AFRICAN PROGRAMME FOR ONGHOCERCIASIS CONTROL (APoc) I, v Period: 14 -23 July 2007 f,'!OQIr T! EIEEI'NEDT E'IEDlUlirJt lVlI f\Lf \/f\l I vr\ By Prof. Louis-Albert TCHUEM TCHUENTE Temporary Advisor, Primary lnvestigator Dr. SamuelWANJl Temporary Advisor, Co-l nvestigator I r.I SITUATION ANALYSIS FOR INTEGRATED MAPPING OF NEGLECTED TROPICAL DISEASES IN EQUATORIAL GUINEA (Onchocerciasis, Lymphatic Filariasis, !oiasis, Schistosomiasis and Soil-Transmitted Helminthiasis) lntegrated Mapping of Neglected Tropical Diseases in Equatorial Guinea ACKNOWLEGEMENTS We would like to thank all people who contributed in any way for their assistance and help with the collection of information and data necessary for this report. This includes Dr. Pierre Mpele, WHO country Representative, Dr. Sima Anacleto, National Onchocerciasis Coordinator, and their staff in Equatorial Guinea, the Vice-Minister of Education, the General lnspector of primary education, the General Director of Health, Director and the staff of APOC in Ouagadougou. The mission was financed by the African Programme for Onchocerciasis Control (APOC), Prof. L.A. Tchuem Tchuent6 National Programme for the Control of Schistosomiasis and lntestinal Helminthiasis in Cameroon P.O. Box 7244Yaound6, Cameroon Dr. S. Wanji Biologist Research Foundation for Tropical Diseases and Environment University of Buea P.O. Box 474Buea Cameroon 2 a lntegrated lvtapping of Neglected Tropical Diseases in Equatorial Guinea TABLE OF COT.ITENTS Itinerary / Summary I. Introduction and Objectives. II. Meetings with NOTF, WHO WR, MOH and MOE authorities. III. Situation analysis of NTD control progralnmes in Equatorial Guinea IIL I. Onchocerciasis and Loiasis III.2. Lymphatic fi lariasis................. III.3. Schistosomiasis and STH........ IV. IMPORTANT CONSIDERATIONS FOR THE INTEGRATED NTD SURVEYS IV. l. Geography, geomorphology, hydrology, climate IV.2. Administrative divisions IV.3. Population (1994 census)...... IV.4. The health system IV.5. The Education system....... V. SURVEY METI{ODOLOGY v.t. FILAzuASIS (LF, ONCHOCERCIASIS, LOIASIS) Study area and sampling Data collection for Lymphatic filariasis..... Data collection for Onchocerciasis and Loiasis....... Study population Conduct of the rapid assessment procedures for loiasis and onchocerciasis (RAPLOA and REA) Administration of RAPLOA questionnaire Nodule palpation (REA) V.2. SCHISTOSOMIASIS AND TNTESTINAL WORMS ...................... Study area and population. Sampling and parasitological assessment Data analysis ............... VI. LOGISTICS AND HUMAN RESOURCES ............. VLl. Human resources Filariasis surve)/ Validation of RAGFIL results........ Schistosomiasis and Soil-Transmitted Helminthiasis survey Data processing and Analysis VI.2. Logistics: important considerations....... Filariasis survey VII. TIME FRAME..... VIII. TENTATIVE BUDGET IX. SUGGESTED PERIOD FOR THE SURVEY 4 5 6 7 7 9 9 J a l0 10 11 l1 1l 1l 13 13 l3 13 t4 t4 a lntegrated Mapping of Neglected Tropical Diseases in Equatorial Guinea Itinerary / Summary Julv 13 2007: Departure Yaounde to Douala July 15 2007: Departure Douala Julv 15 2007:Arrival Malabo July 16 2007: - Prof. Tchuem Tchuent6 and Dr. Wanji met with WHO WR (Dr. Pierre Mpele), NOTF Coordinator (Dr. Sima Anacleto), Mrs. Julie Akame and Mr. Patrice Nkwelle. Presentation of the objectives of the mission and discussion on various points / aspects and organisation. - Participation to the opening ceremony of the meeting on harmonization of common pharmaceutical politic in CEMAC countries, presided by the Minister of Health. Julv 17 2OO7: - Participation to the Meeting of the Equatorial Guinea NOTF, presided by the Minister of Health, with the participation of key partners. - Prof. Tchuem Tchuent6 gave a power point presentation on the situation of neglected tropical diseases in Equatorial Guinea, with emphasis on the importance of diseases mapping and the aims and prospects of our visit. - Meeting and discussion with medical Chiefs of 3 health districts (Riaba, Luba and Baney)who attended the NOTF meeting. - Working session with Dr. Sima Anacleto, and teleconference with the National Coordinator of schistosomiasis control, Dr. Peclro who is based in Bata. Julv 18 2007: - Working session of the consultants at the WHO office. - Visit to Ministry of Health as appointment with the General Director of Health (GDH). However, due to unforeseen last minute commitment of the GDH, the meeting was postponed for the following day. - Visit to the Ministry of Education: discussion with General Director and the General lnspector of primary education. Presentation of the purpose of disease mapping and request of relevant data on school system (school map). However, the MOE responsible highlighted the need to obtain an authorisation from their hierarchy prior to providing any information. - Visit to the health district of Baney: discussion with the medical chief. Julv 19 2007: - Visit to the Ministry of Health: working session with the General Director of Health, Dr. Gregorio Gori ltlomolu. - Visit to the Ministry of Education: meeting with the Vice-Minister of Education, Mr. Carlos Nsu6 Otong, who provided authorization to obtain school map. - Meeting with the General Director of primary education. But the data were not ready and the GD promised to provide these data to Dr. Sima within one week. - Visit to the health district of Luba: discussion with the medical chief. - Debriefing meeting with the WR WHO. Julv 20 2007: Departure Malabo. 21-22 Working session and reporting of consultants Julv 23 2007: Arrival in Yaound6 4 lntegrated Mapping of Neglected Tropical Diseases in Equatorial Guinea l. lntroduction and Objectives The Republic of Equatorial Guinea, one of the smallest countries in continental Africa, comprises a mainland territory, the island of Bioko and the island of Annobon. lt is the smallest country in continental Africa in term of population. ln Equatorial Guinea, onchocersiasis, or river blindness, is one of the most prevalent parasitic diseases. The disease has major health and socio-economic repercussions, and constitutes an important public health problem in this country, particularly in the Bioko lsland. lndeed, the rapid epidemiological mapping of onchocerciasis (REMO) conducted in 1999 showed infection prevalence of 75o/o in the Bioko lsland and only 20% in the Mainland. Further REMO exercises conducted in 2002 by the National Onchocerciasis Task Force (NOTF), with technical and financial support from APOC, confirmed this trend, with prevalence varying from 15 to 73% in rural villages in the island of Bioko, and from 33 to 50% in selected areas of Malabo. Overall, 81% of villages and 91 .6% of areas exhibited infection prevalence over 40o/o in the island and in lVlalabo, respectively. Following the WHO/APOC recognition of Equatorial Guinea as endemic country for onchocerciasis, two control strategies were adopted by the Government in 1998: the vector elimination and the community directed treatment with ivermectin (CDTI). Vector elimination - aerial spraying of insecticide combined with ground larviciding began in 2000 and continued until May 2005 when the last large-scale larviciding spraying was and in 2004 in Malabo city.conducted. Continuous entomological evaluations conducted in 2006 and 2007 revealed the absence of black flies, the vector of onchocerciasis in the island. Community-directed treatment with ivermectin (CDTI) started effectively in 1999. However, therapeutic coverage remained below the threshold of 65%, which is the minimum required in each community in CDTI priority area to have an impact on the transmission of onchocerciasis (Table 1). The low coverage is the result of poor sensitization and mobilization and inadequate participation of communities in ivermectin distribution. The last mass distribution of ivermectin was implemented in 2002 in Bioko lsland (in the rural area) Table 1: Training of health workers and CDDs in CDTI and ivermectin distribution in Bioko Island, t999-2004 Year Training of CDDs and Health workers Communities Population Treatment coverage (%) CDDs HWs Total number Number treated Total number Number treated Geographical Therapeutic t999 40 t2 tz) IJ UJ I IJ L ZJ]J I 1,6 2,0 2000 140 t2 129 68 64 601 7 882 \)1 t2,2 2001 t40 l2 129 67 66 t22 t0 797 5l,9 16,3 2002 t94 t2 129 95 67 679 l0 874 73,6 16,1 2003 2004 234 l8 r29 128 70 903 48 s5l 99,2 68,5 Building on the success of the elimination of the black fly vector in the Bioko lsland, there is a urgent need to strengthen CDTI in order to achieve the objective of eliminating 5 lntegrated Mapping of Neglected Tropical Diseases in Equatorial Guinea onchocerciasis as a public health problem and an impediment to social and economic problem in Equatorial Guinea. Therefore, a new strategic plan to re-launch CDTI was elaborated in early 2007 by the national onchocerciasis Task Force (NOTF) of Equatorial Guinea with financial and technical support from APOC Management. Field activities started in June and training of health workers and Community-Directed Distributors (CDDs)was ongoing in the period the present mission was leaving the country. The objective was to train 170 CDDs in the rural area of the lsland by mid-august and 400 CDDs in Malabo city. The trained CDDs will have completed census in all the communities of Bioko lsland by September 2007. Building on the achievements and ongoing activities, the African Programme for Onchocerciasis Control (APOC) in collaboration with George Washington University and Exxon-Mobil, plan to undertake an integrated campaign for the control of some major Neglected Tropical Diseases (NTD) in Equatorial Guinea. These NTDs include onchocerciasis, lymphatic filariasis, loiasis, schistosomiasis and soil-transmitted helminthiasis. lndeed, polyparasitism is the norm rather than the exception in the developing world - with most people infected by more than one parasitic disease - and today there exist robust, low-cost and effective public health interventions to relieve parasitic infection burden and provide a better quality of life for people in poor settings. The current strategy for NTDs control is to integrate interventions for multiple diseases. This integrated approach is the basis for cost-effectiveness and streamlined. Though this initiative will build on the onchocerciasis control, there is a prerequisite to define the distribution and prevalence levels of the different diseases in order to determine the needs and strategies of control. Therefore, APOC requested Prof. L.A. Tchuem Tchuent6 and Dr. S. Wanji to advise and supervise integrated mapping of targeted neglected tropical diseases in Equatorial Guinea. Within this framework, a first trip was conducted in Equatorial Guinea from 14 - 23 July 2007 by the APOC consultants. The main objectives of this assignment were: . To plan in collaboration with the NOTF, MoH and WHO office in Malabo integrated mapping of neglected tropical diseases (NTDs) in Equatorial Guinea. . To define with local authorities the best period of the year and the appropriate zones for the mapping exercises. ll. Meetings with NOTF, WHO WR, MOH and MOE authorities ln order to gather all relevant information necessary for the situation analysis, the assessment of tne needs, the elaboration of the methodologies, and the planning of the NTDs mapping surveys, several meetings were organised with key stakeholders, including: . WHO country Representative (Dr. Pierre Mpele) . NOTF Coordinator (Dr. Sima Anacleto) . Medical Chiefs of 3 health districts (Riaba, Luba and Baney) 6 lntegrated Mapping of Neglected Tropical Diseases in Equatorial Guinea . Minister of health and social well-being . General Director of Health, ministry of health and social well-being (Dr. Gregorio Gori Momolu) . Vice-Minister of Education, Sciences and Sport (Mr. Carlos Nsu6 Otong) . General Director of primary education, ministry of education, sciences and sport . General lnspector of primary education, ministry of education, sciences and sport ln addition, the following activities were achieved: . Participation to the Meeting of the National Onchocerciasis Task Force (NOTF)' At this occasion, the WHO consultants made a presentation on the situation of neglected tropical diseases in Equatorial Guinea, the progress achieved such as vector elimination in the island of Bioko and the challenges for NTDs control. The importance of disease mapping and the aims and expected outcomes of our visit were highlighted. This meeting provided an opportunity to advocate for NTDs control to important stakeholders. . Teleconference with the National Coordinator of schistosomiasis control, Dr. Pedro. . Field visits in two health districts (Baney and Luba) and discussion with the respective medical chiefs and health staff. . Search of documentation in libraries, bookshops and purchase of relevant books. The rationale and objectives of the assignment, opportunity for eradication of onchocerciasis and other NTDs were presented to the stakeholders. This was followed by discussions on various aspects of the neglected tropical diseases including the situation of disease control, the health system and availability of information required for the development of a work plan. lnformation was gathered on health system, health personnel, equipment, logistics available and on ongoing disease control programme. lll. Situation analysis of NTD control programmes in Equatorial Guinea Presently, among the targeted negiected tropicai cjiseases in Equatorial Guinea, there exists a controi programme for some. However, only the control programme for onchocerciasis is operational. lll.1. Onchocerciasis and Loiasfs lvermectin distribution for the control of onchocerciasis began in Equatorial Guinea in 1992. During 1992-1997, mass distribution of ivermectin by mobile teams was conducted with financial and technical support of the NGO "Universidad de Barcelona" There was little participation of communities in the control activities. in April and October 2002, rapid epidemiological mapping of onchocerciasis (REMO) was carried out by APOC in rural communities and some selected areas of the town of Malabo in the island of Bioko. The mapping revealed that onchocerciasis was endemic in all the four districts of the island. However, the prevalence varied from 15.6% to 73.3 % in the rural villages and from 33.3 o/o to 50o/o in the selected areas of Malabo. 7 lntegrated Mapping of Neglected Tropical Diseases in Equatorial Guinea A REIVIO map was developed for the continental region of the country which indicates high prevalence of onchocerciasis in the Bioko lsland but a low prevalence of in almost the entire territory of the main land. Only a small zone in the centre east of the mainland is indicated to be meso-endemic and necessitates a refinement of the REMO exercise. One could have expected to have onchocerciasis at the following areas of the mainland: (i) North West (boundary with Cameroon) along the Campo River. Onchocerciasis; (ii) the Wele River at Niefang and at Senye; (iii) the Mitemele River at Midyobo and (iv) at Dyeng. However, these a!'eas are indicated green on the present disease map implying they are hypoendemic for onchocerciasis and not eligible for mass distribution of ivermectin. We strongly recommend that for the planned integrated mapping in the continental region, rapid epidemiological assessment (REA) of onchocercisis should be combined with rapid assessment procedures of loiasis (RAPLOA) in order to clarify the present onchocerciasis map of the mainland. The combined survey will be cost:-effective and provide more information on the distribution of onchocerciasis and loiasis in the continental region of the country. The combined RAPLOA/REA exercise should therefore take place only in the continental region. lt is not necessary to carry out REMO in the Bioko lsland since a reliable map of the disease exists (figure 1). Also the RAPLOA exercise will have no positive implication since the mass distribution of Mectizan@ has been going on there for more than a decade. Following the REMO exercise in 1999, mass distribution of ivermectin using the community directed treatment with ivermectin (CDTI) approach was launched only in the Bioko lsland based on the results of the REMO (Figure 1). However, for several reasons including shortage of trained health personnel and absence of government support, the CDTI strategy with active participation of government has not been well implemented. Meanwhile, the results of the hydro-entomological feasibility studies confirmed the black fly vector specie in the Bioko lsland as Simulium yahense Bioko form; that elimination of the vector from the lsland of Bioko is feasible and the possibility of reinvasion is slim. ln 2001, APOC launched vector elimination activities firstly using ground larviciding method and later through aerial spraying of insectides. Since the last two years no infected larva has been found, and although vector monitoring exercise is still maintained, it is evident that the blackfly has been successfully eliminated in the Bioko lsland. ln January 2007, to safeguard the achievement in vector control, APOC management and the WHO office in Malabo began to put in place activities that would revamp and strengthen community participation in community-directed treatment with ivermectin to improve treatment coverage and avoid resurgence of transmission. 8 lntegrated Mapping of Negtected Tropical Diseases in Equatorial Guinea Figure 1: REMO map of Equatorial Guinea \r Legende Deftute CDTI I 0 reDne No CDTI D$txtos fuueres OMS/APOC/1 4Mars2003 ameroon KI .B' -----------'l 0Jo ll l. 2. Lym ph ati c fi I ari asi s A control plan for lymphatic filariasis was elaborated in 2001 for the island and mainland. Some baseline surveys were conducted in 2003 (data available at NOTF); however control activities are not being implemented.. lll.3. Schistosomtasis and STH The schistosomiasis control programnne is part cf the national programme for trypanosomiasis. The coordinator of this programme, Dr Pedro is based in Bata; however almost nothing has been achieved so far, and due to lack of funding, the schistosomiasis control programme is not operational in Equatorial Guinea. There is no programme for the control of soil transmitted helminths (STHs). 9 .{ .r,. ,.. lrtt &': ' "{iiu. ;( ., ;ti .t 1li :' rali'r J, .\ 'i. Jl lntegrated Mapping of Neglected Tropical Diseases in Equatorial Guinea IV. IMPORTANT GONSIDERATIONS FOR THE INTEGRATED NTD SURVEYS 1V.1. Geography, geomorphology, hydrology, climate The Equatorial Guinea is made up of two main regions: The continental region and the island region. The island region has two islands: Bioko and Annobon. The city capital is Malabo and is situated in the Bioko lsland. Bioko lsland The Bioko lsland is an old volcano, with three important picks (Caldera-2260 m, Biao-2009 m, Basile-3O11 m). The Bioko lsland is also characterised by numerous streams which have their springs at higher altitude and which flow on stormy soil. These meandering rivers are fast fiorving with numerous casceCes ,,^vhich are excellent breeding sites for Simulium, vectors of onchocerciasis. The feet of the mountain are occupied by beaches with steeps. The climate of the Bioko lsland has a double influence of ocean and mountain, with important rainfall in the south-west flank and on the summits of the mountain. The locality of Ureka can register 6000 mm of rain fall per year. On the Bioko lsland, there are two seasons: the dry season goes from November to February and the rainy season from March to October. Continental region The continental region, also known as Rio Muni is characterised by a varied landscape, going from the coastal region in the west, to the hilly area in the centre region of the country and the swampy valley in the eastern part of the country. The country stretches out from latitudes -3' south (Bio campo) to -6' south (Asobio). ln the coastal area there are several estuaries where the rivers from inland flow into the sea' The inland is characterised by mountalns ,,",,ith altitudes varying from 600 to 1000m. The most important summits are: Alen, Mitra, Bere and Nzas. These hills are at the origin of cascades on the rivers. Cascades are found in the following rivers: river Campo, river Wele, river Mitemele. These fast flowing rivers can be potential breeding sites for Simulium. The southern parts of the country have numerous swampy valleys, which can be potential breeding sites for mosquitoes, vectors of malaria and lymphatic filariasis. One should also take note of the presence in the south -west coastal region of the small islands of Mbelobi and Corisco. The climate of the continental region is characterised by four seasons as evidenced by the records of the rain fall at Bata. There are two dry seasons and two rainy seasons. The main dry season goes from December to February and the smaller one from July to August. The main rainy season goes from March to June and the smaller one from September to November. l0 lntegrated Mapping of Neglected Tropical Diseases in Equatorial Guinea 1V.2. Ad mi n i strative d ivi si on s The country has two regions: the continental and the island regions. The island region has three provinces: the province of Annobon, which covers the island of Annabon; thaprovinces of Bioko south and Bioko north, situated in the Bioko island' The continental region has four provinces: the centre south province, Nkie Ntem province, littoral province and the Wele Nzas province. The Provinces are further divided into districts. ln total there are 18 districts in Equatorial Guinea. 1V.3. Population (1994 census) The total population of Equatorial Guinea is estimated at 406 151 inhabitants (1994 census): 315 625 in the continental region and 90 526 in the island region. The population distribution is summarized in Table 2. The littoral province, in the continental region is the most densely populated with 100,047. The less populated province is Annobon with 2820 inhabitants, followed by Bioko south with 12 569 inhabitants. 61% of the populations of the Equatorial Guinea live in rural areas. The average population density is 14.5 inhabitants lkm2. 1V.4. The health system The organisation of the health system follows the pattern of the administrative divisions with notably: o the health centres or health post at the village level . the district hospital at the headquarters of districts (18 district hospitals) . Provincial hospital at the headquarters of provinces (7 provincial hospitals) . Regional hospitals at the headquarters of regions (situated at Malabo and Bata) 1V.5. The Education sysfem The education system in the Equatorial Guinea is organised into primary, secondary and higher education. The primary education comprises 848 schools, including 600 government primary schoolg and 248 private primary schools. Overall, there are 1440 teachers. ln the 1999-2000 school years, 73,310 children attended primary schools representing 86% of school age children. The secondary education consists of 51 secondary schools (27 public colleges and 24 private colleges), with 920 secondary school teachers. ln the 1999-2000,,20,671 children attended secondary schools in Equatorial Guinea. The national university of Equatorial Guinea was created in 1995, with one campus in Bata and another one in Malabo. The university has 15 departments, with 16 specialties including health sciences, agriculture, engineering, administration, education, arts, literature etc. ln the 1999-2000 academic year, overall 1328 students were registered at the university, irrespective of levels, programmes and departments' 1l alntegrated Mapping of Neglected Tropical Diseases in Equatorial Guinea Table 2. Population of Equatorial Guinea per region, province and district. ADMINISTRATIVE UNITS TOTAL URBANPOPULATION RURAL POPULATION INSULAR REGION 90526 73376 17150 Province ANNOBON 2820 2820 -District Annobon 2820 2820 Province BIOKO NORD 75137 66676 8461 -District Baney 10698 661 1 4087 -District Atlalabo 64439 60065 4374 Province BIOKO SUD 12569 38BO 8689 -District Luba vzlz JJZJ 5919 -District Riaba 3327 557 2770 CONTINENTAL REGION 315625 84372 231253 Province CENTRE SUD 60341 9632 50709 -District Akurenam 1 1631 1921 9710 -District Evinayong 21353 5181 16172 -Distict Niefans 27357 2530 24827 Province KIE NTEM 92779 11724 81055 -District Ebebiyin 45557 8075 37482 -District lrlilomeseng 29953 2723 27230 -District Nsoc Nsomo 17269 926 16343 Province LITORAL 100047 53762 46285 -District Bata 71 406 50023 21 383 -District Cogo 14607 1309 13298 -District hrlbini 14034 2430 11604 Province WELE NZAS 62458 9254 1751 53204 -District Aconibe 9065 7314 -District Anisok 22613 2105 20508 -District Alongomo 23756 4639 191 17 -District Nsork 7024 759 6265 TOTAL 406151 157748 248403 t2 lntegrated Mapping of Neglected Tropical Diseases in Equatorial Guinea V. SURVEY METHODOLOGY ln order to assess the level of infection and the distribution of the different species of helminths in Equatorial Guinea, parasitological and rapid assessment surveys will be conducted in selected villages/communities and schools all over the country. Though the surveys for the different parasitic infections will be conducted simultaneously in an integrated approach, specific sampling, specimen collection and parasitological methodologies will be employed for the different helminthiasis. v.l. FILARTASTS (LF, ONCHOCERCTASTS, tOrASrg Study area and sampling Cross-sectional survey will be conducted in rural and semi-rural communities (villages) representing potential intervention units for filariasis in both the island and continental areas of the Equatorial Guinea. The first step in the sampling process will be to define the intervention unit (lU). This will be the district. 10% of communities within each lU will be selected for the survey. Selection will be made such that the lU is entirely covered spatially. ln the second step, the available data on filariasis in each lU will be reviewed. New data therefore will be collected from each lU. Data collection for Lymphatic filariasis ln each sampled village at least 50 resident adults (aged > 15 years) will be tested for day- time filarial antigenaemia, using commercial immunochromatographic tests (lCT; Weil ef a\.,1997). A 100-pl sample of finger prick blood will be collected from each subject, with a micropipette, and then dropped on an ICT card (AMRAD lCT, Richmond, Victoria, Australia). The reading will be done within 3-5 minutes. Sample will be deemed negative if the card indicate a negative result after 15 min. Resident adult will be defined as a person who has been resident in the village for at least 10 years and who had not been absent for > 6 months during that period. Testing will be stopped if more than 10 (20o/o) of the 50 adults tested are found positive, since this gave sufficient precision. Othenrvise, testing will continue until a total of 100 adults had been examined. lf all 100 ICT for a randomly selected village are negative, then a check village (i;e. any community in the same lU where local health staff thought, or old survey data indicated, that LF might be present)will be selected for validation. All the surveys will be conducted by a country team that will be trained at the national level. The work will be done under the supervision of external technical experts. An independent team will validate a selected number of communities. The validation will include a comparison of the results of ICT with those of the microscopical examination of smears of "night" blood for microfilariae. The correlation between the two measures of infection will be tested. The geographical coordinates of each of the sample villages will be recorded with a global positioning system (GPS). A geographical information system (GlS will be used to plot the prevalence of antigenaemia of each sampled community on a map, and the prevalence data will be recorded using the HealthMapper software package (World Health Organisation, Geneva). 13 lntegrated Mapping of Neglected Tropical Diseases in Equatorial Guinea Spatial analysis will be based on geostatistical methods (lsaaks and Srivastava, 1989) as pieviously applied to studies of LF distribution (Gyapong and Remme,2001). Prediction of ine distriOution of prevalence across the country will be based on the observations made in the sample villages. This approach r.,i!! consist of four steps that are described in Gyapong et a|.2002. Data collection for Onchocerciasis and Loiasis As described in the situation analysis section, previous REMO data showed the endemicity of onchocerciasis in the island (insular) of Bioko, with prevalence above 40% in the many of the communities. The REMO map for the mainland region of the country indicates a very low prevalence of onchocerciasis in almost the entire territory. Apparently, only a small zone in the centre east of the territory is indicated to be meso endemic and requires a refinement of the REMO results. Nevertheless, comparing the present REMO map of the country with a hypothetical onchocerciasis map prediction from relief and hydrology maps, there is a discrepancy. For example, one could have expected to have areas of high onchocerciasis endemicity in the North West (boundary with Cameroon) along the Campo River. Onchocerciasis could also be expected along the Wele River at Niefang and at Senye; also along the Mitemele River at Midyobo and at Dyeng. The above-mentioned areas are indicated in green colour_on the present REMO map implying they are hypoendemic for onchocerciasis and not eligible for CDTI-lt is suggested to revalidate the REMO in these areas. We therefore strongly suggest that for the envisaged integrated mapping exercise in the continental region, REA should be coupled to RAPLOA in order to clarify the present onchocerciasis map in that part of the country. The combined survey is expected to be cost-effective and provide more information on the distribution of onchocerciasis and loiasis in the continental region of the country. The combined RAPLOA/REA exercise should therefore take place only in the continental region. There is no need to conduct REMO in the Bioko island since a reliable map of the disease exists and vector elimination in the island has been successful. Also the RAPLOA exercise will have no positive implication since the mass distribution of Mectizan has been going on there for more than a decade now. Study population A census will be conducted in each of the villages surveyed to estimate the population size. The study population will consist of males and females aged 15 years and above who have been resident in the village for a minimum of ten consecutive years (for onchocerciasis) and five consecutive years (for loiasis) and who have not taken antifilarial treatment for a minimum period of one year. All eligible members of the community who will consent to participate will be enrolled into the study. Conduct of the rapid assessment procedures for loiasis and onchocerciasis (RAPLOA and REA) Organization of work A form will be designed to collect data and will be divided into three sections: the first section will be for the identification of participants, the second and third sections for the collection of RAPLOA and REA. t4 : lntegrated Mapping of Neglected Tropical Diseases in Equatorial Guinea ln each community surveyed, a team of three technicians will move from one household to another to register eligible participants, administer the RAPLOA questionnaire and carry out a Rapid epidemiological assessment (REA) of onchocerciasis by nodule palpation' Administration of RAPLOA questionnaire The Rapid Assessment Procedure for loiasis will be based on the restricted definition of the eye worm; the past experience of eye worm, conflrmed by a photograph of L. /oa adult worm in the white part of tiie eye aiid with tiie cirri'ation of tire rnost recent episode being between 1 to 7 days (Wanji et al 2005). The questionnaires will be administered to 80 adults in the Spaniih language and where required, interpreters from the community will assist in the interview process according to the RAPLOA guidelines (WHO/TDR, Geneva, 2002) Nodule palpation (REA) The REA will be based on nodule palpation. After undergoing the RAPLOA interview, male patients (30 in number), above twenty years, and who have been in the community continuously for the past ten years, will be examined by the same technician for the presence oi Onchocerca nodules according to previous studies (Ngoumou et al. 1994, Taylor et al. 1992) The geographical co-ordinates of each of the sample villages will be recorded with a global positioning system (GPS). A geographical information system (GlS will be used to plot the prevalence of antigenaemia for each sample community on a map, and the prevalence data will be lecorded using the HealthMapper software package (World Health Organisation, Geneva), Spatial analysis will be based on geostatistical methods (lsaaks and Srivastava, 1989) as pieviously applied to studies of Onchocerciasis and loiasis distribution. Prediction of the distribution of'prevalence across the country will be based on the observations made in the sample villages. V.2. SCHISTOSOMIAS'S AA'D INTESTINAL WORMS Previous studies and attempt to document the epidemiology of schistosomiasis in the mainland show the presence of both intestinal and urinary schistosomiasis. ALL three- S. mansonia, S. haematobium and S. intercalatum were found with varying levels of endemicity. These results of the studies were based on scanty data, therefore not conclusive. Study area and population ln the framework of the integrated mapping, the distribution of schistosomiasis and soil- transmitted helminthiasis will be evaluated with regard to geographical and administrative sub-divisions. Studies will be conducted in schools and the current parasitological infections will be assessed. About 10% of the total number of primary schools in the different districts province will be selected. lt is estimated that approximately 80-90 schools, over the total 848 nationwide primary schools, will be investigated. Sampling and parasitological assessment ln each of the selected school, 50 children from the Sth grade will be selected. Study will be conducted with the approval of the administrative authorities, school inspectors, directors 15 lntegrated Mapping of Neglected Tropical Diseases in Equatorial Guinea and teachers. The schoolchildren will be invited to participate in the study, and will be registered only after explanation of the objectives of the study to them and to their parents or guardian, and after full informed consent has been obtained. From each of the children selected randomly in the schools included in the study, urine and stool samples will be collected. Urine samples will be collected in 60 mL plastic screw- cap vials, between 1 1 .00 and 13.00 hours. Each urine sample will be agitated to ensure adequate dispersal of eggs, 10 mL of urine will be filtered through a Nucleopore@ filter, and the filters will be examined by microscopy for the presence of eggs. Stool samples will be collected in similar screw-cap vials, and will be examined by a single thick smear technique using a 41.7 mg Kato-Katz template. lmportantly, the same Kato slides will allow detecting both intestinal schistosomiasis and intestinal helminth lnfections in the study- populations. Data analysis The different parasitological data will be analysed using appropriate statistical test and methods. This will allow to assess the disease distribution and prevalence, and to recommend the most appropriated control strategies, accordingly. VI. LOGISTICS AND HUMAN RESOURCES V1.1. Human resources Filariasis survey A typical survey team will be made up of 5 members, divided as follows: o 1 team member for REA (Rapid Epidemiological assessment of Onchocerciasis) . 2 members for RAPLOA (Rapid Assessment Procedure for Loiasis) . 2 team members for RAGFIL (Rapid geographical assessment of bancroftian filariasis). We may need three such teams; making a total number of 15 people - 3 for REA, 6 for RAPLOA, 6 for RAGFIL. The work will be carried out under the supervision of an expert on filariasis, assisted by the Equatorial Guinea national coordinator of onchocerciasis and other filariasis control. It will be important that survey team members be recruited from among health personnel working at the district levels. The 15 members should be recruited across country and trained at Malabo. When the research team is working in a given health district, it should be envisaged that a local facilitator be recruited to assist the team during the survey. Such facilitator may be a medical doctor in service at the district hospital, or a senior nurse designated by the medical doctoi'. Validation of RAGFIL results Two independent laboratory technicians (not members of the rapid survey team) will be required to conduct the "night survey" for the microscopical validation of RAGFIL. a 16 a alntegrated Mapping of Neglected Tropical Diseases in Equatorial Guinea Sch i stosom iasis and Soi l-Transm itted He! mi nth iasis su rvey A basic survey team for schistosomiasis and STH will be made up of 5 members, constituted as follows: . 1 surveyor . 2laboratory I microscopist technicians . 2 supporting technicians (1 driver) For an integrated investigation, the schistosomiasis and STH teams will work together with the filariasii team in each district. A detailed work plan will be developed with the survey teams for complementarities of team members and cost-effectiveness of the mapping exercise. Nevertheless, it is anticipated that we may need three teams as described above, making a total number of 3 surveyors, 6 laboratory technicians and 6 supporting technicians. The work will be carried or-rt r-rnder the sr-rpervision of two experts i.e the expert on schistosomiasis and another expert on loiasis, assisted by the Equatorial Guinea national coordinator of schistosomiasis and/or onchocerciasis and other filariasis control. It will be important that surveyors and technicians be recruited amongst health personnels working at the district levels. They should be recruited across country and trained at Malabo. When the mapping team is working in a given health district, it should be envisaged that a local facilitator will be recruited to assist the team during the survey' The tocat facilitator may be a medical doctor in service at the district hospital, or a senior nurse designated by the medical doctor. Data processing and Analysis We will need a bio-statistician to develop the template for the data entry in Epi-lnfo and supervise the data entry. Two computer clerks will be required to enter the data' After cleaning, data will be fonvarded to the epidemiological unit of APOC for analysis' I l7 alntegrated Mapping of Neglected Tropical Diseases in Equatorial Guinea V\.2. Logisfics; important considerations Filariasis survey Schistosomiasis and STH survey a I Items QuantiW Provider Four wheel drive car 3 -1 vehicle available from the Nati onal Onchocerciasis Control programme -2 more vehicle needed, can be rented ICT test for RAGFIL 10000 APOC Gloves 10 packets APOC Slides 15 packets APOC Giemsa stain 3 litres APOC Lancets 12500 APOC Cotton 5 ballots APOC Micro capillary tubes (Without Heparin) 3 packets APOC Microscopes 2 APOC Computer+ printer 1 National onchocerciasis control ramme Photocopv machine 1 WR Malabo Fuel 2000 litres To be bou I Country Map 1/500.000 5 APOC GPS 5 National onchocerciasis control programme Photocopy papers 10 cartons To be bought locally RAPLOA picture 15 WHO/TDR Pencil 2 packets To be bought locally Block notes 30 Pens 1 packets To be bought locally Eraser 15 To be bought locally Tissue paper 3 packets To be bought locall Markers 5 To be bo ht locall lnk for printer 5 To be bought local ly lnk for photocopy machine 5 To be bought lqqelly Items Quantity Availability Four wheel drive car 3 60 mL plastic screw-cap vials 10 000 APOC to provide allmaterials Nucleopore@-filter 5 000 41.7 mg Kato-Katz (kits of 250 units each) 20 Fuel Country Map 1/500.000 5 (shared) GPS 5 (shared) Stationeries / Traininq materials Microscopes 3 (shared) Haemastix strips (50 units per box) 100 Various consumables (gloves, slides, reagents, etc. 18 alntegrated lr,tapiing of Neglected Tropical Diseases in Equatorial Guinea VII. TIME FRAME Steps Activities By who? Duration 1 -Logistic preparation -Recruitment and training of suryeyors, laboratory tech n icians/microscopists, supporting technicians 2 lnternational expert (1 for filariasis and 1 for schistosomiasis and STH), assisted by the national coordinators for filariasis and schistosimiasis control Two weeks 2 Field surveys +RAPLOA +REA/REMO +RAGFIL +SCHISTO +STH Two district covered /team/week, a total of six districts covered per weeks) Survey teams under the supervision of the 2 lnternational and national experts Three weeks 3 -Data entry, processing and cleaning) (Development of template in EPi- lnfo, Data entry, Data cleaning Computer clerk, under the supervision of a biostaticien Two weeks 4 Data analysis Development of country maps for onchocerciasis, schistosomiasis, soiltransmitted helminthiasis, loiasis and lymphatic filariasis for Equatorial Guinea Epidemiologic Unit of APOC Two weeks 19 a,"I.nlntegrated of Neglected Tropical Diseases in Equatorial Guinea VIII. TENTATIVE BUDGET Activities FILARIASIS SURVEY Costs (USD) SCHISTOSOMIASIS AND STH SURVEYS Costs (USD) l.Personnel -Training 5000 6000 -Field work 25200 24000 -Data entry and Processing 6000 5000 I nternational Expertise -Travel -Out of station allowance -Honorarium 14000 1 5000 3. Field Transportation -Fuel & lubricant for vehicles 4000 4000 - Maintenance of vehicles 1 500 1 500 -Hiring of 2 vehicles 9000 Provided by WHO 3.Stationeries 2000 2500 4.Consumable ICT test for RAGFIL From APOC Gloves, From APOC From APOC Slides From APOC From APOC Giemsa stain From APOC Lancets From APOC Cotton From APOC Micro capillary tubes (Without Heparin) From APOC 5. Equipment Microscopes From APOC From APOC Computer+ printer From GTNO From GTNO Photocopy machine From GTNO From GTNO GPS From GTNO From GTNO TOTAL 67,700 58,000 IX. SUGGESTED PERIOD FOR THE SURVEY Taking into account the date of the start of the new academic year, the dry season, the nationll feast, the appropriate period forconducting the studywas suggested between 15 October and 16 November 2007. However, training of the health personnel and nationals who will conduct the mapping and development of daily work plan should be completed before October 15. 20 , I
AFRICAN PROGRAMME FOR ONGHOCERCIASIS CONTROL (APoc) I, v Period: 14 -23 July 2007 f,'!OQIr T! EIEEI'NEDT E'IEDlUlirJt lVlI f\Lf \/f\l I vr\ By Prof. Louis-Albert TCHUEM TCHUENTE Temporary Advisor, Primary lnvestigator Dr. SamuelWANJl Temporary Advisor, Co-l nvestigator I r.I SITUATION ANALYSIS FOR INTEGRATED MAPPING OF NEGLECTED TROPICAL DISEASES IN EQUATORIAL GUINEA (Onchocerciasis, Lymphatic Filariasis, !oiasis, Schistosomiasis and Soil-Transmitted Helminthiasis) lntegrated Mapping of Neglected Tropical Diseases in Equatorial Guinea ACKNOWLEGEMENTS We would like to thank all people who contributed in any way for their assistance and help with the collection of information and data necessary for this report. This includes Dr. Pierre Mpele, WHO country Representative, Dr. Sima Anacleto, National Onchocerciasis Coordinator, and their staff in Equatorial Guinea, the Vice-Minister of Education, the General lnspector of primary education, the General Director of Health, Director and the staff of APOC in Ouagadougou. The mission was financed by the African Programme for Onchocerciasis Control (APOC), Prof. L.A. Tchuem Tchuent6 National Programme for the Control of Schistosomiasis and lntestinal Helminthiasis in Cameroon P.O. Box 7244Yaound6, Cameroon Dr. S. Wanji Biologist Research Foundation for Tropical Diseases and Environment University of Buea P.O. Box 474Buea Cameroon 2 a lntegrated lvtapping of Neglected Tropical Diseases in Equatorial Guinea TABLE OF COT.ITENTS Itinerary / Summary I. Introduction and Objectives. II. Meetings with NOTF, WHO WR, MOH and MOE authorities. III. Situation analysis of NTD control progralnmes in Equatorial Guinea IIL I. Onchocerciasis and Loiasis III.2. Lymphatic fi lariasis................. III.3. Schistosomiasis and STH........ IV. IMPORTANT CONSIDERATIONS FOR THE INTEGRATED NTD SURVEYS IV. l. Geography, geomorphology, hydrology, climate IV.2. Administrative divisions IV.3. Population (1994 census)...... IV.4. The health system IV.5. The Education system....... V. SURVEY METI{ODOLOGY v.t. FILAzuASIS (LF, ONCHOCERCIASIS, LOIASIS) Study area and sampling Data collection for Lymphatic filariasis..... Data collection for Onchocerciasis and Loiasis....... Study population Conduct of the rapid assessment procedures for loiasis and onchocerciasis (RAPLOA and REA) Administration of RAPLOA questionnaire Nodule palpation (REA) V.2. SCHISTOSOMIASIS AND TNTESTINAL WORMS ...................... Study area and population. Sampling and parasitological assessment Data analysis ............... VI. LOGISTICS AND HUMAN RESOURCES ............. VLl. Human resources Filariasis surve)/ Validation of RAGFIL results........ Schistosomiasis and Soil-Transmitted Helminthiasis survey Data processing and Analysis VI.2. Logistics: important considerations....... Filariasis survey VII. TIME FRAME..... VIII. TENTATIVE BUDGET IX. SUGGESTED PERIOD FOR THE SURVEY 4 5 6 7 7 9 9 J a l0 10 11 l1 1l 1l 13 13 l3 13 t4 t4 a lntegrated Mapping of Neglected Tropical Diseases in Equatorial Guinea Itinerary / Summary Julv 13 2007: Departure Yaounde to Douala July 15 2007: Departure Douala Julv 15 2007:Arrival Malabo July 16 2007: - Prof. Tchuem Tchuent6 and Dr. Wanji met with WHO WR (Dr. Pierre Mpele), NOTF Coordinator (Dr. Sima Anacleto), Mrs. Julie Akame and Mr. Patrice Nkwelle. Presentation of the objectives of the mission and discussion on various points / aspects and organisation. - Participation to the opening ceremony of the meeting on harmonization of common pharmaceutical politic in CEMAC countries, presided by the Minister of Health. Julv 17 2OO7: - Participation to the Meeting of the Equatorial Guinea NOTF, presided by the Minister of Health, with the participation of key partners. - Prof. Tchuem Tchuent6 gave a power point presentation on the situation of neglected tropical diseases in Equatorial Guinea, with emphasis on the importance of diseases mapping and the aims and prospects of our visit. - Meeting and discussion with medical Chiefs of 3 health districts (Riaba, Luba and Baney)who attended the NOTF meeting. - Working session with Dr. Sima Anacleto, and teleconference with the National Coordinator of schistosomiasis control, Dr. Peclro who is based in Bata. Julv 18 2007: - Working session of the consultants at the WHO office. - Visit to Ministry of Health as appointment with the General Director of Health (GDH). However, due to unforeseen last minute commitment of the GDH, the meeting was postponed for the following day. - Visit to the Ministry of Education: discussion with General Director and the General lnspector of primary education. Presentation of the purpose of disease mapping and request of relevant data on school system (school map). However, the MOE responsible highlighted the need to obtain an authorisation from their hierarchy prior to providing any information. - Visit to the health district of Baney: discussion with the medical chief. Julv 19 2007: - Visit to the Ministry of Health: working session with the General Director of Health, Dr. Gregorio Gori ltlomolu. - Visit to the Ministry of Education: meeting with the Vice-Minister of Education, Mr. Carlos Nsu6 Otong, who provided authorization to obtain school map. - Meeting with the General Director of primary education. But the data were not ready and the GD promised to provide these data to Dr. Sima within one week. - Visit to the health district of Luba: discussion with the medical chief. - Debriefing meeting with the WR WHO. Julv 20 2007: Departure Malabo. 21-22 Working session and reporting of consultants Julv 23 2007: Arrival in Yaound6 4 lntegrated Mapping of Neglected Tropical Diseases in Equatorial Guinea l. lntroduction and Objectives The Republic of Equatorial Guinea, one of the smallest countries in continental Africa, comprises a mainland territory, the island of Bioko and the island of Annobon. lt is the smallest country in continental Africa in term of population. ln Equatorial Guinea, onchocersiasis, or river blindness, is one of the most prevalent parasitic diseases. The disease has major health and socio-economic repercussions, and constitutes an important public health problem in this country, particularly in the Bioko lsland. lndeed, the rapid epidemiological mapping of onchocerciasis (REMO) conducted in 1999 showed infection prevalence of 75o/o in the Bioko lsland and only 20% in the Mainland. Further REMO exercises conducted in 2002 by the National Onchocerciasis Task Force (NOTF), with technical and financial support from APOC, confirmed this trend, with prevalence varying from 15 to 73% in rural villages in the island of Bioko, and from 33 to 50% in selected areas of Malabo. Overall, 81% of villages and 91 .6% of areas exhibited infection prevalence over 40o/o in the island and in lVlalabo, respectively. Following the WHO/APOC recognition of Equatorial Guinea as endemic country for onchocerciasis, two control strategies were adopted by the Government in 1998: the vector elimination and the community directed treatment with ivermectin (CDTI). Vector elimination - aerial spraying of insecticide combined with ground larviciding began in 2000 and continued until May 2005 when the last large-scale larviciding spraying was and in 2004 in Malabo city.conducted. Continuous entomological evaluations conducted in 2006 and 2007 revealed the absence of black flies, the vector of onchocerciasis in the island. Community-directed treatment with ivermectin (CDTI) started effectively in 1999. However, therapeutic coverage remained below the threshold of 65%, which is the minimum required in each community in CDTI priority area to have an impact on the transmission of onchocerciasis (Table 1). The low coverage is the result of poor sensitization and mobilization and inadequate participation of communities in ivermectin distribution. The last mass distribution of ivermectin was implemented in 2002 in Bioko lsland (in the rural area) Table 1: Training of health workers and CDDs in CDTI and ivermectin distribution in Bioko Island, t999-2004 Year Training of CDDs and Health workers Communities Population Treatment coverage (%) CDDs HWs Total number Number treated Total number Number treated Geographical Therapeutic t999 40 t2 tz) IJ UJ I IJ L ZJ]J I 1,6 2,0 2000 140 t2 129 68 64 601 7 882 \)1 t2,2 2001 t40 l2 129 67 66 t22 t0 797 5l,9 16,3 2002 t94 t2 129 95 67 679 l0 874 73,6 16,1 2003 2004 234 l8 r29 128 70 903 48 s5l 99,2 68,5 Building on the success of the elimination of the black fly vector in the Bioko lsland, there is a urgent need to strengthen CDTI in order to achieve the objective of eliminating 5 lntegrated Mapping of Neglected Tropical Diseases in Equatorial Guinea onchocerciasis as a public health problem and an impediment to social and economic problem in Equatorial Guinea. Therefore, a new strategic plan to re-launch CDTI was elaborated in early 2007 by the national onchocerciasis Task Force (NOTF) of Equatorial Guinea with financial and technical support from APOC Management. Field activities started in June and training of health workers and Community-Directed Distributors (CDDs)was ongoing in the period the present mission was leaving the country. The objective was to train 170 CDDs in the rural area of the lsland by mid-august and 400 CDDs in Malabo city. The trained CDDs will have completed census in all the communities of Bioko lsland by September 2007. Building on the achievements and ongoing activities, the African Programme for Onchocerciasis Control (APOC) in collaboration with George Washington University and Exxon-Mobil, plan to undertake an integrated campaign for the control of some major Neglected Tropical Diseases (NTD) in Equatorial Guinea. These NTDs include onchocerciasis, lymphatic filariasis, loiasis, schistosomiasis and soil-transmitted helminthiasis. lndeed, polyparasitism is the norm rather than the exception in the developing world - with most people infected by more than one parasitic disease - and today there exist robust, low-cost and effective public health interventions to relieve parasitic infection burden and provide a better quality of life for people in poor settings. The current strategy for NTDs control is to integrate interventions for multiple diseases. This integrated approach is the basis for cost-effectiveness and streamlined. Though this initiative will build on the onchocerciasis control, there is a prerequisite to define the distribution and prevalence levels of the different diseases in order to determine the needs and strategies of control. Therefore, APOC requested Prof. L.A. Tchuem Tchuent6 and Dr. S. Wanji to advise and supervise integrated mapping of targeted neglected tropical diseases in Equatorial Guinea. Within this framework, a first trip was conducted in Equatorial Guinea from 14 - 23 July 2007 by the APOC consultants. The main objectives of this assignment were: . To plan in collaboration with the NOTF, MoH and WHO office in Malabo integrated mapping of neglected tropical diseases (NTDs) in Equatorial Guinea. . To define with local authorities the best period of the year and the appropriate zones for the mapping exercises. ll. Meetings with NOTF, WHO WR, MOH and MOE authorities ln order to gather all relevant information necessary for the situation analysis, the assessment of tne needs, the elaboration of the methodologies, and the planning of the NTDs mapping surveys, several meetings were organised with key stakeholders, including: . WHO country Representative (Dr. Pierre Mpele) . NOTF Coordinator (Dr. Sima Anacleto) . Medical Chiefs of 3 health districts (Riaba, Luba and Baney) 6 lntegrated Mapping of Neglected Tropical Diseases in Equatorial Guinea . Minister of health and social well-being . General Director of Health, ministry of health and social well-being (Dr. Gregorio Gori Momolu) . Vice-Minister of Education, Sciences and Sport (Mr. Carlos Nsu6 Otong) . General Director of primary education, ministry of education, sciences and sport . General lnspector of primary education, ministry of education, sciences and sport ln addition, the following activities were achieved: . Participation to the Meeting of the National Onchocerciasis Task Force (NOTF)' At this occasion, the WHO consultants made a presentation on the situation of neglected tropical diseases in Equatorial Guinea, the progress achieved such as vector elimination in the island of Bioko and the challenges for NTDs control. The importance of disease mapping and the aims and expected outcomes of our visit were highlighted. This meeting provided an opportunity to advocate for NTDs control to important stakeholders. . Teleconference with the National Coordinator of schistosomiasis control, Dr. Pedro. . Field visits in two health districts (Baney and Luba) and discussion with the respective medical chiefs and health staff. . Search of documentation in libraries, bookshops and purchase of relevant books. The rationale and objectives of the assignment, opportunity for eradication of onchocerciasis and other NTDs were presented to the stakeholders. This was followed by discussions on various aspects of the neglected tropical diseases including the situation of disease control, the health system and availability of information required for the development of a work plan. lnformation was gathered on health system, health personnel, equipment, logistics available and on ongoing disease control programme. lll. Situation analysis of NTD control programmes in Equatorial Guinea Presently, among the targeted negiected tropicai cjiseases in Equatorial Guinea, there exists a controi programme for some. However, only the control programme for onchocerciasis is operational. lll.1. Onchocerciasis and Loiasfs lvermectin distribution for the control of onchocerciasis began in Equatorial Guinea in 1992. During 1992-1997, mass distribution of ivermectin by mobile teams was conducted with financial and technical support of the NGO "Universidad de Barcelona" There was little participation of communities in the control activities. in April and October 2002, rapid epidemiological mapping of onchocerciasis (REMO) was carried out by APOC in rural communities and some selected areas of the town of Malabo in the island of Bioko. The mapping revealed that onchocerciasis was endemic in all the four districts of the island. However, the prevalence varied from 15.6% to 73.3 % in the rural villages and from 33.3 o/o to 50o/o in the selected areas of Malabo. 7 lntegrated Mapping of Neglected Tropical Diseases in Equatorial Guinea A REIVIO map was developed for the continental region of the country which indicates high prevalence of onchocerciasis in the Bioko lsland but a low prevalence of in almost the entire territory of the main land. Only a small zone in the centre east of the mainland is indicated to be meso-endemic and necessitates a refinement of the REMO exercise. One could have expected to have onchocerciasis at the following areas of the mainland: (i) North West (boundary with Cameroon) along the Campo River. Onchocerciasis; (ii) the Wele River at Niefang and at Senye; (iii) the Mitemele River at Midyobo and (iv) at Dyeng. However, these a!'eas are indicated green on the present disease map implying they are hypoendemic for onchocerciasis and not eligible for mass distribution of ivermectin. We strongly recommend that for the planned integrated mapping in the continental region, rapid epidemiological assessment (REA) of onchocercisis should be combined with rapid assessment procedures of loiasis (RAPLOA) in order to clarify the present onchocerciasis map of the mainland. The combined survey will be cost:-effective and provide more information on the distribution of onchocerciasis and loiasis in the continental region of the country. The combined RAPLOA/REA exercise should therefore take place only in the continental region. lt is not necessary to carry out REMO in the Bioko lsland since a reliable map of the disease exists (figure 1). Also the RAPLOA exercise will have no positive implication since the mass distribution of Mectizan@ has been going on there for more than a decade. Following the REMO exercise in 1999, mass distribution of ivermectin using the community directed treatment with ivermectin (CDTI) approach was launched only in the Bioko lsland based on the results of the REMO (Figure 1). However, for several reasons including shortage of trained health personnel and absence of government support, the CDTI strategy with active participation of government has not been well implemented. Meanwhile, the results of the hydro-entomological feasibility studies confirmed the black fly vector specie in the Bioko lsland as Simulium yahense Bioko form; that elimination of the vector from the lsland of Bioko is feasible and the possibility of reinvasion is slim. ln 2001, APOC launched vector elimination activities firstly using ground larviciding method and later through aerial spraying of insectides. Since the last two years no infected larva has been found, and although vector monitoring exercise is still maintained, it is evident that the blackfly has been successfully eliminated in the Bioko lsland. ln January 2007, to safeguard the achievement in vector control, APOC management and the WHO office in Malabo began to put in place activities that would revamp and strengthen community participation in community-directed treatment with ivermectin to improve treatment coverage and avoid resurgence of transmission. 8 lntegrated Mapping of Negtected Tropical Diseases in Equatorial Guinea Figure 1: REMO map of Equatorial Guinea \r Legende Deftute CDTI I 0 reDne No CDTI D$txtos fuueres OMS/APOC/1 4Mars2003 ameroon KI .B' -----------'l 0Jo ll l. 2. Lym ph ati c fi I ari asi s A control plan for lymphatic filariasis was elaborated in 2001 for the island and mainland. Some baseline surveys were conducted in 2003 (data available at NOTF); however control activities are not being implemented.. lll.3. Schistosomtasis and STH The schistosomiasis control programnne is part cf the national programme for trypanosomiasis. The coordinator of this programme, Dr Pedro is based in Bata; however almost nothing has been achieved so far, and due to lack of funding, the schistosomiasis control programme is not operational in Equatorial Guinea. There is no programme for the control of soil transmitted helminths (STHs). 9 .{ .r,. ,.. lrtt &': ' "{iiu. ;( ., ;ti .t 1li :' rali'r J, .\ 'i. Jl lntegrated Mapping of Neglected Tropical Diseases in Equatorial Guinea IV. IMPORTANT GONSIDERATIONS FOR THE INTEGRATED NTD SURVEYS 1V.1. Geography, geomorphology, hydrology, climate The Equatorial Guinea is made up of two main regions: The continental region and the island region. The island region has two islands: Bioko and Annobon. The city capital is Malabo and is situated in the Bioko lsland. Bioko lsland The Bioko lsland is an old volcano, with three important picks (Caldera-2260 m, Biao-2009 m, Basile-3O11 m). The Bioko lsland is also characterised by numerous streams which have their springs at higher altitude and which flow on stormy soil. These meandering rivers are fast fiorving with numerous casceCes ,,^vhich are excellent breeding sites for Simulium, vectors of onchocerciasis. The feet of the mountain are occupied by beaches with steeps. The climate of the Bioko lsland has a double influence of ocean and mountain, with important rainfall in the south-west flank and on the summits of the mountain. The locality of Ureka can register 6000 mm of rain fall per year. On the Bioko lsland, there are two seasons: the dry season goes from November to February and the rainy season from March to October. Continental region The continental region, also known as Rio Muni is characterised by a varied landscape, going from the coastal region in the west, to the hilly area in the centre region of the country and the swampy valley in the eastern part of the country. The country stretches out from latitudes -3' south (Bio campo) to -6' south (Asobio). ln the coastal area there are several estuaries where the rivers from inland flow into the sea' The inland is characterised by mountalns ,,",,ith altitudes varying from 600 to 1000m. The most important summits are: Alen, Mitra, Bere and Nzas. These hills are at the origin of cascades on the rivers. Cascades are found in the following rivers: river Campo, river Wele, river Mitemele. These fast flowing rivers can be potential breeding sites for Simulium. The southern parts of the country have numerous swampy valleys, which can be potential breeding sites for mosquitoes, vectors of malaria and lymphatic filariasis. One should also take note of the presence in the south -west coastal region of the small islands of Mbelobi and Corisco. The climate of the continental region is characterised by four seasons as evidenced by the records of the rain fall at Bata. There are two dry seasons and two rainy seasons. The main dry season goes from December to February and the smaller one from July to August. The main rainy season goes from March to June and the smaller one from September to November. l0 lntegrated Mapping of Neglected Tropical Diseases in Equatorial Guinea 1V.2. Ad mi n i strative d ivi si on s The country has two regions: the continental and the island regions. The island region has three provinces: the province of Annobon, which covers the island of Annabon; thaprovinces of Bioko south and Bioko north, situated in the Bioko island' The continental region has four provinces: the centre south province, Nkie Ntem province, littoral province and the Wele Nzas province. The Provinces are further divided into districts. ln total there are 18 districts in Equatorial Guinea. 1V.3. Population (1994 census) The total population of Equatorial Guinea is estimated at 406 151 inhabitants (1994 census): 315 625 in the continental region and 90 526 in the island region. The population distribution is summarized in Table 2. The littoral province, in the continental region is the most densely populated with 100,047. The less populated province is Annobon with 2820 inhabitants, followed by Bioko south with 12 569 inhabitants. 61% of the populations of the Equatorial Guinea live in rural areas. The average population density is 14.5 inhabitants lkm2. 1V.4. The health system The organisation of the health system follows the pattern of the administrative divisions with notably: o the health centres or health post at the village level . the district hospital at the headquarters of districts (18 district hospitals) . Provincial hospital at the headquarters of provinces (7 provincial hospitals) . Regional hospitals at the headquarters of regions (situated at Malabo and Bata) 1V.5. The Education sysfem The education system in the Equatorial Guinea is organised into primary, secondary and higher education. The primary education comprises 848 schools, including 600 government primary schoolg and 248 private primary schools. Overall, there are 1440 teachers. ln the 1999-2000 school years, 73,310 children attended primary schools representing 86% of school age children. The secondary education consists of 51 secondary schools (27 public colleges and 24 private colleges), with 920 secondary school teachers. ln the 1999-2000,,20,671 children attended secondary schools in Equatorial Guinea. The national university of Equatorial Guinea was created in 1995, with one campus in Bata and another one in Malabo. The university has 15 departments, with 16 specialties including health sciences, agriculture, engineering, administration, education, arts, literature etc. ln the 1999-2000 academic year, overall 1328 students were registered at the university, irrespective of levels, programmes and departments' 1l alntegrated Mapping of Neglected Tropical Diseases in Equatorial Guinea Table 2. Population of Equatorial Guinea per region, province and district. ADMINISTRATIVE UNITS TOTAL URBANPOPULATION RURAL POPULATION INSULAR REGION 90526 73376 17150 Province ANNOBON 2820 2820 -District Annobon 2820 2820 Province BIOKO NORD 75137 66676 8461 -District Baney 10698 661 1 4087 -District Atlalabo 64439 60065 4374 Province BIOKO SUD 12569 38BO 8689 -District Luba vzlz JJZJ 5919 -District Riaba 3327 557 2770 CONTINENTAL REGION 315625 84372 231253 Province CENTRE SUD 60341 9632 50709 -District Akurenam 1 1631 1921 9710 -District Evinayong 21353 5181 16172 -Distict Niefans 27357 2530 24827 Province KIE NTEM 92779 11724 81055 -District Ebebiyin 45557 8075 37482 -District lrlilomeseng 29953 2723 27230 -District Nsoc Nsomo 17269 926 16343 Province LITORAL 100047 53762 46285 -District Bata 71 406 50023 21 383 -District Cogo 14607 1309 13298 -District hrlbini 14034 2430 11604 Province WELE NZAS 62458 9254 1751 53204 -District Aconibe 9065 7314 -District Anisok 22613 2105 20508 -District Alongomo 23756 4639 191 17 -District Nsork 7024 759 6265 TOTAL 406151 157748 248403 t2 lntegrated Mapping of Neglected Tropical Diseases in Equatorial Guinea V. SURVEY METHODOLOGY ln order to assess the level of infection and the distribution of the different species of helminths in Equatorial Guinea, parasitological and rapid assessment surveys will be conducted in selected villages/communities and schools all over the country. Though the surveys for the different parasitic infections will be conducted simultaneously in an integrated approach, specific sampling, specimen collection and parasitological methodologies will be employed for the different helminthiasis. v.l. FILARTASTS (LF, ONCHOCERCTASTS, tOrASrg Study area and sampling Cross-sectional survey will be conducted in rural and semi-rural communities (villages) representing potential intervention units for filariasis in both the island and continental areas of the Equatorial Guinea. The first step in the sampling process will be to define the intervention unit (lU). This will be the district. 10% of communities within each lU will be selected for the survey. Selection will be made such that the lU is entirely covered spatially. ln the second step, the available data on filariasis in each lU will be reviewed. New data therefore will be collected from each lU. Data collection for Lymphatic filariasis ln each sampled village at least 50 resident adults (aged > 15 years) will be tested for day- time filarial antigenaemia, using commercial immunochromatographic tests (lCT; Weil ef a\.,1997). A 100-pl sample of finger prick blood will be collected from each subject, with a micropipette, and then dropped on an ICT card (AMRAD lCT, Richmond, Victoria, Australia). The reading will be done within 3-5 minutes. Sample will be deemed negative if the card indicate a negative result after 15 min. Resident adult will be defined as a person who has been resident in the village for at least 10 years and who had not been absent for > 6 months during that period. Testing will be stopped if more than 10 (20o/o) of the 50 adults tested are found positive, since this gave sufficient precision. Othenrvise, testing will continue until a total of 100 adults had been examined. lf all 100 ICT for a randomly selected village are negative, then a check village (i;e. any community in the same lU where local health staff thought, or old survey data indicated, that LF might be present)will be selected for validation. All the surveys will be conducted by a country team that will be trained at the national level. The work will be done under the supervision of external technical experts. An independent team will validate a selected number of communities. The validation will include a comparison of the results of ICT with those of the microscopical examination of smears of "night" blood for microfilariae. The correlation between the two measures of infection will be tested. The geographical coordinates of each of the sample villages will be recorded with a global positioning system (GPS). A geographical information system (GlS will be used to plot the prevalence of antigenaemia of each sampled community on a map, and the prevalence data will be recorded using the HealthMapper software package (World Health Organisation, Geneva). 13 lntegrated Mapping of Neglected Tropical Diseases in Equatorial Guinea Spatial analysis will be based on geostatistical methods (lsaaks and Srivastava, 1989) as pieviously applied to studies of LF distribution (Gyapong and Remme,2001). Prediction of ine distriOution of prevalence across the country will be based on the observations made in the sample villages. This approach r.,i!! consist of four steps that are described in Gyapong et a|.2002. Data collection for Onchocerciasis and Loiasis As described in the situation analysis section, previous REMO data showed the endemicity of onchocerciasis in the island (insular) of Bioko, with prevalence above 40% in the many of the communities. The REMO map for the mainland region of the country indicates a very low prevalence of onchocerciasis in almost the entire territory. Apparently, only a small zone in the centre east of the territory is indicated to be meso endemic and requires a refinement of the REMO results. Nevertheless, comparing the present REMO map of the country with a hypothetical onchocerciasis map prediction from relief and hydrology maps, there is a discrepancy. For example, one could have expected to have areas of high onchocerciasis endemicity in the North West (boundary with Cameroon) along the Campo River. Onchocerciasis could also be expected along the Wele River at Niefang and at Senye; also along the Mitemele River at Midyobo and at Dyeng. The above-mentioned areas are indicated in green colour_on the present REMO map implying they are hypoendemic for onchocerciasis and not eligible for CDTI-lt is suggested to revalidate the REMO in these areas. We therefore strongly suggest that for the envisaged integrated mapping exercise in the continental region, REA should be coupled to RAPLOA in order to clarify the present onchocerciasis map in that part of the country. The combined survey is expected to be cost-effective and provide more information on the distribution of onchocerciasis and loiasis in the continental region of the country. The combined RAPLOA/REA exercise should therefore take place only in the continental region. There is no need to conduct REMO in the Bioko island since a reliable map of the disease exists and vector elimination in the island has been successful. Also the RAPLOA exercise will have no positive implication since the mass distribution of Mectizan has been going on there for more than a decade now. Study population A census will be conducted in each of the villages surveyed to estimate the population size. The study population will consist of males and females aged 15 years and above who have been resident in the village for a minimum of ten consecutive years (for onchocerciasis) and five consecutive years (for loiasis) and who have not taken antifilarial treatment for a minimum period of one year. All eligible members of the community who will consent to participate will be enrolled into the study. Conduct of the rapid assessment procedures for loiasis and onchocerciasis (RAPLOA and REA) Organization of work A form will be designed to collect data and will be divided into three sections: the first section will be for the identification of participants, the second and third sections for the collection of RAPLOA and REA. t4 : lntegrated Mapping of Neglected Tropical Diseases in Equatorial Guinea ln each community surveyed, a team of three technicians will move from one household to another to register eligible participants, administer the RAPLOA questionnaire and carry out a Rapid epidemiological assessment (REA) of onchocerciasis by nodule palpation' Administration of RAPLOA questionnaire The Rapid Assessment Procedure for loiasis will be based on the restricted definition of the eye worm; the past experience of eye worm, conflrmed by a photograph of L. /oa adult worm in the white part of tiie eye aiid with tiie cirri'ation of tire rnost recent episode being between 1 to 7 days (Wanji et al 2005). The questionnaires will be administered to 80 adults in the Spaniih language and where required, interpreters from the community will assist in the interview process according to the RAPLOA guidelines (WHO/TDR, Geneva, 2002) Nodule palpation (REA) The REA will be based on nodule palpation. After undergoing the RAPLOA interview, male patients (30 in number), above twenty years, and who have been in the community continuously for the past ten years, will be examined by the same technician for the presence oi Onchocerca nodules according to previous studies (Ngoumou et al. 1994, Taylor et al. 1992) The geographical co-ordinates of each of the sample villages will be recorded with a global positioning system (GPS). A geographical information system (GlS will be used to plot the prevalence of antigenaemia for each sample community on a map, and the prevalence data will be lecorded using the HealthMapper software package (World Health Organisation, Geneva), Spatial analysis will be based on geostatistical methods (lsaaks and Srivastava, 1989) as pieviously applied to studies of Onchocerciasis and loiasis distribution. Prediction of the distribution of'prevalence across the country will be based on the observations made in the sample villages. V.2. SCHISTOSOMIAS'S AA'D INTESTINAL WORMS Previous studies and attempt to document the epidemiology of schistosomiasis in the mainland show the presence of both intestinal and urinary schistosomiasis. ALL three- S. mansonia, S. haematobium and S. intercalatum were found with varying levels of endemicity. These results of the studies were based on scanty data, therefore not conclusive. Study area and population ln the framework of the integrated mapping, the distribution of schistosomiasis and soil- transmitted helminthiasis will be evaluated with regard to geographical and administrative sub-divisions. Studies will be conducted in schools and the current parasitological infections will be assessed. About 10% of the total number of primary schools in the different districts province will be selected. lt is estimated that approximately 80-90 schools, over the total 848 nationwide primary schools, will be investigated. Sampling and parasitological assessment ln each of the selected school, 50 children from the Sth grade will be selected. Study will be conducted with the approval of the administrative authorities, school inspectors, directors 15 lntegrated Mapping of Neglected Tropical Diseases in Equatorial Guinea and teachers. The schoolchildren will be invited to participate in the study, and will be registered only after explanation of the objectives of the study to them and to their parents or guardian, and after full informed consent has been obtained. From each of the children selected randomly in the schools included in the study, urine and stool samples will be collected. Urine samples will be collected in 60 mL plastic screw- cap vials, between 1 1 .00 and 13.00 hours. Each urine sample will be agitated to ensure adequate dispersal of eggs, 10 mL of urine will be filtered through a Nucleopore@ filter, and the filters will be examined by microscopy for the presence of eggs. Stool samples will be collected in similar screw-cap vials, and will be examined by a single thick smear technique using a 41.7 mg Kato-Katz template. lmportantly, the same Kato slides will allow detecting both intestinal schistosomiasis and intestinal helminth lnfections in the study- populations. Data analysis The different parasitological data will be analysed using appropriate statistical test and methods. This will allow to assess the disease distribution and prevalence, and to recommend the most appropriated control strategies, accordingly. VI. LOGISTICS AND HUMAN RESOURCES V1.1. Human resources Filariasis survey A typical survey team will be made up of 5 members, divided as follows: o 1 team member for REA (Rapid Epidemiological assessment of Onchocerciasis) . 2 members for RAPLOA (Rapid Assessment Procedure for Loiasis) . 2 team members for RAGFIL (Rapid geographical assessment of bancroftian filariasis). We may need three such teams; making a total number of 15 people - 3 for REA, 6 for RAPLOA, 6 for RAGFIL. The work will be carried out under the supervision of an expert on filariasis, assisted by the Equatorial Guinea national coordinator of onchocerciasis and other filariasis control. It will be important that survey team members be recruited from among health personnel working at the district levels. The 15 members should be recruited across country and trained at Malabo. When the research team is working in a given health district, it should be envisaged that a local facilitator be recruited to assist the team during the survey. Such facilitator may be a medical doctor in service at the district hospital, or a senior nurse designated by the medical doctoi'. Validation of RAGFIL results Two independent laboratory technicians (not members of the rapid survey team) will be required to conduct the "night survey" for the microscopical validation of RAGFIL. a 16 a alntegrated Mapping of Neglected Tropical Diseases in Equatorial Guinea Sch i stosom iasis and Soi l-Transm itted He! mi nth iasis su rvey A basic survey team for schistosomiasis and STH will be made up of 5 members, constituted as follows: . 1 surveyor . 2laboratory I microscopist technicians . 2 supporting technicians (1 driver) For an integrated investigation, the schistosomiasis and STH teams will work together with the filariasii team in each district. A detailed work plan will be developed with the survey teams for complementarities of team members and cost-effectiveness of the mapping exercise. Nevertheless, it is anticipated that we may need three teams as described above, making a total number of 3 surveyors, 6 laboratory technicians and 6 supporting technicians. The work will be carried or-rt r-rnder the sr-rpervision of two experts i.e the expert on schistosomiasis and another expert on loiasis, assisted by the Equatorial Guinea national coordinator of schistosomiasis and/or onchocerciasis and other filariasis control. It will be important that surveyors and technicians be recruited amongst health personnels working at the district levels. They should be recruited across country and trained at Malabo. When the mapping team is working in a given health district, it should be envisaged that a local facilitator will be recruited to assist the team during the survey' The tocat facilitator may be a medical doctor in service at the district hospital, or a senior nurse designated by the medical doctor. Data processing and Analysis We will need a bio-statistician to develop the template for the data entry in Epi-lnfo and supervise the data entry. Two computer clerks will be required to enter the data' After cleaning, data will be fonvarded to the epidemiological unit of APOC for analysis' I l7 alntegrated Mapping of Neglected Tropical Diseases in Equatorial Guinea V\.2. Logisfics; important considerations Filariasis survey Schistosomiasis and STH survey a I Items QuantiW Provider Four wheel drive car 3 -1 vehicle available from the Nati onal Onchocerciasis Control programme -2 more vehicle needed, can be rented ICT test for RAGFIL 10000 APOC Gloves 10 packets APOC Slides 15 packets APOC Giemsa stain 3 litres APOC Lancets 12500 APOC Cotton 5 ballots APOC Micro capillary tubes (Without Heparin) 3 packets APOC Microscopes 2 APOC Computer+ printer 1 National onchocerciasis control ramme Photocopv machine 1 WR Malabo Fuel 2000 litres To be bou I Country Map 1/500.000 5 APOC GPS 5 National onchocerciasis control programme Photocopy papers 10 cartons To be bought locally RAPLOA picture 15 WHO/TDR Pencil 2 packets To be bought locally Block notes 30 Pens 1 packets To be bought locally Eraser 15 To be bought locally Tissue paper 3 packets To be bought locall Markers 5 To be bo ht locall lnk for printer 5 To be bought local ly lnk for photocopy machine 5 To be bought lqqelly Items Quantity Availability Four wheel drive car 3 60 mL plastic screw-cap vials 10 000 APOC to provide allmaterials Nucleopore@-filter 5 000 41.7 mg Kato-Katz (kits of 250 units each) 20 Fuel Country Map 1/500.000 5 (shared) GPS 5 (shared) Stationeries / Traininq materials Microscopes 3 (shared) Haemastix strips (50 units per box) 100 Various consumables (gloves, slides, reagents, etc. 18 alntegrated lr,tapiing of Neglected Tropical Diseases in Equatorial Guinea VII. TIME FRAME Steps Activities By who? Duration 1 -Logistic preparation -Recruitment and training of suryeyors, laboratory tech n icians/microscopists, supporting technicians 2 lnternational expert (1 for filariasis and 1 for schistosomiasis and STH), assisted by the national coordinators for filariasis and schistosimiasis control Two weeks 2 Field surveys +RAPLOA +REA/REMO +RAGFIL +SCHISTO +STH Two district covered /team/week, a total of six districts covered per weeks) Survey teams under the supervision of the 2 lnternational and national experts Three weeks 3 -Data entry, processing and cleaning) (Development of template in EPi- lnfo, Data entry, Data cleaning Computer clerk, under the supervision of a biostaticien Two weeks 4 Data analysis Development of country maps for onchocerciasis, schistosomiasis, soiltransmitted helminthiasis, loiasis and lymphatic filariasis for Equatorial Guinea Epidemiologic Unit of APOC Two weeks 19 a,"I.nlntegrated of Neglected Tropical Diseases in Equatorial Guinea VIII. TENTATIVE BUDGET Activities FILARIASIS SURVEY Costs (USD) SCHISTOSOMIASIS AND STH SURVEYS Costs (USD) l.Personnel -Training 5000 6000 -Field work 25200 24000 -Data entry and Processing 6000 5000 I nternational Expertise -Travel -Out of station allowance -Honorarium 14000 1 5000 3. Field Transportation -Fuel & lubricant for vehicles 4000 4000 - Maintenance of vehicles 1 500 1 500 -Hiring of 2 vehicles 9000 Provided by WHO 3.Stationeries 2000 2500 4.Consumable ICT test for RAGFIL From APOC Gloves, From APOC From APOC Slides From APOC From APOC Giemsa stain From APOC Lancets From APOC Cotton From APOC Micro capillary tubes (Without Heparin) From APOC 5. Equipment Microscopes From APOC From APOC Computer+ printer From GTNO From GTNO Photocopy machine From GTNO From GTNO GPS From GTNO From GTNO TOTAL 67,700 58,000 IX. SUGGESTED PERIOD FOR THE SURVEY Taking into account the date of the start of the new academic year, the dry season, the nationll feast, the appropriate period forconducting the studywas suggested between 15 October and 16 November 2007. However, training of the health personnel and nationals who will conduct the mapping and development of daily work plan should be completed before October 15. 20 , I