THE DECLINE OF INFECTION MTES SINCE THE START OF VECTOR CONTROL ACTIVITIES: AN ANALYSIS OF EPIDEMIOLOGICAL DATA FOR THE OCP LONG TERM STRATEGY REVIEW Betty Ki rkwood Peter Smi th Tropical Epidemiology Unit London School of Hygiene and Tropical Medicine September 1983 CONTINTS I. INTRODUCTiON 2. DATA ANALYSED 3. GEOGMPHICAL DIVISION OF STUDY YILLAGES Fa ge I 4. RESULTS 4.1 New infections among those born after the start of vector contro'l acti vi ti es (i) Children born between surveys'l and 2 examined at surveY 2 (ii) Children born between surveys I and 2 eramined at surveY 3 (iii) Children born between surveys 2 and 3 examined at surveY 3 4.2 Changes in prevalence and intensity between surveys (i) Villages with 3 or rnre surveys (ii) Prevalence changes between first and subsequent surveys in villages with 2 or more surveys (iii ) Prevalence changes by age and sex between the . first and subsequent surveYs (iv) Intensity changes by age and sex between thefirst and subsequent surveys 6 6 7 lt TABLES I. Geographical division of study villages used to define clusters for analyses of epidemiological dirta Z.gbserved and expected nunbers of children found to be infected at (a) the second survey in a village who were recorded as having been born after the first surveY (b) the second survey in a village who were recorded as hav'ing been born after the first survey but exc'luding ll0 children whose recorded age was inconsistent with i,hem being born since the first surveY (c) the third survey who were recorded as "newborn" at the second survey (d) the third survey who were born between the second and thi rd surveys. 3. (a) "Newborn" children found infected at the second Survey (b) chi'ldren born between the first and second surveys and found - infected at either the second or third survey in vi'llages with three or more surveys. 4. Regression lines fitted tO prevalence changes betxeen surveys in vil'lages with 2 or more surveys. F I GURES l. Map showing the location of viliages and c'lusters 2. Prevalence by date for villages with three or IIDre surveys 3. Prevalences by date for viIlages w'ith three or more surveys: average values for clusters. 4. Changes in prevalences between first and subsequent surveys in each village reiated to the duration of control 5. Comparison of age-sex specific prevalences by duration of control in villages w'ith differing control conditions (a ) C'l us ters 1 , ?, 6 (Good contro'l ) (b) Cluster 5 (Reinvasion) (c) Clusters 9, l0 (Poor control) 6. Comparison of age-sex specific prevalences by duration of control in villages of differing endemicities in areas of good control (Clusters 1, 2 and 6) (a) Hyperendemic (b) Mesoendemic 7. Comparison of age-sex specific intensities of infection by duration of control in villages with differing control conditions (a) Clusters 1, 2, 6 (Good control ) (b) Ctuster 5 .(Reinvasion) (c) Clusters 9, '10 (Poor control ) (APPENDI CES '1. Description of the Vector control situation in each of the l0 vi 1 lage cl usters , bY F l'lal sh 2. Names of vil'lages, their location, dates of surveys and prevalence of infection at each survey for the 143 villages included in the analYsis 3. Changes in prevalence between first and subsequent surveys in eaCh village related to the duration of control. Points relating to surveys in the same vi'llage are ioined. 4. Comparisonof prevalences (and intensities) of infection at each survey by age and sex for vi'l'lages with three or more surveys. -t I. INTRODUCTION In this report we examine the decline in infection rates since vector control activities started as measured by: (i) the number of infections anpng children born since control started; (ii) changes in the prevalence of infection over time in villages in which 3 or more epidemio'logical surveys have been conducted; (iii) changes in the prevalence of infection between the first and subsequent surveys in all villages in which 2 or more surveys have been conductedraccording to the time since vector control activities started; (iv) changes in age and sex specific prevalences and intensities of infection related to the duration of control activities. A preliminary analysis was presented and discussed at a meeting in Geneva, August l5-]9, 1983 with Drs Prost, l,lalsh, Remme, Phillipon, Karam and Grunewald. Various suggestions were made for revised and additional ana'lyses and these have been incorporated into the present report. 2. DATA ANALYSED The analyses have been based on data available by mid-August .l983 from villages 'in phase areas I, II, IIIE and IIIW in which two or more "91oba1" Surveys had been conducted. V'il1ages in which treatment -2- substudies have taken place at any stage were excluded*. Villages first surveyed 4 or more years after control started were also excluded (villages 124, 125, 126), One village was included in the analyses even though the skin snip examinations at the first survey were not made using the standard techniques. It was considered, however, that these results from this vi1'lage (no.63) would be compatible with other surveys (A Prost). 3. GEOGRAPHICAL DIVISION OF STUDY VILLAGES The villages included in the analyses have been grouped into l0 clusters within each of which the vector control situation is thought to have been fairly homogeneous. These clusters were defined by Drs Walsh and Prost from a consideration of the results from entomo'logical surveys only. The cluster definitions are given in Table I and are shown also in Figure 1. Ivory Coast phase IIIl,l was excluded from al1 analyses. A descriptionof each cluster based on the entomological results, due to Dr }.lalsh, is given in Appendix l. Data from a total of I43 vi'l'lages, 66 with 3 or more surveys' were analysed. Thein locations within the clusters are shown in Figure 1. Details of the village names, the dates of the surveys in each and the prevalence of infection found at each survey are given in Appendix 2. * These were villages 22,24,?B (3 surveys) and villages 6,29 (2 surveys). Villages 370 and 37.I (2 surveys) were also excluded since approximately 25% of the population were recorded as hav'ing received treatment at the second survey although these vi1'lages were not coded aS "TR" substudy vi11ages. This percentage is s'imjlar to the percentage treated'in "TR" vi11ages. - 3- i-,;r '. ,c ,rl.'-;:s I i,,r ii-,;r gr".:'r.,iirg ul Li'e il::ri'"t's !':s " fl r-,:de. Ti.ese g.oups are: ,4. a'J ,\ f",.,^S l, 2 .-.,d 6 "i fi -,iiiCh 1-,-,rri.;'f l l'A-c .;r:eJ.1 " jr-rr,ldrr; B. Clrrster 5, a leirrvas'i0n.ireai ,'rrld, C. Clusters 9 and I0 in which control has been "poor". llhen appropriate2vjIlages were also grouped accord'ing to the prevalence of infection prior to the start of control. The categories used for this division were defined according to the age-sex standardised prevalence at the first g1obal survey. Villages with a prevalence of less than 35% were class'ified as "hypoendemic", those with a preva'lence of 35% to 59.9% as "rndsoendemic" and thcse with a prevalence of 6A% or more as "hyperendemic". 4. RESULTS 4..I New infections among those born after the start of vector control activities - Infection rates have been examined separateiy for the fo'llowing groups of children (i) those born between surveys 1 and 2 and examined at survey 2 (ii) those born between surveys I and 2 and e)(amined at survey 3 (iii) those born between surveys 2 and 3 and examined at survey 3. -4- Note that children in group (ii) are a'lso included in group (i) and so the results should not be conbined. They have been presented separately since children found infected at survey 2 wil'l not necessarily be found so againatsurvey 3 and vice-versa. In order to combine these groups without simply excluding the second survey results in villages with 3 surveys it would be necessary to have data on the age and sex specific incidence of both acquiring and losing infections under pre-control conditions in order to calculate expected rates of infection. Such data are not available. (i) Children born between survegs 7 and 2 examined at sutveg 2 4158 children were registered as "newborns" at the second survey and examined for microfilariae. The age of each registered newborn was checked against the interval between surveys for the village. Four "newborns" were found whose age exceeded the interva'l between surveys by more than one year and these were excluded from further analyses*. There were a further ll0 children whose recorded age was suctr that they may have been born up to a year before the first survey. As ages are not recorded precisely in the field surveys (A Prost) it is possible that these children were truely born after the first surveys. Analyses are presented both inc'luding and excluding these l'10 children. * The 4 excluded were a 4 and a 49 year old female. village 139) was positive. 7 year old and 28 28 year old male year old male ( ID l43l 1"4, year oId, 0nIy the -5- l0 of the 4.l54 "newborn" children examined at the second surveys in the villages were found to be infected (Table 2(a)). It is noteworthy that 7 of these children are from villages in cluster I0, an area in which vector control has been relatively poor. Five of these children were from one village (no.l39). Two of the 5 were recorded as 4 years old whereas the interval since the previous survey was on'ly 3 years 3 months and so there is some doubt as to whether or not these were really "newborns". The numbers of children who would have been expected to be infected, if those seen at the second survey had had the same prevalence rates as children of the same age and sex at the first survey, are also shown in Table 2(a). These have been calculated separately for each village cluster. Overall about 107.5 of the newborn children would have been expected to be infected had there been no change in the prevalence rate whereas only l0 were found to be so. Results are shown in Table 2(b) excluding the II0 children whose recorded age at the second survey was inconsistent with them having been born after the first survey. Among the remaining 4044 children 8 were found to be infected against 98.5 expected. Individual details of the "newborn" children found to be infected at survey 2 are given in Table 3(a). ChiTd.ren born between survegs 7 and 2 examined at sur -6- 1494 of those registered aS newborns at the second survey were later examined in a third survey. Two of these children were found to be infected at the second survey but only for one of these 2 was evidence of infection found again at the third survey. Micro- filariae were detected at the third survey in a further two children who had not been found to be infected at the second survey. Details of these children are shown in Table 3(b). 0verall 123..l of the 1494 children born between the first two surveys would have been expdcted to be infected at the third survey' but only 3 infected children were found (Table 2(c))' (iii) ChiTdren born between-Egr 2 and 3 examined at s None of the l25I children born between the second and third surveys and examined for microfilariae at the third survey were found to be infected compared to an expected number of 36.5 (Tab'le 2(d)). 4.2 Changes in prevalence and intensity between surveys (i) vilTages with 3 or npre survegs The prevalences at each survey for the 66 villages with 3 or npre surveys are shown, separately for each cluster of villages, in Figures 2(a) to (h). (There were no villages with 3 or more surveys in clusters 7 and 9). Except in cluster 8, there was a larger decline -7* between surveys 2 and 3 than between surveys I and 2, this difference being rpst marked in clusters 1, ?,4 and 5. The average annual decreases in these two intervals are given in the figures and summarised on Figure 3 which shows an average comparison of the clusters. In this figure the average prevalences and dates of each of the three surveys are p'lotted for each cluster. (ii) Prevafence changes between the first and subse$uent surveys in viLTages with 2 or rpre survegs. , Changes in the prevalence of infection between the first and subsequent surveys in each village have been related to the'duration of control' between the surveys. The 'duration of control' has been defined as fol'lows. For villages surveyed lefore the start of control activities the change'in prevalence was related to the time between the date control activities started and the subsequent survey. For vil'lages first surveyed aftsr the start of control activities the change in prevalence was related to the time between the two surveys. The results are shown for each of the clusters in Figures a(a) to (i). Villages with three or four surveys contribute more than one point to this analysis. For example village 4 in cluster'l contributes 3 points showing the changes between surveys I and 2, I and 3rand I and 4 respectively. The graphs are redrawn in Appendix 3 with results from the same village linked. -8- Anovera]]increaseinthedectineinprevalencewithdurationof control was found in all but cluster 9''The spread of data points in th'is cluster was very srna'll' however (as it was also in cluster 7)' Also shown in Figures 4(a) to (i) are the best fitting linear regression lines re'lating the change in prevalence to the duration ofcontrol.Theestimatesoftheslopesofthe]inesforeachcluster are shown in Tab'le 4' The slope'was significantly different from zero forclustersl,2,4'5and6.Notethattheg5%confidencelimits for the intercept all inc'lude zero showing that these data are consistentwiththeregressionlinepassingthroughzerochangeatthe. start of control' The dotted lines on the figures show the best fittingregressionlinesiftheyareconstrainedtopassthroughthis pointofzerochangeatthestartofcontrol.Inmostinstancethe sorid.rine is lower than the dotted rine after 10ng periods of contror' Thissuggeststhattheannua]rateoffallintheprevalencemaybe lowerintheperiodimmediatelyafterthestartofcontro]thanin subsequentperiods.ThisiSseenmostc]earlyinthosevillageswith threeor.moresurveys(F.igure2)when,inrmstinstancestherateoffa]l betweensurveys]and2waslessthanthatseenbetweensubsequentsurveys. Thepre.contro]endemicitylevelsofthevillagesargindicatedby differentsymbo.ls.Thepatternsofdec]ineapPearsimi]ar. TwodifferentgraphsareshowninFigure4forc]uster2(F'igures 4(b-l) and 4 (b-2))' The groups of points at 34 months and 67 months re.lat.ingtovi11ages7,8,3],32,33,34and35inFigure4(b-1)appearlow ir' . '(' -9- compared to the other results. The linked lines in Appendix 3(b) however show similar rates of decline in these v'i'llages as in the others. These villages were aII seen about two years before control started, which is an unusually iong interval. As trans- mission was thought to have already started to decrease in cluster 2 (Upper Volta II + III) due to climatic conditions and the effect of control to the l,lest in phase I, it might be considered more appropriate to relate the change in prevalence to the tinre since the first survey rather than the start of control in these villages. The resulting graph is shown in Figure 4(b.-2) and the'moved,points in this figure do seem to be more in accord with the other results. It should be stressed that such'ad hoc' changes to data on the basis of resu'lts should be made with extreme caution. For this neason, this adjustment to the duration of control has not been made in the analysis of age-sex specific changes (see beior). (iii) Prevaience changes bg age and sex between the first and subsequent survegs Tlrc changes in the age-sex specific prevalences between the first and subsequent surveys are related to the duration of control between the surveys in Figure 5. The calculations were done separately for each sex and for each of the 3 cluster groups representing differing control conditions. Each graph shows the baseline curve, that is the first - i0 - S,ir'leys af i;tr 0-2 3'*ars, 3-4 years , 5-6 years and 7+ i/e&rs duration of cu;rtrol. These latter Cur"des 'lre each besed oR resul'ts from di f ferent vi'l l ages . They i,ave been adj us i,ed for c'i:;rpariscn ui ih the overall baseline level using. the specific baseline values in their respective vil'tages by calculating "adjusted" age-sex prevalences, for all villages resurveyed in a particular time interval (eg 5-6' years duration of control), as below ; "adjusted" prevalence at resurvey = prevalence at resurvey initial prevalence in these villages x, i ni ti aI preval ence i n a'l I v'i I l ages It can be seen that there is a fairly clear trend of decrease in prevalence in all age-sex groups with increasing duration of control nob only in the areas of good contro'l but also in those of reinvasion and poor control, an exception being among adult males in the last group. These comparisons have been repeated for the areas of good control subdividing vi1'lages according to their initial endemicity. The results for the hyper- and meso-endemic vi'l'lages are shown in Figures 6(a) and (b). The numbers of persons in the hypo-endemic villages were too small to allow this comparison. The trend of decreasing prevalence is present in both these groups but appears more markeij in the meso-endemic villages than in the hyper-endemic ones. - t1 !:9--Jyt:r:*y- -it:q{9-s--.r.g-. 399--*I{ isi*}:;:::gi}e-J*l5l +:g s Ulg:g-*:Il-:s-rJqss Ti,: :i'.,i':s i,r'li-.; .ii-''r-t 51l,0cific ir.'ril'is'il:ics i-'el':rl"e'd to the duration of contro'l are shown separaiely for each cJuster grCIup in Figures 7(a) to (c). Intensity has been measured by the geometric nean microfi'larial count among those infected. The age-sex intensities at the different durations of control have been adiusted in a similar way to the prevalences to allow for the fact that they each are based on different villages by calculating adjusted intensity at resurvey = intensity at resurvey x initial intensity in all vil16ges initial intensitY in these villages The picture is less clear thalr that for preva'lence. In the areas of good contro'I, there is a tendency among those aged more than about 25 years for a decrease in intensity with increasing duration of control, but this is not so apparent among younger persons. This might be expected hovever, dS, in the pre-control situation, persons acquiring new infections, which would tend to be relatively light, formed a significant proportion of the younger age-groups. Thus as the inunediate effect of control would be to eliminate new infections, the average leve'l of infection arnong young positives would tend to be increased, with no light nelJ infections to di'lute it. The constant infectjon rates with age among adults, hcwever, suggest'that the newly infected were a niinority so this effect would not be seen. - ta - i r-r :.:,; , "-. ir.;l i, il i.h;i e .is .: .; l,i'*i of c,.l*irol ;.,-:Jng lilost sge-sex Eroups. .In the i,.i*r'sity ei'ter 3-6 3.r3;/'s of i':'t'rLrol is iii;her all but 25-29 year old fe;r:a'les. As noted above the comparisons at different durations of control are each based on different viliages and adjustments have beenmadeto al'low for this. A clearer picture is obtained if the comparisons are restricted to the sane vi'l1ages. In Appendix 4 the results are shown at each survey for villages with 3 surveys. It should be noted that the intervals between the surveys are not the sane for all the villages and that c'lusters have been combined. Nevertheless there is a clear reduction in preva'lence rate from survey to survey over al1 age groups and in both sexes. Among those aged less than about 20 there is a tendency for the intensity to have increased with each survey. Among the adults the intensities were simi'lar for surveys I and 2 and lower for survey 3. ir",e in Irri..€i'ii X,y xi ;ir'!.,' ..;ii'-.lrl ai'eas of poor corrtrol , holliver, ;i.an the inibia'l lralLres fsr TABLE I: Gr'rographical division of study villages used to define c'lusters for analyses of epidemiological data. The clusters were chosen such that each included villages for which the entomological surveys had suggested that the level of vector contro'l had been s i mi I ar. Cl usterNo. Geographical Area I Upper Volta Phase I (excluding villages .I,19,84,85) + Ghana Phase I (excluding 1?.6, 432) 2 Upper Vo'l ta Phases I I & I I I (excl udi n9 204) 3 Niger 4 Ghana Phase II 5 Ivory Coast Phase I + Upper Volta (l,19,84,85) 6 MaIi Phase I 7 Mali Phase IIIN 8 Togo North + Benin North-West (viIlages 138, 142, 143, 144, 147, 310, 3l'l , 312, 3.l9, 320, 324) 9 Senin East l0 Togo South + Ghana Phase IIIE 'i n : { -J ''. i.,i rl r-- t^c -tr - J -r r-r : jl ! t'r I iag-^ :rl:O ,r',..,1., .r"S Of r-h.ildr,.n iOLnd j.O ,"e,-orCed as having bL.en born be i nfr i *-.:iJ ;1 , after the first Lile ..,.-rl{ s uryey L.,ti' , ty No. ot Ez Exam. tF'q {i O){}.i u o '144 0 4.3gl 0 3.730 C' 30!? o r ,'r .l .lirt,Ooooooo i UTAL Siii O j I. i Cluster Age t-rU a :. 4 ?-t -,: ; Ciuster Age No. o't Ez Exrlm. r., l.:_, t-.r .., U r: TETA,L :,",i . 4 i 6 0 r:,i . I ..,i, .1 liltr- ---' 3 l:.i Jt .,t aa -,- :- ..!a !,, . t', 3irq {. 233 : a]): ilc: i,'ili)] 22u0 0103 0t? rr L' "lir !' iiuUO Tflln', u i ,-iL 1o116 3 '.,b 5 e .tti ') a 4 E l- 7 F .', .i '2.2 5.9 7. t8.4t. o U o ti :: t-; i' U 3.8 II 2 .:, 4 5 & -? I A-7 lr L' L, (i c7C'ct? '- iil,{: (.l On':' O O ,ti i: .Soooooooc't ob(J()oo TOTnt ljn ir .E ? o I :t ! e irI a (r i..il i, -sJut,Ou7 1[)S {} 0 '! t -,ra='..ii4 J:J {r 4E-J Z a-! .36(ri:7{:C*BtlrtFOr]'i TOTAL -,.,,i- i; l: t _r irj r'-63L93c56 1rtCr a3: {i '*t(] (: Lj iii;O TOTAL 3J? T L: E h.? L.5 bE. -l tt (l Lr . .t c -"a t_ - i, '/:' i c' 43 {' J. iii-*, r. r ?;- t.t 3 i, '.t 1 r'. :a -j f. i !- t, !.. {i {, {t cfi. 'i_.. ,- :1 !. {: tJ _1 t TfITAL J t'i !, -i ! .Ll .r.16 5 1 (! (: Jll! 11 1. c &-. Lr 4. .: i.' I i. fr (r I :-1 i. ;? -/ o f: {) i i-; ':UIAL L:4 j.l ,1 J. r+ ;. TI,TAL : -e, -. ! _i * ALL CLUSTERS 4154 IO 107.5 ii I ,l I ir (L a. I;.;, -f!I -:' fr LI ft n io 1 '0 = Observed number of infected children = "Expected" number on at the first survey basis of sex specific prevalence of villages in this cluster at this age ?r cTTTAL TETAL 4r F-d:)J L1&5 0 li,O O f,5 L.' {-!I t-' UL,oooor) rt J ii07 i 670 ,9 C)?,O O ,50 0 JTJ L.' LJ rJO ot UtJ Siit O ?4. i TBTAL TBTAL TOTAL i.^.tj i;O t! !, i-, -;^ tJt Fii, J {)e 66to o{, o o 373 llt l) I L -t I 6 3.9 &i. L 1.d5.87.16.? ., {J o iJ o (t i E 7 BI 3 o J E- :{ tt t, d- s Y o o o IJ o t, o c o U o B (r IJ a 3 4 t 6 7 Ertl "! ul'\ r,vu \JUii li .. - :;pii 'J {-)o{i v t, ra -,, I :. i i:'i at!ir4 O C7tt4 0 4.3 ..56 0 A. I30 0 3.013 s 1.Ooooiios i-t !'t a, oco TBTAL 4gi. ,; I 1. 5 fl I - fi U TOTAL :7ii r., :l s ft t L 3 l) E t, 7 cl L' L il E. a TOTAL TOTAL " . r..- ,: lt4: ?i' r\ o TOTAL -! i.{l ALL CLUSTERS 4f,44 8 98.5 I ABI-E 2 (c ) Observed and expected numbers of children found to be infected at the third survey who were recorded as "newborn" at the second survey Cl uster* Age No. 0 E Exam. Cl uster* Age No. 0 t Exam. o l a -1 ; !1(i T0IAL ;'r " j '' ;''u j E t :- ? r, :, !, TtrTAL L Li j 4 I a ;, I '2 '1c.: .,L -a: TI,TAL ::.:. :-..*l 4 -t c ,1 :' cl TtrTAL al I a 1.C; TBTAL b' TOTAL t: t: ;, 1i' :l ,l .l:-l I I TBTAL TB i4r- * No villages surveyed in Cluster 7 and 9 ALL CLUSTERS 1494 3 I23.I t,r,Bt t 2 l,l) 0bserved and expected numbers of survey who were born between the children found to be infected at second and third surveys. the thi rd Age I;. t -j 4 ;, r_ 1(t TOIAL .i,;- ,: No. 0 Exam. n a' {. {t 4.1 CO16 t 3.4?7 ii 1^o ta.aI'E.ttr i, ,C L' ._, .iic o(, i-: OCOi_lrJ o O Cluster* Age No. 0 E _Exam. TBTAL itl ! t I ? J! T*TAL .,L.7 a. 4 -,, '/o o I {}7 f_; J E, T' {t lt NC (r {r o o4.O U I' ? TOTAL :6;. t ;, cl t f': E -'"t; Lr I, '_ i,l1 i. fi Lt!' IL i rL, :' f .'\ .; = ,. I r-.1-ic,.. T*NJ AL t. lr, $iB T,f,TAL t, j t Cj.-_ .- t i- - L.,: J ';c ir{Jiiaor.r, io I,J?AL ALL CLUSTERS 125.t 0 36.5 *l,lo vi l l ages surveyed in Clusters 7 and 9 a. )',r i i "li:r'r',i,-;rn" ,:lri ldren fr,Jnd i nfected at the second survey 195 * interval between surveys 39 months TABLE 3(b): Children born between the first and third survey in villages with three Endemicity Age Sex mf counts Hyper Meso Hyper Hyper 2 4 3 I F 0, 2 F 0, I l,f 7,14 F O, ? Hyper 2 F 1, 4 3 F 0, I 4* F 0, 2 4* F 29,30 0 F 0, 1 2 F 0, I second survey and found infected at either the second or more surveys Vi I lage Phase Country 7 IIIE IIIE I IIE IIIE UV Togo Togo Togo Cl us ter l{o. 2 l0 l0 IO l3t ts2 .l39 or Viilage Phase Country C'luster No. Endemi ci ty ID Survey Age Sex Mf counts 7 13? IIIE IIIE UV Togo 2 10 Hyper Hyper 142602 143249 *z (+z t3 3 3 ? 3 5 6 6 F M 0, 2 7 ,14 60,64 0' 4 I 3,13 1s2 IC 143281 142202 F MHyper +also appears in Table 3(a) -t: cr) :, ol- -c{-J BOiELL+'lJC oo(Jc .r lts ro CPOL .- cl .^P th ah(l, ^ L..l., be (,).6(l,!o(l,!(, l{- o C'rNo^ r^+) rd b-e x(u(l,+) L(Jo-c(u(uo,gut .-6 (u(l,.6g)!P EO-.6 .E! -ccu= !(t,(u 5goc,uEC-C= .o cloc!(l,ooP(7)(7)c.o,uEo!!ocr(u(l,v, rts .6 ,O -Oo EEf,^{-r@@(u!+t+r+, .6 .6 .tt .o +,EEE a .F .e .rP+'PPU'.V'A ,6(l,(UuJ +++-++ + oq o V o- + + * o o CL + * I )l ; .) \ ,'-) :g f1 <J(\ rot+r+ f\ O \.O =NNJc\l+t+l I orosl'OO GJ Cf, 't+t+l ort C\l Or Or q1llrLf)FC! t+lll (o o lJ) aY) (.o(o c\t c\l C\,1 t+lll c) I orl -o \C)Orf\ .t.r)o\o@l co=r.e +lll sflrr(O@O lf) (\, Lf) c., t+lll OrOr\<fOl cf)Or.o F (\,l+t+r (g f\ f\r.o co$l (f, (, . c\J +ll U'x u, co = =z dIJF v, =Jo @ (f, (\l co r\l o r\ 'NI +ll flJ)r\ rf) (\j|oI cr, (r) . (v +tt r\+(Y) r.ootol or sf . 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"-i ' i -': l-P iltl!ri'ii : I i f -'- 'l l' - a t ailaa o ,iH H i ^lL l\ .t ,: \, 'El ,L \, _t0 Ifol vl -- iil '' -Lr:: -t t)G- Jo .t) .oqB .J ,y c( t)o o uo )o ,cY ,s :. ,Oo -\o , (-a\o o\o GO \ra J ' rr, \t- l ef lt> rO-fr1 -;\J {i or:i JoG,> c4 -3+ b .E eJ- a (l o ,6 * E ") G I t , i t; I ti oIY ii; -l tliI ir --i--i,lrl -!l 'i: trl, 'l r rf, c:- ')o da \o Lrc -r& (Y l)a * t__._ \t ---\' AJ o ----\+ Jo--.---6.! \.o -..-- a-r .-f,- -_-. _ (\l ---- o -:- i' -' - J d :'- -t -- -_ --_ .f -t I : I I | (Zl T 'Lz'-lns t-t71 32va-4 r'rdd N e'Ni? - o- o ; o o cl o lo .r.(;Lrr.(aa\:lu,1 I | , " I ' - l .: f:1& oH 14-- - o- oaao i F 6- Jo .b \, € .t& EY <l- OO\o oo( c/sk G \f tn c.r lt) o .---V) ,i .1 l-.,,r, :, l-,:l't rJi^ :Ja di iferirrg ,:oritrol (a) Clrrsters l, 2, II A LES q w 7o b w 30 lo lo -: o lo lto go la bo !*x :p.'r- iiiC y; ,: i Slir r-'::, coridi ti ons 6 (Good controi ) f n ,],il,r.:s ;.ii.:t Durc.tt;,n ,F crntrol: Base{,L 'o-Qtts 3-1, vs - s-6 firr 7+ 1rs =:--_____:: q P v{, r]- 3 Be o- s- FEtrR le s i5- --... ,:-::,-. : 30-(? trbe,x,)-.'-' t0' t9' U- at' 03e tgeart) I .:(. -a g t -t l} 7 ae {o {$ 3r u lo 0 tol? lu, r-- f; ' ..i;r 5 ri,; i'-.'.,a_siCn) A Pv \Dtl. 3 s a * r)(, u. ? s ,; i _ _3_r+yr5h- .h S -b q"t l, j 1t yee lS - lt- 23- \ i/ -.'I - *.7' - - gr.rtfion of c"ntrel iasd,;'* t';.-\:,' 0- t- ftll.tg5 fl: u, li ii , :J . --j1 ,:1 --"'I s- lo- tt- (F;,Or r-,ii',L.rOl ) tt@ 7o @ 70 Loa rl,F .Y So H2.{' ko s 3o 20 t0 0 Ua 7o to 7o ,\ -- Duratioa at Co"tol t; l/ , // ,/"t,, t Bascti^c 3-+ry5 l-b qrt 1?5 V.ir to- tt- lo- zs- \o-el Agt {3ct'r') f;\.;, $o So -4a 3o LO lo o a tF - t, o rL? s ,/; li r-.\ :, $c t3er^a) i ')- :r+ ,!C- >:..\ : 'li f feri ng :.n;giili c'i t i es (a) Hyperendemic ,,,:r-i f ic 1;rr:'raierices by du, at.ion of in areas of good control (Clusters ,..t;r".,01 in vi11;g,.s of l, 2r 6) loo 1o 80 tT R LES Jo Abo tot-U H50 z &o ot 9o lo t0 l@ 1o t" 7o tto '- dlu 5oII ? to s 3o '. _r. - 0-t 3r5I '!I t' !-o 3rs! ;: s-t!1,s L':' f.r.\i-:' .4"i, gt 1 7+rst: t-t: t: , ..'t.' t l.' 0- 5- lo- Fg rt4LEs 8o lo ls- 20- 25- - ?o-t!-:_-i,- -, - '0+*-, _-_,_ t.t.o^),'-'', j_.*_ ,a- 15 - 2o- LS- 3o'qls-0- .a;r /i1e.o) fft f;' tt)0 1o @ 7o lo 50 l.o 3o 29 l' 0 og, F(,{,L 3 s :_--- -i I :- r",.R\;r ..2) -/ -/- :)- / Ulo lo t, 7o a6ool' Esoll 2 4o s€ 3o ?.c lo FENATES . o- S- $- lS- to- tS- 3o-A'l h.h*) --t' '\:i-* rt*tgJ So+ !: ', .11 , li-lti tr I vi 'l l ages wi th (a) Clusters 3i'ii:X S!;eri'f ic irr'i.ciisi tjes Of jnlecliOn djffering conbrol conditions. l, 2, 6 (Good control) ' by i,r hLirn o{: ,,j;li-r ol in a lool 'e I{l(Lts sol EI&l2l ro{lst?:--{ .o IRI *ml FI?l s sl:lrr, IEl elI rJtstrr, I/"- |i ,l a.'lob .!- a$ €so o rt,Lr o rL ?: ro15 EE Plo ?)o_ z53 la, E ! *. e rl, tsI\lr I i r{ltLES , ,/. 0- r- r?- r!- fs{Ilr-El ./i/;rtil at /- : Durq6.,^ ,t <or.trol: Base lirtc O-lgrs' - 3-4 3rs 5-5 3rs 9r2o- 25-L--' -' -- te tgC"n) la-41 0- t - to- tS - ?e- tS- ls-{.1 Pi; {3*+'r) There were no infected persons in some of and so these poi nts have been omi tted 9+ the yoiinger age-sex grouPs ,-t -]---,---:'::: --i Foo tnote: loo irrAL6Sa-( a 'i 5o ooL vIt32o $? ot clo b .? f3s ? €{, E v c{ E E orl,el I fo 20 lo 5 I I .-e. E Vt E A .l| t- l&tt 3 o ? a Lt F ?3 o zc{,E u dP rl,t0\, 19 /.-.-.' Durr{icn af control : 6a*liru - -:- 3-15's ---::5-b5a 1* y6 5-o- 20- 2s' - b'+1ayly-) =:r;''::-:' 15- b- 2E- .3o-+1 'f,OrAYL6*) infected persons in scme of the youriger age-sex groups points have been omitted FEMALE.5 f .:.: o' 5- fhere ',{ene no and so these Footnote: ;- i: (c) C'l'.r>i."rs 9, 10 (F,:ar r-oii'Lro1) 14ALE' I /r/ ,/ / 2- 00 So ,^l .l- 3 v. LL( a ,bL v u,L 2 $ ?t! G F ?J o \r. ?rt\, E. & t- rD ts-- oo rD 5-o-lJ ;l I ;l I -*t 6 alJ b{,tr ? 15 a Ee tsJ 3 o\J 2t rl, G.t-{,E o{,(S {: lo' l0- 5. 26- ,o-+tAg" LXe-) FEHAL€5 ,t2 t/i/ .-'/ / /*-'! 3D- A ,n 't).'-- / \-- );L--': Duraliora at r*nl,sl.. ga5cUr 3-41ts S-{c 5rr 4a+b- zs- b-+q 44. (-r'u,) s- if- Ai .1 ;lPPti{DIX I : I'I.:,i,,{ii,I'iUI'I OF THE VECTOR C{JTIROL SITU,qTION iN TACH OF THE IO ViLLAGE I]I.U5iTRS by F Halsh* cluster I. upper volta I (excl. I,l9,qt 85) + Ghana I (excl.1?6,432 Control from February 1975. Virtually no transmission throughout except that Village I77 is hear a site with an ATP of a Iittle over I00 in 1975, and with at Ieast some ATP.measurement in most years. 1982 which was good, but not outstanding compared with several otheryears, indicates th'e high l6ve1 of control. For 20 sites IAfp = 63 Xegn = z42o C'luster 2. U.pper Volta II + III (excl. 204) Control since March 1976 and 1977 control in Phase I--. Transmission has except at 2 sites in 1977 which might but whole area strongly .influenced by been virtually zero since the beginning, have i nf'luenced Vi l l age No. 284. . Cluster 3. tliger Control began in 1977. Probab'ly not much influenced by earlier activities, but disease may well have been declining owing to drought since about 1968. gcp control has not been good in this zone, and probably the entomological monitoring is also weak. Vi'llages 229 and 228 are close to a site which has registered ATPs over I00 in 1977, 1978 and 1980. In the last year ATP was 550. Villages 170, l7l are close to a site with ATP a little over I00 in 1977 and 1979. I would expect Hypo to i,leso-endemic type transmission. (Given recent adverse climate probab'ly better than stated.) * extnacled lrom letter to Kirkltood dated 9 Seple;,rber lg83 Al .2 "q-l-irls-Ll *+hltg*II Control from March 1976, but inf'luenced since beginning' Control essent.ially good but.villages in the *orth ir;ere subjected to a local outbreak of vector breeding in'1981 with resulting ATPs over 100 at about eight sites' village I07 is close to a breeding site which causes difficulties in most years. ATPs exceeded 100 there in 1977,1978 and I98l' village 127 is near a site with an ATP 162 in 1978. cluster 5. Ivory coast I + Upper Yolta (l'19'84'85) \ control began-in February 1975. Villages 018, 017, 188-, 189, 184, 185' 186 should all be fairly good, maybe spasnrodic transmission' AII other villages were influenced by 'invading flies until 1979'and subsequently have been subjected to resistant fly populations. Neverthe'less transmission was probably reduced to the hypoendemic type from about 1978. villages situated away from riversareprobablymuchbetteroffthanthoseonriverbanks. Cluster 6. tali I Under control since February 1977 ' Results transmission. Villages 061, 064, 066, '159 are focus which has been under some vector control excellent throughout. No part of the Sikasso or Finkolo since the earlY 1960s. Al .3 Resrrlts have be.:n good since 1977 but area suffers from invading fIies. Thus p,-+bably a i:ig rii i'ferr:nce bel;l;een r"iverine vi't'tages and ot,hers a few km off river. Village ?48 is beside the river while ?47 1s several km off river. Transmission may still be hyperendemic in the former. C'luster 8. Togo Northt Benin North Uest' Control began in March 1977 and has been good. Transmission should be no mcre than spasnpdic. Cluster 9. Benin East Control began in March 1977. Transmission probably spasmodic or possibly Hypo, except at village 330 which is close to a troub'lesome breeding site, registering ATPs over 800 except in 1982 when 382. Cluster 10. Togo South + Ghana IIIE Control legan March 1977. Probably the four northern villages have suffered from Hypo transmission while the 3 lower villages are in an invaded area; However, village 135 is several km from the river. '.r1. I t?r€cu ()ni$ .{lnCt Irl $ $ftI t'.ftr€ o .) .,4 \i-: 1., I:L(J5 ,n o(J+'Eut{ur :rt fU .lJ l: r1-{./| tF o sso 'rO .$, ! rt +J!c50ct (J -to.i, vrG, c, -c, cLo,q,FT'6 cto+rLvt o- o, L+'56 .no .Ooorc,oz, q, vt ag6q, s!. (\I L. +,E =o(J oE a6g 'g E .d oE o(n .U Lo +J V,F oCJZ 0".i"< .r'] r) .f t-O '; N et[! d Fl t ai o <f $ t.t .{l fr@ lfrrf n; NF..tiNt .{t N*[D Ng)N-. nirin ri-inirrtf?fl-r ol(IlN€ (ll-. 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I I II Ii II i I I I r o .9 o I-r =xd, f:IH v) Fl L) cn XHQz Or II I I APPENDIX 4(a): COMP.ARISON OF VILLAGES I'IITH HRLES 0- 5- to- FEiIRLES / PREVALENCES AT EACH SURVEY BY AGE AND SEX FOR 3+ SURVEYSf il J. ^\) '... Surr,rcrl S0 15- ?o- l5- 3o- ?r- 4o- bs'4J. (lears) U-*-/ 0- t- Extracted from 56 vi11ages. to- ls- 20- lt- 30- 3s- 60'6<- So- SS- 6o' \e (gears) preliminary analysis carried out in August 1983 on 6s+ r- loo 5o lo l0 5 a .l J DIX e- \1. I(' a ut Utu(L 3 (5 ? oEft LL 3o\, ? q, E aFtJl o ul() q_ tJ,( A ll,F IUIL 3 (} ? o L € t- ? c o 2t t.lJ L &t- IIJ E o UJ(5 . c. G , APPEN 4(b): COMPARISON OF VILLAGES WITH INTENSITIES BY AGE AND SEX FOR 3+ SURVEYSI XALES {-/ -..c..' ., .7 ;'/ir/ -gu6uc{ I S'rcw{ 2 Sururi 3 0- .'/ // s- to- ls- zo- 2s_ 3p- 35- @- 1,s_ b- sr- 6o_ 6st A3e (ye^ru) FEH R LEs s- lo- lS- 10- 25- b- 35- io- &S- 9- Ss- 6o- 6st fu. (U ears) 0- * Extracted from preliminary analysis carried out in August 1983 ou 56 vi1lages.