Report on the meeting between national coordinators of the Onchocerciasis Control Programme and WHO/OCP: Ouagadougou, 20-23 March 1995

wor{l D IlF.At.]-lI ORG^NIZA]-|ON ORGANISAI'ION MONDlnl.li Dtr LA SAN'I'E ONCHOCI]RCIASIS CONTROL PROGRAMME IN WI]S'T AI"RICA PI{OGRAMME, DI1 LU]TE CONl'l(E L'ONC}IOCERCOSE EN AFRIQUE, DE L'OUEST tTXPER'l' nDVISORY COMMIT'[E Sixtcentlt session Ouaqaclott!.ou. 5-9 Jutte 1995 ocP/EACl6.3 ORICINAL: FRENCI-l REPORT ON THII MEETINC BETWEEN NATIONAL COORDINATORS OF THE ONCHOCERCIASIS CONTROL PROGRAMME AND WHO/OCP Ouagadougou, 20'23 March I 995 l. 2. 3. 4. 5. WORLD HEALTH ORGANIZATION ORGANISATION MONDIALE DE LA SANTE ONCHOCERCIASIS CONTROL PROGRAMME IN WEST AFRICA PROGRAMME DE LUTTE CONTRE L',ONCHOCERCOSE EN AFRIQUE DE L'OUEST REPORT ON THE MEETING BETWEEN NATIONAL COORDINATORS OF THE ONCHOCERCIASIS CONTROL PROGMMME AND WHO/OCP Ouagadougou, 2G23 March 1995 TABLE OF CONTENTS Page TNTRODUCTION I ADOPTIONOFTHEAGENDA ...... I REVTEW OF RECOMMENDATTONS OF THE MARCH 1994 OCP/NATIONAL COORDINATORS'MEETING I REPORT ON VCU MEETINGS HELD BETWEEN MARCH T994 AND MARCH 1995 I DEVOLUTION. ..,,.. 2 5.1. Reflections on discusdons ard decisions of JPCIS concenring devolution, ivermectin distribution and epidemiological qurveillance R€structuring 9f thp OCP Devolgtio4 Unit Devolution activities of the Partidpating Countries 5.3.1. Devolution plans of the P.gtiqipatiqg Countries: Present situation 5.3.2. Activities of the National Onchocerciasis Devolution Comminees (NoDCs) 5.3.3. Onchocerciasis-related devolution activities 5.3.4. Activities related to the othcr endemic diseases included in the devolution plans . 5.3.5. lntegration efforts of the countries framng and retrainlng . . . . . 5.4.1. Fellowships ...,. : . 5,4.2. The Epidemiological SurvLilhnce Support Project (ESSP) and devolution ectivities 5.4.3. Training in epidemiolcigy based on the problem solving modules 5.2. 5.3. 3 3 3 5 6 9 l0 l0 l0 t0 ll ll 5.4.4. Applied epidemiology " bourse for senior health officers (Bamako, Nairobi) 5.4.5.Nationalseminars:;."..j,...........-. 5.4.6. Training in data analysis according to the OCP methodology . . . l2 '12 6. ll EPIDEMIOLOGICAL ACTIVITIES AND IVERMECTIN DISTRIBUTION AS PART OF OCP CONTROL OPERATIONS . . 6.1. Introduction... 6.2. Epiduniologicalevaluations . 6.3. 6.2.1. Original area and C6te d'lvoirc's southern extension 6.2.2. Extension zones (incidence studies) . . . 6.2.3. Other evaluations (Senegal and Mali) Ivernrerctin distribution 6.3.1. I-arge-scale treatment 6.3.2. Management of ivermectin 6.3.3. Different actors Epidemiologicrl research . . 6.4.1. Immunodiagnosis and other tests 6.4.2. Research on macrofilaricides and high doses of ivermectin 6.4.3. Long+erm effect of several ivermectin treatments per year on transmission 6.4.4. Risk of ivermectin resistance and mearu of detection Results of the evaluation of the lvermectln distribution prograrnmes (Guinea, It{ali,Seaegal) ..... ..... t2 t2 t2 t2 l3 l3 l3 l3 l5 r5 l6 l6 l8 6.4. 6.S. 7.1. 7.2. 7.3 l8 l8 t9 l9 l97. 19 l9 l9 20 20 6.6. Modalities of conrmunity treatment ln the countrles DATA ANALYSTS AND INTERPRETATION Epidemiologicalmoddling .. o. o.......... . .... . ... 7. t. 1. Duration of the distribution in zones treated with ivermectin alone 7 .1.2. Duration of combined ivermectin and larvicide treatment Guide for the sureillance and control of onchocerciasis as part of devolution ............... .............. Computer equipment and thelr use ln the Partldpating Countrles . 8. 9. TRANSFER OF RESIDUAL OCP ACTTVITIES 20 8.1. Nature of residual onchocerciasis activitles 20 8.1.1. Medical activities 20 8.1.2. Entomological activities 2l PROBLEMS CONCERNINq THE TRANSFER OF OCP'S ACTTVTTTES 2t , -i- 9.1. Achievements -.oo.....,...o.!.-r..r..o.o...... ........ 2l 9.1.2. Manruls/guidesavailablc ..... 27 9.1.3. Activities already transferred tcchnically 21 ' 9.1.4. logistlcs 28 9.1.5. Financing '..... 2E II INTRODUCTION At the invitation of OCP, the annual meeting between National Coordinators and WHO/OCP was held from 20 to 23 March t995 at the Programme headquarters in Ouagadougou. The meeting was opened by Dr A. Seketeli, Chief of the OCP Devolution Unit and Ag. Programme Director, who welcomed all the parricipants. Present at the opening session were representatives of the I I Participating Countries, of the WHO Regional Director for Africa, of the Expert Advisory Committee, of Helen Keller International (HKI) and the ESSP Project as well as OCP staff members (see list of particiPants appended hereto as Annex l). Dr A. Seketeli asked for a minute's silence to be observed in memory of the late Dr D. Quillevere, former Chief of VCU, before proceeding to the customary courtesies. He recalled the meeting's objectives bcfore thanking the coordinators who had all made efforts to submit their contributions to the meeting to OCP in time. Dr F.K.F. Wurapa and Dr G. Traor€ read messages on behalf of the WHO Regional Director for Africa a{ *. WHO Representativc in Ouagadougou respectively. 2. ADOPTION OF THE AGENDA The agenda proposed by the Chairman, Dr A. S6k6t6li, was adopted without any modification. With a view to the presentation of the joint progress report of the Participating Countries to JPC16 in December 1995 in Washington D.C., Dr L.A. Assogba, Benin's National Coordinator was appointed main rapporteur. Drs J.W. Cabord and J. Amankwa, National Coordinators of Burkina Faso and Ghana respectively, were elected co-rapporteurs. Four OCP staff members were entrusted with lending supPort to the coordinators for the drafting of the rePort. 3. REVTEW OF RECOMMENDATIONS OF THE MARCH 1994 OCP/NATIONAL COORDINATORS' MEETING Most of the recommendations of the March 1994 meeting between OCP and National Coordinators had been implemented. Those which had not been implemented fully were the subject of discussions an account of which has becn given in the different sections of this report. 4. REPORT ON VCU MEETINGS HELD BETWEEN MARCH 1994 AND MARCH 1995 The Ag. Chief of VCU informed rhe meeting of the restructuring of the Vector Control Unit with the replacemeni of the two posts of Chief of Zone by thc posts of Chiefs of Administrative and Technical Services (CAT), the aboiition of the posts of Chief of Entomological Evaluation and the creation of posts of 'CAT assistants" and Coordinator of Entomologicd and Hydrobiological Evaluation (CEEH). He made a brief presentation on the following meetings: meeting of Western and Eastern Zones; Hydrobiologists'meeting; meeting of Ecological Group; AREMT mceting; Insecticide meetinS. The,following points emerged from these meetings: (a) the OCp/Bouake DNA laborarory was functional and carrying out DNA-probe identifrcations of blackfly parasites and adults; ' AREM: Applicd and Rescarch Environmental Monitoring Mceting llt 9.2. Obstacles 9.2.1. Training requirements 9.2.2. Resistance to thc tralxfor process 9.2.3. logistic costs . 9.2.4. Per diem 9.3. hospects: Plannsd timetable for the take-over of residual activities by the Participating Countries 9.3.1. Withdrawal of OCP from epidemiological evaluation and ivermectin distribution activities. 9.3.2. Cessation of VCU activities in the original Programme area and in C6te d'Ivoire's southern extension area. 9.3.3 Western and south-eastern extensions IO. PREPARATIONS FOR THE MIMSTERIAL MEETINC ON PROBLEMS CONCERNING THE INTEGRATION OF RESIDUAL ONCHOCERCIASIS CONTROL ACTIVITIES ,INTO THE HEALTH CARE SYSTEMS OF THE PARTICTPATING COUNTRIES :!, { 10.1. Context of the meeting 10.2. Document to be prepered . . . . . 10.3. Docrnnent drefting committee 10.4. Identilication of portidpants in the meeting 10.5. Date and place of the meeting I l. OTHER MATTERS 12. 'f CONCLUSIONS AND RECOMMENDATIONS ANNEX 34 28 28 28 29 29 29 29 30 30 30 30 30 3l 3l 3l 32 2(b) the Ecological Group's mandate had been expanded to include the study of the consequences of the resettlement in the deserted valleys on the cnvironment and the aquatic ecosystem; (c) with the availability of a scvcnth larvicide, the activities of IRU/Bouake woutd be timited to the evaluation of new formulatiors of &1. H-14, quality control of the larvicides used by the Programme and verification of the susceptibility of the blackflies to the different products; (d) after analysing the entomological and epidemiological results, it had been decided ro srop larviciding and intensify ivermectin coverage on some basins in 1995, i.e., the Alibori, the Sota, the Kulpawn and the Mole in the Eastern zone; the Baoule and the Bagoe (with the exception of the Kankelaba) in the Western zone. 5. DEVOLUTION 5.1. Reflections on discussions and decisions of JPCf5 concerning devolution, ivermectin distribution and epidernlological surveillance Referring to the document 'Concept Paper on Devolution" (JPC.lSflNF/DOC.6, presenred to JPCI5), Dr A. Seketeli rccalled the definition of the devolution process as being the transfer by OCP ro the Participating Countries and the take-over by these countries of residual onchocerciasis control activities (Devolution sensu stricto). He also recalled: -', the strategy for the implemcntation of residual oncho activities: Information/Education/Communication (IEC); epidemiological surveillance of sentinel villages; chemotherapy (ivermectin treatment) ; - the approach adopted by the coururies for a sustainable action based on this strategy (multidisease surveillance and integration); - the role of the different actors in the implementation of the devolution process. Annex 2 summarizes the different points of this presentaaion. He then presented a series of criteria for assessment of the ability of the Panicipating Countries to carry out efficiently the detection and control of recrudescence of onchocerciasis as well as the conditions to be met in order to increase the chances of success of the devolution process (see Annex 3). The recommendation in the report of the EAC Mid+erm Prospective Evaluation approved by JPC15, stipulating that all OCP financial support to ivermectin distributionand epidemiological surveillance should cease by the end of 1997 in the OCP area led to discussions at length during which all the Coordinators clearly explained the diffrculties the countries were having in finding the resources required for these activities. Furthermore, should ivermectin distribution be intemrpted after 1997, the Programme would sec iself deprived of one of the strategies at its disposal for the attainment of its objective. The meeting therefore expressed the wish for the EAC to recorsider its position concerning the continuation of OCP's financial and logistic support to the countries beyond 1997 in these fields of activities (ivermectin distributionand epidemiologicd evaluation) and kindly make another recommendation to the JPC on that subject. An explanatory note was prepared by the meeting on this important subject and is appended hereto as Annex 4. 35.2. Restructuring of the OCP Devolution Unit The Chief of the Devolution Unit presented the Unit's present organization chan (Annex 5a) which comprises two zones (East and West) and the revised version for 1996 (Annex 5b) which envisages the rrrcrger oi three current Units (DEVO. BIS and EPI) into one unit, the Devolution Unit, whose structure comprises four sections, viz.: - Biostatistics and Operational Research - Epidemiological Evaluation, Diagnosis and Treatment - Entomological Activities - Integruion. This last-mentioned section had been created in order to stimulate and support the countries in &eir efforts to integrate residual OCP activities into other health care activities. 5.3. Devolution activities of the Participating Countries 5.3.1. Devolution plans of the Participatine Countries: Present situation Table I shows the present situation of the devolution plans of the elevcn Participating Countries: Table Presentation of the devolution plars of the Participating Countries March l99O Plan reviscd and finalized New'plan finaliud Country Date of finalization Diseascs combined with Onchocerciasis Cost per 5 years Beninl June 1993 - African Human Trypanosomiasis - Schistosomiasis 635 985 887 FCFA Burkina Fasot April 1992 - African Human Trypanosomiasis - Dracunculosis I 6t0 884 2s6 FCFA Cdte d'lvoirct April 1993 African Human Trypanosomiasis Schistosomiasis Dracunculosis 976 660 630 FCFA Ghanal July 1993 - Dracunculosis - Malaria - Lcprosy - Yaws 3 r97 000 us$ Guinea August 1993 African Human Trypanosomiasis Schistosomiasis 7 483 49r USS Guinea-Bissaur April 1992 - Schistosomiasis - Malaria 4 477 t09 US$ Matil Oaober 1993 - African Human Trypanosomiasis - Schistosomiasis I 005 054 703 FCFA Nigerl November 1994 - Schistosomiasis - Dracunculosis 7s5 273 073 FCFA Senegal2 Septembcr 1994 - Schistosomiasis - Dracunculosis 550 953 375 FCFA Sierra Leone2 July 1994 Schistosomiasis Malaria Leprosy Tuberculosis 8 333 303 US$ Togo' April l99a - African Human Trypanosomiasis - Schistosomiasis - Dracunculosis 833 2r6 779 FCFA 1.2. Activities of t (a) State of olliciat acts establishing the NODCs To date, national devolution committees had been officialty established in Senegal, Burkina Faso, C6te d'lvoire, Chan4 Mali, Niger and Togo. Oflicial texts for their crcation were in the process of being adopted in Guinea, Guinea-Bissau, Benin and Sierra Leone' o) Financial contribution of the states to devolution activities Apart from sataries and contributions in other forms the value of which is certainly considerable but whose calculation is complicated, all the countries wene participating in the financing of the devolution activities. Tcble 2: Finenciel contribution of the ltete3 in l99d and estimetc for 1995 j. Country Stete contribution in 1994 Estimate for 1995 Benin 2,910,000 cFA Burkina Faso' $ 16,857 C6te d'lvoirc $ 72,000 Chana $ 34.367 Cuinea $ 13,764 Cuinea-Bissau s 4,773 Mali $ 19,064 Niger 9,270,000 FCFA Senegal Sierra'l-eone $ 33,334 Togo $ 4,700 TOTAL ' Burkina Faso's plan is being financed with a Government loan from the World Bank (c) Mobilization of extemat resources for devolution - Financing of the devolution plans All the participating Countrics had submitted their plans to the World Bank for frnancing' So far' only Burkina Frso,s pr* t ai bccn financcd bt th; worrd -r* rvhich had arso announced the forthcoming fin*cing of the devolution plans of Guinea' C6te d'tvoire and Senegal' Mali and Niger had prepared integrated annual plans of action which had been submitted to the Nethcrlands and the World Bank for financing' The NGo, HKI, had contributed to rhe financing of the lEC/onchocerciasis component of the plans of Burkina Faso and Nige., *"n1e thc pHoEgus rouniation had expressed its intention to finance the 6strengthening of health facilities, cpidemiological evaluations and staff training in Niger's onchocerciasis zones. - Support by OCP Exccptionally, in 1994, OCP financed the monitoring of sentinel villages in Cote d'lvoire and Ghana and the complementsry evaluation in the Bougouriba basin (Zoulo area) in Burkina Faso. It gave logistic support to the Mati, Togo and Niger teams for the surveillance of sentinel villages. . WHO/AFRO WHO, through the AFROPOC budgeS, was supporting the organization of national'training seminars, epidemiological surveitlance of sentinel villages and community ivermectin treatment. The Nationat Devolution Committees wene making bilateral contacts in search of other sources of financing for their plans. (d) Other activities of the NODCs Burkina Faso's NODC had organized the first review wortshop on its national devolution plan. Ghana's NODC had established Oncho Comminees in four districts of the forest area outside OCP and undertaken an evatuation of the epidemiological situation by the method of rapid epidemiological mapping of onchocerciasis (REMO). With the support of OCp, Senegal's NODC organized a working visit for the key district teams in the onchocerciasis programme area and officially launched community ivermectin treatment in the Tambacounda area. Mali's NODC had decided to prepare a devolution document which would take into account the socioeconomic development aspects in the onchocerciasis-freed zones. Alt the national devolution committees had continued to raise the awareness of the political and administrative authorities and of the populations concerning the onchocerciasis control programme. 5.3.3. Onchocerciasis-related devolution activities 5.3.3.1 . InJormotion' Education 'Commwication (IEC) IEC constituted the basis for the success of devolution activities. The meeting welcomed HKI's initiative to help Burliina'Faso and Niger to establish IEC programmes in the onchocerciasis zones. The other coordinators exprcssed the wish to get the same rupp"rt for this important activity in their respective countries. (a) KAP (Knowtedge, Attitude and Practice) surveys KAp surveys on onchocerciasis werc conducted in Burkina Faso and Niger rvith the support of HKI' These,KAp surveys l"O,o the prcparation of educational materiats on onchocerciasis which had been tested ;iliil.i. inJ L"i"r"g oitruin"o in the use of these materials was undeflaken through national seminars' (b) Awareness-raising activities carried out The natiorral teams, the VCU teams and the other actors in the fieltl rcgularly carricd out IEC Bctivities. using diflerL.*r conrnlunication techniques md infonnation aitls and nratcrials avililable (talks/cliscussiorrs' rnaiorrv prograuilnes. filur shows ort ottcltocerciasis. postcrs)' f(c) Irnpact The inrpact of the IEC was perceptible at all levels through a greater communiLy mobilization with a high rate of participation in the ivermectin distribution and epidemiological evaluations campaigns. A greater and grcater number of village volunteers .rvas also being noted in the different onchocerciasis control activities as well as an increasing involvement of the authorities in these same activities. Development companies were continuing to bear the cost of ground larviciding in order to control the nuisance at some sites of socioeconomic importance in Mali and C6te d'lvoire. 5.3.3.2. Epidemiological surveillance of sentinel villages: review ol the situation The map anached hereto as Annex 6 indicates, among other things, the zones eligible for active epidemiological surveillance in those parts of the original Programme area freed from onchocerciasis. So far, a minimum of 253 sentinel villages (Annexes 7a and 7b) in the oncho-freed zones of the original area had been selected to be monitored periodically, once every thrce years, through epidemiological surveys using skin snip. During the past three years (1992, 1993 and 1994), 175 sentinel villages had been the subject of a parasitological evaluation including 83 in 1994. Table 3 summarizes the resuls obtained in the 175 villages evaluated. ln almost all these villages, the rcsutts were excetlent, with prcvalence rates ranging between 0 and SYo and CMFLs2 trelow 0.5 mf/s' eveqrwherc. I 2 CMFL: Community microfilarla load ' 3 Mfls: Microfilariac pcr skin sniP Ili ,l v o\ o\ dc >EU- o9o oq o o\q o oq o t\q o aoq o o Ioq o t- <? oI(.lq o () .E' C) oc\cN cro-E? OHAEttLco- s(n r- o q o 6ttq o a a! Iq o f1 \oq o rn at\ o t eo a -q o , rg .cl z'; (\l c! \o (\l \o o ti € o\9 JLC >E(J- t .1 oIoq o 6q o oq o otoq o o\ .! o Ioq o o c.l oIoq o @ .1 oIoq o \o o q o I !o(, N(.) s Uo\ cr6(l,EAE sE_(r) a!C q o q \o Iq o .1 Iq o c.r Io o d-t \oq o cq o\ aq o € 6l ol I :8 ctS o o o o N €r (\ o.o\ dc >E(J- @q oteq o s c1 aIoq o c'l c! o oq o a EoG)NO .q 6o\ ddt)EiEsb- v, \o ao o q q o (\l t\iq o I a I o;o .(l' z; o\ 9 o o o e l+tt L 6-o= ao () o ,I G, i: =ca .: t DT' z C' .= o !() .o(.) C' CI (J o oooF tr cqJ ca (l oF o Cl, ' (lld * r( J2 o o ' 9 (,L ao c, !D ct I e ra o c,Itr 6l c,t o GII c,0 E c, h. I GF 9['lowever, the 1994 evaluations revealed prevalence rates of more than l0% in two villages: Tchrion rhe Ori Pendjari in.Togo (raw rate of 10.87"\l Zoulo on (he Bougouriba in Burkina Faso (standard rate of 10.7%). The results on the Bougouriba led to a complementary investigation in l5 villages around Zoulo in February-March 1995. Among the 180 positive subjects detected during this complementary evaluation, 29 were less than 20 years old while three were 4, 6 and 8 years old respectively and knew norhing about migrarion. A more indepth analysis of the data was being made and the national coordination offrce had planned to carry out another evaluation in order to better circumscribe the zone ar risk and possibly establish large-scale ivermectin treatment. All these resulrs in Togo and Burkina Faso will be validated as soon as possible through quality controls on the national technicians, to be made by WHO/OCP. 5.3.3.3. Ivermectin treatment (a) Passive treatment From March 1994 to February 1995, 84,581 persons were treated passively with I19,558 ivermectin r:rhlers. represenring about 4. l% of the total numbcr of persons treated (all strategies combined). These 6gures had been underestimated, considering that not all the centres had sent their treatment reports. (b) Treatment of positive cases detected actively During the epidemiological evaluations in the sentinel villages in 1994. about 400 persons detected rvere treated with some 600 tablets of ivermectin. 5.3.3.4. Ground larviciding (a) Against blackfly nuisance Trained narional team technicians and villagers canied out ground larviciding in some sensitive zones where blackfly nuisance posed problems (Mdi, C6te d'Ivoire, Ghana, Togo, Benin and Niger). In view of the high cost of the operation and the risks of resistance, ground-iarviciding should be selective. Ir should be instituted only when blackfly bites had become unbearable and could jeopardize development projects. Training in this technique should be continued and IEC intensif,red in order to sensitize the authorities and populations to the return of uninfected blackflies after the cessation of larviciding. (b) To interrupt transmission Ground larviciding aimed at inrerrupting trarsmissionwas mainly carried out in the Dienkoa (Burkina Faso) and Niger (Mali) basins throughout the year and in thc Sota (Benin), lower Bandama (C6te d'Ivoire) and Kulpawn (Ctr"*) basins in the dry season. On the other river basins still under aerial larviciding' ground larviciding was carried out ils and when necessary as a support. Ground larviciding carried out by @P in the original Programme area would cease latest in 1998. Ivermectin disuibution would be carried out inrensively for the attainment of OCP's objectives in the zones concerned. 5.3.4. Activities related to the other endemic diseases included in the devolution plans The endemic diseases, such as dracunculosis, African human trypanosomiasis, leprosy, tuberculosis, schistosomiasis, malaria and yaws. were the subject of a more or less satisfactory active and passive epidemiological surveillance in most of rhe Participating Countries. Only Burkina Faso whose devolution p-lun ** being financed was able to plan and carry out in concrete terrns an active and passive surveillance Lf tryp*oro*i"rir, dracunculosis and onchocerciasis. The preparation and implementation of a :10 multidisease surveillancc prograrnme liid come up against the difficulty of an absence of a joint prograrnme for the control of the endemic diseases and the weakness of the national health systems. Togo carried out an investigation on three suspected cases of trypanosomiasis reported by GTZ (German Cooperation). These cases were not conlirmed. C6te d'lvoire had trained 192 community health workers (CHWs) and two nurses as part of trypanosomiasis control. These CHWs enumerated 60 043 persons and 24 344 filter-paper blood spots were analysed. Out of 402 seropositives, 34 patients were confirmed. It had planned to establish a laboratory costing 2 500 000 FCFA for the diagnosis and monitoring of trypanosomiasis patiens. Senegal made a joint review of community treatment and dracunculosis eradication activities. In general, national expertise for carrying out control activities against the endemic diseases combined with onchocerciasis in the devolution plars was insufficient. 5.3.5. Inteeration efforts of the countries This integration was already bcing done at thc district and community levels because the resources were limited and the field staff were being used jointly by the different programmes. It was mainly at the central and regional levels that there were still problems because some of the programmes were vertical in nature. The Paniciparing Counrries were making progress in the integration efforts, particularly through integrated training prograrnmes. The health workers in the onchocercal zones were participating really in the onchocerciasis control activities (epidemiological evaluation, ivermectin treatment, ground larviciding for nuisance control and, particularly, IEC campaigns). Generally speaking, all the Participating Countries were gradually integrating onchocerciasis control into the national health system based on the implementation of primary health care (health district). All the countries had started carrying out epidemiological evaluations of onchocerciasis and/or ivermectin distribution as well as evaluatioru of other endemic diseases (schistosomiasis, dracunculosis, yaws) and surveys on non-onchocercd blindness. ti was notd that, with regard to the diseases to be integrated, such as African human trypanosomiasis, ir was necessary to train staff as a matter of priority and have drugs available for the treatment of patients. 5.4. Training and retraining 5.4.1. Fellowships - OCP had continued to award fellowships, laying emphasis on training in epidemiology and public healrh in training institutions in rhe African Region. The number of nationals of the eleven Participating Countries who had benefited from OCP fellowships in the different devolution-related fields, from 1974 to March 1995, was 433 (see Annex 8). .- Ghana's National Coordinator who received a WHO/AFRO fellowship hnished his training in public healih in Septcn.rber 1994 in the United Kingdom. 5..1.1. Thc Epidenrioloqical Sun'eillance Support Prdect (ESSP) and dcvolutiorr activi(ies llurkiru Fasl. Core d'lvoire. M:rli anrl Nigcr had hcnetitcd l'rottt thc trrtittittg givcrr lr1' ESSP. il In Burkrna Faso, [4 new lreads of l-lealth lnformation and Epidemiologrcal Surverllance Ccntres had becn trained. There were l3 ESSPcentres (EpidemiologicalsurveillanceCentres) in Mali and 28 in C6ted'Ivoire. Niger had completed the training cycle in the eight regions, two of which form part of the onchocerciasis zone (Tillabery and Dosso). It had been planned to inaroduce the "Oncho" module in the fourth ESSP training phase which will start in September 1995 in Burkina Faso and C6te d'lvoire. The problem of issuance of certifrcates at the end of the ESSP training w:rs discussed during the rneeting. It was reported that negotiations were being held on that subject with the institutions concerned. The participants recognized ttut the ESSP training was appropriate indeed for the "Devolution" conrext because it was aimed at personnel working at the peripheral level who, right from the beginning, are provided with computer equipment for data analysis with a view to decision-making. The 'DEVO-ONCHO-ADB" training project which is a training project in operational epidemiology and management for the eleven OCP countries, based on the ESSP methodology, should, if financed, allow the countries which had not yet benefited from the ESSP training to get it and those which had got thc first trainings to benefit from an extension. 5.4.3. Trainine in eoidemiolosy based on the problem solving modules WHO/AFRO was continuing to support the countries in the organization of training in epidemiological surveillance of the target diseases at the health district level. Training workshops for trainers based on the "problem solving" modules were organized in Togo, Niger, Burkina Faso, Mali and C6te d'Ivoire. It was highly recommended that the other countries should follow the example of Togo which was carrying out regular training of district health personnel based on the ten "AFRO" epidemiology modules. OCP was conrributing financially to this training in Togo and was ready to do the same for the other countries in accordance wirh the instructions given three or four years ago by the Regional."Director to WHO Representatives in these countries. 5.4.4. Aoplied epidemioloey course for senior health officers (Bamako. Nairobi) In conformiry with its training policy centred, among other things, on epidemiology with a view to guaranteeing rhe success of devolution, OCP financed the participation of the Coordinators of five countries (Benin, Mali, Niger, Senegal and Togo) and the Deputy Coordinator of Guinea in the applied epidemiology course for senior health officers in Bamako. WHO/AFRO financed the participation of Burkina Faso's Coordinator in this course. The Coordinators proposed that the modules be revisd and that an informatics component bc added to the curricula of the Bamako course. The meeting was informed that the Bamako applied epidemiology course for senior health officers would now be held every two years and that of Nairobi was still functional. Ghana's Deputy National Coordinator benefited from an applied epidemiology training in Nairobi financed by WHO/AFRO. t3 The results oI thesc differcnt evaluattons were discussed during tlre lneeting on "Operatronal Rcscarclr and Strategies" held in Ouagadougou on l6 and t7 March 1995. The meering's reporr gives <1crails on rhc results of these epidemiological evaluations as wett as the ensuing decisions concerning tarvicicling cessation. 6.2.2. Extension zones (incidence studies) The preliminary results of the incidence studies which had been going on since t992 in seven villages in the Milo. Niandan. Mafou and Sankarani-Dion (Guinea) basins showed a rlro incidence rate. Sintilar studies were being carried out in C6te d'lvoire, Togo, Benin and Sierra Leone. 6..2.3. The Gambia basin, which had been treated twice pcr year with ivermectin for the pasr five years, was the subject of an epidemiological evaluation 12 months after the last treatmenr. No infection was detected among children aged less than five (never treated with ivermectin); a decrease, ranging between 7l .2 and 93.8%, was noted in the prevalence rates. A quality control bctween the microscopists of the national team and OCP showed good concordance of the results of the twb groups of readers. The meeting recommended that the results of this evaluation be published. In the Bakoye basin in Mali, treated solely with ivermectin once per year for five years, rhe evaluation nrade without quality control also showed a zero incidence rate. Similar studies would be carried our in the Koulountou (Guinea) and Rio Geba (Guinea-Bissau) basins with quality control. 6.3. Ivermectin distribution 6.3. l. Larqe-scale treatment Large-scale treatment was being carried out either by the mobile teams supported by OCP or by rhe conrmunities supported or not by NGOs. Tables 4 and 5 below suinmarize. respectively, the results of the large-scale ivermectin distribution and the overall results (all modes of treatmetrt combined) of the ivermectin trearmenr carried our during the past Perid (March l994-February 1995). Annexes 9 and l0 illustrate rhe same resulrs. presenring their trend during the pa3t four years (1991-1995). t2 5;4.5. National seminars All the Participating Countries regularly organized national training and/or retraining seminars for rhe different actors in the field (medical officers, peripheral health workers, teachers, workers in other sectors, etc.). The themes developed were mainly related to IEC and different aspects of the surveillance and control of onchocerciasis and other endemic diseases. The meeting encouraged this type of training with a view to making the national teams more effective. 5.4.6. Trainine in data analvsis according to the OCP methodolosy OCP had continued the training of some Coordinators and their collaborators in informatics and analysis of epidemiological evaluation data in order to consolidate the achievements of 1993. The Coordinators of Burkina Faso, Benin, C6te d'lvoire, Senegal, Niger and Mali and the EPI chiefs of the national teams of Mali and Guinea participated in the 1994 consolidation sessions. Two technicirns from rhe national teams of Cdte d'lvoire and Niger attended introductory courses in informatics and data entry. The Executive Director of Ghana's Nationat Onchoccrciasis Secretariat attended a refresher course in word processing and the use of spreadsheet. In February-March 1995, the new National Coordinators of Ghana, Sierra Leone and Togo were also given an introductory training in informatics and data analysis and were briefed on OCP's activities. To close this chapter on "Training and retraining', it should be noted that all the participants stressed the need to strengthen the training of intermediate and district-levelpersonnel in order to make the national teafirs more independent. 6. EPIDEMIOLOGICAL ACTIVITIES AND IVERMECTIN DISTRIBUTION AS PART OF OCP CONTROL OPERATIONS 6.1. lntroduction The activities reviewed in this chapter by the meeting are taking place in the zones where OCP is still carrying out irs control operations. These zones (western, southern and south-qstern extensions and "Utatk .po6" in the original area) are therefore, for the moment, not the scene of devolution activities. strictty speaking. However, att the activities there are undertaken either almost exclusively by thc national reams (ivermeciin distribution) or with a strong participation of these teams (epidemiological evaluations). This technical take-over of OCP acrivities in these zones by the nationals is an important step towards the transfer of residual onchocerciasis control activities to the Panicipating Countries. HowQver, for clarification purposes, it should be emphasized that devolution will assume its meaning in these zones only when OCp dlfinitively ceases its actiiiries rhere, as is the case today in virtually the whole of thc original programme area. In the meantime, WHO/OCP's technical, logistic and financial support to the control opeiations in these zones is being, and should be. continued up to the attainment of the Programme's objectives (see Annex 4 also). 6.2. Epidemiological evaluations 6.2.1. Orieina! area and G6te d'lvoire's southern extension lEpidenriotogical evaluarions were carried out in some river basins in rhe originat area and in C'ire d'lvoire.s southern extension area: the Baoule and the Bagoe in Mali. the Marahoue in Cdte d'lvoire, tlte Kulparvn in Ghuna. the Sota in Benin. A conrplenrentary ev;rluatiott was tttadc in tltc Dicllkoa in llurkirra Faso. Actors No. of villages Census population Population treated Coverage rate % No. of tablets Mobile teams/OCP 8,892 1,884,1 l0 I ,360,341 72.2 t.696.230 Communities, National Teams and NGOs 1.680 760,398 597,959 78.6 939.379 TOTAL t0.572 2,&4,508 r,958,300 74.1 2,635,609 l4 Table 4: Summary of large-scale ivermectin distribution according to the actors in the OCP area: , I\Iarch l994-February 1995 Table 5: Summary of ivermectin distribution in the OCP area (March 19921-February 1995) N{ode of treatment No. of villages Census population Population treatd Proportion of treatedltotal % No. of tablets Mobile teams/OCP 8,892 1,884,I l0 r,360,34r 66.6 t,696,230 Conrnrunities NGOs r,680 760,398 597,959 29.3 939,379 Other treatments (passive) and cases detected actively 84,981 4.1 r20,158 TOTAL 2.0/'3.281 r00 2,755,767 l5 In Ghana's forest area. which is outside OCP, the NGO Sight Savers was supporting communiry ivernrectin distribution. In that zone,62,2l I persons were treated with 98,961 tablets. In all, 2,105,492 persons were'treated with some 2,854,728 tablets in the eleven OCP Participating Countries (including Ghana's forest area which is outside OCP). 6.3.2. Management of ivermectin All the eleven Participating Countries were using the same procedure for the acquisition of ivermectin from OCP. The national coordination offices, in turn, provide supplies to those involved in ivermectin distribution in the countries (NGOs, health centres, private institutions). The requirements for large-scale treatment by the national teams were expressed satisfactorily while for community treatment there were still some problems. The annual requirements were calculated by OCP according to weight. The estimation of the doses in rhe field according to height and even age therefore created a temporary shortage of ivermectin in 1994. To avoid this situation in future, and better standardize the method of estimation of requirements, it was recommended that height be used on the basis of the different proportions chosen for a standard population according to a srudy carried out in Nigeria (see Table 6 below). Table 6: Method of estimation of ivermectin requirements using height Height (cm) No. of persons No. of tablets 90-t l9 13% of X = A Ax0.5=Yl r20- r40 18% of X : B B x 1.0 : Y2 r4t r58 34%ofX=C Cxl.5:Y3 159 and above 35%ofX=D Dx2.0:Y4 Population eligible for treatment : X X : 83% of census population Total No. of : Y :Yt+Y2+Y3+Y4 tablets 6.3.3. Different actors The differenr actors in ivermectin distribution are: OCP. national teams, NGOs, private institutions and village communities. Table 7 below gives the list of NGOs involved in ivermectin distribution in the OCP area. t6 Table 7: NGOs involved in ivermectin distribution in the OCP area Organization Country Mode of treatment BMRC Sierra Leone t:rge-scale treatment by mobile teams CBM LUNSAR Sierra Leone Large-scale treatment by mobile teams CFAR Mali Community self-treatment oPc Senegal Mali, Guinea Community self-treatment PhilAfricaine Suisse Guinea Passive Sight Savers Sierra l-€one, Mali, Ghana, Guinea Community self-treatment GTZ Togo Passive and community BMRC CBM CFAR orc GTZ British Medical research Council Christoffel Blinden Mission Centre de Formation des Animatrices rurales Organisation dc la pr6vention de la c6cit6. German Cooperation The Nationat Coordinators were asked to give, henceforth, the rate of panicipation in the ivernrectin rrearmenr. Likewise, they should inform OCP very early of the programrning of con'mruniting treatment and of ivermectin requirements. 6.4. Epidemiological research The search for a new, more sensitive diagnostic test well accepted by the communities and easier to handle was of special importance to the devolution process. 6.4.1. Immunodiagnosis and other tests - Inununodiagnosis Immunodiagnostic research was carried out on 1200 samples taken in Burkina Faso and Niger' (freed zones) "nd Gh.n" (area with trarsmission). Samples were taken also in Guinea. particularly on a cohort of 5-15 years treated only once with ivermectin. A second antigen, C2?, had also been tested in parallel with the tri-cocktail. The following crireria had been established for decision-making: optical density (O. D. ) > 0' 179 for the tri-cocktail and 0.274 for the C27 antigen. l7 - Seroprevalence s l0% = no infection or non-alarnrrng infection - Seroprevalence = ll% = borderline - Seroprevalence >.12% = high risk of infection Using those criteria both for the tri-cocktail and the C27 antigen, the following results were obtained (Table 8). Table 8: Summary of the results of the immunodiagnostic tests Sero-prevalence <10% n% > t2% CountryA/illages No transmission Borderline High risk of transmission Burkina Faso r (8) 7 I 0 Area of no transmission Niger (3) 3 0 0 Area of no transmission Ghana (s) I 0 4 Area with transmission Guinea (8) 4 I 3 Treated only once with ivermectin * ( ) nurnber of villages tested Tlie preliminary results were encouraging and their analysis was continuing. There was very close agreemenr btween the tri-cocktail antigen and the Q7 antigen. Although no test was operational yet in the field, these tests could be [seful to devolution since skin snip was being accepted less and less by the communities. Furthermore, skin snips lose their senlttivity if the skin 'fmicrofilarid loads are too low. - Diethvlcarbamazine (DEC) Patch Test This srudy was carried out in five villages in the Bui area in Ghana. DEC powder mixed in 2% 'nivea' solution was applied on the two iliac crests and covered with a dressing. The reading of the skin reactions was to be made at intervals of 8, 12, 24 and 48 hours after the application. The l2-hourly reading was climinated because it was impracticable in the field. The results (skin-snip sensitivity and specificity) have been summarized in Table 9 below: Table 9: t8 Summary of DEC Patch test results Readings after 8 Hours 24 Hours 48 Hours Sensitivity t4.t% 37.2% 75.6% Specificity 88.r% 82.6Vo 8t.28% Predictive value (positive) o.29 0.43 0.59 Predictive value (negative) o.74 0.79 0.90 The prevalence of infection used in the calculation of the predictive values was 26.3%. As the above Table shows, the specificiry was high (81-88Vo)but the sensitivity was very low except for the only case in which the reading was made after 48 hours, which is not practicable under the working conditions in the field. 6.4.2. Research on macrofilaricides and high doses of ivermectin The discovery of a rnacrofilaricide would be beneficial both to OCP, whose strategy would then be modified, and to the devolution process in the countries. Amocarzine was now in the phase of last trials at the OCRC (Hohoe) in Ghana. If the results of rhe trials proved satisfactory, it would be desirable for this product to be utilizable at least clinically if it could not be used for large-scale treatment. Highdose ivermectin (800 pglkg) trials had shown that they did not cause unbearable side- effects. The srudies were being'continued with a view to knowing whether these high ivermectin doses could have an effect on the adult worms. 6.4.3. lnng-term effect of several ivermectin treatments per year on transmission. Treatments carried out several times per year (two-to four times per year) were in progress in some river basins with a view to studying the long+erm effects of ivermectin on transmission. 6.4.4. Risk of ivermectin resistance and means of detection There was still the possible risk of ivermectin resistance though the probability was relatively low. Particular attention should therefore be paid to this aspect during the treatments in the field in order not to induce resistance. However. since the high doses of ivermectin were well tolerated, they could be used as a stopgap measure against possible cases of resistance. For the detailed resutts of the epidemiological research. reference has to be made to the report of the meeting on "Operational Research and Strategies' held in March 1995. ' ( )nchocerc iasis Chcutot h!'rilp)' Rcscorch Ccntrc r9 6.5. Rcsutts of the evatuation of the ivernrectin distribution prograrnmes (Guinea, IUali, Senegal) The meeting was informed'of the results of the evaluation of the ivermectin distribution prografirmes made in Guinea, Mali and Senegal by a group of OCP consultants. This study. which was carried out in January 1995 on the initiative of Dr E.M. Samba, then OCP Director. had made it possible to assess more objectively the operational modalities of the distribution prograrrmes in the above-mentioned three countries. The evaluation confirmed the ivermectin treatment coverage rate of more than 7O% reportedby OCP as well as the good acceptability of ivermectin by the village communities. The survey showed that the overall coverage obtained by the OCP/mobile teams was higher (80.8%) than that obtained by the community treatment Q4.5%r. On the other hard, the ratc of monitoring of all the treatment cycles by individuals was far higher in the community treatment (52.3%, than in the treatment by the OCP/mobile teams (19.5%). Some shortcomings were noted. particularly with regard to IEC, real participation of the communities in ivermectin distributionactivities, supervisionof these activities and in the management of the drug. 6.6. I\'Iodalities of community treatment in the countries The rneering reviewed the nrodalities of comrnunity treatment in the Participating Countries. It was observed that there were nrany common points in the overall approach: awareness-raising, selecrion and training of village volunteers, monitoring and collection of treatment results. In all cases, the conununities were involved in the ivermectin distribution chain. The Coordinators were encouraged to continue the search for and use of alternative solutions (case of illiterares, for example for the completion of treatment notebooks) and not to seek to standardize the methods ar all iosts. They shouid rely on operational community tiiiiment plans with a flexible implementation and make both internal (self-evaluations) and external evaluations. 7. DATA ANALYSIS AND INTERPRETATION 7. l. Epidemiotogicat modelling 7..1.1. Duration of the distribution in zones treated with ivermectin alone In the zones treated with ivermectin alone, the simulations showed that two treatments per ycar were necessary for l0 yean in order to reduce the riskof recrudescence to about4%, while in the zones where the treatment wa! being carried out once per year, a period of at least 15 years was required to obtain the same results provided a mean coverage rate of 65% was guaranteed. 7.1.2. Duration of combined ivermectin and larvicide treatment The most important conclusion from the analysis of the simulations was that 12 years of combination of vector control and annual ivermectin treatment, with an average coverage of 65%, could reduce the risk of recrudescence to less than I %. 20 7.2. Guide for the surveillance and control of onchocerciasis as part of devolution The points concerning longitudinal analysis of the epidemiological data, entomological surveillancc in the context of devolution and the transfer of epidemiological data to the Participating Countries had been discussed briefly in a draft guide presented to the meeting. 7.3. Computer equipment and their use in the Participating Countries Eight countries out of the eleven had provided their national teams with computer equipment (Benin. Burkina Faso, C6te d'lvoire, Ghana. Mali. Niger, Senegal and Togo). Burkina Faso, C6te d'lvoire and Niger had computers whose capacities were great enough for the transfer and analysis of all the OCP epidemiological data. 8. TRANSFER OF RESIDUAL OCP ACTIVITIES 8.1. Nature of residu'l onchocerciasis control activities This paragraph will be the subject of a detailed document to be prepared by WHO/OCP. 8. l.l. Medical activities (a) IEC It seemed important, more than ever, to continue and intensify the awareness-raising activities rhrough information, education and communication at all levels (central, district, peripheral and panicularly, community) with a view to the detection and conlrol of onchocerciasis recrudescence and the regular taking of ivermectin. The IEC messages should be adapted to the control strategies established. KAP surveys should be carried out in order to correct the shortcomings and improve the perception of the messages by the village communities. (b) Epidemiological surveillance - In the freed zones, the active epidemiological surveillance of the sentinel villages was being carried out by the national tsarnst OCP intervening only in quality control. For the moment, only parasitological surveys based on skin snip were being carried out in the sentinel villages every three years. For any positive case detected, a migration survey is carried out. - In the extension zones under larvicide and ivermectin pressure, the epidemiological surveillance would be based on incidence study. - In the extension zones treatd with ivermectin alone, the epidemiological surveillance would also be based on incidence srudy. Passive epidemiologicalsurveillance would be carried out by the health centres and conrmunities particularly for suspected cases of onchocerciasis (nligrants or natives). (c) Ivernreclin treatnrent - In rhe original area. positive cases of onchocerciasis detected and suspectcd clses should be treated with ivertttectirt: 2t - In the extension areas under larvicide and ivermectin pressurc, all sublccts living in the nroderate and high-risk zones should be treated with ivermectin (see ntaps attached hereto as Annexes t la and I lb). - ln the extension areas solely treated with ivermectin, community and passive treatments should be encouraged. 8. 1.2. Entomoloeical activities (a) In the original Programme area - Ground larviciding to control nuisance: the countries should take over ground larviciding in the socioeconomic development areas. OCP was training the trainers. '-' - Ground larviciding to intemrpt transmission: apart from the Dienkoa and the Niger where OCP was supporting the treatrnent for the control of transmission, there were no other examples, for the moment, where this type of operation had been planned. (b) In the extension areas under larvicide and ivermectin pressure, ground larviciding could be carried out to control nuisance in the socioeconomic development areas. (c) In the extension zones treated with ivermectin alone, ground larviciding to control nuisance could be justified in the socioeconomic development areas. 9. PROBLEMS CONCERNING THE TRANSFER OF OCP'S ACTIVITIES 9.1. Achievernents 9.1.1. Staff trained and available (Tables l0 to 14) OCP had given to each country the list of all those whose training it had financed, from 1974 to date, i.e., a total of 433 workers (see Annex 9). - However, the greater part of this staff are not available in the national teams of the different countries to take part directly in devotution activities. The National Coordinators had been invited to review the situation in order to know the facilities in which these trained persons were currcntly working. Efforts had also been made in the counuies for the training of district workers. 22 l- o a)u a) t o(J u)q) oU oo o E(! 9.U o q, qJ q, q, a ut cllL e, I 6l . o o .176qai a? e.*?88t8 tlooo@ootrEtrtr J(-vyJ4 cld(,cl9J9- i!Gi-r- oooo(uooo !-o-oDG,'d .{ ((lo.o-o.o8838 a??2,(!nirdGa :g :E :g .g .EC c tr c.9 EEEE€ qLqE-o 6 o o.o oddd9z2zz'e llll[il''(coUO* 2 G .9 .g =61(J i(JG, li u.9o; .9E EO Lu) .Ebcot <r =(!? a(J5 'Eb .EE trd =r.68. 6 G' (lF o. oota oL >. >- .9O-O-Footro(J6o-loo ^L!^ .!* o o.= .rzeCr) ++++ o t\ 6l dr !' 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(u o I -o(l 'E c.{ c o c .f$ o o O o <) 'oluc d F (\ o o o tt t\ o o o o .ttL(u o a o (.) oo(l, tu = ((, GI \o(rlq 6l \o \o r a\or- 6 \o o or- \o(/)(\l o G. E c, .s(l F (\l €(\l \o \o NN @\or- € \o o <>r\ \o(') N o inr- ut ruln =z 2 .go E (J()F ru €s 'e @ rn( o\(n \or ( an o(\l € o\\o c.lc.t 1.1 oc.t ! c)c d F ot\ (.l o\ 6h \ora €('l $(\l @ r\ GIci (n ool v) c)o o (tl c) 't,() 2, q) 5 s, trI {. (\lN t\ar 6 o\ €r+ $ $ (\l @ E a)tr .E F f- t(?I Nt\l @ (frol €t+ \o \o (\ € =oU o u, Gt TL E raL. o G C) o -! o ro U (\l c sl() o oo oF .Etro ca lu oo z G' c, .E a(, G' oolutr C)(/) 6]Dq, CI GIotr (, C)tro a GI L(u v) 25 a) t E C) ? CJ v) o(, c) (! qJ L U, ql o 5 ta 't, (, 6) Eq) l-o q, a dl 6 6l .(l !,e 'e!8 gE3Aa .roo() EE €o .:a trg8 laE (-l c !6lF ta o t) o. (u o (, D G, .F o tN t\ o o o o O o O O !oc(t F o r- 6a o o o o o O O o v, q) q) a o ru oo(t, lu 3tl, trl a. N { inr- \o r,.)\o @ o o o o '(, ruc (l, F o(.l 6l t rnr- \o !n\o @ o o o taoa z oc(l, o o()F tu o ct (l (n rf (a c)(\l o N \o(\l or C{ r\ .o otr cl F (i t r o(\l o N \o(\ c\ r{ r- € ar, 0-, t,|, .= v, iar oooo G, .Y .9 .-oE(u 2. q) .o cl (t o o o o r- o \t o o (\l ! Q) st F o o o o r- o l; t o o ol b c , oU o6d(& (\tc! a co d z. .i q) o E o to U (rl tr C, () ,;1 o a0 oF . ).: c c(, co o .9p z (\,(u '= o ,a : a!@o o(r) =(! .2 co ((, t, f(, oq onJ (l, .9 U1 26 o 0I q,(J a ar, o a0 .o a)t ct 1' o o0 o E(! ta$ c, (! (!E89'tr Gt=!5 . (,) !so- tr !',!6O=! .Ee .l4o)(!Ei o)e ! qJ (l,F 27 9. 1 .2. Manuals/quides available The following manuals and guides were made avaitable to the Coordinators. (a) VCU - Cround larviciding - Techniques for the ground control of blackfly larval breeding sites. OCp, October l99l (in English and French) - The inrportance and role of ground larviciding in the Onchocerciasis Conrrol programme in Wesr Africa. Bull. Soc. Path. Ex. 87,1994,278-ZgZ (in French) - Ground larviciding of blackfly breeding sites. Examptes of sites of socioeconomic interest which could eventually be treated from the ground. No.392AlCU TEC/3-15 Og92,) (in English and French). O) EPI - Manual of procedure for ivermectin distribution and monitoring of side-effects (in English and French). - Manual of procedure for skin-snip surveys (simple evaluarion), (in English and French) - Training module for peripheral health workers (in Engrish and French) - Manual of ophthalmological Procedure (detailed evaluation) (in English) - Methodology of incidence study (in French). (c) BIS - Module for training in informatics and epidemiological evaluation dara analysis (in English and French). (d) DEVO 1 . - Main tines of aerotution alivities related to onchocerciasis in the original OCp area.(Revision t: !oc. ,Tl1.iujl?e.3) in Engtish and French. Other manuals were being pt e*"aarj would be available soon (Manual summarizing OCp's rcsiduat activities to be transfered to the countries - Epidemiological Surveillance Guide - Methodology for rhe instirution of community trcatmenttrl a 3one under large-scale ivermectin treatment). 9. I.3. Activities alrbadv iinsfehcd technically ':t'. f.ii ;"g.rffi '*'g1i "1*+ .,1:. . iIiermectin distribution is'dcit:6rut-solely by'the nation;rt teams in.almost all the courrries. Epidemiological cvaluations arc.mrde by the nationals but stilt with the tcchnical support of WHO/OCP staff;.the same applies to thc migration studies and ground larviciding activitics., As regards IEC activities, they are undertaken by national teams with the technical support of NGOs in some cases. For their part, the OCP tcams continue to raisc the awareness of thc authorities ind communities, as a support to the activities carried out by the countries in this field. 2lt t) l..l . [-tlgrstlcs Itt sottre cases. OCP was providing the national teams with logistics and equipmcnr [or dcvolurion rctrvitics. particularly cpiderniological surveillance of sentinel villages. 9.1 5. Finrncine Firtrncing w:rs being provided by the Participating Countries, NGOs, bilareral coop€ration orgrniz-ttioru, WHO and the World Bank. OCP was, in sonre cases. contributing to rhe financing of cpidenriological surveillance of sentinel villages. 9.2. Obstacles 9.2. t. Trainins requirements In addition to the post-graduate training requirements which OCP was conrinuing ro meer rhrough rhe award of fellowships, the information containcd in Tables l0 to l4 indicates that the teams al the central level nced to be strcngthened with: Benin: N{al i: I microscopist I census clerk C6te d'lvoire: I microscopist Senegal: I census clerk Guinea Bissau: I skin-snippcr and I census clerk Funhemrore. All the national teams needed retraining in epidemiological evaluation mcrhodology. All the eleven Participating Countries should strengthen the in-service training of health workers and volunteers for ivermectin distribution and ground larviciding. - The national teanrs must organizc deccntralized trainings in epidemiological surveillance 9.?.2. Resistance to the transfer orocess (a) in OCP Thc obstacles concerned thc non-prcparcdncss of somc staff members to transfcr thcir skills as quickly aspossibletothenationals. Withthemergerofthethreeunits.viz:"Devolution'.'EPl'and"BIS",this res istance phenomenon should disappcar complctcly. (b) at the national lcvel The obstacles nrenlioned by particiPants were: - organizational in nature: in some countries, lhe structures and mechanisms ftrr the intcgration tlf the onchocerciasis control activities into the health centres had not been wcll delined; - related to avrilable resources: 29 . loss of traincd staff. insufficient staff both at the cenrral and peripheral lcvcls . rnsufficient technical cquipmcnt at the district level (punches. microscopcs) . insufficient logisrics in some countries - insrirutional in naturc: . divergent poirus of view of donors concerning the intcgration of heahh progr:uunes (venical vision of some donors) . red tape . context of structural adjustment which limits the recruitment of staff and rhe allocation of opcrating budgets by the governrnents . lack of staff nrotivarion - gcncral in ruturc: . inadcquatc basic training programmes for hedth staff compared to the ficld acrivities in some countries. . insecurity in the countryside in some countries. 9.2.3. Loeistic costs Some of the countries men(ioned the somewhat bad state of the recondirioned vehicles put ar rheir disposal by OCP as pan of devolution. The nraintenancc and functioning of the logistics were costing much to the nationals and they were having difficulties in using these resources. 9.2.4. Per dienr The per diem rate varicd from one country to anorher as well as the payment modalities. Per diem was being paid by OCP during large-scale distributioncarried out ry the mobile t€atns. To minimize costs. the countrics werc moving more and more towards community trcatment ard integration of the rctivities. 93. h,ospects: Ptanned timetable for the take+ver of residust ectivities by the Penicipatiry Cormtries .. : 9.3.1. WitMrawal of OCP from cpidenriological w.atuation and ivermectin distribution activities OCP had planned for a gradual witMrawal of its finarrcid end logistic support to thc Panicipating Countries as and whcn thcy arc in a position to takc over the epidemiological evaluation and ivermectin distribution activities. This withdrawal should bccome a reality by thc end of 1997 in the original Programme area and by the yezr 2OO2 in the cxtension areas. 9.3.2. Ccssation of VCU activitics in the original Procranune area and in C6te d'lvoire's soulhern extension srea brviciding had becn dcfinitivcly stop@ in almost the whole of thc original Programme area with the excrption of: - the Dienkoa in Burkina Faso where OCP-supported ground larviciding by thc national teams would be continued up to 1997 at the latest; 30 the Kankelaba in Mali, where aerial larviciding would be continued up to 1997; the Niger and its tributaries in Mali where ground larviciding would be continued by the national reams, with OCP support, up to 1998: rivers Keran, Kara and Mo in Togo which would be attached to the southern extension zone where larviciding would be continued probably up to the year 2002just as the south-eastern extension zone in Benin: the Bui and its tributaries in Ghana would be treated up to the end of 1996; rivers Sassandra, lower Bandama, lower N'Zi and Comoe in C6te d'lvoire would be treated up to the end of 1998. In conclusion at the end of 1997, larviciding would cease completely in the original area except on the tributaries of the Oti in Togo. 9.3.3. Western and south-easiern extensions The ongoing activities would be continued up to the year 2AO2, with OCP's technical, logistic and fi nancial participation. IO. PREPARATIONS FOR THE MINISTERIAL MEETING ON PROBLEMS CONCERNING THE INTEGRATION OF RESIDUAL ONCHOCERCIASIS CONTROL ACTIVITIES INTO THE HEALTH CARE SYSTEMS OF THE PARTICIPATING COUNTRIES 10.1. Context of the meeting During the JPCI5 in Yamoussoukro, the Ministers of Health of the Participating Countries expressed rhe wish ro meet among themselves in order to srudy more closely the take-over of residual OCP activities and the problems concerning the integration of these activities into the national health systems. '10.2. Document to be prepared ; hhe document to be prepared would comprise the following points: I L transfer of residual OCP activities to the Participating Countries; - problems concerning the transfer of OCP activities to the countries; timetable of OCP withdrawal - nrultidiseasessurveillanceandintegration l :- ability of the counrries to finance the residual activities themselves 1 10.3. Document drafting committee The drafting committee would be composed of the National Coordinators of Benin. Burkina Faso. Chana and Senegal and supported by WI{O/OCP rvhich will also play a coordinating role. 3r 10.4. Identilication of participants in the nreeting Ministcrs of l{ealth of the eleven Participating Countries and their dclegation, WIIO/AI:RO and OCI'}. 10.5. Date and place of the meeting It wal proposed that the meeting be held in Washington D.C. just before the sixteenth JPC session. II. OTHER MATTERS The meeting took note of the proposal made by Professor A. Degremont, EAC member, that henceforth the chairmanship of the National Coordinators' meetings be entrusted to the Coordinators themselves. The next meeting between the National Coordinators and OCP would uke place in Ouagadougou in March 1996 at a date to be specified later on. 32 I] CONCLLISIONS AND RECOMMENDATIONS lvcnttcc(trt tret(ntent wa.s one of the strategies used by OCP with vector control to attain rts ohlcctivc ,'\cctrrdtttgly'rnd irt vrcw of thc sltortage of llnancial rcsourccs ur tllc coulltncs to llcar thc costs inltcrent in this activity, the mceting cxprcsscd thc wish that EAC reconsidcr its recommendari<,ur to J PC that OCP's financial and logistic support to ivermectin distribution and epidemiological evaluarion cersc ls frorn 1998. I{owcver. continued OCP support bcyond 1997 would he conringcnr on rlrc absence of financial support from other sourccs. A special note (Annex 4) prepared for rhar purpose rs atrached (o this reporr. (Nat. Coord./Ocn. The nteeting reviewed the results of the ivcrmectin treatmenr in the Panicipating Countries. lr observed that much remained to be donc in the field of community treatment. It therefore recomntended that the Coordinators pay more ancntion to this approach and report on thc resulrs obtained and the resources brought into play with a vicw to the sustainabiliry of rhis action. (Nat. Coord./DEVO Unit). The meeting expressed its satisfaction with the resuls of thc evaluation carried out by a group of OCP consultants of the ivermectin distribution programmes in Senegal. Guinea and Mali. Among other things. thc shortcornings noted in the fields of l.E.C. and participation of the corrununiries in the activities allowed specific recommendations to be made to each country. The mceting rhercfore supported the reconrmendation by the group of consultants that the evaluation be extendcd to the other Participrting Countries. (OCP). Wrtlt a view to strengthening national technical capabilities as part of devolution, the rnceting recorttrucrtdcrJ that the Participating Countrics pay atiention to the training and rctraining of rhe ti:ttt,',rt;tl tclnts and intenttetliare/district level healrh staff in thc priority l'iclds. Accordrngly. thc cctuntrics *'crc askcd. for exarnple, to proposc national ophthalnrologists lirr rctrarning in the ljcld ol' onc lrt'rce rc ir-s is. (Nat. Coord./DEVO Unit). The rnc'eting notd with satisfaction the progress made in the training of the Coordinators and their collrborators in informatics and collection, analysis and intcrpretation of epidcmiological data. The nteeting reconrnrended that this training be continued and that OCP should do everything possible to undenake a regular field monitoring of the trained teams. (OCPNat. Coord.). The nreeting notd that the tack of an iirformatics component in the curricula of the Bamako and Nairobi Applied Epidemiology Coursc for senior health officers was a handicap and reconrmended that WHO/AFRO take the necessary steps to encourage the heads of these institutions to fill this gap. (AFRO). Nationrl training and retraining seminars corutitutd a means of strengthening the capability of the irational teams in the contcxt of dcvolution. The mecting thcrefore recomrnended that the Participating Countries invest nrore in the organization of such seminars with their own resources. (Nal. Coord/AFRO). t The nreering nored that nrost of those wtro had benefited from OCP felklwships were not participating in rhe acrivities of the mtional teams and recomnrended that the Coordirulors report on tltc situatiolt to the next nleeting. (Nat. Coord.). The lneerrng nored rhe efforts nrade by the Wt{O/Country experts to cttlluhoratc witlt the National Co,.rrdin:trtrrs of sonre courltries in thecontextof devolution. Witha vicw to arrivirtgat cxtcnding lhis collahoratitln with grcatcr eflicicucy tlte ntecting recortuttenrJcd tlrat tltc Coorditutlors trc tttlitrtttcd 1. s. 10. I t. 33 about resources available in the WHO country offrces in order to seck the neccssary support accordrng to their requirements and the activities to bc carried out. (Nat. Coord/AFRO/DEVO Unitl. Thc mceting rccommended thai thc NationalCoordinarors be more active in the search for thc human and material resourccs which thcy necd to make thc national teams operational before the cnd of the Programme aftcr making a judicious estimate of thc rcquircments and a rigorous plaruring of training with a view to thc complete take-over of the aaivitics in their countries. (Nat. Coord/DEVO Uni$. With rhe ccssation of aerial larviciding and the return of thc blackflics, the problen$ of nuisancc and is control was becoming more and morc scrious. Howcvcr. bccause of the high cost of lariciding in gcneral and thc risk of resistance relatcd to ground larviciding in particular, the meeting recommended that this activity bc envisagcd only in rrcas wherc thc problcnr had bccomc unbearable to'the extent of jeopardizing sociocconomic dcvelopment activities and ttut spccial emphasis be laid on thc raising of the awarencss of thc authoritics and populatiors in this field. (Nat. Coord./OCP). J4 ANNEX I LTST OF PARTTCIPANTS OCP and \VIIO l. Dr F.K. Wurapa, Representing the Regional Director, AFRO 2. Dr A. Sdk6t€li, Ag. Programme Director, (Chaimran) 3. Dr G. Traor€ on behalf of the WHO Representative in Burkina Faso 4. Dr H. Agoua. CAT, OCP/Kara 5. Dr L.K.B. Aboboua, CAT, OCP/Bamako (Secretariat) 6. Dr B. Boatin, OCP, Ouagadougou (Vicdhaimran) 7. Dr O. W. Christersen, OCP, Geneva 8. Dr N. DemMl6, OCP, Bamako (Secretariat) 9. Dr A.K. Diallo, OCP, Parakou 10. Dr J.M. Hougard, OCP, Ouagadougou ll. Dr M. Kassambara. OCP. Kara 12. Dr K. Nimaga, OCP, Ouagadougou (Secretariat) 13. M. M. Ouattara, OCP, Ouagadougou 14. M. M. Sarr, OCP, Bouakd 15. M. J.E. Senghor, OCP, Ouagadougou 16. Dr E. Soumbey Alley, OCP, Ouagadougou 17. M. S. Sowah, OCP, Tamal6 18. Dr L. Yam6ogo, OCP, Ouagadougou 19. Dr A. Baba-Moussa, WHO/AFRO, Ouagadougou 20. Dr A. Maiga, OMS/AFRO, Ouagadougou 2l D1 M. Sylla, OCP, Ouagadougou (Secretariat) NATIONAI^s l. Dr L. Assogba, National Oncho Coordinator, Benin (Main rapporteur) 2. Dr J. A. Amankwa, National Devolution Coordinator, Ghana (Co'rapporteur) 3. Dr G.P. Brika, Executive Director, National Devolution Programme, C6te d'lvoire 4. Dr J. Cabor€, National Devolution Coordinator, Burkina Faso (Co-rapporteur) 5. Dr Y. Camara, Epidemiologist, Guinea 6. Dr M. Cor N'Dour, National Oncho Coordinator, Senegal 7. M. J. Fosu, Executive Director, NOS, Ghana 8. Dr G. Kadad6, National Devolution Coordinator, Niger 9. Dr B. Kargbo, National Oncho Coordinator, Sierra l,eone 10. Dr Y. Kass6, National Oncho Coordinator, Guinea I l. Dr A. Pana, National Oncho Coordinator, Togo 12. Dr A. Tamba Nhaque, National Oncho Coordinator, Guinea Bissau 13. Dr K. Tour€, Epidemiologist, Mali 14. Dr M. Traor6, National Oncho Coordinator, Mali OTTIER PARTICIPANTS I. Dr. J. Catray6, Regional Coordinator, ESSP, Burkina Faso 2. Dr. T.D. lngovi. Resident Representantive. HKI. Burkina Faso 3. Prof. A. Degrdmont. EAC menrber .1. Dr Y. Genevier. Public llealth Specialist. World llank. Wasltingtott 35 ANNEX 2 PROCESS OF DEVOLUTION OF OCP TO THE PARTICIPATING COTJNTRIES [. Delinltlon - Trarsfer by OCP to the Participating Countries and - Take-over of the residual onchocerciasis control activities ("devolution sensu stricto") by these countries. 2. Strarqy for irnplementation of residual onctro activides - lnformation, cducation, @mmunication (IEC) - Epidcnriological surveillancc of seruincl villages (detection of possible recrudescence) - Ivermectin treatrnent 3. Approach adopted by the countrie with a view to tsHDS tustsinsble action on the basir of this strate€y. - Integration of residud onchocerciasis conrrol activities into the national hedth systems ("devolution sensu lato'), hencc the idea of prepariug national devolution plans which uke into account both the carrying out of these residud oncho activities and the surveillanccy'control of other diseases. 4. Role of the different actors in the implementation of the devolution process - Role of OCP To develop at the country level, the capacity for early detection and control of any onchocerciasis recrudescence by means of an appropriate chemotherapy. - Role of the countries Y To carry out cffeively thesc. recrudesccncc detection ard control activities as part of integrated multidisease conEol. .. : - Rolc of WHO and other oartners To help the countries to carry out successfully their process of integration of multidisease surveillance activities. l. 36 ANNEX 3 CRITERIA FOR TIIE ASSESSMENT OF THE CAPABILITY OF THE PARTICIPATING COI,JNTRIES TO CARRY OUT EFFECTIYELY ONCHOCERCIASIS RECRI.'DESCENCE DETECTION AND CONTROL Existence of national senior officers and technicians trained in fields related to the devolution of OCP (epidemiology, public health, health services rnanagement, entomology, ophthalmology, etc.). Existence of active epidemiological surveillancc and onchocerciasis treatment mobile teams available at the central and regional or district levels. Existence of fxed health centre medical staff retrained to undertake passive surveillance of onchocerciasis and treatment of onchocerciasis-patients with ivermectin. Existence of personnel trained in methods of analysis and interpretation of epidemiological data collected during onchocerciasis survey. Existence of an active national strucnlre for the coordination of devolution activities (devolution comminee). Existence of a national prognmme aimed at integrating onchocerciasis-related activities with those of other endemic diseases (natiorul devolution plan). 1. Having carried out the onchocerciasis surveillanc€ activities independently and many times before the end of OCP by integrating them with the surveillance activities concerning other endemic diseases ("running-in' of the system by the implementation of the whole or part of the national devolution plan). 8. Gradual financing of the greater part of the onchocerciasis surveillance activities from the country's own resources in order to ensure the sustainability of the activities. 9. Rural communities prepared for an active participation in the activities. 10. 'Existence of an operational epidemiological surveillance network at the national level. How can the cha"ces of success of the devolution pnocess be increased? Participating Countries - To continue to show a hrm will not to see this scourge of onchocerciasis reappear again. To establish a me,chanism for the intercountry coordination of their devolution activities. To release resources for the implementarion of these activities. - To integrate the activities. to the extent possible, with those of the basic health facilities in ' order to ensure their sustainability. '- To let the rural communities themselves participate actively stilt with a view to the sustainability of the activities undertaken. 2. 3. 4. 5. 6. 'l I 37 Annex 3 (cont'd) - To promote, with a view to the safeguarding of environmental resources, socio-economic development in the onchocerciasis-freed areas in order to give the populations the means and motivation for an active participation in activities aimed at the promotion of health in generat and OCP devolution in particular. ocP - To reduce the disease to the lowest possible level so as to prevcnt or delay significantly the emergence of rccrudescence. - To involve as uumy partnerc as possible, at all levels, through a sustained awareness-raising campaign in order to ensure that onchoccrciasis would no longcr become a public health problem. - To make available ard within everyone's reach the necessary dryolution tools (ivermectin, diagnostic mcthods, different systems of distribution of the drug and of treatment of paticnts, rnenuals, etc.). WHO and international community - To contioue with the technical and financial support to OCP up to some time around the year 2W2. - To support the implementation of the devolution plans of the countries. - To help in the strengthening of the health facilities of the counrries. - To support the establishment of a mechanism for the intercountry coordination of devolution sctivities. - To help the countries to carry out socioeconomic developmeru in the onchocerciasis-freed areas. 13. 4. 38 ANNEX 4 TITE NECESSITY FOR CONTINUED OCP NNANCIAL AND LOGISTIC SUPPORT FOR I \ERI\TECTIN DISTRIBUTION AND EPIDEMIOLOGICAL EVALUATION PROGRAMMES TN T}M PARTICIPATTNG COUNTRIES Ivermectin is highly effective in reducing skin and ocular manifestations of onchocerciasis. k also reduces the duration of vector control from 14 to l2 years when applied conscientiously with a relatively high coverage of treatment in combination with vector control. The EAC in its 1994 Mid-Term (Phase IV) Evaluation recommended, and JPC agreed, that OCP should cease all technical, logistics and financial support to ivermectin distribution'and epidemiological evaluation carried out by national teams, as from 1998. However, although the Participating Countries are capable of conducting such activities on rhe technical level, the economic situation in those countries will not allow them to bear the cost of the ivermectin distribution or of epidemiological evaluation as from 1998. Should therefore the distribution of ivermectin be impeded or cease after 1997, due to shortage of financial resources. OCP operations would suffer and the attaiffnent of the Programme objective rvould be in peril insofar as ivermectin plays an important role in OCP control operations. OCP logistics and financial support to the countries for ivermectin distribution and for epidemiological evaluation, when the necessary outside support is not forthcoming, should consequently continue until the year 2002 when the Programme ceases operations. The cost of this support is less than 0.5% of the projected expenditure for the whole o[ the Phasing-out Period. This percentage will decline with time as more effort is made by the countries themselves to find financial support for these activities. Consequently, EAC may wish to review its position on the matter of OCP's financial and logistic support for these activities and, make an appropriate recorrrmendation to JPC in Decemher 1995. 7. 3() ANNITX 5a :3,3s 6L oOAE-o: tr().: I6-O)- O -c6 z?e -x .= ur at?a,= '= c, eECe =:OO <) c, a (J& FF(z) z o:<t-l-)J o H a A -lQ o r{FH t tr o trIlV -tPFUp FilH CN J z oF( F. &H O{ o (l, .g(,)(Eoo !o 5eoo(jlo : oo cfo() co u,c(l, xlt c o o(l, 3I a)o() oa (9 o tdzoN zdt{l-ft, ld o p 9 F z)lr o(. td (J- E F hFo J oEeoJ o e,oL2r{ 6Y 2 co rdzoN z&IdL k = ho ANNEX 5b q a' e a u- E , e o!aU9tE '6o ci oFb9c55-oaQ6 nl >I oldl 5 5 E6EeOo tsz;) zo F J o lrl o O.Uo trl F -\olJi Cf\oo\ u)-dp FU dF(r) J z o F dlr: O. o z Oql-Z < lrl)x -tF >dtrl dJF<oQ2-6<qe da <7- E3EOIl, o o Ez) t! o lI. ul C) LIod2-<<H(ar! vd l-J9<l-Z<oEEetrto tu o. o J (,gl 2. ul Ec2 o c 9 Eg tt) E , :: ,1 I : t ! , I t '! i'f :ri! et:IaearItrq BlJJCi:i ; i!:!l l.'! a;E;I IT: IT: EEi 6Si --o 1'lI.!IS!rt Iq 4 LI ANN EX 6.' :! a- i:l i'i;!:!iac:. .3!'"; ;!i; :tii 5! i:3:-! iiii it ir IIff EN 3 o , eI o!at EE : s: r i!;l :gEg .!i:t aitaa! i I r!s!rl ! I I u; 3t3l If IT --t ti_ !E ig ii t: ii fi !! N o :ttlrit ff !Eaa iT Ti N!ri I i;, :l ltisI \< -e ae\ E E1 :x @ ! ffzt F g1 lrJ urEIatrq iEoOE z0-{-r U:z6 1Elo6gi;fzo- -1 F<lz9tt EI dfi .cSrE^ tr,t3 E=Yxo --ol(,)!:o lrl!.- -Ll6-z uo l! e s te D:ll OC! j'-^'-'..] . {: i tooI =t lr, . . G(9 o GG o 3l g El: l.,E a :J HI Fot.,i lr, Zf<c'N 8Ei trt H= lrl ll, E=ld i", UiZGdl|lJ> tdJ :< HE Hg SEz<OGNF ,l d. F / r.\-. ilxtyry% i I ii i :: -: T!;r5jl ; -i 1!o i3 !! i-C ;;Eii3I r:iEgiiP!'"; E I ! -: l- > ? > .06=L L (- :!;; : i: iEilii! :i:E;:igl:iEi: ;r;!;; Ei;i;;*i gN i:i " 'is!, rt Id A ANNEX 6b ! -Oo !t iril --tP;;:i .?;gi E! x: t; ir =3 :st9 .t :ioox< N (! t C at E !c -; 'Ea! o- .i:; =9 ;! it EIE= si o" :EC- ET a? 5s x- € o 9 o 6 o trJ zq Fg trJ tr.l IJ= trJ + z6ooC20,(-, 91 <t <tZz6 1E -1 OtrY etrfzo- -.1 Fqz 9tlo=9r6il -c lrJ go' a^ trJ aqi YNo\-dt sr f: or1rJ9- - trJ5=z N-- rofl, cEEi E;:FiE i33.! !i Ei3: ii o-l a cij 3i -a !33 3 !ct .c !IC-r!3EtJa Jo Ii aq 5 Ouig3 ic o: >.OO {.-^':. o,DI rl F Ot a attL,Z o< Foufo lrrZot)<ooN-6tr2QcruritrL) - lr,lif,= lrJ lrJ =QZ<O-EEuiuo UTP zG&(lrJs J.z 5 EJtrr Eod;!E B3= ,3- trJ :- G 3 E.a NF J ,,1x,4WW bu-,,P 'a 'l) ANrr'EX 7a ?. -9P :;Ioo,YI$! =!IE EYan o: :8t< iE oaLYug9 tE =aEo ,! sg -t oo @,I a- <lr) ol uJ o)(i- <c <to J-)J- EAE(Er< - lrtJS s3o(, dP >c lrj Jo<E= trJ (} c.G,oot.u.t o7LrF ?=J ')zt9 'JT,t { =otr> *8 bb -Fet EarJ o -t () E io3 ar, =E c 8G 0- tr,J E z L'c a :r ta z o z9 5Jo lrl CI 5 tuo r{I (J 5 a2 o LrJfI(, o)I tr,, a 0- t^rl trJI a)J1 lrj G _ tl ) c 31G (n UJJJ UJz Fztrl ah (n trJ(, JJt t tr, ,o w{ra1': II' t(E(, o u zI k:)F6 ,r'It/- r- z='---------.'-T-1-+u 4r t- ;ry)i ["3:\ 1, '/ .r\ .\ ",\ .-r.4-t-- .,wL .14 ANNEX 7b I\linimum number of sentinel villages to be evaluated as part of devolution in the original Programme area in 195, 1996 and lW| Year Country 1995 1996 1997 Total Burkina Faso 23 2t 36 80 Mali l5 t2 t2 39 C6tg d'lvoire 7 t4 l6 37 Ghana l5 l3 r3 4l Togo 4 6 6 t6 Benin 3 3 2 8 Niger il l0 il 32 Total 78 79 96 253* t9 villages are to be selected in the field - Burkina Faso 2 in 1995 2 in 1997 I in 1996 3 in 1997 I in 1997 - Ghana - Togo OJz<^ <tsx <Ov(JF NO. o N\ON. .o (o6 \o oN ro F-N on R^:(o n\O N 66N. 60N. @6 .o { xJQ) <.a ()L -t- NC' O. ta\o \ON 6 o F\O rtF 6aoON{ Jtl.t E6 o3sl U o. .t. c, 6 ..occo -.c o €83<F ca -t F a\l a o ,.t c,lt . c .cleoJOD GOoc -o - 6e 6F Aj tOF o6\' .t\t (> o>Etteo Ee rO€ t\I nG, m€ .a Or o>!oEO .,Jao aaac N N \' O\ nr .t O. t= 93C- \O- .\t tl n o.o. rn ro .>{t oo E Nr 6 rt \' C' (l .\, N rt lnFrt .\t\tr .rto .ar lc a, e8e8t!a- O}ro )- -- C u -ClDo r.l ri rt \o \' nlt4 ..' Ee!ClC-L, 'c, + "n N. c, .\lt\t c, s n\. ro c, r,F aO crn(t tt aom utux -ar 8E -B IB -c !E -5 -E rE -s -E -L +}.tv t o,(, a CI r a urr! I I vTc Ud : a ul E t -t U I ts ? .Ao aa U ! a T t urC' - J 6 u,t u U 6UJ d c lra va g x 1,JO FLP& FoF 6, U 45 - ANi{r.x 8 I c aL o o 8. 5! C, E I L o o- =o , o q, o E co EL (, U , T IL .8 a o o E o 3 o c a,F frl2H}lA H U(r: H a a a ),. N HADoU o 6<HF.frfsH-gE H-qsE; &3 FTo.A qlTAfH6 tstttBo €}l EI& A(, .o E "9f ur EIHddH(, H E DI2 LT !q t) -l< <gtr)G) o\ I .tr o\ o\ ANNEX 9 .[[ : 'rf 'r!a -' ($uorp61) zo|-( E{ ) FEfr(&Ha lr{ a zhr{ F{U rd a& F1 |r{ rd F] U0IH(, & F] CAo\o\ a c\l o\0\ vto (u C,)tr (.) u,() tr o(J v,tr GI C:) (.) €o rE<a od CUg G:) !o m ca o) :(l) U) E() aa .9 .= E o(JI tf-) .+ c?t c! F. -. o\ € r- \o ta r+ Ca C{ F{ ()F{F{F.F.F{O(>OOOOOOO rlr u7 ANNEX 10 (t) l-<(!\n() I .+ o\o\ ca o\9 I C!o\o\ dv,q)U '(f t *€ga g .- u)E6u) -3aJs E6(.a-. q-ioo !ik -g .tEEiuzz IN lr1& FrU o HHrl E-Z? ?=28fif :EEtr c) tr)vd\/ E{ z)< E-t) frlEz&H: FI ca € \O $ (\l N @ \O !+ 6l -{ 0o \O $ N O(r.lOlOl(rl F{F{F(F{ OOOO $o\ o\ I CA o\o\ c\lo\o\ I o\o\ ru . i."' ,ii,7 / t A?+. U Conokry SENEGAL O 50 lOOtil .+ DISTRIEUTION ANO SEVERITY OF 48 - ANNEX tla ONCHOCERCIASIS IN THE WESTERN EXTENSION I { Zone number Progromme boundory a Areoa uith low or no rlsl of onchocercol Dlindnees Areos wlth moderote risk of onchocercol blinctness Areos wifh high rlsk of onchocercol blindness -l- -(\ \/ r5" I tr , - ,.4] ,of) MALI \ 7,n l i .t x --[] m N Freelown LIBERIA z3 E:, o (r lrJ I z ob .q f - '-'-'. lrJtrJ 1a oo .J Orq tc 'D =tt a(, otI o 'a €(,t atoa ,oE ,o aatN (l, o E oFo atIC Eo E(t oIEI ott 6E CI aoa N oCC IDItt a(, oEt o !a .E C'g '- t o E o5IE .c, aaCoN a at3C o o(, a(, oc(, co o I! 5Ea .E s =I aoo a ii !9t ca EI Eoa(, Co\r .E(, a .1, ift,a aE o .(, B a =oa -Co a a ac oN ! a aC!s! o(, L -a (, oEttC o otia t :,o '8 a =! a oo ! zo6ztrj OFf . xqtwz ' zo frg _G ' +hJFr_ , H.q , 9srFe =oea 386cE lrJ ur()(Joorr(,Qz 6.3 L :HF lrlEt fiE 9Lr<z z9OE E(D6c e,'.n ha6 i