Epidemiological surveillance of a village in onchocerciasis control: volume 2, Community Directed Treatment with Ivermectin – CDTI for community distributors

EPIDEMIOLOGICAL SURVEILLANCE OF A VILLAGE IN ONCHOCERCIASIS CONTROL Useful Manual for Training and for Fields Workers To use in their day-to-day Work Volume 2, Community Directed Treatment with Ivermectin – CDTI for Community Distributors WORLD HEALTH ORGANIZATION Onchocerciasis Control Programme in West Africa (OCP) Epidemiological Surveillance of a Village in Onchocerciasis Control PREFACE Volume 2 – Community Directed Treatment With Ivermectin – CDTI for Community Distributors ii INDEX VOLUME 2, COMMUNITY DIRECTED TREATMENT WITH IVERMECTIN – CDTI FOR COMMUNITY DISTRIBUTORS......................................................................I WORLD HEALTH ORGANIZATION...................................................... i INDEX ..............................................................................................................II PREFACE ....................................................................................................... III INTRODUCTION.............................................................................................1 EDUCATIONAL OBJECTIVES.....................................................................3 PRACTICAL ARRANGEMENTS..................................................................6 DETAILED COURSE TIMETABLE ..............................................................9 ONCHOCERCIASIS AND ITS MANAGEMENT .....................................17 IVERMECTIN - THE MEDICINE FOR ONCHOCERCIASIS................22 HOW TO COMPLETE THE NOTEBOOK PROPERLY..........................27 GIVING OUT IVERMECTIN TO A FAMILY...........................................31 HOW TO WRITE A YEARLY REPORT....................................................36 TEACHING AIDS ..........................................................................................37 ASSESSMENT PLAN ....................................................................................39 CDTI MODULE FOR DISTRIBUTORS – SKILLS ASSESSMENT SHEET ................41 Epidemiological Surveillance of a Village in Onchocerciasis Control PREFACE PREFACE This module is intended for the training of villagers who have been appointed by their fellow villagers to be ivermectin distributors for that village. Trainers for this module should be health centre level nurses, from the health centre which services the villages from which the distributors come and where they will work. Epidemiological Surveillance of a Village in Onchocerciasis Control INTRODUCTION Volume 2 – Community Directed Treatment With Ivermectin – CDTI for Community Distributors 1 INTRODUCTION Onchocerciasis has been eliminated as a disease of public health importance in the West African region. However its final and permanent control requires villagers in every village in affected areas to take ivermectin once a year. It is planned that this should be achieved through the strategy of community directed treatment with ivermectin (CDTI). For practical reasons the villagers themselves will have to organise the yearly treatments - there are simply not enough health workers around to do it for them. Experience has shown that this works best if villagers themselves choose how they will do it, and who will be responsible - in other words, a community directed approach. However villages need to be motivated, trained and supported throughout. This training module is intended for use by those who have to undertake this task - those unsung heroes, the nurses working in primary health centres. Epidemiological Surveillance of a Village in Onchocerciasis Control INTRODUCTION Volume 2 – Community Directed Treatment With Ivermectin – CDTI for Community Distributors 2 In 1998 research was done to determine how well CDTI programmes are faring in 3 of the OCP countries. It was found that the training which the distributors received was often deficient. This manual aims to rectify such deficiencies. If you follow the manual step by step you will provide training of good quality to the distributors, which is essential if the villagers are to continue running the distribution independently. Although we have done our best to prepare a really useful manual, one that should be easy to use, we would appreciate your comments after you have used it. They will help us to make it better. Please write to: PET Unit OCP POBox 549 OUAGADOUGOU Burkina Faso. Epidemiological Surveillance of a Village in Onchocerciasis Control EDUCATIONAL OBJECTIVES Volume 2 – Community Directed Treatment With Ivermectin – CDTI for Community Distributors 3 EDUCATIONAL OBJECTIVES At the end of the module: 1. Trainees have to be able to perform the following tasks: • Take a census of the village, family by family. • Give the correct dose of ivermectin to everyone in the village who qualifies for it, once a year (between January and March) - family by family. • Decide whether a person may be given ivermectin or not. • Decide whether a child is five years or older, and may therefore be given ivermectin. • Measure a person’s height to decide which dose of ivermectin must be given to him/ her. • Give information about onchocerciasis and the CDTI programme to fellow villagers. • Reassure people with mild side-effects, and refer those with serious side-effects to the nearest health centre. Epidemiological Surveillance of a Village in Onchocerciasis Control EDUCATIONAL OBJECTIVES Volume 2 – Community Directed Treatment With Ivermectin – CDTI for Community Distributors 4 • Keep a notebook in which s/he records: ! the names of all the persons in the village ! the ivermectin s/he has received ! the dose of ivermectin given to each person who took it ! in the case of people who didn’t take the ivermectin, the reason why. • Keep the ivermectin s/he has been given in a safe dry place. • Follow up persons in the village who should have got ivermectin but did not, and give it to them later. • Fetch enough ivermectin for his/ her village from the nearest health centre in January every year. • (Optional) Write a short yearly report about the ivermectin used in the village. 2. Trainees have to be able to: • Describe how onchocerciasis is caused, transmitted, prevented and treated. • Discuss who may and may not be given ivermectin. Epidemiological Surveillance of a Village in Onchocerciasis Control EDUCATIONAL OBJECTIVES Volume 2 – Community Directed Treatment With Ivermectin – CDTI for Community Distributors 5 • List the dosage categories for ivermectin. • Describe the most common side-effects of ivermectin. • Discuss suitable places to store drugs like ivermectin. Epidemiological Surveillance of a Village in Onchocerciasis Control PRACTICAL ARRANGEMENTS Volume 2 – Community Directed Treatment With Ivermectin – CDTI for Community Distributors 6 PRACTICAL ARRANGEMENTS The distributors are trained in the village where they live. The training lasts about 6 hours. A detailed timetable is given in the next section. The content must be considered more or less fixed. The exact timing may be altered to fit in with the local situation. You will find that the distributors that are chosen vary a lot: • In some cases the distributors can hardly read and write. You may find it necessary in such cases to do the census and treatment (Session 5) for the whole village together with the distributor. In that way the notebook will be ready for him/ her to use for the following 5 years, and you are more confident that the work will continue in the village. • In other cases the distributors can read and write well, and already know a lot about onchocerciasis and ivermectin. The training in such cases usually goes very quickly. You may find that it is only necessary to do a few families together, and you can leave the distributor with enough ivermectin to do the rest of the census and distribution by him/ herself. Epidemiological Surveillance of a Village in Onchocerciasis Control PRACTICAL ARRANGEMENTS Volume 2 – Community Directed Treatment With Ivermectin – CDTI for Community Distributors 7 NOTE: • Before this training takes place you will have made the first visit to the village, to inform them about the CDTI programme; to ask them to participate; to ask them to select distributors; to ask them to work out what system they want to use for the distribution; and to ask them to prepare the notebook, pen, and stick for measuring height. • The basic instructional methods should be: ! discussion (rather than a lecture) ! demonstration and practical (making sure every trainee practises every skill). • Because of past onchocerciasis control activities, villagers may already know quite a lot about onchocerciasis. This should be taken into account in the training, by giving them every opportunity to share what they already know. • At least two distributors have to be selected and trained, but it is better if there are more - the first two may stop doing the job for some reason. If other villagers are interested in watching the training they should be welcomed. Epidemiological Surveillance of a Village in Onchocerciasis Control PRACTICAL ARRANGEMENTS Volume 2 – Community Directed Treatment With Ivermectin – CDTI for Community Distributors 8 • If the persons chosen by the village are illiterate they will need help from a literate person to keep the records. It is the responsibility of the village to find such a person, and s/he then has to be trained to keep the records. • At the end of the training the distributor enough ivermectin needs to be left with the distributor to finish the job (families still to be done; absentees, pregnant women, sick people). • Please note that the handouts and checklists are primarily intended for you, the trainer, to use. However if the distributors are literate and interested you can leave them a copy of each. If you are going to teach them to write the yearly report, you also need to have a blank form for each of them to copy. Epidemiological Surveillance of a Village in Onchocerciasis Control DETAILED COURSE TIMETABLE Volume 2 – Community Directed Treatment With Ivermectin – CDTI for Community Distributors 9 DETAILED COURSE TIMETABLE The training will last the best part of one day. Trainers should plan the day so that it is convenient for them and the trainee distributors. SESSION 1 Information about onchocerciasis and CDTI Time : 30 minutes Content : • Introductions • What onchocerciasis is. • How one gets onchocerciasis. • The symptoms, signs, diagnosis, treatment. • Preventing the spread of onchocerciasis by mass treeatment. • Why villagers are being asked to help. • What villagers are being asked to do. Method : • Trainer and trainees introduce themselves to each other - where they come from, families etc. Trainer thanks trainees for volunteering to do this important job. • Discussion - trainer goes through each of the points above, finding out what trainees know; adding if necessary. Materials : • Handout : «Onchocerciasis and its management» Epidemiological Surveillance of a Village in Onchocerciasis Control DETAILED COURSE TIMETABLE Volume 2 – Community Directed Treatment With Ivermectin – CDTI for Community Distributors 10 SESSION 2 : Information about ivermectin Time : 30 minutes Content : • What it looks like. • How much it costs. • How it works against the disease. • How often it should be given, and at what time of the year, and for how long. • The kinds of people who may not get it. • The dosage, according to height. NOTE: the side-effects are dealt with in Session 6. Method : • Trainer passes around some ivermectin tablets. • Discussion - trainer goes through each of the points above, finding out what trainees know; adding if necessary. Materials : • Some ivermectin tablets. • Handout: ‘Ivermectin - the medicine for onchocerciasis’. SESSION 3 : The measuring rod and the arm-ear-test Time : 30 minutes Content : • Preparing a measuring rod. • Doing the arm-ear-test to find out if a child is 5 years old yet.. Method : • The trainer shows the rod s/he has brought. • Trainees find a stick and make their own - cutting clear and deep marks in with a knife. • Trainees are asked to fetch a few small children they know. The trainer demonstrates the arm-ear test - trainees try it out themselves. Materials : • The trainer’s own rod. • Suitable unmarked sticks for each trainee. • A sharp knife. • A few small children. Epidemiological Surveillance of a Village in Onchocerciasis Control DETAILED COURSE TIMETABLE Volume 2 – Community Directed Treatment With Ivermectin – CDTI for Community Distributors 11 SESSION 4 Preparing the notebook. Time : 30 minutes Content : • Preparing a few pages of the notebook. • The codes for persons who don’t get treated. Method : • Trainer gives an example of what a page should look like to each trainee personally. • Trainees are asked to try to draw it themselves on the first page of the notebook they have. The trainer helps. They draw as many as there is time for. • The trainer shows the codes, which are discussed. Materials : • Notebook and ballpoint pen (or pencil) for each trainee. • Handout with the codes. • Checklist: ‘How to complete the notebook properly’. Epidemiological Surveillance of a Village in Onchocerciasis Control DETAILED COURSE TIMETABLE Volume 2 – Community Directed Treatment With Ivermectin – CDTI for Community Distributors 12 SESSION 5 : Doing the census and treatment Time : Variable • If the distributors find the writing difficult, the whole village will have to be done by the trainer and the distributors together. • If the distributors are quick on the uptake it will only be necessary to do a few families together, and the distributors can be left to do the rest later. Content : NOTE: Here you have to use the method of arranging treatment that the village has decided upon - e.g. door to door, or at a central place etc. • Performing a family census. ! Greeting the family, explaining the procedure. ! Writing up each family member. • Treating relevant family members with ivermectin. ! Deciding if they may have ivermectin. ! Measuring height and deciding on the dose. ! Writing in the dose or the reason for not giving • Explaining about possible side-effects and asking the family to report them. Method : • Depending on the method the village has chosen, the trainer and trainees will either visit the families in their homes, or the families will come to them at a central place. • The trainer demonstrates, then the trainees practise. • The trainer supervises and gives feedback. Materials : • Families. • Measuring sticks, ivermectin tablets, notebook, pen/ pencil. • Handout: ‘Ivermectin - the medicine of onchocerciasis’. • Checklists: ‘Giving out ivermectin to a family’ and ’How to complete the notebook properly’. Epidemiological Surveillance of a Village in Onchocerciasis Control DETAILED COURSE TIMETABLE Volume 2 – Community Directed Treatment With Ivermectin – CDTI for Community Distributors 13 SESSIOIN 6 : Side-effects of ivermectin Time : 30 minutes Content : • Common side-effects. • Serious side-effects. • What the distributor has to do about them. Method : • Discussion about kinds of side effects: build on what the trainees know. • Similar discussion about serious side effects, which need to be referred to a clinic. • Trainer presents case studies about side effects to trainees to solve. Materials : • Handout: ‘Ivermectin - the medicine of onchocerciasis’. • Case studies. SESSION 7 : Following up persons who did not get ivermectin Time : 30 minutes Content : • Following up people who couldn’t take ivermectin at the time. • Counting how much ivermectin needs to be left behind for them. • How to record it when they do take it. Method : • Discussion: what can you do about people who didn’t get ivermectin when the others did? Trainees are encouraged to come up with their own answers, trainer gives feedback. • Trainer asks: how much ivermectin do I need to leave behind for those people? Trainees go through the notebook, add up (trainer guides if necessary). • Trainer asks: how should we record it in the notebook if such persons have now taken the ivermectin? Trainees suggest, trainer confirms (delete the code, add the number). • Each trainee practises it on his/ her ‘Sample page of the notebook’. Materials : • Handout: ‘Giving out ivermectin to a family’. • The notebook that has just been used in Session 5. • Trainees’ ‘Sample pages of the notebook’. Epidemiological Surveillance of a Village in Onchocerciasis Control DETAILED COURSE TIMETABLE Volume 2 – Community Directed Treatment With Ivermectin – CDTI for Community Distributors 14 SESSION 8 : Receiving and storing ivermectin Time : 30 minutes Content : • Receiving ivermectin and recording it. • Storing ivermectin. Method : • Trainer explains how much ivermectin s/he is going to leave behind today - enough for all who haven’t had so far. The trainees count it out. • Together they enter it on the back page of the notebook, as in the example in the document ‘How to complete the notebook properly’. • Short discussion: where would be a good place to store it? Then distributor chooses a place in his/ her house, trainer gives feedback, they all go to put it there. Materials : • Enough ivermectin tablets. • Handout: ‘Ivermectin - the medicine for onchocerciasis’. SESSION 9 : Planning for next year Time : 30 minutes Content : • Obtaining ivermectin at the start of the following year. • How to use the notebooks the following year. Method : • Trainer asks trainees: ‘How will you get the ivermectin for next year?’ (fetch it at the health centre). ‘And when?’ (in January). Any problems are discussed. • Trainer: ‘Next year I won’t be here when you hand out the ivermectin. How will you go about it?’ The trainees discuss how they will go about things. The trainer asks them to show how they will use the notebook the following year (use the next column). • Trainer: ‘Will everybody get the same number of tablets that they got this year?’. Discussion about children growing, women falling pregnant etc. • Trainer: ‘What about people who have died? and new people who have joined the family?’ - they work out how to adjust the list of family names. Materials : • The notebook. • Handout: ‘Giving out ivermectin to a family’. Epidemiological Surveillance of a Village in Onchocerciasis Control DETAILED COURSE TIMETABLE Volume 2 – Community Directed Treatment With Ivermectin – CDTI for Community Distributors 15 SESSION 10 : Giving information to follow villagers ; oral test Time : 30 minutes Content : This session has two aims: • Firstly the trainees practise giving information about onchocerciasis and the CDTI programme to fellow villagers. • Secondly it is an opportunity to test trainees’ knowledge. Method : • You explain to the trainees that you are going to do a role play with each of them in turn, to see if they know how to answer the questions people have about onchocerciasis and the CDTI programme. The trainer plays the role of a villager and the trainee plays a distributor. • You ask questions that you have prepared, that a villager might ask. They should cover all the areas of knowledge, but especially the important ones (who may not get ivermectin; how to work out the dose). • After speaking to the trainee you also assesses his/ her mastery of skills, using the attached sheet. • You can now decide whether the trainee is likely to work safely. • Then you go on to the next trainee. • When you have finished you give the trainees feedback on how they performed. Materials : • Prepare questions from the handouts. Epidemiological Surveillance of a Village in Onchocerciasis Control DETAILED COURSE TIMETABLE Volume 2 – Community Directed Treatment With Ivermectin – CDTI for Community Distributors 16 SESSION 11 : Writing a yearly report NOTE: This session is optional, and is intended for distributors with reasonable reading and writing skills only. Time : 30 minutes Content : • The contents of yearly report. • When it should be written. • To whom it should be forwarded. Method : • Trainer explains: since the ivermectin is being given free, the Government wants to know how it is being used. So once a year we need a report from every village that is using it. • Discussion: when is the right time to make the report? [right after finishing the distribution, in the first quarter of the year] • Trainer and trainees look together at an example of such a report form. The trainer gives each trainee a copy and a piece of paper, and they draw a copy of the form for themselves. Trainer explains: you make a copy like this every year. • Then they work together to summarise the information they have written up in their notebook so far, and fill it in on the report. Trainer gives feedback. • They make an agreement about when trainees will bring the complete report to the health centre. Materials : • Copies of the yearly report form (see handout : ‘How to write a yearly report’). • Paper. • The distributor’s notebook. SESSION 12 : Reporting to the village authorities. As soon as the training is over, you go with the trainees to report to the village authorities: • Congratulate the trainees on their success. • Stress how important it is that the village should support the distributors. • Make practical arrangements for the next distribution. • Thank everyone concerned. Epidemiological Surveillance of a Village in Onchocerciasis Control ONCHOCERCIASIS AND ITS MANAGEMENT Volume 2 – Community Directed Treatment With Ivermectin – CDTI for Community Distributors 17 Onchocerciasis and its management What is onchocerciasis ? It is a disease caused by worms which live under the skin, and which give birth to very large numbers of small worms all the time. How does one get onchocerciasis ? You get it by being bitten by a blackfly which is carrying the small worms. The blackfly picked up the worms when it bit another person who had the disease. The blackflies breed in rivers. Therefore there are more blackflies near rivers, and people living close to such rivers are more likely to get the disease. That is why the disease is also called ‘river blindness’. What are the symptoms and signs of onchocerciasis ? • The most common symptom is itching, which is caused by the small worms in the skin. It is severe and never stops. Because people scratch such a lot their skin gets rough. The skin may also lose its pigment. • The adult worms may cause painless lumps under the skin. After a while the small worms get into the eyes. This is very serious. The eyesight gets worse and worse, until the person is blind. Such blindness cannot be cured. Epidemiological Surveillance of a Village in Onchocerciasis Control ONCHOCERCIASIS AND ITS MANAGEMENT Volume 2 – Community Directed Treatment With Ivermectin – CDTI for Community Distributors 18 Itching Onchocercal dermititis "Lizard skin" "Leopard skin" Nodule in the forehead Loss of vision It is clear that the symptoms of illness are caused by the small worms in the skin and eyes, and not by the adult ones. Epidemiological Surveillance of a Village in Onchocerciasis Control ONCHOCERCIASIS AND ITS MANAGEMENT Volume 2 – Community Directed Treatment With Ivermectin – CDTI for Community Distributors 19 How can one make sure someone has onchocerciasis? By taking a small piece of skin and examining it with a microscope. If the small worms can be seen, that person has the disease. How does one treat onchocerciasis? There was an old drug called DEC or Notezine, which was no good. It often made people even more sick than they were already. But now there is a new drug called ivermectin, which is completely safe and very effective. It kills the small worms, but not the adult ones. • The ivermectin has to be taken for about 15 years, because the adult worms live that long and the small ones have to be killed yearly until the adults die. • People who take the ivermectin regularly will never develop skin or eye problems. How can one prevent the spread of onchocerciasis? There are two ways: • By killing the blackflies. This is done by putting insecticide into the rivers where the blackflies breed. • By giving ivermectin regularly to everyone living in an area where there has been onchocerciasis. Epidemiological Surveillance of a Village in Onchocerciasis Control ONCHOCERCIASIS AND ITS MANAGEMENT Volume 2 – Community Directed Treatment With Ivermectin – CDTI for Community Distributors 20 Why should everyone be treated in areas where onchocerciasis is present? People who have the small worms in their skin are a danger to others, because the blackflies can transmit the disease from them to other people. We are not sure who has the disease and who not, so it is better for everyone to be treated. In this way everyone is protected. Why should people be treated who are feeling well? In the early stages of the disease people fell well, but they still have the small worms in their skins. So they must be treated. Why are villagers being asked to help with the treatment? • There are thousands of villages in the country. It is not possible for the government to send nurses to every village every year, to give out the treatment. So villagers are being asked to help with this task, because it is in their interest. • Also, ivermectin is a very safe drug. This means it does not have to be given out by doctors and nurses only. What are the villagers being asked to do? • To take the treatment every year. • To decide how they want to organise the distribution of the tablets, and to organise it that way. Epidemiological Surveillance of a Village in Onchocerciasis Control ONCHOCERCIASIS AND ITS MANAGEMENT Volume 2 – Community Directed Treatment With Ivermectin – CDTI for Community Distributors 21 • To select one or more of their fellow villagers to be trained to distribute the tablets in their village once a year. What are the tasks of the distributor chosen by the village? This person will be trained by a nurse or doctor to do the job properly. • He fetches the tablets from the nearest health centre every year, and gives the right amount of tablets to all those villagers who may take them. • He also keeps a record of every treatment. • He is able to tell people in the village what they want to know about onchocerciasis Epidemiological Surveillance of a Village in Onchocerciasis Control IVERMECTIN – THE MEDICINE FOR ONCHOCERCIASIS Volume 2 – Community Directed Treatment With Ivermectin – CDTI for Community Distributors 22 IVERMECTIN - THE MEDICINE FOR ONCHOCERCIASIS What does ivermectin look like? It is small round white tablet with no taste. How much does ivermectin cost? It is given free of charge. How does ivermectin work? It kills all the little worms of onchocerciasis in the skin and eyes. This makes people feel a lot better. It does not kill the adult worms though - that is why treatment has to continue for many years. Sometimes ivermectin also helps by killing other worms in the bowel. Epidemiological Surveillance of a Village in Onchocerciasis Control IVERMECTIN – THE MEDICINE FOR ONCHOCERCIASIS Volume 2 – Community Directed Treatment With Ivermectin – CDTI for Community Distributors 23 Who may get ivermectin, and who not? In areas where there is onchocerciasis everyone should get it, except the following persons: Children under the age of five years should not get it. But they should start as soon as they turn five. Pregnant women should not get it. But they can come back to take it a week after they have had their baby. Women who are breastfeeding a baby who is less than a week old should not get it. But they can take the tablets with them, to take as soon as the as the baby is a week old. People who are very sick should not get it - so sick that they cannot work, play or go to school. But they can come back to take it as soon as they are better. There is a test one can do to find out if a child has turned five yet. You ask the child to try to reach with his arm over the top of his head, and to catch hold of his ear on the other side. If he can do that he is probably five years old or more, and you can safely give him ivermectin. Epidemiological Surveillance of a Village in Onchocerciasis Control IVERMECTIN – THE MEDICINE FOR ONCHOCERCIASIS Volume 2 – Community Directed Treatment With Ivermectin – CDTI for Community Distributors 24 How many tablets of ivermectin should people take? It goes by your height. The person who gives the tablets measures your height with a stick, and then decides how much you should get: If a person is less than 119 cm tall he gets 1 tablet. If a person is between 120 and 140 cm tall he gets 2 tablets. If a person is between 141 and 158 cm tall he gets 3 tablets. If a person is 159 cm or more tall he gets 4 tablets. When should ivermectin be given to people? Once a year, between January and March. This should continue for many years, until the health department says we should stop. Epidemiological Surveillance of a Village in Onchocerciasis Control IVERMECTIN – THE MEDICINE FOR ONCHOCERCIASIS Volume 2 – Community Directed Treatment With Ivermectin – CDTI for Community Distributors 25 How does one take the ivermectin? You can chew it, since it has no taste, or you can swallow it with water. Do some people get a bit sick after taking invermectin ? Yes, some do, but they are very few. They may complain of itching, swelling, body pain and headache, fever, diarrhoea or dizziness. In most cases these symptoms disappear in a day or two, so all you have to do is to reassure people that they will soon get better. Epidemiological Surveillance of a Village in Onchocerciasis Control IVERMECTIN – THE MEDICINE FOR ONCHOCERCIASIS Volume 2 – Community Directed Treatment With Ivermectin – CDTI for Community Distributors 26 This happens within a day of taking the tablets (especially the dizziness, which appears very quickly). If it starts after more than one day it means the person has another illness, and needs to go to the health centre. Some people say ivermectin is a contraceptive. Is this true? It is definitely NOT true. In fact many men report that their potency improves after taking ivermectin. Where do we get ivermectin? We get it from the nearest health centre. When we get new tablets, it is very important to use up the old ones first. Where should we store ivermectin? In a place where it stays dry, and where children can’t get at it. Very rarely these effects are severe. We say they are severe if: The person is so sick that he can’t get up and work, or play, or go to school. The effects don’t get better within two to three days. Such a person should go to a health centre to be treated. Epidemiological Surveillance of a Village in Onchocerciasis Control HOW TO COMPLETE THE NOTEBOOK PROPERLY Volume 2 – Community Directed Treatment With Ivermectin – CDTI for Community Distributors 27 HOW TO COMPLETE THE NOTEBOOK PROPERLY The Department of Health needs information about how ivermectin is used in the villages. This is to know whether the programme is working well. It also tells them how much ivermectin they have to order for the following year. You only need one notebook to write down all the information that is needed. Once a year, in March, when you have finished giving out the year’s tablets, the nurse needs to borrow your book. He will use the information from your book to make a report to the Department of Health. Epidemiological Surveillance of a Village in Onchocerciasis Control HOW TO COMPLETE THE NOTEBOOK PROPERLY Volume 2 – Community Directed Treatment With Ivermectin – CDTI for Community Distributors 28 You are going to write information in your book on two occasions: 1. When you get a new supply of ivermectin tablets. When you get a new supply of ivermectin tablets you must always have your notebook with you. You and the nurse go to the back page in your notebook and fill it in like this, together : Date: 12 January 1998 Number of tablets I had left: 43 Number of new tablets I received today: 750 Total number of tablets I now have: 793 Distributor’s signature: Issa Touré Nurse’s signature: L. D. Ouédraogo Epidemiological Surveillance of a Village in Onchocerciasis Control HOW TO COMPLETE THE NOTEBOOK PROPERLY Volume 2 – Community Directed Treatment With Ivermectin – CDTI for Community Distributors 29 2. When you are giving out ivermectin to a family. You prepare a few pages in your notebook beforehand, like this: Head of family: Name and family name age sex 1998 dose 1999 dose 2000 dose 2001 dose 2002 dose The «1998 », «1999 »..., means the years. If you are starting this work in 1999, you will write «1999 », « 2000 », «2001 », and so on. Epidemiological Surveillance of a Village in Onchocerciasis Control HOW TO COMPLETE THE NOTEBOOK PROPERLY Volume 2 – Community Directed Treatment With Ivermectin – CDTI for Community Distributors 30 You need to know the following codes to use in your notebook: M = male F = female C = a child under 5 years P = a pregnant woman S = a very sick person A = an absent person R = a person who refuses to take the tablets If your notebook is full you ask the village leaders to get you another one. Keep the old one in a safe place in your house, and take the old and the new ones with you when you go to the health centre to report or to fetch more tablets. Epidemiological Surveillance of a Village in Onchocerciasis Control GIVING OUT IVERMECTIN TO A FAMILY Volume 2 – Community Directed Treatment With Ivermectin – CDTI for Community Distributors 31 GIVING OUT IVERMECTIN TO A FAMILY Perhaps the family is going to come to you, or perhaps you are going to visit the family. This depends on the way you and your village have decided to arrange things. In either case, you follow the same steps. 1. You greet the family. 2. You explain what is going to happen. You answer any questions they may have. 3. You write down the name of everybody who takes their meals with that family. a. If someone is away on that day you write down their name too. b. Use one page in the notebook per family. Your trainer will show you how to prepare each page. If the family is big you may have to use two pages for it. c. Use one line per person. Under ‘Name and family name’ you write down the names and family names: ! Start with the head of the family. ! Then his first wife, and all her children (oldest to youngest). Epidemiological Surveillance of a Village in Onchocerciasis Control GIVING OUT IVERMECTIN TO A FAMILY Volume 2 – Community Directed Treatment With Ivermectin – CDTI for Community Distributors 32 ! Then the other wives and their children, in order. ! Then other people living in the family (grandparents, cousins and so on). d. Under ‘sex’ you write M (for male) or F (for female). for each person. e. Under ‘age’, you write each person’s age in years. If people don’t know their age, make a guess. 4. You call the first person on your list: a. You decide: is he allowed to get the ivermectin? b. If it is child less than 5 years old he gets no tablets and you write ‘C’ under the date for this year. If you are not sure of his age, you do the hand-ear test. If the test shows that he is less than 5 years old he gets no tablets and you write ‘C’ under the date for this year. If the test shows he is 5 years old, you give him 1 tablet and write ‘1’ under the date for this year. c. If it is a pregnant woman she gets no tablets and you write ‘P’ under the date for this year. You ask her to come back to you a week after she has delivered. Then you measure her height and give her the right number of tablets. Then you cross out the ‘P’ under the date for this year and write in the number of tablets she got. Epidemiological Surveillance of a Village in Onchocerciasis Control GIVING OUT IVERMECTIN TO A FAMILY Volume 2 – Community Directed Treatment With Ivermectin – CDTI for Community Distributors 33 d. If it is a woman who is breastfeeding a baby who is less than a week old, you measure her height and give her the right number of tablets to take home. You tell her not to take them now, but only when the baby is a week old. You write down the number of tablets you gave her under the date for this year. e. If it is a person who is very sick he gets no tablets and you write ‘S’ under the date for this year. You ask him to come back to you when he is better. Then you measure his height and give him the right number of tablets. Then you cross out the ‘S’ under the date for this year and write in the number of tablets he got. f. If the person is absent you write ‘A’ under the date for this year. When he comes back you visit him, measure his height and give him the right number of tablets. Then you cross out the ‘A’ under the date for this year and write in the number of tablets he got. g. If the person refuses to take the tablets you write ‘R’ under the date for this year. You try to find out why, and try to persuade him to take the tablets. If he agrees after a while you measure his height and give him the right number of tablets. Then you cross out the ‘R’ under the date for this year and write in the number of tablets he got. Epidemiological Surveillance of a Village in Onchocerciasis Control GIVING OUT IVERMECTIN TO A FAMILY Volume 2 – Community Directed Treatment With Ivermectin – CDTI for Community Distributors 34 h. If the person may get ivermectin, you measure his height and give him the right number of tablets. Then you write down the number of tablets he got under the date for this year. 5. You treat the whole family in this way. 6. You explain that they may have some side effects the next day. a. You ask them to come to see you if they do. b. If they are very sick you send them to the health centre. 7. Finally you greet the family and thank them. 8. Next year at the same time you will hand out tablets to everyone in that family again. a. This time your task is easier, because your notebook is already prepared. b. First you find out if the family has changed. If there is a new member of the family (for instance a new baby) you write his name on the line below the last name on the list. If someone has died you write ‘Died’ next to his name, under the date for that year. Epidemiological Surveillance of a Village in Onchocerciasis Control GIVING OUT IVERMECTIN TO A FAMILY Volume 2 – Community Directed Treatment With Ivermectin – CDTI for Community Distributors 35 c. For everyone who is now on the list you have to ask again: may he get the treatment? and what should the dose be? You can’t just use the same dose as before. Women may now be pregnant, and children are growing and may need more tablets. d. This time you write down the number of tablets and the codes under the date for that year. Epidemiological Surveillance of a Village in Onchocerciasis Control HOW TO WRITE A YEARLY REPORT Volume 2 – Community Directed Treatment With Ivermectin – CDTI for Community Distributors 36 HOW TO WRITE A YEARLY REPORT Here is an example, which the distributors can copy and then fill in: YEARLY REPORT FOR ............ Village: District: Number of inhabitants counted: Number of people treated: Number of people not treated: With 1 tablet Children under 5 years With 2 tablets Pregnant women With 3 tablets Very sick With 4 tablets refusing TOTAL TREATED absent TOTAL NOT TREATED Ivermectin used: Number of tablets left at start of the year Number of tablets given to village Number of tablets used Number of tablets lost/spoilt Number of remaining tablets Name of village distributor(s) making report : ....................................................... Signature:............................................... Date: ..................... Epidemiological Surveillance of a Village in Onchocerciasis Control TEACHING AIDS Volume 2 – Community Directed Treatment With Ivermectin – CDTI for Community Distributors 37 TEACHING AIDS Case studies Trainees need to learn to take decisions about what kind of side effect is serious and needs to be referred. Case study 1 : You are working in your fields when a little girl runs up. She says her mother is very sick, and they think it may be due to the ivermectin which she took yesterday. You go with her to the house. You find Mrs Traoré doing the cleaning in the house. She says she is itching a lot, and has a headache. What do you do? OR: You find Mrs Traoré lying on her bed. Her legs are fairly swollen (right more than left) and she says her body is aching all over. She also has a fever. What do you do? Case study 2 : While you are busy giving out tablets to a family, someone comes running to tell you that there is a problem in the family where you were busy an hour or two ago. You find Mr Coulibaly lying on his bed. He says he fainted a few minutes ago, but is feeling better now, just a bit dizzy. What do you do? Epidemiological Surveillance of a Village in Onchocerciasis Control TEACHING AIDS Volume 2 – Community Directed Treatment With Ivermectin – CDTI for Community Distributors 38 Case study 3 : It is two days since you finished giving out ivermectin in the village. You are called to see Mrs Ouédraogo who has a headache and a fever. She says it started this morning, and she is feeling very ill indeed. What do you do? You can make up more along the same vein! Epidemiological Surveillance of a Village in Onchocerciasis Control ASSESSMENT PLAN Volume 2 – Community Directed Treatment With Ivermectin – CDTI for Community Distributors 39 ASSESSMENT PLAN The course is short, since the knowledge to be learnt is not much and the skills are not very complicated. It is however essential to assess the trainees, to be sure whether they have learnt what they were supposed to. The plan for conducting such assessment is as follows: SKILLS There are a few well-defined skills that the distributors have to learn. You have to observe very closely during the practical work, to see if the trainees have really mastered the skills. At the end of the day you assess the trainees’ competence for each skill, using the skills assessment sheet below. KNOWLEDGE AND DECISIONS In session 10 a short oral exam is conducted with each trainee, to see if s/he has mastered the key facts, and can make decisions with that knowledge. This takes the form of a few short questions (to assess knowledge) and a few short problems (to assess how they use that knowledge to make decisions). These are asked during a role play. The questions are taken from the two handouts and the problems as well (e.g. ‘Why is it that some persons don’t get the tablets?’ ‘Who are they?’). Epidemiological Surveillance of a Village in Onchocerciasis Control ASSESSMENT PLAN Volume 2 – Community Directed Treatment With Ivermectin – CDTI for Community Distributors 40 This test should cover the following areas Trainees need a high mark to pass - especially the contra-indications for giving ivermectin must be 100% correct. DECISION TO PASS OR FAIL The question is: are you happy that the distributor will perform safely in the village, when s/he is alone? If the answer if ‘yes’ s/he passes; if not, s/he fails and the weak areas in the training have to be repeated. ! how onchocerciasis is caused, transmitted, prevented and treated ! who may and may not be given ivermectin (very important) ! the dosage categories for ivermectin (very important) ! the most common side-effects of ivermectin, and what to do about them ! suitable places to store drugs like ivermectin Epidemiological Surveillance of a Village in Onchocerciasis Control SKILLS ASSESSMENT SHEET Volume 2 – Community Directed Treatment With Ivermectin – CDTI for Community Distributors 41 CDTI Module for distributors – Skills assessment sheet Trainees’names : Date : 3 = excellent 2 = good : pass 1 = poor : needs more practice. Write the score in pencil in the relevant block. This means you can change it later when the trainee has improved. 3 2 1 • Decide whether a person may get ivermectin or not. • Decide whether a child is five years or older. • Measure a person’s height. • Calculate the right dose of ivermectin to give. • Handle side-effects properly. • Keep a handbook in which s/he records: - The ivermectin s/he has received - Particulars of every member of every family - each dose of ivermectin s/he has given out - persons not getting ivermectin, with reasons. • Keep ivermectin in a safe dry place • Give information about onchocerciasis and CDTI to fellow villagers. • Writing a yearly report. Average mark for skills (1, 11/2, 2, 21/2, 3) Assessors :