APOC impact assessment team two's field mission report. Uganda 4th - 24th August 1998

APOC IMPACT ASSESSMENT STUDIES TEAM TWO'S FIELD MISSION REPORT. UGANDA 4TH - 24TH AUGUST 1998 2 Nl11 ,cI, l99g TABLE OF CONTENT I. DATES OF VISIT INTRODUCTION TERMS OF REFERENCE CON4POSITION OF STUDY TEAM PLACES VISITED REPORT OF ACTIVITIES CONSTRAINTS CONCLUSIONS AND RECOMMEDATIONS ACKNOWLEDGEMENT APPENDICES(A) PERSONS MET(B) PRELIMINARY GROUP REPORTS 2. 3. 4. 5. 6. 7. 8. 9. 10 2 lvermectin [mpact Assessment - Mission Report to Uganda 12 APOC IMPACT ASSESSMENT STUDIES TEAM TWO'S FIELD MISSION REPORT BY DR. KECHI F. OGBUAGU DATES OF VISIT - August 3'd - 24th 1998 INTRODUCTION: It is estimated that 15 million people suffer from the debilitating effects of onchocersiasis in Africa alone. With its demonstrated beneficial effects on the various manifestations of onchocercal disease, lvermectin has revolutionized the treatment of onchocerciasis in many parts of the world. ApOC was therefore established with the overall objective of 'establishing sustainable community directed lvermectin delivery systems, covering 50 million people in 19 countries which fall outside the scope of the ongoing African Onchocerciasis Control Program (OCP). These systems will be established and entirely self sustaining within the 1996-2007 time period.' The need to evaluate the clinical, epidemiological and socio-economic impact of APOC operations was felt and this culminated in the appointment of two Coordinators, Prof. Eka Braide and Dr. tt/ichel Boussinesq, to carry out preparatory activities and subsequently supervise and coordinate the impact evaluation activities. ln addition four teams of scientists, with adequate experience and geographical/language mix, each team consisting of a clinician/dermatologist, an ophthalmologist, an entomologist and a social scientist, were appointed to carry out the evaluation activities in 15 selected sites in 9 countries, of which Uganda is one. The present study is the initial/baseline study. lt will be followed by a second assessment in 3-5 years time and a final assessment in 8-10 years. 3: TERMS OF REFERENCE: 3.1. To assess the dermatological impact of onchocerciasis control (CDTI) in APOC countries. . To determine the change in prevalence of onchocercal reactive skin lesions and depigmentation (DPIM): . To determine the change in the proportion of the population with symptoms/signs of severe itching: To determine the incidence of onchocercal depigmentationa J lverrnectin [mpact Assessment - Mission Report to Uganda 4. 1. 2. 3. 4. 5. b. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. COMPOSITION OF STUDY TEAM: NAME DESIGNATION Dr. Kechi F. Ogbuagu Clinician/Team Leader Dr. Femi Babalola Ophthalmologist Dr. Maegga, Bertha T.A. Entomologist Mrs. Victoria Matovu Social Scientist Dr. Kambugu Andrew D. Local Clinician Dr. Christopher N. Magimbi Local Ophthalmologist Ms Kasigala M. Deborah Senior Ophthalmic Nursing Sister Mr. Dauda Waiswa Local Sociologist Kasiimire Margaret WU Jones Assistant Nabukenya Christine Muwoonge WU Jones Assistant Mr. T. L. Lakwo Loca! Entomologist Mugaba Zakia Data Entry Clerk Rwaheru Jackson Data Entry Clerk Ephraim Tukesiga LocalTechnologist Joseph Wamani Local Technologist Mr. Ephraim Mutuuzi Local assistant Lwanga Robert Driver Charles Kwesiga Driver AbdulAzizi Driver 5 lvermectin Irnpact Assessment - Mission Report to Uganda 5: PLACES VISITED . WHO WR's Office in Kampala . National Onchocerciasis Control Coordinator's office in Vector Control Division, Ministry of Health - Kampala. . Onchocerciasis Control Office in [/barara District. . District Medical Office in Bushenyi district. . Local Government Headquarters in Bushenyi District. SITES UTILISED FOR STUDY Nyabubare [/ugombwa Kagarama Rwemitago Kyamabale Ryemondo The last two villages, Kyamabale and Ryemondo are located in a parish also called Nyabubare. The study commenced in Kyamabale, Ryemondo and Rwemitago, where the Sociology group had carried out detailed socio-economic studies. However it was found that the prevalence of onchocercal skin and eye lesions appeared to be relatively low in these communities and that in addition, the lvermectin coverage rates were also quite high. The Study Team therefore moved further inland to Nyabubare, Mugombwa and Kagarama villages were treatment coverage rates were believed by the NOTF to be lower. All these study areas are located in Ryelu Sub-County, Bushenyi District, in Southwestern Uganda. 6 lverrnectin Impact Assessment - Nlission Report to Uganda 6 REPORT OF ACTIVITIES: PREPARATORY ACTIVIT!ES IN KAMPALA:6.1. The Team was able to assemble as pianned in Kampala, on the Sth of August 1998. tVrs. Victoria l/latovu, the Social Scientist, had just concluded the socio- economic study as per schedule and was able to brief the Team on essential demographic and socio-economic characteristics of the study communities. Dr. Richard Ndyomugyenyi, the National Coordinator of the Onchocerciasis Control Programme was also available to provide information on preparations so far made and to introduce the Team to the WHO, Uganda. The Team was introduced to various key WHO Officials which included, [Vr. Kapitaine Khantaway and [/r. Sam Kyakutaga. The Team officially briefed the WR, WHO Uganda, on the 6th of August. Purchase of locally available equipment began on the afternoon of the 5th. Con(act was also made with Ouagadougou in view of the fact that non of the equipment expected to be purchased by APOC had arrived. The WR's office was also unable to lend a camera for the photography of skin lesions as suggested in APOC communications, so there was also a need to purchase a camera in Uganda. By the afternoon of the 7th the purchase of locally available equipment had been completed, however the equipment from Ouagadougou had still not been received. Half the Team proceeded to Bushenyi, the study district. The rest of the Team had to proceed to the field on the 8th in order to begin the preliminary field preparations/logistic preparations, inspite of the fact that the equipment had not been received. 6.2: FIELD WORK IN BUSHENYI SUMMARY OF ACTIVITIES 8th August 1998 - The team leader arrived in lshaka at 4.30 p.m. from Kampala. An informal meeting was convened on the same day starting 7.45 p.m. During this meeting the Team leader, Dr. K. Ogbuagu requested the team members to introduce themselves. Later, she gave a brief account about the background of the study and what is expected of the members. She further urged cooperation among team members and requested them to be accommodating. lt was agreed that study sites be visited the following day and that courtesy calls be paid to village and district community leaders The meeting was adjourned at 9.10pm. gth August 1998 - The team visited Rwemitago village where the Local Council I (LCl) Chairman [/lr. Tuwesigye lsaac was met and briefed about the study. ln the neighboring village, Nyabubare, the Vice-Chairman, LCI was met and delegated to inform the community about the same. Later the team visited 7 Ivermectrn Irnpact Assessment - Mission Report to Uganda Ndagaro parish close to Rwemitago village where the entomological team visited a stream. A young boy aged 20 found bathing in this stream was interviewed about the presence of the vector flies. He claimed some knowledge on the same however; the team planned comprehensive prospecting the following day. Finally Buhinda (Nyabubale) treatment Centre was visited and arrangements were made for the clinical team to be based here for this study. 1Oth August 1998 -The team paid courtesy visits to the District Authorities between 9.45 AM. - 10.00 A.tU. Although the DIVO was out of office the Vice- chairman LCV lVr. Bamuyaga was met. The team leader introduced the team members and gave a brief background about the study. The Vice-Chairman narrated the seriousness of Onchocerciasis in certain villages, which had led to population migration before the introduction of lvermectin distribution. He however, promised the cooperation of the community. Also met was the Chief Administrative Officer (CAO) [/r. Bitarabeho. The team left for the field at 10.1sArV. 1Oth - 22nd August 1998 Detailed work as per protocol was carried out by the clinical/dermatological, ophthamological and entomology teams at the sites listed above. The detailed reports from each group are attached for further information. The equipment from Ouagadougou was received a few days after fieldwork had started. The Slit Lamp was found to have been sent without the power pack and the stand and thus could not function. 6.3': . RETURN TO KAMPALA: The Clinical and Entomology groups were able to conclude fieldwork and return to Kampala on the 20th of August, where reporl writing was immediately commenced. The Team also had the opportunity on the 21st of August to make contact with APOC to clarify logistic issues and to debrief the WR about the impact assessment mission. The Ophthalmology group concluded field activities on the 23rd of August. 8 Iverrnectin Inrpact Assessnrent - lVlission Report to Uganda 7. CONSTRAINTS: Delay in Provision of Equipment - The fact that essential equipment had not been available on ground on arrival of the Team in Kampala proved to be a major impediment to the early take off of field activities. ln addition some of the equipment such as the Slit-Lamp when finally received and assembled were found to have essential components missing. Availability of Computers - Only one laptop was made available to the Team This proved to be a major constraint. lt was impossible to cover the number of patients required to be examined using the WU-Jones computerized machine and at the same time enter data in the field. This issue needs to be seriously addressed before the next assessment exercise. Transportation - lnspite of the fact that three vehicles were available to the Team for the better part of the duration of the study, transportation was still a problem in view of the large number of personnel and equipment which needed to be transported on a daily basis to sites often very many kilometers from the hotels. This was further compounded by the fact that some groups, particularly the Entomology Group, had of necessity, sites and time schedules very different from that of the of the rest of the Team and therefore required a vehicle all to themselves. 8. CONCLUSIONS AND RECOMMENDATIONS The tVlission was on the whole considered to have been successful. The objectives of the exercise were achieved. However the prevalence of both skin and eye lesions appeared to be relatively low in the communities studied. ln addition, the lvermectin distribution system in the Southern part of Uganda appears to have been quite extensive. Even in the relatively under-served communities, which were selected for study, a good proportion of the population appeared to have received lvermectin at least two-three times within the past few years. The exact figures on this will be available after data entry and preliminary anallsis has been done. The entomology group noted that, from available information on vectors of onchocerciasis in the study area, and the current short term study, it was difficult to conclude whether there is enough intensive fly biting activity and O. volvulus transmission to support the selection of this area for APOC lmpact Assessment evaluation. ln summary it is suggested that to ensure the greater success and efficiency of future Missions, that the following issues need to be addressed. 1. All equipment i.e. both those to be locally purchased or to be supplied by APOC should not only have been procured before the arrival of the Team in the Country of study, but should also have been assembled and tested prior to the 9 lvernrectin Irnpact Assessment - Mrssion Report to Uganda arrival of the team 2. Al least four computers need to be available for the use of the Team. Two to be used as WU Jones machines and two for data entry. lt is therefore recommended that one additional portable computer be purchased for each Team and that two other PCs be hired in each Country for the duration of each study. 3. With regard to the study in Uganda in particular, it is recommended that a 7- day monthly study be conducted by the national entomological team between September and December 1998. ln December the data collection trip will be joined by the external entomologist. From these wet season observations, a decision will be made, as to whether the site is suitable for the evaluation of transmission indices for impact assessment of CDTI. Fufthermore, during this period various samples for vector identification will be collected and preserved by the Local Team, ready for processing and analysis whenever reagents become available. The recommendation above necessitates a request for a small budgetary increase. This is because it is absolutely necessary for the local entomology technologists to get to sites that are remote from public transport routes. The NOTF is willing to provide a motor vehicle, but cannot carter for fuel and oil. lt is therefore requested that the entomology technologists be allowed 7 and not 5 days for the coming, crucial 4 months. This will provide them with sufficient time to reach the out of the way tracks, to trap crabs and also catch flies in the most suitable sites. The terrain is extremely steep and difficult; thus five days will cut the real working days to 2 -3, which is considered insufficient in the absence of other sources of supporting information. Considering that most communities in accessible, onchocerciasis areas of Uganda have been under large scale lvermectin treatment for the past 6-7 years, it is may be advisable prior to the next treatment cycle, which marks f[the beginning of CDTI in our study atea, that the villages of Kagarama, I , llNyabubale and Ngoro be skin snipped to determine current skin mf rates. The I i ffobservation on skin mf rates can then be used as a starting point for CDTI, ij llcomOarable to whatever entomological transmission indices will be observed pre y / lltreatment. 4. Finally, sites selected for the impact assessment studies need to be thoroughly screened particularly with regard to the validation of information provided about endemicity levels and treatment coverage rates, prior to the commencement of impact studies in any site. Iverrnectin Inrpact Assessrlent - Missron Report to Uganda t0 9. ACKNOWLEDGMENT We are particularly grateful to the following individuals and groups for their untiring assistance and support in so many ways during the period of the study: Dr. Hatib Njie, IMr. Kapitaine Khantaway, Mr. Sam Byakutaga, Dr. Richard Ndyomugyenyi, Dr. Josephine Namboze, Prof. Richard Biritwum, the Local Council Officers in Bushenyi, and all the good people of Bushenyi who warmed us with thelr friendliness and cooperation. I am also deeply grateful to all the members of Team Two for their unrelenting hard work and 'Espirit de Corps' and in particular to tVr. Tom Lakwo for rapportoeuring and [/ls tt/ugaba Zakia for the typing of this report. We are equally grateful to Prof. Eka Braide for her untiring preparatory activities for this exercise and for her guidance and motherly support throughout the whole exercise. Finally we wish to thank Dr. fi/oukallia Noma in particular and the r,vhole of APOC management for their cooperation and support and for the opportunity given us to participate in this exercise. Ivermectin Irnpact Assessment - Missron Report to Uganda II 10.' . APPENDICES APPENDIX 1 PERSONS MET . Dr. Hatib Njie . [/lr. Kapitaine Khantaway . [\r'lr. Sam Byakutaga . Prof. Richard Biritwum . Dr. Josephine Namboze . Dr. Richard Ndyoumugyenyi . Dr. David Okello . [Vlr. Richard Womugasho . [Vlr. Twesigye lsaac . Mr. Bamuyaga . [/r. Bitarabeho . 'Mr. D. tr/ugisa SUMMARY REPORTS (Attached) - WR, WHO Kampala - WHO , Kampala - WHO, Kampala - WHO, Kampala - WHO, Kampala - National Onchocerciasis Control - [t/akerere Medical School - District Onchocerciasis Control Coordinator - Bushenyi district. - Chairman Local Council l, Rwemitago - Vice-Chairman Local Council V, Bushenyi district. - Chief Administrative Officer - Vice-Chairman LCl, Nyabubale Village APPENDIX 2 2 Iverrnectin Impact Assessment - Mission Report to Uganda l I Table 2A: IMPACT ASSESSMENT: REVIEW BUDGET FOR ENTOMOLOGICAL STUDIES FROM SEPTEMBER, 1998 TO AUGUST, 1999 (UGANDA). " Technologist will have 7 days/month in the initial 4 months (Sept. - Dec) to allow comprehensive assessment of the vector situation. Transportation Vehicle to be provided by NOTF for 11 months Fuel & oil entomo/Technologist Days Number Total USD $ 1 63 3 2,900 Entomol ist S tston 10 1 500 *Technologist (entomologY) 63 2 3 t 7 BO F catchers 55 2 550 Driver 63 1 1,575 Total USD $ 9,305 ! 4,t