In the western border with DRC is the big Kivu Lake, and Burera and Ruhondo Lakes in the north near the Ugandan border. There are a lot of numerous small lakes in the eastern part of the country such as Cyohoha, Riveru, Sake Ihem, Nasho etc.Most of these lakes in the east are characterized by swampy vegetation.These swamps together with National parks at Nkageru on the east and Birunga on the north as well as forest reserves at Nyungwe and Gishwati constitute un- inhahabited or sparcely populated zones of the country. All these together with the altitude influence the vegetation of the country. The western part is characterized mainly by mountainous forest vegetation especially m the forest reserves. As a result of deforestation for agriculture and overgrazing, Some of the areas are now more or less Savanna grossland and mosaic forest. However, aforestation programme is on the increase to conserve the environment. It is important to point out here that en the eastern area, the numerous Swampylakes and rivers create same vegetation. Concerning agriculture, the high Rwanda's population density means that there is a chronic pressure on cultivated land.There is only one hectare of arable land per inhabitant, and demographic growth of 3.3o/o annually has caused serious soil erosion.One result has been growing pressure on yield. The traditional importance of livestock has produced problems of land deterioration due to overgrazing. The cuttinng down of trees during cultivation, timber, and for firewood and charcool, the principal energy source for the rural populaton, creates further soil erosion. Agricultural production is overshelmingly on small family plots. The main food crops are plantains, Sweet/irish potates, beans, banana, sorghum, cassava and maize as well as Sugar can and ricewhich are grown in the east on the marshy plains along the Ugandan border. 3.2 ptr't\/Ir) TRAININ 11 AND IMPI tr'N/II'NTATIrlN One of the major objectives of this mission was capacity building. To achieve this, a six-man National team (see appendix 1) was trained in Kigali for 3 days on all the aspects of the WHO recommended Rapid Epidemiological Mapping of Onchocerciasis (REMO) documents ( Ngoumou and Walsh,1993; WHO, 1995b). In addition, the team was also exposed to the biology and ecology of the disease vector ; epidemiology, clinicopathological aspects, and 6and the socioeconomic impact of the disease on the population as wellas the need and current control strategy adopted by WHO/APOC. As pointed out earlier in the introduction, there are no records of onchocerciasis in the country. In the worlds of Fain ( 1991 ) investigations were also carried out in Rwanda but no onchocerciasis has been observed in this country . As a result we had difficulty in the choice of the area for the field practicum. After due considerations of the geography and available literature, we decided to use selected in Cyangugu Sanitary Region for the practicum.This Sanitary Region is in the South West border with Burundi - an area considered comparatively closer to endemic Provinces of Bururi and Rutana discussed by Newell (1995) and Newell at al (t997). At the end of the practicum, two separate sub-teams were created. One sub-team, for the east Sanitory Regions of Byumba,IJmutara, Kibungo, Kigali Central, Kigali Provincial and Ruhangeri was led by the National Coordinator, Dr.Mugisha and facilitated and supervised by Dr. Namssenmo the other sub-team for the western Sanitary Regions of Cyangungu, Gikongoro, Butare, Gitarama, Kibuye and Gisenyi was led by Dr. Sahabo and facilitated and supervised by Professor Nwoke. Two alher personnels (District and Region) joined the Sub- teams each day. Having established the timetable of activity, adequate logistic and materal support as well as efficient communication link between the team and Sanitary Region, the sub-team went ahead for the implementation of the nation-wide REMO exercise in the country. At the end of the field exercise, the results were impressive and consistent ; and it was very clear that the exercise was a huge success, notwithstanding the inherent difficulties associated with extensive and intensive village studies. 4.0 RESULTS AND DISCUSSION With the support of WHO/APOC, a nation-wide Rappid Epidemiological Mapping of Onchocerciasis (REMO) was conducted in Rwanda, July 24-August 21,1999. Before this exercise, what was known about human onchocercasis in the country was based comments such as the one made by Fain (1991). A total of 104 REMO sample villages from 12 Sanitary Regions of the countryb were selected for clinical examinations for onchocercal modules in accordance with the recommended -t l.l EElr ta, z.tl P 'A)E TAI4A z= trE oo|!ll: ozz> PY.J -i{;^ =Avvdvda, -OU\O F TAJFfrean FJl!!t <E =[!ZzF= <F >o '.2, t^ >o F i |.] F l.) F( r+ljlz olnF - X q.,r ar Fo 2o - X - oln z -l - :l, E EUC 2, oo 90 A -l F S EE c7 w I n EE El s^ o U) L1l z I q.r .J 7 P q.l n z 1., o t0 oa 0c :. EE -l Fln a te D' .{ (D oe 5 oo (}J NJ { \o o\ q ? <z rD =')+de .D6 o\ UI 6 O N) N) N.) >\ (,) N.))J u) = <z !e =yet)Ijoai;(D v) tD I (D X O 0q ^\ \o6 \o5 i.J m O :. U.) N) { \o :1 o\ 5 oo :\ oo @ t^ oo\) P{ GEs<Zo\X =5vD9-.ED95 ore ='(D(D 65 6 !n{ @ b N) \o !.) UJ oo(}J L,J { :- @ @ 90 o\ i\ N) uP \o @ @ o\\)(,l o\\)(,l oo bo o\X ==d\v---. fAqE 5 F(JJ )J\) O NJ I{ P N) L'I - N.) oo i') N) N)u N) N)(Jr b NJ oo [.J G E { <Z -\VE.E.- --v.v--r. E6' qB 5 N) A N) - t) N) NJ :^ NJ I\e oiE5 q-f e.Dr P REE ::,^P I o\"i o.=(D =tr ?i9 z9 LD aqE po0qt r,tD r9 O :^ O b SI \o O t\) P N)\o O P \o P O \S I 8WHO guidelines (Ngooumou& Walsh, 1993).Of this number, 6 (5.8%) of them were inaccessible/non-exsting at the time of the study. REMO exercise was successfully conducted in98 (94.2%) of the villages selected.The results (Table 1) showed that human onchocerciasis was apparently absent in 84 (85.7%) of the villages examined while few cases of onchocercal nodules were observed in 14(14. carrylng persons ln these vlllage 3%) of the villages. These s were very the source of infection.Again, inall the villages with rates were between 2.0o/o and 5.0% (Appendix III). It distribution. They did not follow1n any pattem or river system(possible breeding sites/transmission foci) to enable one identify cases of nodules, the community nodule seems that these few sooradic cases are one imported cases from endemic areas from Democratic f one t Tffifugee problems as well'AS re-settlement programmes withn the sub-region. This is especially important because in 1991, Fain, while discussing the distribution and prevalence of onchocerciasis and its ocular complications inZaire and Burundi commented that " were also carried out in Rwanda but no onchocerciasis has been observed in s country Fain,1991) It is important to observe here that some of the rivers in the country present visual characteristics capable of supporting the breeding of vector species.May be the more or less temperate climate of the country or physico-chemical properties of these rivers are not favourable for the aquatic stages ; and adult survival and disease transmission. It may be that the Simulium species supported by these rivers are non-human biting such as the Ketaketa form observed by Vajime (1987) colonizing waters in the Nyika highlands of Malawi-and this is within the same Rift Valley zone with Rwanda. It may be also that the flies are biting but there are no parasites in the population to be transmitted. 5.0 RE,FERENCES Fain, A (1991). Distribution and prevalence of onchocerciasis and its ocular complications in Zaire and Burundi.. 't4/HO / ONCHO/91/66.WHO GENEVA. Molyneux, DH and Davies, JB (1997). Onchocerciasis control : Moving tawards the. Millennium. Parasitol. Today. 13(1 1) :418-423 Newell, ED (1995). Les foyers d'onchocercose au Burundi : leur 6tendue et la population a Ann. Soc. Belge Med. Trop.75:273-281 Newell, ED et al (1997). Endemicit6 et manifestations cliniques de l'onchocercose dans la province de Bururi, Burundi. Trop. Med. Inter. Hith.2(3):218-226 Ngoumou, P. and Walsh, JF (1993). Amanual for Rapid Epidemiological Mapping of Onchocerciasis (REM O). T D R/T D E/ O N C H O/ 9-r. 4. WHO Geneva Nwoke, BEB (1990). The socioeconomic aspects of human onchocerciasis in Africa. The present appraisal. J. Hyg. Epidemiol. Microbiol. Immunol3aQ : 37 -44 9REMME, RH et al (1998). Ocular onchocerciasis and intensity of infection in the community I. West African Savanna. Trop. Med. Parasitol.40 :340-347 Taylor, HR et al (1992). The selection of communities for treatment of onchocerciasis with ivermection. Trop. Med. Parasitol. 43 :2367-270 Vajime, CG (1987). Report on a short term mission to Malawi. Cytotaxonomy of the $imulium damnosum complex in the Thyolo Highlands of Malawi. 34 pp. ( July 1987), Zaria, Nigeria. WHO (1992). Methods for community diagnosis of onchocerciosis to guide ivermectin-based control in Africa. TDR / TDE / ONCHO/92.2. WHO Geneva. WHO (1995 a). Onchocerciasis and its Control. Report of a WHO Expert Committee on Onchocerciasis Control. WHO Tech. Rep. Ser ;852. Geneva. WHO (1995 b). Supplementary guide-line for Rapid Epidemiological Mapping of Onchocerciasis (REMO). TDR/ TDE / ONCHO/95.1. WHO Geneva. 6.0 ACKNOWLEDGEMENT We are grateful to APOC for the opportunity given to us to serve and contribute, and to WR Lagos, Bangui and Kigali for their efforts to facilitate our mission. We are indepted to MINISANTE Kigali and all our colleagues :Dr. Mugisha ( the National Coorrdinators), Dr. Sahabo, Mr. Ruzindana, Mr.Rwayrtare, Mrs.Nyiraharelimana and Beatrice Dusabemaliya for their support and goodwill throughout the study. The success of this exercise was made comparatively easier by the expertise and professionalion as well as committment exhibited by the project drivers,- Mr. Uwanyirigira and ABDULLAH during this mission. To all that contributed to the success of this study, we say thank you. 10 7.0. APPENDIX 7.1. Mission Schedule (July 23 - August23,l999) luly 23 July 24 July 25-28 July 29- 31 August l - 13 August 13 August 14-21 August 22 August 23 : Arrival of Dr Namssenmo : Arrival of Prof.B.E.B.Nwoke : Meeting with MOH, WHO, Putting togelher relevant maps, literature, documents, and materials for REMO training and field exercise. : Training of National team in Kigali : REMO practicum and the actual field study in selected villages Arrival in Kigali to complete the REMO exercise in Kigali Regions : Appraisal/completion of REMO in Kigali Regions , data coalition, and entry, reporting and briefing : Departure of Prof Nwoke : Departure of Dr Namssenmo 11. 7.z.LTST OF NATIONALS TRAINED. A. Dr V6ronique MUGISHA B. Dr Ruben SAHABO C. Emmanuel RUZINDANA D. Epiphanie NYIRAHARELIMANA E. B6atrice DUSABEMALIYA F. 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